Abortion Risks - User contributions [en]

Risk factors

2026-04-03T14:11:13Z

Barb: /* Additional Research Regarding Risk Factors for Adverse Emotional Consequences of Abortion */

=== COMPLETE LIST OF RISK FACTORS IDENTIFIED IN THE 2008 APA TASK FORCE REPORT ===

(see pages 5, 11, and 92 of the [http://www.apa.org/pi/women/programs/abortion/index.aspx Report of the APA Task Force on Mental Health and Abortion])

#terminating a pregnancy that is wanted or meaningful
#perceived pressure from others to terminate a pregnancy
#perceived opposition to the abortion from partners, family, and/or friends
#lack of perceived social support from others
#various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life)
#a history of mental health problems prior to the pregnancy
#feelings of stigma
#perceived need for secrecy
#exposure to antiabortion picketing
#use of avoidance and denial coping strategies
#Feelings of commitment to the pregnancy
#ambivalence about the abortion decision
#low perceived ability to cope with the abortion
#history of prior abortion
#late term abortion
#By parsing of the APA summary conclusion that "adult women who have an unplanned pregnancy the relative risk of mental health problems is no greater if they have a single elective first-trimester abortion than if they deliver that pregnancy," it also appears that the APA is identifying the following as risk factors

::*being an adolescent (not an adult)
::*having a non-elective, "therapeutic" abortion

===COMPLETE LIST OF RISK FACTORS IDENTIFIED IN THE NAF's "A Clinician's Guide to Medical and Surgical Abortion"===

====Predisposing Factors for Negative Reactions ====
(Excerpted from Chapter 3, p29 - Table 3-2.
#Low self-efficacy: expecting depression, severe grief or guilt, and regret after the abortion
#Low self-esteem prior to the abortion
#An existing mental illness or disorder prior to the abortion
#Significant ambivalence about the decision
#Lack of emotional support and receiving criticism from significant people in their lives
#Perceived coercion to have the abortion
#Belief that a fetus is the same as a 4-year-old human and that abortion is murder
#Fetal abnormality or other medical indications for the abortion
#Usual coping style is repressing thoughts or denial
#Unresolved past losses and perceptions of abortion as a loss
#Experiencing social stigma and antiabortion demonstrators on the day of the abortion
#Commitment to the pregnancy

====Risk Factors for Physical Complications====
(Excerpted from Chapter 5, "Medical Evaluation and Management")

#Prior History of anemeia, siezures, asthma, diabetes, mellitus, heart disease, infectious diseases, and conditions that necessitate chronic steroid use
#History of bleeding disorders
#Current symptoms of respiratory illness
#Current medications
#Medical allergies
#History of sexually transmitted disease
#Previous surgical procedures
#Previous history of induced abortion
#Recent or current substance abuse
#Previous reactions to anesthetics
#History of sexual abuse or domestic/partner violence
#History of contraceptive use
#History of cervical dysplasia
#Rho(D) antigen status
#Anatomic variation of the female genital tract
#Genital tract infection
#Urinary tract infection
#HIV infection or AIDS
#Hypertension

==Most Complete List of Risk Factors for Negative Psychological Reactions to Abortion==

The lists of risk factors chosen by the APA and the National Abortion Federation is based on a subjective judgments and do not include a complete list of risk factors that have been statistically validated in peer reviewed medical literature.

For a more comprehensive list of risk factors for psychological reactions to abortion, including citations to all the studies for each risk factor, see [http://afterabortion.org/1993/identifying-high-risk-abortion-patients-2/ see ''Identifying High Risk Abortion Patients'' here.]

For an even more complete treatment of why these risk factors have been identified and why it is important to screen for them, download [http://www.afterabortion.org/news/Duty2Screen.pdf Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment.]

==Four Types of Women==
According to Philip Ney, from a clinical perspective there are four groups of women having abortion:

#'''Tough and committed.''' Those who insist that abortion is a woman’s right.
#'''Vulnerable.''' Those who are basically unstable who are pushed into a definable mental illness by the trauma of abortion.
#'''Sensitive.''' Those who are reasonably mentally healthy but because of their sensitivities, they are deeply hurt by having an abortion and develop psychiatric symptoms which a researcher defines as an illness.
#'''Resilient.''' Those who choose abortion as the least worst alternative and don’t appear to be affected for years until poor health or stressful circumstance undermine their ego defenses.

==Additional Research Regarding Risk Factors for Adverse Emotional Consequences of Abortion==

'''[https://pubmed.ncbi.nlm.nih.gov/41928440/ Identifying underlying factors in risk factors and emotional sequelae self-attributed to abortion: development and validation of a brief assessment tool]. Reardon DC. J Psychosom Obstet Gynaecol. 2026 Dec 31;47(1):2654140. doi: 10.1080/0167482X.2026.2654140. Epub 2026 Apr 2. PMID: 41928440.'''<blockquote>'''Background:''' Risk factors for adverse emotional and psychological reactions to abortion have not been studied for their interactions. This study used factor analytic methods to develop concise screening scales for pre-abortion risk and post-abortion outcomes.

'''Methods:''' A topic-blind electronic survey was administered to a random sample of U.S. women aged 41-45. Among 2,191 respondents with reproductive histories, 466 (21.3%) reported a prior induced abortion; 409 completed the full survey. Participants rated 10 risk-factor and 25 outcome statements using 0-100 visual analog scales. Exploratory factor analysis (EFA) identified latent constructs, confirmatory factor analysis (CFA) tested model fit, and structural equation modeling (SEM) assessed relationships between risk and outcome factors.

'''Results:''' Risk-factor EFA supported two domains: attachment/support and internal conflict. Outcome EFA identified three domains: internalized distress, intrusive symptoms, and behavioral risks. CFA demonstrated good fit (CFI > .90; RMSEA < .08). SEM showed attachment/support more strongly predicted internalized distress (''β'' = .65), intrusive symptoms (''β'' = .58), and behavioral risks (''β'' = .34) than internal conflict (''β'' = .21-.30). Attachment/support and behavioral risks predicted greater survey-related stress (R² = .30).

'''Conclusions:''' Two core risk dimensions predict post-abortion emotional and behavioral outcomes, supporting further development of factor-based screening tools for counseling.</blockquote>

'''[https://www.ncbi.nlm.nih.gov/pubmed/28969621 Neuroticism-related personality traits are associated with posttraumatic stress after abortion: findings from a Swedish multi-center cohort study.] Wallin Lundell I1,2, Sundström Poromaa I3, Ekselius L4, Georgsson S5,6, Frans Ö7, Helström L8, Högberg U3, Skoog Svanberg A3. ''BMC Womens Health.'' 2017 Oct 2;17(1):96. doi: 10.1186/s12905-017-0417-8.'''

:Among 512 women with no PTSD symptoms, 9.4% experienced all the criteria necessary for a PTSD diagnosis by the three or six month post-abortion assessment. Pre-abortion screening for higher neuroticism-related personality traits can be used to identify the women at greatest risk of abortion associated PTSD. This finding is consistent with [https://www.ncbi.nlm.nih.gov/pubmed/14744527/ other studies showing neurotisicm being associated with greater susceptibility to PTSD].

''"Complicated Mourning: Dynamics of Impacted Pre and Post-Abortion Grief," Anne Speckland, Vincent Rue, Pre and Perinatal Psychology Journal 8(81 ):5, Fall, 1993. ''
:Emotional harm from abortion is more likely when one or more of the following risk factors are present: prior history of mental illness; immature interpersonal relationships; unstable, conflicted relationship with one's partner; history of negative relationship with one's mother; ambivalence regarding abortion; religious and cultural background hostile to abortion; single status especially if no born children; adolescent; second-trimester abortion; abortion for genetic reason; pressure and coercion to abort; prior abortion; prior children; maternal orientation.

''"Adolescent Abortion Option," G. Zakus, S. Wilday, Social Work in Health Care, 12(4):77, Summer, 1987. ''
:Certain categories of women are much more likely to have post-abortion problems sometimes many months or years later. These include: being forced or coerced into abortion; women who place great emphasis on future fertility plans; women with pre- existing psychiatric problems; women suffering from unresolved grief reactions or women with a history of sexual abuse, including incest, molestation or rape.

''"Outcome Following Therapeutic Abortion," R.C. Payne, A.R. Kravitz, M.T. Notman, J.V. Anderson, Arch. Gen. Psychiatry 33:725, June, 1976. ''
:This study measured short- term outcomes of anxiety, depression, anger, guilt and shame following abortion. The authors concluded that women who are most vulnerable to difficulty are those who are single and nulliparous, those with previous history of serious emotional problems, conflicted relationships to lovers, past negative relationships to mother, ambivalence toward abortion or negative religious or cultural attitudes about abortion.

''"The Decision-Making Process and the Outcome of Therapeutic Abortion, C," Friedman, R. Greenspan and F. Mittleman, American Journal of Psychiatry 131(12): 1332-1337, December 1974. ''
:There is high risk for post-abortion psychiatric illness when there is (1) Strong ambivalence; (2) Coercion; (3) Medical indication; (4) Concomitant psychiatric illness and (5) A woman feeling the decision was not her own.

''Broen AN, Moum T, Bodtker AS, Ekeberg O: Reasons for induced abortion and their relation to women's emotional distress: a prospective, two-year follow-up study. Gen Hosp Psychiatry 2005, 27:36-43.''
:Pressure from the male partner was significantly associated with more negative emotional reactions following an abortion.

'''''[https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/reactions-to-abortion-and-subsequent-mental-health/667F92342F6A90F4FB3F8235187F7DBB Reactions to abortion and subsequent mental health.] Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2009 Nov;195(5):420-6.'''''
: BACKGROUND: There has been continued interest in the extent to which women have positive and negative reactions to abortion. AIMS: To document emotional reactions to abortion, and to examine the links between reactions to abortion and subsequent mental health outcomes.
: METHOD: Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30.
: RESULTS: Abortion was associated with high rates of both positive and negative emotional reactions; however, '''nearly 90% of respondents believed that the abortion was the right decision'''. Analyses showed that the number of '''negative responses to the abortion was associated with increased levels of subsequent mental health disorders (P<0.05)'''. Further analyses suggested that, after adjustment for confounding, '''those having an abortion and reporting negative reactions had rates of mental health disorders that were approximately 1.4-1.8 times higher than those not having an abortion'''.
: CONCLUSIONS: Abortion was associated with both positive and negative emotional reactions. The extent of negative emotional reactions appeared to modify the links between abortion and subsequent mental health problems.
: NOTE: '''>85% reported at least one negative emotional reaction; >55% reported at least one strong (“very much”) negative reaction.''' According to the authors: "These findings clearly suggested that unwanted pregnancy leading to abortion was likely to be a risk factor for subsequent mental health problems, whereas unwanted pregnancy leading to live birth was not a risk factor for these problems."

==Risk Factors for Multiple Abortions==

''[http://pubmedcentralcanada.ca/articlerender.cgi?tool=pubmed&pubmedid=15738488 Characteristics of women undergoing repeat induced abortion.]] Fisher WA, Singh SS, Shuper PA, Carey M, Otchet F, MacLean-Brine D, et al. CMAJ 2005;172(5):637-41''
:Background: Although repeat induced abortion is common, data concerning characteristics of women undergoing this procedure are lacking. We conducted this study to identify the characteristics, including history of physical abuse by a male partner and history of sexual abuse, of women who present for repeat induced abortion.

:Methods: We surveyed a consecutive series of women presenting for initial or repeat pregnancy termination to a regional provider of abortion services for a wide geographic area in southwestern Ontario between August 1998 and May 1999. Self-reported demographic characteristics, attitudes and practices regarding contraception, history of relationship violence, history of sexual abuse or coercion, and related variables were assessed as potential correlates of repeat induced abortion. We used χ2 tests for linear trend to examine characteristics of women undergoing a first, second, or third or subsequent abortion. We analyzed significant correlates of repeat abortion using stepwise multivariate multinomial logistic regression to identify factors uniquely associated with repeat abortion.

:Results: Of the 1221 women approached, 1145 (93.8%) consented to participate. Data regarding first versus repeat abortion were available for 1127 women. A total of 68.2%, 23.1% and 8.7% of the women were seeking a first, second, or third or subsequent abortion respectively. Adjusted odds ratios for undergoing repeat versus a first abortion increased significantly with increased age (second abortion: 1.08, 95% confidence interval [CI] 1.04–1.09; third or subsequent abortion: 1.11, 95% CI 1.07–1.15), oral contraceptive use at the time of conception (second abortion: 2.17, 95% CI 1.52–3.09; third or subsequent abortion: 2.60, 95% CI 1.51–4.46), history of physical abuse by a male partner (second abortion: 2.04, 95% CI 1.39–3.01; third or subsequent abortion: 2.78, 95% CI 1.62–4.79), history of sexual abuse or violence (second abortion: 1.58, 95% CI 1.11–2.25; third or subsequent abortion: 2.53, 95% CI 1.50–4.28), history of sexually transmitted disease (second abortion: 1.50, 95% CI 0.98–2.29; third or subsequent abortion: 2.26, 95% CI 1.28–4.02) and being born outside Canada (second abortion: 1.83, 95% CI 1.19–2.79; third or subsequent abortion: 1.75, 95% CI 0.90–3.41).

:Interpretation: Among other factors, a history of physical or sexual abuse was associated with repeat induced abortion. Presentation for repeat abortion may be an important indication to screen for a current or past history of relationship violence and sexual abuse.

==Screening for Coercion==
The American College of Obstetricians and Gynecologists recommends that their members [http://www.philly.com/philly/health/topics/HealthDay660940_20120124_Ob-Gyns_Should_Screen_for_Domestic_Abuse__Experts.html screen all patients for intimate partner violence], including during prenatal visits.

"Women of all ages experience intimate partner violence, but it is most prevalent among reproductive-age women," Dr. Maureen Phipps, chair of the college's Committee on Health Care for Underserved Women, said in the news release. "We have a prime opportunity to identify and help women who are being abused by incorporating this screening into our routine office visits with each and every patient."

Clearly, this recommendation should extend to abortion providers as there is ample evidence that pregnant women are more likely to face coercion to have an unwanted abortion which can escalate to acts of violence.

==Pre-Abortion and Post-Abortion Screening Recommendations==

*Miller WB, Pasta DJ, Dean CL. Testing a model of the psychological consequences of abortion. In: The New Civil War: The Psychology, Culture, and Politics of Abortion. Vol ; 1998:235-267. doi:10.1037/10302-010.

*Steinberg JR, McCulloch CE, Adler NE. Abortion and mental health: findings from the national comorbidity survey-replication. Obstet Gynecol. 2014;123(2 Pt 1):263-270. doi:10.1097/AOG.0000000000000092.
:"Women seeking abortions may be at higher risk of prior untreated mental health disorders and the abortion care setting may be an important intervention point for mental health screening and referrals."

*Lask B. Short term psychiatric sequelae to therapeutic termination of pregnancy. Br J Psychiatry. 1975;126(2):173-177. http://www.scopus.com/inward/record.url?eid=2-s2.0-0016745377&partnerID=tZOtx3y1.

*Major B, Cozzarelli C. Psychosocial predictors of adjustment to abortion. J Soc Issues. 1992. http://onlinelibrary.wiley.com/doi/10.1111/j.1540-4560.1992.tb00900.x/abstract. Accessed November 30, 2016.

*Belsey EM, Greer HS, Lal S, Lewis SC, Beard RW. Predictive factors in emotional response to abortion: King’s termination study--IV. Soc Sci Med. 1977;11(2):71-82. http://www.ncbi.nlm.nih.gov/pubmed/594780. Accessed December 20, 2016.

==Recommendations for Funding Major Longitudinal Studies==

*Miller WB, Pasta DJ, Dean CL. Testing a model of the psychological consequences of abortion. In: The New Civil War: The Psychology, Culture, and Politics of Abortion. Vol ; 1998:235-267. doi:10.1037/10302-010.

*Fergusson, David.

==Recommendation for Routine Psychological Screening of Pregnant Women==

Effects of posttraumatic stress disorder on pregnancy outcomes. Rogal SS1, Poschman K, Belanger K, Howell HB, Smith MV, Medina J, Yonkers KA. J Affect Disord. 2007 Sep;102(1-3):137-43. Epub 2007 Feb 8.

:Associations between PTSD, depression and substance use in pregnant women and preterm and low birth weight delivery "support the utility of screening for mental health disorders in pregnancy."

Pregnant Women With Posttraumatic Stress Disorder and Risk of Preterm Birth. Yonkers KA1, Smith MV2, Forray A3, Epperson CN4, Costello D3, Lin H5, Belanger K5. JAMA Psychiatry. 2014 Jun 11. doi: 10.1001/jamapsychiatry.2014.558.

:"Women with likely diagnoses of both PTSD and a major depressive episode are at a 4-fold increased risk of preterm birth; this risk is greater than, and independent of, antidepressant and benzodiazepine use and is not simply a function of mood or anxiety symptoms."

'''ACOG also recommends routine psychosocial screening of pregnant women:''' "Psychosocial screening of all women seeking pregnancy evaluation or prenatal care should be performed regardless of social status, educational level, or race and ethnicity." (See ''[http://www.ncbi.nlm.nih.gov/pubmed/16880322 ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention.''] Obstet Gynecol. 2006 Aug;108(2):469-77.)

'''Proposed Statute to Require Physicians to Screen for Risk Factors'''

See [http://stopforcedabortions.org/index.htm StopForcedAbortions.org]

==Other Literature Identifying Risk Factors==

'''[http://www.afterabortion.org/news/Duty2Screen.pdf Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment.] Reardon DC. J Contemp Health Law Policy. 2003 Winter;20(1):33-114.'''

:An excellent literature review of risk factors identified in the literature through 2003.

''"The Psychological Complications of Therapeutic Abortion," G Zolese and CVR Blacker, Br J Psychiatry 160: 724, 1992 ''

:"Certain groups are especially at risk from adverse psychological sequelae; these include those with a past psychiatric history, younger women, those with poor social support, the multiparous, and those belonging to sociocultural groups antagonistic to abortion. ... A better understanding of the nature of the risk factors would enable clinicians to identify vulnerable women for whom some form of psychological intervention might be beneficial." Women who choose abortion are not amenable to endless questions on how they feel, are less likely to return for follow-up, and baseline assessments before they become pregnant are impossible.

'''Psychosocial consequences of therapeutic abortion. King's termination study III. Greer HS, Lal S, Lewis SC, Belsey EM, Beard RW. Br J Psychiatry 1976;128:74-9.'''

==Other Medical Procedures Preceded by Screening==
See [http://abortionrisks.org/index.php?title=Abortion_Counseling#Screening_For_Other_Elective_Surgeries Screening For Other Elective Surgeries]

David M. Fergusson

2026-03-27T16:08:21Z

Barb: /* Studies By David M. Fergusson */

== Studies By David M. Fergusson ==
[http://www.ncbi.nlm.nih.gov/pubmed/23553240 Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence.] Fergusson DM, Horwood LJ, Boden JM. Aust N Z J Psychiatry. 2013 Apr 3. [Epub ahead of print]

:This review of the literature and prospective study, the authors conclude there is no evidence of any mental health benefits from abortion, rather the evidence indicates that in the general population of women there is at least some negative mental health impact due to abortion. This means that abortions that there is no justification for providing abortion to reduce mental health problems, which is the legal justification used for over 90% of abortions in the United Kingdom.

:Abstract
::Objective:There have been debates about the linkages between abortion and mental health. Few reviews have considered the extent to which abortion has therapeutic benefits that mitigate the mental health risks of abortion. The aim of this review was to conduct a re-appraisal of the evidence to examine the research hypothesis that abortion reduces rates of mental health problems in women having unwanted or unintended pregnancy.
::Methods:Analysis of recent reviews (Coleman, 2011; National Collaborating Centre for Mental Health, 2011) identified eight publications reporting 14 adjusted odds ratios (AORs) spanning five outcome domains: anxiety; depression; alcohol misuse; illicit drug use/misuse; and suicidal behaviour. For each outcome, pooled AORs were estimated using a random-effects model.
::Results:There was consistent evidence to show that abortion was not associated with a reduction in rates of mental health problems (p>0.75). Abortion was associated with small to moderate increases in risks of anxiety (AOR 1.28, 95% CI 0.97-1.70; p<0.08), alcohol misuse (AOR 2.34, 95% CI 1.05-5.21; p<0.05), illicit drug use/misuse (AOR 3.91, 95% CI 1.13-13.55; p<0.05), and suicidal behaviour (AOR 1.69, 95% CI 1.12-2.54; p<0.01).
::Conclusions:There is no available evidence to suggest that abortion has therapeutic effects in reducing the mental health risks of unwanted or unintended pregnancy. There is suggestive evidence that abortion may be associated with small to moderate increases in risks of some mental health problems.
'''''Reactions to abortion and subsequent mental health. Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2009 Nov;195(5):420-6.'''''
: BACKGROUND: There has been continued interest in the extent to which women have positive and negative reactions to abortion. AIMS: To document emotional reactions to abortion, and to examine the links between reactions to abortion and subsequent mental health outcomes.
: METHOD: Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30.
: RESULTS: Abortion was associated with high rates of both positive and negative emotional reactions; however, '''nearly 90% of respondents believed that the abortion was the right decision'''. Analyses showed that the number of '''negative responses to the abortion was associated with increased levels of subsequent mental health disorders (P<0.05)'''. Further analyses suggested that, after adjustment for confounding, '''those having an abortion and reporting negative reactions had rates of mental health disorders that were approximately 1.4-1.8 times higher than those not having an abortion'''.
: CONCLUSIONS: Abortion was associated with both positive and negative emotional reactions. The extent of negative emotional reactions appeared to modify the links between abortion and subsequent mental health problems.
: NOTE: '''>85% reported at least one negative emotional reaction; >55% reported at least one strong (“very much”) negative reaction.''' According to the authors: "These findings clearly suggested that unwanted pregnancy leading to abortion was likely to be a risk factor for subsequent mental health problems, whereas unwanted pregnancy leading to live birth was not a risk factor for these problems."

:

''[http://www.ncbi.nlm.nih.gov/pubmed/19043144?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed Abortion and mental health disorders: evidence from a 30-year longitudinal study.] Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2008 Dec;193(6):444-51.''

:BACKGROUND: Research on the links between abortion and mental health has been limited by design problems and relatively weak evidence.
:AIMS: To examine the links between pregnancy outcomes and mental health outcomes.
:METHOD: Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30.
:RESULTS: After adjustment for confounding, abortion was associated with a small increase in the risk of mental disorders; women who had had abortions had rates of mental disorder that were about 30% higher. There were no consistent associations between other pregnancy outcomes and mental health. Estimates of attributable risk indicated that exposure to abortion accounted for 1.5% to 5.5% of the overall rate of mental disorders.
:CONCLUSIONS: The evidence is consistent with the view that abortion may be associated with a small increase in risk of mental disorders. Other pregnancy outcomes were not related to increased risk of mental health problems.

''[http://www.ncbi.nlm.nih.gov/pubmed/16405636?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed Abortion in young women and subsequent mental health.]'' Fergusson DM, John Horwood L, Ridder EM. J Child Psychol Psychiatry. 2006 Jan;47(1):16-24.

:BACKGROUND: The extent to which abortion has harmful consequences for mental health remains controversial. We aimed to examine the linkages between having an abortion and mental health outcomes over the interval from age 15-25 years.
:METHODS: Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors.
:RESULTS: Forty-one percent of women had become pregnant on at least one occasion prior to age 25, with 14.6% having an abortion. Those having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors.
:CONCLUSIONS: The findings suggest that abortion in young women may be associated with increased risks of mental health problems.

== Commentaries ==

''[http://wthrockmorton.com/wp-content/uploads/2008/09/abortion-mh-editorial-2008.pdf Abortion and mental health] (commentary) Fergusson DM. Psychiatric Bulletin (2008), 32, 321-324.''

== Media Coverage ==

[http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10607135 Abortion link to mental illness] New Zealand Herald Nov 4, 2009

[http://www.telegraph.co.uk/health/healthnews/6481289/Abortion-can-put-women-at-increased-risk-of-mental-health-problems-says-study.html Daily Telegraph]

[[Category:Research]][[Category:Persons_of_Note]]

Risk factors

2026-03-27T16:01:52Z

Barb: /* Additional Research Regarding Risk Factors for Adverse Emotional Consequences of Abortion */

=== COMPLETE LIST OF RISK FACTORS IDENTIFIED IN THE 2008 APA TASK FORCE REPORT ===

(see pages 5, 11, and 92 of the [http://www.apa.org/pi/women/programs/abortion/index.aspx Report of the APA Task Force on Mental Health and Abortion])

#terminating a pregnancy that is wanted or meaningful
#perceived pressure from others to terminate a pregnancy
#perceived opposition to the abortion from partners, family, and/or friends
#lack of perceived social support from others
#various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life)
#a history of mental health problems prior to the pregnancy
#feelings of stigma
#perceived need for secrecy
#exposure to antiabortion picketing
#use of avoidance and denial coping strategies
#Feelings of commitment to the pregnancy
#ambivalence about the abortion decision
#low perceived ability to cope with the abortion
#history of prior abortion
#late term abortion
#By parsing of the APA summary conclusion that "adult women who have an unplanned pregnancy the relative risk of mental health problems is no greater if they have a single elective first-trimester abortion than if they deliver that pregnancy," it also appears that the APA is identifying the following as risk factors

::*being an adolescent (not an adult)
::*having a non-elective, "therapeutic" abortion

===COMPLETE LIST OF RISK FACTORS IDENTIFIED IN THE NAF's "A Clinician's Guide to Medical and Surgical Abortion"===

====Predisposing Factors for Negative Reactions ====
(Excerpted from Chapter 3, p29 - Table 3-2.
#Low self-efficacy: expecting depression, severe grief or guilt, and regret after the abortion
#Low self-esteem prior to the abortion
#An existing mental illness or disorder prior to the abortion
#Significant ambivalence about the decision
#Lack of emotional support and receiving criticism from significant people in their lives
#Perceived coercion to have the abortion
#Belief that a fetus is the same as a 4-year-old human and that abortion is murder
#Fetal abnormality or other medical indications for the abortion
#Usual coping style is repressing thoughts or denial
#Unresolved past losses and perceptions of abortion as a loss
#Experiencing social stigma and antiabortion demonstrators on the day of the abortion
#Commitment to the pregnancy

====Risk Factors for Physical Complications====
(Excerpted from Chapter 5, "Medical Evaluation and Management")

#Prior History of anemeia, siezures, asthma, diabetes, mellitus, heart disease, infectious diseases, and conditions that necessitate chronic steroid use
#History of bleeding disorders
#Current symptoms of respiratory illness
#Current medications
#Medical allergies
#History of sexually transmitted disease
#Previous surgical procedures
#Previous history of induced abortion
#Recent or current substance abuse
#Previous reactions to anesthetics
#History of sexual abuse or domestic/partner violence
#History of contraceptive use
#History of cervical dysplasia
#Rho(D) antigen status
#Anatomic variation of the female genital tract
#Genital tract infection
#Urinary tract infection
#HIV infection or AIDS
#Hypertension

==Most Complete List of Risk Factors for Negative Psychological Reactions to Abortion==

The lists of risk factors chosen by the APA and the National Abortion Federation is based on a subjective judgments and do not include a complete list of risk factors that have been statistically validated in peer reviewed medical literature.

For a more comprehensive list of risk factors for psychological reactions to abortion, including citations to all the studies for each risk factor, see [http://afterabortion.org/1993/identifying-high-risk-abortion-patients-2/ see ''Identifying High Risk Abortion Patients'' here.]

For an even more complete treatment of why these risk factors have been identified and why it is important to screen for them, download [http://www.afterabortion.org/news/Duty2Screen.pdf Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment.]

==Four Types of Women==
According to Philip Ney, from a clinical perspective there are four groups of women having abortion:

#'''Tough and committed.''' Those who insist that abortion is a woman’s right.
#'''Vulnerable.''' Those who are basically unstable who are pushed into a definable mental illness by the trauma of abortion.
#'''Sensitive.''' Those who are reasonably mentally healthy but because of their sensitivities, they are deeply hurt by having an abortion and develop psychiatric symptoms which a researcher defines as an illness.
#'''Resilient.''' Those who choose abortion as the least worst alternative and don’t appear to be affected for years until poor health or stressful circumstance undermine their ego defenses.

==Additional Research Regarding Risk Factors for Adverse Emotional Consequences of Abortion==

'''[https://www.ncbi.nlm.nih.gov/pubmed/28969621 Neuroticism-related personality traits are associated with posttraumatic stress after abortion: findings from a Swedish multi-center cohort study.] Wallin Lundell I1,2, Sundström Poromaa I3, Ekselius L4, Georgsson S5,6, Frans Ö7, Helström L8, Högberg U3, Skoog Svanberg A3. ''BMC Womens Health.'' 2017 Oct 2;17(1):96. doi: 10.1186/s12905-017-0417-8.'''

:Among 512 women with no PTSD symptoms, 9.4% experienced all the criteria necessary for a PTSD diagnosis by the three or six month post-abortion assessment. Pre-abortion screening for higher neuroticism-related personality traits can be used to identify the women at greatest risk of abortion associated PTSD. This finding is consistent with [https://www.ncbi.nlm.nih.gov/pubmed/14744527/ other studies showing neurotisicm being associated with greater susceptibility to PTSD].

''"Complicated Mourning: Dynamics of Impacted Pre and Post-Abortion Grief," Anne Speckland, Vincent Rue, Pre and Perinatal Psychology Journal 8(81 ):5, Fall, 1993. ''
:Emotional harm from abortion is more likely when one or more of the following risk factors are present: prior history of mental illness; immature interpersonal relationships; unstable, conflicted relationship with one's partner; history of negative relationship with one's mother; ambivalence regarding abortion; religious and cultural background hostile to abortion; single status especially if no born children; adolescent; second-trimester abortion; abortion for genetic reason; pressure and coercion to abort; prior abortion; prior children; maternal orientation.

''"Adolescent Abortion Option," G. Zakus, S. Wilday, Social Work in Health Care, 12(4):77, Summer, 1987. ''
:Certain categories of women are much more likely to have post-abortion problems sometimes many months or years later. These include: being forced or coerced into abortion; women who place great emphasis on future fertility plans; women with pre- existing psychiatric problems; women suffering from unresolved grief reactions or women with a history of sexual abuse, including incest, molestation or rape.

''"Outcome Following Therapeutic Abortion," R.C. Payne, A.R. Kravitz, M.T. Notman, J.V. Anderson, Arch. Gen. Psychiatry 33:725, June, 1976. ''
:This study measured short- term outcomes of anxiety, depression, anger, guilt and shame following abortion. The authors concluded that women who are most vulnerable to difficulty are those who are single and nulliparous, those with previous history of serious emotional problems, conflicted relationships to lovers, past negative relationships to mother, ambivalence toward abortion or negative religious or cultural attitudes about abortion.

''"The Decision-Making Process and the Outcome of Therapeutic Abortion, C," Friedman, R. Greenspan and F. Mittleman, American Journal of Psychiatry 131(12): 1332-1337, December 1974. ''
:There is high risk for post-abortion psychiatric illness when there is (1) Strong ambivalence; (2) Coercion; (3) Medical indication; (4) Concomitant psychiatric illness and (5) A woman feeling the decision was not her own.

''Broen AN, Moum T, Bodtker AS, Ekeberg O: Reasons for induced abortion and their relation to women's emotional distress: a prospective, two-year follow-up study. Gen Hosp Psychiatry 2005, 27:36-43.''
:Pressure from the male partner was significantly associated with more negative emotional reactions following an abortion.

'''''[https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/reactions-to-abortion-and-subsequent-mental-health/667F92342F6A90F4FB3F8235187F7DBB Reactions to abortion and subsequent mental health.] Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2009 Nov;195(5):420-6.'''''
: BACKGROUND: There has been continued interest in the extent to which women have positive and negative reactions to abortion. AIMS: To document emotional reactions to abortion, and to examine the links between reactions to abortion and subsequent mental health outcomes.
: METHOD: Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30.
: RESULTS: Abortion was associated with high rates of both positive and negative emotional reactions; however, '''nearly 90% of respondents believed that the abortion was the right decision'''. Analyses showed that the number of '''negative responses to the abortion was associated with increased levels of subsequent mental health disorders (P<0.05)'''. Further analyses suggested that, after adjustment for confounding, '''those having an abortion and reporting negative reactions had rates of mental health disorders that were approximately 1.4-1.8 times higher than those not having an abortion'''.
: CONCLUSIONS: Abortion was associated with both positive and negative emotional reactions. The extent of negative emotional reactions appeared to modify the links between abortion and subsequent mental health problems.
: NOTE: '''>85% reported at least one negative emotional reaction; >55% reported at least one strong (“very much”) negative reaction.''' According to the authors: "These findings clearly suggested that unwanted pregnancy leading to abortion was likely to be a risk factor for subsequent mental health problems, whereas unwanted pregnancy leading to live birth was not a risk factor for these problems."

==Risk Factors for Multiple Abortions==

''[http://pubmedcentralcanada.ca/articlerender.cgi?tool=pubmed&pubmedid=15738488 Characteristics of women undergoing repeat induced abortion.]] Fisher WA, Singh SS, Shuper PA, Carey M, Otchet F, MacLean-Brine D, et al. CMAJ 2005;172(5):637-41''
:Background: Although repeat induced abortion is common, data concerning characteristics of women undergoing this procedure are lacking. We conducted this study to identify the characteristics, including history of physical abuse by a male partner and history of sexual abuse, of women who present for repeat induced abortion.

:Methods: We surveyed a consecutive series of women presenting for initial or repeat pregnancy termination to a regional provider of abortion services for a wide geographic area in southwestern Ontario between August 1998 and May 1999. Self-reported demographic characteristics, attitudes and practices regarding contraception, history of relationship violence, history of sexual abuse or coercion, and related variables were assessed as potential correlates of repeat induced abortion. We used χ2 tests for linear trend to examine characteristics of women undergoing a first, second, or third or subsequent abortion. We analyzed significant correlates of repeat abortion using stepwise multivariate multinomial logistic regression to identify factors uniquely associated with repeat abortion.

:Results: Of the 1221 women approached, 1145 (93.8%) consented to participate. Data regarding first versus repeat abortion were available for 1127 women. A total of 68.2%, 23.1% and 8.7% of the women were seeking a first, second, or third or subsequent abortion respectively. Adjusted odds ratios for undergoing repeat versus a first abortion increased significantly with increased age (second abortion: 1.08, 95% confidence interval [CI] 1.04–1.09; third or subsequent abortion: 1.11, 95% CI 1.07–1.15), oral contraceptive use at the time of conception (second abortion: 2.17, 95% CI 1.52–3.09; third or subsequent abortion: 2.60, 95% CI 1.51–4.46), history of physical abuse by a male partner (second abortion: 2.04, 95% CI 1.39–3.01; third or subsequent abortion: 2.78, 95% CI 1.62–4.79), history of sexual abuse or violence (second abortion: 1.58, 95% CI 1.11–2.25; third or subsequent abortion: 2.53, 95% CI 1.50–4.28), history of sexually transmitted disease (second abortion: 1.50, 95% CI 0.98–2.29; third or subsequent abortion: 2.26, 95% CI 1.28–4.02) and being born outside Canada (second abortion: 1.83, 95% CI 1.19–2.79; third or subsequent abortion: 1.75, 95% CI 0.90–3.41).

:Interpretation: Among other factors, a history of physical or sexual abuse was associated with repeat induced abortion. Presentation for repeat abortion may be an important indication to screen for a current or past history of relationship violence and sexual abuse.

==Screening for Coercion==
The American College of Obstetricians and Gynecologists recommends that their members [http://www.philly.com/philly/health/topics/HealthDay660940_20120124_Ob-Gyns_Should_Screen_for_Domestic_Abuse__Experts.html screen all patients for intimate partner violence], including during prenatal visits.

"Women of all ages experience intimate partner violence, but it is most prevalent among reproductive-age women," Dr. Maureen Phipps, chair of the college's Committee on Health Care for Underserved Women, said in the news release. "We have a prime opportunity to identify and help women who are being abused by incorporating this screening into our routine office visits with each and every patient."

Clearly, this recommendation should extend to abortion providers as there is ample evidence that pregnant women are more likely to face coercion to have an unwanted abortion which can escalate to acts of violence.

==Pre-Abortion and Post-Abortion Screening Recommendations==

*Miller WB, Pasta DJ, Dean CL. Testing a model of the psychological consequences of abortion. In: The New Civil War: The Psychology, Culture, and Politics of Abortion. Vol ; 1998:235-267. doi:10.1037/10302-010.

*Steinberg JR, McCulloch CE, Adler NE. Abortion and mental health: findings from the national comorbidity survey-replication. Obstet Gynecol. 2014;123(2 Pt 1):263-270. doi:10.1097/AOG.0000000000000092.
:"Women seeking abortions may be at higher risk of prior untreated mental health disorders and the abortion care setting may be an important intervention point for mental health screening and referrals."

*Lask B. Short term psychiatric sequelae to therapeutic termination of pregnancy. Br J Psychiatry. 1975;126(2):173-177. http://www.scopus.com/inward/record.url?eid=2-s2.0-0016745377&partnerID=tZOtx3y1.

*Major B, Cozzarelli C. Psychosocial predictors of adjustment to abortion. J Soc Issues. 1992. http://onlinelibrary.wiley.com/doi/10.1111/j.1540-4560.1992.tb00900.x/abstract. Accessed November 30, 2016.

*Belsey EM, Greer HS, Lal S, Lewis SC, Beard RW. Predictive factors in emotional response to abortion: King’s termination study--IV. Soc Sci Med. 1977;11(2):71-82. http://www.ncbi.nlm.nih.gov/pubmed/594780. Accessed December 20, 2016.

==Recommendations for Funding Major Longitudinal Studies==

*Miller WB, Pasta DJ, Dean CL. Testing a model of the psychological consequences of abortion. In: The New Civil War: The Psychology, Culture, and Politics of Abortion. Vol ; 1998:235-267. doi:10.1037/10302-010.

*Fergusson, David.

==Recommendation for Routine Psychological Screening of Pregnant Women==

Effects of posttraumatic stress disorder on pregnancy outcomes. Rogal SS1, Poschman K, Belanger K, Howell HB, Smith MV, Medina J, Yonkers KA. J Affect Disord. 2007 Sep;102(1-3):137-43. Epub 2007 Feb 8.

:Associations between PTSD, depression and substance use in pregnant women and preterm and low birth weight delivery "support the utility of screening for mental health disorders in pregnancy."

Pregnant Women With Posttraumatic Stress Disorder and Risk of Preterm Birth. Yonkers KA1, Smith MV2, Forray A3, Epperson CN4, Costello D3, Lin H5, Belanger K5. JAMA Psychiatry. 2014 Jun 11. doi: 10.1001/jamapsychiatry.2014.558.

:"Women with likely diagnoses of both PTSD and a major depressive episode are at a 4-fold increased risk of preterm birth; this risk is greater than, and independent of, antidepressant and benzodiazepine use and is not simply a function of mood or anxiety symptoms."

'''ACOG also recommends routine psychosocial screening of pregnant women:''' "Psychosocial screening of all women seeking pregnancy evaluation or prenatal care should be performed regardless of social status, educational level, or race and ethnicity." (See ''[http://www.ncbi.nlm.nih.gov/pubmed/16880322 ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention.''] Obstet Gynecol. 2006 Aug;108(2):469-77.)

'''Proposed Statute to Require Physicians to Screen for Risk Factors'''

See [http://stopforcedabortions.org/index.htm StopForcedAbortions.org]

==Other Literature Identifying Risk Factors==

'''[http://www.afterabortion.org/news/Duty2Screen.pdf Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment.] Reardon DC. J Contemp Health Law Policy. 2003 Winter;20(1):33-114.'''

:An excellent literature review of risk factors identified in the literature through 2003.

''"The Psychological Complications of Therapeutic Abortion," G Zolese and CVR Blacker, Br J Psychiatry 160: 724, 1992 ''

:"Certain groups are especially at risk from adverse psychological sequelae; these include those with a past psychiatric history, younger women, those with poor social support, the multiparous, and those belonging to sociocultural groups antagonistic to abortion. ... A better understanding of the nature of the risk factors would enable clinicians to identify vulnerable women for whom some form of psychological intervention might be beneficial." Women who choose abortion are not amenable to endless questions on how they feel, are less likely to return for follow-up, and baseline assessments before they become pregnant are impossible.

'''Psychosocial consequences of therapeutic abortion. King's termination study III. Greer HS, Lal S, Lewis SC, Belsey EM, Beard RW. Br J Psychiatry 1976;128:74-9.'''

==Other Medical Procedures Preceded by Screening==
See [http://abortionrisks.org/index.php?title=Abortion_Counseling#Screening_For_Other_Elective_Surgeries Screening For Other Elective Surgeries]

Long-Terms Effects of Abortion

2026-03-27T15:57:49Z

Barb: /* Older Papers Regarding Long-Term Effects */

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[[Submit_LongTerm |Please Submit New Material for This Protected Page Here]]

==Physical Effects of Psychological Illness==

[https://www.ncbi.nlm.nih.gov/pubmed/?term=Association+of+Mental+Disorders+With+Subsequent+Chronic+Physical+Conditions%3A+World+Mental+Health+Surveys+From+17+Countries Association of Mental Disorders With Subsequent Chronic Physical Conditions: World Mental Health Surveys From 17 Countries.] Scott KM, Lim C, Al-Hamzawi A, et al. JAMA Psychiatry. 2016;73(2):150-158. doi:10.1001/jamapsychiatry.2015.2688.

RESULTS: Most associations between 16 mental disorders and subsequent onset or diagnosis of 10 physical conditions were statistically significant, with odds ratios (ORs) (95% CIs) ranging from 1.2 (1.0-1.5) to 3.6 (2.0-6.6). The associations were attenuated after adjustment for mental disorder comorbidity, but mood, anxiety, substance use, and impulse control disorders remained significantly associated with onset of between 7 and all 10 of the physical conditions (ORs [95% CIs] from 1.2 [1.1-1.3] to 2.0 [1.4-2.8]). An increasing number of mental disorders experienced over the life course was significantly associated with increasing odds of onset or diagnosis of all 10 types of physical conditions, with ORs (95% CIs) for 1 mental disorder ranging from 1.3 (1.1-1.6) to 1.8 (1.4-2.2) and ORs (95% CIs) for 5 or more mental disorders ranging from 1.9 (1.4-2.7) to 4.0 (2.5-6.5). In population-attributable risk estimates, specific mental disorders were associated with 1.5% to 13.3% of physical condition onsets.

:CONCLUSIONS AND RELEVANCE: These findings suggest that mental disorders of all kinds are associated with an increased risk of onset of a wide range of chronic physical conditions. Current efforts to improve the physical health of individuals with mental disorders may be too narrowly focused on the small group with the most severe mental disorders. Interventions aimed at the primary prevention of chronic physical diseases should optimally be integrated into treatment of all mental disorders in primary and secondary care from early in the disorder course.

'''The above findings may be relevant to the reduced life expectancy of women who have a history of abortion.'''

==Review Papers==
'''[https://pmc.ncbi.nlm.nih.gov/articles/PMC11625657/#bjo17889-sec-0016 Pregnancy and birth complications and long-term maternal mental health outcomes: A systematic review and meta-analysis.] Bodunde EO, Buckley D, O'Neill E, Al Khalaf S, Maher GM, O'Connor K, McCarthy FP, Kublickiene K, Matvienko-Sikar K, Khashan AS. BJOG. 2025 Jan;132(2):131-142. doi: 10.1111/1471-0528.17889.'''<blockquote>Background: Few studies have examined the associations between pregnancy and birth complications and long‐term (>12 months) maternal mental health outcomes.

Objectives: To review the published literature on pregnancy and birth complications and long‐term maternal mental health outcomes.

Search strategy:Systematic search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (Embase), PsycInfo®, PubMed® and Web of Science from inception until August 2022.

Selection criteria: Three reviewers independently reviewed titles, abstracts and full texts.

Data collection and analysis: Two reviewers independently extracted data and appraised study quality. Random‐effects meta‐analyses were used to calculate pooled estimates. The Meta‐analyses of Observational Studies in Epidemiology (MOOSE) guidelines were followed. The protocol was prospectively registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022359017).

Main results: Of the 16 310 articles identified, 33 studies were included (3 973 631 participants). T'''ermination of pregnancy was associated with depression (pooled adjusted odds ratio, aOR 1.49, 95% CI 1.20–1.83) and anxiety disorder (pooled aOR 1.43, 95% CI 1.20–1.71).''' Miscarriage was associated with depression (pooled aOR 1.97, 95% CI 1.38–2.82) and anxiety disorder (pooled aOR 1.24, 95% CI 1.11–1.39). Sensitivity analyses excluding early pregnancy loss and termination reported similar results. Preterm birth was associated with depression (pooled aOR 1.37, 95% CI 1.32–1.42), anxiety disorder (pooled aOR 0.97, 95% CI 0.41–2.27) and post‐traumatic stress disorder (PTSD) (pooled aOR 1.75, 95% CI 0.52–5.89). Caesarean section was not significantly associated with PTSD (pooled aOR 2.51, 95% CI 0.75–8.37). There were few studies on other mental disorders and therefore it was not possible to perform meta‐analyses.

Conclusions: Exposure to complications during pregnancy and birth increases the odds of long‐term depression, anxiety disorder and PTSD.</blockquote>''[http://www.ncbi.nlm.nih.gov/pubmed/23859662 Abortion and subsequent mental health: Review of the literature.] Bellieni CV, Buonocore G.'' Psychiatry Clin Neurosci. 2013 Jul;67(5):301-10. doi: 10.1111/pcn.12067.

:Abstract
:The risk that abortion may be correlated with subsequent mental disorders needs a careful assessment, in order to offer women full information when facing a difficult pregnancy. All research papers published between 1995 and 2011, were examined, to retrieve those assessing any correlation between abortion and subsequent mental problems. A total of 36 studies were retrieved, and six of them were excluded for methodological bias. Depression, anxiety disorders (e.g. post-traumatic stress disorder) and substance abuse disorders were the most studied outcome. Abortion versus childbirth: 13 studies showed a clear risk for at least one of the reported mental problems in the abortion group versus childbirth, five papers showed no difference, in particular if women do not consider their experience of fetal loss to be difficult, or if after a fetal reduction the desired fetus survives. Only one paper reported a worse mental outcome for childbearing. Abortion versus unplanned pregnancies ending with childbirth: four studies found a higher risk in the abortion groups and three, no difference. Abortion versus miscarriage: three studies showed a greater risk of mental disorders due to abortion, four found no difference and two found that short-term anxiety and depression were higher in the miscarriage group, while long-term anxiety and depression were present only in the abortion group. In conclusion, fetal loss seems to expose women to a higher risk for mental disorders than childbirth; some studies show that abortion can be considered a more relevant risk factor than miscarriage; more research is needed in this field.

''[http://www.ncbi.nlm.nih.gov/pubmed/23553240 Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence.] Fergusson DM, Horwood LJ, Boden JM. Aust N Z J Psychiatry. 2013 Apr 3.''

:Objective:There have been debates about the linkages between abortion and mental health. Few reviews have considered the extent to which abortion has therapeutic benefits that mitigate the mental health risks of abortion. The aim of this review was to conduct a re-appraisal of the evidence to examine the research hypothesis that abortion reduces rates of mental health problems in women having unwanted or unintended pregnancy.
:Methods:Analysis of recent reviews (Coleman, 2011; National Collaborating Centre for Mental Health, 2011) identified eight publications reporting 14 adjusted odds ratios (AORs) spanning five outcome domains: anxiety; depression; alcohol misuse; illicit drug use/misuse; and suicidal behaviour. For each outcome, pooled AORs were estimated using a random-effects model.
:Results:There was consistent evidence to show that abortion was not associated with a reduction in rates of mental health problems (p>0.75). Abortion was associated with small to moderate increases in risks of anxiety (AOR 1.28, 95% CI 0.97-1.70; p<0.08), alcohol misuse (AOR 2.34, 95% CI 1.05-5.21; p<0.05), illicit drug use/misuse (AOR 3.91, 95% CI 1.13-13.55; p<0.05), and suicidal behaviour (AOR 1.69, 95% CI 1.12-2.54; p<0.01).Conclusions:There is no available evidence to suggest that abortion has therapeutic effects in reducing the mental health risks of unwanted or unintended pregnancy. There is suggestive evidence that abortion may be associated with small to moderate increases in risks of some mental health problems.

''[http://www.ncbi.nlm.nih.gov/pubmed/21881096 Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009.] Coleman PK. Br J Psychiatry. 2011 Sep;199(3):180-6. doi: 10.1192/bjp.bp.110.077230.''

:BACKGROUND: Given the methodological limitations of recently published qualitative reviews of abortion and mental health, a quantitative synthesis was deemed necessary to represent more accurately the published literature and to provide clarity to clinicians.
:AIMS: To measure the association between abortion and indicators of adverse mental health, with subgroup effects calculated based on comparison groups (no abortion, unintended pregnancy delivered, pregnancy delivered) and particular outcomes. A secondary objective was to calculate population-attributable risk (PAR) statistics for each outcome.
:METHOD: After the application of methodologically based selection criteria and extraction rules to minimise bias, the sample comprised 22 studies, 36 measures of effect and 877 181 participants (163 831 experienced an abortion). Random effects pooled odds ratios were computed using adjusted odds ratios from the original studies and PAR statistics were derived from the pooled odds ratios.
:RESULTS: Women who had undergone an abortion experienced an 81% increased risk of mental health problems, and nearly 10% of the incidence of mental health problems was shown to be attributable to abortion. The strongest subgroup estimates of increased risk occurred when abortion was compared with term pregnancy and when the outcomes pertained to substance use and suicidal behaviour.
:CONCLUSIONS: This review offers the largest quantitative estimate of mental health risks associated with abortion available in the world literature. Calling into question the conclusions from traditional reviews, the results revealed a moderate to highly increased risk of mental health problems after abortion. Consistent with the tenets of evidence-based medicine, this information should inform the delivery of abortion services.

''[http://www.ncbi.nlm.nih.gov/pubmed/19968372 Abortion and mental health: Evaluating the evidence.] Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C.A m Psychol. 2009 Dec;64(9):863-90. doi: 10.1037/a0017497.

:''ABSTRACT:'' The authors evaluated empirical research addressing the relationship between induced abortion and women's mental health. Two issues were addressed: (a) the relative risks associated with abortion compared with the risks associated with its alternatives and (b) sources of variability in women's responses following abortion. This article reflects and updates the report of the American Psychological Association Task Force on Mental Health and Abortion (2008). Major methodological problems pervaded most of the research reviewed. The most rigorous studies indicated that within the United States, the relative risk of mental health problems among adult women who have a single, legal, first-trimester abortion of an unwanted pregnancy is no greater than the risk among women who deliver an unwanted pregnancy. Evidence did not support the claim that observed associations between abortion and mental health problems are caused by abortion per se as opposed to other preexisting and co-occurring risk factors. Most adult women who terminate a pregnancy do not experience mental health problems. Some women do, however. It is important that women's varied experiences of abortion be recognized, validated, and understood.

:'''NOTE:''' This is an abbreviated version of the [[APA_Abortion_Report|2008 APA Task Force Report on Abortion and Mental Health]] and the strengths and weaknesses of this report should be reviewed [[APA_Abortion_Report|here]].

''[[NCCMH Review |Induced Abortion and Mental Health]], NCCMH Published December 2011 ''
:See [[NCCMH Review]] for summary and comments.

''[[Charles_et_al|Abortion and long-term mental health outcomes: a systematic review of the evidence.]] Authors: Vignetta E. Charles, Chelsea B. Polis, Srinivas K. Sridhara, Robert W. Blum Contraception 78(2008) 436-450''
:See [[Charles_et_al]] for summary and comments.

:[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2488341/#!po=90.6250 Experiences of abortion: a narrative review of qualitative studies.] Lie ML, Robson SC, May CR.BMC Health Serv Res. 2008 Jul 17;8:150. doi: 10.1186/1472-6963-8-150.
*"Feelings of ambivalence in the decision-making process were highlighted in a Swedish study [26], where women felt positive towards the right to abortion, but negative about their own decision to abort."
*"Complex emotional experiences appear to be integral to TOP. These include regret and guilt [17,22], distress and anxiety [17,22,27] and grief, loss, emptiness and suffering [21]."

'''[http://www.ncbi.nlm.nih.gov/pubmed/19799479 Psychiatric complications of abortion]'''. [Article in Spanish] Gurpegui M, Jurado D. Cuad Bioet. 2009 Sep-Dec;20(70):381-92.
:INTRODUCTION: The psychiatric consequences of induced abortion continue to be the object of controversy. The reactions of women when they became aware of conception are very variable. Pregnancy, whether initially intended or unintended, may provoke stress; and miscarriage may bring about feelings of loss and grief reaction. Therefore, induced abortion, with its emotional implications (of relief, shame and guilt) not surprisingly is a stressful adverse life event.

:METHODOLOGICAL CONSIDERATIONS: There is agreement among researchers on the need to compare the mental health outcomes (or the psychiatric complications) with appropriate groups, including women with unintended pregnancies ending in live births and women with miscarriages. There is also agreement on the need to control for the potential confounding effects of multiple variables: demographic, contextual, personal development, previous or current traumatic experiences, and mental health prior to the obstetric event. Any psychiatric outcome is multi-factorial in origin and the impact of life events depend on how they are perceived, the psychological defence mechanisms (unconscious to a great extent) and the coping style. The fact of voluntarily aborting has an undeniable ethical dimension in which facts and values are interwoven.

:RESULT: No research study has found that induced abortion is associated with a better mental health outcome, although the results of some studies are interpreted as <<neutral>> or <<mixed.>> Some general population studies point out significant associations with alcohol or illegal drug dependence, mood disorders (including depression) and some anxiety disorders. Some of these associations have been confirmed, and nuanced, by longitudinal prospective studies which support causal relationships.

:CONCLUSION: With the available data, it is advisable to devote efforts to the mental health care of women who have had an induced abortion. Reasons of the woman's mental health by no means can be invoked, on empirical bases, for inducing an abortion.

[http://www.ncbi.nlm.nih.gov/pubmed/20303829 Abortion among young women and subsequent life outcomes.] Casey PR. Best Pract Res Clin Obstet Gynaecol. 2010 Aug;24(4):491-502. doi: 10.1016/j.bpobgyn.2010.02.007. Epub 2010 Mar 20.

:This article will discuss the nature of the association between abortion and mental health problems. Studies arguing about both sides of the debate as to whether abortion per se is responsible will be presented. The prevalence of various psychiatric disorders will be outlined and where there is dispute between studies, these will be highlighted. The impact of abortion on other areas such as education, partner relationships and sexual function will also be considered. The absence of specific interventions will be highlighted. Suggestions for early identification of illness will be made.

==Adjustments at the Time of Menopause==

'''[https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-024-07005-w The association between repeated abortions during childbearing age and the psychological well-being of postmenopausal women in Southwest China: an observational study.] Li, X., Peng, A., Li, L. ''et al.'' ''BMC Pregnancy Childbirth'' 24, 805 (2024). <nowiki>https://doi.org/10.1186/s12884-024-07005-w</nowiki>'''<blockquote>Background

The issue of whether abortion increases the risk of future mental health problems for women remains a debated topic, and there is a lack of evidence from large-scale studies conducted in China. This study aimed to investigate the potential associations between abortions, particularly repeated abortions, and the mental health status of postmenopausal women in Southwest China.

Methods

The data were obtained from the baseline survey of a multi-center natural population cohort study in cooperated with medical consortia in Southwest China. A standard structured questionnaire was used to assess abortion status among women of childbearing age. The 7-item Generalized Anxiety Disorder Scale (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9) were used to evaluate psychological well-being. Subsequently, multiple logistic regression analysis was employed to examine the associations between the quantity and reasons for abortions and the mental health status of postmenopausal women.

Results

A total of 9991 postmenopausal women were enrolled (mean age: 60.51 years), of whom 11.09% (1108 individuals) reported mental health problems (5.54% for depression and 8.27% for anxiety). Multiple logistic regression analysis revealed that, compared with women without any history of abortion, postmenopausal women who reported three or more abortions during their childbearing years were likely to have worse mental health conditions (OR [95% CI]: 1.37 [1.13, 1.67]). Additionally, women who reported a history of abortions for socio-economic reasons were also correlated with an increased risk of mental health issues after menopause (OR [95% CI]: 1.34 [1.08, 1.66]).

Conclusions

Women who reported a history of three or more abortions were at an increased risk of experiencing mental health issues after menopause. Reproductive-age women should enhance their contraceptive awareness to prevent unintended pregnancies and subsequent abortions. Healthcare institutions are recommended to strengthen psychological counseling for women who have undergone abortions.</blockquote>

[http://www.tandfonline.com/doi/full/10.1080/02646838.2010.513046 Long term follow‐up of emotional experiences after termination of pregnancy: women’s views at menopause.] Dykes K, Slade P, Haywood, A. Journal of Reproductive and Infant Psychology. 29(1) 2011. DOI:10.1080/02646838.2010.513046

:Abstract: The objective was to explore women’s long‐term experiences and perspectives on their terminations of pregnancy (TOP) when perimenopausal. Eight women attending a menopause clinic who had experienced termination a minimum of 10 years previously (mean 24 years) completed semi‐structured interviews. Transcripts were analysed using Template Analysis. Five TOP themes were identified: ‘Impression left’ involved sadness, regret, and guilt which affected women’s self‐perceptions. ‘Judgement’ encompassed judgement on themselves and how censure was feared from others. ‘Growth and development’ noted the development of resilience and compassion for others. ‘Coming to terms and managing effects’ identified beliefs in the correctness of the decision, but effortful avoidance of thoughts still intruding into life. ‘Contradictions’ identified dramatic inconsistencies within almost all individual accounts indicating lack of resolution and full acceptance. Considering menopause and TOP together revealed a further three themes; Changes to thinking, Menopause as a time of reflection and Linkages or separateness. For some women termination may be continually reappraised in their changing life context and remain an active yet hidden feature managed through active avoidance. Menopause was viewed as a time of vulnerability to TOP‐related negative thoughts, especially where wishes for more children were unfulfilled. Accessibility of post‐termination counselling throughout life is recommended.

==Psychiatric or Psychological Hospitalization or Consultation==

'''[https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-024-07005-w The association between repeated abortions during childbearing age and the psychological well-being of postmenopausal women in Southwest China: an observational study.] Li, X., Peng, A., Li, L. ''et al.'' ''BMC Pregnancy Childbirth'' 24, 805 (2024). <nowiki>https://doi.org/10.1186/s12884-024-07005-w</nowiki>'''<blockquote>Background

The issue of whether abortion increases the risk of future mental health problems for women remains a debated topic, and there is a lack of evidence from large-scale studies conducted in China. This study aimed to investigate the potential associations between abortions, particularly repeated abortions, and the mental health status of postmenopausal women in Southwest China.

Methods

The data were obtained from the baseline survey of a multi-center natural population cohort study in cooperated with medical consortia in Southwest China. A standard structured questionnaire was used to assess abortion status among women of childbearing age. The 7-item Generalized Anxiety Disorder Scale (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9) were used to evaluate psychological well-being. Subsequently, multiple logistic regression analysis was employed to examine the associations between the quantity and reasons for abortions and the mental health status of postmenopausal women.

Results

A total of 9991 postmenopausal women were enrolled (mean age: 60.51 years), of whom 11.09% (1108 individuals) reported mental health problems (5.54% for depression and 8.27% for anxiety). Multiple logistic regression analysis revealed that, compared with women without any history of abortion, postmenopausal women who reported three or more abortions during their childbearing years were likely to have worse mental health conditions (OR [95% CI]: 1.37 [1.13, 1.67]). Additionally, women who reported a history of abortions for socio-economic reasons were also correlated with an increased risk of mental health issues after menopause (OR [95% CI]: 1.34 [1.08, 1.66]).

Conclusions

Women who reported a history of three or more abortions were at an increased risk of experiencing mental health issues after menopause. Reproductive-age women should enhance their contraceptive awareness to prevent unintended pregnancies and subsequent abortions. Healthcare institutions are recommended to strengthen psychological counseling for women who have undergone abortions.</blockquote>'''''[https://pubmed.ncbi.nlm.nih.gov/38771715/ A Reanalysis of Mental Disorders Risk Following First-Trimester Abortions in Denmark.]'' Reardon DC Issues Law Med. 2024 Spring;39(1):66-75. PMID: 38771715.'''<blockquote>'''Background:''' A previous Danish study of monthly and tri-monthly rates of first-time psychiatric contact following first induced abortions reported higher rates compared to first live births but similar rates compared to nine months pre-abortion. Therefore, the researchers concluded abortion has no independent effect on mental health; any differences between psychiatric contacts after abortion and delivery are entirely attributable to pre-existing mental health differences. However, these conclusions are inconsistent with similar studies that used longer time frames. Reanalysis of the published Danish data over slightly longer time frames may reconcile this discordance.

'''Method:''' Monthly and tri-monthly data was extracted for reanalysis of cumulative effects over nine- and twelvemonths post-abortion.

'''Results:''' Across all psychiatric diagnoses, cumulative average monthly rate of first-time psychiatric contact increased from an odds ratio of 1.12 (95% CI: 1.02 to 1.22) at 9-months to 1.49 (95% CI: 1.37 to 1.63) at 12 months post-abortion as compared to the 9 months pre-abortion rate. At 12 months post-abortion, first-time psychiatric contact was higher across all four diagnostic groupings and highest for personality or behavioral disorders (OR=1.87; 95% CI:1.48 to 2.36) and neurotic, stress related, or somatoform disorders (OR=1.60; 95% CI: 1.41 to 1.81).

'''Conclusions:''' Our reanalysis revealed that the Danish data is consistent with the larger body of both record-based and survey- based studies when viewed over periods of observation of at least nine months. Longer periods of observation are necessary to capture both anniversary reactions and the exhaustion of coping mechanisms which may delay observation of post-abortion effects.</blockquote>

''[http://abortionrisks.org/index.php?title=Munk-Olsen_et_al Induced First-Trimester Abortion and Risk of Mental Disorder.] Trine Munk-Olsen, Ph.D., Thomas Munk Laursen, Ph.D., Carsten B. Pedersen, Dr.Med.Sc., Øjvind Lidegaard, Dr.Med.Sc., and Preben Bo Mortensen, Dr.Med.Sc. N Engl J Med 2011;364:332-9.''

: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. 

:'''Editor's Note''': Please see the [http://abortionrisks.org/index.php?title=Munk-Olsen_et_al extended review of this study] for a more detailed discussion of the methodological limitations which slanting of the study design.

''[http://www.cmaj.ca/cgi/content/full/168/10/1253 Psychiatric admissions of low income women following abortion and childbirth.] Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Can Med Assoc J. 2003; 168(10):1253-7''
: Background: Controversy exists about whether abortion or childbirth is associated with greater psychological risks. We compared psychiatric admission rates of women in time periods from 90 days to 4 years after either abortion or childbirth.

:Methods: We used California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth during 1989. Only women who had no psychiatric admissions or pregnancy events during the year before the target pregnancy event were included (n = 56 741). Psychiatric admissions were examined using logistic regression analyses, controlling for age and months of eligibility for Medi-Cal services.

:Results: Overall, women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age.

:Interpretation: Subsequent psychiatric admissions are more common among low-income women who have an induced abortion than among those who carry a pregnancy to term, both in the short and longer term.

NOTES:
*Tables showing when the psychiatric hospitalization occurred illustrate a marked peak closer to the time of the pregnancy event, providing support for a causal interpretation.
*Using the same population, the authors also examined outpatient treatment for psychiatric disorders and also found higher rates of outpatient treatment following abortion. See next entry below
* The abortion group had 160% more total in-patient mental health claims than the birth group. Percentages equaled 120%, 90%, 110%, 60%, and 50% for the first 180 days, one year, two years, three years, and four years respectively.
*Across the four years, the abortion group had 70% more in-patient mental health claims than the birth group. Percentages equaled 90%, 110%, and 200% for depressive psychosis, single episode, depressive psychosis, recurrent episode, and bipolar disorder, respectfully

''[http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2002-15486-015&CFID=27122313&CFTOKEN=47942096 State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years.]'' Coleman PK, Reardon DC, Rue VM, Cougle JR. American Journal of Orthopsychiatry, 2002; 72(1):141–52. ''

:(Abstract) In this record-based study, rates of 1st-time outpatient mental health treatment for 4 years following an abortion or a birth among women (aged 13-49 yrs) 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.

''Report of the Committee on the Abortion Law, RF Badgley et al, (Ottawa:Supply and Services, 1977) pp. 313-321 ''
:A Saskatchewan, Canada study found that postabortion women had "mental disorders" 40.8% more often than postpartum women. An Alberta, Canada study found that among women who had abortions, 24% made visits to psychiatrists compared to 3% in the general population.

''''[http://www.scribd.com/doc/132704966/Virginia-DMAS-analysis-of-health-claims-following-abortion-and-childbirth Virginia DMAS analysis of health claims following abortion and childbirth. Nelson J. Department of Medical Assistance Services. Richmond, VA. March 21, 1997. Reply to request by Delegate Bob Marshall.

:This was an exploratory investigation by the Virginia Department of Medical Assistance Services (DMAS) to compare health claims of women who aborted and women who had normal births. The study examined medicaid claims paid by DMAS over a three year period for 122 women who had a first live birth and 122 women with a first abortion.

:In this study population, women who had abortions had statistically significant 62% percent increase in subsequent mental health claims (43% higher costs), and a 12% increase in claims (53% higher costs) for treatments resulting from accidents. They were 275% more likely to undergo a subsequent clinical psychiatric evaluation and 206% more likely to receive individual medical psychotherapy, and were 720% more likely to receive pharmacologic management in association with minimal psychotherapy.

''"Health Services Utilization After Induced Abortion in Ontario: A Comparison Between Community Clinics and Hospitals," T Ostbye et al, Am J Medical Quality 16(3):99-106, 2001''
:In Canada, a study of Ontario Health Insurance Plan claims in 1995 found that women who were three months postabortion from hospital day surgery had a rate of hospitalization for psychiatric problems of 5.2 per 1000 vs. 1.1 per 1000 for age matched controls without induced abortions. Three month postabortion women who had abortions at a community clinic had a rate of hospitalization for psychiatric problems of 1.9 per 1000 vs. 0.60 per 1000 for age-matched controls who did not have induced abortions. The incidence of postabortion psychiatric hospitalization was significantly higher if there had been preabortion hospitalization for psychiatric problems, preabortion emergency room consultation, or preabortion hospital admissions. Ed. Note: Flaws in the available data and study design limit the value of this study.

''"Postabortion or Postpartum Psychotic Reactions," H David et al, Family Planning Perspectives 13(2): 892, 1981 ''
:A Danish register linkage study over a three month period found that the rate of psychiatric hospital admissions was 18.4 per 10,000 postabortion women, 12.0 pr 10,000 postpartum women, and 7.5 per 10,000 women of childbearing age generally.

''"Risk of Admission to Psychiatric Institutions among Danish Women Who Experienced Induced Abortion: An Analysis Based on A National Record Linkage," Ronald Somers, Dissertation Abstracts Int'l, Public Health 2621-B, 1979 ''
:The age-adjusted incidence of psychiatric hospitalization was 3.42%, 4.06%, and 6.0% for women with one, two, and three induced abortions respectively compared with 2.56%, 1.97% and 2.15% for women with one, two and three live births respectively. The age- adjusted percentage of psychiatric hospitalization for aborting women was 1.49% for married women, 2.38%for single women, 4.21% for separated women, and 5.16% for divorced women. Aborting women under 30 years of age exhibited higher overall and diagnosis specific psychiatric hospital admission rates than women of this age in general. Teenagers who had abortions had 2.9 times the rate of psychiatric hospital admissions compared to teenage women in general. The highest rate of psychiatric hospital admissions was 9.45% among women age 35-39 with more than one abortion during the study period.

''"State-funded abortions vs. deliveries: A comparison of subsequent mental health claims over 6 years," PK Coleman and D Reardon, Poster session presented at the American Psychological Society 12th Annual Convention, Miami, FL, June, 2000 ''
:In a study of California women who received state funded medical care and who either had an abortion or gave birth in 1989, postabortion women were more than twice as likely to have from two to nine treatments for mental health as women who carried to term.

''"Psychosocial Characteristics of Psychiatric Inpatients with Reproductive Losses," T Thomas et al, Journal of Health Care for the Poor and Underserved 7(1):15, 1996 ''
:Postabortion women were more likely to require psychiatric hospitalization, have been subjected to sexual abuse, and be diagnosed for psychoactive substance abuse disorder compared to childless women.

''"Past Trauma and Present Functioning of Patients Attending a Women's Psychiatric Clinic," EFM Borins and PJ Forsythe, Am J Psychiatry 142(4):460, 1985 ''
:In a Canadian study of women attending a hospital based women's psychiatric clinic, a past abortion correlated significantly with three or more trauma factors.

''Proceedings of the Conference on Psycho-Social Factors in Transnational Planning, W Pasini and J Kellerhals, (Washington D.C.: American Institute for Research, 1970) p.44 ''
:A three fold increase in previous psychiatric consultations was found in women seeking repeat abortions compared to maternity patients.

'''''Long term follow-up of emotional experiences after termination of pregnancy: women's views at menopause. Dykesa K, Sladeb P; Haywood A. Journal of Reproductive and Infant Psychology,, First published on: 20 October 2010'''''
:Abstract
:The objective was to explore women’s long-term experiences and perspectives on their terminations of pregnancy (TOP) when perimenopausal. Eight women attending a menopause clinic who had experienced termination a minimum of 10 years previously (mean 24 years) completed semi-structured interviews. Transcripts were analysed using Template Analysis. Five TOP themes were identified: ‘Impression left’ involved sadness, regret, and guilt which affected women’s self-perceptions. ‘Judgement’ encompassed judgement on themselves and how censure was feared from others. ‘Growth and development’ noted the development of resilience and compassion for others. ‘Coming to terms and managing effects’ identified beliefs in the correctness of the decision, but effortful avoidance of thoughts still intruding into life. ‘Contradictions’ identified dramatic inconsistencies within almost all individual accounts indicating lack of resolution and full acceptance. Considering menopause and TOP together revealed a further three themes; Changes to thinking, Menopause as a time of reflection and Linkages or separateness. For some women termination may be continually reappraised in their changing life context and remain an active yet hidden feature managed through active avoidance. Menopause was viewed as a time of vulnerability to TOP-related negative thoughts, especially where wishes for more children were unfulfilled. Accessibility of post-termination counselling throughout life is recommended.

''[http://www.ncbi.nlm.nih.gov/pubmed/21146202 Conduct disorder symptoms and subsequent pregnancy, child-birth and abortion: A population-based longitudinal study of adolescents.] Pedersen W, Mastekaasa A. J Adolesc. 2010 Dec 9.''
:Abstract: Research on teenage pregnancy and abortion has primarily focused on socio-economic disadvantage. However, a few studies suggest that risk of unwanted pregnancy is related to conduct disorder symptoms. We examined the relationship between level of conduct disorder symptoms at age 15 and subsequent pregnancy, child-birth and abortion. A population-based, representative sample of Norwegian adolescent girls (N = 769) was followed from early adolescence until their mid-20s. Even with control for socio-demographic and family variables, conduct disorder symptoms at age 15 were strongly associated with pregnancy in the 15-19 age group, and a weaker association persisted in the 20-28 age group. Similar results were obtained for abortions, but here a strong relationship with conduct disorder symptoms was found even after age 20. After adjustment, no significant association between conduct disorder symptoms and subsequent child-birth was observed. More targeted preventive programmes aimed at girls with conduct disorder symptoms may be warranted.

===Benefits of Childbirth===

'''''[http://www.informaworld.com/smpp/content~db=all~content=a923120522~frm=titlelink Motherhood: is it good for women's mental health?] Holtona S, Fishera J, Rowea H. Journal of Reproductive and Infant Psychology, Volume 28, Issue 3 August 2010 , pages 223 - 239'''''

:Abstract
:There is ongoing debate regarding whether the child-bearing years, including the postpartum period, are a time of increased risk for mental health problems in women. Comparisons of the mental health of mothers and childless women have inconsistent findings. This is probably attributable to differences in the kinds of mothers and non-mothers investigated, and variations in the conceptualisation of mental health, but suggests that firm conclusions about the relationship between motherhood and women's mental health remain less clear than claimed. This study investigated the relationship between motherhood and mental health in a population-based, cross-sectional survey of a broadly representative sample of 569 women aged 30-34 years living in Victoria, one Australian state, in 2005. It was found that the rates of mental health conditions in mothers, including those who had given birth in the preceding year, were no higher than in women without children. Further, mothers reported significantly better subjective well-being and greater life satisfaction than childless women. These data suggest that being a mother is associated with enhanced mental health for women, and challenge the view that the child-bearing years are a period of diminished psychological well-being for women.

'''[http://www.ncbi.nlm.nih.gov/pubmed/19188541 Risks and predictors of readmission for a mental disorder during the postpartum period.] Munk-Olsen T, Laursen TM, Mendelson T, Pedersen CB, Mors O, Mortensen PB. Arch Gen Psychiatry. 2009 Feb;66(2):189-95. doi: 10.1001/archgenpsychiatry.2008.528.'''

:CONCLUSIONS: "Mothers with mental disorders have lower readmission rates compared with women with mental disorders who do not have children." In other words, being a mother may contribute to stabilizing mental health.

===Mania and Bipolar Disorder===

[http://www.ncbi.nlm.nih.gov/pubmed/23381493 Post-abortion mania.] Sharma V, Sommerdyk C, Sharma S. Arch Womens Ment Health. 2013 Apr;16(2):167-9. doi: 10.1007/s00737-013-0328-0. Epub 2013 Feb 5.

:Abstract: We describe case histories of three women with post-abortion mania, including two women who underwent a change in diagnosis from bipolar II to bipolar I disorder and another woman who had no prior history of psychiatric disturbance. It is argued that the study of post-abortion mania should provide an opportunity to better understand the aetiology of puerperal mania.

[http://bjp.rcpsych.org/content/176/1/92.1.long Post-abortion mania.] I. F. Brockington The British Journal of Psychiatry Jan 2000, 176 (1) 92; DOI: 10.1192/bjp.176.1.92

:The author comments on case study a describing a woman who suffered from five episodes of puerperal mania and two of post-abortion psychosis, one after a therapeutic abortion and one after a spontaneous abortion. The author notes that the association of acute psychosis with abortion in women susceptible to puerperal psychosis had been noted in at least nine reports, summarized in Brockington's book ''Motherhood & Mental Health.''

==Turn Away Study==
'''[http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128832#sec013 Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study] Rocca CH, Kimport K, Roberts SC, Gould H, Neuhaus J, Foster DG. PLoS One. 2015 Jul 8;10(7):e0128832. doi: 10.1371/journal.pone.0128832. eCollection 2015.'''

Abstract
:BACKGROUND: Arguments that abortion causes women emotional harm are used to regulate abortion, particularly later procedures, in the United States. However, existing research is inconclusive. We examined women's emotions and reports of whether the abortion decision was the right one for them over the three years after having an induced abortion.

:METHODS: We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities across the United States, selected based on having the latest gestational age limit within 150 miles. Two groups of women (n=667) were followed prospectively for three years: women having first-trimester procedures and women terminating pregnancies within two weeks under facilities' gestational age limits at the same facilities. Participants completed semiannual phone surveys to assess whether they felt that having the abortion was the right decision for them; negative emotions (regret, anger, guilt, sadness) about the abortion; and positive emotions (relief, happiness). Multivariable mixed-effects models were used to examine changes in each outcome over time, to compare the two groups, and to identify associated factors.

:RESULTS: The predicted probability of reporting that abortion was the right decision was over 99% at all time points over three years. Women with more planned pregnancies and who had more difficulty deciding to terminate the pregnancy had lower odds of reporting the abortion was the right decision (aOR=0.71 [0.60, 0.85] and 0.46 [0.36, 0.64], respectively). Both negative and positive emotions declined over time, with no differences between women having procedures near gestational age limits versus first-trimester abortions. Higher perceived community abortion stigma and lower social support were associated with more negative emotions (b=0.45 [0.31, 0.58] and b=-0.61 [-0.93, -0.29], respectively).

:CONCLUSIONS: Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years. Emotional support may be beneficial for women having abortions who report intended pregnancies or difficulty deciding.

===Comments & Criticisms===
# This study's findings and conclusions are overreaching in many regards, beginning with the fact that the sample of women is not representative of the national population of women having abortions due to high rates of self-exclusion plus high drop out rates. To quote from the study: "Overall, 37.5% of eligible women consented to participate, and 85% of those completed baseline interviews (n = 956). Among the Near-Limit and First-Trimester Abortion groups, 92% completed six-month interviews, and 69% were retained at three years; 93% completed at least one follow-up interview." This means 62.5% of women refused to participate in the study.
# With 62.5% of eligible women refusing to participate in the study, it is improper for the authors to suggest that their findings reflect the general experiences of most women. There are numerous [[risk factors]] which have been identified as predicting which women will have the most severe post-abortion reactions. One of these risk factors, for example, is ambivalence about having an abortion or carrying to term. Another is the expectation that one will have more negative feelings about the abortion. In a similar post-abortion interview study by [[Soderberg]], the author reported that in interviews with those declining to participate "the reason for non-participation seemed to be a sense of guilt and remorse that they did not wish to discuss. An answer often given was: ' Do do not want to talk about it. I just want to forget.'"
# It is very likely that the self-selected 37.5% of women agreeing to participate were more highly confident of their decision to abort prior to their abortions and anticipated fewer negative outcomes. This concern about selection bias is highlighted by the study's own finding that "women feeling more relief and happiness at baseline were less likely to be lost [to follow-up]." Clearly, due to the large numbers of women choosing not to be questioned about their experience, and the large drop out of those who did agree, this sample is not representative of the national population of women having abortions.
# Despite the initial selection bias, 15% of those agreeing to be interviewed subsequently opted out of the baseline interview and another 31% opted out within the three year followup period. This indicates that even among women who expected little or no negative reactions, the stress of participating in follow up interviews lead to a change of mind. The authors also make much of the claim that 93% of the participants "completed at least one follow up interview" which the media outlets incorrectly reported as meaning [http://www.medicalnewstoday.com/articles/296756.php"Only 7% of the participants dropped out of the study during follow-up."]
# According to an [http://www.ansirh.org/wp-content/uploads/Turnaway-Study-Infographic_7-8-2015.pdf infographic about the study] published by the research group, the followup interviews were actually continued every six months for five years, not just three. Why then did this report limit itself to three years rather than cover the full five years covered by the study?
# The bias of the research team is made clear in [http://www.ansirh.org/news/new_ANSIRH.php press releases] and a [http://www.ansirh.org/wp-content/uploads/Turnaway-Study-Infographic_7-8-2015.pdf infographic] purporting to summarize the study. In these "summaries" the research group conceals the details regarding the high non-participation rate and boldly claims "95% of women who had abortions felt it was the right decision, both immediately and over 3 years," omitting the fact that 62.5% refused to answer the question at the time of their abortion and of those interviewed at the time 31% were out of the study by the third year. Notably, the problem of high non-participation and drop out rates is not mentioned in the abstract, press release, or other summarizing materials published by the authors. To the contrary, they consistently imply that their results apply to the entire population of women having abortions.
#Another oddity, the authors report that in the final group analyzed, average age 25, 62% were raising children. This would appear to be a very high rate that is not typical of national averages for women seeking abortion.
#The study population is also non-representative of the women having abortion in that it included 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester. This is totally disproportionate. It again shows that the authors should not be extending conclusions about this non-representative sample to the general population.
#The focus of this report in on women's persistent satisfaction with their abortion decisions, "decision rightness," as measured by a single question of whether or not the "abortion was right for them." Women were asked to answer this question "yes", "no" or "uncertain." A better research approach would have been to have this question rated on a numeric scale (1 to 10, for example) in order to better identify any shift in attitudes.
#Questions regarding decision satisfaction may produce [https://en.wikipedia.org/wiki/Reaction_formation reaction formation] and therefore defensive answers affirming the rightness of a decision even if there are actually unresolved anxieties or other issues. (To voice dissatisfaction may invite anxiety provoking thoughts. Responding the way one is expect to respond, avoids reflection). Additional questions should have been asked to better gauge the subjects thoughts. For example, in the [[Soderberg]] study, including a one year post-abortion interview of 847 women (after a 33% self-exclusion rate), 80% of the women were satisfied with their decision to abort but 76% also stated that they would never abort again if faced with an unwanted pregnancy. A woman expressing unwillingness to not have another abortion may tell us more than her expression of the "rightness" of a past abortion decision that cannot be changed.
#While the report and [http://www.ansirh.org/news/new_ANSIRH.php accompanying press release] claim that this study proved there is "no evidence of widespread 'post-abortion trauma syndrome,' in fact it did not use any standard scales for assessment of psychological well being. They certainly did not overcome the findings of record linkage studies which have shown an [http://www.cmaj.ca/content/168/10/1253.full elevated risk of psychiatric admissions] following abortion or [http://www.bmj.com/content/313/7070/1431 elevated rates of suicide]. Instead, their assessment of psychological health is all inferred from an assessment of just six emotional reactions they associated with their abortion: relief, happiness, regret, guilt, sadness and anger. Women rated each emotion on a five point scale from "not at all" to "extremely" and a scale was constructed by combining all four negative emotions and another from combining the two positive emotions.
#The authors report a decline in the negative emotions reported by the women remaining in the study over the three year period.
#Notably, the claim of declining regret and declining negative reactions is at odds with [[Brenda Major]]'s two year longitudinal study, which also had high drop out rates, which found that there was a trend in decline in relief and increase in negative emotions over the two year period among those who did not drop out of her study. (See Major B, et al. Psychological responses of women after first-trimester abortion. Archives of General Psychiatry. 2000: 57(8), 777-84.)
#From the observation that the scale created from four negative reactions showed a modest decline in negative reactions over three years, the authors they draw the very broad conclusion that there is no evidence of widespread negative psychological reactions to abortion. This conclusion ignores the fact that many psychological problems are characterized by denial and repression of negative emotions.
#But there is clear evidence from other studies that many women experience symptoms of post-traumatic stress disorder which includes symptoms of denial and avoidance behavior. In a study by Rue, for example, among women reporting intrusive memories or thoughts related to their abortion, only half denied that these thoughts were attributed (caused) by their abortions. In other words, it is not always easy for women to recognize which feelings may be attributable to their abortions. For example, it is only when in post-abortion counseling that many women may attribute increased feelings of anger after their abortions to unresolved feelings over the abortion which they were projecting onto other people and situations. This is all fairly basic psychology. Negative emotions often crop up in other parts of our lives because we have trouble dealing with them at the source. Therefore, women reporting less "anger" relative to their abortion may in fact have more feelings of anger in their lives than before their abortion but are simply attributing it to other issues. This demonstrates the difficulty in trying to judge the post-abortion emotional adjustment of women based on just six oversimplified questions about six basic emotions.
#Another difficulty raised by the researchers methodology is that their interviews apparently did not inquire about any steps women took to resolve negative emotions. It is necessary to know if women who had negative feelings sought any help to deal with those feelings, perhaps with a therapist, a pastor, or family or friends. The increase in the number of women participating in post-abortion programs should, for example, help to reduce the longevity of negative reactions to abortion. But if this is the case, the conclusion of the authors that negative reactions to abortion naturally diminish over time may be wrong if, in fact, the decrease is due to women receiving post-abortion psychological or spiritual counseling. In other words, if the decline in negative reactions is real (and not due to denial, repression, or just a desire to rush through the phone interview to collect the $50 gift card) it is important to understand the reason for this. Is it due to support given to those having negative feelings, or is it "natural" and permanent?

==Older Papers Regarding Long-Term Effects==
''[http://www.ncbi.nlm.nih.gov/pubmed/19880932?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=1 Reactions to abortion and subsequent mental health.] Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2009 Nov;195(5):420-6.''

:BACKGROUND: There has been continued interest in the extent to which women have positive and negative reactions to abortion. AIMS: To document emotional reactions to abortion, and to examine the links between reactions to abortion and subsequent mental health outcomes.

:METHOD: Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30.

:RESULTS: Abortion was associated with high rates of both positive and negative emotional reactions; however, nearly 90% of respondents believed that the abortion was the right decision. Analyses showed that the number of negative responses to the abortion was associated with increased levels of subsequent mental health disorders (P<0.05). Further analyses suggested that, after adjustment for confounding, those having an abortion and reporting negative reactions had rates of mental health disorders that were approximately 1.4-1.8 times higher than those not having an abortion.

:CONCLUSIONS: Abortion was associated with both positive and negative emotional reactions. The extent of negative emotional reactions appeared to modify the links between abortion and subsequent mental health problems.
<blockquote>NOTE:

>85% reported at least one negative emotional reaction

>55% reported at least one strong (“very much”) negative reaction</blockquote>

[[Broen]] AN, Moum T, Bodtker AS, Ekeberg O: [http://www.ncbi.nlm.nih.gov/pubmed/15694217?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Reasons for induced abortion and their relation to women's emotional distress: a prospective, two-year follow-up study.] Gen Hosp Psychiatry 2005, 27:36-43.
:OBJECTIVE: The present study aimed to identify the most important reasons for induced abortion and to examine their relationship to emotional distress at follow-up. :
:METHODS: Eighty women were included in the study. The women were interviewed 10 days, 6 months (T2) and 2 years (T3) after they underwent an abortion. At all time points, the participants completed the Impact of Event Scale and a questionnaire about feelings connected to the abortion.
:RESULTS: Reasons related to education, job and finances were highly rated. Also, "a child should be wished for," "male partner does not favour having a child at the moment," "tired, worn out" and "have enough children" were important reasons. "Pressure from male partner" was listed as the 11th most important reason. When the reasons for abortion and background variables were included in multiple regression analyses, the strongest predictor of emotional distress at T2 and T3 was "pressure from male partner."
:CONCLUSION: Male pressure on women to have an induced abortion has a significant, negative influence on women's psychological responses in the 2 years following the event. Women who gave the reason "have enough children" for choosing abortion reported slightly better psychological outcomes at T3.

[http://www.ncbi.nlm.nih.gov/pubmed/15039513?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Psychological Impact on Women of Miscarriage Versus Induced Abortion: A 2-Year follow-up study.] [[Broen]] AN, Moum T, Bödtker AS, Ekeberg O. Psychosomatic Medicine, 2004, 66:265-271.

:"The feeling relief (at T1) had no significant influence on the IES scores at T3, unadjusted or adjusted." (p 268) This supports an argument that researchers who place too much emphasis on measure of relief may be missing the full picture.

p270, "mental health before the event suprisingly had no significant independent influence on IES scores."

 [http://www.ncbi.nlm.nih.gov/pubmed/16343341?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum The course of mental health after miscarriage and induced abortion: a five-year follow-up study.] [[Broen]] AN, Moum T, Bødtker AS, Ekeberg O. BMC Medicine 2005, 3:18 (12 December 2005)

:Broen et al.'s results show that women who had a miscarriage suffer more mental distress up until six months after the event than women who had an abortion. Women who had an abortion, however, experienced more mental distress long after the event - two and five years afterwards - than women who had a miscarriage. Women who experienced induced abortion had significantly greater IES scores for avoidance and for the feelings of guilt, shame and relief than the miscarriage group at two and five years after the pregnancy termination (IES avoidance means: 3.2 vs 9.3 at T3, respectively, p < 0.001; 1.5 vs 8.3 at T4, respectively, p < 0.001). Compared with the general population, women who had undergone induced abortion had significantly higher HADS anxiety scores at all four interviews (p < 0.01 to p < 0.001), while women who had had a miscarriage had significantly higher anxiety scores only at T1 (p < 0.01).

 [http://www.ncbi.nlm.nih.gov/pubmed/16553180?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Predictors of anxiety and depression following pregnancy termination: a longitudinal five-year follow-up study.] [[Broen]] AN, Moum T, Bödtker AS, Ekeberg O. Acta Obstet Gynecol Scand. 2006;85(3):317-23.

:BACKGROUND: The aims of the study were to assess anxiety and depression in women who had experienced either a miscarriage or an induced abortion, to compare the women's level of distress with that of a general population sample, and to find predictors of anxiety and depression six months and five years after the event. METHODS: A prospective, longitudinal follow-up study. Women who experienced miscarriage (n = 40) and induced abortion (n = 80) were interviewed ten days (T1), six months (T2), two years (T3), and five years (T4) after the event. On each occasion, they completed the Hospital Anxiety and Depression Scale and the Life Events Scale. Paired-sample t-test, logistic regression, and multiple linear regression statistical tests were used. RESULTS: Women with miscarriage had significantly more anxiety and depression at T1 than the general population, while women with induced abortion had significantly more anxiety at all time points and more depression at T1 and T2. In both groups, important predictors of anxiety and depression at T2 and T4 were recent life events and poor former psychiatric health. Childbirth events between T1 and T4 had no significant influence on the scores. For women with induced abortion, doubt about the decision to abort was related to depression at T2 (p <0.05), while a negative attitude towards induced abortion was associated with anxiety at T2 (p <0.05) and T4 (p <0.05). CONCLUSION: Correlates of anxiety and depression may be used to better identify women who are at risk of negative psychological responses following pregnancy termination.

''"Induced Elective Abortion and Perinatal Grief," Gail B. Williams, Dissertation Abstracts Int'l. 53(3): 1296B, Sept. 1992. ''
:A study of 83 white women with one first trimester abortion, no documented psychiatric history and no self-reported prenatal losses in the last 5 years an average of 11 years postabortion. The Grief Experience Inventory was used as a test instrument and found a range of scores from 27-82. 50 represents at least minimal grief on 12 bereavement/research scales. Various scales measured included anger/hostility, social isolation, loss of control, death anxiety, loss of vigor, physical symptoms, dependency, somatization, sleep disturbance, loss of appetite, optimism/despair, denial. It was concluded that some women experienced persistence of various aspects of grief for long periods of time following induced abortion.

''The Psycho-Social Aspects of Stress Following Abortion, Anne C. Speckhard, (Kansas City: Sheed and Ward, 1987)''
:In a study of 30 women stressed by abortion after 5-10 years following their abortion, women reported feelings of sadness, regret, remorse or a sense of loss [100 percent]; feelings of depression [92 percent]; feelings of anger [92 percent]; feelings of guilt [92 percent]; fear that others would learn of the pregnancy and abortion experience [89 percent]; many expressed surprise at the intensity of the emotional reaction to the abortion [85 percent]; Other adverse reactions included feelings of lowered self-worth [81 percent]; feelings of victimization [81 percent]; preoccupation with the characteristics of the aborted child [81 percent]; feelings of depressed effect or suppressed ability to experience pain [73 percent]; and feelings of discomfort around infants and small children [73 percent]. In this study the most common behavioral reactions included frequent crying [81 percent]; inability to communicate with others concerning the pregnancy and abortion experience [77 percent]; flashbacks of the abortion experience [73 percent]; sexual inhibition [69 percent]; suicide ideation [65 percent] and increased alcohol use [61 percent].

''"Aborted Women: Silent No More," David C. Reardon, (Chicago: Loyola Press, 1987)''
:In a detailed study of 252 women with prior abortions who are members of Women Exploited by Abortion approximately 10 years after their abortion, 95% were now dissatisfied with the abortion choice and 94% attributed negative psychological effects to their abortion.

''"Mental Disorders After Abortion," B. Jansson, Acta Psychiatrica Scandinavica41:87 (1965). ''
:In a Swedish study of 57 women with prior psychiatric problems who subsequently had induced abortions, three committed suicide as determined by long-term follow-up studies 8-13 years after their abortion. In contrast, of 195 women with previous psychiatric problems who carried children to term, none committed suicide.

''"Risk of Admission to Psychiatric Institutions Among Danish Women Who Experience induced Abortion," Ronald L. Somers, Ph.D. Thesis/ UCLA (1979) ''
:Among women with 2 or more abortions the rate of psychiatric admissions among women 35-39 (approx. 9%) was about 4 times higher than women 25-29 years of age (approx. 2.3%) and 8-18 times higher than women 20-24 years of age (0.5-1.1%) during 1973- 1975.

''"Psychological Aspects of Abortion," Edna Ortof in Psychological Aspects of Pregnancy, Birthing and Bonding, ed. Barbara L. Blum (New York: Human Sciences Press, 1980) ''
:Several examples of post-abortion dreams are provided. One woman had the following dream 11, years after a self-induced abortion:
:"I was in my old home town with two girlfriends and about to go horseback riding... (but) we couldn't get a horse. Then some lady came over and handed me a bundle wrapped in a sheet and blankets/ like a baby. I was delighted to hold it... when I opened the bundle ... there was a kid there and it looked like it was shrinking. Like it was wasting away and I wanted the mother to come and take it away before it would die in my arms... The more I looked, the more anxious I got." The therapist reported this woman had an enormous sense of unfinished business about the pregnancy and abortion. She still had periodic intercourse without use of contraceptives with the prospective father hoping to "undo" that event. At times her guilt was overwhelming and her sense of loss increased with the passing years.

''A Survey of Post-Abortion Reactions, David C. Reardon, (Springfield, Illinois: Elliot Institute, 1987) ''
:A 1987 survey of 100 women an average of 11 years post-abortion who were contacted through state Women Exploited by Abortion chapters found that only 54% felt they had fully reconciled their abortion experience; 62% experienced the majority of their negative experience one year or more post-abortion; 97% regretted having the abortion; 62% said they felt more callused and hardened; 70% felt a need to stifle feelings; 45% said they had feelings of relief after abortion; 42% became sexually promiscuous; 50% reported aversion to sexual intercourse or sexual unresponsiveness; 54% thought the abortion choice was inconsistent with their own ideals; 64% ended the relationship with their sexual partner following the abortion (41% within one month, 9% more within 6 months and 14% more within one year.

''The Long-Term Psychological Effects of Abortion, Catherine A Barnard, (Portsmouth, NH: Institute for Pregnancy Loss, 1990) Summarized in Association for Interdisciplinary Research in Values and Social Change Newsletter 3(4):1 (1991) ''
:A random sample of 984 women who had abortions during 1984-84 at a clinic in Baltimore, Maryland were selected for study. However, only 160 women could be contacted 3-5 years later, Of the 160 contacted only 80 actually completed the research packets. Research instruments used were the DSM-IIIR, Impact of Events Scale, and the Millon Clinical Mulitaxial Inventory. The prevalence of Post Traumatic Disorder was 18.8%. High stress levels ranging from 39-45% were prevalent in such areas as sleep disorers, hypervigalence, or flashbacks. The variables that predicted high stress reactions were: a negative relationship with mother, a past history of emotional problems in the family of origin, a conflictual relationship with the father of the child, and poor aftercare at the clinic. The number of reported prior abortions did not predict the incidence of PTSD. 30% of the women had abortions between 14-18 years of age and few were religious at the time of their abortion.

''"Methodological considerations in empirical research on abortion," RL Anderson et al in Post-Abortion Syndrome. Its Wide Ramifications, ed. Peter Doherty (1995) 103 ''
:A study at Pine Rest Christian Hospital in Grand Rapids, Michigan which provided psychiatric outpatient services, compared women who presented with a history of elective abortion and sought psychiatric outpatient services in response to a negative adjustment to abortion ( the abortion distressed group), to a control group which also had a history of elective abortion but who presented for outpatient psychiatric services for reasons which were not abortion related. (the abortion non-distressed group). The average length of time from the abortion to the time of the study was 9 years. Seventy-three percent (73%) of the abortion distressed group met the criteria for Post Traumatic Stress Disorder (DSM-IIIR) which was significantly higher than the abortion non-distressed group. Women in the abortion distressed group more often reported they believed abortion to be morally wrong compared to the abortion non-distressed group. There were no significant differences among groups in psychopathology as measured by MMPI-2, on overall social support, or religiosity. Abortion distressed women experienced fewer recent adverse life events compared to abortion non-distressed women.

''Canonical variates of postabortion syndrome, Helen P Vaughan, (Portsmouth, NH: Institute for Pregnancy Loss, 1990) ''
:Questionnaires were distributed nationwide to 62 crisis pregnancy centers to women who had reported symptoms of postabortion syndrome and 232 questionnaires were returned. The mean length of time from their abortion was 11 years. It was found that postabortion syndrome was comprised of anger, guilt, grief, depression, and stress reactions. Two different dimensions of negative postabortion adjustment were noted. One dimension included high levels of anger and guilt, with a significant absence of any grief feelings. The second dimension showed high guilt and stress with a significant absence of anger. The various personality characteristics and circumstances of women in each dimension were discussed.

''" Psychological Profile of dysphoric women postabortion," KN Franco et al, Journal of the American Medical Women's Association 44(4): 113, 1989 ''
: Eighty-one women in a patient-led postabortion support group years who described themselves as having poorly assimilated their abortion experience 1-15 years postabortion were studied. 78% were single at the time of their abortion and only 19% married the father of the child. The Bech Depression Inventory for women with one abortion was 4.7(none to minimal depression) and for women with multiple abortions was 9.4(moderate depression). The Millon Clinical Mulitaxial Inventory (MCMI) suggested personal pathology in the form of anxiety (48%), somatoform disorders (58%), and dysthymia (36%). Those with multiple abortions scored on the borderline personality subscales. Some 48% of the group underwent psychotherapy after their abortion; 50% of women with multiple abortions made a suicide attempt sometime after their abortions; anniversary reactions were clearly reported by 42% of the sample. For additional studies on this sample of postabortion women see "Anniversary Reactions and Due Date Responses Following Abortion," K Franco et al, Psychother Psychosom 52:151, 1989; "Abortion in Adolescence," NB Campbell et al, Adolescence, 23(92), 1988

''Post-Abortion Trauma, 9 steps to Recovery, Jeanette Vought, (Grand Rapids: Zondervan, 1991). ''
:In a study of women in a religiously-based postabortion recovery group 10-15 years post- abortion, 90% reported guilt and shame related to their abortion, 74% feelings of isolation, 60% expressed anger toward others, 24% were more fearful of sexual intercourse after their abortion, 31% tried to avoid pregnant women, 53% said they desired to get pregnant again to compensate for their loss; 76% suffered from depression, 78% struggled with low self-esteem and 49% said they felt alienated from God. Following their abortion, women reported insomnia (25%), negative and hurtful relationships with men (38%, abortion had a negative effect on parenting (32.4%), frequent alcohol use (17.8%), frequent drug use (9.2%) as well as other negative personal or relational problems.

''"Physical and Psychological Injury Following Abortion: Akron Pregnancy Services Survey," L.H. Gsellman, Association For Interdisciplinary Research Newsletter 5(4):1-8, Sept/Oct 1993. ''
:In a questionnaire study of 344 post-abortal women receiving a variety of services at a pregnancy service center an average of 6 years following their abortion, 66% expressed guilt, 54% expressed regret or remorse, 46% had an inability to forgive self, 57% reported crying or depression, 38% reported lower self-esteem and 36% reported anger or rage, 16% reported suicidal impulses and 7% made suicide attempts. 18.4% of the abortions were at 13 weeks gestation or more; 22% reported two abortions and 4.3% reported three or more abortions.

''"Prolonged Grieving After Abortion. A Descriptive Study," D Brown et al, The Journal of Clinical Ethics 4(2):118, 1993. ''
:Upon request, women from a large protestant congregation in Florida wrote descriptive letters on the negative effects of abortion. 45 letters contained sufficient information to compile statistical information, 81% were first trimester abortions and 71% occurred after Roe v Wade was decided. 42% reported negative emotional sequelae that lasted over 10 years. Frequently mentioned long term experiences included guilt feelings (73.3%), fantasizing about the aborted fetus( 57.8%), masking their experience with the appearance of well-being (35.5%), suicide ideation (15.5%), recurrent nightmares(15.5%), marital discord (15.5%), phobic responses to infants (13.3%), as well as fear of men (8.9%) and disinterest in sex (6.7%).

==Long-Term Effects of Unintended Pregnancy==

[http://ajph.aphapublications.org/doi/10.2105/AJPH.2015.302973 The Implications of Unintended Pregnancies for Mental Health in Later Life.] Herd P, Higgins J, Sicinski K, Merkurieva I. American Journal of Public Health: March 2016, Vol. 106, No. 3, pp. 421-429.

:Abstract: Despite decades of research on unintended pregnancies, we know little about the health implications for the women who experience them. Moreover, no study has examined the implications for women whose pregnancies occurred before Roe v. Wade was decided—nor whether the mental health consequences of these unintended pregnancies continue into later life. Using the Wisconsin Longitudinal Study, a 60-year ongoing survey, we examined associations between unwanted and mistimed pregnancies and mental health in later life, controlling for factors such as early life socioeconomic conditions, adolescent IQ, and personality. We found that in this cohort of mostly married and White women, who completed their pregnancies before the legalization of abortion, unwanted pregnancies were strongly associated with poorer mental health outcomes in later life.

:'''NOTE:'''This study examined data collected from two interviews of 4,809 women who graduated from a Wisconsin high school in 1957, one in in 1975 and the other in 1992. In the 1992 data they found a slightly higher rate of depression among the women who reported giving birth to an unintended pregnancy prior to 1975. From this they conclude that “Experiencing unwanted pregnancies, especially after a woman or couple has reached a desired number of children, appears to be strongly associated with poor mental health effects for women later in life."

:This is a very weak and poorly designed study. The authors fail to control for important variables associated with depression in 1992, the year in which depression was assessed. For example, marital status, number of children, and frequency of religious attendance are examined for 19972, but not 1992.

:Also, the authors are making the assumption that the women in the study have no history of abortion, either before 1972 or after 1972. They are also presuming that "most" of these women's pregnancies were prior to 1972, but women graduating in 1957 were mostly 30-31 when abortion was legalized in 1972 . . . and just 27-28 when it was legalized in Colorado in 1967. In the mid and late 60's there was a significant effort to legalize abortion and widespread referrals to doctors doing illegal abortions.

:The study also fails to account for exposure to miscarriage and neonatal losses. In addition, their citations to the literate are also limited to assertions that parenting is stressful while ignoring other studies, like [http://americanvalues.org/catalog/pdfs/the_motherhood_study.pdf The Motherhood Study], which have documented the health benefits of being a parent.

Mifepristone

2026-03-25T21:59:00Z

Barb:

== Mifepristone is also known as RU-486, the abortion pill, medical abortion, or chemical abortion ==
'''[https://pubmed.ncbi.nlm.nih.gov/36592459/ Short-Term Adverse Outcomes After Mifepristone-Misoprostol Versus Procedural Induced Abortion : A Population-Based Propensity-Weighted Study]. Liu, N., & Ray, J. G. (2023). ''Annals of Internal Medicine'', ''176''(2). <nowiki>https://doi.org/10.7326/M22-2568</nowiki>'''<blockquote>'''Background:''' Prior studies comparing first-trimester pharmaceutical induced abortion (IA) with procedural IA were prone to selection bias, were underpowered to assess serious adverse events (SAEs), and did not account for confounding by indication. Starting in 2017, mifepristone-misoprostol was dispensed at no cost in outpatient pharmacies across Ontario, Canada.

'''Objective:''' To compare short-term risk for adverse outcomes after early IA by mifepristone-misoprostol versus by procedural IA.

'''Design:''' Population-based cohort study.

'''Setting:''' Ontario, Canada.

'''Patients:''' All women who had first-trimester IA.

'''Measurements:''' A total of 39 856 women dispensed mifepristone-misoprostol as outpatients were compared with 65 176 women undergoing procedural IA at 14 weeks' gestation or earlier within nonhospital outpatient clinics (comparison 1). A total of 39 856 women prescribed mifepristone-misoprostol were compared with 8861 women undergoing ambulatory hospital-based procedural IA at an estimated 9 weeks' gestation or less (comparison 2). The primary composite outcome was any SAE within 42 days after IA, including severe maternal morbidity, end-organ damage, intensive care unit admission, or death. A coprimary broader outcome comprised any SAE, hemorrhage, retained products of conception, infection, or transfusion. Stabilized inverse probability of treatment weighting accounted for confounding between exposure groups.

'''Results:''' Mean age at IA was about 29 years (SD, 7); 33% were primigravidae. Six percent resided in rural areas, and 25% resided in low-income neighborhoods. In comparison 1, SAEs occurred among 133 women after mifepristone-misoprostol IA (3.3 per 1000) versus 114 after procedural IA (1.8 per 1000) (relative risk [RR], 1.87 [95% CI, 1.44 to 2.43]; absolute risk difference [ARD], 1.5 per 1000 [CI, 0.9 to 2.2]). The respective rates of any adverse event were 28.9 versus 12.4 per 1000 (RR, 2.33 [CI, 2.11 to 2.57]; ARD, 16.5 per 1000 [CI, 14.5 to 18.4]). In comparison 2, SAEs occurred among 133 (3.4 per 1000) and 27 (3.3 per 1000) women, respectively (RR, 1.04 [CI, 0.61 to 1.78]). The respective rates of any adverse event were 31.2 versus 24.9 per 1000 (RR, 1.25 [CI, 1.04 to 1.51]).

'''Limitation:''' A woman prescribed mifepristone-misoprostol may not have taken the medication, and the exact gestational age at IA was not always known.

'''Conclusion:''' Although rare, short-term adverse events are more likely after mifepristone-misoprostol IA than procedural IA, especially for less serious adverse outcomes.</blockquote>
'''[https://www.racgp.org.au/getattachment/9fc860a4-006d-47e7-a4fb-f114d49be141/Mifepristone-in-South-Australia.aspx Mifepristone in South Australia: The First 1343 Tablets]. Mulligan, E., & Messenger, H. (2011).Australian Family Physician, 40(5), 342–345. <nowiki>https://search.informit.org/doi/10.3316/informit.977747514951146</nowiki>'''
: The study found 3.3% of the women who used RU-486 in the first trimester of pregnancy reported to an emergency room compared with 2.2% who used a surgical method and •5.7% of the women who used RU-486 had to be re-admitted to hospitals compared with 0.4% of surgical abortion patients.
:
'''[https://lozierinstitute.org/wp-content/uploads/2021/12/Unwanted-Abortions-Unnecessary-Abortions-Unsafe-Abortions-1.pdf Overlooked Dangers of Mifepristone, the FDA’s Reduced REMS, and Self-Managed Abortion Policies: Unwanted Abortions, Unnecessary Abortions, Unsafe Abortions.] Reardon, David C., et al. ''American Report Series'' 20 (2021).'''
: It has been argued that abortions induced with mifepristone and misoprostol (or even misoprostol alone) are so safe and efficacious that they can be self-prescribed and self-managed, As a step toward this goal, some have advocated for elimination of the FDA requirements which limit the ability to prescribe mifepristone to any healthcare provider prepared to: (a) accurately assess the gestational age of the pregnancy, (b) diagnose ectopic pregnancies, and (c) provide referrals for surgical intervention in cases of severe bleeding or incomplete abortion. These arguments for reducing or eliminating physician oversight of chemical abortions are based on four premises. First, abortion is a human right that advances the equality, wellbeing, and self-determination of women. Second, the risks of mifepristone/misoprostol abortions are negligible. Third, self-managed abortions are an effective means by which women can control their reproductive lives and achieve their goals. Fourth, physician oversight is unnecessary and counterproductive. If these four premises are true, they present a strong basis for allowing the purchase of mifepristone/misoprostol as an over-the-counter drug. In the discussion which follows, we will show that the four premises above are, in fact, contradicted by real world experience and the best available medical evidence. The first premise is ideological and not supported by data. As a counterargument, we will show that that chemical abortion is often used contrary to women’s self-determination and best interests. The second premise is based primarily on research performed by authors with significant ideological and financial conflicts of interest and entanglement with the manufacturer of mifepristone. Moreover, the FDA has failed to require any systematic investigation of complications associated with mifepristone. Our counterargument will summarize a substantial body of studies documenting detailed evidence of physical and psychological complications associated with chemical abortions, which have simply been ignored, not disproven, by mifepristone advocates. The third premise, that chemical abortions are efficacious, is also ideological and unsupported by any meaningful data. Our counterargument will demonstrate that the actual objectives of women undergoing abortions are not being met, much less reliably quantified. The fourth premise, asserting that physician oversight of chemical abortions is unnecessary is also ideologically driven and unsupported by reliable evidence. Our counterargument will demonstrate that the role of physicians in pre-abortion screening, medical administration, and follow-up should be increased, not eliminated. We conclude with recommendations for modifying FDA’s current Risk Evaluation and Mitigation Strategy [REMS] applicable to mifepristone in order to provide better data.
:

'''[https://pubmed.ncbi.nlm.nih.gov/38777160/ Medication and procedural abortions before 13 weeks gestation and risk of psychiatric disorders.] Steinberg, J. R., Laursen, T. M., Lidegaard, Ø., & Munk-Olsen, T. (2024).''American Journal of Obstetrics and Gynecology'', ''231''(4), 437.e1-437.e18. <nowiki>https://doi.org/10.1016/J.AJOG.2024.05.025</nowiki>'''<blockquote>'''Background:''' The proportion of abortions provided by medication in the United States and worldwide has increased greatly since the U.S. Food and Drug Administration approved mifepristone in 2000. While existing research has shown that abortion does not increase risk of mental health problems, no population-based study has examined specifically whether a procedural or medication abortion increases risk of mental health disorders.

'''Objective:''' This study examined whether mental health disorders increased in the shorter and longer-term after a medication or procedural abortion.

'''Study design:''' Using Danish population registers' data, we conducted a prospective cohort study in which we included 72,424 females born in Denmark between 1980 and 2006, who were ages 12 to 38 during the study period and had a first first-trimester abortion before 13 weeks gestation in 2000 to 2018. Females with no previous psychiatric diagnoses were followed from 1 year before their abortion until their first psychiatric diagnosis, December 31, 2018, emigration from Demark, or death, whichever came first. Risk of any first psychiatric disorder was defined as a recorded psychiatric diagnosis at an in- or out-patient facility from the 1 year after to more than 5 years after a medication or procedural abortion relative to the year beforehand. Results were adjusted for calendar year, age, gestational age, partner status, prior mental and physical health, childbirth history, childhood environment, and parental mental health history.

'''Results:''' Females having medication (n=37,155) and procedural abortions (n=35,269) had the same risk of any first psychiatric diagnosis in the year after their abortion relative to the year before their abortion (medication abortion adjusted incidence rate ratio [MaIRR]=1.02, 95% confidence interval [CI]: 0.93-1.12; procedural abortion adjusted incidence rate ratio [PaIRR]=0.94, 95% CI: 0.86-1.02). Moreover, as more time from the abortion passed, the risk of a psychiatric diagnoses decreased relative to the year before their abortion for each abortion method (MaIRR 1-2 years after=0.89, 95% CI: 0.80-0.98; PaIRR 1-2 years after=0.81, 95% CI: 0.88-1.05; MaIRR 2-5 years after=0.77, 95% CI: 0.71-0.84; PaIRR 2-5 years after=0.72, 95% CI: 0.67-0.78; MaIRR 5+ years after=0.58, 95% CI: 0.53-0.63; PaIRR 5+ years after=0.54, 95% CI: 0.50-0.58).

'''Conclusion:''' Because the risk of psychiatric diagnoses was the same in the year after relative to the year before a medication and procedural abortion and the risk did not increase as more time after the abortion increased, neither abortion method increased risk of mental health disorders in the shorter or longer-term.</blockquote>

'''[https://pubmed.ncbi.nlm.nih.gov/34778493/ A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999-2015.]''' '''Health Serv Res Manag Epidemiol. 2021 Nov 9;8:23333928211053965. doi: 10.1177/23333928211053965.''' <blockquote>
'''Introduction:''' Existing research on postabortion emergency room visits is sparse and limited by methods which underestimate the incidence of adverse events following abortion. Postabortion emergency room (ER) use since Food and Drug Administration approval of chemical abortion in 2000 can identify trends in the relative morbidity burden of chemical versus surgical procedures.

'''Objective:''' To complete the first longitudinal cohort study of postabortion emergency room use following chemical and surgical abortions.

'''Methods:''' A population-based longitudinal cohort study of 423 000 confirmed induced abortions and 121,283 subsequent ER visits occurring within 30 days of the procedure, in the years 1999-2015, to Medicaid-eligible women over 13 years of age with at least one pregnancy outcome, in the 17 states which provided public funding for abortion.

'''Results:''' ER visits are at greater risk to occur following a chemical rather than a surgical abortion: all ER visits (OR 1.22, CL 1.19-1.24); miscoded spontaneous (OR 1.88, CL 1.81-1.96); and abortion-related (OR 1.53, CL 1.49-1.58). ER visit rates per 1000 abortions grew faster for chemical abortions, and by 2015, chemical versus surgical rates were 354.8 versus 357.9 for all ER visits; 31.5 versus 8.6 for miscoded spontaneous abortion visits; and 51.7 versus 22.0 for abortion-related visits. Abortion-related visits as a percent of total visits are twice as high for chemical abortions, reaching 14.6% by 2015. Miscoded spontaneous abortion visits as a percent of total visits are nearly 4 times as high for chemical abortions, reaching 8.9% of total visits and 60.9% of abortion-related visits by 2015.

'''Conclusion:''' The incidence and per-abortion rate of ER visits following any induced abortion are growing, but chemical abortion is consistently and progressively associated with more postabortion ER visit morbidity than surgical abortion. There is also a distinct trend of a growing number of women miscoded as receiving treatment for spontaneous abortion in the ER following a chemical abortion.</blockquote>
'''[https://pubmed.ncbi.nlm.nih.gov/35633832/ A Post Hoc Exploratory Analysis: Induced Abortion Complications Mistaken for Miscarriage in the Emergency Room are a Risk Factor for Hospitalization]. Studnicki J, Longbons T, Harrison DJ, Skop I, Cirucci C, Reardon DC, Craver C, Fisher JW, Tsulukidze M. Health Serv Res Manag Epidemiol. 2022 May 20;9:23333928221103107. doi: 10.1177/23333928221103107.''' <blockquote>
'''Introduction:''' Previous research indicates that an increasing number of women who go to an emergency room for complications following an induced abortion are treated for a miscarriage, meaning their abortion is miscoded or concealed.

'''Objective:''' To determine if the failure to identify a prior induced abortion during an ER visit is a risk factor for higher rates of subsequent hospitalization.

'''Methods:''' Post hoc analysis of hospital admissions following an induced abortion and ER visit within 30 days: 4273 following surgical abortion and 408 following chemical abortion; abortion not miscoded versus miscoded or concealed at prior ER visit.

'''Results:''' Chemical abortion patients whose abortions are misclassified as miscarriages during an ER visit subsequently experience on average 3.2 hospital admissions within 30 days. 86% of the patients ultimately have surgical removal of retained products of conception (RPOC). Chemical abortions are more likely than surgical abortions (OR 1.80, CL 1.38-2.35) to result in an RPOC admission, and chemical abortions concealed are more likely to result (OR 2.18, CL 1.65-2.88) in a subsequent RPOC admission than abortions without miscoding. Surgical abortions miscoded/concealed are similarly twice as likely to result in hospital admission than those without miscoding.

'''Conclusion:''' Patient concealment and/or physician failure to identify a prior abortion during an ER visit is a significant risk factor for a subsequent hospital admission. Patients and ER personnel should be made aware of this risk.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/23090524/ Extending outpatient medical abortion services through 70 days of gestational age.] Winikoff B, Dzuba IG, Chong E, Goldberg AB, Lichtenberg ES, Ball C, Dean G, Sacks D, Crowden WA, Swica Y. Obstet Gynecol. 2012 Nov;120(5):1070-6. doi: 10.1097/aog.0b013e31826c315f. PMID: 23090524.'''<blockquote>'''Objective:''' To estimate the efficacy and acceptability of medical abortion at 64-70 days from last menstrual period (LMP) and to compare it with the already proven 57-63 days from LMP gestational age range.

'''Methods:''' This prospective, comparative, open-label trial enrolled 729 women with pregnancies 57-70 days from LMP requesting abortion at six U.S. clinics. Medical abortions were managed with 200 mg mifepristone and 800 micrograms buccal misoprostol and sites' service delivery protocols. Follow-up visits occurred 7-14 days after mifepristone, with an abortion considered complete if surgical intervention was not performed. Success, ongoing pregnancy, and acceptability rates were compared.

'''Results:''' A total of 629 cases were analyzable for efficacy. Success rates were similar in the two groups (57-63 days group: 93.5%, 95% confidence interval [CI] 90-96; 64-70 days group: 92.8%, 95% CI 89-95). Ongoing pregnancy rates also did not differ significantly (57-63 days: '''3.1%''', 95% CI 1.6-5.8; 64-70 days: '''3.0%''', 95% CI 1.5-5.7). Acceptability was high and similar in both arms, with most women (57-63 days: 87.4%; 64-70 days: 88.3%) reporting that their experience was either very satisfactory or satisfactory.

'''Conclusion:''' Medical abortion with mifepristone and misoprostol in current outpatient settings is an efficacious and acceptable method of ending pregnancies 64-70 days from LMP and can be offered without alteration of existing services.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/22240172/ Risk factors of surgical evacuation following second-trimester medical termination of pregnancy.] Mentula M, Heikinheimo O. Contraception. 2012 Aug;86(2):141-6. doi: 10.1016/j.contraception.2011.11.070. Epub 2012 Jan 10. PMID: 22240172.'''<blockquote>'''Background:''' Second-trimester medical termination of pregnancy (TOP) is associated with a higher risk of surgical evacuation than earlier medical TOP. Little is known about risk factors of surgical evacuation. Therefore, we assessed these risk factors among women undergoing second-trimester medical TOP.

'''Study design:''' Data on 227 women were derived from a prospective randomized trial comparing 1- and 2-day mifepristone-misoprostol intervals in second-trimester medical TOP between 2008 and 2010.

'''Results:''' The rate of surgical evacuation was 30.8%. The risk of surgical evacuation was increased by a history of curettage [odds ratio (OR) 4.4; 95% confidence interval (CI) 1.7-11.7], fetal indications for TOP (OR 6.1; 95% CI 1.1-34.4), age above 24 years (OR 2.4; 95% CI 1.1-5.3) and a 2-day interval (OR 2.2; 95% CI 1.1-4.1).

'''Conclusions:''' History of curettage, fetal indication, increasing age and 2-day interval between mifepristone and misoprostol increase the risk of surgical evacuation in cases of second-trimester medical TOP. These findings are important when optimizing clinical service in second-trimester TOP.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/21317416/ Immediate adverse events after second trimester medical termination of pregnancy: results of a nationwide registry study.] Mentula MJ, Niinimäki M, Suhonen S, Hemminki E, Gissler M, Heikinheimo O. Hum Reprod. 2011 Apr;26(4):927-32. doi: 10.1093/humrep/der016. Epub 2011 Feb 11. PMID: 21317416.'''<blockquote>'''BACKGROUND''' Increasing gestational age is associated with an increased risk of complications in studies assessing surgical termination of pregnancy (TOP). Medical TOP is widely used during the second trimester and little is known about the frequency of complications. This epidemiological study was undertaken to assess the frequency of adverse events following the second trimester medical TOP and to compare it with that after first trimester medical TOP.

'''METHODS''' This register-based cohort study covered 18 248 women who underwent medical TOP in Finland between 1 January 2003 and 31 December 2006. The women were identified from the Abortion Registry. Adverse events related to medical TOP within 6 weeks were obtained from the Hospital Discharge Registry.

'''RESULTS''' When compared with first trimester medical TOP, second trimester medical TOP increased the risk of surgical evacuation [Adj. odds ratio (OR) 7.8; 95% confidence interval (CI) 6.8-8.9], especially immediately after fetal expulsion (Adj. OR 15.2; 95% CI 12.8-18.0). The risk of infection was also elevated (Adj. OR 2.1; 95% CI 1.5-2.9). Within the second trimester, increased length of gestation did not influence the risk of surgical evacuation or infection after medical TOP.

'''CONCLUSIONS''' Medical TOP during the second trimester is generally safe. Surgical evacuation of the uterus is avoided in about two-thirds of cases, though it is much more common than after first trimester medical TOP. The risks of surgical evacuation and infection do not increase with gestational weeks in the second trimester TOP.</blockquote>

'''[https://pubmed.ncbi.nlm.nih.gov/19888037/ Immediate complications after medical compared with surgical termination of pregnancy.] Niinimäki M, Pouta A, Bloigu A, Gissler M, Hemminki E, Suhonen S, Heikinheimo O. Obstet Gynecol. 2009 Oct;114(4):795-804. doi: 10.1097/AOG.0b013e3181b5ccf9. PMID: 19888037.'''<blockquote>'''Objective:''' To estimate the immediate adverse events and safety of medical compared with surgical abortion using high-quality registry data.

'''Methods:''' All women in Finland undergoing induced abortion from 2000-2006 with a gestational duration of 63 days or less (n=42,619) were followed up until 42 days postabortion using national health registries. The incidence and risk factors of adverse events after medical (n=22,368) and surgical (n=20,251) abortion were compared. Univariable and multivariable association models were used to analyze the risk of the three main complications (hemorrhage, infection, and incomplete abortion) and surgical (re)evacuation.

'''Results:''' The overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort (20.0% compared with 5.6%, P<.001). Hemorrhage (15.6% compared with 2.1%, P<.001) and incomplete abortion (6.7% compared with 1.6%, P<.001) were more common after medical abortion. The rate of surgical (re)evacuation was 5.9% after medical abortion and 1.8% after surgical abortion (P<.001). Although rare, injuries requiring operative treatment or operative complications occurred more often with surgical termination of pregnancy (0.6% compared with 0.03%, P<.001). No differences were noted in the incidence of infections (1.7% compared with 1.7%, P=.85), thromboembolic disease, psychiatric morbidity, or death.

'''Conclusion:''' Both methods of abortion are generally safe, but medical termination is associated with a higher incidence of adverse events. These observations are relevant when counseling women seeking early abortion.</blockquote>

'''" Pain control in medical abortion", E Wiebe, Int'l J Gynecology & Obstetrics 74:275-280,2001'''

:A Canadian study of abortion procedures using methotrexate and misoprostol reported that the mean pain
Score was 6.2 on a scale from 1-10. Severe pain (scores of 9 or 10) was reported by 23.4% of the women.
Women experiencing severe pain were more likely to have a lower maternal age, lower parity, higher
anxiety and depression, and less satisfaction with the procedure. The authors reported that pain medication
given before the onset of the procedure did not reduce the amount of severe pain.

:

'''[http://www.frcblog.com/wp-content/uploads/2011/05/Australian-AERs_RU486_201105mulligan.pdf Mifepristone in South Australia] Mulligan E, Messenger H. Australian Family Physician. MAY 2011.'''
:The study found 3.3% of the women who used RU-486 in the first trimester of pregnancy reported to an emergency room compared with 2.2% who used a surgical method and •5.7% of the women who used RU-486 had to be re-admitted to hospitals compared with 0.4% of surgical abortion patients.
[http://www.lifenews.com/2011/05/10/study-high-of-women-using-abortion-drug-hospitalized/ Additional information ]
:

'''Psychological distress symptoms in women undergoing medical vs. surgical termination of pregnancy. Lowenstein L, Deutcsh M, Gruberg R, Solt I, Yagil Y, Nevo O, et al. (2006), General Hospital Psychiatry, 28(1):43–47.'''
:Compared to women choosing surgical abortion, those choosing chemical abortion had higher obsessive-compulsive symptoms, higher levels of guilt, higher interpersonal sensitivity scores, more paranoid ideation, and more general psychiatric symptoms.

'''A comparison of medical and surgical methods of termination of pregnancy: Choice, psychological consequences, and satisfaction with care. Slade, P., Heke, S., Fletcher, J., & Stewart, P. (1998). British Journal of Obstetrics and Gynecology, 105, 1288-1295.'''
:Those who had a medical abortion rated it as more stressful and experienced more disruption in their lives. “One of the main differences between these two methods of termination is the consciousness and participation of the patient in the medical procedure in a process that involves blood, pain, and death.”

'''Patient preference in a randomized study comparing medical and surgical abortion at 10-13 weeks gestation. Ashok P.W., Hamoda, H., Flett, G. M. M., Kidd, A., Fitzmaurice, A., Templeton, A. (2005). Contraception, 71, 143-148.'''
:46.8% of women undergoing a medical abortion experienced a significant decline in self-esteem 2-3 weeks following the abortion. This was a higher percentage than among those who had a surgical abortion (39.5%).

'''Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomized controlled trial, Kelly, T., Suddes, J., Howel, D., Hewison, J., & Robson, S. (2010). BJOG, 117, 1512-20.'''
:Women who had chemical abortions had higher PTSD intrusion scores, such as nightmares, than women who had surgical abortions

'''''Posttraumatic Stress Disorder and psychological distress following medical and surgical abortion.''''' C. Rousset, C. Brulfert, N. Séjourné, N. Goutaudier & H. Chabrol Journal of Reproductive and Infant Psychology, (2011) Volume 29(5), 506-517.

: Method: Eighty-six women were approached a few hours after the abortion and then 6 weeks later. Several questionnaires were completed: the Impact of Event Scale Revised (IES-R), the Multidimensional Scale of Social Support (MSPSS), the Peritraumatic Dissociative Experience Questionnaire (PDEQ), the Peritraumatic Emotions List (PEL), the Hospital Anxiety and Depression Scale (HADS), the Perinatal Grief Scale (PGS) and the Texas Grief Inventory (TGI). Results: Six weeks after the abortion, 38% of women reported a potential PTSD and a significant decrease of the anxious symptomatology was also highlighted. Peritraumatic dissociation and peritraumatic emotions were the main predictors of the intensity of post-abortum PTSD symptoms. Compared to surgical abortion, medical abortion was associated with increasing the risk of developing a possible PTSD. Conclusion: By providing evidence on some of the main risk factors, this study highlights the need for psychological support for women and strategies of prevention to be developed.

''' 
[http://www.lifenews.com/2014/12/03/doctor-saves-106-babies-after-the-abortion-has-already-started-wait-until-you-see-how/ Abortion Pill Reversal can be successful]'''
:Article regarding a medical protocol for women who change their minds to stop the RU-486 induced abortion.
'''[http://www.nejm.org/doi/full/10.1056/NEJMc1001014 Fatal Clostridium sordellii Infections after Medical Abortions] N Engl J Med 2010; 363:1382-1383September 30, 2010'''
:Clostridial toxic shock is a rare and largely fatal syndrome among reproductive-age women. Eight cases were reported after medical abortions using mifepristone and misoprostol between 2000 and 2009 bringing the risk of clostridial toxic shock to 0.58 per 100,000 medical abortions.
[http://www.lifenews.com/2014/12/03/doctor-saves-106-babies-after-the-abortion-has-already-started-wait-until-you-see-how/ Abortion Pill Reversal can be successful]

: Article regarding a medical protocol for women who change their minds to stop the RU-486 induced abortion.

'''" Pain control in medical abortion", E Wiebe, Int'l J Gynecology & Obstetrics 74:275-280,2001'''

A Canadian study of abortion procedures using methotrexate and misoprostol reported that the mean pain Score was 6.2 on a scale from 1-10. Severe pain (scores of 9 or 10) was reported by 23.4% of the women. Women experiencing severe pain were more likely to have a lower maternal age, lower parity, higher anxiety and depression, and less satisfaction with the procedure. The authors reported that pain medication given before the onset of the procedure did not reduce the amount of severe pain.

:

[http://www.lifenews.com/2011/05/10/study-high-of-women-using-abortion-drug-hospitalized/ Additional information]

Main Page

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= Abortion Risks: Medical Studies, Articles, Commentary, and Resources =

This site hosts the largest bibliography of medical studies related to abortion on the internet, carefully organized by specific topics. You will also find articles and commentaries on important issues.

'''Best Summaries'''
* [[New Summary of Evidence Linking Abortion to Mental Health Problems|Updated 2026 Summary of Evidence Proving that Abortion is an Independent Risk Factor for More Mental Health Problems]]
* [https://pubmed.ncbi.nlm.nih.gov/30397472/ The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities]
* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5692130/ Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis]
* [[Index|Index to ''Detrimental Effects of Abortion: An Annotated Bibliography'']]
*
'''Special Projects'''
* [[APA Abortion Report]]
* [[Turn Away Study|Turnaway Study]]
* [[NCCMH Review]]
* [[Abortion Counseling]]
* [[Strahan Articles|Area for Tom Strahan's articles]]
'''Related sites include'''
:[http://www.afterabortion.org AfterAbortion.org]
:[http://www.TheUnchoice.org TheUnchoice.org]

Abortion Costs Are Kept Artificially Low

2026-03-12T21:27:25Z

Barb: Created page with " According to a December 30, 2000 [https://web.archive.org/web/20090512001334/https://www.nytimes.com/2000/12/30/us/as-abortion-rate-decreases-clinics-compete-for-patients.html front page investigative report] from the ''New York Times'' tough competition has resulted in cost cutting measures that involve the use of untrained staff and variations from recommended procedures.<blockquote>“…unlike other areas of medicine, where prices have surged over the years, compet..."

According to a December 30, 2000 [https://web.archive.org/web/20090512001334/https://www.nytimes.com/2000/12/30/us/as-abortion-rate-decreases-clinics-compete-for-patients.html front page investigative report] from the ''New York Times'' tough competition has resulted in cost cutting measures that involve the use of untrained staff and variations from recommended procedures.<blockquote>“…unlike other areas of medicine, where prices have surged over the years, competition among abortion clinics has kept prices so low that an abortion in many cities costs less now than it did 25 years ago, without even adjusting for the nearly 500 percent inflation in medical services. If abortion had kept up with inflation in medical services, a '''$300 abortion in 1972 would cost $2,251''' today [December of 2000]….

“‘The fees are not set by the cost of the services but by the cost of the competition,’ said Dr. Warren Hern, owner of the Boulder Abortion Clinic in Colorado. And, he said, ‘the competition for patients is absolutely ruthless.

“Ms. Allen and Ms. Miller [owners of an Arizona abortion clinic] still have to watch every penny. Like other clinics, the owners save money by training a low-paid staff to do everything but the actual surgery, from drawing blood to doing lab tests. Most of the time, no patients are scheduled and the staff cleans and does paper work. But when the doctor comes, a parade of patients is ready for the procedure, which takes just two or three minutes in the first trimester of pregnancy…

“Now, clinics are grappling with the mifepristone dilemma. Owners feel they have to offer the recently approved abortion pill, formerly known as RU-486, because women are asking for it and seem to expect it. But its price — $270 for three pills — will be a problem. Many owners say that if they charge what it costs to provide the three pills plus the three office visits, the lab work, and the counseling, they will lose customers to competitors who say they will keep the price much lower.

“Some have found creative solutions. Ms. Chelian said she is considering offering women just one pill instead of three and to have them sign a form saying they understand that one pill is not the approved dose but that studies have shown that one pill is effective. Then she can charge them just $80 more than for a surgical abortion.

“Carmen Franco, who owns six clinics in Detroit, said she expects to charge women $450 for a mifepristone abortion with the full three-pill dose. It is less than her costs. But, she said, by making it available, she expects to draw patients to the clinic where they can see the full range of options she provides. ‘We probably will use it as a loss leader,’ she said.”</blockquote>The specialization of abortion services has led to competitive marketing practices that emphasize high volume and low cost. The cost cutting measures have often involved compromises in the standard of care necessary to safe guard women’s health and have led to charges that many free standing abortion clinics operate on an “assembly line” basis. In many cases, the time set aside for counseling women is extremely limited. This is especially disturbing since the irrevocable decision to abort is very complex one, often made in highly emotional situations with great ambivalence, and includes many risks. Furthermore, in many cases, this very limited screening and counseling that is provided is undertaken by employees who lack any professional accreditation as medical or psychological counselors.

The cost-cutting measures employed by “assembly line” abortion clinics have reduced costs to a point that it is difficult for other physicians who would employ a higher standard of care to provide abortions at a comparable cost. Many physicians who would otherwise be willing to perform abortions simply cannot afford to provide abortion services at a competitive rate without making similar sacrifices in the standard of care they believe would be most appropriate.<blockquote>“Dr. Hern used to have plenty of patients for first-trimester abortions at his clinic in Boulder, where he was charging $375. Then, a Planned Parenthood clinic opened in nearby Fort Collins, charging less than $300. Subsidized by the nonprofit Planned Parenthood Foundation, the clinic was able to keep its fees lower than Dr. Hern could even contemplate.

”Within a month after that clinic opened, my patient numbers dropped by 25 percent,” Dr. Hern said.

Independent abortion providers say Planned Parenthood clinics can easily undercut them. ”I would sort of compare them to Wal-Mart coming in and taking over from all the mom and pops’,” said Dr. William West, who works at an abortion clinic in Dallas.”</blockquote>

=== Calculating how much abortions should cost today ===

[https://www.officialdata.org/Medical-care/price-inflation/1972-to-2026?amount=300 OfficialData.org (Medical Care Price Inflation]): Based on Bureau of Labor Statistics data, this calculator shows that first-trimester abortions priced at $300 in 1972 should be priced at $4,744.55 in 2026. But according to [https://www.plannedparenthood.org/blog/how-much-does-an-abortion-cost#:~:text=Abortion%20pills%20(AKA%20medication%20abortion,can%20be%20between%20$1%2C500%2D2%2C000. Planned Parenthood] today:<blockquote>Abortion pills (AKA medication abortion) can cost up to around $800, but it’s often less. The average cost at Planned Parenthood is around $580.

An in-clinic abortion in the first trimester can cost up to around $800, but it’s often less. The average cost of a first trimester in-clinic abortion at Planned Parenthood is about $600. The cost of a second trimester abortion at Planned Parenthood varies depending on how many weeks pregnant you are. If early in the second trimester, the average cost is $715. If later in the second trimester, it can be between $1,500-2,000. </blockquote>The cost of abortion, in my view, is kept low and subsidized by population control advocates targeting low income women through "abortion grants" and fundraising intended to eliminate any financial obstacles in the way of aborting a "useless eater" (to use the term of the early population controllers who were most blunt about their intentions).

Validity of Studies

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Barb: /* Research Validating Abortion Associated PTSD */

{{DEA}}
{{PsychIndex}}

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==Validity of Studies==

''Women’s Health after Abortion.The Medical and Psychological Evidence, E Ring-Cassidy, I Gentiles (Toronto: The deVeber Institute for Bioethics and Social Research, 2002) 255.''

:Research on the effects of abortion on women’s health, especially in North America, is highly prone to the problem of selective citation. Some researchers refer only to previous studies with which they agree and do not consult, or mention those studies whose conclusions differ from their own.

''"The Psychological Complications of Therapeutic Abortion," G Zolese and CVR Blacker, Br J Psychiatry 160: 724, 1992 ''
:Women who choose abortion are not amenable to endless questions on how they feel, are less likely to return for follow-up, and baseline assessments before they become pregnant are impossible. Most psychological studies were conducted when standardized psychiatric instruments were not available or used self-devised questionnaires without proven reliability.

''From the Patient’s Perspective - Quality of Abortion Care, Picker Institute.'' (1999). Boston, MA.
:A survey of 2,215 abortion patients in 12 abortion clinics in the US found that two out of three women do not return for follow-up appointments at the abortion clinic. (comment: Poor followup may result in underestimation of the problem of significant adjustment problems post-abortion.)

''"Emotional Sequelae of Elective Abortion," I Kent et al, British Columbia Medical Journal 20:118, 1978''
:Sharp discrepancies were noted between data derived from a questionnaire survey administered through a general practice with the responses of women in a therapy group with deep and painful feelings not emerging in a questionnaire survey.

''Aborted Women: Silent No More, David C Reardon, (Chicago: Loyola University Press, 1987 ''
:In a survey of long-term effects of abortion on women, over 70% reported there was a time when they would have denied the existence of any reactions from their abortion. For some, denial lasted only a few months; for others it lasted over 10-15 years. Subsequently, they were able to share the severe adverse effects of abortion on their lives.

''"Underreporting Sensitive Behaviors: The Case of Young Women's Willingness to Report Abortion," LB Smith et al, Health Psychology 18(1): 37, 1999''
:U.S. young women were likely not to disclose prior induced abortion when interviewed. They were more likely to disclose smoking habits than abortion history.

''"Some Problems Caused by Not Having a Conceptual Foundation for Health Research: An Illustration From Studies of the Psychological Effects of Abortion," EJ Posavac and TQ Miller, Psychology and Health 5:13, 1990''
:The authors reviewed 24 empirical studies and concluded that psychological research was of poor quality, failed to state the basis of the theory to be tested, failed to track women over time, and made superficial assessments.

''"Psychological Impact of Abortion: Methodological and Outcomes Summary of Emperical Research Between 1966 and 1988," JL Rogers et al, Health Care for Women Int'l10:347,1989. ''
:Concludes that the literature on the psychological sequelae is seriously flawed and makes suggestions for critique of the literature. The authors conclude that both advocates and opponents of abortion can prove their points by judiciously referring only to articles supporting their political agenda.

''"Mental Health and Abortions: Review and Analysis," Philip G. Ney and A. Wickett, Psychiatric Univ. Ottawa 14(4): 506-516, (1989) ''
:A review of the literature shows a need for more long-term, in-depth studies; there's no satisfactory evidence that abortion improves the psychological state of those not mentally ill; mental ill-health is worsened by abortion; there is an alarming rate of post-abortion complications such as pelvic inflammatory disease and subsequent infertility.

''"Psychiatric Aspects of Therapeutic Abortion," B. Doane and B. Quigley, CMA Journal 125:427-432, September 1, 1981 ''
:Concludes that a search of the literature on the psychiatric aspects of abortion reveal poor study design, lack of clear criteria for decisions for or against abortion, poor definition of psychologic symptoms experienced by patients, absence of control groups in clinical studies, indecisiveness and uncritical attitudes in writers from various disciplines. The study also concludes that "there is little evidence that differences in abortion legislation account for significant differences in the psychologic reactions of patients to abortion."

''"Psychological and Social Aspects of Induced Abortion," J.A. Handy, British Journal of Clinical Psychology, February 21, 1982, Part I, pp. 29-41 ''
:A good summary of prior studies on the effects of abortion; states that a variety of methodological faults makes the results of many studies difficult to interpret.

''"Interpreting Literature on Abortion," (letter), WL Larimore, DB Larson, KA Sherrill, American Family Physician 46(3):665-666, Sept 1992''
:Various review articles on abortion share few of the same references, interpretation of the same article differs between reviewers.

''"Abortion: A Social-Psychological Perspective," Nancy Adler, Journal of Social Issues 35(l): 100-119 (1979) ''
:Concludes there is a need for continuing research on the negative effects of abortion and for intervention designed to diminish those negative effects for all concerned.

''"Psychiatric Sequelae of Induced Abortion," Mary Gibbons, Journal of the Royal College of General Practitioners 34:146-150(1984) ''
:Observes that many studies concluding that few psychiatric problems follow induced abortion were deficient in methodology, material or length of follow-up. It concludes that a large amount of the previously reported research on the psychiatric indications of abortion may be unreliable.

== Qualitative Studies==
''[http://onlinelibrary.wiley.com/doi/10.1363/4310311/abstract Social Sources of Women's Emotional Difficulty After Abortion: Lessons from Women's Abortion Narratives.] Kimport, K., Foster, K. and Weitz, T. A. (2011), Perspectives on Sexual and Reproductive Health, 43: 103–109.''
:CONTEXT: The experiences of women who have negative emotional outcomes, including regret, following an abortion have received little research attention. Qualitative research can elucidate these women’s experiences and ways their needs can be met and emotional distress reduced.

:METHODS: Twenty-one women who had emotional difficulties related to an abortion participated in semi-structured, in-depth telephone interviews in 2009. Of these, 14 women were recruited from abortion support talklines; seven were recruited from a separate research project on women’s experience of abortion. Transcripts were analyzed using the principles of grounded theory to identify key themes.

:RESULTS: Two social aspects of the abortion experience produced, exacerbated or mitigated respondents’ negative emotional experience. Negative outcomes were experienced when the woman did not feel that the abortion was primarily her decision (e.g., because her partner abdicated responsibility for the pregnancy, leaving her feeling as though she had no other choice) or did not feel that she had clear emotional support after the abortion. Evidence also points to a division of labor between women and men regarding pregnancy prevention, abortion and childrearing; as a result, the majority of abortion-related emotional burdens fall on women. Experiencing decisional autonomy or social support reduced respondents’ emotional distress.

:CONCLUSIONS: Supporting a woman’s abortion decision-making process, addressing the division of labor between women and men regarding pregnancy prevention, abortion and childrearing, and offering nonjudgmental support may guide interventions designed to reduce emotional distress after abortion.

Editor comments: This may be the first study ever published by the Guttmacher Institute on emotional problems post-abortion. While it is a very limited study that is qualitative in nature with a very small sample size, what is useful are the admissions that:
# post-abortion psychological problems are not religiously based;
# a woman seeking an abortion needs nonjudgmental support in the decision making process;
# secret abortions are likely to cause emotional difficulties;
# relationship counseling services are needed echoing our previous research; and
# disengaging partner, family and friends during the abortion decision making stage is ill-advised.

==Risk Factors for Adverse Emotional Consequences of Abortion==

''[http://www.afterabortion.info/news/Duty2Screen.pdf Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment.]'' Reardon DC. The Journal of Contemporary Health Law & Policy J Contemp Health Law Policy. 2003 Winter;20(1):33-114

:A comprehensive review of the literature on risk factors associated with abortion. Includes tables with over 40 statistically validated risk factors and citations to the studies identifying and validating these risk factors. The complete text of [http://www.afterabortion.info/news/Duty2Screen.pdf Abortion Decisions and the Duty to Screen] is available through this link.

:See also [[Risk_factors]]

''"Complicated Mourning: Dynamics of Impacted Pre and Post-Abortion Grief," Anne Speckland, Vincent Rue, Pre and Perinatal Psychology Journal 8(81 ):5, Fall, 1993. ''
:Emotional harm from abortion is more likely when one or more of the following risk factors are present: prior history of mental illness; immature interpersonal relationships; unstable, conflicted relationship with one's partner; history of negative relationship with one's mother; ambivalence regarding abortion; religious and cultural background hostile to abortion; single status especially if no born children; adolescent; second-trimester abortion; abortion for genetic reason; pressure and coercion to abort; prior abortion; prior children; maternal orientation.

''"Adolescent Abortion Option," G. Zakus, S. Wilday, Social Work in Health Care, 12(4):77, Summer, 1987. ''
:Certain categories of women are much more likely to have post-abortion problems sometimes many months or years later. These include: being forced or coerced into abortion; women who place great emphasis on future fertility plans; women with pre- existing psychiatric problems; women suffering from unresolved grief reactions or women with a history of sexual abuse, including incest, molestation or rape.

''"Outcome Following Therapeutic Abortion," R.C. Payne, A.R. Kravitz, M.T. Notman, J.V. Anderson, Arch. Gen. Psychiatry 33:725, June, 1976. ''
:This study measured short- term outcomes of anxiety, depression, anger, guilt and shame following abortion. The authors concluded that women who are most vulnerable to difficulty are those who are single and nulliparous, those with previous history of serious emotional problems, conflicted relationships to lovers, past negative relationships to mother, ambivalence toward abortion or negative religious or cultural attitudes about abortion.

''"The Decision-Making Process and the Outcome of Therapeutic Abortion, C," Friedman, R. Greenspan and F. Mittleman, American Journal of Psychiatry 131(12): 1332-1337, December 1974. ''
:There is high risk for post-abortion psychiatric illness when there is (1) Strong ambivalence; (2) Coercion; (3) Medical indication; (4) Concomitant psychiatric illness and (5) A woman feeling the decision was not her own.

''"Women's Emotions One Week After Receiving or Being Denied an Abortion in the United States." Rocca CH, Kimport H, Gould H, Foster DG. Perspectives on Sexual and Reproductive Health, 45(3)(2013).''

:Methods: Baseline data from a longitudinal study of women seeking abortion at 30 U.S. facilities between 2008 and 2010 were used to examine emotions among 843 women who received an abortion just prior to the facility's gestational age limit, were denied an abortion because they presented just beyond the gestational limit or obtained a first-trimester abortion. Multivariable analyses were used to compare women's emotions about their pregnancy and about their receipt or denial of abortion after one week, and to identify variables associated with experiencing primarily negative emotions postabortion.

:Results: Compared with women who obtained a near-limit abortion, those denied the abortion felt more regret and anger (scoring, on average, 0.4–0.5 points higher on a 0–4 scale), and less relief and happiness (scoring 1.4 and 0.3 points lower, respectively). Among women who had obtained the abortion, the greater the extent to which they had planned the pregnancy or had difficulty deciding to seek abortion, the more likely they were to feel primarily negative emotions (odds ratios, 1.2 and 2.5, respectively). Most (95%) women who had obtained the abortion felt it was the right decision, as did 89% of those who expressed regret.

:Conclusions: Difficulty with the abortion decision and the degree to which the pregnancy had been planned were most important for women's postabortion emotional state. Experiencing negative emotions postabortion is different from believing that abortion was not the right decision.

:'''Editor comments:''' Despite a low participation rate (38%), this study reported: 53% of women who aborted felt guilt, 41% regret, 64% sadness and 31% anger. And this was only one week post-abortion! Interestingly, only one out of four pregnancy partners wanted the abortion. As to decision difficulty for the women, more than one out of two (56%) indicated the abortion decision was “somewhat or very difficult.”

===Prior History of Psychiatric Illness===

[https://www.ncbi.nlm.nih.gov/pubmed/27760409 Incidence and recurrence of common mental disorders after abortion: Results from a prospective cohort study.] van Ditzhuijzen J, Ten Have M, de Graaf R, Lugtig P, van Nijnatten CH, Vollebergh WA. J Psychiatr Res. 2017 Jan;84:200-206. doi: 10.1016/j.jpsychires.2016.10.006. Epub 2016 Oct 11.

:Abstract: Research in the field of mental health consequences of abortion is characterized by methodological limitations. We used exact matching on carefully selected confounders in a prospective cohort study of 325 women who had an abortion of an unwanted pregnancy and compared them 1-to-1 to controls who did not have this experience. Outcome measures were incidence and recurrence of common DSM-IV mental disorders (mood, anxiety, substance use disorders, and the aggregate measure 'any mental disorder') as measured with the Composite International Diagnostic Interview (CIDI) version 3.0, in the 2.5-3 years after the abortion. Although non-matched data suggested otherwise, women in the abortion group did not show significantly higher odds for incidence of 'any mental disorder', or mood, anxiety and substance use disorders, compared to matched controls who were similar in background variables but did not have an this experience. Having an abortion did not increase the odds for recurrence of the three disorder categories, but for any mental disorder the higher odds in the abortion group remained significant after matching. It is unlikely that termination of an unwanted pregnancy increases the risk on incidence of common mental disorders in women without a psychiatric history. However, it might increase the risk of recurrence among women with a history of mental disorders.

:'''NOTES:''' Main problems: This study used a very small number of women and therefore had very low statstical power, resulting in very wide confidence intervals which could clearly include much higher rates of psychological illness.

:Second, the control group doubtlessly includes women concealing abortion history.

:Third, the abortion group has highly self-censured indicating that women at greatest risk of negative reactions excluded themselves from the study sample or dropped out. 56% of the 2443 initially asked to participate refused outright. By the time the first interview (20-40 days after the abortion) was scheduled, 22% of those previously agreeing refused and another 42% could not be contacted (perhaps gave false contact info or otherwise avoided the interview. As a result, only 35.8% of those who initially they were willing to participate, and 13% of those eligible to participate, actually did participate at the T0 interview. '''The T1 interview, three years post-abortion, saw a drop out rate of 19%, from 325 to 264 participants. Thus, the T1 data represented just 29% of those who agreed to be studied and just 11% of the eligible sample.''' (See [http://www.journalofpsychiatricresearch.com/article/S0022-3956(13)00236-7/pdf van Ditzhuijzen 2013] for a complete flow chart of participation and drop outs from invite through T0.)

:It is also notable that recurrent 20.7% of women having abortions reported recurrent substance use disorders at three years post-abortion compared to 0% for their matched control group. This was not discussed by the study's authors. Notably, substance use is one of the most frequent problems.

[http://www.sciencedirect.com/science/article/pii/S0022395613002367 Psychiatric history of women who have had an abortion.] van Ditzhuijzen J, ten Have M, de Graaf R, van Nijnatten CH, Vollebergh WA.
J Psychiatr Res. 2013 Nov;47(11):1737-43. doi: 10.1016/j.jpsychires.2013.07.024.

:Abstract. Prior research has focused primarily on the mental health consequences of abortion; little is known about mental health before abortion. In this study, the psychiatric history of women who have had an abortion is investigated. 325 Women who recently had an abortion were compared with 1902 women from the population-based Netherlands Mental Health Survey and Incidence Study (NEMESIS-2). Lifetime prevalence estimates of various mental disorders were measured using the Composite International Diagnostic Interview 3.0. Compared to the reference sample, women in the abortion sample were three times more likely to report a history of any mental disorder (OR = 3.06, 95% CI = 2.36–3.98). The highest odds were found for conduct disorder (OR = 6.97, 95% CI = 4.41–11.01) and drug dependence (OR = 4.96, 95% CI = 2.55–9.66). Similar results were found for lifetime-minus-last-year prevalence estimates and for women who had first-time abortions only. The results support the notion that psychiatric history may explain associations that have been found between abortion and mental health. Psychiatric history should therefore be taken into account when investigating the mental health consequences of abortion.

[https://www.ncbi.nlm.nih.gov/pubmed/26002806 The impact of psychiatric history on women's pre- and postabortion experiences.] van Ditzhuijzen J, Ten Have M, de Graaf R, van Nijnatten CH, Vollebergh WA. Contraception. 2015 Sep;92(3):246-53. doi: 10.1016/j.contraception.2015.05.003.
:OBJECTIVE: The objective of this study is to investigate to what extent psychiatric history affects preabortion decision difficulty, experienced burden, and postabortion emotions and coping. Women with and without a history of mental disorders might respond differently to unwanted pregnancy and subsequent abortion.
:STUDY DESIGN: Women who had an abortion (n=325) were classified as either with or without a history of mental disorders, using the Composite International Diagnostic Interview version 3.0. The two groups were compared on preabortion doubt, postabortion decision uncertainty, experienced pressure, experienced burden of unwanted pregnancy and abortion, and postabortion emotions, self-efficacy and coping. The study was conducted in the Netherlands. Data were collected using structured face-to-face interviews and analyzed with regression analyses.
:RESULTS: Compared to women without prior mental disorders, women with a psychiatric history were more likely to report higher levels of doubt [odds ratio (OR)=2.30; confidence interval (CI)=1.29-4.09], more burden of the pregnancy (OR=2.23; CI=1.34-3.70) and the abortion (OR=1.93; CI=1.12-3.34) and more negative postabortion emotions (β=.16; CI=.05-.28). They also scored lower on abortion-specific self-efficacy (β=-.11; CI=-.22 to .00) and higher on emotion-oriented (β=.22; .11-.33) and avoidance-oriented coping (β=.12; CI=.01-.24). The two groups did not differ significantly in terms of experienced pressure, decision uncertainty and positive postabortion emotions.
:CONCLUSIONS: Psychiatric history strongly affects women's pre- and postabortion experiences. Women with a history of mental disorders experience a more stressful pre- and postabortion period in terms of preabortion doubt, burden of pregnancy and abortion, and postabortion emotions, self-efficacy and coping.
:IMPLICATIONS: Negative abortion experiences may, at least partially, stem from prior or underlying mental health problems.

[Is underage abortion associated with adverse outcomes in early adulthood? A longitudinal birth cohort study up to 25 years of age.]
Leppälahti S, Heikinheimo O, Kalliala I, Santalahti P, Gissler M. Hum Reprod. 2016 Sep;31(9):2142-9. doi: 10.1093/humrep/dew178.

:STUDY QUESTION: Is underage abortion associated with adverse socioeconomic and health outcomes in early adulthood when compared with underage delivery?
:SUMMARY ANSWER: Underage abortion was not found to be associated with mental health problems in early adulthood, and socioeconomic outcomes were better among those who experienced abortion compared with those who gave birth.
:WHAT IS KNOWN ALREADY: Teenage motherhood has been linked with numerous adverse outcomes in later life, including low educational levels and poor physical and mental health. Whether abortion at a young age predisposes to similar consequences is not clear.
:STUDY DESIGN, SIZE, DURATION: This nationwide, retrospective cohort study from Finland, included all women born in 1987 (n = 29 041) and followed until 2012.
:PARTICIPANTS/MATERIALS, SETTING, METHODS: We analysed socioeconomic, psychiatric and risk-taking-related health outcomes up to 25 years of age after underage (<18 years) abortion (n = 1041, 3.6%) and after childbirth (n = 394, 1.4%). Before and after conception analyses within the study groups were performed to further examine the association between abortion and adverse health outcomes. A group with no pregnancies up to 20 years of age (n = 25 312, 88.0%) served as an external reference group.
:MAIN RESULTS AND THE ROLE OF CHANCE: We found no significant differences between the underage abortion and the childbirth group regarding risks of psychiatric disorders (adjusted odds ratio 0.96 [0.67-1.40]) or suffering from intentional or unintentional poisoning by medications or drugs (1.06 [0.57-1.98]). Compared with those who gave birth, girls who underwent abortion were less likely to achieve only a low educational level (0.41 [95% confidence interval 0.31-0.54]) or to be welfare-dependent (0.31 [0.22-0.45]), but more likely to suffer from injuries (1.51 [1.09-2.10]). Compared with the external control group, both pregnancy groups were disadvantaged already prior to the pregnancy. Psychiatric disorders and risk-taking-related health outcomes, including injury, were increased in the abortion group and in the childbirth group similarly on both sides of the pregnancy.
:LIMITATIONS, REASONS FOR CAUTION: The retrospective nature of the study remains a limitation. The identification of study subjects in order to collect additional data was not allowed for ethical reasons. Therefore further confounding factors, such as the intentionality of the pregnancy, could not be checked.
:WIDER IMPLICATIONS OF THE FINDINGS: Previous studies have found that abortion is not harmful to mental health in the majority of adult women. Our study adds to the current understanding in suggesting that this is also the case concerning underage girls. Furthermore, women with a history of underage abortion had better socioeconomic outcomes compared with those who gave birth. These findings can be generalized to settings of high-quality social and health-care services, where abortion is accessible and affordable to all citizens. Social and health-care professionals who care for and counsel underage girls facing unplanned pregnancy should acknowledge this information.
:STUDY FUNDING/COMPETING INTERESTS: This study was financially supported by the Finnish Cultural Foundation and the Päivikki and Sakari Sohlberg Foundation. The researchers are independent of funders and the funders had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report or in the decision to submit the article for publication. The authors have no competing interests.

[https://www.ncbi.nlm.nih.gov/pubmed/26117381 Induced abortions and birth outcomes of women with a history of severe psychosocial problems in adolescence.] Lehti V, Gissler M, Suvisaari J, Manninen M. Eur Psychiatry. 2015 Sep;30(6):750-5. doi: 10.1016/j.eurpsy.2015.05.005

:OBJECTIVE: To increase knowledge on the reproductive health of women who have been placed in a residential school, a child welfare facility for adolescents with severe psychosocial problems.
:METHODS: All women (n=291) who lived in the Finnish residential schools on the last day of the years 1991, 1996, 2001 and 2006 were included in this study and compared with matched general population controls. Register-based information on induced abortions and births was collected until the end of the year 2011.
:RESULTS: Compared to controls, women with a residential school history had more induced abortions. A higher proportion of their births took place when they were teenagers or even minors. They were more often single, smoked significantly more during pregnancy and had a higher risk of having a preterm birth or a baby with a low birth weight.
:CONCLUSIONS: The findings have implications for the planning of preventive and supportive interventions that aim to increase the well-being of women with a residential school history and their offspring.

===Prior History of Abortion===
[https://www.ncbi.nlm.nih.gov/pubmed/22981048 A study of psychiatric morbidity during second trimester of pregnancy subsequent to abortion in the previous pregnancy.] Chalana H, Sachdeva JK. Asian J Psychiatr. 2012 Sep;5(3):215-9. doi: 10.1016/j.ajp.2011.11.006.

:INTRODUCTION: Pregnancy plays a unique role in the transformation of women towards completeness. For those women who have had a previous unsuccessful outcome, pregnancy may bring a lot of inevitable negative emotions. We studied psychiatric morbidity during second trimester of pregnancy subsequent to abortion in the previous pregnancy.
:METHODS: The study was carried out in Dayanand Medical College and Hospital, Ludhiana, India. A total of 120 patients were divided into 4 groups depending on their pregnancy status. All the groups were compared with each other regarding their psychiatric morbidities, which were measured using various rating scales such as Hamilton Depression rating scale, Hamilton Anxiety Rating Scale, State Trait Anxiety Inventory, Presumptive Stressful Life events Scale, and Brief Psychotic Rating Scale.
:RESULTS: We found that subjects with history of previous abortion, whether single or more had significantly higher mean depression and anxiety score than primigravida or subjects with history of previous successful pregnancy; depression and anxiety scores decreased with increase in time gap between abortion and current pregnancy. High anxiety was found in 36.67%(11) of females with history of previous abortion. We also found that 36.67%(11) of subjects with previous single abortion and 30%(9) of subjects with previous 2 or more abortions were suffering from depressive episode. None of the female suffered from psychotic disorder.
:CONCLUSIONS: The incidence of depression and anxiety is high in pregnancy after previous abortion and more in subjects who conceive earlier after previous abortion. These results warrant the need for screening all pregnancies for psychiatric morbidity after a previous abortion.
:

==Postpartum Disorder Following Pregnancy Loss==

[http://www.ncbi.nlm.nih.gov/pubmed/24007380 Increased risk for postpartum psychiatric disorders among women with past pregnancy loss.] Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

:Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.
:Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

:Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

:Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

'''[http://www.ncbi.nlm.nih.gov/pubmed/22622194 "Predictors of postpartum post-traumatic stress disorder in primiparous mothers.][Article in French]'''
Montmasson H1, Bertrand P, Perrotin F, El-Hage W. J Gynecol Obstet Biol Reprod (Paris). 2012 Oct;41(6):553-60. doi: 10.1016/j.jgyn.2012.04.010. Epub 2012 May 21.

:A history of abortion was associated with a six fold increased risk of subsequent postpartum PTSD.

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084335/ Previous prenatal loss as a predictor of perinatal depression and anxiety.] Blackmore ER, Côté-Arsenault D, Tang W, Glover V, Evans J, Golding J, O'Connor TG. Br J Psychiatry. 2011 May;198(5):373-8. doi: 10.1192/bjp.bp.110.083105. Epub 2011 Mar 3.

:Results: Generalised estimating equations indicated that the number of previous miscarriages/stillbirths significantly predicted symptoms of depression (β = 0.18, s.e. = 0.07, P<0.01) and anxiety (β = 0.14, s.e. = 0.05, P<0.01) in a subsequent pregnancy, independent of key psychosocial and obstetric factors. This association remained constant across the pre- and postnatal period, indicating that the impact of a previous prenatal loss did not diminish significantly following the birth of a healthy child.

:Conclusions: Depression and anxiety associated with a previous prenatal loss shows a persisting pattern that continues after the birth of a subsequent (healthy) child. Interventions targeting women with previous prenatal loss may improve the health outcomes of women and their children.

===Other Studies Suggestive of Psychiatric Stress During Subsequent Pregnancies===

[http://www.ncbi.nlm.nih.gov/pubmed/12501082 A history of induced abortion in relation to substance use during subsequent pregnancies carried to term.] Coleman PK, Reardon DC, Rue VM, Cougle J. Am J Obstet Gynecol. 2002 Dec;187(6):1673-8.

[http://www.ncbi.nlm.nih.gov/pubmed/15788495 Hospitalization for mental illness among parents after the death of a child.] Li J, Laursen TM, Precht DH, Olsen J, Mortensen PB. N Engl J Med. 2005;352(12):1190-1196. doi:10.1056/NEJMoa033160.

==Abortion Compared to Birth or Miscarriage==
[http://www.ncbi.nlm.nih.gov/pubmed/15039513?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Psychological Impact on Women of Miscarriage Versus Induced Abortion: A 2-Year follow-up study.] [[Broen]] AN, Moum T, Bödtker AS, Ekeberg O. Psychosomatic Medicine, 2004, 66:265-271.

:"The feeling relief (at T1) had no significant influence on the IES scores at T3, unadjusted or adjusted." (p 268) This supports an argument that researchers who place too much emphasis on measure of relief may be missing the full picture.

p270, "mental health before the event suprisingly had no significant independent influence on IES scores."

 [http://www.ncbi.nlm.nih.gov/pubmed/15694217?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Reasons for induced abortion and their relation to women's emotional distress: a prospective, two-year follow-up study.] [[Broen]] AN, Moum T, Bodtker AS, Ekeberg O. Gen Hosp Psychiatry 2005, 27:36-43.

:OBJECTIVE: The present study aimed to identify the most important reasons for induced abortion and to examine their relationship to emotional distress at follow-up. METHODS: Eighty women were included in the study. The women were interviewed 10 days, 6 months (T2) and 2 years (T3) after they underwent an abortion. At all time points, the participants completed the Impact of Event Scale and a questionnaire about feelings connected to the abortion. RESULTS: Reasons related to education, job and finances were highly rated. Also, "a child should be wished for," "male partner does not favour having a child at the moment," "tired, worn out" and "have enough children" were important reasons. "Pressure from male partner" was listed as the 11th most important reason. When the reasons for abortion and background variables were included in multiple regression analyses, the strongest predictor of emotional distress at T2 and T3 was "pressure from male partner." CONCLUSION: Male pressure on women to have an induced abortion has a significant, negative influence on women's psychological responses in the 2 years following the event. Women who gave the reason "have enough children" for choosing abortion reported slightly better psychological outcomes at T3.

 [http://www.ncbi.nlm.nih.gov/pubmed/16343341?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum The course of mental health after miscarriage and induced abortion: a five-year follow-up study.] [[Broen]] AN, Moum T, Bødtker AS, Ekeberg O. BMC Medicine 2005, 3:18 (12 December 2005)

:Broen et al.'s results show that women who had a miscarriage suffer more mental distress up until six months after the event than women who had an abortion. Women who had an abortion, however, experienced more mental distress long after the event - two and five years afterwards - than women who had a miscarriage. Women who experienced induced abortion had significantly greater IES scores for avoidance and for the feelings of guilt, shame and relief than the miscarriage group at two and five years after the pregnancy termination (IES avoidance means: 3.2 vs 9.3 at T3, respectively, p < 0.001; 1.5 vs 8.3 at T4, respectively, p < 0.001). Compared with the general population, women who had undergone induced abortion had significantly higher HADS anxiety scores at all four interviews (p < 0.01 to p < 0.001), while women who had had a miscarriage had significantly higher anxiety scores only at T1 (p < 0.01).

 [http://www.ncbi.nlm.nih.gov/pubmed/16553180?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Predictors of anxiety and depression following pregnancy termination: a longitudinal five-year follow-up study.] [[Broen]] AN, Moum T, Bödtker AS, Ekeberg O. Acta Obstet Gynecol Scand. 2006;85(3):317-23.

:BACKGROUND: The aims of the study were to assess anxiety and depression in women who had experienced either a miscarriage or an induced abortion, to compare the women's level of distress with that of a general population sample, and to find predictors of anxiety and depression six months and five years after the event.

:METHODS: A prospective, longitudinal follow-up study. Women who experienced miscarriage (n = 40) and induced abortion (n = 80) were interviewed ten days (T1), six months (T2), two years (T3), and five years (T4) after the event. On each occasion, they completed the Hospital Anxiety and Depression Scale and the Life Events Scale. Paired-sample t-test, logistic regression, and multiple linear regression statistical tests were used.

:RESULTS: Women with miscarriage had significantly more anxiety and depression at T1 than the general population, while women with induced abortion had significantly more anxiety at all time points and more depression at T1 and T2. In both groups, important predictors of anxiety and depression at T2 and T4 were recent life events and poor former psychiatric health. Childbirth events between T1 and T4 had no significant influence on the scores. For women with induced abortion, doubt about the decision to abort was related to depression at T2 (p <0.05), while a negative attitude towards induced abortion was associated with anxiety at T2 (p <0.05) and T4 (p <0.05).

:CONCLUSION: Correlates of anxiety and depression may be used to better identify women who are at risk of negative psychological responses following pregnancy termination.

''"[http://www.springerlink.com/content/w773590gq50677jv/ Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth—a 14-month follow up study]" Kersting A, et al. Arch Womens Ment Health. 2009 Aug;12(4):193-201. Epub 2009 Mar 6.''
:(ABSTRACT) The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting
psychological impact.

''Trauma and grief 2-7 years after termination of pregnancy because of fetal anomalies-a pilot study. Kersting A, et al. J of Psychosomatic Obstetrics & Gynecology 2005; 26(1): 9-14.''
:The aim of the study was to obtain information on the long-term posttraumatic stress response and grief several years after termination of pregnancy due to fetal malformation. We investigated 83 women who had undergone termination of pregnancy between 1995 and 1999 and compared them with 60 women 14 days after termination of pregnancy and 65 women after the spontaneous delivery of a full-term healthy child. Women 2-7 years after termination of pregnancy were expected to show a significantly lower degree of traumatic experience and grief than women 14 days after termination of pregnancy. Contrary to the hypothesis, however, the results showed no significant intergroup differences with respect to the degree of traumatic experience. With the exception of one subscale (fear of loss), this also applied to the grief reported by the women. However, both groups differed significantly in their posttraumatic stress response from women who had given spontaneous birth to a full-term healthy child. The results indicate that termination of pregnancy is to be seen as an emotionally traumatic major life event which leads to severe posttraumatic stress response and intense grief reactions that are still detectable some years later.

[http://www.ncbi.nlm.nih.gov/pubmed/24007380 Increased risk for postpartum psychiatric disorders among women with past pregnancy loss.] Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

:Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.
:Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

:Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

:Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

''Abortion in young women and subsequent mental health.'' Fergusson DM, John Horwood L, Ridder EM. J Child Psychol Psychiatry. 2006 Jan;47(1):16-24.

:Background: The extent to which abortion has harmful consequences for mental health remains controversial. We aimed to examine the linkages between having an abortion and mental health outcomes over the interval from age 15-25 years. Methods: Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors. Results: Forty-one percent of women had become pregnant on at least one occasion prior to age 25, with 14.6% having an abortion. Those having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors. Conclusions: The findings suggest that abortion in young women may be associated with increased risks of mental health problems.

[http://www.ncbi.nlm.nih.gov/pubmed/24154514 Women's experiences in relation to stillbirth and risk factors for long-term post-traumatic stress symptoms: a retrospective study.] Gravensteen IK, Helgadóttir LB, Jacobsen EM, Rådestad I, Sandset PM, Ekeberg O. BMJ Open. 2013 Oct 22;3(10):e003323. doi: 10.1136/bmjopen-2013-003323.

:OBJECTIVES: (1) To investigate the experiences of women with a previous stillbirth and their appraisal of the care they received at the hospital. (2) To assess the long-term level of post-traumatic stress symptoms (PTSS) in this group and identify risk factors for this outcome.
:DESIGN: A retrospective study.
:SETTING:Two university hospitals.
:PARTICIPANTS: The study population comprised 379 women with a verified diagnosis of stillbirth (≥23 gestational weeks or birth weight ≥500 g) in a singleton or twin pregnancy 5-18 years previously. 101 women completed a comprehensive questionnaire in two parts.
:PRIMARY AND SECONDARY OUTCOME MEASURES: The women's experiences and appraisal of the care provided by healthcare professionals before, during and after stillbirth. PTSS at follow-up was assessed using the Impact of Event Scale (IES).
:RESULTS: The great majority saw (98%) and held (82%) their baby. Most women felt that healthcare professionals were supportive during the delivery (85.6%) and showed respect towards their baby (94.9%). The majority (91.1%) had received some form of short-term follow-up. One-third showed clinically significant long-term PTSS (IES ≥ 20). Independent risk factors were younger age (OR 6.60, 95% CI 1.99 to 21.83), induced abortion prior to stillbirth (OR 5.78, 95% CI 1.56 to 21.38) and higher parity (OR 3.46, 95% CI 1.19 to 10.07) at the time of stillbirth. Having held the baby (OR 0.17, 95% CI 0.05 to 0.56) was associated with less PTSS.
:CONCLUSIONS: The great majority saw and held their baby and were satisfied with the support from healthcare professionals. One in three women presented with a clinically significant level of PTSS 5-18 years after stillbirth. Having held the baby was protective, whereas '''prior induced abortion was a risk factor for a high level of PTSS'''.

'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334933/ Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review.]''' Daugirdaitė V, van den Akker O, Purewal S. J Pregnancy. 2015;2015:646345. doi: 10.1155/2015/646345. Epub 2015 Feb 5.

:OBJECTIVE: The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF).

:METHODS:Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines.

:RESULTS: Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss.

:CONCLUSIONS: This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

''[http://www.cmaj.ca/cgi/content/full/168/10/1253 Psychiatric admissions of low income women following abortion and childbirth.] Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Can Med Assoc J. 2003; 168(10):1253-7''
: Background: Controversy exists about whether abortion or childbirth is associated with greater psychological risks. We compared psychiatric admission rates of women in time periods from 90 days to 4 years after either abortion or childbirth.

:Methods: We used California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth during 1989. Only women who had no psychiatric admissions or pregnancy events during the year before the target pregnancy event were included (n = 56 741). Psychiatric admissions were examined using logistic regression analyses, controlling for age and months of eligibility for Medi-Cal services.

:Results: Overall, women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age.

:Interpretation: Subsequent psychiatric admissions are more common among low-income women who have an induced abortion than among those who carry a pregnancy to term, both in the short and longer term.

NOTES:
*Tables showing when the psychiatric hospitalization occurred illustrate a marked peak closer to the time of the pregnancy event, providing support for a causal interpretation.
*Using the same population, the authors also examined outpatient treatment for psychiatric disorders and also found higher rates of outpatient treatment following abortion. See next entry below
* The abortion group had 160% more total in-patient mental health claims than the birth group. Percentages equaled 120%, 90%, 110%, 60%, and 50% for the first 180 days, one year, two years, three years, and four years respectively.
*Across the four years, the abortion group had 70% more in-patient mental health claims than the birth group. Percentages equaled 90%, 110%, and 200% for depressive psychosis, single episode, depressive psychosis, recurrent episode, and bipolar disorder, respectfully

''[http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2002-15486-015&CFID=27122313&CFTOKEN=47942096 State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years.]'' Coleman PK, Reardon DC, Rue VM, Cougle JR. American Journal of Orthopsychiatry, 2002; 72(1):141–52. ''

:(Abstract) In this record-based study, rates of 1st-time outpatient mental health treatment for 4 years following an abortion or a birth among women (aged 13-49 yrs) 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.

''"Postabortion or Postpartum Psychotic Reactions," H David et al, Family Planning Perspectives 13(2): 892, 1981 ''
:A Danish register linkage study over a three month period found that the rate of psychiatric hospital admissions was 18.4 per 10,000 postabortion women, 12.0 pr 10,000 postpartum women, and 7.5 per 10,000 women of childbearing age generally.

==Post-Traumatic Stress Disorder / Post-Abortion Syndrome / PTSD==

The observation that abortion may cause or aggravate traumatic reactions, including [[post-traumatic stress disorder]] has been very controversial. Psychologist [[Vincent Rue]] was the first to propose this association and he was the first to use the term [[post-abortion syndrome]] to describe PTSD resulting from abortion.

See also Dr. Anne Speckhard's comments [[Women's Perspectives on Abortion Relative to PTSD]]

===Background===

''[http://www.ima.org.il/imaj/ar12jun-02.pdf Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion] Inbal Shlomi Polachek, MD, Liat Huller Harari, MD, Micha Baum, MD and Rael D. Strous, MD. IMAJ 2011: 14: June: 347-353''

''[http://www.sciencenews.org/view/generic/id/58820/title/Genetic_changes_show_up_in_people_with_PTSD Genetic changes show up in people with PTSD]" Nathan Seppa, Science News, Web edition : Monday, May 3rd, 2010''
:"The team found that the people with PTSD showed less methylation in several immune system genes and more methylation in genes linked to the growth of brain cells. 'There is evidence that PTSD is involved in immune dysfunction, and we suggest that that’s part of a larger process,' Galea says. Although previous studies have also suggested a PTSD link to immune gene activation, the connection is unclear."

''"The Conception of the Repetition-Compulsion," E. Bibring, Psychoanalytic Quarterly 12:486-519(1943). ''
:Repetition-compulsion is a regulating mechanism with the task of discharging tensions caused by traumatic experiences after they have been bound in fractional amounts.

''"Two cases of post-abortion psychosis," W. Pasini and H. Stockhammer, Annales Medico Psichologiques [Paris] 128(4): 555-564 (1973). ''
:Two cases of post-abortion psychosis are presented. One resulted in suicide while the other thought a nurse was attempting to poison her. One abortion was illegal, the other legal. A possible neurological basis for post-abortion psychological problems was presented. (French)

''Psycho-Social Stress Following Induced Abortion, Anne Speckhard, (Kansas City: Sheed and Ward, 1987). ''
:A study of 30 women who reported stress following their abortion found grief reactions, fear and anxiety, changes in sexual relationships, unresolved fertility issues, increased drug and alcohol use, changes in eating behaviors, increased isolation, lowered self-worth and suicide ideation and attempts.

''Diagnostic and Statistical Manual of Mental Disorders-Revised, DSM-III-R 309.89 (Post Traumatic Stress Disorder), (Washington, D.C.: American Psychiatric Press, 1987), pp. 20, 250.''
:Abortion is included as a possible psychosocial stressor under physical injury or illness. (Ed Note: Abortion as a possible psychosocial stressor was not included in DSM-IV manual)

''The Long-Term Psycho-social Effects of Abortion, Catherine A. Barnard (Portsmouth, N.H.: Institute For Pregnancy Loss, 1990). ''
:Some 18.8% of women who had undergone induced abortion 3-5 years previously reported all Post Traumatic Stress Syndrome criteria (DSM-III R). Some 39-45% of women still had sleep disorders, hyper-vigilance and flashbacks of the abortion experience. Some 16.9% had high intrusion scores and 23.4% had high avoidance scores on the Impact of Events Scale. Women showed elevated scores on the MCMI test in areas of histrionic, anti-social narcissism, paranoid personality disorder and elevated anxiety compared with the sample on which the test had been normed.

''The Mourning After Help for Post Abortion Syndrome, Terry L. Selby with Marc Bockman (Grand Rapids: Baker Book House, 1990). ''
:Designed for the clinical counselor. It has valuable chapters on subjects such as grief, denial the importance of faith and detailed case histories which provide valuable insights.

''Post-Abortion Trauma: 9 Steps to Recovery, Jeanette Vought, (Grand Rapids: Zondervan, 1991) ''
:Experiences of men and women in a religiously-based postabortion recovery group.

''"Post Abortion Syndrome. An Emerging Public Health Concern," Anne C. Speckhard and Vincent M. Rue, Journal of Social Issues, Vol. 48(3):95-119, 1992. ''
:Concludes that post abortion syndrome is a type of Post Traumatic Stress Disorder composed of the following basic components (a) exposure to or participation in an abortion experience, which is perceived as the traumatic and intentional destruction of one's unborn child; (b) uncontrolled negative re-experiencing of the abortion event; (c) unsuccessful attempts to avoid or deny painful abortion recollections, resulting in reduced responsiveness; and (d) experiencing associated symptoms not present before the abortion, including guilt and surviving.

''"Post-Trauma Sequelae Following Abortion and Other Traumatic Events," J.O. Brende, Association for Interdisciplinary Research in Values and Social Change 7(1): 1-8, July/August 1994 ''
:Case studies include a lonely woman with a history of multiple traumas, including sexual assault. After a divorce, she moved in with a man who promised to take care of her but eventually began to abuse her. When she became pregnant, he abandoned her, and she had an abortion. Severely depressed, she began to rely heavily on sleeping pills and alcohol to sleep because of nightmares and a repetitive dream about reaching for an infant that floated beyond her reach. One night, she overdosed on her pills but telephoned a friend who called for help. Her suicide was prevented and she was admitted to a psychiatric hospital for treatment. It was during this hospitalization that she received help, the first step toward breaking her victimization cycle.
:A second case study involved a 21- year old woman who visited an abortion facility to obtain an abortion. However, the abortion was incomplete and she had bleeding, cramping and a low grade fever. She was admitted to a hospital where an intact fetus was observed on ultrasound. An abortion was performed and fetal parts were removed. Predisposing factors for trauma included her impulsive decision to have the abortion and poor treatment by the doctor at the abortion facility. She sought counseling 3 ½ months after the abortion, after six months, and again 9 ½ months after the abortion when her depression worsened and she overdosed on medications. She then had six counseling sessions and was diagnosed with Post-Traumatic Stress Disorder. After 2 ½ years she had intrusive images, flashbacks, and reliving experiences; anger at the doctor and others; grief; distractibility; selective concentration; vivid memory of the abortion; numbing and detachment; startle reactions; fear of men and of having sex ; physical symptoms including abdominal and stomach pain.

''"Fragmentation of the Personality Associated with Post-Abortion Trauma," J.O. Brende, Association for Interdisciplinary Research in Values and Social Change 8(3): 1-8, July/August 1995 ''
:People enduring extreme stress often suffer profound rupture in the very fabric of the self. Severity of fragmentation is dependent upon several variables (1) the degree to which the trauma is experienced as a violation, (2) the presence or absence of support, (3) the presence of shame or self-blame, and (4) the loss of idealism and purpose.

''"Methodological considerations in empirical research on abortion," RL Anderson et al in Post-Abortion Syndrome: Its Wide Ramifications, Ed Peter Doherty, (Portland: Four Courts Press, 1995) 103-115 ''
:A study at an psychiatric outpatient service, compared women who presented with a history of elective abortion and sought psychiatric services in response to negative adjustment to abortion, with women with a history of elective abortion who presented seeking outpatient services for reasons that were not abortion-related. A second control group consisted of women who sought outpatient services but denied any abortion history. 73% of the abortion- distressed group met the criteria for DSM-IIIR. Abortion distressed women reported more frequently that they believed abortion to be morally wrong and had fewer recent adverse life events than abortion non-distressed women.

''"Post-Abortion Perceptions: A Comparison of Self-Identified Distressed and Non-distressed Populations," G. Kam Congleton, L.G. Calhoun. The Int'l J. Social Psychiatry 39(4): 255-265, 1993 ''
:Women reporting distress were more often currently affiliated with conservative churches and reported a lower degree of social support and confidence in the abortion decision. They were also more likely to recall experiencing feelings of loss immediately postabortion.

[http://archpsyc.jamanetwork.com/article.aspx?articleID=1904804&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMAPsychiatry%3AOnlineFirst09%2F17%2F2014 Posttraumatic Stress Disorder Symptoms and Food Addiction in Women by Timing and Type of Trauma Exposure]
Susan M. Mason, PhD, Alan J. Flint, DPH, MD, Andrea L. Roberts, PhD, et al. JAMA Psychiatry. Published online September 17, 2014. doi:10.1001/jamapsychiatry.2014.1208

:While this study did not report on abortion, it did find that "The prevalence of food addiction increased with the number of lifetime PTSD symptoms, and women with the greatest number of PTSD symptoms (6-7 symptoms) had more than twice the prevalence of food addiction as women with neither PTSD symptoms nor trauma histories (prevalence ratio, 2.68; 95% CI, 2.41-2.97). Symptoms of PTSD were more strongly related to food addiction when symptom onset occurred at an earlier age."

===Variation in Propensity to PTSD===

[http://ajp.psychiatryonline.org/cgi/content/short/168/1/9?rss=1 Toward the Predeployment Detection of Risk for PTSD] Douglas L. Delahanty, Ph.D. Am J Psychiatry 168:9-11, January 2011
:A summary of several studies identifying biological markers that can be used to identify persions who are at greater risk of developing PTSD in reaction to a traumatic experience.

"[http://www.sciencemag.org/news/2011/02/marker-ptsd-women]"
:"Only a small minority of people who fall victim to a violent attack or witness a bloody accident suffer the recurring nightmares, hypervigilance, and other symptoms of posttraumatic stress disorder (PTSD). Women seem to be twice as susceptible as men, but otherwise researchers know virtually nothing about who is most at risk or why. Now a study has linked a genetic mutation and blood levels of a particular peptide—a compound made from a short string of the same building blocks that make up proteins—to the severity of PTSD symptoms in women. The finding could lead to tests to identify people who may need extra help after a traumatic event."

[https://www.ncbi.nlm.nih.gov/pubmed/28179812 Stress-related disorders, pituitary adenylate cyclase-activating peptide (PACAP)ergic system, and sex differences.] Ramikie TS, Ressler KJ. Dialogues Clin Neurosci. 2016 Dec;18(4):403-413.

[http://utvet.com/UofTptsdStudy.html Study may help curb cases of combat-stress disorder:]
UT examining genes, reactions of Fort Hood troops to find risk factors.

[http://www.nasw.org/determining-soldiers-vulnerability-ptsd-and-anxiety-disorders http://www.nasw.org/determining-soldiers-vulnerability-ptsd-and-anxiety-disorders]

[http://ptsd.about.com/od/ptsdandthemilitary/a/PTSDvulnerable.htm What Increases Risk for PTSD in Military Service Members?]

Agaibi, C.E., & Wilson, J.P. (2005). Trauma, PTSD, and resilience: A review of the literature. Trauma, Violence, and Abuse, 6, 195-216.

Brailey, K., Vasterling, J.J., Proctor, S.P., Constans, J.I., & Friedman, M.J. (2007). PTSD symptoms, life events, and unit cohesion in U.S. soldiers: Baseline findings from the Neurocognition Deployment Health Study. Journal of Traumatic Stress, 20, 495-503.

Erbes, C., Westermeyer, J., Engdahl, B., & Johnsen, E. (2007). Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Military Medicine, 172, 359-363.

Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.

Ozer, E.J., Best, S.R., Lipsey, T.L., & Weiss, D.S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52-73.

[http://www.medpagetoday.com/PublicHealthPolicy/MilitaryMedicine/17380 Smaller Brain Linked to Soldiers' PTSD Risk]

[http://www.empowher.com/posttraumatic-stress-disorder-ptsd/content/us-military-studying-ptsd-risk-factors U.S. Military Studying PTSD Risk Factors]

===Research Validating Abortion Associated PTSD===
'''[https://pubmed.ncbi.nlm.nih.gov/41724312/ Posttraumatic stress disorder after second trimester medical termination of pregnancy]. Anselem O, et al.Am J Obstet Gynecol. 2026 Feb 20:S0002-9378(26)00085-2. doi: 10.1016/j.ajog.2026.02.021. Epub ahead of print. PMID: 41724312.'''<blockquote>'''Objectives:''' To evaluate the risk of posttraumatic stress disorder (PTSD) after indicated second-trimester termination of pregnancy (TOP) and to identify factors associated with a probable diagnosis of severe PTSD.

'''Study design:''' Secondary analysis of a multicenter randomized controlled trial comparing the efficacy of cervical dilators inserted concurrently with misoprostol with that of misoprostol alone for women undergoing TOP between 150/7 and 276/7 weeks of gestation. PTSD was evaluated by the Impact of Event Scale-Revised (IES-R) questionnaire, self-administered 1-4 months after TOP. This 22-item scale is designed to assess subjective distress caused by traumatic events and has been validated in perinatal care. The literature suggests that a score ≥33 indicates a probable diagnosis of PTSD and a score ≥37 a probable diagnosis of severe PTSD. Maternal and obstetric characteristics associated with a score ≥37 were studied with mixed models. We present results after multiple imputation to take selective dropouts and missing information at follow-up into account and for complete cases.

'''Results:''' Among the 347 women enrolled, 247 (71.2%) IES-R questionnaires were available. Median time between TOP and completion of the questionnaire was 7 weeks (IQR, 4.9-13.3). The mean IES-R score was 32.1 (SD 15.4) The IES-R score was ≥33 for 44.9% (95%CI, 38.4-51.4) of women and ≥37 for 35.8% (95%CI, 29.7-41.8). After multivariate analysis, obstetric or labor-related characteristics such as parity, gestational age over 22 weeks, use of cervical dilators, labor > 12 h, and pain or complications during delivery or postpartum were not associated with an IES-R ≥37. The results were similar in complete cases.

'''Conclusion:''' Nearly half of women undergoing medically indicated second-trimester TOP were at risk of PTSD and more than one-third of severe PTSD. The absence of risk factors underlines the potential benefits of systematic psychological evaluation after TOP for all women.

'''Keywords:''' Termination of pregnancy (TOP); mental health; post-traumatic stress disorder (PTSD).</blockquote>

'''[https://pubmed.ncbi.nlm.nih.gov/31956603/ The Severity of Post-abortion Stress in Spontaneous, Induced and Forensic Medical Center Permitted Abortion in Shiraz, Iran, in 2018.] Alipanahpour S, Zarshenas M, Ghodrati F, Akbarzadeh M. Iran J Nurs Midwifery Res. 2019 Dec 27;25(1):84-90. doi: 10.4103/ijnmr.IJNMR_36_19. PMID: 31956603; PMCID: PMC6952917.'''<blockquote>'''Background:''' Abortion and loss of pregnancy in the first trimester may affect maternal mortality and morbidity. This study aimed to determine the severity of post-abortion stress in spontaneous abortion, induced abortion, and Forensic Medical Center (FMC) referral abortions immediately after abortion and after 1 month of follow-up in Shiraz, Iran, in 2018.

'''Materials and methods:''' This cross-sectional study was conducted on 104 mothers selected through convenience sampling method in 2018. The data collection tools included a demographic characteristics questionnaire and the Mississippi Post-Traumatic Stress Disorder (M-PTSD) Scale that were filled out by mothers immediately and 1 month after the abortion. Data were analyzed using one-way ANOVA and post-hoc LSD test in SPSS software. Moreover, ''p'' < 0.05 was considered as statistically significant.

'''Results:''' The mean (SD) of post-traumatic stress scores was 83.87 (18.35) and 77.40 (9.88) in spontaneous abortion, 82.28 (13.27) and 75.71 (14.73) in FMC permitted abortions, and 86.66 (10.10) and 74.98 (12.99) in induced abortions immediately and 1 month after abortion, respectively. Stress was reduced in the three groups of mothers, after one month of severe value. The score for frequency of stress was 3.10% in FMC-permitted abortions and 5.10% in induced abortions; moreover, no stress was observed in the spontaneous abortion cases.

'''Conclusions:''' Stress was gradually reduced over time. The level of PTSD was lower after 1 month in women who had experienced spontaneous abortion. Given that 1 month after abortion, women are still often moderately stressed, follow-up care, and appropriate counseling for these women are necessary.</blockquote>

'''[https://pmc.ncbi.nlm.nih.gov/articles/PMC12357282/ A multi-component psychosocial intervention programme to reduce psychological distress and enhance social support for women undergoing termination of pregnancy for foetal anomaly in China: A randomised controlled trial.] Qin C, Li Y, Wang Y, Huang C, Xiao G, Zeng L, He Y, Jiang W, Xie J Int J Nurs Stud Adv. 2025 Jul 29;9:100389. doi: 10.1016/j.ijnsa.2025.100389. PMID: 40822251; PMCID: PMC12357282.'''<blockquote>Background
Termination of pregnancy for foetal anomaly causes significant psychological distress, yet evidence-based psychosocial interventions tailored to the needs of women experiencing termination of pregnancy for foetal anomaly remain limited.
Objective
To evaluate the effectiveness of a multi-component psychosocial intervention designed to reduce depression and post-traumatic stress disorder (PTSD) and enhance psychological flexibility and social support among women following termination of pregnancy for foetal anomaly.
Methods
A single-blinded, two-arm randomised controlled trial was conducted in two maternity hospitals in Hunan Province, China. Eighty-six participants were randomly allocated to the multi-component psychosocial intervention group (''n'' = 41) or the control group (''n'' = 45). The multi-component psychosocial intervention included informational support, Acceptance and Commitment Therapy, and social support involving an online peer support group and family engagement. Depression, PTSD, psychological flexibility and social support were assessed at baseline, immediately (T1), one-month (T2) and three-months (T3) post-intervention.
Results
Although the intervention group showed greater reductions in depressive symptoms (EPDS: ''β'' = 0.92, 95 % CI: –1.38 to 3.21, ''p'' = 0.435) and post-traumatic stress symptoms (IES-R: ''β'' = 5.31, 95 % CI: –1.25 to 11.86, ''p'' = 0.113) compared to the control group, these differences did not reach statistical significance. Significant group-by-time effects emerged for PTSD-related avoidance symptoms (''β'' = 2.98, 95 % CI: 0.27 to 5.70, ''p'' = 0.031; ''d'' = 0.49), perceived social support (''β'' = –1.56, 95 % CI: –3.10 to –0.02, ''p'' = 0.047; ''d'' = 0.38) and utilisation of social support (-0.83, 95 % CI: -1.48 to -0.18, ''p'' = 0.013; ''d'' = 0.55) at T3. Participants with baseline EPDS > 9 (''n'' = 54) showed stronger effects, with significant improvements in depression (''β'' = 2.02, 95 % CI: 0.38 to 3.66, ''p'' = 0.016) and experiential avoidance (''β'' = 2.54, 95 % CI: 0.30 to 4.78; ''p'' = 0.026) at T1, PTSD (''β'' = 11.75, 95 % CI: 2.39 to 21.12, ''p'' = 0.014; ''d'' = 0.61) and utilisation of social support (''β'' = -0.95, 95 % CI: -1.85 to -0.04; ''p'' = 0.040, ''d'' = 0.65) at T3. No adverse events occurred.
Conclusions
The multi-component psychosocial intervention programme reduced PTSD-related avoidance symptoms and enhanced social support. Participants with depressive symptoms experienced immediate improvements in depression and psychological flexibility, with sustained benefits in PTSD and utilisation of social support over three months. Tailoring the intervention components to individual needs may benefit women undergoing termination of pregnancy for foetal anomaly. Further research should compare women with and without baseline psychological distress to determine who benefits most from this intervention.</blockquote>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952917/ The Severity of Post-abortion Stress in Spontaneous, Induced and Forensic Medical Center Permitted Abortion in Shiraz, Iran, in 2018.] Alipanahpour S, Zarshenas M, Ghodrati F, Akbarzadeh M. Iran J Nurs Midwifery Res. 2019 Dec 27;25(1):84-90.

:Background: Abortion and loss of pregnancy in the first trimester may affect maternal mortality and morbidity. This study aimed to determine the severity of post-abortion stress in spontaneous abortion, induced abortion, and Forensic Medical Center (FMC) referral abortions immediately after abortion and after 1 month of follow-up in Shiraz, Iran, in 2018.

:Materials and methods: This cross-sectional study was conducted on 104 mothers selected through convenience sampling method in 2018. The data collection tools included a demographic characteristics questionnaire and the Mississippi Post-Traumatic Stress Disorder (M-PTSD) Scale that were filled out by mothers immediately and 1 month after the abortion. Data were analyzed using one-way ANOVA and post-hoc LSD test in SPSS software. Moreover, p < 0.05 was considered as statistically significant.

:Results: The mean (SD) of post-traumatic stress scores was 83.87 (18.35) and 77.40 (9.88) in spontaneous abortion, 82.28 (13.27) and 75.71 (14.73) in FMC permitted abortions, and 86.66 (10.10) and 74.98 (12.99) in induced abortions immediately and 1 month after abortion, respectively. Stress was reduced in the three groups of mothers, after one month of severe value. The score for frequency of stress was 3.10% in FMC-permitted abortions and 5.10% in induced abortions; moreover, no stress was observed in the spontaneous abortion cases.

:Conclusions: Stress was gradually reduced over time. The level of PTSD was lower after 1 month in women who had experienced spontaneous abortion. Given that 1 month after abortion, women are still often moderately stressed, follow-up care, and appropriate counseling for these women are necessary.

'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4746441/ Does abortion increase women's risk for post-traumatic stress? Findings from a prospective longitudinal cohort study.] Biggs MA, Rowland B, McCulloch CE, Foster DG. BMJ Open. 2016;6(2)'''

:7% of the Turnaway Study attributed their PTSS symptoms to their abortions.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952917/ The Severity of Post-abortion Stress in Spontaneous, Induced and Forensic Medical Center Permitted Abortion in Shiraz, Iran, in 2018.] Alipanahpour S1, Zarshenas M2, Ghodrati F3, Akbarzadeh M4. Iran J Nurs Midwifery Res. 2019 Dec 27;25(1):84-90. doi: 10.4103/ijnmr.IJNMR_36_19. eCollection 2020 Jan-Feb.

:BACKGROUND: Abortion and loss of pregnancy in the first trimester may affect maternal mortality and morbidity. This study aimed to determine the severity of post-abortion stress in spontaneous abortion, induced abortion, and Forensic Medical Center (FMC) referral abortions immediately after abortion and after 1 month of follow-up in Shiraz, Iran, in 2018.

:MATERIALS AND METHODS: This cross-sectional study was conducted on 104 mothers selected through convenience sampling method in 2018. The data collection tools included a demographic characteristics questionnaire and the Mississippi Post-Traumatic Stress Disorder (M-PTSD) Scale that were filled out by mothers immediately and 1 month after the abortion. Data were analyzed using one-way ANOVA and post-hoc LSD test in SPSS software. Moreover, p < 0.05 was considered as statistically significant.

:RESULTS: The mean (SD) of post-traumatic stress scores was 83.87 (18.35) and 77.40 (9.88) in spontaneous abortion, 82.28 (13.27) and 75.71 (14.73) in FMC permitted abortions, and 86.66 (10.10) and 74.98 (12.99) in induced abortions immediately and 1 month after abortion, respectively. Stress was reduced in the three groups of mothers, after one month of severe value. The score for frequency of stress was 3.10% in FMC-permitted abortions and 5.10% in induced abortions; moreover, no stress was observed in the spontaneous abortion cases.

:CONCLUSIONS: Stress was gradually reduced over time. The level of PTSD was lower after 1 month in women who had experienced spontaneous abortion. Given that 1 month after abortion, women are still often moderately stressed, follow-up care, and appropriate counseling for these women are necessary

'''[https://www.ncbi.nlm.nih.gov/pubmed/28969621 Neuroticism-related personality traits are associated with posttraumatic stress after abortion: findings from a Swedish multi-center cohort study.] Wallin Lundell I1,2, Sundström Poromaa I3, Ekselius L4, Georgsson S5,6, Frans Ö7, Helström L8, Högberg U3, Skoog Svanberg A3. ''BMC Womens Health.'' 2017 Oct 2;17(1):96. doi: 10.1186/s12905-017-0417-8.'''

:BACKGROUND: Most women who choose to terminate a pregnancy cope well following an abortion, although some women experience severe psychological distress. The general interpretation in the field is that the most consistent predictor of mental disorders after induced abortion is the mental health issues that women present with prior to the abortion. We have previously demonstrated that few women develop posttraumatic stress disorder (PTSD) or posttraumatic stress symptoms (PTSS) after induced abortion. Neuroticism is one predictor of importance for PTSD, and may thus be relevant as a risk factor for the development of PTSD or PTSS after abortion. We therefore compared Neuroticism-related personality trait scores of women who developed PTSD or PTSS after abortion to those of women with no evidence of PTSD or PTSS before or after the abortion.
:METHODS: A Swedish multi-center cohort study including six Obstetrics and Gynecology Departments, where 1294 abortion-seeking women were included. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used to evaluate PTSD and PTSS. Measurements were made at the first visit and at three and six month after the abortion. The Swedish universities Scales of Personality (SSP) was used for assessment of Neuroticism-related personality traits. Multiple logistic regression analyses were performed to investigate the risk factors for development of PTSD or PTSS post abortion.
:RESULTS: Women who developed PTSD or PTSS after the abortion had higher scores than the comparison group on several of the personality traits associated with Neuroticism, specifically Somatic Trait Anxiety, Psychic Trait Anxiety, Stress Susceptibility and Embitterment. Women who reported high, or very high, scores on Neuroticism had adjusted odds ratios for PTSD/PTSS development of 2.6 (CI 95% 1.2-5.6) and 2.9 (CI 95% 1.3-6.6), respectively.
:CONCLUSION: High scores on Neuroticism-related personality traits influence the risk of PTSD or PTSS post abortion. This finding supports the argument that the most consistent predictor of mental disorders after abortion is pre-existing mental health status.
:*Editor Note: Among 512 women with no prior PTSD symptoms, 9.4% experienced all the criteria necessary for a PTSD diagnosis by the three or six month post-abortion assessment. Pre-abortion screening for higher neuroticism-related personality traits can be used to identify the women at greatest risk of abortion associated PTSD. This finding is consistent with [https://www.ncbi.nlm.nih.gov/pubmed/14744527/ other studies showing neurotisicm being associated with greater susceptibility to PTSD].

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334933/ Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review.] Daugirdaitė V, van den Akker O, Purewal S. J Pregnancy. 2015;2015:646345. doi: 10.1155/2015/646345. Epub 2015 Feb 5.

:OBJECTIVE: The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF).
:METHODS: Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines.
:RESULTS: Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss.
:CONCLUSIONS: This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

'''[http://www.ncbi.nlm.nih.gov/pubmed/22622194 "Predictors of postpartum post-traumatic stress disorder in primiparous mothers.][Article in French]'''
Montmasson H1, Bertrand P, Perrotin F, El-Hage W. J Gynecol Obstet Biol Reprod (Paris). 2012 Oct;41(6):553-60. doi: 10.1016/j.jgyn.2012.04.010. Epub 2012 May 21.

A history of abortion was associated with a six fold increased risk of subsequent postpartum PTSD.

'''''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939862 Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy].''''' Hamama L, Rauch SA, Sperlich M, Defever E, Seng JS. Depress Anxiety. 2010 Jun 23.

: Abstract
: '''Background''': Few studies have considered whether elective and/or spontaneous abortion (EAB/SAB) may be risk factors for mental health sequelae in subsequent pregnancy. This paper examines the impact of EAB/SAB on mental health during subsequent pregnancy in a sample of women involved in a larger prospective study of posttraumatic stress disorder (PTSD) across the childbearing year (n=1,581). '''Methods''': Women expecting their first baby completed standardized telephone assessments including demographics, trauma history, PTSD, depression, and pregnancy wantedness, and religiosity. '''Results''': Fourteen percent (n=221) experienced a prior elective abortion (EAB), 13.1% (n=206) experienced a prior spontaneous abortion (SAB), and 1.4% (n=22) experienced both. Of those women who experienced either an EAB or SAB, 13.9% (n=220) appraised the EAB or SAB experience as having been "a hard time" (i.e., potentially traumatic) and 32.6% (n=132) rated it as their index trauma (i.e., their worst or second worst lifetime exposure). Among the subset of 405 women with prior EAB or SAB, the rate of PTSD during the subsequent pregnancy was 12.6% (n-51), the rate of depression was 16.8% (n=68), and 5.4% (n-22) met criteria for both disorders. '''Conclusions''': History of sexual trauma predicted appraising the experience of EAB or SAB as "a hard time." Wanting to be pregnant sooner was predictive of appraising the experience of EAB or SAB as the worst or second worst (index) trauma. EAB or SAB was appraised as less traumatic than sexual or medical trauma exposures and conveyed relatively lower risk for PTSD. The patterns of predictors for depression were similar

'''[http://www.ncbi.nlm.nih.gov/pubmed/22840934 Psychological problems sequalae in adolescents after artificial abortion.]''' Zulčić-Nakić V, Pajević I, Hasanović M, Pavlović S, Ljuca D. J Pediatr Adolesc Gynecol. 2012 Aug;25(4):241-7. doi: 10.1016/j.jpag.2011.12.072.

:STUDY AND OBJECTIVES: Controversy exists over psychological risks associated with unwanted pregnancy and consecutive abortion. The aim of this study was to assess the psychological health of female adolescents following artificial abortion up to 12(th) week of pregnancy. DESIGN: The control case study. SETTING: The study was carried out in the Department of Gynecology and Obstetrics, University Clinical Center Tuzla, in Bosnia-Herzegovina.
:PARTICIPANTS: We assessed 120 female adolescents. The mean (SD) age of the patients was 17.7 (1.5) years experiencing sexual intercourse in the age of 14-19 years for trauma experiences, presence of posttraumatic stress symptoms, depression and anxiety as state, and anxiety as trait. Sixty adolescents had intentional artificial abortion and 60 had sexual intercourse but did not become pregnant. MAIN OUTCOME MEASURES: We used the PTSD Questionnaire, the Beck Depression Inventory, and the Spielberger State Trait Anxiety Inventory (Form Y) for assessment of anxiety in adolescents. Basic socio-demographic data were also collected. RESULTS: PTSD presented significantly more often in adolescents who aborted pregnancy (30%), than in adolescents who did not abort (13.3%) (odds ratio = 4.91 (95%CI 0.142-0.907) P = 0.03). Anxiety as state and as trait were significantly higher in the abortion group, as the mean (SD) anxiety score of patients was 59.8 (8.9), 57.9 (9.7) respectively, than in non-abortion group 49.5 (8.8), 47.3 (9.9) respectively (t = 6.392, P < 0.001; t = 5.914, P < 0.001, respectively). Adolescents who aborted pregnancy had significantly higher depression symptoms severity 29.2 (5.6) than controls 15.2 (3.3) (t = 8.322, P < 0.001), and they presented significantly more often depression (75%), than adolescents who did not abort (10%) (χ(2) = 53.279, P < 0.001). Logistic regression showed that only experience of life threatening(s) and injury of other person(s) reliably predicted PTSD, whereas abortion and experience of life threatening(s) reliably predicted depression. CONCLUSION: Adolescents who aborted pregnancy presented significantly greater prevalence of PTSD and depression, and significantly greater depression severity and anxiety as state and trait than those who did not abort. Abortion predicted depression only, and did not predict PTSD.

''''[http://www.ncbi.nlm.nih.gov/pubmed/23576135 The Characteristics and Severity of Psychological Distress After Abortion Among University Students.]''''Curley M, Johnston C. J Behav Health Serv Res. 2013 Apr 12. [Epub ahead of print]

''Abstract''

:Controversy over abortion inhibits recognition and treatment for women who experience psychological distress after abortion (PAD). This study identified the characteristics, severity, and treatment preferences of university students who experienced PAD. Of 151 females, 89 experienced an abortion. Psychological outcomes were compared among those who preferred or did not prefer psychological services after abortion to those who were never pregnant. All who had abortions reported symptoms of post-traumatic stress disorder (PTSD) and grief lasting on average 3 years. Yet, those who preferred services experienced heightened psychological trauma indicative of partial or full PTSD (Impact of Event Scale, M = 26.86 versus 16.84, p < .05), perinatal grief (Perinatal Grief Scale, M 62.54 versus 50.89, p < 0.05), dysthymia (BDI M = 11.01 versus 9.28, p < 0.05), (M = 41.86 versus 39.36, p < 0.05), and co-existing mental health problems. PAD appeared multi-factorial, associated with the abortion and overall emotional health. Thus, psychological interventions for PAD need to be developed as a public health priority.

''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1899490/ Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation.]'' Suliman S, Ericksen T, Labuschgne P, de Wit R, Stein DJ, Seedat S. BMC Psychiatry. 2007 Jun 12;7:24.

:Examining symptom domains preabortion, and 1 and 3 months later, the authors evaluated 155 women who had abortions in Cape Town, South Africa. They reported:
::1. “High rates of PTSD characterize women who have undergone voluntary pregnancy termination.” p. 8 (almost one fifth of the sample met criteria for PTSD)
::2. The percent of women who met PTSD criteria increased by 61% from pre-abortion baseline to 3 months post-abortion (11.3 to 18.2)
::3. Women who met PTSD criteria pre-abortion experienced significantly more physical pain post-abortion
::4. “Thus it would follow that screening women pre-termination for PTSD and disability and post-termination for high levels of dissociation is important in order to help identify women at risk of PTSD and to provide follow-up care.” p. 6
::5. "[t]here was a high rate of attrition over the course of the study leaving a small final sample (37% of the original sample). It might be that participants who were lost to follow-up were lost because of their higher levels of postabortion distress (i.e. PTSD and other psychopathology)."
::6. The rates of depression and anxiety were high both pre-abortion and at three months post-abortion, but were not significantly higher. Regarding depression, at pre-termination 21.9% of the sample had high depression scores compared to 20% at 1 and 3 months. 'High' state anxiety (STAI) at pre-abortion was reported by 63.9%, and this dropped to 56.3% of women at both 1 and 3 months. Note: Pre-depresssion and anxiety scores are measured at the height of the crisis when the woman is about to have an abortion. It does not reflect pre-pregnancy scores. In addition, the high attrition rate and short time frame (3 months) must also be considered in properly interpreting this data. 7. "[W]omen with PTSD 3 months after termination were further along in their pregnancy than those without PTSD (gestational age: With PTSD: 13.2 ± 3.3; Without PTSD: 9.7 ± 4.2; p = 0.023)."

'''''[http://www.tandfonline.com/doi/abs/10.1080/02646838.2012.654489 Posttraumatic Stress Disorder and psychological distress following medical and surgical abortion.]''''' C. Rousset, C. Brulfert, N. Séjourné, N. Goutaudier & H. Chabrol Journal of Reproductive and Infant Psychology, (2011) Volume 29(5), 506-517.

:Method: Eighty-six women were approached a few hours after the abortion and then 6 weeks later. Several questionnaires were completed: the Impact of Event Scale Revised (IES-R), the Multidimensional Scale of Social Support (MSPSS), the Peritraumatic Dissociative Experience Questionnaire (PDEQ), the Peritraumatic Emotions List (PEL), the Hospital Anxiety and Depression Scale (HADS), the Perinatal Grief Scale (PGS) and the Texas Grief Inventory (TGI). Results: Six weeks after the abortion, 38% of women reported a potential PTSD and a significant decrease of the anxious symptomatology was also highlighted. Peritraumatic dissociation and peritraumatic emotions were the main predictors of the intensity of post-abortum PTSD symptoms. Compared to surgical abortion, medical abortion was associated with increasing the risk of developing a possible PTSD. Conclusion: By providing evidence on some of the main risk factors, this study highlights the need for psychological support for women and strategies of prevention to be developed.

[http://www.ajol.info/index.php/safp/article/viewFile/13106/15689 The prevalence of post-abortion syndrome in patients presenting at Kalafong hospital's family medicine clinic after having a termination of pregnancy.] van Rooyen M, Smith S. South African Family Practice (2004) 46 (5), pp 21-24.

:Background: Post-abortion syndrome (PAS) is said to be the emotional, psychological, physical and spiritual trauma caused by an abortion, which is an event outside the normal range of human experience. Post-abortion syndrome is a type of post-traumatic disorder and is characterised by a stressor (the abortion), the event being re-experienced, avoidance and/or numbing of general responsiveness, and physical symptoms such as insomnia and depression. The question was asked whether the patients at Kalafong Hospital experienced any of the after-effects of a termination of pregnancy and whether these effects would fulfill the criteria of post-abortion syndrome.

:Method: A prospective descriptive study was done over a six-month period. All female patients presenting at the Family Medicine Clinic of Kalafong Hospital who were known to have had a previous abortion on request were asked to participate in the study. After obtaining informed consent, a structured questionnaire on their psychological symptoms was completed by the participants with the help of the researcher. The questionnaire contained demographic data, as well as questions on the above-mentioned symptoms of PAS. To fulfill the criteria of PAS, the symptoms should have been present for more than a month and must have affected the subject’s daily functioning.

:Results: Of the 48 woman recruited, 16 (33%) fulfilled the criteria of PAS, and more than 50% of the women had had some or other emotional or psychological after-effect.

:Conclusion: This study showed that one out of every three women presenting at Kalafong Hospital after abortion fulfilled the criteria of PAS. Since family physicians are committed to their patients and regard it as their duty to address problems prevalent in the community they serve, it is necessary to investigate further the possible link between termination of pregnancy and the emotional problems identified. It is imperative that women requesting termination of pregnancy receive comprehensive counseling prior to the procedure, as well as support thereafter,to ensure that they are not unnecessarily traumatised.

:Note: Other reactions were insomnia (23%), irritability (69%) feeling of being more alert (46%), being startled more easily (79%), depressed mood (75%), suicidal thoughts (40%), feelings of guilt (67%), low self esteem (54%) substance abuse (2%), change in eating habits (23%) and decreased libido (79%).

'''''[http://www.hindawi.com/journals/jp/2010/130519.html Late-Term Elective Abortion and Susceptibility to Posttraumatic Stress Symptoms.] ''''' Journal of Pregnancy Volume 2010 (2010)Coleman PK, Coyle CT, Rue VM

:An average of 15 years after their abortions, 52.5% of women with a history of a first trimester abortion and 67.4% with a history of a second or third trimester abortion, met the DSM-IV symptom criteria for PTSD.

[http://www3.interscience.wiley.com/journal/123554306/abstract?CRETRY=1&SRETRY=0 Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy]Hamama L, et al. ''Depression and Anxiety'' Published Online: 23 Jun 2010
:(Abstract)Background: Few studies have considered whether elective and/or spontaneous abortion (EAB/SAB) may be risk factors for mental health sequelae in subsequent pregnancy. This paper examines the impact of EAB/SAB on mental health during subsequent pregnancy in a sample of women involved in a larger prospective study of posttraumatic stress disorder (PTSD) across the childbearing year (n=1,581).
:Methods: Women expecting their first baby completed standardized telephone assessments including demographics, trauma history, PTSD, depression, and pregnancy wantedness, and religiosity.
:Results: Fourteen percent (n=221) experienced a prior elective abortion (EAB), 13.1% (n=206) experienced a prior spontaneous abortion (SAB), and 1.4% (n=22) experienced both. Of those women who experienced either an EAB or SAB, 13.9% (n=220) appraised the EAB or SAB experience as having been a hard time (i.e., potentially traumatic) and 32.6% (n=132) rated it as their index trauma (i.e., their worst or second worst lifetime exposure). Among the subset of 405 women with prior EAB or SAB, the rate of PTSD during the subsequent pregnancy was 12.6% (n-51), the rate of depression was 16.8% (n=68), and 5.4% (n-22) met criteria for both disorders.
:Conclusions: History of sexual trauma predicted appraising the experience of EAB or SAB as a hard time. Wanting to be pregnant sooner was predictive of appraising the experience of EAB or SAB as the worst or second worst (index) trauma. EAB or SAB was appraised as less traumatic than sexual or medical trauma exposures and conveyed relatively lower risk for PTSD. The patterns of predictors for depression were similar. Depression and Anxiety

:Editor Notes: Among women having an elective abortion, 28.6 percent rated it as the first or second worst lifetime experience. During the subsequent pregnancy, among women with a history of elective abortion 12.5% met the criteria for a PTSD diagnosis, 17.9 percent experienced major depression in the past year, and 4.5 percent had both PTSD and depression. Among those reporting that they had a "hard time" with their abortion or miscarriage, 32% were diagnosed with PTSD and 28 percent had major depression, and 17.3% had both.

''[http://tmt.sagepub.com/cgi/content/abstract/1534765609347550v1 "Inadequate Preabortion Counseling and Decision Conflict as Predictors of Subsequent Relationship Difficulties and Psychological Stress in Men and Women"] Catherine T. Coyle, Priscilla K. Coleman, and Vincent M. Rue, ''Traumatology'' first published on November 16, 2009 as doi:10.1177/1534765609347550

:(Abstract)The purpose of this study was to examine associations between perceptions of preabortion counseling adequacy and partner congruence in abortion decisions and two sets of outcome variables involving relationship problems and individual psychological stress. Data were collected through online surveys from 374 women who had a prior abortion and 198 men whose partners had experienced elective abortion. For women, perceptions of preabortion counseling inadequacy predicted relationship problems, symptoms of intrusion, avoidance, and hyperarousal, and meeting full diagnostic criteria for posttraumatic stress disorder (PTSD) with controls for demographic and personal/situational variables used. For men, perceptions of inadequate counseling predicted relationship problems and symptoms of intrusion and avoidance with the same controls used. Incongruence in the decision to abort predicted intrusion and meeting diagnostic criteria for PTSD among women with controls used, whereas for men, decision incongruence predicted intrusion, hyperarousal, meeting diagnostic criteria for PTSD, and relationship problems. Findings suggest that both perceptions of inadequate preabortion counseling and incongruence in the abortion decision with one’s partner are related to adverse personal and interpersonal outcomes.

''"[http://www.springerlink.com/content/w773590gq50677jv/ Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth—a 14-month follow up study]" Kersting A, et al. Arch Womens Ment Health. 2009 Aug;12(4):193-201. Epub 2009 Mar 6.''
:(ABSTRACT) The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting psychological impact.

'''[http://www.ncbi.nlm.nih.gov/pubmed/20860598 Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomised controlled trial.]''' Kelly T, Suddes J, Howel D, Hewison J, Robson S. BJOG. 2010 Nov;117(12):1512-20. OBJECTIVE: To compare the psychological impact, acceptability and clinical effectiveness of medical versus surgical termination of pregnancy (TOP) at 13-20 weeks of gestation.

:One hundred and twenty two women were randomised: 60 had medical (drug induced) abortions (MTOP) and 62 had surgical abortions. Twelve women opted to continue their pregnancy. Follow-up rates were low (n=66/110; 60%). At 2 weeks post-procedure the average IES scores reported for surgical abortion was 30.1 and for medical abortion was 36.8. For scores over 26, there is a 75% chance of PTSD. [http://www.psychotherapy-center.com/Measuring_the_Impact_of_an_Event.html 1] and the event may be classified as a "Powerful Impact Event—you are certainly affected."[http://www.psychotherapy-center.com/Measuring_the_Impact_of_an_Event.html 1] An IES score over 35 is considered a good cutoff score for probable PTSD. [http://www.psychotherapy-center.com/Measuring_the_Impact_of_an_Event.html 1] With means of 30.1 and 36.8, it would appear that a high percentage of women in both the MTOP and STOP group exceeded the cutoff score for probable PTSD.

:Also, given the fact there was a 60% non-participation rate in this study, it is likely that the mean IES scores reported here are much lower than they would have been with 100% participation since it is likely that women who were most disturbed by the abortion were least likely to participate.

''"Past trauma and Present Functioning of Patients Attending a Women's Psychiatric Clinic," EFM Borins, PJ Forsythe, Am J Psychiatry 142(4) :460, 1985 ''
:In a Canadian study, abortion correlated significantly with three or more trauma factors.

''"Iatrogenic Post-Traumatic Stress Disorder," (letter), R. Fisch and 0. Tadmor, The Lancet, December 9, 1989, p. 1397. ''
:PTSD following induced abortion with post-abortion complications was reported. Soon after the abortion the patient exhibited severe anxiety, depression, recurrent intrusive thoughts and images related to the abortion, insomnia, recurrent nightmares, avoidance behavior along with other social problems continuing over two and a half years without much remission.

''"Obsessive-Compulsive Disorder Apparently Related to Abortion," Ronald K. McGraw, American Journal of Psychotherapy 43(2):269-276, April 1989. ''
:A married woman with a history of three abortions was obsessed with the idea she would become pregnant by someone other than her husband although she was not sexually active outside her marriage, and she compulsively underwent repeated pregnancy tests although there was no sign of pregnancy. If she became pregnant she thought she would die in childbirth. It was concluded that the obsessive-compulsive disorder was precipitated by routine medical tests that brought back memories of the prior abortions with associated guilt and fear of punishment.

''"Incidence of complicated grief and post-traumatic stress in a post-abortion population," Leslie M. Butterfield, Ph.D. Dissertation, Virginia Commonwealth University (1988), Dissertation Abstracts International 49(8): 3431-B, February 1989, Order No. DA 8813540. ''
:Stress responses were found in 55% of women six months following first trimester abortion. Posttraumatic stress was heightened by loss of partner and wishful thinking. Social support seeking and problem-focused coping was negatively associate with post- traumatic stress and grief. Women consistently showed death anxiety on the Grief Experience Inventory (GEI).

''"Abortion Trauma: Application of a Conflict Model," R.C. Erikson, Pre and Perinatal Psychology Journal 8(l): 33. Fall, 1993. ''
:Elective abortion is a potentially traumatizing event. Clinic experience indicates the symptoms and development of post traumatic stress disorder following abortion. A conflict model of trauma is presented with the woman as both victim and aggressor.

''"Post Traumatic Stress Disorders in Women Following Abortion: Some Considerations and Implications for Martial/Couple Therapy," D Bagarozzi, Int'l Journal of Family and Marriage (Delhi, India) 1 (2): 51, 1993 ''
:Clinical examples of abortion related post traumatic stress disorder.

''"Psychological Responses of Women After First-Trimester Abortion," B Major et al, Arch Gen Psychiatry 57:777, 2000 ''
:This study reported that 6 of 442 women ( 1.36%) reported abortion related PTSD two years postabortion according to DSM-IV criteria as assessed with a modified measure asking specifically about abortion. A history of depression was significantly associated with a higher risk of experience abortion related PTSD.
:An increasing number of women had negative emotional reactions with the passage of time. In this study it appears that the standard for identifying a case of abortion-related PTSD was set to exceptionally high level. First, women were required to the cause of each symptom as having been directly related to the abortion. Nightmares that they did not associate to their abortion, for example, would not have been included as an intrusive symptom. In addition, it appears that only women who rated the degree of the reaction at the highest level, for every PTSD symptom, were included. Women with a moderate level of distress in one symptom area, for example, were not counted as having PTSD. This high standard is useful for verifying with a high degree of certainty that abortion is the direct cause of PTSD in at least some cases. On the other hand, because the standard appears to be set higher than is normally the case in population studies of PTSD, the findings may under represent the actual incidence rate.

'''''[https://pdfs.semanticscholar.org/36a1/9b0aefacdaa17a74511036cfb5a1e6e4786a.pdf Posttraumatic stress disorder and pregnancy complications.]'' Seng JS, Oakley DJ, Sampselle CM, Killion C, Graham-Bermann S, Liberzon I. Obstetrics and gynecology. 2001 Jan; 97(1): 17-22'''
:OBJECTIVE: To assess the associations between specific pregnancy complications and posttraumatic stress disorder based on neurobiologic and behavioral characteristics, using Michigan Medicaid claims data from 1994-1996.
:METHODS: Two thousand, two hundred nineteen female recipients of Michigan Medicaid who were of childbearing age had posttraumatic stress disorder on the basis of International Classification of Diseases, 9th Revision (ICD-9) codes. Twenty percent (n = 455) of those recipients and 30% of randomly selected comparison women with no mental health diagnostic codes (n = 638; P <.001) had ICD-9 diagnostic codes for pregnancy complications. We used multiple logistic regression to investigate associations between specific pregnancy complications and posttraumatic stress disorder, controlling for demographic and psychosocial variables. Obstetric complications were hypothesized based on high-risk behaviors and neurobiologic alterations in stress axis function in posttraumatic stress disorder.
:RESULTS: After controlling for demographic and psychosocial factors, women with posttraumatic stress disorder had higher odds ratios (ORs) for ectopic pregnancy (OR 1.7, 95% confidence interval [CI] 1.1, 2.8), spontaneous abortion (OR 1.9, 95% CI 1.3, 2.9), hyperemesis (OR 3.9, 95% CI 2.0, 7.4), preterm contractions (OR 1.4, 95% CI 1.1, 1.9), and excessive fetal growth (OR 1.5, 95% CI 1.0, 2.2). Hypothesized labor differences were not confirmed and no differences were found for complications not thought to be related to traumatic stress.
:CONCLUSIONS: Pregnant women with posttraumatic stress disorder might be at higher risk for certain conditions, and assessment and treatment for undiagnosed posttraumatic stress might be warranted for women with those obstetric complications. Prospective studies are needed to confirm present findings and to determine potential biologic mechanisms. Treatment of traumatic stress symptoms might improve pregnancy morbidity and maternal mental health.
:NOTE: women's most common attribution for PTSD was violence and the second most common attribution was for prior pregnancy loss.

''Trauma and grief 2-7 years after termination of pregnancy because of fetal anomalies-a pilot study. Kersting A, et al. J of Psychosomatic Obstetrics & Gynecology 2005; 26(1): 9-14.''
:The aim of the study was to obtain information on the long-term posttraumatic stress response and grief several years after termination of pregnancy due to fetal malformation. We investigated 83 women who had undergone termination of pregnancy between 1995 and 1999 and compared them with 60 women 14 days after termination of pregnancy and 65 women after the spontaneous delivery of a full-term healthy child. Women 2-7 years after termination of pregnancy were expected to show a significantly lower degree of traumatic experience and grief than women 14 days after termination of pregnancy. Contrary to the hypothesis, however, the results showed no significant intergroup differences with respect to the degree of traumatic experience. With the exception of one subscale (fear of loss), this also applied to the grief reported by the women. However, both groups differed significantly in their posttraumatic stress response from women who had given spontaneous birth to a full-term healthy child. The results indicate that termination of pregnancy is to be seen as an emotionally traumatic major life event which leads to severe posttraumatic stress response and intense grief reactions that are still detectable some years later.

''Assessing traumatic reactions of abortion with the emotional stroop.'' Toledano, Levana. Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 64(9-B), 2004. pp. 4639.
:Two groups of women were included in this study: 59 women who had undergone an abortion and a control group of 28 women who had comparable surgical procedures. The mean age of the participants was 29.82, with ages ranging from 18 to 50 years. Symptoms of PTSD were assessed using the Posttraumatic Diagnostic Scale (PDS), the Impact of Event Scale (IES), and the Emotional Stroop paradigm. The Emotional Stroop procedure utilized was a color-naming task comprised of abortion-relevant words (i.e., sex, pregnant, fetus), positive words, neutral words, and obsessive-compulsive disorder (OCD) words. Levels of depression and anxiety were assessed with the Beck Depression Inventory-II (BDI-II), and the State-Trait Anxiety Inventory (STAI). The role of social support at the time of abortion was measured via the Multidimensional Scale of Perceived Social Support (MSPSS). Background variables such as religiosity, the presence or absence of coercion, marital status, gestational length, number of children, and age were also explored as possible risk factors mediating responses to abortion. Multivariate tests indicated the presence of PTSD in both groups of women, but to a greater extent in the post-abortion group. The two groups reported similarly elevated scores for anxiety. Post-abortion women exhibited significantly longer response latencies on the Stroop for abortion/trauma-relevant stimuli as compared to the control group. There were no significant differences found between groups on measures of depression. Significant risk factors included low levels of perceived social support, younger age, and the presence of coercion. Implications for community and clinical psychology are outlined.

''Postabortion Grief: Evaluating the Possible Efficacy of a Spiritual Group Intervention.'' SD Layer, C Roberts, K Wild, J Walters. Research on Social Work Practice, Vol. 14, No. 5, 344-350 (2004)
:Objective: Although not every woman is negatively affected by an abortion, researchers have identified a subgroup of women susceptible to grief and trauma. The primary providers for postabortion grief (PAG) groups are community faith-based agencies. Principle features of PAG are shame and post-traumatic stress disorder (PTSD) symptoms. Method: This study measured the efficacy of a spiritually based grief group intervention for women grieving an abortion. Thirty-five women completed the Impact of Event Scale-Revised(IES-R) and the Internalized Shame Scale (ISS) pre- and postintervention along with posttest open-ended questions. Results: Postintervention measures indicated significant decrease in shame (p < .000) and PTSD symptoms (p < .002). More than 80% reported their religious beliefs and the spiritual intervention played a strong to very strong role in the group. Conclusion: Social workers need to screen for PAG with a postabortive woman and when appropriate refer her to agencies offering such groups.

''Abortion in young women and subsequent mental health.'' Fergusson DM, John Horwood L, Ridder EM. J Child Psychol Psychiatry. 2006 Jan;47(1):16-24.

:Background: The extent to which abortion has harmful consequences for mental health remains controversial. We aimed to examine the linkages between having an abortion and mental health outcomes over the interval from age 15-25 years. Methods: Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors. Results: Forty-one percent of women had become pregnant on at least one occasion prior to age 25, with 14.6% having an abortion. Those having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors. Conclusions: The findings suggest that abortion in young women may be associated with increased risks of mental health problems.

''Induced abortion and traumatic stress: A preliminary comparison of American and Russian women.'' Rue VM, Coleman PK, Rue JJ, Reardon DC. Med Sci Monit, 2004 10(10): SR5-16.
:BACKGROUND: Individual and situational risk factors associated with negative postabortion psychological sequelae have been identified, but the degree of posttraumatic stress reactions and the effects of culture are largely unknown.
:MATERIAL/METHODS: Retrospective data were collected using the Institute for Pregnancy Loss Questionnaire (IPLQ) and the Traumatic Stress Institute's (TSI) Belief Scale administered at health care facilities to 548 women (331 Russian and 217 American) who had experienced one or more abortions, but no other pregnancy losses.
:RESULTS: Overall, the findings here indicated that American women were more negatively influenced by their abortion experiences than Russian women. While 65% of American women and 13.1% of Russian women experienced multiple symptoms of increased arousal, re-experiencing and avoidance associated with posttraumatic stress disorder (PTSD), 14.3% of American and 0.9% of Russian women met the full diagnostic criteria for PTSD. Russian women had significantly higher scores on the TSI Belief Scale than American women, indicating more disruption of cognitive schemas. In this sample, American women were considerably more likely to have experienced childhood and adult traumatic experiences than Russian women. Predictors of positive and negative outcomes associated with abortion differed across the two cultures.
:CONCLUSIONS: Posttraumatic stress reactions were found to be associated with abortion. Consistent with previous research, the data here suggest abortion can increase stress and decrease coping abilities, particularly for those women who have a history of adverse childhood events and prior traumata. Study limitations preclude drawing definitive conclusions, but the findings do suggest additional cross-cultural research is warranted.

[http://www.ncbi.nlm.nih.gov/pubmed/24007380 Increased risk for postpartum psychiatric disorders among women with past pregnancy loss.] Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

:Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.
:Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

:Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

:Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

[http://www.ncbi.nlm.nih.gov/pubmed/24154514 Women's experiences in relation to stillbirth and risk factors for long-term post-traumatic stress symptoms: a retrospective study.] Gravensteen IK, Helgadóttir LB, Jacobsen EM, Rådestad I, Sandset PM, Ekeberg O. BMJ Open. 2013 Oct 22;3(10):e003323. doi: 10.1136/bmjopen-2013-003323.

:OBJECTIVES: (1) To investigate the experiences of women with a previous stillbirth and their appraisal of the care they received at the hospital. (2) To assess the long-term level of post-traumatic stress symptoms (PTSS) in this group and identify risk factors for this outcome.
:DESIGN: A retrospective study.
:SETTING:Two university hospitals.
:PARTICIPANTS: The study population comprised 379 women with a verified diagnosis of stillbirth (≥23 gestational weeks or birth weight ≥500 g) in a singleton or twin pregnancy 5-18 years previously. 101 women completed a comprehensive questionnaire in two parts.
:PRIMARY AND SECONDARY OUTCOME MEASURES: The women's experiences and appraisal of the care provided by healthcare professionals before, during and after stillbirth. PTSS at follow-up was assessed using the Impact of Event Scale (IES).
:RESULTS: The great majority saw (98%) and held (82%) their baby. Most women felt that healthcare professionals were supportive during the delivery (85.6%) and showed respect towards their baby (94.9%). The majority (91.1%) had received some form of short-term follow-up. One-third showed clinically significant long-term PTSS (IES ≥ 20). Independent risk factors were younger age (OR 6.60, 95% CI 1.99 to 21.83), induced abortion prior to stillbirth (OR 5.78, 95% CI 1.56 to 21.38) and higher parity (OR 3.46, 95% CI 1.19 to 10.07) at the time of stillbirth. Having held the baby (OR 0.17, 95% CI 0.05 to 0.56) was associated with less PTSS.
:CONCLUSIONS: The great majority saw and held their baby and were satisfied with the support from healthcare professionals. One in three women presented with a clinically significant level of PTSS 5-18 years after stillbirth. Having held the baby was protective, whereas '''prior induced abortion was a risk factor for a high level of PTSS'''.

'''[http://www.ncbi.nlm.nih.gov/pubmed/24875400 Voluntary and involuntary childlessness in female veterans: associations with sexual assault.]''' Ryan GL, Mengeling MA, Booth BM, Torner JC, Syrop CH, Sadler AG. Fertil Steril. 2014 Aug;102(2):539-47. doi: 10.1016/j.fertnstert.2014.04.042. Epub 2014 May 27.

:In a sample of 1,004 female veterans enrolled at VA medical centers, 620 had a history of at least one attempted or completed sexual assault. Those with a history of sexual assault were "more often self-reported a history of pregnancy termination (31% vs. 19%) and infertility (23% vs. 12%), as well as sexually transmitted infection (42% vs. 27%), posttraumatic stress disorder (32% vs. 10%), and postpartum dysphoria (62% vs. 44%). Lifetime sexual assault was independently associated with termination and infertility in multivariate models; sexually transmitted infection, posttraumatic stress disorder, and postpartum dysphoria were not. The LSA by period of life was as follows: 41% of participants in childhood, 15% in adulthood before the military, 33% in military, and 13% after the military (not mutually exclusive). Among the 511 who experienced a completed LSA, 23% self-reported delaying or foregoing pregnancy because of their assault."

'''[http://www.ncbi.nlm.nih.gov/pubmed/21186554 Investigation of risk factors for acute stress reaction following induced abortion].''' Vukelić J, Kapamadzija A, Kondić B.
[Article in Serbian] Med Pregl. 2010 May-Jun;63(5-6):399-403.

:INTRODUCTION: Termination of pregnancy-induced abortion is inevitable in family planning as the final solution in resolving unwanted pregnancies. It can be the cause of major physical and phychological consequences on women's health. Diverse opinions on psychological consequences of induced abortion can be found in literature.
:MATERIAL AND METHODS: A prospective study was performed in order to predict acute stress disorder (ASD) after the induced abortion and the possibility of post-traumatic stress disorder (PTSD). Seven days after the induced abortion, 40 women had to fill in: (1) a special questionnaire made for this investigation, with questions linked to some risk factors inducing stress, (2) Likert's emotional scale and 3. Bryant's acute stress reaction scale.
:RESULTS: After an induced abortion 52.5% women had ASD and 32.5% women had PTSD. Women with ASD after the abortion developed more sense of guilt, irritability, shame, self-judgement, fear from God and self-hatred. They were less educated, had lower income, they were more religious, did not approve of abortion and had worse relationship with their partners after the abortion in comparison to women without ASD. Age, number of previous abortions and decision to abort did not differ between the two groups.
:DISCUSSION: Induced abortion represents a predisposing factor for ASD and PTSD in women. Some psycho-social factors contribute to the development of stress after abortion. Serbia has a task to reduce the number of abortions which is very high, in order, to preserve reproductive and psychological health of women.

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3879178/] Wallin Lundell I, Georgsson Öhman S, Frans Ö, Helström L, Högberg U, Nyberg S, Sundström Poromaa I, Sydsjö G, Östlund I, Skoog Svanberg A. BMC Womens Health. 2013 Dec 23;13:52. doi: 10.1186/1472-6874-13-52. See also: [http://www.diva-portal.org/smash/get/diva2:740899/FULLTEXT01.pdf Induced Abortions and Posttraumatic Stress - Is there any relation? A Swedish multi-centre study] INGER WALLIN LUNDELL 2014 Dissertation.

:Background: Induced abortion is a common medical intervention. Whether psychological sequelae might follow induced abortion has long been a subject of concern among researchers and little is known about the relationship between posttraumatic stress disorder (PTSD) and induced abortion. Thus, the aim of the study was to assess the prevalence of PTSD and posttraumatic stress symptoms (PTSS) before and at three and six months after induced abortion, and to describe the characteristics of the women who developed PTSD or PTSS after the abortion.

:Methods: This multi-centre cohort study included six departments of Obstetrics and Gynaecology in Sweden. The study included 1457 women who requested an induced abortion, among whom 742 women responded at the three-month follow-up and 641 women at the six-month follow-up. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used for research diagnoses of PTSD and PTSS, and anxiety and depressive symptoms were evaluated by the Hospital Anxiety and Depression Scale (HADS). Measurements were made at the first visit and at three and six months after the abortion. The 95% confidence intervals for the prevalence of lifetime or ongoing PTSD and PTSS were calculated using the normal approximation. The chi-square test and the Student’s t-test were used to compare data between groups.

:Results: The prevalence of ongoing PTSD and PTSS before the abortion was 4.3% and 23.5%, respectively, concomitant with high levels of anxiety and depression. At three months the corresponding rates were 2.0% and 4.6%, at six months 1.9% and 6.1%, respectively. Dropouts had higher rates of PTSD and PTSS. Fifty-one women developed PTSD or PTSS during the observation period. They were young, less well educated, needed counselling, and had high levels of anxiety and depressive symptoms. During the observation period 57 women had trauma experiences, among whom 11 developed PTSD or PTSS and reported a traumatic experience in relation to the abortion.

:Conclusion: Few women developed PTSD or PTSS after the abortion. The majority did so because of trauma experiences unrelated to the induced abortion. Concomitant symptoms of depression and anxiety call for clinical alertness and support.

===Case Study of PTSD Treatment===
''The Assessment and Treatment of Post-Abortion Syndrome: A Systematic Case Study From Southern Africa'' Boulind M, Edward D. Journal of Psychology in Africa 2008 18(4); 539-548.

Abstract: This article reports a clinical case study of “Grace”, a black Zimbabwean woman with post-abortion syndrome (PAS), a form of post-traumatic stress disorder precipitated by aborting an unwanted pregnancy. She was treated by a middle class white South African trainee Clinical Psychologist. The case narrative documents the assessment and the course of treatment which was guided by ongoing case formulation based on current evidence-based models. Factors that made her vulnerable to developing PTSD included active suppression of the memory of the event and lack of social support. An understanding of these factors was used to guide an effective intervention. In spite of the differences in culture and background between client and therapist, there was considerable commonality in their experience as young women and students who each had to balance personal and occupational priorities. The narrative also highlights the commonalities of Grace’s experiences with those reported in the literature on post-abortion syndrome, which is mostly from the U. S. A. and Europe.

===Related Information===

''[http://www.ncbi.nlm.nih.gov/pubmed/25666812 How women perceive abortion care: A study focusing on healthy women and those with mental and posttraumatic stress.]''Wallin Lundell I1, Öhman SG, Sundström Poromaa I, Högberg U, Sydsjö G, Skoog Svanberg A. Eur J Contracept Reprod Health Care. 2015 Feb 9:1-12.

:Abstract: Objectives To identify perceived deficiencies in the quality of abortion care among healthy women and those with mental stress.
:Methods: This multi-centre cohort study included six obstetrics and gynaecology departments in Sweden. Posttraumatic stress (PTSD/PTSS) was assessed using the Screen Questionnaire-Posttraumatic Stress Disorder; anxiety and depressive symptoms, using the Hospital Anxiety Depression Scale; and abortion quality perceptions, using a modified version of the Quality from the Patient's Perspective questionnaire. Pain during medical abortion was assessed in a subsample using a visual analogue scale.
:Results: Overall, 16% of the participants assessed the abortion care as being deficient, and 22% experienced intense pain during medical abortion. Women with PTSD/PTSS more often perceived the abortion care as deficient overall and differed from healthy women in reports of deficiencies in support, respectful treatment, opportunities for privacy and rest, and availability of support from a significant person during the procedure. There was a marginally significant difference between PTSD/PTSS and the comparison group for insufficient pain alleviation.
:Conclusions: Women with PTSD/PTSS perceived abortion care to be deficient more often than did healthy women. These women do require extra support, relatively simple efforts to provide adequate pain alleviation, support and privacy during abortion may improve abortion care.

[http://www.biomedcentral.com/1472-6874/13/52 Posttraumatic stress among women after induced abortion: a Swedish multi-centre cohort study.] Wallin Lundell I, Georgsson Öhman S, Frans O, Helström L, Högberg U, Nyberg S, Sundström Poromaa I, Sydsjö G, Ostlund I, Skoog Svanberg A. BMC Womens Health. 2013 Dec 23;13(1):52.

:BACKGROUND: Induced abortion is a common medical intervention. Whether psychological sequelae might follow induced abortion has long been a subject of concern among researchers and little is known about the relationship between posttraumatic stress disorder (PTSD) and induced abortion. Thus, the aim of the study was to assess the prevalence of PTSD and posttraumatic stress symptoms (PTSS) before and at three and six months after induced abortion, and to describe the characteristics of the women who developed PTSD or PTSS after the abortion.

:METHODS: This multi-centre cohort study included six departments of Obstetrics and Gynaecology in Sweden. The study included 1457 women who requested an induced abortion, among whom 742 women responded at the three-month follow-up and 641 women at the six-month follow-up. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used for research diagnoses of PTSD and PTSS, and anxiety and depressive symptoms were evaluated by the Hospital Anxiety and Depression Scale (HADS). Measurements were made at the first visit and at three and six months after the abortion. The 95% confidence intervals for the prevalence of lifetime or ongoing PTSD and PTSS were calculated using the normal approximation. The chi-square test and the Student's t-test were used to compare data between groups.

:RESULTS: The prevalence of ongoing PTSD and PTSS before the abortion was 4.3% and 23.5%, respectively, concomitant with high levels of anxiety and depression. At three months the corresponding rates were 2.0% and 4.6%, at six months 1.9% and 6.1%, respectively. Dropouts had higher rates of PTSD and PTSS. Fifty-one women developed PTSD or PTSS during the observation period. They were young, less well educated, needed counselling, and had high levels of anxiety and depressive symptoms. During the observation period 57 women had trauma experiences, among whom 11 developed PTSD or PTSS and reported a traumatic experience in relation to the abortion.

:CONCLUSION: Few women developed PTSD or PTSS after the abortion. The majority did so because of trauma experiences unrelated to the induced abortion. Concomitant symptoms of depression and anxiety call for clinical alertness and support

:'''Reviewer Comments (Donna Harrison, MD)'''

:But what does the data in the paper actually demonstrate?
:“Response rates were 742/1381 (54%) at the three-month follow-up and 641/1381 (46%) at the six-month assessment (Figure 1).” So, less than half of the study respondents actually completed the study. Let’s look at these dropouts a little closer:

:“Dropouts at the three-month assessments were younger, more often born outside Sweden, had a lower level of education, reported tobacco use more often but less alcohol use, had more anxiety and depressive symptoms and were more often using antidepressant treatment. In addition, they had more often had a previous abortion and had less often received counselling before the abortion (Table 1), and they also had higher rates of lifetime PTSD, ongoing PTSD and PTSS at the baseline assessment than the responders (Table 2). Dropouts at the six month assessment had lower levels of education and had more often had a previous induced abortion (Table 1), but did not differ from responders in rates of lifetime PTSD, ongoing PTSD or PTSS (Table 2)”

:So, in the baseline assessment, prior to the abortion being studied, there is a subset of women who later became dropouts of this study. This subset of women, who had higher PTSD scores, more anxiety and depression, and were more often using antidepressants had one additional characteristic which distinguished them from the responders: “they had more often had a previous abortion”.

:A reasonable researcher might ask '''why the experience of a previous abortion would correlate with the presence of higher PTSD scores, more anxiety and depression and greater frequency of use of antidepressants BEFORE the abortion being studied'''.

:A reasonable researcher might also ask whether this loss of half of the study population might affect the statistical conclusions of the study.

:A reasonable researcher might also wonder why a 3month and 6 month follow up time interval was chosen for an outcome such as PTSD which has been well established to occur much later; years after the event? In fact, the “baseline” PTSD data, which collected information on abortion history BEFORE THE ABORTION IN THE STUDY, might actually shed more light on the long term psychological outcome, than a 3 and 6 month follow up.

:This study is an excellent illustration of what pro-abortion researchers call “Research for Advocacy” and what the rest of the world calls “spin”. As pro-life physicians, we are called to read further than the abstract and conclusion, and to really consider the scientific data being presented. We need to look at whether or not the data actually supports the published conclusions.

::Another analysis using the same data set was published by the same research team: "[http://www.ncbi.nlm.nih.gov/pubmed/23978220 The prevalence of posttraumatic stress among women requesting induced abortion.]"

''Posttraumatic stress disorder following medical illness and treatment.'' JE Tedstone, N Tarrier. Clin Psychol Rev. 2003 May;23(3):409-48.
:Studies describing posttraumatic stress disorder (PTSD) as a result of physical illness and its treatment were reviewed. PTSD was described in studies investigating myocardial infarction (MI), cardiac surgery, haemorrhage and stroke, childbirth, miscarriage, '''abortion''' and gynaecological procedures, intensive care treatment, human immunodeficiency virus (HIV) infection, awareness under anaesthesia, and in a group of miscellaneous conditions. Cancer medicine was not included as it had been the subject of a recent review in this journal. Studies were reviewed in terms of the prevalence rates for PTSD, intrusive and avoidance symptoms, predictive and associated factors and the consequences of PTSD on healthcare utilization and outcome.

''[http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.437 Which Medical Conditions Account For The Rise In Health Care Spending?]'' Kenneth E. Thorpe, Curtis S. Florence, Peter Joski. Health Affairs, 10.1377/hlthaff.w4.437
:Between 1987 and 2000, the 15 costliest medical conditions were heart disease, '''mental disorders,''' lung disease, cancer, trauma, high blood pressure, diabetes, back problems, arthritis, stroke and other brain blockages, skin disorders, pneumonia, infectious disease, hormone disorders, and kidney disease. For their study, Thorpe and colleagues used two U.S. government surveys -- the 1987 National Medical Expenditure Survey of 34,000 people and the 2000 Medical Expenditure Panel Survey of 25,000 people New patients accounted for 59 percent of the rise in spending on mental disorders, the report found. While mental disorders did not become more common, twice as many people sought treatment for them between 1987 and 2000.

[http://www.ncbi.nlm.nih.gov/pubmed/19115456 Prevalence and prediction of re-experiencing and avoidance after elective surgical abortion: a prospective study.] van Emmerik AA, Kamphuis JH, Emmelkamp PM. Clin Psychol Psychother. 2008 Nov-Dec;15(6):378-85. doi: 10.1002/cpp.586.

:OBJECTIVE: This study investigated short-term re-experiencing and avoidance after elective surgical abortion. In addition, it was prospectively investigated whether peritraumatic dissociation and pre-abortion dissociative tendencies and alexithymia predict re-experiencing and avoidance.
:METHOD: In a prospective observational design, Dutch-speaking women presenting for first trimester elective surgical abortion completed self-report measures for dissociative tendency and alexithymia. Peritraumatic dissociation was measured immediately post-abortion. Re-experiencing and avoidance were measured 2 months post-abortion.
:RESULTS: Participants reported moderately elevated levels of re-experiencing and avoidance that exceeded a clinical cut-off point for 19.4% of the participants. Peritraumatic dissociation predicted intrusion and avoidance at 2 months. In addition, avoidance was predicted by the alexithymic aspect of difficulty describing feelings.
:CONCLUSIONS: Re-experiencing and avoidance after elective surgical abortion represent a significant clinical problem that is predicted by peritraumatic dissociation and alexithymia. Psychological screening and intervention might be a useful adjunct to elective abortion procedures.

'''[http://www.ncbi.nlm.nih.gov/pubmed/19560116 Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months.]''' Korenromp MJ1, Page-Christiaens GC, van den Bout J, Mulder EJ, Visser GH. Am J Obstet Gynecol. 2009 Aug;201(2):160.e1-7. doi: 10.1016/j.ajog.2009.04.007. Epub 2009 Jun 26.Author information

:OBJECTIVE: We studied psychological outcomes and predictors for adverse outcome in 147 women 4, 8, and 16 months after termination of pregnancy for fetal anomaly.
:STUDY DESIGN: We conducted a longitudinal study with validated self-completed questionnaires.
:RESULTS: Four months after termination 46% of women showed pathological levels of posttraumatic stress symptoms, decreasing to 20.5% after 16 months. As to depression, these figures were 28% and 13%, respectively. Late onset of problematic adaptation did not occur frequently. Outcome at 4 months was the most important predictor of persistent impaired psychological outcome. Other predictors were low self-efficacy, high level of doubt during decision making, lack of partner support, being religious, and advanced gestational age. Strong feelings of regret for the decision were mentioned by 2.7% of women.
:CONCLUSION: Termination of pregnancy for fetal anomaly has significant psychological consequences for 20% of women up to > 1 year. Only few women mention feelings of regret.

'''[http://www.ncbi.nlm.nih.gov/pubmed/18468755 Abortion and anxiety: what's the relationship?]''' Steinberg JR1, Russo NF. Soc Sci Med. 2008 Jul;67(2):238-52. doi: 10.1016/j.socscimed.2008.03.033. Epub 2008 May 28.

:"[M]ultiple abortions were found to be associated with much higher rates of PTSD and social anxiety," though the author, pro-choice activits, insist "this relationship was largely explained by pre-pregnancy mental health disorders and their association with higher rates of violence."

===Systematic Reviews===

'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334933/ Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review.]''' Daugirdaitė V, van den Akker O, Purewal S. J Pregnancy. 2015;2015:646345. doi: 10.1155/2015/646345. Epub 2015 Feb 5.

:OBJECTIVE: The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF).

:METHODS:Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines.

:RESULTS: Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss.

:CONCLUSIONS: This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

== Moral Injury ==
[https://pubmed.ncbi.nlm.nih.gov/41208181/ Is termination of a desired pregnancy due to possible fetal abnormalities a case of moral injury? A preliminary report.] Sartel-Raviv S, Levi-Belz Y, Bar V, Zerach G. Death Stud. 2025 Nov 9:1-11. doi: 10.1080/07481187.2025.2585935. Epub ahead of print. PMID: 41208181.

<blockquote>Abstract

Termination of pregnancy (TOP) due to possible fetal abnormalities is known to be associated with various mental health problems. This study examines associations between potentially morally injurious events (PMIEs), moral injury outcomes (MI), posttraumatic stress disorder (PTSD), and prolonged grief (PG) among treatment-seeking women following late pregnancy loss. A volunteer sample of (''n'' = 132) Israeli women who attended a reproductive psychiatry clinic following TOP (''n'' = 99) or pregnancy loss due to intrauterine fetal demise (IUFD; ''n'' = 33), responded to self-report questionnaires in a cross-sectional, comparative study. Results show that among participants in the TOP group, PMIEs-self predicted MI outcomes of shame, and PMIEs-betrayal predicted MI outcomes of trust violation. Importantly, following exposure to PMIE-self, MI outcomes of trust violation significantly predicted both PTSD and PG symptoms. This study emphasized that TOP due to possible fetal abnormalities, may constitute a morally injurious experience, highlighting the need for clinical interventions addressing MI.</blockquote>

==Sleep Disorders==

Sleep disorders are associated with PTSD and increased risk of suicide See [[Sleep Disorders]]

Mifepristone

2026-01-27T19:12:18Z

Barb:

== Mifepristone is also known as RU-486, the abortion pill, medical abortion, or chemical abortion ==
'''[https://pubmed.ncbi.nlm.nih.gov/36592459/ Short-Term Adverse Outcomes After Mifepristone-Misoprostol Versus Procedural Induced Abortion : A Population-Based Propensity-Weighted Study]. Liu, N., & Ray, J. G. (2023). ''Annals of Internal Medicine'', ''176''(2). <nowiki>https://doi.org/10.7326/M22-2568</nowiki>'''<blockquote>'''Background:''' Prior studies comparing first-trimester pharmaceutical induced abortion (IA) with procedural IA were prone to selection bias, were underpowered to assess serious adverse events (SAEs), and did not account for confounding by indication. Starting in 2017, mifepristone-misoprostol was dispensed at no cost in outpatient pharmacies across Ontario, Canada.

'''Objective:''' To compare short-term risk for adverse outcomes after early IA by mifepristone-misoprostol versus by procedural IA.

'''Design:''' Population-based cohort study.

'''Setting:''' Ontario, Canada.

'''Patients:''' All women who had first-trimester IA.

'''Measurements:''' A total of 39 856 women dispensed mifepristone-misoprostol as outpatients were compared with 65 176 women undergoing procedural IA at 14 weeks' gestation or earlier within nonhospital outpatient clinics (comparison 1). A total of 39 856 women prescribed mifepristone-misoprostol were compared with 8861 women undergoing ambulatory hospital-based procedural IA at an estimated 9 weeks' gestation or less (comparison 2). The primary composite outcome was any SAE within 42 days after IA, including severe maternal morbidity, end-organ damage, intensive care unit admission, or death. A coprimary broader outcome comprised any SAE, hemorrhage, retained products of conception, infection, or transfusion. Stabilized inverse probability of treatment weighting accounted for confounding between exposure groups.

'''Results:''' Mean age at IA was about 29 years (SD, 7); 33% were primigravidae. Six percent resided in rural areas, and 25% resided in low-income neighborhoods. In comparison 1, SAEs occurred among 133 women after mifepristone-misoprostol IA (3.3 per 1000) versus 114 after procedural IA (1.8 per 1000) (relative risk [RR], 1.87 [95% CI, 1.44 to 2.43]; absolute risk difference [ARD], 1.5 per 1000 [CI, 0.9 to 2.2]). The respective rates of any adverse event were 28.9 versus 12.4 per 1000 (RR, 2.33 [CI, 2.11 to 2.57]; ARD, 16.5 per 1000 [CI, 14.5 to 18.4]). In comparison 2, SAEs occurred among 133 (3.4 per 1000) and 27 (3.3 per 1000) women, respectively (RR, 1.04 [CI, 0.61 to 1.78]). The respective rates of any adverse event were 31.2 versus 24.9 per 1000 (RR, 1.25 [CI, 1.04 to 1.51]).

'''Limitation:''' A woman prescribed mifepristone-misoprostol may not have taken the medication, and the exact gestational age at IA was not always known.

'''Conclusion:''' Although rare, short-term adverse events are more likely after mifepristone-misoprostol IA than procedural IA, especially for less serious adverse outcomes.</blockquote>
'''[http://www.frcblog.com/wp-content/uploads/2011/05/Australian-AERs_RU486_201105mulligan.pdf Mifepristone in South Australia] Mulligan E, Messenger H. Australian Family Physician. MAY 2011.'''
: The study found 3.3% of the women who used RU-486 in the first trimester of pregnancy reported to an emergency room compared with 2.2% who used a surgical method and •5.7% of the women who used RU-486 had to be re-admitted to hospitals compared with 0.4% of surgical abortion patients.
:
'''[https://lozierinstitute.org/wp-content/uploads/2021/12/Unwanted-Abortions-Unnecessary-Abortions-Unsafe-Abortions-1.pdf Overlooked Dangers of Mifepristone, the FDA’s Reduced REMS, and Self-Managed Abortion Policies: Unwanted Abortions, Unnecessary Abortions, Unsafe Abortions.] Reardon, David C., et al. ''American Report Series'' 20 (2021).'''
: It has been argued that abortions induced with mifepristone and misoprostol (or even misoprostol alone) are so safe and efficacious that they can be self-prescribed and self-managed, As a step toward this goal, some have advocated for elimination of the FDA requirements which limit the ability to prescribe mifepristone to any healthcare provider prepared to: (a) accurately assess the gestational age of the pregnancy, (b) diagnose ectopic pregnancies, and (c) provide referrals for surgical intervention in cases of severe bleeding or incomplete abortion. These arguments for reducing or eliminating physician oversight of chemical abortions are based on four premises. First, abortion is a human right that advances the equality, wellbeing, and self-determination of women. Second, the risks of mifepristone/misoprostol abortions are negligible. Third, self-managed abortions are an effective means by which women can control their reproductive lives and achieve their goals. Fourth, physician oversight is unnecessary and counterproductive. If these four premises are true, they present a strong basis for allowing the purchase of mifepristone/misoprostol as an over-the-counter drug. In the discussion which follows, we will show that the four premises above are, in fact, contradicted by real world experience and the best available medical evidence. The first premise is ideological and not supported by data. As a counterargument, we will show that that chemical abortion is often used contrary to women’s self-determination and best interests. The second premise is based primarily on research performed by authors with significant ideological and financial conflicts of interest and entanglement with the manufacturer of mifepristone. Moreover, the FDA has failed to require any systematic investigation of complications associated with mifepristone. Our counterargument will summarize a substantial body of studies documenting detailed evidence of physical and psychological complications associated with chemical abortions, which have simply been ignored, not disproven, by mifepristone advocates. The third premise, that chemical abortions are efficacious, is also ideological and unsupported by any meaningful data. Our counterargument will demonstrate that the actual objectives of women undergoing abortions are not being met, much less reliably quantified. The fourth premise, asserting that physician oversight of chemical abortions is unnecessary is also ideologically driven and unsupported by reliable evidence. Our counterargument will demonstrate that the role of physicians in pre-abortion screening, medical administration, and follow-up should be increased, not eliminated. We conclude with recommendations for modifying FDA’s current Risk Evaluation and Mitigation Strategy [REMS] applicable to mifepristone in order to provide better data.
:

'''[https://pubmed.ncbi.nlm.nih.gov/38777160/ Medication and procedural abortions before 13 weeks gestation and risk of psychiatric disorders.] Steinberg, J. R., Laursen, T. M., Lidegaard, Ø., & Munk-Olsen, T. (2024).''American Journal of Obstetrics and Gynecology'', ''231''(4), 437.e1-437.e18. <nowiki>https://doi.org/10.1016/J.AJOG.2024.05.025</nowiki>'''<blockquote>'''Background:''' The proportion of abortions provided by medication in the United States and worldwide has increased greatly since the U.S. Food and Drug Administration approved mifepristone in 2000. While existing research has shown that abortion does not increase risk of mental health problems, no population-based study has examined specifically whether a procedural or medication abortion increases risk of mental health disorders.

'''Objective:''' This study examined whether mental health disorders increased in the shorter and longer-term after a medication or procedural abortion.

'''Study design:''' Using Danish population registers' data, we conducted a prospective cohort study in which we included 72,424 females born in Denmark between 1980 and 2006, who were ages 12 to 38 during the study period and had a first first-trimester abortion before 13 weeks gestation in 2000 to 2018. Females with no previous psychiatric diagnoses were followed from 1 year before their abortion until their first psychiatric diagnosis, December 31, 2018, emigration from Demark, or death, whichever came first. Risk of any first psychiatric disorder was defined as a recorded psychiatric diagnosis at an in- or out-patient facility from the 1 year after to more than 5 years after a medication or procedural abortion relative to the year beforehand. Results were adjusted for calendar year, age, gestational age, partner status, prior mental and physical health, childbirth history, childhood environment, and parental mental health history.

'''Results:''' Females having medication (n=37,155) and procedural abortions (n=35,269) had the same risk of any first psychiatric diagnosis in the year after their abortion relative to the year before their abortion (medication abortion adjusted incidence rate ratio [MaIRR]=1.02, 95% confidence interval [CI]: 0.93-1.12; procedural abortion adjusted incidence rate ratio [PaIRR]=0.94, 95% CI: 0.86-1.02). Moreover, as more time from the abortion passed, the risk of a psychiatric diagnoses decreased relative to the year before their abortion for each abortion method (MaIRR 1-2 years after=0.89, 95% CI: 0.80-0.98; PaIRR 1-2 years after=0.81, 95% CI: 0.88-1.05; MaIRR 2-5 years after=0.77, 95% CI: 0.71-0.84; PaIRR 2-5 years after=0.72, 95% CI: 0.67-0.78; MaIRR 5+ years after=0.58, 95% CI: 0.53-0.63; PaIRR 5+ years after=0.54, 95% CI: 0.50-0.58).

'''Conclusion:''' Because the risk of psychiatric diagnoses was the same in the year after relative to the year before a medication and procedural abortion and the risk did not increase as more time after the abortion increased, neither abortion method increased risk of mental health disorders in the shorter or longer-term.</blockquote>

'''[https://pubmed.ncbi.nlm.nih.gov/34778493/ A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999-2015.]''' '''Health Serv Res Manag Epidemiol. 2021 Nov 9;8:23333928211053965. doi: 10.1177/23333928211053965.''' <blockquote>
'''Introduction:''' Existing research on postabortion emergency room visits is sparse and limited by methods which underestimate the incidence of adverse events following abortion. Postabortion emergency room (ER) use since Food and Drug Administration approval of chemical abortion in 2000 can identify trends in the relative morbidity burden of chemical versus surgical procedures.

'''Objective:''' To complete the first longitudinal cohort study of postabortion emergency room use following chemical and surgical abortions.

'''Methods:''' A population-based longitudinal cohort study of 423 000 confirmed induced abortions and 121,283 subsequent ER visits occurring within 30 days of the procedure, in the years 1999-2015, to Medicaid-eligible women over 13 years of age with at least one pregnancy outcome, in the 17 states which provided public funding for abortion.

'''Results:''' ER visits are at greater risk to occur following a chemical rather than a surgical abortion: all ER visits (OR 1.22, CL 1.19-1.24); miscoded spontaneous (OR 1.88, CL 1.81-1.96); and abortion-related (OR 1.53, CL 1.49-1.58). ER visit rates per 1000 abortions grew faster for chemical abortions, and by 2015, chemical versus surgical rates were 354.8 versus 357.9 for all ER visits; 31.5 versus 8.6 for miscoded spontaneous abortion visits; and 51.7 versus 22.0 for abortion-related visits. Abortion-related visits as a percent of total visits are twice as high for chemical abortions, reaching 14.6% by 2015. Miscoded spontaneous abortion visits as a percent of total visits are nearly 4 times as high for chemical abortions, reaching 8.9% of total visits and 60.9% of abortion-related visits by 2015.

'''Conclusion:''' The incidence and per-abortion rate of ER visits following any induced abortion are growing, but chemical abortion is consistently and progressively associated with more postabortion ER visit morbidity than surgical abortion. There is also a distinct trend of a growing number of women miscoded as receiving treatment for spontaneous abortion in the ER following a chemical abortion.</blockquote>
'''[https://pubmed.ncbi.nlm.nih.gov/35633832/ A Post Hoc Exploratory Analysis: Induced Abortion Complications Mistaken for Miscarriage in the Emergency Room are a Risk Factor for Hospitalization]. Studnicki J, Longbons T, Harrison DJ, Skop I, Cirucci C, Reardon DC, Craver C, Fisher JW, Tsulukidze M. Health Serv Res Manag Epidemiol. 2022 May 20;9:23333928221103107. doi: 10.1177/23333928221103107.''' <blockquote>
'''Introduction:''' Previous research indicates that an increasing number of women who go to an emergency room for complications following an induced abortion are treated for a miscarriage, meaning their abortion is miscoded or concealed.

'''Objective:''' To determine if the failure to identify a prior induced abortion during an ER visit is a risk factor for higher rates of subsequent hospitalization.

'''Methods:''' Post hoc analysis of hospital admissions following an induced abortion and ER visit within 30 days: 4273 following surgical abortion and 408 following chemical abortion; abortion not miscoded versus miscoded or concealed at prior ER visit.

'''Results:''' Chemical abortion patients whose abortions are misclassified as miscarriages during an ER visit subsequently experience on average 3.2 hospital admissions within 30 days. 86% of the patients ultimately have surgical removal of retained products of conception (RPOC). Chemical abortions are more likely than surgical abortions (OR 1.80, CL 1.38-2.35) to result in an RPOC admission, and chemical abortions concealed are more likely to result (OR 2.18, CL 1.65-2.88) in a subsequent RPOC admission than abortions without miscoding. Surgical abortions miscoded/concealed are similarly twice as likely to result in hospital admission than those without miscoding.

'''Conclusion:''' Patient concealment and/or physician failure to identify a prior abortion during an ER visit is a significant risk factor for a subsequent hospital admission. Patients and ER personnel should be made aware of this risk.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/23090524/ Extending outpatient medical abortion services through 70 days of gestational age.] Winikoff B, Dzuba IG, Chong E, Goldberg AB, Lichtenberg ES, Ball C, Dean G, Sacks D, Crowden WA, Swica Y. Obstet Gynecol. 2012 Nov;120(5):1070-6. doi: 10.1097/aog.0b013e31826c315f. PMID: 23090524.'''<blockquote>'''Objective:''' To estimate the efficacy and acceptability of medical abortion at 64-70 days from last menstrual period (LMP) and to compare it with the already proven 57-63 days from LMP gestational age range.

'''Methods:''' This prospective, comparative, open-label trial enrolled 729 women with pregnancies 57-70 days from LMP requesting abortion at six U.S. clinics. Medical abortions were managed with 200 mg mifepristone and 800 micrograms buccal misoprostol and sites' service delivery protocols. Follow-up visits occurred 7-14 days after mifepristone, with an abortion considered complete if surgical intervention was not performed. Success, ongoing pregnancy, and acceptability rates were compared.

'''Results:''' A total of 629 cases were analyzable for efficacy. Success rates were similar in the two groups (57-63 days group: 93.5%, 95% confidence interval [CI] 90-96; 64-70 days group: 92.8%, 95% CI 89-95). Ongoing pregnancy rates also did not differ significantly (57-63 days: '''3.1%''', 95% CI 1.6-5.8; 64-70 days: '''3.0%''', 95% CI 1.5-5.7). Acceptability was high and similar in both arms, with most women (57-63 days: 87.4%; 64-70 days: 88.3%) reporting that their experience was either very satisfactory or satisfactory.

'''Conclusion:''' Medical abortion with mifepristone and misoprostol in current outpatient settings is an efficacious and acceptable method of ending pregnancies 64-70 days from LMP and can be offered without alteration of existing services.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/22240172/ Risk factors of surgical evacuation following second-trimester medical termination of pregnancy.] Mentula M, Heikinheimo O. Contraception. 2012 Aug;86(2):141-6. doi: 10.1016/j.contraception.2011.11.070. Epub 2012 Jan 10. PMID: 22240172.'''<blockquote>'''Background:''' Second-trimester medical termination of pregnancy (TOP) is associated with a higher risk of surgical evacuation than earlier medical TOP. Little is known about risk factors of surgical evacuation. Therefore, we assessed these risk factors among women undergoing second-trimester medical TOP.

'''Study design:''' Data on 227 women were derived from a prospective randomized trial comparing 1- and 2-day mifepristone-misoprostol intervals in second-trimester medical TOP between 2008 and 2010.

'''Results:''' The rate of surgical evacuation was 30.8%. The risk of surgical evacuation was increased by a history of curettage [odds ratio (OR) 4.4; 95% confidence interval (CI) 1.7-11.7], fetal indications for TOP (OR 6.1; 95% CI 1.1-34.4), age above 24 years (OR 2.4; 95% CI 1.1-5.3) and a 2-day interval (OR 2.2; 95% CI 1.1-4.1).

'''Conclusions:''' History of curettage, fetal indication, increasing age and 2-day interval between mifepristone and misoprostol increase the risk of surgical evacuation in cases of second-trimester medical TOP. These findings are important when optimizing clinical service in second-trimester TOP.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/21317416/ Immediate adverse events after second trimester medical termination of pregnancy: results of a nationwide registry study.] Mentula MJ, Niinimäki M, Suhonen S, Hemminki E, Gissler M, Heikinheimo O. Hum Reprod. 2011 Apr;26(4):927-32. doi: 10.1093/humrep/der016. Epub 2011 Feb 11. PMID: 21317416.'''<blockquote>'''BACKGROUND''' Increasing gestational age is associated with an increased risk of complications in studies assessing surgical termination of pregnancy (TOP). Medical TOP is widely used during the second trimester and little is known about the frequency of complications. This epidemiological study was undertaken to assess the frequency of adverse events following the second trimester medical TOP and to compare it with that after first trimester medical TOP.

'''METHODS''' This register-based cohort study covered 18 248 women who underwent medical TOP in Finland between 1 January 2003 and 31 December 2006. The women were identified from the Abortion Registry. Adverse events related to medical TOP within 6 weeks were obtained from the Hospital Discharge Registry.

'''RESULTS''' When compared with first trimester medical TOP, second trimester medical TOP increased the risk of surgical evacuation [Adj. odds ratio (OR) 7.8; 95% confidence interval (CI) 6.8-8.9], especially immediately after fetal expulsion (Adj. OR 15.2; 95% CI 12.8-18.0). The risk of infection was also elevated (Adj. OR 2.1; 95% CI 1.5-2.9). Within the second trimester, increased length of gestation did not influence the risk of surgical evacuation or infection after medical TOP.

'''CONCLUSIONS''' Medical TOP during the second trimester is generally safe. Surgical evacuation of the uterus is avoided in about two-thirds of cases, though it is much more common than after first trimester medical TOP. The risks of surgical evacuation and infection do not increase with gestational weeks in the second trimester TOP.</blockquote>

'''[https://pubmed.ncbi.nlm.nih.gov/19888037/ Immediate complications after medical compared with surgical termination of pregnancy.] Niinimäki M, Pouta A, Bloigu A, Gissler M, Hemminki E, Suhonen S, Heikinheimo O. Obstet Gynecol. 2009 Oct;114(4):795-804. doi: 10.1097/AOG.0b013e3181b5ccf9. PMID: 19888037.'''<blockquote>'''Objective:''' To estimate the immediate adverse events and safety of medical compared with surgical abortion using high-quality registry data.

'''Methods:''' All women in Finland undergoing induced abortion from 2000-2006 with a gestational duration of 63 days or less (n=42,619) were followed up until 42 days postabortion using national health registries. The incidence and risk factors of adverse events after medical (n=22,368) and surgical (n=20,251) abortion were compared. Univariable and multivariable association models were used to analyze the risk of the three main complications (hemorrhage, infection, and incomplete abortion) and surgical (re)evacuation.

'''Results:''' The overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort (20.0% compared with 5.6%, P<.001). Hemorrhage (15.6% compared with 2.1%, P<.001) and incomplete abortion (6.7% compared with 1.6%, P<.001) were more common after medical abortion. The rate of surgical (re)evacuation was 5.9% after medical abortion and 1.8% after surgical abortion (P<.001). Although rare, injuries requiring operative treatment or operative complications occurred more often with surgical termination of pregnancy (0.6% compared with 0.03%, P<.001). No differences were noted in the incidence of infections (1.7% compared with 1.7%, P=.85), thromboembolic disease, psychiatric morbidity, or death.

'''Conclusion:''' Both methods of abortion are generally safe, but medical termination is associated with a higher incidence of adverse events. These observations are relevant when counseling women seeking early abortion.</blockquote>

'''" Pain control in medical abortion", E Wiebe, Int'l J Gynecology & Obstetrics 74:275-280,2001'''

:A Canadian study of abortion procedures using methotrexate and misoprostol reported that the mean pain
Score was 6.2 on a scale from 1-10. Severe pain (scores of 9 or 10) was reported by 23.4% of the women.
Women experiencing severe pain were more likely to have a lower maternal age, lower parity, higher
anxiety and depression, and less satisfaction with the procedure. The authors reported that pain medication
given before the onset of the procedure did not reduce the amount of severe pain.

:

'''[http://www.frcblog.com/wp-content/uploads/2011/05/Australian-AERs_RU486_201105mulligan.pdf Mifepristone in South Australia] Mulligan E, Messenger H. Australian Family Physician. MAY 2011.'''
:The study found 3.3% of the women who used RU-486 in the first trimester of pregnancy reported to an emergency room compared with 2.2% who used a surgical method and •5.7% of the women who used RU-486 had to be re-admitted to hospitals compared with 0.4% of surgical abortion patients.
[http://www.lifenews.com/2011/05/10/study-high-of-women-using-abortion-drug-hospitalized/ Additional information ]
:

'''Psychological distress symptoms in women undergoing medical vs. surgical termination of pregnancy. Lowenstein L, Deutcsh M, Gruberg R, Solt I, Yagil Y, Nevo O, et al. (2006), General Hospital Psychiatry, 28(1):43–47.'''
:Compared to women choosing surgical abortion, those choosing chemical abortion had higher obsessive-compulsive symptoms, higher levels of guilt, higher interpersonal sensitivity scores, more paranoid ideation, and more general psychiatric symptoms.

'''A comparison of medical and surgical methods of termination of pregnancy: Choice, psychological consequences, and satisfaction with care. Slade, P., Heke, S., Fletcher, J., & Stewart, P. (1998). British Journal of Obstetrics and Gynecology, 105, 1288-1295.'''
:Those who had a medical abortion rated it as more stressful and experienced more disruption in their lives. “One of the main differences between these two methods of termination is the consciousness and participation of the patient in the medical procedure in a process that involves blood, pain, and death.”

'''Patient preference in a randomized study comparing medical and surgical abortion at 10-13 weeks gestation. Ashok P.W., Hamoda, H., Flett, G. M. M., Kidd, A., Fitzmaurice, A., Templeton, A. (2005). Contraception, 71, 143-148.'''
:46.8% of women undergoing a medical abortion experienced a significant decline in self-esteem 2-3 weeks following the abortion. This was a higher percentage than among those who had a surgical abortion (39.5%).

'''Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomized controlled trial, Kelly, T., Suddes, J., Howel, D., Hewison, J., & Robson, S. (2010). BJOG, 117, 1512-20.'''
:Women who had chemical abortions had higher PTSD intrusion scores, such as nightmares, than women who had surgical abortions

'''''Posttraumatic Stress Disorder and psychological distress following medical and surgical abortion.''''' C. Rousset, C. Brulfert, N. Séjourné, N. Goutaudier & H. Chabrol Journal of Reproductive and Infant Psychology, (2011) Volume 29(5), 506-517.

: Method: Eighty-six women were approached a few hours after the abortion and then 6 weeks later. Several questionnaires were completed: the Impact of Event Scale Revised (IES-R), the Multidimensional Scale of Social Support (MSPSS), the Peritraumatic Dissociative Experience Questionnaire (PDEQ), the Peritraumatic Emotions List (PEL), the Hospital Anxiety and Depression Scale (HADS), the Perinatal Grief Scale (PGS) and the Texas Grief Inventory (TGI). Results: Six weeks after the abortion, 38% of women reported a potential PTSD and a significant decrease of the anxious symptomatology was also highlighted. Peritraumatic dissociation and peritraumatic emotions were the main predictors of the intensity of post-abortum PTSD symptoms. Compared to surgical abortion, medical abortion was associated with increasing the risk of developing a possible PTSD. Conclusion: By providing evidence on some of the main risk factors, this study highlights the need for psychological support for women and strategies of prevention to be developed.

''' 
[http://www.lifenews.com/2014/12/03/doctor-saves-106-babies-after-the-abortion-has-already-started-wait-until-you-see-how/ Abortion Pill Reversal can be successful]'''
:Article regarding a medical protocol for women who change their minds to stop the RU-486 induced abortion.
'''[http://www.nejm.org/doi/full/10.1056/NEJMc1001014 Fatal Clostridium sordellii Infections after Medical Abortions] N Engl J Med 2010; 363:1382-1383September 30, 2010'''
:Clostridial toxic shock is a rare and largely fatal syndrome among reproductive-age women. Eight cases were reported after medical abortions using mifepristone and misoprostol between 2000 and 2009 bringing the risk of clostridial toxic shock to 0.58 per 100,000 medical abortions.
[http://www.lifenews.com/2014/12/03/doctor-saves-106-babies-after-the-abortion-has-already-started-wait-until-you-see-how/ Abortion Pill Reversal can be successful]

: Article regarding a medical protocol for women who change their minds to stop the RU-486 induced abortion.

'''" Pain control in medical abortion", E Wiebe, Int'l J Gynecology & Obstetrics 74:275-280,2001'''

A Canadian study of abortion procedures using methotrexate and misoprostol reported that the mean pain Score was 6.2 on a scale from 1-10. Severe pain (scores of 9 or 10) was reported by 23.4% of the women. Women experiencing severe pain were more likely to have a lower maternal age, lower parity, higher anxiety and depression, and less satisfaction with the procedure. The authors reported that pain medication given before the onset of the procedure did not reduce the amount of severe pain.

:

[http://www.lifenews.com/2011/05/10/study-high-of-women-using-abortion-drug-hospitalized/ Additional information]

Mifepristone

2026-01-23T20:35:57Z

Barb:

== Mifepristone is also known as RU-486, the abortion pill, medical abortion, or chemical abortion ==
'''[https://pubmed.ncbi.nlm.nih.gov/36592459/ Short-Term Adverse Outcomes After Mifepristone-Misoprostol Versus Procedural Induced Abortion : A Population-Based Propensity-Weighted Study]. Liu, N., & Ray, J. G. (2023). ''Annals of Internal Medicine'', ''176''(2). <nowiki>https://doi.org/10.7326/M22-2568</nowiki>'''<blockquote>'''Background:''' Prior studies comparing first-trimester pharmaceutical induced abortion (IA) with procedural IA were prone to selection bias, were underpowered to assess serious adverse events (SAEs), and did not account for confounding by indication. Starting in 2017, mifepristone-misoprostol was dispensed at no cost in outpatient pharmacies across Ontario, Canada.

'''Objective:''' To compare short-term risk for adverse outcomes after early IA by mifepristone-misoprostol versus by procedural IA.

'''Design:''' Population-based cohort study.

'''Setting:''' Ontario, Canada.

'''Patients:''' All women who had first-trimester IA.

'''Measurements:''' A total of 39 856 women dispensed mifepristone-misoprostol as outpatients were compared with 65 176 women undergoing procedural IA at 14 weeks' gestation or earlier within nonhospital outpatient clinics (comparison 1). A total of 39 856 women prescribed mifepristone-misoprostol were compared with 8861 women undergoing ambulatory hospital-based procedural IA at an estimated 9 weeks' gestation or less (comparison 2). The primary composite outcome was any SAE within 42 days after IA, including severe maternal morbidity, end-organ damage, intensive care unit admission, or death. A coprimary broader outcome comprised any SAE, hemorrhage, retained products of conception, infection, or transfusion. Stabilized inverse probability of treatment weighting accounted for confounding between exposure groups.

'''Results:''' Mean age at IA was about 29 years (SD, 7); 33% were primigravidae. Six percent resided in rural areas, and 25% resided in low-income neighborhoods. In comparison 1, SAEs occurred among 133 women after mifepristone-misoprostol IA (3.3 per 1000) versus 114 after procedural IA (1.8 per 1000) (relative risk [RR], 1.87 [95% CI, 1.44 to 2.43]; absolute risk difference [ARD], 1.5 per 1000 [CI, 0.9 to 2.2]). The respective rates of any adverse event were 28.9 versus 12.4 per 1000 (RR, 2.33 [CI, 2.11 to 2.57]; ARD, 16.5 per 1000 [CI, 14.5 to 18.4]). In comparison 2, SAEs occurred among 133 (3.4 per 1000) and 27 (3.3 per 1000) women, respectively (RR, 1.04 [CI, 0.61 to 1.78]). The respective rates of any adverse event were 31.2 versus 24.9 per 1000 (RR, 1.25 [CI, 1.04 to 1.51]).

'''Limitation:''' A woman prescribed mifepristone-misoprostol may not have taken the medication, and the exact gestational age at IA was not always known.

'''Conclusion:''' Although rare, short-term adverse events are more likely after mifepristone-misoprostol IA than procedural IA, especially for less serious adverse outcomes.</blockquote>
'''[http://www.frcblog.com/wp-content/uploads/2011/05/Australian-AERs_RU486_201105mulligan.pdf Mifepristone in South Australia] Mulligan E, Messenger H. Australian Family Physician. MAY 2011.'''
: The study found 3.3% of the women who used RU-486 in the first trimester of pregnancy reported to an emergency room compared with 2.2% who used a surgical method and •5.7% of the women who used RU-486 had to be re-admitted to hospitals compared with 0.4% of surgical abortion patients.
:
'''[https://lozierinstitute.org/wp-content/uploads/2021/12/Unwanted-Abortions-Unnecessary-Abortions-Unsafe-Abortions-1.pdf Overlooked Dangers of Mifepristone, the FDA’s Reduced REMS, and Self-Managed Abortion Policies: Unwanted Abortions, Unnecessary Abortions, Unsafe Abortions.] Reardon, David C., et al. ''American Report Series'' 20 (2021).'''
: It has been argued that abortions induced with mifepristone and misoprostol (or even misoprostol alone) are so safe and efficacious that they can be self-prescribed and self-managed, As a step toward this goal, some have advocated for elimination of the FDA requirements which limit the ability to prescribe mifepristone to any healthcare provider prepared to: (a) accurately assess the gestational age of the pregnancy, (b) diagnose ectopic pregnancies, and (c) provide referrals for surgical intervention in cases of severe bleeding or incomplete abortion. These arguments for reducing or eliminating physician oversight of chemical abortions are based on four premises. First, abortion is a human right that advances the equality, wellbeing, and self-determination of women. Second, the risks of mifepristone/misoprostol abortions are negligible. Third, self-managed abortions are an effective means by which women can control their reproductive lives and achieve their goals. Fourth, physician oversight is unnecessary and counterproductive. If these four premises are true, they present a strong basis for allowing the purchase of mifepristone/misoprostol as an over-the-counter drug. In the discussion which follows, we will show that the four premises above are, in fact, contradicted by real world experience and the best available medical evidence. The first premise is ideological and not supported by data. As a counterargument, we will show that that chemical abortion is often used contrary to women’s self-determination and best interests. The second premise is based primarily on research performed by authors with significant ideological and financial conflicts of interest and entanglement with the manufacturer of mifepristone. Moreover, the FDA has failed to require any systematic investigation of complications associated with mifepristone. Our counterargument will summarize a substantial body of studies documenting detailed evidence of physical and psychological complications associated with chemical abortions, which have simply been ignored, not disproven, by mifepristone advocates. The third premise, that chemical abortions are efficacious, is also ideological and unsupported by any meaningful data. Our counterargument will demonstrate that the actual objectives of women undergoing abortions are not being met, much less reliably quantified. The fourth premise, asserting that physician oversight of chemical abortions is unnecessary is also ideologically driven and unsupported by reliable evidence. Our counterargument will demonstrate that the role of physicians in pre-abortion screening, medical administration, and follow-up should be increased, not eliminated. We conclude with recommendations for modifying FDA’s current Risk Evaluation and Mitigation Strategy [REMS] applicable to mifepristone in order to provide better data.
:

'''[https://pubmed.ncbi.nlm.nih.gov/38777160/ Medication and procedural abortions before 13 weeks gestation and risk of psychiatric disorders.] Steinberg, J. R., Laursen, T. M., Lidegaard, Ø., & Munk-Olsen, T. (2024).''American Journal of Obstetrics and Gynecology'', ''231''(4), 437.e1-437.e18. <nowiki>https://doi.org/10.1016/J.AJOG.2024.05.025</nowiki>'''<blockquote>'''Background:''' The proportion of abortions provided by medication in the United States and worldwide has increased greatly since the U.S. Food and Drug Administration approved mifepristone in 2000. While existing research has shown that abortion does not increase risk of mental health problems, no population-based study has examined specifically whether a procedural or medication abortion increases risk of mental health disorders.

'''Objective:''' This study examined whether mental health disorders increased in the shorter and longer-term after a medication or procedural abortion.

'''Study design:''' Using Danish population registers' data, we conducted a prospective cohort study in which we included 72,424 females born in Denmark between 1980 and 2006, who were ages 12 to 38 during the study period and had a first first-trimester abortion before 13 weeks gestation in 2000 to 2018. Females with no previous psychiatric diagnoses were followed from 1 year before their abortion until their first psychiatric diagnosis, December 31, 2018, emigration from Demark, or death, whichever came first. Risk of any first psychiatric disorder was defined as a recorded psychiatric diagnosis at an in- or out-patient facility from the 1 year after to more than 5 years after a medication or procedural abortion relative to the year beforehand. Results were adjusted for calendar year, age, gestational age, partner status, prior mental and physical health, childbirth history, childhood environment, and parental mental health history.

'''Results:''' Females having medication (n=37,155) and procedural abortions (n=35,269) had the same risk of any first psychiatric diagnosis in the year after their abortion relative to the year before their abortion (medication abortion adjusted incidence rate ratio [MaIRR]=1.02, 95% confidence interval [CI]: 0.93-1.12; procedural abortion adjusted incidence rate ratio [PaIRR]=0.94, 95% CI: 0.86-1.02). Moreover, as more time from the abortion passed, the risk of a psychiatric diagnoses decreased relative to the year before their abortion for each abortion method (MaIRR 1-2 years after=0.89, 95% CI: 0.80-0.98; PaIRR 1-2 years after=0.81, 95% CI: 0.88-1.05; MaIRR 2-5 years after=0.77, 95% CI: 0.71-0.84; PaIRR 2-5 years after=0.72, 95% CI: 0.67-0.78; MaIRR 5+ years after=0.58, 95% CI: 0.53-0.63; PaIRR 5+ years after=0.54, 95% CI: 0.50-0.58).

'''Conclusion:''' Because the risk of psychiatric diagnoses was the same in the year after relative to the year before a medication and procedural abortion and the risk did not increase as more time after the abortion increased, neither abortion method increased risk of mental health disorders in the shorter or longer-term.</blockquote>

'''[https://pubmed.ncbi.nlm.nih.gov/34778493/ A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999-2015.]''' '''Health Serv Res Manag Epidemiol. 2021 Nov 9;8:23333928211053965. doi: 10.1177/23333928211053965.''' <blockquote>
'''Introduction:''' Existing research on postabortion emergency room visits is sparse and limited by methods which underestimate the incidence of adverse events following abortion. Postabortion emergency room (ER) use since Food and Drug Administration approval of chemical abortion in 2000 can identify trends in the relative morbidity burden of chemical versus surgical procedures.

'''Objective:''' To complete the first longitudinal cohort study of postabortion emergency room use following chemical and surgical abortions.

'''Methods:''' A population-based longitudinal cohort study of 423 000 confirmed induced abortions and 121,283 subsequent ER visits occurring within 30 days of the procedure, in the years 1999-2015, to Medicaid-eligible women over 13 years of age with at least one pregnancy outcome, in the 17 states which provided public funding for abortion.

'''Results:''' ER visits are at greater risk to occur following a chemical rather than a surgical abortion: all ER visits (OR 1.22, CL 1.19-1.24); miscoded spontaneous (OR 1.88, CL 1.81-1.96); and abortion-related (OR 1.53, CL 1.49-1.58). ER visit rates per 1000 abortions grew faster for chemical abortions, and by 2015, chemical versus surgical rates were 354.8 versus 357.9 for all ER visits; 31.5 versus 8.6 for miscoded spontaneous abortion visits; and 51.7 versus 22.0 for abortion-related visits. Abortion-related visits as a percent of total visits are twice as high for chemical abortions, reaching 14.6% by 2015. Miscoded spontaneous abortion visits as a percent of total visits are nearly 4 times as high for chemical abortions, reaching 8.9% of total visits and 60.9% of abortion-related visits by 2015.

'''Conclusion:''' The incidence and per-abortion rate of ER visits following any induced abortion are growing, but chemical abortion is consistently and progressively associated with more postabortion ER visit morbidity than surgical abortion. There is also a distinct trend of a growing number of women miscoded as receiving treatment for spontaneous abortion in the ER following a chemical abortion.</blockquote>
'''[https://pubmed.ncbi.nlm.nih.gov/35633832/ A Post Hoc Exploratory Analysis: Induced Abortion Complications Mistaken for Miscarriage in the Emergency Room are a Risk Factor for Hospitalization]. Studnicki J, Longbons T, Harrison DJ, Skop I, Cirucci C, Reardon DC, Craver C, Fisher JW, Tsulukidze M. Health Serv Res Manag Epidemiol. 2022 May 20;9:23333928221103107. doi: 10.1177/23333928221103107.''' <blockquote>
'''Introduction:''' Previous research indicates that an increasing number of women who go to an emergency room for complications following an induced abortion are treated for a miscarriage, meaning their abortion is miscoded or concealed.

'''Objective:''' To determine if the failure to identify a prior induced abortion during an ER visit is a risk factor for higher rates of subsequent hospitalization.

'''Methods:''' Post hoc analysis of hospital admissions following an induced abortion and ER visit within 30 days: 4273 following surgical abortion and 408 following chemical abortion; abortion not miscoded versus miscoded or concealed at prior ER visit.

'''Results:''' Chemical abortion patients whose abortions are misclassified as miscarriages during an ER visit subsequently experience on average 3.2 hospital admissions within 30 days. 86% of the patients ultimately have surgical removal of retained products of conception (RPOC). Chemical abortions are more likely than surgical abortions (OR 1.80, CL 1.38-2.35) to result in an RPOC admission, and chemical abortions concealed are more likely to result (OR 2.18, CL 1.65-2.88) in a subsequent RPOC admission than abortions without miscoding. Surgical abortions miscoded/concealed are similarly twice as likely to result in hospital admission than those without miscoding.

'''Conclusion:''' Patient concealment and/or physician failure to identify a prior abortion during an ER visit is a significant risk factor for a subsequent hospital admission. Patients and ER personnel should be made aware of this risk.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/23090524/ Extending outpatient medical abortion services through 70 days of gestational age.] Winikoff B, Dzuba IG, Chong E, Goldberg AB, Lichtenberg ES, Ball C, Dean G, Sacks D, Crowden WA, Swica Y. Obstet Gynecol. 2012 Nov;120(5):1070-6. doi: 10.1097/aog.0b013e31826c315f. PMID: 23090524.'''<blockquote>'''Objective:''' To estimate the efficacy and acceptability of medical abortion at 64-70 days from last menstrual period (LMP) and to compare it with the already proven 57-63 days from LMP gestational age range.

'''Methods:''' This prospective, comparative, open-label trial enrolled 729 women with pregnancies 57-70 days from LMP requesting abortion at six U.S. clinics. Medical abortions were managed with 200 mg mifepristone and 800 micrograms buccal misoprostol and sites' service delivery protocols. Follow-up visits occurred 7-14 days after mifepristone, with an abortion considered complete if surgical intervention was not performed. Success, ongoing pregnancy, and acceptability rates were compared.

'''Results:''' A total of 629 cases were analyzable for efficacy. Success rates were similar in the two groups (57-63 days group: 93.5%, 95% confidence interval [CI] 90-96; 64-70 days group: 92.8%, 95% CI 89-95). Ongoing pregnancy rates also did not differ significantly (57-63 days: '''3.1%''', 95% CI 1.6-5.8; 64-70 days: '''3.0%''', 95% CI 1.5-5.7). Acceptability was high and similar in both arms, with most women (57-63 days: 87.4%; 64-70 days: 88.3%) reporting that their experience was either very satisfactory or satisfactory.

'''Conclusion:''' Medical abortion with mifepristone and misoprostol in current outpatient settings is an efficacious and acceptable method of ending pregnancies 64-70 days from LMP and can be offered without alteration of existing services.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/22240172/ Risk factors of surgical evacuation following second-trimester medical termination of pregnancy.] Mentula M, Heikinheimo O. Contraception. 2012 Aug;86(2):141-6. doi: 10.1016/j.contraception.2011.11.070. Epub 2012 Jan 10. PMID: 22240172.'''<blockquote>'''Background:''' Second-trimester medical termination of pregnancy (TOP) is associated with a higher risk of surgical evacuation than earlier medical TOP. Little is known about risk factors of surgical evacuation. Therefore, we assessed these risk factors among women undergoing second-trimester medical TOP.

'''Study design:''' Data on 227 women were derived from a prospective randomized trial comparing 1- and 2-day mifepristone-misoprostol intervals in second-trimester medical TOP between 2008 and 2010.

'''Results:''' The rate of surgical evacuation was 30.8%. The risk of surgical evacuation was increased by a history of curettage [odds ratio (OR) 4.4; 95% confidence interval (CI) 1.7-11.7], fetal indications for TOP (OR 6.1; 95% CI 1.1-34.4), age above 24 years (OR 2.4; 95% CI 1.1-5.3) and a 2-day interval (OR 2.2; 95% CI 1.1-4.1).

'''Conclusions:''' History of curettage, fetal indication, increasing age and 2-day interval between mifepristone and misoprostol increase the risk of surgical evacuation in cases of second-trimester medical TOP. These findings are important when optimizing clinical service in second-trimester TOP.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/21317416/ Immediate adverse events after second trimester medical termination of pregnancy: results of a nationwide registry study.] Mentula MJ, Niinimäki M, Suhonen S, Hemminki E, Gissler M, Heikinheimo O. Hum Reprod. 2011 Apr;26(4):927-32. doi: 10.1093/humrep/der016. Epub 2011 Feb 11. PMID: 21317416.'''<blockquote>'''BACKGROUND''' Increasing gestational age is associated with an increased risk of complications in studies assessing surgical termination of pregnancy (TOP). Medical TOP is widely used during the second trimester and little is known about the frequency of complications. This epidemiological study was undertaken to assess the frequency of adverse events following the second trimester medical TOP and to compare it with that after first trimester medical TOP.

'''METHODS''' This register-based cohort study covered 18 248 women who underwent medical TOP in Finland between 1 January 2003 and 31 December 2006. The women were identified from the Abortion Registry. Adverse events related to medical TOP within 6 weeks were obtained from the Hospital Discharge Registry.

'''RESULTS''' When compared with first trimester medical TOP, second trimester medical TOP increased the risk of surgical evacuation [Adj. odds ratio (OR) 7.8; 95% confidence interval (CI) 6.8-8.9], especially immediately after fetal expulsion (Adj. OR 15.2; 95% CI 12.8-18.0). The risk of infection was also elevated (Adj. OR 2.1; 95% CI 1.5-2.9). Within the second trimester, increased length of gestation did not influence the risk of surgical evacuation or infection after medical TOP.

'''CONCLUSIONS''' Medical TOP during the second trimester is generally safe. Surgical evacuation of the uterus is avoided in about two-thirds of cases, though it is much more common than after first trimester medical TOP. The risks of surgical evacuation and infection do not increase with gestational weeks in the second trimester TOP.</blockquote>

'''[https://pubmed.ncbi.nlm.nih.gov/19888037/ Immediate complications after medical compared with surgical termination of pregnancy.] Niinimäki M, Pouta A, Bloigu A, Gissler M, Hemminki E, Suhonen S, Heikinheimo O. Obstet Gynecol. 2009 Oct;114(4):795-804. doi: 10.1097/AOG.0b013e3181b5ccf9. PMID: 19888037.'''<blockquote>'''Objective:''' To estimate the immediate adverse events and safety of medical compared with surgical abortion using high-quality registry data.

'''Methods:''' All women in Finland undergoing induced abortion from 2000-2006 with a gestational duration of 63 days or less (n=42,619) were followed up until 42 days postabortion using national health registries. The incidence and risk factors of adverse events after medical (n=22,368) and surgical (n=20,251) abortion were compared. Univariable and multivariable association models were used to analyze the risk of the three main complications (hemorrhage, infection, and incomplete abortion) and surgical (re)evacuation.

'''Results:''' The overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort (20.0% compared with 5.6%, P<.001). Hemorrhage (15.6% compared with 2.1%, P<.001) and incomplete abortion (6.7% compared with 1.6%, P<.001) were more common after medical abortion. The rate of surgical (re)evacuation was 5.9% after medical abortion and 1.8% after surgical abortion (P<.001). Although rare, injuries requiring operative treatment or operative complications occurred more often with surgical termination of pregnancy (0.6% compared with 0.03%, P<.001). No differences were noted in the incidence of infections (1.7% compared with 1.7%, P=.85), thromboembolic disease, psychiatric morbidity, or death.

'''Conclusion:''' Both methods of abortion are generally safe, but medical termination is associated with a higher incidence of adverse events. These observations are relevant when counseling women seeking early abortion.</blockquote>

'''" Pain control in medical abortion", E Wiebe, Int'l J Gynecology & Obstetrics 74:275-280,2001'''

:A Canadian study of abortion procedures using methotrexate and misoprostol reported that the mean pain
Score was 6.2 on a scale from 1-10. Severe pain (scores of 9 or 10) was reported by 23.4% of the women.
Women experiencing severe pain were more likely to have a lower maternal age, lower parity, higher
anxiety and depression, and less satisfaction with the procedure. The authors reported that pain medication
given before the onset of the procedure did not reduce the amount of severe pain.

:

'''[http://www.frcblog.com/wp-content/uploads/2011/05/Australian-AERs_RU486_201105mulligan.pdf Mifepristone in South Australia] Mulligan E, Messenger H. Australian Family Physician. MAY 2011.'''
:The study found 3.3% of the women who used RU-486 in the first trimester of pregnancy reported to an emergency room compared with 2.2% who used a surgical method and •5.7% of the women who used RU-486 had to be re-admitted to hospitals compared with 0.4% of surgical abortion patients.
[http://www.lifenews.com/2011/05/10/study-high-of-women-using-abortion-drug-hospitalized/ Additional information ]
:

'''Psychological distress symptoms in women undergoing medical vs. surgical termination of pregnancy. Lowenstein L, Deutcsh M, Gruberg R, Solt I, Yagil Y, Nevo O, et al. (2006), General Hospital Psychiatry, 28(1):43–47.'''
:Compared to women choosing surgical abortion, those choosing chemical abortion had higher obsessive-compulsive symptoms, higher levels of guilt, higher interpersonal sensitivity scores, more paranoid ideation, and more general psychiatric symptoms.

'''A comparison of medical and surgical methods of termination of pregnancy: Choice, psychological consequences, and satisfaction with care. Slade, P., Heke, S., Fletcher, J., & Stewart, P. (1998). British Journal of Obstetrics and Gynecology, 105, 1288-1295.'''
:Those who had a medical abortion rated it as more stressful and experienced more disruption in their lives. “One of the main differences between these two methods of termination is the consciousness and participation of the patient in the medical procedure in a process that involves blood, pain, and death.”

'''Patient preference in a randomized study comparing medical and surgical abortion at 10-13 weeks gestation. Ashok P.W., Hamoda, H., Flett, G. M. M., Kidd, A., Fitzmaurice, A., Templeton, A. (2005). Contraception, 71, 143-148.'''
:46.8% of women undergoing a medical abortion experienced a significant decline in self-esteem 2-3 weeks following the abortion. This was a higher percentage than among those who had a surgical abortion (39.5%).

'''Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomized controlled trial, Kelly, T., Suddes, J., Howel, D., Hewison, J., & Robson, S. (2010). BJOG, 117, 1512-20.'''
:Women who had chemical abortions had higher PTSD intrusion scores, such as nightmares, than women who had surgical abortions
''' 
[http://www.lifenews.com/2014/12/03/doctor-saves-106-babies-after-the-abortion-has-already-started-wait-until-you-see-how/ Abortion Pill Reversal can be successful]'''
:Article regarding a medical protocol for women who change their minds to stop the RU-486 induced abortion.
'''[http://www.nejm.org/doi/full/10.1056/NEJMc1001014 Fatal Clostridium sordellii Infections after Medical Abortions] N Engl J Med 2010; 363:1382-1383September 30, 2010'''
:Clostridial toxic shock is a rare and largely fatal syndrome among reproductive-age women. Eight cases were reported after medical abortions using mifepristone and misoprostol between 2000 and 2009 bringing the risk of clostridial toxic shock to 0.58 per 100,000 medical abortions.
[http://www.lifenews.com/2014/12/03/doctor-saves-106-babies-after-the-abortion-has-already-started-wait-until-you-see-how/ Abortion Pill Reversal can be successful]

: Article regarding a medical protocol for women who change their minds to stop the RU-486 induced abortion.

'''" Pain control in medical abortion", E Wiebe, Int'l J Gynecology & Obstetrics 74:275-280,2001'''

A Canadian study of abortion procedures using methotrexate and misoprostol reported that the mean pain Score was 6.2 on a scale from 1-10. Severe pain (scores of 9 or 10) was reported by 23.4% of the women. Women experiencing severe pain were more likely to have a lower maternal age, lower parity, higher anxiety and depression, and less satisfaction with the procedure. The authors reported that pain medication given before the onset of the procedure did not reduce the amount of severe pain.

:

[http://www.lifenews.com/2011/05/10/study-high-of-women-using-abortion-drug-hospitalized/ Additional information]

Mifepristone

2026-01-23T20:25:35Z

Barb: /* Mifepristone is also known as RU-486, the abortion pill, medical abortion, or chemical abortion */

== Mifepristone is also known as RU-486, the abortion pill, medical abortion, or chemical abortion ==
'''[https://pubmed.ncbi.nlm.nih.gov/36592459/ Short-Term Adverse Outcomes After Mifepristone-Misoprostol Versus Procedural Induced Abortion : A Population-Based Propensity-Weighted Study]. Liu, N., & Ray, J. G. (2023). ''Annals of Internal Medicine'', ''176''(2). <nowiki>https://doi.org/10.7326/M22-2568</nowiki>'''<blockquote>'''Background:''' Prior studies comparing first-trimester pharmaceutical induced abortion (IA) with procedural IA were prone to selection bias, were underpowered to assess serious adverse events (SAEs), and did not account for confounding by indication. Starting in 2017, mifepristone-misoprostol was dispensed at no cost in outpatient pharmacies across Ontario, Canada.

'''Objective:''' To compare short-term risk for adverse outcomes after early IA by mifepristone-misoprostol versus by procedural IA.

'''Design:''' Population-based cohort study.

'''Setting:''' Ontario, Canada.

'''Patients:''' All women who had first-trimester IA.

'''Measurements:''' A total of 39 856 women dispensed mifepristone-misoprostol as outpatients were compared with 65 176 women undergoing procedural IA at 14 weeks' gestation or earlier within nonhospital outpatient clinics (comparison 1). A total of 39 856 women prescribed mifepristone-misoprostol were compared with 8861 women undergoing ambulatory hospital-based procedural IA at an estimated 9 weeks' gestation or less (comparison 2). The primary composite outcome was any SAE within 42 days after IA, including severe maternal morbidity, end-organ damage, intensive care unit admission, or death. A coprimary broader outcome comprised any SAE, hemorrhage, retained products of conception, infection, or transfusion. Stabilized inverse probability of treatment weighting accounted for confounding between exposure groups.

'''Results:''' Mean age at IA was about 29 years (SD, 7); 33% were primigravidae. Six percent resided in rural areas, and 25% resided in low-income neighborhoods. In comparison 1, SAEs occurred among 133 women after mifepristone-misoprostol IA (3.3 per 1000) versus 114 after procedural IA (1.8 per 1000) (relative risk [RR], 1.87 [95% CI, 1.44 to 2.43]; absolute risk difference [ARD], 1.5 per 1000 [CI, 0.9 to 2.2]). The respective rates of any adverse event were 28.9 versus 12.4 per 1000 (RR, 2.33 [CI, 2.11 to 2.57]; ARD, 16.5 per 1000 [CI, 14.5 to 18.4]). In comparison 2, SAEs occurred among 133 (3.4 per 1000) and 27 (3.3 per 1000) women, respectively (RR, 1.04 [CI, 0.61 to 1.78]). The respective rates of any adverse event were 31.2 versus 24.9 per 1000 (RR, 1.25 [CI, 1.04 to 1.51]).

'''Limitation:''' A woman prescribed mifepristone-misoprostol may not have taken the medication, and the exact gestational age at IA was not always known.

'''Conclusion:''' Although rare, short-term adverse events are more likely after mifepristone-misoprostol IA than procedural IA, especially for less serious adverse outcomes.</blockquote>
'''[http://www.frcblog.com/wp-content/uploads/2011/05/Australian-AERs_RU486_201105mulligan.pdf Mifepristone in South Australia] Mulligan E, Messenger H. Australian Family Physician. MAY 2011.'''
: The study found 3.3% of the women who used RU-486 in the first trimester of pregnancy reported to an emergency room compared with 2.2% who used a surgical method and •5.7% of the women who used RU-486 had to be re-admitted to hospitals compared with 0.4% of surgical abortion patients.
:

'''[https://pubmed.ncbi.nlm.nih.gov/38777160/ Medication and procedural abortions before 13 weeks gestation and risk of psychiatric disorders.] Steinberg, J. R., Laursen, T. M., Lidegaard, Ø., & Munk-Olsen, T. (2024).''American Journal of Obstetrics and Gynecology'', ''231''(4), 437.e1-437.e18. <nowiki>https://doi.org/10.1016/J.AJOG.2024.05.025</nowiki>'''<blockquote>'''Background:''' The proportion of abortions provided by medication in the United States and worldwide has increased greatly since the U.S. Food and Drug Administration approved mifepristone in 2000. While existing research has shown that abortion does not increase risk of mental health problems, no population-based study has examined specifically whether a procedural or medication abortion increases risk of mental health disorders.

'''Objective:''' This study examined whether mental health disorders increased in the shorter and longer-term after a medication or procedural abortion.

'''Study design:''' Using Danish population registers' data, we conducted a prospective cohort study in which we included 72,424 females born in Denmark between 1980 and 2006, who were ages 12 to 38 during the study period and had a first first-trimester abortion before 13 weeks gestation in 2000 to 2018. Females with no previous psychiatric diagnoses were followed from 1 year before their abortion until their first psychiatric diagnosis, December 31, 2018, emigration from Demark, or death, whichever came first. Risk of any first psychiatric disorder was defined as a recorded psychiatric diagnosis at an in- or out-patient facility from the 1 year after to more than 5 years after a medication or procedural abortion relative to the year beforehand. Results were adjusted for calendar year, age, gestational age, partner status, prior mental and physical health, childbirth history, childhood environment, and parental mental health history.

'''Results:''' Females having medication (n=37,155) and procedural abortions (n=35,269) had the same risk of any first psychiatric diagnosis in the year after their abortion relative to the year before their abortion (medication abortion adjusted incidence rate ratio [MaIRR]=1.02, 95% confidence interval [CI]: 0.93-1.12; procedural abortion adjusted incidence rate ratio [PaIRR]=0.94, 95% CI: 0.86-1.02). Moreover, as more time from the abortion passed, the risk of a psychiatric diagnoses decreased relative to the year before their abortion for each abortion method (MaIRR 1-2 years after=0.89, 95% CI: 0.80-0.98; PaIRR 1-2 years after=0.81, 95% CI: 0.88-1.05; MaIRR 2-5 years after=0.77, 95% CI: 0.71-0.84; PaIRR 2-5 years after=0.72, 95% CI: 0.67-0.78; MaIRR 5+ years after=0.58, 95% CI: 0.53-0.63; PaIRR 5+ years after=0.54, 95% CI: 0.50-0.58).

'''Conclusion:''' Because the risk of psychiatric diagnoses was the same in the year after relative to the year before a medication and procedural abortion and the risk did not increase as more time after the abortion increased, neither abortion method increased risk of mental health disorders in the shorter or longer-term.</blockquote>

'''[https://pubmed.ncbi.nlm.nih.gov/34778493/ A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999-2015.]''' '''Health Serv Res Manag Epidemiol. 2021 Nov 9;8:23333928211053965. doi: 10.1177/23333928211053965.''' <blockquote>
'''Introduction:''' Existing research on postabortion emergency room visits is sparse and limited by methods which underestimate the incidence of adverse events following abortion. Postabortion emergency room (ER) use since Food and Drug Administration approval of chemical abortion in 2000 can identify trends in the relative morbidity burden of chemical versus surgical procedures.

'''Objective:''' To complete the first longitudinal cohort study of postabortion emergency room use following chemical and surgical abortions.

'''Methods:''' A population-based longitudinal cohort study of 423 000 confirmed induced abortions and 121,283 subsequent ER visits occurring within 30 days of the procedure, in the years 1999-2015, to Medicaid-eligible women over 13 years of age with at least one pregnancy outcome, in the 17 states which provided public funding for abortion.

'''Results:''' ER visits are at greater risk to occur following a chemical rather than a surgical abortion: all ER visits (OR 1.22, CL 1.19-1.24); miscoded spontaneous (OR 1.88, CL 1.81-1.96); and abortion-related (OR 1.53, CL 1.49-1.58). ER visit rates per 1000 abortions grew faster for chemical abortions, and by 2015, chemical versus surgical rates were 354.8 versus 357.9 for all ER visits; 31.5 versus 8.6 for miscoded spontaneous abortion visits; and 51.7 versus 22.0 for abortion-related visits. Abortion-related visits as a percent of total visits are twice as high for chemical abortions, reaching 14.6% by 2015. Miscoded spontaneous abortion visits as a percent of total visits are nearly 4 times as high for chemical abortions, reaching 8.9% of total visits and 60.9% of abortion-related visits by 2015.

'''Conclusion:''' The incidence and per-abortion rate of ER visits following any induced abortion are growing, but chemical abortion is consistently and progressively associated with more postabortion ER visit morbidity than surgical abortion. There is also a distinct trend of a growing number of women miscoded as receiving treatment for spontaneous abortion in the ER following a chemical abortion.</blockquote>
'''[https://pubmed.ncbi.nlm.nih.gov/35633832/ A Post Hoc Exploratory Analysis: Induced Abortion Complications Mistaken for Miscarriage in the Emergency Room are a Risk Factor for Hospitalization]. Studnicki J, Longbons T, Harrison DJ, Skop I, Cirucci C, Reardon DC, Craver C, Fisher JW, Tsulukidze M. Health Serv Res Manag Epidemiol. 2022 May 20;9:23333928221103107. doi: 10.1177/23333928221103107.''' <blockquote>
'''Introduction:''' Previous research indicates that an increasing number of women who go to an emergency room for complications following an induced abortion are treated for a miscarriage, meaning their abortion is miscoded or concealed.

'''Objective:''' To determine if the failure to identify a prior induced abortion during an ER visit is a risk factor for higher rates of subsequent hospitalization.

'''Methods:''' Post hoc analysis of hospital admissions following an induced abortion and ER visit within 30 days: 4273 following surgical abortion and 408 following chemical abortion; abortion not miscoded versus miscoded or concealed at prior ER visit.

'''Results:''' Chemical abortion patients whose abortions are misclassified as miscarriages during an ER visit subsequently experience on average 3.2 hospital admissions within 30 days. 86% of the patients ultimately have surgical removal of retained products of conception (RPOC). Chemical abortions are more likely than surgical abortions (OR 1.80, CL 1.38-2.35) to result in an RPOC admission, and chemical abortions concealed are more likely to result (OR 2.18, CL 1.65-2.88) in a subsequent RPOC admission than abortions without miscoding. Surgical abortions miscoded/concealed are similarly twice as likely to result in hospital admission than those without miscoding.

'''Conclusion:''' Patient concealment and/or physician failure to identify a prior abortion during an ER visit is a significant risk factor for a subsequent hospital admission. Patients and ER personnel should be made aware of this risk.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/22240172/ Risk factors of surgical evacuation following second-trimester medical termination of pregnancy.] Mentula M, Heikinheimo O. Contraception. 2012 Aug;86(2):141-6. doi: 10.1016/j.contraception.2011.11.070. Epub 2012 Jan 10. PMID: 22240172.'''<blockquote>'''Background:''' Second-trimester medical termination of pregnancy (TOP) is associated with a higher risk of surgical evacuation than earlier medical TOP. Little is known about risk factors of surgical evacuation. Therefore, we assessed these risk factors among women undergoing second-trimester medical TOP.

'''Study design:''' Data on 227 women were derived from a prospective randomized trial comparing 1- and 2-day mifepristone-misoprostol intervals in second-trimester medical TOP between 2008 and 2010.

'''Results:''' The rate of surgical evacuation was 30.8%. The risk of surgical evacuation was increased by a history of curettage [odds ratio (OR) 4.4; 95% confidence interval (CI) 1.7-11.7], fetal indications for TOP (OR 6.1; 95% CI 1.1-34.4), age above 24 years (OR 2.4; 95% CI 1.1-5.3) and a 2-day interval (OR 2.2; 95% CI 1.1-4.1).

'''Conclusions:''' History of curettage, fetal indication, increasing age and 2-day interval between mifepristone and misoprostol increase the risk of surgical evacuation in cases of second-trimester medical TOP. These findings are important when optimizing clinical service in second-trimester TOP.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/21317416/ Immediate adverse events after second trimester medical termination of pregnancy: results of a nationwide registry study.] Mentula MJ, Niinimäki M, Suhonen S, Hemminki E, Gissler M, Heikinheimo O. Hum Reprod. 2011 Apr;26(4):927-32. doi: 10.1093/humrep/der016. Epub 2011 Feb 11. PMID: 21317416.'''<blockquote>'''BACKGROUND''' Increasing gestational age is associated with an increased risk of complications in studies assessing surgical termination of pregnancy (TOP). Medical TOP is widely used during the second trimester and little is known about the frequency of complications. This epidemiological study was undertaken to assess the frequency of adverse events following the second trimester medical TOP and to compare it with that after first trimester medical TOP.

'''METHODS''' This register-based cohort study covered 18 248 women who underwent medical TOP in Finland between 1 January 2003 and 31 December 2006. The women were identified from the Abortion Registry. Adverse events related to medical TOP within 6 weeks were obtained from the Hospital Discharge Registry.

'''RESULTS''' When compared with first trimester medical TOP, second trimester medical TOP increased the risk of surgical evacuation [Adj. odds ratio (OR) 7.8; 95% confidence interval (CI) 6.8-8.9], especially immediately after fetal expulsion (Adj. OR 15.2; 95% CI 12.8-18.0). The risk of infection was also elevated (Adj. OR 2.1; 95% CI 1.5-2.9). Within the second trimester, increased length of gestation did not influence the risk of surgical evacuation or infection after medical TOP.

'''CONCLUSIONS''' Medical TOP during the second trimester is generally safe. Surgical evacuation of the uterus is avoided in about two-thirds of cases, though it is much more common than after first trimester medical TOP. The risks of surgical evacuation and infection do not increase with gestational weeks in the second trimester TOP.</blockquote>

'''[https://pubmed.ncbi.nlm.nih.gov/19888037/ Immediate complications after medical compared with surgical termination of pregnancy.] Niinimäki M, Pouta A, Bloigu A, Gissler M, Hemminki E, Suhonen S, Heikinheimo O. Obstet Gynecol. 2009 Oct;114(4):795-804. doi: 10.1097/AOG.0b013e3181b5ccf9. PMID: 19888037.'''<blockquote>'''Objective:''' To estimate the immediate adverse events and safety of medical compared with surgical abortion using high-quality registry data.

'''Methods:''' All women in Finland undergoing induced abortion from 2000-2006 with a gestational duration of 63 days or less (n=42,619) were followed up until 42 days postabortion using national health registries. The incidence and risk factors of adverse events after medical (n=22,368) and surgical (n=20,251) abortion were compared. Univariable and multivariable association models were used to analyze the risk of the three main complications (hemorrhage, infection, and incomplete abortion) and surgical (re)evacuation.

'''Results:''' The overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort (20.0% compared with 5.6%, P<.001). Hemorrhage (15.6% compared with 2.1%, P<.001) and incomplete abortion (6.7% compared with 1.6%, P<.001) were more common after medical abortion. The rate of surgical (re)evacuation was 5.9% after medical abortion and 1.8% after surgical abortion (P<.001). Although rare, injuries requiring operative treatment or operative complications occurred more often with surgical termination of pregnancy (0.6% compared with 0.03%, P<.001). No differences were noted in the incidence of infections (1.7% compared with 1.7%, P=.85), thromboembolic disease, psychiatric morbidity, or death.

'''Conclusion:''' Both methods of abortion are generally safe, but medical termination is associated with a higher incidence of adverse events. These observations are relevant when counseling women seeking early abortion.</blockquote>

'''" Pain control in medical abortion", E Wiebe, Int'l J Gynecology & Obstetrics 74:275-280,2001'''

:A Canadian study of abortion procedures using methotrexate and misoprostol reported that the mean pain
Score was 6.2 on a scale from 1-10. Severe pain (scores of 9 or 10) was reported by 23.4% of the women.
Women experiencing severe pain were more likely to have a lower maternal age, lower parity, higher
anxiety and depression, and less satisfaction with the procedure. The authors reported that pain medication
given before the onset of the procedure did not reduce the amount of severe pain.

:

'''[http://www.frcblog.com/wp-content/uploads/2011/05/Australian-AERs_RU486_201105mulligan.pdf Mifepristone in South Australia] Mulligan E, Messenger H. Australian Family Physician. MAY 2011.'''
:The study found 3.3% of the women who used RU-486 in the first trimester of pregnancy reported to an emergency room compared with 2.2% who used a surgical method and •5.7% of the women who used RU-486 had to be re-admitted to hospitals compared with 0.4% of surgical abortion patients.
[http://www.lifenews.com/2011/05/10/study-high-of-women-using-abortion-drug-hospitalized/ Additional information ]
:

'''Psychological distress symptoms in women undergoing medical vs. surgical termination of pregnancy. Lowenstein L, Deutcsh M, Gruberg R, Solt I, Yagil Y, Nevo O, et al. (2006), General Hospital Psychiatry, 28(1):43–47.'''
:Compared to women choosing surgical abortion, those choosing chemical abortion had higher obsessive-compulsive symptoms, higher levels of guilt, higher interpersonal sensitivity scores, more paranoid ideation, and more general psychiatric symptoms.

'''A comparison of medical and surgical methods of termination of pregnancy: Choice, psychological consequences, and satisfaction with care. Slade, P., Heke, S., Fletcher, J., & Stewart, P. (1998). British Journal of Obstetrics and Gynecology, 105, 1288-1295.'''
:Those who had a medical abortion rated it as more stressful and experienced more disruption in their lives. “One of the main differences between these two methods of termination is the consciousness and participation of the patient in the medical procedure in a process that involves blood, pain, and death.”

'''Patient preference in a randomized study comparing medical and surgical abortion at 10-13 weeks gestation. Ashok P.W., Hamoda, H., Flett, G. M. M., Kidd, A., Fitzmaurice, A., Templeton, A. (2005). Contraception, 71, 143-148.'''
:46.8% of women undergoing a medical abortion experienced a significant decline in self-esteem 2-3 weeks following the abortion. This was a higher percentage than among those who had a surgical abortion (39.5%).

'''Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomized controlled trial, Kelly, T., Suddes, J., Howel, D., Hewison, J., & Robson, S. (2010). BJOG, 117, 1512-20.'''
:Women who had chemical abortions had higher PTSD intrusion scores, such as nightmares, than women who had surgical abortions
''' 
[http://www.lifenews.com/2014/12/03/doctor-saves-106-babies-after-the-abortion-has-already-started-wait-until-you-see-how/ Abortion Pill Reversal can be successful]'''
:Article regarding a medical protocol for women who change their minds to stop the RU-486 induced abortion.
'''[http://www.nejm.org/doi/full/10.1056/NEJMc1001014 Fatal Clostridium sordellii Infections after Medical Abortions] N Engl J Med 2010; 363:1382-1383September 30, 2010'''
:Clostridial toxic shock is a rare and largely fatal syndrome among reproductive-age women. Eight cases were reported after medical abortions using mifepristone and misoprostol between 2000 and 2009 bringing the risk of clostridial toxic shock to 0.58 per 100,000 medical abortions.
[http://www.lifenews.com/2014/12/03/doctor-saves-106-babies-after-the-abortion-has-already-started-wait-until-you-see-how/ Abortion Pill Reversal can be successful]

: Article regarding a medical protocol for women who change their minds to stop the RU-486 induced abortion.

'''" Pain control in medical abortion", E Wiebe, Int'l J Gynecology & Obstetrics 74:275-280,2001'''

A Canadian study of abortion procedures using methotrexate and misoprostol reported that the mean pain Score was 6.2 on a scale from 1-10. Severe pain (scores of 9 or 10) was reported by 23.4% of the women. Women experiencing severe pain were more likely to have a lower maternal age, lower parity, higher anxiety and depression, and less satisfaction with the procedure. The authors reported that pain medication given before the onset of the procedure did not reduce the amount of severe pain.

:

[http://www.lifenews.com/2011/05/10/study-high-of-women-using-abortion-drug-hospitalized/ Additional information]

Long-Terms Effects of Abortion

2025-12-31T14:39:18Z

Barb: /* Review Papers */

{{DEA}}
{{PsychIndex}}

[[Submit_LongTerm |Please Submit New Material for This Protected Page Here]]

==Physical Effects of Psychological Illness==

[https://www.ncbi.nlm.nih.gov/pubmed/?term=Association+of+Mental+Disorders+With+Subsequent+Chronic+Physical+Conditions%3A+World+Mental+Health+Surveys+From+17+Countries Association of Mental Disorders With Subsequent Chronic Physical Conditions: World Mental Health Surveys From 17 Countries.] Scott KM, Lim C, Al-Hamzawi A, et al. JAMA Psychiatry. 2016;73(2):150-158. doi:10.1001/jamapsychiatry.2015.2688.

RESULTS: Most associations between 16 mental disorders and subsequent onset or diagnosis of 10 physical conditions were statistically significant, with odds ratios (ORs) (95% CIs) ranging from 1.2 (1.0-1.5) to 3.6 (2.0-6.6). The associations were attenuated after adjustment for mental disorder comorbidity, but mood, anxiety, substance use, and impulse control disorders remained significantly associated with onset of between 7 and all 10 of the physical conditions (ORs [95% CIs] from 1.2 [1.1-1.3] to 2.0 [1.4-2.8]). An increasing number of mental disorders experienced over the life course was significantly associated with increasing odds of onset or diagnosis of all 10 types of physical conditions, with ORs (95% CIs) for 1 mental disorder ranging from 1.3 (1.1-1.6) to 1.8 (1.4-2.2) and ORs (95% CIs) for 5 or more mental disorders ranging from 1.9 (1.4-2.7) to 4.0 (2.5-6.5). In population-attributable risk estimates, specific mental disorders were associated with 1.5% to 13.3% of physical condition onsets.

:CONCLUSIONS AND RELEVANCE: These findings suggest that mental disorders of all kinds are associated with an increased risk of onset of a wide range of chronic physical conditions. Current efforts to improve the physical health of individuals with mental disorders may be too narrowly focused on the small group with the most severe mental disorders. Interventions aimed at the primary prevention of chronic physical diseases should optimally be integrated into treatment of all mental disorders in primary and secondary care from early in the disorder course.

'''The above findings may be relevant to the reduced life expectancy of women who have a history of abortion.'''

==Review Papers==
'''[https://pmc.ncbi.nlm.nih.gov/articles/PMC11625657/#bjo17889-sec-0016 Pregnancy and birth complications and long-term maternal mental health outcomes: A systematic review and meta-analysis.] Bodunde EO, Buckley D, O'Neill E, Al Khalaf S, Maher GM, O'Connor K, McCarthy FP, Kublickiene K, Matvienko-Sikar K, Khashan AS. BJOG. 2025 Jan;132(2):131-142. doi: 10.1111/1471-0528.17889.'''<blockquote>Background: Few studies have examined the associations between pregnancy and birth complications and long‐term (>12 months) maternal mental health outcomes.

Objectives: To review the published literature on pregnancy and birth complications and long‐term maternal mental health outcomes.

Search strategy:Systematic search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (Embase), PsycInfo®, PubMed® and Web of Science from inception until August 2022.

Selection criteria: Three reviewers independently reviewed titles, abstracts and full texts.

Data collection and analysis: Two reviewers independently extracted data and appraised study quality. Random‐effects meta‐analyses were used to calculate pooled estimates. The Meta‐analyses of Observational Studies in Epidemiology (MOOSE) guidelines were followed. The protocol was prospectively registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022359017).

Main results: Of the 16 310 articles identified, 33 studies were included (3 973 631 participants). T'''ermination of pregnancy was associated with depression (pooled adjusted odds ratio, aOR 1.49, 95% CI 1.20–1.83) and anxiety disorder (pooled aOR 1.43, 95% CI 1.20–1.71).''' Miscarriage was associated with depression (pooled aOR 1.97, 95% CI 1.38–2.82) and anxiety disorder (pooled aOR 1.24, 95% CI 1.11–1.39). Sensitivity analyses excluding early pregnancy loss and termination reported similar results. Preterm birth was associated with depression (pooled aOR 1.37, 95% CI 1.32–1.42), anxiety disorder (pooled aOR 0.97, 95% CI 0.41–2.27) and post‐traumatic stress disorder (PTSD) (pooled aOR 1.75, 95% CI 0.52–5.89). Caesarean section was not significantly associated with PTSD (pooled aOR 2.51, 95% CI 0.75–8.37). There were few studies on other mental disorders and therefore it was not possible to perform meta‐analyses.

Conclusions: Exposure to complications during pregnancy and birth increases the odds of long‐term depression, anxiety disorder and PTSD.</blockquote>''[http://www.ncbi.nlm.nih.gov/pubmed/23859662 Abortion and subsequent mental health: Review of the literature.] Bellieni CV, Buonocore G.'' Psychiatry Clin Neurosci. 2013 Jul;67(5):301-10. doi: 10.1111/pcn.12067.

:Abstract
:The risk that abortion may be correlated with subsequent mental disorders needs a careful assessment, in order to offer women full information when facing a difficult pregnancy. All research papers published between 1995 and 2011, were examined, to retrieve those assessing any correlation between abortion and subsequent mental problems. A total of 36 studies were retrieved, and six of them were excluded for methodological bias. Depression, anxiety disorders (e.g. post-traumatic stress disorder) and substance abuse disorders were the most studied outcome. Abortion versus childbirth: 13 studies showed a clear risk for at least one of the reported mental problems in the abortion group versus childbirth, five papers showed no difference, in particular if women do not consider their experience of fetal loss to be difficult, or if after a fetal reduction the desired fetus survives. Only one paper reported a worse mental outcome for childbearing. Abortion versus unplanned pregnancies ending with childbirth: four studies found a higher risk in the abortion groups and three, no difference. Abortion versus miscarriage: three studies showed a greater risk of mental disorders due to abortion, four found no difference and two found that short-term anxiety and depression were higher in the miscarriage group, while long-term anxiety and depression were present only in the abortion group. In conclusion, fetal loss seems to expose women to a higher risk for mental disorders than childbirth; some studies show that abortion can be considered a more relevant risk factor than miscarriage; more research is needed in this field.

''[http://www.ncbi.nlm.nih.gov/pubmed/23553240 Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence.] Fergusson DM, Horwood LJ, Boden JM. Aust N Z J Psychiatry. 2013 Apr 3.''

:Objective:There have been debates about the linkages between abortion and mental health. Few reviews have considered the extent to which abortion has therapeutic benefits that mitigate the mental health risks of abortion. The aim of this review was to conduct a re-appraisal of the evidence to examine the research hypothesis that abortion reduces rates of mental health problems in women having unwanted or unintended pregnancy.
:Methods:Analysis of recent reviews (Coleman, 2011; National Collaborating Centre for Mental Health, 2011) identified eight publications reporting 14 adjusted odds ratios (AORs) spanning five outcome domains: anxiety; depression; alcohol misuse; illicit drug use/misuse; and suicidal behaviour. For each outcome, pooled AORs were estimated using a random-effects model.
:Results:There was consistent evidence to show that abortion was not associated with a reduction in rates of mental health problems (p>0.75). Abortion was associated with small to moderate increases in risks of anxiety (AOR 1.28, 95% CI 0.97-1.70; p<0.08), alcohol misuse (AOR 2.34, 95% CI 1.05-5.21; p<0.05), illicit drug use/misuse (AOR 3.91, 95% CI 1.13-13.55; p<0.05), and suicidal behaviour (AOR 1.69, 95% CI 1.12-2.54; p<0.01).Conclusions:There is no available evidence to suggest that abortion has therapeutic effects in reducing the mental health risks of unwanted or unintended pregnancy. There is suggestive evidence that abortion may be associated with small to moderate increases in risks of some mental health problems.

''[http://www.ncbi.nlm.nih.gov/pubmed/21881096 Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009.] Coleman PK. Br J Psychiatry. 2011 Sep;199(3):180-6. doi: 10.1192/bjp.bp.110.077230.''

:BACKGROUND: Given the methodological limitations of recently published qualitative reviews of abortion and mental health, a quantitative synthesis was deemed necessary to represent more accurately the published literature and to provide clarity to clinicians.
:AIMS: To measure the association between abortion and indicators of adverse mental health, with subgroup effects calculated based on comparison groups (no abortion, unintended pregnancy delivered, pregnancy delivered) and particular outcomes. A secondary objective was to calculate population-attributable risk (PAR) statistics for each outcome.
:METHOD: After the application of methodologically based selection criteria and extraction rules to minimise bias, the sample comprised 22 studies, 36 measures of effect and 877 181 participants (163 831 experienced an abortion). Random effects pooled odds ratios were computed using adjusted odds ratios from the original studies and PAR statistics were derived from the pooled odds ratios.
:RESULTS: Women who had undergone an abortion experienced an 81% increased risk of mental health problems, and nearly 10% of the incidence of mental health problems was shown to be attributable to abortion. The strongest subgroup estimates of increased risk occurred when abortion was compared with term pregnancy and when the outcomes pertained to substance use and suicidal behaviour.
:CONCLUSIONS: This review offers the largest quantitative estimate of mental health risks associated with abortion available in the world literature. Calling into question the conclusions from traditional reviews, the results revealed a moderate to highly increased risk of mental health problems after abortion. Consistent with the tenets of evidence-based medicine, this information should inform the delivery of abortion services.

''[http://www.ncbi.nlm.nih.gov/pubmed/19968372 Abortion and mental health: Evaluating the evidence.] Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C.A m Psychol. 2009 Dec;64(9):863-90. doi: 10.1037/a0017497.

:''ABSTRACT:'' The authors evaluated empirical research addressing the relationship between induced abortion and women's mental health. Two issues were addressed: (a) the relative risks associated with abortion compared with the risks associated with its alternatives and (b) sources of variability in women's responses following abortion. This article reflects and updates the report of the American Psychological Association Task Force on Mental Health and Abortion (2008). Major methodological problems pervaded most of the research reviewed. The most rigorous studies indicated that within the United States, the relative risk of mental health problems among adult women who have a single, legal, first-trimester abortion of an unwanted pregnancy is no greater than the risk among women who deliver an unwanted pregnancy. Evidence did not support the claim that observed associations between abortion and mental health problems are caused by abortion per se as opposed to other preexisting and co-occurring risk factors. Most adult women who terminate a pregnancy do not experience mental health problems. Some women do, however. It is important that women's varied experiences of abortion be recognized, validated, and understood.

:'''NOTE:''' This is an abbreviated version of the [[APA_Abortion_Report|2008 APA Task Force Report on Abortion and Mental Health]] and the strengths and weaknesses of this report should be reviewed [[APA_Abortion_Report|here]].

''[[NCCMH Review |Induced Abortion and Mental Health]], NCCMH Published December 2011 ''
:See [[NCCMH Review]] for summary and comments.

''[[Charles_et_al|Abortion and long-term mental health outcomes: a systematic review of the evidence.]] Authors: Vignetta E. Charles, Chelsea B. Polis, Srinivas K. Sridhara, Robert W. Blum Contraception 78(2008) 436-450''
:See [[Charles_et_al]] for summary and comments.

:[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2488341/#!po=90.6250 Experiences of abortion: a narrative review of qualitative studies.] Lie ML, Robson SC, May CR.BMC Health Serv Res. 2008 Jul 17;8:150. doi: 10.1186/1472-6963-8-150.
*"Feelings of ambivalence in the decision-making process were highlighted in a Swedish study [26], where women felt positive towards the right to abortion, but negative about their own decision to abort."
*"Complex emotional experiences appear to be integral to TOP. These include regret and guilt [17,22], distress and anxiety [17,22,27] and grief, loss, emptiness and suffering [21]."

'''[http://www.ncbi.nlm.nih.gov/pubmed/19799479 Psychiatric complications of abortion]'''. [Article in Spanish] Gurpegui M, Jurado D. Cuad Bioet. 2009 Sep-Dec;20(70):381-92.
:INTRODUCTION: The psychiatric consequences of induced abortion continue to be the object of controversy. The reactions of women when they became aware of conception are very variable. Pregnancy, whether initially intended or unintended, may provoke stress; and miscarriage may bring about feelings of loss and grief reaction. Therefore, induced abortion, with its emotional implications (of relief, shame and guilt) not surprisingly is a stressful adverse life event.

:METHODOLOGICAL CONSIDERATIONS: There is agreement among researchers on the need to compare the mental health outcomes (or the psychiatric complications) with appropriate groups, including women with unintended pregnancies ending in live births and women with miscarriages. There is also agreement on the need to control for the potential confounding effects of multiple variables: demographic, contextual, personal development, previous or current traumatic experiences, and mental health prior to the obstetric event. Any psychiatric outcome is multi-factorial in origin and the impact of life events depend on how they are perceived, the psychological defence mechanisms (unconscious to a great extent) and the coping style. The fact of voluntarily aborting has an undeniable ethical dimension in which facts and values are interwoven.

:RESULT: No research study has found that induced abortion is associated with a better mental health outcome, although the results of some studies are interpreted as <<neutral>> or <<mixed.>> Some general population studies point out significant associations with alcohol or illegal drug dependence, mood disorders (including depression) and some anxiety disorders. Some of these associations have been confirmed, and nuanced, by longitudinal prospective studies which support causal relationships.

:CONCLUSION: With the available data, it is advisable to devote efforts to the mental health care of women who have had an induced abortion. Reasons of the woman's mental health by no means can be invoked, on empirical bases, for inducing an abortion.

[http://www.ncbi.nlm.nih.gov/pubmed/20303829 Abortion among young women and subsequent life outcomes.] Casey PR. Best Pract Res Clin Obstet Gynaecol. 2010 Aug;24(4):491-502. doi: 10.1016/j.bpobgyn.2010.02.007. Epub 2010 Mar 20.

:This article will discuss the nature of the association between abortion and mental health problems. Studies arguing about both sides of the debate as to whether abortion per se is responsible will be presented. The prevalence of various psychiatric disorders will be outlined and where there is dispute between studies, these will be highlighted. The impact of abortion on other areas such as education, partner relationships and sexual function will also be considered. The absence of specific interventions will be highlighted. Suggestions for early identification of illness will be made.

==Adjustments at the Time of Menopause==

'''[https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-024-07005-w The association between repeated abortions during childbearing age and the psychological well-being of postmenopausal women in Southwest China: an observational study.] Li, X., Peng, A., Li, L. ''et al.'' ''BMC Pregnancy Childbirth'' 24, 805 (2024). <nowiki>https://doi.org/10.1186/s12884-024-07005-w</nowiki>'''<blockquote>Background

The issue of whether abortion increases the risk of future mental health problems for women remains a debated topic, and there is a lack of evidence from large-scale studies conducted in China. This study aimed to investigate the potential associations between abortions, particularly repeated abortions, and the mental health status of postmenopausal women in Southwest China.

Methods

The data were obtained from the baseline survey of a multi-center natural population cohort study in cooperated with medical consortia in Southwest China. A standard structured questionnaire was used to assess abortion status among women of childbearing age. The 7-item Generalized Anxiety Disorder Scale (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9) were used to evaluate psychological well-being. Subsequently, multiple logistic regression analysis was employed to examine the associations between the quantity and reasons for abortions and the mental health status of postmenopausal women.

Results

A total of 9991 postmenopausal women were enrolled (mean age: 60.51 years), of whom 11.09% (1108 individuals) reported mental health problems (5.54% for depression and 8.27% for anxiety). Multiple logistic regression analysis revealed that, compared with women without any history of abortion, postmenopausal women who reported three or more abortions during their childbearing years were likely to have worse mental health conditions (OR [95% CI]: 1.37 [1.13, 1.67]). Additionally, women who reported a history of abortions for socio-economic reasons were also correlated with an increased risk of mental health issues after menopause (OR [95% CI]: 1.34 [1.08, 1.66]).

Conclusions

Women who reported a history of three or more abortions were at an increased risk of experiencing mental health issues after menopause. Reproductive-age women should enhance their contraceptive awareness to prevent unintended pregnancies and subsequent abortions. Healthcare institutions are recommended to strengthen psychological counseling for women who have undergone abortions.</blockquote>

[http://www.tandfonline.com/doi/full/10.1080/02646838.2010.513046 Long term follow‐up of emotional experiences after termination of pregnancy: women’s views at menopause.] Dykes K, Slade P, Haywood, A. Journal of Reproductive and Infant Psychology. 29(1) 2011. DOI:10.1080/02646838.2010.513046

:Abstract: The objective was to explore women’s long‐term experiences and perspectives on their terminations of pregnancy (TOP) when perimenopausal. Eight women attending a menopause clinic who had experienced termination a minimum of 10 years previously (mean 24 years) completed semi‐structured interviews. Transcripts were analysed using Template Analysis. Five TOP themes were identified: ‘Impression left’ involved sadness, regret, and guilt which affected women’s self‐perceptions. ‘Judgement’ encompassed judgement on themselves and how censure was feared from others. ‘Growth and development’ noted the development of resilience and compassion for others. ‘Coming to terms and managing effects’ identified beliefs in the correctness of the decision, but effortful avoidance of thoughts still intruding into life. ‘Contradictions’ identified dramatic inconsistencies within almost all individual accounts indicating lack of resolution and full acceptance. Considering menopause and TOP together revealed a further three themes; Changes to thinking, Menopause as a time of reflection and Linkages or separateness. For some women termination may be continually reappraised in their changing life context and remain an active yet hidden feature managed through active avoidance. Menopause was viewed as a time of vulnerability to TOP‐related negative thoughts, especially where wishes for more children were unfulfilled. Accessibility of post‐termination counselling throughout life is recommended.

==Psychiatric or Psychological Hospitalization or Consultation==

'''[https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-024-07005-w The association between repeated abortions during childbearing age and the psychological well-being of postmenopausal women in Southwest China: an observational study.] Li, X., Peng, A., Li, L. ''et al.'' ''BMC Pregnancy Childbirth'' 24, 805 (2024). <nowiki>https://doi.org/10.1186/s12884-024-07005-w</nowiki>'''<blockquote>Background

The issue of whether abortion increases the risk of future mental health problems for women remains a debated topic, and there is a lack of evidence from large-scale studies conducted in China. This study aimed to investigate the potential associations between abortions, particularly repeated abortions, and the mental health status of postmenopausal women in Southwest China.

Methods

The data were obtained from the baseline survey of a multi-center natural population cohort study in cooperated with medical consortia in Southwest China. A standard structured questionnaire was used to assess abortion status among women of childbearing age. The 7-item Generalized Anxiety Disorder Scale (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9) were used to evaluate psychological well-being. Subsequently, multiple logistic regression analysis was employed to examine the associations between the quantity and reasons for abortions and the mental health status of postmenopausal women.

Results

A total of 9991 postmenopausal women were enrolled (mean age: 60.51 years), of whom 11.09% (1108 individuals) reported mental health problems (5.54% for depression and 8.27% for anxiety). Multiple logistic regression analysis revealed that, compared with women without any history of abortion, postmenopausal women who reported three or more abortions during their childbearing years were likely to have worse mental health conditions (OR [95% CI]: 1.37 [1.13, 1.67]). Additionally, women who reported a history of abortions for socio-economic reasons were also correlated with an increased risk of mental health issues after menopause (OR [95% CI]: 1.34 [1.08, 1.66]).

Conclusions

Women who reported a history of three or more abortions were at an increased risk of experiencing mental health issues after menopause. Reproductive-age women should enhance their contraceptive awareness to prevent unintended pregnancies and subsequent abortions. Healthcare institutions are recommended to strengthen psychological counseling for women who have undergone abortions.</blockquote>'''''[https://pubmed.ncbi.nlm.nih.gov/38771715/ A Reanalysis of Mental Disorders Risk Following First-Trimester Abortions in Denmark.]'' Reardon DC Issues Law Med. 2024 Spring;39(1):66-75. PMID: 38771715.'''<blockquote>'''Background:''' A previous Danish study of monthly and tri-monthly rates of first-time psychiatric contact following first induced abortions reported higher rates compared to first live births but similar rates compared to nine months pre-abortion. Therefore, the researchers concluded abortion has no independent effect on mental health; any differences between psychiatric contacts after abortion and delivery are entirely attributable to pre-existing mental health differences. However, these conclusions are inconsistent with similar studies that used longer time frames. Reanalysis of the published Danish data over slightly longer time frames may reconcile this discordance.

'''Method:''' Monthly and tri-monthly data was extracted for reanalysis of cumulative effects over nine- and twelvemonths post-abortion.

'''Results:''' Across all psychiatric diagnoses, cumulative average monthly rate of first-time psychiatric contact increased from an odds ratio of 1.12 (95% CI: 1.02 to 1.22) at 9-months to 1.49 (95% CI: 1.37 to 1.63) at 12 months post-abortion as compared to the 9 months pre-abortion rate. At 12 months post-abortion, first-time psychiatric contact was higher across all four diagnostic groupings and highest for personality or behavioral disorders (OR=1.87; 95% CI:1.48 to 2.36) and neurotic, stress related, or somatoform disorders (OR=1.60; 95% CI: 1.41 to 1.81).

'''Conclusions:''' Our reanalysis revealed that the Danish data is consistent with the larger body of both record-based and survey- based studies when viewed over periods of observation of at least nine months. Longer periods of observation are necessary to capture both anniversary reactions and the exhaustion of coping mechanisms which may delay observation of post-abortion effects.</blockquote>

''[http://abortionrisks.org/index.php?title=Munk-Olsen_et_al Induced First-Trimester Abortion and Risk of Mental Disorder.] Trine Munk-Olsen, Ph.D., Thomas Munk Laursen, Ph.D., Carsten B. Pedersen, Dr.Med.Sc., Øjvind Lidegaard, Dr.Med.Sc., and Preben Bo Mortensen, Dr.Med.Sc. N Engl J Med 2011;364:332-9.''

: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. 

:'''Editor's Note''': Please see the [http://abortionrisks.org/index.php?title=Munk-Olsen_et_al extended review of this study] for a more detailed discussion of the methodological limitations which slanting of the study design.

''[http://www.cmaj.ca/cgi/content/full/168/10/1253 Psychiatric admissions of low income women following abortion and childbirth.] Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Can Med Assoc J. 2003; 168(10):1253-7''
: Background: Controversy exists about whether abortion or childbirth is associated with greater psychological risks. We compared psychiatric admission rates of women in time periods from 90 days to 4 years after either abortion or childbirth.

:Methods: We used California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth during 1989. Only women who had no psychiatric admissions or pregnancy events during the year before the target pregnancy event were included (n = 56 741). Psychiatric admissions were examined using logistic regression analyses, controlling for age and months of eligibility for Medi-Cal services.

:Results: Overall, women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age.

:Interpretation: Subsequent psychiatric admissions are more common among low-income women who have an induced abortion than among those who carry a pregnancy to term, both in the short and longer term.

NOTES:
*Tables showing when the psychiatric hospitalization occurred illustrate a marked peak closer to the time of the pregnancy event, providing support for a causal interpretation.
*Using the same population, the authors also examined outpatient treatment for psychiatric disorders and also found higher rates of outpatient treatment following abortion. See next entry below
* The abortion group had 160% more total in-patient mental health claims than the birth group. Percentages equaled 120%, 90%, 110%, 60%, and 50% for the first 180 days, one year, two years, three years, and four years respectively.
*Across the four years, the abortion group had 70% more in-patient mental health claims than the birth group. Percentages equaled 90%, 110%, and 200% for depressive psychosis, single episode, depressive psychosis, recurrent episode, and bipolar disorder, respectfully

''[http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2002-15486-015&CFID=27122313&CFTOKEN=47942096 State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years.]'' Coleman PK, Reardon DC, Rue VM, Cougle JR. American Journal of Orthopsychiatry, 2002; 72(1):141–52. ''

:(Abstract) In this record-based study, rates of 1st-time outpatient mental health treatment for 4 years following an abortion or a birth among women (aged 13-49 yrs) 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.

''Report of the Committee on the Abortion Law, RF Badgley et al, (Ottawa:Supply and Services, 1977) pp. 313-321 ''
:A Saskatchewan, Canada study found that postabortion women had "mental disorders" 40.8% more often than postpartum women. An Alberta, Canada study found that among women who had abortions, 24% made visits to psychiatrists compared to 3% in the general population.

''''[http://www.scribd.com/doc/132704966/Virginia-DMAS-analysis-of-health-claims-following-abortion-and-childbirth Virginia DMAS analysis of health claims following abortion and childbirth. Nelson J. Department of Medical Assistance Services. Richmond, VA. March 21, 1997. Reply to request by Delegate Bob Marshall.

:This was an exploratory investigation by the Virginia Department of Medical Assistance Services (DMAS) to compare health claims of women who aborted and women who had normal births. The study examined medicaid claims paid by DMAS over a three year period for 122 women who had a first live birth and 122 women with a first abortion.

:In this study population, women who had abortions had statistically significant 62% percent increase in subsequent mental health claims (43% higher costs), and a 12% increase in claims (53% higher costs) for treatments resulting from accidents. They were 275% more likely to undergo a subsequent clinical psychiatric evaluation and 206% more likely to receive individual medical psychotherapy, and were 720% more likely to receive pharmacologic management in association with minimal psychotherapy.

''"Health Services Utilization After Induced Abortion in Ontario: A Comparison Between Community Clinics and Hospitals," T Ostbye et al, Am J Medical Quality 16(3):99-106, 2001''
:In Canada, a study of Ontario Health Insurance Plan claims in 1995 found that women who were three months postabortion from hospital day surgery had a rate of hospitalization for psychiatric problems of 5.2 per 1000 vs. 1.1 per 1000 for age matched controls without induced abortions. Three month postabortion women who had abortions at a community clinic had a rate of hospitalization for psychiatric problems of 1.9 per 1000 vs. 0.60 per 1000 for age-matched controls who did not have induced abortions. The incidence of postabortion psychiatric hospitalization was significantly higher if there had been preabortion hospitalization for psychiatric problems, preabortion emergency room consultation, or preabortion hospital admissions. Ed. Note: Flaws in the available data and study design limit the value of this study.

''"Postabortion or Postpartum Psychotic Reactions," H David et al, Family Planning Perspectives 13(2): 892, 1981 ''
:A Danish register linkage study over a three month period found that the rate of psychiatric hospital admissions was 18.4 per 10,000 postabortion women, 12.0 pr 10,000 postpartum women, and 7.5 per 10,000 women of childbearing age generally.

''"Risk of Admission to Psychiatric Institutions among Danish Women Who Experienced Induced Abortion: An Analysis Based on A National Record Linkage," Ronald Somers, Dissertation Abstracts Int'l, Public Health 2621-B, 1979 ''
:The age-adjusted incidence of psychiatric hospitalization was 3.42%, 4.06%, and 6.0% for women with one, two, and three induced abortions respectively compared with 2.56%, 1.97% and 2.15% for women with one, two and three live births respectively. The age- adjusted percentage of psychiatric hospitalization for aborting women was 1.49% for married women, 2.38%for single women, 4.21% for separated women, and 5.16% for divorced women. Aborting women under 30 years of age exhibited higher overall and diagnosis specific psychiatric hospital admission rates than women of this age in general. Teenagers who had abortions had 2.9 times the rate of psychiatric hospital admissions compared to teenage women in general. The highest rate of psychiatric hospital admissions was 9.45% among women age 35-39 with more than one abortion during the study period.

''"State-funded abortions vs. deliveries: A comparison of subsequent mental health claims over 6 years," PK Coleman and D Reardon, Poster session presented at the American Psychological Society 12th Annual Convention, Miami, FL, June, 2000 ''
:In a study of California women who received state funded medical care and who either had an abortion or gave birth in 1989, postabortion women were more than twice as likely to have from two to nine treatments for mental health as women who carried to term.

''"Psychosocial Characteristics of Psychiatric Inpatients with Reproductive Losses," T Thomas et al, Journal of Health Care for the Poor and Underserved 7(1):15, 1996 ''
:Postabortion women were more likely to require psychiatric hospitalization, have been subjected to sexual abuse, and be diagnosed for psychoactive substance abuse disorder compared to childless women.

''"Past Trauma and Present Functioning of Patients Attending a Women's Psychiatric Clinic," EFM Borins and PJ Forsythe, Am J Psychiatry 142(4):460, 1985 ''
:In a Canadian study of women attending a hospital based women's psychiatric clinic, a past abortion correlated significantly with three or more trauma factors.

''Proceedings of the Conference on Psycho-Social Factors in Transnational Planning, W Pasini and J Kellerhals, (Washington D.C.: American Institute for Research, 1970) p.44 ''
:A three fold increase in previous psychiatric consultations was found in women seeking repeat abortions compared to maternity patients.

'''''Long term follow-up of emotional experiences after termination of pregnancy: women's views at menopause. Dykesa K, Sladeb P; Haywood A. Journal of Reproductive and Infant Psychology,, First published on: 20 October 2010'''''
:Abstract
:The objective was to explore women’s long-term experiences and perspectives on their terminations of pregnancy (TOP) when perimenopausal. Eight women attending a menopause clinic who had experienced termination a minimum of 10 years previously (mean 24 years) completed semi-structured interviews. Transcripts were analysed using Template Analysis. Five TOP themes were identified: ‘Impression left’ involved sadness, regret, and guilt which affected women’s self-perceptions. ‘Judgement’ encompassed judgement on themselves and how censure was feared from others. ‘Growth and development’ noted the development of resilience and compassion for others. ‘Coming to terms and managing effects’ identified beliefs in the correctness of the decision, but effortful avoidance of thoughts still intruding into life. ‘Contradictions’ identified dramatic inconsistencies within almost all individual accounts indicating lack of resolution and full acceptance. Considering menopause and TOP together revealed a further three themes; Changes to thinking, Menopause as a time of reflection and Linkages or separateness. For some women termination may be continually reappraised in their changing life context and remain an active yet hidden feature managed through active avoidance. Menopause was viewed as a time of vulnerability to TOP-related negative thoughts, especially where wishes for more children were unfulfilled. Accessibility of post-termination counselling throughout life is recommended.

''[http://www.ncbi.nlm.nih.gov/pubmed/21146202 Conduct disorder symptoms and subsequent pregnancy, child-birth and abortion: A population-based longitudinal study of adolescents.] Pedersen W, Mastekaasa A. J Adolesc. 2010 Dec 9.''
:Abstract: Research on teenage pregnancy and abortion has primarily focused on socio-economic disadvantage. However, a few studies suggest that risk of unwanted pregnancy is related to conduct disorder symptoms. We examined the relationship between level of conduct disorder symptoms at age 15 and subsequent pregnancy, child-birth and abortion. A population-based, representative sample of Norwegian adolescent girls (N = 769) was followed from early adolescence until their mid-20s. Even with control for socio-demographic and family variables, conduct disorder symptoms at age 15 were strongly associated with pregnancy in the 15-19 age group, and a weaker association persisted in the 20-28 age group. Similar results were obtained for abortions, but here a strong relationship with conduct disorder symptoms was found even after age 20. After adjustment, no significant association between conduct disorder symptoms and subsequent child-birth was observed. More targeted preventive programmes aimed at girls with conduct disorder symptoms may be warranted.

===Benefits of Childbirth===

'''''[http://www.informaworld.com/smpp/content~db=all~content=a923120522~frm=titlelink Motherhood: is it good for women's mental health?] Holtona S, Fishera J, Rowea H. Journal of Reproductive and Infant Psychology, Volume 28, Issue 3 August 2010 , pages 223 - 239'''''

:Abstract
:There is ongoing debate regarding whether the child-bearing years, including the postpartum period, are a time of increased risk for mental health problems in women. Comparisons of the mental health of mothers and childless women have inconsistent findings. This is probably attributable to differences in the kinds of mothers and non-mothers investigated, and variations in the conceptualisation of mental health, but suggests that firm conclusions about the relationship between motherhood and women's mental health remain less clear than claimed. This study investigated the relationship between motherhood and mental health in a population-based, cross-sectional survey of a broadly representative sample of 569 women aged 30-34 years living in Victoria, one Australian state, in 2005. It was found that the rates of mental health conditions in mothers, including those who had given birth in the preceding year, were no higher than in women without children. Further, mothers reported significantly better subjective well-being and greater life satisfaction than childless women. These data suggest that being a mother is associated with enhanced mental health for women, and challenge the view that the child-bearing years are a period of diminished psychological well-being for women.

'''[http://www.ncbi.nlm.nih.gov/pubmed/19188541 Risks and predictors of readmission for a mental disorder during the postpartum period.] Munk-Olsen T, Laursen TM, Mendelson T, Pedersen CB, Mors O, Mortensen PB. Arch Gen Psychiatry. 2009 Feb;66(2):189-95. doi: 10.1001/archgenpsychiatry.2008.528.'''

:CONCLUSIONS: "Mothers with mental disorders have lower readmission rates compared with women with mental disorders who do not have children." In other words, being a mother may contribute to stabilizing mental health.

===Mania and Bipolar Disorder===

[http://www.ncbi.nlm.nih.gov/pubmed/23381493 Post-abortion mania.] Sharma V, Sommerdyk C, Sharma S. Arch Womens Ment Health. 2013 Apr;16(2):167-9. doi: 10.1007/s00737-013-0328-0. Epub 2013 Feb 5.

:Abstract: We describe case histories of three women with post-abortion mania, including two women who underwent a change in diagnosis from bipolar II to bipolar I disorder and another woman who had no prior history of psychiatric disturbance. It is argued that the study of post-abortion mania should provide an opportunity to better understand the aetiology of puerperal mania.

[http://bjp.rcpsych.org/content/176/1/92.1.long Post-abortion mania.] I. F. Brockington The British Journal of Psychiatry Jan 2000, 176 (1) 92; DOI: 10.1192/bjp.176.1.92

:The author comments on case study a describing a woman who suffered from five episodes of puerperal mania and two of post-abortion psychosis, one after a therapeutic abortion and one after a spontaneous abortion. The author notes that the association of acute psychosis with abortion in women susceptible to puerperal psychosis had been noted in at least nine reports, summarized in Brockington's book ''Motherhood & Mental Health.''

==Turn Away Study==
'''[http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128832#sec013 Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study] Rocca CH, Kimport K, Roberts SC, Gould H, Neuhaus J, Foster DG. PLoS One. 2015 Jul 8;10(7):e0128832. doi: 10.1371/journal.pone.0128832. eCollection 2015.'''

Abstract
:BACKGROUND: Arguments that abortion causes women emotional harm are used to regulate abortion, particularly later procedures, in the United States. However, existing research is inconclusive. We examined women's emotions and reports of whether the abortion decision was the right one for them over the three years after having an induced abortion.

:METHODS: We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities across the United States, selected based on having the latest gestational age limit within 150 miles. Two groups of women (n=667) were followed prospectively for three years: women having first-trimester procedures and women terminating pregnancies within two weeks under facilities' gestational age limits at the same facilities. Participants completed semiannual phone surveys to assess whether they felt that having the abortion was the right decision for them; negative emotions (regret, anger, guilt, sadness) about the abortion; and positive emotions (relief, happiness). Multivariable mixed-effects models were used to examine changes in each outcome over time, to compare the two groups, and to identify associated factors.

:RESULTS: The predicted probability of reporting that abortion was the right decision was over 99% at all time points over three years. Women with more planned pregnancies and who had more difficulty deciding to terminate the pregnancy had lower odds of reporting the abortion was the right decision (aOR=0.71 [0.60, 0.85] and 0.46 [0.36, 0.64], respectively). Both negative and positive emotions declined over time, with no differences between women having procedures near gestational age limits versus first-trimester abortions. Higher perceived community abortion stigma and lower social support were associated with more negative emotions (b=0.45 [0.31, 0.58] and b=-0.61 [-0.93, -0.29], respectively).

:CONCLUSIONS: Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years. Emotional support may be beneficial for women having abortions who report intended pregnancies or difficulty deciding.

===Comments & Criticisms===
# This study's findings and conclusions are overreaching in many regards, beginning with the fact that the sample of women is not representative of the national population of women having abortions due to high rates of self-exclusion plus high drop out rates. To quote from the study: "Overall, 37.5% of eligible women consented to participate, and 85% of those completed baseline interviews (n = 956). Among the Near-Limit and First-Trimester Abortion groups, 92% completed six-month interviews, and 69% were retained at three years; 93% completed at least one follow-up interview." This means 62.5% of women refused to participate in the study.
# With 62.5% of eligible women refusing to participate in the study, it is improper for the authors to suggest that their findings reflect the general experiences of most women. There are numerous [[risk factors]] which have been identified as predicting which women will have the most severe post-abortion reactions. One of these risk factors, for example, is ambivalence about having an abortion or carrying to term. Another is the expectation that one will have more negative feelings about the abortion. In a similar post-abortion interview study by [[Soderberg]], the author reported that in interviews with those declining to participate "the reason for non-participation seemed to be a sense of guilt and remorse that they did not wish to discuss. An answer often given was: ' Do do not want to talk about it. I just want to forget.'"
# It is very likely that the self-selected 37.5% of women agreeing to participate were more highly confident of their decision to abort prior to their abortions and anticipated fewer negative outcomes. This concern about selection bias is highlighted by the study's own finding that "women feeling more relief and happiness at baseline were less likely to be lost [to follow-up]." Clearly, due to the large numbers of women choosing not to be questioned about their experience, and the large drop out of those who did agree, this sample is not representative of the national population of women having abortions.
# Despite the initial selection bias, 15% of those agreeing to be interviewed subsequently opted out of the baseline interview and another 31% opted out within the three year followup period. This indicates that even among women who expected little or no negative reactions, the stress of participating in follow up interviews lead to a change of mind. The authors also make much of the claim that 93% of the participants "completed at least one follow up interview" which the media outlets incorrectly reported as meaning [http://www.medicalnewstoday.com/articles/296756.php"Only 7% of the participants dropped out of the study during follow-up."]
# According to an [http://www.ansirh.org/wp-content/uploads/Turnaway-Study-Infographic_7-8-2015.pdf infographic about the study] published by the research group, the followup interviews were actually continued every six months for five years, not just three. Why then did this report limit itself to three years rather than cover the full five years covered by the study?
# The bias of the research team is made clear in [http://www.ansirh.org/news/new_ANSIRH.php press releases] and a [http://www.ansirh.org/wp-content/uploads/Turnaway-Study-Infographic_7-8-2015.pdf infographic] purporting to summarize the study. In these "summaries" the research group conceals the details regarding the high non-participation rate and boldly claims "95% of women who had abortions felt it was the right decision, both immediately and over 3 years," omitting the fact that 62.5% refused to answer the question at the time of their abortion and of those interviewed at the time 31% were out of the study by the third year. Notably, the problem of high non-participation and drop out rates is not mentioned in the abstract, press release, or other summarizing materials published by the authors. To the contrary, they consistently imply that their results apply to the entire population of women having abortions.
#Another oddity, the authors report that in the final group analyzed, average age 25, 62% were raising children. This would appear to be a very high rate that is not typical of national averages for women seeking abortion.
#The study population is also non-representative of the women having abortion in that it included 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester. This is totally disproportionate. It again shows that the authors should not be extending conclusions about this non-representative sample to the general population.
#The focus of this report in on women's persistent satisfaction with their abortion decisions, "decision rightness," as measured by a single question of whether or not the "abortion was right for them." Women were asked to answer this question "yes", "no" or "uncertain." A better research approach would have been to have this question rated on a numeric scale (1 to 10, for example) in order to better identify any shift in attitudes.
#Questions regarding decision satisfaction may produce [https://en.wikipedia.org/wiki/Reaction_formation reaction formation] and therefore defensive answers affirming the rightness of a decision even if there are actually unresolved anxieties or other issues. (To voice dissatisfaction may invite anxiety provoking thoughts. Responding the way one is expect to respond, avoids reflection). Additional questions should have been asked to better gauge the subjects thoughts. For example, in the [[Soderberg]] study, including a one year post-abortion interview of 847 women (after a 33% self-exclusion rate), 80% of the women were satisfied with their decision to abort but 76% also stated that they would never abort again if faced with an unwanted pregnancy. A woman expressing unwillingness to not have another abortion may tell us more than her expression of the "rightness" of a past abortion decision that cannot be changed.
#While the report and [http://www.ansirh.org/news/new_ANSIRH.php accompanying press release] claim that this study proved there is "no evidence of widespread 'post-abortion trauma syndrome,' in fact it did not use any standard scales for assessment of psychological well being. They certainly did not overcome the findings of record linkage studies which have shown an [http://www.cmaj.ca/content/168/10/1253.full elevated risk of psychiatric admissions] following abortion or [http://www.bmj.com/content/313/7070/1431 elevated rates of suicide]. Instead, their assessment of psychological health is all inferred from an assessment of just six emotional reactions they associated with their abortion: relief, happiness, regret, guilt, sadness and anger. Women rated each emotion on a five point scale from "not at all" to "extremely" and a scale was constructed by combining all four negative emotions and another from combining the two positive emotions.
#The authors report a decline in the negative emotions reported by the women remaining in the study over the three year period.
#Notably, the claim of declining regret and declining negative reactions is at odds with [[Brenda Major]]'s two year longitudinal study, which also had high drop out rates, which found that there was a trend in decline in relief and increase in negative emotions over the two year period among those who did not drop out of her study. (See Major B, et al. Psychological responses of women after first-trimester abortion. Archives of General Psychiatry. 2000: 57(8), 777-84.)
#From the observation that the scale created from four negative reactions showed a modest decline in negative reactions over three years, the authors they draw the very broad conclusion that there is no evidence of widespread negative psychological reactions to abortion. This conclusion ignores the fact that many psychological problems are characterized by denial and repression of negative emotions.
#But there is clear evidence from other studies that many women experience symptoms of post-traumatic stress disorder which includes symptoms of denial and avoidance behavior. In a study by Rue, for example, among women reporting intrusive memories or thoughts related to their abortion, only half denied that these thoughts were attributed (caused) by their abortions. In other words, it is not always easy for women to recognize which feelings may be attributable to their abortions. For example, it is only when in post-abortion counseling that many women may attribute increased feelings of anger after their abortions to unresolved feelings over the abortion which they were projecting onto other people and situations. This is all fairly basic psychology. Negative emotions often crop up in other parts of our lives because we have trouble dealing with them at the source. Therefore, women reporting less "anger" relative to their abortion may in fact have more feelings of anger in their lives than before their abortion but are simply attributing it to other issues. This demonstrates the difficulty in trying to judge the post-abortion emotional adjustment of women based on just six oversimplified questions about six basic emotions.
#Another difficulty raised by the researchers methodology is that their interviews apparently did not inquire about any steps women took to resolve negative emotions. It is necessary to know if women who had negative feelings sought any help to deal with those feelings, perhaps with a therapist, a pastor, or family or friends. The increase in the number of women participating in post-abortion programs should, for example, help to reduce the longevity of negative reactions to abortion. But if this is the case, the conclusion of the authors that negative reactions to abortion naturally diminish over time may be wrong if, in fact, the decrease is due to women receiving post-abortion psychological or spiritual counseling. In other words, if the decline in negative reactions is real (and not due to denial, repression, or just a desire to rush through the phone interview to collect the $50 gift card) it is important to understand the reason for this. Is it due to support given to those having negative feelings, or is it "natural" and permanent?

==Older Papers Regarding Long-Term Effects==
''[http://www.ncbi.nlm.nih.gov/pubmed/19880932?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=1 Reactions to abortion and subsequent mental health.] Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2009 Nov;195(5):420-6.''

:BACKGROUND: There has been continued interest in the extent to which women have positive and negative reactions to abortion. AIMS: To document emotional reactions to abortion, and to examine the links between reactions to abortion and subsequent mental health outcomes.

:METHOD: Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30.

:RESULTS: Abortion was associated with high rates of both positive and negative emotional reactions; however, nearly 90% of respondents believed that the abortion was the right decision. Analyses showed that the number of negative responses to the abortion was associated with increased levels of subsequent mental health disorders (P<0.05). Further analyses suggested that, after adjustment for confounding, those having an abortion and reporting negative reactions had rates of mental health disorders that were approximately 1.4-1.8 times higher than those not having an abortion.

:CONCLUSIONS: Abortion was associated with both positive and negative emotional reactions. The extent of negative emotional reactions appeared to modify the links between abortion and subsequent mental health problems.

[[Broen]] AN, Moum T, Bodtker AS, Ekeberg O: [http://www.ncbi.nlm.nih.gov/pubmed/15694217?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Reasons for induced abortion and their relation to women's emotional distress: a prospective, two-year follow-up study.] Gen Hosp Psychiatry 2005, 27:36-43.
:OBJECTIVE: The present study aimed to identify the most important reasons for induced abortion and to examine their relationship to emotional distress at follow-up. :
:METHODS: Eighty women were included in the study. The women were interviewed 10 days, 6 months (T2) and 2 years (T3) after they underwent an abortion. At all time points, the participants completed the Impact of Event Scale and a questionnaire about feelings connected to the abortion.
:RESULTS: Reasons related to education, job and finances were highly rated. Also, "a child should be wished for," "male partner does not favour having a child at the moment," "tired, worn out" and "have enough children" were important reasons. "Pressure from male partner" was listed as the 11th most important reason. When the reasons for abortion and background variables were included in multiple regression analyses, the strongest predictor of emotional distress at T2 and T3 was "pressure from male partner."
:CONCLUSION: Male pressure on women to have an induced abortion has a significant, negative influence on women's psychological responses in the 2 years following the event. Women who gave the reason "have enough children" for choosing abortion reported slightly better psychological outcomes at T3.

[http://www.ncbi.nlm.nih.gov/pubmed/15039513?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Psychological Impact on Women of Miscarriage Versus Induced Abortion: A 2-Year follow-up study.] [[Broen]] AN, Moum T, Bödtker AS, Ekeberg O. Psychosomatic Medicine, 2004, 66:265-271.

:"The feeling relief (at T1) had no significant influence on the IES scores at T3, unadjusted or adjusted." (p 268) This supports an argument that researchers who place too much emphasis on measure of relief may be missing the full picture.

p270, "mental health before the event suprisingly had no significant independent influence on IES scores."

 [http://www.ncbi.nlm.nih.gov/pubmed/16343341?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum The course of mental health after miscarriage and induced abortion: a five-year follow-up study.] [[Broen]] AN, Moum T, Bødtker AS, Ekeberg O. BMC Medicine 2005, 3:18 (12 December 2005)

:Broen et al.'s results show that women who had a miscarriage suffer more mental distress up until six months after the event than women who had an abortion. Women who had an abortion, however, experienced more mental distress long after the event - two and five years afterwards - than women who had a miscarriage. Women who experienced induced abortion had significantly greater IES scores for avoidance and for the feelings of guilt, shame and relief than the miscarriage group at two and five years after the pregnancy termination (IES avoidance means: 3.2 vs 9.3 at T3, respectively, p < 0.001; 1.5 vs 8.3 at T4, respectively, p < 0.001). Compared with the general population, women who had undergone induced abortion had significantly higher HADS anxiety scores at all four interviews (p < 0.01 to p < 0.001), while women who had had a miscarriage had significantly higher anxiety scores only at T1 (p < 0.01).

 [http://www.ncbi.nlm.nih.gov/pubmed/16553180?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Predictors of anxiety and depression following pregnancy termination: a longitudinal five-year follow-up study.] [[Broen]] AN, Moum T, Bödtker AS, Ekeberg O. Acta Obstet Gynecol Scand. 2006;85(3):317-23.

:BACKGROUND: The aims of the study were to assess anxiety and depression in women who had experienced either a miscarriage or an induced abortion, to compare the women's level of distress with that of a general population sample, and to find predictors of anxiety and depression six months and five years after the event. METHODS: A prospective, longitudinal follow-up study. Women who experienced miscarriage (n = 40) and induced abortion (n = 80) were interviewed ten days (T1), six months (T2), two years (T3), and five years (T4) after the event. On each occasion, they completed the Hospital Anxiety and Depression Scale and the Life Events Scale. Paired-sample t-test, logistic regression, and multiple linear regression statistical tests were used. RESULTS: Women with miscarriage had significantly more anxiety and depression at T1 than the general population, while women with induced abortion had significantly more anxiety at all time points and more depression at T1 and T2. In both groups, important predictors of anxiety and depression at T2 and T4 were recent life events and poor former psychiatric health. Childbirth events between T1 and T4 had no significant influence on the scores. For women with induced abortion, doubt about the decision to abort was related to depression at T2 (p <0.05), while a negative attitude towards induced abortion was associated with anxiety at T2 (p <0.05) and T4 (p <0.05). CONCLUSION: Correlates of anxiety and depression may be used to better identify women who are at risk of negative psychological responses following pregnancy termination.

''"Induced Elective Abortion and Perinatal Grief," Gail B. Williams, Dissertation Abstracts Int'l. 53(3): 1296B, Sept. 1992. ''
:A study of 83 white women with one first trimester abortion, no documented psychiatric history and no self-reported prenatal losses in the last 5 years an average of 11 years postabortion. The Grief Experience Inventory was used as a test instrument and found a range of scores from 27-82. 50 represents at least minimal grief on 12 bereavement/research scales. Various scales measured included anger/hostility, social isolation, loss of control, death anxiety, loss of vigor, physical symptoms, dependency, somatization, sleep disturbance, loss of appetite, optimism/despair, denial. It was concluded that some women experienced persistence of various aspects of grief for long periods of time following induced abortion.

''The Psycho-Social Aspects of Stress Following Abortion, Anne C. Speckhard, (Kansas City: Sheed and Ward, 1987)''
:In a study of 30 women stressed by abortion after 5-10 years following their abortion, women reported feelings of sadness, regret, remorse or a sense of loss [100 percent]; feelings of depression [92 percent]; feelings of anger [92 percent]; feelings of guilt [92 percent]; fear that others would learn of the pregnancy and abortion experience [89 percent]; many expressed surprise at the intensity of the emotional reaction to the abortion [85 percent]; Other adverse reactions included feelings of lowered self-worth [81 percent]; feelings of victimization [81 percent]; preoccupation with the characteristics of the aborted child [81 percent]; feelings of depressed effect or suppressed ability to experience pain [73 percent]; and feelings of discomfort around infants and small children [73 percent]. In this study the most common behavioral reactions included frequent crying [81 percent]; inability to communicate with others concerning the pregnancy and abortion experience [77 percent]; flashbacks of the abortion experience [73 percent]; sexual inhibition [69 percent]; suicide ideation [65 percent] and increased alcohol use [61 percent].

''"Aborted Women: Silent No More," David C. Reardon, (Chicago: Loyola Press, 1987)''
:In a detailed study of 252 women with prior abortions who are members of Women Exploited by Abortion approximately 10 years after their abortion, 95% were now dissatisfied with the abortion choice and 94% attributed negative psychological effects to their abortion.

''"Mental Disorders After Abortion," B. Jansson, Acta Psychiatrica Scandinavica41:87 (1965). ''
:In a Swedish study of 57 women with prior psychiatric problems who subsequently had induced abortions, three committed suicide as determined by long-term follow-up studies 8-13 years after their abortion. In contrast, of 195 women with previous psychiatric problems who carried children to term, none committed suicide.

''"Risk of Admission to Psychiatric Institutions Among Danish Women Who Experience induced Abortion," Ronald L. Somers, Ph.D. Thesis/ UCLA (1979) ''
:Among women with 2 or more abortions the rate of psychiatric admissions among women 35-39 (approx. 9%) was about 4 times higher than women 25-29 years of age (approx. 2.3%) and 8-18 times higher than women 20-24 years of age (0.5-1.1%) during 1973- 1975.

''"Psychological Aspects of Abortion," Edna Ortof in Psychological Aspects of Pregnancy, Birthing and Bonding, ed. Barbara L. Blum (New York: Human Sciences Press, 1980) ''
:Several examples of post-abortion dreams are provided. One woman had the following dream 11, years after a self-induced abortion:
:"I was in my old home town with two girlfriends and about to go horseback riding... (but) we couldn't get a horse. Then some lady came over and handed me a bundle wrapped in a sheet and blankets/ like a baby. I was delighted to hold it... when I opened the bundle ... there was a kid there and it looked like it was shrinking. Like it was wasting away and I wanted the mother to come and take it away before it would die in my arms... The more I looked, the more anxious I got." The therapist reported this woman had an enormous sense of unfinished business about the pregnancy and abortion. She still had periodic intercourse without use of contraceptives with the prospective father hoping to "undo" that event. At times her guilt was overwhelming and her sense of loss increased with the passing years.

''A Survey of Post-Abortion Reactions, David C. Reardon, (Springfield, Illinois: Elliot Institute, 1987) ''
:A 1987 survey of 100 women an average of 11 years post-abortion who were contacted through state Women Exploited by Abortion chapters found that only 54% felt they had fully reconciled their abortion experience; 62% experienced the majority of their negative experience one year or more post-abortion; 97% regretted having the abortion; 62% said they felt more callused and hardened; 70% felt a need to stifle feelings; 45% said they had feelings of relief after abortion; 42% became sexually promiscuous; 50% reported aversion to sexual intercourse or sexual unresponsiveness; 54% thought the abortion choice was inconsistent with their own ideals; 64% ended the relationship with their sexual partner following the abortion (41% within one month, 9% more within 6 months and 14% more within one year.

''The Long-Term Psychological Effects of Abortion, Catherine A Barnard, (Portsmouth, NH: Institute for Pregnancy Loss, 1990) Summarized in Association for Interdisciplinary Research in Values and Social Change Newsletter 3(4):1 (1991) ''
:A random sample of 984 women who had abortions during 1984-84 at a clinic in Baltimore, Maryland were selected for study. However, only 160 women could be contacted 3-5 years later, Of the 160 contacted only 80 actually completed the research packets. Research instruments used were the DSM-IIIR, Impact of Events Scale, and the Millon Clinical Mulitaxial Inventory. The prevalence of Post Traumatic Disorder was 18.8%. High stress levels ranging from 39-45% were prevalent in such areas as sleep disorers, hypervigalence, or flashbacks. The variables that predicted high stress reactions were: a negative relationship with mother, a past history of emotional problems in the family of origin, a conflictual relationship with the father of the child, and poor aftercare at the clinic. The number of reported prior abortions did not predict the incidence of PTSD. 30% of the women had abortions between 14-18 years of age and few were religious at the time of their abortion.

''"Methodological considerations in empirical research on abortion," RL Anderson et al in Post-Abortion Syndrome. Its Wide Ramifications, ed. Peter Doherty (1995) 103 ''
:A study at Pine Rest Christian Hospital in Grand Rapids, Michigan which provided psychiatric outpatient services, compared women who presented with a history of elective abortion and sought psychiatric outpatient services in response to a negative adjustment to abortion ( the abortion distressed group), to a control group which also had a history of elective abortion but who presented for outpatient psychiatric services for reasons which were not abortion related. (the abortion non-distressed group). The average length of time from the abortion to the time of the study was 9 years. Seventy-three percent (73%) of the abortion distressed group met the criteria for Post Traumatic Stress Disorder (DSM-IIIR) which was significantly higher than the abortion non-distressed group. Women in the abortion distressed group more often reported they believed abortion to be morally wrong compared to the abortion non-distressed group. There were no significant differences among groups in psychopathology as measured by MMPI-2, on overall social support, or religiosity. Abortion distressed women experienced fewer recent adverse life events compared to abortion non-distressed women.

''Canonical variates of postabortion syndrome, Helen P Vaughan, (Portsmouth, NH: Institute for Pregnancy Loss, 1990) ''
:Questionnaires were distributed nationwide to 62 crisis pregnancy centers to women who had reported symptoms of postabortion syndrome and 232 questionnaires were returned. The mean length of time from their abortion was 11 years. It was found that postabortion syndrome was comprised of anger, guilt, grief, depression, and stress reactions. Two different dimensions of negative postabortion adjustment were noted. One dimension included high levels of anger and guilt, with a significant absence of any grief feelings. The second dimension showed high guilt and stress with a significant absence of anger. The various personality characteristics and circumstances of women in each dimension were discussed.

''" Psychological Profile of dysphoric women postabortion," KN Franco et al, Journal of the American Medical Women's Association 44(4): 113, 1989 ''
: Eighty-one women in a patient-led postabortion support group years who described themselves as having poorly assimilated their abortion experience 1-15 years postabortion were studied. 78% were single at the time of their abortion and only 19% married the father of the child. The Bech Depression Inventory for women with one abortion was 4.7(none to minimal depression) and for women with multiple abortions was 9.4(moderate depression). The Millon Clinical Mulitaxial Inventory (MCMI) suggested personal pathology in the form of anxiety (48%), somatoform disorders (58%), and dysthymia (36%). Those with multiple abortions scored on the borderline personality subscales. Some 48% of the group underwent psychotherapy after their abortion; 50% of women with multiple abortions made a suicide attempt sometime after their abortions; anniversary reactions were clearly reported by 42% of the sample. For additional studies on this sample of postabortion women see "Anniversary Reactions and Due Date Responses Following Abortion," K Franco et al, Psychother Psychosom 52:151, 1989; "Abortion in Adolescence," NB Campbell et al, Adolescence, 23(92), 1988

''Post-Abortion Trauma, 9 steps to Recovery, Jeanette Vought, (Grand Rapids: Zondervan, 1991). ''
:In a study of women in a religiously-based postabortion recovery group 10-15 years post- abortion, 90% reported guilt and shame related to their abortion, 74% feelings of isolation, 60% expressed anger toward others, 24% were more fearful of sexual intercourse after their abortion, 31% tried to avoid pregnant women, 53% said they desired to get pregnant again to compensate for their loss; 76% suffered from depression, 78% struggled with low self-esteem and 49% said they felt alienated from God. Following their abortion, women reported insomnia (25%), negative and hurtful relationships with men (38%, abortion had a negative effect on parenting (32.4%), frequent alcohol use (17.8%), frequent drug use (9.2%) as well as other negative personal or relational problems.

''"Physical and Psychological Injury Following Abortion: Akron Pregnancy Services Survey," L.H. Gsellman, Association For Interdisciplinary Research Newsletter 5(4):1-8, Sept/Oct 1993. ''
:In a questionnaire study of 344 post-abortal women receiving a variety of services at a pregnancy service center an average of 6 years following their abortion, 66% expressed guilt, 54% expressed regret or remorse, 46% had an inability to forgive self, 57% reported crying or depression, 38% reported lower self-esteem and 36% reported anger or rage, 16% reported suicidal impulses and 7% made suicide attempts. 18.4% of the abortions were at 13 weeks gestation or more; 22% reported two abortions and 4.3% reported three or more abortions.

''"Prolonged Grieving After Abortion. A Descriptive Study," D Brown et al, The Journal of Clinical Ethics 4(2):118, 1993. ''
:Upon request, women from a large protestant congregation in Florida wrote descriptive letters on the negative effects of abortion. 45 letters contained sufficient information to compile statistical information, 81% were first trimester abortions and 71% occurred after Roe v Wade was decided. 42% reported negative emotional sequelae that lasted over 10 years. Frequently mentioned long term experiences included guilt feelings (73.3%), fantasizing about the aborted fetus( 57.8%), masking their experience with the appearance of well-being (35.5%), suicide ideation (15.5%), recurrent nightmares(15.5%), marital discord (15.5%), phobic responses to infants (13.3%), as well as fear of men (8.9%) and disinterest in sex (6.7%).

==Long-Term Effects of Unintended Pregnancy==

[http://ajph.aphapublications.org/doi/10.2105/AJPH.2015.302973 The Implications of Unintended Pregnancies for Mental Health in Later Life.] Herd P, Higgins J, Sicinski K, Merkurieva I. American Journal of Public Health: March 2016, Vol. 106, No. 3, pp. 421-429.

:Abstract: Despite decades of research on unintended pregnancies, we know little about the health implications for the women who experience them. Moreover, no study has examined the implications for women whose pregnancies occurred before Roe v. Wade was decided—nor whether the mental health consequences of these unintended pregnancies continue into later life. Using the Wisconsin Longitudinal Study, a 60-year ongoing survey, we examined associations between unwanted and mistimed pregnancies and mental health in later life, controlling for factors such as early life socioeconomic conditions, adolescent IQ, and personality. We found that in this cohort of mostly married and White women, who completed their pregnancies before the legalization of abortion, unwanted pregnancies were strongly associated with poorer mental health outcomes in later life.

:'''NOTE:'''This study examined data collected from two interviews of 4,809 women who graduated from a Wisconsin high school in 1957, one in in 1975 and the other in 1992. In the 1992 data they found a slightly higher rate of depression among the women who reported giving birth to an unintended pregnancy prior to 1975. From this they conclude that “Experiencing unwanted pregnancies, especially after a woman or couple has reached a desired number of children, appears to be strongly associated with poor mental health effects for women later in life."

:This is a very weak and poorly designed study. The authors fail to control for important variables associated with depression in 1992, the year in which depression was assessed. For example, marital status, number of children, and frequency of religious attendance are examined for 19972, but not 1992.

:Also, the authors are making the assumption that the women in the study have no history of abortion, either before 1972 or after 1972. They are also presuming that "most" of these women's pregnancies were prior to 1972, but women graduating in 1957 were mostly 30-31 when abortion was legalized in 1972 . . . and just 27-28 when it was legalized in Colorado in 1967. In the mid and late 60's there was a significant effort to legalize abortion and widespread referrals to doctors doing illegal abortions.

:The study also fails to account for exposure to miscarriage and neonatal losses. In addition, their citations to the literate are also limited to assertions that parenting is stressful while ignoring other studies, like [http://americanvalues.org/catalog/pdfs/the_motherhood_study.pdf The Motherhood Study], which have documented the health benefits of being a parent.

Guilt

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==Guilt==

===Background Studies===
:Guilt is much understood in contemporary society. Some believe that guilt is only relative to the culture, while others believe that results from violation of some basic value intrinsic in human nature.

''"The Psychophysiology of Confession: Linking Inhibitory and Psychosomatic Processes," J.W. Pennebaker et al, J. Personality and Social Psychology 52(4): 781, 1987.''
:Failure to confide traumatic events was found to be stressful and associated with long- term health problems.

''"Sin, The Lesser of Two Evils," O. Hobart Mowrer, American Psychologist, May, 1960, pp. 301-304. ''
:Comments by the author:
:For several decades we psychologists looked upon the whole matter of sin and moral accountability as a great incubus and acclaimed our liberation from it as epochmaking.... In reconsidering the possibility that sin must, after all, be taken seriously, many psychologists seem perplexed as to what attitude one should take toward the sinner. Non- judgmental, nondirective, warm accepting, ethically neutral are words generally used.... We have reasoned the way to get the neurotic to accept and love himself is for us to love and accept him, an inference which flows equally from the Freudian assumption that the patient is not really guilty or sinful but only fancies himself so and from the view of Rogers that we are all inherently good and are corrupted by our experiences with the external, everyday world.
:But what is here generally overlooked, it seems, is that recovery (constructive change, redemption) is most assuredly attained, not by helping a person reject and rise above his sins, but by helping him accept them. This is the paradox which we have not at all understood and which is the very crux of the problem. Just so long as a person lives under the shadow of real, unacknowledged, and unexcited guilt, he cannot (if he has any character at all) "accept himself"; and all our efforts to reassure him and accept him will avail nothing. He will continue to hate himself and to suffer the inevitable consequences of self-hatred. But the moment he (with or without "assistance") begins to accept his guilt and his sinfulness, the possibility of radical reformation opens up; and with this, the individual may, legitimately, though not without pain and effort, pass from deep, pervasive self-rejection and self-torture to a new freedom of self-respect and peace.

''"The Myth of Mental illness," Thomas Szasz, American Psychologist 15:113-118 (1960).''
:"The notion of mental illness has outlived whatever usefulness it might have had and..- now functions merely as a convenient myth...mental illness is a myth whose function is to disguise and thus render more palatable the bitter pill of moral conflicts in human relations."

''"The Theology of Therapy: The Breach of the First Amendment through the Medicalization of Morals," Thomas Szasz, N.Y.U. Review of Law and Social Change (1975); also. "The Control of Conduct: The Ethics of Helping People," Szasz, Crim. Law Bulletin II, pp. 617-622, September-October 1975. ''
:"In the Therapeutic State many medical acts are considered scientific when, in fact, they are moral, and many psychiatric acts are considered medical, when, in fact, they are religious."
:Szasz observes a close parallel between church and state relations 200 years ago and between medicine and state relations today. He notes that "in each case (church or medicine) we are faced with a social institution to which men and women turn to for protection when they feel most endangered. Hence, they want their protector to be as powerful as possible. [But] protection from injuries and diseases requires knowledge and skills, not power; protection from guilt and shame requires honesty and courage, not power; power is necessary to oppose the external enemies of freedom but not the internal enemies of freedom."

''"Guilt and Guilt Feelings," Martin Buber, Proceedings of the International Conference on Medical Psychotherapy, Vol. Ill, International Conference of Mental Health, London, 1948. (New York: Columbia University Press, 1948). ''
:Comments by the author:
:As a result of the teachings of Freud, who presented the naturalism of the enlightenment with a scientific system.. .guilt was simply not allowed to acquire an ontic character; it had to be derived from the transgression against ancient and modern taboos, against parental and social tribunals. The feeling of guilt was now to be understood as essentially only the consequence of dread of punishment and censure by this tribunal. (p. 115)
:Guilt does not exist because a taboo exists to which one fails to give obedience, but rather that taboo and the placing of taboo have been made possible only through the fact that the leaders of early communities knew and made use of a primal fact of man as man- the fact that man can become guilty and know it. (pp-116-117)
:The psychotherapist is no pastor of souls and no substitute for one. It is never his task to mediate a salvation; his task is only to further a healing, (p. 119)
:The therapist in order to do this must recognize one thing steadfastly and recognize it ever again: There exists real guilt, fundamentally different from all the anxiety induced bugbears that are generated in the cavern of the unconscious. Personal guilt, whose reality some schools of psychoanalysis contest and others ignore, does not permit itself to be reduced to the trespass against a powerful taboo, (pp. 119-120)
:Each man stands in an objective relationship to others; the totality of this relationship constitutes his life as one that factually participates in the being of the world. It is this relationship, in fact, that first makes it at all possible for him to expand his environment into a world. It is his share in the human order of being, the share for which he bears responsibility.
:Injuring a relationship means that at this place the human order of being is injured. No one other than he who inflicted the wound can heal it. He who knows the fact of this guilt and is a helper can help him try to heal the wound (p. 120).
:The doctor is not concerned with whether or not the demand of the society is right or not. This does not concern the doctor as doctor; he is incompetent here.. .nor can faith be his affair. Here the action commences within the relation between the guilty man and his God and remains therein. The therapist may lead up to conscience but no farther. Conscience means to us the capacity and tendency of man radically to distinguish between those of his past and future actions which should be approved and those which should be disapproved. Conscience only rarely fully coincides with a standard received from the society or community. Self-illumination, perseverance and reconciliation is required. (pp. 120-121)

''Toward a Psychology of Being, Abraham Maslow (Princeton: F. Van Nostrand Co.,1962) ''
:"Intrinsic conscience" is the necessity of being true to one's inner self, and not denying it our of weakness or for special advantage.

''Conscience and Guilt, Tames A. Knight, (New York: Appleton-Century-Crofts, 1969).''
:The bond between the principle and the act is conscience. There is something wrong with psychology's emphasis on "adjustment", rather than "goodness." Real guilt follows in the wake of wrongdoing, seen and accepted as such by the doer, who seeks expiation and makes restitution.

===Abortion-Related Guilt/Regret/Violation of Conscience or Belief===
:By adopting a pragmatic approach to abortion-decision making, higher ethical, moral or religious standards are frequently violated as the following studies demonstrate.

'''[http://sm-hs.eu/index.php/smhs/article/viewFile/sm-hs.2015.021/1186 Associations of Pregnancy Loss and Psychological State.] Serapinas D. Health Sciences 25(2):4-8, 2015. doi:10.5200/sm-hs.2015.021'''

:Summary: Miscarriage and induced abortion are life events that can potentially cause mental distress. The objective of this study was literature review and to perform case study to determine whether there are any differences in the patterns of psychological symptoms after these two events and to point the importance of informed consent. In our study 20 women who experienced miscarriages and 20 women who underwent induced abortions were interviewed in Vilnius out patients clinics. We found that women who had pregnancy termination had more mental distress than women who experienced a miscarriage (guilty, anxiety, anger, episodes of crying etc). Women under going abortion had significantly more conflicts in their partnerships. Separation occurred in about one-quarter of all couples. In conclusion women who had undergone an abortion exhibited higher frequency of psychological symptoms than after miscarriage. Although an answer to the causal question is not readily discerned based on the data available, as more prospective studies with numerous controls are being published, indirect evidence for a causal connection is beginning to emerge. So we may consider that it is necessary still before induced abortion procedure to inform the couples about an increasing possibility of mental distress.

:Key Findings: "The main finding of our study is, that women who had pregnancy termination had more mental distress than women who experienced a miscarriage. (guilty 16 vs 10; anxiety 17 vs 8 , suicidal minds 7 vs 3, episodes of crying 15 vs 10, anger 13 vs 2, community avoidance 12 vs 4, p < 0.05)." "After termination of pregnancy, 4 couples of 20 separated. The majority of women (n = 18) did not report changes in their sexual behaviour after miscarriage. On the other hand, 13 of women after abortion presented a decrease in sexual desire. Changes in eating (mostly lack of appetite) habits mentioned 10 women in abortion group and 5 women in miscarriage group (p < 0.05). In abortion group 16 women mentioned that after event their sleep become more disturbed (insomnia, nightmires), while in control group 12 had such problems (p>0.05). The start of use of anxiolitics [to treat anxiety] mentioned 11 women in analyzed group and 9 women in miscarriage group (p>0.05). "

''"Many in Survey Who Had Abortion Cite Guilt Feelings," George Skelton, Los Angeles Times, March 19, 1989 p.28''
:In a national U.S. telephone survey by the Los Angeles Times in March, 1989, 56% of women who admitted to at least one abortion expressed a sense of guilt and 26% said they now mostly regretted their abortion.

''"Abortion Counselling. A New Component of Medical Care," Uta Landy, Clinics in Obstetrics and Gynecology 13(1):33, 1986''
:An article by the former executive director of the National Abortion Federation based on observations of its members stated that women obtaining abortions will make the decision by a "spontaneous" response without much thought, engage in denial or procrastination, be overly rational, or allow others to make the decision for them thus making it more likely that the women will have later regrets.

''"Testing a Model of the Psychological Consequences of Abortion," WB Miller et al in The New Civil War. The Psychology, Culture, and Politics of Abortion, Ed. LJ Beckman and SM Harvey, (Washington, D.C.:American Psychological Association, 1998) 235''
:Women about to undergo abortion with Mifepristone exhibited acute stress and appeared to be trying to control their response to the unwanted pregnancy/abortion situation by not thinking about it The researchers concluded that there is a broad, multidimensional affective response.At two weeks postabortion 29.7% of the women expressed some guilt. At 6-8 months 35.9% of postabortion women expressed some guilt. The authors concluded that long term studies should be undertaken to ascertain the psychological effects of abortion.

''"Physical and Psychological Injury in Women Following Abortion:Akron Pregnancy Services Study," L Gsellman, Association for Interdisciplinary Research in Values and Social Change Newsletter 5(4):1-8, 1993''
:In a questionnaire survey of postabortion women receiving a variety of services at a pregnancy services center, 66% expressed guilt and 54% expressed remorse or regret approximately 6 years postabortion.

''"Induced Abortion as a Violation of Conscience of the Woman," Thomas Strahan, Life and Learning VI.. Proceedings of the Sixth University Faculty for Life Conference. (June, 1996, ed. Joseph W. Koterski''
:A majority of U.S. women appear to violate their conscience by obtaining an induced abortion. Among the reasons are a belief that if it is legal it must be all right; encouragement of her male partner or others, including abortion facility workers to obtain an abortion, lack of respect for the moral or religious beliefs of the woman, and a frequent crisis situation where the woman may be easily influenced by others or use primitive coping methods.

''"Objective Versus Subjective Responses to Abortion," James M Robbins, Journal of Counsulting and Clinical Psychology 47(5): 994-995, 1979''
:In a study of medically indigent unmarried black women who had abortions, deep regret was reported by 14.6%, some regret by 34.1%, a little regret by 19.5%, and no regret by 31.7% one year postabortion.

''"Obsessive-Compulsive Neurosis After Viewing the Fetus During Therapeutic Abortion," S Lipper and W Feigenbaum, Am J Psychotherapy 30:666-674, 1976''
:Following her abortion, a woman was preoccupied with thoughts of being " dirty" and washed her hands 30-40 times a day.

''"Unsafe Abortions: Methods Used and Characteristics of Patients Attending Hospitals in Nairobi, Lima, and Manila," A Ankomah et al, Health Care for Women Int'l 18:43, 1997''
:The beliefs of women regarding when abortion is justified conflicted with their actions in a study of postabortion women in Kenya, Peru and the Philippines. The authors concluded, " it can be seen that abortion is not an acceptable option even for those who resort to it , and that it is employed as the final option."

==Ambivalence or Inner Conflict==
:Ambivalence is common both pre and postabortion. It appears to be acceptable at one level of consciousness, but unacceptable at a different level.

''"The Ambivalence of Abortion," Linda Bird Francke (1978).''
:Interviews with various people involved in abortion. Demonstrates ambivalence as well as many other emotions and considerable confused thought. For an extensive discussion of this book see Rachael Weeping, James T. Burtchaell (1982,1984)

''"Abortion: Subjective Attitudes and Feelings," Ellen Freeman, Family Planning Perspectives 10:150-155, 1978.''
:This article concludes that feelings of ambivalence, both before and after the abortion, are common..

''"The Psychological Reaction of Patients to Legalized Abortion," J Osofsky and H Osofsky, American Journal Orthopsychiatry 42(1): 48-60, January, 1972.''
:A leading early study on the effects of abortion, often cited. Psychological evaluation of 250 postaborted women reported 24% experiencing guilt (much or moderate); 47% reported the decision was either considerably difficult (28%) or mildly difficult (19.5%). Some 32.5% expressed the desire for the child as the reason for difficulty. 45%-48% expressed happiness or much relief following abortion.

''"Pregnancy Decision Making as A Significant Life Event: A Commitment Approach," J Lydon et al, Journal of Personality and Social Psychology 71(1): 141-151, 1996.''
:Initial commitment to the pregnancy predicted subsequent depression, guilt and hostility among those who had abortions. Women who previously had at least one prior abortion reported more commitment to the pregnancy than women with no prior abortion history.

''Fragmentation of the Personality Associated with Post-Abortion Trauma , Joel O Brende, Association for Interdisciplinary Research in Values and Social Change Newsletter 8(3): 1-8. July/Aug 1995.''
:People enduring extreme stress often suffer profound rupture in the very fabric of the self. Factors which are likely to produce dissociation, memory lapses, and evidence of self- fragmentation, include (1) the severity of the violation, (2) lack of support from others, (3) subsequent self-blame and shame, (4) loss of idealism and purpose. Fragmentation predisposes to unstable and destructive relationships.

''"Post-Abortion Syndrome as a Variant of Post Traumatic Stress Syndrome," Robert C Erikson, Association for Interdisciplinary Research in Values and Social Change Newsletter 3(4):5-6, Winter, 1991.''
:Conflict between incompatible goals of attachment and destruction leads to the experience of stress.

''“ Voluntary interruption of pregnancy: comparative study between 1982 and 1996 in the main center of Cote d’Or. Study of women having repeat voluntary interruption of pregnancy”, S Douvier et al, Gycecol Obstet Fertil 29(3): 200, Mar 2001''

:A French study of women who had repeated abortion in 1996 found that this group had been characterized by unstable couples and ambivalence with a wish of pregnancy but no wish of children.

==Anxiety==

'''[https://pmc.ncbi.nlm.nih.gov/articles/PMC11625657/#bjo17889-sec-0016 Pregnancy and birth complications and long-term maternal mental health outcomes: A systematic review and meta-analysis.] Bodunde EO, Buckley D, O'Neill E, Al Khalaf S, Maher GM, O'Connor K, McCarthy FP, Kublickiene K, Matvienko-Sikar K, Khashan AS. BJOG. 2025 Jan;132(2):131-142. doi: 10.1111/1471-0528.17889.'''<blockquote>Background: Few studies have examined the associations between pregnancy and birth complications and long‐term (>12 months) maternal mental health outcomes.

Objectives: To review the published literature on pregnancy and birth complications and long‐term maternal mental health outcomes.

Search strategy:Systematic search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (Embase), PsycInfo®, PubMed® and Web of Science from inception until August 2022.

Selection criteria: Three reviewers independently reviewed titles, abstracts and full texts.

Data collection and analysis: Two reviewers independently extracted data and appraised study quality. Random‐effects meta‐analyses were used to calculate pooled estimates. The Meta‐analyses of Observational Studies in Epidemiology (MOOSE) guidelines were followed. The protocol was prospectively registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022359017).

Main results: Of the 16 310 articles identified, 33 studies were included (3 973 631 participants). T'''ermination of pregnancy was associated with depression (pooled adjusted odds ratio, aOR 1.49, 95% CI 1.20–1.83) and anxiety disorder (pooled aOR 1.43, 95% CI 1.20–1.71).''' Miscarriage was associated with depression (pooled aOR 1.97, 95% CI 1.38–2.82) and anxiety disorder (pooled aOR 1.24, 95% CI 1.11–1.39). Sensitivity analyses excluding early pregnancy loss and termination reported similar results. Preterm birth was associated with depression (pooled aOR 1.37, 95% CI 1.32–1.42), anxiety disorder (pooled aOR 0.97, 95% CI 0.41–2.27) and post‐traumatic stress disorder (PTSD) (pooled aOR 1.75, 95% CI 0.52–5.89). Caesarean section was not significantly associated with PTSD (pooled aOR 2.51, 95% CI 0.75–8.37). There were few studies on other mental disorders and therefore it was not possible to perform meta‐analyses.

Conclusions: Exposure to complications during pregnancy and birth increases the odds of long‐term depression, anxiety disorder and PTSD.</blockquote>'''[https://www.ncbi.nlm.nih.gov/pubmed/28079434 Previous pregnancy outcomes and subsequent pregnancy anxiety in a Quebec prospective cohort.] Shapiro GD, Séguin JR, Muckle G, Monnier P, Fraser WD. J Psychosom Obstet Gynaecol. 2017 Jun;38(2):121-132. doi: 10.1080/0167482X.2016.1271979. Epub 2017 Jan 12.'''

:INTRODUCTION: Pregnancy anxiety is an important psychosocial risk factor that may be more strongly associated with adverse birth outcomes than other measures of stress. Better understanding of the upstream predictors and causes of pregnancy anxiety could help to identify high-risk women for adverse maternal and infant outcomes. The objective of the present study was to measure the associations between five past pregnancy outcomes (live preterm birth (PTB), live term birth, miscarriage at <20 weeks, stillbirth at ≥20 weeks, and elective abortion) and pregnancy anxiety at three trimesters in a subsequent pregnancy.

:METHODS: Analyses were conducted using data from the 3D Cohort Study, a Canadian birth cohort. Data on maternal demographic characteristics and pregnancy history for each known previous pregnancy were collected via interviewer-administered questionnaires at study entry. Pregnancy anxiety for the index study pregnancy was measured prospectively by self-administered questionnaire following three prenatal study visits.

:RESULTS: Of 2366 participants in the 3D Study, 1505 had at least one previous pregnancy. In linear regression analyses with adjustment for confounding variables, prior live term birth was associated with lower pregnancy anxiety in all three trimesters, whereas prior miscarriage was significantly associated with higher pregnancy anxiety in the first trimester. Prior stillbirth was associated with greater pregnancy anxiety in the third trimester. Prior elective abortion was significantly associated with higher pregnancy anxiety scores in the first and second trimesters, with an association of similar magnitude observed in the third trimester.

:DISCUSSION: Our findings suggest that the outcomes of previous pregnancies should be incorporated, along with demographic and psychosocial characteristics, into conceptual models framing pregnancy anxiety.

'''[https://pubmed.ncbi.nlm.nih.gov/31485778/ Prevalence of depression and anxiety in women with recurrent pregnancy loss and the associated risk factors]. He L, Wang T, Xu H, Chen C, Liu Z, Kang X, Zhao A. Arch Gynecol Obstet. 2019 Oct;300(4):1061-1066. doi: 10.1007/s00404-019-05264-z. Epub 2019 Aug 21. PMID: 31485778.'''<blockquote>'''Objective:''' To investigate the prevalence and explore potential risk factors of depression and anxiety in patients with recurrent pregnancy loss (RPL).

'''Methods:''' 1138 non-pregnant women aged 20-40 years old who attempted to conceive were invited to complete a questionnaire, including basic information, Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS).

'''Results:''' 782 RPL women, 218 women with one pregnancy loss and 138 women with no history of pregnancy loss were included in this study. We found that both RPL patients and women with one pregnancy loss had significantly higher SDS and SAS scores than the control group (P = 0.006, 0.003). Furthermore, in RPL patients, those with lower education level (lower than university), lower household income (< 10,000 yuan) and '''history of induced abortion''' had significantly higher levels of depression and anxiety. Women with multiple pregnancy losses ( ≥ 3) and no live birth had significantly higher SDS scores. Women who had been married for 3 years or more had a significantly higher SAS score. Logistic regression revealed that lower education level (lower than university) was an independent risk factor for depression (adjusted OR = 1.75, 95% CI 1.10-2.77, P = 0.018) and anxiety (adjusted OR = 1.80, 95% CI 1.04-3.13, P = 0.037), and women with three or more pregnancy losses had increased odds of depression than those with two pregnancy losses (adjusted OR = 1.82, 95% CI 1.15-2.88, P = 0.012).

'''Conclusion:''' RPL patients are more likely to develop depression and anxiety than women with no history of pregnancy loss. Lower education level and multiple pregnancy losses (≥ 3) appear to be two independent risk factors of depression and anxiety in women with RPL. Women with one pregnancy loss also show a significant higher level for depression and anxiety. Appropriate psychological intervention can be considered for such patients.</blockquote>

[https://www.ncbi.nlm.nih.gov/pubmed/27500660 Anxiety and quality of life after first-trimester termination of pregnancy: a prospective study.] Toffol E, Pohjoranta E, Suhonen S, Hurskainen R, Partonen T, Mentula M, Heikinheimo O. Acta Obstet Gynecol Scand. 2016 Oct;95(10):1171-80. doi: 10.1111/aogs.12959.

:INTRODUCTION: Possible effects of termination of pregnancy (TOP) on mental health are a matter of debate.

:MATERIAL AND METHODS: We assessed anxiety and quality of life during a one-year follow up after first-trimester TOP using the State-Trait Anxiety Inventory (STAI) Scale and EuroQoL Quality of Life Questionnaire (EQ-5D, EQ-VAS) in 742 women participating in a randomized controlled trial on early provision of intrauterine contraception. The measurements were performed before TOP, at 3 months and 1 year after TOP. Inclusion criteria were age ≥18 years, residence in Helsinki, duration of gestation <12 weeks, non-medical indication for TOP, and approval of intrauterine contraception. The trial was registered with Clinical Trials.

:RESULTS: When compared with baseline, the overall anxiety level was significantly lower and quality of life higher at 3 months and at 1 year. Reduction of anxiety and improvement of quality of life was especially evident (p < 0.001) in the 58% of women reporting clinically relevant anxiety at baseline. High levels of anxiety at baseline, history of psychiatric morbidity and smoking predicted significantly greater risk of poorer quality of life and elevated level of anxiety during the follow up.

:CONCLUSIONS: TOP is associated with a significant overall reduction of anxiety and an improvement of quality of life among women undergoing it for non-medical indications. High baseline anxiety, history of psychiatric morbidity and smoking are risk factors of persistently high levels of anxiety and poor quality of life after an induced abortion. These data are important when designing and providing post-abortion care.

'''Editor Notes:'''

* It appears the researchers are burying data. This is the only explanation for why did they excluded analysis of the trait anxiety subscale. Also, since the original objective was to "assess the mental well being of women during the first year after TOP," surely they must have also included scales for depression, PTSD, and more. Indeed, they later admit that they had more mental health variables, but they don't report any test of these others as outcome variables. Clearly, they are reporting on the anxiety state subscale and very similar quality of life index only because the produced baseline scores that allowed them to spin the results in a way that advance their agenda.

*The baseline scores for both anxiety and the quality of life indexes are clearly depressed by the fact that they are accessed on a day of high stress--the day these women are undergoing an abortion. Obviously, the proper baseline would be an assessment a week or month before these women became pregnant. Only then could see if they "bounced back" from their abortions to their pre-pregnancy state. Otherwise, the baseline measure may simply be a measure of a "worst day" in these women's lives and the subsequent "bounce back" is simply evidence that time heals . . . or at least moderates anxiety.

*In the methods section, the researchers reveal that that alcohol use, drug use, smoking, and psychiatric morbidity varied across the three time frames measured. But they don't use any of these as outcome variables to show us how they varied over time. Instead, they inappropriately employ them control variables. The use as control variables is inappropriate since they are not "independent factors" but may also be affected by exposure to abortion and other pregnancy losses. They also reveal that they have data on prior history of abortion and miscarriage. Their analyses should include measures of how multiple pregnancy losses may impact these findings...especially at baseline. If women with a prior pregnancy loss have higher anxiety levels at baseline, that would be a meaningful finding.

* High attrition rate. Control group loss 52% at 3 months and 57% at one year. The intervention group was modestly better since an inserted IUD gave them more motivation to participate at 3 months. Complete data was available for only 45% of the women. The claim that approximately 70% are represented in the results is based on the inflating qualifier "baseline plus at least partial follow-up data were available for approximately 70% of the original sample."

*Notably, women who had surgical abortion did not experience any improvement in anxiety or quality of life scores. The "benefit" were exclusive to women who had medical abortions. (p1175 col 1) The "benefits" were also associated with only the NLG-IUS IUD but not the Cu-IUD.

''' [http://smo.sagepub.com/content/4/2050312116665997.full Abortion, substance abuse and mental health in early adulthood: Thirteen-year longitudinal evidence from the United States.] Sullins DP. SAGE Open Medicine 2016 vol: 4 (0) pp: 2050312116665997'''

:'''Objective:''' To examine the links between pregnancy outcomes (birth, abortion, or involuntary pregnancy loss) and mental health outcomes for US women during the transition into adulthood to determine the extent of increased risk, if any, associated with exposure to induced abortion.

:'''Method:''' Panel data on pregnancy history and mental health history for a nationally representative cohort of 8005 women at (average) ages 15, 22, and 28 years from the National Longitudinal Study of Adolescent to Adult Health were examined for risk of depression, anxiety, suicidal ideation, alcohol abuse, drug abuse, cannabis abuse, and nicotine dependence by pregnancy outcome (birth, abortion, and involuntary pregnancy loss). Risk ratios were estimated for time-dynamic outcomes from population-averaged longitudinal logistic and Poisson regression models.

:'''Results''': After extensive adjustment for confounding, other pregnancy outcomes, and sociodemographic differences, abortion was consistently associated with increased risk of mental health disorder. Overall risk was elevated 45% (risk ratio, 1.45; 95% confidence interval, 1.30–1.62; p < 0.0001). Risk of mental health disorder with pregnancy loss was mixed, but also elevated 24% (risk ratio, 1.24; 95% confidence interval, 1.13–1.37; p < 0.0001) overall. Birth was weakly associated with reduced mental disorders. One-eleventh (8.7%; 95% confidence interval, 6.0–11.3) of the prevalence of mental disorders examined over the period were attributable to abortion.

:'''Conclusion''': Evidence from the United States confirms previous findings from Norway and New Zealand that, unlike other pregnancy outcomes, abortion is consistently associated with a moderate increase in risk of mental health disorders during late adolescence and early adulthood.

:NOTE:Table 1: Anxiety, adjusted OR 1.23 (95% CI 0.97-1.55); Number of mental health problems OR=1.54 (95% CI 1.42-1.68) ( "Exposure to induced abortion was consistently associated with increased rate of most mental disorders, with ORs ranging from 1.02 to 2.83. This trend is summarized in the fact that women exposed to abortion from ages 15 to 29 (on average) experienced overall rates of mental health problems 1.34 (95% confidence interval (CI), 1.22–1.47) times higher than those not exposed to abortion (p < 0.001)."

''[http://www.ncbi.nlm.nih.gov/pubmed/26939616 Anxiety and depression in patients with advanced ovarian cancer: a prospective study.] Mielcarek P, Nowicka-Sauer K, Kozaka J. J Psychosom Obstet Gynaecol. 2016 Mar 3:1-11.''
:INTRODUCTION: Women with advanced ovarian cancer with long-term survival are at persistent risk of anxiety and reactive depression due to poor prognosis and risk of burdensome symptoms. The aim of the study was to assess changes in anxiety and depression during multimodality ovarian cancer treatment and to identify correlates of anxiety and depression.
:METHOD: The study included 106 consecutive patients with advanced ovarian cancer. Mean age of the study group was 53.9 years (SD = 10.8, range: 23-79). The participants completed Hospital Anxiety and Depression Scale and State-Trait Anxiety Inventory four times: prior to and one week after surgery, and before the second and the fourth course of adjuvant chemotherapy. Multivariate analysis was performed to identify the independent determinants of distress at various stages of treatment.
:RESULTS: The level of anxiety and the prevalence of pathological anxiety (74%) were the highest prior to surgery and gradually decreased thereafter. Irrespective of the treatment stage, the level of anxiety was higher than the corresponding level of depression. '''History of abortion''', presence of intestinal stoma, poor general status, residual disease and time from the initial diagnosis were the main determinants of distress in ovarian cancer patients.
:CONCLUSIONS: Significant changes in the level of anxiety and slight fluctuations in the depression level experienced during ovarian cancer treatment are mostly determined by clinical variables. Identification of individuals with psychological comorbidities is a vital component of patient-oriented multidisciplinary care.

''[http://www.psikofarmakoloji.org/pdf/22_1_8.pdf The Impact of Prior Abortion on Anxiety and Depression Symptoms During a Subsequent Pregnancy: Data From a Population-Based Cohort Study in China] Huang Z, et al. Bulletin of Clinical Psychopharmacology 2012;22(1):51-8''

:'''Objective:''' The aim of the study was to assess anxiety and depression in women with history of spontaneous abortion or induced abortion during a subsequent pregnancy.

:'''Methods:''' The data were consecutively obtained from seven maternal and child health (MCH) Centers in the Anhui Province of China. The sociodemographic characteristics of the women, the number of previous pregnancies, number of living children, and gestational age of the current pregnancy were ascertained at the time of the interview.

:'''Results:''' The pregnant women who were in the first trimester of their pregnancy reported significantly higher scores than those in the second trimester both on SAS (Zung’s Self-Rating Anxiety Scale) and CES-D (The Center for Epidemiologic Studies-Depression Scale) (SAS score means: 32.11 vs 31.68, P=0.000; CES-D score means: 4.59 vs 4.06, P=0.012). The women with a history of induced abortions were significantly more likely to report more “cases” of depression (OR = 1.543, 95% CI = 1.055- 254) and more “cases” of anxiety (OR = 2.142, 95% CI = 1.294-3.561) during the first trimester than those with no history of abortion. Controlling for confounding variables yielded similar results. However, “cases” of depression and “cases” of anxiety were equally common in women with history of spontaneous abortions and in those with no abortion history.

:'''Conclusions:''' These results suggest women who have experienced a previous induced abortion have omnipresent anxiety and depression symptoms during a subsequent pregnancy, specially during the first trimester.

''[http://www.ncbi.nlm.nih.gov/pubmed/16026402 Psychological sequelae of medical and surgical abortion at 10-13 weeks gestation.]'' Ashok PW, Hamoda H, Flett GM, Kidd A, Fitzmaurice A, Templeton A. Acta Obstet Gynecol Scand. 2005 Aug;84(8):761-6.

METHODS: Partially randomized patient preference trial in a Scottish Teaching Hospital was conducted. The hospital anxiety and depression scales were used to assess emotional distress. Anxiety levels were also assessed using visual analog scales while semantic differential rating scales were used to measure self-esteem. A total of 368 women were randomized, while 77 entered the preference cohort.

RESULTS: There were no significant differences in hospital anxiety and depression scales scores for anxiety or depression between the two groups of women having medical or surgical abortion. Visual analog scales showed higher anxiety levels in women randomized to surgery prior to abortion (P < 0.0001), while women randomized to surgical treatment were less anxious after abortion (P < 0.0001). Semantic differential rating scores showed a fall in self-esteem in the randomized medical group compared to those undergoing surgery (P = 0.02).

''Associations Between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample. Mota NP, Burnett M, Sareen J. The Canadian Journal of Psychiatry, Vol 55, No 4, April 2010 ''
:Methods: Data came from the National Comorbidity Survey Replication (n = 3310 women, aged 18 years and older). The World Health Organization–Composite International Diagnostic Interview was used to assess mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and lifetime abortion in women. Multiple logistic regression analyses were employed to examine associations between abortion and lifetime mood, anxiety, substance use, eating, and disruptive behaviour disorders, as well as suicidal ideation and suicide attempts. We calculated the percentage of respondents whose mental disorder came after the first abortion. The role of violence was also explored. Population attributable fractions were calculated for significant associations between abortion and mental
disorders.
:Results: After adjusting for sociodemographics, abortion was associated with an increased likelihood of several mental disorders—mood disorders (adjusted odds ratio [AOR] ranging from 1.75 to 1.91), anxiety disorders (AOR ranging from 1.87 to 1.91), substance use disorders (AOR ranging from 3.14 to 4.99), as well as suicidal ideation and suicide attempts (AOR ranging from 1.97 to 2.18). Adjusting for violence weakened some of these associations. For all disorders examined, less than one-half of women reported that their mental disorder had begun after the first abortion. Population attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse).
:Conclusions: Our study confirms a strong association between abortion and mental disorders. Possible mechanisms of this relation are discussed.

''The Long Term Psychological Effects of Abortion, Catherine A Barnard. (Portsmouth, NH: Institute for Pregnancy Loss, 1990).''
:47.5% of women exhibited an elevated level of anxiety on the Millon Clinical-Multi-Axial Inventory 3-5 years postabortion.

''"Emotional Distress Patterns Among Women Having First or Repeat Abortions," EW Freeman, Obstetrics and Gynecology 55(5):630, 1980.''
:Phobic anxiety was identified as a postabortion reaction and was higher among women repeating abortion compared to women with one abortion.

''"Incidence of complicated grief and post-traumatic stress in a post-abortion population," LM Butterfield, Dissertation Abstracts Int'l 49(8): 3431-B, 1988. ''
:Postabortion women consistently showed death anxiety on the Grief Experience Inventory.

''"Psychological Responses Following Medical Abortion (using Mifepristone and Gemepost) and Surgical Vacuum Aspiration," R Henshaw et al, Acta Obstet Gynecol Scand 73:812, 1994.''
:A Scottish study found that postabortion anxiety correlated with cigarette smoking with the most anxious women having the heaviest smoking habits.

''The effects of induced abortion on emotional experiences and relationships: a critical review of the literature.'' Bradshaw Z, Slade P. Clin Psychol Rev. 2003 Dec; 23(7): 929-58.
: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.

''Assessing traumatic reactions of abortion with the emotional stroop.]Toledano, Levana. Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 64(9-B), 2004. pp. 4639. Hofstra U., US''
:The primary purpose of this study was to investigate whether PTSD and its related symptoms are present in a sample of women following abortion. Two groups of women were included in this study: 59 women who had undergone an abortion and a control group of 28 women who had comparable surgical procedures. The mean age of the participants was 29.82, with ages ranging from 18 to 50 years. Symptoms of PTSD were assessed using the Posttraumatic Diagnostic Scale (PDS), the Impact of Event Scale (IES), and the Emotional Stroop paradigm. The Emotional Stroop procedure utilized was a color-naming task comprised of abortion-relevant words (i.e., sex, pregnant, fetus), positive words, neutral words, and obsessive-compulsive disorder (OCD) words. Levels of depression and anxiety were assessed with the Beck Depression Inventory-II (BDI-II), and the State-Trait Anxiety Inventory (STAI). The role of social support at the time of abortion was measured via the Multidimensional Scale of Perceived Social Support (MSPSS). Background variables such as religiosity, the presence or absence of coercion, marital status, gestational length, number of children, and age were also explored as possible risk factors mediating responses to abortion. Multivariate tests indicated the presence of PTSD in both groups of women, but to a greater extent in the post-abortion group. The two groups reported similarly elevated scores for anxiety. Post-abortion women exhibited significantly longer response latencies on the Stroop for abortion/trauma-relevant stimuli as compared to the control group. There were no significant differences found between groups on measures of depression. Significant risk factors included low levels of perceived social support, younger age, and the presence of coercion. Implications for community and clinical psychology are outlined. (PsycINFO Database Record (c) 2004 APA, all rights reserved)

''Generalized anxiety following unintended pregnancies resolved through childbirth and abortion: a cohort study of the 1995 National Survey of Family Growth.'' Cougle JR, Reardon DC, Coleman PK. J Anxiety Disord. 2005;19(1):137-42.

:Women with a history of abortion are significantly more likely to subsequently have elevated rates of general anxiety disorder.

''Abortion in young women and subsequent mental health.'' Fergusson DM, John Horwood L, Ridder EM. J Child Psychol Psychiatry. 2006 Jan;47(1):16-24.
:Methods: Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors.
:Results: Forty-one percent of women had become pregnant on at least one occasion prior to age 25, with 14.6% having an abortion. Those having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors.
:Conclusions: The findings suggest that abortion in young women may be associated with increased risks of mental health problems.

''[http://www.ncbi.nlm.nih.gov/pubmed/16343341?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum The course of mental health after miscarriage and induced abortion: a five-year follow-up study.] [[Broen]] AN, Moum T, Bødtker AS, Ekeberg O. BMC Medicine 2005, 3:18 (12 December 2005)''
:Broen et al.'s results show that women who had a miscarriage suffer more mental distress up until six months after the event than women who had an abortion. Women who had an abortion, however, experienced more mental distress long after the event - two and five years afterwards - than women who had a miscarriage. Women who experienced induced abortion had significantly greater IES scores for avoidance and for the feelings of guilt, shame and relief than the miscarriage group at two and five years after the pregnancy termination (IES avoidance means: 3.2 vs 9.3 at T3, respectively, p < 0.001; 1.5 vs 8.3 at T4, respectively, p < 0.001). Compared with the general population, women who had undergone induced abortion had significantly higher HADS anxiety scores at all four interviews (p < 0.01 to p < 0.001), while women who had had a miscarriage had significantly higher anxiety scores only at T1 (p < 0.01).

==[[Sleep Disorders]]==

See [[Sleep Disorders]]

==Intrusion/Avoidance/Dreams/Nightmares==
:This section demonstrates that it is easier to physically remove the aborted child from the body of the mother than remove the image from the mind of the mother.

''Introduction to Psychodynamics: A New Synthesis, MJ Horowitz (New York: Basic Books, 1988) 48''
:Four stages of grief are identified (1) outcry, (2) denial, (3) intrusion, and (4) working through. When the intrusion phase is prolonged, the bereaved person may be troubled by recurring thoughts or images including nightmares and flashback experiences which may interfere with sleep and daytimes activities for months and years beyond the time expected for normal grieving.

''"Postabortion Syndrome: An Emerging Public Health Concern," AC Speckhard and VM Rue, Journal of Social Issues 48(3):95, 1992.''
:Intrusive nightmares of postabortion women fall into three general categories: horrors about how the fetal child dies, fearful symbols of judgment and penalty, and searching for something precious that cannot be found.

''The Negative Impact of Abortion on Women and Families, E Joanne Angelo in Post-Abortion Aftermath, ed. Michael T Mannion (Kansas City, MO: Sheed&Ward, 1994) 50.''
:Clinical psychiatrist E Joanne Angelo has observed: " the woman has often formed a mental image of her child which haunts her day and night- an image of an infant being torn to pieces, sucked down a tube, crying out in pain, or reaching out to her for help. She may have named her baby and have regularly occurring conversations with him or her in mind begging forgiveness for what she has done."

''Experiencing Abortion, Eve Kushner (New York: Harrington Park Press, 1997) 166.''
:One 22 year old woman, the night after her abortion said, " I felt my baby's spirit come to visit me." She adds that the spirit "found its body gone. Then it disappeared. I was positive that's what happened and I cried like I never had before, sobbing and sobbing. The world seemed so empty, with nothing left to live for."

''Abortion. Loss and Renewal in the Search for Identity, Eva Pattis Zoja (English Trans. Henry Martin (New York: Routladge, 1997) 91-94''
:This book describes a woman's dream 5 days before her abortion: " We've only got five more days. Then you will have to go. It's going to be horrible and I'm the one who has made that decision. For now, we're still together, we've still got a little time, I'll be with you, up until the end." The night before the abortion, this same woman had this dream: " It was the morning of the abortion. I knew I had to go to the hospital. My partner and two little boys had given me gifts; it seemed like my birthday. My younger sister was also there; there was a family atmosphere. Everybody was ready to accompany me. It made it easy to enter the hospital."
:Seven months later, at precisely the time when the baby was due, this same woman had the following dream: " I was in the bathroom at the home of my parents. I was sitting on the toilet, and I thought that I was having my period. I realized that a tiny baby had fallen out into the water, where it was moving about like a sea horse. I saw that it was alive, but the front of its head seemed squashed, as though it had no brain. It was a spontaneous miscarriage. I felt very sorry for it. I knew that the child couldn't survive; it would die as soon as I lifted it out of the water. I took it out of the water and held it in my hand. I didn't want it to die alone. There were people around me, and I found that very disturbing. I looked for a place in which to be alone, and found the room I had had as a little girl. Then Maria entered, an aunt of whom I was very fond. Finally alone and quiet, I saw that the child had died in the palm of my hand. I knew that I was supposed to burn the body. Now it looked like a sheet of paper, and I set fire to one of its corners. It burned and burned, but didn't turn to ashes; it took on a series of very bright colors, like the colors of a figure in enamel. It had turned into a Christ child, and was alive and smiling."

''The Long Term Psychological Effects of Abortion, Catherine A Barnard, (Portsmouth NH: Institute for Pregnancy Loss, 1990.)''
:In a study of women 3-5 years postabortion, 23% had recurrent and distressing dreams of the event, 45% had a sense of reliving the experience, 29% had recurrent and intrusive recollections of the event, 45% had hypervigilance, 35% made efforts to avoid feelings associated with the event, and 11% made efforts to avoid activities associated with the event.

''"Abortion in Adolescence," NB Campbell et al, Adolescence Vol XXIII No.92: 813, 1988 ''
:Women in a postabortion support group who had abortions as teenagers were more likely to have nightmares after abortion (80%) compared to women who had abortions as adults (43%)

''"Therapeutic Abortion During Adolescence: Psychiatric Observations," P Barglow and S Weinstein, Journal of Youth and Adolescence 2(4): 331, 1973''
:This article describes numerous dreams and nightmares of adolescents, both pre and postabortion. The authors stated," almost all adolescent subjects experienced the abortion procedure as frightening, dangerous, and punitive, and often as temporarily overwhelming." Dreams represented the fetus as a baby, child, or animal such as a worm, frog, parakeet, cat or even a dinosaur. The abortion procedure, hospital, or doctor appeared without disguise in 95% of the dreams." Examples of the content of these dreams include a 16 year old girl with a Black Muslim mother. The girl wept and screamed in terror during the abortion procedure. Her preabortion dream: " I dreamed the devil performed the abortion. He just reached up his black hand, pulled it out, and then danced around me with it in his hands while laughing and yelling";Another who had a conflict with her mother dreamt following her abortion " My mother and four men chased me into a white garage. The men held me and my mother made a cut in my vagina while I screamed"; A 16 year old who underwent a second abortion who was evaluated for severe depression and suicidal preoccupation after her abortion had the following dream before her abortion. "I had a nightmare that there was an atomic war and that I alone was left in the world."

''"Prolonged Grieving After Abortion: A Descriptive Study," D Brown et al, The Journal of Clinical Ethics 4(2):118, 1993''
:Postabortion women frequently fantasized about the aborted fetus and had other intrusive thoughts when reminded of pregnancy or childbirth.

''"A consideration of ketamine dreams," P Hejja, S Galloon, Can Anaesth Soc J 22(1): 100-105, Jan, 1975''
:This study used ketamine anesthesia to attempt to reduce the incidence of unpleasant dreams at the time of abortion.

''"Induced Elective Abortion and Perinatal Grief," GB Williams, Dissertation Abstracts Int'l 53(3): 1296-B, 1992.''
:Inability to control overt emotional responses had the highest scores in a Grief Experience Inventory 11 years postabortion.

''“ Memories Unleashed” in Forbidden Grief. The Unspoken Pain of Abortion, Theresa Burke and David Reardon (Springfield, Il: Acorn Books, 2002) 121- 132''

:Describes flashbacks, dreams and nightmares, hallucinations, trauma and memory of postabortion women.

Depression

2025-12-31T14:38:17Z

Barb: /* Abortion-Related Depression */

{{DEA}}
{{PsychIndex}}

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==General Background Studies==

''"The effect of adolescent virginity status on psychological well-being" J. J. Sabiaa, D.I. Rees. Journal of Health Economics Volume 27, Issue 5, September 2008, Pages 1368-1381''

Examining data from the National Longitudinal Study of Adolescent Health to explore virginity status affects self-esteem and depression, it was found that sexually active female adolescents are at increased risk of exhibiting the symptoms of depression relative to their counterparts who are not sexually active (19% vs 9.2%).

''"Depressive symptoms during pregnancy: Relationship to poor health behaviors," B. Zuckerman et al.. Am. J. Obstet. Gynecol. 160: 1107-1111, 1989.''
:In a study of 1014 women of mostly poor and minority status at Boston City Hospital between 1984-1987, depressive symptoms during pregnancy were associated with increased life stress, decreased social support, poor weight gain, and use of cigarettes, alcohol and cocaine.

''"Increasing Rates of Depression," . G.L. Klerman, M.M. Weissman, JAMA 261 (15):2229-2235, April 21, 1989.''
:Several studies have observed important changes in rates of depression among those born after W.W.II including a decrease in the age of onset with an increase in the late teenage and early adult years; an increase between 1960 and 1975 in the rates of depression for all ages; the risk of depression is consistently 2 to 3 times higher among women than men of all ages.

''"Continuing Female Predominance In Depressive Illness, A.C," Leon, G.L. Klerman, P. Wickramaratne, Am.J. Public Health 83 (5): 754, May, 1993.''
:Women continued to show higher rates of depression than men. Regardless of sex or period of time, subjects seemed to be at greatest risk of a first major depressive episode between ages 16-25.

''"Social Adjustment and Depression: A Longitudinal Study," E. S. Paykel and M. Weissman, Archives of General Psychiatry 28: 659-663 (1973).''
:Depressed women showed residual dysfunctions in the areas of interpersonal friction and inhibited communication that remained relatively unchanged even when other symptoms of depression and sodal maladjustment dissipated.

''"Interpersonal Consequences to Depression," C. L. Hammen, and S.D. Peters, Journal of Abnormal Psychology 87: 322-332 (1978).''
:Depressed persons elicit more negative reactions from others than non-depressed.

''"Irrational Beliefs in Depression," R.E. Nelson, J. of Consulting and Clinical Psychology 45: 1190-1191 (1977).''
:The strongest correlates of depression are general irrationality, a need to excel in all endeavors, a need to feel worthwhile as a person, a feeling that things are terrible when they are not like one wants, obsessive worry, and a belief that it is impossible to overcome one's past.

''"Life Events and Depressive Order Reviewed," I and II, C. Lloyd, Archives of General Psychiatry 37: 529-535 May, 1980.''
:Loss of parents may double or triple the depressive factor.

''"Epidemiology of Affective Disorders," Robert Hirschfield and C.K. Grass, Archives of General Psychiatry 39(1): 35 (1982). ''
:A good summary of the literature.

''"Hostility and Depression," E.S. Gershon, M. Cromer and G.L. Klerman, Psychiatry 31: 224-235 (1968).''
:Hostility may have separate mechanisms both for its initiation and its defensive alterations. The expression of hostility may drain off the awareness of depression. It may express a "great despairing cry for love."

''"Life Events and Depression: A Controlled Study," E.S. Paykel, J.K. Myers, M. Dienelt, Archives of General Psychiatry 21: 753-760 (1969).''
:Study noted an excessive number of stressful life events prior to depression.

''"Masked Depression in Children and Adolescents," Kurt Glaser, American Journal of Psychotherapy 566-574 (1966).''
:Behavior problems and delinquent behavior such as temper tantrums, disobedience, truancy, running away from home, failure to achieve in school may indicate depressive feelings.

''"Sex Differences and the Epidemiology of Depression," Myron Weissman and Gerald Klerman, Archives of General Psychiatry 34: 98-111 (January 1977).''
:Authors review various studies and conclude that women predominate among depressives; psycho-social explanations include social status hypothesis of social discrimination against women. It is hypothesized that inequities lead to legal and economic helplessness, dependency on others, chronically low self-esteem, low aspirations and ultimately clinical depression. The learned helplessness theory proposes that socially conditioned, stereotypical images produce in women a cognitive set against assertion which is reinforced by societal expectations. Learned helplessness is characteristic of depression.

''"Toward a Comprehensive Theory of Depression: A Cross Disciplinary Appraisal of Objects. Games and Meaning," Ernest Becker, Journal of Nervous and Mental Disease 135: 26- 35 (1962). Comments by the author: ''
:Until Edward Bibring's theory, self-directed aggression was considered a primary mechanism in depression. Bibring signaled a radical departure from previous theory when he postulated that self-directed aggression was secondary to an undermining of self- esteem. Thereby, he delivered an apparently telling blow to formulations around the concepts of morality and aggression.
:In the classical psychoanalytic formulation of depression, mourning and melancholic states, loss of a loved object was considered to be a crucial dynamic. The ego which (theoretically) grows by ideationally gathering objects into itself, was thought to sometimes massive trauma when loved objects had to be relinquished. The loss of an object in the real world meant a corresponding depletion of the ego.
:The sociological view has stressed not object depletion in the ego as the motivation for funeral and mourning rites, but rather the social dramatization of solidarity at the loss of one of society's performance members. Ceremonies of mourning serve as a reaffirmation of social cohesiveness even though single performers drop out of the plot.
:To lose an object is to lose someone to whom one has made appeal for self-validation.
:It was formerly thought that depression was rare among the "simpler peoples for several reasons--it was thought that the accumulation of guilt so prominent in the depressive syndrome-there was also the lingering myth of the happy savage.
:The most difficult realization for man is the possibility that life has no meaning.
:"Acknowledgment of personal sin or confession of guilt may sometimes be a defense against the possibility that there may be no meaning in the world....
:Guilt in oneself is easier to face than lack of meaning in life." (quoted from On Shame and Search for Identity Helen Merrell Lynd, Harcourt-Brace [1958] p. 58)
:The more people to whom one can make appeal for his identity, the easier it is to sustain life-meaning. Object loss hits hardest when self-justification is limited to a few objects.

''"The Mechanism of Depression," E. Bibring, in Greenacre, P., Ed., Affective Disorders, (New York: International Universities Press, 1953) pp. 13-48. ''

''Depression, A.T. Beck, (New York: Hoeber, 1967) ''
:Ed Note: This is an important work on depression.

== Pregnancy outcome associated Distress ==
'''[https://pubmed.ncbi.nlm.nih.gov/36306037/ Long-term influence of unintended pregnancy on psychological distress: a large sample retrospective cross-sectional study.] Sasaki N, Ikeda M, Nishi D. Arch Womens Ment Health. 2022 Dec;25(6):1119-1127. doi: 10.1007/s00737-022-01273-1. Epub 2022 Oct 28. PMID: 36306037.'''<blockquote>This study examined the associations between childbirth decisions in women with unintended pregnancies and long-term psychological distress. An online survey of women selected from a representative research panel was conducted in July 2021. Among participants who experienced an unintended pregnancy, the childbirth decision was categorized: (i) wanted birth, (ii) abortion, (iii) adoption, and (iv) unwanted birth. Participants who made childbirth decisions more than 1 year ago were included. ANCOVA was conducted with psychological distress (Kessler 6) as the dependent variable and education, marital status, years from the decision, age of the first pregnancy, economic situation at the unintended pregnancy, and the number of persons consulted at the unintended pregnancy as covariates. Logistic regression analysis was conducted for high distress (K6 ≥ 13) by adjusting the same covariates. A total of 47,401 respondents participated in the study. Women with an experience of unintended pregnancy experienced more than 1 year before the study were analyzed (n = 7162). Psychological distress was the lowest for wanted birth and increased for abortion, adoption, and unwanted birth. In the adjusted model, abortion was associated with lower distress scores than both adoption and unwanted birth. Compared to the wanted birth, adoption and unwanted birth showed significantly higher levels of distress (adjusted odds ratio [aOR] = 2.03 [95% CI 1.36-3.04], aOR = 1.64 [95% CI 1.04-2.58], respectively). Long-term effects on psychological distress differed according to the childbirth decisions in unintended pregnancy. Healthcare professionals should be aware of this hidden effect of unintended pregnancy experience on women's mental health.</blockquote><blockquote>'''Notes:''' This study actually showed higher rates of distress among women who aborted versus unintended pregnancies carried to term (OR 1.57; 95% CI 1.38-1.78). This was reduced to slightly less than statistical significance by controlling for covariates that may not have been appropriate. But most importantly, the results did not show statistically significantly higher levels of distress for women who wanted an abortion but did not have one or for those who placed the child for adoption compared to women who had abortions. In other words, there was no significant benefit to abortion compared to any other group but significantly higher levels of stress compared to the unintended pregnancy carried to term overall group.

It is also notable that 98% of unintended pregnancies that were carried to term were identified as "wanted births." </blockquote>

==Abortion-Related Depression==

'''[https://pmc.ncbi.nlm.nih.gov/articles/PMC11625657/#bjo17889-sec-0016 Pregnancy and birth complications and long-term maternal mental health outcomes: A systematic review and meta-analysis.] Bodunde EO, Buckley D, O'Neill E, Al Khalaf S, Maher GM, O'Connor K, McCarthy FP, Kublickiene K, Matvienko-Sikar K, Khashan AS. BJOG. 2025 Jan;132(2):131-142. doi: 10.1111/1471-0528.17889.'''<blockquote>Background: Few studies have examined the associations between pregnancy and birth complications and long‐term (>12 months) maternal mental health outcomes.

Objectives: To review the published literature on pregnancy and birth complications and long‐term maternal mental health outcomes.

Search strategy:Systematic search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (Embase), PsycInfo®, PubMed® and Web of Science from inception until August 2022.

Selection criteria: Three reviewers independently reviewed titles, abstracts and full texts.

Data collection and analysis: Two reviewers independently extracted data and appraised study quality. Random‐effects meta‐analyses were used to calculate pooled estimates. The Meta‐analyses of Observational Studies in Epidemiology (MOOSE) guidelines were followed. The protocol was prospectively registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022359017).

Main results: Of the 16 310 articles identified, 33 studies were included (3 973 631 participants). T'''ermination of pregnancy was associated with depression (pooled adjusted odds ratio, aOR 1.49, 95% CI 1.20–1.83) and anxiety disorder (pooled aOR 1.43, 95% CI 1.20–1.71).''' Miscarriage was associated with depression (pooled aOR 1.97, 95% CI 1.38–2.82) and anxiety disorder (pooled aOR 1.24, 95% CI 1.11–1.39). Sensitivity analyses excluding early pregnancy loss and termination reported similar results. Preterm birth was associated with depression (pooled aOR 1.37, 95% CI 1.32–1.42), anxiety disorder (pooled aOR 0.97, 95% CI 0.41–2.27) and post‐traumatic stress disorder (PTSD) (pooled aOR 1.75, 95% CI 0.52–5.89). Caesarean section was not significantly associated with PTSD (pooled aOR 2.51, 95% CI 0.75–8.37). There were few studies on other mental disorders and therefore it was not possible to perform meta‐analyses.

Conclusions: Exposure to complications during pregnancy and birth increases the odds of long‐term depression, anxiety disorder and PTSD.</blockquote>

'''[https://pubmed.ncbi.nlm.nih.gov/31485778/ Prevalence of depression and anxiety in women with recurrent pregnancy loss and the associated risk factors.] He L, Wang T, Xu H, Chen C, Liu Z, Kang X, Zhao A. Arch Gynecol Obstet. 2019 Oct;300(4):1061-1066. doi: 10.1007/s00404-019-05264-z. Epub 2019 Aug 21. PMID: 31485778.'''<blockquote>'''Objective:''' To investigate the prevalence and explore potential risk factors of depression and anxiety in patients with recurrent pregnancy loss (RPL).

'''Methods:''' 1138 non-pregnant women aged 20-40 years old who attempted to conceive were invited to complete a questionnaire, including basic information, Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS).

'''Results:''' 782 RPL women, 218 women with one pregnancy loss and 138 women with no history of pregnancy loss were included in this study. We found that both RPL patients and women with one pregnancy loss had significantly higher SDS and SAS scores than the control group (P = 0.006, 0.003). Furthermore, in RPL patients, those with lower education level (lower than university), lower household income (< 10,000 yuan) and history of induced abortion had significantly higher levels of depression and anxiety. Women with multiple pregnancy losses ( ≥ 3) and no live birth had significantly higher SDS scores. Women who had been married for 3 years or more had a significantly higher SAS score. Logistic regression revealed that lower education level (lower than university) was an independent risk factor for depression (adjusted OR = 1.75, 95% CI 1.10-2.77, P = 0.018) and anxiety (adjusted OR = 1.80, 95% CI 1.04-3.13, P = 0.037), and women with three or more pregnancy losses had increased odds of depression than those with two pregnancy losses (adjusted OR = 1.82, 95% CI 1.15-2.88, P = 0.012).

'''Conclusion:''' RPL patients are more likely to develop depression and anxiety than women with no history of pregnancy loss. Lower education level and multiple pregnancy losses (≥ 3) appear to be two independent risk factors of depression and anxiety in women with RPL. Women with one pregnancy loss also show a significant higher level for depression and anxiety. Appropriate psychological intervention can be considered for such patients.</blockquote>

'''[https://www.sciencedirect.com/science/article/abs/pii/S0165032719301727?via%3Dihub Association between induced abortion, spontaneous abortion, and infertility respectively and the risk of psychiatric disorders in 57,770 women followed in gynecological practices in Germany.] Jacob L, Gerhard C, Kostev K, Kalder M. J Affect Disord. 2019 May 15;251:107-113. doi: 10.1016/j.jad.2019.03.060. Epub 2019 Mar 20.'''

:Our goal was to analyze the association between induced abortion, spontaneous abortion, and infertility respectively and the risk of psychiatric disorders in 57,770 women followed in gynecological practices in Germany.

:METHODS: This case-control study was based on data from the Disease Analyzer database (IQVIA). Women with a first documentation of depression, anxiety, adjustment disorder, or somatoform disorder in one of 281 gynecological practices in Germany between January 2013 and December 2017 were included in this study (index date). Controls without depression, anxiety, adjustment disorder, or somatoform disorder were matched (1:1) to cases by age, index year, and physician. A total of 57,770 women were included in the present study. The main outcome of the study was the risk of psychiatric disorders (i.e. depression, anxiety, adjustment disorder, somatoform disorder) as a function of induced abortion, spontaneous abortion, and infertility.

:RESULTS: The mean age was 29.2 years (SD = 6.4 years) in women with and without psychiatric disorders. Induced abortion (odds ratios [ORs] ranging from 1.75 to 2.01), spontaneous abortion (ORs ranging from 2.16 to 2.60), and infertility (OR = 2.13) were positively associated with the risk of psychiatric disorders.

:CONCLUSIONS: A positive relationship between induced abortion, spontaneous abortion, and infertility respectively and psychiatric disorders was observed in gynecological practices in Germany.

'''[https://www.sciencedirect.com/science/article/pii/S0022395619302730 Relationship between induced abortion and the incidence of depression, anxiety disorder, adjustment disorder, and somatoform disorder in Germany.] Jacob L, Gerhard C, Kostev K, Kalder M. J Affect Disord. 2019 May 15;251:107-113. doi: 10.1016/j.jad.2019.03.060. Epub
'''
:Methods: Women who had undergone induced abortions for the first time in 281 gynecological practices in Germany between January 2007 and December 2016 were included (index date). Women with live births were matched (1:1) to those with induced abortion by age, index year, and physician. The main outcome of the study was the incidence of depression, anxiety disorder, adjustment disorder, and somatoform disorder as a function of induced abortion. Survival analyses and Cox regression models were used to investigate the association between induced abortion and psychiatric disorders.

:Results: This study included 17581 women who had had an induced abortion and 17581 women who had had a live birth. Within 10 years of the index date, 6.7% of the participants with induced abortions and 5.4% of those with live births were diagnosed with depression (log-rank p-value = 0.003). The respective figures were 3.4% and 2.7% for anxiety disorder (log-rank p-value = 0.255), 6.2% and 5.6% for adjustment disorder (log-rank p-value = 0.116), and 19.3% and 13.3% for somatoform disorder (log-rank p-value<0.001). Induced abortion was significantly associated with depression (hazard ratio [HR] = 1.34), adjustment disorder (HR = 1.45) and somatoform disorder (HR = 1.56), but not with anxiety disorder (HR = 1.17).

:Conclusions: There was a positive association between induced abortion and several psychiatric disorders in Germany. Further analyses are recommended to assess how induced abortion can have such a negative impact on mental health.

'''[https://www.ncbi.nlm.nih.gov/pubmed/29847626 Examining the Association of Antidepressant Prescriptions With First Abortion and First Childbirth] Steinberg, J. R., Laursen, T. M., Adler, N. E., & Gasse, C. JAMA Psychiatry. 2018 May 30. doi: 10.1001/jamapsychiatry.2018.0849.'''

:IMPORTANCE The repercussions of abortion for mental health have been used to justify state policies that limit access to abortion in the United States. Much earlier research has relied on self-report of abortion or mental health conditions or on convenience samples. This study uses data that rely on neither.
:OBJECTIVE To examine whether first-trimester first abortion or first childbirth is associated with an increase in women’s initiation of a first-time prescription for an antidepressant.
:DESIGN, SETTING, AND PARTICIPANTS This study linked data and identified a cohort ofwomen from Danish population registries whowere born in Denmark between January 1, 1980, and December 30, 1994. Overall, 396 397 womenwere included in this study; of these women, 30834 had a first-trimester first abortion and 85 592 had a first childbirth.
:MAIN OUTCOMES AND MEASURE First-time antidepressant prescription redemptionswere determined and used as indication of an episode of depression or anxiety, and incident rate ratios (IRRs) were calculated comparing women who had an abortion vs women who did not have an abortion and women who had a childbirth vs women who did not have a childbirth.
:RESULTS Of 396 397 women whose data were analyzed, 17 294 (4.4%) had a record of at least 1 first-trimester abortion and no children, 72 052 (18.2%) had at least 1 childbirth and no abortions, 13 540 (3.4%) had at least 1 abortion and 1 childbirth, and 293 511 (74.1%) had neither an abortion nor a childbirth. A total of 59465 (15.0%) had a record of first antidepressant use. In the basic and fully adjusted models, relative to women who had not had an abortion, women who had a first abortion had a higher risk of first-time antidepressant use. However, the fully adjusted IRRs that compared women who had an abortion with women who did not have an abortion were not statistically different in the year before the abortion (IRR, 1.46; 95% CI, 1.38-1.54) and the year after the abortion (IRR, 1.54; 95% CI, 1.45-1.62) (P = .10) and decreased as time from the abortion increased (1-5 years: IRR, 1.24; 95% CI, 1.19-1.29; >5 years: IRR, 1.12; 95% CI, 1.05-1.18). The fully adjusted IRRs that compared women who gave birth with women who did not give birth were lower in the year before childbirth (IRR, 0.47; 95% CI, 0.43-0.50) compared with the year after childbirth (IRR, 0.93; 95% CI, 0.88-0.98) (P < .001) and increased as time from the childbirth increased (1-5 years: IRR, 1.52; 95% CI, 1.47-1.56; >5 years: IRR, 1.99; 95% CI, 1.91-2.09). Across all women in the sample, the strongest risk factors associated with antidepressant use in the fully adjusted model were having a previous psychiatric contact (IRR, 3.70; 95% CI, 3.62-3.78), having previously obtained an antianxiety medication (IRR, 3.03; 95% CI, 2.99-3.10), and having previously obtained antipsychotic medication (IRR, 1.88; 95% CI, 1.81-1.96).
:CONCLUSIONS AND RELEVANCE Women who have abortions are more likely to use antidepressants compared with women who do not have abortions. However, additional aforementioned findings from this study support the conclusion that increased use of antidepressants is not attributable to having had an abortion but to differences in risk factors for depression. Thus, policies based on the notion that abortion harms women's mental health may be misinformed.

Notes: See extensive notes about the [http://abortionrisks.org/index.php?title=Munk-Olsen_et_al#Criticisms problems with this study here].

''' [http://smo.sagepub.com/content/4/2050312116665997.full Abortion, substance abuse and mental health in early adulthood: Thirteen-year longitudinal evidence from the United States.] Sullins DP. SAGE Open Medicine 2016 vol: 4 (0) pp: 2050312116665997'''

:'''Objective:''' To examine the links between pregnancy outcomes (birth, abortion, or involuntary pregnancy loss) and mental health outcomes for US women during the transition into adulthood to determine the extent of increased risk, if any, associated with exposure to induced abortion.

:'''Method:''' Panel data on pregnancy history and mental health history for a nationally representative cohort of 8005 women at (average) ages 15, 22, and 28 years from the National Longitudinal Study of Adolescent to Adult Health were examined for risk of depression, anxiety, suicidal ideation, alcohol abuse, drug abuse, cannabis abuse, and nicotine dependence by pregnancy outcome (birth, abortion, and involuntary pregnancy loss). Risk ratios were estimated for time-dynamic outcomes from population-averaged longitudinal logistic and Poisson regression models.

:'''Results''': After extensive adjustment for confounding, other pregnancy outcomes, and sociodemographic differences, abortion was consistently associated with increased risk of mental health disorder. Overall risk was elevated 45% (risk ratio, 1.45; 95% confidence interval, 1.30–1.62; p < 0.0001). Risk of mental health disorder with pregnancy loss was mixed, but also elevated 24% (risk ratio, 1.24; 95% confidence interval, 1.13–1.37; p < 0.0001) overall. Birth was weakly associated with reduced mental disorders. One-eleventh (8.7%; 95% confidence interval, 6.0–11.3) of the prevalence of mental disorders examined over the period were attributable to abortion.

:'''Conclusion''': Evidence from the United States confirms previous findings from Norway and New Zealand that, unlike other pregnancy outcomes, abortion is consistently associated with a moderate increase in risk of mental health disorders during late adolescence and early adulthood.

:NOTE:Table 1: Depression, adjusted OR 1.30 (95% CI 1.09-1.56); Number of mental health problems OR=1.54 (95% CI 1.42-1.68) ( "Exposure to induced abortion was consistently associated with increased rate of most mental disorders, with ORs ranging from 1.02 to 2.83. This trend is summarized in the fact that women exposed to abortion from ages 15 to 29 (on average) experienced overall rates of mental health problems 1.34 (95% confidence interval (CI), 1.22–1.47) times higher than those not exposed to abortion (p < 0.001)."

'''[http://gorm.com.tr/index.php/GORM/article/view/521/484 Depression Following Induced Abortion.] Koyun, A., Kır Şahin, F., Çevrioğlu, S., Demirel, R., & Geçici, Ö. (2016). Gynecology Obstetrics & Reproductive Medicine, 13(2). doi:http://dx.doi.org/10.21613/GORM.2007.521'''

:OBJECTIVE: To evaluate the effects of number of abortions and time passed after abortion in women with a history of induced abortion on the development of depression.

:STUDY DESIGN: Women who admitted to family planning center during November 2003 – February 2004, answered a questionnaire. Depression levels between women who had induced abortion and those who did not were compared. Women with a history of previous abortion were classified according to the time passed after abortion (0-3 months, 3-6 months, more than 6 months). Depression levels were evaluated using Beck depression scale.

:RESULTS: Rates of clinical depression in women with a history of induced abortion were increased (p<0,05). Depression scores were increased in women who have had induced abortions (p<0,001).

:CONCLUSİONS: In women with a history of induced abortion, short term depression scores were found to be increased and clinical depression rates were markedly increased. Long term effects of this psychological trauma is a topic to be investigated. Our research data shows us that it may be helpful to provide pre- and postabortive psychological counseling to decrease the frequency and severity of depression encountered after induced abortion.

:Note. The researchers also observed a dose effect, with multiple abortions increasing depression risk.

''[http://www.ncbi.nlm.nih.gov/pubmed/18539697 Abortion and depression: a population-based longitudinal study of young women.] Pedersen W. Scand J Public Health. 2008 Jun;36(4):424-8. ''

:AIM: Induced abortion is an experience shared by a large number of women in Norway, but we know little about the likely social or mental health-related implications of undergoing induced abortion. International studies suggest an increased risk of adverse outcomes such as depression, but many studies are weakened by poor design. One particular problem is the lack of control for confounding factors likely to increase the risk of both abortion and depression. The aim of the study was to investigate whether induced abortion was a risk factor for subsequent depression.

:METHODS: A representative sample of women from the normal population (n=768) was monitored between the ages of 15 and 27 years. Questions covered depression, induced abortion and childbirth, as well as sociodemographic variables, family relationships and a number of individual characteristics, such as schooling and occupational history and conduct problems.

:RESULTS: Young women who reported having had an abortion in their twenties were more likely to score above the cut-off point for depression (odds ratio (OR) 3.5; 95% confidence interval (CI) 2.0-6.1). Controlling for third variables reduced the association, but it remained significant (OR 2.9; 95% CI 1.7-5.6). There was no association between teenage abortion and subsequent depression.

:CONCLUSIONS: Young adult women who undergo induced abortion may be at increased risk for subsequent depression.

'''[https://www.ncbi.nlm.nih.gov/pubmed/18302736 Depression and termination of pregnancy (induced abortion) in a national cohort of young Australian women: the confounding effect of women's experience of violence.] Taft AJ, Watson LF. BMC Public Health. 2008 Feb 26;8:75. doi: 10.1186/1471-2458-8-75.'''

BACKGROUND: Termination of pregnancy is a common and safe medical procedure in countries where it is legal. One in four Australian women terminates a pregnancy, most often when young. There is inconclusive evidence about whether pregnancy termination affects women's rates of depression. There is evidence of a strong association between partner violence and depression. Our objective was to examine the associations with depression of women's experience of violence, pregnancy termination, births and socio-demographic characteristics, among a population-based sample of young Australian women.

METHODS: The data from the Younger cohort of the Australian Longitudinal Study on Women's Health comprised 14,776 women aged 18-23 in Survey I (1996) of whom 9683 aged 22-27 also responded to Survey 2 (2000). With linked data, we distinguished terminations, violence and depression reported before and after 1996.We used logistic regression to examine the association of depression (CES-D 10) as both a dichotomous and linear measure in 2000 with pregnancy termination, numbers of births and with violence separately and then in mutually adjusted models with sociodemographic variables.

RESULTS: 30% of young women were depressed. Eleven percent (n = 1076) reported a termination by 2000. A first termination before 1996 and between 1996 and 2000 were both associated with depression in a univariate model (OR 1.37, 95%CI 1.12 to 1.66; OR 1.52, 95%CI 1.24 to 1.87). However, after adjustment for violence, numbers of births and sociodemographic variables (OR 1.22, 95%CI 0.99 to 1.51) this became only marginally significant, a similar association with having two or more births (1.26, 95%CI. 1.00 to 1.58). In contrast, any form of violence but especially that of partner violence in 1996 or 2000, was significantly associated with depression: in univariate (OR 2.31, 95%CI 1.97 to 2.70 or 2.45, 95% CI 1.99 to 3.04) and multivariate models (AOR 2.06, 95%CI 1.74 to 2.43 or 2.12, 95%CI 1.69 to 2.65). Linear regression showed a four fold greater effect of violence than termination or births.

:CONCLUSION: Violence, especially partner violence, makes a significantly greater contribution to women's depression compared with pregnancy termination or births. Any strategy to reduce the burden of women's depression should include prevention or reduction of violence against women and strengthening women's sexual and reproductive health to ensure that pregnancies are planned and wanted.

''[http://bjp.rcpsych.org/cgi/content/abstract/193/6/455 Pregnancy loss and psychiatric disorders in young women: an Australian birth cohort study]'' Kaeleen Dingle, Rosa Alati, Alexandra Clavarino, Jake M. Najman, and Gail M. Williams BJP 2008 193: 455-460.

:Young women reporting a pregnancy loss had nearly three times the odds of experiencing a lifetime illicit drug disorder (excluding cannabis): abortion odds ratio (OR)=3.6 (95% CI 2.0–6.7) and miscarriage OR=2.6 (95% CI 1.2–5.4). Abortion was associated with alcohol use disorder (OR=2.1, 95% CI 1.3–3.5) and 12-month depression (OR=1.9, 95% CI 1.1–3.1).

''[http://publications.cpa-apc.org/media.php?mid=951 Associations Between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample]. Mota NP, Burnett M, Sareen J. The Canadian Journal of Psychiatry, Vol 55, No 4, April 2010 ''
:Methods: Data came from the National Comorbidity Survey Replication (n = 3310 women, aged 18 years and older). The World Health Organization–Composite International Diagnostic Interview was used to assess mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and lifetime abortion in women. Multiple logistic regression analyses were employed to examine associations between abortion and lifetime mood, anxiety, substance use, eating, and disruptive behaviour disorders, as well as suicidal ideation and suicide attempts. We calculated the percentage of respondents whose mental disorder came after the first abortion. The role of violence was also explored. Population attributable fractions were calculated for significant associations between abortion and mental disorders.
:Results: After adjusting for sociodemographics, abortion was associated with an increased likelihood of several mental disorders—mood disorders (adjusted odds ratio [AOR] ranging from 1.75 to 1.91), anxiety disorders (AOR ranging from 1.87 to 1.91), substance use disorders (AOR ranging from 3.14 to 4.99), as well as suicidal ideation and suicide attempts (AOR ranging from 1.97 to 2.18). Adjusting for violence weakened some of these associations. For all disorders examined, less than one-half of women reported that their mental disorder had begun after the first abortion. Population attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse).
:Conclusions: Our study confirms a strong association between abortion and mental disorders. Possible mechanisms of this relation are discussed.

''[http://www.cmaj.ca/cgi/content/full/168/10/1253 Psychiatric admissions of low income women following abortion and childbirth.] Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Can Med Assoc J. 2003; 168(10):1253-7''

:A study of California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth (n = 56 741 revealed taht women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age. Similar findings were reported in regard to outpatient treatment for the same women. See, ''[http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2002-15486-015&CFID=27122313&CFTOKEN=47942096 State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years.] Coleman PK, Reardon DC, Rue VM, Cougle JR. American Journal of Orthopsychiatry, 2002; 72(1):141–52. ''

''[http://www3.interscience.wiley.com/journal/120750852/abstract Using telemedicine for termination of pregnancy with mifepristone and misoprostol in settings where there is no access to safe services.] Gomperts R, Jelinska K, Davies S, Gemzell-Danielsson K, Lleiverda G. BJOG 2008;115:1171–8.''

About 30 percent of women taking abortion drugs purchased via the Internet reported depression and negative feelings accompanying the abortion.

''[http://www.ncbi.nlm.nih.gov/pubmed/18539697?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Abortion and depression: A population-based longitudinal study of young women.] Pedersen W. Scand J Public Health. 2008 Jul;36(4):424-8.''
:ABSTRACT
:AIM: Induced abortion is an experience shared by a large number of women in Norway, but we know little about the likely social or mental health-related implications of undergoing induced abortion. International studies suggest an increased risk of adverse outcomes such as depression, but many studies are weakened by poor design. One particular problem is the lack of control for confounding factors likely to increase the risk of both abortion and depression. The aim of the study was to investigate whether induced abortion was a risk factor for subsequent depression. METHODS: A representative sample of women from the normal population (n=768) was monitored between the ages of 15 and 27 years. Questions covered depression, induced abortion and childbirth, as well as sociodemographic variables, family relationships and a number of individual characteristics, such as schooling and occupational history and conduct problems. RESULTS: Young women who reported having had an abortion in their twenties were more likely to score above the cut-off point for depression (odds ratio (OR) 3.5; 95% confidence interval (CI) 2.0-6.1). Controlling for third variables reduced the association, but it remained significant (OR 2.9; 95% CI 1.7-5.6). There was no association between teenage abortion and subsequent depression. CONCLUSIONS: Young adult women who undergo induced abortion may be at increased risk for subsequent depression.

''Depression and termination of pregnancy (induced abortion) in a national cohort of young Australian women: the confounding effect of women's experience of violence. Taft AJ, Watson LF. BMC Public Health. 2008 Feb 26;8:75.''
:"The data from the Younger cohort of the Australian Longitudinal Study on Women's Health comprised 14,776 women aged 18-23 in Survey I (1996) of whom 9683 aged 22-27 also responded to Survey 2 (2000). With linked data, we distinguished terminations, violence and depression reported before and after 1996.We used logistic regression to examine the association of depression (CES-D 10) as both a dichotomous and linear measure in 2000 with pregnancy termination, numbers of births and with violence separately and then in mutually adjusted models with sociodemographic variables. RESULTS: 30% of young women were depressed. Eleven percent (n = 1076) reported a termination by 2000. A first termination before 1996 and between 1996 and 2000 were both associated with depression in a univariate model (OR 1.37, 95%CI 1.12 to 1.66; OR 1.52, 95%CI 1.24 to 1.87). However, after adjustment for violence, numbers of births and sociodemographic variables (OR 1.22, 95%CI 0.99 to 1.51) this became only marginally significant, a similar association with having two or more births (1.26, 95%CI. 1.00 to 1.58).In contrast, any form of violence but especially that of partner violence in 1996 or 2000, was significantly associated with depression: in univariate (OR 2.31, 95%CI 1.97 to 2.70 or 2.45, 95% CI 1.99 to 3.04) and multivariate models (AOR 2.06, 95%CI 1.74 to 2.43 or 2.12, 95%CI 1.69 to 2.65). Linear regression showed a four fold greater effect of violence than termination or births. CONCLUSION: Violence, especially partner violence, makes a significantly greater contribution to women's depression compared with pregnancy termination or births. Any strategy to reduce the burden of women's depression should include prevention or reduction of violence against women and strengthening women's sexual and reproductive health to ensure that pregnancies are planned and wanted."

''"A Developmental Approach to Post-Abortion Depression," Frederick M. Burkle, The Practitioner 218:217, February 1977. ''
:If the loss is valued depression will occur. To resolve the depression a process of mourning must occur.

''"Reproductive Factors Affecting the Course of Affective Illness in Women," B.L. Parry, Psychiatric Clinics of North America 12(1): 207, March, 1989 ''
:Major depressive disorders are increasing with time, the age of onset is becoming earlier, and women continue to show an increased incidence of the disorder. Women are vulnerable to depressions associated with abortion.

''"Testing a Model of the Psychological Consequences of Abortion," WB Miller et al in The New Civil War. The Psychology, Culture, and Politics of Abortion, ed. Linda J. Beckman and S Marie Harvey. (Washington, D.C.: American Psychological Association, 1998) ''
:A multi-dimensional study of the psychological effects of induced abortion using mifepristone/misoprostol concluded that studies which emphasize unitary responses to abortion such as feelings of shame or guilt, loss or depression, and relief may be missing an important broader picture as what appears to happen following abortion involves not so much a unitary as a broad, multidimensional affective response. Findings suggest that during the first few days or weeks following an abortion, many women's reactions are incomplete and not necessarily representative of subsequent reactions. It is also very likely that different kinds of women follow a different time course. More studies are needed that examine the short-term consequences using sequential "snap shots" and there is more need for more postabortion longitudinal research.

''"Personality and Self-Efficacy as Predictors of Coping with Abortion," C Cozzarelli, Journal of Personality and Social Psychology 65(6): 1224-1236, 1993 ''
:A wide range of depression scores was obtained on women immediately following abortion and at three weeks post-abortion.

==Bipolar Disorder==

'''[http://www.ncbi.nlm.nih.gov/pubmed/25827504 Unplanned pregnancies and reproductive health among women with bipolar disorder.] Marengo E, Martino DJ, Igoa A, Scápola M, Fassi G, Baamonde MU, Strejilevich SA. J Affect Disord. 2015 Jun 1;178:201-5.'''

:Background: The aim of this study was to investigate reproductive health and level of planning of pregnancies among women with bipolar disorder (BDW).

:Methods:63 euthymic women, with bipolar disorder type I, II or not otherwise specified diagnosis, were included and were matched with a control group of 63 healthy women. Demographic and clinical data, structured reproductive health measures and planning level of pregnancies were obtained and compared between groups.

:Results: Lower level of planning of pregnancies and higher frequency of unplanned pregnancies were found among BDW. Women with bipolar disorder reported history of voluntary interruption of pregnancies more frequent than women from control group. Current reproductive health care showed no differences between groups.

:Limitations: Data based on self-report of participants and retrospective nature of some collected measures may be affected by information bias. The pregnancy planning measure has not been validated in this population before. Demographic and clinical characteristics of the sample study limit generalization of these findings.

:Conclusions: Adverse reproductive events, as unplanned pregnancies and elective interruption of pregnancies, may be more frequent among BDW. Clinician must be aware of the reproductive health during treatment of young BDW and take measures to improve better family planning access.

:Specifics: 42.4% of the women with bipolar disorder had a history of abortion compared to only 13.5% of the control group. There was no significant difference in pregnancy rates or use of contraceptives.

''[http://www.cmaj.ca/cgi/content/full/168/10/1253 Psychiatric admissions of low income women following abortion and childbirth.] Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Can Med Assoc J. 2003; 168(10):1253-7''

:A study of California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth (n = 56 741) of bipolar disorder (OR 3.0, 95% CI 1.5–6.0).

''[http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2002-15486-015&CFID=27122313&CFTOKEN=47942096 State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years.] Coleman PK, Reardon DC, Rue VM, Cougle JR. American Journal of Orthopsychiatry, 2002; 72(1):141–52.''

:Women with a history of abortion were 95% more likely (OR 1.95 95% CI 1.21-3.16) to be treated for bipolar disorder on an outpatient basis than women who carried to term.

== 2010 ==
'''''[http://www.guttmacher.org/pubs/psrh/full/4223010.pdf Do Depression and Low Self-Esteem Follow Abortion Among Adolescents? Evidence from a National Study]''''' Perspectives on Sexual and Reproductive Health, 42(4):230–235, (2010) Warren, Harvey, and Henderson.

Abstract
:METHODS: Data from the National Longitudinal Study of Adolescent Health were used to examine whether abortion in adolescence was associated with subsequent depression and low self-esteem. In all, 289 female respondents reported at least one pregnancy between Wave 1 (1994–1995) and Wave 2 (1996) of the survey. Of these, 69 reported an induced abortion. Population-averaged lagged logistic regression models were used to assess associations between abortion and depression and low self-esteem within a year of the pregnancy and approximately five years later, at Wave 3 (2001–2002).

:RESULTS: Abortion was not associated with depression or low self-esteem at either time point. Socioeconomic and demographic characteristics did not substantially modify the relationships between abortion and the outcomes.

:CONCLUSIONS: Adolescents who have an abortion do not appear to be at elevated risk for depression or low self esteem in the short term or up to five years after the abortion.

::EDITOR'S COMMENTS
<blockquote>
#This journal is published by the pro-abortion Alan Guttmacher Institute which was founded by Planned Parenthood.
#The sample of women who aborted was very small (n= 69) reducing the statistical power.
##This is very important because with small sample size it is much more ''likely'' that one will not find any statistically significant results.
##The authors acknowledge on page 234 that “The lack of association between abortion and our outcomes could reflect other factors including insufficient sample size to detect an effect.”
##Very few control variables were employed despite the fact that this data set contains dozens of personal history, personality, relationship, situational, familial, and demographic variables that could have been controlled to isolate the effect of abortion.
##A common tactic of researchers trying to prove "no association" between A and B is to report results based on a small sample and may also include the use of only those control variables which reduce the statistical association.
##The 95% confidence interval reported by the authors (.027-2.09) indicates that it is 95% likely that the true risk of depression following abortion may be anywhere between 27% and 209% of depression rate found among teens who have not been pregnant. In other words, these findings do not contradict research showing higher rates of depression associated with abortion. Given the small sample size, this broad confidence interval is fully consistent with studies using larger populations which find the range of depression to be in the range of 110% to 200% higher than for women without a history of abortion.

#The outcome measures were superficial assessments. Specifically, the measure of depression was an abbreviated 9 item scale and self-esteem was measure with only 4 items.
#The choice of the comparison group is suspect. The comparison group could have been unintended pregnancy carried to term since the data is available in ADD Health, but the researchers chose the broader “no pregnancy” group as their control group. Another study published regarding the same data set which did use unintended pregnancy delivered as the control group found significant associations between abortion history and marijuana usage, having received counseling for psychological or emotional problems, and sleep difficulties. Seeking professional counseling services is a much more valid measure of psychological distress than abbreviated self-report measures, one of which is merely “predictive of depression”. (See Coleman, P. K. (2006). Resolution of unwanted pregnancy during adolescence through abortion versus childbirth: Individual and family predictors and psychological consequences. The Journal of Youth and Adolescence, 35, 903-911.)
</blockquote>

==Depression Shortly Prior to Abortion==

''"Bluestein and CM Rutledge, Family Practice Research Journal 13(2): 149-156, 1993 ''
:Moderate to severe depression was found in women seeking abortion. Depression symptoms increased as measures of denial, difficulties with communicating with male partner, pregnancy symptoms, contraceptive use and dissatisfaction with abortion increased.

''"Postabortion Psychological Adjustment: Are Minors at Increased Risk?" LM Pope et al, Journal of Adolescent Health 29:2-11, 2001 ''
:Thirty-five percent of young women aged 14-21 exhibited moderate to severe depression on the Beck Depression Inventory shortly prior to abortion.

''"Psychological Factors that predict reaction to abortion," D.T. Moseley, D.R. Follingstad, H. Harley, R.V. Heckel, J. of Clinical Psychology 37(2):276,1981 ''
:A University of South Carolina study on women who elected abortion in an urban southern area administered the Multiple Affective Adjective Check List (MAACL) to women when they entered the clinic and a post-test in the recovery room prior to discharge following their abortion. Pre-abortion depression was much higher than the MAACL norms previously reported. Significant decreases in anxiety and depression were noted following abortion but not with respect to hostility. A woman's relationship with her partner was a crucial factor in post-abortion adjustment. Women with negative feelings toward their partners had higher levels of pre-abortion depression and post-abortion depression compared to women who were assisted in the decision by their sexual partners.

''"Coping with Abortion," L. Cohen and S. Roth, Journal of Human Stress, Fall, 1984, pp. 140-145. ''
:Researchers at Duke University of 55 women presenting for abortion a private clinic in Raleigh, NC evaluated symptoms of intrusion, avoidance, depression and anxiety upon their arrival at the clinic and in the recovery room after their abortion. The level of anxiety and depression was measured by the Symptom Checklist-90 (SCL-90). The mean level of depression decreased from 24.1 initially to 18.4 following abortion. Women exhibiting high avoidance had significantly higher level of depression both before and after their abortion compared to women exhibiting low avoidance.

''"Psychological Factors Involved in Request for Elective Abortion, M," Blumenfield. The Journal of Clinical Psychiatry, Jan. 1978, pp. 17-25. ''
:A study of 13 women requesting a first abortion and 13 women requesting a repeat abortion was undertaken at Kings County Hospital Clinic in New York utilizing a largely open-ended interview. The purpose was to determine the surrounding circumstances which gave rise to the request for abortion. It was found that the failure of contraception was not due to lack of access to adequate contraception. In 9 of 26 cases there was evidence of underlying psychological conflicts in the woman. These women were frequently lonely and/or depressed frequently because of isolation, loss of support, loss or separation from loved ones, or due to conflicts with partners. The data suggested that many of the male partners had a strong wish to father a child. The author stated "a pregnancy which leads to a request for an abortion usually reflects an underlying unresolved conflict which is being acted out through the pregnancy--a request for a repeat abortion would seem to indicate that the ambivalence has persisted and is being acted out through pregnancy once again or that a new circumstance has reawakened underlying conflicts.")

==Depression During Subsequent Pregnancies==

'''See also [[Depression#Postpartum_Depression]]'''

'''[http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13233/full Previous pregnancy loss has an adverse impact on distress and behaviour in subsequent pregnancy.] McCarthy F, Moss-Morris R, Khashan A, et al.BJOG An Int J Obstet Gynaecol. 2015;122(13):1757-1764. doi:10.1111/1471-0528.13233.'''

:Objective: To investigate whether women with previous miscarriages or terminations have higher levels of anxiety, depression, stress, and altered behaviours in a subsequent pregnancy.

:Design:A retrospective analysis of 5575 women recruited into the Screening for Pregnancy Endpoints (SCOPE) study, a prospective cohort study.

:Setting:Auckland, New Zealand, Adelaide, Australia, Cork, Ireland, and Manchester, Leeds, and London, UK.

:Population:Healthy nulliparous women with singleton pregnancies.

:Methods: Outcomes were recorded at 15 and 20 weeks of gestation.

:Main outcome measures: Short-form State–Trait Anxiety Inventory (STAI) score, Perceived Stress Scale score, Edinburgh Postnatal Depression Scale score, and pregnancy-related behaviour measured using behavioural responses to pregnancy score.

:Results: Of the 5465 women included in the final analysis, 559 (10%) had one and 94 (2%) had two previous miscarriages, and 415 (8%) had one and 66 (1%) had two previous terminations of pregnancy. Women with one previous miscarriage had increased anxiety (adjusted mean difference 1.85; 95% confidence interval, 95% CI 0.61–3.09), perceived stress (adjusted mean difference 0.76; 95% CI 0.48–1.03), depression (adjusted odds ratio, aOR 1.26; 95% CI 1.08–1.45), and limiting/resting behaviour in pregnancy (adjusted mean difference 0.80; 95% CI 0.62–0.97). In women with two miscarriages, depression was more common (aOR 1.65; 95% CI 1.01–2.70) and they had higher scores for limiting/resting behaviour in pregnancy (adjusted mean difference 1.70; 95% CI 0.90–2.53) at 15 weeks of gestation.

:Women with one previous termination displayed elevated perceived stress (adjusted mean difference 0.65; 95% CI 0.08–1.23) and depression (aOR 1.25; 95% 1.08–1.45) at 15 weeks of gestation. Women with two previous terminations displayed increased perceived stress (adjusted mean difference 1.43; 95% CI 0.00–2.87) and depression (aOR 1.67; 95% 1.28–2.18).

:Conclusions:
This study highlights the psychological implications of miscarriage and termination of pregnancy.

'''Psychosocial Factors of Antenatal Anxiety and Depression in Pakistan: Is Social Support a Mediator? Fischer G, ed. Waqas A, Raza N, Lodhi HW, Muhammad Z, Jamal M, Rehman A. PLoS One. 2015;10(1):e0116510. doi:10.1371/journal.pone.0116510.'''
:History of abortion significanty associated with anxiety and depression in subsequent pregnancies.

'''Frequency and Associated Factors for Anxiety and Depression in Pregnant Women: A Hospital-Based Cross-Sectional Study. Ali NS, Azam IS, Ali BS, Tabbusum G, Moin SS. Sci World J. 2012;2012:1-9. doi:10.1100/2012/653098.'''

:Results: Depression was associated with previous adverse pregnancy outcome in past including death of a child, stillbirth or abortion ( P - value = 0 .013 )

'''Depression during pregnancy: Prevalence and obstetric risk factors among pregnant women attending a tertiary care hospital in Navi Mumbai. Ajinkya S, Jadhav PR, Srivastava NN. Ind Psychiatry J. 2013;22(1):37-40. doi:10.4103/0972-6748.123615.'''
:RESULTS Prevalence of depression during pregnancy was found to be 9.18% based upon BDI, and it was significantly associated with several obstetric risk factors like gravidity (P = 0.0092), unplanned pregnancy (P = 0.001), history of abortions (P = 0.0001), and a history of obstetric complications, both present (P = 0.0001) and past (P = 0.0001).

''[http://www.jad-journal.com/article/S0165-0327(15)30233-0/fulltext Identifying the women at risk of antenatal anxiety and depression: A systematic review] Biaggi A, Conroy S, Pawlby S, Pariante CM. J Affect Disord. 2015 Nov 18;191:62-77.''

:BACKGROUND: Pregnancy is a time of increased vulnerability for the development of anxiety and depression. This systematic review aims to identify the main risk factors involved in the onset of antenatal anxiety and depression.

:METHODS: A systematic literature analysis was conducted, using PubMed, PsychINFO, and the Cochrane Library. Original papers were included if they were written in English and published between 1st January 2003 and 31st August 2015, while literature reviews and meta-analyses were consulted regardless of publication date. A final number of 97 papers were selected.

:RESULTS: The most relevant factors associated with antenatal depression or anxiety were: lack of partner or of social support; history of abuse or of domestic violence; personal history of mental illness; unplanned or unwanted pregnancy; adverse events in life and high perceived stress; present/past pregnancy complications; and pregnancy loss.

:LIMITATIONS: The review does not include a meta-analysis, which may have added additional information about the differential impact of each risk factor. Moreover, it does not specifically examine factors that may influence different types of anxiety disorders, or the recurrence or persistence of depression or anxiety from pregnancy to the postpartum period.

:CONCLUSIONS: The results show the complex aetiology of antenatal depression and anxiety. The administration of a screening tool to identify women at risk of anxiety and depression during pregnancy should be universal practice in order to promote the long-term wellbeing of mothers and babies, and the knowledge of specific risk factors may help creating such screening tool targeting women at higher risk.

'''Prevalence of anxiety and depression during pregnancy in a private setting sample. Faisal-Cury A, Rossi Menezes P. Arch Womens Ment Health. 2007;10(1):25-32. doi:10.1007/s00737-006-0164-6.'''

:OBJECTIVES To estimate the prevalence and risk factors for antenatal anxiety (AA) and antenatal depression (AD).
:METHODS We performed a cross sectional study of 432 women attending a private clinic in the city of Osasco, São Paulo, from 5/27/1998 to 5/13/2002. The following instruments were used: Spielberger state-trait anxiety inventory (STAI), Beck depression inventory (BDI), and a questionnaire for socio-demographic and obstetric data. Inclusion criteria were: pregnant women with no past or present history of depression, psychiatric treatment, alcohol or drug abuse and no clinical and obstetric complications. The prevalence of AA, according to STAI, and AD, according to Beck Inventory, were estimated with 95% confidence intervals (95% CI). Odds ratios and 95% CI were used to examine the association between AA and AD and exposures variables.
:RESULTS The prevalence of AA, state and trait were 59.5 (95 CI%: 54.8:64.1%) and 45.3% (95% CI: 40.6:50.0), respectively. The prevalence of AD was 19.6 (95% CI:15.9:23.4). In the multivariate analysis, AA-trait (OR: 5.26; 95% CI 2.17:12.5, p < 0.001), AA-state (OR: 2.27; 95% CI 1.08:4.76, p = 0.02) and AD (OR: 2.43; 95% CI 1.40:4.34, p = 0.002) were associated with lower women's educational level. AA-trait (OR: 3.43; 95% CI 1.68:7.00, p = 0.001), AA-state (OR: 2.22; CI 95% 1.09:4.53, p = 0.02) and AD (OR: 2.82; CI 95% 1.35:5.97, p = 0.005) were also associated with not being married. AA-trait was associated with lower women's income (OR: 2.22; 95% CI 0.98:5.26, p = 0.05) and not being white (OR: 1.7; 95% CI 1.00:2.91, p = 0.04), while AD was associated with lower couple's income (OR: 2.43; 95% CI 1.40:4.34, p = 0.001) and greater number of previous abortions (OR: 2.21; 95% CI 1.23:3.97, p = 0.009).
:CONCLUSIONS Prevalence of AA and AD were high in this sample of women attending a private care setting, particularly AA state and trace. AA and AD were associated with similar socio-demographic and socio-economic risk factors, suggesting some common environmental stressors may be involved.

''[http://www.psikofarmakoloji.org/pdf/22_1_8.pdf The Impact of Prior Abortion on Anxiety and Depression Symptoms During a Subsequent Pregnancy: Data From a Population-Based Cohort Study in China] Huang Z, et al. Bulletin of Clinical Psychopharmacology 2012;22(1):51-8''

:'''Objective:''' The aim of the study was to assess anxiety and depression in women with history of spontaneous abortion or induced abortion during a subsequent pregnancy.

:'''Methods:''' The data were consecutively obtained from seven maternal and child health (MCH) Centers in the Anhui Province of China. The sociodemographic characteristics of the women, the number of previous pregnancies, number of living children, and gestational age of the current pregnancy were ascertained at the time of the interview.

:'''Results:''' The pregnant women who were in the first trimester of their pregnancy reported significantly higher scores than those in the second trimester both on SAS (Zung’s Self-Rating Anxiety Scale) and CES-D (The Center for Epidemiologic Studies-Depression Scale) (SAS score means: 32.11 vs 31.68, P=0.000; CES-D score means: 4.59 vs 4.06, P=0.012). The women with a history of induced abortions were significantly more likely to report more “cases” of depression (OR = 1.543, 95% CI = 1.055- 254) and more “cases” of anxiety (OR = 2.142, 95% CI = 1.294-3.561) during the first trimester than those with no history of abortion. Controlling for confounding variables yielded similar results. However, “cases” of depression and “cases” of anxiety were equally common in women with history of spontaneous abortions and in those with no abortion history.

:'''Conclusions:''' These results suggest women who have experienced a previous induced abortion have omnipresent anxiety and depression symptoms during a subsequent pregnancy, specially during the first trimester.

''"Abortion and Subsequent Pregnancy," C.F. Bradley, Canadian Journal Psychiatry29:494, Oct-1984. ''
:A study of 254 pregnant women in Victoria, B.C. were followed from the second trimester of their pregnancy until 12 months post-partum. Twenty-eight women had a prior induced abortion and 216 had no prior induced abortion. Women who had a prior abortion had significantly higher levels of depressive effect in the third trimester of pregnancy (35 weeks gestation) and also at intervals of I month, 6 months and 12 months in the post- partum period. A Depressive Adjective Checklist developed by other researchers was used as the evaluation tool. Women with prior abortions also described themselves as less well-adjusted during the prenatal period and had lower self-esteem in the post- partum period than those without any abortion history. The author suggested that it may have been those factors which were related to their depressive mood.

''"The Relationship Between Previous Elective Abortions and Postpartum," Depressive Reactions. N.E. Devore, Journal of Obstetric Gynecologic and Neonatal Nursing, July/August 1979, pp-237-240''
:In a study of 73 women among the obstetrical population at the Hospital of Albert Einstein College during 1975-76, 25 pregnant women who had one abortion and 48 women who were pregnant for the first time were interviewed 6-8 weeks postpartum. Seventy-one percent of the women with abortion history reported they were depressed at the time of the abortion, yet only 12% reported that they had received emotional counseling at the time of the abortion. The range of time from the earlier abortion to the current pregnancy was 2-8 years, mean 3.9 years. Using the Beck Depression Inventory, the study found postpartum moderate depression in 16% of women with a prior abortion compared to 12% of the women without any abortion. Eighty percent of the women with abortion history compared to 56% without abortion history reported the "baby blues." The study suggested that a few women who have had a previous elective abortion will still experience feelings of guilt or depression in connection with it. Spontaneous comment from the women with abortion history suggested that anxiety during pregnancy concurring the infants health was a greater source of discomfort than was post-partum depression.

''"Previous induced abortion and ante-natal depression in primipare: preliminary report of a survey of mental health in pregnancy," R. Kumar, K. Robson, Psychological Medicine8:711-715, 1978 ''
:A British study of 119 pregnant women found an association between a previous abortion (legal or illegal) and depression and anxiety in an early subsequent pregnancy. An intensification of fears of fetal abnormality was noted in women having had a prior abortion. The study concluded that "unresolved feelings of guilt, grief and loss may remain dormant long after an abortion until they are apparently re-awakened by another pregnancy. Normal anxieties about the now desired fetus are intensified and such fears are often spontaneously interpreted in terms of retribution."

''A Prospective Study of Emotional Disorders in Childbearing Women, R Kumar, K Robson, Brit J Psychiat 144:35-47, 1984 ''
:Prior induced abortion was associated with ante-natal depression and anxiety; thoughts about obtaining abortion was associated with both ante-natal and post-natal depression and anxiety.

''"Psychiatric Morbidity in a Pregnant Population in Nigeria," OA Abiodun et. al General Hospital Psychiatry 15: 125-128, 1993 ''
:A previous history of induced abortion was significantly associated with psychiatric morbidity (mostly anxiety and neurotic depression) among 240 married Christian and Muslim women attending an antenatal clinic.

''"Psychological and social correlates of the onset of affective disorders among pregnant women," T Kitamura et al, Psychological Medicine 23:967-975, 1993 ''
:A Japanese study found that among women with previous pregnancy, pregnancy-related affective disorder was recognized among 27% of those expecting their first baby where there had been a previous termination of pregnancy compared to 3% of women who had no previous termination of pregnancy.

==Anniversary Depressive Reactions==

''"Aftermath of Abortion. Anniversary Depression and Abdominal Pain. J.O," Cavenar Jr A.A. Maltbie, J.L. Sullivan, Bulletin of the Menninger Clinic 42(5):433438, 1978 ''
:A case study was presented in which a woman had an apparently uneventful abortion, but which resulted in a depressive reaction which arose during the week of her expected delivery, necessitating psychiatric care.

''"Adolescent Suicide Attempts Following Elective Abortion," C Tischler, Pediatrics 68(5):670, 1981 ''
:Adolescents attempted suicide on the perceived due date for their aborted child.

''"Psychoses Following Therapeutic Abortion," J.G. Spaulding, J.O. Cavenar, Am.J.. Psychiatry 135(3):364, March 1978. (A case study of a 24 year old unmarried women who experienced post abortion insomnia, anorexia, agitation and severe depression that necessitated hospitalization 9 months after the time the child would have been conceived. ''

''"Postabortion Depressive Reactions in College Women," N.B. Gould, J.Am. College Health Association 28:316320, 1980. ''
:In a study of college women at Harvard University during 1978-79, cases of 3 women who had abortions are described who each experienced depressive reactions at the time of the expected delivery date which adversely affected classroom performance.

''"Post-Abortion Perceptions: A Comparison of Self-Identified Distressed and Nondistressed Populations," GK Congleton and LG Calhoun, The International Journal of Social Psychiatry 39(4): 255, 1993 ''
:Women who reported post-abortion distress were more likely to report depression around the anniversary date of the abortion or the due date for birth compared to women who reported relieving/neutral responses specifically related to the baby, insomnia, inability to concentrate on studies, divisiveness in their relationships with partners, suicidal ideation, bouts of crying, inability to be consoled.

''"Anniversary Reactions and Due Date Responses Following Abortion, K," Franco, N. Campbell, M. Taburrino. S. Jurs. J. Pentz, C. Evans, Psychother Psychosom 52:151-154, 1989. ''
:In a study of 83 women in a patient-led post abortion support group in Ohio, 30 reported anniversary reactions associated with the abortion or the due date. Mean scores on the Beck Depression Inventory were 6.5 for those reporting anniversary reactions and 5.5 for those not reporting anniversary reactions. Those reporting anniversary reactions frequently reported physical symptoms including abdominal pain, dyspareunia, headaches and chest pain.

==Depressive Reactions from Genetic Abortion==

''"[http://www.springerlink.com/content/w773590gq50677jv/ Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth--a 14-month follow up study."] Kersting A, Kroker K, Steinhard J, Hoernig-Franz I, Wesselmann U, Luedorff K, Ohrmann P, Arolt V, Suslow T. Arch Womens Ment Health. 2009 Aug;12(4):193-201. Epub 2009 Mar 6.''
:"The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting psychological impact."

''"The psychological sequelae of abortion performed for a genetic indication," B.D. Blumberg, M.S. Globus, K.H. Hanson, Am.J. Obstet Gynecol 122(7):799, August 1, 1975. ''
:In a study of 13 families where abortion was undergone due to a genetic defect in the fetus, the incidence of depression among women was as high as 92% among the women and 82% among the men. This was higher than elective abortion. Four families experienced separations during the pregnancy-abortion period.

''"Sequelae and Support After Termination of Pregnancy for Fetal Malformation," J. Lloyd and KM Laurence, British Medical Journal 290:907-909, March 1985. ''
:Seventy-seven percent of the women experienced an acute grief reaction following termination of pregnancy for fetal malformation. Forty-six percent still remained symptomatic after six months, some requiring psychiatric support. Depression with anxiety, often with considerable repressed anger, was noted. Severity of the reaction ranged from mild tearfulness, sadness, lethargy and insomnia to incapacitating grief with somatic symptoms, and finally to complete withdrawal. There was no opportunity to mourn. Some women had named the baby, usually secretly, which seemed to help the grieving process. Several would have liked some burial or formal recognition of the death. Several had problems severe enough to influence reproductive behavior.

==Short Term Depressive Reactions==

[https://www.ncbi.nlm.nih.gov/pubmed/19701863 Medical or surgical abortion and psychiatric outcomes.] Yilmaz N1, Kanat-Pektas M, Kilic S, Gulerman C. J Matern Fetal Neonatal Med. 2010 Jun;23(6):541-4. doi: 10.3109/14767050903191301.
:AIM: The objectives of this study are to compare the risk of psychological depression after medical and surgical abortions in first two trimesters and to evaluate the risk factors for post-abortion depression.
:METHOD: A retrospective study was conducted throughout 367 women who underwent surgical abortion and 458 women who underwent medical abortion between January 2006 and January 2007 in Dr. Zekai Tahir Burak Women's Health Hospital. Women were assessed by clinical psychologists one week after the intervention. The clinical characteristics and psychological assessment of these women were statistically correlated by means of non-parametric tests.
:RESULTS: Of the study population, 27.1% was diagnosed with post-abortion depression. The frequency of post-abortion depression was 34.3% in surgical abortion patients and 22.8% in medical abortion patients. The women who underwent surgical abortion were found to have significantly elevated risk of post-abortion depression. The women with a high risk of post-abortion depression were significantly younger and had a more frequent history of psychiatric and depressive disorders.
:CONCLUSION: An important quotient of women experiences post-abortion mood depression which is significantly more frequent after surgical abortion. Women with past psychiatric and anxiety disorders should be carefully monitored for depression when they would undergo an abortion.

''"Outcome Following Therapeutic Abortion," E.C. Payne, A.R. Kravitz, M.T. Notman, J.V. Anderson, Arch Gen Psychiatry 33:725, June 1976. ''
:A study of 102 women evaluated anxiety depression, anger, guilt and shame in women prior to abortion and at 24 hours, 6 weeks and 6 months following their abortion with respect to a multiple number of variables. Depressive reactions were significantly reduced following abortions although mild to moderate depression was still present in women 6 months after their abortion. Factors that significantly increased the likelihood of post abortion depression were immature object relationships, younger women, Catholic religion, no prior children, previous mental illness, borderline personality, a negative relationship with mother, a bad relationship with children, conflict with lover, ambivalence to abortion.

''"Induced abortion operations and their early sequelae," P.I. Frank, C.R. Kay, S.L. Winsgrave, Journal of the Royal College of General Practitioners 35:175, 1985. ''
:In this British study those with a history of depression had a rate of post abortion depression which was 2.59 times higher than expected.

''"Pregnancy Decision Making as a Significant Life Event: A Commitment Approach," J Lydon et al, Journal of Personality and Social Psychology 71(1): 141-151, 1996 ''
:Initial commitment to the pregnancy prior to abortion predicted subsequent depression, guilt and hostility postabortion.

''"Therapeutic Abortion and a Prior Psychiatric History," J.A. Ewing, B.A. Rouse, Am J. Psychiatry 130(l):37, January, 1973. ''
:A North Carolina study of 126 women who had abortions in 1970-71 found that 36% of the women with a history of psychiatric problems reported depression following abortion compared with only 11% of the women who reported no prior psychiatric history. The responses ranged from a few weeks to two years post abortion. Women with a psychiatric history prior to abortion also had higher incidence of crying spells, anxiety, sleeplessness, worry and guilt.

''"Depressive Symptoms in Late Adolescent and Young Adult Females: Effects of Pregnancy Resolution," J. Mesaros, D. Larson and J. Lyons, presented to the American Society for Psychosomatic Obstetrics and Gynecology, New York, New York, March 1990 ''
:A case / control of study of depressive symptoms in women 17-25 years of age compared women with prior induced abortion, delivery, spontaneous abortion and never pregnant on the Center for Epidemiologic Studies Depression Scale. Women with prior abortion had the highest frequency of depressive symptoms. Higher scores were found in women where there was a perceived loss of control in the decision to terminate, negative feelings about the termination and little meaningful religious experience.

''"Attributions, Expectations and Coping with Abortion," B. Major, P. Mueller, K. Hildebrandt, J. of Personality and Social Psychology 48(3):585, 1985. ''
:A study of 247 women who underwent abortions in a free-standing abortion clinic in a large U.S. metropolitan area found that their immediate (30 minutes post abortion) depression level following their abortion was mean of 4.17 (range 0-22) on the Beck Depression Inventory. Three weeks later on a sample of 99 women who later responded the mean response on the Beck Depression Inventory was a mean of 2.93 (range 0-17) on the Beck Depression Inventory.

''"Law. Preventive Psychiatry and Therapeutic Abortion," H.I. Levene, F. J. Rigney, The J. of Nervous and Mental Disease 151(l):51, 1970. ''
:A California study of 70 women who were granted a therapeutic abortion under California law found that 14% reported an increase in depressive symptomology 3-5 months post abortion.

''"Short-term Psychiatric Sequelae to Therapeutic Termination of Pregnancy," B. Lask, Br. J. Psychiatry 126:173-177, 1975. ''
:Fifty inpatients from a London hospital who underwent abortion were interviewed 6 months later. Thirty-two per cent had unfavorable outcomes. The outcome was considered unfavorable when the following criteria were fulfilled: (1) the patient regretted termination: (2) the patient had moderate or severe feelings of loss, guilt or self-reproach: (3) there was evidence of mental illness in the same degree as, or more severe than before the abortion. When moderate or severe adverse sequelae were reported, these were usually associated with depressive states. These varied in intensity from mild to sufficiently severe to necessitate hospital admission.

''"Women's Self-Reported Responses to Abortion," G.M. Burnell, M.A. Norfleet, The Journal of Psychology 12(l):71-76 ''
:A study of 158 women who were members of a prepaid health plan in northern California reported in responding to a mailed questionnaire found that 17% reported depression following abortion which was the highest endorsement under a section entitled -worsened adjustment after abortion. The length of time from the time of the abortion and the questionnaire varied. A majority of the women completed the questionnaire within one and a half years after abortion.

''"Long-term psychiatric follow-up," C. McCance, P. Olley, V. Edward in Experience with Abortion. Ed. G. Horobin, (Cambridge: Cambridge Univ. Press, 1973) 245-300. ''
:This study found that 20% of the original sample of women who underwent induced abortion were depressed 13-24 months thereafter according to the Beck Depression Inventory.

''"Psychological Responses of Women After First-Trimester Abortion," B Major et al, Arch Gen Psychiatry 57:777, 2000 ''
:20% of women had depression 2 years postabortion. Prepregnancy depression was a risk factor for postabortion depression. Negative postabortion emotions increased over time. Younger age and more children preabortion also predicted more negative abortion responses.

''"Emotional Distress Patterns Among Women Having First or Repeat Abortions," E.W. Freeman, K. Rickels, G.R. Huggins, Obstetrics and Gynecology 55(5):630, May, 1980. ''
:A study of 413 women at the University Hospital in 1977-78 using the SCL-90, a multidimensional self-report inventory measured depression before abortion and 2 weeks following abortion. The adjusted mean value prior to abortion was 1.06. After 2 weeks the adjusted mean value was 0.60 (one abortion) and 0.74 (two abortions). Women who repeated abortions showed significantly higher scores on interpersonal sensitivity, paranoid ideation, phobic anxiety and sleep disturbance compared to women with one abortion.

''"Before and after therapeutic abortion," P. Mackenzie, Canadian Medical Association Journal 111:667, October 5, 1974.''
:A 1973 study at Queens University School of Medicine of 150 Canadian women two weeks post abortion had 53% respond to a questionnaire survey. Based on self reports of the women 39% said they were depressed a lot from the pregnancy (21% said they were a little depressed). Two weeks post abortion 4% said they were depressed a lot from the abortion and 28% said they were depressed a little and 39% said they were not at all depressed.

''"Induced abortion after feeling fetal movements: Its causes and emotional consequences," C. Brewer, J. Biosocial Science 10:203-208. ''
:In a study of 40 women who had abortions between 20-24 weeks gestation. Twenty-five were followed-up 30 months post abortion. Five reported feeling depressed about their abortion. One had taken time off from school or work for this reason. None had sought specialist advice.

==Long Term Depressive Reactions==
:: Defined here as reactions five years or more since abortion.

'''[http://www.jad-journal.com/article/S0165-0327(15)00003-8/fulltext#s0035 Hormone-related factors and post-menopausal onset depression: Results from KNHANES (2010–2012)''' Sun Jae Jung, Aesun Shin, Daehee Kang. J Affective Disorders. April 1, 2015 p 176–183.
:Method: Of 13,918 women who participated in the Korean National Health and Nutrition Examination Survey (KNHANES) V, a total of 4869 post-menopausal women who had completed information on depression onset age and additional reproductive factors were included in the analysis. A multivariate logistic regression was applied to calculate the odds ratios between reproductive factors and post-menopausal onset depression.

:Relevant Finding: Induced abortion was significantly associated with a 40% increased risk of post-menopausal onset depression. (RR=1.40 CI=1.03–1.90)

''"Psychological profile of dysphoric women post abortion," K.N. Franco, M. Tamburrino, N. Campbell, J. Pentz, S. Jurs, J. of the American Medical Women's Assoc. 44(4):113, July/Aug. 1989. ''
:In a survey of 81 women approximately 10 years post abortion who were in a patient led support group for women who described themselves as having poorly assimilated their abortion experience, the mean Beck Depression Inventory Score for all women studied was 5.3 (mild depression). For women with one abortion it was 4.7 (none to minimal depression). For women with multiple abortions it was 9.4 (moderate depression). Other risk factors for post abortion dysphoria were pre morbid psychiatric illness, lack of family support, ambivalence and feeling coerced into having a abortion.

''Post-Abortion Trauma, Jeanette Vought, (Grand Rapids: Zondervan Publishing House, 1991). ''
:A study of 68 religiously oriented, primarily Protestant women who were studied 10-15 years post-abortion, 76% reported depression as one of the emotional effects of abortion.

''"A Survey of Postabortion Reactions," David C. Reardon, (Springfield, IL: The Elliot Institute for Social Science Research, 1987). ''
:In a 1987 Survey of Postabortion reactions among 100 women members of Women Exploited by Abortion an average of 11 years since their abortion, 87% agreed or strongly agreed with the statement, "After my abortion I experienced feelings of depression." Fifty per cent of these women were 20 years of age or younger at the time of their abortion.

''Psycho-Social Stress Following Abortion, Anne Speckhard, (Kansas City MO: Sheed & Ward, 1987). ''
:In a study of 30 women who reported chronic and long term stress from their abortion 92% expressed feelings of depression following abortion. Fifty per cent of these women had their abortion in the second trimester (46%) or third trimester (4%) of their pregnancy. The majority (64%) had their abortion 5-10 years previously, 20% were less than 5 years and 16% ranged from 11-25 years post abortion.

''"Depression associated with abortion and childbirth: A long-term analysis of the NLSY cohort," JR Cougle et al, Clinical Method & Health Research NetPrints, April 25, 2001 (Abstract)''
:This study used the National Longitudinal Survey of Youth which contains a number of psychological variables related to pregnancy outcome. Compared to post-childbirth women, women who had abortions were found to have significantly higher depression scores as measured an average of 10 years after their pregnancy outcome. Post-abortion women were also 41% more likely to score in the "high risk " range for clinical depression compared to non-aborting women. A self-assessment questionnaire administered in 1998 also found that aborting women were 73% more likely to complain of "depression, excessive worry, or nervous trouble of any kind" compared to women with other pregnancy outcomes.

''"Psychiatric history and mental status," W.L. Sands in Diagnosing Mental lllness:Evaluation in Psychiatry and Psychology, Eds. Freedman and Kaplan, (New York: Athenum, 1973) 31.''
:"The significance of abortions may not be revealed until later periods of emotional depression. During depressions occurring in the fifth or sixth decades of the patient's life, the psychiatrist frequently hears expressions of remorse and guilt concerning abortions that occurred twenty or more years earlier."

==Postpartum Depression & Antenatal Depression==
See also: [[Depression|Postpartum_Depression_During_Subsequent_Pregnancies]]

Format: AbstractSend to

'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6264030/ Prevalence and determinants of antenatal depression among pregnant women in Ethiopia: a systematic review and meta-analysis.] Zegeye A, Alebel A, Gebrie A, Tesfaye B, Belay YA, Adane F, Abie W. ''BMC Pregnancy Childbirth''. 2018 Nov 29;18(1):462. doi: 10.1186/s12884-018-2101-x.'''

:BACKGROUND: Antenatal depression is more prevalent in low and middle income countries as compared to high income countries. It has now been documented as a global public health problem owing to its severity, chronic nature and recurrence as well as its negative influence on the general health of women and development of children. However, in Ethiopia, there are few studies with highly variable and inconsistent findings. Therefore, the aim of this study was to determine the prevalence of antenatal depression and its determinants among pregnant women in Ethiopia.

:METHODS: In this systematic review and meta-analysis, we exhaustively searched several databases including PubMed, Google Scholar, Science Direct and Cochrane Library. To estimate the pooled prevalence, studies reporting the prevalence of antenatal depression and its determinants were included. Data were extracted using a standardized data extraction format prepared in Microsoft Excel and transferred to STATA 14 statistical software for analysis. To assess heterogeneity, the Cochrane Q test statistics and I2 test were used. Since the included studies exhibit considerable heterogeneity, a random effect meta- analysis model was used to estimate the pooled prevalence of antenatal depression. Finally, the association between determinant factors and antenatal depression were assessed.

:RESULTS: The overall pooled prevalence of antenatal depression, in Ethiopia, was 24.2% (95% CI: 19.8, 28.6). The subgroup analysis of this study indicated that the highest prevalence was reported from Addis Ababa region with a prevalence of 26.9% (21.9-32.1) whereas the lowest prevalence was reported from Amhara region, 17.25 (95% CI: 6.34, 28.17). '''Presence of previous history of abortion (OR: 3.0, 95% CI: 2.1, 4.4),''' presence of marital conflict (OR: 7.2; 95% CI: 2.7, 19.0), lack of social support from husband (OR: 3.2: 95% CI: 1.2, 8.9), and previous history of pregnancy complication (OR: 3.2: 95% CI: 1.8, 5.8) were found to be determinants of antenatal depression.

:CONCLUSION: The pooled prevalence of antenatal depression, in Ethiopia, was relatively high. Presence of previous history of: abortion, presence of marital conflict, lack of social support from husband, presence of previous history of pregnancy complications were the main determinants of antenatal depression in Ethiopia.

[https://www.ncbi.nlm.nih.gov/pubmed/28112056 Obstetrical, pregnancy and socio-economic predictors for new-onset severe postpartum psychiatric disorders in primiparous women.] Meltzer-Brody S, Maegbaek ML, Medland SE, Miller WC, Sullivan P, Munk-Olsen T. Psychol Med. 2017 Jan 23:1-15. doi: 10.1017/S0033291716003020. [Epub ahead of print]

METHOD: A population-based cohort study using Danish registers was conducted in 392,458 primiparous women with a singleton delivery between 1995 and 2012 and ''no previous psychiatric history.'' The main outcome was first-onset postpartum psychiatric episodes. Incidence rate ratios (IRRs) were calculated for any psychiatric contact in four quarters for the first year postpartum.

Results: Previous abortion was associated with a significantly higher rate of any postpartum pyschiatric disorder (without substance abuse), IRR 1.13 (1.04-1.22), and postpartum depression, IR 1.18 (1.03-1.37), and acute stress reactions, IRR 1.11 (0.98-1.26).

:All-Cause Mortality in Women With Severe Postpartum Psychiatric Disorders. Johannsen BM, Larsen JT, Laursen TM, Bergink V, Meltzer-Brody S, Munk-Olsen T. Am J Psychiatry. 2016 Jun 1;173(6):635-42. doi: 10.1176/appi.ajp.2015.14121510. Epub 2016 Mar 4.
:-- Women with postpartum psychiatric disorders had a higher MRR (3.74; 95% CI=3.06-4.57) than non-postpartum-onset mothers (MRR=2.73; 95% CI=2.67-2.79) when compared with mothers with no psychiatric history. However, childless women with psychiatric diagnoses had the highest MRR (6.15; 95% CI=5.94-6.38). Unnatural cause of death represented 40.6% of fatalities among women with postpartum psychiatric disorders, and within the first year after diagnosis, suicide risk was drastically increased (MRR=289.42; 95% CI=144.02-581.62) when compared with mothers with no psychiatric history.

[http://www.ncbi.nlm.nih.gov/pubmed/24007380 Increased risk for postpartum psychiatric disorders among women with past pregnancy loss.] Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

:Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.
:Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

:Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

:Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

'''[http://www.ncbi.nlm.nih.gov/pubmed/22622194 "Predictors of postpartum post-traumatic stress disorder in primiparous mothers.][Article in French]'''
Montmasson H1, Bertrand P, Perrotin F, El-Hage W. J Gynecol Obstet Biol Reprod (Paris). 2012 Oct;41(6):553-60. doi: 10.1016/j.jgyn.2012.04.010. Epub 2012 May 21.

A history of abortion was associated with a six fold increased risk of subsequent postpartum PTSD.

[http://bmjopen.bmj.com/content/3/11/e004047.long Fear of childbirth predicts postpartum depression: a population-based analysis of 511 422 singleton births in Finland.] Räisänen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. BMJ Open. 2013 Nov 28;3(11):e004047. doi: 10.1136/bmjopen-2013-004047.

Abstract
:OBJECTIVES: To study how reproductive risks and perinatal outcomes are associated with postpartum depression treated in specialised healthcare defined according to the International Classification of Diseases (ICD)-10 codes, separately among women with and without a history of depression.

:DESIGN: A retrospective population-based case-control study.

:SETTING: Data gathered from three national health registers for the years 2002-2010.

:PARTICIPANTS: All singleton births (n=511 422) in Finland.

:PRIMARY OUTCOME MEASURES: Prevalence of postpartum depression and the risk factors associated with it.

:RESULTS: In total, 0.3% (1438 of 511 422) of women experienced postpartum depression, the prevalence being 0.1% (431 of 511 422) in women without and 5.3% (1007 of 18 888) in women with a history of depression. After adjustment for possible covariates, a history of depression was found to be the strongest risk factor for postpartum depression. Other strong predisposing factors for postpartum depression were fear of childbirth, caesarean birth, nulliparity and major congenital anomaly. Specifically, among the 30% of women with postpartum depression but without a history of depression, postpartum depression was shown to be associated with fear of childbirth (adjusted OR (aOR 2.71, 95% CI 1.98 to 3.71), caesarean birth (aOR 1.38, 95% CI 1.08 to 1.77), preterm birth (aOR 1.65, 95% CI 1.08 to 2.56) and major congenital anomaly (aOR 1.67, 95% CI 1.15 to 2.42), compared with women with no postpartum depression and no history of depression.

:CONCLUSIONS: A history of depression was found to be the most important predisposing factor of postpartum depression. Women without previous episodes of depression were at an increased risk of postpartum depression if adverse events occurred during the course of pregnancy, especially if they showed physician-diagnosed fear of childbirth.

:Editor's Note: Women with a history of abortion were 41% more likely to have post-partum depression compared to both women without any history of prior depression (OR=1.41; CI 1.08 to 1.84) and compared women with a prior history of depression (OR=1.41; CI = 1.21 to 1.67), as shown in Table 4. Prior miscarriage was not significantly associated with a higher risk of post-partum depression.

:Re-analysis of Table 1, indicates that among the subset of all women without a prior history of depression, those who had a history of abortion were 49% more likely to experience post-partum depression (95% CI 1.15 to 1.93; incident rate per 100,000 of 123 versus 82.)

[http://repository.ksu.edu.sa/jspui/bitstream/123456789/19373/1/%D8%A7%D9%84%D8%B1%D8%B3%D8%A7%D9%84%D8%A9%20%D9%83%D8%A7%D9%85%D9%84%D8%A9.pdf Identification of Factors Associated with Postpartum Depression among Saudi Females in Riyadh City] Nesreen Al-Shami. King Saud University College of Nursing, Department of Maternal and Child Health Nursing. June 2, 2010.

:A study of 200 women drawn from four hospitals in Riyadh City all of whom had reported postpartum depression. Survey instruments were used to measure socioeconomic factors, gynecological and obstetric history, life stressor events, and post-partum depression symptoms.
:Risk factors for postpartum depression include first birth, ambivalence about the pregnancy, lack of social support, economical problems, history of abortion, died infant, gender of infant, medical or surgical history, number of pregnancies, type of delivery, life stressor event, lack of partner, and a history of depression or another depression illness.

''"The Relationship Between Previous Elective Abortions and Postpartum, Depressive Reactions." N.E. Devore, Journal of Obstetric Gynecologic and Neonatal Nursing, July/August 1979, pp-237-240''
:In a study of 73 women among the obstetrical population at the Hospital of Albert Einstein College during 1975-76, 25 pregnant women who had one abortion and 48 women who were pregnant for the first time were interviewed 6-8 weeks postpartum. Seventy-one percent of the women with abortion history reported they were depressed at the time of the abortion, yet only 12% reported that they had received emotional counseling at the time of the abortion. The range of time from the earlier abortion to the current pregnancy was 2-8 years, mean 3.9 years. Using the Beck Depression Inventory, the study found postpartum moderate depression in 16% of women with a prior abortion compared to 12% of the women without any abortion. Eighty percent of the women with abortion history compared to 56% without abortion history reported the "baby blues." The study suggested that a few women who have had a previous elective abortion will still experience feelings of guilt or depression in connection with it. Spontaneous comment from the women with abortion history suggested that anxiety during pregnancy concurring the infants health was a greater source of discomfort than was post-partum depression.

[http://www.ncbi.nlm.nih.gov/pubmed/24007380 Increased risk for postpartum psychiatric disorders among women with past pregnancy loss.] Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

:Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.
:Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

:Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

:Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

[http://www.ejog.org/article/S0301-2115(12)00447-2/fulltext Pregnancy loss and anxiety and depression during subsequent pregnancies: data from the C-ABC study.] Gong X, Hao J, Tao F, Zhang J, Wang H, Xu R. Eur J Obstet Gynecol Reprod Biol. 2013 Jan;166(1):30-6. doi: 10.1016/j.ejogrb.2012.09.024. Epub 2012 Nov 10.Source
School of Public Health, Anhui Medical University, Hefei, Anhui, China.

:OBJECTIVE: Previous studies have shown that pregnancy loss may affect the mental health of women in subsequent pregnancies. The China Anhui Birth Defects and Child Development cohort study therefore aimed to investigate the influence of pregnancy loss on anxiety and depression in subsequent pregnancies.

:STUDY DESIGN: In total, 20,308 pregnant women provided written informed consent and completed the study questionnaire. The Self-rating Anxiety Scale and Center for Epidemiologic Studies-Depression Scale were used to evaluate anxiety and depression in pregnant women. Pearson's χ(2) test and binary logistic regression were used for statistical analyses.

:RESULTS: Of 20,308 pregnant women, 1495 (7.36%) had a history of miscarriage and 7686 (37.85%) had a history of induced abortion. The binary logistic regression model found that pregnant women with a history of miscarriage had a significantly higher risk of anxiety and depression in the first trimester than primigravidae after stratified analysis according to the timing of the first prenatal visit (p<0.05). Compared with pregnant women with no history of miscarriage, women who had a history of miscarriage and an interpregnancy interval of less than 6 months had increased risk of anxiety symptoms (p<0.05) and depression symptoms (p<0.05) during the first trimester. Women with an interpregnancy interval of 7-12 months had a 2.511-fold higher risk of depression (p<0.05) than women with no history of miscarriage. These findings were not changed after adjustment for maternal age, maternal education, family income, place of residence and pre-pregnancy body mass index.

:CONCLUSIONS: Women with a history of miscarriage experienced significant anxiety and depression during their next pregnancy. A short interpregnancy interval and the first trimester are risk factors for adverse mental health

Validity of Studies

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==Validity of Studies==

''Women’s Health after Abortion.The Medical and Psychological Evidence, E Ring-Cassidy, I Gentiles (Toronto: The deVeber Institute for Bioethics and Social Research, 2002) 255.''

:Research on the effects of abortion on women’s health, especially in North America, is highly prone to the problem of selective citation. Some researchers refer only to previous studies with which they agree and do not consult, or mention those studies whose conclusions differ from their own.

''"The Psychological Complications of Therapeutic Abortion," G Zolese and CVR Blacker, Br J Psychiatry 160: 724, 1992 ''
:Women who choose abortion are not amenable to endless questions on how they feel, are less likely to return for follow-up, and baseline assessments before they become pregnant are impossible. Most psychological studies were conducted when standardized psychiatric instruments were not available or used self-devised questionnaires without proven reliability.

''From the Patient’s Perspective - Quality of Abortion Care, Picker Institute.'' (1999). Boston, MA.
:A survey of 2,215 abortion patients in 12 abortion clinics in the US found that two out of three women do not return for follow-up appointments at the abortion clinic. (comment: Poor followup may result in underestimation of the problem of significant adjustment problems post-abortion.)

''"Emotional Sequelae of Elective Abortion," I Kent et al, British Columbia Medical Journal 20:118, 1978''
:Sharp discrepancies were noted between data derived from a questionnaire survey administered through a general practice with the responses of women in a therapy group with deep and painful feelings not emerging in a questionnaire survey.

''Aborted Women: Silent No More, David C Reardon, (Chicago: Loyola University Press, 1987 ''
:In a survey of long-term effects of abortion on women, over 70% reported there was a time when they would have denied the existence of any reactions from their abortion. For some, denial lasted only a few months; for others it lasted over 10-15 years. Subsequently, they were able to share the severe adverse effects of abortion on their lives.

''"Underreporting Sensitive Behaviors: The Case of Young Women's Willingness to Report Abortion," LB Smith et al, Health Psychology 18(1): 37, 1999''
:U.S. young women were likely not to disclose prior induced abortion when interviewed. They were more likely to disclose smoking habits than abortion history.

''"Some Problems Caused by Not Having a Conceptual Foundation for Health Research: An Illustration From Studies of the Psychological Effects of Abortion," EJ Posavac and TQ Miller, Psychology and Health 5:13, 1990''
:The authors reviewed 24 empirical studies and concluded that psychological research was of poor quality, failed to state the basis of the theory to be tested, failed to track women over time, and made superficial assessments.

''"Psychological Impact of Abortion: Methodological and Outcomes Summary of Emperical Research Between 1966 and 1988," JL Rogers et al, Health Care for Women Int'l10:347,1989. ''
:Concludes that the literature on the psychological sequelae is seriously flawed and makes suggestions for critique of the literature. The authors conclude that both advocates and opponents of abortion can prove their points by judiciously referring only to articles supporting their political agenda.

''"Mental Health and Abortions: Review and Analysis," Philip G. Ney and A. Wickett, Psychiatric Univ. Ottawa 14(4): 506-516, (1989) ''
:A review of the literature shows a need for more long-term, in-depth studies; there's no satisfactory evidence that abortion improves the psychological state of those not mentally ill; mental ill-health is worsened by abortion; there is an alarming rate of post-abortion complications such as pelvic inflammatory disease and subsequent infertility.

''"Psychiatric Aspects of Therapeutic Abortion," B. Doane and B. Quigley, CMA Journal 125:427-432, September 1, 1981 ''
:Concludes that a search of the literature on the psychiatric aspects of abortion reveal poor study design, lack of clear criteria for decisions for or against abortion, poor definition of psychologic symptoms experienced by patients, absence of control groups in clinical studies, indecisiveness and uncritical attitudes in writers from various disciplines. The study also concludes that "there is little evidence that differences in abortion legislation account for significant differences in the psychologic reactions of patients to abortion."

''"Psychological and Social Aspects of Induced Abortion," J.A. Handy, British Journal of Clinical Psychology, February 21, 1982, Part I, pp. 29-41 ''
:A good summary of prior studies on the effects of abortion; states that a variety of methodological faults makes the results of many studies difficult to interpret.

''"Interpreting Literature on Abortion," (letter), WL Larimore, DB Larson, KA Sherrill, American Family Physician 46(3):665-666, Sept 1992''
:Various review articles on abortion share few of the same references, interpretation of the same article differs between reviewers.

''"Abortion: A Social-Psychological Perspective," Nancy Adler, Journal of Social Issues 35(l): 100-119 (1979) ''
:Concludes there is a need for continuing research on the negative effects of abortion and for intervention designed to diminish those negative effects for all concerned.

''"Psychiatric Sequelae of Induced Abortion," Mary Gibbons, Journal of the Royal College of General Practitioners 34:146-150(1984) ''
:Observes that many studies concluding that few psychiatric problems follow induced abortion were deficient in methodology, material or length of follow-up. It concludes that a large amount of the previously reported research on the psychiatric indications of abortion may be unreliable.

== Qualitative Studies==
''[http://onlinelibrary.wiley.com/doi/10.1363/4310311/abstract Social Sources of Women's Emotional Difficulty After Abortion: Lessons from Women's Abortion Narratives.] Kimport, K., Foster, K. and Weitz, T. A. (2011), Perspectives on Sexual and Reproductive Health, 43: 103–109.''
:CONTEXT: The experiences of women who have negative emotional outcomes, including regret, following an abortion have received little research attention. Qualitative research can elucidate these women’s experiences and ways their needs can be met and emotional distress reduced.

:METHODS: Twenty-one women who had emotional difficulties related to an abortion participated in semi-structured, in-depth telephone interviews in 2009. Of these, 14 women were recruited from abortion support talklines; seven were recruited from a separate research project on women’s experience of abortion. Transcripts were analyzed using the principles of grounded theory to identify key themes.

:RESULTS: Two social aspects of the abortion experience produced, exacerbated or mitigated respondents’ negative emotional experience. Negative outcomes were experienced when the woman did not feel that the abortion was primarily her decision (e.g., because her partner abdicated responsibility for the pregnancy, leaving her feeling as though she had no other choice) or did not feel that she had clear emotional support after the abortion. Evidence also points to a division of labor between women and men regarding pregnancy prevention, abortion and childrearing; as a result, the majority of abortion-related emotional burdens fall on women. Experiencing decisional autonomy or social support reduced respondents’ emotional distress.

:CONCLUSIONS: Supporting a woman’s abortion decision-making process, addressing the division of labor between women and men regarding pregnancy prevention, abortion and childrearing, and offering nonjudgmental support may guide interventions designed to reduce emotional distress after abortion.

Editor comments: This may be the first study ever published by the Guttmacher Institute on emotional problems post-abortion. While it is a very limited study that is qualitative in nature with a very small sample size, what is useful are the admissions that:
# post-abortion psychological problems are not religiously based;
# a woman seeking an abortion needs nonjudgmental support in the decision making process;
# secret abortions are likely to cause emotional difficulties;
# relationship counseling services are needed echoing our previous research; and
# disengaging partner, family and friends during the abortion decision making stage is ill-advised.

==Risk Factors for Adverse Emotional Consequences of Abortion==

''[http://www.afterabortion.info/news/Duty2Screen.pdf Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment.]'' Reardon DC. The Journal of Contemporary Health Law & Policy J Contemp Health Law Policy. 2003 Winter;20(1):33-114

:A comprehensive review of the literature on risk factors associated with abortion. Includes tables with over 40 statistically validated risk factors and citations to the studies identifying and validating these risk factors. The complete text of [http://www.afterabortion.info/news/Duty2Screen.pdf Abortion Decisions and the Duty to Screen] is available through this link.

:See also [[Risk_factors]]

''"Complicated Mourning: Dynamics of Impacted Pre and Post-Abortion Grief," Anne Speckland, Vincent Rue, Pre and Perinatal Psychology Journal 8(81 ):5, Fall, 1993. ''
:Emotional harm from abortion is more likely when one or more of the following risk factors are present: prior history of mental illness; immature interpersonal relationships; unstable, conflicted relationship with one's partner; history of negative relationship with one's mother; ambivalence regarding abortion; religious and cultural background hostile to abortion; single status especially if no born children; adolescent; second-trimester abortion; abortion for genetic reason; pressure and coercion to abort; prior abortion; prior children; maternal orientation.

''"Adolescent Abortion Option," G. Zakus, S. Wilday, Social Work in Health Care, 12(4):77, Summer, 1987. ''
:Certain categories of women are much more likely to have post-abortion problems sometimes many months or years later. These include: being forced or coerced into abortion; women who place great emphasis on future fertility plans; women with pre- existing psychiatric problems; women suffering from unresolved grief reactions or women with a history of sexual abuse, including incest, molestation or rape.

''"Outcome Following Therapeutic Abortion," R.C. Payne, A.R. Kravitz, M.T. Notman, J.V. Anderson, Arch. Gen. Psychiatry 33:725, June, 1976. ''
:This study measured short- term outcomes of anxiety, depression, anger, guilt and shame following abortion. The authors concluded that women who are most vulnerable to difficulty are those who are single and nulliparous, those with previous history of serious emotional problems, conflicted relationships to lovers, past negative relationships to mother, ambivalence toward abortion or negative religious or cultural attitudes about abortion.

''"The Decision-Making Process and the Outcome of Therapeutic Abortion, C," Friedman, R. Greenspan and F. Mittleman, American Journal of Psychiatry 131(12): 1332-1337, December 1974. ''
:There is high risk for post-abortion psychiatric illness when there is (1) Strong ambivalence; (2) Coercion; (3) Medical indication; (4) Concomitant psychiatric illness and (5) A woman feeling the decision was not her own.

''"Women's Emotions One Week After Receiving or Being Denied an Abortion in the United States." Rocca CH, Kimport H, Gould H, Foster DG. Perspectives on Sexual and Reproductive Health, 45(3)(2013).''

:Methods: Baseline data from a longitudinal study of women seeking abortion at 30 U.S. facilities between 2008 and 2010 were used to examine emotions among 843 women who received an abortion just prior to the facility's gestational age limit, were denied an abortion because they presented just beyond the gestational limit or obtained a first-trimester abortion. Multivariable analyses were used to compare women's emotions about their pregnancy and about their receipt or denial of abortion after one week, and to identify variables associated with experiencing primarily negative emotions postabortion.

:Results: Compared with women who obtained a near-limit abortion, those denied the abortion felt more regret and anger (scoring, on average, 0.4–0.5 points higher on a 0–4 scale), and less relief and happiness (scoring 1.4 and 0.3 points lower, respectively). Among women who had obtained the abortion, the greater the extent to which they had planned the pregnancy or had difficulty deciding to seek abortion, the more likely they were to feel primarily negative emotions (odds ratios, 1.2 and 2.5, respectively). Most (95%) women who had obtained the abortion felt it was the right decision, as did 89% of those who expressed regret.

:Conclusions: Difficulty with the abortion decision and the degree to which the pregnancy had been planned were most important for women's postabortion emotional state. Experiencing negative emotions postabortion is different from believing that abortion was not the right decision.

:'''Editor comments:''' Despite a low participation rate (38%), this study reported: 53% of women who aborted felt guilt, 41% regret, 64% sadness and 31% anger. And this was only one week post-abortion! Interestingly, only one out of four pregnancy partners wanted the abortion. As to decision difficulty for the women, more than one out of two (56%) indicated the abortion decision was “somewhat or very difficult.”

===Prior History of Psychiatric Illness===

[https://www.ncbi.nlm.nih.gov/pubmed/27760409 Incidence and recurrence of common mental disorders after abortion: Results from a prospective cohort study.] van Ditzhuijzen J, Ten Have M, de Graaf R, Lugtig P, van Nijnatten CH, Vollebergh WA. J Psychiatr Res. 2017 Jan;84:200-206. doi: 10.1016/j.jpsychires.2016.10.006. Epub 2016 Oct 11.

:Abstract: Research in the field of mental health consequences of abortion is characterized by methodological limitations. We used exact matching on carefully selected confounders in a prospective cohort study of 325 women who had an abortion of an unwanted pregnancy and compared them 1-to-1 to controls who did not have this experience. Outcome measures were incidence and recurrence of common DSM-IV mental disorders (mood, anxiety, substance use disorders, and the aggregate measure 'any mental disorder') as measured with the Composite International Diagnostic Interview (CIDI) version 3.0, in the 2.5-3 years after the abortion. Although non-matched data suggested otherwise, women in the abortion group did not show significantly higher odds for incidence of 'any mental disorder', or mood, anxiety and substance use disorders, compared to matched controls who were similar in background variables but did not have an this experience. Having an abortion did not increase the odds for recurrence of the three disorder categories, but for any mental disorder the higher odds in the abortion group remained significant after matching. It is unlikely that termination of an unwanted pregnancy increases the risk on incidence of common mental disorders in women without a psychiatric history. However, it might increase the risk of recurrence among women with a history of mental disorders.

:'''NOTES:''' Main problems: This study used a very small number of women and therefore had very low statstical power, resulting in very wide confidence intervals which could clearly include much higher rates of psychological illness.

:Second, the control group doubtlessly includes women concealing abortion history.

:Third, the abortion group has highly self-censured indicating that women at greatest risk of negative reactions excluded themselves from the study sample or dropped out. 56% of the 2443 initially asked to participate refused outright. By the time the first interview (20-40 days after the abortion) was scheduled, 22% of those previously agreeing refused and another 42% could not be contacted (perhaps gave false contact info or otherwise avoided the interview. As a result, only 35.8% of those who initially they were willing to participate, and 13% of those eligible to participate, actually did participate at the T0 interview. '''The T1 interview, three years post-abortion, saw a drop out rate of 19%, from 325 to 264 participants. Thus, the T1 data represented just 29% of those who agreed to be studied and just 11% of the eligible sample.''' (See [http://www.journalofpsychiatricresearch.com/article/S0022-3956(13)00236-7/pdf van Ditzhuijzen 2013] for a complete flow chart of participation and drop outs from invite through T0.)

:It is also notable that recurrent 20.7% of women having abortions reported recurrent substance use disorders at three years post-abortion compared to 0% for their matched control group. This was not discussed by the study's authors. Notably, substance use is one of the most frequent problems.

[http://www.sciencedirect.com/science/article/pii/S0022395613002367 Psychiatric history of women who have had an abortion.] van Ditzhuijzen J, ten Have M, de Graaf R, van Nijnatten CH, Vollebergh WA.
J Psychiatr Res. 2013 Nov;47(11):1737-43. doi: 10.1016/j.jpsychires.2013.07.024.

:Abstract. Prior research has focused primarily on the mental health consequences of abortion; little is known about mental health before abortion. In this study, the psychiatric history of women who have had an abortion is investigated. 325 Women who recently had an abortion were compared with 1902 women from the population-based Netherlands Mental Health Survey and Incidence Study (NEMESIS-2). Lifetime prevalence estimates of various mental disorders were measured using the Composite International Diagnostic Interview 3.0. Compared to the reference sample, women in the abortion sample were three times more likely to report a history of any mental disorder (OR = 3.06, 95% CI = 2.36–3.98). The highest odds were found for conduct disorder (OR = 6.97, 95% CI = 4.41–11.01) and drug dependence (OR = 4.96, 95% CI = 2.55–9.66). Similar results were found for lifetime-minus-last-year prevalence estimates and for women who had first-time abortions only. The results support the notion that psychiatric history may explain associations that have been found between abortion and mental health. Psychiatric history should therefore be taken into account when investigating the mental health consequences of abortion.

[https://www.ncbi.nlm.nih.gov/pubmed/26002806 The impact of psychiatric history on women's pre- and postabortion experiences.] van Ditzhuijzen J, Ten Have M, de Graaf R, van Nijnatten CH, Vollebergh WA. Contraception. 2015 Sep;92(3):246-53. doi: 10.1016/j.contraception.2015.05.003.
:OBJECTIVE: The objective of this study is to investigate to what extent psychiatric history affects preabortion decision difficulty, experienced burden, and postabortion emotions and coping. Women with and without a history of mental disorders might respond differently to unwanted pregnancy and subsequent abortion.
:STUDY DESIGN: Women who had an abortion (n=325) were classified as either with or without a history of mental disorders, using the Composite International Diagnostic Interview version 3.0. The two groups were compared on preabortion doubt, postabortion decision uncertainty, experienced pressure, experienced burden of unwanted pregnancy and abortion, and postabortion emotions, self-efficacy and coping. The study was conducted in the Netherlands. Data were collected using structured face-to-face interviews and analyzed with regression analyses.
:RESULTS: Compared to women without prior mental disorders, women with a psychiatric history were more likely to report higher levels of doubt [odds ratio (OR)=2.30; confidence interval (CI)=1.29-4.09], more burden of the pregnancy (OR=2.23; CI=1.34-3.70) and the abortion (OR=1.93; CI=1.12-3.34) and more negative postabortion emotions (β=.16; CI=.05-.28). They also scored lower on abortion-specific self-efficacy (β=-.11; CI=-.22 to .00) and higher on emotion-oriented (β=.22; .11-.33) and avoidance-oriented coping (β=.12; CI=.01-.24). The two groups did not differ significantly in terms of experienced pressure, decision uncertainty and positive postabortion emotions.
:CONCLUSIONS: Psychiatric history strongly affects women's pre- and postabortion experiences. Women with a history of mental disorders experience a more stressful pre- and postabortion period in terms of preabortion doubt, burden of pregnancy and abortion, and postabortion emotions, self-efficacy and coping.
:IMPLICATIONS: Negative abortion experiences may, at least partially, stem from prior or underlying mental health problems.

[Is underage abortion associated with adverse outcomes in early adulthood? A longitudinal birth cohort study up to 25 years of age.]
Leppälahti S, Heikinheimo O, Kalliala I, Santalahti P, Gissler M. Hum Reprod. 2016 Sep;31(9):2142-9. doi: 10.1093/humrep/dew178.

:STUDY QUESTION: Is underage abortion associated with adverse socioeconomic and health outcomes in early adulthood when compared with underage delivery?
:SUMMARY ANSWER: Underage abortion was not found to be associated with mental health problems in early adulthood, and socioeconomic outcomes were better among those who experienced abortion compared with those who gave birth.
:WHAT IS KNOWN ALREADY: Teenage motherhood has been linked with numerous adverse outcomes in later life, including low educational levels and poor physical and mental health. Whether abortion at a young age predisposes to similar consequences is not clear.
:STUDY DESIGN, SIZE, DURATION: This nationwide, retrospective cohort study from Finland, included all women born in 1987 (n = 29 041) and followed until 2012.
:PARTICIPANTS/MATERIALS, SETTING, METHODS: We analysed socioeconomic, psychiatric and risk-taking-related health outcomes up to 25 years of age after underage (<18 years) abortion (n = 1041, 3.6%) and after childbirth (n = 394, 1.4%). Before and after conception analyses within the study groups were performed to further examine the association between abortion and adverse health outcomes. A group with no pregnancies up to 20 years of age (n = 25 312, 88.0%) served as an external reference group.
:MAIN RESULTS AND THE ROLE OF CHANCE: We found no significant differences between the underage abortion and the childbirth group regarding risks of psychiatric disorders (adjusted odds ratio 0.96 [0.67-1.40]) or suffering from intentional or unintentional poisoning by medications or drugs (1.06 [0.57-1.98]). Compared with those who gave birth, girls who underwent abortion were less likely to achieve only a low educational level (0.41 [95% confidence interval 0.31-0.54]) or to be welfare-dependent (0.31 [0.22-0.45]), but more likely to suffer from injuries (1.51 [1.09-2.10]). Compared with the external control group, both pregnancy groups were disadvantaged already prior to the pregnancy. Psychiatric disorders and risk-taking-related health outcomes, including injury, were increased in the abortion group and in the childbirth group similarly on both sides of the pregnancy.
:LIMITATIONS, REASONS FOR CAUTION: The retrospective nature of the study remains a limitation. The identification of study subjects in order to collect additional data was not allowed for ethical reasons. Therefore further confounding factors, such as the intentionality of the pregnancy, could not be checked.
:WIDER IMPLICATIONS OF THE FINDINGS: Previous studies have found that abortion is not harmful to mental health in the majority of adult women. Our study adds to the current understanding in suggesting that this is also the case concerning underage girls. Furthermore, women with a history of underage abortion had better socioeconomic outcomes compared with those who gave birth. These findings can be generalized to settings of high-quality social and health-care services, where abortion is accessible and affordable to all citizens. Social and health-care professionals who care for and counsel underage girls facing unplanned pregnancy should acknowledge this information.
:STUDY FUNDING/COMPETING INTERESTS: This study was financially supported by the Finnish Cultural Foundation and the Päivikki and Sakari Sohlberg Foundation. The researchers are independent of funders and the funders had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report or in the decision to submit the article for publication. The authors have no competing interests.

[https://www.ncbi.nlm.nih.gov/pubmed/26117381 Induced abortions and birth outcomes of women with a history of severe psychosocial problems in adolescence.] Lehti V, Gissler M, Suvisaari J, Manninen M. Eur Psychiatry. 2015 Sep;30(6):750-5. doi: 10.1016/j.eurpsy.2015.05.005

:OBJECTIVE: To increase knowledge on the reproductive health of women who have been placed in a residential school, a child welfare facility for adolescents with severe psychosocial problems.
:METHODS: All women (n=291) who lived in the Finnish residential schools on the last day of the years 1991, 1996, 2001 and 2006 were included in this study and compared with matched general population controls. Register-based information on induced abortions and births was collected until the end of the year 2011.
:RESULTS: Compared to controls, women with a residential school history had more induced abortions. A higher proportion of their births took place when they were teenagers or even minors. They were more often single, smoked significantly more during pregnancy and had a higher risk of having a preterm birth or a baby with a low birth weight.
:CONCLUSIONS: The findings have implications for the planning of preventive and supportive interventions that aim to increase the well-being of women with a residential school history and their offspring.

===Prior History of Abortion===
[https://www.ncbi.nlm.nih.gov/pubmed/22981048 A study of psychiatric morbidity during second trimester of pregnancy subsequent to abortion in the previous pregnancy.] Chalana H, Sachdeva JK. Asian J Psychiatr. 2012 Sep;5(3):215-9. doi: 10.1016/j.ajp.2011.11.006.

:INTRODUCTION: Pregnancy plays a unique role in the transformation of women towards completeness. For those women who have had a previous unsuccessful outcome, pregnancy may bring a lot of inevitable negative emotions. We studied psychiatric morbidity during second trimester of pregnancy subsequent to abortion in the previous pregnancy.
:METHODS: The study was carried out in Dayanand Medical College and Hospital, Ludhiana, India. A total of 120 patients were divided into 4 groups depending on their pregnancy status. All the groups were compared with each other regarding their psychiatric morbidities, which were measured using various rating scales such as Hamilton Depression rating scale, Hamilton Anxiety Rating Scale, State Trait Anxiety Inventory, Presumptive Stressful Life events Scale, and Brief Psychotic Rating Scale.
:RESULTS: We found that subjects with history of previous abortion, whether single or more had significantly higher mean depression and anxiety score than primigravida or subjects with history of previous successful pregnancy; depression and anxiety scores decreased with increase in time gap between abortion and current pregnancy. High anxiety was found in 36.67%(11) of females with history of previous abortion. We also found that 36.67%(11) of subjects with previous single abortion and 30%(9) of subjects with previous 2 or more abortions were suffering from depressive episode. None of the female suffered from psychotic disorder.
:CONCLUSIONS: The incidence of depression and anxiety is high in pregnancy after previous abortion and more in subjects who conceive earlier after previous abortion. These results warrant the need for screening all pregnancies for psychiatric morbidity after a previous abortion.
:

==Postpartum Disorder Following Pregnancy Loss==

[http://www.ncbi.nlm.nih.gov/pubmed/24007380 Increased risk for postpartum psychiatric disorders among women with past pregnancy loss.] Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

:Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.
:Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

:Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

:Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

'''[http://www.ncbi.nlm.nih.gov/pubmed/22622194 "Predictors of postpartum post-traumatic stress disorder in primiparous mothers.][Article in French]'''
Montmasson H1, Bertrand P, Perrotin F, El-Hage W. J Gynecol Obstet Biol Reprod (Paris). 2012 Oct;41(6):553-60. doi: 10.1016/j.jgyn.2012.04.010. Epub 2012 May 21.

:A history of abortion was associated with a six fold increased risk of subsequent postpartum PTSD.

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084335/ Previous prenatal loss as a predictor of perinatal depression and anxiety.] Blackmore ER, Côté-Arsenault D, Tang W, Glover V, Evans J, Golding J, O'Connor TG. Br J Psychiatry. 2011 May;198(5):373-8. doi: 10.1192/bjp.bp.110.083105. Epub 2011 Mar 3.

:Results: Generalised estimating equations indicated that the number of previous miscarriages/stillbirths significantly predicted symptoms of depression (β = 0.18, s.e. = 0.07, P<0.01) and anxiety (β = 0.14, s.e. = 0.05, P<0.01) in a subsequent pregnancy, independent of key psychosocial and obstetric factors. This association remained constant across the pre- and postnatal period, indicating that the impact of a previous prenatal loss did not diminish significantly following the birth of a healthy child.

:Conclusions: Depression and anxiety associated with a previous prenatal loss shows a persisting pattern that continues after the birth of a subsequent (healthy) child. Interventions targeting women with previous prenatal loss may improve the health outcomes of women and their children.

===Other Studies Suggestive of Psychiatric Stress During Subsequent Pregnancies===

[http://www.ncbi.nlm.nih.gov/pubmed/12501082 A history of induced abortion in relation to substance use during subsequent pregnancies carried to term.] Coleman PK, Reardon DC, Rue VM, Cougle J. Am J Obstet Gynecol. 2002 Dec;187(6):1673-8.

[http://www.ncbi.nlm.nih.gov/pubmed/15788495 Hospitalization for mental illness among parents after the death of a child.] Li J, Laursen TM, Precht DH, Olsen J, Mortensen PB. N Engl J Med. 2005;352(12):1190-1196. doi:10.1056/NEJMoa033160.

==Abortion Compared to Birth or Miscarriage==
[http://www.ncbi.nlm.nih.gov/pubmed/15039513?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Psychological Impact on Women of Miscarriage Versus Induced Abortion: A 2-Year follow-up study.] [[Broen]] AN, Moum T, Bödtker AS, Ekeberg O. Psychosomatic Medicine, 2004, 66:265-271.

:"The feeling relief (at T1) had no significant influence on the IES scores at T3, unadjusted or adjusted." (p 268) This supports an argument that researchers who place too much emphasis on measure of relief may be missing the full picture.

p270, "mental health before the event suprisingly had no significant independent influence on IES scores."

 [http://www.ncbi.nlm.nih.gov/pubmed/15694217?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Reasons for induced abortion and their relation to women's emotional distress: a prospective, two-year follow-up study.] [[Broen]] AN, Moum T, Bodtker AS, Ekeberg O. Gen Hosp Psychiatry 2005, 27:36-43.

:OBJECTIVE: The present study aimed to identify the most important reasons for induced abortion and to examine their relationship to emotional distress at follow-up. METHODS: Eighty women were included in the study. The women were interviewed 10 days, 6 months (T2) and 2 years (T3) after they underwent an abortion. At all time points, the participants completed the Impact of Event Scale and a questionnaire about feelings connected to the abortion. RESULTS: Reasons related to education, job and finances were highly rated. Also, "a child should be wished for," "male partner does not favour having a child at the moment," "tired, worn out" and "have enough children" were important reasons. "Pressure from male partner" was listed as the 11th most important reason. When the reasons for abortion and background variables were included in multiple regression analyses, the strongest predictor of emotional distress at T2 and T3 was "pressure from male partner." CONCLUSION: Male pressure on women to have an induced abortion has a significant, negative influence on women's psychological responses in the 2 years following the event. Women who gave the reason "have enough children" for choosing abortion reported slightly better psychological outcomes at T3.

 [http://www.ncbi.nlm.nih.gov/pubmed/16343341?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum The course of mental health after miscarriage and induced abortion: a five-year follow-up study.] [[Broen]] AN, Moum T, Bødtker AS, Ekeberg O. BMC Medicine 2005, 3:18 (12 December 2005)

:Broen et al.'s results show that women who had a miscarriage suffer more mental distress up until six months after the event than women who had an abortion. Women who had an abortion, however, experienced more mental distress long after the event - two and five years afterwards - than women who had a miscarriage. Women who experienced induced abortion had significantly greater IES scores for avoidance and for the feelings of guilt, shame and relief than the miscarriage group at two and five years after the pregnancy termination (IES avoidance means: 3.2 vs 9.3 at T3, respectively, p < 0.001; 1.5 vs 8.3 at T4, respectively, p < 0.001). Compared with the general population, women who had undergone induced abortion had significantly higher HADS anxiety scores at all four interviews (p < 0.01 to p < 0.001), while women who had had a miscarriage had significantly higher anxiety scores only at T1 (p < 0.01).

 [http://www.ncbi.nlm.nih.gov/pubmed/16553180?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Predictors of anxiety and depression following pregnancy termination: a longitudinal five-year follow-up study.] [[Broen]] AN, Moum T, Bödtker AS, Ekeberg O. Acta Obstet Gynecol Scand. 2006;85(3):317-23.

:BACKGROUND: The aims of the study were to assess anxiety and depression in women who had experienced either a miscarriage or an induced abortion, to compare the women's level of distress with that of a general population sample, and to find predictors of anxiety and depression six months and five years after the event.

:METHODS: A prospective, longitudinal follow-up study. Women who experienced miscarriage (n = 40) and induced abortion (n = 80) were interviewed ten days (T1), six months (T2), two years (T3), and five years (T4) after the event. On each occasion, they completed the Hospital Anxiety and Depression Scale and the Life Events Scale. Paired-sample t-test, logistic regression, and multiple linear regression statistical tests were used.

:RESULTS: Women with miscarriage had significantly more anxiety and depression at T1 than the general population, while women with induced abortion had significantly more anxiety at all time points and more depression at T1 and T2. In both groups, important predictors of anxiety and depression at T2 and T4 were recent life events and poor former psychiatric health. Childbirth events between T1 and T4 had no significant influence on the scores. For women with induced abortion, doubt about the decision to abort was related to depression at T2 (p <0.05), while a negative attitude towards induced abortion was associated with anxiety at T2 (p <0.05) and T4 (p <0.05).

:CONCLUSION: Correlates of anxiety and depression may be used to better identify women who are at risk of negative psychological responses following pregnancy termination.

''"[http://www.springerlink.com/content/w773590gq50677jv/ Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth—a 14-month follow up study]" Kersting A, et al. Arch Womens Ment Health. 2009 Aug;12(4):193-201. Epub 2009 Mar 6.''
:(ABSTRACT) The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting
psychological impact.

''Trauma and grief 2-7 years after termination of pregnancy because of fetal anomalies-a pilot study. Kersting A, et al. J of Psychosomatic Obstetrics & Gynecology 2005; 26(1): 9-14.''
:The aim of the study was to obtain information on the long-term posttraumatic stress response and grief several years after termination of pregnancy due to fetal malformation. We investigated 83 women who had undergone termination of pregnancy between 1995 and 1999 and compared them with 60 women 14 days after termination of pregnancy and 65 women after the spontaneous delivery of a full-term healthy child. Women 2-7 years after termination of pregnancy were expected to show a significantly lower degree of traumatic experience and grief than women 14 days after termination of pregnancy. Contrary to the hypothesis, however, the results showed no significant intergroup differences with respect to the degree of traumatic experience. With the exception of one subscale (fear of loss), this also applied to the grief reported by the women. However, both groups differed significantly in their posttraumatic stress response from women who had given spontaneous birth to a full-term healthy child. The results indicate that termination of pregnancy is to be seen as an emotionally traumatic major life event which leads to severe posttraumatic stress response and intense grief reactions that are still detectable some years later.

[http://www.ncbi.nlm.nih.gov/pubmed/24007380 Increased risk for postpartum psychiatric disorders among women with past pregnancy loss.] Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

:Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.
:Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

:Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

:Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

''Abortion in young women and subsequent mental health.'' Fergusson DM, John Horwood L, Ridder EM. J Child Psychol Psychiatry. 2006 Jan;47(1):16-24.

:Background: The extent to which abortion has harmful consequences for mental health remains controversial. We aimed to examine the linkages between having an abortion and mental health outcomes over the interval from age 15-25 years. Methods: Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors. Results: Forty-one percent of women had become pregnant on at least one occasion prior to age 25, with 14.6% having an abortion. Those having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors. Conclusions: The findings suggest that abortion in young women may be associated with increased risks of mental health problems.

[http://www.ncbi.nlm.nih.gov/pubmed/24154514 Women's experiences in relation to stillbirth and risk factors for long-term post-traumatic stress symptoms: a retrospective study.] Gravensteen IK, Helgadóttir LB, Jacobsen EM, Rådestad I, Sandset PM, Ekeberg O. BMJ Open. 2013 Oct 22;3(10):e003323. doi: 10.1136/bmjopen-2013-003323.

:OBJECTIVES: (1) To investigate the experiences of women with a previous stillbirth and their appraisal of the care they received at the hospital. (2) To assess the long-term level of post-traumatic stress symptoms (PTSS) in this group and identify risk factors for this outcome.
:DESIGN: A retrospective study.
:SETTING:Two university hospitals.
:PARTICIPANTS: The study population comprised 379 women with a verified diagnosis of stillbirth (≥23 gestational weeks or birth weight ≥500 g) in a singleton or twin pregnancy 5-18 years previously. 101 women completed a comprehensive questionnaire in two parts.
:PRIMARY AND SECONDARY OUTCOME MEASURES: The women's experiences and appraisal of the care provided by healthcare professionals before, during and after stillbirth. PTSS at follow-up was assessed using the Impact of Event Scale (IES).
:RESULTS: The great majority saw (98%) and held (82%) their baby. Most women felt that healthcare professionals were supportive during the delivery (85.6%) and showed respect towards their baby (94.9%). The majority (91.1%) had received some form of short-term follow-up. One-third showed clinically significant long-term PTSS (IES ≥ 20). Independent risk factors were younger age (OR 6.60, 95% CI 1.99 to 21.83), induced abortion prior to stillbirth (OR 5.78, 95% CI 1.56 to 21.38) and higher parity (OR 3.46, 95% CI 1.19 to 10.07) at the time of stillbirth. Having held the baby (OR 0.17, 95% CI 0.05 to 0.56) was associated with less PTSS.
:CONCLUSIONS: The great majority saw and held their baby and were satisfied with the support from healthcare professionals. One in three women presented with a clinically significant level of PTSS 5-18 years after stillbirth. Having held the baby was protective, whereas '''prior induced abortion was a risk factor for a high level of PTSS'''.

'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334933/ Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review.]''' Daugirdaitė V, van den Akker O, Purewal S. J Pregnancy. 2015;2015:646345. doi: 10.1155/2015/646345. Epub 2015 Feb 5.

:OBJECTIVE: The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF).

:METHODS:Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines.

:RESULTS: Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss.

:CONCLUSIONS: This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

''[http://www.cmaj.ca/cgi/content/full/168/10/1253 Psychiatric admissions of low income women following abortion and childbirth.] Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Can Med Assoc J. 2003; 168(10):1253-7''
: Background: Controversy exists about whether abortion or childbirth is associated with greater psychological risks. We compared psychiatric admission rates of women in time periods from 90 days to 4 years after either abortion or childbirth.

:Methods: We used California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth during 1989. Only women who had no psychiatric admissions or pregnancy events during the year before the target pregnancy event were included (n = 56 741). Psychiatric admissions were examined using logistic regression analyses, controlling for age and months of eligibility for Medi-Cal services.

:Results: Overall, women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age.

:Interpretation: Subsequent psychiatric admissions are more common among low-income women who have an induced abortion than among those who carry a pregnancy to term, both in the short and longer term.

NOTES:
*Tables showing when the psychiatric hospitalization occurred illustrate a marked peak closer to the time of the pregnancy event, providing support for a causal interpretation.
*Using the same population, the authors also examined outpatient treatment for psychiatric disorders and also found higher rates of outpatient treatment following abortion. See next entry below
* The abortion group had 160% more total in-patient mental health claims than the birth group. Percentages equaled 120%, 90%, 110%, 60%, and 50% for the first 180 days, one year, two years, three years, and four years respectively.
*Across the four years, the abortion group had 70% more in-patient mental health claims than the birth group. Percentages equaled 90%, 110%, and 200% for depressive psychosis, single episode, depressive psychosis, recurrent episode, and bipolar disorder, respectfully

''[http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2002-15486-015&CFID=27122313&CFTOKEN=47942096 State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years.]'' Coleman PK, Reardon DC, Rue VM, Cougle JR. American Journal of Orthopsychiatry, 2002; 72(1):141–52. ''

:(Abstract) In this record-based study, rates of 1st-time outpatient mental health treatment for 4 years following an abortion or a birth among women (aged 13-49 yrs) 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.

''"Postabortion or Postpartum Psychotic Reactions," H David et al, Family Planning Perspectives 13(2): 892, 1981 ''
:A Danish register linkage study over a three month period found that the rate of psychiatric hospital admissions was 18.4 per 10,000 postabortion women, 12.0 pr 10,000 postpartum women, and 7.5 per 10,000 women of childbearing age generally.

==Post-Traumatic Stress Disorder / Post-Abortion Syndrome / PTSD==

The observation that abortion may cause or aggravate traumatic reactions, including [[post-traumatic stress disorder]] has been very controversial. Psychologist [[Vincent Rue]] was the first to propose this association and he was the first to use the term [[post-abortion syndrome]] to describe PTSD resulting from abortion.

See also Dr. Anne Speckhard's comments [[Women's Perspectives on Abortion Relative to PTSD]]

===Background===

''[http://www.ima.org.il/imaj/ar12jun-02.pdf Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion] Inbal Shlomi Polachek, MD, Liat Huller Harari, MD, Micha Baum, MD and Rael D. Strous, MD. IMAJ 2011: 14: June: 347-353''

''[http://www.sciencenews.org/view/generic/id/58820/title/Genetic_changes_show_up_in_people_with_PTSD Genetic changes show up in people with PTSD]" Nathan Seppa, Science News, Web edition : Monday, May 3rd, 2010''
:"The team found that the people with PTSD showed less methylation in several immune system genes and more methylation in genes linked to the growth of brain cells. 'There is evidence that PTSD is involved in immune dysfunction, and we suggest that that’s part of a larger process,' Galea says. Although previous studies have also suggested a PTSD link to immune gene activation, the connection is unclear."

''"The Conception of the Repetition-Compulsion," E. Bibring, Psychoanalytic Quarterly 12:486-519(1943). ''
:Repetition-compulsion is a regulating mechanism with the task of discharging tensions caused by traumatic experiences after they have been bound in fractional amounts.

''"Two cases of post-abortion psychosis," W. Pasini and H. Stockhammer, Annales Medico Psichologiques [Paris] 128(4): 555-564 (1973). ''
:Two cases of post-abortion psychosis are presented. One resulted in suicide while the other thought a nurse was attempting to poison her. One abortion was illegal, the other legal. A possible neurological basis for post-abortion psychological problems was presented. (French)

''Psycho-Social Stress Following Induced Abortion, Anne Speckhard, (Kansas City: Sheed and Ward, 1987). ''
:A study of 30 women who reported stress following their abortion found grief reactions, fear and anxiety, changes in sexual relationships, unresolved fertility issues, increased drug and alcohol use, changes in eating behaviors, increased isolation, lowered self-worth and suicide ideation and attempts.

''Diagnostic and Statistical Manual of Mental Disorders-Revised, DSM-III-R 309.89 (Post Traumatic Stress Disorder), (Washington, D.C.: American Psychiatric Press, 1987), pp. 20, 250.''
:Abortion is included as a possible psychosocial stressor under physical injury or illness. (Ed Note: Abortion as a possible psychosocial stressor was not included in DSM-IV manual)

''The Long-Term Psycho-social Effects of Abortion, Catherine A. Barnard (Portsmouth, N.H.: Institute For Pregnancy Loss, 1990). ''
:Some 18.8% of women who had undergone induced abortion 3-5 years previously reported all Post Traumatic Stress Syndrome criteria (DSM-III R). Some 39-45% of women still had sleep disorders, hyper-vigilance and flashbacks of the abortion experience. Some 16.9% had high intrusion scores and 23.4% had high avoidance scores on the Impact of Events Scale. Women showed elevated scores on the MCMI test in areas of histrionic, anti-social narcissism, paranoid personality disorder and elevated anxiety compared with the sample on which the test had been normed.

''The Mourning After Help for Post Abortion Syndrome, Terry L. Selby with Marc Bockman (Grand Rapids: Baker Book House, 1990). ''
:Designed for the clinical counselor. It has valuable chapters on subjects such as grief, denial the importance of faith and detailed case histories which provide valuable insights.

''Post-Abortion Trauma: 9 Steps to Recovery, Jeanette Vought, (Grand Rapids: Zondervan, 1991) ''
:Experiences of men and women in a religiously-based postabortion recovery group.

''"Post Abortion Syndrome. An Emerging Public Health Concern," Anne C. Speckhard and Vincent M. Rue, Journal of Social Issues, Vol. 48(3):95-119, 1992. ''
:Concludes that post abortion syndrome is a type of Post Traumatic Stress Disorder composed of the following basic components (a) exposure to or participation in an abortion experience, which is perceived as the traumatic and intentional destruction of one's unborn child; (b) uncontrolled negative re-experiencing of the abortion event; (c) unsuccessful attempts to avoid or deny painful abortion recollections, resulting in reduced responsiveness; and (d) experiencing associated symptoms not present before the abortion, including guilt and surviving.

''"Post-Trauma Sequelae Following Abortion and Other Traumatic Events," J.O. Brende, Association for Interdisciplinary Research in Values and Social Change 7(1): 1-8, July/August 1994 ''
:Case studies include a lonely woman with a history of multiple traumas, including sexual assault. After a divorce, she moved in with a man who promised to take care of her but eventually began to abuse her. When she became pregnant, he abandoned her, and she had an abortion. Severely depressed, she began to rely heavily on sleeping pills and alcohol to sleep because of nightmares and a repetitive dream about reaching for an infant that floated beyond her reach. One night, she overdosed on her pills but telephoned a friend who called for help. Her suicide was prevented and she was admitted to a psychiatric hospital for treatment. It was during this hospitalization that she received help, the first step toward breaking her victimization cycle.
:A second case study involved a 21- year old woman who visited an abortion facility to obtain an abortion. However, the abortion was incomplete and she had bleeding, cramping and a low grade fever. She was admitted to a hospital where an intact fetus was observed on ultrasound. An abortion was performed and fetal parts were removed. Predisposing factors for trauma included her impulsive decision to have the abortion and poor treatment by the doctor at the abortion facility. She sought counseling 3 ½ months after the abortion, after six months, and again 9 ½ months after the abortion when her depression worsened and she overdosed on medications. She then had six counseling sessions and was diagnosed with Post-Traumatic Stress Disorder. After 2 ½ years she had intrusive images, flashbacks, and reliving experiences; anger at the doctor and others; grief; distractibility; selective concentration; vivid memory of the abortion; numbing and detachment; startle reactions; fear of men and of having sex ; physical symptoms including abdominal and stomach pain.

''"Fragmentation of the Personality Associated with Post-Abortion Trauma," J.O. Brende, Association for Interdisciplinary Research in Values and Social Change 8(3): 1-8, July/August 1995 ''
:People enduring extreme stress often suffer profound rupture in the very fabric of the self. Severity of fragmentation is dependent upon several variables (1) the degree to which the trauma is experienced as a violation, (2) the presence or absence of support, (3) the presence of shame or self-blame, and (4) the loss of idealism and purpose.

''"Methodological considerations in empirical research on abortion," RL Anderson et al in Post-Abortion Syndrome: Its Wide Ramifications, Ed Peter Doherty, (Portland: Four Courts Press, 1995) 103-115 ''
:A study at an psychiatric outpatient service, compared women who presented with a history of elective abortion and sought psychiatric services in response to negative adjustment to abortion, with women with a history of elective abortion who presented seeking outpatient services for reasons that were not abortion-related. A second control group consisted of women who sought outpatient services but denied any abortion history. 73% of the abortion- distressed group met the criteria for DSM-IIIR. Abortion distressed women reported more frequently that they believed abortion to be morally wrong and had fewer recent adverse life events than abortion non-distressed women.

''"Post-Abortion Perceptions: A Comparison of Self-Identified Distressed and Non-distressed Populations," G. Kam Congleton, L.G. Calhoun. The Int'l J. Social Psychiatry 39(4): 255-265, 1993 ''
:Women reporting distress were more often currently affiliated with conservative churches and reported a lower degree of social support and confidence in the abortion decision. They were also more likely to recall experiencing feelings of loss immediately postabortion.

[http://archpsyc.jamanetwork.com/article.aspx?articleID=1904804&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMAPsychiatry%3AOnlineFirst09%2F17%2F2014 Posttraumatic Stress Disorder Symptoms and Food Addiction in Women by Timing and Type of Trauma Exposure]
Susan M. Mason, PhD, Alan J. Flint, DPH, MD, Andrea L. Roberts, PhD, et al. JAMA Psychiatry. Published online September 17, 2014. doi:10.1001/jamapsychiatry.2014.1208

:While this study did not report on abortion, it did find that "The prevalence of food addiction increased with the number of lifetime PTSD symptoms, and women with the greatest number of PTSD symptoms (6-7 symptoms) had more than twice the prevalence of food addiction as women with neither PTSD symptoms nor trauma histories (prevalence ratio, 2.68; 95% CI, 2.41-2.97). Symptoms of PTSD were more strongly related to food addiction when symptom onset occurred at an earlier age."

===Variation in Propensity to PTSD===

[http://ajp.psychiatryonline.org/cgi/content/short/168/1/9?rss=1 Toward the Predeployment Detection of Risk for PTSD] Douglas L. Delahanty, Ph.D. Am J Psychiatry 168:9-11, January 2011
:A summary of several studies identifying biological markers that can be used to identify persions who are at greater risk of developing PTSD in reaction to a traumatic experience.

"[http://www.sciencemag.org/news/2011/02/marker-ptsd-women]"
:"Only a small minority of people who fall victim to a violent attack or witness a bloody accident suffer the recurring nightmares, hypervigilance, and other symptoms of posttraumatic stress disorder (PTSD). Women seem to be twice as susceptible as men, but otherwise researchers know virtually nothing about who is most at risk or why. Now a study has linked a genetic mutation and blood levels of a particular peptide—a compound made from a short string of the same building blocks that make up proteins—to the severity of PTSD symptoms in women. The finding could lead to tests to identify people who may need extra help after a traumatic event."

[https://www.ncbi.nlm.nih.gov/pubmed/28179812 Stress-related disorders, pituitary adenylate cyclase-activating peptide (PACAP)ergic system, and sex differences.] Ramikie TS, Ressler KJ. Dialogues Clin Neurosci. 2016 Dec;18(4):403-413.

[http://utvet.com/UofTptsdStudy.html Study may help curb cases of combat-stress disorder:]
UT examining genes, reactions of Fort Hood troops to find risk factors.

[http://www.nasw.org/determining-soldiers-vulnerability-ptsd-and-anxiety-disorders http://www.nasw.org/determining-soldiers-vulnerability-ptsd-and-anxiety-disorders]

[http://ptsd.about.com/od/ptsdandthemilitary/a/PTSDvulnerable.htm What Increases Risk for PTSD in Military Service Members?]

Agaibi, C.E., & Wilson, J.P. (2005). Trauma, PTSD, and resilience: A review of the literature. Trauma, Violence, and Abuse, 6, 195-216.

Brailey, K., Vasterling, J.J., Proctor, S.P., Constans, J.I., & Friedman, M.J. (2007). PTSD symptoms, life events, and unit cohesion in U.S. soldiers: Baseline findings from the Neurocognition Deployment Health Study. Journal of Traumatic Stress, 20, 495-503.

Erbes, C., Westermeyer, J., Engdahl, B., & Johnsen, E. (2007). Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Military Medicine, 172, 359-363.

Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.

Ozer, E.J., Best, S.R., Lipsey, T.L., & Weiss, D.S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52-73.

[http://www.medpagetoday.com/PublicHealthPolicy/MilitaryMedicine/17380 Smaller Brain Linked to Soldiers' PTSD Risk]

[http://www.empowher.com/posttraumatic-stress-disorder-ptsd/content/us-military-studying-ptsd-risk-factors U.S. Military Studying PTSD Risk Factors]

===Research Validating Abortion Associated PTSD===

'''[https://pubmed.ncbi.nlm.nih.gov/31956603/ The Severity of Post-abortion Stress in Spontaneous, Induced and Forensic Medical Center Permitted Abortion in Shiraz, Iran, in 2018.] Alipanahpour S, Zarshenas M, Ghodrati F, Akbarzadeh M. Iran J Nurs Midwifery Res. 2019 Dec 27;25(1):84-90. doi: 10.4103/ijnmr.IJNMR_36_19. PMID: 31956603; PMCID: PMC6952917.'''<blockquote>'''Background:''' Abortion and loss of pregnancy in the first trimester may affect maternal mortality and morbidity. This study aimed to determine the severity of post-abortion stress in spontaneous abortion, induced abortion, and Forensic Medical Center (FMC) referral abortions immediately after abortion and after 1 month of follow-up in Shiraz, Iran, in 2018.

'''Materials and methods:''' This cross-sectional study was conducted on 104 mothers selected through convenience sampling method in 2018. The data collection tools included a demographic characteristics questionnaire and the Mississippi Post-Traumatic Stress Disorder (M-PTSD) Scale that were filled out by mothers immediately and 1 month after the abortion. Data were analyzed using one-way ANOVA and post-hoc LSD test in SPSS software. Moreover, ''p'' < 0.05 was considered as statistically significant.

'''Results:''' The mean (SD) of post-traumatic stress scores was 83.87 (18.35) and 77.40 (9.88) in spontaneous abortion, 82.28 (13.27) and 75.71 (14.73) in FMC permitted abortions, and 86.66 (10.10) and 74.98 (12.99) in induced abortions immediately and 1 month after abortion, respectively. Stress was reduced in the three groups of mothers, after one month of severe value. The score for frequency of stress was 3.10% in FMC-permitted abortions and 5.10% in induced abortions; moreover, no stress was observed in the spontaneous abortion cases.

'''Conclusions:''' Stress was gradually reduced over time. The level of PTSD was lower after 1 month in women who had experienced spontaneous abortion. Given that 1 month after abortion, women are still often moderately stressed, follow-up care, and appropriate counseling for these women are necessary.</blockquote>

'''[https://pmc.ncbi.nlm.nih.gov/articles/PMC12357282/ A multi-component psychosocial intervention programme to reduce psychological distress and enhance social support for women undergoing termination of pregnancy for foetal anomaly in China: A randomised controlled trial.] Qin C, Li Y, Wang Y, Huang C, Xiao G, Zeng L, He Y, Jiang W, Xie J Int J Nurs Stud Adv. 2025 Jul 29;9:100389. doi: 10.1016/j.ijnsa.2025.100389. PMID: 40822251; PMCID: PMC12357282.'''<blockquote>Background
Termination of pregnancy for foetal anomaly causes significant psychological distress, yet evidence-based psychosocial interventions tailored to the needs of women experiencing termination of pregnancy for foetal anomaly remain limited.
Objective
To evaluate the effectiveness of a multi-component psychosocial intervention designed to reduce depression and post-traumatic stress disorder (PTSD) and enhance psychological flexibility and social support among women following termination of pregnancy for foetal anomaly.
Methods
A single-blinded, two-arm randomised controlled trial was conducted in two maternity hospitals in Hunan Province, China. Eighty-six participants were randomly allocated to the multi-component psychosocial intervention group (''n'' = 41) or the control group (''n'' = 45). The multi-component psychosocial intervention included informational support, Acceptance and Commitment Therapy, and social support involving an online peer support group and family engagement. Depression, PTSD, psychological flexibility and social support were assessed at baseline, immediately (T1), one-month (T2) and three-months (T3) post-intervention.
Results
Although the intervention group showed greater reductions in depressive symptoms (EPDS: ''β'' = 0.92, 95 % CI: –1.38 to 3.21, ''p'' = 0.435) and post-traumatic stress symptoms (IES-R: ''β'' = 5.31, 95 % CI: –1.25 to 11.86, ''p'' = 0.113) compared to the control group, these differences did not reach statistical significance. Significant group-by-time effects emerged for PTSD-related avoidance symptoms (''β'' = 2.98, 95 % CI: 0.27 to 5.70, ''p'' = 0.031; ''d'' = 0.49), perceived social support (''β'' = –1.56, 95 % CI: –3.10 to –0.02, ''p'' = 0.047; ''d'' = 0.38) and utilisation of social support (-0.83, 95 % CI: -1.48 to -0.18, ''p'' = 0.013; ''d'' = 0.55) at T3. Participants with baseline EPDS > 9 (''n'' = 54) showed stronger effects, with significant improvements in depression (''β'' = 2.02, 95 % CI: 0.38 to 3.66, ''p'' = 0.016) and experiential avoidance (''β'' = 2.54, 95 % CI: 0.30 to 4.78; ''p'' = 0.026) at T1, PTSD (''β'' = 11.75, 95 % CI: 2.39 to 21.12, ''p'' = 0.014; ''d'' = 0.61) and utilisation of social support (''β'' = -0.95, 95 % CI: -1.85 to -0.04; ''p'' = 0.040, ''d'' = 0.65) at T3. No adverse events occurred.
Conclusions
The multi-component psychosocial intervention programme reduced PTSD-related avoidance symptoms and enhanced social support. Participants with depressive symptoms experienced immediate improvements in depression and psychological flexibility, with sustained benefits in PTSD and utilisation of social support over three months. Tailoring the intervention components to individual needs may benefit women undergoing termination of pregnancy for foetal anomaly. Further research should compare women with and without baseline psychological distress to determine who benefits most from this intervention.</blockquote>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952917/ The Severity of Post-abortion Stress in Spontaneous, Induced and Forensic Medical Center Permitted Abortion in Shiraz, Iran, in 2018.] Alipanahpour S, Zarshenas M, Ghodrati F, Akbarzadeh M. Iran J Nurs Midwifery Res. 2019 Dec 27;25(1):84-90.

:Background: Abortion and loss of pregnancy in the first trimester may affect maternal mortality and morbidity. This study aimed to determine the severity of post-abortion stress in spontaneous abortion, induced abortion, and Forensic Medical Center (FMC) referral abortions immediately after abortion and after 1 month of follow-up in Shiraz, Iran, in 2018.

:Materials and methods: This cross-sectional study was conducted on 104 mothers selected through convenience sampling method in 2018. The data collection tools included a demographic characteristics questionnaire and the Mississippi Post-Traumatic Stress Disorder (M-PTSD) Scale that were filled out by mothers immediately and 1 month after the abortion. Data were analyzed using one-way ANOVA and post-hoc LSD test in SPSS software. Moreover, p < 0.05 was considered as statistically significant.

:Results: The mean (SD) of post-traumatic stress scores was 83.87 (18.35) and 77.40 (9.88) in spontaneous abortion, 82.28 (13.27) and 75.71 (14.73) in FMC permitted abortions, and 86.66 (10.10) and 74.98 (12.99) in induced abortions immediately and 1 month after abortion, respectively. Stress was reduced in the three groups of mothers, after one month of severe value. The score for frequency of stress was 3.10% in FMC-permitted abortions and 5.10% in induced abortions; moreover, no stress was observed in the spontaneous abortion cases.

:Conclusions: Stress was gradually reduced over time. The level of PTSD was lower after 1 month in women who had experienced spontaneous abortion. Given that 1 month after abortion, women are still often moderately stressed, follow-up care, and appropriate counseling for these women are necessary.

'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4746441/ Does abortion increase women's risk for post-traumatic stress? Findings from a prospective longitudinal cohort study.] Biggs MA, Rowland B, McCulloch CE, Foster DG. BMJ Open. 2016;6(2)'''

:7% of the Turnaway Study attributed their PTSS symptoms to their abortions.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952917/ The Severity of Post-abortion Stress in Spontaneous, Induced and Forensic Medical Center Permitted Abortion in Shiraz, Iran, in 2018.] Alipanahpour S1, Zarshenas M2, Ghodrati F3, Akbarzadeh M4. Iran J Nurs Midwifery Res. 2019 Dec 27;25(1):84-90. doi: 10.4103/ijnmr.IJNMR_36_19. eCollection 2020 Jan-Feb.

:BACKGROUND: Abortion and loss of pregnancy in the first trimester may affect maternal mortality and morbidity. This study aimed to determine the severity of post-abortion stress in spontaneous abortion, induced abortion, and Forensic Medical Center (FMC) referral abortions immediately after abortion and after 1 month of follow-up in Shiraz, Iran, in 2018.

:MATERIALS AND METHODS: This cross-sectional study was conducted on 104 mothers selected through convenience sampling method in 2018. The data collection tools included a demographic characteristics questionnaire and the Mississippi Post-Traumatic Stress Disorder (M-PTSD) Scale that were filled out by mothers immediately and 1 month after the abortion. Data were analyzed using one-way ANOVA and post-hoc LSD test in SPSS software. Moreover, p < 0.05 was considered as statistically significant.

:RESULTS: The mean (SD) of post-traumatic stress scores was 83.87 (18.35) and 77.40 (9.88) in spontaneous abortion, 82.28 (13.27) and 75.71 (14.73) in FMC permitted abortions, and 86.66 (10.10) and 74.98 (12.99) in induced abortions immediately and 1 month after abortion, respectively. Stress was reduced in the three groups of mothers, after one month of severe value. The score for frequency of stress was 3.10% in FMC-permitted abortions and 5.10% in induced abortions; moreover, no stress was observed in the spontaneous abortion cases.

:CONCLUSIONS: Stress was gradually reduced over time. The level of PTSD was lower after 1 month in women who had experienced spontaneous abortion. Given that 1 month after abortion, women are still often moderately stressed, follow-up care, and appropriate counseling for these women are necessary

'''[https://www.ncbi.nlm.nih.gov/pubmed/28969621 Neuroticism-related personality traits are associated with posttraumatic stress after abortion: findings from a Swedish multi-center cohort study.] Wallin Lundell I1,2, Sundström Poromaa I3, Ekselius L4, Georgsson S5,6, Frans Ö7, Helström L8, Högberg U3, Skoog Svanberg A3. ''BMC Womens Health.'' 2017 Oct 2;17(1):96. doi: 10.1186/s12905-017-0417-8.'''

:BACKGROUND: Most women who choose to terminate a pregnancy cope well following an abortion, although some women experience severe psychological distress. The general interpretation in the field is that the most consistent predictor of mental disorders after induced abortion is the mental health issues that women present with prior to the abortion. We have previously demonstrated that few women develop posttraumatic stress disorder (PTSD) or posttraumatic stress symptoms (PTSS) after induced abortion. Neuroticism is one predictor of importance for PTSD, and may thus be relevant as a risk factor for the development of PTSD or PTSS after abortion. We therefore compared Neuroticism-related personality trait scores of women who developed PTSD or PTSS after abortion to those of women with no evidence of PTSD or PTSS before or after the abortion.
:METHODS: A Swedish multi-center cohort study including six Obstetrics and Gynecology Departments, where 1294 abortion-seeking women were included. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used to evaluate PTSD and PTSS. Measurements were made at the first visit and at three and six month after the abortion. The Swedish universities Scales of Personality (SSP) was used for assessment of Neuroticism-related personality traits. Multiple logistic regression analyses were performed to investigate the risk factors for development of PTSD or PTSS post abortion.
:RESULTS: Women who developed PTSD or PTSS after the abortion had higher scores than the comparison group on several of the personality traits associated with Neuroticism, specifically Somatic Trait Anxiety, Psychic Trait Anxiety, Stress Susceptibility and Embitterment. Women who reported high, or very high, scores on Neuroticism had adjusted odds ratios for PTSD/PTSS development of 2.6 (CI 95% 1.2-5.6) and 2.9 (CI 95% 1.3-6.6), respectively.
:CONCLUSION: High scores on Neuroticism-related personality traits influence the risk of PTSD or PTSS post abortion. This finding supports the argument that the most consistent predictor of mental disorders after abortion is pre-existing mental health status.
:*Editor Note: Among 512 women with no prior PTSD symptoms, 9.4% experienced all the criteria necessary for a PTSD diagnosis by the three or six month post-abortion assessment. Pre-abortion screening for higher neuroticism-related personality traits can be used to identify the women at greatest risk of abortion associated PTSD. This finding is consistent with [https://www.ncbi.nlm.nih.gov/pubmed/14744527/ other studies showing neurotisicm being associated with greater susceptibility to PTSD].

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334933/ Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review.] Daugirdaitė V, van den Akker O, Purewal S. J Pregnancy. 2015;2015:646345. doi: 10.1155/2015/646345. Epub 2015 Feb 5.

:OBJECTIVE: The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF).
:METHODS: Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines.
:RESULTS: Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss.
:CONCLUSIONS: This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

'''[http://www.ncbi.nlm.nih.gov/pubmed/22622194 "Predictors of postpartum post-traumatic stress disorder in primiparous mothers.][Article in French]'''
Montmasson H1, Bertrand P, Perrotin F, El-Hage W. J Gynecol Obstet Biol Reprod (Paris). 2012 Oct;41(6):553-60. doi: 10.1016/j.jgyn.2012.04.010. Epub 2012 May 21.

A history of abortion was associated with a six fold increased risk of subsequent postpartum PTSD.

'''''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939862 Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy].''''' Hamama L, Rauch SA, Sperlich M, Defever E, Seng JS. Depress Anxiety. 2010 Jun 23.

: Abstract
: '''Background''': Few studies have considered whether elective and/or spontaneous abortion (EAB/SAB) may be risk factors for mental health sequelae in subsequent pregnancy. This paper examines the impact of EAB/SAB on mental health during subsequent pregnancy in a sample of women involved in a larger prospective study of posttraumatic stress disorder (PTSD) across the childbearing year (n=1,581). '''Methods''': Women expecting their first baby completed standardized telephone assessments including demographics, trauma history, PTSD, depression, and pregnancy wantedness, and religiosity. '''Results''': Fourteen percent (n=221) experienced a prior elective abortion (EAB), 13.1% (n=206) experienced a prior spontaneous abortion (SAB), and 1.4% (n=22) experienced both. Of those women who experienced either an EAB or SAB, 13.9% (n=220) appraised the EAB or SAB experience as having been "a hard time" (i.e., potentially traumatic) and 32.6% (n=132) rated it as their index trauma (i.e., their worst or second worst lifetime exposure). Among the subset of 405 women with prior EAB or SAB, the rate of PTSD during the subsequent pregnancy was 12.6% (n-51), the rate of depression was 16.8% (n=68), and 5.4% (n-22) met criteria for both disorders. '''Conclusions''': History of sexual trauma predicted appraising the experience of EAB or SAB as "a hard time." Wanting to be pregnant sooner was predictive of appraising the experience of EAB or SAB as the worst or second worst (index) trauma. EAB or SAB was appraised as less traumatic than sexual or medical trauma exposures and conveyed relatively lower risk for PTSD. The patterns of predictors for depression were similar

'''[http://www.ncbi.nlm.nih.gov/pubmed/22840934 Psychological problems sequalae in adolescents after artificial abortion.]''' Zulčić-Nakić V, Pajević I, Hasanović M, Pavlović S, Ljuca D. J Pediatr Adolesc Gynecol. 2012 Aug;25(4):241-7. doi: 10.1016/j.jpag.2011.12.072.

:STUDY AND OBJECTIVES: Controversy exists over psychological risks associated with unwanted pregnancy and consecutive abortion. The aim of this study was to assess the psychological health of female adolescents following artificial abortion up to 12(th) week of pregnancy. DESIGN: The control case study. SETTING: The study was carried out in the Department of Gynecology and Obstetrics, University Clinical Center Tuzla, in Bosnia-Herzegovina.
:PARTICIPANTS: We assessed 120 female adolescents. The mean (SD) age of the patients was 17.7 (1.5) years experiencing sexual intercourse in the age of 14-19 years for trauma experiences, presence of posttraumatic stress symptoms, depression and anxiety as state, and anxiety as trait. Sixty adolescents had intentional artificial abortion and 60 had sexual intercourse but did not become pregnant. MAIN OUTCOME MEASURES: We used the PTSD Questionnaire, the Beck Depression Inventory, and the Spielberger State Trait Anxiety Inventory (Form Y) for assessment of anxiety in adolescents. Basic socio-demographic data were also collected. RESULTS: PTSD presented significantly more often in adolescents who aborted pregnancy (30%), than in adolescents who did not abort (13.3%) (odds ratio = 4.91 (95%CI 0.142-0.907) P = 0.03). Anxiety as state and as trait were significantly higher in the abortion group, as the mean (SD) anxiety score of patients was 59.8 (8.9), 57.9 (9.7) respectively, than in non-abortion group 49.5 (8.8), 47.3 (9.9) respectively (t = 6.392, P < 0.001; t = 5.914, P < 0.001, respectively). Adolescents who aborted pregnancy had significantly higher depression symptoms severity 29.2 (5.6) than controls 15.2 (3.3) (t = 8.322, P < 0.001), and they presented significantly more often depression (75%), than adolescents who did not abort (10%) (χ(2) = 53.279, P < 0.001). Logistic regression showed that only experience of life threatening(s) and injury of other person(s) reliably predicted PTSD, whereas abortion and experience of life threatening(s) reliably predicted depression. CONCLUSION: Adolescents who aborted pregnancy presented significantly greater prevalence of PTSD and depression, and significantly greater depression severity and anxiety as state and trait than those who did not abort. Abortion predicted depression only, and did not predict PTSD.

''''[http://www.ncbi.nlm.nih.gov/pubmed/23576135 The Characteristics and Severity of Psychological Distress After Abortion Among University Students.]''''Curley M, Johnston C. J Behav Health Serv Res. 2013 Apr 12. [Epub ahead of print]

''Abstract''

:Controversy over abortion inhibits recognition and treatment for women who experience psychological distress after abortion (PAD). This study identified the characteristics, severity, and treatment preferences of university students who experienced PAD. Of 151 females, 89 experienced an abortion. Psychological outcomes were compared among those who preferred or did not prefer psychological services after abortion to those who were never pregnant. All who had abortions reported symptoms of post-traumatic stress disorder (PTSD) and grief lasting on average 3 years. Yet, those who preferred services experienced heightened psychological trauma indicative of partial or full PTSD (Impact of Event Scale, M = 26.86 versus 16.84, p < .05), perinatal grief (Perinatal Grief Scale, M 62.54 versus 50.89, p < 0.05), dysthymia (BDI M = 11.01 versus 9.28, p < 0.05), (M = 41.86 versus 39.36, p < 0.05), and co-existing mental health problems. PAD appeared multi-factorial, associated with the abortion and overall emotional health. Thus, psychological interventions for PAD need to be developed as a public health priority.

''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1899490/ Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation.]'' Suliman S, Ericksen T, Labuschgne P, de Wit R, Stein DJ, Seedat S. BMC Psychiatry. 2007 Jun 12;7:24.

:Examining symptom domains preabortion, and 1 and 3 months later, the authors evaluated 155 women who had abortions in Cape Town, South Africa. They reported:
::1. “High rates of PTSD characterize women who have undergone voluntary pregnancy termination.” p. 8 (almost one fifth of the sample met criteria for PTSD)
::2. The percent of women who met PTSD criteria increased by 61% from pre-abortion baseline to 3 months post-abortion (11.3 to 18.2)
::3. Women who met PTSD criteria pre-abortion experienced significantly more physical pain post-abortion
::4. “Thus it would follow that screening women pre-termination for PTSD and disability and post-termination for high levels of dissociation is important in order to help identify women at risk of PTSD and to provide follow-up care.” p. 6
::5. "[t]here was a high rate of attrition over the course of the study leaving a small final sample (37% of the original sample). It might be that participants who were lost to follow-up were lost because of their higher levels of postabortion distress (i.e. PTSD and other psychopathology)."
::6. The rates of depression and anxiety were high both pre-abortion and at three months post-abortion, but were not significantly higher. Regarding depression, at pre-termination 21.9% of the sample had high depression scores compared to 20% at 1 and 3 months. 'High' state anxiety (STAI) at pre-abortion was reported by 63.9%, and this dropped to 56.3% of women at both 1 and 3 months. Note: Pre-depresssion and anxiety scores are measured at the height of the crisis when the woman is about to have an abortion. It does not reflect pre-pregnancy scores. In addition, the high attrition rate and short time frame (3 months) must also be considered in properly interpreting this data. 7. "[W]omen with PTSD 3 months after termination were further along in their pregnancy than those without PTSD (gestational age: With PTSD: 13.2 ± 3.3; Without PTSD: 9.7 ± 4.2; p = 0.023)."

'''''[http://www.tandfonline.com/doi/abs/10.1080/02646838.2012.654489 Posttraumatic Stress Disorder and psychological distress following medical and surgical abortion.]''''' C. Rousset, C. Brulfert, N. Séjourné, N. Goutaudier & H. Chabrol Journal of Reproductive and Infant Psychology, (2011) Volume 29(5), 506-517.

:Method: Eighty-six women were approached a few hours after the abortion and then 6 weeks later. Several questionnaires were completed: the Impact of Event Scale Revised (IES-R), the Multidimensional Scale of Social Support (MSPSS), the Peritraumatic Dissociative Experience Questionnaire (PDEQ), the Peritraumatic Emotions List (PEL), the Hospital Anxiety and Depression Scale (HADS), the Perinatal Grief Scale (PGS) and the Texas Grief Inventory (TGI). Results: Six weeks after the abortion, 38% of women reported a potential PTSD and a significant decrease of the anxious symptomatology was also highlighted. Peritraumatic dissociation and peritraumatic emotions were the main predictors of the intensity of post-abortum PTSD symptoms. Compared to surgical abortion, medical abortion was associated with increasing the risk of developing a possible PTSD. Conclusion: By providing evidence on some of the main risk factors, this study highlights the need for psychological support for women and strategies of prevention to be developed.

[http://www.ajol.info/index.php/safp/article/viewFile/13106/15689 The prevalence of post-abortion syndrome in patients presenting at Kalafong hospital's family medicine clinic after having a termination of pregnancy.] van Rooyen M, Smith S. South African Family Practice (2004) 46 (5), pp 21-24.

:Background: Post-abortion syndrome (PAS) is said to be the emotional, psychological, physical and spiritual trauma caused by an abortion, which is an event outside the normal range of human experience. Post-abortion syndrome is a type of post-traumatic disorder and is characterised by a stressor (the abortion), the event being re-experienced, avoidance and/or numbing of general responsiveness, and physical symptoms such as insomnia and depression. The question was asked whether the patients at Kalafong Hospital experienced any of the after-effects of a termination of pregnancy and whether these effects would fulfill the criteria of post-abortion syndrome.

:Method: A prospective descriptive study was done over a six-month period. All female patients presenting at the Family Medicine Clinic of Kalafong Hospital who were known to have had a previous abortion on request were asked to participate in the study. After obtaining informed consent, a structured questionnaire on their psychological symptoms was completed by the participants with the help of the researcher. The questionnaire contained demographic data, as well as questions on the above-mentioned symptoms of PAS. To fulfill the criteria of PAS, the symptoms should have been present for more than a month and must have affected the subject’s daily functioning.

:Results: Of the 48 woman recruited, 16 (33%) fulfilled the criteria of PAS, and more than 50% of the women had had some or other emotional or psychological after-effect.

:Conclusion: This study showed that one out of every three women presenting at Kalafong Hospital after abortion fulfilled the criteria of PAS. Since family physicians are committed to their patients and regard it as their duty to address problems prevalent in the community they serve, it is necessary to investigate further the possible link between termination of pregnancy and the emotional problems identified. It is imperative that women requesting termination of pregnancy receive comprehensive counseling prior to the procedure, as well as support thereafter,to ensure that they are not unnecessarily traumatised.

:Note: Other reactions were insomnia (23%), irritability (69%) feeling of being more alert (46%), being startled more easily (79%), depressed mood (75%), suicidal thoughts (40%), feelings of guilt (67%), low self esteem (54%) substance abuse (2%), change in eating habits (23%) and decreased libido (79%).

'''''[http://www.hindawi.com/journals/jp/2010/130519.html Late-Term Elective Abortion and Susceptibility to Posttraumatic Stress Symptoms.] ''''' Journal of Pregnancy Volume 2010 (2010)Coleman PK, Coyle CT, Rue VM

:An average of 15 years after their abortions, 52.5% of women with a history of a first trimester abortion and 67.4% with a history of a second or third trimester abortion, met the DSM-IV symptom criteria for PTSD.

[http://www3.interscience.wiley.com/journal/123554306/abstract?CRETRY=1&SRETRY=0 Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy]Hamama L, et al. ''Depression and Anxiety'' Published Online: 23 Jun 2010
:(Abstract)Background: Few studies have considered whether elective and/or spontaneous abortion (EAB/SAB) may be risk factors for mental health sequelae in subsequent pregnancy. This paper examines the impact of EAB/SAB on mental health during subsequent pregnancy in a sample of women involved in a larger prospective study of posttraumatic stress disorder (PTSD) across the childbearing year (n=1,581).
:Methods: Women expecting their first baby completed standardized telephone assessments including demographics, trauma history, PTSD, depression, and pregnancy wantedness, and religiosity.
:Results: Fourteen percent (n=221) experienced a prior elective abortion (EAB), 13.1% (n=206) experienced a prior spontaneous abortion (SAB), and 1.4% (n=22) experienced both. Of those women who experienced either an EAB or SAB, 13.9% (n=220) appraised the EAB or SAB experience as having been a hard time (i.e., potentially traumatic) and 32.6% (n=132) rated it as their index trauma (i.e., their worst or second worst lifetime exposure). Among the subset of 405 women with prior EAB or SAB, the rate of PTSD during the subsequent pregnancy was 12.6% (n-51), the rate of depression was 16.8% (n=68), and 5.4% (n-22) met criteria for both disorders.
:Conclusions: History of sexual trauma predicted appraising the experience of EAB or SAB as a hard time. Wanting to be pregnant sooner was predictive of appraising the experience of EAB or SAB as the worst or second worst (index) trauma. EAB or SAB was appraised as less traumatic than sexual or medical trauma exposures and conveyed relatively lower risk for PTSD. The patterns of predictors for depression were similar. Depression and Anxiety

:Editor Notes: Among women having an elective abortion, 28.6 percent rated it as the first or second worst lifetime experience. During the subsequent pregnancy, among women with a history of elective abortion 12.5% met the criteria for a PTSD diagnosis, 17.9 percent experienced major depression in the past year, and 4.5 percent had both PTSD and depression. Among those reporting that they had a "hard time" with their abortion or miscarriage, 32% were diagnosed with PTSD and 28 percent had major depression, and 17.3% had both.

''[http://tmt.sagepub.com/cgi/content/abstract/1534765609347550v1 "Inadequate Preabortion Counseling and Decision Conflict as Predictors of Subsequent Relationship Difficulties and Psychological Stress in Men and Women"] Catherine T. Coyle, Priscilla K. Coleman, and Vincent M. Rue, ''Traumatology'' first published on November 16, 2009 as doi:10.1177/1534765609347550

:(Abstract)The purpose of this study was to examine associations between perceptions of preabortion counseling adequacy and partner congruence in abortion decisions and two sets of outcome variables involving relationship problems and individual psychological stress. Data were collected through online surveys from 374 women who had a prior abortion and 198 men whose partners had experienced elective abortion. For women, perceptions of preabortion counseling inadequacy predicted relationship problems, symptoms of intrusion, avoidance, and hyperarousal, and meeting full diagnostic criteria for posttraumatic stress disorder (PTSD) with controls for demographic and personal/situational variables used. For men, perceptions of inadequate counseling predicted relationship problems and symptoms of intrusion and avoidance with the same controls used. Incongruence in the decision to abort predicted intrusion and meeting diagnostic criteria for PTSD among women with controls used, whereas for men, decision incongruence predicted intrusion, hyperarousal, meeting diagnostic criteria for PTSD, and relationship problems. Findings suggest that both perceptions of inadequate preabortion counseling and incongruence in the abortion decision with one’s partner are related to adverse personal and interpersonal outcomes.

''"[http://www.springerlink.com/content/w773590gq50677jv/ Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth—a 14-month follow up study]" Kersting A, et al. Arch Womens Ment Health. 2009 Aug;12(4):193-201. Epub 2009 Mar 6.''
:(ABSTRACT) The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting psychological impact.

'''[http://www.ncbi.nlm.nih.gov/pubmed/20860598 Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomised controlled trial.]''' Kelly T, Suddes J, Howel D, Hewison J, Robson S. BJOG. 2010 Nov;117(12):1512-20. OBJECTIVE: To compare the psychological impact, acceptability and clinical effectiveness of medical versus surgical termination of pregnancy (TOP) at 13-20 weeks of gestation.

:One hundred and twenty two women were randomised: 60 had medical (drug induced) abortions (MTOP) and 62 had surgical abortions. Twelve women opted to continue their pregnancy. Follow-up rates were low (n=66/110; 60%). At 2 weeks post-procedure the average IES scores reported for surgical abortion was 30.1 and for medical abortion was 36.8. For scores over 26, there is a 75% chance of PTSD. [http://www.psychotherapy-center.com/Measuring_the_Impact_of_an_Event.html 1] and the event may be classified as a "Powerful Impact Event—you are certainly affected."[http://www.psychotherapy-center.com/Measuring_the_Impact_of_an_Event.html 1] An IES score over 35 is considered a good cutoff score for probable PTSD. [http://www.psychotherapy-center.com/Measuring_the_Impact_of_an_Event.html 1] With means of 30.1 and 36.8, it would appear that a high percentage of women in both the MTOP and STOP group exceeded the cutoff score for probable PTSD.

:Also, given the fact there was a 60% non-participation rate in this study, it is likely that the mean IES scores reported here are much lower than they would have been with 100% participation since it is likely that women who were most disturbed by the abortion were least likely to participate.

''"Past trauma and Present Functioning of Patients Attending a Women's Psychiatric Clinic," EFM Borins, PJ Forsythe, Am J Psychiatry 142(4) :460, 1985 ''
:In a Canadian study, abortion correlated significantly with three or more trauma factors.

''"Iatrogenic Post-Traumatic Stress Disorder," (letter), R. Fisch and 0. Tadmor, The Lancet, December 9, 1989, p. 1397. ''
:PTSD following induced abortion with post-abortion complications was reported. Soon after the abortion the patient exhibited severe anxiety, depression, recurrent intrusive thoughts and images related to the abortion, insomnia, recurrent nightmares, avoidance behavior along with other social problems continuing over two and a half years without much remission.

''"Obsessive-Compulsive Disorder Apparently Related to Abortion," Ronald K. McGraw, American Journal of Psychotherapy 43(2):269-276, April 1989. ''
:A married woman with a history of three abortions was obsessed with the idea she would become pregnant by someone other than her husband although she was not sexually active outside her marriage, and she compulsively underwent repeated pregnancy tests although there was no sign of pregnancy. If she became pregnant she thought she would die in childbirth. It was concluded that the obsessive-compulsive disorder was precipitated by routine medical tests that brought back memories of the prior abortions with associated guilt and fear of punishment.

''"Incidence of complicated grief and post-traumatic stress in a post-abortion population," Leslie M. Butterfield, Ph.D. Dissertation, Virginia Commonwealth University (1988), Dissertation Abstracts International 49(8): 3431-B, February 1989, Order No. DA 8813540. ''
:Stress responses were found in 55% of women six months following first trimester abortion. Posttraumatic stress was heightened by loss of partner and wishful thinking. Social support seeking and problem-focused coping was negatively associate with post- traumatic stress and grief. Women consistently showed death anxiety on the Grief Experience Inventory (GEI).

''"Abortion Trauma: Application of a Conflict Model," R.C. Erikson, Pre and Perinatal Psychology Journal 8(l): 33. Fall, 1993. ''
:Elective abortion is a potentially traumatizing event. Clinic experience indicates the symptoms and development of post traumatic stress disorder following abortion. A conflict model of trauma is presented with the woman as both victim and aggressor.

''"Post Traumatic Stress Disorders in Women Following Abortion: Some Considerations and Implications for Martial/Couple Therapy," D Bagarozzi, Int'l Journal of Family and Marriage (Delhi, India) 1 (2): 51, 1993 ''
:Clinical examples of abortion related post traumatic stress disorder.

''"Psychological Responses of Women After First-Trimester Abortion," B Major et al, Arch Gen Psychiatry 57:777, 2000 ''
:This study reported that 6 of 442 women ( 1.36%) reported abortion related PTSD two years postabortion according to DSM-IV criteria as assessed with a modified measure asking specifically about abortion. A history of depression was significantly associated with a higher risk of experience abortion related PTSD.
:An increasing number of women had negative emotional reactions with the passage of time. In this study it appears that the standard for identifying a case of abortion-related PTSD was set to exceptionally high level. First, women were required to the cause of each symptom as having been directly related to the abortion. Nightmares that they did not associate to their abortion, for example, would not have been included as an intrusive symptom. In addition, it appears that only women who rated the degree of the reaction at the highest level, for every PTSD symptom, were included. Women with a moderate level of distress in one symptom area, for example, were not counted as having PTSD. This high standard is useful for verifying with a high degree of certainty that abortion is the direct cause of PTSD in at least some cases. On the other hand, because the standard appears to be set higher than is normally the case in population studies of PTSD, the findings may under represent the actual incidence rate.

'''''[https://pdfs.semanticscholar.org/36a1/9b0aefacdaa17a74511036cfb5a1e6e4786a.pdf Posttraumatic stress disorder and pregnancy complications.]'' Seng JS, Oakley DJ, Sampselle CM, Killion C, Graham-Bermann S, Liberzon I. Obstetrics and gynecology. 2001 Jan; 97(1): 17-22'''
:OBJECTIVE: To assess the associations between specific pregnancy complications and posttraumatic stress disorder based on neurobiologic and behavioral characteristics, using Michigan Medicaid claims data from 1994-1996.
:METHODS: Two thousand, two hundred nineteen female recipients of Michigan Medicaid who were of childbearing age had posttraumatic stress disorder on the basis of International Classification of Diseases, 9th Revision (ICD-9) codes. Twenty percent (n = 455) of those recipients and 30% of randomly selected comparison women with no mental health diagnostic codes (n = 638; P <.001) had ICD-9 diagnostic codes for pregnancy complications. We used multiple logistic regression to investigate associations between specific pregnancy complications and posttraumatic stress disorder, controlling for demographic and psychosocial variables. Obstetric complications were hypothesized based on high-risk behaviors and neurobiologic alterations in stress axis function in posttraumatic stress disorder.
:RESULTS: After controlling for demographic and psychosocial factors, women with posttraumatic stress disorder had higher odds ratios (ORs) for ectopic pregnancy (OR 1.7, 95% confidence interval [CI] 1.1, 2.8), spontaneous abortion (OR 1.9, 95% CI 1.3, 2.9), hyperemesis (OR 3.9, 95% CI 2.0, 7.4), preterm contractions (OR 1.4, 95% CI 1.1, 1.9), and excessive fetal growth (OR 1.5, 95% CI 1.0, 2.2). Hypothesized labor differences were not confirmed and no differences were found for complications not thought to be related to traumatic stress.
:CONCLUSIONS: Pregnant women with posttraumatic stress disorder might be at higher risk for certain conditions, and assessment and treatment for undiagnosed posttraumatic stress might be warranted for women with those obstetric complications. Prospective studies are needed to confirm present findings and to determine potential biologic mechanisms. Treatment of traumatic stress symptoms might improve pregnancy morbidity and maternal mental health.
:NOTE: women's most common attribution for PTSD was violence and the second most common attribution was for prior pregnancy loss.

''Trauma and grief 2-7 years after termination of pregnancy because of fetal anomalies-a pilot study. Kersting A, et al. J of Psychosomatic Obstetrics & Gynecology 2005; 26(1): 9-14.''
:The aim of the study was to obtain information on the long-term posttraumatic stress response and grief several years after termination of pregnancy due to fetal malformation. We investigated 83 women who had undergone termination of pregnancy between 1995 and 1999 and compared them with 60 women 14 days after termination of pregnancy and 65 women after the spontaneous delivery of a full-term healthy child. Women 2-7 years after termination of pregnancy were expected to show a significantly lower degree of traumatic experience and grief than women 14 days after termination of pregnancy. Contrary to the hypothesis, however, the results showed no significant intergroup differences with respect to the degree of traumatic experience. With the exception of one subscale (fear of loss), this also applied to the grief reported by the women. However, both groups differed significantly in their posttraumatic stress response from women who had given spontaneous birth to a full-term healthy child. The results indicate that termination of pregnancy is to be seen as an emotionally traumatic major life event which leads to severe posttraumatic stress response and intense grief reactions that are still detectable some years later.

''Assessing traumatic reactions of abortion with the emotional stroop.'' Toledano, Levana. Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 64(9-B), 2004. pp. 4639.
:Two groups of women were included in this study: 59 women who had undergone an abortion and a control group of 28 women who had comparable surgical procedures. The mean age of the participants was 29.82, with ages ranging from 18 to 50 years. Symptoms of PTSD were assessed using the Posttraumatic Diagnostic Scale (PDS), the Impact of Event Scale (IES), and the Emotional Stroop paradigm. The Emotional Stroop procedure utilized was a color-naming task comprised of abortion-relevant words (i.e., sex, pregnant, fetus), positive words, neutral words, and obsessive-compulsive disorder (OCD) words. Levels of depression and anxiety were assessed with the Beck Depression Inventory-II (BDI-II), and the State-Trait Anxiety Inventory (STAI). The role of social support at the time of abortion was measured via the Multidimensional Scale of Perceived Social Support (MSPSS). Background variables such as religiosity, the presence or absence of coercion, marital status, gestational length, number of children, and age were also explored as possible risk factors mediating responses to abortion. Multivariate tests indicated the presence of PTSD in both groups of women, but to a greater extent in the post-abortion group. The two groups reported similarly elevated scores for anxiety. Post-abortion women exhibited significantly longer response latencies on the Stroop for abortion/trauma-relevant stimuli as compared to the control group. There were no significant differences found between groups on measures of depression. Significant risk factors included low levels of perceived social support, younger age, and the presence of coercion. Implications for community and clinical psychology are outlined.

''Postabortion Grief: Evaluating the Possible Efficacy of a Spiritual Group Intervention.'' SD Layer, C Roberts, K Wild, J Walters. Research on Social Work Practice, Vol. 14, No. 5, 344-350 (2004)
:Objective: Although not every woman is negatively affected by an abortion, researchers have identified a subgroup of women susceptible to grief and trauma. The primary providers for postabortion grief (PAG) groups are community faith-based agencies. Principle features of PAG are shame and post-traumatic stress disorder (PTSD) symptoms. Method: This study measured the efficacy of a spiritually based grief group intervention for women grieving an abortion. Thirty-five women completed the Impact of Event Scale-Revised(IES-R) and the Internalized Shame Scale (ISS) pre- and postintervention along with posttest open-ended questions. Results: Postintervention measures indicated significant decrease in shame (p < .000) and PTSD symptoms (p < .002). More than 80% reported their religious beliefs and the spiritual intervention played a strong to very strong role in the group. Conclusion: Social workers need to screen for PAG with a postabortive woman and when appropriate refer her to agencies offering such groups.

''Abortion in young women and subsequent mental health.'' Fergusson DM, John Horwood L, Ridder EM. J Child Psychol Psychiatry. 2006 Jan;47(1):16-24.

:Background: The extent to which abortion has harmful consequences for mental health remains controversial. We aimed to examine the linkages between having an abortion and mental health outcomes over the interval from age 15-25 years. Methods: Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors. Results: Forty-one percent of women had become pregnant on at least one occasion prior to age 25, with 14.6% having an abortion. Those having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors. Conclusions: The findings suggest that abortion in young women may be associated with increased risks of mental health problems.

''Induced abortion and traumatic stress: A preliminary comparison of American and Russian women.'' Rue VM, Coleman PK, Rue JJ, Reardon DC. Med Sci Monit, 2004 10(10): SR5-16.
:BACKGROUND: Individual and situational risk factors associated with negative postabortion psychological sequelae have been identified, but the degree of posttraumatic stress reactions and the effects of culture are largely unknown.
:MATERIAL/METHODS: Retrospective data were collected using the Institute for Pregnancy Loss Questionnaire (IPLQ) and the Traumatic Stress Institute's (TSI) Belief Scale administered at health care facilities to 548 women (331 Russian and 217 American) who had experienced one or more abortions, but no other pregnancy losses.
:RESULTS: Overall, the findings here indicated that American women were more negatively influenced by their abortion experiences than Russian women. While 65% of American women and 13.1% of Russian women experienced multiple symptoms of increased arousal, re-experiencing and avoidance associated with posttraumatic stress disorder (PTSD), 14.3% of American and 0.9% of Russian women met the full diagnostic criteria for PTSD. Russian women had significantly higher scores on the TSI Belief Scale than American women, indicating more disruption of cognitive schemas. In this sample, American women were considerably more likely to have experienced childhood and adult traumatic experiences than Russian women. Predictors of positive and negative outcomes associated with abortion differed across the two cultures.
:CONCLUSIONS: Posttraumatic stress reactions were found to be associated with abortion. Consistent with previous research, the data here suggest abortion can increase stress and decrease coping abilities, particularly for those women who have a history of adverse childhood events and prior traumata. Study limitations preclude drawing definitive conclusions, but the findings do suggest additional cross-cultural research is warranted.

[http://www.ncbi.nlm.nih.gov/pubmed/24007380 Increased risk for postpartum psychiatric disorders among women with past pregnancy loss.] Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

:Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.
:Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

:Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

:Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

[http://www.ncbi.nlm.nih.gov/pubmed/24154514 Women's experiences in relation to stillbirth and risk factors for long-term post-traumatic stress symptoms: a retrospective study.] Gravensteen IK, Helgadóttir LB, Jacobsen EM, Rådestad I, Sandset PM, Ekeberg O. BMJ Open. 2013 Oct 22;3(10):e003323. doi: 10.1136/bmjopen-2013-003323.

:OBJECTIVES: (1) To investigate the experiences of women with a previous stillbirth and their appraisal of the care they received at the hospital. (2) To assess the long-term level of post-traumatic stress symptoms (PTSS) in this group and identify risk factors for this outcome.
:DESIGN: A retrospective study.
:SETTING:Two university hospitals.
:PARTICIPANTS: The study population comprised 379 women with a verified diagnosis of stillbirth (≥23 gestational weeks or birth weight ≥500 g) in a singleton or twin pregnancy 5-18 years previously. 101 women completed a comprehensive questionnaire in two parts.
:PRIMARY AND SECONDARY OUTCOME MEASURES: The women's experiences and appraisal of the care provided by healthcare professionals before, during and after stillbirth. PTSS at follow-up was assessed using the Impact of Event Scale (IES).
:RESULTS: The great majority saw (98%) and held (82%) their baby. Most women felt that healthcare professionals were supportive during the delivery (85.6%) and showed respect towards their baby (94.9%). The majority (91.1%) had received some form of short-term follow-up. One-third showed clinically significant long-term PTSS (IES ≥ 20). Independent risk factors were younger age (OR 6.60, 95% CI 1.99 to 21.83), induced abortion prior to stillbirth (OR 5.78, 95% CI 1.56 to 21.38) and higher parity (OR 3.46, 95% CI 1.19 to 10.07) at the time of stillbirth. Having held the baby (OR 0.17, 95% CI 0.05 to 0.56) was associated with less PTSS.
:CONCLUSIONS: The great majority saw and held their baby and were satisfied with the support from healthcare professionals. One in three women presented with a clinically significant level of PTSS 5-18 years after stillbirth. Having held the baby was protective, whereas '''prior induced abortion was a risk factor for a high level of PTSS'''.

'''[http://www.ncbi.nlm.nih.gov/pubmed/24875400 Voluntary and involuntary childlessness in female veterans: associations with sexual assault.]''' Ryan GL, Mengeling MA, Booth BM, Torner JC, Syrop CH, Sadler AG. Fertil Steril. 2014 Aug;102(2):539-47. doi: 10.1016/j.fertnstert.2014.04.042. Epub 2014 May 27.

:In a sample of 1,004 female veterans enrolled at VA medical centers, 620 had a history of at least one attempted or completed sexual assault. Those with a history of sexual assault were "more often self-reported a history of pregnancy termination (31% vs. 19%) and infertility (23% vs. 12%), as well as sexually transmitted infection (42% vs. 27%), posttraumatic stress disorder (32% vs. 10%), and postpartum dysphoria (62% vs. 44%). Lifetime sexual assault was independently associated with termination and infertility in multivariate models; sexually transmitted infection, posttraumatic stress disorder, and postpartum dysphoria were not. The LSA by period of life was as follows: 41% of participants in childhood, 15% in adulthood before the military, 33% in military, and 13% after the military (not mutually exclusive). Among the 511 who experienced a completed LSA, 23% self-reported delaying or foregoing pregnancy because of their assault."

'''[http://www.ncbi.nlm.nih.gov/pubmed/21186554 Investigation of risk factors for acute stress reaction following induced abortion].''' Vukelić J, Kapamadzija A, Kondić B.
[Article in Serbian] Med Pregl. 2010 May-Jun;63(5-6):399-403.

:INTRODUCTION: Termination of pregnancy-induced abortion is inevitable in family planning as the final solution in resolving unwanted pregnancies. It can be the cause of major physical and phychological consequences on women's health. Diverse opinions on psychological consequences of induced abortion can be found in literature.
:MATERIAL AND METHODS: A prospective study was performed in order to predict acute stress disorder (ASD) after the induced abortion and the possibility of post-traumatic stress disorder (PTSD). Seven days after the induced abortion, 40 women had to fill in: (1) a special questionnaire made for this investigation, with questions linked to some risk factors inducing stress, (2) Likert's emotional scale and 3. Bryant's acute stress reaction scale.
:RESULTS: After an induced abortion 52.5% women had ASD and 32.5% women had PTSD. Women with ASD after the abortion developed more sense of guilt, irritability, shame, self-judgement, fear from God and self-hatred. They were less educated, had lower income, they were more religious, did not approve of abortion and had worse relationship with their partners after the abortion in comparison to women without ASD. Age, number of previous abortions and decision to abort did not differ between the two groups.
:DISCUSSION: Induced abortion represents a predisposing factor for ASD and PTSD in women. Some psycho-social factors contribute to the development of stress after abortion. Serbia has a task to reduce the number of abortions which is very high, in order, to preserve reproductive and psychological health of women.

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3879178/] Wallin Lundell I, Georgsson Öhman S, Frans Ö, Helström L, Högberg U, Nyberg S, Sundström Poromaa I, Sydsjö G, Östlund I, Skoog Svanberg A. BMC Womens Health. 2013 Dec 23;13:52. doi: 10.1186/1472-6874-13-52. See also: [http://www.diva-portal.org/smash/get/diva2:740899/FULLTEXT01.pdf Induced Abortions and Posttraumatic Stress - Is there any relation? A Swedish multi-centre study] INGER WALLIN LUNDELL 2014 Dissertation.

:Background: Induced abortion is a common medical intervention. Whether psychological sequelae might follow induced abortion has long been a subject of concern among researchers and little is known about the relationship between posttraumatic stress disorder (PTSD) and induced abortion. Thus, the aim of the study was to assess the prevalence of PTSD and posttraumatic stress symptoms (PTSS) before and at three and six months after induced abortion, and to describe the characteristics of the women who developed PTSD or PTSS after the abortion.

:Methods: This multi-centre cohort study included six departments of Obstetrics and Gynaecology in Sweden. The study included 1457 women who requested an induced abortion, among whom 742 women responded at the three-month follow-up and 641 women at the six-month follow-up. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used for research diagnoses of PTSD and PTSS, and anxiety and depressive symptoms were evaluated by the Hospital Anxiety and Depression Scale (HADS). Measurements were made at the first visit and at three and six months after the abortion. The 95% confidence intervals for the prevalence of lifetime or ongoing PTSD and PTSS were calculated using the normal approximation. The chi-square test and the Student’s t-test were used to compare data between groups.

:Results: The prevalence of ongoing PTSD and PTSS before the abortion was 4.3% and 23.5%, respectively, concomitant with high levels of anxiety and depression. At three months the corresponding rates were 2.0% and 4.6%, at six months 1.9% and 6.1%, respectively. Dropouts had higher rates of PTSD and PTSS. Fifty-one women developed PTSD or PTSS during the observation period. They were young, less well educated, needed counselling, and had high levels of anxiety and depressive symptoms. During the observation period 57 women had trauma experiences, among whom 11 developed PTSD or PTSS and reported a traumatic experience in relation to the abortion.

:Conclusion: Few women developed PTSD or PTSS after the abortion. The majority did so because of trauma experiences unrelated to the induced abortion. Concomitant symptoms of depression and anxiety call for clinical alertness and support.

===Case Study of PTSD Treatment===
''The Assessment and Treatment of Post-Abortion Syndrome: A Systematic Case Study From Southern Africa'' Boulind M, Edward D. Journal of Psychology in Africa 2008 18(4); 539-548.

Abstract: This article reports a clinical case study of “Grace”, a black Zimbabwean woman with post-abortion syndrome (PAS), a form of post-traumatic stress disorder precipitated by aborting an unwanted pregnancy. She was treated by a middle class white South African trainee Clinical Psychologist. The case narrative documents the assessment and the course of treatment which was guided by ongoing case formulation based on current evidence-based models. Factors that made her vulnerable to developing PTSD included active suppression of the memory of the event and lack of social support. An understanding of these factors was used to guide an effective intervention. In spite of the differences in culture and background between client and therapist, there was considerable commonality in their experience as young women and students who each had to balance personal and occupational priorities. The narrative also highlights the commonalities of Grace’s experiences with those reported in the literature on post-abortion syndrome, which is mostly from the U. S. A. and Europe.

===Related Information===

''[http://www.ncbi.nlm.nih.gov/pubmed/25666812 How women perceive abortion care: A study focusing on healthy women and those with mental and posttraumatic stress.]''Wallin Lundell I1, Öhman SG, Sundström Poromaa I, Högberg U, Sydsjö G, Skoog Svanberg A. Eur J Contracept Reprod Health Care. 2015 Feb 9:1-12.

:Abstract: Objectives To identify perceived deficiencies in the quality of abortion care among healthy women and those with mental stress.
:Methods: This multi-centre cohort study included six obstetrics and gynaecology departments in Sweden. Posttraumatic stress (PTSD/PTSS) was assessed using the Screen Questionnaire-Posttraumatic Stress Disorder; anxiety and depressive symptoms, using the Hospital Anxiety Depression Scale; and abortion quality perceptions, using a modified version of the Quality from the Patient's Perspective questionnaire. Pain during medical abortion was assessed in a subsample using a visual analogue scale.
:Results: Overall, 16% of the participants assessed the abortion care as being deficient, and 22% experienced intense pain during medical abortion. Women with PTSD/PTSS more often perceived the abortion care as deficient overall and differed from healthy women in reports of deficiencies in support, respectful treatment, opportunities for privacy and rest, and availability of support from a significant person during the procedure. There was a marginally significant difference between PTSD/PTSS and the comparison group for insufficient pain alleviation.
:Conclusions: Women with PTSD/PTSS perceived abortion care to be deficient more often than did healthy women. These women do require extra support, relatively simple efforts to provide adequate pain alleviation, support and privacy during abortion may improve abortion care.

[http://www.biomedcentral.com/1472-6874/13/52 Posttraumatic stress among women after induced abortion: a Swedish multi-centre cohort study.] Wallin Lundell I, Georgsson Öhman S, Frans O, Helström L, Högberg U, Nyberg S, Sundström Poromaa I, Sydsjö G, Ostlund I, Skoog Svanberg A. BMC Womens Health. 2013 Dec 23;13(1):52.

:BACKGROUND: Induced abortion is a common medical intervention. Whether psychological sequelae might follow induced abortion has long been a subject of concern among researchers and little is known about the relationship between posttraumatic stress disorder (PTSD) and induced abortion. Thus, the aim of the study was to assess the prevalence of PTSD and posttraumatic stress symptoms (PTSS) before and at three and six months after induced abortion, and to describe the characteristics of the women who developed PTSD or PTSS after the abortion.

:METHODS: This multi-centre cohort study included six departments of Obstetrics and Gynaecology in Sweden. The study included 1457 women who requested an induced abortion, among whom 742 women responded at the three-month follow-up and 641 women at the six-month follow-up. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used for research diagnoses of PTSD and PTSS, and anxiety and depressive symptoms were evaluated by the Hospital Anxiety and Depression Scale (HADS). Measurements were made at the first visit and at three and six months after the abortion. The 95% confidence intervals for the prevalence of lifetime or ongoing PTSD and PTSS were calculated using the normal approximation. The chi-square test and the Student's t-test were used to compare data between groups.

:RESULTS: The prevalence of ongoing PTSD and PTSS before the abortion was 4.3% and 23.5%, respectively, concomitant with high levels of anxiety and depression. At three months the corresponding rates were 2.0% and 4.6%, at six months 1.9% and 6.1%, respectively. Dropouts had higher rates of PTSD and PTSS. Fifty-one women developed PTSD or PTSS during the observation period. They were young, less well educated, needed counselling, and had high levels of anxiety and depressive symptoms. During the observation period 57 women had trauma experiences, among whom 11 developed PTSD or PTSS and reported a traumatic experience in relation to the abortion.

:CONCLUSION: Few women developed PTSD or PTSS after the abortion. The majority did so because of trauma experiences unrelated to the induced abortion. Concomitant symptoms of depression and anxiety call for clinical alertness and support

:'''Reviewer Comments (Donna Harrison, MD)'''

:But what does the data in the paper actually demonstrate?
:“Response rates were 742/1381 (54%) at the three-month follow-up and 641/1381 (46%) at the six-month assessment (Figure 1).” So, less than half of the study respondents actually completed the study. Let’s look at these dropouts a little closer:

:“Dropouts at the three-month assessments were younger, more often born outside Sweden, had a lower level of education, reported tobacco use more often but less alcohol use, had more anxiety and depressive symptoms and were more often using antidepressant treatment. In addition, they had more often had a previous abortion and had less often received counselling before the abortion (Table 1), and they also had higher rates of lifetime PTSD, ongoing PTSD and PTSS at the baseline assessment than the responders (Table 2). Dropouts at the six month assessment had lower levels of education and had more often had a previous induced abortion (Table 1), but did not differ from responders in rates of lifetime PTSD, ongoing PTSD or PTSS (Table 2)”

:So, in the baseline assessment, prior to the abortion being studied, there is a subset of women who later became dropouts of this study. This subset of women, who had higher PTSD scores, more anxiety and depression, and were more often using antidepressants had one additional characteristic which distinguished them from the responders: “they had more often had a previous abortion”.

:A reasonable researcher might ask '''why the experience of a previous abortion would correlate with the presence of higher PTSD scores, more anxiety and depression and greater frequency of use of antidepressants BEFORE the abortion being studied'''.

:A reasonable researcher might also ask whether this loss of half of the study population might affect the statistical conclusions of the study.

:A reasonable researcher might also wonder why a 3month and 6 month follow up time interval was chosen for an outcome such as PTSD which has been well established to occur much later; years after the event? In fact, the “baseline” PTSD data, which collected information on abortion history BEFORE THE ABORTION IN THE STUDY, might actually shed more light on the long term psychological outcome, than a 3 and 6 month follow up.

:This study is an excellent illustration of what pro-abortion researchers call “Research for Advocacy” and what the rest of the world calls “spin”. As pro-life physicians, we are called to read further than the abstract and conclusion, and to really consider the scientific data being presented. We need to look at whether or not the data actually supports the published conclusions.

::Another analysis using the same data set was published by the same research team: "[http://www.ncbi.nlm.nih.gov/pubmed/23978220 The prevalence of posttraumatic stress among women requesting induced abortion.]"

''Posttraumatic stress disorder following medical illness and treatment.'' JE Tedstone, N Tarrier. Clin Psychol Rev. 2003 May;23(3):409-48.
:Studies describing posttraumatic stress disorder (PTSD) as a result of physical illness and its treatment were reviewed. PTSD was described in studies investigating myocardial infarction (MI), cardiac surgery, haemorrhage and stroke, childbirth, miscarriage, '''abortion''' and gynaecological procedures, intensive care treatment, human immunodeficiency virus (HIV) infection, awareness under anaesthesia, and in a group of miscellaneous conditions. Cancer medicine was not included as it had been the subject of a recent review in this journal. Studies were reviewed in terms of the prevalence rates for PTSD, intrusive and avoidance symptoms, predictive and associated factors and the consequences of PTSD on healthcare utilization and outcome.

''[http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.437 Which Medical Conditions Account For The Rise In Health Care Spending?]'' Kenneth E. Thorpe, Curtis S. Florence, Peter Joski. Health Affairs, 10.1377/hlthaff.w4.437
:Between 1987 and 2000, the 15 costliest medical conditions were heart disease, '''mental disorders,''' lung disease, cancer, trauma, high blood pressure, diabetes, back problems, arthritis, stroke and other brain blockages, skin disorders, pneumonia, infectious disease, hormone disorders, and kidney disease. For their study, Thorpe and colleagues used two U.S. government surveys -- the 1987 National Medical Expenditure Survey of 34,000 people and the 2000 Medical Expenditure Panel Survey of 25,000 people New patients accounted for 59 percent of the rise in spending on mental disorders, the report found. While mental disorders did not become more common, twice as many people sought treatment for them between 1987 and 2000.

[http://www.ncbi.nlm.nih.gov/pubmed/19115456 Prevalence and prediction of re-experiencing and avoidance after elective surgical abortion: a prospective study.] van Emmerik AA, Kamphuis JH, Emmelkamp PM. Clin Psychol Psychother. 2008 Nov-Dec;15(6):378-85. doi: 10.1002/cpp.586.

:OBJECTIVE: This study investigated short-term re-experiencing and avoidance after elective surgical abortion. In addition, it was prospectively investigated whether peritraumatic dissociation and pre-abortion dissociative tendencies and alexithymia predict re-experiencing and avoidance.
:METHOD: In a prospective observational design, Dutch-speaking women presenting for first trimester elective surgical abortion completed self-report measures for dissociative tendency and alexithymia. Peritraumatic dissociation was measured immediately post-abortion. Re-experiencing and avoidance were measured 2 months post-abortion.
:RESULTS: Participants reported moderately elevated levels of re-experiencing and avoidance that exceeded a clinical cut-off point for 19.4% of the participants. Peritraumatic dissociation predicted intrusion and avoidance at 2 months. In addition, avoidance was predicted by the alexithymic aspect of difficulty describing feelings.
:CONCLUSIONS: Re-experiencing and avoidance after elective surgical abortion represent a significant clinical problem that is predicted by peritraumatic dissociation and alexithymia. Psychological screening and intervention might be a useful adjunct to elective abortion procedures.

'''[http://www.ncbi.nlm.nih.gov/pubmed/19560116 Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months.]''' Korenromp MJ1, Page-Christiaens GC, van den Bout J, Mulder EJ, Visser GH. Am J Obstet Gynecol. 2009 Aug;201(2):160.e1-7. doi: 10.1016/j.ajog.2009.04.007. Epub 2009 Jun 26.Author information

:OBJECTIVE: We studied psychological outcomes and predictors for adverse outcome in 147 women 4, 8, and 16 months after termination of pregnancy for fetal anomaly.
:STUDY DESIGN: We conducted a longitudinal study with validated self-completed questionnaires.
:RESULTS: Four months after termination 46% of women showed pathological levels of posttraumatic stress symptoms, decreasing to 20.5% after 16 months. As to depression, these figures were 28% and 13%, respectively. Late onset of problematic adaptation did not occur frequently. Outcome at 4 months was the most important predictor of persistent impaired psychological outcome. Other predictors were low self-efficacy, high level of doubt during decision making, lack of partner support, being religious, and advanced gestational age. Strong feelings of regret for the decision were mentioned by 2.7% of women.
:CONCLUSION: Termination of pregnancy for fetal anomaly has significant psychological consequences for 20% of women up to > 1 year. Only few women mention feelings of regret.

'''[http://www.ncbi.nlm.nih.gov/pubmed/18468755 Abortion and anxiety: what's the relationship?]''' Steinberg JR1, Russo NF. Soc Sci Med. 2008 Jul;67(2):238-52. doi: 10.1016/j.socscimed.2008.03.033. Epub 2008 May 28.

:"[M]ultiple abortions were found to be associated with much higher rates of PTSD and social anxiety," though the author, pro-choice activits, insist "this relationship was largely explained by pre-pregnancy mental health disorders and their association with higher rates of violence."

===Systematic Reviews===

'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334933/ Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review.]''' Daugirdaitė V, van den Akker O, Purewal S. J Pregnancy. 2015;2015:646345. doi: 10.1155/2015/646345. Epub 2015 Feb 5.

:OBJECTIVE: The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF).

:METHODS:Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines.

:RESULTS: Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss.

:CONCLUSIONS: This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

== Moral Injury ==
[https://pubmed.ncbi.nlm.nih.gov/41208181/ Is termination of a desired pregnancy due to possible fetal abnormalities a case of moral injury? A preliminary report.] Sartel-Raviv S, Levi-Belz Y, Bar V, Zerach G. Death Stud. 2025 Nov 9:1-11. doi: 10.1080/07481187.2025.2585935. Epub ahead of print. PMID: 41208181.

<blockquote>Abstract

Termination of pregnancy (TOP) due to possible fetal abnormalities is known to be associated with various mental health problems. This study examines associations between potentially morally injurious events (PMIEs), moral injury outcomes (MI), posttraumatic stress disorder (PTSD), and prolonged grief (PG) among treatment-seeking women following late pregnancy loss. A volunteer sample of (''n'' = 132) Israeli women who attended a reproductive psychiatry clinic following TOP (''n'' = 99) or pregnancy loss due to intrauterine fetal demise (IUFD; ''n'' = 33), responded to self-report questionnaires in a cross-sectional, comparative study. Results show that among participants in the TOP group, PMIEs-self predicted MI outcomes of shame, and PMIEs-betrayal predicted MI outcomes of trust violation. Importantly, following exposure to PMIE-self, MI outcomes of trust violation significantly predicted both PTSD and PG symptoms. This study emphasized that TOP due to possible fetal abnormalities, may constitute a morally injurious experience, highlighting the need for clinical interventions addressing MI.</blockquote>

==Sleep Disorders==

Sleep disorders are associated with PTSD and increased risk of suicide See [[Sleep Disorders]]

Turn Away Study

2025-11-21T15:20:02Z

Barb: /* Other Criticisms */

The Turnaway Study is an ongoing study of women who had first and second trimester abortions compared to women who were "turned away" from late term abortions because they approached the clinics in their state after the gestational age limit for performing abortions. The [http://www.ansirh.org/research/turnaway.php Turnaway Study] is conducted by the pro-abortion advocacy group [http://www.ansirh.org/ Advancing New Standards in Reproductive Health (ANSIRH)] which is a project of the Bixby Center for Global Reproductive Health at the University of California, San Francisco.

The Turnaway Study is seriously flawed by the [[Turn_Away_Study#Non-Representative_Sample non-representative sample of women| non-representative selection of women]] used in the study. More detailed criticisms are further down this page. Here are some of the major points:

*Of women approached to participate 62.5% declined. Another 15% dropped out before the baseline interview one week after their abortions. As a result, only 31% participated in the baseline interview. In addition, women continued to drop out at each six month followup period, with an additional 20% drop out at one year, 36% dropout by the third year, and 46% dropout by the fifth year. Despite the low retention rate, the authors mislead readers by declaring that 93% participated "in at least one" of the six month followups, implying high retention when in fact less than 17% of eligible participants, and 46% of those who initially agreed, actually participated in year five.
**A low participation rate will often result in automatic rejection of studies by many medical journals. For example, the journal ''Obstetrics & Gynecology'' requires a minimum response rate of 60% or higher, twice that of the TurnAway Study.
**In comparison, [https://pubmed.ncbi.nlm.nih.gov/18711183/ 90 of 98 consecutive women (92%) invited to participate in a survey before, six months after, and one year after a prophylactic mastectomy (BPM)] to evaluate the impact of BPM on emotions, mental health, body image, and sexuality. This is nearly three times the participation rate of the Turnaway Study sample.
*While not explicitly stated by the researchers, the numbers they do reveal indicate that only 27.0% of the eligible women were interviewed at the three year follow-up and only 17% participated at the five year mark. Of the 37% who agreed to participate (1132) only 84% participated at week 1, 66% at year one, 53% at year three, and 46% at year five.
*There are well known [[risk factors]] which predict which women are most likely to have negative reactions to abortion, many of which would make women less likely to agree to participate in a follow up interviews . . . even if there was an offer to be paid. For example, from the [[Risk_factors| APA list of risk factors]]:
:*perceived need for secrecy;
:*feelings of stigma;
:*use of avoidance and denial coping strategies;
:*low perceived ability to cope with the abortion;
:*perceived pressure from others to terminate a pregnancy.
*The sample is disproportionately filled with women having late abortions. The sample used includes 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester.
*Women who had abortions due to suspected fetal anomalies were excluded. Probably because research shows high rates of psychological disruption after abortion in these types of cases, therefore excluding this segment of women was a way to reduce the effects associated with abortion. This is extremely misleading, of course, since this is a common reason for abortion . . . especially in the second and third trimester.
*Demographically, the sample used is not representative of women having abortions. The average age at the time of the abortion was 25, of which 62% were raising children.
*The comparison group, the Turn Away group (n=210), includes 50 women who later terminated at another facility or had a miscarriage. So 24% of this group, to which the researchers are comparing women who abort, actually includes women who experienced pregnancy losses. Yet the researchers barely disclose this fact, giving the false impression that their study is comparing women who had abortions to women who carried to term. In fact, they are comparing a group of women who had abortions to a group of women including those who (a) carried to term, (b) had abortions in a state other than where they first sought one, or (c) miscarried or had a still birth.

=Decision Rightness with Regard to Abortion in the Turnaway Study=

'''[http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128832#sec013 Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study] Rocca CH, Kimport K, Roberts SC, Gould H, Neuhaus J, Foster DG. PLoS One. 2015 Jul 8;10(7):e0128832. doi: 10.1371/journal.pone.0128832. eCollection 2015.'''

Abstract
:BACKGROUND: Arguments that abortion causes women emotional harm are used to regulate abortion, particularly later procedures, in the United States. However, existing research is inconclusive. We examined women's emotions and reports of whether the abortion decision was the right one for them over the three years after having an induced abortion.

:METHODS: We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities across the United States, selected based on having the latest gestational age limit within 150 miles. Two groups of women (n=667) were followed prospectively for three years: women having first-trimester procedures and women terminating pregnancies within two weeks under facilities' gestational age limits at the same facilities. Participants completed semiannual phone surveys to assess whether they felt that having the abortion was the right decision for them; negative emotions (regret, anger, guilt, sadness) about the abortion; and positive emotions (relief, happiness). Multivariable mixed-effects models were used to examine changes in each outcome over time, to compare the two groups, and to identify associated factors.

:RESULTS: The predicted probability of reporting that abortion was the right decision was over 99% at all time points over three years. Women with more planned pregnancies and who had more difficulty deciding to terminate the pregnancy had lower odds of reporting the abortion was the right decision (aOR=0.71 [0.60, 0.85] and 0.46 [0.36, 0.64], respectively). Both negative and positive emotions declined over time, with no differences between women having procedures near gestational age limits versus first-trimester abortions. Higher perceived community abortion stigma and lower social support were associated with more negative emotions (b=0.45 [0.31, 0.58] and b=-0.61 [-0.93, -0.29], respectively).

:CONCLUSIONS: Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years. Emotional support may be beneficial for women having abortions who report intended pregnancies or difficulty deciding.

:Note: the conclusions should be reframed to note that the conclusions only apply to the 27% of eligible women on whom the researchers had data at the three year mark.

===News Coverage===
[http://time.com/3956781/women-abortion-regret-reproductive-health/ Hardly Any Women Regret Having an Abortion, a New Study Finds.] Jenkins N. Time. Published July 14, 2015.
[https://www.washingtonpost.com/news/wonk/wp/2015/07/14/95-percent-of-women-whove-had-an-abortion-say-it-was-the-right-decision/ 95 percent of women who’ve had an abortion say it was the right decision.] Ingraham C. Washington Post. Published July 14, 2015.

===Criticisms of the Turnaway Study===

====Non-Representative Sample====

# This study's findings and conclusions are overreaching in many regards, beginning with the fact that the sample of women is not representative of the national population of women having abortions due to high rates of self-exclusion plus high drop out rates. To quote from the study: "Overall, 37.5% of eligible women consented to participate, and 85% of those completed baseline interviews (n = 956). Among the Near-Limit and First-Trimester Abortion groups, 92% completed six-month interviews, and 69% were retained at three years; 93% completed at least one follow-up interview." This means 62.5% of women refused to participate in the study, at first request, and another 15% dropped out before or during the baseline interview, yielding a 31.9% participation rate at baseline.
# There are well known [[risk factors]] which predict which women are most likely to have negative reactions to abortion, many of which would make women less likely to agree to participate in a follow up interviews . . . even if there was an offer to be paid. For example, from the [http://abortionrisks.org/index.php?title=Risk_factors APA list of risk factors]: perceived need for secrecy; feelings of stigma; use of avoidance and denial coping strategies; low perceived ability to cope with the abortion; perceived pressure from others to terminate a pregnancy.
# With 68.1% of eligible women refusing to participate in the study at baseline, it is improper for the authors to suggest that their findings reflect the general experiences of most women. There are numerous [[risk factors]] which have been identified as predicting which women will have the most severe post-abortion reactions. One of these risk factors, for example, is ambivalence about having an abortion or carrying to term. Another is the expectation that one will have more negative feelings about the abortion. In a similar post-abortion interview study by [[Soderberg]], the author reported that in interviews with those declining to participate "the reason for non-participation seemed to be a sense of guilt and remorse that they did not wish to discuss. An answer often given was: ' Do do not want to talk about it. I just want to forget.'"
#It is very likely that the self-selected 31.9% of women participating at baseline were more highly confident of their decision to abort prior to their abortions and anticipated fewer negative outcomes. This concern about selection bias is highlighted by the study's own finding that "women feeling more relief and happiness at baseline were less likely to be lost [to follow-up]." Clearly, due to the large numbers of women choosing not to be questioned about their experience, and the large drop out of those who did agree, this sample is not representative of the national population of women having abortions.
# There may have been additional selection bias on the part of the participating abortion clinics. According to the portion of study protocol that was published: "It is up to the clinic staff at each recruitment site to keep track of when to recruit abortion clients to match to the turnaways recruited." In other words, the clinic staff exercised considerable leeway in deciding when to invite women to participate, and this leeway could have been exercised in ways to exclude women whom they may have anticipated were among the worst candidates for abortion.
# Despite the initial selection bias, 15% of those agreeing to be interviewed subsequently opted out of the baseline interview and another 31% opted out within the three year followup period. This means that at the three year followup, only 27.0% of the eligible women were interviewed. This continuing drop out rate suggests even among women who expected little or no negative reactions, the stress of participating in follow up interviews lead to a change of mind. Previous research shows that [http://www.ncbi.nlm.nih.gov/pubmed/?term=10718164 women with a history of abortion feel more discomfort in answering questions about their reproductive history].
#Another oddity, the authors report that in the final group analyzed, average age 25, 62% were raising children. This would appear to be a very high rate that is not typical of national averages for women seeking abortion.
#The study population is also non-representative of the women having abortion in that it included 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester. This is totally disproportionate. It again shows that the authors should not be extending conclusions about this non-representative sample to the general population.
#The authors report that sample has an elevated number of low socioeconomic backgrounds. That, too, makes the sample non-representative. The offer of $50 per interview may also have created a participation bias.
#The comparison group, the Turn Away group (n=210), includes 50 women who later terminated at another facility or had a miscarriage. So 24% of this group, to which the researchers are comparing women who abort, actually includes women who experienced pregnancy losses. Yet the researchers barely disclose this fact, giving the false impression that their study is comparing women who had abortions to women who carried to term.
#Women who had abortions due to suspected fetal anomalies were excluded. Probably because research shows high rates of psychological disruption after abortion in these types of cases, therefore excluding this segment of women was a way to reduce the effects associated with abortion. This is extremely misleading, of course, since this is a common reason for abortion . . . especially in the second and third trimester.
#A low participation rate will often result in automatic rejection of studies by many medical journals. For example, the journal ''Obstetrics & Gynecology'' requires a minimum response rate of 60% or higher, twice that of the TurnAway Study.
#The actual question women were asked was “Given your situation, was the decision to have an abortion the right decision for you?” They were not given a scale to show degrees of agreement or disagreement. The only options were yes, no, or don't know. For the purposes of their analyses, "don't know" was treated as no. But in any event the preable, "Given your situation," essentially turned the question into "Did you make the best decision you could, given your situation?"
#The claim that 98% are satisfied with their decision (based on this binary assessment) is in sharp contrast to a study by [https://jamanetwork.com/journals/jamapsychiatry/fullarticle/481643#yoa8222t3 Brenda Major], another pro-abortion researcher. In her study the related question was phrased very differently. "Three hundred six (69%) of 441 women said they would definitely or probably have the abortion again if they had to make the decision over; 84 (19%) of 441 said that they would definitely not or probably not; and 51 (12%) of 441 were undecided." Note, Major does not report the "definitely" and "probably" groups separately. They are collapsed to imply greater certainty than "probably" entails. According to Major's paper, the details of the question were "At T4, women were asked, "If you had the decision to make over again under the same circumstances that you were in 2 years ago, would you make the same decision to have the abortion?" They responded on a scale from 1 (definitely no) to 5 (definitely yes)."

=====Misrepresentation of Study Design=====
The authors frequently describe their study as a "prospective longitudinal cohort study." Actually, it is only a "case series study" of the remnant of women (27%) who came to a few abortion clinics who were willing to continue to participate in this study. But since they do not have data collected on the women prior to seeking abortion, much less becoming pregnant, they are not truly prospective cohort studies but rather case series, as clarified by [https://www.ncbi.nlm.nih.gov/pubmed/22213493 Dekkers et al, (2012)] "a cohort study, in principle, enables the calculation of an absolute risk or a rate for the outcome, such a calculation is not possible in a case series." and [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998589/ Song & Chung, 2010]:
:An important distinction lies between cohort studies and case-series. The distinguishing feature between these two types of studies is the presence of a control, or unexposed, group. Contrasting with epidemiological cohort studies, case-series are descriptive studies following one small group of subjects. In essence, they are extensions of case reports. Usually the cases are obtained from the authors' experiences, generally involve a small number of patients, and more importantly, lack a control group.12 There is often confusion in designating studies as “cohort studies” when only one group of subjects is examined. Yet, unless a second comparative group serving as a control is present, these studies are defined as case-series.

While it is true that the authors are attempting to claim that their sample of "women denied abortions" is the "unexposed group," this is clearly not true for three reasons:

:(a) all the women were already exposed to a problem pregnancy,

:(b) all the women have already had gone through the process of seeking an abortion...which itself may be all or a portion of the traumatic part of some abortion experiences...especially when they are subsequently raising a child whom they recall at one point having planned to abort (which can cause cognitive dissonance), and

:(c) the "unexposed group" clearly includes women who actually have had multiple pregnancy experiences, including abortions and miscarriage, either before or after the index pregnancy, or both. (Indeed, in at least of of their studies, they controlled for parity (the number of pregnancies a woman has had), but not for prior or subsequent pregnancy losses, which is inconsistent.)

The false description of the Turnaway study as "prospective longitudinal cohort study" is a very important because it gives the false impression that the authors have applied the criteria of such studies, which are designed to follow a group of people ''before'' they are exposed to the subject of interest, in this case a pregnancy subject to abortion. In fact, this is a self-selected case series, with very high attrition rate, which consists entirely of women who are candidates for abortion.

This is another example of the authors efforts to present their findings as generalizable to the entire population of women when in fact there is no evidence, and every indication given the high refusal and drop out rate, that the findings of the remnant of women remaining in this study are applicable only to that remnant.

=====Dropouts and Refusers are at Higher Risk=====

The final sample was only 516 women, which is only 17% of the original 3,045 asked to participate in the study. Clearly, women experiencing the most post-abortion distress are more likely to refuse to participate or drop out. Indeed, the expectation of not coping well with an abortion is predictive of greater post-abortion distress and likely a major reason women would not choose to open themselves up to subsequent telephone interviews.

There is research evidence that low participation rates and / or high dropout rates distort the results of studies and lead to incorrect conclusions:

:After a workplace disaster in Norway, 246 employees were required to participate in medical evaluations for PTSD [http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.1989.tb05262.x/abstract (Weisaeth, 1989)]. At baseline pre-disaster, employees had a record of cooperation with the company medical officer. After the disaster, some were resistant and required repeated contacts; eventually participation reached 100%. The initial resistance was significantly associated with severity of PTSD at 7 months. The authors stated that if the initial refusals had been accepted, “the potential loss to the follow-up would have included 42% of the PTSD cases, and 64% of the severe PTSD cases would have fallen out, resulting in distorted prevalence rates of PTSD” (Weisaeth, 1989, p. 131). Additionally, “The initial resistance in many who later developed PTSD was found to relate to the psychological defenses such as avoidance which is seen both PTSD and acute post-traumatic stress syndrome” (Shuping, 2016, citing Weisaeth).

Additional evidence of selection bias problems are reported by [[Soderberg]]

====Inappropriate Measures & Study Design Flaws====
#The focus of this report in on women's persistent satisfaction with their abortion decisions, "decision rightness," as measured by a single question: "“Given your situation, was the decision to have an abortion the right decision for you?” Women were asked to answer this question "yes", "no" or "uncertain." This measure is flaws in several ways:
## A better research approach would have been to have this question rated on a numeric scale (1 to 10, for example) in order to better identify any shift in attitudes.
##There is no report of tests to verify the [http://www.relevantinsights.com/validity-and-reliability#sthash.x00kiuAX.dpbs validity and reliability of the questions used]. In other words, the authors do not report on any efforts made to evaluate whether the question(s) used provide reliable consistency...or are even understood by women in the same way. For example, do all women interpret the question in the same way? Or were there different nuances in understanding? Was it "right" as in "moral"? Or right as in "the best choice I could make at the time?" Or right in that it was the best choice any person could make? Was it right meaning one would make the same choice if one became pregnant again? Was it right in that "It made my life far better"? Or was it right only in the sense that "What's done is done, and I'm moving my life forward doing the best I can so that is my focus so I guess it was right . . . or at least what I have to work with."
##A feeling that a person made the right decision due to circumstances at that time is not the same as an assertion that it was the right decision regardless of circumstances or "if I knew what I knew now."
##The decisions assessment were conducted through telephone interviews approximately every six months. A well known problem with interview based studies is that many participants will try to please the interviewer by giving the answer they believe is expected of them. Similarly, some interviewers may be more prone to elicit certain types of response. The investigators did not report on any tests made to verify that such influences were not at play.
#As a general rule, questions regarding decision satisfaction (even about things such as the purchase of a purse) may produce [https://en.wikipedia.org/wiki/Reaction_formation reaction formation] and therefore defensive answers affirming the rightness of a decision even if there are actually unresolved anxieties or other issues. (To voice dissatisfaction may invite anxiety provoking thoughts. Responding the way one is expect to respond, avoids reflection).
#Rather than rely on a single question about the "rightness" of the abortion decision, additional questions should have been asked to better gauge the subjects thoughts. For example, in the [[Soderberg]] study, including a one year post-abortion interview of 847 women (after a 33% self-exclusion rate), 80% of the women reported they were satisfied with their decision to abort but at the same time 76% also stated that they would never abort again if faced with an unwanted pregnancy. In this case, the second question offers a great deal of additional insight. A woman expressing unwillingness to not have another abortion may be telling us more than her abortion experience than she is when she says that a past decision was "right."
#Another difficulty raised by the researcher's methodology is that their interviews apparently did not inquire about any steps women took to resolve negative emotions. It is necessary to know if women who had negative feelings sought any help to deal with those feelings, perhaps with a therapist, a pastor, or family or friends. The increase in the number of women participating in post-abortion programs should, for example, help to reduce the longevity of negative reactions to abortion. But if this is the case, the conclusion of the authors that negative reactions to abortion naturally diminish over time may be wrong if, in fact, the decrease is due to women receiving post-abortion psychological or spiritual counseling. In other words, if the decline in negative reactions is real (and not due to denial, repression, or just a desire to rush through the phone interview to collect the $50 gift card) it is important to understand the reason for this. Is it due to support given to those having negative feelings, or is it "natural" and permanent?
#The authors did not use any validated measures of psychological illness, as has been done in many other studies. Instead the assessment of psychological health is all inferred from a two scales created from six questions in which rated six emotions associated with their abortion women rated each emotion on a five point scale from "not at all" to "extremely." The six emotions were: relief, happiness, regret, guilt, sadness and anger. From these six self-assessments, reported by telephone to an interviewer, the scores for the four negative emotions were combined for a single scale and the two positive emotion scores were combined for a positive emotion scale. These scales were not tested for [http://www.relevantinsights.com/validity-and-reliability#sthash.x00kiuAX.dpbs validity or reliability]. Nor were they tested as a measure of overall psychological health or, conversely, psychological illness.
#The comparison group, the Turn Away group (n=210), includes 50 women who later terminated at another facility or had a miscarriage. So 24% of this group to which the researchers are comparing women who abort actually includes women who experienced pregnancy losses. Yet the researchers barely disclose this fact, giving the false impression that their study is comparing women who had abortions to women who carried to term.
#There was not anonymity. Women were interviewed by a paid staff person asking each question. The interviewing process itself may impact answers as respondents may be inclined to answer questions in a way that they believe will better satisfy the interviewer. In short, it is well established that there are differences in response to a written anonymous questionnaire compared to a verbal interview.
#There is no transparency. The authors of the study have refused to publish their questionnaires. This suggest that there may be questions that they have chosen to not report upon. It also prevents investigation of whether any series of questions were presented in a way that led respondents toward a specific answer in later questions.

====Inconsistency With Prior Research Findings====
#As mentioned above, a similarly designed followup study by [[Soderberg]] study reported that 80% of the women reported they were satisfied with their decision to abort but at the same time 76% also stated that they would never abort again if faced with an unwanted pregnancy. Soderberg also found that even though many women reported satisfaction with their decision they also experienced negative psychological outcomes, with 50-60% of women undergoing induced abortion experienced some measure of emotional distress, classified as severe in 30% of cases.
#Notably, the claim of declining regret and declining negative reactions is at odds with [[Brenda Major]]'s two year longitudinal study, which also had high drop out rates, which found that there was a trend in decline in relief and increase in negative emotions over the two year period among those who did not drop out of her study. (See Major B, et al. Psychological responses of women after first-trimester abortion. Archives of General Psychiatry. 2000: 57(8), 777-84.)
#Their claim that there is no evidence of mental health problems after abortion is not consistent with the findings of studies utilizing validated measures of mental health, including a [http://www.ncbi.nlm.nih.gov/pubmed/16343341 five year longitudinal study] nor with the [http://www.ncbi.nlm.nih.gov/pubmed/19880932 Christchurch Health and Development Study, a lifetime longitudinal study].
#Their findings are not consistent with findings of record linkage studies which have shown an [http://www.cmaj.ca/content/168/10/1253.full elevated risk of psychiatric admissions] following abortion, an [http://www.bmj.com/content/313/7070/1431 elevated rates of suicide] and elevated rates of [http://www.ncbi.nlm.nih.gov/pubmed/?term=reardpn+dc+sleep sleep disorders].
#Their findings are not consistent with the results of meta-analyses comparing a large number of studies, including reviews by [http://www.ncbi.nlm.nih.gov/pubmed/23859662 Bellini], [http://www.ncbi.nlm.nih.gov/pubmed/23553240 Fergusson], and [http://bjp.rcpsych.org/content/199/3/180.long Coleman].

====Unreported Details====
# According to an [http://www.ansirh.org/wp-content/uploads/Turnaway-Study-Infographic_7-8-2015.pdf infographic about the study] published by the research group, the followup interviews were actually continued every six months for five years, not just three. Why then did this report limit itself to three years rather than cover the full five years covered by the study?
#The study population included 413 women who had an abortion near the end of the second trimester and only 254 women having an abortion in the first trimester. Overall, only 31% participated at the baseline interview (35.7% agreed to be interviewed, but 15% of those dropped out before or during the baseline interview). The authors should report the drop out rate for each of the two groups: first trimester and second trimester.

====Overreaching Conclusions====
#While the report and [http://www.ansirh.org/news/new_ANSIRH.php accompanying press release] claim that this study proved there is "no evidence of widespread 'post-abortion trauma syndrome,' in fact it did not use any standard scales for assessment of psychological well being.
# The bias of the research team is made clear in [http://www.ansirh.org/news/new_ANSIRH.php press releases] and a [http://www.ansirh.org/wp-content/uploads/Turnaway-Study-Infographic_7-8-2015.pdf infographic] purporting to summarize the study. In these "summaries" the research group conceals the details regarding the high non-participation rate and boldly claims "95% of women who had abortions felt it was the right decision, both immediately and over 3 years," omitting the fact that 62.5% refused to answer the question at the time of their abortion and of those interviewed at the time 31% were out of the study by the third year. Notably, the problem of high non-participation and drop out rates is not mentioned in the abstract, press release, or other summarizing materials published by the authors. To the contrary, they consistently imply that their results apply to the entire population of women having abortions.
#The authors make much of the claim that 93% of the participants "completed at least one follow up interview" which the media outlets incorrectly reported as meaning [http://www.medicalnewstoday.com/articles/296756.php"Only 7% of the participants dropped out of the study during follow-up."] It would have been far more accurate to state that of the "Only 37.5% of eligible women agreed to be interviewed, of whom 85% actually did complete the complete baseline interviews (n = 956). Of this group, only 7% refused to do at least one followup interview."
#From the observation that the scale created from four negative reactions showed a modest decline in negative reactions over three years, the authors they draw the very broad conclusion that there is no evidence of widespread negative psychological reactions to abortion. As indicated above, this conclusion is contradicted by better designed studies. Moreover, this conclusion ignores the fact that many psychological problems are characterized by denial and repression of negative emotions. There is, in fact, clear evidence from other studies that [[PTSD |many women experience symptoms of post-traumatic stress disorder]] which includes symptoms of denial and avoidance behavior. In a study by Rue, for example, among women reporting intrusive memories or thoughts related to their abortion, only half denied that these thoughts were attributed (caused) by their abortions. In other words, it is not always easy for women to recognize which feelings may be attributable to their abortions. For example, it is only when in post-abortion counseling that many women may attribute increased feelings of anger after their abortions to unresolved feelings over the abortion which they were projecting onto other people and situations. This is all fairly basic psychology. Negative emotions often crop up in other parts of our lives because we have trouble dealing with them at the source. Therefore, women reporting less "anger" relative to their abortion may in fact have more feelings of anger in their lives than before their abortion but are simply attributing it to other issues. This demonstrates the difficulty in trying to judge the post-abortion emotional adjustment of women based on just six oversimplified questions about six basic emotions.
#The Turn Away Study hangs its claim to uniqueness on the fact that it utilizes as it group for comparison only women who initially sought to terminate a pregnancy but were denied abortions because they were beyond the gestation age cut off in various states and then carried to term. But this group of women giving birth is a very small and distinct sample, numbering only a few thousand women per year in the United States. Most importantly, this distinction should be clearly applied to all of the discussion and conclusions offered by the Turn Away Study authors, but it is not. Rather than frame their conclusions as applying to the very small women in the US each year who seek an abortion at or after the gestation date limit on legal abortions in various states, they seek to apply their conclusions to all women having abortions and all women carrying unplanned pregnancies to term.

::But even the above clarification limiting the findings to women denied abortions would not be inaccurate because the "turn away" group is not made up only of women who subsequently carried to term. Instead, it includes who found an abortion elsewhere and those who miscarried, making up approximately 24% of the total "turn away" group.

::So, to be completely accurate, the Turn Away Study's sloppy methodology mixes different experience and outcomes into the "turn away group" in a way that obscures rather than clarifies the differences between women who (a) have late term abortions and (b) those who carry to term or have late term abortions elsewhere.

::Notably, if the Turn Away Study abstracts, conclusions, and press releases were actually rewritten to accurately describe the makeup of the "turn away group" the conclusions drawn from these studies would be so narrow as to be almost meaningless. On the other hand, because the authors generally mention those limitations only once in the methods section of their studies, and then in the conclusion section, abstract, and press releases make it appear that their findings apply to the general population of women having abortions and those who carry unintended pregnancies to term, they are clearly overreaching what their data actually shows. They are merely using their weak data as an excuse to make general pronouncements about "safe abortion" without actually having meaningful data to support those broad claims.

====Refusal to Share Details and Data====
The authors have refused to share or publish the complete questionnaires used to collect data. They have also refused to share details of their analyses or any of their data for reanalysis by others.

====Exaggerations of ANSIRH News Release====

The ANSIRH news release, headlined "[https://www.ansirh.org/news/no-evidence-emerging-mental-health-problems-after-having-abortion No evidence of emerging mental health problems after having an abortion]" declares:

:Published in JAMA Psychiatry, “Women’s mental health and well-being five years after receiving or being denied an abortion: A prospective, longitudinal cohort study,” analysis from ANSIRH’s Turnaway Study, found that having an abortion does not adversely affect women’s mental health either at the time of the abortion or over five years after receiving abortion care. We also found that denying women abortion has negative consequences to their mental health and well-being in the short-term.

:We found no evidence that women who have abortions risk developing depression, anxiety, low self-esteem or less life satisfaction as a result of the abortion, either immediately following, or for up to five years after the abortion. However, women who were denied an abortion had more anxiety, lower self-esteem, and less life satisfaction immediately after being turned away. Over the subsequent five years, symptoms of anxiety and depression decreased and self-esteem and life satisfaction improved significantly, both for women who received an abortion and for women who were denied care.

:''The study provides the best evidence we have to date on the mental health effects of having an abortion'', by comparing women who received an abortion to those who were denied one, and following them for five years.

'''Note:''' The claim that this is the best evidence to date is totally bogus. The release totally ignores the fact that the small minority of women agreeing to participate in the study are not representative of most women, and further pretends that there is "no evidence" of mental health risks of abortion except for their own study. And the firs paragraph assertion that there are negative consequences to being denied an abortion fails to note that this assertion is based on just one assessment, one week after women seeking abortion were told it was past the gestational limit, and that by the time of the second assessment at six months there was no higher rates of depression, anxiety, or self esteem problems. In short, the press release has a lot of over generalizations based on a very thin evidence.

=====Letter from David Reardon to PLOS One =====
Dear PLOS One Editors,

I am writing to register a formal complaint against the authors of a PLOS ONE article who I believe have made disingenuous representations to PLOS ONE in order to improperly withhold data.

I have previously been a reviewer for another article submitted to another journal by this team of researchers and in that case also they refused to provide additional requested information, including a refusal to be provided with a blank copy of their survey form so I could review the exact wording of their questions.

Specifically, the article is [http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128832 Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study] by Corrine H. Rocca, et al.

When I emailed Dr. Rocca to request access to the data repository for reanalysis, she responded:

To excuse themselves from providing any data the authors state:
::The Data Availability Statement for the paper is on the first page of the publication: “The authors are not able to provide any data beyond what is presented in the manuscript due to restrictions that study participants agreed to when they signed the consent form, which was approved by the UCSF IRB. The authors have included sufficient details in the Methods section of the manuscript for others to replicate the analysis in a similar setting, using a similar study population.”

Regarding the first sentence of this claim, while clearly it would be appropriate to guarantee to participants that no identifying information would be released to others, what possible restrictions would participants be required to agree to that would preclude sharing non-identifying data with other researchers?

So I emailed Dr. Rocca the following request: "Would you please provide a blank copy of the consent form that the study participants signed, where I assume the restrictions on data sharing are described?"

She refused to reply.

Therefore, I am specifically requesting that PLOS ONE require Dr. Rocca to provide a copy of the consent form which the participants signed so that the claim that the non-identifying data cannot be made available based on promises made to the participants may be verified.

If Dr. Rocca should refuse to provide documentation supporting her claims, the journal should retract the paper due to her clear effort to evade the data availability requirements of the PLOS journals

I would note that the Turnaway Study data set, on which this PLOS ONE article is based, has been employed in numerous published articles authored by scores of authors. It is unreasonable to expect that the participants were promised that only a specific list of researchers would be allowed to analyze the non-personal data.

Regarding the claim that "The authors have included sufficient details in the Methods section of the manuscript for others to replicate the analysis in a similar setting, using a similar study population," this is another bogus assertion. As mentioned above, the authors have refused to share even the blank survey instruments used to collect the data so specific questions cannot be replicated.

Furthermore, the ANSIRH team collecting the data is closely aligned with abortion advocacy which is the only reason they were provided access to abortion patients at 30 abortion clinics.

Obviously, abortion is a very contentious issue both politically and academically. Clearly, researchers who are critical of the claim that abortion has no mental health effects are not allowed the access to abortion patients which has been granted to ANSIRH. Therefore, it is impossible for large segments of the research community to "replicate the analysis in a similar setting," as Rocca asserts. Indeed, it is my clear impression, based on Rocca's refusal to provide any additional information even to reviewers, is that she and her team are seeking to limit access to the data and their study methodology precisely to prevent any reanalyzes which may undermine their own preferred spin on the data they collected.

More importantly, the PLOS journals requirements for data sharing exist precisely to alleviate the high cost of replicating data collection and to facilitate reanalyzes of existing data sets.

Please investigate the concerns outlined above, beginning with a request for documentation regarding precisely what was promised to the Turnaway Study participants.

Thank you.

Sincerely yours,

David C. Reardon, Ph.D.
Elliot Institute

*PLOS One declined the request to ask Dr. Rocca to provide any evidence that the consent form did indeed bar sharing non-personal data with other researchers.

*It was subsequently revealed in Dr. Foster's book ''The Turnaway Study'' that in 2018 they decided to work with a previously unknown researcher, Sarah Miller, an economist who suggested they use the personal information of the women in their sample to request their credit scores from credit agencies in order to examine the effects of having an abortion on credit scores. Clearly, the claim that they were not allowed to share data made in PLOS publication was a lie.

===Critique by Priscilla Coleman===

The following is reprinted with permission from '''WECARE''''s website where it is titled '''[http://www.wecareexperts.org/content/turnaway-study-analyzed-wecare-director-latest-attempt-reverse-evidence-based-women-centered The Turnaway Study Analyzed by WECARE Director: The Latest Attempt to Reverse Evidence-based, Women-Centered Advances in Abortion Policy]'''

The PLoS ONE study titled “Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study” is riddled with serious design flaws that render the results meaningless. The problematic issues are described in detail below followed by evidence that the true motivation for publishing the study is likely political. In recent years, credible science has informed policy with 26 states, now requiring information regarding mental health effects be shared with women considering abortion. This study is a poor attempt to provide counter “evidence” and obscure the reality of women’s suffering, reminiscent of the highly flawed research from the 70s and 80s.

'''Methodological Issues:'''

1) As reported by the authors, the consent to participate rate is only 37.5%. This is unacceptable, as the missing 62.5% who were approached and declined were likely the women who had the most adverse psychological reactions to their abortions. With sensitive topic research, securing a high initial consent rate is vitally important and in order to approach being representative, a minimum of 70% should be retained.

2) The authors note that the sample was comprised of a high concentration of women from low socioeconomic backgrounds, rendering the sample not representative of US women undergoing abortion today. There is an ethical concern here as a well, since providing $350 to participate is coercive, as it would be difficult for most of the women to turn down the money.

3) The authors fail to reveal the specific consent to participate rates for each group. Because prior research has demonstrated that second trimester abortions are potentially more traumatizing than first trimester procedures, it is likely that a significantly higher percentage of women in the first-trimester group consented to participate; and the percentage of willing to participate, second trimester participants was likely well under 37.5%. If the rates were comparable, why not report this? Failure to report critical information increases suspicion that this “near limit’ group is in no way representative.

4) In the Turnaway Study, women who secured abortions near the gestational limits included women for whom the legal cut off ranged from 10 weeks through the end of the second trimester. There is a wealth of data indicating that women’s reasons for choosing abortion and their emotional responses to the procedure differ significantly at varying points of pregnancy. Women aborting at such widely different points should therefore not be lumped together, particularly when gestational age information is available in the data.

5) No information is provided regarding how the sites were actually chosen. What type of sampling plan was employed? Why were only those identified with the National Abortion Federation used? What cities were included? Which areas of the country were sampled?

6) The majority of the outcome measures are single items, and this is problematic given the many psychometrically sound multiple item instruments available in the literature for the variables examined. Well-trained behavioral science researchers should not attempt to measure complex human emotions in such a superficial manner; and ethically responsible scientists would not extrapolate from such minimalistic assessments to women’s emotional reactions to one of life’s more challenging decisions.

'''Bias issues:'''

7) The authors’ uneasiness with recent litigation is stated in the opening paragraph: “''Arguments about emotional harms from induced abortion—including decision regret and increasing negative emotions over time—have been leveraged to support abortion regulation in the United States. To uphold a 2007 law banning a later abortions, Justice Kennedy of the Supreme Court stated: “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort...” In support of a state-level ban, a researcher testified that abortion “carries greater risk of emotional harm than childbirth.” Arguments about emotional harm have been used to forward parental consent, mandatory ultrasound viewing, and waiting period legislation as well.''” This is a rather odd way to open a supposed scientific investigation and the authors’ unapologetic decision to do so reveals their rather transparent political motivation (i.e., to provide counter results no matter what the scientific cost).

8) The authors’ effort to draw sweeping conclusions from this single, seriously compromised study is evident in their remarks regarding the implications of the study: “''Results from this study suggest that claims that many women experience abortion decision regret are likely unfounded''.” As scientists we never make such sweeping conclusions based on a single study, particularly when there is an abundant literature comprised of hundreds of sophisticated studies wherein the conclusions are quite discrepant. Courts throughout the US have concluded that women should be appraised of the risks before consenting to abortion; it almost seems silly that these researchers hope to shift the tide based on this study alone.

9) Funding was secured from the David and Lucille Packard Foundation among other sources with a political agenda. As described on their website, “''Our work in the United States seeks to advance reproductive health and rights for women and young people by improving access to quality comprehensive sexuality education, family planning and safe abortion care''.”

= Effect of abortion vs. carrying to term on a woman's relationship with the man involved in the pregnancy =

[http://www.ncbi.nlm.nih.gov/pubmed/25199435 Effect of abortion vs. carrying to term on a woman's relationship with the man involved in the pregnancy.] Mauldon J, Foster DG, Roberts SC. Perspect Sex Reprod Health. 2015 Mar;47(1):11-8. doi: 10.1363/47e2315. Epub 2014 Sep 8.

:CONTEXT:When a woman who seeks an abortion cannot obtain one, having a child may reshape her relationship with the man involved in the pregnancy. No research has compared how relationship trajectories are affected by different outcomes of an unwanted pregnancy.
:METHODS:Data from the Turnaway Study, a prospective longitudinal study of women who sought abortion in 2008-2010 at one of 30 U.S. facilities, are used to assess relationships over two years among 862 women who had abortions or were denied them because they had passed the facility's gestational age limit. Mixed-effects models analyze effects of abortion or birth on women's relationships with the men involved.
:RESULTS: At conception, most women (80%) were in romantic relationships with the men involved. One week after seeking abortion, 61% were; two years later, 37% were. Compared with women who obtained an abortion near the facility's gestational age limit, women who gave birth had greater odds of having ongoing contact with the man (odds ratio at two years, 1.7). The odds of romantic involvement at two years did not differ by group; however, the decline in romantic involvement was initially slower among those giving birth. Relationship quality did not differ between groups.
:CONCLUSIONS: Giving birth temporarily prolonged romantic relationships of women in this study; most romantic relationships ended soon, whether or not the woman had an abortion. However, giving birth increased the odds of nonromantic contact between women and the men involved throughout the ensuing two years.

=PTSD in the Turnaway Study Sample=

[[https://bmjopen.bmj.com/content/6/2/e009698 Does abortion increase women’s risk for post-traumatic stress? Findings from a prospective longitudinal cohort study.]] Biggs, M. A., Rowland, B., McCulloch, C. E., & Foster, D. G. (2016). BMJ Open, 6(2).
:In this self-selected sample of a minority of women who had abortions, at the baseline interview one week after their abortions, 39% reported at least one symptom of post-trauamtic stress syndrome and 16% reported three or more symptoms placing them at risk of PTSD. When asked to attribute the cause of their stress, 7% of the women attributed subsequent symptoms of post-traumatic stress to their abortions. Among those with any symptoms, 30% attributed their symptoms to a history of exposure to violence or abuse, 20% to non-violent relationship issues (20%), 19% to their abortion, and 15% to a non-violent death or illness of a loved one, and 6% attributing it to personal health-related issues (6%). Negative reactions were not necessarily reflected in repudiation of their decision to have an abortion, however, "By the end of the study period, four of the seven women who reported the index pregnancy as the source of their PTSS still felt the abortion was the right decision for them (not shown in table)." Remember, however, the "right decision" measure is based on a single yes, no question.

= Claimed Examination of Physical Health Effects =
[http://www.sciencedirect.com/science/article/pii/S1049386715001589 Side Effects, Physical Health Consequences, and Mortality Associated with Abortion and Birth after an Unwanted Pregnancy] Gerdts C, Dobkin L, Foster DG, Schwarz EB. Womens Health Issues. 2016 Jan-Feb;26(1):55-9. doi: 10.1016/j.whi.2015.10.001

:INTRODUCTION: The safety of abortion in the United States has been documented extensively. In the context of unwanted pregnancy, however, there are few data comparing the health consequences of having an abortion versus carrying an unwanted pregnancy to term.

:METHODS: We examine and compare the self-reported physical health consequences after birth and abortion among participants of the Turnaway Study, which recruited women seeking abortions at 30 clinics across the United States. We also investigate and report maternal mortality among all women enrolled in the study.

:RESULTS: In our study sample, women who gave birth reported potentially life-threatening complications, such as eclampsia and postpartum hemorrhage, whereas those having abortions did not. Women who gave birth reported the need to limit physical activity for a period of time three times longer than that reported by women who received abortions. Among all women enrolled in the Turnaway Study, one maternal death was identified-one woman who had been denied an abortion died from a condition that confers a higher risk of death among pregnant women.

:CONCLUSION: These results reinforce the existing data on the safety of induced abortion when compared with childbirth, and highlight the risk of serious morbidity and mortality associated with childbirth after unwanted pregnancy.

Note: In addition to the usual problems of this study in regard to its use of a non-representative sample, the measures used are inaccurate. Moreover, the claimed assessment of physical health was based on just two questions (with no examination of actual medical records): 1) “Did you experience any side effects or health problems from your [birth/abortion]?” and 2) “Was there a period after your [birth/abortion] when you were physically unable to do daily activities such as walking, climbing steps or doing errands?”

Abortion related deaths are defined by the Centers for Disease Control (CDC) in the United States as any death due to "1) a direct complication of an abortion, 2) an indirect complication caused by the chain of events initiated by the abortion, or 3) an aggravation of a preexisting condition by the physiologic or psychologic effects of the abortion, regardless of the amount of time between the abortion and the death" (Bartlett, L. a, Berg, C. J., Shulman, H. B., Zane, S. B., Green, C. a, Whitehead, S., & Atrash, H. K. (2004). Risk factors for legal induced abortion-related mortality in the United States. Obstetrics and Gynecology, 103(4), 729–737.) But in the Turnaway Study, the researchers excluded examination of deaths beyond 42 days . . . and, of course, ignored all the record linkage studies showing higher mortality rates after abortion.

=Substance Use in the Turnaway Study=

Receiving versus being denied an abortion and subsequent drug use.Roberts SC, Rocca CH, Foster DG. Drug Alcohol Depend. 2014 Jan 1;134:63-70. doi: 10.1016/j.drugalcdep.2013.09.013. Epub 2013 Sep 23.

:BACKGROUND: Some research finds that women receiving abortions are at increased risk of subsequent drug use and drug use disorders. This literature is rife with methodological problems, particularly inappropriate comparison groups.
:METHODS: This study used data from the Turnaway Study, a prospective, longitudinal study of women who sought abortions at 30 sites across the U.S. Participants included women presenting just prior to an abortion facility's gestational age limit who received abortions (Near Limit Abortion Group, n=452), just beyond the gestational limit who were denied abortions (Turnaways, n=231), and who received first trimester abortions (First Trimester Abortion Group, n=273). This study examined the relationship between receiving versus being denied an abortion and subsequent drug use over two years. Trajectories of drug use were compared using multivariate mixed effects regression.
:RESULTS: Any drug use, frequency of drug use, and marijuana use did not change over time among women in any group. There were no differential changes over time in any drug use, frequency of drug use, or marijuana use between groups. However, Turnaways who ultimately gave birth increased use of drugs other than marijuana compared to women in the Near Limit Abortion Group (p=.041), who did not increase use.
:CONCLUSION: Women receiving abortions did not increase drug use over two years or have higher levels of drug use than women denied abortions. Assertions that abortion leads women to use drugs to cope with the stress of abortion are not supported.

=Non-Representative Sample=
[https://pubmed.ncbi.nlm.nih.gov/24439937/ Implementing a prospective study of women seeking abortion in the United States: understanding and overcoming barriers to recruitment] Womens Health Issues . Jan-Feb 2014;24(1):e115-23. doi: 10.1016/j.whi.2013.10.004.

Background: The Turnaway Study is designed to prospectively study the outcomes of women who sought-but did not all obtain-abortions. This design permits more accurate inferences about the health consequences of abortion for women, but requires the recruitment of a large number of women from remote health care facilities to a study a sensitive topic. This paper explores the Turnaway Study's recruitment process.

Methods: From 2008 to 2010, the staff at 30 abortion-providing facilities recruited eligible female patients. Eight interventions were evaluated using multilevel logistic regression for their impact on eligible patients being approached, approached patients agreeing to go through informed consent by phone, and enrolled patients completing the baseline interview.

Findings: After site visits, patients had roughly twice the odds of being approached by facility staff and twice the odds of then agreeing to go through informed consent. When all recruitment steps were considered together, the net effect of site visits was to increase the odds that eligible patients participated by nearly a factor of six. After the introduction of a patient gift card incentive, patients had over three times the odds of agreeing to go through informed consent. ''With each passing month, however, staff demonstrated a 9% reduced odds of approaching eligible patients about the study''.

Conclusion: Prioritizing scientific rigor over the convenience of using existing datasets, the Turnaway Study confronted recruitment challenges common to medical practice-based studies and unique to sensitive services. Visiting sites and communicating frequently with facility staff, as well as offering incentives to patients to hear more about the study before informed consent, may help to increase participation in prospective health studies and facilitate evaluation of sensitive women's health services.

NOTE: It is elsewhere reported that two-thirds of the participants came from just three of the 30 clinics participating.

= Women’s Mental Health andWell-being 5 Years After Receiving or Being Denied an Abortion =

[http://jamanetwork.com/journals/jamapsychiatry/article-abstract/2592320 Women’s Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study.] Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. JAMA psychiatry. December 2016. doi:10.1001/jamapsychiatry.2016.3478.

:Objective To assess women's psychological well-being 5 years after receiving or being denied an abortion. Design, Setting, and Participants This study presents data from the Turnaway Study, a prospective longitudinal study with a quasi-experimental design. Women were recruited from January 1, 2008, to December 31, 2010, from 30 abortion facilities in 21 states throughout the United States, interviewed via telephone 1 week after seeking an abortion, and then interviewed semiannually for 5 years, totaling 11 interview waves. Interviews were completed January 31, 2016. We examined the psychological trajectories of women who received abortions just under the facility's gestational limit (near-limit group) and compared them with women who sought but were denied an abortion because they were just beyond the facility gestational limit (turnaway group, which includes the turnaway-birth and turnaway-no-birth groups). We used mixed effects linear and logistic regression analyses to assess whether psychological trajectories differed by study group.

:Main Outcomes and Measures We included 6 measures of mental health and well-being: 2 measures of depression and 2 measures of anxiety assessed using the Brief Symptom Inventory, as well as self-esteem, and life satisfaction. Results Of the 956 women (mean [SD] age, 24.9 [5.8] years) in the study, at 1 week after seeking an abortion, compared with the near-limit group, women denied an abortion reported more anxiety symptoms (turnaway-births, 0.57; 95% CI, 0.01 to 1.13; turnaway-no-births, 2.29; 95% CI, 1.39 to 3.18), lower self-esteem (turnaway-births, -0.33; 95% CI, -0.56 to -0.09; turnaway-no-births, -0.40; 95% CI, -0.78 to -0.02), lower life satisfaction (turnaway-births, -0.16; 95% CI, -0.38 to 0.06; turnaway-no-births, -0.41; 95% CI, -0.77 to -0.06), and similar levels of depression (turnaway-births, 0.13; 95% CI, -0.46 to 0.72; turnaway-no-births, 0.44; 95% CI, -0.50 to 1.39).

:Conclusions and Relevance In this study, compared with having an abortion, being denied an abortion may be associated with greater risk of initially experiencing adverse psychological outcomes. Psychological well-being improved over time so that both groups of women eventually converged. These findings do not support policies that restrict women's access to abortion on the basis that abortion harms women's mental health.

==Criticisms==
* The authors hide the fact that only 11% of the eligible women participated in this study thru the fifth year, making it impossible to generalize any findings from this highly self-selected sample, especially when women having negative reactions would be most likely to drop out.
* Moreover, the only elevated risk persisted for only a few weeks after "being denied" an abortion, while women are still under stress and trying to sort out their lives. Most importantly, the study actually found NO negative mental health effects after the child was born, either in the first year or over the five years examined.
* All the general problems discussed at the top of this page also apply.
*It is also worth noting that at one week after the abortion, those denied abortion had an average depression score of .13 compared to .44 for women who had an abortion . . . in other words, while turnaways had higher anxiety they had less depression than those who had aborted. The difference in depression scores was not statistically significant due to the low power of this study, but it demonstrates the authors' tendency to overgeneralize findings in away that minimizes effects of abortion and magnifies the effects of being denied an abortion.
* Another problem is that the "control group" is not clear and clean. They are treating women in the turnaway group as their control group, but in fact they elsewhere report that [https://pdfs.semanticscholar.org/bc37/113def0d0b90f94bea2acee1e8ec1dfcfcea.pdf 40% of the turnaway group had a prior history of abortion]. In other words, they are comparing a group of women who have a one or more abortions to another group of women of whom at least 40% have had one or more abortions, and are pretending that the prior abortions in the second group don't matter in a study about abortion and mental health.

==Media Coverage==
[https://time.com/4599806/abortion-doesnt-negatively-affect-womens-mental-health-study/ Abortion Doesn't Negatively Affect Women's Mental Health: Study] ''Time'' Dec 14, 2016
[https://www.nytimes.com/2016/12/14/health/abortion-mental-health.html?_r=0 Abortion Is Found to Have Little Effect on Women’s Mental Health] New York Times Dec 14, 2016
[http://www.newsweek.com/abortion-mental-health-link-study-531643 No Evidence Abortion Leads to Long-Term Depression and Anxiety] Newsweek 12/14/16
[http://www.psychiatryadvisor.com/depressive-disorder/study-refutes-assumption-that-women-experience-adverse-psychological-outcomes-following-an-abortion/article/627466/ Worse Psychological Outcomes for Women Denied Abortion] Psychiatry Advisor
[http://www.salon.com/2016/12/14/abortion-isnt-linked-with-mental-illness-study-shows-but-being-denied-one-might-be/ Abortion isn’t linked with mental illness, study shows — but being denied one might be] Salon
[http://www.medpagetoday.com/obgyn/pregnancy/62066 More Mental Health Issues Among Women Denied Abortions] MedPage Today
[http://www.ajmc.com/focus-of-the-week/1216/women-denied-abortions-report-worse-mental-health-outcomes#sthash.hg4xgfZw.dpuf Women Denied Abortions Report Worse Mental Health Outcomes] AJMC Managed Markets Network
[http://www.webmd.com/women/news/20161214/women-denied-an-abortion-endure-mental-health-toll-study#1 Women Denied Abortion Endure Mental Health Toll] WebMD. Dec. 14, 2016

[http://www.medicaldaily.com/abortion-study-2016-most-women-didnt-struggle-decision-terminate-400937 Abortion Study 2016: Most Women Didn't Struggle With Decision To Terminate] Medical Daily Oct 2016
[http://www.livescience.com/57225-denying-abortion-access-harms-womens-mental-health.html Denying Abortion Access May Harm Women's Mental Health] Dec 15, 2016
[http://time.com/4599806/abortion-doesnt-negatively-affect-womens-mental-health-study/ Abortion Doesn't Negatively Affect Women's Mental Health: Study] Time. Dec 14, 2016
[http://www.thedailybeast.com/articles/2016/12/14/study-abortion-doesn-t-harm-women-s-mental-health-but-denying-one-does.html Study: Abortion Doesn't Harm Women's Mental Health, but Denying One Does.] The Daily Beast. Dec 14, 2016
[http://www.slate.com/blogs/xx_factor/2016/12/14/new_longitudinal_study_confirms_that_women_who_get_abortions_do_not_suffer.html New Longitudinal Study Confirms That Women Who Get Abortions Do Not Suffer Psychological Harm] Slate Dec 14, 2016

==Critique by Priscilla Coleman==

*"[https://www.mercatornet.com/features/view/the-continuing-saga-of-efforts-to-deny-the-heartache-of-abortion/19163 The continuing saga of efforts to deny the heartache of abortion]," by Priscilla Coleman

= Suicidal Thoughts =
'''Biggs MA, Gould H, Barar RE, Foster DG. [https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2018.18010091?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Five-year suicidal ideation trajectories among women receiving or being denied an abortion.] Am J Psychiatry 2018;175:845–52. <nowiki>https://doi.org/10.1176/appi.ajp.2018.18010091</nowiki>.'''

In this study the authors conclude "Levels of suicidal ideation were similarly low between women who had abortions and women who were denied abortions. Policies requiring that women be warned that they are at increased risk of becoming suicidal if they choose abortion are not evidence based." But once again, their reporting and conclusions are selectively chosen to distract readers from findings which actually show higher rates of suicidality among the abortion women. In Table 2, the average mean score on the suicidality scale over the full five years was significantly lower for the Turnaway Birth Group (0.67) as compared to both the first trimester abortion group (0.88) and the near-limit abortion (0.94) at one week after going to the abortion clinic. This was also true at the first interview, one week after being invited to participate at the abortion clinic: Turnaway Birth Group (1.29), first trimester abortion group (1.53) and the near-limit abortion (1.92), and for the Turnaway Group still seeking abortion (2.02). Yet, while this difference is shown in the tables, it is never discussed, Instead, the authors focus on the decline in suicidality scores across the five years and assert that since there is a similar decline in rates, that means that abortion is not associated with suicidality. Which is clearly not even logically true. Much less, it ignores the fact that suicidality was significnatly associated with abortions at numerous points in sequence of surveys.

Notably, Table 3 also shows the birth group having the lowest risk of suicidality, but they try to justify ignoring this finding by computations of the 95% confidence intervals which reveal that their data set is so small that their confidence intervals have a huge range, for example for the Turnaway birth group, the OR=1.07 95% CI = 0.14 to 8.01. What that huge range means is that their data set is simply too small to detect any effects.

They also ignore the likelihood that the high dropout rate may have helped to reduce the suicidality measured over time, if the most distressed women were most likely to drop out. Notably, they do include an "attrition analysis" in which they assert that in testing scores related to depression, anxiety, history of child abuse and past-year intimate partner violence were not significantly associated with loss to follow-up (though they withheld the data). But why in the world did they not report whether suicidality was associated with dropouts---unless it was associated with dropouts and they wanted to distract readers with an offering of other variables for which it is not associated. This is almost surely truly a tell.

=Peer Reviewed Criticisms of the Turnaway Studies=

[https://pmc.ncbi.nlm.nih.gov/articles/PMC6161227/ The Embrace of the Proabortion Turnaway Study: Wishful Thinking? or Willful Deceptions?]

[https://pmc.ncbi.nlm.nih.gov/articles/PMC11559533/ A Forensic Investigation and Critique of Suicidal Ideation Reported in a Turnaway Study]

[https://doi.org/10.70257/twgf1217 Turnaway Study Report Unethically Violated Participants' Privacy and Misleads Public with a Non-Representative Sample, Selective Reporting, and Overstated Conclusions]

[https://www.researchgate.net/publication/361369761_The_Turnaway_Study_A_Case_of_Self-Correction_in_Science_Upended_by_Political_Motivation_and_Unvetted_Findings The Turnaway Study: A Case of Self-Correction in Science Upended by Political Motivation and Unvetted Findings]

== Other Critiques ==
[https://afterabortion.org/theyre-still-trying-to-disprove-post-abortion-trauma-syndrome/ They're Still Trying to Disprove Post-Abortion Trauma Syndrome]

[http://liveactionnews.org/flawed-biased-turnaway-study-now-claims-95-women-happy-abortion/ Flawed, Biased Turnaway Study Now Claims 95 Percent of Women Happy After Abortion]

[http://reclaimingourchildren.typepad.com/lumina_a_ray_of_light_aft/2015/07/hardly-any-women-regret-having-an-abortion-only-millions-of-us.html Hardly Any Women Regret Having an Abortion -- Only Millions of Us!]

Takeaways from the UCSF Abortion "Turnaway" Study (Series from NRL News Today):
[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study/#.VaafirV_Dkc Part I: Set up for a Spin]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-2/#.VaagarV_Dkc Part II: Finding What They Looked For]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-3/#more-20901 Part III: Spinning the Consequences of Abortion]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-4/#more-20951Part IV: Research Team with an Agenda]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-5/#.VaagnbV_Dkf Part V: How Bias Can Tilt Results]

=Review of the Book=
The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having―or Being Denied―an Abortion
by Diana Greene Foster Ph.D. New York. Scribner. 2020.

The principle goal of Foster's book is to insist that there is "no evidence that abortion hurts women" while there are "many ways in which women are hurt by carrying an unwanted pregnancy to term"(p 21). From this vantage point, she argues against any and every abortion law regulating informed consent, disclosure of risks, waiting periods, and constraints on late term abortions. In short: abortion is good. Delivering unplanned pregnancies is frought with risk.

Foster consistently exaggerates the importance of her case series study. Any evidence to the contrary is ignored and all public policies that she opposes (such as risk disclosure requirements, waiting periods, term limits, and safety regulations) are "proven" to be unnecessary.)

Foster's studies and books have been promoted and lauded by all of the pro-abortion media. She even basks in repeating the description of her study by ill-informed reporter for New York Times Magazine "as the 'most rigorous' study to look at whether women develop mental health problems following an abortion."(p. 7) That's total nonsense, but it serves to advance her political goals, so Foster introduces her study with this accolade in an effort to distract readers from the many serious flaws of her work.

Her first lie is that her study is a prospective longitudinal study, like that which was recommended by Surgeon General C. Everett Koop. In fact, a prospective study on abortion would require gathering data on subjects ''before'' they become pregnant so one can examine mental and physical health before and after the pregnancy and its outcome (birth, abortion, or natural loss). But the Turnaway Study only begins to gather data a full week ''after'' women had their abortions, or in the subset of women "denied" an abortion, after they went to the abortion clinic. This means it is a "case series" study--one that follows cases. It is not a prospective study--one that has objective data prior to outcomes of interest.

The second lie is one of omission. She never tells readers of the body of research that shows that there is a dose effect--negative emotions increase with each exposure to a pregnancy loss, whether it is an abortion or miscarriage. This is important because her study totally ignored prior and subsequent pregnancy history. It is likely that to 20-40% of those who were turned away and gave birth had a prior abortion or an abortion after the delivery. As a result, Foster is comparing women who have a known abortion to women with an unknown mix of abortion histories. This is simply bad science.

The third lie is in framing, delay, and dismissal. Readers are led to believe that her survey of "a thousand women" gathered from 30 abortion clinics is truly representative of the national population of women seeking abortions. It is not until page 253 that Foster admits that only 31% of the women invited to participate in the study participated in even the first interview, a week after going to the clinic. This is a horrible participation rate. Based on research from other studies, the most likely explanation is self-censure: the women who expect to have the most negative feelings following their abortions are least likely to want to have those feelings stirred up by interviews weeks, months, and years later. But Foster doesn't mention this research. Instead, she simply dismisses the low participation rate as being most likely due women finding it he inconvenient. At this point, Foster could also have mentioned that participants were even offered a $50 gift card for every interview, but this fact (along with many others) are revealed only in addenda to her published medical studies, not her in her book, news releases, summaries or other propaganda pieces. For example, another omitted detail is that of 31% who did participate in the first interview, only about half (17%) remained in the study for the whole five years. Fifty bucks per interview was simply not enough to prevent high drop out rates. Again, it is quite likely that the women dropping out were most likely to be experiencing the most negative feelings.

It is also not until page 253 that we learn that the invitation process was also not random. Clinic workers had the liberty to decide who they wanted to invite. In fact, two-thirds of the participants came from just three of the 30 clinics participating.

Readers are also not informed that the study ignored prior and subsequent abortions, in both the aborting group and those who carried to term. As many as 20-40% of those who were turned away and gave birth had a prior abortion or an abortion after the delivery. This is simply ignored. As a result, Foster is comparing women who have a known abortion to women with an unknown mix of abortion histories. This is simply bad science.

==Inconsistencies==
*page21 -"We find no evidence that abortion hurts women." p.125 - 39% of women in the sample had symptoms of post-traumatic stress, and 16% were at risk of post-traumatic stress disorder. Of those at risk, 19% attributed their traumatic reactions to their abortions, yet the researchers dismiss this finding as "no evidence that abortion hurts women" on the grounds that it was more common for women to attribute their PTSD to experiences of violence, or other health issues. Similarly, their claim that there are no negative reactions is contradicted by their own findings that (p 121) 74% reported sadness, 66% regret, 62% guilt and 43% anger.

*p100-Here Foster says that "the initial motivation for the entire Turnaway Study, after all, was to answer the question ''Does abortion hurt women?''" But on page 4 she stated that the original intent was simply to address the question "I wonder what happens to the women we turn away." If the real intent was to investigate potential harm to women, this was the wrong study design since it lacked any information about women before they sought abortion, especially before they were pregnant . . . plus it ignores any effects of prior or subsequent abortions on women, confining itself to just the one abortion at the time volunteers joined the study.

*p121 - After being told they were over the time limit and could not have an abortion, 60% of women denied abortions reported feeling happy about their pregnancy and [https://pdfs.semanticscholar.org/bc37/113def0d0b90f94bea2acee1e8ec1dfcfcea.pdf 43% were happy about being turned away, with 49% reporting they also felt relief a week after being turned away. Their levels of sadness and guilt were also lower than that of those who aborted].

*p107-108 - Claims: "Actually, women seeking abortions are no different from women in general." But this contradicts the claim if other pro-abortion researchers, such as Steinberg and Munk-Olsen, that women who have abortions are over twice as likely to have prior mental health problems, which is how they explain the higher rates of psychological problems found among women who have abortions in large scale population studies...which are not subject to the non-random self-selected sample problems attached to Foster's study. In short, there is a lot of research indicating that women who have abortions ARE different from the general population, but this is another example of Foster's penchant for propaganda rather than fact.

==Nuances Admitted==
*p99-100 - Foster admits that at least some women who have difficulty coping after an abortion may attempt to re-frame and rationalize their decision as being for the best: "None of us know, as we move through our lives, what would have been at the end of the roads not taken. I suspect that whichever path we take, when we look back, we want to feel like we made the best decisions possible—that everything worked out for the best. So Martina's statement that "I don't regret the abortion at all. I'm where I am supposed to be in my life" could be an after-the fact rationalization of her experience." This admission totally undercuts the significance of Foster's claim that 95% of women are happy with their decision to have an abortion.

*p102-103 - Foster reports that "Approximately one in five women seeking abortion in the Turnaway Study thought abortion was morally wrong or should be illegal." {The study reported that another 15% believe it is morally wrong in some circumstances.} She also states that in another study she conducted of women in an abortion clinic waiting room "4% agreed with the statement 'At my stage of pregnancy, I think abortion is the same as killing a baby that's already born.'"

*p121 - Foster admits that answers to questions can be easily misinterpreted, giving as an example "It was terrible" could mean the experience was terrible or being in the situation to require an abortion was terrible. Similarly, feeling "relief" could mean feeling relieved that the experience is over or relieved not to be pregnant. Using the same logic, she notes that while the majority of women (60%) who were told they couldn't have an abortion were reported feeling happy about their pregnancy seven days later, this high level of happiness did not mean they "were entirely glad they became pregnant." Mixed emotions are common. So claims that most women feel "relief" after an abortion simply don't tell us enough about what kind of relief they are feeling, much less that they are not also feeling negative emotions.

*p122 - "Over the five years, women who reported having more difficulty deciding to seek an abortion also felt more negative emotions, as did women who perceived that abortion was looked down upon in their communities and women with less social support." In addition, women who had a greater desire or openness to becoming pregnant were also more likely to have negative feelings.

==Denying an Abortion Does No Harm, Most are Happy to Have Child==
*p109-There is no mental health harm from being denied an abortion. In fact, the majority of women who were denied abortions reported feeling happy at that result (p121).

*p109-Foster was surprised to find that women who were denied abortions had no additional mental health harm. "I expected that raising a child one wasn't planning to have might be associated with depression or anxiety. But this is not what we found over the long run. Carrying an unwanted pregnancy to term was not associated with mental health harm. Women are resilient to the experience of giving birth following an unwanted pregnancy, at least in terms of their mental health."

*P109- In an effort to salvage that narrative that denying abortion "hurts" women, she can only point to a single finding just one week after women sought an abortion showing that Turnaways had somewhat higher rates of anxiety compared to women who aborted a week earlier. But at that same time, the women who aborted reported higher rates of sadness, guilt and depression than the turnaways. Bottom line: the Turnaway Study actually supports the idea that banning abortions would not cause any significant mental health harm to women. In fact, just one week after going to the clinic, '''60% of those who were still pregnant reported being happy about their pregnancy''' compared to just 27% of those who had abortions. Among those who had near term abortions, 62% reported feeling guilty compared to just 30% of the Turnaways.

*p 126 - "One week after abortion denial, 65% of participants reported still wishing they could have had the abortion [35% were happy they did not have it]; after the birth, only 12% of women reported that they still wished that they could have had the abortion." By the first birthday, it dropped to 7% and then down to 4% at the last interview, 4.5 years later. Those "women who had less social support from family and friends and women who had an easy time decision to have the abortion were the ones who were more likely to continue to wish they had received an abortion."

*p 126 - Among women who had their babies, those who reported the most negative emotions were those who placed their children for adoption. At the 4.5 year followup, 15% of women who placed the child for adoption compared to just 2% of women who parented their child, reported that they still wished they could have had the abortion.

==Inconsistencies regarding mental health==

*p121--In Foster's 2013 paper examining emotions relative to their pregnancies one week after seeking an abortion, among all groups of women, 74% reported sadness, 66% regret, 62% guilt, 43% anger, 25% relief and 33% happiness. Regarding their abortion experiences, 64% sadness, 41% regret, 53% guilt, 31% anger, 83% relief, and 52% happiness. But turnaways were twice as likely to subsequently report happiness about their pregnancy, 43% said they were happy to not have had the abortion, and 49% said they were relieved not to have had the abortion. Also, 60% of Turnaways report happiness about their pregnancies compared to 25% of women who had a first trimester abortion. This suggests that Turnaways may have delayed seeking an abortion because they actually were hoping to keep their children.

*Note: In their 2015 report on "decision rightness" the Turnaway team reports that at the baseline (one week after their abortions) 95% of women answered yes to "“Given your situation, was the decision to have an abortion the right decision for you?" But in the same interview, 66% and 41% reported regret relative to the pregnancy and the abortion respectively. As noted above, a majority also reported guilt and high rates of sadness and anger. Therefore, women do not equate "decision rightness" with their overall feelings about their abortion experience, and it is totally inappropriate for Foster and her team to promote the idea that 95% decision rightness means that regret and other negative reactions are rare.

*p124 - Foster complains that Justice Kennedy upheld a law regulating abortion on the grounds that "some women come to regret their choice to abort." She fails to point out that her own study confirmed Kennedy's statement, with 33-65% of women reporting regret. Instead, she focuses strictly on the fact that in their unrepresentative, non-random sample of volunteers 95% of women answered yes to "Given your situation, was the decision to have an abortion the right decision for you?" Yet, previously, she also acknowledged that there is a very common tendency to rationalize previous decisions as the best choice one could make "given your situation." In short, saying you made the best decision you could "given your situation" at a particular time is not the same as saying "That decision was great. It really improved my life. I've never had any regrets about it." In fact, it could mean: "It was my only option at that time. But I've suffered many regrets, guilt, feelings of loss and emptiness since then."

*p126 - Based on the high "decision rightness" results, Foster claims: "The Turnaway Study provides strong evidence that the vast majority of women do not experience difficulty coping with their abortions..." That is pure nonsense. The study actually reveals that large percentages of women report feeling regret (41-66%), guilt(53-63%), sadness (64-74%), anger(31-43%), depression, anxiety and even PTSD (7-39%). "Decision rightness" is not the same as a claim that "I've had no difficulties coping with my abortion." It is a false equivalence. Moreover, because the Turnaway Study used a non-random invitation of a self-censuring population of women which created a bias toward women expected to be satisfied with their abortion decisions, this non-representative sample really can't tell us anything at all about what "the vast majority of women" experience.

==Shortcomings==

*Readers are never told that the study is based on a non-random, self-selected group of volunteers. Both the invitation process and self-selection bias make it likely that the sample group are much more likely to have positive experiences with abortion than the general population.

*Moreover, it is not until page 253 that not told about the Turnaway Study's horrible participation rate. Only 31% of the women invited to participate in the study participated in even a single interview, much less ten. It is simply impossible to predict what "the majority" of any surveyed group feel about any subject only 31% are willing to answer any questions. This is why many journals do not accept studies with less than 60% participation rates. Regarding this low participation rate, Foster simply waves it aside, reassuring readers that the low participation rate as being most likely due to the inconvenience. She does not even address the evidence from other studies indicating that women who expect to have negative feelings are least likely to participate in subsequent interviews.

*Surprisingly, Foster also fails to mention the fact that in order to tempt women to participate, they were offered a $50 gift card for every interview they completed...up to ten interviews, $500. In short, the self-selection bias is toward women who expect to have the least negative reactions and the most interest in $50 per interview. This financial inducement is omitted from her book

*In addition, she does not fully explain that the invitation process was also not random. Clinic workers had the liberty to decide who they wanted to invite to participate. In fact, she reports that two-thirds of the participants came from just three of the 30 clinics participating. That suggests that the entire population of women eligible to be invited was likely at least ten times greater, meaning they only interviewed 3% or less of the eligible population.

*Nor does she address the problem of drop out rates. Of those who initially agreed to be interviewed, 15% dropped out before the first interview a week after the abortion. Another 8% dropped out between the one week post-abortion interview and the six-month interview. Over the course of the 10 interviews over a 4.5 year period the participation rate dropped from 31% down to 17%. Again, it is most likely that the women experiencing the most negative feelings were most likely to dropout as time progressed.

*Readers are also not informed that the study ignored prior and subsequent abortions, in both the aborting group and those who carried to term. While never mentioned in the book, in an obscure note in just one of their studies it is revealed that [https://pdfs.semanticscholar.org/bc37/113def0d0b90f94bea2acee1e8ec1dfcfcea.pdf 40% of the turnaway group had a prior history of abortion]. In other words, Foster was actually comparing a group of women, 100% of whom have had one or more abortions, to a "control" group of whom at least 40% have had one or more abortions. But she simply presumes these prior abortions don't matter. She then argues that the similarities between these groups proves that abortion has no effects on mental health, a conclusion that requires us to ignore all prior and subsequent abortions. This is simply bad logic and bad science. But because it advances the pro-abortion propaganda line, so it gets labeled the "most rigorous" research ever done!

*Similarly, her studies ignore whether or not women in either group had a history of multiple abortions. That's a serious problem since the research is clear that there is a dose effect--negative reactions increase with exposure to multiple abortions.

==Physical Risks and Mortality Rates==

*With such a small, non-random sample size, the Turnaway Study is unable to give any reliable data on physical complications.

*p142 - Foster asserts that complication rates for abortion (at 2%) are far lower than "for wisdom-tooth extraction (7%), tonscillectomy (8-9%) and childbirth (29%)" but the source she cites does not mention any of these latter procedures, much less the rates, and is itself restricted only to complications of abortion treated in emergency rooms. It excludes treatments at other medical providers, much less untreated complications.

*p136 - Mortality Rates. Foster reports that two women in the birth group had deaths related to childbirth. This is over a 100 times the national maternal mortality rate. On the other hand, she also reports, but dismisses as incidental, that there were four deaths among the women who had abortions. That finding, however, is consistent with eleven [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5692130/ record linkage studies showing an elevated risk of death from all causes following abortion]]--most especially in relation to suicide, accidents (risk taking or self destructive behavior) and heart disease (a stress related illness).

*p151 - Foster claims "Not only is abortion a safe medical procedure; it's alternative—continuing pregnancy and giving birth—is far riskier." This is a common pro-abortion claim, but it is not supported by record linkage studies which prove that abortion is associated with in increased risk of death compared to childbirth, and also higher rates of psychological problems, substance abuse, and cardiac diseases (most likely due to stress).

==The Testimonies==
The statistical studies that the Turnaway Study team has published in medical journals includes only numbers describing specific questions asked in the study. In her Turnaway Study book, Foster includes the personal testimonies of numerous women. What is interesting about these studies is that they underscore the fact that women who say they made the right decision to abort will also frequently describe negative emotions and reactions.

*p61 - Jessica describes her abortion as "a sacrifice I had to do. It that wouldn't have happened, I might not be here today. Or my kids might be in foster care. I try to think of the positives. There was a reason. Everything happens for a reason. You might not understand that reason, but one day you will." She believes in God, believes life is sacred, yet also believes God let doctors to "figure out" how to do abortions for a purpose. "There is a good purpose usually for everything, some way or another. I don't talk about it. It still is referred to as the A-word if it's spoken of at all. You've got to make sacrifices sometimes no matter how bad it hurts. Sometimes that's just life. . . . The only complete meltdown I've had about it was when my kids went to, like, a festival with their aunt and uncle.... They came home with balloons, and they were anti-abortion [slogan] balloons." After Jessica grew angry and popped the balloons, "My kids cried, and my oldest one told me he hated me. I couldn't tell him why, and he didn't understand. Mama just popped my balloon, that's all he knew. My friend lives across the road, and I told her I wasn't feeling good. Could the kids come play? When they went to her house, I just cried."

*p160 - Foster describes Kiara as someone who benefited from her abortion, and indeed Kiara states that the "mistake" of her pregnancy and abortion taught her to be more careful about never going through all that again. But she also describes feeling guilty about the abortion, a need for forgiveness, that she asked God for forgiveness, and believes she has been forgiven. She believes that if she had not had the abortion, she might not have experienced the growth she has had. In other words, there are parts of her life, including a later child, that she values and would certainly not want to lose if, by magic, regretting her abortion would suddenly put her on a different path where she doesn't know what would have happened. "I've always felt that life was precious.... I don't think [the abortion] changed my perspective. It just made me appreciate others who have gone through that situation, whereas before I was like, 'What? How can you do that?' But, it just kind of opened my mind to people and their situations but did not necessarily change my outlook on life itself."

==Chapter 6 - Women's Lives==
This is an excellent example of how the Foster and the Turnaway team use tiny bits of data to leap to grand conclusions.

===Aspirational Goals===

*p166-170 - They asked women one week after their abortions "How do you think your life will be a year from now?" They then rated these as either aspirational (positive), neutral, or negative goals, and did an analysis strictly of the aspirational goals. Their finding was that there was no difference in women who gave birth were most likely to describe an aspirational goal relative to their children (specifically their unborn child), which is hardly surprising since those who aborted a week earlier are not going to have a baby! But their "big" finding is that women who aborted were more likely to voice aspirational goals regarding work, relationships, education, et cetera. 86% of women who had aborted reported an aspirational goal one week later compared to "only" 56% of women who had been turned away from the abortion clinic (30% of whom were in the process of seeking and getting an abortion elsewhere). In other words, Foster and her team are trying to argue that a higher rate of "having an aspirational goal" one week after seeking an abortion (whether it was performed or denied) is in and of itself a great benefit to women, and women who are denied abortions are denied this intangible benefit because only 56% vs 86% will voice an aspirational goal when asked an open ended question one week later. That is quite a stretch! What is especially important to note, however, is that their own analysis showed that women who gave birth were just as likely to achieve their aspirational goals as those who had abortions. Perhaps most telling, however, is that Foster and her team did not look at the differences in aspirational goals in the years following childbirth. This is likely because they could find no differences or the differences were in favor of childbirth rather than abortion, and so were never published since they could not be spun to advance their pro-abortion agenda.

*p183 - They were also asked "How do you think your life will be different five years from now?" For this question, the percentage of aspirational goals went up for both groups: 91% for those who had aborted and 83% for those who had been turned away. The Turnaway team could not find any differences in percentages women having achieved these five year goals a the end of the study.

===Changing Attitudes Toward Abortion===

*p171- In one of their [https://link.springer.com/article/10.1007/s13178-018-0325-1 studies of how participants attitudes toward abortion changed], Foster reports that women who gave birth after being denied an abortion were three times more likely (21% vs 9%) to become less supportive of abortion rights while those who had abortions were 5 times more likely (33% to 6%) to become more supportive of abortion. Overall, their views tended to follow their experience.

===Economic Differences===

*p174-177- The Turnaway study provide only a cursory look at the differences in economic lives of their study population. The first benchmark they examined was the number of women below the poverty line. Conveniently, being pregnant, much less giving birth to a child, changes the calculation of the poverty line. So it is no surprise that immediately following their abortions there was an immediate drop of the percentage of women below the federal poverty line for household income. But most surprising, as shown in Figure 7 on page 177, women who gave birth had a greater drop in poverty from six months after seeking an abortion through 4.5 years. In other words, having an abortion did not produce any sustained improvement in household income while the economic hardship associated with having a child rapidly declined with every passing year.

*p178-1880- Without the permission of her volunteers, Foster submitted their personal contact information to credit bureaus to obtain their credit histories. In an analysis of the credit history, she claims that being denied an abortion increased the average past-due debt of turnaways to $1750 compared to $938 in the years prior to their pregnancy. Foster and her colleagues also found that 4.5 years after seeking an abortion, turnaways had an average credit score of about 550 compared to 558 among those who had abortions, a difference of less than 1.5% among a non-representative sample of volunteers. Based on these thin pieces of evidence, Foster claims that her Turnaway Study has proven that denying women abortions harms their socioeconomic status.

*Note: There is evidence from [https://www.sciencedirect.com/science/article/pii/S0022347618312976 one of their papers] indicating that women in the Turnaway group were economically worse off at the baseline. Therefore, any economic differences observed at 4.5 years after seeking an abortion may have predated the pregnancy. In addition, as mentioned previously, there is a lot of self-selection bias in the Turnaway samples. It is well known that women who anticipate more problems dealing with their abortion are less likely to participate in surveys. Since the Turnaway group did not have an abortion, it is likely they felt less anxiety in dealing with subsequent surveys. Also, the promise of a $50 gift card with each interview was likely most tempting to those who were worse off financially. Both of these factors may have contributed to a distortion of the sample toward poorer women.
*Regarding any alleged economic harms to being denied an abortion, It is important to examine this peer-reviewed critique [https://doi.org/10.70257/twgf1217 Turnaway Study Report Unethically Violated Participants' Privacy and Misleads Public with a Non-Representative Sample, Selective Reporting, and Overstated Conclusions]
**"Results from the Turnaway Study, conducted by Advancing New Standards in Reproductive Health (ANSRH), have widely been represented as definitive proof that women denied access to abortion will suffer severe injury to their health and economic wellbeing. Yet a careful examination reveals that the study is based on a non-random, non-representative sample of women that grossly underrepresents the experiences of the majority of women undergoing abortions. In addition, a reanalysis of its reported results reveal that the effect size of the outcomes observed have been grossly overstated, leading to conclusions that are not supported by the results. There also appears to be selective reporting and misrepresentation of results previously published. In addition, inconsistencies in ANSRH's published record strongly suggest that the credit history reports of the Turnaway Study participants were obtained without their informed consent."

===Subsequent Educational Attainment===

*p181 - Looking at education, Foster could find no differences in the high school graduation rates between those who aborted and turnaways. Regarding advance degrees, the two groups were also similar in terms of completing advance degrees but turnaways (most of whom had additional child care responsibilities) were more likely to seek lower level degrees which required less time commitment during the 4.5 years they were followed.

*p185 - Foster concludes this chapter with another overly broad, unsupported, and unqualified politicized assertion. "The Turnaway Study shows that women who are denied wanted abortions scale back their short-term plans and suffer economic hardship for years." But the scaling back of short term plans is based on a single question one week after being turned away while women are still trying to sort out their futures. Many of them also report being happy that they will now focus on having their babies, while others are in fact seeking abortions at other clinics, perhaps in other states. And the claim that they "suffer economic hardship for years" measures out to having a 2% lower credit score! She is clearly exaggerating the meanings of both "suffer" and "economic hardship."

==Chapter 6 - Children==

===Existing Children===
*p200-202 - Foster argues that among women with children under age five prior to seeking the abortion of interest, the children of those who had abortions enjoyed more economic security during the 4.5 years the group was followed than the children of those who carried to term. But this finding is not reliable for drawing any conclusions based on the facts that (1) the study uses a nonrandom sample of volunteers and a high degree of psychological factors and stigma that magnify self-selection bias, (2) only 55 women in the Turnaway group had children under the age of 5, so the sample size is very small, and (3) the sample groups were disproportionately made up of women who were poor, below the federal poverty line, for whom a $50 gift card promised at each interview might be a compelling incentive. Given that women who carried to term did not face post-abortion shame as a disincentive to participate, it is likely that the poorer a turnaway woman was the more likely the $50 incentive would have encouraged her participation. In short, it is not surprising that the turnaway group was disproportionately poorer. Plus, the addition of an additional child in the family structure changes the calculation of the federal poverty line and influences eligibility for food stamps and other public aid programs. With all these factors in mind, Foster's finding that 19% of turnaways with previous children compared to 10% of women who aborted with previous children received public assistance is simply non-news. A woman with two children rather than one, will be eligible for more public assistance.

*p202-203 - Foster also looked at how the women rated their children's development, using the Parents' Evaluation of Developmental Status: Developmental Milestones questionnaire. Based on her very small sample size, she found that 74% compared to 77% of children under the age of five (for the turnaway group compared to the abortion group of women) met or exceeded the Developmental Milestones. Based on this very small, 3% difference, Foster argues that denying women abortions causes developmental harm to their already born children. But this is clearly an exaggerated conclusion based on very little evidence and a very little difference in that evidence. Plus, the fact that Foster refuses to make her data available for analysis by other researchers suggests that she may be engaged in selective reporting. Results that might show benefits to Turnaway women and their children don't get reported, only the results that she can use to advance her political agenda.

===Children Born Afterward===

*P204- Among turnaways, 64% reported they still wished they could have had the abortion, but this dropped to 12% six months later, after the child was born, and down to just 4% at the last interview, 4.5 years later. Foster admits these women were mostly happy they had their babies, though she does not report the actual percentages of emotions related to abortion or the pregnancy for any of the groups studied throughout the 4.5 years.

*206-208 - Foster reports that they used the Postpartum Bonding Questionnaire to evaluate the emotional bonding women felt for children under 18 months old to compare who women evaluated their bond after (a) being turned away from an abortion, and (b) for those women who had abortions and then delivered. They reported that 9% of Turnaway women compared to 3% of the Abortion group reported bonding problems with the child. This finding needs to be interpreted in light of the fact that women in the second group were (a) a self-selected population of women at least risk of negative reactions to abortion and (b) were an average of three years older and more likely to be living with a male partner (which presumably reduces stress during the first 18 months with the child).

*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248140/ In the study examining these two groups], subsequent children born to women who had abortions were more likely to be premature and have low birth weight, but the authors fail to discuss this.

Turn Away Study

2025-11-20T23:35:57Z

Barb: /* Other Criticisms */

The Turnaway Study is an ongoing study of women who had first and second trimester abortions compared to women who were "turned away" from late term abortions because they approached the clinics in their state after the gestational age limit for performing abortions. The [http://www.ansirh.org/research/turnaway.php Turnaway Study] is conducted by the pro-abortion advocacy group [http://www.ansirh.org/ Advancing New Standards in Reproductive Health (ANSIRH)] which is a project of the Bixby Center for Global Reproductive Health at the University of California, San Francisco.

The Turnaway Study is seriously flawed by the [[Turn_Away_Study#Non-Representative_Sample non-representative sample of women| non-representative selection of women]] used in the study. More detailed criticisms are further down this page. Here are some of the major points:

*Of women approached to participate 62.5% declined. Another 15% dropped out before the baseline interview one week after their abortions. As a result, only 31% participated in the baseline interview. In addition, women continued to drop out at each six month followup period, with an additional 20% drop out at one year, 36% dropout by the third year, and 46% dropout by the fifth year. Despite the low retention rate, the authors mislead readers by declaring that 93% participated "in at least one" of the six month followups, implying high retention when in fact less than 17% of eligible participants, and 46% of those who initially agreed, actually participated in year five.
**A low participation rate will often result in automatic rejection of studies by many medical journals. For example, the journal ''Obstetrics & Gynecology'' requires a minimum response rate of 60% or higher, twice that of the TurnAway Study.
**In comparison, [https://pubmed.ncbi.nlm.nih.gov/18711183/ 90 of 98 consecutive women (92%) invited to participate in a survey before, six months after, and one year after a prophylactic mastectomy (BPM)] to evaluate the impact of BPM on emotions, mental health, body image, and sexuality. This is nearly three times the participation rate of the Turnaway Study sample.
*While not explicitly stated by the researchers, the numbers they do reveal indicate that only 27.0% of the eligible women were interviewed at the three year follow-up and only 17% participated at the five year mark. Of the 37% who agreed to participate (1132) only 84% participated at week 1, 66% at year one, 53% at year three, and 46% at year five.
*There are well known [[risk factors]] which predict which women are most likely to have negative reactions to abortion, many of which would make women less likely to agree to participate in a follow up interviews . . . even if there was an offer to be paid. For example, from the [[Risk_factors| APA list of risk factors]]:
:*perceived need for secrecy;
:*feelings of stigma;
:*use of avoidance and denial coping strategies;
:*low perceived ability to cope with the abortion;
:*perceived pressure from others to terminate a pregnancy.
*The sample is disproportionately filled with women having late abortions. The sample used includes 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester.
*Women who had abortions due to suspected fetal anomalies were excluded. Probably because research shows high rates of psychological disruption after abortion in these types of cases, therefore excluding this segment of women was a way to reduce the effects associated with abortion. This is extremely misleading, of course, since this is a common reason for abortion . . . especially in the second and third trimester.
*Demographically, the sample used is not representative of women having abortions. The average age at the time of the abortion was 25, of which 62% were raising children.
*The comparison group, the Turn Away group (n=210), includes 50 women who later terminated at another facility or had a miscarriage. So 24% of this group, to which the researchers are comparing women who abort, actually includes women who experienced pregnancy losses. Yet the researchers barely disclose this fact, giving the false impression that their study is comparing women who had abortions to women who carried to term. In fact, they are comparing a group of women who had abortions to a group of women including those who (a) carried to term, (b) had abortions in a state other than where they first sought one, or (c) miscarried or had a still birth.

=Decision Rightness with Regard to Abortion in the Turnaway Study=

'''[http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128832#sec013 Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study] Rocca CH, Kimport K, Roberts SC, Gould H, Neuhaus J, Foster DG. PLoS One. 2015 Jul 8;10(7):e0128832. doi: 10.1371/journal.pone.0128832. eCollection 2015.'''

Abstract
:BACKGROUND: Arguments that abortion causes women emotional harm are used to regulate abortion, particularly later procedures, in the United States. However, existing research is inconclusive. We examined women's emotions and reports of whether the abortion decision was the right one for them over the three years after having an induced abortion.

:METHODS: We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities across the United States, selected based on having the latest gestational age limit within 150 miles. Two groups of women (n=667) were followed prospectively for three years: women having first-trimester procedures and women terminating pregnancies within two weeks under facilities' gestational age limits at the same facilities. Participants completed semiannual phone surveys to assess whether they felt that having the abortion was the right decision for them; negative emotions (regret, anger, guilt, sadness) about the abortion; and positive emotions (relief, happiness). Multivariable mixed-effects models were used to examine changes in each outcome over time, to compare the two groups, and to identify associated factors.

:RESULTS: The predicted probability of reporting that abortion was the right decision was over 99% at all time points over three years. Women with more planned pregnancies and who had more difficulty deciding to terminate the pregnancy had lower odds of reporting the abortion was the right decision (aOR=0.71 [0.60, 0.85] and 0.46 [0.36, 0.64], respectively). Both negative and positive emotions declined over time, with no differences between women having procedures near gestational age limits versus first-trimester abortions. Higher perceived community abortion stigma and lower social support were associated with more negative emotions (b=0.45 [0.31, 0.58] and b=-0.61 [-0.93, -0.29], respectively).

:CONCLUSIONS: Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years. Emotional support may be beneficial for women having abortions who report intended pregnancies or difficulty deciding.

:Note: the conclusions should be reframed to note that the conclusions only apply to the 27% of eligible women on whom the researchers had data at the three year mark.

===News Coverage===
[http://time.com/3956781/women-abortion-regret-reproductive-health/ Hardly Any Women Regret Having an Abortion, a New Study Finds.] Jenkins N. Time. Published July 14, 2015.
[https://www.washingtonpost.com/news/wonk/wp/2015/07/14/95-percent-of-women-whove-had-an-abortion-say-it-was-the-right-decision/ 95 percent of women who’ve had an abortion say it was the right decision.] Ingraham C. Washington Post. Published July 14, 2015.

===Criticisms of the Turnaway Study===

====Non-Representative Sample====

# This study's findings and conclusions are overreaching in many regards, beginning with the fact that the sample of women is not representative of the national population of women having abortions due to high rates of self-exclusion plus high drop out rates. To quote from the study: "Overall, 37.5% of eligible women consented to participate, and 85% of those completed baseline interviews (n = 956). Among the Near-Limit and First-Trimester Abortion groups, 92% completed six-month interviews, and 69% were retained at three years; 93% completed at least one follow-up interview." This means 62.5% of women refused to participate in the study, at first request, and another 15% dropped out before or during the baseline interview, yielding a 31.9% participation rate at baseline.
# There are well known [[risk factors]] which predict which women are most likely to have negative reactions to abortion, many of which would make women less likely to agree to participate in a follow up interviews . . . even if there was an offer to be paid. For example, from the [http://abortionrisks.org/index.php?title=Risk_factors APA list of risk factors]: perceived need for secrecy; feelings of stigma; use of avoidance and denial coping strategies; low perceived ability to cope with the abortion; perceived pressure from others to terminate a pregnancy.
# With 68.1% of eligible women refusing to participate in the study at baseline, it is improper for the authors to suggest that their findings reflect the general experiences of most women. There are numerous [[risk factors]] which have been identified as predicting which women will have the most severe post-abortion reactions. One of these risk factors, for example, is ambivalence about having an abortion or carrying to term. Another is the expectation that one will have more negative feelings about the abortion. In a similar post-abortion interview study by [[Soderberg]], the author reported that in interviews with those declining to participate "the reason for non-participation seemed to be a sense of guilt and remorse that they did not wish to discuss. An answer often given was: ' Do do not want to talk about it. I just want to forget.'"
#It is very likely that the self-selected 31.9% of women participating at baseline were more highly confident of their decision to abort prior to their abortions and anticipated fewer negative outcomes. This concern about selection bias is highlighted by the study's own finding that "women feeling more relief and happiness at baseline were less likely to be lost [to follow-up]." Clearly, due to the large numbers of women choosing not to be questioned about their experience, and the large drop out of those who did agree, this sample is not representative of the national population of women having abortions.
# There may have been additional selection bias on the part of the participating abortion clinics. According to the portion of study protocol that was published: "It is up to the clinic staff at each recruitment site to keep track of when to recruit abortion clients to match to the turnaways recruited." In other words, the clinic staff exercised considerable leeway in deciding when to invite women to participate, and this leeway could have been exercised in ways to exclude women whom they may have anticipated were among the worst candidates for abortion.
# Despite the initial selection bias, 15% of those agreeing to be interviewed subsequently opted out of the baseline interview and another 31% opted out within the three year followup period. This means that at the three year followup, only 27.0% of the eligible women were interviewed. This continuing drop out rate suggests even among women who expected little or no negative reactions, the stress of participating in follow up interviews lead to a change of mind. Previous research shows that [http://www.ncbi.nlm.nih.gov/pubmed/?term=10718164 women with a history of abortion feel more discomfort in answering questions about their reproductive history].
#Another oddity, the authors report that in the final group analyzed, average age 25, 62% were raising children. This would appear to be a very high rate that is not typical of national averages for women seeking abortion.
#The study population is also non-representative of the women having abortion in that it included 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester. This is totally disproportionate. It again shows that the authors should not be extending conclusions about this non-representative sample to the general population.
#The authors report that sample has an elevated number of low socioeconomic backgrounds. That, too, makes the sample non-representative. The offer of $50 per interview may also have created a participation bias.
#The comparison group, the Turn Away group (n=210), includes 50 women who later terminated at another facility or had a miscarriage. So 24% of this group, to which the researchers are comparing women who abort, actually includes women who experienced pregnancy losses. Yet the researchers barely disclose this fact, giving the false impression that their study is comparing women who had abortions to women who carried to term.
#Women who had abortions due to suspected fetal anomalies were excluded. Probably because research shows high rates of psychological disruption after abortion in these types of cases, therefore excluding this segment of women was a way to reduce the effects associated with abortion. This is extremely misleading, of course, since this is a common reason for abortion . . . especially in the second and third trimester.
#A low participation rate will often result in automatic rejection of studies by many medical journals. For example, the journal ''Obstetrics & Gynecology'' requires a minimum response rate of 60% or higher, twice that of the TurnAway Study.
#The actual question women were asked was “Given your situation, was the decision to have an abortion the right decision for you?” They were not given a scale to show degrees of agreement or disagreement. The only options were yes, no, or don't know. For the purposes of their analyses, "don't know" was treated as no. But in any event the preable, "Given your situation," essentially turned the question into "Did you make the best decision you could, given your situation?"
#The claim that 98% are satisfied with their decision (based on this binary assessment) is in sharp contrast to a study by [https://jamanetwork.com/journals/jamapsychiatry/fullarticle/481643#yoa8222t3 Brenda Major], another pro-abortion researcher. In her study the related question was phrased very differently. "Three hundred six (69%) of 441 women said they would definitely or probably have the abortion again if they had to make the decision over; 84 (19%) of 441 said that they would definitely not or probably not; and 51 (12%) of 441 were undecided." Note, Major does not report the "definitely" and "probably" groups separately. They are collapsed to imply greater certainty than "probably" entails. According to Major's paper, the details of the question were "At T4, women were asked, "If you had the decision to make over again under the same circumstances that you were in 2 years ago, would you make the same decision to have the abortion?" They responded on a scale from 1 (definitely no) to 5 (definitely yes)."

=====Misrepresentation of Study Design=====
The authors frequently describe their study as a "prospective longitudinal cohort study." Actually, it is only a "case series study" of the remnant of women (27%) who came to a few abortion clinics who were willing to continue to participate in this study. But since they do not have data collected on the women prior to seeking abortion, much less becoming pregnant, they are not truly prospective cohort studies but rather case series, as clarified by [https://www.ncbi.nlm.nih.gov/pubmed/22213493 Dekkers et al, (2012)] "a cohort study, in principle, enables the calculation of an absolute risk or a rate for the outcome, such a calculation is not possible in a case series." and [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998589/ Song & Chung, 2010]:
:An important distinction lies between cohort studies and case-series. The distinguishing feature between these two types of studies is the presence of a control, or unexposed, group. Contrasting with epidemiological cohort studies, case-series are descriptive studies following one small group of subjects. In essence, they are extensions of case reports. Usually the cases are obtained from the authors' experiences, generally involve a small number of patients, and more importantly, lack a control group.12 There is often confusion in designating studies as “cohort studies” when only one group of subjects is examined. Yet, unless a second comparative group serving as a control is present, these studies are defined as case-series.

While it is true that the authors are attempting to claim that their sample of "women denied abortions" is the "unexposed group," this is clearly not true for three reasons:

:(a) all the women were already exposed to a problem pregnancy,

:(b) all the women have already had gone through the process of seeking an abortion...which itself may be all or a portion of the traumatic part of some abortion experiences...especially when they are subsequently raising a child whom they recall at one point having planned to abort (which can cause cognitive dissonance), and

:(c) the "unexposed group" clearly includes women who actually have had multiple pregnancy experiences, including abortions and miscarriage, either before or after the index pregnancy, or both. (Indeed, in at least of of their studies, they controlled for parity (the number of pregnancies a woman has had), but not for prior or subsequent pregnancy losses, which is inconsistent.)

The false description of the Turnaway study as "prospective longitudinal cohort study" is a very important because it gives the false impression that the authors have applied the criteria of such studies, which are designed to follow a group of people ''before'' they are exposed to the subject of interest, in this case a pregnancy subject to abortion. In fact, this is a self-selected case series, with very high attrition rate, which consists entirely of women who are candidates for abortion.

This is another example of the authors efforts to present their findings as generalizable to the entire population of women when in fact there is no evidence, and every indication given the high refusal and drop out rate, that the findings of the remnant of women remaining in this study are applicable only to that remnant.

=====Dropouts and Refusers are at Higher Risk=====

The final sample was only 516 women, which is only 17% of the original 3,045 asked to participate in the study. Clearly, women experiencing the most post-abortion distress are more likely to refuse to participate or drop out. Indeed, the expectation of not coping well with an abortion is predictive of greater post-abortion distress and likely a major reason women would not choose to open themselves up to subsequent telephone interviews.

There is research evidence that low participation rates and / or high dropout rates distort the results of studies and lead to incorrect conclusions:

:After a workplace disaster in Norway, 246 employees were required to participate in medical evaluations for PTSD [http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.1989.tb05262.x/abstract (Weisaeth, 1989)]. At baseline pre-disaster, employees had a record of cooperation with the company medical officer. After the disaster, some were resistant and required repeated contacts; eventually participation reached 100%. The initial resistance was significantly associated with severity of PTSD at 7 months. The authors stated that if the initial refusals had been accepted, “the potential loss to the follow-up would have included 42% of the PTSD cases, and 64% of the severe PTSD cases would have fallen out, resulting in distorted prevalence rates of PTSD” (Weisaeth, 1989, p. 131). Additionally, “The initial resistance in many who later developed PTSD was found to relate to the psychological defenses such as avoidance which is seen both PTSD and acute post-traumatic stress syndrome” (Shuping, 2016, citing Weisaeth).

Additional evidence of selection bias problems are reported by [[Soderberg]]

====Inappropriate Measures & Study Design Flaws====
#The focus of this report in on women's persistent satisfaction with their abortion decisions, "decision rightness," as measured by a single question: "“Given your situation, was the decision to have an abortion the right decision for you?” Women were asked to answer this question "yes", "no" or "uncertain." This measure is flaws in several ways:
## A better research approach would have been to have this question rated on a numeric scale (1 to 10, for example) in order to better identify any shift in attitudes.
##There is no report of tests to verify the [http://www.relevantinsights.com/validity-and-reliability#sthash.x00kiuAX.dpbs validity and reliability of the questions used]. In other words, the authors do not report on any efforts made to evaluate whether the question(s) used provide reliable consistency...or are even understood by women in the same way. For example, do all women interpret the question in the same way? Or were there different nuances in understanding? Was it "right" as in "moral"? Or right as in "the best choice I could make at the time?" Or right in that it was the best choice any person could make? Was it right meaning one would make the same choice if one became pregnant again? Was it right in that "It made my life far better"? Or was it right only in the sense that "What's done is done, and I'm moving my life forward doing the best I can so that is my focus so I guess it was right . . . or at least what I have to work with."
##A feeling that a person made the right decision due to circumstances at that time is not the same as an assertion that it was the right decision regardless of circumstances or "if I knew what I knew now."
##The decisions assessment were conducted through telephone interviews approximately every six months. A well known problem with interview based studies is that many participants will try to please the interviewer by giving the answer they believe is expected of them. Similarly, some interviewers may be more prone to elicit certain types of response. The investigators did not report on any tests made to verify that such influences were not at play.
#As a general rule, questions regarding decision satisfaction (even about things such as the purchase of a purse) may produce [https://en.wikipedia.org/wiki/Reaction_formation reaction formation] and therefore defensive answers affirming the rightness of a decision even if there are actually unresolved anxieties or other issues. (To voice dissatisfaction may invite anxiety provoking thoughts. Responding the way one is expect to respond, avoids reflection).
#Rather than rely on a single question about the "rightness" of the abortion decision, additional questions should have been asked to better gauge the subjects thoughts. For example, in the [[Soderberg]] study, including a one year post-abortion interview of 847 women (after a 33% self-exclusion rate), 80% of the women reported they were satisfied with their decision to abort but at the same time 76% also stated that they would never abort again if faced with an unwanted pregnancy. In this case, the second question offers a great deal of additional insight. A woman expressing unwillingness to not have another abortion may be telling us more than her abortion experience than she is when she says that a past decision was "right."
#Another difficulty raised by the researcher's methodology is that their interviews apparently did not inquire about any steps women took to resolve negative emotions. It is necessary to know if women who had negative feelings sought any help to deal with those feelings, perhaps with a therapist, a pastor, or family or friends. The increase in the number of women participating in post-abortion programs should, for example, help to reduce the longevity of negative reactions to abortion. But if this is the case, the conclusion of the authors that negative reactions to abortion naturally diminish over time may be wrong if, in fact, the decrease is due to women receiving post-abortion psychological or spiritual counseling. In other words, if the decline in negative reactions is real (and not due to denial, repression, or just a desire to rush through the phone interview to collect the $50 gift card) it is important to understand the reason for this. Is it due to support given to those having negative feelings, or is it "natural" and permanent?
#The authors did not use any validated measures of psychological illness, as has been done in many other studies. Instead the assessment of psychological health is all inferred from a two scales created from six questions in which rated six emotions associated with their abortion women rated each emotion on a five point scale from "not at all" to "extremely." The six emotions were: relief, happiness, regret, guilt, sadness and anger. From these six self-assessments, reported by telephone to an interviewer, the scores for the four negative emotions were combined for a single scale and the two positive emotion scores were combined for a positive emotion scale. These scales were not tested for [http://www.relevantinsights.com/validity-and-reliability#sthash.x00kiuAX.dpbs validity or reliability]. Nor were they tested as a measure of overall psychological health or, conversely, psychological illness.
#The comparison group, the Turn Away group (n=210), includes 50 women who later terminated at another facility or had a miscarriage. So 24% of this group to which the researchers are comparing women who abort actually includes women who experienced pregnancy losses. Yet the researchers barely disclose this fact, giving the false impression that their study is comparing women who had abortions to women who carried to term.
#There was not anonymity. Women were interviewed by a paid staff person asking each question. The interviewing process itself may impact answers as respondents may be inclined to answer questions in a way that they believe will better satisfy the interviewer. In short, it is well established that there are differences in response to a written anonymous questionnaire compared to a verbal interview.
#There is no transparency. The authors of the study have refused to publish their questionnaires. This suggest that there may be questions that they have chosen to not report upon. It also prevents investigation of whether any series of questions were presented in a way that led respondents toward a specific answer in later questions.

====Inconsistency With Prior Research Findings====
#As mentioned above, a similarly designed followup study by [[Soderberg]] study reported that 80% of the women reported they were satisfied with their decision to abort but at the same time 76% also stated that they would never abort again if faced with an unwanted pregnancy. Soderberg also found that even though many women reported satisfaction with their decision they also experienced negative psychological outcomes, with 50-60% of women undergoing induced abortion experienced some measure of emotional distress, classified as severe in 30% of cases.
#Notably, the claim of declining regret and declining negative reactions is at odds with [[Brenda Major]]'s two year longitudinal study, which also had high drop out rates, which found that there was a trend in decline in relief and increase in negative emotions over the two year period among those who did not drop out of her study. (See Major B, et al. Psychological responses of women after first-trimester abortion. Archives of General Psychiatry. 2000: 57(8), 777-84.)
#Their claim that there is no evidence of mental health problems after abortion is not consistent with the findings of studies utilizing validated measures of mental health, including a [http://www.ncbi.nlm.nih.gov/pubmed/16343341 five year longitudinal study] nor with the [http://www.ncbi.nlm.nih.gov/pubmed/19880932 Christchurch Health and Development Study, a lifetime longitudinal study].
#Their findings are not consistent with findings of record linkage studies which have shown an [http://www.cmaj.ca/content/168/10/1253.full elevated risk of psychiatric admissions] following abortion, an [http://www.bmj.com/content/313/7070/1431 elevated rates of suicide] and elevated rates of [http://www.ncbi.nlm.nih.gov/pubmed/?term=reardpn+dc+sleep sleep disorders].
#Their findings are not consistent with the results of meta-analyses comparing a large number of studies, including reviews by [http://www.ncbi.nlm.nih.gov/pubmed/23859662 Bellini], [http://www.ncbi.nlm.nih.gov/pubmed/23553240 Fergusson], and [http://bjp.rcpsych.org/content/199/3/180.long Coleman].

====Unreported Details====
# According to an [http://www.ansirh.org/wp-content/uploads/Turnaway-Study-Infographic_7-8-2015.pdf infographic about the study] published by the research group, the followup interviews were actually continued every six months for five years, not just three. Why then did this report limit itself to three years rather than cover the full five years covered by the study?
#The study population included 413 women who had an abortion near the end of the second trimester and only 254 women having an abortion in the first trimester. Overall, only 31% participated at the baseline interview (35.7% agreed to be interviewed, but 15% of those dropped out before or during the baseline interview). The authors should report the drop out rate for each of the two groups: first trimester and second trimester.

====Overreaching Conclusions====
#While the report and [http://www.ansirh.org/news/new_ANSIRH.php accompanying press release] claim that this study proved there is "no evidence of widespread 'post-abortion trauma syndrome,' in fact it did not use any standard scales for assessment of psychological well being.
# The bias of the research team is made clear in [http://www.ansirh.org/news/new_ANSIRH.php press releases] and a [http://www.ansirh.org/wp-content/uploads/Turnaway-Study-Infographic_7-8-2015.pdf infographic] purporting to summarize the study. In these "summaries" the research group conceals the details regarding the high non-participation rate and boldly claims "95% of women who had abortions felt it was the right decision, both immediately and over 3 years," omitting the fact that 62.5% refused to answer the question at the time of their abortion and of those interviewed at the time 31% were out of the study by the third year. Notably, the problem of high non-participation and drop out rates is not mentioned in the abstract, press release, or other summarizing materials published by the authors. To the contrary, they consistently imply that their results apply to the entire population of women having abortions.
#The authors make much of the claim that 93% of the participants "completed at least one follow up interview" which the media outlets incorrectly reported as meaning [http://www.medicalnewstoday.com/articles/296756.php"Only 7% of the participants dropped out of the study during follow-up."] It would have been far more accurate to state that of the "Only 37.5% of eligible women agreed to be interviewed, of whom 85% actually did complete the complete baseline interviews (n = 956). Of this group, only 7% refused to do at least one followup interview."
#From the observation that the scale created from four negative reactions showed a modest decline in negative reactions over three years, the authors they draw the very broad conclusion that there is no evidence of widespread negative psychological reactions to abortion. As indicated above, this conclusion is contradicted by better designed studies. Moreover, this conclusion ignores the fact that many psychological problems are characterized by denial and repression of negative emotions. There is, in fact, clear evidence from other studies that [[PTSD |many women experience symptoms of post-traumatic stress disorder]] which includes symptoms of denial and avoidance behavior. In a study by Rue, for example, among women reporting intrusive memories or thoughts related to their abortion, only half denied that these thoughts were attributed (caused) by their abortions. In other words, it is not always easy for women to recognize which feelings may be attributable to their abortions. For example, it is only when in post-abortion counseling that many women may attribute increased feelings of anger after their abortions to unresolved feelings over the abortion which they were projecting onto other people and situations. This is all fairly basic psychology. Negative emotions often crop up in other parts of our lives because we have trouble dealing with them at the source. Therefore, women reporting less "anger" relative to their abortion may in fact have more feelings of anger in their lives than before their abortion but are simply attributing it to other issues. This demonstrates the difficulty in trying to judge the post-abortion emotional adjustment of women based on just six oversimplified questions about six basic emotions.
#The Turn Away Study hangs its claim to uniqueness on the fact that it utilizes as it group for comparison only women who initially sought to terminate a pregnancy but were denied abortions because they were beyond the gestation age cut off in various states and then carried to term. But this group of women giving birth is a very small and distinct sample, numbering only a few thousand women per year in the United States. Most importantly, this distinction should be clearly applied to all of the discussion and conclusions offered by the Turn Away Study authors, but it is not. Rather than frame their conclusions as applying to the very small women in the US each year who seek an abortion at or after the gestation date limit on legal abortions in various states, they seek to apply their conclusions to all women having abortions and all women carrying unplanned pregnancies to term.

::But even the above clarification limiting the findings to women denied abortions would not be inaccurate because the "turn away" group is not made up only of women who subsequently carried to term. Instead, it includes who found an abortion elsewhere and those who miscarried, making up approximately 24% of the total "turn away" group.

::So, to be completely accurate, the Turn Away Study's sloppy methodology mixes different experience and outcomes into the "turn away group" in a way that obscures rather than clarifies the differences between women who (a) have late term abortions and (b) those who carry to term or have late term abortions elsewhere.

::Notably, if the Turn Away Study abstracts, conclusions, and press releases were actually rewritten to accurately describe the makeup of the "turn away group" the conclusions drawn from these studies would be so narrow as to be almost meaningless. On the other hand, because the authors generally mention those limitations only once in the methods section of their studies, and then in the conclusion section, abstract, and press releases make it appear that their findings apply to the general population of women having abortions and those who carry unintended pregnancies to term, they are clearly overreaching what their data actually shows. They are merely using their weak data as an excuse to make general pronouncements about "safe abortion" without actually having meaningful data to support those broad claims.

====Refusal to Share Details and Data====
The authors have refused to share or publish the complete questionnaires used to collect data. They have also refused to share details of their analyses or any of their data for reanalysis by others.

====Exaggerations of ANSIRH News Release====

The ANSIRH news release, headlined "[https://www.ansirh.org/news/no-evidence-emerging-mental-health-problems-after-having-abortion No evidence of emerging mental health problems after having an abortion]" declares:

:Published in JAMA Psychiatry, “Women’s mental health and well-being five years after receiving or being denied an abortion: A prospective, longitudinal cohort study,” analysis from ANSIRH’s Turnaway Study, found that having an abortion does not adversely affect women’s mental health either at the time of the abortion or over five years after receiving abortion care. We also found that denying women abortion has negative consequences to their mental health and well-being in the short-term.

:We found no evidence that women who have abortions risk developing depression, anxiety, low self-esteem or less life satisfaction as a result of the abortion, either immediately following, or for up to five years after the abortion. However, women who were denied an abortion had more anxiety, lower self-esteem, and less life satisfaction immediately after being turned away. Over the subsequent five years, symptoms of anxiety and depression decreased and self-esteem and life satisfaction improved significantly, both for women who received an abortion and for women who were denied care.

:''The study provides the best evidence we have to date on the mental health effects of having an abortion'', by comparing women who received an abortion to those who were denied one, and following them for five years.

'''Note:''' The claim that this is the best evidence to date is totally bogus. The release totally ignores the fact that the small minority of women agreeing to participate in the study are not representative of most women, and further pretends that there is "no evidence" of mental health risks of abortion except for their own study. And the firs paragraph assertion that there are negative consequences to being denied an abortion fails to note that this assertion is based on just one assessment, one week after women seeking abortion were told it was past the gestational limit, and that by the time of the second assessment at six months there was no higher rates of depression, anxiety, or self esteem problems. In short, the press release has a lot of over generalizations based on a very thin evidence.

=====Letter from David Reardon to PLOS One =====
Dear PLOS One Editors,

I am writing to register a formal complaint against the authors of a PLOS ONE article who I believe have made disingenuous representations to PLOS ONE in order to improperly withhold data.

I have previously been a reviewer for another article submitted to another journal by this team of researchers and in that case also they refused to provide additional requested information, including a refusal to be provided with a blank copy of their survey form so I could review the exact wording of their questions.

Specifically, the article is [http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128832 Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study] by Corrine H. Rocca, et al.

When I emailed Dr. Rocca to request access to the data repository for reanalysis, she responded:

To excuse themselves from providing any data the authors state:
::The Data Availability Statement for the paper is on the first page of the publication: “The authors are not able to provide any data beyond what is presented in the manuscript due to restrictions that study participants agreed to when they signed the consent form, which was approved by the UCSF IRB. The authors have included sufficient details in the Methods section of the manuscript for others to replicate the analysis in a similar setting, using a similar study population.”

Regarding the first sentence of this claim, while clearly it would be appropriate to guarantee to participants that no identifying information would be released to others, what possible restrictions would participants be required to agree to that would preclude sharing non-identifying data with other researchers?

So I emailed Dr. Rocca the following request: "Would you please provide a blank copy of the consent form that the study participants signed, where I assume the restrictions on data sharing are described?"

She refused to reply.

Therefore, I am specifically requesting that PLOS ONE require Dr. Rocca to provide a copy of the consent form which the participants signed so that the claim that the non-identifying data cannot be made available based on promises made to the participants may be verified.

If Dr. Rocca should refuse to provide documentation supporting her claims, the journal should retract the paper due to her clear effort to evade the data availability requirements of the PLOS journals

I would note that the Turnaway Study data set, on which this PLOS ONE article is based, has been employed in numerous published articles authored by scores of authors. It is unreasonable to expect that the participants were promised that only a specific list of researchers would be allowed to analyze the non-personal data.

Regarding the claim that "The authors have included sufficient details in the Methods section of the manuscript for others to replicate the analysis in a similar setting, using a similar study population," this is another bogus assertion. As mentioned above, the authors have refused to share even the blank survey instruments used to collect the data so specific questions cannot be replicated.

Furthermore, the ANSIRH team collecting the data is closely aligned with abortion advocacy which is the only reason they were provided access to abortion patients at 30 abortion clinics.

Obviously, abortion is a very contentious issue both politically and academically. Clearly, researchers who are critical of the claim that abortion has no mental health effects are not allowed the access to abortion patients which has been granted to ANSIRH. Therefore, it is impossible for large segments of the research community to "replicate the analysis in a similar setting," as Rocca asserts. Indeed, it is my clear impression, based on Rocca's refusal to provide any additional information even to reviewers, is that she and her team are seeking to limit access to the data and their study methodology precisely to prevent any reanalyzes which may undermine their own preferred spin on the data they collected.

More importantly, the PLOS journals requirements for data sharing exist precisely to alleviate the high cost of replicating data collection and to facilitate reanalyzes of existing data sets.

Please investigate the concerns outlined above, beginning with a request for documentation regarding precisely what was promised to the Turnaway Study participants.

Thank you.

Sincerely yours,

David C. Reardon, Ph.D.
Elliot Institute

*PLOS One declined the request to ask Dr. Rocca to provide any evidence that the consent form did indeed bar sharing non-personal data with other researchers.

*It was subsequently revealed in Dr. Foster's book ''The Turnaway Study'' that in 2018 they decided to work with a previously unknown researcher, Sarah Miller, an economist who suggested they use the personal information of the women in their sample to request their credit scores from credit agencies in order to examine the effects of having an abortion on credit scores. Clearly, the claim that they were not allowed to share data made in PLOS publication was a lie.

===Critique by Priscilla Coleman===

The following is reprinted with permission from '''WECARE''''s website where it is titled '''[http://www.wecareexperts.org/content/turnaway-study-analyzed-wecare-director-latest-attempt-reverse-evidence-based-women-centered The Turnaway Study Analyzed by WECARE Director: The Latest Attempt to Reverse Evidence-based, Women-Centered Advances in Abortion Policy]'''

The PLoS ONE study titled “Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study” is riddled with serious design flaws that render the results meaningless. The problematic issues are described in detail below followed by evidence that the true motivation for publishing the study is likely political. In recent years, credible science has informed policy with 26 states, now requiring information regarding mental health effects be shared with women considering abortion. This study is a poor attempt to provide counter “evidence” and obscure the reality of women’s suffering, reminiscent of the highly flawed research from the 70s and 80s.

'''Methodological Issues:'''

1) As reported by the authors, the consent to participate rate is only 37.5%. This is unacceptable, as the missing 62.5% who were approached and declined were likely the women who had the most adverse psychological reactions to their abortions. With sensitive topic research, securing a high initial consent rate is vitally important and in order to approach being representative, a minimum of 70% should be retained.

2) The authors note that the sample was comprised of a high concentration of women from low socioeconomic backgrounds, rendering the sample not representative of US women undergoing abortion today. There is an ethical concern here as a well, since providing $350 to participate is coercive, as it would be difficult for most of the women to turn down the money.

3) The authors fail to reveal the specific consent to participate rates for each group. Because prior research has demonstrated that second trimester abortions are potentially more traumatizing than first trimester procedures, it is likely that a significantly higher percentage of women in the first-trimester group consented to participate; and the percentage of willing to participate, second trimester participants was likely well under 37.5%. If the rates were comparable, why not report this? Failure to report critical information increases suspicion that this “near limit’ group is in no way representative.

4) In the Turnaway Study, women who secured abortions near the gestational limits included women for whom the legal cut off ranged from 10 weeks through the end of the second trimester. There is a wealth of data indicating that women’s reasons for choosing abortion and their emotional responses to the procedure differ significantly at varying points of pregnancy. Women aborting at such widely different points should therefore not be lumped together, particularly when gestational age information is available in the data.

5) No information is provided regarding how the sites were actually chosen. What type of sampling plan was employed? Why were only those identified with the National Abortion Federation used? What cities were included? Which areas of the country were sampled?

6) The majority of the outcome measures are single items, and this is problematic given the many psychometrically sound multiple item instruments available in the literature for the variables examined. Well-trained behavioral science researchers should not attempt to measure complex human emotions in such a superficial manner; and ethically responsible scientists would not extrapolate from such minimalistic assessments to women’s emotional reactions to one of life’s more challenging decisions.

'''Bias issues:'''

7) The authors’ uneasiness with recent litigation is stated in the opening paragraph: “''Arguments about emotional harms from induced abortion—including decision regret and increasing negative emotions over time—have been leveraged to support abortion regulation in the United States. To uphold a 2007 law banning a later abortions, Justice Kennedy of the Supreme Court stated: “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort...” In support of a state-level ban, a researcher testified that abortion “carries greater risk of emotional harm than childbirth.” Arguments about emotional harm have been used to forward parental consent, mandatory ultrasound viewing, and waiting period legislation as well.''” This is a rather odd way to open a supposed scientific investigation and the authors’ unapologetic decision to do so reveals their rather transparent political motivation (i.e., to provide counter results no matter what the scientific cost).

8) The authors’ effort to draw sweeping conclusions from this single, seriously compromised study is evident in their remarks regarding the implications of the study: “''Results from this study suggest that claims that many women experience abortion decision regret are likely unfounded''.” As scientists we never make such sweeping conclusions based on a single study, particularly when there is an abundant literature comprised of hundreds of sophisticated studies wherein the conclusions are quite discrepant. Courts throughout the US have concluded that women should be appraised of the risks before consenting to abortion; it almost seems silly that these researchers hope to shift the tide based on this study alone.

9) Funding was secured from the David and Lucille Packard Foundation among other sources with a political agenda. As described on their website, “''Our work in the United States seeks to advance reproductive health and rights for women and young people by improving access to quality comprehensive sexuality education, family planning and safe abortion care''.”

= Effect of abortion vs. carrying to term on a woman's relationship with the man involved in the pregnancy =

[http://www.ncbi.nlm.nih.gov/pubmed/25199435 Effect of abortion vs. carrying to term on a woman's relationship with the man involved in the pregnancy.] Mauldon J, Foster DG, Roberts SC. Perspect Sex Reprod Health. 2015 Mar;47(1):11-8. doi: 10.1363/47e2315. Epub 2014 Sep 8.

:CONTEXT:When a woman who seeks an abortion cannot obtain one, having a child may reshape her relationship with the man involved in the pregnancy. No research has compared how relationship trajectories are affected by different outcomes of an unwanted pregnancy.
:METHODS:Data from the Turnaway Study, a prospective longitudinal study of women who sought abortion in 2008-2010 at one of 30 U.S. facilities, are used to assess relationships over two years among 862 women who had abortions or were denied them because they had passed the facility's gestational age limit. Mixed-effects models analyze effects of abortion or birth on women's relationships with the men involved.
:RESULTS: At conception, most women (80%) were in romantic relationships with the men involved. One week after seeking abortion, 61% were; two years later, 37% were. Compared with women who obtained an abortion near the facility's gestational age limit, women who gave birth had greater odds of having ongoing contact with the man (odds ratio at two years, 1.7). The odds of romantic involvement at two years did not differ by group; however, the decline in romantic involvement was initially slower among those giving birth. Relationship quality did not differ between groups.
:CONCLUSIONS: Giving birth temporarily prolonged romantic relationships of women in this study; most romantic relationships ended soon, whether or not the woman had an abortion. However, giving birth increased the odds of nonromantic contact between women and the men involved throughout the ensuing two years.

=PTSD in the Turnaway Study Sample=

[[https://bmjopen.bmj.com/content/6/2/e009698 Does abortion increase women’s risk for post-traumatic stress? Findings from a prospective longitudinal cohort study.]] Biggs, M. A., Rowland, B., McCulloch, C. E., & Foster, D. G. (2016). BMJ Open, 6(2).
:In this self-selected sample of a minority of women who had abortions, at the baseline interview one week after their abortions, 39% reported at least one symptom of post-trauamtic stress syndrome and 16% reported three or more symptoms placing them at risk of PTSD. When asked to attribute the cause of their stress, 7% of the women attributed subsequent symptoms of post-traumatic stress to their abortions. Among those with any symptoms, 30% attributed their symptoms to a history of exposure to violence or abuse, 20% to non-violent relationship issues (20%), 19% to their abortion, and 15% to a non-violent death or illness of a loved one, and 6% attributing it to personal health-related issues (6%). Negative reactions were not necessarily reflected in repudiation of their decision to have an abortion, however, "By the end of the study period, four of the seven women who reported the index pregnancy as the source of their PTSS still felt the abortion was the right decision for them (not shown in table)." Remember, however, the "right decision" measure is based on a single yes, no question.

= Claimed Examination of Physical Health Effects =
[http://www.sciencedirect.com/science/article/pii/S1049386715001589 Side Effects, Physical Health Consequences, and Mortality Associated with Abortion and Birth after an Unwanted Pregnancy] Gerdts C, Dobkin L, Foster DG, Schwarz EB. Womens Health Issues. 2016 Jan-Feb;26(1):55-9. doi: 10.1016/j.whi.2015.10.001

:INTRODUCTION: The safety of abortion in the United States has been documented extensively. In the context of unwanted pregnancy, however, there are few data comparing the health consequences of having an abortion versus carrying an unwanted pregnancy to term.

:METHODS: We examine and compare the self-reported physical health consequences after birth and abortion among participants of the Turnaway Study, which recruited women seeking abortions at 30 clinics across the United States. We also investigate and report maternal mortality among all women enrolled in the study.

:RESULTS: In our study sample, women who gave birth reported potentially life-threatening complications, such as eclampsia and postpartum hemorrhage, whereas those having abortions did not. Women who gave birth reported the need to limit physical activity for a period of time three times longer than that reported by women who received abortions. Among all women enrolled in the Turnaway Study, one maternal death was identified-one woman who had been denied an abortion died from a condition that confers a higher risk of death among pregnant women.

:CONCLUSION: These results reinforce the existing data on the safety of induced abortion when compared with childbirth, and highlight the risk of serious morbidity and mortality associated with childbirth after unwanted pregnancy.

Note: In addition to the usual problems of this study in regard to its use of a non-representative sample, the measures used are inaccurate. Moreover, the claimed assessment of physical health was based on just two questions (with no examination of actual medical records): 1) “Did you experience any side effects or health problems from your [birth/abortion]?” and 2) “Was there a period after your [birth/abortion] when you were physically unable to do daily activities such as walking, climbing steps or doing errands?”

Abortion related deaths are defined by the Centers for Disease Control (CDC) in the United States as any death due to "1) a direct complication of an abortion, 2) an indirect complication caused by the chain of events initiated by the abortion, or 3) an aggravation of a preexisting condition by the physiologic or psychologic effects of the abortion, regardless of the amount of time between the abortion and the death" (Bartlett, L. a, Berg, C. J., Shulman, H. B., Zane, S. B., Green, C. a, Whitehead, S., & Atrash, H. K. (2004). Risk factors for legal induced abortion-related mortality in the United States. Obstetrics and Gynecology, 103(4), 729–737.) But in the Turnaway Study, the researchers excluded examination of deaths beyond 42 days . . . and, of course, ignored all the record linkage studies showing higher mortality rates after abortion.

=Substance Use in the Turnaway Study=

Receiving versus being denied an abortion and subsequent drug use.Roberts SC, Rocca CH, Foster DG. Drug Alcohol Depend. 2014 Jan 1;134:63-70. doi: 10.1016/j.drugalcdep.2013.09.013. Epub 2013 Sep 23.

:BACKGROUND: Some research finds that women receiving abortions are at increased risk of subsequent drug use and drug use disorders. This literature is rife with methodological problems, particularly inappropriate comparison groups.
:METHODS: This study used data from the Turnaway Study, a prospective, longitudinal study of women who sought abortions at 30 sites across the U.S. Participants included women presenting just prior to an abortion facility's gestational age limit who received abortions (Near Limit Abortion Group, n=452), just beyond the gestational limit who were denied abortions (Turnaways, n=231), and who received first trimester abortions (First Trimester Abortion Group, n=273). This study examined the relationship between receiving versus being denied an abortion and subsequent drug use over two years. Trajectories of drug use were compared using multivariate mixed effects regression.
:RESULTS: Any drug use, frequency of drug use, and marijuana use did not change over time among women in any group. There were no differential changes over time in any drug use, frequency of drug use, or marijuana use between groups. However, Turnaways who ultimately gave birth increased use of drugs other than marijuana compared to women in the Near Limit Abortion Group (p=.041), who did not increase use.
:CONCLUSION: Women receiving abortions did not increase drug use over two years or have higher levels of drug use than women denied abortions. Assertions that abortion leads women to use drugs to cope with the stress of abortion are not supported.

=Non-Representative Sample=
[https://pubmed.ncbi.nlm.nih.gov/24439937/ Implementing a prospective study of women seeking abortion in the United States: understanding and overcoming barriers to recruitment] Womens Health Issues . Jan-Feb 2014;24(1):e115-23. doi: 10.1016/j.whi.2013.10.004.

Background: The Turnaway Study is designed to prospectively study the outcomes of women who sought-but did not all obtain-abortions. This design permits more accurate inferences about the health consequences of abortion for women, but requires the recruitment of a large number of women from remote health care facilities to a study a sensitive topic. This paper explores the Turnaway Study's recruitment process.

Methods: From 2008 to 2010, the staff at 30 abortion-providing facilities recruited eligible female patients. Eight interventions were evaluated using multilevel logistic regression for their impact on eligible patients being approached, approached patients agreeing to go through informed consent by phone, and enrolled patients completing the baseline interview.

Findings: After site visits, patients had roughly twice the odds of being approached by facility staff and twice the odds of then agreeing to go through informed consent. When all recruitment steps were considered together, the net effect of site visits was to increase the odds that eligible patients participated by nearly a factor of six. After the introduction of a patient gift card incentive, patients had over three times the odds of agreeing to go through informed consent. ''With each passing month, however, staff demonstrated a 9% reduced odds of approaching eligible patients about the study''.

Conclusion: Prioritizing scientific rigor over the convenience of using existing datasets, the Turnaway Study confronted recruitment challenges common to medical practice-based studies and unique to sensitive services. Visiting sites and communicating frequently with facility staff, as well as offering incentives to patients to hear more about the study before informed consent, may help to increase participation in prospective health studies and facilitate evaluation of sensitive women's health services.

NOTE: It is elsewhere reported that two-thirds of the participants came from just three of the 30 clinics participating.

= Women’s Mental Health andWell-being 5 Years After Receiving or Being Denied an Abortion =

[http://jamanetwork.com/journals/jamapsychiatry/article-abstract/2592320 Women’s Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study.] Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. JAMA psychiatry. December 2016. doi:10.1001/jamapsychiatry.2016.3478.

:Objective To assess women's psychological well-being 5 years after receiving or being denied an abortion. Design, Setting, and Participants This study presents data from the Turnaway Study, a prospective longitudinal study with a quasi-experimental design. Women were recruited from January 1, 2008, to December 31, 2010, from 30 abortion facilities in 21 states throughout the United States, interviewed via telephone 1 week after seeking an abortion, and then interviewed semiannually for 5 years, totaling 11 interview waves. Interviews were completed January 31, 2016. We examined the psychological trajectories of women who received abortions just under the facility's gestational limit (near-limit group) and compared them with women who sought but were denied an abortion because they were just beyond the facility gestational limit (turnaway group, which includes the turnaway-birth and turnaway-no-birth groups). We used mixed effects linear and logistic regression analyses to assess whether psychological trajectories differed by study group.

:Main Outcomes and Measures We included 6 measures of mental health and well-being: 2 measures of depression and 2 measures of anxiety assessed using the Brief Symptom Inventory, as well as self-esteem, and life satisfaction. Results Of the 956 women (mean [SD] age, 24.9 [5.8] years) in the study, at 1 week after seeking an abortion, compared with the near-limit group, women denied an abortion reported more anxiety symptoms (turnaway-births, 0.57; 95% CI, 0.01 to 1.13; turnaway-no-births, 2.29; 95% CI, 1.39 to 3.18), lower self-esteem (turnaway-births, -0.33; 95% CI, -0.56 to -0.09; turnaway-no-births, -0.40; 95% CI, -0.78 to -0.02), lower life satisfaction (turnaway-births, -0.16; 95% CI, -0.38 to 0.06; turnaway-no-births, -0.41; 95% CI, -0.77 to -0.06), and similar levels of depression (turnaway-births, 0.13; 95% CI, -0.46 to 0.72; turnaway-no-births, 0.44; 95% CI, -0.50 to 1.39).

:Conclusions and Relevance In this study, compared with having an abortion, being denied an abortion may be associated with greater risk of initially experiencing adverse psychological outcomes. Psychological well-being improved over time so that both groups of women eventually converged. These findings do not support policies that restrict women's access to abortion on the basis that abortion harms women's mental health.

==Criticisms==
* The authors hide the fact that only 11% of the eligible women participated in this study thru the fifth year, making it impossible to generalize any findings from this highly self-selected sample, especially when women having negative reactions would be most likely to drop out.
* Moreover, the only elevated risk persisted for only a few weeks after "being denied" an abortion, while women are still under stress and trying to sort out their lives. Most importantly, the study actually found NO negative mental health effects after the child was born, either in the first year or over the five years examined.
* All the general problems discussed at the top of this page also apply.
*It is also worth noting that at one week after the abortion, those denied abortion had an average depression score of .13 compared to .44 for women who had an abortion . . . in other words, while turnaways had higher anxiety they had less depression than those who had aborted. The difference in depression scores was not statistically significant due to the low power of this study, but it demonstrates the authors' tendency to overgeneralize findings in away that minimizes effects of abortion and magnifies the effects of being denied an abortion.
* Another problem is that the "control group" is not clear and clean. They are treating women in the turnaway group as their control group, but in fact they elsewhere report that [https://pdfs.semanticscholar.org/bc37/113def0d0b90f94bea2acee1e8ec1dfcfcea.pdf 40% of the turnaway group had a prior history of abortion]. In other words, they are comparing a group of women who have a one or more abortions to another group of women of whom at least 40% have had one or more abortions, and are pretending that the prior abortions in the second group don't matter in a study about abortion and mental health.

==Media Coverage==
[https://time.com/4599806/abortion-doesnt-negatively-affect-womens-mental-health-study/ Abortion Doesn't Negatively Affect Women's Mental Health: Study] ''Time'' Dec 14, 2016
[https://www.nytimes.com/2016/12/14/health/abortion-mental-health.html?_r=0 Abortion Is Found to Have Little Effect on Women’s Mental Health] New York Times Dec 14, 2016
[http://www.newsweek.com/abortion-mental-health-link-study-531643 No Evidence Abortion Leads to Long-Term Depression and Anxiety] Newsweek 12/14/16
[http://www.psychiatryadvisor.com/depressive-disorder/study-refutes-assumption-that-women-experience-adverse-psychological-outcomes-following-an-abortion/article/627466/ Worse Psychological Outcomes for Women Denied Abortion] Psychiatry Advisor
[http://www.salon.com/2016/12/14/abortion-isnt-linked-with-mental-illness-study-shows-but-being-denied-one-might-be/ Abortion isn’t linked with mental illness, study shows — but being denied one might be] Salon
[http://www.medpagetoday.com/obgyn/pregnancy/62066 More Mental Health Issues Among Women Denied Abortions] MedPage Today
[http://www.ajmc.com/focus-of-the-week/1216/women-denied-abortions-report-worse-mental-health-outcomes#sthash.hg4xgfZw.dpuf Women Denied Abortions Report Worse Mental Health Outcomes] AJMC Managed Markets Network
[http://www.webmd.com/women/news/20161214/women-denied-an-abortion-endure-mental-health-toll-study#1 Women Denied Abortion Endure Mental Health Toll] WebMD. Dec. 14, 2016

[http://www.medicaldaily.com/abortion-study-2016-most-women-didnt-struggle-decision-terminate-400937 Abortion Study 2016: Most Women Didn't Struggle With Decision To Terminate] Medical Daily Oct 2016
[http://www.livescience.com/57225-denying-abortion-access-harms-womens-mental-health.html Denying Abortion Access May Harm Women's Mental Health] Dec 15, 2016
[http://time.com/4599806/abortion-doesnt-negatively-affect-womens-mental-health-study/ Abortion Doesn't Negatively Affect Women's Mental Health: Study] Time. Dec 14, 2016
[http://www.thedailybeast.com/articles/2016/12/14/study-abortion-doesn-t-harm-women-s-mental-health-but-denying-one-does.html Study: Abortion Doesn't Harm Women's Mental Health, but Denying One Does.] The Daily Beast. Dec 14, 2016
[http://www.slate.com/blogs/xx_factor/2016/12/14/new_longitudinal_study_confirms_that_women_who_get_abortions_do_not_suffer.html New Longitudinal Study Confirms That Women Who Get Abortions Do Not Suffer Psychological Harm] Slate Dec 14, 2016

==Critique by Priscilla Coleman==

*"[https://www.mercatornet.com/features/view/the-continuing-saga-of-efforts-to-deny-the-heartache-of-abortion/19163 The continuing saga of efforts to deny the heartache of abortion]," by Priscilla Coleman

= Suicidal Thoughts =
'''Biggs MA, Gould H, Barar RE, Foster DG. [https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2018.18010091?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Five-year suicidal ideation trajectories among women receiving or being denied an abortion.] Am J Psychiatry 2018;175:845–52. <nowiki>https://doi.org/10.1176/appi.ajp.2018.18010091</nowiki>.'''

In this study the authors conclude "Levels of suicidal ideation were similarly low between women who had abortions and women who were denied abortions. Policies requiring that women be warned that they are at increased risk of becoming suicidal if they choose abortion are not evidence based." But once again, their reporting and conclusions are selectively chosen to distract readers from findings which actually show higher rates of suicidality among the abortion women. In Table 2, the average mean score on the suicidality scale over the full five years was significantly lower for the Turnaway Birth Group (0.67) as compared to both the first trimester abortion group (0.88) and the near-limit abortion (0.94) at one week after going to the abortion clinic. This was also true at the first interview, one week after being invited to participate at the abortion clinic: Turnaway Birth Group (1.29), first trimester abortion group (1.53) and the near-limit abortion (1.92), and for the Turnaway Group still seeking abortion (2.02). Yet, while this difference is shown in the tables, it is never discussed, Instead, the authors focus on the decline in suicidality scores across the five years and assert that since there is a similar decline in rates, that means that abortion is not associated with suicidality. Which is clearly not even logically true. Much less, it ignores the fact that suicidality was significnatly associated with abortions at numerous points in sequence of surveys.

Notably, Table 3 also shows the birth group having the lowest risk of suicidality, but they try to justify ignoring this finding by computations of the 95% confidence intervals which reveal that their data set is so small that their confidence intervals have a huge range, for example for the Turnaway birth group, the OR=1.07 95% CI = 0.14 to 8.01. What that huge range means is that their data set is simply too small to detect any effects.

They also ignore the likelihood that the high dropout rate may have helped to reduce the suicidality measured over time, if the most distressed women were most likely to drop out. Notably, they do include an "attrition analysis" in which they assert that in testing scores related to depression, anxiety, history of child abuse and past-year intimate partner violence were not significantly associated with loss to follow-up (though they withheld the data). But why in the world did they not report whether suicidality was associated with dropouts---unless it was associated with dropouts and they wanted to distract readers with an offering of other variables for which it is not associated. This is almost surely truly a tell.

=Other Criticisms=

[https://pmc.ncbi.nlm.nih.gov/articles/PMC11559533/ A Forensic Investigation and Critique of Suicidal Ideation Reported in a Turnaway Study]

[https://doi.org/10.70257/twgf1217 Turnaway Study Report Unethically Violated Participants' Privacy and Misleads Public with a Non-Representative Sample, Selective Reporting, and Overstated Conclusions]

[https://afterabortion.org/theyre-still-trying-to-disprove-post-abortion-trauma-syndrome/ They're Still Trying to Disprove Post-Abortion Trauma Syndrome]

[http://liveactionnews.org/flawed-biased-turnaway-study-now-claims-95-women-happy-abortion/ Flawed, Biased Turnaway Study Now Claims 95 Percent of Women Happy After Abortion]

[http://reclaimingourchildren.typepad.com/lumina_a_ray_of_light_aft/2015/07/hardly-any-women-regret-having-an-abortion-only-millions-of-us.html Hardly Any Women Regret Having an Abortion -- Only Millions of Us!]

Takeaways from the UCSF Abortion "Turnaway" Study (Series from NRL News Today):
[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study/#.VaafirV_Dkc Part I: Set up for a Spin]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-2/#.VaagarV_Dkc Part II: Finding What They Looked For]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-3/#more-20901 Part III: Spinning the Consequences of Abortion]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-4/#more-20951Part IV: Research Team with an Agenda]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-5/#.VaagnbV_Dkf Part V: How Bias Can Tilt Results]

=Review of the Book=
The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having―or Being Denied―an Abortion
by Diana Greene Foster Ph.D. New York. Scribner. 2020.

The principle goal of Foster's book is to insist that there is "no evidence that abortion hurts women" while there are "many ways in which women are hurt by carrying an unwanted pregnancy to term"(p 21). From this vantage point, she argues against any and every abortion law regulating informed consent, disclosure of risks, waiting periods, and constraints on late term abortions. In short: abortion is good. Delivering unplanned pregnancies is frought with risk.

Foster consistently exaggerates the importance of her case series study. Any evidence to the contrary is ignored and all public policies that she opposes (such as risk disclosure requirements, waiting periods, term limits, and safety regulations) are "proven" to be unnecessary.)

Foster's studies and books have been promoted and lauded by all of the pro-abortion media. She even basks in repeating the description of her study by ill-informed reporter for New York Times Magazine "as the 'most rigorous' study to look at whether women develop mental health problems following an abortion."(p. 7) That's total nonsense, but it serves to advance her political goals, so Foster introduces her study with this accolade in an effort to distract readers from the many serious flaws of her work.

Her first lie is that her study is a prospective longitudinal study, like that which was recommended by Surgeon General C. Everett Koop. In fact, a prospective study on abortion would require gathering data on subjects ''before'' they become pregnant so one can examine mental and physical health before and after the pregnancy and its outcome (birth, abortion, or natural loss). But the Turnaway Study only begins to gather data a full week ''after'' women had their abortions, or in the subset of women "denied" an abortion, after they went to the abortion clinic. This means it is a "case series" study--one that follows cases. It is not a prospective study--one that has objective data prior to outcomes of interest.

The second lie is one of omission. She never tells readers of the body of research that shows that there is a dose effect--negative emotions increase with each exposure to a pregnancy loss, whether it is an abortion or miscarriage. This is important because her study totally ignored prior and subsequent pregnancy history. It is likely that to 20-40% of those who were turned away and gave birth had a prior abortion or an abortion after the delivery. As a result, Foster is comparing women who have a known abortion to women with an unknown mix of abortion histories. This is simply bad science.

The third lie is in framing, delay, and dismissal. Readers are led to believe that her survey of "a thousand women" gathered from 30 abortion clinics is truly representative of the national population of women seeking abortions. It is not until page 253 that Foster admits that only 31% of the women invited to participate in the study participated in even the first interview, a week after going to the clinic. This is a horrible participation rate. Based on research from other studies, the most likely explanation is self-censure: the women who expect to have the most negative feelings following their abortions are least likely to want to have those feelings stirred up by interviews weeks, months, and years later. But Foster doesn't mention this research. Instead, she simply dismisses the low participation rate as being most likely due women finding it he inconvenient. At this point, Foster could also have mentioned that participants were even offered a $50 gift card for every interview, but this fact (along with many others) are revealed only in addenda to her published medical studies, not her in her book, news releases, summaries or other propaganda pieces. For example, another omitted detail is that of 31% who did participate in the first interview, only about half (17%) remained in the study for the whole five years. Fifty bucks per interview was simply not enough to prevent high drop out rates. Again, it is quite likely that the women dropping out were most likely to be experiencing the most negative feelings.

It is also not until page 253 that we learn that the invitation process was also not random. Clinic workers had the liberty to decide who they wanted to invite. In fact, two-thirds of the participants came from just three of the 30 clinics participating.

Readers are also not informed that the study ignored prior and subsequent abortions, in both the aborting group and those who carried to term. As many as 20-40% of those who were turned away and gave birth had a prior abortion or an abortion after the delivery. This is simply ignored. As a result, Foster is comparing women who have a known abortion to women with an unknown mix of abortion histories. This is simply bad science.

==Inconsistencies==
*page21 -"We find no evidence that abortion hurts women." p.125 - 39% of women in the sample had symptoms of post-traumatic stress, and 16% were at risk of post-traumatic stress disorder. Of those at risk, 19% attributed their traumatic reactions to their abortions, yet the researchers dismiss this finding as "no evidence that abortion hurts women" on the grounds that it was more common for women to attribute their PTSD to experiences of violence, or other health issues. Similarly, their claim that there are no negative reactions is contradicted by their own findings that (p 121) 74% reported sadness, 66% regret, 62% guilt and 43% anger.

*p100-Here Foster says that "the initial motivation for the entire Turnaway Study, after all, was to answer the question ''Does abortion hurt women?''" But on page 4 she stated that the original intent was simply to address the question "I wonder what happens to the women we turn away." If the real intent was to investigate potential harm to women, this was the wrong study design since it lacked any information about women before they sought abortion, especially before they were pregnant . . . plus it ignores any effects of prior or subsequent abortions on women, confining itself to just the one abortion at the time volunteers joined the study.

*p121 - After being told they were over the time limit and could not have an abortion, 60% of women denied abortions reported feeling happy about their pregnancy and [https://pdfs.semanticscholar.org/bc37/113def0d0b90f94bea2acee1e8ec1dfcfcea.pdf 43% were happy about being turned away, with 49% reporting they also felt relief a week after being turned away. Their levels of sadness and guilt were also lower than that of those who aborted].

*p107-108 - Claims: "Actually, women seeking abortions are no different from women in general." But this contradicts the claim if other pro-abortion researchers, such as Steinberg and Munk-Olsen, that women who have abortions are over twice as likely to have prior mental health problems, which is how they explain the higher rates of psychological problems found among women who have abortions in large scale population studies...which are not subject to the non-random self-selected sample problems attached to Foster's study. In short, there is a lot of research indicating that women who have abortions ARE different from the general population, but this is another example of Foster's penchant for propaganda rather than fact.

==Nuances Admitted==
*p99-100 - Foster admits that at least some women who have difficulty coping after an abortion may attempt to re-frame and rationalize their decision as being for the best: "None of us know, as we move through our lives, what would have been at the end of the roads not taken. I suspect that whichever path we take, when we look back, we want to feel like we made the best decisions possible—that everything worked out for the best. So Martina's statement that "I don't regret the abortion at all. I'm where I am supposed to be in my life" could be an after-the fact rationalization of her experience." This admission totally undercuts the significance of Foster's claim that 95% of women are happy with their decision to have an abortion.

*p102-103 - Foster reports that "Approximately one in five women seeking abortion in the Turnaway Study thought abortion was morally wrong or should be illegal." {The study reported that another 15% believe it is morally wrong in some circumstances.} She also states that in another study she conducted of women in an abortion clinic waiting room "4% agreed with the statement 'At my stage of pregnancy, I think abortion is the same as killing a baby that's already born.'"

*p121 - Foster admits that answers to questions can be easily misinterpreted, giving as an example "It was terrible" could mean the experience was terrible or being in the situation to require an abortion was terrible. Similarly, feeling "relief" could mean feeling relieved that the experience is over or relieved not to be pregnant. Using the same logic, she notes that while the majority of women (60%) who were told they couldn't have an abortion were reported feeling happy about their pregnancy seven days later, this high level of happiness did not mean they "were entirely glad they became pregnant." Mixed emotions are common. So claims that most women feel "relief" after an abortion simply don't tell us enough about what kind of relief they are feeling, much less that they are not also feeling negative emotions.

*p122 - "Over the five years, women who reported having more difficulty deciding to seek an abortion also felt more negative emotions, as did women who perceived that abortion was looked down upon in their communities and women with less social support." In addition, women who had a greater desire or openness to becoming pregnant were also more likely to have negative feelings.

==Denying an Abortion Does No Harm, Most are Happy to Have Child==
*p109-There is no mental health harm from being denied an abortion. In fact, the majority of women who were denied abortions reported feeling happy at that result (p121).

*p109-Foster was surprised to find that women who were denied abortions had no additional mental health harm. "I expected that raising a child one wasn't planning to have might be associated with depression or anxiety. But this is not what we found over the long run. Carrying an unwanted pregnancy to term was not associated with mental health harm. Women are resilient to the experience of giving birth following an unwanted pregnancy, at least in terms of their mental health."

*P109- In an effort to salvage that narrative that denying abortion "hurts" women, she can only point to a single finding just one week after women sought an abortion showing that Turnaways had somewhat higher rates of anxiety compared to women who aborted a week earlier. But at that same time, the women who aborted reported higher rates of sadness, guilt and depression than the turnaways. Bottom line: the Turnaway Study actually supports the idea that banning abortions would not cause any significant mental health harm to women. In fact, just one week after going to the clinic, '''60% of those who were still pregnant reported being happy about their pregnancy''' compared to just 27% of those who had abortions. Among those who had near term abortions, 62% reported feeling guilty compared to just 30% of the Turnaways.

*p 126 - "One week after abortion denial, 65% of participants reported still wishing they could have had the abortion [35% were happy they did not have it]; after the birth, only 12% of women reported that they still wished that they could have had the abortion." By the first birthday, it dropped to 7% and then down to 4% at the last interview, 4.5 years later. Those "women who had less social support from family and friends and women who had an easy time decision to have the abortion were the ones who were more likely to continue to wish they had received an abortion."

*p 126 - Among women who had their babies, those who reported the most negative emotions were those who placed their children for adoption. At the 4.5 year followup, 15% of women who placed the child for adoption compared to just 2% of women who parented their child, reported that they still wished they could have had the abortion.

==Inconsistencies regarding mental health==

*p121--In Foster's 2013 paper examining emotions relative to their pregnancies one week after seeking an abortion, among all groups of women, 74% reported sadness, 66% regret, 62% guilt, 43% anger, 25% relief and 33% happiness. Regarding their abortion experiences, 64% sadness, 41% regret, 53% guilt, 31% anger, 83% relief, and 52% happiness. But turnaways were twice as likely to subsequently report happiness about their pregnancy, 43% said they were happy to not have had the abortion, and 49% said they were relieved not to have had the abortion. Also, 60% of Turnaways report happiness about their pregnancies compared to 25% of women who had a first trimester abortion. This suggests that Turnaways may have delayed seeking an abortion because they actually were hoping to keep their children.

*Note: In their 2015 report on "decision rightness" the Turnaway team reports that at the baseline (one week after their abortions) 95% of women answered yes to "“Given your situation, was the decision to have an abortion the right decision for you?" But in the same interview, 66% and 41% reported regret relative to the pregnancy and the abortion respectively. As noted above, a majority also reported guilt and high rates of sadness and anger. Therefore, women do not equate "decision rightness" with their overall feelings about their abortion experience, and it is totally inappropriate for Foster and her team to promote the idea that 95% decision rightness means that regret and other negative reactions are rare.

*p124 - Foster complains that Justice Kennedy upheld a law regulating abortion on the grounds that "some women come to regret their choice to abort." She fails to point out that her own study confirmed Kennedy's statement, with 33-65% of women reporting regret. Instead, she focuses strictly on the fact that in their unrepresentative, non-random sample of volunteers 95% of women answered yes to "Given your situation, was the decision to have an abortion the right decision for you?" Yet, previously, she also acknowledged that there is a very common tendency to rationalize previous decisions as the best choice one could make "given your situation." In short, saying you made the best decision you could "given your situation" at a particular time is not the same as saying "That decision was great. It really improved my life. I've never had any regrets about it." In fact, it could mean: "It was my only option at that time. But I've suffered many regrets, guilt, feelings of loss and emptiness since then."

*p126 - Based on the high "decision rightness" results, Foster claims: "The Turnaway Study provides strong evidence that the vast majority of women do not experience difficulty coping with their abortions..." That is pure nonsense. The study actually reveals that large percentages of women report feeling regret (41-66%), guilt(53-63%), sadness (64-74%), anger(31-43%), depression, anxiety and even PTSD (7-39%). "Decision rightness" is not the same as a claim that "I've had no difficulties coping with my abortion." It is a false equivalence. Moreover, because the Turnaway Study used a non-random invitation of a self-censuring population of women which created a bias toward women expected to be satisfied with their abortion decisions, this non-representative sample really can't tell us anything at all about what "the vast majority of women" experience.

==Shortcomings==

*Readers are never told that the study is based on a non-random, self-selected group of volunteers. Both the invitation process and self-selection bias make it likely that the sample group are much more likely to have positive experiences with abortion than the general population.

*Moreover, it is not until page 253 that not told about the Turnaway Study's horrible participation rate. Only 31% of the women invited to participate in the study participated in even a single interview, much less ten. It is simply impossible to predict what "the majority" of any surveyed group feel about any subject only 31% are willing to answer any questions. This is why many journals do not accept studies with less than 60% participation rates. Regarding this low participation rate, Foster simply waves it aside, reassuring readers that the low participation rate as being most likely due to the inconvenience. She does not even address the evidence from other studies indicating that women who expect to have negative feelings are least likely to participate in subsequent interviews.

*Surprisingly, Foster also fails to mention the fact that in order to tempt women to participate, they were offered a $50 gift card for every interview they completed...up to ten interviews, $500. In short, the self-selection bias is toward women who expect to have the least negative reactions and the most interest in $50 per interview. This financial inducement is omitted from her book

*In addition, she does not fully explain that the invitation process was also not random. Clinic workers had the liberty to decide who they wanted to invite to participate. In fact, she reports that two-thirds of the participants came from just three of the 30 clinics participating. That suggests that the entire population of women eligible to be invited was likely at least ten times greater, meaning they only interviewed 3% or less of the eligible population.

*Nor does she address the problem of drop out rates. Of those who initially agreed to be interviewed, 15% dropped out before the first interview a week after the abortion. Another 8% dropped out between the one week post-abortion interview and the six-month interview. Over the course of the 10 interviews over a 4.5 year period the participation rate dropped from 31% down to 17%. Again, it is most likely that the women experiencing the most negative feelings were most likely to dropout as time progressed.

*Readers are also not informed that the study ignored prior and subsequent abortions, in both the aborting group and those who carried to term. While never mentioned in the book, in an obscure note in just one of their studies it is revealed that [https://pdfs.semanticscholar.org/bc37/113def0d0b90f94bea2acee1e8ec1dfcfcea.pdf 40% of the turnaway group had a prior history of abortion]. In other words, Foster was actually comparing a group of women, 100% of whom have had one or more abortions, to a "control" group of whom at least 40% have had one or more abortions. But she simply presumes these prior abortions don't matter. She then argues that the similarities between these groups proves that abortion has no effects on mental health, a conclusion that requires us to ignore all prior and subsequent abortions. This is simply bad logic and bad science. But because it advances the pro-abortion propaganda line, so it gets labeled the "most rigorous" research ever done!

*Similarly, her studies ignore whether or not women in either group had a history of multiple abortions. That's a serious problem since the research is clear that there is a dose effect--negative reactions increase with exposure to multiple abortions.

==Physical Risks and Mortality Rates==

*With such a small, non-random sample size, the Turnaway Study is unable to give any reliable data on physical complications.

*p142 - Foster asserts that complication rates for abortion (at 2%) are far lower than "for wisdom-tooth extraction (7%), tonscillectomy (8-9%) and childbirth (29%)" but the source she cites does not mention any of these latter procedures, much less the rates, and is itself restricted only to complications of abortion treated in emergency rooms. It excludes treatments at other medical providers, much less untreated complications.

*p136 - Mortality Rates. Foster reports that two women in the birth group had deaths related to childbirth. This is over a 100 times the national maternal mortality rate. On the other hand, she also reports, but dismisses as incidental, that there were four deaths among the women who had abortions. That finding, however, is consistent with eleven [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5692130/ record linkage studies showing an elevated risk of death from all causes following abortion]]--most especially in relation to suicide, accidents (risk taking or self destructive behavior) and heart disease (a stress related illness).

*p151 - Foster claims "Not only is abortion a safe medical procedure; it's alternative—continuing pregnancy and giving birth—is far riskier." This is a common pro-abortion claim, but it is not supported by record linkage studies which prove that abortion is associated with in increased risk of death compared to childbirth, and also higher rates of psychological problems, substance abuse, and cardiac diseases (most likely due to stress).

==The Testimonies==
The statistical studies that the Turnaway Study team has published in medical journals includes only numbers describing specific questions asked in the study. In her Turnaway Study book, Foster includes the personal testimonies of numerous women. What is interesting about these studies is that they underscore the fact that women who say they made the right decision to abort will also frequently describe negative emotions and reactions.

*p61 - Jessica describes her abortion as "a sacrifice I had to do. It that wouldn't have happened, I might not be here today. Or my kids might be in foster care. I try to think of the positives. There was a reason. Everything happens for a reason. You might not understand that reason, but one day you will." She believes in God, believes life is sacred, yet also believes God let doctors to "figure out" how to do abortions for a purpose. "There is a good purpose usually for everything, some way or another. I don't talk about it. It still is referred to as the A-word if it's spoken of at all. You've got to make sacrifices sometimes no matter how bad it hurts. Sometimes that's just life. . . . The only complete meltdown I've had about it was when my kids went to, like, a festival with their aunt and uncle.... They came home with balloons, and they were anti-abortion [slogan] balloons." After Jessica grew angry and popped the balloons, "My kids cried, and my oldest one told me he hated me. I couldn't tell him why, and he didn't understand. Mama just popped my balloon, that's all he knew. My friend lives across the road, and I told her I wasn't feeling good. Could the kids come play? When they went to her house, I just cried."

*p160 - Foster describes Kiara as someone who benefited from her abortion, and indeed Kiara states that the "mistake" of her pregnancy and abortion taught her to be more careful about never going through all that again. But she also describes feeling guilty about the abortion, a need for forgiveness, that she asked God for forgiveness, and believes she has been forgiven. She believes that if she had not had the abortion, she might not have experienced the growth she has had. In other words, there are parts of her life, including a later child, that she values and would certainly not want to lose if, by magic, regretting her abortion would suddenly put her on a different path where she doesn't know what would have happened. "I've always felt that life was precious.... I don't think [the abortion] changed my perspective. It just made me appreciate others who have gone through that situation, whereas before I was like, 'What? How can you do that?' But, it just kind of opened my mind to people and their situations but did not necessarily change my outlook on life itself."

==Chapter 6 - Women's Lives==
This is an excellent example of how the Foster and the Turnaway team use tiny bits of data to leap to grand conclusions.

===Aspirational Goals===

*p166-170 - They asked women one week after their abortions "How do you think your life will be a year from now?" They then rated these as either aspirational (positive), neutral, or negative goals, and did an analysis strictly of the aspirational goals. Their finding was that there was no difference in women who gave birth were most likely to describe an aspirational goal relative to their children (specifically their unborn child), which is hardly surprising since those who aborted a week earlier are not going to have a baby! But their "big" finding is that women who aborted were more likely to voice aspirational goals regarding work, relationships, education, et cetera. 86% of women who had aborted reported an aspirational goal one week later compared to "only" 56% of women who had been turned away from the abortion clinic (30% of whom were in the process of seeking and getting an abortion elsewhere). In other words, Foster and her team are trying to argue that a higher rate of "having an aspirational goal" one week after seeking an abortion (whether it was performed or denied) is in and of itself a great benefit to women, and women who are denied abortions are denied this intangible benefit because only 56% vs 86% will voice an aspirational goal when asked an open ended question one week later. That is quite a stretch! What is especially important to note, however, is that their own analysis showed that women who gave birth were just as likely to achieve their aspirational goals as those who had abortions. Perhaps most telling, however, is that Foster and her team did not look at the differences in aspirational goals in the years following childbirth. This is likely because they could find no differences or the differences were in favor of childbirth rather than abortion, and so were never published since they could not be spun to advance their pro-abortion agenda.

*p183 - They were also asked "How do you think your life will be different five years from now?" For this question, the percentage of aspirational goals went up for both groups: 91% for those who had aborted and 83% for those who had been turned away. The Turnaway team could not find any differences in percentages women having achieved these five year goals a the end of the study.

===Changing Attitudes Toward Abortion===

*p171- In one of their [https://link.springer.com/article/10.1007/s13178-018-0325-1 studies of how participants attitudes toward abortion changed], Foster reports that women who gave birth after being denied an abortion were three times more likely (21% vs 9%) to become less supportive of abortion rights while those who had abortions were 5 times more likely (33% to 6%) to become more supportive of abortion. Overall, their views tended to follow their experience.

===Economic Differences===

*p174-177- The Turnaway study provide only a cursory look at the differences in economic lives of their study population. The first benchmark they examined was the number of women below the poverty line. Conveniently, being pregnant, much less giving birth to a child, changes the calculation of the poverty line. So it is no surprise that immediately following their abortions there was an immediate drop of the percentage of women below the federal poverty line for household income. But most surprising, as shown in Figure 7 on page 177, women who gave birth had a greater drop in poverty from six months after seeking an abortion through 4.5 years. In other words, having an abortion did not produce any sustained improvement in household income while the economic hardship associated with having a child rapidly declined with every passing year.

*p178-1880- Without the permission of her volunteers, Foster submitted their personal contact information to credit bureaus to obtain their credit histories. In an analysis of the credit history, she claims that being denied an abortion increased the average past-due debt of turnaways to $1750 compared to $938 in the years prior to their pregnancy. Foster and her colleagues also found that 4.5 years after seeking an abortion, turnaways had an average credit score of about 550 compared to 558 among those who had abortions, a difference of less than 1.5% among a non-representative sample of volunteers. Based on these thin pieces of evidence, Foster claims that her Turnaway Study has proven that denying women abortions harms their socioeconomic status.

*Note: There is evidence from [https://www.sciencedirect.com/science/article/pii/S0022347618312976 one of their papers] indicating that women in the Turnaway group were economically worse off at the baseline. Therefore, any economic differences observed at 4.5 years after seeking an abortion may have predated the pregnancy. In addition, as mentioned previously, there is a lot of self-selection bias in the Turnaway samples. It is well known that women who anticipate more problems dealing with their abortion are less likely to participate in surveys. Since the Turnaway group did not have an abortion, it is likely they felt less anxiety in dealing with subsequent surveys. Also, the promise of a $50 gift card with each interview was likely most tempting to those who were worse off financially. Both of these factors may have contributed to a distortion of the sample toward poorer women.
*Regarding any alleged economic harms to being denied an abortion, It is important to examine this peer-reviewed critique [https://doi.org/10.70257/twgf1217 Turnaway Study Report Unethically Violated Participants' Privacy and Misleads Public with a Non-Representative Sample, Selective Reporting, and Overstated Conclusions]
**"Results from the Turnaway Study, conducted by Advancing New Standards in Reproductive Health (ANSRH), have widely been represented as definitive proof that women denied access to abortion will suffer severe injury to their health and economic wellbeing. Yet a careful examination reveals that the study is based on a non-random, non-representative sample of women that grossly underrepresents the experiences of the majority of women undergoing abortions. In addition, a reanalysis of its reported results reveal that the effect size of the outcomes observed have been grossly overstated, leading to conclusions that are not supported by the results. There also appears to be selective reporting and misrepresentation of results previously published. In addition, inconsistencies in ANSRH's published record strongly suggest that the credit history reports of the Turnaway Study participants were obtained without their informed consent."

===Subsequent Educational Attainment===

*p181 - Looking at education, Foster could find no differences in the high school graduation rates between those who aborted and turnaways. Regarding advance degrees, the two groups were also similar in terms of completing advance degrees but turnaways (most of whom had additional child care responsibilities) were more likely to seek lower level degrees which required less time commitment during the 4.5 years they were followed.

*p185 - Foster concludes this chapter with another overly broad, unsupported, and unqualified politicized assertion. "The Turnaway Study shows that women who are denied wanted abortions scale back their short-term plans and suffer economic hardship for years." But the scaling back of short term plans is based on a single question one week after being turned away while women are still trying to sort out their futures. Many of them also report being happy that they will now focus on having their babies, while others are in fact seeking abortions at other clinics, perhaps in other states. And the claim that they "suffer economic hardship for years" measures out to having a 2% lower credit score! She is clearly exaggerating the meanings of both "suffer" and "economic hardship."

==Chapter 6 - Children==

===Existing Children===
*p200-202 - Foster argues that among women with children under age five prior to seeking the abortion of interest, the children of those who had abortions enjoyed more economic security during the 4.5 years the group was followed than the children of those who carried to term. But this finding is not reliable for drawing any conclusions based on the facts that (1) the study uses a nonrandom sample of volunteers and a high degree of psychological factors and stigma that magnify self-selection bias, (2) only 55 women in the Turnaway group had children under the age of 5, so the sample size is very small, and (3) the sample groups were disproportionately made up of women who were poor, below the federal poverty line, for whom a $50 gift card promised at each interview might be a compelling incentive. Given that women who carried to term did not face post-abortion shame as a disincentive to participate, it is likely that the poorer a turnaway woman was the more likely the $50 incentive would have encouraged her participation. In short, it is not surprising that the turnaway group was disproportionately poorer. Plus, the addition of an additional child in the family structure changes the calculation of the federal poverty line and influences eligibility for food stamps and other public aid programs. With all these factors in mind, Foster's finding that 19% of turnaways with previous children compared to 10% of women who aborted with previous children received public assistance is simply non-news. A woman with two children rather than one, will be eligible for more public assistance.

*p202-203 - Foster also looked at how the women rated their children's development, using the Parents' Evaluation of Developmental Status: Developmental Milestones questionnaire. Based on her very small sample size, she found that 74% compared to 77% of children under the age of five (for the turnaway group compared to the abortion group of women) met or exceeded the Developmental Milestones. Based on this very small, 3% difference, Foster argues that denying women abortions causes developmental harm to their already born children. But this is clearly an exaggerated conclusion based on very little evidence and a very little difference in that evidence. Plus, the fact that Foster refuses to make her data available for analysis by other researchers suggests that she may be engaged in selective reporting. Results that might show benefits to Turnaway women and their children don't get reported, only the results that she can use to advance her political agenda.

===Children Born Afterward===

*P204- Among turnaways, 64% reported they still wished they could have had the abortion, but this dropped to 12% six months later, after the child was born, and down to just 4% at the last interview, 4.5 years later. Foster admits these women were mostly happy they had their babies, though she does not report the actual percentages of emotions related to abortion or the pregnancy for any of the groups studied throughout the 4.5 years.

*206-208 - Foster reports that they used the Postpartum Bonding Questionnaire to evaluate the emotional bonding women felt for children under 18 months old to compare who women evaluated their bond after (a) being turned away from an abortion, and (b) for those women who had abortions and then delivered. They reported that 9% of Turnaway women compared to 3% of the Abortion group reported bonding problems with the child. This finding needs to be interpreted in light of the fact that women in the second group were (a) a self-selected population of women at least risk of negative reactions to abortion and (b) were an average of three years older and more likely to be living with a male partner (which presumably reduces stress during the first 18 months with the child).

*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248140/ In the study examining these two groups], subsequent children born to women who had abortions were more likely to be premature and have low birth weight, but the authors fail to discuss this.

Turn Away Study

2025-11-20T23:34:21Z

Barb: /* Economic Differences */

The Turnaway Study is an ongoing study of women who had first and second trimester abortions compared to women who were "turned away" from late term abortions because they approached the clinics in their state after the gestational age limit for performing abortions. The [http://www.ansirh.org/research/turnaway.php Turnaway Study] is conducted by the pro-abortion advocacy group [http://www.ansirh.org/ Advancing New Standards in Reproductive Health (ANSIRH)] which is a project of the Bixby Center for Global Reproductive Health at the University of California, San Francisco.

The Turnaway Study is seriously flawed by the [[Turn_Away_Study#Non-Representative_Sample non-representative sample of women| non-representative selection of women]] used in the study. More detailed criticisms are further down this page. Here are some of the major points:

*Of women approached to participate 62.5% declined. Another 15% dropped out before the baseline interview one week after their abortions. As a result, only 31% participated in the baseline interview. In addition, women continued to drop out at each six month followup period, with an additional 20% drop out at one year, 36% dropout by the third year, and 46% dropout by the fifth year. Despite the low retention rate, the authors mislead readers by declaring that 93% participated "in at least one" of the six month followups, implying high retention when in fact less than 17% of eligible participants, and 46% of those who initially agreed, actually participated in year five.
**A low participation rate will often result in automatic rejection of studies by many medical journals. For example, the journal ''Obstetrics & Gynecology'' requires a minimum response rate of 60% or higher, twice that of the TurnAway Study.
**In comparison, [https://pubmed.ncbi.nlm.nih.gov/18711183/ 90 of 98 consecutive women (92%) invited to participate in a survey before, six months after, and one year after a prophylactic mastectomy (BPM)] to evaluate the impact of BPM on emotions, mental health, body image, and sexuality. This is nearly three times the participation rate of the Turnaway Study sample.
*While not explicitly stated by the researchers, the numbers they do reveal indicate that only 27.0% of the eligible women were interviewed at the three year follow-up and only 17% participated at the five year mark. Of the 37% who agreed to participate (1132) only 84% participated at week 1, 66% at year one, 53% at year three, and 46% at year five.
*There are well known [[risk factors]] which predict which women are most likely to have negative reactions to abortion, many of which would make women less likely to agree to participate in a follow up interviews . . . even if there was an offer to be paid. For example, from the [[Risk_factors| APA list of risk factors]]:
:*perceived need for secrecy;
:*feelings of stigma;
:*use of avoidance and denial coping strategies;
:*low perceived ability to cope with the abortion;
:*perceived pressure from others to terminate a pregnancy.
*The sample is disproportionately filled with women having late abortions. The sample used includes 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester.
*Women who had abortions due to suspected fetal anomalies were excluded. Probably because research shows high rates of psychological disruption after abortion in these types of cases, therefore excluding this segment of women was a way to reduce the effects associated with abortion. This is extremely misleading, of course, since this is a common reason for abortion . . . especially in the second and third trimester.
*Demographically, the sample used is not representative of women having abortions. The average age at the time of the abortion was 25, of which 62% were raising children.
*The comparison group, the Turn Away group (n=210), includes 50 women who later terminated at another facility or had a miscarriage. So 24% of this group, to which the researchers are comparing women who abort, actually includes women who experienced pregnancy losses. Yet the researchers barely disclose this fact, giving the false impression that their study is comparing women who had abortions to women who carried to term. In fact, they are comparing a group of women who had abortions to a group of women including those who (a) carried to term, (b) had abortions in a state other than where they first sought one, or (c) miscarried or had a still birth.

=Decision Rightness with Regard to Abortion in the Turnaway Study=

'''[http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128832#sec013 Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study] Rocca CH, Kimport K, Roberts SC, Gould H, Neuhaus J, Foster DG. PLoS One. 2015 Jul 8;10(7):e0128832. doi: 10.1371/journal.pone.0128832. eCollection 2015.'''

Abstract
:BACKGROUND: Arguments that abortion causes women emotional harm are used to regulate abortion, particularly later procedures, in the United States. However, existing research is inconclusive. We examined women's emotions and reports of whether the abortion decision was the right one for them over the three years after having an induced abortion.

:METHODS: We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities across the United States, selected based on having the latest gestational age limit within 150 miles. Two groups of women (n=667) were followed prospectively for three years: women having first-trimester procedures and women terminating pregnancies within two weeks under facilities' gestational age limits at the same facilities. Participants completed semiannual phone surveys to assess whether they felt that having the abortion was the right decision for them; negative emotions (regret, anger, guilt, sadness) about the abortion; and positive emotions (relief, happiness). Multivariable mixed-effects models were used to examine changes in each outcome over time, to compare the two groups, and to identify associated factors.

:RESULTS: The predicted probability of reporting that abortion was the right decision was over 99% at all time points over three years. Women with more planned pregnancies and who had more difficulty deciding to terminate the pregnancy had lower odds of reporting the abortion was the right decision (aOR=0.71 [0.60, 0.85] and 0.46 [0.36, 0.64], respectively). Both negative and positive emotions declined over time, with no differences between women having procedures near gestational age limits versus first-trimester abortions. Higher perceived community abortion stigma and lower social support were associated with more negative emotions (b=0.45 [0.31, 0.58] and b=-0.61 [-0.93, -0.29], respectively).

:CONCLUSIONS: Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years. Emotional support may be beneficial for women having abortions who report intended pregnancies or difficulty deciding.

:Note: the conclusions should be reframed to note that the conclusions only apply to the 27% of eligible women on whom the researchers had data at the three year mark.

===News Coverage===
[http://time.com/3956781/women-abortion-regret-reproductive-health/ Hardly Any Women Regret Having an Abortion, a New Study Finds.] Jenkins N. Time. Published July 14, 2015.
[https://www.washingtonpost.com/news/wonk/wp/2015/07/14/95-percent-of-women-whove-had-an-abortion-say-it-was-the-right-decision/ 95 percent of women who’ve had an abortion say it was the right decision.] Ingraham C. Washington Post. Published July 14, 2015.

===Criticisms of the Turnaway Study===

====Non-Representative Sample====

# This study's findings and conclusions are overreaching in many regards, beginning with the fact that the sample of women is not representative of the national population of women having abortions due to high rates of self-exclusion plus high drop out rates. To quote from the study: "Overall, 37.5% of eligible women consented to participate, and 85% of those completed baseline interviews (n = 956). Among the Near-Limit and First-Trimester Abortion groups, 92% completed six-month interviews, and 69% were retained at three years; 93% completed at least one follow-up interview." This means 62.5% of women refused to participate in the study, at first request, and another 15% dropped out before or during the baseline interview, yielding a 31.9% participation rate at baseline.
# There are well known [[risk factors]] which predict which women are most likely to have negative reactions to abortion, many of which would make women less likely to agree to participate in a follow up interviews . . . even if there was an offer to be paid. For example, from the [http://abortionrisks.org/index.php?title=Risk_factors APA list of risk factors]: perceived need for secrecy; feelings of stigma; use of avoidance and denial coping strategies; low perceived ability to cope with the abortion; perceived pressure from others to terminate a pregnancy.
# With 68.1% of eligible women refusing to participate in the study at baseline, it is improper for the authors to suggest that their findings reflect the general experiences of most women. There are numerous [[risk factors]] which have been identified as predicting which women will have the most severe post-abortion reactions. One of these risk factors, for example, is ambivalence about having an abortion or carrying to term. Another is the expectation that one will have more negative feelings about the abortion. In a similar post-abortion interview study by [[Soderberg]], the author reported that in interviews with those declining to participate "the reason for non-participation seemed to be a sense of guilt and remorse that they did not wish to discuss. An answer often given was: ' Do do not want to talk about it. I just want to forget.'"
#It is very likely that the self-selected 31.9% of women participating at baseline were more highly confident of their decision to abort prior to their abortions and anticipated fewer negative outcomes. This concern about selection bias is highlighted by the study's own finding that "women feeling more relief and happiness at baseline were less likely to be lost [to follow-up]." Clearly, due to the large numbers of women choosing not to be questioned about their experience, and the large drop out of those who did agree, this sample is not representative of the national population of women having abortions.
# There may have been additional selection bias on the part of the participating abortion clinics. According to the portion of study protocol that was published: "It is up to the clinic staff at each recruitment site to keep track of when to recruit abortion clients to match to the turnaways recruited." In other words, the clinic staff exercised considerable leeway in deciding when to invite women to participate, and this leeway could have been exercised in ways to exclude women whom they may have anticipated were among the worst candidates for abortion.
# Despite the initial selection bias, 15% of those agreeing to be interviewed subsequently opted out of the baseline interview and another 31% opted out within the three year followup period. This means that at the three year followup, only 27.0% of the eligible women were interviewed. This continuing drop out rate suggests even among women who expected little or no negative reactions, the stress of participating in follow up interviews lead to a change of mind. Previous research shows that [http://www.ncbi.nlm.nih.gov/pubmed/?term=10718164 women with a history of abortion feel more discomfort in answering questions about their reproductive history].
#Another oddity, the authors report that in the final group analyzed, average age 25, 62% were raising children. This would appear to be a very high rate that is not typical of national averages for women seeking abortion.
#The study population is also non-representative of the women having abortion in that it included 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester. This is totally disproportionate. It again shows that the authors should not be extending conclusions about this non-representative sample to the general population.
#The authors report that sample has an elevated number of low socioeconomic backgrounds. That, too, makes the sample non-representative. The offer of $50 per interview may also have created a participation bias.
#The comparison group, the Turn Away group (n=210), includes 50 women who later terminated at another facility or had a miscarriage. So 24% of this group, to which the researchers are comparing women who abort, actually includes women who experienced pregnancy losses. Yet the researchers barely disclose this fact, giving the false impression that their study is comparing women who had abortions to women who carried to term.
#Women who had abortions due to suspected fetal anomalies were excluded. Probably because research shows high rates of psychological disruption after abortion in these types of cases, therefore excluding this segment of women was a way to reduce the effects associated with abortion. This is extremely misleading, of course, since this is a common reason for abortion . . . especially in the second and third trimester.
#A low participation rate will often result in automatic rejection of studies by many medical journals. For example, the journal ''Obstetrics & Gynecology'' requires a minimum response rate of 60% or higher, twice that of the TurnAway Study.
#The actual question women were asked was “Given your situation, was the decision to have an abortion the right decision for you?” They were not given a scale to show degrees of agreement or disagreement. The only options were yes, no, or don't know. For the purposes of their analyses, "don't know" was treated as no. But in any event the preable, "Given your situation," essentially turned the question into "Did you make the best decision you could, given your situation?"
#The claim that 98% are satisfied with their decision (based on this binary assessment) is in sharp contrast to a study by [https://jamanetwork.com/journals/jamapsychiatry/fullarticle/481643#yoa8222t3 Brenda Major], another pro-abortion researcher. In her study the related question was phrased very differently. "Three hundred six (69%) of 441 women said they would definitely or probably have the abortion again if they had to make the decision over; 84 (19%) of 441 said that they would definitely not or probably not; and 51 (12%) of 441 were undecided." Note, Major does not report the "definitely" and "probably" groups separately. They are collapsed to imply greater certainty than "probably" entails. According to Major's paper, the details of the question were "At T4, women were asked, "If you had the decision to make over again under the same circumstances that you were in 2 years ago, would you make the same decision to have the abortion?" They responded on a scale from 1 (definitely no) to 5 (definitely yes)."

=====Misrepresentation of Study Design=====
The authors frequently describe their study as a "prospective longitudinal cohort study." Actually, it is only a "case series study" of the remnant of women (27%) who came to a few abortion clinics who were willing to continue to participate in this study. But since they do not have data collected on the women prior to seeking abortion, much less becoming pregnant, they are not truly prospective cohort studies but rather case series, as clarified by [https://www.ncbi.nlm.nih.gov/pubmed/22213493 Dekkers et al, (2012)] "a cohort study, in principle, enables the calculation of an absolute risk or a rate for the outcome, such a calculation is not possible in a case series." and [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998589/ Song & Chung, 2010]:
:An important distinction lies between cohort studies and case-series. The distinguishing feature between these two types of studies is the presence of a control, or unexposed, group. Contrasting with epidemiological cohort studies, case-series are descriptive studies following one small group of subjects. In essence, they are extensions of case reports. Usually the cases are obtained from the authors' experiences, generally involve a small number of patients, and more importantly, lack a control group.12 There is often confusion in designating studies as “cohort studies” when only one group of subjects is examined. Yet, unless a second comparative group serving as a control is present, these studies are defined as case-series.

While it is true that the authors are attempting to claim that their sample of "women denied abortions" is the "unexposed group," this is clearly not true for three reasons:

:(a) all the women were already exposed to a problem pregnancy,

:(b) all the women have already had gone through the process of seeking an abortion...which itself may be all or a portion of the traumatic part of some abortion experiences...especially when they are subsequently raising a child whom they recall at one point having planned to abort (which can cause cognitive dissonance), and

:(c) the "unexposed group" clearly includes women who actually have had multiple pregnancy experiences, including abortions and miscarriage, either before or after the index pregnancy, or both. (Indeed, in at least of of their studies, they controlled for parity (the number of pregnancies a woman has had), but not for prior or subsequent pregnancy losses, which is inconsistent.)

The false description of the Turnaway study as "prospective longitudinal cohort study" is a very important because it gives the false impression that the authors have applied the criteria of such studies, which are designed to follow a group of people ''before'' they are exposed to the subject of interest, in this case a pregnancy subject to abortion. In fact, this is a self-selected case series, with very high attrition rate, which consists entirely of women who are candidates for abortion.

This is another example of the authors efforts to present their findings as generalizable to the entire population of women when in fact there is no evidence, and every indication given the high refusal and drop out rate, that the findings of the remnant of women remaining in this study are applicable only to that remnant.

=====Dropouts and Refusers are at Higher Risk=====

The final sample was only 516 women, which is only 17% of the original 3,045 asked to participate in the study. Clearly, women experiencing the most post-abortion distress are more likely to refuse to participate or drop out. Indeed, the expectation of not coping well with an abortion is predictive of greater post-abortion distress and likely a major reason women would not choose to open themselves up to subsequent telephone interviews.

There is research evidence that low participation rates and / or high dropout rates distort the results of studies and lead to incorrect conclusions:

:After a workplace disaster in Norway, 246 employees were required to participate in medical evaluations for PTSD [http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.1989.tb05262.x/abstract (Weisaeth, 1989)]. At baseline pre-disaster, employees had a record of cooperation with the company medical officer. After the disaster, some were resistant and required repeated contacts; eventually participation reached 100%. The initial resistance was significantly associated with severity of PTSD at 7 months. The authors stated that if the initial refusals had been accepted, “the potential loss to the follow-up would have included 42% of the PTSD cases, and 64% of the severe PTSD cases would have fallen out, resulting in distorted prevalence rates of PTSD” (Weisaeth, 1989, p. 131). Additionally, “The initial resistance in many who later developed PTSD was found to relate to the psychological defenses such as avoidance which is seen both PTSD and acute post-traumatic stress syndrome” (Shuping, 2016, citing Weisaeth).

Additional evidence of selection bias problems are reported by [[Soderberg]]

====Inappropriate Measures & Study Design Flaws====
#The focus of this report in on women's persistent satisfaction with their abortion decisions, "decision rightness," as measured by a single question: "“Given your situation, was the decision to have an abortion the right decision for you?” Women were asked to answer this question "yes", "no" or "uncertain." This measure is flaws in several ways:
## A better research approach would have been to have this question rated on a numeric scale (1 to 10, for example) in order to better identify any shift in attitudes.
##There is no report of tests to verify the [http://www.relevantinsights.com/validity-and-reliability#sthash.x00kiuAX.dpbs validity and reliability of the questions used]. In other words, the authors do not report on any efforts made to evaluate whether the question(s) used provide reliable consistency...or are even understood by women in the same way. For example, do all women interpret the question in the same way? Or were there different nuances in understanding? Was it "right" as in "moral"? Or right as in "the best choice I could make at the time?" Or right in that it was the best choice any person could make? Was it right meaning one would make the same choice if one became pregnant again? Was it right in that "It made my life far better"? Or was it right only in the sense that "What's done is done, and I'm moving my life forward doing the best I can so that is my focus so I guess it was right . . . or at least what I have to work with."
##A feeling that a person made the right decision due to circumstances at that time is not the same as an assertion that it was the right decision regardless of circumstances or "if I knew what I knew now."
##The decisions assessment were conducted through telephone interviews approximately every six months. A well known problem with interview based studies is that many participants will try to please the interviewer by giving the answer they believe is expected of them. Similarly, some interviewers may be more prone to elicit certain types of response. The investigators did not report on any tests made to verify that such influences were not at play.
#As a general rule, questions regarding decision satisfaction (even about things such as the purchase of a purse) may produce [https://en.wikipedia.org/wiki/Reaction_formation reaction formation] and therefore defensive answers affirming the rightness of a decision even if there are actually unresolved anxieties or other issues. (To voice dissatisfaction may invite anxiety provoking thoughts. Responding the way one is expect to respond, avoids reflection).
#Rather than rely on a single question about the "rightness" of the abortion decision, additional questions should have been asked to better gauge the subjects thoughts. For example, in the [[Soderberg]] study, including a one year post-abortion interview of 847 women (after a 33% self-exclusion rate), 80% of the women reported they were satisfied with their decision to abort but at the same time 76% also stated that they would never abort again if faced with an unwanted pregnancy. In this case, the second question offers a great deal of additional insight. A woman expressing unwillingness to not have another abortion may be telling us more than her abortion experience than she is when she says that a past decision was "right."
#Another difficulty raised by the researcher's methodology is that their interviews apparently did not inquire about any steps women took to resolve negative emotions. It is necessary to know if women who had negative feelings sought any help to deal with those feelings, perhaps with a therapist, a pastor, or family or friends. The increase in the number of women participating in post-abortion programs should, for example, help to reduce the longevity of negative reactions to abortion. But if this is the case, the conclusion of the authors that negative reactions to abortion naturally diminish over time may be wrong if, in fact, the decrease is due to women receiving post-abortion psychological or spiritual counseling. In other words, if the decline in negative reactions is real (and not due to denial, repression, or just a desire to rush through the phone interview to collect the $50 gift card) it is important to understand the reason for this. Is it due to support given to those having negative feelings, or is it "natural" and permanent?
#The authors did not use any validated measures of psychological illness, as has been done in many other studies. Instead the assessment of psychological health is all inferred from a two scales created from six questions in which rated six emotions associated with their abortion women rated each emotion on a five point scale from "not at all" to "extremely." The six emotions were: relief, happiness, regret, guilt, sadness and anger. From these six self-assessments, reported by telephone to an interviewer, the scores for the four negative emotions were combined for a single scale and the two positive emotion scores were combined for a positive emotion scale. These scales were not tested for [http://www.relevantinsights.com/validity-and-reliability#sthash.x00kiuAX.dpbs validity or reliability]. Nor were they tested as a measure of overall psychological health or, conversely, psychological illness.
#The comparison group, the Turn Away group (n=210), includes 50 women who later terminated at another facility or had a miscarriage. So 24% of this group to which the researchers are comparing women who abort actually includes women who experienced pregnancy losses. Yet the researchers barely disclose this fact, giving the false impression that their study is comparing women who had abortions to women who carried to term.
#There was not anonymity. Women were interviewed by a paid staff person asking each question. The interviewing process itself may impact answers as respondents may be inclined to answer questions in a way that they believe will better satisfy the interviewer. In short, it is well established that there are differences in response to a written anonymous questionnaire compared to a verbal interview.
#There is no transparency. The authors of the study have refused to publish their questionnaires. This suggest that there may be questions that they have chosen to not report upon. It also prevents investigation of whether any series of questions were presented in a way that led respondents toward a specific answer in later questions.

====Inconsistency With Prior Research Findings====
#As mentioned above, a similarly designed followup study by [[Soderberg]] study reported that 80% of the women reported they were satisfied with their decision to abort but at the same time 76% also stated that they would never abort again if faced with an unwanted pregnancy. Soderberg also found that even though many women reported satisfaction with their decision they also experienced negative psychological outcomes, with 50-60% of women undergoing induced abortion experienced some measure of emotional distress, classified as severe in 30% of cases.
#Notably, the claim of declining regret and declining negative reactions is at odds with [[Brenda Major]]'s two year longitudinal study, which also had high drop out rates, which found that there was a trend in decline in relief and increase in negative emotions over the two year period among those who did not drop out of her study. (See Major B, et al. Psychological responses of women after first-trimester abortion. Archives of General Psychiatry. 2000: 57(8), 777-84.)
#Their claim that there is no evidence of mental health problems after abortion is not consistent with the findings of studies utilizing validated measures of mental health, including a [http://www.ncbi.nlm.nih.gov/pubmed/16343341 five year longitudinal study] nor with the [http://www.ncbi.nlm.nih.gov/pubmed/19880932 Christchurch Health and Development Study, a lifetime longitudinal study].
#Their findings are not consistent with findings of record linkage studies which have shown an [http://www.cmaj.ca/content/168/10/1253.full elevated risk of psychiatric admissions] following abortion, an [http://www.bmj.com/content/313/7070/1431 elevated rates of suicide] and elevated rates of [http://www.ncbi.nlm.nih.gov/pubmed/?term=reardpn+dc+sleep sleep disorders].
#Their findings are not consistent with the results of meta-analyses comparing a large number of studies, including reviews by [http://www.ncbi.nlm.nih.gov/pubmed/23859662 Bellini], [http://www.ncbi.nlm.nih.gov/pubmed/23553240 Fergusson], and [http://bjp.rcpsych.org/content/199/3/180.long Coleman].

====Unreported Details====
# According to an [http://www.ansirh.org/wp-content/uploads/Turnaway-Study-Infographic_7-8-2015.pdf infographic about the study] published by the research group, the followup interviews were actually continued every six months for five years, not just three. Why then did this report limit itself to three years rather than cover the full five years covered by the study?
#The study population included 413 women who had an abortion near the end of the second trimester and only 254 women having an abortion in the first trimester. Overall, only 31% participated at the baseline interview (35.7% agreed to be interviewed, but 15% of those dropped out before or during the baseline interview). The authors should report the drop out rate for each of the two groups: first trimester and second trimester.

====Overreaching Conclusions====
#While the report and [http://www.ansirh.org/news/new_ANSIRH.php accompanying press release] claim that this study proved there is "no evidence of widespread 'post-abortion trauma syndrome,' in fact it did not use any standard scales for assessment of psychological well being.
# The bias of the research team is made clear in [http://www.ansirh.org/news/new_ANSIRH.php press releases] and a [http://www.ansirh.org/wp-content/uploads/Turnaway-Study-Infographic_7-8-2015.pdf infographic] purporting to summarize the study. In these "summaries" the research group conceals the details regarding the high non-participation rate and boldly claims "95% of women who had abortions felt it was the right decision, both immediately and over 3 years," omitting the fact that 62.5% refused to answer the question at the time of their abortion and of those interviewed at the time 31% were out of the study by the third year. Notably, the problem of high non-participation and drop out rates is not mentioned in the abstract, press release, or other summarizing materials published by the authors. To the contrary, they consistently imply that their results apply to the entire population of women having abortions.
#The authors make much of the claim that 93% of the participants "completed at least one follow up interview" which the media outlets incorrectly reported as meaning [http://www.medicalnewstoday.com/articles/296756.php"Only 7% of the participants dropped out of the study during follow-up."] It would have been far more accurate to state that of the "Only 37.5% of eligible women agreed to be interviewed, of whom 85% actually did complete the complete baseline interviews (n = 956). Of this group, only 7% refused to do at least one followup interview."
#From the observation that the scale created from four negative reactions showed a modest decline in negative reactions over three years, the authors they draw the very broad conclusion that there is no evidence of widespread negative psychological reactions to abortion. As indicated above, this conclusion is contradicted by better designed studies. Moreover, this conclusion ignores the fact that many psychological problems are characterized by denial and repression of negative emotions. There is, in fact, clear evidence from other studies that [[PTSD |many women experience symptoms of post-traumatic stress disorder]] which includes symptoms of denial and avoidance behavior. In a study by Rue, for example, among women reporting intrusive memories or thoughts related to their abortion, only half denied that these thoughts were attributed (caused) by their abortions. In other words, it is not always easy for women to recognize which feelings may be attributable to their abortions. For example, it is only when in post-abortion counseling that many women may attribute increased feelings of anger after their abortions to unresolved feelings over the abortion which they were projecting onto other people and situations. This is all fairly basic psychology. Negative emotions often crop up in other parts of our lives because we have trouble dealing with them at the source. Therefore, women reporting less "anger" relative to their abortion may in fact have more feelings of anger in their lives than before their abortion but are simply attributing it to other issues. This demonstrates the difficulty in trying to judge the post-abortion emotional adjustment of women based on just six oversimplified questions about six basic emotions.
#The Turn Away Study hangs its claim to uniqueness on the fact that it utilizes as it group for comparison only women who initially sought to terminate a pregnancy but were denied abortions because they were beyond the gestation age cut off in various states and then carried to term. But this group of women giving birth is a very small and distinct sample, numbering only a few thousand women per year in the United States. Most importantly, this distinction should be clearly applied to all of the discussion and conclusions offered by the Turn Away Study authors, but it is not. Rather than frame their conclusions as applying to the very small women in the US each year who seek an abortion at or after the gestation date limit on legal abortions in various states, they seek to apply their conclusions to all women having abortions and all women carrying unplanned pregnancies to term.

::But even the above clarification limiting the findings to women denied abortions would not be inaccurate because the "turn away" group is not made up only of women who subsequently carried to term. Instead, it includes who found an abortion elsewhere and those who miscarried, making up approximately 24% of the total "turn away" group.

::So, to be completely accurate, the Turn Away Study's sloppy methodology mixes different experience and outcomes into the "turn away group" in a way that obscures rather than clarifies the differences between women who (a) have late term abortions and (b) those who carry to term or have late term abortions elsewhere.

::Notably, if the Turn Away Study abstracts, conclusions, and press releases were actually rewritten to accurately describe the makeup of the "turn away group" the conclusions drawn from these studies would be so narrow as to be almost meaningless. On the other hand, because the authors generally mention those limitations only once in the methods section of their studies, and then in the conclusion section, abstract, and press releases make it appear that their findings apply to the general population of women having abortions and those who carry unintended pregnancies to term, they are clearly overreaching what their data actually shows. They are merely using their weak data as an excuse to make general pronouncements about "safe abortion" without actually having meaningful data to support those broad claims.

====Refusal to Share Details and Data====
The authors have refused to share or publish the complete questionnaires used to collect data. They have also refused to share details of their analyses or any of their data for reanalysis by others.

====Exaggerations of ANSIRH News Release====

The ANSIRH news release, headlined "[https://www.ansirh.org/news/no-evidence-emerging-mental-health-problems-after-having-abortion No evidence of emerging mental health problems after having an abortion]" declares:

:Published in JAMA Psychiatry, “Women’s mental health and well-being five years after receiving or being denied an abortion: A prospective, longitudinal cohort study,” analysis from ANSIRH’s Turnaway Study, found that having an abortion does not adversely affect women’s mental health either at the time of the abortion or over five years after receiving abortion care. We also found that denying women abortion has negative consequences to their mental health and well-being in the short-term.

:We found no evidence that women who have abortions risk developing depression, anxiety, low self-esteem or less life satisfaction as a result of the abortion, either immediately following, or for up to five years after the abortion. However, women who were denied an abortion had more anxiety, lower self-esteem, and less life satisfaction immediately after being turned away. Over the subsequent five years, symptoms of anxiety and depression decreased and self-esteem and life satisfaction improved significantly, both for women who received an abortion and for women who were denied care.

:''The study provides the best evidence we have to date on the mental health effects of having an abortion'', by comparing women who received an abortion to those who were denied one, and following them for five years.

'''Note:''' The claim that this is the best evidence to date is totally bogus. The release totally ignores the fact that the small minority of women agreeing to participate in the study are not representative of most women, and further pretends that there is "no evidence" of mental health risks of abortion except for their own study. And the firs paragraph assertion that there are negative consequences to being denied an abortion fails to note that this assertion is based on just one assessment, one week after women seeking abortion were told it was past the gestational limit, and that by the time of the second assessment at six months there was no higher rates of depression, anxiety, or self esteem problems. In short, the press release has a lot of over generalizations based on a very thin evidence.

=====Letter from David Reardon to PLOS One =====
Dear PLOS One Editors,

I am writing to register a formal complaint against the authors of a PLOS ONE article who I believe have made disingenuous representations to PLOS ONE in order to improperly withhold data.

I have previously been a reviewer for another article submitted to another journal by this team of researchers and in that case also they refused to provide additional requested information, including a refusal to be provided with a blank copy of their survey form so I could review the exact wording of their questions.

Specifically, the article is [http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0128832 Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study] by Corrine H. Rocca, et al.

When I emailed Dr. Rocca to request access to the data repository for reanalysis, she responded:

To excuse themselves from providing any data the authors state:
::The Data Availability Statement for the paper is on the first page of the publication: “The authors are not able to provide any data beyond what is presented in the manuscript due to restrictions that study participants agreed to when they signed the consent form, which was approved by the UCSF IRB. The authors have included sufficient details in the Methods section of the manuscript for others to replicate the analysis in a similar setting, using a similar study population.”

Regarding the first sentence of this claim, while clearly it would be appropriate to guarantee to participants that no identifying information would be released to others, what possible restrictions would participants be required to agree to that would preclude sharing non-identifying data with other researchers?

So I emailed Dr. Rocca the following request: "Would you please provide a blank copy of the consent form that the study participants signed, where I assume the restrictions on data sharing are described?"

She refused to reply.

Therefore, I am specifically requesting that PLOS ONE require Dr. Rocca to provide a copy of the consent form which the participants signed so that the claim that the non-identifying data cannot be made available based on promises made to the participants may be verified.

If Dr. Rocca should refuse to provide documentation supporting her claims, the journal should retract the paper due to her clear effort to evade the data availability requirements of the PLOS journals

I would note that the Turnaway Study data set, on which this PLOS ONE article is based, has been employed in numerous published articles authored by scores of authors. It is unreasonable to expect that the participants were promised that only a specific list of researchers would be allowed to analyze the non-personal data.

Regarding the claim that "The authors have included sufficient details in the Methods section of the manuscript for others to replicate the analysis in a similar setting, using a similar study population," this is another bogus assertion. As mentioned above, the authors have refused to share even the blank survey instruments used to collect the data so specific questions cannot be replicated.

Furthermore, the ANSIRH team collecting the data is closely aligned with abortion advocacy which is the only reason they were provided access to abortion patients at 30 abortion clinics.

Obviously, abortion is a very contentious issue both politically and academically. Clearly, researchers who are critical of the claim that abortion has no mental health effects are not allowed the access to abortion patients which has been granted to ANSIRH. Therefore, it is impossible for large segments of the research community to "replicate the analysis in a similar setting," as Rocca asserts. Indeed, it is my clear impression, based on Rocca's refusal to provide any additional information even to reviewers, is that she and her team are seeking to limit access to the data and their study methodology precisely to prevent any reanalyzes which may undermine their own preferred spin on the data they collected.

More importantly, the PLOS journals requirements for data sharing exist precisely to alleviate the high cost of replicating data collection and to facilitate reanalyzes of existing data sets.

Please investigate the concerns outlined above, beginning with a request for documentation regarding precisely what was promised to the Turnaway Study participants.

Thank you.

Sincerely yours,

David C. Reardon, Ph.D.
Elliot Institute

*PLOS One declined the request to ask Dr. Rocca to provide any evidence that the consent form did indeed bar sharing non-personal data with other researchers.

*It was subsequently revealed in Dr. Foster's book ''The Turnaway Study'' that in 2018 they decided to work with a previously unknown researcher, Sarah Miller, an economist who suggested they use the personal information of the women in their sample to request their credit scores from credit agencies in order to examine the effects of having an abortion on credit scores. Clearly, the claim that they were not allowed to share data made in PLOS publication was a lie.

===Critique by Priscilla Coleman===

The following is reprinted with permission from '''WECARE''''s website where it is titled '''[http://www.wecareexperts.org/content/turnaway-study-analyzed-wecare-director-latest-attempt-reverse-evidence-based-women-centered The Turnaway Study Analyzed by WECARE Director: The Latest Attempt to Reverse Evidence-based, Women-Centered Advances in Abortion Policy]'''

The PLoS ONE study titled “Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study” is riddled with serious design flaws that render the results meaningless. The problematic issues are described in detail below followed by evidence that the true motivation for publishing the study is likely political. In recent years, credible science has informed policy with 26 states, now requiring information regarding mental health effects be shared with women considering abortion. This study is a poor attempt to provide counter “evidence” and obscure the reality of women’s suffering, reminiscent of the highly flawed research from the 70s and 80s.

'''Methodological Issues:'''

1) As reported by the authors, the consent to participate rate is only 37.5%. This is unacceptable, as the missing 62.5% who were approached and declined were likely the women who had the most adverse psychological reactions to their abortions. With sensitive topic research, securing a high initial consent rate is vitally important and in order to approach being representative, a minimum of 70% should be retained.

2) The authors note that the sample was comprised of a high concentration of women from low socioeconomic backgrounds, rendering the sample not representative of US women undergoing abortion today. There is an ethical concern here as a well, since providing $350 to participate is coercive, as it would be difficult for most of the women to turn down the money.

3) The authors fail to reveal the specific consent to participate rates for each group. Because prior research has demonstrated that second trimester abortions are potentially more traumatizing than first trimester procedures, it is likely that a significantly higher percentage of women in the first-trimester group consented to participate; and the percentage of willing to participate, second trimester participants was likely well under 37.5%. If the rates were comparable, why not report this? Failure to report critical information increases suspicion that this “near limit’ group is in no way representative.

4) In the Turnaway Study, women who secured abortions near the gestational limits included women for whom the legal cut off ranged from 10 weeks through the end of the second trimester. There is a wealth of data indicating that women’s reasons for choosing abortion and their emotional responses to the procedure differ significantly at varying points of pregnancy. Women aborting at such widely different points should therefore not be lumped together, particularly when gestational age information is available in the data.

5) No information is provided regarding how the sites were actually chosen. What type of sampling plan was employed? Why were only those identified with the National Abortion Federation used? What cities were included? Which areas of the country were sampled?

6) The majority of the outcome measures are single items, and this is problematic given the many psychometrically sound multiple item instruments available in the literature for the variables examined. Well-trained behavioral science researchers should not attempt to measure complex human emotions in such a superficial manner; and ethically responsible scientists would not extrapolate from such minimalistic assessments to women’s emotional reactions to one of life’s more challenging decisions.

'''Bias issues:'''

7) The authors’ uneasiness with recent litigation is stated in the opening paragraph: “''Arguments about emotional harms from induced abortion—including decision regret and increasing negative emotions over time—have been leveraged to support abortion regulation in the United States. To uphold a 2007 law banning a later abortions, Justice Kennedy of the Supreme Court stated: “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort...” In support of a state-level ban, a researcher testified that abortion “carries greater risk of emotional harm than childbirth.” Arguments about emotional harm have been used to forward parental consent, mandatory ultrasound viewing, and waiting period legislation as well.''” This is a rather odd way to open a supposed scientific investigation and the authors’ unapologetic decision to do so reveals their rather transparent political motivation (i.e., to provide counter results no matter what the scientific cost).

8) The authors’ effort to draw sweeping conclusions from this single, seriously compromised study is evident in their remarks regarding the implications of the study: “''Results from this study suggest that claims that many women experience abortion decision regret are likely unfounded''.” As scientists we never make such sweeping conclusions based on a single study, particularly when there is an abundant literature comprised of hundreds of sophisticated studies wherein the conclusions are quite discrepant. Courts throughout the US have concluded that women should be appraised of the risks before consenting to abortion; it almost seems silly that these researchers hope to shift the tide based on this study alone.

9) Funding was secured from the David and Lucille Packard Foundation among other sources with a political agenda. As described on their website, “''Our work in the United States seeks to advance reproductive health and rights for women and young people by improving access to quality comprehensive sexuality education, family planning and safe abortion care''.”

= Effect of abortion vs. carrying to term on a woman's relationship with the man involved in the pregnancy =

[http://www.ncbi.nlm.nih.gov/pubmed/25199435 Effect of abortion vs. carrying to term on a woman's relationship with the man involved in the pregnancy.] Mauldon J, Foster DG, Roberts SC. Perspect Sex Reprod Health. 2015 Mar;47(1):11-8. doi: 10.1363/47e2315. Epub 2014 Sep 8.

:CONTEXT:When a woman who seeks an abortion cannot obtain one, having a child may reshape her relationship with the man involved in the pregnancy. No research has compared how relationship trajectories are affected by different outcomes of an unwanted pregnancy.
:METHODS:Data from the Turnaway Study, a prospective longitudinal study of women who sought abortion in 2008-2010 at one of 30 U.S. facilities, are used to assess relationships over two years among 862 women who had abortions or were denied them because they had passed the facility's gestational age limit. Mixed-effects models analyze effects of abortion or birth on women's relationships with the men involved.
:RESULTS: At conception, most women (80%) were in romantic relationships with the men involved. One week after seeking abortion, 61% were; two years later, 37% were. Compared with women who obtained an abortion near the facility's gestational age limit, women who gave birth had greater odds of having ongoing contact with the man (odds ratio at two years, 1.7). The odds of romantic involvement at two years did not differ by group; however, the decline in romantic involvement was initially slower among those giving birth. Relationship quality did not differ between groups.
:CONCLUSIONS: Giving birth temporarily prolonged romantic relationships of women in this study; most romantic relationships ended soon, whether or not the woman had an abortion. However, giving birth increased the odds of nonromantic contact between women and the men involved throughout the ensuing two years.

=PTSD in the Turnaway Study Sample=

[[https://bmjopen.bmj.com/content/6/2/e009698 Does abortion increase women’s risk for post-traumatic stress? Findings from a prospective longitudinal cohort study.]] Biggs, M. A., Rowland, B., McCulloch, C. E., & Foster, D. G. (2016). BMJ Open, 6(2).
:In this self-selected sample of a minority of women who had abortions, at the baseline interview one week after their abortions, 39% reported at least one symptom of post-trauamtic stress syndrome and 16% reported three or more symptoms placing them at risk of PTSD. When asked to attribute the cause of their stress, 7% of the women attributed subsequent symptoms of post-traumatic stress to their abortions. Among those with any symptoms, 30% attributed their symptoms to a history of exposure to violence or abuse, 20% to non-violent relationship issues (20%), 19% to their abortion, and 15% to a non-violent death or illness of a loved one, and 6% attributing it to personal health-related issues (6%). Negative reactions were not necessarily reflected in repudiation of their decision to have an abortion, however, "By the end of the study period, four of the seven women who reported the index pregnancy as the source of their PTSS still felt the abortion was the right decision for them (not shown in table)." Remember, however, the "right decision" measure is based on a single yes, no question.

= Claimed Examination of Physical Health Effects =
[http://www.sciencedirect.com/science/article/pii/S1049386715001589 Side Effects, Physical Health Consequences, and Mortality Associated with Abortion and Birth after an Unwanted Pregnancy] Gerdts C, Dobkin L, Foster DG, Schwarz EB. Womens Health Issues. 2016 Jan-Feb;26(1):55-9. doi: 10.1016/j.whi.2015.10.001

:INTRODUCTION: The safety of abortion in the United States has been documented extensively. In the context of unwanted pregnancy, however, there are few data comparing the health consequences of having an abortion versus carrying an unwanted pregnancy to term.

:METHODS: We examine and compare the self-reported physical health consequences after birth and abortion among participants of the Turnaway Study, which recruited women seeking abortions at 30 clinics across the United States. We also investigate and report maternal mortality among all women enrolled in the study.

:RESULTS: In our study sample, women who gave birth reported potentially life-threatening complications, such as eclampsia and postpartum hemorrhage, whereas those having abortions did not. Women who gave birth reported the need to limit physical activity for a period of time three times longer than that reported by women who received abortions. Among all women enrolled in the Turnaway Study, one maternal death was identified-one woman who had been denied an abortion died from a condition that confers a higher risk of death among pregnant women.

:CONCLUSION: These results reinforce the existing data on the safety of induced abortion when compared with childbirth, and highlight the risk of serious morbidity and mortality associated with childbirth after unwanted pregnancy.

Note: In addition to the usual problems of this study in regard to its use of a non-representative sample, the measures used are inaccurate. Moreover, the claimed assessment of physical health was based on just two questions (with no examination of actual medical records): 1) “Did you experience any side effects or health problems from your [birth/abortion]?” and 2) “Was there a period after your [birth/abortion] when you were physically unable to do daily activities such as walking, climbing steps or doing errands?”

Abortion related deaths are defined by the Centers for Disease Control (CDC) in the United States as any death due to "1) a direct complication of an abortion, 2) an indirect complication caused by the chain of events initiated by the abortion, or 3) an aggravation of a preexisting condition by the physiologic or psychologic effects of the abortion, regardless of the amount of time between the abortion and the death" (Bartlett, L. a, Berg, C. J., Shulman, H. B., Zane, S. B., Green, C. a, Whitehead, S., & Atrash, H. K. (2004). Risk factors for legal induced abortion-related mortality in the United States. Obstetrics and Gynecology, 103(4), 729–737.) But in the Turnaway Study, the researchers excluded examination of deaths beyond 42 days . . . and, of course, ignored all the record linkage studies showing higher mortality rates after abortion.

=Substance Use in the Turnaway Study=

Receiving versus being denied an abortion and subsequent drug use.Roberts SC, Rocca CH, Foster DG. Drug Alcohol Depend. 2014 Jan 1;134:63-70. doi: 10.1016/j.drugalcdep.2013.09.013. Epub 2013 Sep 23.

:BACKGROUND: Some research finds that women receiving abortions are at increased risk of subsequent drug use and drug use disorders. This literature is rife with methodological problems, particularly inappropriate comparison groups.
:METHODS: This study used data from the Turnaway Study, a prospective, longitudinal study of women who sought abortions at 30 sites across the U.S. Participants included women presenting just prior to an abortion facility's gestational age limit who received abortions (Near Limit Abortion Group, n=452), just beyond the gestational limit who were denied abortions (Turnaways, n=231), and who received first trimester abortions (First Trimester Abortion Group, n=273). This study examined the relationship between receiving versus being denied an abortion and subsequent drug use over two years. Trajectories of drug use were compared using multivariate mixed effects regression.
:RESULTS: Any drug use, frequency of drug use, and marijuana use did not change over time among women in any group. There were no differential changes over time in any drug use, frequency of drug use, or marijuana use between groups. However, Turnaways who ultimately gave birth increased use of drugs other than marijuana compared to women in the Near Limit Abortion Group (p=.041), who did not increase use.
:CONCLUSION: Women receiving abortions did not increase drug use over two years or have higher levels of drug use than women denied abortions. Assertions that abortion leads women to use drugs to cope with the stress of abortion are not supported.

=Non-Representative Sample=
[https://pubmed.ncbi.nlm.nih.gov/24439937/ Implementing a prospective study of women seeking abortion in the United States: understanding and overcoming barriers to recruitment] Womens Health Issues . Jan-Feb 2014;24(1):e115-23. doi: 10.1016/j.whi.2013.10.004.

Background: The Turnaway Study is designed to prospectively study the outcomes of women who sought-but did not all obtain-abortions. This design permits more accurate inferences about the health consequences of abortion for women, but requires the recruitment of a large number of women from remote health care facilities to a study a sensitive topic. This paper explores the Turnaway Study's recruitment process.

Methods: From 2008 to 2010, the staff at 30 abortion-providing facilities recruited eligible female patients. Eight interventions were evaluated using multilevel logistic regression for their impact on eligible patients being approached, approached patients agreeing to go through informed consent by phone, and enrolled patients completing the baseline interview.

Findings: After site visits, patients had roughly twice the odds of being approached by facility staff and twice the odds of then agreeing to go through informed consent. When all recruitment steps were considered together, the net effect of site visits was to increase the odds that eligible patients participated by nearly a factor of six. After the introduction of a patient gift card incentive, patients had over three times the odds of agreeing to go through informed consent. ''With each passing month, however, staff demonstrated a 9% reduced odds of approaching eligible patients about the study''.

Conclusion: Prioritizing scientific rigor over the convenience of using existing datasets, the Turnaway Study confronted recruitment challenges common to medical practice-based studies and unique to sensitive services. Visiting sites and communicating frequently with facility staff, as well as offering incentives to patients to hear more about the study before informed consent, may help to increase participation in prospective health studies and facilitate evaluation of sensitive women's health services.

NOTE: It is elsewhere reported that two-thirds of the participants came from just three of the 30 clinics participating.

= Women’s Mental Health andWell-being 5 Years After Receiving or Being Denied an Abortion =

[http://jamanetwork.com/journals/jamapsychiatry/article-abstract/2592320 Women’s Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study.] Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. JAMA psychiatry. December 2016. doi:10.1001/jamapsychiatry.2016.3478.

:Objective To assess women's psychological well-being 5 years after receiving or being denied an abortion. Design, Setting, and Participants This study presents data from the Turnaway Study, a prospective longitudinal study with a quasi-experimental design. Women were recruited from January 1, 2008, to December 31, 2010, from 30 abortion facilities in 21 states throughout the United States, interviewed via telephone 1 week after seeking an abortion, and then interviewed semiannually for 5 years, totaling 11 interview waves. Interviews were completed January 31, 2016. We examined the psychological trajectories of women who received abortions just under the facility's gestational limit (near-limit group) and compared them with women who sought but were denied an abortion because they were just beyond the facility gestational limit (turnaway group, which includes the turnaway-birth and turnaway-no-birth groups). We used mixed effects linear and logistic regression analyses to assess whether psychological trajectories differed by study group.

:Main Outcomes and Measures We included 6 measures of mental health and well-being: 2 measures of depression and 2 measures of anxiety assessed using the Brief Symptom Inventory, as well as self-esteem, and life satisfaction. Results Of the 956 women (mean [SD] age, 24.9 [5.8] years) in the study, at 1 week after seeking an abortion, compared with the near-limit group, women denied an abortion reported more anxiety symptoms (turnaway-births, 0.57; 95% CI, 0.01 to 1.13; turnaway-no-births, 2.29; 95% CI, 1.39 to 3.18), lower self-esteem (turnaway-births, -0.33; 95% CI, -0.56 to -0.09; turnaway-no-births, -0.40; 95% CI, -0.78 to -0.02), lower life satisfaction (turnaway-births, -0.16; 95% CI, -0.38 to 0.06; turnaway-no-births, -0.41; 95% CI, -0.77 to -0.06), and similar levels of depression (turnaway-births, 0.13; 95% CI, -0.46 to 0.72; turnaway-no-births, 0.44; 95% CI, -0.50 to 1.39).

:Conclusions and Relevance In this study, compared with having an abortion, being denied an abortion may be associated with greater risk of initially experiencing adverse psychological outcomes. Psychological well-being improved over time so that both groups of women eventually converged. These findings do not support policies that restrict women's access to abortion on the basis that abortion harms women's mental health.

==Criticisms==
* The authors hide the fact that only 11% of the eligible women participated in this study thru the fifth year, making it impossible to generalize any findings from this highly self-selected sample, especially when women having negative reactions would be most likely to drop out.
* Moreover, the only elevated risk persisted for only a few weeks after "being denied" an abortion, while women are still under stress and trying to sort out their lives. Most importantly, the study actually found NO negative mental health effects after the child was born, either in the first year or over the five years examined.
* All the general problems discussed at the top of this page also apply.
*It is also worth noting that at one week after the abortion, those denied abortion had an average depression score of .13 compared to .44 for women who had an abortion . . . in other words, while turnaways had higher anxiety they had less depression than those who had aborted. The difference in depression scores was not statistically significant due to the low power of this study, but it demonstrates the authors' tendency to overgeneralize findings in away that minimizes effects of abortion and magnifies the effects of being denied an abortion.
* Another problem is that the "control group" is not clear and clean. They are treating women in the turnaway group as their control group, but in fact they elsewhere report that [https://pdfs.semanticscholar.org/bc37/113def0d0b90f94bea2acee1e8ec1dfcfcea.pdf 40% of the turnaway group had a prior history of abortion]. In other words, they are comparing a group of women who have a one or more abortions to another group of women of whom at least 40% have had one or more abortions, and are pretending that the prior abortions in the second group don't matter in a study about abortion and mental health.

==Media Coverage==
[https://time.com/4599806/abortion-doesnt-negatively-affect-womens-mental-health-study/ Abortion Doesn't Negatively Affect Women's Mental Health: Study] ''Time'' Dec 14, 2016
[https://www.nytimes.com/2016/12/14/health/abortion-mental-health.html?_r=0 Abortion Is Found to Have Little Effect on Women’s Mental Health] New York Times Dec 14, 2016
[http://www.newsweek.com/abortion-mental-health-link-study-531643 No Evidence Abortion Leads to Long-Term Depression and Anxiety] Newsweek 12/14/16
[http://www.psychiatryadvisor.com/depressive-disorder/study-refutes-assumption-that-women-experience-adverse-psychological-outcomes-following-an-abortion/article/627466/ Worse Psychological Outcomes for Women Denied Abortion] Psychiatry Advisor
[http://www.salon.com/2016/12/14/abortion-isnt-linked-with-mental-illness-study-shows-but-being-denied-one-might-be/ Abortion isn’t linked with mental illness, study shows — but being denied one might be] Salon
[http://www.medpagetoday.com/obgyn/pregnancy/62066 More Mental Health Issues Among Women Denied Abortions] MedPage Today
[http://www.ajmc.com/focus-of-the-week/1216/women-denied-abortions-report-worse-mental-health-outcomes#sthash.hg4xgfZw.dpuf Women Denied Abortions Report Worse Mental Health Outcomes] AJMC Managed Markets Network
[http://www.webmd.com/women/news/20161214/women-denied-an-abortion-endure-mental-health-toll-study#1 Women Denied Abortion Endure Mental Health Toll] WebMD. Dec. 14, 2016

[http://www.medicaldaily.com/abortion-study-2016-most-women-didnt-struggle-decision-terminate-400937 Abortion Study 2016: Most Women Didn't Struggle With Decision To Terminate] Medical Daily Oct 2016
[http://www.livescience.com/57225-denying-abortion-access-harms-womens-mental-health.html Denying Abortion Access May Harm Women's Mental Health] Dec 15, 2016
[http://time.com/4599806/abortion-doesnt-negatively-affect-womens-mental-health-study/ Abortion Doesn't Negatively Affect Women's Mental Health: Study] Time. Dec 14, 2016
[http://www.thedailybeast.com/articles/2016/12/14/study-abortion-doesn-t-harm-women-s-mental-health-but-denying-one-does.html Study: Abortion Doesn't Harm Women's Mental Health, but Denying One Does.] The Daily Beast. Dec 14, 2016
[http://www.slate.com/blogs/xx_factor/2016/12/14/new_longitudinal_study_confirms_that_women_who_get_abortions_do_not_suffer.html New Longitudinal Study Confirms That Women Who Get Abortions Do Not Suffer Psychological Harm] Slate Dec 14, 2016

==Critique by Priscilla Coleman==

*"[https://www.mercatornet.com/features/view/the-continuing-saga-of-efforts-to-deny-the-heartache-of-abortion/19163 The continuing saga of efforts to deny the heartache of abortion]," by Priscilla Coleman

= Suicidal Thoughts =
'''Biggs MA, Gould H, Barar RE, Foster DG. [https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2018.18010091?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Five-year suicidal ideation trajectories among women receiving or being denied an abortion.] Am J Psychiatry 2018;175:845–52. <nowiki>https://doi.org/10.1176/appi.ajp.2018.18010091</nowiki>.'''

In this study the authors conclude "Levels of suicidal ideation were similarly low between women who had abortions and women who were denied abortions. Policies requiring that women be warned that they are at increased risk of becoming suicidal if they choose abortion are not evidence based." But once again, their reporting and conclusions are selectively chosen to distract readers from findings which actually show higher rates of suicidality among the abortion women. In Table 2, the average mean score on the suicidality scale over the full five years was significantly lower for the Turnaway Birth Group (0.67) as compared to both the first trimester abortion group (0.88) and the near-limit abortion (0.94) at one week after going to the abortion clinic. This was also true at the first interview, one week after being invited to participate at the abortion clinic: Turnaway Birth Group (1.29), first trimester abortion group (1.53) and the near-limit abortion (1.92), and for the Turnaway Group still seeking abortion (2.02). Yet, while this difference is shown in the tables, it is never discussed, Instead, the authors focus on the decline in suicidality scores across the five years and assert that since there is a similar decline in rates, that means that abortion is not associated with suicidality. Which is clearly not even logically true. Much less, it ignores the fact that suicidality was significnatly associated with abortions at numerous points in sequence of surveys.

Notably, Table 3 also shows the birth group having the lowest risk of suicidality, but they try to justify ignoring this finding by computations of the 95% confidence intervals which reveal that their data set is so small that their confidence intervals have a huge range, for example for the Turnaway birth group, the OR=1.07 95% CI = 0.14 to 8.01. What that huge range means is that their data set is simply too small to detect any effects.

They also ignore the likelihood that the high dropout rate may have helped to reduce the suicidality measured over time, if the most distressed women were most likely to drop out. Notably, they do include an "attrition analysis" in which they assert that in testing scores related to depression, anxiety, history of child abuse and past-year intimate partner violence were not significantly associated with loss to follow-up (though they withheld the data). But why in the world did they not report whether suicidality was associated with dropouts---unless it was associated with dropouts and they wanted to distract readers with an offering of other variables for which it is not associated. This is almost surely truly a tell.

=Other Criticisms=

[https://afterabortion.org/theyre-still-trying-to-disprove-post-abortion-trauma-syndrome/ They're Still Trying to Disprove Post-Abortion Trauma Syndrome]

[http://liveactionnews.org/flawed-biased-turnaway-study-now-claims-95-women-happy-abortion/ Flawed, Biased Turnaway Study Now Claims 95 Percent of Women Happy After Abortion]

[http://reclaimingourchildren.typepad.com/lumina_a_ray_of_light_aft/2015/07/hardly-any-women-regret-having-an-abortion-only-millions-of-us.html Hardly Any Women Regret Having an Abortion -- Only Millions of Us!]

Takeaways from the UCSF Abortion "Turnaway" Study (Series from NRL News Today):
[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study/#.VaafirV_Dkc Part I: Set up for a Spin]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-2/#.VaagarV_Dkc Part II: Finding What They Looked For]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-3/#more-20901 Part III: Spinning the Consequences of Abortion]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-4/#more-20951Part IV: Research Team with an Agenda]

[http://www.nationalrighttolifenews.org/news/2013/01/takeaways-from-the-ucsf-abortion-turnaway-study-5/#.VaagnbV_Dkf Part V: How Bias Can Tilt Results]

=Review of the Book=
The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having―or Being Denied―an Abortion
by Diana Greene Foster Ph.D. New York. Scribner. 2020.

The principle goal of Foster's book is to insist that there is "no evidence that abortion hurts women" while there are "many ways in which women are hurt by carrying an unwanted pregnancy to term"(p 21). From this vantage point, she argues against any and every abortion law regulating informed consent, disclosure of risks, waiting periods, and constraints on late term abortions. In short: abortion is good. Delivering unplanned pregnancies is frought with risk.

Foster consistently exaggerates the importance of her case series study. Any evidence to the contrary is ignored and all public policies that she opposes (such as risk disclosure requirements, waiting periods, term limits, and safety regulations) are "proven" to be unnecessary.)

Foster's studies and books have been promoted and lauded by all of the pro-abortion media. She even basks in repeating the description of her study by ill-informed reporter for New York Times Magazine "as the 'most rigorous' study to look at whether women develop mental health problems following an abortion."(p. 7) That's total nonsense, but it serves to advance her political goals, so Foster introduces her study with this accolade in an effort to distract readers from the many serious flaws of her work.

Her first lie is that her study is a prospective longitudinal study, like that which was recommended by Surgeon General C. Everett Koop. In fact, a prospective study on abortion would require gathering data on subjects ''before'' they become pregnant so one can examine mental and physical health before and after the pregnancy and its outcome (birth, abortion, or natural loss). But the Turnaway Study only begins to gather data a full week ''after'' women had their abortions, or in the subset of women "denied" an abortion, after they went to the abortion clinic. This means it is a "case series" study--one that follows cases. It is not a prospective study--one that has objective data prior to outcomes of interest.

The second lie is one of omission. She never tells readers of the body of research that shows that there is a dose effect--negative emotions increase with each exposure to a pregnancy loss, whether it is an abortion or miscarriage. This is important because her study totally ignored prior and subsequent pregnancy history. It is likely that to 20-40% of those who were turned away and gave birth had a prior abortion or an abortion after the delivery. As a result, Foster is comparing women who have a known abortion to women with an unknown mix of abortion histories. This is simply bad science.

The third lie is in framing, delay, and dismissal. Readers are led to believe that her survey of "a thousand women" gathered from 30 abortion clinics is truly representative of the national population of women seeking abortions. It is not until page 253 that Foster admits that only 31% of the women invited to participate in the study participated in even the first interview, a week after going to the clinic. This is a horrible participation rate. Based on research from other studies, the most likely explanation is self-censure: the women who expect to have the most negative feelings following their abortions are least likely to want to have those feelings stirred up by interviews weeks, months, and years later. But Foster doesn't mention this research. Instead, she simply dismisses the low participation rate as being most likely due women finding it he inconvenient. At this point, Foster could also have mentioned that participants were even offered a $50 gift card for every interview, but this fact (along with many others) are revealed only in addenda to her published medical studies, not her in her book, news releases, summaries or other propaganda pieces. For example, another omitted detail is that of 31% who did participate in the first interview, only about half (17%) remained in the study for the whole five years. Fifty bucks per interview was simply not enough to prevent high drop out rates. Again, it is quite likely that the women dropping out were most likely to be experiencing the most negative feelings.

It is also not until page 253 that we learn that the invitation process was also not random. Clinic workers had the liberty to decide who they wanted to invite. In fact, two-thirds of the participants came from just three of the 30 clinics participating.

Readers are also not informed that the study ignored prior and subsequent abortions, in both the aborting group and those who carried to term. As many as 20-40% of those who were turned away and gave birth had a prior abortion or an abortion after the delivery. This is simply ignored. As a result, Foster is comparing women who have a known abortion to women with an unknown mix of abortion histories. This is simply bad science.

==Inconsistencies==
*page21 -"We find no evidence that abortion hurts women." p.125 - 39% of women in the sample had symptoms of post-traumatic stress, and 16% were at risk of post-traumatic stress disorder. Of those at risk, 19% attributed their traumatic reactions to their abortions, yet the researchers dismiss this finding as "no evidence that abortion hurts women" on the grounds that it was more common for women to attribute their PTSD to experiences of violence, or other health issues. Similarly, their claim that there are no negative reactions is contradicted by their own findings that (p 121) 74% reported sadness, 66% regret, 62% guilt and 43% anger.

*p100-Here Foster says that "the initial motivation for the entire Turnaway Study, after all, was to answer the question ''Does abortion hurt women?''" But on page 4 she stated that the original intent was simply to address the question "I wonder what happens to the women we turn away." If the real intent was to investigate potential harm to women, this was the wrong study design since it lacked any information about women before they sought abortion, especially before they were pregnant . . . plus it ignores any effects of prior or subsequent abortions on women, confining itself to just the one abortion at the time volunteers joined the study.

*p121 - After being told they were over the time limit and could not have an abortion, 60% of women denied abortions reported feeling happy about their pregnancy and [https://pdfs.semanticscholar.org/bc37/113def0d0b90f94bea2acee1e8ec1dfcfcea.pdf 43% were happy about being turned away, with 49% reporting they also felt relief a week after being turned away. Their levels of sadness and guilt were also lower than that of those who aborted].

*p107-108 - Claims: "Actually, women seeking abortions are no different from women in general." But this contradicts the claim if other pro-abortion researchers, such as Steinberg and Munk-Olsen, that women who have abortions are over twice as likely to have prior mental health problems, which is how they explain the higher rates of psychological problems found among women who have abortions in large scale population studies...which are not subject to the non-random self-selected sample problems attached to Foster's study. In short, there is a lot of research indicating that women who have abortions ARE different from the general population, but this is another example of Foster's penchant for propaganda rather than fact.

==Nuances Admitted==
*p99-100 - Foster admits that at least some women who have difficulty coping after an abortion may attempt to re-frame and rationalize their decision as being for the best: "None of us know, as we move through our lives, what would have been at the end of the roads not taken. I suspect that whichever path we take, when we look back, we want to feel like we made the best decisions possible—that everything worked out for the best. So Martina's statement that "I don't regret the abortion at all. I'm where I am supposed to be in my life" could be an after-the fact rationalization of her experience." This admission totally undercuts the significance of Foster's claim that 95% of women are happy with their decision to have an abortion.

*p102-103 - Foster reports that "Approximately one in five women seeking abortion in the Turnaway Study thought abortion was morally wrong or should be illegal." {The study reported that another 15% believe it is morally wrong in some circumstances.} She also states that in another study she conducted of women in an abortion clinic waiting room "4% agreed with the statement 'At my stage of pregnancy, I think abortion is the same as killing a baby that's already born.'"

*p121 - Foster admits that answers to questions can be easily misinterpreted, giving as an example "It was terrible" could mean the experience was terrible or being in the situation to require an abortion was terrible. Similarly, feeling "relief" could mean feeling relieved that the experience is over or relieved not to be pregnant. Using the same logic, she notes that while the majority of women (60%) who were told they couldn't have an abortion were reported feeling happy about their pregnancy seven days later, this high level of happiness did not mean they "were entirely glad they became pregnant." Mixed emotions are common. So claims that most women feel "relief" after an abortion simply don't tell us enough about what kind of relief they are feeling, much less that they are not also feeling negative emotions.

*p122 - "Over the five years, women who reported having more difficulty deciding to seek an abortion also felt more negative emotions, as did women who perceived that abortion was looked down upon in their communities and women with less social support." In addition, women who had a greater desire or openness to becoming pregnant were also more likely to have negative feelings.

==Denying an Abortion Does No Harm, Most are Happy to Have Child==
*p109-There is no mental health harm from being denied an abortion. In fact, the majority of women who were denied abortions reported feeling happy at that result (p121).

*p109-Foster was surprised to find that women who were denied abortions had no additional mental health harm. "I expected that raising a child one wasn't planning to have might be associated with depression or anxiety. But this is not what we found over the long run. Carrying an unwanted pregnancy to term was not associated with mental health harm. Women are resilient to the experience of giving birth following an unwanted pregnancy, at least in terms of their mental health."

*P109- In an effort to salvage that narrative that denying abortion "hurts" women, she can only point to a single finding just one week after women sought an abortion showing that Turnaways had somewhat higher rates of anxiety compared to women who aborted a week earlier. But at that same time, the women who aborted reported higher rates of sadness, guilt and depression than the turnaways. Bottom line: the Turnaway Study actually supports the idea that banning abortions would not cause any significant mental health harm to women. In fact, just one week after going to the clinic, '''60% of those who were still pregnant reported being happy about their pregnancy''' compared to just 27% of those who had abortions. Among those who had near term abortions, 62% reported feeling guilty compared to just 30% of the Turnaways.

*p 126 - "One week after abortion denial, 65% of participants reported still wishing they could have had the abortion [35% were happy they did not have it]; after the birth, only 12% of women reported that they still wished that they could have had the abortion." By the first birthday, it dropped to 7% and then down to 4% at the last interview, 4.5 years later. Those "women who had less social support from family and friends and women who had an easy time decision to have the abortion were the ones who were more likely to continue to wish they had received an abortion."

*p 126 - Among women who had their babies, those who reported the most negative emotions were those who placed their children for adoption. At the 4.5 year followup, 15% of women who placed the child for adoption compared to just 2% of women who parented their child, reported that they still wished they could have had the abortion.

==Inconsistencies regarding mental health==

*p121--In Foster's 2013 paper examining emotions relative to their pregnancies one week after seeking an abortion, among all groups of women, 74% reported sadness, 66% regret, 62% guilt, 43% anger, 25% relief and 33% happiness. Regarding their abortion experiences, 64% sadness, 41% regret, 53% guilt, 31% anger, 83% relief, and 52% happiness. But turnaways were twice as likely to subsequently report happiness about their pregnancy, 43% said they were happy to not have had the abortion, and 49% said they were relieved not to have had the abortion. Also, 60% of Turnaways report happiness about their pregnancies compared to 25% of women who had a first trimester abortion. This suggests that Turnaways may have delayed seeking an abortion because they actually were hoping to keep their children.

*Note: In their 2015 report on "decision rightness" the Turnaway team reports that at the baseline (one week after their abortions) 95% of women answered yes to "“Given your situation, was the decision to have an abortion the right decision for you?" But in the same interview, 66% and 41% reported regret relative to the pregnancy and the abortion respectively. As noted above, a majority also reported guilt and high rates of sadness and anger. Therefore, women do not equate "decision rightness" with their overall feelings about their abortion experience, and it is totally inappropriate for Foster and her team to promote the idea that 95% decision rightness means that regret and other negative reactions are rare.

*p124 - Foster complains that Justice Kennedy upheld a law regulating abortion on the grounds that "some women come to regret their choice to abort." She fails to point out that her own study confirmed Kennedy's statement, with 33-65% of women reporting regret. Instead, she focuses strictly on the fact that in their unrepresentative, non-random sample of volunteers 95% of women answered yes to "Given your situation, was the decision to have an abortion the right decision for you?" Yet, previously, she also acknowledged that there is a very common tendency to rationalize previous decisions as the best choice one could make "given your situation." In short, saying you made the best decision you could "given your situation" at a particular time is not the same as saying "That decision was great. It really improved my life. I've never had any regrets about it." In fact, it could mean: "It was my only option at that time. But I've suffered many regrets, guilt, feelings of loss and emptiness since then."

*p126 - Based on the high "decision rightness" results, Foster claims: "The Turnaway Study provides strong evidence that the vast majority of women do not experience difficulty coping with their abortions..." That is pure nonsense. The study actually reveals that large percentages of women report feeling regret (41-66%), guilt(53-63%), sadness (64-74%), anger(31-43%), depression, anxiety and even PTSD (7-39%). "Decision rightness" is not the same as a claim that "I've had no difficulties coping with my abortion." It is a false equivalence. Moreover, because the Turnaway Study used a non-random invitation of a self-censuring population of women which created a bias toward women expected to be satisfied with their abortion decisions, this non-representative sample really can't tell us anything at all about what "the vast majority of women" experience.

==Shortcomings==

*Readers are never told that the study is based on a non-random, self-selected group of volunteers. Both the invitation process and self-selection bias make it likely that the sample group are much more likely to have positive experiences with abortion than the general population.

*Moreover, it is not until page 253 that not told about the Turnaway Study's horrible participation rate. Only 31% of the women invited to participate in the study participated in even a single interview, much less ten. It is simply impossible to predict what "the majority" of any surveyed group feel about any subject only 31% are willing to answer any questions. This is why many journals do not accept studies with less than 60% participation rates. Regarding this low participation rate, Foster simply waves it aside, reassuring readers that the low participation rate as being most likely due to the inconvenience. She does not even address the evidence from other studies indicating that women who expect to have negative feelings are least likely to participate in subsequent interviews.

*Surprisingly, Foster also fails to mention the fact that in order to tempt women to participate, they were offered a $50 gift card for every interview they completed...up to ten interviews, $500. In short, the self-selection bias is toward women who expect to have the least negative reactions and the most interest in $50 per interview. This financial inducement is omitted from her book

*In addition, she does not fully explain that the invitation process was also not random. Clinic workers had the liberty to decide who they wanted to invite to participate. In fact, she reports that two-thirds of the participants came from just three of the 30 clinics participating. That suggests that the entire population of women eligible to be invited was likely at least ten times greater, meaning they only interviewed 3% or less of the eligible population.

*Nor does she address the problem of drop out rates. Of those who initially agreed to be interviewed, 15% dropped out before the first interview a week after the abortion. Another 8% dropped out between the one week post-abortion interview and the six-month interview. Over the course of the 10 interviews over a 4.5 year period the participation rate dropped from 31% down to 17%. Again, it is most likely that the women experiencing the most negative feelings were most likely to dropout as time progressed.

*Readers are also not informed that the study ignored prior and subsequent abortions, in both the aborting group and those who carried to term. While never mentioned in the book, in an obscure note in just one of their studies it is revealed that [https://pdfs.semanticscholar.org/bc37/113def0d0b90f94bea2acee1e8ec1dfcfcea.pdf 40% of the turnaway group had a prior history of abortion]. In other words, Foster was actually comparing a group of women, 100% of whom have had one or more abortions, to a "control" group of whom at least 40% have had one or more abortions. But she simply presumes these prior abortions don't matter. She then argues that the similarities between these groups proves that abortion has no effects on mental health, a conclusion that requires us to ignore all prior and subsequent abortions. This is simply bad logic and bad science. But because it advances the pro-abortion propaganda line, so it gets labeled the "most rigorous" research ever done!

*Similarly, her studies ignore whether or not women in either group had a history of multiple abortions. That's a serious problem since the research is clear that there is a dose effect--negative reactions increase with exposure to multiple abortions.

==Physical Risks and Mortality Rates==

*With such a small, non-random sample size, the Turnaway Study is unable to give any reliable data on physical complications.

*p142 - Foster asserts that complication rates for abortion (at 2%) are far lower than "for wisdom-tooth extraction (7%), tonscillectomy (8-9%) and childbirth (29%)" but the source she cites does not mention any of these latter procedures, much less the rates, and is itself restricted only to complications of abortion treated in emergency rooms. It excludes treatments at other medical providers, much less untreated complications.

*p136 - Mortality Rates. Foster reports that two women in the birth group had deaths related to childbirth. This is over a 100 times the national maternal mortality rate. On the other hand, she also reports, but dismisses as incidental, that there were four deaths among the women who had abortions. That finding, however, is consistent with eleven [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5692130/ record linkage studies showing an elevated risk of death from all causes following abortion]]--most especially in relation to suicide, accidents (risk taking or self destructive behavior) and heart disease (a stress related illness).

*p151 - Foster claims "Not only is abortion a safe medical procedure; it's alternative—continuing pregnancy and giving birth—is far riskier." This is a common pro-abortion claim, but it is not supported by record linkage studies which prove that abortion is associated with in increased risk of death compared to childbirth, and also higher rates of psychological problems, substance abuse, and cardiac diseases (most likely due to stress).

==The Testimonies==
The statistical studies that the Turnaway Study team has published in medical journals includes only numbers describing specific questions asked in the study. In her Turnaway Study book, Foster includes the personal testimonies of numerous women. What is interesting about these studies is that they underscore the fact that women who say they made the right decision to abort will also frequently describe negative emotions and reactions.

*p61 - Jessica describes her abortion as "a sacrifice I had to do. It that wouldn't have happened, I might not be here today. Or my kids might be in foster care. I try to think of the positives. There was a reason. Everything happens for a reason. You might not understand that reason, but one day you will." She believes in God, believes life is sacred, yet also believes God let doctors to "figure out" how to do abortions for a purpose. "There is a good purpose usually for everything, some way or another. I don't talk about it. It still is referred to as the A-word if it's spoken of at all. You've got to make sacrifices sometimes no matter how bad it hurts. Sometimes that's just life. . . . The only complete meltdown I've had about it was when my kids went to, like, a festival with their aunt and uncle.... They came home with balloons, and they were anti-abortion [slogan] balloons." After Jessica grew angry and popped the balloons, "My kids cried, and my oldest one told me he hated me. I couldn't tell him why, and he didn't understand. Mama just popped my balloon, that's all he knew. My friend lives across the road, and I told her I wasn't feeling good. Could the kids come play? When they went to her house, I just cried."

*p160 - Foster describes Kiara as someone who benefited from her abortion, and indeed Kiara states that the "mistake" of her pregnancy and abortion taught her to be more careful about never going through all that again. But she also describes feeling guilty about the abortion, a need for forgiveness, that she asked God for forgiveness, and believes she has been forgiven. She believes that if she had not had the abortion, she might not have experienced the growth she has had. In other words, there are parts of her life, including a later child, that she values and would certainly not want to lose if, by magic, regretting her abortion would suddenly put her on a different path where she doesn't know what would have happened. "I've always felt that life was precious.... I don't think [the abortion] changed my perspective. It just made me appreciate others who have gone through that situation, whereas before I was like, 'What? How can you do that?' But, it just kind of opened my mind to people and their situations but did not necessarily change my outlook on life itself."

==Chapter 6 - Women's Lives==
This is an excellent example of how the Foster and the Turnaway team use tiny bits of data to leap to grand conclusions.

===Aspirational Goals===

*p166-170 - They asked women one week after their abortions "How do you think your life will be a year from now?" They then rated these as either aspirational (positive), neutral, or negative goals, and did an analysis strictly of the aspirational goals. Their finding was that there was no difference in women who gave birth were most likely to describe an aspirational goal relative to their children (specifically their unborn child), which is hardly surprising since those who aborted a week earlier are not going to have a baby! But their "big" finding is that women who aborted were more likely to voice aspirational goals regarding work, relationships, education, et cetera. 86% of women who had aborted reported an aspirational goal one week later compared to "only" 56% of women who had been turned away from the abortion clinic (30% of whom were in the process of seeking and getting an abortion elsewhere). In other words, Foster and her team are trying to argue that a higher rate of "having an aspirational goal" one week after seeking an abortion (whether it was performed or denied) is in and of itself a great benefit to women, and women who are denied abortions are denied this intangible benefit because only 56% vs 86% will voice an aspirational goal when asked an open ended question one week later. That is quite a stretch! What is especially important to note, however, is that their own analysis showed that women who gave birth were just as likely to achieve their aspirational goals as those who had abortions. Perhaps most telling, however, is that Foster and her team did not look at the differences in aspirational goals in the years following childbirth. This is likely because they could find no differences or the differences were in favor of childbirth rather than abortion, and so were never published since they could not be spun to advance their pro-abortion agenda.

*p183 - They were also asked "How do you think your life will be different five years from now?" For this question, the percentage of aspirational goals went up for both groups: 91% for those who had aborted and 83% for those who had been turned away. The Turnaway team could not find any differences in percentages women having achieved these five year goals a the end of the study.

===Changing Attitudes Toward Abortion===

*p171- In one of their [https://link.springer.com/article/10.1007/s13178-018-0325-1 studies of how participants attitudes toward abortion changed], Foster reports that women who gave birth after being denied an abortion were three times more likely (21% vs 9%) to become less supportive of abortion rights while those who had abortions were 5 times more likely (33% to 6%) to become more supportive of abortion. Overall, their views tended to follow their experience.

===Economic Differences===

*p174-177- The Turnaway study provide only a cursory look at the differences in economic lives of their study population. The first benchmark they examined was the number of women below the poverty line. Conveniently, being pregnant, much less giving birth to a child, changes the calculation of the poverty line. So it is no surprise that immediately following their abortions there was an immediate drop of the percentage of women below the federal poverty line for household income. But most surprising, as shown in Figure 7 on page 177, women who gave birth had a greater drop in poverty from six months after seeking an abortion through 4.5 years. In other words, having an abortion did not produce any sustained improvement in household income while the economic hardship associated with having a child rapidly declined with every passing year.

*p178-1880- Without the permission of her volunteers, Foster submitted their personal contact information to credit bureaus to obtain their credit histories. In an analysis of the credit history, she claims that being denied an abortion increased the average past-due debt of turnaways to $1750 compared to $938 in the years prior to their pregnancy. Foster and her colleagues also found that 4.5 years after seeking an abortion, turnaways had an average credit score of about 550 compared to 558 among those who had abortions, a difference of less than 1.5% among a non-representative sample of volunteers. Based on these thin pieces of evidence, Foster claims that her Turnaway Study has proven that denying women abortions harms their socioeconomic status.

*Note: There is evidence from [https://www.sciencedirect.com/science/article/pii/S0022347618312976 one of their papers] indicating that women in the Turnaway group were economically worse off at the baseline. Therefore, any economic differences observed at 4.5 years after seeking an abortion may have predated the pregnancy. In addition, as mentioned previously, there is a lot of self-selection bias in the Turnaway samples. It is well known that women who anticipate more problems dealing with their abortion are less likely to participate in surveys. Since the Turnaway group did not have an abortion, it is likely they felt less anxiety in dealing with subsequent surveys. Also, the promise of a $50 gift card with each interview was likely most tempting to those who were worse off financially. Both of these factors may have contributed to a distortion of the sample toward poorer women.
*Regarding any alleged economic harms to being denied an abortion, It is important to examine this peer-reviewed critique [https://doi.org/10.70257/twgf1217 Turnaway Study Report Unethically Violated Participants' Privacy and Misleads Public with a Non-Representative Sample, Selective Reporting, and Overstated Conclusions]
**"Results from the Turnaway Study, conducted by Advancing New Standards in Reproductive Health (ANSRH), have widely been represented as definitive proof that women denied access to abortion will suffer severe injury to their health and economic wellbeing. Yet a careful examination reveals that the study is based on a non-random, non-representative sample of women that grossly underrepresents the experiences of the majority of women undergoing abortions. In addition, a reanalysis of its reported results reveal that the effect size of the outcomes observed have been grossly overstated, leading to conclusions that are not supported by the results. There also appears to be selective reporting and misrepresentation of results previously published. In addition, inconsistencies in ANSRH's published record strongly suggest that the credit history reports of the Turnaway Study participants were obtained without their informed consent."

===Subsequent Educational Attainment===

*p181 - Looking at education, Foster could find no differences in the high school graduation rates between those who aborted and turnaways. Regarding advance degrees, the two groups were also similar in terms of completing advance degrees but turnaways (most of whom had additional child care responsibilities) were more likely to seek lower level degrees which required less time commitment during the 4.5 years they were followed.

*p185 - Foster concludes this chapter with another overly broad, unsupported, and unqualified politicized assertion. "The Turnaway Study shows that women who are denied wanted abortions scale back their short-term plans and suffer economic hardship for years." But the scaling back of short term plans is based on a single question one week after being turned away while women are still trying to sort out their futures. Many of them also report being happy that they will now focus on having their babies, while others are in fact seeking abortions at other clinics, perhaps in other states. And the claim that they "suffer economic hardship for years" measures out to having a 2% lower credit score! She is clearly exaggerating the meanings of both "suffer" and "economic hardship."

==Chapter 6 - Children==

===Existing Children===
*p200-202 - Foster argues that among women with children under age five prior to seeking the abortion of interest, the children of those who had abortions enjoyed more economic security during the 4.5 years the group was followed than the children of those who carried to term. But this finding is not reliable for drawing any conclusions based on the facts that (1) the study uses a nonrandom sample of volunteers and a high degree of psychological factors and stigma that magnify self-selection bias, (2) only 55 women in the Turnaway group had children under the age of 5, so the sample size is very small, and (3) the sample groups were disproportionately made up of women who were poor, below the federal poverty line, for whom a $50 gift card promised at each interview might be a compelling incentive. Given that women who carried to term did not face post-abortion shame as a disincentive to participate, it is likely that the poorer a turnaway woman was the more likely the $50 incentive would have encouraged her participation. In short, it is not surprising that the turnaway group was disproportionately poorer. Plus, the addition of an additional child in the family structure changes the calculation of the federal poverty line and influences eligibility for food stamps and other public aid programs. With all these factors in mind, Foster's finding that 19% of turnaways with previous children compared to 10% of women who aborted with previous children received public assistance is simply non-news. A woman with two children rather than one, will be eligible for more public assistance.

*p202-203 - Foster also looked at how the women rated their children's development, using the Parents' Evaluation of Developmental Status: Developmental Milestones questionnaire. Based on her very small sample size, she found that 74% compared to 77% of children under the age of five (for the turnaway group compared to the abortion group of women) met or exceeded the Developmental Milestones. Based on this very small, 3% difference, Foster argues that denying women abortions causes developmental harm to their already born children. But this is clearly an exaggerated conclusion based on very little evidence and a very little difference in that evidence. Plus, the fact that Foster refuses to make her data available for analysis by other researchers suggests that she may be engaged in selective reporting. Results that might show benefits to Turnaway women and their children don't get reported, only the results that she can use to advance her political agenda.

===Children Born Afterward===

*P204- Among turnaways, 64% reported they still wished they could have had the abortion, but this dropped to 12% six months later, after the child was born, and down to just 4% at the last interview, 4.5 years later. Foster admits these women were mostly happy they had their babies, though she does not report the actual percentages of emotions related to abortion or the pregnancy for any of the groups studied throughout the 4.5 years.

*206-208 - Foster reports that they used the Postpartum Bonding Questionnaire to evaluate the emotional bonding women felt for children under 18 months old to compare who women evaluated their bond after (a) being turned away from an abortion, and (b) for those women who had abortions and then delivered. They reported that 9% of Turnaway women compared to 3% of the Abortion group reported bonding problems with the child. This finding needs to be interpreted in light of the fact that women in the second group were (a) a self-selected population of women at least risk of negative reactions to abortion and (b) were an average of three years older and more likely to be living with a male partner (which presumably reduces stress during the first 18 months with the child).

*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248140/ In the study examining these two groups], subsequent children born to women who had abortions were more likely to be premature and have low birth weight, but the authors fail to discuss this.

NCCMH Review

2025-10-21T22:56:43Z

Barb: /* History of NCCMH Review */

Induced Abortion and Mental Health, NCCMH Published December 2011

::'''citation:''' National Collaborating Centre for Mental Health. Induced abortion and mental health: a systematic review of the mental health outcomes of induced abortion, including their prevalence and associated factors. London (UK): Academy of Medical Royal Colleges; 2011.

The full report can be downloaded from the [https://www.aomrc.org.uk/wp-content/uploads/2016/05/Induced_Abortion_Mental_Health_1211.pdf AoMRC reports and guidance page.] A record of [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf all comments received and the developers’ responses] can be [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf downloaded here.]

The [https://www.scribd.com/embeds/327609067/content?start_page=1&view_mode=scroll&access_key=key-r3mNJH1gDsAHIiLuduFC&show_recommendations=true first draft] and [https://www.scribd.com/document/327608591/Induced-Abortion-and-Mental-Health-Systematic-Review-Consultation-6-April-to-29-June-2011-Comments-and-Responses the comments and responses on the first draft] can also be downloaded from Scribd.

===History of NCCMH Review===

In 2006, the U.K.'s House of Commons Science and Technology Committee undertook an inquiry into the health effects of abortion on women which included a request (paragraph 139) for the RCP to update their 1994 statement on abortion in light of more recent studies.<ref>House of Commons Science and Technology Committee (2006). ''[https://publications.parliament.uk/pa/cm200607/cmselect/cmsctech/1045/1045i.pdf Scientific Developments Relating to the Abortion Act 1967. Volume 1]''</ref> In 2008, the RCP did update their position statement to recommend that women should be screened for risk factors that may be associated with subsequent development of mental health problems and should be counselled about the possible mental health risks of abortion.<ref>Templeton, Sarah-Kate (2008-03-16). "[https://www.thetimes.com/uk/healthcare/article/royal-college-warns-abortions-can-lead-to-mental-illness-p8glm5s5k8h Royal college warns abortions can lead to mental illness]". ''The Sunday Times''. ISSN 0956-1382.</ref> <ref name=":0">Fergusson, David M. (September 2008). "[https://www.researchgate.net/publication/274356401_Abortion_and_mental_health Abortion and mental health". ''Psychiatric Bulletin''.] '''32''' (9): 321–324. doi:10.1192/pb.bp.108.021022. This Appendix to this paper includes the complete 14th March, 2008 RCP revised Position Statement on Women's Mental Health in Relation to Induced Abortion.</ref> The revised RCP position statement included a recommendation for a systematic review of abortion and mental health with special consideration of "whether there is evidence for psychiatric indications for abortion."<ref name=":0" /> Following the publication of a number of studies between 2002 and 2008 revealing that women who have abortions experience common disorders such as anxiety or depression at a rate about three times higher than other women, Royal College of Psychiatrists issued a [http://www.thesundaytimes.co.uk/sto/style/living/Health/article82769.ece position paper on abortion] ((Royal College of Psychiatrists. Position statement on women’s mental health in relation to induced abortion. 14 March 2008. Royal College of Psychiatrists, 2008) acknowledging that some women may have adverse reactions to abortion and further recommended:
:Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.

A commentary upon the revised position statement and the history of this statement is provided in an [http://pb.rcpsych.org/content/32/9/321.full editorial by David Fergusson, published in ''The Psychiatrist''].

This statement also called for a systematic review of the evidence, which led to the commissioning of Britain's National Collaborating Centre for Mental Health (NCCMH)to undertake such a review. The NCCMH subsequently undertook a review which was limited to addressing just three questions related to abortion and mental health.

====Questions Addressed in the Review====
The reviewers chose to limit their report to three questions: (1) How prevalent are mental health problems in women who have an induced abortion? 2. What factors are associated with poor mental health outcomes following an induced abortion? 3. Are mental health problems more common in women who have an induced abortion when compared with women who deliver an unwanted pregnancy?

Note, the first question, dealing with prevalence, is easily answered by record linkage studies from which the mental health treatment rates of women having abortions can be tabulated. The question does not ask how much of the observed mental health problems are attributable to abortion, but rather how common are mental health problems among women with a history of abortion. The results unequivocally show that rates of mental health problems among women with a history of abortion are higher than rates for other groups of women, including the general population of women and women giving birth who do not have a history of abortion. Yet this is not fully discussed in the conclusions, which instead shift the discussion to evidence that women who have mental health problems after an abortion may also have higher rates of mental health problems before having abortions. Which actually raises a new issue which the reviewers refused to address, namely, is there evidence that women with pre-existing mental health problems get better or worse following an abortion.

Regarding the second question, the reviewers actually failed to systematically investigate all risk factors that predict poor mental health outcomes.

Regarding the third question, the reviewers acknowledged that the definition of what constitutes "an unwanted pregnancy" is imprecise and also that they were declining to investigate the alternative of whether there are any mental health benefits of abortion, which is actually the pertinent issue under UK law. (see [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf pages 39, 43, 91 ]

=====Studies and Data Excluded in Investigating these Three Questions=====

The reviewers chose to exclude:
# Any studies related to mood disorders, including reactions such as guilt, shame and regret. Although the - although these were considered important - and also assessments of mental state within 90 days of an abortion. This was because the research was not about “transient reactions to a stressful event”.occurring within the first 90 days of an abortion
# Any studies of qualitative data (qualitative interviews, case studies, self-reports etc) (p135 We agree that qualitative evidence is important in this area.Unfortunately it was beyond the scope and resources of the review to consider qualitative evidence")
# Any data relative to negative effects associated with aborting a wanted pregnancy for "therapeutic" reasons.

====Questions Excluded from Investigation====

The report deliberately excluded any investigation of key questions
# In what cases may abortion contribute to the mental health of women
# Whether abortion makes pre-existing mental health problems more severe or difficult to treat

Research questions excluded from the review, and the reason for excluding them, are described in the companion document "[http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf Comments and Responses], see especially pages 95-103.]"

In their request for public comments, the NCCMH panel was asked to investigate, or at least comment on, the following questions. The panel declined to do so, stating these questions were "beyond the scope and remit of the present review, which was to focus on the three research questions posed." Notably, the panel itself posed the three questions it chose to investigate, and in doing so prevented their review from being a comprehensive examination of abortion and mental health issues. (Indeed, [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf the phrase "beyond the scope"] was used 45 times to evade questions raised by commentators.)

----

Questions ignored:

*(p35)

This draft makes no attempt to answer the issues raised by the
Abortion Act and its amendments. Indeed the authors make
assumptions not contained in the Act that women have an
unfettered right to choose an abortion. The act is clear that
abortion is a medical matter and can only be performed if and
when it is necessary to improve or preserve a woman’s health.
The real question to be addressed is, what is the evidence of
benefit., not what is the data for harm. This was studiously
avoided by the authors of this draft. The Fellows of Psychiatry
erred in not making their mandate clear and relevant.
If a woman has a right to have an abortion when she so elects,
then abortion is not a medical matter and should be performed by
technicians If a woman has a right to good medical treatment that
may include having an abortion on her physician’s
recommendation, then this review is valid only if it addresses
these questions:

a) '''Indication''' Is there a pathological process in pregnant
women in general and this patient in particular that warrants
having an abortion? (It must be recognized that pregnancy is not
a disease.)

b) '''Benefit''' What is the evidence that an abortion will benefit
women with this condition (pregnancy) and this patient in
particular?

c) '''Harms.''' What are the adverse effects from an abortion and if
there are some, do they outweigh the anticipated benefit?

d) '''Other options''' Have all less invasive, more reversible
treatments been offered, tried and failed before an abortion is
recommended?

e) '''In good faith''' Is the physician who is providing this
procedure doing so in good faith? Has the abortionist carefully
studied to relevant literature in order to practice evidence based
medicine, honed his/her skills and performed a careful followed
up on his/her ex-abortion patients to know personally that he/she
will be providing good treatment?

f) '''Adoption etc.''' Has the physician facilitated all options to
abortion of a truly unwanted child, i.e., adoption, fostering etc.

g) '''Informed consent.''' Has the physician made a clear
recommendation to the patient with evidence to support that
recommendation, options available, potential benefits and
hazards, and shown the ambivalent woman the ultrasound of her
fetus? Has he/she been given fully informed consent which
requires the patient have full opportunity to ask questions, get a
2nd opinion and make a decision with enough time to do so and
without pressure from mate, family, IPPF, physician etc.

It must be remembered that until any treatment is well proven, it
must be considered as experimental and constrained as such.

Moreover the burden of proof rests with the performing
physician, his/her supporters and those who fund this activity to
show abortion is necessary, beneficial etc. not on those who
question abortion is a valid treatment to show it is harmful.

----
*(p43-44)

The [https://abortionrisks.org/docs/Rawlinson(1994)Abortionreport.pdf Rawlinson Report]<ref>House of Lords Commission of Inquiry. [https://abortionrisks.org/docs/Rawlinson(1994)Abortionreport.pdf The physical and psycho-social effects of abortion on women: a report by the Commission of Inquiry into the Operation and Consequences of the Abortion Act] (1994).</ref> and the RCOP response
(http://extras.timesonline.co.uk/rowlinsonreport.pdf) highlights
important issues that should be much more carefully addressed
in this new report.

The Rawlinson report gave a summary of the RCOP's testimony
and response to questions asked stating "there are no psychiatric
indications for abortion." As per Ney’s elaboration, this concern
that there are “no [psychiatric] indications for abortion” refers to
the lack of medical indications that the abortion will produce
positive mental health effects.

Properly understood, this statement was an attempt to summarize the RCOP’s failure to report to the committee any
statistically validated psychiatric criteria which can be used to
identifying when an individual woman is likely to either (a) derive
psychiatric benefits from an abortion, or (b) be successfully
protected from psychological harm that would otherwise occur if
the pregnancy continued.

There is still a lack of any such criteria.

It should be carefully noted that the RCOP’s letter of response
did not refute the Rawlinson Reports finding that there are no
indications for abortion. If they had any indications, they would
have stated so in their response. For example, they might have
noted that abortion is medically indicated for bi-polar women
faced with an unwanted pregnancy, if there was any statistically
validated evidence to support that claim, but there was none.

RCOG letter of response shifted attention away the actual claim
of fact regarding lack of known indications for abortion to a
distinctly separate issue, namely that "the risks to psychological
health from the termination of pregnancy in the first trimester are
much less than the risks associated with proceeding with a
pregnancy which is clearly harming the mother's mental health."
(emphasis added.)

Notably, this statement has a huge qualifying clause which is
exceptionally vague. The letter fails to give any means of
determining when and how often a pregnancy is “clearly harming
a mother's mental health.”

It actually implies that In cases where the pregnancy is not
clearly harming a mother’s mental health, abortion may involve
equal or greater risks. So the standard of identifying when a
pregnancy is clearly harming mental health should be examined
to identify the indicators for abortion which were requested by the
Rawlinson committee.

Moreover, there is no research that has examined the assertion
made by this qualifier. Specifically, there are no studies
comparing psychiatric outcomes for women whose
pregnancies were clearly harming their mental health who
had abortions versus those who did not
.
In this light, it seems clear that the statement on page 61 of the
report, contested by the RCOG’s letter of response, merely
conflates the finding that there are no psychiatric indications for
abortion into the statement that there is no psychiatric
justification for abortion.

While there is plenty of room to debate whether “justification” can
rightly be substituted for “indications,” two key question remain
unanswered: (1) What evidence demonstrates when, if ever,
abortion is likely to improve a woman’s mental health? And (2) what
does the best evidence show regarding when, if ever, abortion
protects future mental health, i.e., by reducing psychological
stresses without creating new psychological stresses?

These are questions which should be clearly articulated in this
report, even if the only answer that can be given is that the
research done to date has failed to address these important
questions.

----
*p46

First, good medical care involves at least four components:

(a) accurate diagnosis of the problem,

(b) identification of treatments most likely to be efficacious,

(c) evaluation of treatment risks, and

(d) a risk / benefit analysis regarding treatment alternatives.

Unfortunately, in the context of the abortion controversy, these
distinct steps are often confused or conflated. An unspoken, but
medically inappropriate paradigm appears to exist with regard to
abortion, namely:

(a) if the woman requests the abortion, and

(b) there is no clear risk that she will die on the operating table,
and

(c) critics abortion have not proven, beyond all reasonable
doubt, that abortion is and of itself the sole cause of all the risks
statistically associated with abortion, then

(d) physicians should feel free to recommend or perform
abortions on request.

This medical decision paradigm is simply not justified by the
principles of evidence based medicine and medical ethics which
apply to any other procedure.

'''Therefore, to shed light on the core issues regarding
abortion decision making, especially in the context of UK
law, this literature review should identify and grade the
medical evidence relative to two very specific questions:'''

First: “What medical conditions and/or psychosocial indicators
predict when the risks of continuing a pregnancy are greater than
if the pregnancy were terminated?” These are the indications for
induced abortion.

Secondly, what are the statistically validated risk factors which
can help to identify the subsets of women who appear to be at
greater risk of negative effects associated with a history of one or
more abortions? These risk factors are the medical
contraindications for induced abortion.

----
*(p63)

The glaring gap in this draft is the lack any consideration of the
effect of abortion on men and children. It makes this report
invalid, if for no other reason than because what effects spouse
and children will have a pronounced effect on the woman’s
mental health.

----
*(p65)

1/2
Since many post-aborted women use repression as a coping
mechanism, there may be a long period of denial before a
woman seeks psychiatric care. These repressed feelings may
cause psychosomatic illnesses and psychiatric or behavioural
disorders in other areas of her life.

As a result, some counsellors report that unacknowledged post-abortion distress is the causative factor in many of their female
patients, even though their patients have come to them seeking
therapy for seemingly unrelated problems.
Kent, et al., “Bereavement in Post-Abortive Women: A Clinical
Report”, World Journal of Psychosynthesis (Autumn-Winter
1981), volume 13, no’s 3-4

Note the area of Sexual Dysfunction – Thirty to fifty per cent of
aborted women report experiencing sexual difficulties, of both
short and long duration, beginning immediately after their
abortions. These problems may include one or more of the
following: loss of pleasure derived from sexual intercourse,
increased pain, an aversion to sexual activity, and/or males in
general, or the development of a promiscuous lifestyle.
Speckhard, Psych-social Stress Following Abortion, Sheed &
Ward, Kansas City, MO 1987; and Belsey et al., “Predictive
Factors in Emotional Response to Abortion: King’s Termination
Study – IV,” Soc. Sci. & Med., 11:71-82 (1977)

:Response of reviewers: Although these are important points, they are beyond the scope of the present review.

----

*(p95)

1. "Question 3 should be reworded to properly reflect UK law, as follows: 3. Are mental health problems less common in women who have an induced abortion, when compared with women who deliver an unplanned or unwanted pregnancy? [This was recommended since UK law allows induced abortion only when the health risks of abortion are less than those of allowing the pregnancy to continue.]"

----

*(p95) 1. How prevalent are mental health problems in women who do not terminate an unplanned or unwanted pregnancy compared to the general population and to women who deliver a wanted pregnancy?

2. What factors are associated with improved mental health following abortion compared to similar women who carry an unplanned or unwanted pregnancy to term?

3. What factors are associated with a lower decline in mental health following abortion when compared to women who do not terminate an unplanned or unwanted pregnancy?

4. Among women who do experience negative reactions which they attribute to their abortions, what reactions are reported and what treatments are effective?

5. Is presenting for an abortion, or a history of abortion, a meaningful diagnostic marker for higher rates of mental illness and related problems?

6. Does abortion ever cause or exacerbate mental health problems in women, even in rare cases? (p95)

----
*

=== Some Conclusions ===
*The most reliable predictor of post-abortion mental health problems is having a history of mental health problems prior to the abortion.
*A range of other factors produced more mixed results, although there is some suggestion that life events, pressure from a partner to have an abortion, and negative attitudes towards abortions in general and towards a woman’s personal experience of the abortion, may have a negative impact on mental health.
*Women who show a negative emotional reaction immediately following an abortion are likely to have a poorer mental health outcome.
*This section of the review aimed to assess factors associated with mental health problems following an abortion. Identifying these factors would enable healthcare professionals to monitor and provide greater support for women identified as potentially ‘at risk’.

=== From News Releases ===

While acknowledging that women with a history of abortion have higher rates of mental illness than the general population, the director of NCCMH of Tim Kendall, said, “It could be that these women have a mental health problem before the pregnancy. On the other hand, it could be the unwanted pregnancy that's causing the problem. Or both explanations could be true. We can't be absolutely sure from the studies whether that's the case - but common sense would say it's quite likely to be both. The evidence shows though that whether these women have abortions - or go on to give birth - their risk of having mental health problems will not increase. They carry roughly equal risks. We believe this is the most comprehensive and detailed review of the mental health outcomes of abortion to date worldwide.”

Sophie Corlett, director of external relations at the mental health charity Mind, said of the report, “It is important that medical professionals are given the correct information to provide support for all women, but particularly those with a pre-existing history of mental health problems. This study makes it absolutely clear that this group is at the greatest risk of developing post-pregnancy mental health problems and should be given extra support in light of this.”

Dr Peter Saunders, chief executive of the Christian Medical Fellowship, said, “This new review shows that abortion does not improve mental health outcomes for women with unplanned pregnancies, despite 98% of the 200,000 abortions being carried out in this country each year on mental health grounds. This means that when doctors authorize abortions in order to protect a woman's mental health they are doing so on the basis of a false belief not supported by the medical evidence. In other words the vast majority of abortions in this country are technically illegal.”

== Critique by Priscilla Coleman ==

The Royal College of Psychiatrist’s recently conducted review of scientific literature published from 1990 to the present on abortion and mental health is hauntingly similar to the American Psychological Association Task Force Report released in 2008. The report by the RCP is, however, far more complex and on the surface it may appear to be more rigorous than the APA report. An enormous amount of time, energy, and expense has been funneled into a work product that was not undertaken in a scientifically responsible manner. In this critique, I provide evidence that should incite scientists and clinicians to reject the conclusions of the report and work together to provide an accurate and truly exhaustive review of the peer-reviewed research.

==== Unjustified Dismissal of Studies====
The RCP review incorporates four types of studies: 1) reviews of the literature; 2) empirical studies addressing the prevalence of post-abortion mental health problems; 3) empirical studies identifying risk factors for post-abortion mental health problems; and 4) empirical studies comparing mental health outcomes between women who choose abortion and delivery. In each category, there are studies that are ignored and large numbers of studies that are entirely dismissed for vague and/or inappropriate reasons. With regard to the first type of study, only 3 reports are considered (APA Task Force Report, 2008; Charles et al., 2008; Coleman, 2011). The authors of the RCP report “missed” 19 reviews of the literature (listed at the end of this document), published between 1990 and 2011. Moreover, no criteria were identified for selection of particular reviews to discuss and to provide context for the current report. In relation to the third type of study, only 27 studies are included in the RCP report. At the end of this document, citations to 20 relevant and unmentioned articles published in highly respected peer-reviewed journals are provided. They are not listed in Appendix 7 of the RCP report, which contains all included and excluded studies.

Among the scores of studies identified and excluded across study types 2 through 4 above, the most common reasons are the nebulously defined “no usable data” and “less than 90 days follow-up.” The latter resulted in elimination of 35 peer-reviewed studies in each of the prevalence, risk factor, and comparison study types. The RCP authors state that ''“Because the review aimed to assess mental health problems and substance use and not transient reactions to a stressful event, negative reactions and assessments of mental state confined to less than 90 days following the abortion were excluded from the review.”'' This is highly problematic for various reasons. First, elimination of studies that only measured women’s mental health up to 90 days, does not effectively remove cases of transient reactions. Just because the authors of these dozens of studies did not follow the women long-term, it does not mean that the women were not still suffering quite significantly beyond the early assessment. Moreover, when investigating the mental health implications of an event, it is logical to measure outcomes soon after the event has occurred as opposed to waiting months or years to gather data. As more time elapses between the stressor and the outcome(s), healing may naturally occur, there may be events that moderate the effects, and more confounding variables may be introduced. Finally, focusing only on mental health events that occur later in time effectively misses the serious and more acute episodes that are effectively treated soon after exposure.

Ironically, many of the studies removed from the analyses due to the abbreviated length of follow-up, had incorporated controls for prior psychological history and other study strengths. As a result, the samples of studies included in each section of the RCP review were not representative of the best available evidence and many of the eliminated effects coincidentally revealed adverse post-abortion consequences. In the category wherein the authors sought to derive prevalence estimates, only 34 studies were retained, including 27 without controls for previous mental health. In contrast, in the Coleman review, 14 out of the 22 studies had controls for psychological history.

====Factual Errors====
Perhaps even more disturbing than the elimination of large segments of the literature, are the factual inaccuracies that are present in the RCP report. As the author of the Coleman (2011) review cited in the report, I was alarmed to see the content in “Section 1.4.4: Summary of Key Findings from the APA, Charles, and Coleman Reviews.” The first 6 points are not reflective of the conclusions derived from the meta-analysis and the 7th and final point in this section wrongly states, with reference to the meta-analysis that “previous mental health problems were not controlled for within the review.” '''In fact, as noted above, the meta-analysis incorporated more studies into the final analyses with controls for prior psychological problems than the current review. Moreover, the conclusions derived from the meta-analysis were based on more studies with controls for prior psychological history than the Charles and the APA reviews as well.'''

I do not have the time or interest in identifying all errors present, but a few others jumped out at me. First, several studies are eliminated from the RCP report, because the outcome(s) assessed are lifetime estimates of mental health problems, deemed inappropriate by the RCP team. Nevertheless, the Coleman et al. (2009) and the Mota et al. (2010) articles, which relied upon lifetime estimates, are included in the prevalence section of the report. Inclusion reflects an inaccurate read of the two studies. I also noticed my affiliation is stated as the Department of Psychiatry at Bowling Green State University. I wish we had a medical school, it would make retrieval of articles much less expensive, but unfortunately we do not.

====Problematic “Quality Assessments”====
This review is being pitched as methodologically superior to all previously conducted reviews, largely because of the criteria employed to critique individual studies and to rate the overall quality of evidence. However, the quality scales employed to rate each individual study are not well-validated and require a significant level of subjective interpretation, opening the results to considerable bias. The main problems with the quality scale employed to rate the individual studies are as follows: 1) the categories used are missing key methodological features including initial consent to participate rates and retention of participants across the study period; 2) the relative importance assigned to the included criteria is arbitrary, as opposed to being based on consensus in the scientific community; 3) the specific requirements for assigning a “+” or “-” within the various categories are not provided; 4) the authors fail to explain (as their predecessors, Charles et al. 2008 did) how combinations of pluses and minuses in the distinct categories add up to an overall rating ranging from “Very Poor” to “Very Good.” Incredulously, the Gilchrist et al. (1995) study received a rating of “Good”, when very few controls for confounding 3rd variables were employed, meaning the comparison groups may very well have differed systematically with regard to income, relationship quality including exposure to domestic violence, social support, and other potentially critical factors. Further Gilchrist et al. reported retaining only 34.4% of the termination group and only 43.4% of the group that did not request a termination at the end of the study. No standardized measures for mental health diagnoses were employed and evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The GPs were volunteers and no attempt was made to control for selection bias. Despite these facts, the study received a mark of “+ thorough” for confounder control, a “+” for representativeness, and a “+” for validated tools. I can provide a similar rebuttal to many more of the individual study ratings provided by the RCP; and the reader should not trust these “quality” assessments.

Similarly, when it came to evaluating the quality of evidence associated with specific outcomes, such as anxiety, depression, suicide ideation, drug or alcohol abuse, psychiatric treatment, etc. with regard to the comparative studies, “Grade Working Group grades of evidence” were employed by the RCP. The anchors on this scale are vague and oftentimes only one reason is identified as the basis for a “Very Low” rating. For example, in the category of “Any Psychiatric Treatment,” which actually only included the Munk-Olsen et al. study (p.104), the basis for the “Very Low” (very uncertain about the estimate) rating was not controlling for pregnancy intention. As if this isn’t problematic enough, when the study is again evaluated (see pages 198 and 199), it is rated as “Good” in the comparison category. There are loose, poorly conceived rationales and inconsistencies like this throughout the report and the problem lies in the application of an inadequate quality assessment protocol for individual studies and for the body of evidence.

====Faulty Conclusions====
Each section in the RCP report includes conclusions that are based on a very small number of studies that are not properly rated for quality. The results should, therefore, not be trusted as a basis for professional training protocols or health care policy initiatives. To illustrate how incomplete and misleading the conclusions provided by the RCP are, I will use one example. I recently identified 119 studies published between 1972 and 2011 using the MEDLINE, PubMed, and PsycINFO data bases specifically related to risk-factors associated with post-abortion psychological health. Below is a list of the most common risk factors derived from the 119 peer-reviewed journal articles identified.

:a. Timing during adolescence or younger age (18 studies confirm: 2 studies do not)

:b. Religious, frequent church attendance, personal values conflict with abortion (18 studies confirm; 1 study does not)

:c. Decision ambivalence or difficulty, doubt once decision was made, or high degree of decisional distress (29 studies confirm; 3 studies do not)

:d. Desire for the pregnancy, psychological investment in the pregnancy, belief in the humanity of the fetus and/or attachment to fetus (21 studies confirm; 1 does not)

:e. Negative feelings and attitudes related to the abortion (16 confirm; 1 does not)

:f. Pressure or coercion to abort (10 studies confirm; 1 does not)

:g. Conflicted, unsupportive relationship with father of child (24 confirm; 6 do not)

:h. Conflicted, unsupportive relationships with others (28 confirm; 7 do not)

:i. Character traits indicative of emotional immaturity, emotional instability, or difficulties coping including low self-esteem, low self-efficacy, problems describing feelings, being withdrawn, avoidant coping, blaming oneself for difficulties etc. (42 studies confirm; 1 study does not)

:j. Pre-abortion mental health/psychiatric problems (35 studies confirm; 3 studies do not)

:k. Indicators of poor quality abortion care (feeling misinformed/inadequate counseling, negative perceptions of staff, etc.) (10 studies confirm)

The RCP conclusions relative to studies addressing risk factors for post-abortion mental health problems make no mention of most of the variables described above. They simply state (based on 27 studies) that ''“The most reliable predictor of post-abortion mental health problems is having a history of mental health problems prior to abortion” and “A range of other factors produced more mixed results, although there is some suggestion that life events, pressure from a partner to have an abortion, and negative attitudes towards abortion in general and towards a woman’s personal experience of the abortion, may have a negative impact on mental health.”''

I am one academic, without a lab full of graduate students and with a heavy teaching load (not a Department of Psychiatry), yet I was able to find all these studies. Why wasn’t this high powered research team able to do a better job? Simply glancing at titles and abstracts to determine which studies merit further attention will not yield the information needed and resulted in a short-sighted view of the available evidence.

Before I leave this section on poorly developed conclusions, I should note how curious it was to read one of the conclusions under the risk factor section: ''“Women who show a negative emotional reaction immediately following an abortion are likely to have a poorer mental health outcome.”'' How can this “conclusion” be derived if studies that only examined women in the first 3 months following abortion were eliminated? Moreover, if this is true, why would these studies have been eliminated in the first place? Shouldn’t the researchers be most concerned with those most likely to be adversely impacted?

====Appropriateness of Meta-Analysis====
Counter to the claims of the authors of this report, a quantitative review or meta-analysis can be performed when there is heterogeneity present in the effects one wishes to summarize. The random effects model is specifically designed to address heterogeneity. In addition, separate meta-analyses, based on distinct comparison groups and outcomes can be performed. There is no excuse not to perform extensive meta-analyses from the vast literature that has accumulated. Such an approach is much more reliable and the results derived yield more valid conclusions than a narrative review; data that can be translated more readily into practice.

====A Call for Change====
The bottom-line conclusion of the RCP review, based on only 4 studies, is that abortion is no riskier to women’s mental health than unintended pregnancy delivered. When this report was released a few days ago, several of my colleagues emailed “Here we go again…” Many of us are left wondering, how many of these purposefully driven “systematic reviews” have to be published with results splashed all over the world, before women’s psychological health will finally take precedence over political, economic, and ideological agendas? This report constitutes no less than a crafty abuse of science and if the merits of this report are not seriously challenged, we will shamefully grow more distant from our ability to meet the needs of countless women. Until there is acknowledgement than scores of women suffer from their decision to undergo an abortion, we will remain in the dark ages relative to the development of treatment protocols, training of professionals, and our ability to compassionately assist women to achieve the understanding and closure they need to resume healthy lives.

==== Narrative Reviews Not Addressed====
1) Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Science 1990 6; 248(4951):41-4. Psychological responses after abortion.

2) Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Psychological factors in abortion. A review. Am Psychol. 1992;47(10):1194-204.

3) Adler NE, Ozer EJ, Tschann J. Abortion among adolescents. Am Psychol. 2003; 58(3):211-7.

4) Allanson S, Astbury JJ. Psychosom Obstet Gynaecol. 1995;16(3):123-36.The abortion decision: reasons and ambivalence.

5) Bhatia MS, Bohra N. The other side of abortion. Nurs J India. 1990; 81(2):66, 70.

6) Cameron S. Induced abortion and psychological sequelae. Best Practice & Research. Clinical Obstetrics & Gynaecology 2010; Vol. 24 (5), pp. 657-65.

7) Coleman PK, Reardon DC, Strahan T, Cougle R. The psychology of abortion: A review and suggestions for future research. Psychology & Health 2005; 20(2), p237-271.

8) Dagg PK. The psychological sequelae of therapeutic abortion--denied and completed. Am J Psychiatry. 1991;148(5):578-85.

9) Harris AA. Supportive counseling before and after elective pregnancy termination. Midwifery Women’s Health. 2004; 49(2):105-12.

10) Lie ML, Robson SC, May CR. Experiences of abortion: a narrative review of qualitative studies. BMC Health Serv Res. 2008; 8:150.

11) Lipp A. Termination of pregnancy: a review of psychological effects on women. Nursing Times 2009; 105 (1), pp. 26-9.

12) Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C. Abortion and mental health: Evaluating the evidence. Am Psychol. 2009; 64(9):863-90.

13) Major B, Cozzarelli C. Psychosocial Predictors of Adjustment to Abortion. Journal of Social Issues 1992; 48 (3), p121-142.

14) Robinson GE, Stotland NL, Russo NF, Lang JA, Occhiogrosso M. Is there an "abortion trauma syndrome"? Critiquing the evidence. Harvard Review of Psychiatry 2009; 17 (4), pp. 268-90.

15) Rosenfeld JA. Emotional responses to therapeutic abortion. Am Fam Physician. 1992; 45(1):137-40.

16) Speckland A., Rue V. Complicated Mourning: Dynamics of Impacted Pre and Post-Abortion Grief," Pre and Perinatal Psychology Journal 1993; 8 (1):5-32.

17) Stotland NL. Psychosocial aspects of induced abortion. Clin Obstet Gynecol. 1997 Sep;40(3):673-86.

18) Turell SC, Armsworth MW, Gaa JP. Emotional response to abortion: a critical review of the literature. Women Ther. 1990;9(4):49-68.

19) Zolese G, Blacker CV. The psychological complications of therapeutic abortion. Br J Psychiatry. 1992; 160:742-9.

====Studies of Statistically Validated Risk Factors Not Addressed====

1) Allanson S. Abortion decision and ambivalence: Insights via an abortion decision balance sheet. Clinical Psychologist 2007; 11 (2), p50-60.

2) Brown D, Elkins TE, Larson DB. Prolonged grieving after abortion: a descriptive study. J Clin Ethics 1993; 4(2):118-23.

3) Fielding SL, Schaff EA. Social context and the experience of a sample of U.S. women taking RU-486 (mifepristone) for early abortion. Qualitative Health Research 2004; 14 (5), pp. 612-27.

4) Hill RP, Patterson MJ, Maloy K. Women and abortion: a phenomenological analysis. Adv Consum Res. 1994; 21:13-4.

5) Kero A, Lalos A. Ambivalence--a logical response to legal abortion: a prospective study among women and men. J Psychosom Obstet Gynaecol. 2000; 21(2):81-91.

6) Linares LO, Leadbeater BJ, Jaffe L, Kato PM, Diaz A. Predictors of repeat pregnancy outcome among black and Puerto Rican adolescent mothers. J Dev Behav Pediatr. 1992;13(2):89-94.

7) Mufel N, Speckhard AC, Sivuha S. Predictors of posttraumatic stress disorder following abortion in a former Soviet Union country. Journal of Prenatal & Perinatal Psychology & Health 2002; 17(1), pp. 41-61.

8) Osler M, David HP, Morgall JM. Multiple induced abortions: Danish experience. Patient Educ Couns. 1997; 31(1):83-9.

9) Østbye T, Wenghofer EF, Woodward CA, Gold G, Craighead J. Health services utilization after induced abortions in Ontario: a comparison between community clinics and hospitals. American Journal of Medical Quality 2001; 16 (3), pp. 99-106.

10) Prommanart N, Phatharayuttawat S, Boriboonhirunsarn D, Sunsaneevithayakul P. J Maternal grief after abortion and related factors. Med Assoc Thai. 2004;87(11):1275-80.

11) Remennick L, Segal R. Socio-cultural context and women's experiences of abortion: Israeli women and Russian immigrants compared. Culture, Health & Sexuality 2001; 3(1), p49-66.

12) Slade P, Heke S, Fletcher J, Stewart P. Termination of pregnancy: patients' perceptions of care. J Fam Plann Reprod Health Care. 2001;27(2):72-7.

13) Tamburrino MB, Franco KN, Campbell NB, Pentz JE, Evans CL, Jurs SG. Postabortion dysphoria and religion. South Med J. 1990;83(7):736-8.

14) Thomas T, Tori CD. Sequelae of abortion and relinquishment of child custody among women with major psychiatric disorders. Psychol Rep. 1999; 84(3 Pt 1):773-90.

15) Törnbom M, Ingelhammar E, Lilja H, Möller A, Svanberg Repeat abortion: a comparative study. B.J Psychosom Obstet Gynaecol. 1996; 17(4):208-14.

16) van Emmerik AA, Kamphuis JH, Emmelkamp PM. Clin Psychol Psychother. 2008; 15(6):378-85.

17) Vukelić J, Kapamadzija A, Kondić B. Investigation of risk factors for acute stress reaction following induced abortion. ed Pregl. 2010; 63(5-6):399-403.

18) Wiebe ER; Adams LC. Women's experience of viewing the products of conception after an abortion. Contraception 2009; 80 (6), pp. 575-7.

19) Wiebe ER, Trouton KJ, Fielding SL, Grant H, Henderson A. Anxieties and attitudes towards abortion in women presenting for medical and surgical abortions. J Obstet Gynaecol Can. 2004;26(10):881-5.

20) Wells N. Pain and distress during abortion Health Care Women Int. 1991; 12(3):293-302.

== Comments of Anne Speckhard, Ph.D. ==

In regard to NCCMH review, I would suggest that it completely fails to address the reality that each woman's unique and individual view of her abortion experience is the most important defining issue for what constitutes a trauma.

That means that if she perceives her pregnancy as involving a human life (i.e. in our research we keyed this as recognition of human life) and then furthermore attaches to that life (i.e. feels any type of attachment, refers to the embryo/fetus as "my baby", or herself as a mother, etc.) she has perceived/defined the abortion event in a manner that will make it likely to experience it as a criterion A stressor event capable of causing posttraumatic stress disorder.

We found these two variables - the woman's own recognition of life and attachment to be the highest predictors in our research of PTSD responses after an abortion.

On the other hand if she sees the abortion as nothing much for her, i.e. it is not experienced as a traumatic and she will not experience PTSD symptoms unless she is traumatized by other things which can also be additive in the first case (coercion to get the abortion, a very painful invasive experience, an abusive doctor or clinic protocol, even protestors outside the clinic, etc.)

From an outsiders perspective the first case (recognizing fetal life and attaching to it) can be seen as sick (the normal pro-choice view - that she is sick to define her pregnancy abortion experience so personally and relationally because after all it is not a human child) and the second case can also be seen as sick - morally detached, insensitive, or unhealthy because for her the abortion doesn't carry enough weight to be likely to cause her trauma (the view being expounded here from a pro-life perspective). Both are outsiders perspectives and can be argued strongly depending on the view of pregnancy that person holds. But what is operational for the woman and whether or not she suffers PTSD is not the view of the outsider but the woman's own view. She will experience trauma based on her own perceptions.

Likewise her own unique view can change overtime. She may be callous to her abortion at the time she has it but years later encounter a sonogram that deconstructs her first view that it's not a life worth worrying about and become deeply traumatized that what she aborted was (again in her view) deeply human and something she may at this late stage wish to make a relationship to (i.e. creating psychological presence of an aborted fetal child that she now grieves over). Again this is from her perspective and that is the only thing that matters as far as getting PTSD - in this case a delayed reaction.

Of course how others define things can also cause mental health problems. A woman who is traumatized but is told by her society to buck up as it was nothing has to go underground with her feelings and a woman who is condemned for feeling nothing can also find that difficult to deal with.

In either case though I want to emphasize for this discussion we really have to take into account the woman's own perspective.

I realize that says nothing about the critique of the study under question but I did want to comment that how we define "sick" is also often defined by our own views of the experience. Whereas actually becoming "sick" from an abortion experience may have much more to do with the individualistically defined view of the woman herself.

Anne Speckhard, Ph.D.

Adjunct Associate Professor of Psychiatry

Georgetown University Medical School
[http://annespeckhard.com annespeckhard.com]

==Comments of Philip Ney, M.D.==
This report confirms what has been known for at least 3 decades, abortion not only does not prevent mental illness, it aggravates every known mental illness. Abortion is contraindicated as treatment for mental ills. It must be made very clear to politicians etc, that this study only confirms the fact that abortion is not good treatment.

Without defining "wantedness" these authors write a conclusion that unwantedness is the real problem. Isn't it convenient? Now they can make wantedness mean anything that suits their purpose. My own research team has studied wantedness and found, (no surprise) that wantedness fluctuates hourly, depending on hormones, mood, partner, finances etc but following the first trimester when nausea and vomiting, partners hesitance dominate, wantedness grows throughout the pregnancy. Moreover wanting a child has very little relationship to wanting to not be pregnant. "Intendedness" is no better. So basing the results of such high blown research on such an ephemeral criteria is about as bad research as there can be.

No country in the world recognizes abortion as a woman's unfettered right. There is in no country I know where a woman can at any time in her pregnancy, for any reason, walk up to a physician and state "It's my right. I demand you abort my pregnancy right now." Why? Because it is illegal to practice bad medicine. And since the evidence from all studies and surveys shows there is no benefit, only various degrees of harm, abortion is bad medicine. This is what we must emphasize. On the other hand, abortion is legal everywhere if it is necessary to treat a disease like eclampsia, sometimes.

Statistics can blind as easily as illluminate. We must not forget that statistics are to find canaries (rare events) as they used to say in medical school or to determine if some small measure is significant ( important enough to be bothered with). If when you give some new medication to your patients and 1/2 die, statistics aren't needed. We are dealing with events that make huge differences in people. It is to our embarrassment we have such difficulty quantifying these changes. I believe in that regard, smaller samples using the subject as there own control and using Visual Analogue scales which can represent fine slices of the continuum which are almost always there, is the way forward. Besides its less expensive.

'''NOTE:''' A more complete review of the NCCMH review by Dr. Ney is "[http://www.webmedcentral.com/article_view/4429 A Common Sense Scientific Critique of the NCCMH and Royal College of Psychiatry Review]" WebMedCentral. REPRODUCTION 2013;4(10):WMC004429

==Comments of Martha Shuping, M.D.==
It has been shown in a number of studies that prior mental health, before the abortion, is a risk factor for more problems after the abortion. I don’t think anyone on either side of the issue disputes that. It is well established.

Therefore, it certainly accurate for the NCCMH report to note this fact. The problem is they treat it as being practically the only relevant finding and draw unsupported and misleading conclusions from it.

If you have a preconceived bias to defend abortion as a basic human right, it would be convenient to also believe that if people were having problems after abortion, it was purely and simply due to the fact that they were troubled individuals to start with.

Interestingly, in some countries, abortion has been legal specifically in cases in which the woman is believed to be suicidal. I know women in England who tell me they were coached by counselors to tell the doctor, “I will commit suicide if I have to have this baby,” and they were not really suicidal but they said it to get the abortion. So abortion is permitted or advocated in some cases because a woman has mental health problems though the data indicate that these are the women who are more vulnerable to problems after abortion. It would make sense to spend some time doing more counseling at the front end to explore whether this woman truly wants the abortion, whether she understands her risks and so on, rather than actually advocating for the abortion, since this is a vulnerable population, and their mental health actually may be worsened by the abortion rather than improved by the abortion. So it is paradoxical in a way that these are the very women who in countries are given access to abortion when others are not or where it is viewed in some way as a solution, when of course abortion has never been demonstrated as evidence based treatment for suicidal ideation or for any psychiatric illness.

From my own experience with large numbers of women in abortion recovery programs, I believe that many women are having mental health problems after abortion who did not have problems before, and also that those who did have problems before now have problems that are qualitatively and quantitatively more severe after the abortion.

The women themselves can often pinpoint the start of their problems to the time of the abortion, and their symptoms often specifically relate to the abortion such as nightmares about dead babies or dreams about crying babies, having panic attacks when they are around things or places that remind them of the abortion, and so on. But you do not get at this type of information in the larger studies with huge databases; you only get the general before and after perhaps from insurance claims or health records as far as past diagnoses and dates of treatment.

When one is doing record based studies, there is important information to be gained, but in doing qualitative studies, or doing studies that could be designed to interview women very specifically about their experience, one might discover there are specific aspects about the symptoms that tend to indicate the post-abortion symptoms are related to the abortion, and not related to prior mental health issues. Someone could have had transient depression during high school or college, but then develop PTSD after the abortion. If they are having nightmares about dead babies after the abortion but not before, and then finding they need to consume alcohol to sleep at night, these would seem to be new problems.

From my experience, my opinion is that there are many women with new onset of mental health problems after abortion, and many with different and more severe problems after the abortion. I think this has not been fully captured or demonstrated by current studies. But certainly there are some excellent studies that do control for prior mental health and show that past abortion is in itself a risk factor for mental health problems. These studies support what I have seen in clinical experience. It is not “only” the past mental health that is the complete and total cause of all abortion related problems, because some studies controlled for prior mental health and still show abortion as a risk factor for mental health problems after abortion.

-------

A major weakness of this review is the oversimplified way in which they collapse mental health problems into being all the same. If there are “problems” after birth and “problems” after abortion, the reviewers treat these as equal without looking at the nature of the problems and how long these problems last.

This occurs, for example, in a study looking at Medicaid claims to see if there was any mental health treatment in the year prior to the abortion, and then perhaps look at claims after. In these exploratory studies, they are just looking for the “yes” that there was past mental health treatment, and not necessarily the number of times treatment was received or the seriousness of the disorder or how long it lasted. Typically researchers would only be considering whether or not there was a diagnosis or treatment. And it would tend to serve the viewpoint of those who favor abortion if it was all treated equally.

Similarly, the reviewers appear to asserting that while, yes, there can be problems after abortion, there can also be problems after childbirth, and so it is all equal.

But they are not equal. Consider, for example, a woman I know who was in her 80’s who was still having grief and guilt concerning a past abortion from about fifty years earlier, who contacted me for help with an abortion related issue. Also, on abortion recovery weekends, I have taken women in their 60’s who are now grandmothers who still have grief and guilt concerning past abortions.

So, yes, it is true that women can have post-partum depression after having a baby, but my experience with post-partum depression is that it resolves on medication within a few weeks. I have never seen women in their 60’s or their 80’s with post-partum depression. In contrast, I have experience with women in their 60’s and even 80’s who are still having symptoms they specifically attribute to their abortion, which seem to be abortion related.

So, no, the severity or the duration of the post-abortion problems are not being considered.

Keep in mind that many women do meet criteria for posttraumatic stress disorder after abortion, for example, about 18% in a 2007 study by Suliman in South Africa. The authors considered this “high.” They were concerned that almost one in five women in their study had PTSD after their abortion.

There are studies showing that PTSD is a very long lasting disorder that can be very disabling, so it is a more serious psychiatric illness.

Studies that only look at mental health after abortion vs. mental health after childbirth are perhaps unintentionally misleading if they consider only whether the person was diagnosed or whether the person had treatment in a particular time frame in a “yes or no” fashion. It is important to know the nature, severity and duration of the disorders in question and that would be more difficult information to obtain. You can find out from medical records or insurance claims whether or not a person had treatment in a particular period of time after the end of the pregnancy, yes or no. But to follow women to see who is still experiencing symptoms in their 60’s or 80’s would be a very long study indeed, and it is difficult to study women for decades.

Similarly, if we are considering mental health before the abortion vs. mental health after the abortion, it would also be good to consider not simply whether or not treatment occurred, but what was the severity and duration of the illness, and again this can be difficult to determine. For some women, their symptoms may emerge later, and may be severe and long-lasting, sometimes persisting for decades.

These questions are not being carefully considered, but they would be difficult studies to do.

But, there are clearly are studies that use control groups, that do control fro prior mental health, and that show abortion itself is a risk factor for mental health problems in women after abortion. It by no means only women with prior mental health problems who are having the problems after abortion. But when they do make the comparison and treat the problems before and after as equivalent, they have not truly demonstrated whether the two conditions are in fact equivalent.

==Other Notes==

===Rating Scale Misleading===
The rating scale for studies was strongly criticized by a number of reviewers during the first draft for it's failure to rank studies for women refusing to participate or dropping out of the study before completion. The review team acknowledged this problem but provided only a fake fix.

The "fix" was adding a new category, "Representativeness" to table 3, p28. As described on page 29, the criteria for this scale were so watered down that all the studies with high drop out rates were still allowed to score high. Indeed, a study could have over a 50% refusal or drop out rate and still be rated as "+" as long as the authors provided even a mediocre statistical comparison of the participants and non-participants....even if the comparison showed significant differences!

The rating scale appears to have also been designed, or at least interpreted, to specifically justify rating the Finland record based studies on suicide as "very poor" -- even though they revealed a 650% increased risk of suicide. They also ignored the Morgan study, published in BMJ with data.

===Incorrectly classified studies===
*Three prospective cohort studies using record linkage (Coleman2003A, Reardon2002A, Reardon2003A) were improperly listed as "retrospective." Oddly, Munk-Olsen2011 which used the same methodology was correctly listed. In the discussion section (p59) the authors also wrongly describe these three studies as based on a sample of women whose first pregnancies ended in abortion. In fact, the sample included all women who had any pregnancy outcome within a specific period, and as a cross sectional snapshot, it did not have information on whether these were first, second, third or higher order pregnancies.

*Findings from the above studies were not completely reported in Table 9, including for example, the rates reported for bipolar disorder in Reardon2002A (OR 3.0, 95% CI 1.5-6.0). They were also rated as "poor" while Munk-Olsen2011 was rated good, even though there was no significant difference in study design. Indeed, Munk-Olsen2011 is arguably much poorer given mixing of women into both groups, shorter followup (only one year rather than four years), the failure to control for mental health treatment rates prior to pregnancy for delivering women, and other roblems.

*A number of studies are described as prospective (the Broen, Major, Rizzardo and Suliman) when they would be better described as case series studies, since they have no data prior to the abortion and simply follow the cases for a period of time.

*Reardon2006 was excluded for the specious reason "sleep disorders beyond scope of the review"--but that was an arbitrary decision, since clearly sleep disorders can be due to mental health problems, indeed, they are strongly linked to PTSD.

===Misc===
*They incorrectly excluded Soderberg (p171) stating that the sample included distressed women. In fact, the sample included all women who had abortions.

==Official Comments and Responses==

The most complete listing of shortcomings of this review, including explanations for why key issues were not covered in the report, are found in the NCCMH's companion document to the report "[http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf Comments and Responses], see especially pages 95-103.]"

NCCMH Review

2025-10-21T22:38:20Z

Barb: /* History of NCCMH Review */

Induced Abortion and Mental Health, NCCMH Published December 2011

::'''citation:''' National Collaborating Centre for Mental Health. Induced abortion and mental health: a systematic review of the mental health outcomes of induced abortion, including their prevalence and associated factors. London (UK): Academy of Medical Royal Colleges; 2011.

The full report can be downloaded from the [https://www.aomrc.org.uk/wp-content/uploads/2016/05/Induced_Abortion_Mental_Health_1211.pdf AoMRC reports and guidance page.] A record of [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf all comments received and the developers’ responses] can be [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf downloaded here.]

The [https://www.scribd.com/embeds/327609067/content?start_page=1&view_mode=scroll&access_key=key-r3mNJH1gDsAHIiLuduFC&show_recommendations=true first draft] and [https://www.scribd.com/document/327608591/Induced-Abortion-and-Mental-Health-Systematic-Review-Consultation-6-April-to-29-June-2011-Comments-and-Responses the comments and responses on the first draft] can also be downloaded from Scribd.

===History of NCCMH Review===

In 2006, the U.K.'s House of Commons Science and Technology Committee undertook an inquiry into the health effects of abortion on women which included a request (paragraph 139) for the RCP to update their 1994 statement on abortion in light of more recent studies.<ref>House of Commons Science and Technology Committee (2006). ''[https://publications.parliament.uk/pa/cm200607/cmselect/cmsctech/1045/1045i.pdf Scientific Developments Relating to the Abortion Act 1967. Volume 1]''</ref> In 2008, the RCP did update their position statement to recommend that women should be screened for risk factors that may be associated with subsequent development of mental health problems and should be counselled about the possible mental health risks of abortion.<ref>Templeton, Sarah-Kate (2008-03-16). "[https://www.thetimes.com/uk/healthcare/article/royal-college-warns-abortions-can-lead-to-mental-illness-p8glm5s5k8h Royal college warns abortions can lead to mental illness]". ''The Sunday Times''. ISSN 0956-1382.</ref> <ref name=":0">Fergusson, David M. (September 2008). "[https://www.researchgate.net/publication/274356401_Abortion_and_mental_health Abortion and mental health". ''Psychiatric Bulletin''.] '''32''' (9): 321–324. doi:10.1192/pb.bp.108.021022. This Appendix to this paper includes the complete 14th March, 2008 RCP revised Position Statement on Women's Mental Health in Relation to Induced Abortion.</ref> The revised RCP position statement included a recommendation for a systematic review of abortion and mental health with special consideration of "whether there is evidence for psychiatric indications for abortion."<ref name=":0" /> Following the publication of a number of studies between 2002 and 2008 revealing that women who have abortions experience common disorders such as anxiety or depression at a rate about three times higher than other women, Royal College of Psychiatrists issued a [http://www.thesundaytimes.co.uk/sto/style/living/Health/article82769.ece position paper on abortion] ((Royal College of Psychiatrists. Position statement on women’s mental health in relation to induced abortion. 14 March 2008. Royal College of Psychiatrists, 2008) acknowledging that some women may have adverse reactions to abortion and further recommended:
:Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.

A commentary upon the revised position statement and the history of this statement is provided in an [http://pb.rcpsych.org/content/32/9/321.full editorial by David Fergusson, published in ''The Psychiatrist''].

This statement also called for a systematic review of the evidence, which led to the commissioning of Britain's National Collaborating Centre for Mental Health (NCCMH)to undertake such a review. The NCCMH subsequently undertook a review which was limited to addressing just three questions related to abortion and mental health.

====Questions Addressed in the Review====
The reviewers chose to limit their report to three questions: (1) How prevalent are mental health problems in women who have an induced abortion? 2. What factors are associated with poor mental health outcomes following an induced abortion? 3. Are mental health problems more common in women who have an induced abortion when compared with women who deliver an unwanted pregnancy?

Note, the first question, dealing with prevalence, is easily answered by record linkage studies from which the mental health treatment rates of women having abortions can be tabulated. The question does not ask how much of the observed mental health problems are attributable to abortion, but rather how common are mental health problems among women with a history of abortion. The results unequivocally show that rates of mental health problems among women with a history of abortion are higher than rates for other groups of women, including the general population of women and women giving birth who do not have a history of abortion. Yet this is not fully discussed in the conclusions, which instead shift the discussion to evidence that women who have mental health problems after an abortion may also have higher rates of mental health problems before having abortions. Which actually raises a new issue which the reviewers refused to address, namely, is there evidence that women with pre-existing mental health problems get better or worse following an abortion.

Regarding the second question, the reviewers actually failed to systematically investigate all risk factors that predict poor mental health outcomes.

Regarding the third question, the reviewers acknowledged that the definition of what constitutes "an unwanted pregnancy" is imprecise and also that they were declining to investigate the alternative of whether there are any mental health benefits of abortion, which is actually the pertinent issue under UK law. (see [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf pages 39, 43, 91 ]

=====Studies and Data Excluded in Investigating these Three Questions=====

The reviewers chose to exclude:
# Any studies related to mood disorders, including reactions such as guilt, shame and regret. Although the - although these were considered important - and also assessments of mental state within 90 days of an abortion. This was because the research was not about “transient reactions to a stressful event”.occurring within the first 90 days of an abortion
# Any studies of qualitative data (qualitative interviews, case studies, self-reports etc) (p135 We agree that qualitative evidence is important in this area.Unfortunately it was beyond the scope and resources of the review to consider qualitative evidence")
# Any data relative to negative effects associated with aborting a wanted pregnancy for "therapeutic" reasons.

====Questions Excluded from Investigation====

The report deliberately excluded any investigation of key questions
# In what cases may abortion contribute to the mental health of women
# Whether abortion makes pre-existing mental health problems more severe or difficult to treat

Research questions excluded from the review, and the reason for excluding them, are described in the companion document "[http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf Comments and Responses], see especially pages 95-103.]"

In their request for public comments, the NCCMH panel was asked to investigate, or at least comment on, the following questions. The panel declined to do so, stating these questions were "beyond the scope and remit of the present review, which was to focus on the three research questions posed." Notably, the panel itself posed the three questions it chose to investigate, and in doing so prevented their review from being a comprehensive examination of abortion and mental health issues. (Indeed, [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf the phrase "beyond the scope"] was used 45 times to evade questions raised by commentators.)

----

Questions ignored:

*(p35)

This draft makes no attempt to answer the issues raised by the
Abortion Act and its amendments. Indeed the authors make
assumptions not contained in the Act that women have an
unfettered right to choose an abortion. The act is clear that
abortion is a medical matter and can only be performed if and
when it is necessary to improve or preserve a woman’s health.
The real question to be addressed is, what is the evidence of
benefit., not what is the data for harm. This was studiously
avoided by the authors of this draft. The Fellows of Psychiatry
erred in not making their mandate clear and relevant.
If a woman has a right to have an abortion when she so elects,
then abortion is not a medical matter and should be performed by
technicians If a woman has a right to good medical treatment that
may include having an abortion on her physician’s
recommendation, then this review is valid only if it addresses
these questions:

a) '''Indication''' Is there a pathological process in pregnant
women in general and this patient in particular that warrants
having an abortion? (It must be recognized that pregnancy is not
a disease.)

b) '''Benefit''' What is the evidence that an abortion will benefit
women with this condition (pregnancy) and this patient in
particular?

c) '''Harms.''' What are the adverse effects from an abortion and if
there are some, do they outweigh the anticipated benefit?

d) '''Other options''' Have all less invasive, more reversible
treatments been offered, tried and failed before an abortion is
recommended?

e) '''In good faith''' Is the physician who is providing this
procedure doing so in good faith? Has the abortionist carefully
studied to relevant literature in order to practice evidence based
medicine, honed his/her skills and performed a careful followed
up on his/her ex-abortion patients to know personally that he/she
will be providing good treatment?

f) '''Adoption etc.''' Has the physician facilitated all options to
abortion of a truly unwanted child, i.e., adoption, fostering etc.

g) '''Informed consent.''' Has the physician made a clear
recommendation to the patient with evidence to support that
recommendation, options available, potential benefits and
hazards, and shown the ambivalent woman the ultrasound of her
fetus? Has he/she been given fully informed consent which
requires the patient have full opportunity to ask questions, get a
2nd opinion and make a decision with enough time to do so and
without pressure from mate, family, IPPF, physician etc.

It must be remembered that until any treatment is well proven, it
must be considered as experimental and constrained as such.

Moreover the burden of proof rests with the performing
physician, his/her supporters and those who fund this activity to
show abortion is necessary, beneficial etc. not on those who
question abortion is a valid treatment to show it is harmful.

----
*(p43-44)

The Rawlinson Report and the RCOP response
(http://extras.timesonline.co.uk/rowlinsonreport.pdf) highlights
important issues that should be much more carefully addressed
in this new report.

The Rawlinson report gave a summary of the RCOP's testimony
and response to questions asked stating "there are no psychiatric
indications for abortion." As per Ney’s elaboration, this concern
that there are “no [psychiatric] indications for abortion” refers to
the lack of medical indications that the abortion will produce
positive mental health effects.

Properly understood, this statement was an attempt to summarize the RCOP’s failure to report to the committee any
statistically validated psychiatric criteria which can be used to
identifying when an individual woman is likely to either (a) derive
psychiatric benefits from an abortion, or (b) be successfully
protected from psychological harm that would otherwise occur if
the pregnancy continued.

There is still a lack of any such criteria.

It should be carefully noted that the RCOP’s letter of response
did not refute the Rawlinson Reports finding that there are no
indications for abortion. If they had any indications, they would
have stated so in their response. For example, they might have
noted that abortion is medically indicated for bi-polar women
faced with an unwanted pregnancy, if there was any statistically
validated evidence to support that claim, but there was none.

RCOG letter of response shifted attention away the actual claim
of fact regarding lack of known indications for abortion to a
distinctly separate issue, namely that "the risks to psychological
health from the termination of pregnancy in the first trimester are
much less than the risks associated with proceeding with a
pregnancy which is clearly harming the mother's mental health."
(emphasis added.)

Notably, this statement has a huge qualifying clause which is
exceptionally vague. The letter fails to give any means of
determining when and how often a pregnancy is “clearly harming
a mother's mental health.”

It actually implies that In cases where the pregnancy is not
clearly harming a mother’s mental health, abortion may involve
equal or greater risks. So the standard of identifying when a
pregnancy is clearly harming mental health should be examined
to identify the indicators for abortion which were requested by the
Rawlinson committee.

Moreover, there is no research that has examined the assertion
made by this qualifier. Specifically, there are no studies
comparing psychiatric outcomes for women whose
pregnancies were clearly harming their mental health who
had abortions versus those who did not
.
In this light, it seems clear that the statement on page 61 of the
report, contested by the RCOG’s letter of response, merely
conflates the finding that there are no psychiatric indications for
abortion into the statement that there is no psychiatric
justification for abortion.

While there is plenty of room to debate whether “justification” can
rightly be substituted for “indications,” two key question remain
unanswered: (1) What evidence demonstrates when, if ever,
abortion is likely to improve a woman’s mental health? And (2) what
does the best evidence show regarding when, if ever, abortion
protects future mental health, i.e., by reducing psychological
stresses without creating new psychological stresses?

These are questions which should be clearly articulated in this
report, even if the only answer that can be given is that the
research done to date has failed to address these important
questions.

----
*p46

First, good medical care involves at least four components:

(a) accurate diagnosis of the problem,

(b) identification of treatments most likely to be efficacious,

(c) evaluation of treatment risks, and

(d) a risk / benefit analysis regarding treatment alternatives.

Unfortunately, in the context of the abortion controversy, these
distinct steps are often confused or conflated. An unspoken, but
medically inappropriate paradigm appears to exist with regard to
abortion, namely:

(a) if the woman requests the abortion, and

(b) there is no clear risk that she will die on the operating table,
and

(c) critics abortion have not proven, beyond all reasonable
doubt, that abortion is and of itself the sole cause of all the risks
statistically associated with abortion, then

(d) physicians should feel free to recommend or perform
abortions on request.

This medical decision paradigm is simply not justified by the
principles of evidence based medicine and medical ethics which
apply to any other procedure.

'''Therefore, to shed light on the core issues regarding
abortion decision making, especially in the context of UK
law, this literature review should identify and grade the
medical evidence relative to two very specific questions:'''

First: “What medical conditions and/or psychosocial indicators
predict when the risks of continuing a pregnancy are greater than
if the pregnancy were terminated?” These are the indications for
induced abortion.

Secondly, what are the statistically validated risk factors which
can help to identify the subsets of women who appear to be at
greater risk of negative effects associated with a history of one or
more abortions? These risk factors are the medical
contraindications for induced abortion.

----
*(p63)

The glaring gap in this draft is the lack any consideration of the
effect of abortion on men and children. It makes this report
invalid, if for no other reason than because what effects spouse
and children will have a pronounced effect on the woman’s
mental health.

----
*(p65)

1/2
Since many post-aborted women use repression as a coping
mechanism, there may be a long period of denial before a
woman seeks psychiatric care. These repressed feelings may
cause psychosomatic illnesses and psychiatric or behavioural
disorders in other areas of her life.

As a result, some counsellors report that unacknowledged post-abortion distress is the causative factor in many of their female
patients, even though their patients have come to them seeking
therapy for seemingly unrelated problems.
Kent, et al., “Bereavement in Post-Abortive Women: A Clinical
Report”, World Journal of Psychosynthesis (Autumn-Winter
1981), volume 13, no’s 3-4

Note the area of Sexual Dysfunction – Thirty to fifty per cent of
aborted women report experiencing sexual difficulties, of both
short and long duration, beginning immediately after their
abortions. These problems may include one or more of the
following: loss of pleasure derived from sexual intercourse,
increased pain, an aversion to sexual activity, and/or males in
general, or the development of a promiscuous lifestyle.
Speckhard, Psych-social Stress Following Abortion, Sheed &
Ward, Kansas City, MO 1987; and Belsey et al., “Predictive
Factors in Emotional Response to Abortion: King’s Termination
Study – IV,” Soc. Sci. & Med., 11:71-82 (1977)

:Response of reviewers: Although these are important points, they are beyond the scope of the present review.

----

*(p95)

1. "Question 3 should be reworded to properly reflect UK law, as follows: 3. Are mental health problems less common in women who have an induced abortion, when compared with women who deliver an unplanned or unwanted pregnancy? [This was recommended since UK law allows induced abortion only when the health risks of abortion are less than those of allowing the pregnancy to continue.]"

----

*(p95) 1. How prevalent are mental health problems in women who do not terminate an unplanned or unwanted pregnancy compared to the general population and to women who deliver a wanted pregnancy?

2. What factors are associated with improved mental health following abortion compared to similar women who carry an unplanned or unwanted pregnancy to term?

3. What factors are associated with a lower decline in mental health following abortion when compared to women who do not terminate an unplanned or unwanted pregnancy?

4. Among women who do experience negative reactions which they attribute to their abortions, what reactions are reported and what treatments are effective?

5. Is presenting for an abortion, or a history of abortion, a meaningful diagnostic marker for higher rates of mental illness and related problems?

6. Does abortion ever cause or exacerbate mental health problems in women, even in rare cases? (p95)

----
*

=== Some Conclusions ===
*The most reliable predictor of post-abortion mental health problems is having a history of mental health problems prior to the abortion.
*A range of other factors produced more mixed results, although there is some suggestion that life events, pressure from a partner to have an abortion, and negative attitudes towards abortions in general and towards a woman’s personal experience of the abortion, may have a negative impact on mental health.
*Women who show a negative emotional reaction immediately following an abortion are likely to have a poorer mental health outcome.
*This section of the review aimed to assess factors associated with mental health problems following an abortion. Identifying these factors would enable healthcare professionals to monitor and provide greater support for women identified as potentially ‘at risk’.

=== From News Releases ===

While acknowledging that women with a history of abortion have higher rates of mental illness than the general population, the director of NCCMH of Tim Kendall, said, “It could be that these women have a mental health problem before the pregnancy. On the other hand, it could be the unwanted pregnancy that's causing the problem. Or both explanations could be true. We can't be absolutely sure from the studies whether that's the case - but common sense would say it's quite likely to be both. The evidence shows though that whether these women have abortions - or go on to give birth - their risk of having mental health problems will not increase. They carry roughly equal risks. We believe this is the most comprehensive and detailed review of the mental health outcomes of abortion to date worldwide.”

Sophie Corlett, director of external relations at the mental health charity Mind, said of the report, “It is important that medical professionals are given the correct information to provide support for all women, but particularly those with a pre-existing history of mental health problems. This study makes it absolutely clear that this group is at the greatest risk of developing post-pregnancy mental health problems and should be given extra support in light of this.”

Dr Peter Saunders, chief executive of the Christian Medical Fellowship, said, “This new review shows that abortion does not improve mental health outcomes for women with unplanned pregnancies, despite 98% of the 200,000 abortions being carried out in this country each year on mental health grounds. This means that when doctors authorize abortions in order to protect a woman's mental health they are doing so on the basis of a false belief not supported by the medical evidence. In other words the vast majority of abortions in this country are technically illegal.”

== Critique by Priscilla Coleman ==

The Royal College of Psychiatrist’s recently conducted review of scientific literature published from 1990 to the present on abortion and mental health is hauntingly similar to the American Psychological Association Task Force Report released in 2008. The report by the RCP is, however, far more complex and on the surface it may appear to be more rigorous than the APA report. An enormous amount of time, energy, and expense has been funneled into a work product that was not undertaken in a scientifically responsible manner. In this critique, I provide evidence that should incite scientists and clinicians to reject the conclusions of the report and work together to provide an accurate and truly exhaustive review of the peer-reviewed research.

==== Unjustified Dismissal of Studies====
The RCP review incorporates four types of studies: 1) reviews of the literature; 2) empirical studies addressing the prevalence of post-abortion mental health problems; 3) empirical studies identifying risk factors for post-abortion mental health problems; and 4) empirical studies comparing mental health outcomes between women who choose abortion and delivery. In each category, there are studies that are ignored and large numbers of studies that are entirely dismissed for vague and/or inappropriate reasons. With regard to the first type of study, only 3 reports are considered (APA Task Force Report, 2008; Charles et al., 2008; Coleman, 2011). The authors of the RCP report “missed” 19 reviews of the literature (listed at the end of this document), published between 1990 and 2011. Moreover, no criteria were identified for selection of particular reviews to discuss and to provide context for the current report. In relation to the third type of study, only 27 studies are included in the RCP report. At the end of this document, citations to 20 relevant and unmentioned articles published in highly respected peer-reviewed journals are provided. They are not listed in Appendix 7 of the RCP report, which contains all included and excluded studies.

Among the scores of studies identified and excluded across study types 2 through 4 above, the most common reasons are the nebulously defined “no usable data” and “less than 90 days follow-up.” The latter resulted in elimination of 35 peer-reviewed studies in each of the prevalence, risk factor, and comparison study types. The RCP authors state that ''“Because the review aimed to assess mental health problems and substance use and not transient reactions to a stressful event, negative reactions and assessments of mental state confined to less than 90 days following the abortion were excluded from the review.”'' This is highly problematic for various reasons. First, elimination of studies that only measured women’s mental health up to 90 days, does not effectively remove cases of transient reactions. Just because the authors of these dozens of studies did not follow the women long-term, it does not mean that the women were not still suffering quite significantly beyond the early assessment. Moreover, when investigating the mental health implications of an event, it is logical to measure outcomes soon after the event has occurred as opposed to waiting months or years to gather data. As more time elapses between the stressor and the outcome(s), healing may naturally occur, there may be events that moderate the effects, and more confounding variables may be introduced. Finally, focusing only on mental health events that occur later in time effectively misses the serious and more acute episodes that are effectively treated soon after exposure.

Ironically, many of the studies removed from the analyses due to the abbreviated length of follow-up, had incorporated controls for prior psychological history and other study strengths. As a result, the samples of studies included in each section of the RCP review were not representative of the best available evidence and many of the eliminated effects coincidentally revealed adverse post-abortion consequences. In the category wherein the authors sought to derive prevalence estimates, only 34 studies were retained, including 27 without controls for previous mental health. In contrast, in the Coleman review, 14 out of the 22 studies had controls for psychological history.

====Factual Errors====
Perhaps even more disturbing than the elimination of large segments of the literature, are the factual inaccuracies that are present in the RCP report. As the author of the Coleman (2011) review cited in the report, I was alarmed to see the content in “Section 1.4.4: Summary of Key Findings from the APA, Charles, and Coleman Reviews.” The first 6 points are not reflective of the conclusions derived from the meta-analysis and the 7th and final point in this section wrongly states, with reference to the meta-analysis that “previous mental health problems were not controlled for within the review.” '''In fact, as noted above, the meta-analysis incorporated more studies into the final analyses with controls for prior psychological problems than the current review. Moreover, the conclusions derived from the meta-analysis were based on more studies with controls for prior psychological history than the Charles and the APA reviews as well.'''

I do not have the time or interest in identifying all errors present, but a few others jumped out at me. First, several studies are eliminated from the RCP report, because the outcome(s) assessed are lifetime estimates of mental health problems, deemed inappropriate by the RCP team. Nevertheless, the Coleman et al. (2009) and the Mota et al. (2010) articles, which relied upon lifetime estimates, are included in the prevalence section of the report. Inclusion reflects an inaccurate read of the two studies. I also noticed my affiliation is stated as the Department of Psychiatry at Bowling Green State University. I wish we had a medical school, it would make retrieval of articles much less expensive, but unfortunately we do not.

====Problematic “Quality Assessments”====
This review is being pitched as methodologically superior to all previously conducted reviews, largely because of the criteria employed to critique individual studies and to rate the overall quality of evidence. However, the quality scales employed to rate each individual study are not well-validated and require a significant level of subjective interpretation, opening the results to considerable bias. The main problems with the quality scale employed to rate the individual studies are as follows: 1) the categories used are missing key methodological features including initial consent to participate rates and retention of participants across the study period; 2) the relative importance assigned to the included criteria is arbitrary, as opposed to being based on consensus in the scientific community; 3) the specific requirements for assigning a “+” or “-” within the various categories are not provided; 4) the authors fail to explain (as their predecessors, Charles et al. 2008 did) how combinations of pluses and minuses in the distinct categories add up to an overall rating ranging from “Very Poor” to “Very Good.” Incredulously, the Gilchrist et al. (1995) study received a rating of “Good”, when very few controls for confounding 3rd variables were employed, meaning the comparison groups may very well have differed systematically with regard to income, relationship quality including exposure to domestic violence, social support, and other potentially critical factors. Further Gilchrist et al. reported retaining only 34.4% of the termination group and only 43.4% of the group that did not request a termination at the end of the study. No standardized measures for mental health diagnoses were employed and evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The GPs were volunteers and no attempt was made to control for selection bias. Despite these facts, the study received a mark of “+ thorough” for confounder control, a “+” for representativeness, and a “+” for validated tools. I can provide a similar rebuttal to many more of the individual study ratings provided by the RCP; and the reader should not trust these “quality” assessments.

Similarly, when it came to evaluating the quality of evidence associated with specific outcomes, such as anxiety, depression, suicide ideation, drug or alcohol abuse, psychiatric treatment, etc. with regard to the comparative studies, “Grade Working Group grades of evidence” were employed by the RCP. The anchors on this scale are vague and oftentimes only one reason is identified as the basis for a “Very Low” rating. For example, in the category of “Any Psychiatric Treatment,” which actually only included the Munk-Olsen et al. study (p.104), the basis for the “Very Low” (very uncertain about the estimate) rating was not controlling for pregnancy intention. As if this isn’t problematic enough, when the study is again evaluated (see pages 198 and 199), it is rated as “Good” in the comparison category. There are loose, poorly conceived rationales and inconsistencies like this throughout the report and the problem lies in the application of an inadequate quality assessment protocol for individual studies and for the body of evidence.

====Faulty Conclusions====
Each section in the RCP report includes conclusions that are based on a very small number of studies that are not properly rated for quality. The results should, therefore, not be trusted as a basis for professional training protocols or health care policy initiatives. To illustrate how incomplete and misleading the conclusions provided by the RCP are, I will use one example. I recently identified 119 studies published between 1972 and 2011 using the MEDLINE, PubMed, and PsycINFO data bases specifically related to risk-factors associated with post-abortion psychological health. Below is a list of the most common risk factors derived from the 119 peer-reviewed journal articles identified.

:a. Timing during adolescence or younger age (18 studies confirm: 2 studies do not)

:b. Religious, frequent church attendance, personal values conflict with abortion (18 studies confirm; 1 study does not)

:c. Decision ambivalence or difficulty, doubt once decision was made, or high degree of decisional distress (29 studies confirm; 3 studies do not)

:d. Desire for the pregnancy, psychological investment in the pregnancy, belief in the humanity of the fetus and/or attachment to fetus (21 studies confirm; 1 does not)

:e. Negative feelings and attitudes related to the abortion (16 confirm; 1 does not)

:f. Pressure or coercion to abort (10 studies confirm; 1 does not)

:g. Conflicted, unsupportive relationship with father of child (24 confirm; 6 do not)

:h. Conflicted, unsupportive relationships with others (28 confirm; 7 do not)

:i. Character traits indicative of emotional immaturity, emotional instability, or difficulties coping including low self-esteem, low self-efficacy, problems describing feelings, being withdrawn, avoidant coping, blaming oneself for difficulties etc. (42 studies confirm; 1 study does not)

:j. Pre-abortion mental health/psychiatric problems (35 studies confirm; 3 studies do not)

:k. Indicators of poor quality abortion care (feeling misinformed/inadequate counseling, negative perceptions of staff, etc.) (10 studies confirm)

The RCP conclusions relative to studies addressing risk factors for post-abortion mental health problems make no mention of most of the variables described above. They simply state (based on 27 studies) that ''“The most reliable predictor of post-abortion mental health problems is having a history of mental health problems prior to abortion” and “A range of other factors produced more mixed results, although there is some suggestion that life events, pressure from a partner to have an abortion, and negative attitudes towards abortion in general and towards a woman’s personal experience of the abortion, may have a negative impact on mental health.”''

I am one academic, without a lab full of graduate students and with a heavy teaching load (not a Department of Psychiatry), yet I was able to find all these studies. Why wasn’t this high powered research team able to do a better job? Simply glancing at titles and abstracts to determine which studies merit further attention will not yield the information needed and resulted in a short-sighted view of the available evidence.

Before I leave this section on poorly developed conclusions, I should note how curious it was to read one of the conclusions under the risk factor section: ''“Women who show a negative emotional reaction immediately following an abortion are likely to have a poorer mental health outcome.”'' How can this “conclusion” be derived if studies that only examined women in the first 3 months following abortion were eliminated? Moreover, if this is true, why would these studies have been eliminated in the first place? Shouldn’t the researchers be most concerned with those most likely to be adversely impacted?

====Appropriateness of Meta-Analysis====
Counter to the claims of the authors of this report, a quantitative review or meta-analysis can be performed when there is heterogeneity present in the effects one wishes to summarize. The random effects model is specifically designed to address heterogeneity. In addition, separate meta-analyses, based on distinct comparison groups and outcomes can be performed. There is no excuse not to perform extensive meta-analyses from the vast literature that has accumulated. Such an approach is much more reliable and the results derived yield more valid conclusions than a narrative review; data that can be translated more readily into practice.

====A Call for Change====
The bottom-line conclusion of the RCP review, based on only 4 studies, is that abortion is no riskier to women’s mental health than unintended pregnancy delivered. When this report was released a few days ago, several of my colleagues emailed “Here we go again…” Many of us are left wondering, how many of these purposefully driven “systematic reviews” have to be published with results splashed all over the world, before women’s psychological health will finally take precedence over political, economic, and ideological agendas? This report constitutes no less than a crafty abuse of science and if the merits of this report are not seriously challenged, we will shamefully grow more distant from our ability to meet the needs of countless women. Until there is acknowledgement than scores of women suffer from their decision to undergo an abortion, we will remain in the dark ages relative to the development of treatment protocols, training of professionals, and our ability to compassionately assist women to achieve the understanding and closure they need to resume healthy lives.

==== Narrative Reviews Not Addressed====
1) Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Science 1990 6; 248(4951):41-4. Psychological responses after abortion.

2) Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Psychological factors in abortion. A review. Am Psychol. 1992;47(10):1194-204.

3) Adler NE, Ozer EJ, Tschann J. Abortion among adolescents. Am Psychol. 2003; 58(3):211-7.

4) Allanson S, Astbury JJ. Psychosom Obstet Gynaecol. 1995;16(3):123-36.The abortion decision: reasons and ambivalence.

5) Bhatia MS, Bohra N. The other side of abortion. Nurs J India. 1990; 81(2):66, 70.

6) Cameron S. Induced abortion and psychological sequelae. Best Practice & Research. Clinical Obstetrics & Gynaecology 2010; Vol. 24 (5), pp. 657-65.

7) Coleman PK, Reardon DC, Strahan T, Cougle R. The psychology of abortion: A review and suggestions for future research. Psychology & Health 2005; 20(2), p237-271.

8) Dagg PK. The psychological sequelae of therapeutic abortion--denied and completed. Am J Psychiatry. 1991;148(5):578-85.

9) Harris AA. Supportive counseling before and after elective pregnancy termination. Midwifery Women’s Health. 2004; 49(2):105-12.

10) Lie ML, Robson SC, May CR. Experiences of abortion: a narrative review of qualitative studies. BMC Health Serv Res. 2008; 8:150.

11) Lipp A. Termination of pregnancy: a review of psychological effects on women. Nursing Times 2009; 105 (1), pp. 26-9.

12) Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C. Abortion and mental health: Evaluating the evidence. Am Psychol. 2009; 64(9):863-90.

13) Major B, Cozzarelli C. Psychosocial Predictors of Adjustment to Abortion. Journal of Social Issues 1992; 48 (3), p121-142.

14) Robinson GE, Stotland NL, Russo NF, Lang JA, Occhiogrosso M. Is there an "abortion trauma syndrome"? Critiquing the evidence. Harvard Review of Psychiatry 2009; 17 (4), pp. 268-90.

15) Rosenfeld JA. Emotional responses to therapeutic abortion. Am Fam Physician. 1992; 45(1):137-40.

16) Speckland A., Rue V. Complicated Mourning: Dynamics of Impacted Pre and Post-Abortion Grief," Pre and Perinatal Psychology Journal 1993; 8 (1):5-32.

17) Stotland NL. Psychosocial aspects of induced abortion. Clin Obstet Gynecol. 1997 Sep;40(3):673-86.

18) Turell SC, Armsworth MW, Gaa JP. Emotional response to abortion: a critical review of the literature. Women Ther. 1990;9(4):49-68.

19) Zolese G, Blacker CV. The psychological complications of therapeutic abortion. Br J Psychiatry. 1992; 160:742-9.

====Studies of Statistically Validated Risk Factors Not Addressed====

1) Allanson S. Abortion decision and ambivalence: Insights via an abortion decision balance sheet. Clinical Psychologist 2007; 11 (2), p50-60.

2) Brown D, Elkins TE, Larson DB. Prolonged grieving after abortion: a descriptive study. J Clin Ethics 1993; 4(2):118-23.

3) Fielding SL, Schaff EA. Social context and the experience of a sample of U.S. women taking RU-486 (mifepristone) for early abortion. Qualitative Health Research 2004; 14 (5), pp. 612-27.

4) Hill RP, Patterson MJ, Maloy K. Women and abortion: a phenomenological analysis. Adv Consum Res. 1994; 21:13-4.

5) Kero A, Lalos A. Ambivalence--a logical response to legal abortion: a prospective study among women and men. J Psychosom Obstet Gynaecol. 2000; 21(2):81-91.

6) Linares LO, Leadbeater BJ, Jaffe L, Kato PM, Diaz A. Predictors of repeat pregnancy outcome among black and Puerto Rican adolescent mothers. J Dev Behav Pediatr. 1992;13(2):89-94.

7) Mufel N, Speckhard AC, Sivuha S. Predictors of posttraumatic stress disorder following abortion in a former Soviet Union country. Journal of Prenatal & Perinatal Psychology & Health 2002; 17(1), pp. 41-61.

8) Osler M, David HP, Morgall JM. Multiple induced abortions: Danish experience. Patient Educ Couns. 1997; 31(1):83-9.

9) Østbye T, Wenghofer EF, Woodward CA, Gold G, Craighead J. Health services utilization after induced abortions in Ontario: a comparison between community clinics and hospitals. American Journal of Medical Quality 2001; 16 (3), pp. 99-106.

10) Prommanart N, Phatharayuttawat S, Boriboonhirunsarn D, Sunsaneevithayakul P. J Maternal grief after abortion and related factors. Med Assoc Thai. 2004;87(11):1275-80.

11) Remennick L, Segal R. Socio-cultural context and women's experiences of abortion: Israeli women and Russian immigrants compared. Culture, Health & Sexuality 2001; 3(1), p49-66.

12) Slade P, Heke S, Fletcher J, Stewart P. Termination of pregnancy: patients' perceptions of care. J Fam Plann Reprod Health Care. 2001;27(2):72-7.

13) Tamburrino MB, Franco KN, Campbell NB, Pentz JE, Evans CL, Jurs SG. Postabortion dysphoria and religion. South Med J. 1990;83(7):736-8.

14) Thomas T, Tori CD. Sequelae of abortion and relinquishment of child custody among women with major psychiatric disorders. Psychol Rep. 1999; 84(3 Pt 1):773-90.

15) Törnbom M, Ingelhammar E, Lilja H, Möller A, Svanberg Repeat abortion: a comparative study. B.J Psychosom Obstet Gynaecol. 1996; 17(4):208-14.

16) van Emmerik AA, Kamphuis JH, Emmelkamp PM. Clin Psychol Psychother. 2008; 15(6):378-85.

17) Vukelić J, Kapamadzija A, Kondić B. Investigation of risk factors for acute stress reaction following induced abortion. ed Pregl. 2010; 63(5-6):399-403.

18) Wiebe ER; Adams LC. Women's experience of viewing the products of conception after an abortion. Contraception 2009; 80 (6), pp. 575-7.

19) Wiebe ER, Trouton KJ, Fielding SL, Grant H, Henderson A. Anxieties and attitudes towards abortion in women presenting for medical and surgical abortions. J Obstet Gynaecol Can. 2004;26(10):881-5.

20) Wells N. Pain and distress during abortion Health Care Women Int. 1991; 12(3):293-302.

== Comments of Anne Speckhard, Ph.D. ==

In regard to NCCMH review, I would suggest that it completely fails to address the reality that each woman's unique and individual view of her abortion experience is the most important defining issue for what constitutes a trauma.

That means that if she perceives her pregnancy as involving a human life (i.e. in our research we keyed this as recognition of human life) and then furthermore attaches to that life (i.e. feels any type of attachment, refers to the embryo/fetus as "my baby", or herself as a mother, etc.) she has perceived/defined the abortion event in a manner that will make it likely to experience it as a criterion A stressor event capable of causing posttraumatic stress disorder.

We found these two variables - the woman's own recognition of life and attachment to be the highest predictors in our research of PTSD responses after an abortion.

On the other hand if she sees the abortion as nothing much for her, i.e. it is not experienced as a traumatic and she will not experience PTSD symptoms unless she is traumatized by other things which can also be additive in the first case (coercion to get the abortion, a very painful invasive experience, an abusive doctor or clinic protocol, even protestors outside the clinic, etc.)

From an outsiders perspective the first case (recognizing fetal life and attaching to it) can be seen as sick (the normal pro-choice view - that she is sick to define her pregnancy abortion experience so personally and relationally because after all it is not a human child) and the second case can also be seen as sick - morally detached, insensitive, or unhealthy because for her the abortion doesn't carry enough weight to be likely to cause her trauma (the view being expounded here from a pro-life perspective). Both are outsiders perspectives and can be argued strongly depending on the view of pregnancy that person holds. But what is operational for the woman and whether or not she suffers PTSD is not the view of the outsider but the woman's own view. She will experience trauma based on her own perceptions.

Likewise her own unique view can change overtime. She may be callous to her abortion at the time she has it but years later encounter a sonogram that deconstructs her first view that it's not a life worth worrying about and become deeply traumatized that what she aborted was (again in her view) deeply human and something she may at this late stage wish to make a relationship to (i.e. creating psychological presence of an aborted fetal child that she now grieves over). Again this is from her perspective and that is the only thing that matters as far as getting PTSD - in this case a delayed reaction.

Of course how others define things can also cause mental health problems. A woman who is traumatized but is told by her society to buck up as it was nothing has to go underground with her feelings and a woman who is condemned for feeling nothing can also find that difficult to deal with.

In either case though I want to emphasize for this discussion we really have to take into account the woman's own perspective.

I realize that says nothing about the critique of the study under question but I did want to comment that how we define "sick" is also often defined by our own views of the experience. Whereas actually becoming "sick" from an abortion experience may have much more to do with the individualistically defined view of the woman herself.

Anne Speckhard, Ph.D.

Adjunct Associate Professor of Psychiatry

Georgetown University Medical School
[http://annespeckhard.com annespeckhard.com]

==Comments of Philip Ney, M.D.==
This report confirms what has been known for at least 3 decades, abortion not only does not prevent mental illness, it aggravates every known mental illness. Abortion is contraindicated as treatment for mental ills. It must be made very clear to politicians etc, that this study only confirms the fact that abortion is not good treatment.

Without defining "wantedness" these authors write a conclusion that unwantedness is the real problem. Isn't it convenient? Now they can make wantedness mean anything that suits their purpose. My own research team has studied wantedness and found, (no surprise) that wantedness fluctuates hourly, depending on hormones, mood, partner, finances etc but following the first trimester when nausea and vomiting, partners hesitance dominate, wantedness grows throughout the pregnancy. Moreover wanting a child has very little relationship to wanting to not be pregnant. "Intendedness" is no better. So basing the results of such high blown research on such an ephemeral criteria is about as bad research as there can be.

No country in the world recognizes abortion as a woman's unfettered right. There is in no country I know where a woman can at any time in her pregnancy, for any reason, walk up to a physician and state "It's my right. I demand you abort my pregnancy right now." Why? Because it is illegal to practice bad medicine. And since the evidence from all studies and surveys shows there is no benefit, only various degrees of harm, abortion is bad medicine. This is what we must emphasize. On the other hand, abortion is legal everywhere if it is necessary to treat a disease like eclampsia, sometimes.

Statistics can blind as easily as illluminate. We must not forget that statistics are to find canaries (rare events) as they used to say in medical school or to determine if some small measure is significant ( important enough to be bothered with). If when you give some new medication to your patients and 1/2 die, statistics aren't needed. We are dealing with events that make huge differences in people. It is to our embarrassment we have such difficulty quantifying these changes. I believe in that regard, smaller samples using the subject as there own control and using Visual Analogue scales which can represent fine slices of the continuum which are almost always there, is the way forward. Besides its less expensive.

'''NOTE:''' A more complete review of the NCCMH review by Dr. Ney is "[http://www.webmedcentral.com/article_view/4429 A Common Sense Scientific Critique of the NCCMH and Royal College of Psychiatry Review]" WebMedCentral. REPRODUCTION 2013;4(10):WMC004429

==Comments of Martha Shuping, M.D.==
It has been shown in a number of studies that prior mental health, before the abortion, is a risk factor for more problems after the abortion. I don’t think anyone on either side of the issue disputes that. It is well established.

Therefore, it certainly accurate for the NCCMH report to note this fact. The problem is they treat it as being practically the only relevant finding and draw unsupported and misleading conclusions from it.

If you have a preconceived bias to defend abortion as a basic human right, it would be convenient to also believe that if people were having problems after abortion, it was purely and simply due to the fact that they were troubled individuals to start with.

Interestingly, in some countries, abortion has been legal specifically in cases in which the woman is believed to be suicidal. I know women in England who tell me they were coached by counselors to tell the doctor, “I will commit suicide if I have to have this baby,” and they were not really suicidal but they said it to get the abortion. So abortion is permitted or advocated in some cases because a woman has mental health problems though the data indicate that these are the women who are more vulnerable to problems after abortion. It would make sense to spend some time doing more counseling at the front end to explore whether this woman truly wants the abortion, whether she understands her risks and so on, rather than actually advocating for the abortion, since this is a vulnerable population, and their mental health actually may be worsened by the abortion rather than improved by the abortion. So it is paradoxical in a way that these are the very women who in countries are given access to abortion when others are not or where it is viewed in some way as a solution, when of course abortion has never been demonstrated as evidence based treatment for suicidal ideation or for any psychiatric illness.

From my own experience with large numbers of women in abortion recovery programs, I believe that many women are having mental health problems after abortion who did not have problems before, and also that those who did have problems before now have problems that are qualitatively and quantitatively more severe after the abortion.

The women themselves can often pinpoint the start of their problems to the time of the abortion, and their symptoms often specifically relate to the abortion such as nightmares about dead babies or dreams about crying babies, having panic attacks when they are around things or places that remind them of the abortion, and so on. But you do not get at this type of information in the larger studies with huge databases; you only get the general before and after perhaps from insurance claims or health records as far as past diagnoses and dates of treatment.

When one is doing record based studies, there is important information to be gained, but in doing qualitative studies, or doing studies that could be designed to interview women very specifically about their experience, one might discover there are specific aspects about the symptoms that tend to indicate the post-abortion symptoms are related to the abortion, and not related to prior mental health issues. Someone could have had transient depression during high school or college, but then develop PTSD after the abortion. If they are having nightmares about dead babies after the abortion but not before, and then finding they need to consume alcohol to sleep at night, these would seem to be new problems.

From my experience, my opinion is that there are many women with new onset of mental health problems after abortion, and many with different and more severe problems after the abortion. I think this has not been fully captured or demonstrated by current studies. But certainly there are some excellent studies that do control for prior mental health and show that past abortion is in itself a risk factor for mental health problems. These studies support what I have seen in clinical experience. It is not “only” the past mental health that is the complete and total cause of all abortion related problems, because some studies controlled for prior mental health and still show abortion as a risk factor for mental health problems after abortion.

-------

A major weakness of this review is the oversimplified way in which they collapse mental health problems into being all the same. If there are “problems” after birth and “problems” after abortion, the reviewers treat these as equal without looking at the nature of the problems and how long these problems last.

This occurs, for example, in a study looking at Medicaid claims to see if there was any mental health treatment in the year prior to the abortion, and then perhaps look at claims after. In these exploratory studies, they are just looking for the “yes” that there was past mental health treatment, and not necessarily the number of times treatment was received or the seriousness of the disorder or how long it lasted. Typically researchers would only be considering whether or not there was a diagnosis or treatment. And it would tend to serve the viewpoint of those who favor abortion if it was all treated equally.

Similarly, the reviewers appear to asserting that while, yes, there can be problems after abortion, there can also be problems after childbirth, and so it is all equal.

But they are not equal. Consider, for example, a woman I know who was in her 80’s who was still having grief and guilt concerning a past abortion from about fifty years earlier, who contacted me for help with an abortion related issue. Also, on abortion recovery weekends, I have taken women in their 60’s who are now grandmothers who still have grief and guilt concerning past abortions.

So, yes, it is true that women can have post-partum depression after having a baby, but my experience with post-partum depression is that it resolves on medication within a few weeks. I have never seen women in their 60’s or their 80’s with post-partum depression. In contrast, I have experience with women in their 60’s and even 80’s who are still having symptoms they specifically attribute to their abortion, which seem to be abortion related.

So, no, the severity or the duration of the post-abortion problems are not being considered.

Keep in mind that many women do meet criteria for posttraumatic stress disorder after abortion, for example, about 18% in a 2007 study by Suliman in South Africa. The authors considered this “high.” They were concerned that almost one in five women in their study had PTSD after their abortion.

There are studies showing that PTSD is a very long lasting disorder that can be very disabling, so it is a more serious psychiatric illness.

Studies that only look at mental health after abortion vs. mental health after childbirth are perhaps unintentionally misleading if they consider only whether the person was diagnosed or whether the person had treatment in a particular time frame in a “yes or no” fashion. It is important to know the nature, severity and duration of the disorders in question and that would be more difficult information to obtain. You can find out from medical records or insurance claims whether or not a person had treatment in a particular period of time after the end of the pregnancy, yes or no. But to follow women to see who is still experiencing symptoms in their 60’s or 80’s would be a very long study indeed, and it is difficult to study women for decades.

Similarly, if we are considering mental health before the abortion vs. mental health after the abortion, it would also be good to consider not simply whether or not treatment occurred, but what was the severity and duration of the illness, and again this can be difficult to determine. For some women, their symptoms may emerge later, and may be severe and long-lasting, sometimes persisting for decades.

These questions are not being carefully considered, but they would be difficult studies to do.

But, there are clearly are studies that use control groups, that do control fro prior mental health, and that show abortion itself is a risk factor for mental health problems in women after abortion. It by no means only women with prior mental health problems who are having the problems after abortion. But when they do make the comparison and treat the problems before and after as equivalent, they have not truly demonstrated whether the two conditions are in fact equivalent.

==Other Notes==

===Rating Scale Misleading===
The rating scale for studies was strongly criticized by a number of reviewers during the first draft for it's failure to rank studies for women refusing to participate or dropping out of the study before completion. The review team acknowledged this problem but provided only a fake fix.

The "fix" was adding a new category, "Representativeness" to table 3, p28. As described on page 29, the criteria for this scale were so watered down that all the studies with high drop out rates were still allowed to score high. Indeed, a study could have over a 50% refusal or drop out rate and still be rated as "+" as long as the authors provided even a mediocre statistical comparison of the participants and non-participants....even if the comparison showed significant differences!

The rating scale appears to have also been designed, or at least interpreted, to specifically justify rating the Finland record based studies on suicide as "very poor" -- even though they revealed a 650% increased risk of suicide. They also ignored the Morgan study, published in BMJ with data.

===Incorrectly classified studies===
*Three prospective cohort studies using record linkage (Coleman2003A, Reardon2002A, Reardon2003A) were improperly listed as "retrospective." Oddly, Munk-Olsen2011 which used the same methodology was correctly listed. In the discussion section (p59) the authors also wrongly describe these three studies as based on a sample of women whose first pregnancies ended in abortion. In fact, the sample included all women who had any pregnancy outcome within a specific period, and as a cross sectional snapshot, it did not have information on whether these were first, second, third or higher order pregnancies.

*Findings from the above studies were not completely reported in Table 9, including for example, the rates reported for bipolar disorder in Reardon2002A (OR 3.0, 95% CI 1.5-6.0). They were also rated as "poor" while Munk-Olsen2011 was rated good, even though there was no significant difference in study design. Indeed, Munk-Olsen2011 is arguably much poorer given mixing of women into both groups, shorter followup (only one year rather than four years), the failure to control for mental health treatment rates prior to pregnancy for delivering women, and other roblems.

*A number of studies are described as prospective (the Broen, Major, Rizzardo and Suliman) when they would be better described as case series studies, since they have no data prior to the abortion and simply follow the cases for a period of time.

*Reardon2006 was excluded for the specious reason "sleep disorders beyond scope of the review"--but that was an arbitrary decision, since clearly sleep disorders can be due to mental health problems, indeed, they are strongly linked to PTSD.

===Misc===
*They incorrectly excluded Soderberg (p171) stating that the sample included distressed women. In fact, the sample included all women who had abortions.

==Official Comments and Responses==

The most complete listing of shortcomings of this review, including explanations for why key issues were not covered in the report, are found in the NCCMH's companion document to the report "[http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf Comments and Responses], see especially pages 95-103.]"

NCCMH Review

2025-10-21T21:33:49Z

Barb: /* History of NCCMH Review */

Induced Abortion and Mental Health, NCCMH Published December 2011

::'''citation:''' National Collaborating Centre for Mental Health. Induced abortion and mental health: a systematic review of the mental health outcomes of induced abortion, including their prevalence and associated factors. London (UK): Academy of Medical Royal Colleges; 2011.

The full report can be downloaded from the [https://www.aomrc.org.uk/wp-content/uploads/2016/05/Induced_Abortion_Mental_Health_1211.pdf AoMRC reports and guidance page.] A record of [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf all comments received and the developers’ responses] can be [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf downloaded here.]

The [https://www.scribd.com/embeds/327609067/content?start_page=1&view_mode=scroll&access_key=key-r3mNJH1gDsAHIiLuduFC&show_recommendations=true first draft] and [https://www.scribd.com/document/327608591/Induced-Abortion-and-Mental-Health-Systematic-Review-Consultation-6-April-to-29-June-2011-Comments-and-Responses the comments and responses on the first draft] can also be downloaded from Scribd.

===History of NCCMH Review===

In 2006, the U.K.'s House of Commons Science and Technology Committee undertook an inquiry into the health effects of abortion on women which included a request (paragraph 139) for the RCP to update their 1994 statement on abortion in light of more recent studies.<ref>House of Commons Science and Technology Committee (2006). ''[https://publications.parliament.uk/pa/cm200607/cmselect/cmsctech/1045/1045i.pdf Scientific Developments Relating to the Abortion Act 1967. Volume 1]''</ref> In 2008, the RCP did update their position statement to recommend that women should be screened for risk factors that may be associated with subsequent development of mental health problems and should be counselled about the possible mental health risks of abortion.<ref>Templeton, Sarah-Kate (2008-03-16). "[https://www.thetimes.com/uk/healthcare/article/royal-college-warns-abortions-can-lead-to-mental-illness-p8glm5s5k8h Royal college warns abortions can lead to mental illness]". ''The Sunday Times''. ISSN 0956-1382.</ref> <ref>Fergusson, David M. (September 2008). "[https://www.thetimes.com/uk/healthcare/article/royal-college-warns-abortions-can-lead-to-mental-illness-p8glm5s5k8h Abortion and mental health]". ''Psychiatric Bulletin''. '''32''' (9): 321–324. doi:10.1192/pb.bp.108.021022</ref> The revised RCP position statement included a recommendation for a systematic review of abortion and mental health with special consideration of "whether there is evidence for psychiatric indications for abortion." Following the publication of a number of studies between 2002 and 2008 revealing that women who have abortions experience common disorders such as anxiety or depression at a rate about three times higher than other women, Royal College of Psychiatrists issued a [http://www.thesundaytimes.co.uk/sto/style/living/Health/article82769.ece position paper on abortion] ((Royal College of Psychiatrists. Position statement on women’s mental health in relation to induced abortion. 14 March 2008. Royal College of Psychiatrists, 2008) acknowledging that some women may have adverse reactions to abortion and further recommended:
:Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.

A commentary upon the revised position statement and the history of this statement is provided in an [http://pb.rcpsych.org/content/32/9/321.full editorial by David Fergusson, published in ''The Psychiatrist''].

This statement also called for a systematic review of the evidence, which led to the commissioning of Britain's National Collaborating Centre for Mental Health (NCCMH)to undertake such a review. The NCCMH subsequently undertook a review which was limited to addressing just three questions related to abortion and mental health.

====Questions Addressed in the Review====
The reviewers chose to limit their report to three questions: (1) How prevalent are mental health problems in women who have an induced abortion? 2. What factors are associated with poor mental health outcomes following an induced abortion? 3. Are mental health problems more common in women who have an induced abortion when compared with women who deliver an unwanted pregnancy?

Note, the first question, dealing with prevalence, is easily answered by record linkage studies from which the mental health treatment rates of women having abortions can be tabulated. The question does not ask how much of the observed mental health problems are attributable to abortion, but rather how common are mental health problems among women with a history of abortion. The results unequivocally show that rates of mental health problems among women with a history of abortion are higher than rates for other groups of women, including the general population of women and women giving birth who do not have a history of abortion. Yet this is not fully discussed in the conclusions, which instead shift the discussion to evidence that women who have mental health problems after an abortion may also have higher rates of mental health problems before having abortions. Which actually raises a new issue which the reviewers refused to address, namely, is there evidence that women with pre-existing mental health problems get better or worse following an abortion.

Regarding the second question, the reviewers actually failed to systematically investigate all risk factors that predict poor mental health outcomes.

Regarding the third question, the reviewers acknowledged that the definition of what constitutes "an unwanted pregnancy" is imprecise and also that they were declining to investigate the alternative of whether there are any mental health benefits of abortion, which is actually the pertinent issue under UK law. (see [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf pages 39, 43, 91 ]

=====Studies and Data Excluded in Investigating these Three Questions=====

The reviewers chose to exclude:
# Any studies related to mood disorders, including reactions such as guilt, shame and regret. Although the - although these were considered important - and also assessments of mental state within 90 days of an abortion. This was because the research was not about “transient reactions to a stressful event”.occurring within the first 90 days of an abortion
# Any studies of qualitative data (qualitative interviews, case studies, self-reports etc) (p135 We agree that qualitative evidence is important in this area.Unfortunately it was beyond the scope and resources of the review to consider qualitative evidence")
# Any data relative to negative effects associated with aborting a wanted pregnancy for "therapeutic" reasons.

====Questions Excluded from Investigation====

The report deliberately excluded any investigation of key questions
# In what cases may abortion contribute to the mental health of women
# Whether abortion makes pre-existing mental health problems more severe or difficult to treat

Research questions excluded from the review, and the reason for excluding them, are described in the companion document "[http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf Comments and Responses], see especially pages 95-103.]"

In their request for public comments, the NCCMH panel was asked to investigate, or at least comment on, the following questions. The panel declined to do so, stating these questions were "beyond the scope and remit of the present review, which was to focus on the three research questions posed." Notably, the panel itself posed the three questions it chose to investigate, and in doing so prevented their review from being a comprehensive examination of abortion and mental health issues. (Indeed, [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf the phrase "beyond the scope"] was used 45 times to evade questions raised by commentators.)

----

Questions ignored:

*(p35)

This draft makes no attempt to answer the issues raised by the
Abortion Act and its amendments. Indeed the authors make
assumptions not contained in the Act that women have an
unfettered right to choose an abortion. The act is clear that
abortion is a medical matter and can only be performed if and
when it is necessary to improve or preserve a woman’s health.
The real question to be addressed is, what is the evidence of
benefit., not what is the data for harm. This was studiously
avoided by the authors of this draft. The Fellows of Psychiatry
erred in not making their mandate clear and relevant.
If a woman has a right to have an abortion when she so elects,
then abortion is not a medical matter and should be performed by
technicians If a woman has a right to good medical treatment that
may include having an abortion on her physician’s
recommendation, then this review is valid only if it addresses
these questions:

a) '''Indication''' Is there a pathological process in pregnant
women in general and this patient in particular that warrants
having an abortion? (It must be recognized that pregnancy is not
a disease.)

b) '''Benefit''' What is the evidence that an abortion will benefit
women with this condition (pregnancy) and this patient in
particular?

c) '''Harms.''' What are the adverse effects from an abortion and if
there are some, do they outweigh the anticipated benefit?

d) '''Other options''' Have all less invasive, more reversible
treatments been offered, tried and failed before an abortion is
recommended?

e) '''In good faith''' Is the physician who is providing this
procedure doing so in good faith? Has the abortionist carefully
studied to relevant literature in order to practice evidence based
medicine, honed his/her skills and performed a careful followed
up on his/her ex-abortion patients to know personally that he/she
will be providing good treatment?

f) '''Adoption etc.''' Has the physician facilitated all options to
abortion of a truly unwanted child, i.e., adoption, fostering etc.

g) '''Informed consent.''' Has the physician made a clear
recommendation to the patient with evidence to support that
recommendation, options available, potential benefits and
hazards, and shown the ambivalent woman the ultrasound of her
fetus? Has he/she been given fully informed consent which
requires the patient have full opportunity to ask questions, get a
2nd opinion and make a decision with enough time to do so and
without pressure from mate, family, IPPF, physician etc.

It must be remembered that until any treatment is well proven, it
must be considered as experimental and constrained as such.

Moreover the burden of proof rests with the performing
physician, his/her supporters and those who fund this activity to
show abortion is necessary, beneficial etc. not on those who
question abortion is a valid treatment to show it is harmful.

----
*(p43-44)

The Rawlinson Report and the RCOP response
(http://extras.timesonline.co.uk/rowlinsonreport.pdf) highlights
important issues that should be much more carefully addressed
in this new report.

The Rawlinson report gave a summary of the RCOP's testimony
and response to questions asked stating "there are no psychiatric
indications for abortion." As per Ney’s elaboration, this concern
that there are “no [psychiatric] indications for abortion” refers to
the lack of medical indications that the abortion will produce
positive mental health effects.

Properly understood, this statement was an attempt to summarize the RCOP’s failure to report to the committee any
statistically validated psychiatric criteria which can be used to
identifying when an individual woman is likely to either (a) derive
psychiatric benefits from an abortion, or (b) be successfully
protected from psychological harm that would otherwise occur if
the pregnancy continued.

There is still a lack of any such criteria.

It should be carefully noted that the RCOP’s letter of response
did not refute the Rawlinson Reports finding that there are no
indications for abortion. If they had any indications, they would
have stated so in their response. For example, they might have
noted that abortion is medically indicated for bi-polar women
faced with an unwanted pregnancy, if there was any statistically
validated evidence to support that claim, but there was none.

RCOG letter of response shifted attention away the actual claim
of fact regarding lack of known indications for abortion to a
distinctly separate issue, namely that "the risks to psychological
health from the termination of pregnancy in the first trimester are
much less than the risks associated with proceeding with a
pregnancy which is clearly harming the mother's mental health."
(emphasis added.)

Notably, this statement has a huge qualifying clause which is
exceptionally vague. The letter fails to give any means of
determining when and how often a pregnancy is “clearly harming
a mother's mental health.”

It actually implies that In cases where the pregnancy is not
clearly harming a mother’s mental health, abortion may involve
equal or greater risks. So the standard of identifying when a
pregnancy is clearly harming mental health should be examined
to identify the indicators for abortion which were requested by the
Rawlinson committee.

Moreover, there is no research that has examined the assertion
made by this qualifier. Specifically, there are no studies
comparing psychiatric outcomes for women whose
pregnancies were clearly harming their mental health who
had abortions versus those who did not
.
In this light, it seems clear that the statement on page 61 of the
report, contested by the RCOG’s letter of response, merely
conflates the finding that there are no psychiatric indications for
abortion into the statement that there is no psychiatric
justification for abortion.

While there is plenty of room to debate whether “justification” can
rightly be substituted for “indications,” two key question remain
unanswered: (1) What evidence demonstrates when, if ever,
abortion is likely to improve a woman’s mental health? And (2) what
does the best evidence show regarding when, if ever, abortion
protects future mental health, i.e., by reducing psychological
stresses without creating new psychological stresses?

These are questions which should be clearly articulated in this
report, even if the only answer that can be given is that the
research done to date has failed to address these important
questions.

----
*p46

First, good medical care involves at least four components:

(a) accurate diagnosis of the problem,

(b) identification of treatments most likely to be efficacious,

(c) evaluation of treatment risks, and

(d) a risk / benefit analysis regarding treatment alternatives.

Unfortunately, in the context of the abortion controversy, these
distinct steps are often confused or conflated. An unspoken, but
medically inappropriate paradigm appears to exist with regard to
abortion, namely:

(a) if the woman requests the abortion, and

(b) there is no clear risk that she will die on the operating table,
and

(c) critics abortion have not proven, beyond all reasonable
doubt, that abortion is and of itself the sole cause of all the risks
statistically associated with abortion, then

(d) physicians should feel free to recommend or perform
abortions on request.

This medical decision paradigm is simply not justified by the
principles of evidence based medicine and medical ethics which
apply to any other procedure.

'''Therefore, to shed light on the core issues regarding
abortion decision making, especially in the context of UK
law, this literature review should identify and grade the
medical evidence relative to two very specific questions:'''

First: “What medical conditions and/or psychosocial indicators
predict when the risks of continuing a pregnancy are greater than
if the pregnancy were terminated?” These are the indications for
induced abortion.

Secondly, what are the statistically validated risk factors which
can help to identify the subsets of women who appear to be at
greater risk of negative effects associated with a history of one or
more abortions? These risk factors are the medical
contraindications for induced abortion.

----
*(p63)

The glaring gap in this draft is the lack any consideration of the
effect of abortion on men and children. It makes this report
invalid, if for no other reason than because what effects spouse
and children will have a pronounced effect on the woman’s
mental health.

----
*(p65)

1/2
Since many post-aborted women use repression as a coping
mechanism, there may be a long period of denial before a
woman seeks psychiatric care. These repressed feelings may
cause psychosomatic illnesses and psychiatric or behavioural
disorders in other areas of her life.

As a result, some counsellors report that unacknowledged post-abortion distress is the causative factor in many of their female
patients, even though their patients have come to them seeking
therapy for seemingly unrelated problems.
Kent, et al., “Bereavement in Post-Abortive Women: A Clinical
Report”, World Journal of Psychosynthesis (Autumn-Winter
1981), volume 13, no’s 3-4

Note the area of Sexual Dysfunction – Thirty to fifty per cent of
aborted women report experiencing sexual difficulties, of both
short and long duration, beginning immediately after their
abortions. These problems may include one or more of the
following: loss of pleasure derived from sexual intercourse,
increased pain, an aversion to sexual activity, and/or males in
general, or the development of a promiscuous lifestyle.
Speckhard, Psych-social Stress Following Abortion, Sheed &
Ward, Kansas City, MO 1987; and Belsey et al., “Predictive
Factors in Emotional Response to Abortion: King’s Termination
Study – IV,” Soc. Sci. & Med., 11:71-82 (1977)

:Response of reviewers: Although these are important points, they are beyond the scope of the present review.

----

*(p95)

1. "Question 3 should be reworded to properly reflect UK law, as follows: 3. Are mental health problems less common in women who have an induced abortion, when compared with women who deliver an unplanned or unwanted pregnancy? [This was recommended since UK law allows induced abortion only when the health risks of abortion are less than those of allowing the pregnancy to continue.]"

----

*(p95) 1. How prevalent are mental health problems in women who do not terminate an unplanned or unwanted pregnancy compared to the general population and to women who deliver a wanted pregnancy?

2. What factors are associated with improved mental health following abortion compared to similar women who carry an unplanned or unwanted pregnancy to term?

3. What factors are associated with a lower decline in mental health following abortion when compared to women who do not terminate an unplanned or unwanted pregnancy?

4. Among women who do experience negative reactions which they attribute to their abortions, what reactions are reported and what treatments are effective?

5. Is presenting for an abortion, or a history of abortion, a meaningful diagnostic marker for higher rates of mental illness and related problems?

6. Does abortion ever cause or exacerbate mental health problems in women, even in rare cases? (p95)

----
*

=== Some Conclusions ===
*The most reliable predictor of post-abortion mental health problems is having a history of mental health problems prior to the abortion.
*A range of other factors produced more mixed results, although there is some suggestion that life events, pressure from a partner to have an abortion, and negative attitudes towards abortions in general and towards a woman’s personal experience of the abortion, may have a negative impact on mental health.
*Women who show a negative emotional reaction immediately following an abortion are likely to have a poorer mental health outcome.
*This section of the review aimed to assess factors associated with mental health problems following an abortion. Identifying these factors would enable healthcare professionals to monitor and provide greater support for women identified as potentially ‘at risk’.

=== From News Releases ===

While acknowledging that women with a history of abortion have higher rates of mental illness than the general population, the director of NCCMH of Tim Kendall, said, “It could be that these women have a mental health problem before the pregnancy. On the other hand, it could be the unwanted pregnancy that's causing the problem. Or both explanations could be true. We can't be absolutely sure from the studies whether that's the case - but common sense would say it's quite likely to be both. The evidence shows though that whether these women have abortions - or go on to give birth - their risk of having mental health problems will not increase. They carry roughly equal risks. We believe this is the most comprehensive and detailed review of the mental health outcomes of abortion to date worldwide.”

Sophie Corlett, director of external relations at the mental health charity Mind, said of the report, “It is important that medical professionals are given the correct information to provide support for all women, but particularly those with a pre-existing history of mental health problems. This study makes it absolutely clear that this group is at the greatest risk of developing post-pregnancy mental health problems and should be given extra support in light of this.”

Dr Peter Saunders, chief executive of the Christian Medical Fellowship, said, “This new review shows that abortion does not improve mental health outcomes for women with unplanned pregnancies, despite 98% of the 200,000 abortions being carried out in this country each year on mental health grounds. This means that when doctors authorize abortions in order to protect a woman's mental health they are doing so on the basis of a false belief not supported by the medical evidence. In other words the vast majority of abortions in this country are technically illegal.”

== Critique by Priscilla Coleman ==

The Royal College of Psychiatrist’s recently conducted review of scientific literature published from 1990 to the present on abortion and mental health is hauntingly similar to the American Psychological Association Task Force Report released in 2008. The report by the RCP is, however, far more complex and on the surface it may appear to be more rigorous than the APA report. An enormous amount of time, energy, and expense has been funneled into a work product that was not undertaken in a scientifically responsible manner. In this critique, I provide evidence that should incite scientists and clinicians to reject the conclusions of the report and work together to provide an accurate and truly exhaustive review of the peer-reviewed research.

==== Unjustified Dismissal of Studies====
The RCP review incorporates four types of studies: 1) reviews of the literature; 2) empirical studies addressing the prevalence of post-abortion mental health problems; 3) empirical studies identifying risk factors for post-abortion mental health problems; and 4) empirical studies comparing mental health outcomes between women who choose abortion and delivery. In each category, there are studies that are ignored and large numbers of studies that are entirely dismissed for vague and/or inappropriate reasons. With regard to the first type of study, only 3 reports are considered (APA Task Force Report, 2008; Charles et al., 2008; Coleman, 2011). The authors of the RCP report “missed” 19 reviews of the literature (listed at the end of this document), published between 1990 and 2011. Moreover, no criteria were identified for selection of particular reviews to discuss and to provide context for the current report. In relation to the third type of study, only 27 studies are included in the RCP report. At the end of this document, citations to 20 relevant and unmentioned articles published in highly respected peer-reviewed journals are provided. They are not listed in Appendix 7 of the RCP report, which contains all included and excluded studies.

Among the scores of studies identified and excluded across study types 2 through 4 above, the most common reasons are the nebulously defined “no usable data” and “less than 90 days follow-up.” The latter resulted in elimination of 35 peer-reviewed studies in each of the prevalence, risk factor, and comparison study types. The RCP authors state that ''“Because the review aimed to assess mental health problems and substance use and not transient reactions to a stressful event, negative reactions and assessments of mental state confined to less than 90 days following the abortion were excluded from the review.”'' This is highly problematic for various reasons. First, elimination of studies that only measured women’s mental health up to 90 days, does not effectively remove cases of transient reactions. Just because the authors of these dozens of studies did not follow the women long-term, it does not mean that the women were not still suffering quite significantly beyond the early assessment. Moreover, when investigating the mental health implications of an event, it is logical to measure outcomes soon after the event has occurred as opposed to waiting months or years to gather data. As more time elapses between the stressor and the outcome(s), healing may naturally occur, there may be events that moderate the effects, and more confounding variables may be introduced. Finally, focusing only on mental health events that occur later in time effectively misses the serious and more acute episodes that are effectively treated soon after exposure.

Ironically, many of the studies removed from the analyses due to the abbreviated length of follow-up, had incorporated controls for prior psychological history and other study strengths. As a result, the samples of studies included in each section of the RCP review were not representative of the best available evidence and many of the eliminated effects coincidentally revealed adverse post-abortion consequences. In the category wherein the authors sought to derive prevalence estimates, only 34 studies were retained, including 27 without controls for previous mental health. In contrast, in the Coleman review, 14 out of the 22 studies had controls for psychological history.

====Factual Errors====
Perhaps even more disturbing than the elimination of large segments of the literature, are the factual inaccuracies that are present in the RCP report. As the author of the Coleman (2011) review cited in the report, I was alarmed to see the content in “Section 1.4.4: Summary of Key Findings from the APA, Charles, and Coleman Reviews.” The first 6 points are not reflective of the conclusions derived from the meta-analysis and the 7th and final point in this section wrongly states, with reference to the meta-analysis that “previous mental health problems were not controlled for within the review.” '''In fact, as noted above, the meta-analysis incorporated more studies into the final analyses with controls for prior psychological problems than the current review. Moreover, the conclusions derived from the meta-analysis were based on more studies with controls for prior psychological history than the Charles and the APA reviews as well.'''

I do not have the time or interest in identifying all errors present, but a few others jumped out at me. First, several studies are eliminated from the RCP report, because the outcome(s) assessed are lifetime estimates of mental health problems, deemed inappropriate by the RCP team. Nevertheless, the Coleman et al. (2009) and the Mota et al. (2010) articles, which relied upon lifetime estimates, are included in the prevalence section of the report. Inclusion reflects an inaccurate read of the two studies. I also noticed my affiliation is stated as the Department of Psychiatry at Bowling Green State University. I wish we had a medical school, it would make retrieval of articles much less expensive, but unfortunately we do not.

====Problematic “Quality Assessments”====
This review is being pitched as methodologically superior to all previously conducted reviews, largely because of the criteria employed to critique individual studies and to rate the overall quality of evidence. However, the quality scales employed to rate each individual study are not well-validated and require a significant level of subjective interpretation, opening the results to considerable bias. The main problems with the quality scale employed to rate the individual studies are as follows: 1) the categories used are missing key methodological features including initial consent to participate rates and retention of participants across the study period; 2) the relative importance assigned to the included criteria is arbitrary, as opposed to being based on consensus in the scientific community; 3) the specific requirements for assigning a “+” or “-” within the various categories are not provided; 4) the authors fail to explain (as their predecessors, Charles et al. 2008 did) how combinations of pluses and minuses in the distinct categories add up to an overall rating ranging from “Very Poor” to “Very Good.” Incredulously, the Gilchrist et al. (1995) study received a rating of “Good”, when very few controls for confounding 3rd variables were employed, meaning the comparison groups may very well have differed systematically with regard to income, relationship quality including exposure to domestic violence, social support, and other potentially critical factors. Further Gilchrist et al. reported retaining only 34.4% of the termination group and only 43.4% of the group that did not request a termination at the end of the study. No standardized measures for mental health diagnoses were employed and evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The GPs were volunteers and no attempt was made to control for selection bias. Despite these facts, the study received a mark of “+ thorough” for confounder control, a “+” for representativeness, and a “+” for validated tools. I can provide a similar rebuttal to many more of the individual study ratings provided by the RCP; and the reader should not trust these “quality” assessments.

Similarly, when it came to evaluating the quality of evidence associated with specific outcomes, such as anxiety, depression, suicide ideation, drug or alcohol abuse, psychiatric treatment, etc. with regard to the comparative studies, “Grade Working Group grades of evidence” were employed by the RCP. The anchors on this scale are vague and oftentimes only one reason is identified as the basis for a “Very Low” rating. For example, in the category of “Any Psychiatric Treatment,” which actually only included the Munk-Olsen et al. study (p.104), the basis for the “Very Low” (very uncertain about the estimate) rating was not controlling for pregnancy intention. As if this isn’t problematic enough, when the study is again evaluated (see pages 198 and 199), it is rated as “Good” in the comparison category. There are loose, poorly conceived rationales and inconsistencies like this throughout the report and the problem lies in the application of an inadequate quality assessment protocol for individual studies and for the body of evidence.

====Faulty Conclusions====
Each section in the RCP report includes conclusions that are based on a very small number of studies that are not properly rated for quality. The results should, therefore, not be trusted as a basis for professional training protocols or health care policy initiatives. To illustrate how incomplete and misleading the conclusions provided by the RCP are, I will use one example. I recently identified 119 studies published between 1972 and 2011 using the MEDLINE, PubMed, and PsycINFO data bases specifically related to risk-factors associated with post-abortion psychological health. Below is a list of the most common risk factors derived from the 119 peer-reviewed journal articles identified.

:a. Timing during adolescence or younger age (18 studies confirm: 2 studies do not)

:b. Religious, frequent church attendance, personal values conflict with abortion (18 studies confirm; 1 study does not)

:c. Decision ambivalence or difficulty, doubt once decision was made, or high degree of decisional distress (29 studies confirm; 3 studies do not)

:d. Desire for the pregnancy, psychological investment in the pregnancy, belief in the humanity of the fetus and/or attachment to fetus (21 studies confirm; 1 does not)

:e. Negative feelings and attitudes related to the abortion (16 confirm; 1 does not)

:f. Pressure or coercion to abort (10 studies confirm; 1 does not)

:g. Conflicted, unsupportive relationship with father of child (24 confirm; 6 do not)

:h. Conflicted, unsupportive relationships with others (28 confirm; 7 do not)

:i. Character traits indicative of emotional immaturity, emotional instability, or difficulties coping including low self-esteem, low self-efficacy, problems describing feelings, being withdrawn, avoidant coping, blaming oneself for difficulties etc. (42 studies confirm; 1 study does not)

:j. Pre-abortion mental health/psychiatric problems (35 studies confirm; 3 studies do not)

:k. Indicators of poor quality abortion care (feeling misinformed/inadequate counseling, negative perceptions of staff, etc.) (10 studies confirm)

The RCP conclusions relative to studies addressing risk factors for post-abortion mental health problems make no mention of most of the variables described above. They simply state (based on 27 studies) that ''“The most reliable predictor of post-abortion mental health problems is having a history of mental health problems prior to abortion” and “A range of other factors produced more mixed results, although there is some suggestion that life events, pressure from a partner to have an abortion, and negative attitudes towards abortion in general and towards a woman’s personal experience of the abortion, may have a negative impact on mental health.”''

I am one academic, without a lab full of graduate students and with a heavy teaching load (not a Department of Psychiatry), yet I was able to find all these studies. Why wasn’t this high powered research team able to do a better job? Simply glancing at titles and abstracts to determine which studies merit further attention will not yield the information needed and resulted in a short-sighted view of the available evidence.

Before I leave this section on poorly developed conclusions, I should note how curious it was to read one of the conclusions under the risk factor section: ''“Women who show a negative emotional reaction immediately following an abortion are likely to have a poorer mental health outcome.”'' How can this “conclusion” be derived if studies that only examined women in the first 3 months following abortion were eliminated? Moreover, if this is true, why would these studies have been eliminated in the first place? Shouldn’t the researchers be most concerned with those most likely to be adversely impacted?

====Appropriateness of Meta-Analysis====
Counter to the claims of the authors of this report, a quantitative review or meta-analysis can be performed when there is heterogeneity present in the effects one wishes to summarize. The random effects model is specifically designed to address heterogeneity. In addition, separate meta-analyses, based on distinct comparison groups and outcomes can be performed. There is no excuse not to perform extensive meta-analyses from the vast literature that has accumulated. Such an approach is much more reliable and the results derived yield more valid conclusions than a narrative review; data that can be translated more readily into practice.

====A Call for Change====
The bottom-line conclusion of the RCP review, based on only 4 studies, is that abortion is no riskier to women’s mental health than unintended pregnancy delivered. When this report was released a few days ago, several of my colleagues emailed “Here we go again…” Many of us are left wondering, how many of these purposefully driven “systematic reviews” have to be published with results splashed all over the world, before women’s psychological health will finally take precedence over political, economic, and ideological agendas? This report constitutes no less than a crafty abuse of science and if the merits of this report are not seriously challenged, we will shamefully grow more distant from our ability to meet the needs of countless women. Until there is acknowledgement than scores of women suffer from their decision to undergo an abortion, we will remain in the dark ages relative to the development of treatment protocols, training of professionals, and our ability to compassionately assist women to achieve the understanding and closure they need to resume healthy lives.

==== Narrative Reviews Not Addressed====
1) Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Science 1990 6; 248(4951):41-4. Psychological responses after abortion.

2) Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Psychological factors in abortion. A review. Am Psychol. 1992;47(10):1194-204.

3) Adler NE, Ozer EJ, Tschann J. Abortion among adolescents. Am Psychol. 2003; 58(3):211-7.

4) Allanson S, Astbury JJ. Psychosom Obstet Gynaecol. 1995;16(3):123-36.The abortion decision: reasons and ambivalence.

5) Bhatia MS, Bohra N. The other side of abortion. Nurs J India. 1990; 81(2):66, 70.

6) Cameron S. Induced abortion and psychological sequelae. Best Practice & Research. Clinical Obstetrics & Gynaecology 2010; Vol. 24 (5), pp. 657-65.

7) Coleman PK, Reardon DC, Strahan T, Cougle R. The psychology of abortion: A review and suggestions for future research. Psychology & Health 2005; 20(2), p237-271.

8) Dagg PK. The psychological sequelae of therapeutic abortion--denied and completed. Am J Psychiatry. 1991;148(5):578-85.

9) Harris AA. Supportive counseling before and after elective pregnancy termination. Midwifery Women’s Health. 2004; 49(2):105-12.

10) Lie ML, Robson SC, May CR. Experiences of abortion: a narrative review of qualitative studies. BMC Health Serv Res. 2008; 8:150.

11) Lipp A. Termination of pregnancy: a review of psychological effects on women. Nursing Times 2009; 105 (1), pp. 26-9.

12) Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C. Abortion and mental health: Evaluating the evidence. Am Psychol. 2009; 64(9):863-90.

13) Major B, Cozzarelli C. Psychosocial Predictors of Adjustment to Abortion. Journal of Social Issues 1992; 48 (3), p121-142.

14) Robinson GE, Stotland NL, Russo NF, Lang JA, Occhiogrosso M. Is there an "abortion trauma syndrome"? Critiquing the evidence. Harvard Review of Psychiatry 2009; 17 (4), pp. 268-90.

15) Rosenfeld JA. Emotional responses to therapeutic abortion. Am Fam Physician. 1992; 45(1):137-40.

16) Speckland A., Rue V. Complicated Mourning: Dynamics of Impacted Pre and Post-Abortion Grief," Pre and Perinatal Psychology Journal 1993; 8 (1):5-32.

17) Stotland NL. Psychosocial aspects of induced abortion. Clin Obstet Gynecol. 1997 Sep;40(3):673-86.

18) Turell SC, Armsworth MW, Gaa JP. Emotional response to abortion: a critical review of the literature. Women Ther. 1990;9(4):49-68.

19) Zolese G, Blacker CV. The psychological complications of therapeutic abortion. Br J Psychiatry. 1992; 160:742-9.

====Studies of Statistically Validated Risk Factors Not Addressed====

1) Allanson S. Abortion decision and ambivalence: Insights via an abortion decision balance sheet. Clinical Psychologist 2007; 11 (2), p50-60.

2) Brown D, Elkins TE, Larson DB. Prolonged grieving after abortion: a descriptive study. J Clin Ethics 1993; 4(2):118-23.

3) Fielding SL, Schaff EA. Social context and the experience of a sample of U.S. women taking RU-486 (mifepristone) for early abortion. Qualitative Health Research 2004; 14 (5), pp. 612-27.

4) Hill RP, Patterson MJ, Maloy K. Women and abortion: a phenomenological analysis. Adv Consum Res. 1994; 21:13-4.

5) Kero A, Lalos A. Ambivalence--a logical response to legal abortion: a prospective study among women and men. J Psychosom Obstet Gynaecol. 2000; 21(2):81-91.

6) Linares LO, Leadbeater BJ, Jaffe L, Kato PM, Diaz A. Predictors of repeat pregnancy outcome among black and Puerto Rican adolescent mothers. J Dev Behav Pediatr. 1992;13(2):89-94.

7) Mufel N, Speckhard AC, Sivuha S. Predictors of posttraumatic stress disorder following abortion in a former Soviet Union country. Journal of Prenatal & Perinatal Psychology & Health 2002; 17(1), pp. 41-61.

8) Osler M, David HP, Morgall JM. Multiple induced abortions: Danish experience. Patient Educ Couns. 1997; 31(1):83-9.

9) Østbye T, Wenghofer EF, Woodward CA, Gold G, Craighead J. Health services utilization after induced abortions in Ontario: a comparison between community clinics and hospitals. American Journal of Medical Quality 2001; 16 (3), pp. 99-106.

10) Prommanart N, Phatharayuttawat S, Boriboonhirunsarn D, Sunsaneevithayakul P. J Maternal grief after abortion and related factors. Med Assoc Thai. 2004;87(11):1275-80.

11) Remennick L, Segal R. Socio-cultural context and women's experiences of abortion: Israeli women and Russian immigrants compared. Culture, Health & Sexuality 2001; 3(1), p49-66.

12) Slade P, Heke S, Fletcher J, Stewart P. Termination of pregnancy: patients' perceptions of care. J Fam Plann Reprod Health Care. 2001;27(2):72-7.

13) Tamburrino MB, Franco KN, Campbell NB, Pentz JE, Evans CL, Jurs SG. Postabortion dysphoria and religion. South Med J. 1990;83(7):736-8.

14) Thomas T, Tori CD. Sequelae of abortion and relinquishment of child custody among women with major psychiatric disorders. Psychol Rep. 1999; 84(3 Pt 1):773-90.

15) Törnbom M, Ingelhammar E, Lilja H, Möller A, Svanberg Repeat abortion: a comparative study. B.J Psychosom Obstet Gynaecol. 1996; 17(4):208-14.

16) van Emmerik AA, Kamphuis JH, Emmelkamp PM. Clin Psychol Psychother. 2008; 15(6):378-85.

17) Vukelić J, Kapamadzija A, Kondić B. Investigation of risk factors for acute stress reaction following induced abortion. ed Pregl. 2010; 63(5-6):399-403.

18) Wiebe ER; Adams LC. Women's experience of viewing the products of conception after an abortion. Contraception 2009; 80 (6), pp. 575-7.

19) Wiebe ER, Trouton KJ, Fielding SL, Grant H, Henderson A. Anxieties and attitudes towards abortion in women presenting for medical and surgical abortions. J Obstet Gynaecol Can. 2004;26(10):881-5.

20) Wells N. Pain and distress during abortion Health Care Women Int. 1991; 12(3):293-302.

== Comments of Anne Speckhard, Ph.D. ==

In regard to NCCMH review, I would suggest that it completely fails to address the reality that each woman's unique and individual view of her abortion experience is the most important defining issue for what constitutes a trauma.

That means that if she perceives her pregnancy as involving a human life (i.e. in our research we keyed this as recognition of human life) and then furthermore attaches to that life (i.e. feels any type of attachment, refers to the embryo/fetus as "my baby", or herself as a mother, etc.) she has perceived/defined the abortion event in a manner that will make it likely to experience it as a criterion A stressor event capable of causing posttraumatic stress disorder.

We found these two variables - the woman's own recognition of life and attachment to be the highest predictors in our research of PTSD responses after an abortion.

On the other hand if she sees the abortion as nothing much for her, i.e. it is not experienced as a traumatic and she will not experience PTSD symptoms unless she is traumatized by other things which can also be additive in the first case (coercion to get the abortion, a very painful invasive experience, an abusive doctor or clinic protocol, even protestors outside the clinic, etc.)

From an outsiders perspective the first case (recognizing fetal life and attaching to it) can be seen as sick (the normal pro-choice view - that she is sick to define her pregnancy abortion experience so personally and relationally because after all it is not a human child) and the second case can also be seen as sick - morally detached, insensitive, or unhealthy because for her the abortion doesn't carry enough weight to be likely to cause her trauma (the view being expounded here from a pro-life perspective). Both are outsiders perspectives and can be argued strongly depending on the view of pregnancy that person holds. But what is operational for the woman and whether or not she suffers PTSD is not the view of the outsider but the woman's own view. She will experience trauma based on her own perceptions.

Likewise her own unique view can change overtime. She may be callous to her abortion at the time she has it but years later encounter a sonogram that deconstructs her first view that it's not a life worth worrying about and become deeply traumatized that what she aborted was (again in her view) deeply human and something she may at this late stage wish to make a relationship to (i.e. creating psychological presence of an aborted fetal child that she now grieves over). Again this is from her perspective and that is the only thing that matters as far as getting PTSD - in this case a delayed reaction.

Of course how others define things can also cause mental health problems. A woman who is traumatized but is told by her society to buck up as it was nothing has to go underground with her feelings and a woman who is condemned for feeling nothing can also find that difficult to deal with.

In either case though I want to emphasize for this discussion we really have to take into account the woman's own perspective.

I realize that says nothing about the critique of the study under question but I did want to comment that how we define "sick" is also often defined by our own views of the experience. Whereas actually becoming "sick" from an abortion experience may have much more to do with the individualistically defined view of the woman herself.

Anne Speckhard, Ph.D.

Adjunct Associate Professor of Psychiatry

Georgetown University Medical School
[http://annespeckhard.com annespeckhard.com]

==Comments of Philip Ney, M.D.==
This report confirms what has been known for at least 3 decades, abortion not only does not prevent mental illness, it aggravates every known mental illness. Abortion is contraindicated as treatment for mental ills. It must be made very clear to politicians etc, that this study only confirms the fact that abortion is not good treatment.

Without defining "wantedness" these authors write a conclusion that unwantedness is the real problem. Isn't it convenient? Now they can make wantedness mean anything that suits their purpose. My own research team has studied wantedness and found, (no surprise) that wantedness fluctuates hourly, depending on hormones, mood, partner, finances etc but following the first trimester when nausea and vomiting, partners hesitance dominate, wantedness grows throughout the pregnancy. Moreover wanting a child has very little relationship to wanting to not be pregnant. "Intendedness" is no better. So basing the results of such high blown research on such an ephemeral criteria is about as bad research as there can be.

No country in the world recognizes abortion as a woman's unfettered right. There is in no country I know where a woman can at any time in her pregnancy, for any reason, walk up to a physician and state "It's my right. I demand you abort my pregnancy right now." Why? Because it is illegal to practice bad medicine. And since the evidence from all studies and surveys shows there is no benefit, only various degrees of harm, abortion is bad medicine. This is what we must emphasize. On the other hand, abortion is legal everywhere if it is necessary to treat a disease like eclampsia, sometimes.

Statistics can blind as easily as illluminate. We must not forget that statistics are to find canaries (rare events) as they used to say in medical school or to determine if some small measure is significant ( important enough to be bothered with). If when you give some new medication to your patients and 1/2 die, statistics aren't needed. We are dealing with events that make huge differences in people. It is to our embarrassment we have such difficulty quantifying these changes. I believe in that regard, smaller samples using the subject as there own control and using Visual Analogue scales which can represent fine slices of the continuum which are almost always there, is the way forward. Besides its less expensive.

'''NOTE:''' A more complete review of the NCCMH review by Dr. Ney is "[http://www.webmedcentral.com/article_view/4429 A Common Sense Scientific Critique of the NCCMH and Royal College of Psychiatry Review]" WebMedCentral. REPRODUCTION 2013;4(10):WMC004429

==Comments of Martha Shuping, M.D.==
It has been shown in a number of studies that prior mental health, before the abortion, is a risk factor for more problems after the abortion. I don’t think anyone on either side of the issue disputes that. It is well established.

Therefore, it certainly accurate for the NCCMH report to note this fact. The problem is they treat it as being practically the only relevant finding and draw unsupported and misleading conclusions from it.

If you have a preconceived bias to defend abortion as a basic human right, it would be convenient to also believe that if people were having problems after abortion, it was purely and simply due to the fact that they were troubled individuals to start with.

Interestingly, in some countries, abortion has been legal specifically in cases in which the woman is believed to be suicidal. I know women in England who tell me they were coached by counselors to tell the doctor, “I will commit suicide if I have to have this baby,” and they were not really suicidal but they said it to get the abortion. So abortion is permitted or advocated in some cases because a woman has mental health problems though the data indicate that these are the women who are more vulnerable to problems after abortion. It would make sense to spend some time doing more counseling at the front end to explore whether this woman truly wants the abortion, whether she understands her risks and so on, rather than actually advocating for the abortion, since this is a vulnerable population, and their mental health actually may be worsened by the abortion rather than improved by the abortion. So it is paradoxical in a way that these are the very women who in countries are given access to abortion when others are not or where it is viewed in some way as a solution, when of course abortion has never been demonstrated as evidence based treatment for suicidal ideation or for any psychiatric illness.

From my own experience with large numbers of women in abortion recovery programs, I believe that many women are having mental health problems after abortion who did not have problems before, and also that those who did have problems before now have problems that are qualitatively and quantitatively more severe after the abortion.

The women themselves can often pinpoint the start of their problems to the time of the abortion, and their symptoms often specifically relate to the abortion such as nightmares about dead babies or dreams about crying babies, having panic attacks when they are around things or places that remind them of the abortion, and so on. But you do not get at this type of information in the larger studies with huge databases; you only get the general before and after perhaps from insurance claims or health records as far as past diagnoses and dates of treatment.

When one is doing record based studies, there is important information to be gained, but in doing qualitative studies, or doing studies that could be designed to interview women very specifically about their experience, one might discover there are specific aspects about the symptoms that tend to indicate the post-abortion symptoms are related to the abortion, and not related to prior mental health issues. Someone could have had transient depression during high school or college, but then develop PTSD after the abortion. If they are having nightmares about dead babies after the abortion but not before, and then finding they need to consume alcohol to sleep at night, these would seem to be new problems.

From my experience, my opinion is that there are many women with new onset of mental health problems after abortion, and many with different and more severe problems after the abortion. I think this has not been fully captured or demonstrated by current studies. But certainly there are some excellent studies that do control for prior mental health and show that past abortion is in itself a risk factor for mental health problems. These studies support what I have seen in clinical experience. It is not “only” the past mental health that is the complete and total cause of all abortion related problems, because some studies controlled for prior mental health and still show abortion as a risk factor for mental health problems after abortion.

-------

A major weakness of this review is the oversimplified way in which they collapse mental health problems into being all the same. If there are “problems” after birth and “problems” after abortion, the reviewers treat these as equal without looking at the nature of the problems and how long these problems last.

This occurs, for example, in a study looking at Medicaid claims to see if there was any mental health treatment in the year prior to the abortion, and then perhaps look at claims after. In these exploratory studies, they are just looking for the “yes” that there was past mental health treatment, and not necessarily the number of times treatment was received or the seriousness of the disorder or how long it lasted. Typically researchers would only be considering whether or not there was a diagnosis or treatment. And it would tend to serve the viewpoint of those who favor abortion if it was all treated equally.

Similarly, the reviewers appear to asserting that while, yes, there can be problems after abortion, there can also be problems after childbirth, and so it is all equal.

But they are not equal. Consider, for example, a woman I know who was in her 80’s who was still having grief and guilt concerning a past abortion from about fifty years earlier, who contacted me for help with an abortion related issue. Also, on abortion recovery weekends, I have taken women in their 60’s who are now grandmothers who still have grief and guilt concerning past abortions.

So, yes, it is true that women can have post-partum depression after having a baby, but my experience with post-partum depression is that it resolves on medication within a few weeks. I have never seen women in their 60’s or their 80’s with post-partum depression. In contrast, I have experience with women in their 60’s and even 80’s who are still having symptoms they specifically attribute to their abortion, which seem to be abortion related.

So, no, the severity or the duration of the post-abortion problems are not being considered.

Keep in mind that many women do meet criteria for posttraumatic stress disorder after abortion, for example, about 18% in a 2007 study by Suliman in South Africa. The authors considered this “high.” They were concerned that almost one in five women in their study had PTSD after their abortion.

There are studies showing that PTSD is a very long lasting disorder that can be very disabling, so it is a more serious psychiatric illness.

Studies that only look at mental health after abortion vs. mental health after childbirth are perhaps unintentionally misleading if they consider only whether the person was diagnosed or whether the person had treatment in a particular time frame in a “yes or no” fashion. It is important to know the nature, severity and duration of the disorders in question and that would be more difficult information to obtain. You can find out from medical records or insurance claims whether or not a person had treatment in a particular period of time after the end of the pregnancy, yes or no. But to follow women to see who is still experiencing symptoms in their 60’s or 80’s would be a very long study indeed, and it is difficult to study women for decades.

Similarly, if we are considering mental health before the abortion vs. mental health after the abortion, it would also be good to consider not simply whether or not treatment occurred, but what was the severity and duration of the illness, and again this can be difficult to determine. For some women, their symptoms may emerge later, and may be severe and long-lasting, sometimes persisting for decades.

These questions are not being carefully considered, but they would be difficult studies to do.

But, there are clearly are studies that use control groups, that do control fro prior mental health, and that show abortion itself is a risk factor for mental health problems in women after abortion. It by no means only women with prior mental health problems who are having the problems after abortion. But when they do make the comparison and treat the problems before and after as equivalent, they have not truly demonstrated whether the two conditions are in fact equivalent.

==Other Notes==

===Rating Scale Misleading===
The rating scale for studies was strongly criticized by a number of reviewers during the first draft for it's failure to rank studies for women refusing to participate or dropping out of the study before completion. The review team acknowledged this problem but provided only a fake fix.

The "fix" was adding a new category, "Representativeness" to table 3, p28. As described on page 29, the criteria for this scale were so watered down that all the studies with high drop out rates were still allowed to score high. Indeed, a study could have over a 50% refusal or drop out rate and still be rated as "+" as long as the authors provided even a mediocre statistical comparison of the participants and non-participants....even if the comparison showed significant differences!

The rating scale appears to have also been designed, or at least interpreted, to specifically justify rating the Finland record based studies on suicide as "very poor" -- even though they revealed a 650% increased risk of suicide. They also ignored the Morgan study, published in BMJ with data.

===Incorrectly classified studies===
*Three prospective cohort studies using record linkage (Coleman2003A, Reardon2002A, Reardon2003A) were improperly listed as "retrospective." Oddly, Munk-Olsen2011 which used the same methodology was correctly listed. In the discussion section (p59) the authors also wrongly describe these three studies as based on a sample of women whose first pregnancies ended in abortion. In fact, the sample included all women who had any pregnancy outcome within a specific period, and as a cross sectional snapshot, it did not have information on whether these were first, second, third or higher order pregnancies.

*Findings from the above studies were not completely reported in Table 9, including for example, the rates reported for bipolar disorder in Reardon2002A (OR 3.0, 95% CI 1.5-6.0). They were also rated as "poor" while Munk-Olsen2011 was rated good, even though there was no significant difference in study design. Indeed, Munk-Olsen2011 is arguably much poorer given mixing of women into both groups, shorter followup (only one year rather than four years), the failure to control for mental health treatment rates prior to pregnancy for delivering women, and other roblems.

*A number of studies are described as prospective (the Broen, Major, Rizzardo and Suliman) when they would be better described as case series studies, since they have no data prior to the abortion and simply follow the cases for a period of time.

*Reardon2006 was excluded for the specious reason "sleep disorders beyond scope of the review"--but that was an arbitrary decision, since clearly sleep disorders can be due to mental health problems, indeed, they are strongly linked to PTSD.

===Misc===
*They incorrectly excluded Soderberg (p171) stating that the sample included distressed women. In fact, the sample included all women who had abortions.

==Official Comments and Responses==

The most complete listing of shortcomings of this review, including explanations for why key issues were not covered in the report, are found in the NCCMH's companion document to the report "[http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf Comments and Responses], see especially pages 95-103.]"

New Summary of Evidence Linking Abortion to Mental Health Problems

2025-10-10T17:27:51Z

Barb: /* Differences in Mental Health Outcomes Reported by Auger (2025) */

=== Overview ===
Peer-reviewed research published after 2010 has explored potential negative mental health effects associated with induced abortion, often through systematic reviews, cohort studies, and cross-sectional analyses. While the broader literature includes debates and studies finding no causal links, the following summarizes key publications that specifically report negative associations, such as increased risks of depression, anxiety, substance use disorders, and other mental health issues. These findings are drawn from diverse populations and methodologies, with some highlighting factors like pre-existing conditions or unwanted pregnancies as moderators. Prevalence rates and risks vary, and many studies note limitations like self-reporting biases or heterogeneity in data.

=== Systematic Reviews and Meta-Analyses ===
A 2011 quantitative synthesis analyzed 22 studies (published 1995–2009, but the review itself post-2010) involving over 877,000 participants, finding that women with a history of abortion had an 81% increased risk of mental health problems overall, including 37% higher risk of depression, 110% higher risk of alcohol misuse, and 155% higher risk of suicidal behaviors.<ref>Coleman PK. [https://pubmed.ncbi.nlm.nih.gov/21881096/ Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009]. Br J Psychiatry. 2011 Sep;199(3):180-6. doi: 10.1192/bjp.bp.110.077230. PMID: 21881096.</ref> The analysis controlled for variables like prior mental health but faced criticism for methodological flaws in subsequent critiques.

A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior. Anxiety risks were higher but not statistically significant.

The 2018 comprehensive literature review by Reardon examined the abortion and mental health controversy, identifying common ground and disagreements. It noted that abortion is consistently associated with elevated rates of mental illness compared to women without an abortion history, and that the abortion experience directly contributes to mental health problems for at least some women. Risk factors such as pre-existing mental illness were highlighted as predictors of greater vulnerability. The review emphasized obstacles like multiple causation pathways, indeterminate reaction timelines, and ideological biases in research. It reported relative risks from various studies, with abortion linked to higher mental health risks (e.g., relative risk ratios from 1.5 to 5.5 for conditions like depression and anxiety across datasets). Population attributable risks were estimated at 8-28% for mental illnesses post-abortion. Recommendations included mixed research teams and better data sharing to address biases. Figures included relative risk comparisons and population attributable fractions for suicide attempts and other outcomes.

A 2023 systematic review and meta-analysis estimated the global prevalence of post-abortion depression at 34.5% (95% CI: 23.34–45.68) based on 15 observational studies involving 18,207 participants, primarily published between 2010 and 2023.<ref>Gebeyehu, N.A., Tegegne, K.D., Abebe, K. ''et al.'' Global prevalence of post-abortion depression: systematic review and Meta-analysis. ''BMC Psychiatry'' 23, 786 (2023). <nowiki>https://doi.org/10.1186/s12888-023-05278-7</nowiki>https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-023-05278-7</ref> The studies were mainly cross-sectional or cohort designs from regions including Asia, Europe, Africa, and Australia, with higher prevalence in lower-middle-income countries (42.91%) and Asia (37.5%). Associated factors included socioeconomic status, geographical location, and screening tools used (e.g., higher rates with the Center for Epidemiological Studies Depression Scale). Limitations included publication bias, lack of representation from some continents, and inconsistent diagnostic criteria.

=== Cohort and Longitudinal Studies ===
A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior.<ref>Fergusson, David M., L. John Horwood, and Joseph M. Boden. "Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence." ''Australian & New Zealand journal of psychiatry'' 47.9 (2013): 819-827.</ref> Anxiety risks were higher but not statistically significant.

In a 2016 U.S. longitudinal study using National Longitudinal Study of Adolescent to Adult Health data (Sullins), abortion was linked to a 54% increased risk of mental health disorders in late adolescence and early adulthood, with additive effects for multiple abortions.<ref>D. P. Sullins, “Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States,” SAGE Open Med 4 (2016)</ref> The study suggested emotional distress from the abortion experience itself contributed to these outcomes.

A 2017 prospective cohort study in the Netherlands (van Ditzhuijzen et al.) reported increased recurrence of common mental disorders post-abortion among women with prior mental health histories, identifying pre-existing conditions as a key risk factor.<ref>J. van Ditzhuijzen et al., “Incidence and Recurrence of Common Mental Disorders after Abortion: Results from a Prospective Cohort Study,” J Psychiatr Res 84 (2017).</ref>

A 2023 cohort study by Studnicki et al. followed 4,848 continuously eligible Medicaid beneficiaries (aged 16 in 1999) through 2015, comparing first-pregnancy abortion (n=1,331) to birth (n=3,517) cohorts.<ref>Studnicki, James, et al. "A cohort study of mental health services utilization following a first pregnancy abortion or birth." ''International Journal of Women's Health'' (2023): 955-963.</ref> Women with abortions had higher risks post-pregnancy outcome: outpatient visits (RR 2.10, 95% CI 2.08-2.12; OR 3.36, 95% CI 3.29-3.42), inpatient admissions (RR 2.75, 95% CI 2.38-3.18; OR 5.67, 95% CI 4.39-7.32), and inpatient days of stay (RR 7.38, 95% CI 6.83-7.97; OR 19.64, 95% CI 17.70-21.78). Abortion cohort women had shorter pre-outcome exposure (6.43 vs. 7.80 years) but longer post-outcome (10.57 vs. 9.20 years). Pre-outcome utilization was higher in the birth cohort, challenging the notion that pre-existing conditions fully explain post-abortion effects. Figures showed utilization rates per patient per year for outpatient visits, inpatient admissions, and days of stay. No conflicts of interest were reported.

A 2025 retrospective cohort study by Auger et al. analyzed 1,257,528 pregnancies (28,721 induced abortions and 1,228,807 births) in Quebec, Canada, from 2006 to 2022, following participants up to 17 years post-pregnancy.<ref>Auger, Nathalie, et al. "Induced abortion and implications for long-term mental health: a cohort study of 1.2 million pregnancies." ''Journal of Psychiatric Research'' (2025).</ref> Hazard ratios were calculated after adjusting for age and time period at the time of the pregnancy, preexisting mental illnesses, comorbidity (obesity, hypertension, diabetes mellitus, dyslipidemia), socioeconomic status, education, employment, rural/urban residence. Rates of mental health-related hospitalizations were higher following induced abortions (104.0 per 10,000 person-years) than other pregnancies (42.0 per 10,000 person-years). Induced abortion was associated with increased risks of hospitalization for psychiatric disorders (HR 1.81, 95% CI 1.72-1.90), substance use disorders (HR 2.57, 95% CI 2.41-2.75), and suicide attempts (HR 2.16, 95% CI 1.91-2.43). Associations were stronger for women with pre-existing mental illness or those under 25 years old, and risks were elevated within five years post-abortion but decreased over time. The study adjusted for pregnancy characteristics but did not explicitly detail limitations in the abstract. The adjusted population attributable risk (PAR) calculations suggest that 2.0% of all psychiatric admissions, 2.2% of suicide attempts and 2.6% of substance use disorders are attributable to abortion. The PAF estimates the fraction of each disease in the population that would be eliminated if the exposure were removed, assuming the adjusted HR represents a causal effect and that all confounders have been adequately measured and controlled for. Notably, among women with prior mental health issues, psychiatric hospitalization was nine times more likely for those who had abortions. In contrast, among women without prior mental health issues, abortion was linked to only a 50% increased risk of psychiatric hospitalization. The risk of psychiatric admissions generally declined over time, nearly disappearing after twelve years. The exception was for substance use disorders, which while declining remained significantly elevated throughout the sixteen years examined by the research team. The study also observed that the risk of psychiatric treatment increased with the number of abortions women experienced. This is a “dose effect.” It means each abortion exposure increased the risk of a mental health disorder requiring hospitalization. Observation of a dose effect is generally considered to be strong evidence of a direct causal pathway between a risk factor (abortion) and a statistically associated outcome (hospitalization for mental health).

=== Differences in Mental Health Outcomes Reported by Auger (2025) ===
{| class="wikitable"
|
| colspan="2" |'''Rate per 10,000 person-years'''
|'''Adjusted HR'''
|'''Adj PAR'''
|-
|
| colspan="2" |'''(95% CI)'''
|'''(95% CI)a'''
|
|-
|
|'''Abortion'''
|'''Live birth'''
|
|
|-
|'''Any mental health admission'''
|104.0 (100.2-108.0)
|41.8 (41.5-42.2)
|1.92 (1.83-2.01)
|2.02%
|-
|'''Psychiatric disorder'''
|85.1 (81.7-88.7)
|37.0 (36.6-37.3)
|1.81 (1.73-1.91)
|1.81%
|-
|Bipolar
|8.7 (7.7-9.9)
|4.3 (4.2-4.5)
|1.45 (1.25-1.68)
|1.01%
|-
|Depression
|24.7 (22.9-26.6)
|12.1 (11.9-12.3)
|1.65 (1.51-1.80)
|1.43%
|-
|Anxiety and stress
|54.8 (52.1-57.7)
|23.8 (23.6-24.1)
|1.81 (1.70-1.92)
|1.81%
|-
|Eating
|2.4 (1.9-3.1)
|0.7 (0.7-0.8)
|2.25 (1.67-3.04)
|2.78%
|-
|Psychosis
|9.2 (8.1-10.4)
|3.1 (3.0-3.2)
|2.06 (1.78-2.39)
|2.38%
|-
|Personality
|33.0 (30.9-35.3)
|9.7 (9.5-9.9)
|2.26 (2.08-2.45)
|2.78%
|-
|'''Substance use disorder'''
|56.7 (53.9-59.6)
|14.9 (14.7-15.1)
|2.58 (2.42-2.76)
|3.47%
|-
|Alcohol
|27.8 (25.9-29.8)
|7.4 (7.2-7.6)
|2.50 (2.28-2.74)
|3.30%
|-
|Opioids
|6.0 (5.1-7.0)
|1.2 (1.1-1.3)
|3.26 (2.69-3.95)
|4.89%
|-
|Cannabis
|17.7 (16.2-19.3)
|4.3 (4.2-4.4)
|2.58 (2.30-2.89)
|3.47%
|-
|Cocaine
|13.6 (12.3-15.1)
|2.5 (2.4-2.5)
|3.47 (3.02-3.98)
|5.31%
|-
|Stimulant
|15.7 (14.3-17.3)
|3.5 (3.4-3.6)
|2.78 (2.45-3.15)
|3.89%
|-
|Hallucinogen
|0.8 (0.5-1.2)
|0.1 (0.1-0.1)
|5.19 (2.78-9.67)
|8.66%
|-
|Sedative
|10.5 (9.3-11.8)
|2.5 (2.4-2.6)
|2.86 (2.46-3.31)
|4.05%
|-
|Other illicit substance
|0.5 (0.3-0.9)
|0.1 (0.1-0.1)
|5.37 (2.57-11.23)
|9.11%
|-
|'''Suicide attempt'''
|14.7 (13.3-16.2)
|4.4 (4.3-4.5)
|2.16 (1.92-2.43)
|2.58%
|}

=== Cross-Sectional and Regional Studies ===
A 2012 cross-sectional study in Tehran, Iran (Dadkhah et al.), involving 261 women seeking post-abortion care, found that over one-third experienced psychological side effects, including depression (60.5%), worry about future conception (53.6%), abnormal eating behaviors (48.7%), decreased self-esteem (43.7%), nightmares (39.5%), guilt (37.5%), and regret (33.3%).<ref>Pourreza A, Batebi A. Psychological Consequences of Abortion among the Post Abortion Care Seeking Women in Tehran. Iran J Psychiatry. 2011 Winter;6(1):31-6. PMID: 22952518; PMCID: PMC3395931.</ref> Less common were suicide attempts (4.7%), smoking (2.7%), and drug abuse (1.5%). The study highlighted cultural stigmas exacerbating these effects.

The best data on American women is found in a 2016 study using the National Longitudinal Study of Adolescent to Adult Health (Add Health) that provided three models of analyses, including controls for eight confounding factors.<ref name=":0">Donald Paul Sullins, ''Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States'', 4 SAGE Open Med. 6 (2016).</ref> In addition, the author conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” These lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. This study also identified a dose effect, with ''each exposure to abortion'' (up to four) associated with a 23 percent increase of relative risk of subsequent mental disorders.<ref name=":0" /> In addition, a subsequent 2019 analysis using the same data set revealed that approximately 20% of the women having abortions reported wanting the child.<ref>Donald Paul Sullins, ''Affective and Substance Abuse Disorders Following Abortion by Pregnancy Intention in the United States : A Longitudinal Cohort Study'', 55 Medicina (Mex.) 2 (2019).</ref> Unsurprisingly, the women who aborted wanted children experienced 122% higher rate of depression and a 244% higher rate of suicidality. In addition, the author conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” These lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. The study also identified a dose effect, with each exposure to abortion (up to four) associated with a 23 percent (95% CI, 1.16–1.30) increase of relative risk of subsequent mental disorders. In addition, a subsequent 2019 analysis using the same data set revealed that approximately 20% of the women having abortions reported wanting the child.[81] Unsurprisingly, the women who aborted wanted children experienced higher rates of depression (RR 2.22, 95% CI 1.3–3.8) and suicidality (RR 3.44 95% CI 1.5–7.7). Notably, no refutation of these findings has been published. They are undisputed.

A 2025 cross-sectional survey by Reardon involved 2,829 American females aged 41-45, examining suicide risks by pregnancy outcomes. Aborting women were twice as likely to have attempted suicide compared to others. Those with abortions, especially coerced or unwanted ones, reported higher self-assessed contributions of the abortion to suicidal thoughts, self-destructive behaviors, and attempts (measured via visual analog scales). The study challenged the hypothesis that pre-existing mental health fully explains elevated suicide rates post-abortion, as women's self-reports indicated direct contributions from the abortion experience. No conflicts were noted.

=== Additional Context from Reviews ===
The literature published since 2010 has focused on controlling for the effects of prior mental health and has revealed links between abortion and worsened mental health for some women.

'''References'''
<references />

New Summary of Evidence Linking Abortion to Mental Health Problems

2025-10-09T23:22:29Z

Barb: /* Cohort and Longitudinal Studies */

=== Overview ===
Peer-reviewed research published after 2010 has explored potential negative mental health effects associated with induced abortion, often through systematic reviews, cohort studies, and cross-sectional analyses. While the broader literature includes debates and studies finding no causal links, the following summarizes key publications that specifically report negative associations, such as increased risks of depression, anxiety, substance use disorders, and other mental health issues. These findings are drawn from diverse populations and methodologies, with some highlighting factors like pre-existing conditions or unwanted pregnancies as moderators. Prevalence rates and risks vary, and many studies note limitations like self-reporting biases or heterogeneity in data.

=== Systematic Reviews and Meta-Analyses ===
A 2011 quantitative synthesis analyzed 22 studies (published 1995–2009, but the review itself post-2010) involving over 877,000 participants, finding that women with a history of abortion had an 81% increased risk of mental health problems overall, including 37% higher risk of depression, 110% higher risk of alcohol misuse, and 155% higher risk of suicidal behaviors.<ref>Coleman PK. [https://pubmed.ncbi.nlm.nih.gov/21881096/ Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009]. Br J Psychiatry. 2011 Sep;199(3):180-6. doi: 10.1192/bjp.bp.110.077230. PMID: 21881096.</ref> The analysis controlled for variables like prior mental health but faced criticism for methodological flaws in subsequent critiques.

A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior. Anxiety risks were higher but not statistically significant.

The 2018 comprehensive literature review by Reardon examined the abortion and mental health controversy, identifying common ground and disagreements. It noted that abortion is consistently associated with elevated rates of mental illness compared to women without an abortion history, and that the abortion experience directly contributes to mental health problems for at least some women. Risk factors such as pre-existing mental illness were highlighted as predictors of greater vulnerability. The review emphasized obstacles like multiple causation pathways, indeterminate reaction timelines, and ideological biases in research. It reported relative risks from various studies, with abortion linked to higher mental health risks (e.g., relative risk ratios from 1.5 to 5.5 for conditions like depression and anxiety across datasets). Population attributable risks were estimated at 8-28% for mental illnesses post-abortion. Recommendations included mixed research teams and better data sharing to address biases. Figures included relative risk comparisons and population attributable fractions for suicide attempts and other outcomes.

A 2023 systematic review and meta-analysis estimated the global prevalence of post-abortion depression at 34.5% (95% CI: 23.34–45.68) based on 15 observational studies involving 18,207 participants, primarily published between 2010 and 2023.<ref>Gebeyehu, N.A., Tegegne, K.D., Abebe, K. ''et al.'' Global prevalence of post-abortion depression: systematic review and Meta-analysis. ''BMC Psychiatry'' 23, 786 (2023). <nowiki>https://doi.org/10.1186/s12888-023-05278-7</nowiki>https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-023-05278-7</ref> The studies were mainly cross-sectional or cohort designs from regions including Asia, Europe, Africa, and Australia, with higher prevalence in lower-middle-income countries (42.91%) and Asia (37.5%). Associated factors included socioeconomic status, geographical location, and screening tools used (e.g., higher rates with the Center for Epidemiological Studies Depression Scale). Limitations included publication bias, lack of representation from some continents, and inconsistent diagnostic criteria.

=== Cohort and Longitudinal Studies ===
A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior.<ref>Fergusson, David M., L. John Horwood, and Joseph M. Boden. "Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence." ''Australian & New Zealand journal of psychiatry'' 47.9 (2013): 819-827.</ref> Anxiety risks were higher but not statistically significant.

In a 2016 U.S. longitudinal study using National Longitudinal Study of Adolescent to Adult Health data (Sullins), abortion was linked to a 54% increased risk of mental health disorders in late adolescence and early adulthood, with additive effects for multiple abortions.<ref>D. P. Sullins, “Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States,” SAGE Open Med 4 (2016)</ref> The study suggested emotional distress from the abortion experience itself contributed to these outcomes.

A 2017 prospective cohort study in the Netherlands (van Ditzhuijzen et al.) reported increased recurrence of common mental disorders post-abortion among women with prior mental health histories, identifying pre-existing conditions as a key risk factor.<ref>J. van Ditzhuijzen et al., “Incidence and Recurrence of Common Mental Disorders after Abortion: Results from a Prospective Cohort Study,” J Psychiatr Res 84 (2017).</ref>

A 2023 cohort study by Studnicki et al. followed 4,848 continuously eligible Medicaid beneficiaries (aged 16 in 1999) through 2015, comparing first-pregnancy abortion (n=1,331) to birth (n=3,517) cohorts.<ref>Studnicki, James, et al. "A cohort study of mental health services utilization following a first pregnancy abortion or birth." ''International Journal of Women's Health'' (2023): 955-963.</ref> Women with abortions had higher risks post-pregnancy outcome: outpatient visits (RR 2.10, 95% CI 2.08-2.12; OR 3.36, 95% CI 3.29-3.42), inpatient admissions (RR 2.75, 95% CI 2.38-3.18; OR 5.67, 95% CI 4.39-7.32), and inpatient days of stay (RR 7.38, 95% CI 6.83-7.97; OR 19.64, 95% CI 17.70-21.78). Abortion cohort women had shorter pre-outcome exposure (6.43 vs. 7.80 years) but longer post-outcome (10.57 vs. 9.20 years). Pre-outcome utilization was higher in the birth cohort, challenging the notion that pre-existing conditions fully explain post-abortion effects. Figures showed utilization rates per patient per year for outpatient visits, inpatient admissions, and days of stay. No conflicts of interest were reported.

A 2025 retrospective cohort study by Auger et al. analyzed 1,257,528 pregnancies (28,721 induced abortions and 1,228,807 births) in Quebec, Canada, from 2006 to 2022, following participants up to 17 years post-pregnancy.<ref>Auger, Nathalie, et al. "Induced abortion and implications for long-term mental health: a cohort study of 1.2 million pregnancies." ''Journal of Psychiatric Research'' (2025).</ref> Hazard ratios were calculated after adjusting for age and time period at the time of the pregnancy, preexisting mental illnesses, comorbidity (obesity, hypertension, diabetes mellitus, dyslipidemia), socioeconomic status, education, employment, rural/urban residence. Rates of mental health-related hospitalizations were higher following induced abortions (104.0 per 10,000 person-years) than other pregnancies (42.0 per 10,000 person-years). Induced abortion was associated with increased risks of hospitalization for psychiatric disorders (HR 1.81, 95% CI 1.72-1.90), substance use disorders (HR 2.57, 95% CI 2.41-2.75), and suicide attempts (HR 2.16, 95% CI 1.91-2.43). Associations were stronger for women with pre-existing mental illness or those under 25 years old, and risks were elevated within five years post-abortion but decreased over time. The study adjusted for pregnancy characteristics but did not explicitly detail limitations in the abstract. The adjusted population attributable risk (PAR) calculations suggest that 2.0% of all psychiatric admissions, 2.2% of suicide attempts and 2.6% of substance use disorders are attributable to abortion. The PAF estimates the fraction of each disease in the population that would be eliminated if the exposure were removed, assuming the adjusted HR represents a causal effect and that all confounders have been adequately measured and controlled for. Notably, among women with prior mental health issues, psychiatric hospitalization was nine times more likely for those who had abortions. In contrast, among women without prior mental health issues, abortion was linked to only a 50% increased risk of psychiatric hospitalization. The risk of psychiatric admissions generally declined over time, nearly disappearing after twelve years. The exception was for substance use disorders, which while declining remained significantly elevated throughout the sixteen years examined by the research team. The study also observed that the risk of psychiatric treatment increased with the number of abortions women experienced. This is a “dose effect.” It means each abortion exposure increased the risk of a mental health disorder requiring hospitalization. Observation of a dose effect is generally considered to be strong evidence of a direct causal pathway between a risk factor (abortion) and a statistically associated outcome (hospitalization for mental health).

=== '''Differences in Mental Health Outcomes Reported by Auger (2025)''' ===
{| class="wikitable"
|
| colspan="2" |'''Rate per 10,000 person-years'''
|'''Adjusted HR'''
|'''Adj PAR'''
|-
|
| colspan="2" |'''(95% CI)'''
|'''(95% CI)a'''
|
|-
|
|'''Abortion'''
|'''Live birth'''
|
|
|-
|'''Any mental health admission'''
|104.0 (100.2-108.0)
|41.8 (41.5-42.2)
|1.92 (1.83-2.01)
|2.02%
|-
|'''Psychiatric disorder'''
|85.1 (81.7-88.7)
|37.0 (36.6-37.3)
|1.81 (1.73-1.91)
|1.81%
|-
|Bipolar
|8.7 (7.7-9.9)
|4.3 (4.2-4.5)
|1.45 (1.25-1.68)
|1.01%
|-
|Depression
|24.7 (22.9-26.6)
|12.1 (11.9-12.3)
|1.65 (1.51-1.80)
|1.43%
|-
|Anxiety and stress
|54.8 (52.1-57.7)
|23.8 (23.6-24.1)
|1.81 (1.70-1.92)
|1.81%
|-
|Eating
|2.4 (1.9-3.1)
|0.7 (0.7-0.8)
|2.25 (1.67-3.04)
|2.78%
|-
|Psychosis
|9.2 (8.1-10.4)
|3.1 (3.0-3.2)
|2.06 (1.78-2.39)
|2.38%
|-
|Personality
|33.0 (30.9-35.3)
|9.7 (9.5-9.9)
|2.26 (2.08-2.45)
|2.78%
|-
|'''Substance use disorder'''
|56.7 (53.9-59.6)
|14.9 (14.7-15.1)
|2.58 (2.42-2.76)
|3.47%
|-
|Alcohol
|27.8 (25.9-29.8)
|7.4 (7.2-7.6)
|2.50 (2.28-2.74)
|3.30%
|-
|Opioids
|6.0 (5.1-7.0)
|1.2 (1.1-1.3)
|3.26 (2.69-3.95)
|4.89%
|-
|Cannabis
|17.7 (16.2-19.3)
|4.3 (4.2-4.4)
|2.58 (2.30-2.89)
|3.47%
|-
|Cocaine
|13.6 (12.3-15.1)
|2.5 (2.4-2.5)
|3.47 (3.02-3.98)
|5.31%
|-
|Stimulant
|15.7 (14.3-17.3)
|3.5 (3.4-3.6)
|2.78 (2.45-3.15)
|3.89%
|-
|Hallucinogen
|0.8 (0.5-1.2)
|0.1 (0.1-0.1)
|5.19 (2.78-9.67)
|8.66%
|-
|Sedative
|10.5 (9.3-11.8)
|2.5 (2.4-2.6)
|2.86 (2.46-3.31)
|4.05%
|-
|Other illicit substance
|0.5 (0.3-0.9)
|0.1 (0.1-0.1)
|5.37 (2.57-11.23)
|9.11%
|-
|'''Suicide attempt'''
|14.7 (13.3-16.2)
|4.4 (4.3-4.5)
|2.16 (1.92-2.43)
|2.58%
|}

=== Cross-Sectional and Regional Studies ===
A 2012 cross-sectional study in Tehran, Iran (Dadkhah et al.), involving 261 women seeking post-abortion care, found that over one-third experienced psychological side effects, including depression (60.5%), worry about future conception (53.6%), abnormal eating behaviors (48.7%), decreased self-esteem (43.7%), nightmares (39.5%), guilt (37.5%), and regret (33.3%).<ref>Pourreza A, Batebi A. Psychological Consequences of Abortion among the Post Abortion Care Seeking Women in Tehran. Iran J Psychiatry. 2011 Winter;6(1):31-6. PMID: 22952518; PMCID: PMC3395931.</ref> Less common were suicide attempts (4.7%), smoking (2.7%), and drug abuse (1.5%). The study highlighted cultural stigmas exacerbating these effects.

The best data on American women is found in a 2016 study using the National Longitudinal Study of Adolescent to Adult Health (Add Health) that provided three models of analyses, including controls for eight confounding factors.<ref name=":0">Donald Paul Sullins, ''Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States'', 4 SAGE Open Med. 6 (2016).</ref> In addition, the author conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” These lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. This study also identified a dose effect, with ''each exposure to abortion'' (up to four) associated with a 23 percent increase of relative risk of subsequent mental disorders.<ref name=":0" /> In addition, a subsequent 2019 analysis using the same data set revealed that approximately 20% of the women having abortions reported wanting the child.<ref>Donald Paul Sullins, ''Affective and Substance Abuse Disorders Following Abortion by Pregnancy Intention in the United States : A Longitudinal Cohort Study'', 55 Medicina (Mex.) 2 (2019).</ref> Unsurprisingly, the women who aborted wanted children experienced 122% higher rate of depression and a 244% higher rate of suicidality. In addition, the author conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” These lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. The study also identified a dose effect, with each exposure to abortion (up to four) associated with a 23 percent (95% CI, 1.16–1.30) increase of relative risk of subsequent mental disorders. In addition, a subsequent 2019 analysis using the same data set revealed that approximately 20% of the women having abortions reported wanting the child.[81] Unsurprisingly, the women who aborted wanted children experienced higher rates of depression (RR 2.22, 95% CI 1.3–3.8) and suicidality (RR 3.44 95% CI 1.5–7.7). Notably, no refutation of these findings has been published. They are undisputed.

A 2025 cross-sectional survey by Reardon involved 2,829 American females aged 41-45, examining suicide risks by pregnancy outcomes. Aborting women were twice as likely to have attempted suicide compared to others. Those with abortions, especially coerced or unwanted ones, reported higher self-assessed contributions of the abortion to suicidal thoughts, self-destructive behaviors, and attempts (measured via visual analog scales). The study challenged the hypothesis that pre-existing mental health fully explains elevated suicide rates post-abortion, as women's self-reports indicated direct contributions from the abortion experience. No conflicts were noted.

=== Additional Context from Reviews ===
The literature published since 2010 has focused on controlling for the effects of prior mental health and has revealed links between abortion and worsened mental health for some women.

'''References'''
<references />

Abortion and Maternal Mortality

2025-10-08T17:13:45Z

Barb: /* Record Based Studies */

{{DEA}} {{PhysicalIndex}} [[Submit Maternal Mortality|Please Submit New Material for This Protected Page Here]]

 

== Review Articles Relative to Maternal Death from Abortion ==
[https://www.tandfonline.com/doi/abs/10.1080/07399332.2019.1566332 The risk of cardiovascular disease in women with a history of miscarriage and/or stillbirth.] Asgharvahedi F, Gholizadeh L, Siabani S. Health Care Women Int. 2019 Oct;40(10):1117-1131. doi: 10.1080/07399332.2019.1566332. Epub 2019 Apr 5.

:Cardiovascular disease (CVD) remains the main cause of morbidity and mortality in women worldwide. Apart from the well-established risk factors, some adverse pregnancy outcomes have been found to be associated with increased risk of CVD in women. We reviewed the literature on the risk of CVD in women with a history of pregnancy loss (miscarriage and/or stillbirth). Electronic databases including MEDLINE and CINAHL were searched for English language articles published from 2000 to July 2016. Following the application of study inclusion and exclusion criteria, we selected seven studies for review. Women with history of miscarriage and/or stillbirth are more likely to develop coronary heart disease (CHD), but not stroke in their later life compared with women without these conditions. The risk is particularly greater in women with multiple miscarriages or stillbirths. Health professionals should be aware of the risk associated with miscarriage and stillbirth, and use maternal history to identify, refer, closely monitor, and engage these high risk women in healthy lifestyle and risk factor modification programs.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5692130/ Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis.] Reardon DC, Thorp JM. SAGE Open Med. 2017 Nov 13;5:2050312117740490. doi: 10.1177/2050312117740490. eCollection 2017.

:OBJECTIVES: Measures of pregnancy associated deaths provide important guidance for public health initiatives. Record linkage studies have significantly improved identification of deaths associated with childbirth but relatively few have also examined deaths associated with pregnancy loss even though higher rates of maternal death have been associated with the latter. Following PRISMA guidelines we undertook a systematic review of record linkage studies examining the relative mortality risks associated with pregnancy loss to develop a narrative synthesis, a meta-analysis, and to identify research opportunities.

:METHODS: MEDLINE and SCOPUS were searched in July 2015 using combinations of: mortality, maternal death, record linkage, linked records, pregnancy associated mortality, and pregnancy associated death to identify papers using linkage of death certificates to independent records identifying pregnancy outcomes. Additional studies were identified by examining all citations for relevant studies.

:RESULTS: Of 989 studies, 11 studies from three countries reported mortality rates associated with termination of pregnancy, miscarriage or failed pregnancy. Within a year of their pregnancy outcomes, women experiencing a pregnancy loss are over twice as likely to die compared to women giving birth. The heightened risk is apparent within 180 days and remains elevated for many years. There is a dose effect, with exposure to each pregnancy loss associated with increasing risk of death. Higher rates of death from suicide, accidents, homicide and some natural causes, such as circulatory diseases, may be from elevated stress and risk taking behaviors.

:CONCLUSIONS: Both miscarriage and termination of pregnancy are markers for reduced life expectancy. This association should inform research and new public health initiatives including screening and interventions for patients exhibiting known risk factors.

''''[http://www.aaplog.org/wp-content/uploads/2013/07/LNQ61-Maternal-Mortality-Review-7-17-13.pdf The maternal mortality myth in the context of legalized abortion.] Calhoun B. The Linacre Quarterly, Volume 80, Number 3, August 2013 , pp. 264-276(13)''''

:Abstract:
:It was quoted recently in the literature that “The risk of death associated with childbirth is approximately 14 times higher than with abortion.” This statement is unsupported by the literature and there is no credible scientific basis to support it. A reasonable woman would find any discussion about the risk of dying from a procedure as material, i.e., important and significant. In order for the physician‐patient informed consent dialogue to address this critical issue, the physician must rely upon objective and accurate information concerning abortion. There are numerous and complicated methodological factors that make a valid scientific assessment of abortion mortality extremely difficult. Among the many factors responsible are incomplete reporting, definitional incompatibilities, voluntary data collection, research bias, reliance upon estimations, political correctness, inaccurate and/or incomplete death certificate completion, incomparability with maternal mortality statistics, and failing to include other causes of death such as suicides. Given the importance of this disclosure about abortion mortality, the lack of credible and reliable scientific evidence supporting this representation requires substantial discussion.

''''[http://www.afterabortion.org/research/DeathsAssocWithAbortionJCHLP.pdf Deaths associated with abortion compared to childbirth: a review of new and old data and the medical and legal implications.] Reardon DC, Strahan TW, Thorp JM, Shuping MW. The Journal of Contemporary Health Law & Policy 2004; 20(2):279‑327.''''

:The best available evidence now contradicts the “established medical fact,” relied upon in Roe v Wade, claiming that the maternal mortality rate for abortion is lower than that of childbirth. Recent analyses of large medical databases linked to death certificates have now shown that when mortality rates associated with abortion and childbirth are examined using a single uniform standard, significantly higher mortality rates are associated with abortion. These record linkage studies have demonstrated that pregnancy-associated deaths are actually two to four times higher for aborting women compared to delivering women.

:This is an important paper examining why previous evidence was flawed and what objective record based studies really show.

''''[http://www.ncbi.nlm.nih.gov/pubmed/7129852 Therapeutic abortion: the medical argument.] Murphy JF, O'Driscoll K. Irish Medical Journal. 1982 Aug;75(8):304-6.''''

:'''Editors note:''' There is no evidence that abortion can be used to actually reduce maternal mortality rates because there is no evidence that those women at risk of dying during a pregnancy are at less risk of dying from an abortion.

:'''Abstract''':This document analyzes all cases of maternal death between 1970-79 at the National Maternity Hospital, Dublin, Ireland, and speculates as to the number of lives which might have been saved by therapeutic abortion. 74,317 births were considered; there were 21 deaths, or a mortality rate of 0.28/1000. 7 women died for reasons that had nothing to do with pregnancy: 3 cases of malignant disease, 2 of cerebrovascular accident, 1 of road accident, and 1 of Weil's disease. Therapeutic abortion would not have altered the outcome of pregnancy in these cases. 11 women died of pregnancy complications, 4 of infection, 3 of embolism, 2 of hemorrhage, 1 of eclampsia, and 1 of liver rupture. These deaths, however, could not have been prevented by therapeutic abortion, since these complications could not have been foreseen. 3 women died of diseases which could be said to have made pregnancy more dangerous. However, in the 1st case no disease was suspected until necropsy demonstrated the lesion; in the 2nd case the fatal outcome was interpreted as the terminal state of a chronic process which would have occurred whether or not the woman had been pregnant. Only in the 3rd instance a reasonable case could have been made in favor of therapeutic abortion. However, the woman in question had purposely sought pregnancy for the 2nd time in 2 years, fully aware of the risk involved; she would not have accepted a therapeutic abortion. Thus, the conclusion seems to be that, in the series presented, therapeutic abortion would not have saved a single life. The most recent publication on therapeutic abortion, bearing on 57,228 deliveries at the Mount Sinai Hospital in New York between 1953-64, indicates that in over 69 cases of therapeutic abortion the degree of risk to the mother's life was debatable.

''''[http://www.hindawi.com/journals/scientifica/2012/980812/ Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later] Thorp JM. Scientifica Volume 2012 (2012), Article ID 980812.'''':

:Includes a review of record linkage studies showing higher rates of mortality after abortion and identifies failures in systematic tracking of abortion related deaths in the United States.

''''[http://www.webmd.com/breast-cancer/guide/breast-cancer-during-pregnancy Breast Cancer and Pregnancy] WebMD''''
:"Pregnancy termination will not improve the mother's chances of surviving breast cancer. In addition, there is no evidence that breast cancer can harm the baby. What may harm the baby are some of the treatments for breast cancer."
:See also: [http://www.ncbi.nlm.nih.gov/pubmed/21050304 Breast cancer in pregnancy.] Rovera F, Frattini F, Coglitore A, Marelli M, Rausei S, Dionigi G, Boni L, Dionigi R. Breast J. 2010 Sep-Oct;16 Suppl 1:S22-5.

== Record Based Studies ==

'''[https://pubmed.ncbi.nlm.nih.gov/34773878/ Premature mortality after pregnancy loss: Trends at 1, 5, 10 years, and beyond.] Auger N, Ghadirian M, Low N, Healy-Profitós J, Wei SQ. Eur J Obstet Gynecol Reprod Biol. 2021 Dec;267:155-160. doi: 10.1016/j.ejogrb.2021.10.033. Epub 2021 Nov 1. PMID: 34773878.'''<blockquote>'''Objective:''' Little is known on the long-term risk of mortality following pregnancy loss. We assessed risks of premature mortality up to three decades after miscarriage, induced abortion, ectopic or molar pregnancy, and stillbirth relative to live birth.

'''Study design:''' We carried out a longitudinal cohort study of 1,293,640 pregnant women with 18,896,737 person-years of follow-up in Quebec, Canada, from 1989 to 2018. We followed the women up to 29 years after their last pregnancy event to determine the time and cause of future in-hospital deaths before age 75 years. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of miscarriage, induced abortion, ectopic pregnancy, molar pregnancy, and stillbirth with premature mortality, compared with live birth.

'''Results:''' Premature mortality rates were higher for most types of pregnancy loss than live birth. Compared with live birth, pregnancy loss was associated with an elevated risk of premature mortality (HRmiscarriage 1.48, 95% CI 1.33, 1.65; HRinduced abortion 1.50, 95% CI 1.39, 1.62; HRectopic 1.55, 95% CI 1.35, 1.79; and HRstillbirth 1.68, 95%. CI 1.17, 2.41). Molar pregnancy was not associated with premature mortality (HR 0.87, 95% CI 0.33, 2.32). Miscarriage and induced abortion were associated with most causes of death, whereas ectopic pregnancy was associated with cardiovascular (HR 2.18, 95 % CI 1.39, 3.42), cancer (HR 1.38, 95 % CI 1.11, 1.73), and suicide-related mortality (HR 4.94, 95 % CI 2.29, 10.68). Stillbirth was associated with cardiovascular mortality (HR 4.91, 95 % CI 2.33, 10.36).

'''Conclusion:''' Pregnancy loss is associated with an elevated risk of premature mortality up to three decades later, particularly cardiovascular, cancer, and suicide-related deaths.</blockquote>

=== '''Adjusted PAR for all-cause premature mortality''' ===
{| class="wikitable"
!Pregnancy type
!Adjusted HR
!Exposure proportion
!Adjusted PAR (%)
|-
|Miscarriage
|1.48
|0.024
|'''1.15%'''
|-
|Induced abortion
|1.50
|0.041
|'''1.98%'''
|-
|Unspecified abortion
|1.77
|0.012
|'''0.91%'''
|-
|Ectopic pregnancy
|1.55
|0.011
|'''0.60%'''
|-
|Molar pregnancy
|0.87
|0.001
|'''≈ 0%'''
|-
|Stillbirth
|1.68
|0.002
|'''0.14%'''
|}
'''Cause of Death: Adjusted HR and PAR for women who aborted compared to women whose last pregnancy was a live birth'''
{| class="wikitable"
|'''Cause'''
|'''Adjusted HR (from Table 4)'''
|'''Adjusted PAR (%)'''
|-
|Cancer
|1.14
|0.57
|-
|Cardiovascular
|1.6
|2.4
|-
|Endocrine
|1
|0
|-
|Gastrointestinal
|1.53
|2.13
|-
|Injury
|2.03
|4.05
|-
|Nervous system
|1.82
|3.25
|-
|Obstetric
|0.86
| -0.58
|-
|Other causes
|2.45
|5.61
|-
|Pulmonary
|1.37
|1.49
|-
|Renal
|2.42
|5.5
|-
|Sepsis/shock/organ failure
|1.84
|3.33
|-
|Suicide
|2.41
|5.47
|}

'''[https://pmc.ncbi.nlm.nih.gov/articles/PMC11246836/ Association between Abortion and All-Cause and Cause-Specific Premature Mortality: A Prospective Cohort Study from the UK Biobank.] Yin S, Yang Y, Wang Q, Guo W, He Q, Yuan L, Si K. Health Data Sci. 2024 Jul 15;4:0147. doi: 10.34133/hds.0147. PMID: 39011272; PMCID: PMC11246836.'''<blockquote>
'''Background:''' Concerns have been raised about the increasing prevalence of both spontaneous and induced abortions worldwide, yet their effect on premature mortality remains poorly understood. We aimed to examine the associations between abortion and all-cause and cause-specific premature mortality, and the potential effect modification by maternal characteristics. '''Methods:''' Women aged 39 to 71 years at baseline (2006 to 2010) with prior pregnancies were derived from the UK Biobank and categorized as no abortion history, spontaneous abortion alone, induced abortion alone, and both spontaneous and induced abortions. All-cause and cause-specific mortality were ascertained through linkage to death certificate data, with premature death defined as occurring before the age of 70. '''Results:''' Of the 225,049 ever gravid women, 43,418 (19.3%) reported spontaneous abortion alone, 27,135 (12.1%) reported induced abortion alone, and 10,448 (4.6%) reported both spontaneous and induced abortions. During a median of 14.4 years of follow-up, 5,353 deaths were recorded, including 3,314 cancer-related and 1,444 cardiovascular deaths. Compared with no abortion history, spontaneous abortion alone was associated with an increased risk of all-cause premature mortality (adjusted hazard ratio [aHR] 1.10, 95% confidence interval [CI] 1.02 to 1.17), and induced abortion alone was associated with increased risks of all-cause (aHR 1.12, 95% CI 1.04 to 1.22) and cardiovascular mortality (aHR 1.27, 95% CI 1.09 to 1.48). The aHRs for all-cause and cardiovascular mortality were higher for recurrent abortions, whether spontaneous or induced (''P'' trend < 0.05). The increased risk of all-cause mortality associated with induced abortion was higher in women with hypertensive disorders of pregnancy than in those without (40% vs. 9%, ''P'' interaction = 0.045). '''Conclusions:''' Either spontaneous or induced abortion alone was associated with an increased risk of premature mortality, with induced abortion alone particularly linked to cardiovascular death. Future studies are encouraged to explore the underlying mechanisms.</blockquote>

'''[https://www.ncbi.nlm.nih.gov/pubmed/28510640 Increased risk of premature death following teenage abortion and childbirth-a longitudinal cohort study.] Jalanko E, Leppälahti S, Heikinheimo O, Gissler M. Eur J Public Health. 2017 May 16. doi: 10.1093/eurpub/ckx065.'''

:Abstract: Teenage pregnancy is associated with an increased risk of premature death. However, it is not known whether the outcome of pregnancy, i.e. induced abortion or childbirth, affects this risk. A Finnish population-based register study involving a cohort of 13 691 nulliparous teenagers who conceived in 1987-89; 6652 of them underwent induced abortion and 7039 delivered. The control group consisted of 41 012 coeval women without teenage pregnancy. Follow-up started at the end of pregnancy and lasted until 6th June 2013. Women with teenage pregnancy had a higher risk of overall mortality vs. controls (mortality rate ratio [MRR] 1.6, [95% CI 1.4-1.8]) and were more likely to die prematurely as a result of suicide, alcohol-related causes, circulatory diseases and motor vehicle accidents. A low educational level appeared to explain these excess risks, except for suicide (adj. MRR 1.5, [95% CI 1.1-2.0]). After adjusting for confounders, the childbirth group faced lower risks of suicide (adj. MRR 0.5, [95% CI 0.3-0.9]) and dying from injury and poisoning (adj. MRR 0.6, [95% CI 0.4-0.8]) compared with women who had undergone abortion. A low educational level is associated with the increased risk of premature death among women with a history of teenage pregnancy, except for suicide. Extra efforts should be made to encourage pregnant teenagers to continue education, and to provide psychosocial support to teenagers who undergo induced abortion.

''''[http://www.ncbi.nlm.nih.gov/pubmed/22954474 Reproductive history patterns and long-term mortality rates: a Danish, population-based record linkage study.] Coleman PK, Reardon DC, Calhoun BC. Eur J Public Health. 2012 Sep 5.''''

:Abstract
:BACKGROUND: Inconsistent definitions and incomplete data have left society largely in the dark regarding mortality risks generally associated with pregnancy and with particular outcomes, immediately after resolution and over the long-term. Population-based record-linkage studies provide an accurate means for deriving maternal mortality rate data.

:METHOD: In this Danish population-based study, records of women born between 1962 and 1993 (n = 1 001 266) were examined to identify associations between patterns of pregnancy resolution and mortality rates across 25 years.

:RESULTS: With statistical controls for number of pregnancies, birth year and age at last pregnancy, the combination of induced abortion(s) and natural loss(es) was associated with more than three times higher mortality rate than only birth(s). Moderate risks were identified with only induced abortion, only natural loss and having experienced all outcomes compared with only birth(s). Risk of death was more than six times greater among women who had never been pregnant compared with those who only had birth(s). Increased risks of death were 45%, 114% and 191% for 1, 2 and 3 abortions, respectively, compared with no abortions after controlling for other reproductive outcomes and last pregnancy age. Increased risks of death were equal to 44%, 86% and 150% for 1, 2 and 3 natural losses, respectively, compared with none after including statistical controls. Finally, decreased mortality risks were observed for women who had experienced two and three or more births compared with no births.

:CONCLUSION: This study offers a broad perspective on reproductive history and mortality rates, with the results indicating a need for further research on possible underlying mechanisms.

''''[http://www.ncbi.nlm.nih.gov/pubmed/22936199 Short and long term mortality rates associated with first pregnancy outcome: Population register based study for Denmark 1980-2004.] Reardon DC, Coleman PK. Med Sci Monit. 2012 Aug 30;18(9):PH71-76.''''

:Abstract
:BACKGROUND: There is a growing interest in examining death rates associated with different pregnancy outcomes for time periods beyond one year. Previous population studies, however, have failed to control for complete reproductive histories. In this study we seek to eliminate the potential confounding effect of unknown prior pregnancy history by examining mortality rates associated specifically with first pregnancy outcome alone. We also examine differences in mortality rates associated with early abortion and late abortions (after 12 weeks).

:METHOD: Medical records for the entire population of women born in Denmark between 1962 and 1991 and were alive in 1980, were linked to death certificates. Mortality rates associated with first pregnancy outcomes (delivery, miscarriage, abortion, and late abortion) were calculated. Odds ratios examining death rates based on reproductive outcomes, adjusted for age at first pregnancy and year of women's births, were also calculated.

:RESULTS: A total of 463,473 women had their first pregnancy between 1980 and 2004, of whom 2,238 died. In nearly all time periods examined, mortality rates associated with miscarriage or abortion of a first pregnancy were higher than those associated with birth. Compared to women who delivered, the age and birth year adjusted cumulative risk of death for women who had a first trimester abortion was significantly higher in all periods examined, from 180 days (OR=1.84; 1.11 <95% CI <3.71) through 10 years (1.39; 1.22 <95% CI <1.61), as was the risk for women who had abortions after 12 weeks from one year (OR=4.31; 2.18 <95% CI <8.54) through 10 years (OR=2.41; 1.56 <95% CI <2.41). For women who miscarried, the risk was significantly higher for cumulative deaths through 4 years (OR=1.75; 1.34 <95% CI <2.27) and at 10 years (OR=1.48; 1.18 <95% CI <1.85).

:CONCLUSIONS: Compared to women who delivered, women who had an early or late abortion had significantly higher mortality rates within 1 through 10 years. A lesser effect may also be present relative to miscarriage. Recommendations for additional research are offered.

''''[http://afterabortion.org/research/DeathsAssociatedWithAbortion.pdf Deaths associated with pregnancy outcome: a record linkage study of low income women.] Reardon DC, Ney PG , Scheuren FJ, Cougle JR, Coleman, PK, Strahan T. Southern Medical Journal, August 2002, 95(8):834-841.''''

:BACKGROUND: A national study in Finland showed significantly higher death rates associated with abortion than with childbirth. Our objective was to examine this association using an American population over a longer period.

:METHODS: California Medicaid records for 173,279 women who had an induced abortion or a delivery in 1989 were linked to death certificates for 1989 to 1997.

:RESULTS: Compared with women who delivered, those who aborted had a significantly higher age-adjusted risk of death from all causes (1.62), from suicide (2.54), and from accidents (1.82), as well as a higher relative risk of death from natural causes (1.44), including the acquired immunodeficiency syndrome (AIDS) (2.18), circulatory diseases (2.87), and cerebrovascular disease (5.46). Results are stratified by age and time.

:CONCLUSIONS: Higher death rates associated with abortion persist over time and across socioeconomic boundaries. This may be explained by self-destructive tendencies, depression, and other unhealthy behavior aggravated by the abortion experience.

:NOTE: The elevated risk from death from circulatory diseased and cerebrovascular disease may be partially explained by a finding that abortion is associated with elevated rates of metabolic syndrome which is a cause of increased cardiovascular disease. See: [http://www.ncbi.nlm.nih.gov/pubmed/23389282 Association between history of abortion and metabolic syndrome in middle-aged and elderly Chinese women.] Xu B, Zhang J, Xu Y, Lu J, Xu M, Chen Y, Bi Y, Ning G. Front Med. 2013 Mar;7(1):132-7.

''''"Chili Study"''''

:[http://www.c-fam.org/publications/id.1571/pub_detail.asp Preliminary findings by a prominent biomedical researcher] examining the dramatic decrease in maternal mortality, over the past fifty years in the Latin American nation of Chile, appear to undercut claims by global abortion lobbyists that liberal abortion laws are necessary to reduce maternal mortality rates.

:According Dr. Elard Koch, an epidemiologist on the faculty of medicine at the University of Chile, Chile's promotion of "safe pregnancy" measures such as "prenatal detection" and accessibility to professional birth attendants in a hospital setting are primarily responsible for the decrease in maternal mortality. The maternal mortality rate declined from 275 maternal deaths per 100,000 live births in 1960 to 18.7 deaths in 2000, the largest reduction in any Latin country.
:This news follows a report from the World Economic Forum in December which showed that countries with restrictive abortion laws are often the leaders in reducing maternal mortality. Ireland, which is under pressure to change its Constitutional protection of the unborn child, leads the world in maternal health performance, with 1 death for every 100,000 live births. Poland, which has tightened its abortion law, ranks 27 on the WEF list with 8 deaths per 100,000. In the United States, where there are virtually no restrictions on abortion, the ratio is 17 deaths per 100,000. [http://www.c-fam.org/publications/id.1533/pub_detail.asp C-FAM cites] other examples from its analysis of the WEF report which prove the point.

'''[http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0036613 Women's Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: A Natural Experiment in Chile from 1957 to 2007]''' Koch E, Thorp J, Bravo M, Gatica S, Romero CX, et al. (2012) PLoS ONE 7(5): e36613.
:An analysis of maternal mortality rates in Chile over a 50 year period shows that the decline 93% in mortality rates during that time was not hindered by the 1989 laws prohibiting abortion.

'''[http://www.eurekalert.org/pub_releases/2014-11/mi-tca110614.php The Chilean abortion paradox: Even when prohibited by law, abortion rates decrease]'''
:Abortion-related mortality has steadily declined in Chile after its prohibition by law in 1989: "Chile displays a continuous decreasing trend of hospital discharges due to complications of abortions suspected to be illegally induced -represented by specific codes of the World Health Organisation classification- at a rate of 2% per year since 2001. In contrast, a decreasing trend was not observed in hospital discharges due to other types of abortion, such as spontaneous abortion or ectopic pregnancies, which have remained constant during the same period. The high quality of Chilean vital statistics indicates these findings are unlikely to be the result of an artifact of the registry system. Rather, a decrease in hospital discharges due to complications from illegal abortion appears to explain virtually all the reduction in hospital discharges due to any type of abortion in Chile during the last decade."

'''[http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0036613 Women's education level, maternal health facilities, abortion legislation and maternal deaths: a natural experiment in Chile from 1957 to 2007.] Koch E, Thorp J, Bravo M, Gatica S, Romero CX, Aguilera H, Ahlers I (2012) PLoS ONE 7(5):e36613. DOI:10.1371/journal.pone.0036613.'''

:Background: The aim of this study was to assess the main factors related to maternal mortality reduction in large time series available in Chile in context of the United Nations' Millennium Development Goals (MDGs).

:Methods: Time series of maternal mortality ratio (MMR) from official data (National Institute of Statistics, 1957–2007) along with parallel time series of education years, income per capita, fertility rate (TFR), birth order, clean water, sanitary sewer, and delivery by skilled attendants were analysed using autoregressive models (ARIMA). Historical changes on the mortality trend including the effect of different educational and maternal health policies implemented in 1965, and legislation that prohibited abortion in 1989 were assessed utilizing segmented regression techniques.

:Results: During the 50-year study period, the MMR decreased from 293.7 to 18.2/100,000 live births, a decrease of 93.8%. Women's education level modulated the effects of TFR, birth order, delivery by skilled attendants, clean water, and sanitary sewer access. In the fully adjusted model, for every additional year of maternal education there was a corresponding decrease in the MMR of 29.3/100,000 live births. A rapid phase of decline between 1965 and 1981 (−13.29/100,000 live births each year) and a slow phase between 1981 and 2007 (−1.59/100,000 live births each year) were identified. After abortion was prohibited, the MMR decreased from 41.3 to 12.7 per 100,000 live births (−69.2%). The slope of the MMR did not appear to be altered by the change in abortion law.

:Conclusion: Increasing education level appears to favourably impact the downward trend in the MMR, modulating other key factors such as access and utilization of maternal health facilities, changes in women's reproductive behaviour and improvements of the sanitary system. Consequently, different MDGs can act synergistically to improve maternal health. The reduction in the MMR is not related to the legal status of abortion.

'''Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states. Koch E, Chireau M, Pliego F, Stanford J, Haddad S, Calhoun B, Aracena P, Bravo M, Gatica S, Thorp J. BMJ Open. 2015 Feb 23;5(2):e006013. doi: 10.1136/bmjopen-2014-006013.'''

:OBJECTIVE: To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health.

:DESIGN: Population-based natural experiment.

:SETTING AND DATA SOURCES: Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011.

:MAIN OUTCOMES: Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR).

:INDEPENDENT VARIABLES: Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence.

:MAIN RESULTS: Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=-0.061 to -1.100), skilled attendance at birth (β=-0.032 to -0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=-0.566 to -0.962), clean water (β=-0.048 to -0.730), sanitation (β=-0.052 to -0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=-14.329) and MMRAO (β=-1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R(2)) 51-88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates.

:CONCLUSIONS: Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.

:'''NOTE:''' A critique of the above study by Darney et al. titled [https://pubmed.ncbi.nlm.nih.gov/27546094/ Maintaining rigor in research: flaws in a recent study and a reanalysis of the relationship between state abortion laws and maternal mortality in Mexico] was itself so flawed that the journal [https://pubmed.ncbi.nlm.nih.gov/30526954/ Contraception retracted it.]

'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3526871/ Fundamental discrepancies in abortion estimates and abortion-related mortality: A reevaluation of recent studies in Mexico with special reference to the International Classification of Diseases.] Koch E, Aracena P, Gatica S, Bravo M, Huerta-Zepeda A, Calhoun BC. Int J Womens Health. 2012;4:613-23. doi: 10.2147/IJWH.S38063. Epub 2012 Dec 5.'''

:Abstract: In countries where induced abortion is legally restricted, as in most of Latin America, evaluation of statistics related to induced abortions and abortion-related mortality is challenging. The present article reexamines recent reports estimating the number of induced abortions and abortion-related mortality in Mexico, with special reference to the International Classification of Diseases (ICD). We found significant overestimations of abortion figures in the Federal District of Mexico (up to 10-fold), where elective abortion has been legal since 2007. Significant overestimation of maternal and abortion-related mortality during the last 20 years in the entire Mexican country (up to 35%) was also found. Such overestimations are most likely due to the use of incomplete in-hospital records as well as subjective opinion surveys regarding induced abortion figures, and due to the consideration of causes of death that are unrelated to induced abortion, including flawed denominators of live births. Contrary to previous publications, we found important progress in maternal health, reflected by the decrease in overall maternal mortality (30.6%) from 1990 to 2010. The use of specific ICD codes revealed that the mortality ratio associated with induced abortion decreased 22.9% between 2002 and 2008 (from 1.48 to 1.14 deaths per 100,000 live births). Currently, approximately 98% of maternal deaths in Mexico are related to causes other than induced abortion, such as hemorrhage, hypertension and eclampsia, indirect causes, and other pathological conditions. Therefore, only marginal or null effects would be expected from changes in the legal status of abortion on overall maternal mortality rates. Rather, maternal health in Mexico would greatly benefit from increasing access to emergency and specialized obstetric care. Finally, more reliable methodologies to assess abortion-related deaths are clearly required.

''"Pregnancy-associated deaths in Finland 1987-1994-definition problems and benefits of record linkage," M Gissler et al, Acta Obstet Gynecol Scand 76:651-657, 1997. ''

:Death certificates of all women of child-bearing age were linked to birth, abortion, and other pregnancies to identify women who had been pregnant during the last year of their life. Only in 22% of the death certificates was pregnancy or its end mentioned. The mortality rate was 27 per 100,000 live births, 48 per 100,000 miscarriages or ectopic pregnancies, and 101 per 100,000 abortions. After abortion, the mortality risk was increased for accidents, suicides, and homicides.

 ''"Suicide Deaths Associated with Pregnancy Outcome: A Record Linkage Study of 173,279 Low Income American Women," DC Reardon et al, Clinical Medicine & Health Research2001030003, April 25, 2001. ''

:A record-linkage study of low income women eligible for state-funded medical insurance in California identified all paid claims for abortion or delivery in 1989. These were linked to the state death registry. Compared to women who delivered, those who aborted had a significantly higher age adjusted risk of dying from all causes (1.62), from suicide (2.54), accidents (1.82), and non-violent causes (1.44), including AIDS (2.18), circulatory diseases (2.87), and cerebrovascular disease (5.46). The results remained significant over an eight year period and over four of six age groups examined.

 ''"Hidden From View: Violent Deaths Among Pregnant Women in the District of Columbia, 1988-1996," CJ Krulewitch et al, J Midwifery & Women's Health 46(1): 4, Jan/Feb 2001. ''

:From 1988-1996 the District of Columbia officially reported 21 maternal deaths using standard definitions for pregnancy-related death, but did not include women who died from pregnancy associated but not pregnancy related causes. Thirty additional deaths were identified from autopsy reports , which documented evidence of pregnancy. Of these 30 deaths, homicide was documented as the manner of death in 13 cases (43.3%). Three out of four women with evidence of pregnancy who died from homicide were in their first 20 weeks of pregnancy.

 ''"Enhanced Surveillance for Pregnancy-Associated Mortality- Maryland, 1993-1998," IL Horon and D Cheng, JAMA 285(11):1455, March 21, 2001. ''

:A study of pregnancy-associated deaths in Maryland found that among all deaths occurring up to one year after delivery or termination, it was found that homicide (50 deaths) was the most frequent cause of death, with deaths from cardiovascular disorders the second leading cause of death (48 deaths). Death certificates only accounted for 67 out of 247 deaths. Record linkage and medical examiner records provided the balance of the information.

''''Increased mortality among patients admitted with major psychiatric disorders: a register-based study comparing mortality in unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia.
Laursen TM, Munk-Olsen T, Nordentoft M, Mortensen PB. J Clin Psychiatry. 2007 Jun;68(6):899-907.''''

CONTEXT: Persons suffering from severe mental disorder have an excess mortality compared to persons with no mental disorder. However, the magnitude of the excess mortality differs from one mental disorder to another, and the impact on mortality if a first-degree family member suffers from a mental disorder has never been examined in a population-based study.

OBJECTIVE: Our objective was to examine and compare mortality rates after admission with schizophrenia, schizoaffective disorder, unipolar depressive disorder, or bipolar affective disorder and to examine the impact of family history of psychiatric admission on mortality.

METHOD: We established a register-based cohort study of 5.5 million persons born in Denmark who were alive on or born after January 1, 1973 and alive on their 15th birthday. Mortality rate ratios were estimated by survival analysis, using Poisson regression.

RESULTS: Unipolar depressive disorder, bipolar affective disorder, and schizoaffective disorder were associated with the same pattern of excess mortality. Schizophrenia had a lower mortality from unnatural causes of death and a higher mortality from natural causes compared to the 3 other disorders. Family history of psychiatric admission was associated with excess mortality.

CONCLUSION: Patients suffering from the 4 disorders all had an excess mortality, but the pattern of excess mortality was not the same. There was an excess mortality associated with mental disorder in a first-degree family member, but this only explained a small part of the general excess mortality associated with the 4 mental disorders examined.

Death after legally induced abortion. A comprehensive approach for determination of abortion-related deaths based on record linkage. J D Shelton, A K Schoenbucher Public Health Rep. 1978 Jul-Aug; 93(4): 375–378.
:Shelton linked data from the state of Georgia covering an average of eight months after 19,877 abortions. In that case, ten deaths were found, of which eight were related to violent causes (three suicides, two homicides, and three accidents of which one may have been a suicide). The expected number of deaths due to violent causes was 5.7.
:The finding of a heightened risk of death from violent causes reported in this small CDC were dismissed by the authors, but in retrospect are consistent with the findings of the Gissler and Reardon studies.
:This study did not include a full year follow-up and used a very small sample (only 10 deaths) compared to the thousands of deaths examined by Gissler and Reardon.

[http://www.ncbi.nlm.nih.gov/pubmed/17592915 Increased mortality among patients admitted with major psychiatric disorders: a register-based study comparing mortality in unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia.] Laursen TM, Munk-Olsen T, Nordentoft M, Mortensen PB. J Clin Psychiatry. 2007 Jun;68(6):899-907.

Persons suffering from severe mental disorder have an excess mortality compared to persons with no mental disorder. In this study of the population of Denmark, unipolar depressive disorder, bipolar affective disorder, and schizoaffective disorder were associated with the same pattern of excess mortality. Family history of psychiatric admission was associated with excess mortality.

This finding is consistent with the hypothesis that the mental health effects associated with abortion may contribute to the higher rates of mortality associated with abortion.

[http://www.ncbi.nlm.nih.gov/pubmed/23225729 Childlessness, parental mortality and psychiatric illness: a natural experiment based on in vitro fertility treatment and adoption.] Agerbo E, Mortensen PB, Munk-Olsen T. J Epidemiol Community Health. 2013 Apr;67(4):374-6.

Childlessness increases the risk of premature mortality and psychiatric illness. The crude death rate ratio in women who become mothers to a biological child is 0.25 (95% CI 0.16 to 0.39). In other words, childless women seeking in vitro experience a fourfold higher rate of death, that is, 4.02 (2.56 to 6.31). The analogous death rate in fathers is approximately halved: 0.51 (0.39 to 0.68) and 0.55 (0.32 to 0.96) associated with having a biological child and an adopted child, respectively. With substance use disorders being the exception, none of the crude rates of psychiatric illness in parents of a biological child were statistically distinguishable from the rates in the childless.

[http://www.ncbi.nlm.nih.gov/pubmed/23225729 Childlessness, parental mortality and psychiatric illness: a natural experiment based on in vitro fertility treatment and adoption. Agerbo E, Mortensen PB, Munk-Olsen T. J Epidemiol Community Health. 2013 Apr;67(4):374-6. doi: 10.1136/jech-2012-201387. Epub 2012 Dec 5.]

:While this study did not examine mortality associated with abortion, it did report a four fold higher risk of death among childless women...which may be affected by abortion rates. Additional analyses is warranted to look at mortality rates among the childless relative to exposure to abortion and miscarriage compared to to women with no pregnancy history.

'''[http://www.ncbi.nlm.nih.gov/pubmed/22622483 Legal restrictions and complications of abortion: insights from data on complication rates in the United States.] Rolnick JA, Vorhies JS. J Public Health Policy. 2012 Aug;33(3):348-62.'''

:Abstract: Although US federal law requires all American states to permit abortion within their borders, states retain authority to impose restrictions.We used hospital discharge data to study the rates of major abortion complications in 23 states from 2001 to 2008 and their relationship to two laws: (i) restrictions on Medicaid – the state insurance programs for the poor – funding, and (ii) mandatory delays before abortion. Of 131 000 000 discharges in the data set, 10 980 involved an abortion complication. The national rate for complications was 1.90 per 1000 abortions (95 per cent CI: 1.57–2.23). Eleven states required mandatory delays and 12 restricted funding for Medicaid participants. After controlling for socioeconomic characteristics and the pregnancy complication rate, legal restrictions were associated with lower complication rates: mandatory delays (OR 0.79(0.65–0.95)) and restricted Medicaid funding (OR 0.74 (0.61–0.90)). This result may reflect the fact that states without restrictions perform a higher percentage of second-trimester abortions. This study is the first to assess the association between legal restrictions on abortion and complication rates.

== Elevated Risk of Death in Later Pregnancies ==
Marmian (2000): "The Placenta Accreta Spectrum (PAS) includes placenta accreta, placenta increta, and placenta percreta. In 1950, the incidence of PAS was 1:30,000 deliveries, but in 2016, the incidence was reported to be 1:272 deliveries (Mogos et al. 2016). This 110-fold increase in incidence raises the risk of pregnancy-related mortality. Occurring in women with a history of uterine surgery, including induced abortion (Baldwin et al. 2018), PAS can cause massive hemorrhage, and deaths occur even in tertiary hospitals (Klemetti et al. 2012).

== Loss of Woman-Years Estimate ==

According to Gissler (1997), the total age-adjusted mortality rate per 100,000 for a one year period was 58.8 for nonpregnant women, 103.2 for abortion, and 29.4 for birth. Assuming an average life expectancy of 76 for women, and the average premature death occurring at age 28, yields a loss of 2,131 woman-years per 100,000 abortions compared to non-pregnant women, and 3,542 woman-years per 100,000 abortions compared to delivering women. These lost woman-year estimates, however, capture only the losses stemming from excess deaths within the first year of an abortion.

Reardon (2002) examines an eight year period after pregnancy outcome, reporting approximately 300 excess premature deaths per 100,000 women who had abortions (compared to those who delivered) over an eight year period, with an average age of at death of 28. Deducted from the average life expectancy (around 76), this translates to 48 woman years lost per death or a loss of 14,400 woman-years per 100,000 abortions.

Reardon (2012) examines a ten year period following first pregnancy outcomes. This study reports that the excess number of deaths within 10 years was 230 per 100,000 abortions of a first pregnancy. The average age of death was 27.4. Ignoring deaths after the 10 year window, and assuming an average life span of 76 years, this translates to 11,178 woman years lost per 100,000 abortions.

Projecting the latter (11,178 per 100,000) on the estimated 60 million abortions in the United States since 1973, yields an estimated loss of 6,706,800 woman-years.

Projected on the worldwide estimated number of 1.5 billion, yields an estimated loss of 167.7 million woman-years.

== Other Peer Reviewed Studies ==

''''[https://www.ncbi.nlm.nih.gov/pubmed/22270271 The Comparative Safety of Legal Induced Abortion and Childbirth in the United States.] Obstetrics & Gynecology. Raymond, Elizabeth G.; Grimes, David A. 119(2, Part 1):215-219, February 2012.''''

:This is an old-style comparison of nationally reported rates for abortion deaths (absent any standardized method for identifying abortion associated deaths) to nationally reported maternal deaths, which concludes that abortion is 14 times safer than childbirth. Notably, the authors carefully constructed their "review" of the literature to ignore all of record based studies (see above) which contradict their claim that mortality rates associated with abortion are lower than those associated with childbirth. A more complete criticism of this "review" is found in [http://afterabortion.org/2012/re-hash-of-abortion-safety-claim-ignores-all-inconvenient-evidence-to-the-contrary/ "Rehash of Abortion Safety Claim Ignores All Inconvenient Evidence to the Contrary."]

'''[http://journals.lww.com/obgynsurvey/pages/articleviewer.aspx?year=2005&issue=03000&article=00023&type=abstract Pregnancy-Associated Death: A Qualitative Systematic Review of Homicide and Suicide]''' Shadigian EM; Bauer ST; Obstetrical & Gynecological Survey 60:183-190, 2005.
:(abstract) A systematic review of the literature on maternal homicide and suicide was performed to understand the causes of pregnancy-associated death. Forty-four studies examined homicide and/or suicide and pregnancy-associated death (defined as the death of a woman, from any cause, while she is pregnant or within 1 year of termination of pregnancy) (1). Of these studies, 747 homicides and 349 suicides were identified. All studies were included except duplicate datasets, case reports of less than 3 events, suicide attempts, unpublished manuscripts, review articles, or non-English studies. Homicide is a leading cause of pregnancy-associated death and suicide is also an important cause of death among pregnant and recently pregnant women. Healthcare providers should understand that homicide is a leading cause of pregnancy-associated death, most commonly as a result of partner violence. Therefore, screening for both partner violence and suicidal ideation are essential components of comprehensive medical care for women during and after pregnancy.

''"Legal abortion in the U.S.: trends and mortality," HK Atrash, HW Lawson, JC Smith, Contemporary OB/GYN 35:58, Feb. 1990 ''

:Abortion-related deaths are defined as deaths (1) resulting from a direct complication; (2) an indirect complication caused by the chain of events initiated by the abortion, or (3) an aggravation of a pre-existing condition by the physiologic or psychologic effects of the abortion. Any death attributable to abortion is considered abortion related regardless of how long it occurred after the abortion. Ed Note: there are a number of definitions of abortion-related deaths or pregnancy related deaths. This is one of them.

 ''"Abortion Mortality. United States, 1972 through 1987," H.W. Lawson et. al. Am. J. Obstet. Gynecol. 171: 1365-1372,1994. ''

:The Centers for Disease Control reported that 240 U.S. women died from legal induced abortion between 1972-1987 with a decreasing overall rate of 4.1 per 100,000 abortions in 1972 to 0.4 per 1000 abortions in 1987. Those at increased risk of death from legal induced abortion included women 40 years old or more, black women and those of the minority races, abortions at 16 weeks gestation or greater and use of general anesthesia.

 ''"Pregnancy-Related Mortality in the United States. 1987-1990." C.J. Berg et. al, Obstet. Gynecol. 88: 161-167,1996. ''

:The Centers for Disease Control reported that the pregnancy-related mortality ratio of deaths per 100,000 live births increased from 7.2 in 1987 to 10.0 in 1990. A higher risk of pregnancy-related death was found with increasing maternal age, increasing live birth order, no prenatal care, and among unmarried women. The leading causes of pregnancy- related death were hemorrhage, embolism, and hypertensive disorders of pregnancy. The CDC reported a total of 1453 pregnancy-related deaths during this period including 797 deaths where there was a live birth, 103 deaths with stillbirth, 156 deaths from ectopic pregnancy, 81 deaths from abortion (spontaneous or induced), 6 deaths from molar pregnancy, 112 deaths where the baby was undelivered and 198 deaths where the outcome of the pregnancy was unknown.

 ''"Pregnancy-Related Mortality Surveillance-United States, 1987-1990," LM Koonin et al, MMWR 46(SS-4): 17-36 (August 8, 1997).''

:The causes of pregnancy-related death where there is a live birth are: hemorrhage (21.1%), embolism (23.4%), pregnancy-induced hypertension (23.8%), infection (12.1%), cardiomyopathy (6.1%), anesthesia complications (2.7%) The causes of pregnancy- related deaths where there is an abortion (induced or spontaneous) are: hemorrhage (18.5%), embolism (11.1%), pregnancy-induced hypertension (1.2%), infection (49.4%), anesthesia complications (8.6%).

 ''"An Assessment of the Incidence of Maternal Mortality in the United States," T. Smith, J. Hughes, P. Pekow and R. Rochat, Am. J. Public Health 74: 780-783, 1984 ''

:The incidence of maternal mortality is higher than vital statistics reports indicate. The person certifying the cause of death may not know that a woman had a recent pregnancy. Also, the definition of maternal death can greatly affect the reported incidence of maternal mortality.

 ''"Legal Abortion Mortality in the United States: 1972 to 1982," H. Atrash, H.T. MacKay, N. Binkin and C. Hogue, American Journal Obstetrics and Gynecology, 156(3): 611, March 1987. ''

:Although there is no certainty that all legal abortion-related deaths from 1972 to 1982 were reported to the Center for Disease Control [CDC], it is believed that the use of multiple reporting sources decreases the likelihood that deaths are missed. A study of maternal deaths in the U.S. between 1974-1978, relying only on vital records, identified only 141 abortion-related deaths, 63 of which were related to legal abortion. See "Causes of Maternal Mortality in the U.S." Kaunitz, et al., Obstet. Gynecol. 65:605-612, 1985. In comparison, CDC's surveillance of abortion [maternal] mortality identified 188 abortion- related deaths during the same period, 92 of which were related to legal abortion.

 ''"Causes of Maternal Mortality in the United States," A. Kaunitz, J. Hughes, D. Grimes, J. Smith, R. Rochat and M. Kafrissen, Obstetrics and Gynecology 65: 605-612, May 1985. ''

:From 1974-1978, the most common causes of maternal deaths, excluding other unspecified causes, were embolism (191), hypertensive disease of pregnancy (421), obstetric hemorrhage (331), ectopic pregnancies (254), obstetric infection (199), cerebro vascular accident (107) and anesthesia/analgesia complications (98). There were 135 deaths from upper genital tract infections among the deaths for obstetric infection. Among deaths due to obstetric hemorrhage 33 were from retained placenta and 19 from placenta previa. Ed. Note - Prior induced abortion may have been an implicating factor in some of these deaths.

 ''"Legal Abortion in the U.S.: Trends and Mortality," H.K. Atrash, H. Lawson and J. Smith, Contemporary Ob/Gyn 35(2):58-69 Feb 1990. ''

:According to the Centers for Disease Control the relative risk of death for black women and other minorities increased from 2.4 per 100,000 abortions during 1972-1978 to 2.9 per 100,000 abortions during 1979-1985). (The cause of death from legal abortion during 1979-1985 was hemorrhage (22.2%); infection (13.9%); embolism (15.3%); anesthesia (29.2%) and other (19.4%).

 ''"Fatal Hemorrhage from Legal Abortion in the United States," D. Grimes, et al., Surgery, Gynecology and Obstetrics, 157: 461-6, November 1983. ''

:From 1972-1979, hemorrhage was the third most frequent cause of death from legal abortion, accounting for 15% of deaths. If abortions are performed in free-standing clinics, the capability for rapid transportation to a nearby well-equipped hospital must be assured. Inordinate delays while waiting for an ambulance contributed to several deaths. The back- up hospital must have the ability to begin a laparotomy quickly and to transfuse large amounts of blood products.

 ''"Legal Abortion Mortality and General Anesthesia," H. Atrash, Am. J. Obstet and Gynecol 158:420-424(1988). ''

:The percentage of deaths from legal abortion caused by general anesthesia complications increased from 7.7% between 1972-75 to 29.4% between 1980-85. At least 23 of the 27 deaths were due to hypoventilation and/or loss of airway resulting in hypoxia.

 ''"Anesthesia or Analgesia Related Deaths of Women from Legal Abortion: The Need for Increased Regulation," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change Research Bulletin 12(1):1-8, Nov/Dec 1997.''

 ''"Economic Consequences of Pelvic Inflammatory Disease in the United States," James Curran, American Journal of Obstetrics and Gynecology, 138(7):848-851, Part 2, December 1,1980. ''

:Between 1970 and 1975, an average of 897 women hospitalized for PID died each year. Fifty percent of the morbidity and deaths from ectopic pregnancy can be attributed to PID. The extent to which induced abortion may have contributed to these deaths was not stated.

 ''"Abortion Related Maternal Mortality: An In-Depth Analysis," T. Hilgers and D. O'Hare, in New Perspectives on Human Abortion, ed. T. Hilgers, D. Horan and D. Mall, (Frederick MD: University Publications of America, 1981). ''

:Analyzes state and national statistics and concludes that the legalization of abortion has had no effect on the already existing downward trend in the maternal mortality rate. Prior maternal deaths for criminal abortion have been replaced by maternal deaths for legal abortion. Maternal mortality rates are generally expressed as the number of maternal deaths which occur during the entire course of pregnancy and the first three to six months following completion of the pregnancy per 100/000 live births.

 ''"Fatal Ectopic Pregnancy After Attempted Legally Induced Abortion," G. Rubin, W. Cates, J. Gold, R. Rochat and C. Tyler, Journal of the American Medical Association, 244(15): 1705-1708 October 10, 1980. ''

:Ten cases of death caused by ruptured ectopic pregnancy after attempted legal abortion were identified by the Center for Disease Control [seven blacks, three whites, five nulliparous] from 1973 to 1978. In seven cases tissue obtained at the abortion was sent for outside pathological exam, but results came back too late. The study concluded that an important factor in preventing fatal ectopic pregnancy is the identification of products of conception at the time of the abortion while patient is still available for re-examination. Deaths occurred from one to 44 days following the attempted abortion. See also "Missed Tubal Abortion," Burrows, et al., American Journal of Obstetrics and Gynecology, 136(5): 691-92, March 1,1980; "Ectopic Pregnancy and First Trimester Abortion," Schonberg, Obstet. Gynecol. (Supp.), 49:73 (1977). Planned Parenthood reported only 11 cases of tubal pregnancy among 41,753 women presented for elective, first-trimester abortions, only two of which were diagnosed prior to rupture.

 ''"Fatal pulmonary embolism during legal induced abortion in the United States from 1972 to 1985," H.W. Lawson, H.K. Atrash, A.L. Franks, Am.J. Obstetrics and Gynecology, 162: 986-990,1990. ''

:Of the 213 deaths from legal abortion from 1972-1985, 21 % were due to air, blood clot or amniotic fluid embolism. The risk of death from embolism was higher among minority women and women aged 34-44 years and abortion at later stages of pregnancy.

 ''"Cluster of Abortion Deaths at a Single Facility," M.E. Kafrissen, D.A. Grimes, C.J.R. Hogue, J.J. Sacks, Obstetrics and Gynecology 68: 387,1986. ''

:Four abortion related deaths at a single facility were reported from 1979 to 1983. Two abortion deaths occurred when an unlicensed person performed the abortions. It was recommended that prompt treatment of abortion complications and community-based surveillance of serious morbidity should be done.

 ''"Ectopic Pregnancy in the United States. 1970-1986," H. Lawson, H. Atrash, A. Saftlas and E. Finch, Centers for Disease Control, Morbidity and Mortality Weekly Report, 38(SS- 2) Sept. 1989. ''

:Ectopic pregnancy rose from 17,800 cases in 1970 to 73,700 cases in 1986. Nearly 800,000 women have been hospitalized for ectopic pregnancy since 1970. Thirty-six women reportedly died from ectopic pregnancy in 1986.

 ''"Mortality From Abortion and Childbirth," (letter), M. Lanska D. Lanska and A. Rimm, JAMA 250(3): 361-362 July 15, 1983. ''

:Maternal mortality following a cesarean section is approximately 100 per 100,000 births which is roughly 10-20 times greater than the maternal mortality following vaginal delivery. Cesarean sections, while accounting for only 10% of the deliveries, account for 90% of the maternal mortality associated with childbirth. The results suggest that the mortality rate among women who have had abortions (1.9 per 100,000 legal abortions) is almost twice as high as maternal mortality rates for women who have had vaginal deliveries (1.1 per 100,000 live births.

 ''"Trends in the United States cesarean section rate and reasons for the 1980-1985 rise," S. Taffel, P. Placek and T. Liss, Am. J. Public Health 77: 955 (1987). ''

:Deliveries by cesarean section in the U.S. increased from 5.5% in 1970 to 16.5% in 1980 and to 27.7% of all deliveries in 1985.

 ''"Maternal Mortality in the United States: Report From the Maternal Mortality Collaborative," R. Rochat, L. Koonin, H. Atrash, J. Jewett, Obstetrics and Gynecology 72: 91 1988. ''

:Of the leading causes of direct maternal deaths during 1980-85,45.5% were known to have been associated with delivery by cesarean section. It was concluded that maternal deaths from childbirth and abortion are under-reported.

 ''"Ectopic pregnancy concurrent with induced abortion: Incidence and mortality," H.K. Atrash, Am. J. Obstet. Gynecol. 162(3):726-730, March 1990. ''

:From 1972-1985, 24 women who underwent an induced abortion died as a result of a concurrent ectopic pregnancy. The death-to-case rate was 1.3 times higher in ectopic pregnancy concurrent with induced abortion than for women not undergoing induced abortion. Most of the deaths of women with ectopic pregnancy who underwent abortion were attributed to the failure to diagnose ectopic pregnancy before the women left the facility. Tissue examination to assure there is a product of conception at the time of the abortion is necessary.

 ''"Centers for Disease Control, Abortion Surveillance, 1981," U.S. Dept. of Health and Human Services, Public Health Services, November 1985 p. 9 ''

:Between 1972 and 1981 the Centers for Disease Control reported that 21 deaths from ectopic pregnancy occured soon after an attempted legally induced abortion. In the 1978 abortion surveillance report the CDC considered such deaths as abortion-related and included them as a separate subcategory of legal induced abortion. In 1979 the CDC began the independent surveillance of ectopic pregnancy-related mortality and published its first ectopic pregnancy surveillance report in 1982. In the abortion surveillance report of 1981 (and apparently in years following), the CDC excluded all deaths associated with ectopic pregnancies.

== Mortality Elevated by Substance Use & Other Abortion Associated Mental Health Maladies ==
'''[http://archpsyc.jamanetwork.com/article.aspx?articleID=2474998&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMAPsychiatry%3AOnlineFirst12%2F23%2F2015 Association of Mental Disorders With Subsequent Chronic Physical Conditions
World Mental Health Surveys From 17 Countries] Scott KM, et al. JAMA Psychiatry. Published online December 23, 2015. doi:10.1001/jamapsychiatry.2015.2688
'''
:Objective To investigate associations of 16 temporally prior DSM-IV mental disorders with the subsequent onset or diagnosis of 10 chronic physical conditions.

:Design, Setting, and Participants Eighteen face-to-face, cross-sectional household surveys of community-dwelling adults were conducted in 17 countries (47 609 individuals; 2 032 942 person-years) from January 1, 2001, to December 31, 2011. The Composite International Diagnostic Interview was used to retrospectively assess the lifetime prevalence and age at onset of DSM-IV–identified mental disorders. Data analysis was performed from January 3, 2012, to September 30, 2015.

:Main Outcomes and Measures Lifetime history of physical conditions was ascertained via self-report of physician’s diagnosis and year of onset or diagnosis. Survival analyses estimated the associations of temporally prior first onset of mental disorders with subsequent onset or diagnosis of physical conditions.

:Results Most associations between 16 mental disorders and subsequent onset or diagnosis of 10 physical conditions were statistically significant, with odds ratios (ORs) (95% CIs) ranging from 1.2 (1.0-1.5) to 3.6 (2.0-6.6). The associations were attenuated after adjustment for mental disorder comorbidity, but mood, anxiety, substance use, and impulse control disorders remained significantly associated with onset of between 7 and all 10 of the physical conditions (ORs [95% CIs] from 1.2 [1.1-1.3] to 2.0 [1.4-2.8]). An increasing number of mental disorders experienced over the life course was significantly associated with increasing odds of onset or diagnosis of all 10 types of physical conditions, with ORs (95% CIs) for 1 mental disorder ranging from 1.3 (1.1-1.6) to 1.8 (1.4-2.2) and ORs (95% CIs) for 5 or more mental disorders ranging from 1.9 (1.4-2.7) to 4.0 (2.5-6.5). In population-attributable risk estimates, specific mental disorders were associated with 1.5% to 13.3% of physical condition onsets.

:Conclusions and Relevance These findings suggest that mental disorders of all kinds are associated with an increased risk of onset of a wide range of chronic physical conditions. Current efforts to improve the physical health of individuals with mental disorders may be too narrowly focused on the small group with the most severe mental disorders. Interventions aimed at the primary prevention of chronic physical diseases should optimally be integrated into treatment of all mental disorders in primary and secondary care from early in the disorder course.

[http://www.ncbi.nlm.nih.gov/pubmed/25243359 Mortality and life expectancy of people with alcohol use disorder in Denmark, Finland and Sweden.] Westman J, Wahlbeck K, Laursen TM, Gissler M, Nordentoft M, Hällgren J, Arffman M, Ösby U. Acta Psychiatr Scand. 2015 Apr;131(4):297-306. doi: 10.1111/acps.12330. Epub 2014 Sep 20

:"People hospitalized with alcohol use disorder have an average life expectancy of 47-53 years (men) and 50-58 years (women) and die 24-28 years earlier than people in the general population."

[http://www.ncbi.nlm.nih.gov/pubmed/22293064 Mortality and potential years of life lost attributable to alcohol consumption in Canada in 2005.] Shield KD, Taylor B, Kehoe T, Patra J, Rehm J. BMC Public Health. 2012 Jan 31;12:91. doi: 10.1186/1471-2458-12-91.

[http://www.ncbi.nlm.nih.gov/pubmed/23831731 Alcohol-attributable mortality and years of potential life lost in Chile in 2009.] Castillo-Carniglia A, Kaufman JS, Pino P. Alcohol Alcohol. 2013 Nov-Dec;48(6):729-36. doi: 10.1093/alcalc/agt066. Epub 2013 Jul 5.

[http://www.ncbi.nlm.nih.gov/pubmed/23460733 Alcohol-attributable mortality in France.] Guérin S, Laplanche A, Dunant A, Hill C. Eur J Public Health. 2013 Aug;23(4):588-93. doi: 10.1093/eurpub/ckt015. Epub 2013 Mar 4.

[http://www.ncbi.nlm.nih.gov/pubmed/24845076 Alcohol-attributable mortality in Switzerland in 2011--age-specific causes of death and impact of heavy versus non-heavy drinking.] Marmet S, Rehm J, Gmel G, Frick H, Gmel G. Swiss Med Wkly. 2014 May 20;144:w13947. doi: 10.4414/smw.2014.13947. eCollection 2014.

[http://www.ncbi.nlm.nih.gov/pubmed/23372832 Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden.] Nordentoft M1, Wahlbeck K, Hällgren J, Westman J, Osby U, Alinaghizadeh H, Gissler M, Laursen TM. PLoS One. 2013;8(1):e55176. doi: 10.1371/journal.pone.0055176. Epub 2013 Jan 25.

:[http://www.ncbi.nlm.nih.gov/pubmed/21440382 Associations between substance use disorder sub-groups, life expectancy and all-cause mortality in a large British specialist mental healthcare service.] Hayes RD, Chang CK, Fernandes A, Broadbent M, Lee W, Hotopf M, Stewart R. Drug Alcohol Depend. 2011 Oct 1;118(1):56-61. doi: 10.1016/j.drugalcdep.2011.02.021. Epub 2011 Mar 26.

== General Literature ==

''[http://www.npr.org/series/133208980/post-mortem-death-investigation-in-america Post Moretem: Death Investigation in America]'' -- (February, 2011) An NPR News investigation in partnership with ProPublica and PBS Frontline explores the nation's 2,300 coroner and medical examiner offices, and finds a troubled system that literally buries its mistakes.

:This expose underscores the unreliability of relying on death certificates to quantify deaths associated with abortion and childbirth

''[http://www.c-fam.org/publications/id.1533/pub_detail.asp Permissive Abortion Laws May Be Hazardous To Mothers' Health, Per New Report]''

:The [http://www.weforum.org/pdf/gendergap/report2009.pdf Global Gender Report, 2009] from the World Economic Forum (WEF) shows that countries with restrictive abortion laws are often the leaders in reducing maternal mortality, and those with permissive laws often lag. According to the report, the pro-life nation of Ireland has topped the global rankings once again with the best maternal health performance.
:"An examination and comparison of several countries included in the WEF survey show that legal abortion does not mean lower maternal mortality rates.  

:"Both Ireland and Poland, favorite targets of the abortion lobby for their strong restrictions on abortion, have better maternal mortality ratios than the United States. Ireland ranks first in the survey with 1 death for every 100,000 live births. In recent years Poland has tightened its abortion law and ranks number 27 on the list with 8 deaths per 100,000. In the United States where there are virtually no restrictions on abortion, the maternal mortality ratio is 17 out of 100,000 live births."

 

''Lime 5. Exploited by Choice, Mark Crucher, (Denton, Texas: Life Dynamics, Inc., 1996) 135-155 ''

:Describes the reporting of flawed data on maternal deaths by the Centers for Disease Control. Examples include: lack of information in medical records, failure to recognize that there was a recent abortion, improper classification, differing definitions of maternal death, confidentiality, lack of cooperation between various government agencies, CDC officials connected to the abortion industry.

 ''Communication dated Tune 5. 1987 from Commissioner of Health, City of New York to All Gynecologists, Anesthesiologists, Administrators and Others Concerned with the Provision of Abortion Services in Victims of Choice, Kevin Sherlock, (Akron, Ohio: Brennyman Books, 1996) ''

:The New York City Health Department, apparently relying on data likely to have been provided by the Alan Guttmacher Institute, reported that 146 women died from legal abortion between 1981-1984, yet the Centers for Disease Control reported only 42 deaths from legal abortion during that same period. Ed Note: This is a good example of the underreporting of deaths from legal abortion.

''Victims of Choice, Kevin Sherlock, (Akron, OH: Brennyman Books, 1996) ''

:In an investigation and subsequent analysis of 87 abortion-related deaths of U.S. women between 1980-1989 in 28 states, 47 were classified as unspecified abortion, 33 as legal abortion, and 7 did not include a code classification. Death certificates or coroner reports used 27 different terms or phrases to describe abortion. If the term abortion, septic abortion, induced abortion or incomplete abortion was used on death certificates or coroner/medical examiner reports, deaths were classified as unspecified abortion. Where the term termination of pregnancy or elective abortion was used, about 2/3 were classified as legal abortion deaths. Where the term therapeutic abortion was used, virtually all were classified as legal abortion deaths. Ed Note: It appeared that most, if not all, of these abortion-related deaths were from legal abortion. The wide range of terms used to describe abortion appeared to be a major factor in misclassification.

 ''"Induced Abortion as a Contributing Factor in Maternal Mortality or Pregnancy- Related Death in Women," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change 10(3): 1-8, Nov/Dec, 1996. ''

:Prior induced abortion is a cause of complications in subsequent pregnancies including placenta previa, retained placenta, abrupdo placentae, premature rupture of membranes, and obstetrical infections. Also, induced abortion increases the incidence of suicide compared to other pregnancy outcomes, as well as ruptured ectopic pregnancy. Induced abortion does not provide the protective effect of childbirth and increases the incidence of hypertensive disorders of pregnancy. All of these increase the incidence of maternal mortality.

 ''"Brief of Amicus Curiae Feminists for Life of America. Women Exploited by Abortion, etc," Christine Smith Torre, Webster v. Reproductive Health Services 88-605 1988 at p. 22 ''

:The state of California reported no deaths from abortion during 1982 and 1984, yet there was incontrovertible evidence from death certificates, police reports, coroner's reports and other sources that at least four women and teenage girls died from legal abortions in Los Angeles County alone during 1983 and 1984.

''Aborted Women: Silent No More, David C. Reardon, (Chicago: Loyola Press, 1987) 109. ''

:In an investigation of four Chicago-based abortion clinics (out of more than 20 in the state), investigative reporters for the Chicago Sun-times uncovered 12 abortion deaths that had never been reported. Even when abortion-related deaths such as these are uncovered, they are not generally included in the "official" total since they were not reported as such on the original death certificates. Citing "The Abortion Profiteers," Pamela Zekeman and Pamela Warrick, Chicago Sun-Times, November 12, 1978 (Special Reprint December 3,1978); Abortion: Questions and Answers J. Willke and B. Willke ( Cincinnati: Hayes Publishing, 1985); "Medical Hazards of Abortion," Thomas Hilgers, in Abortion and Social Justice. ed. T. Hilgers and D. Horan, (New York: Sheed and Ward, 1972)

 ''"Before and After Legalization," in Aborted Women: Silent No More, David C. Reardon, (Chicago: Loyola Press, 1987) 282-300. ''

:Examines reporting of abortion related deaths before and after legalization. Abortion related deaths were much more likely to be reported when it was still a criminal act. Numerous factors, including the lack of a formal reporting mechanism, render post- legalization assessments of abortion related deaths unreliable.

 ''"The Cover-Up: Why U.S. Abortion Mortality Statistics are Meaningless," David C. Reardon, The Post-Abortion Review 8(2):4, April-June 2000. Posted at www.afterabortion.org/PAR/V8.''

:This article identifies examples of documented abortion related deaths that have been excluded from government figures. The rules regarding coding cause of death using the International Classification of Diseases preclude identifying medical procedures as the cause of death. This coding rule contributes to the lack of good statistics on abortion related deaths.

'''[http://www.nejm.org/doi/full/10.1056/NEJM200404293501821 Abortion, Health, and the Law]''' N Engl J Med 2004; 350:1908-1910 April 29, 2004

Greene and Ecker's interesting exploration of difficulties in risk–benefit analyses with regard to therapeutic abortions (Jan. 8 issue)[1] is, unfortunately, flawed by the use of disparate comparisons. For example, they cite sources that use dissimilar definitions, populations, and means of case identification to calculate comparative death rates for abortion and childbirth. This approach is problematic, since efforts to track deaths associated with pregnancy and abortion are hampered by inaccurate death certificates and inconsistent definitions.[2] Citing the only two record-based, case–control studies that directly compared death rates associated with abortion and childbirth would have been more informative.[2,3] Both reveal significantly higher mortality rates associated with abortion than with other outcomes of pregnancy. The one-year age-adjusted odds ratio for death among pregnant women as compared with nonpregnant women was 0.50 for those who gave birth, 0.87 for those who had a miscarriage, and 1.76 for those who had an abortion.[2]
The authors also fail to note that couples in which the woman undergoes a therapeutic abortion have high rates of psychiatric sequelae and divorce.4 Although it is known that elective abortion is more strongly associated with subsequent psychiatric hospitalization than is childbirth,[5] there have been no comparative studies of therapeutic abortion. Therefore, case–control studies are required to support the authors' risk–benefit analysis.
#Greene MF, Ecker JL. Abortion, health, and the law. N Engl J Med 2004;350:184-186
#Gissler M, Kauppila R, Merilainen J, Toukomaa H, Hemminki E. Pregnancy-associated deaths in Finland 1987-1994 -- definition problems and benefits of record linkage. Acta Obstet Gynecol Scand 1997;76:651-657
#Reardon DC, Ney PG, Scheuren F, Cougle J, Coleman PK, Strahan TW. Deaths associated with pregnancy outcome: a record linkage study of low income women. South Med J 2002;95:834-841
#Lloyd J, Laurence KM. Sequelae and support after termination of pregnancy for fetal malformation. Br Med J (Clin Red Ed) 1985;290:907-909
#Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low-income women following abortion and childbirth. CMAJ 2003;168:1253-1256

== Benefits of Childbirth ==

In addition to the record based studies from Finland showing lower mortality rates for childbearing women compared to non-pregnant women, additional research shows that women who have larger families have greater longevity.

'''[http://ageing.oxfordjournals.org/content/early/2012/03/14/ageing.afs016.short?rss=1 Childbearing history and late-life mortality: the Dubbo study of Australian elderly]''' Simons LA, Simons J, Friedlander Y, McCallum J. Age Ageing. 2012 Mar 29.

::Overall, the more kids a woman had, the less likely she was to die during this time.
Compared with women who were childless, death ratesin women with two kids were 17 per
cent lower. Death rates were 30 per cent lower among women with five children, and 40
per cent lower in those with six or more kids.

:Objective: to examine the association of parity with mortality in later life.

:Design: a longitudinal, community-based study.

:Setting: semi-rural town of Dubbo, NSW, Australia.

:Subjects: a total of 1,571 women and 1,233 men 60 years and older first examined in 1988–89.

:Outcome measures: all-cause and cause-specific mortality rates analysed over 16-year follow-up. Hazard ratios obtained from proportional hazards models employing conventional predictors, potential confounders and measure of parity.

:Results: increasing parity in women was weakly associated with overweight, diabetes and hypertension. All-cause mortality fell progressively with increasing parity in women (hazard ratio and 95% confidence intervals): childless, 1.00; 1 child, 1.03 (0.75–1.43); 2 children, 0.83 (0.61–1.11); 3 children, 0.80 (0.60–1.08); 4 children, 0.91 (0.66–1.25); 5 children, 0.70 (0.49–1.01); 6+ children, 0.60 (0.43–0.85) (trend for parity P < 0.002). This result was similar whether or not hypertension, diabetes and overweight were included in multivariate models adjusting for social variables and other confounders. The reduction in all-cause mortality was accompanied by a parallel reduction in deaths from cancer and respiratory conditions, while coronary heart disease mortality increased 60–111% in all parous women.

:Conclusion: there was increased all-cause mortality in later life in childless women, accompanied by reduced mortality as parity increased. Underlying mechanisms are unclear but findings may have public health importance.

[[Category:Research]]

Psychiatric or Psychological Hospitalization or Consultation

2025-10-08T17:00:39Z

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===Psychiatric or Psychological Hospitalization or Consultation===

[https://pubmed.ncbi.nlm.nih.gov/40408979/ Induced abortion and implications for long-term mental health: a cohort study of 1.2 million pregnancies.] Auger N, Healy-Profitós J, Ayoub A, Lewin A, Low N. J Psychiatr Res. 2025 Jul;187:304-310. doi: 10.1016/j.jpsychires.2025.05.031. Epub 2025 May 16. PMID: 40408979.<blockquote>
'''Background:''' The relationship between induced abortion and long-term mental health is not clear. We assessed whether having an induced abortion was associated with an increase in the long-term risk of mental health hospitalization.

'''Methods:''' We carried out a retrospective cohort study of 28,721 induced abortions and 1,228,807 births in hospitals of Quebec, Canada, between 2006 and 2022. The exposure was induced abortion compared with other pregnancies, and the outcome was hospitalization for a psychiatric disorder, substance use disorder, or suicide attempt over time. We followed patients up to 17 years after the end of pregnancy to identify mental health-related hospitalizations. We calculated hazard ratios (HR) and 95 % confidence intervals (CI) for the association between induced abortion and mental health hospitalization, adjusted for pregnancy characteristics.

'''Results:''' Rates of mental health-related hospitalization were higher following induced abortions than other pregnancies (104.0 vs. 42.0 per 10,000 person-years). Abortion was associated with hospitalization for psychiatric disorders (HR 1.81, 95 % CI 1.72-1.90), substance use disorders (HR 2.57, 95 % CI 2.41-2.75), and suicide attempts (HR 2.16, 95 % CI 1.91-2.43) compared with other pregnancies. The associations were greater for patients who had preexisting mental illness or were aged less than 25 years at the time of the abortion. Abortion was strongly associated with mental health hospitalization within five years but risks waned over time.

'''Conclusion:''' Induced abortion is associated with an increased risk of mental health-related hospitalization in the long term but the association weakens with time.

Note: The supplementary Table S2, compared to live birth, the suicide attempts were twice as likely after an abortion (HR=2.16 95% CI 1.92-2.43)

</blockquote>Association between abortion and mental health hospitalization, excluding stillbirths from the comparison group. Adjusted hazard ratio (HR) and adjusted population attributable risk (PAR).
{| class="wikitable"
| rowspan="3" |
| colspan="2" |'''Rate per 10,000 person-years'''
|'''Adjusted HR'''
| rowspan="3" |'''Adj PAR'''
|-
| colspan="2" |(95% CI)
| rowspan="2" |(95% CI)a
|-
|Abortion
|Live birth
|-
|'''Any mental health admission'''
|104.0 (100.2-108.0)
|41.8 (41.5-42.2)
|1.92 (1.83-2.01)
|2.02%
|-
|'''Psychiatric disorder'''
|85.1 (81.7-88.7)
|37.0 (36.6-37.3)
|1.81 (1.73-1.91)
|1.81%
|-
|Bipolar
|8.7 (7.7-9.9)
|4.3 (4.2-4.5)
|1.45 (1.25-1.68)
|1.01%
|-
|Depression
|24.7 (22.9-26.6)
|12.1 (11.9-12.3)
|1.65 (1.51-1.80)
|1.43%
|-
|Anxiety and stress
|54.8 (52.1-57.7)
|23.8 (23.6-24.1)
|1.81 (1.70-1.92)
|1.81%
|-
|Eating
|2.4 (1.9-3.1)
|0.7 (0.7-0.8)
|2.25 (1.67-3.04)
|2.78%
|-
|Psychosis
|9.2 (8.1-10.4)
|3.1 (3.0-3.2)
|2.06 (1.78-2.39)
|2.38%
|-
|Personality
|33.0 (30.9-35.3)
|9.7 (9.5-9.9)
|2.26 (2.08-2.45)
|2.78%
|-
|'''Substance use disorder'''
|56.7 (53.9-59.6)
|14.9 (14.7-15.1)
|2.58 (2.42-2.76)
|3.47%
|-
|Alcohol
|27.8 (25.9-29.8)
|7.4 (7.2-7.6)
|2.50 (2.28-2.74)
|3.30%
|-
|Opioids
|6.0 (5.1-7.0)
|1.2 (1.1-1.3)
|3.26 (2.69-3.95)
|4.89%
|-
|Cannabis
|17.7 (16.2-19.3)
|4.3 (4.2-4.4)
|2.58 (2.30-2.89)
|3.47%
|-
|Cocaine
|13.6 (12.3-15.1)
|2.5 (2.4-2.5)
|3.47 (3.02-3.98)
|5.31%
|-
|Stimulant
|15.7 (14.3-17.3)
|3.5 (3.4-3.6)
|2.78 (2.45-3.15)
|3.89%
|-
|Hallucinogen
|0.8 (0.5-1.2)
|0.1 (0.1-0.1)
|5.19 (2.78-9.67)
|8.66%
|-
|Sedative
|10.5 (9.3-11.8)
|2.5 (2.4-2.6)
|2.86 (2.46-3.31)
|4.05%
|-
|Other illicit substance
|0.5 (0.3-0.9)
|0.1 (0.1-0.1)
|5.37 (2.57-11.23)
|9.11%
|-
|'''Suicide attempt'''
|14.7 (13.3-16.2)
|4.4 (4.3-4.5)
|2.16 (1.92-2.43)
|2.58%
|}
aHazard ratio for abortion vs live birth, adjusted for age, comorbidity, preexisting mental illness, material deprivation, rural residence, and time period

'''[https://pubmed.ncbi.nlm.nih.gov/38771715/ A Reanalysis of Mental Disorders Risk Following First-Trimester Abortions in Denmark.] Reardon DC. Issues Law Med. 2024 Spring;39(1):66-75. PMID: 38771715.'''<blockquote>'''Background:''' A previous Danish study of monthly and tri-monthly rates of first-time psychiatric contact following first induced abortions reported higher rates compared to first live births but similar rates compared to nine months pre-abortion. Therefore, the researchers concluded abortion has no independent effect on mental health; any differences between psychiatric contacts after abortion and delivery are entirely attributable to pre-existing mental health differences. However, these conclusions are inconsistent with similar studies that used longer time frames. Reanalysis of the published Danish data over slightly longer time frames may reconcile this discordance.

'''Method:''' Monthly and tri-monthly data was extracted for reanalysis of cumulative effects over nine- and twelvemonths post-abortion.

'''Results:''' Across all psychiatric diagnoses, cumulative average monthly rate of first-time psychiatric contact increased from an odds ratio of 1.12 (95% CI: 1.02 to 1.22) at 9-months to 1.49 (95% CI: 1.37 to 1.63) at 12 months post-abortion as compared to the 9 months pre-abortion rate. At 12 months post-abortion, first-time psychiatric contact was higher across all four diagnostic groupings and highest for personality or behavioral disorders (OR=1.87; 95% CI:1.48 to 2.36) and neurotic, stress related, or somatoform disorders (OR=1.60; 95% CI: 1.41 to 1.81).

'''Conclusions:''' Our reanalysis revealed that the Danish data is consistent with the larger body of both record-based and survey- based studies when viewed over periods of observation of at least nine months. Longer periods of observation are necessary to capture both anniversary reactions and the exhaustion of coping mechanisms which may delay observation of post-abortion effects.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/38777160/ Medication and procedural abortions before 13 weeks gestation and risk of psychiatric disorders.] Am J Obstet Gynecol. Steinberg JR, Laursen TM, Lidegaard Ø, Munk-Olsen T. 2024 Oct;231(4):437.e1-437.e18. doi: 10.1016/j.ajog.2024.05.025. Epub 2024 May 20. PMID: 38777160.'''<blockquote>'''Background:''' The proportion of abortions provided by medication in the United States and worldwide has increased greatly since the U.S. Food and Drug Administration approved mifepristone in 2000. While existing research has shown that abortion does not increase risk of mental health problems, no population-based study has examined specifically whether a procedural or medication abortion increases risk of mental health disorders.

'''Objective:''' This study examined whether mental health disorders increased in the shorter and longer-term after a medication or procedural abortion.

'''Study design:''' Using Danish population registers' data, we conducted a prospective cohort study in which we included 72,424 females born in Denmark between 1980 and 2006, who were ages 12 to 38 during the study period and had a first first-trimester abortion before 13 weeks gestation in 2000 to 2018. Females with no previous psychiatric diagnoses were followed from 1 year before their abortion until their first psychiatric diagnosis, December 31, 2018, emigration from Demark, or death, whichever came first. Risk of any first psychiatric disorder was defined as a recorded psychiatric diagnosis at an in- or out-patient facility from the 1 year after to more than 5 years after a medication or procedural abortion relative to the year beforehand. Results were adjusted for calendar year, age, gestational age, partner status, prior mental and physical health, childbirth history, childhood environment, and parental mental health history.

'''Results:''' Females having medication (n=37,155) and procedural abortions (n=35,269) had the same risk of any first psychiatric diagnosis in the year after their abortion relative to the year before their abortion (medication abortion adjusted incidence rate ratio [MaIRR]=1.02, 95% confidence interval [CI]: 0.93-1.12; procedural abortion adjusted incidence rate ratio [PaIRR]=0.94, 95% CI: 0.86-1.02). Moreover, as more time from the abortion passed, the risk of a psychiatric diagnoses decreased relative to the year before their abortion for each abortion method (MaIRR 1-2 years after=0.89, 95% CI: 0.80-0.98; PaIRR 1-2 years after=0.81, 95% CI: 0.88-1.05; MaIRR 2-5 years after=0.77, 95% CI: 0.71-0.84; PaIRR 2-5 years after=0.72, 95% CI: 0.67-0.78; MaIRR 5+ years after=0.58, 95% CI: 0.53-0.63; PaIRR 5+ years after=0.54, 95% CI: 0.50-0.58).

'''Conclusion:''' Because the risk of psychiatric diagnoses was the same in the year after relative to the year before a medication and procedural abortion and the risk did not increase as more time after the abortion increased, neither abortion method increased risk of mental health disorders in the shorter or longer-term.

'''Note:''' Most notably, the authors of this study chose not to provide any comparison to first psychiatric diagnosis rates of the general population, or women without a history of abortion who had natural pregnancy losses or caried a first pregnancy to term.</blockquote>

'''''[http://abortionrisks.org/index.php?title=Munk-Olsen_et_al Induced First-Trimester Abortion and Risk of Mental Disorder.] Trine Munk-Olsen, Ph.D., Thomas Munk Laursen, Ph.D., Carsten B. Pedersen, Dr.Med.Sc., Øjvind Lidegaard, Dr.Med.Sc., and Preben Bo Mortensen, Dr.Med.Sc. N Engl J Med 2011;364:332-9.'''''<blockquote>
:'''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.
:'''Editor's Note''': Please see the [http://abortionrisks.org/index.php?title=Munk-Olsen_et_al extended review of this study] for a more detailed discussion of the methodological limitations which slanting of the study design.
</blockquote>

''[http://www.cmaj.ca/cgi/content/full/168/10/1253 Psychiatric admissions of low income women following abortion and childbirth.] Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Can Med Assoc J. 2003; 168(10):1253-7''
: Background: Controversy exists about whether abortion or childbirth is associated with greater psychological risks. We compared psychiatric admission rates of women in time periods from 90 days to 4 years after either abortion or childbirth.

:Methods: We used California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth during 1989. Only women who had no psychiatric admissions or pregnancy events during the year before the target pregnancy event were included (n = 56 741). Psychiatric admissions were examined using logistic regression analyses, controlling for age and months of eligibility for Medi-Cal services.

:Results: Overall, women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age.

:Interpretation: Subsequent psychiatric admissions are more common among low-income women who have an induced abortion than among those who carry a pregnancy to term, both in the short and longer term.

NOTES:
*Tables showing when the psychiatric hospitalization occurred illustrate a marked peak closer to the time of the pregnancy event, providing support for a causal interpretation.
*Using the same population, the authors also examined outpatient treatment for psychiatric disorders and also found higher rates of outpatient treatment following abortion. See next entry below
* The abortion group had 160% more total in-patient mental health claims than the birth group. Percentages equaled 120%, 90%, 110%, 60%, and 50% for the first 180 days, one year, two years, three years, and four years respectively.
*Across the four years, the abortion group had 70% more in-patient mental health claims than the birth group. Percentages equaled 90%, 110%, and 200% for depressive psychosis, single episode, depressive psychosis, recurrent episode, and bipolar disorder, respectfully

''[http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2002-15486-015&CFID=27122313&CFTOKEN=47942096 State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years.]'' Coleman PK, Reardon DC, Rue VM, Cougle JR. American Journal of Orthopsychiatry, 2002; 72(1):141–52. ''

:(Abstract) In this record-based study, rates of 1st-time outpatient mental health treatment for 4 years following an abortion or a birth among women (aged 13-49 yrs) 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.

''Report of the Committee on the Abortion Law, RF Badgley et al, (Ottawa:Supply and Services, 1977) pp. 313-321 ''
:A Saskatchewan, Canada study found that postabortion women had "mental disorders" 40.8% more often than postpartum women. An Alberta, Canada study found that among women who had abortions, 24% made visits to psychiatrists compared to 3% in the general population.

''''[http://www.scribd.com/doc/132704966/Virginia-DMAS-analysis-of-health-claims-following-abortion-and-childbirth Virginia DMAS analysis of health claims following abortion and childbirth. Nelson J. Department of Medical Assistance Services. Richmond, VA. March 21, 1997. Reply to request by Delegate Bob Marshall.

:This was an exploratory investigation by the Virginia Department of Medical Assistance Services (DMAS) to compare health claims of women who aborted and women who had normal births. The study examined medicaid claims paid by DMAS over a three year period for 122 women who had a first live birth and 122 women with a first abortion.

:In this study population, women who had abortions had statistically significant 62% percent increase in subsequent mental health claims (43% higher costs), and a 12% increase in claims (53% higher costs) for treatments resulting from accidents. They were 275% more likely to undergo a subsequent clinical psychiatric evaluation and 206% more likely to receive individual medical psychotherapy, and were 720% more likely to receive pharmacologic management in association with minimal psychotherapy.

''"Health Services Utilization After Induced Abortion in Ontario: A Comparison Between Community Clinics and Hospitals," T Ostbye et al, Am J Medical Quality 16(3):99-106, 2001''
:In Canada, a study of Ontario Health Insurance Plan claims in 1995 found that women who were three months postabortion from hospital day surgery had a rate of hospitalization for psychiatric problems of 5.2 per 1000 vs. 1.1 per 1000 for age matched controls without induced abortions. Three month postabortion women who had abortions at a community clinic had a rate of hospitalization for psychiatric problems of 1.9 per 1000 vs. 0.60 per 1000 for age-matched controls who did not have induced abortions. The incidence of postabortion psychiatric hospitalization was significantly higher if there had been preabortion hospitalization for psychiatric problems, preabortion emergency room consultation, or preabortion hospital admissions. Ed. Note: Flaws in the available data and study design limit the value of this study.

''"Postabortion or Postpartum Psychotic Reactions," H David et al, Family Planning Perspectives 13(2): 892, 1981 ''
:A Danish register linkage study over a three month period found that the rate of psychiatric hospital admissions was 18.4 per 10,000 postabortion women, 12.0 pr 10,000 postpartum women, and 7.5 per 10,000 women of childbearing age generally.

''"Risk of Admission to Psychiatric Institutions among Danish Women Who Experienced Induced Abortion: An Analysis Based on A National Record Linkage," Ronald Somers, Dissertation Abstracts Int'l, Public Health 2621-B, 1979 ''
:The age-adjusted incidence of psychiatric hospitalization was 3.42%, 4.06%, and 6.0% for women with one, two, and three induced abortions respectively compared with 2.56%, 1.97% and 2.15% for women with one, two and three live births respectively. The age- adjusted percentage of psychiatric hospitalization for aborting women was 1.49% for married women, 2.38%for single women, 4.21% for separated women, and 5.16% for divorced women. Aborting women under 30 years of age exhibited higher overall and diagnosis specific psychiatric hospital admission rates than women of this age in general. Teenagers who had abortions had 2.9 times the rate of psychiatric hospital admissions compared to teenage women in general. The highest rate of psychiatric hospital admissions was 9.45% among women age 35-39 with more than one abortion during the study period.

''"State-funded abortions vs. deliveries: A comparison of subsequent mental health claims over 6 years," PK Coleman and D Reardon, Poster session presented at the American Psychological Society 12th Annual Convention, Miami, FL, June, 2000 ''
:In a study of California women who received state funded medical care and who either had an abortion or gave birth in 1989, postabortion women were more than twice as likely to have from two to nine treatments for mental health as women who carried to term.

''"Psychosocial Characteristics of Psychiatric Inpatients with Reproductive Losses," T Thomas et al, Journal of Health Care for the Poor and Underserved 7(1):15, 1996 ''
:Postabortion women were more likely to require psychiatric hospitalization, have been subjected to sexual abuse, and be diagnosed for psychoactive substance abuse disorder compared to childless women.

''"Past Trauma and Present Functioning of Patients Attending a Women's Psychiatric Clinic," EFM Borins and PJ Forsythe, Am J Psychiatry 142(4):460, 1985 ''
:In a Canadian study of women attending a hospital based women's psychiatric clinic, a past abortion correlated significantly with three or more trauma factors.

''Proceedings of the Conference on Psycho-Social Factors in Transnational Planning, W Pasini and J Kellerhals, (Washington D.C.: American Institute for Research, 1970) p.44 ''
:A three fold increase in previous psychiatric consultations was found in women seeking repeat abortions compared to maternity patients.

'''[http://bjp.rcpsych.org/content/171/1/69 Family planning needs and STD risk behaviours of female psychiatric out-patients.] J H Coverdale , S H Turbott , H Roberts The British Journal of Psychiatry Jul 1997, 171 (1) 69-72; DOI: 10.1192/bjp.171.1.69'''

:METHOD Sixty-six female out-patients with major psychiatric disorders, including schizophrenia, bipolar disorder and mood disorders, completed a semi-structured interview (response rate = 63%) and were individually matched for age and ethnicity with 66 women who had never been treated for psychiatric illness. They answered questions on child-rearing and on their methods of contraception in relation to their attitudes towards pregnancy, as well as on their risk for STDs.

:RESULTS Compared with controls, the female patients reported having had significantly more induced abortions. 17 patients (39.5%) and 8 controls (13.8%) had had one or more induced abortions (p 0.01).

New Summary of Evidence Linking Abortion to Mental Health Problems

2025-10-08T16:56:40Z

Barb: /* Differences in Mental Health Outcomes Reported by Auger (2025) */

=== Overview ===
Peer-reviewed research published after 2010 has explored potential negative mental health effects associated with induced abortion, often through systematic reviews, cohort studies, and cross-sectional analyses. While the broader literature includes debates and studies finding no causal links, the following summarizes key publications that specifically report negative associations, such as increased risks of depression, anxiety, substance use disorders, and other mental health issues. These findings are drawn from diverse populations and methodologies, with some highlighting factors like pre-existing conditions or unwanted pregnancies as moderators. Prevalence rates and risks vary, and many studies note limitations like self-reporting biases or heterogeneity in data.

=== Systematic Reviews and Meta-Analyses ===
A 2011 quantitative synthesis analyzed 22 studies (published 1995–2009, but the review itself post-2010) involving over 877,000 participants, finding that women with a history of abortion had an 81% increased risk of mental health problems overall, including 37% higher risk of depression, 110% higher risk of alcohol misuse, and 155% higher risk of suicidal behaviors.<ref>Coleman PK. [https://pubmed.ncbi.nlm.nih.gov/21881096/ Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009]. Br J Psychiatry. 2011 Sep;199(3):180-6. doi: 10.1192/bjp.bp.110.077230. PMID: 21881096.</ref> The analysis controlled for variables like prior mental health but faced criticism for methodological flaws in subsequent critiques.

A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior. Anxiety risks were higher but not statistically significant.

The 2018 comprehensive literature review by Reardon examined the abortion and mental health controversy, identifying common ground and disagreements. It noted that abortion is consistently associated with elevated rates of mental illness compared to women without an abortion history, and that the abortion experience directly contributes to mental health problems for at least some women. Risk factors such as pre-existing mental illness were highlighted as predictors of greater vulnerability. The review emphasized obstacles like multiple causation pathways, indeterminate reaction timelines, and ideological biases in research. It reported relative risks from various studies, with abortion linked to higher mental health risks (e.g., relative risk ratios from 1.5 to 5.5 for conditions like depression and anxiety across datasets). Population attributable risks were estimated at 8-28% for mental illnesses post-abortion. Recommendations included mixed research teams and better data sharing to address biases. Figures included relative risk comparisons and population attributable fractions for suicide attempts and other outcomes.

A 2023 systematic review and meta-analysis estimated the global prevalence of post-abortion depression at 34.5% (95% CI: 23.34–45.68) based on 15 observational studies involving 18,207 participants, primarily published between 2010 and 2023.<ref>Gebeyehu, N.A., Tegegne, K.D., Abebe, K. ''et al.'' Global prevalence of post-abortion depression: systematic review and Meta-analysis. ''BMC Psychiatry'' 23, 786 (2023). <nowiki>https://doi.org/10.1186/s12888-023-05278-7</nowiki>https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-023-05278-7</ref> The studies were mainly cross-sectional or cohort designs from regions including Asia, Europe, Africa, and Australia, with higher prevalence in lower-middle-income countries (42.91%) and Asia (37.5%). Associated factors included socioeconomic status, geographical location, and screening tools used (e.g., higher rates with the Center for Epidemiological Studies Depression Scale). Limitations included publication bias, lack of representation from some continents, and inconsistent diagnostic criteria.

=== Cohort and Longitudinal Studies ===
A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior.<ref>Kheriaty, Aaron. [https://issuesinlawandmedicine.com/wp-content/uploads/2025/04/ILM_V40n1_2025_full_issue.pdf#page=7 Abortion and Mental Health: What Can We Conclude?]. ''Issues L. & Med.'' 40 (2025): 3.</ref> Anxiety risks were higher but not statistically significant.

In a 2016 U.S. longitudinal study using National Longitudinal Study of Adolescent to Adult Health data (Sullins), abortion was linked to a 54% increased risk of mental health disorders in late adolescence and early adulthood, with additive effects for multiple abortions.<ref>D. P. Sullins, “Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States,” SAGE Open Med 4 (2016)</ref> The study suggested emotional distress from the abortion experience itself contributed to these outcomes.

A 2017 prospective cohort study in the Netherlands (van Ditzhuijzen et al.) reported increased recurrence of common mental disorders post-abortion among women with prior mental health histories, identifying pre-existing conditions as a key risk factor.<ref>J. van Ditzhuijzen et al., “Incidence and Recurrence of Common Mental Disorders after Abortion: Results from a Prospective Cohort Study,” J Psychiatr Res 84 (2017).</ref>

A 2023 cohort study by Studnicki et al. followed 4,848 continuously eligible Medicaid beneficiaries (aged 16 in 1999) through 2015, comparing first-pregnancy abortion (n=1,331) to birth (n=3,517) cohorts. Women with abortions had higher risks post-pregnancy outcome: outpatient visits (RR 2.10, 95% CI 2.08-2.12; OR 3.36, 95% CI 3.29-3.42), inpatient admissions (RR 2.75, 95% CI 2.38-3.18; OR 5.67, 95% CI 4.39-7.32), and inpatient days of stay (RR 7.38, 95% CI 6.83-7.97; OR 19.64, 95% CI 17.70-21.78). Abortion cohort women had shorter pre-outcome exposure (6.43 vs. 7.80 years) but longer post-outcome (10.57 vs. 9.20 years). Pre-outcome utilization was higher in the birth cohort, challenging the notion that pre-existing conditions fully explain post-abortion effects. Figures showed utilization rates per patient per year for outpatient visits, inpatient admissions, and days of stay. No conflicts of interest were reported.

A 2025 retrospective cohort study by Auger et al. analyzed 1,257,528 pregnancies (28,721 induced abortions and 1,228,807 births) in Quebec, Canada, from 2006 to 2022, following participants up to 17 years post-pregnancy. Hazard ratios were calculated after adjusting for age and time period at the time of the pregnancy, preexisting mental illnesses, comorbidity (obesity, hypertension, diabetes mellitus, dyslipidemia), socioeconomic status, education, employment, rural/urban residence. Rates of mental health-related hospitalizations were higher following induced abortions (104.0 per 10,000 person-years) than other pregnancies (42.0 per 10,000 person-years). Induced abortion was associated with increased risks of hospitalization for psychiatric disorders (HR 1.81, 95% CI 1.72-1.90), substance use disorders (HR 2.57, 95% CI 2.41-2.75), and suicide attempts (HR 2.16, 95% CI 1.91-2.43). Associations were stronger for women with pre-existing mental illness or those under 25 years old, and risks were elevated within five years post-abortion but decreased over time. The study adjusted for pregnancy characteristics but did not explicitly detail limitations in the abstract. The adjusted population attributable risk (PAR) calculations suggest that 2.0% of all psychiatric admissions, 2.2% of suicide attempts and 2.6% of substance use disorders are attributable to abortion. The PAF estimates the fraction of each disease in the population that would be eliminated if the exposure were removed, assuming the adjusted HR represents a causal effect and that all confounders have been adequately measured and controlled for. Notably, among women with prior mental health issues, psychiatric hospitalization was nine times more likely for those who had abortions. In contrast, among women without prior mental health issues, abortion was linked to only a 50% increased risk of psychiatric hospitalization. The risk of psychiatric admissions generally declined over time, nearly disappearing after twelve years. The exception was for substance use disorders, which while declining remained significantly elevated throughout the sixteen years examined by the research team. The study also observed that the risk of psychiatric treatment increased with the number of abortions women experienced. This is a “dose effect.” It means each abortion exposure increased the risk of a mental health disorder requiring hospitalization. Observation of a dose effect is generally considered to be strong evidence of a direct causal pathway between a risk factor (abortion) and a statistically associated outcome (hospitalization for mental health).

=== '''Differences in Mental Health Outcomes Reported by Auger (2025)''' ===
{| class="wikitable"
|
| colspan="2" |'''Rate per 10,000 person-years'''
|'''Adjusted HR'''
|'''Adj PAR'''
|-
|
| colspan="2" |'''(95% CI)'''
|'''(95% CI)a'''
|
|-
|
|'''Abortion'''
|'''Live birth'''
|
|
|-
|'''Any mental health admission'''
|104.0 (100.2-108.0)
|41.8 (41.5-42.2)
|1.92 (1.83-2.01)
|2.02%
|-
|'''Psychiatric disorder'''
|85.1 (81.7-88.7)
|37.0 (36.6-37.3)
|1.81 (1.73-1.91)
|1.81%
|-
|Bipolar
|8.7 (7.7-9.9)
|4.3 (4.2-4.5)
|1.45 (1.25-1.68)
|1.01%
|-
|Depression
|24.7 (22.9-26.6)
|12.1 (11.9-12.3)
|1.65 (1.51-1.80)
|1.43%
|-
|Anxiety and stress
|54.8 (52.1-57.7)
|23.8 (23.6-24.1)
|1.81 (1.70-1.92)
|1.81%
|-
|Eating
|2.4 (1.9-3.1)
|0.7 (0.7-0.8)
|2.25 (1.67-3.04)
|2.78%
|-
|Psychosis
|9.2 (8.1-10.4)
|3.1 (3.0-3.2)
|2.06 (1.78-2.39)
|2.38%
|-
|Personality
|33.0 (30.9-35.3)
|9.7 (9.5-9.9)
|2.26 (2.08-2.45)
|2.78%
|-
|'''Substance use disorder'''
|56.7 (53.9-59.6)
|14.9 (14.7-15.1)
|2.58 (2.42-2.76)
|3.47%
|-
|Alcohol
|27.8 (25.9-29.8)
|7.4 (7.2-7.6)
|2.50 (2.28-2.74)
|3.30%
|-
|Opioids
|6.0 (5.1-7.0)
|1.2 (1.1-1.3)
|3.26 (2.69-3.95)
|4.89%
|-
|Cannabis
|17.7 (16.2-19.3)
|4.3 (4.2-4.4)
|2.58 (2.30-2.89)
|3.47%
|-
|Cocaine
|13.6 (12.3-15.1)
|2.5 (2.4-2.5)
|3.47 (3.02-3.98)
|5.31%
|-
|Stimulant
|15.7 (14.3-17.3)
|3.5 (3.4-3.6)
|2.78 (2.45-3.15)
|3.89%
|-
|Hallucinogen
|0.8 (0.5-1.2)
|0.1 (0.1-0.1)
|5.19 (2.78-9.67)
|8.66%
|-
|Sedative
|10.5 (9.3-11.8)
|2.5 (2.4-2.6)
|2.86 (2.46-3.31)
|4.05%
|-
|Other illicit substance
|0.5 (0.3-0.9)
|0.1 (0.1-0.1)
|5.37 (2.57-11.23)
|9.11%
|-
|'''Suicide attempt'''
|14.7 (13.3-16.2)
|4.4 (4.3-4.5)
|2.16 (1.92-2.43)
|2.58%
|}

=== Cross-Sectional and Regional Studies ===
A 2012 cross-sectional study in Tehran, Iran (Dadkhah et al.), involving 261 women seeking post-abortion care, found that over one-third experienced psychological side effects, including depression (60.5%), worry about future conception (53.6%), abnormal eating behaviors (48.7%), decreased self-esteem (43.7%), nightmares (39.5%), guilt (37.5%), and regret (33.3%).<ref>Pourreza A, Batebi A. Psychological Consequences of Abortion among the Post Abortion Care Seeking Women in Tehran. Iran J Psychiatry. 2011 Winter;6(1):31-6. PMID: 22952518; PMCID: PMC3395931.</ref> Less common were suicide attempts (4.7%), smoking (2.7%), and drug abuse (1.5%). The study highlighted cultural stigmas exacerbating these effects.

The best data on American women is found in a 2016 study using the National Longitudinal Study of Adolescent to Adult Health (Add Health) that provided three models of analyses, including controls for eight confounding factors.<ref name=":0">Donald Paul Sullins, ''Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States'', 4 SAGE Open Med. 6 (2016).</ref> In addition, the author conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” These lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. This study also identified a dose effect, with ''each exposure to abortion'' (up to four) associated with a 23 percent increase of relative risk of subsequent mental disorders.<ref name=":0" /> In addition, a subsequent 2019 analysis using the same data set revealed that approximately 20% of the women having abortions reported wanting the child.<ref>Donald Paul Sullins, ''Affective and Substance Abuse Disorders Following Abortion by Pregnancy Intention in the United States : A Longitudinal Cohort Study'', 55 Medicina (Mex.) 2 (2019).</ref> Unsurprisingly, the women who aborted wanted children experienced 122% higher rate of depression and a 244% higher rate of suicidality. In addition, the author conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” These lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. The study also identified a dose effect, with each exposure to abortion (up to four) associated with a 23 percent (95% CI, 1.16–1.30) increase of relative risk of subsequent mental disorders. In addition, a subsequent 2019 analysis using the same data set revealed that approximately 20% of the women having abortions reported wanting the child.[81] Unsurprisingly, the women who aborted wanted children experienced higher rates of depression (RR 2.22, 95% CI 1.3–3.8) and suicidality (RR 3.44 95% CI 1.5–7.7). Notably, no refutation of these findings has been published. They are undisputed.

A 2025 cross-sectional survey by Reardon involved 2,829 American females aged 41-45, examining suicide risks by pregnancy outcomes. Aborting women were twice as likely to have attempted suicide compared to others. Those with abortions, especially coerced or unwanted ones, reported higher self-assessed contributions of the abortion to suicidal thoughts, self-destructive behaviors, and attempts (measured via visual analog scales). The study challenged the hypothesis that pre-existing mental health fully explains elevated suicide rates post-abortion, as women's self-reports indicated direct contributions from the abortion experience. No conflicts were noted.

=== Additional Context from Reviews ===
The literature published since 2010 has focused on controlling for the effects of prior mental health and has revealed links between abortion and worsened mental health for some women.

'''References'''
<references />

Self-Destructive Behavior

2025-10-07T20:32:54Z

Barb: /* Abortion Related Suicide: Case Studies */

{{DEA}}
{{PsychIndex}}[[Category:Suicide]]

[[Submit_SelfDestructive |Please Submit New Material for This Protected Page Here]]

See also [[Substance Abuse]]

==Suicide Associated with Abortion==

===Specific Cases of Abortion Related Suicide===

See [[Suicide - Case Studies]]

===Statistically Significant Studies===
'''[https://pubmed.ncbi.nlm.nih.gov/34773878/ Premature mortality after pregnancy loss: Trends at 1, 5, 10 years, and beyond.] Auger N, Ghadirian M, Low N, Healy-Profitós J, Wei SQ. Eur J Obstet Gynecol Reprod Biol. 2021 Dec;267:155-160. doi: 10.1016/j.ejogrb.2021.10.033. Epub 2021 Nov 1. PMID: 34773878.'''

'''Objective:''' Little is known on the long-term risk of mortality following pregnancy loss. We assessed risks of premature mortality up to three decades after miscarriage, induced abortion, ectopic or molar pregnancy, and stillbirth relative to live birth.

'''Study design:''' We carried out a longitudinal cohort study of 1,293,640 pregnant women with 18,896,737 person-years of follow-up in Quebec, Canada, from 1989 to 2018. We followed the women up to 29 years after their last pregnancy event to determine the time and cause of future in-hospital deaths before age 75 years. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of miscarriage, induced abortion, ectopic pregnancy, molar pregnancy, and stillbirth with premature mortality, compared with live birth.

'''Results:''' Premature mortality rates were higher for most types of pregnancy loss than live birth. Compared with live birth, pregnancy loss was associated with an elevated risk of premature mortality (HRmiscarriage 1.48, 95% CI 1.33, 1.65; HRinduced abortion 1.50, 95% CI 1.39, 1.62; HRectopic 1.55, 95% CI 1.35, 1.79; and HRstillbirth 1.68, 95%. CI 1.17, 2.41). Molar pregnancy was not associated with premature mortality (HR 0.87, 95% CI 0.33, 2.32). Miscarriage and induced abortion were associated with most causes of death, whereas ectopic pregnancy was associated with cardiovascular (HR 2.18, 95 % CI 1.39, 3.42), cancer (HR 1.38, 95 % CI 1.11, 1.73), and suicide-related mortality (HR 4.94, 95 % CI 2.29, 10.68). Stillbirth was associated with cardiovascular mortality (HR 4.91, 95 % CI 2.33, 10.36).

'''Conclusion:''' Pregnancy loss is associated with an elevated risk of premature mortality up to three decades later, particularly cardiovascular, cancer, and suicide-related deaths.

'''Suicide Specific Results:''' HR Induced Abortion HR 2.41 (1.37 to 4.22) Miscarriage 2.79 (1.29, 6.04); HR Unspecified Abortion 3.31 (1.44, 7.58) Hazard ratio for pregnancy loss relative to live birth, adjusted for maternal age, gravidity, preexisting comorbidity, socioeconomic deprivation, rurality, Aboriginal region, and time period

'''[https://pubmed.ncbi.nlm.nih.gov/40408979/ Induced abortion and implications for long-term mental health: a cohort study of 1.2 million pregnancies.] Auger N, Healy-Profitós J, Ayoub A, Lewin A, Low N. J Psychiatr Res. 2025 Jul;187:304-310. doi: 10.1016/j.jpsychires.2025.05.031. Epub 2025 May 16. PMID: 40408979.'''<blockquote>'''Background:''' The relationship between induced abortion and long-term mental health is not clear. We assessed whether having an induced abortion was associated with an increase in the long-term risk of mental health hospitalization.

'''Methods:''' We carried out a retrospective cohort study of 28,721 induced abortions and 1,228,807 births in hospitals of Quebec, Canada, between 2006 and 2022. The exposure was induced abortion compared with other pregnancies, and the outcome was hospitalization for a psychiatric disorder, substance use disorder, or suicide attempt over time. We followed patients up to 17 years after the end of pregnancy to identify mental health-related hospitalizations. We calculated hazard ratios (HR) and 95 % confidence intervals (CI) for the association between induced abortion and mental health hospitalization, adjusted for pregnancy characteristics.

'''Results:''' Rates of mental health-related hospitalization were higher following induced abortions than other pregnancies (104.0 vs. 42.0 per 10,000 person-years). Abortion was associated with hospitalization for psychiatric disorders (HR 1.81, 95 % CI 1.72-1.90), substance use disorders (HR 2.57, 95 % CI 2.41-2.75), and suicide attempts (HR 2.16, 95 % CI 1.91-2.43) compared with other pregnancies. The associations were greater for patients who had preexisting mental illness or were aged less than 25 years at the time of the abortion. Abortion was strongly associated with mental health hospitalization within five years but risks waned over time.

'''Conclusion:''' Induced abortion is associated with an increased risk of mental health-related hospitalization in the long term but the association weakens with time.

'''Note:''' The supplementary Table S2, compared to live birth, '''the suicide attempts were twice as likely after an abortion (HR=2.16 95% CI 1.92-2.43)'''</blockquote>'''Reardon DC. [https://www.tandfonline.com/doi/full/10.1080/0167482X.2025.2455086 Suicide risks associated with pregnancy outcomes: a national cross-sectional survey of American females 41-45 years of age.] J Psychosom Obstet Gynaecol. 2025 Dec;46(1):2455086.'''<blockquote>'''Objective:''' Numerous studies have linked abortion to an elevated risk of suicide. One hypothesis is that this association is entirely incidental and most likely fully explained by preexisting mental illness. This hypothesis can be tested by examining women’s own self-assessments of the degree, if any, that abortion and other pregnancy outcomes contributed to suicidal thoughts and behaviors.

'''Methods:''' A topic blind survey was distributed to 2829 American females 41–45years of age. Respondents were asked about any history of attempted suicide(s) and reproductive histories. Grouped by reproductive history, respondents were then asked to rank on visual analog scales the degree, if any, to which their pregnancy outcome contributed to suicidal thoughts, self-destructive behaviors, and any attempted suicides.

'''Results:''' Aborting women were twice as likely to have attempted suicide compared to other women. Aborting women, especially those who underwent coerced or unwanted abortions, were significantly more likely to say their pregnancy outcomes directly contributed to suicidal thoughts and behaviors compared to women in all other groups.

'''Conclusions:''' The hypothesis that higher rates of suicide following abortion can be entirely explained by preexisting mental health problems is inconsistent with women’s own self-assessments of the degree their abortions directly contributed to suicidal and self-destructive behaviors.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/36808811/ Hospitalisation for non-lethal self-harm and premature mortality in the 3 years following adolescent pregnancy: Population-based nationwide cohort study.] Goueslard K, Jollant F, Cottenet J, Bechraoui-Quantin S, Rozenberg P, Simon E, Quantin C. BJOG. 2023 Aug;130(9):1016-1027. doi: 10.1111/1471-0528.17432. Epub 2023 Mar 16. PMID: 36808811.'''<blockquote>'''Objective:''' To evaluate the risk of non-lethal self-harm and mortality related to adolescent pregnancy.

'''Design:''' Nationwide population-based retrospective cohort.

'''Setting:''' Data were extracted from the French national health data system.

'''Population:''' We included all adolescents aged 12-18 years with an International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) code for pregnancy in 2013-2014.

'''Methods:''' Pregnant adolescents were compared with age-matched non-pregnant adolescents and with first-time pregnant women aged 19-25 years.

'''Main outcome measures:''' Any hospitalisation for non-lethal self-harm and mortality during a 3-year follow-up period. Adjustment variables were age, a history of hospitalisation for physical diseases, psychiatric disorders, self-harm and reimbursed psychotropic drugs. Cox proportional hazards regression models were used.

'''Results:''' In 2013-2014, 35 449 adolescent pregnancies were recorded in France. After adjustment, pregnant adolescents had an increased risk of subsequent hospitalisation for non-lethal self-harm in comparison with both non-pregnant adolescents (n = 70 898) (1.3% vs 0.2%, HR 3.06, 95% CI 2.57-3.66) and pregnant young women (n = 233 406) (0.5%, HR 2.41, 95% CI 2.14-2.71). Rates of hospitalisation for non-lethal self-harm were lower during pregnancy and higher between 12 and 8 months pre-delivery, 3-7 months postpartum and in the month following abortion. Mortality was significantly higher in pregnant adolescents (0.7‰) versus pregnant young women (0.4‰, HR 1.74, 95% CI 1.12-2.72), but not versus non-pregnant adolescents (0.4‰, HR 1.61, 95% CI 0.92-2.83). {'''The risk of hospitalization for nonlethal self-harm among teenagers was highest after induced abortion (HR, 3.5 [95% CI, 2.9-4.2])).'''

'''Conclusions:''' Adolescent pregnancy is associated with an increased risk of hospitalisation for non-lethal self-harm and premature death. Careful psychological evaluation and support should be systematically implemented for adolescents who are pregnant.</blockquote>'''[https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2816198 Teen Pregnancy and Risk of Premature Mortality.] ''Ray JG, Fu L, Austin PC, et al. JAMA Netw Open.'' 2024;7(3):e241833. doi:10.1001/jamanetworkopen.2024.1833'''<blockquote>'''Objective''' To evaluate the risk of premature mortality from 12 years of age onward in association with number of teen pregnancies and age at pregnancy.

'''Design, Setting, and Participants''' This population-based cohort study was conducted among all females alive at 12 years of age from April 1, 1991, to March 31, 2021, in Ontario, Canada (the most populous province, which has universal health care and data collection). The study period ended March 31, 2022.

'''Exposures''' The main exposure was number of teen pregnancies between 12 and 19 years of age (0, 1, or ≥2). Secondary exposures included how the teen pregnancy ended (birth or miscarriage vs induced abortion) and age at first teen pregnancy.

'''Main Outcomes and Measures''' The main outcome was all-cause mortality starting at 12 years of age. Hazard ratios (HRs) were adjusted for year of birth, comorbidities at 9 to 11 years of age, and area-level education, income level, and rurality.

'''Results''' Of 2 242 929 teenagers, 163 124 (7.3%) experienced a pregnancy at a median age of 18 years (IQR, 17-19 years). Of those with a teen pregnancy, 60 037 (36.8%) ended in a birth (of which 59 485 [99.1%] were live births), and 106 135 (65.1%) ended in induced abortion. The median age at the end of follow-up was 25 years (IQR, 18-32 years) for those without a teen pregnancy and 31 years (IQR, 25-36 years) for those with a teen pregnancy. There were 6030 deaths (1.9 per 10 000 person-years [95% CI, 1.9-2.0 per 10 000 person-years]) among those without a teen pregnancy, 701 deaths (4.1 per 10 000 person-years [95% CI, 3.8-4.5 per 10 000 person-years]) among those with 1 teen pregnancy, and 345 deaths (6.1 per 10 000 person-years [95% CI, 5.5-6.8 per 10 000 person-years]) among those with 2 or more teen pregnancies; adjusted HRs (AHRs) were 1.51 (95% CI, 1.39-1.63) for those with 1 pregnancy and 2.14 (95% CI, 1.92-2.39) for those with 2 or more pregnancies. Comparing those with vs without a teen pregnancy, the AHR for premature death was 1.25 (95% CI, 1.12-1.40) from noninjury, 2.06 (95% CI, 1.75-2.43) from unintentional injury, and 2.02 (95% CI, 1.54-2.65) from intentional injury.

'''Conclusions and Relevance''' In this population-based cohort study of 2.2 million female teenagers, teen pregnancy was associated with future premature mortality. It should be assessed whether supports for female teenagers who experience a pregnancy can enhance the prevention of subsequent premature mortality in young and middle adulthood.</blockquote>

'''Premature mortality after pregnancy loss: Trends at 1, 5, 10 years, and beyond. Auger N, Ghadirian M, Low N, Healy-Profitós J, Wei SQ. Eur J Obstet Gynecol Reprod Biol. 2021 Dec;267:155-160. doi: 10.1016/j.ejogrb.2021.10.033. Epub 2021 Nov 1. PMID: 34773878.'''<blockquote>'''Objective:''' Little is known on the long-term risk of mortality following pregnancy loss. We assessed risks of premature mortality up to three decades after miscarriage, induced abortion, ectopic or molar pregnancy, and stillbirth relative to live birth.

'''Study design:''' We carried out a longitudinal cohort study of 1,293,640 pregnant women with 18,896,737 person-years of follow-up in Quebec, Canada, from 1989 to 2018. We followed the women up to 29 years after their last pregnancy event to determine the time and cause of future in-hospital deaths before age 75 years. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of miscarriage, induced abortion, ectopic pregnancy, molar pregnancy, and stillbirth with premature mortality, compared with live birth.

'''Results:''' Premature mortality rates were higher for most types of pregnancy loss than live birth. Compared with live birth, pregnancy loss was associated with an elevated risk of premature mortality (HRmiscarriage 1.48, 95% CI 1.33, 1.65; HRinduced abortion 1.50, 95% CI 1.39, 1.62; HRectopic 1.55, 95% CI 1.35, 1.79; and HRstillbirth 1.68, 95%. CI 1.17, 2.41). Molar pregnancy was not associated with premature mortality (HR 0.87, 95% CI 0.33, 2.32). '''Miscarriage and induced abortion were associated with most causes of death,''' whereas ectopic pregnancy was associated with cardiovascular (HR 2.18, 95 % CI 1.39, 3.42), cancer (HR 1.38, 95 % CI 1.11, 1.73), and suicide-related mortality (HR 4.94, 95 % CI 2.29, 10.68). Stillbirth was associated with cardiovascular mortality (HR 4.91, 95 % CI 2.33, 10.36).

'''Conclusion:''' Pregnancy loss is associated with an elevated risk of premature mortality up to three decades later, particularly cardiovascular, cancer, and suicide-related deaths.</blockquote>

'''[https://www.mdpi.com/1010-660X/55/11/741 Affective and Substance Abuse Disorders Following Abortion by Pregnancy Intention in the United States: A Longitudinal Cohort Study.] Sullins DP. Medicina (Kaunas). 2019 Nov 15;55(11). pii: E741. doi: 10.3390/medicina55110741.'''

:'''Background and Objectives:''' Psychological outcomes following termination of wanted pregnancies have not previously been studied. Does excluding such abortions affect estimates of psychological distress following abortion? To address this question this study examines long-term psychological outcomes by pregnancy intention (wanted or unwanted) following induced abortion relative to childbirth in the United States.

:'''Materials and Methods:''' Panel data on a nationally-representative cohort of 3935 ever-pregnant women assessed at mean age of 15, 22, and 28 years were examined from the National Longitudinal Survey of Adolescent to Adult Health (Add Health). Relative risk (RR) and incident rate ratios (IRR) for time-dynamic mental health outcomes, conditioned by pregnancy intention and abortion exposure, were estimated from population-averaged longitudinal logistic and Poisson regression models, with extensive adjustment for sociodemographic differences, pregnancy and mental health history, and other confounding factors. Outcomes were assessed using the Diagnostic and Statistical Manual, Version 4, American Psychiatric Association (DSM-IV) diagnostic criteria or another validated index for suicidal ideation, depression, and anxiety (affective problems); drug abuse, opioid abuse, alcohol abuse, and cannabis abuse (substance abuse problems); and summary total disorders.

:'''Results:''' Women who terminated one or more wanted pregnancies experienced a 43% higher risk of affective problems (RR 1.69, 95% CI 1.3-2.2) relative to childbirth, compared to women terminating only unwanted pregnancies (RR 1.18, 95% CI 1.0-1.4). Risks of depression (RR 2.22, 95% CI 1.3-3.8) and suicidality (RR 3.44 95% CI 1.5-7.7) were especially elevated with wanted pregnancy abortion. Relative risk of substance abuse disorders with any abortion was high, at about 2.0, but unaffected by pregnancy intention. Excluding wanted pregnancies artifactually reduced estimates of affective disorders by 72% from unity, substance abuse disorders by 11% from unity, and total disorders by 21% from unity.

:'''Conclusions:''' Excluding wanted pregnancies moderately understates overall risk and strongly understates affective risk of mental health difficulties for women following abortion. Compared to corresponding births, abortions of wanted pregnancies are associated with a greater risk of negative psychological affect, particularly depression and suicide ideation, but not greater risk of substance abuse, than are abortions of unwanted pregnancies. Clinical, research, and policy implications are discussed briefly.

[https://www.ncbi.nlm.nih.gov/pubmed/31104119 Maternal suicide in Italy.] Lega I, Maraschini A, D'Aloja P, Andreozzi S, Spettoli D, Giangreco M, Vichi M, Loghi M, Donati S; Regional maternal mortality working group. Arch Womens Ment Health. 2019 May 18. doi: 10.1007/s00737-019-00977-1.

:Abstract: Suicide has been identified as one of the most common causes of death among women within 1 year after the end of pregnancy in several high-income countries. The aim of this study was to provide the first estimate of the maternal suicide ratio and a description of the characteristics of women who died by suicide during pregnancy or within 1 year after giving birth, induced abortion or miscarriage (i.e., maternal suicide) in 10 Italian regions, covering 77% of total national births. Maternal suicides were identified through the linkage between regional death registries and hospital discharge databases. Background population data was collected from the national hospital discharge, abortion and mortality databases. The previous psychiatric history of the women who died by maternal suicide was retrieved from the regionally available data sources. A total of 67 cases of maternal suicide were identified, corresponding to a maternal suicide ratio of 2.30 per 100,000 live births in 2006-2012. The suicide rate was 1.18 per 100,000 after giving birth (n = 2,876,193), 2.77 after an induced abortion (n = 650,549) and 2.90 after a miscarriage (n = 379,583). The majority of the women who died by maternal suicide (34/57) had a previous psychiatric history; 15/18 previously diagnosed mental disorders were not registered along with the index pregnancy obstetric records. Suicide is a relevant cause of maternal death in Italy. The continuity of care between primary, mental health and maternity care were found to be critical. Clinicians should be aware of the issue, as they may play an important role in preventing suicide in their patients.

'''[https://www.sciencedirect.com/science/article/pii/S1028455918303024 The association between abortion experience and postmenopausal suicidal ideation and mental health: Results from the 5th Korean National Health and Nutrition Examination Survey.] Jeong Ha Wie, Su Kyung Nam, Hyun Sun Ko, Jong Chul Shin, In Yang Park, Young Lee. Taiwanese Journal of Obstetrics and Gynecology Volume 58, Issue 1, January 2019, Pages 153-158'''

:Objective:The association between abortion and postmenopausal mental health has not been clearly established in Asian women. The objective of this study was to evaluate the effect of abortion experiences on suicidal ideation and mental health in Korean postmenopausal women.

:Materials and methods: This study included 5133 postmenopausal women registered in the Korean National Health and Nutrition Examination Survey between 2010 and 2012. Difference in suicidal ideation according to type and number of abortions was analyzed. We used survey multiple logistic regression analysis to evaluate the effect of abortion experiences on the risk for suicidal ideation expressed as adjusted odd ratios (ORs) with 95% confidence intervals (95%CIs).

:Results: The risk of suicidal ideation was significantly higher in women who experienced more than three abortions (27.9%). While the incidence of suicidal ideation was not significantly affected by the number of spontaneous abortions (p = 0.718), suicidal ideation was significantly more frequent in women who had undergone ≥ three abortions (p = 0.003). After adjusting for demographic confounding factors, women who underwent ≥ three induced abortions had higher risk for suicidal ideation (OR: 1.510; 95% CI: 1.189–1.919; p = 0.031). This risk remained elevated even after controlling for depression (OR: 1.391; 95% CI: 1.1086–1.871, p = 0.002). Moreover, the risk of experiencing a depressive mood in daily life was also increased with increasing number of induced abortions even after controlling for depression (OR: 1.657; 95% CI: 1.274–2.156, p = 0.002).

:Conclusion: Undergoing three or more induced abortions during reproductive age was associated with postmenopausal suicidal ideation, stress, and depression. However, such association was not noted in those with spontaneous abortion, even in women with more miscarriages. Thus, clinicians should evaluate depression and suicidal ideation in women with multiple induced abortions.

'''[[https://www.ncbi.nlm.nih.gov/pubmed/29266732 Do stillbirth, miscarriage, and termination of pregnancy increase risks of attempted and completed suicide within a year? A population-based nested case-control study.]] Weng SC, Chang JC, Yeh MK, Wang SM, Lee CS, Chen YH. BJOG. 2018 Jul;125(8):983-990. doi: 10.1111/1471-0528.15105. Epub 2018 Feb 7.'''

:OBJECTIVE: To investigate the risks of attempted and completed suicide in women who experienced a stillbirth, miscarriage, or termination of pregnancy within 1 year postnatally and compare this risk with that in women who experienced a live birth.

:SETTING: Linking three nationwide population-based data sets in Taiwan: the National Health Insurance Research Database, the National Birth Registry and the National Death Registry.

:SAMPLE: In all, 485 and 350 cases of attempted and completed suicide, respectively, were identified during 2001-11; for each case, ten controls were randomly selected and matched to the cases according to the age and year of delivery.

:MAIN OUTCOME MEASURES: Attempted and completed suicidal statuses were determined.

:RESULTS: The rates of attempted suicide increased in the women who experienced fetal loss. The risk of completed suicide was higher in women who experienced a stillbirth [adjusted odds ratio (aOR) 5.2; 95% CI 1.77-15.32], miscarriage (aOR 3.81; 95% CI 2.81-5.15), or termination of pregnancy (aOR 3.12; 95% CI 1.77-5.5) than in those who had a live birth. Furthermore, the risk of attempted suicide was significantly higher in women who experienced a miscarriage (aOR 2.1; 95% CI 1.66-2.65) or termination of pregnancy (aOR 2.5; 95% CI 1.63-3.82). In addition to marital and educational statuses, psychological illness increased the risk of suicidal behaviour.

:CONCLUSIONS: The risk of suicide might increase in women who experience fetal loss within 1 year postnatally. Healthcare professionals and family members should enhance their sensitivity to care for possible mental distress, particularly for women who have experienced a stillbirth.

'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5952593/ Association between induced abortion and suicidal ideation among unmarried female migrant workers in three metropolitan cities in China: a cross-sectional study.] Luo M, Jiang X, Wang Y, Wang Z, Shen Q, Li R, Cai Y. ''BMC Public Health''. 2018 May 15;18(1):625. doi: 10.1186/s12889-018-5527-1.'''

:BACKGROUND: Despite reports of mental health issues, suicidality has not been closely examined among the migrant population. The association between induced abortion and suicidal ideation is unknown among unmarried female migrant workers of reproductive age in China. This study aims to examine induced abortion and suicidality among the Chinese migrant population.

:METHODS: We recruited 5115 unmarried female migrant workers during 2015 to 2016 from Shanghai, Beijing and Guangzhou, and collected demographic, psychosocial, reproductive and mental health information using structured questionnaires. We used logistic regression models to examine the association between lifetime induced abortion and suicidal ideation during the past year among the subjects.

:RESULTS: Overall, 8.2% of the subjects had suicidal ideation during the past year, and 15.5% of the subjects experienced induced abortion. Induced abortion was associated with nearly twice the odds of having past-year suicidal ideation (Odds ratio, OR = 1.89; 95% confidence interval, CI: 1.46, 2.44) after adjusting for age, education, years in the working place, tobacco use, alcohol consumption, daily internet use, attitude towards premarital pregnancy, multiple induced abortion, self-esteem, loneliness, depression, and anxiety disorders. The association was stronger in those aged > 25 (OR = 3.37, 95% CI = 2.16, 5.28), with > 5 years of stay in the working place (OR = 2.98, 95% CI = 2.02, 4.39), the non-anxiety group (OR = 2.28, 95% CI = 1.74, 3.00), and the non-depression group (OR = 2.94, 95% CI = 2.08, 4.15).

:CONCLUSIONS: Induced abortion was associated with increased odds for suicidal ideation among the unmarried female migrant workers in urban cities in China. More attention should be paid to the mental health of the population.

''' [http://smo.sagepub.com/content/4/2050312116665997.full Abortion, substance abuse and mental health in early adulthood: Thirteen-year longitudinal evidence from the United States.] Sullins DP. SAGE Open Medicine 2016 vol: 4 (0) pp: 2050312116665997'''

:'''Objective:''' To examine the links between pregnancy outcomes (birth, abortion, or involuntary pregnancy loss) and mental health outcomes for US women during the transition into adulthood to determine the extent of increased risk, if any, associated with exposure to induced abortion.

:'''Method:''' Panel data on pregnancy history and mental health history for a nationally representative cohort of 8005 women at (average) ages 15, 22, and 28 years from the National Longitudinal Study of Adolescent to Adult Health were examined for risk of depression, anxiety, suicidal ideation, alcohol abuse, drug abuse, cannabis abuse, and nicotine dependence by pregnancy outcome (birth, abortion, and involuntary pregnancy loss). Risk ratios were estimated for time-dynamic outcomes from population-averaged longitudinal logistic and Poisson regression models.

:'''Results''': After extensive adjustment for confounding, other pregnancy outcomes, and sociodemographic differences, abortion was consistently associated with increased risk of mental health disorder. Overall risk was elevated 45% (risk ratio, 1.45; 95% confidence interval, 1.30–1.62; p < 0.0001). Risk of mental health disorder with pregnancy loss was mixed, but also elevated 24% (risk ratio, 1.24; 95% confidence interval, 1.13–1.37; p < 0.0001) overall. Birth was weakly associated with reduced mental disorders. One-eleventh (8.7%; 95% confidence interval, 6.0–11.3) of the prevalence of mental disorders examined over the period were attributable to abortion.

:'''Conclusion''': Evidence from the United States confirms previous findings from Norway and New Zealand that, unlike other pregnancy outcomes, abortion is consistently associated with a moderate increase in risk of mental health disorders during late adolescence and early adulthood.

:Note: Adjusted odds ratio for suicidal ideation was 1.69 (95% CI 1.28-2.22)

'''[http://papers.ssrn.com/sol3/papers.cfm?abstract_id=821304 "Mandatory Waiting Periods for Abortions and Female Mental Health."] J Klick. Health Matrix: Journal of Law-Medicine, Vol. 16, p. 183, 2006.'''
:Panel data analyses suggests mandatory waiting periods prior to an abortion reduce suicide rates between 10 and 30 percent. These findings are statistically significant and appear to be robust in that the trend in findings remains the same after various attempts to control for other factors.

'''[http://www.ncbi.nlm.nih.gov/pubmed/25420710 Decreased suicide rate after induced abortion, after the Current Care Guidelines in Finland 1987 - 2012.] Gissler M, Karalis E, Ulander VM. Scand J Public Health. 2014 Nov 24. pii: 1403494814560844.'''

:Abstract

:Aim: Women with a recent induced abortion have a 3-fold risk for suicide, compared to non-pregnant women. The increased risk was recognised in unofficial guidelines (1996) and Current Care Guidelines (2001) on abortion treatment, highlighting the importance of a check-up 2 - 3 weeks after the termination, to monitor for mental health disorders. We studied the suicide trends after induced abortion in 1987 - 2012 in Finland.

:Methods: We linked the Register on Induced Abortions (N = 284,751) and Cause-of-Death Register (N = 3798 suicides) to identify women who had committed suicide within 1 year after an induced abortion (N = 79). The abortion rates per 100,000 person-years were calculated for 1987 - 1996 (period with no guidelines), 1997 - 2001 (with unofficial guidelines) and 2002 - 2012 (with Current Care Guidelines).

:Results: The suicide rate after induced abortion declined by 24%, from 32.4/100,000 in 1987 - 1996 to 24.3/100,000 in 1997 - 2001 and then 24.8/100,000 in 2002 - 2012. The age-adjusted suicide rate among women aged 15 - 49 decreased by 13%; from 11.4/100,000 to 10.4/100,000 and 9.9/100,000, respectively. After induced abortions, the suicide rate increased by 30% among teenagers (to 25/100,000), stagnated for women aged 20 - 24 (at 32/100,000), but decreased by 43% (to 21/100,000) for women aged 25 - 49.

:Conclusions: The excess risk for suicide after induced abortion decreased, but the change was not statistically significant. Women with a recent induced abortion still have a 2-fold suicide risk. A mandatory check-up may decrease this risk. The causes for the increased suicide risk, including mental health prior to pregnancy and the social circumstances, should be investigated further.

'''[http://www.ncbi.nlm.nih.gov/pubmed/24562317 Parental bonding and suicidality in pregnant teenagers: a population-based study in southern Brazil.] Coelho FM1, Pinheiro RT, Silva RA, de Ávila Quevedo L, de Mattos Souza LD, de Matos MB, Castelli RD, Pinheiro KA. Soc Psychiatry Psychiatr Epidemiol. 2014 Feb 22. [Epub ahead of print]'''
:A cross-sectional study of 828 pregnant teenagers revealed that prior abortion was a risk factor for a history of suicide attempts among 18 and 19 year olds, with attempted suicide rates 2.76 times higher.

'''Associations Between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample. Mota NP, Burnett M, Sareen J. The Canadian Journal of Psychiatry, Vol 55, No 4, April 2010 '''
:Methods: Data came from the National Comorbidity Survey Replication (n = 3310 women, aged 18 years and older). The World Health Organization–Composite International Diagnostic Interview was used to assess mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and lifetime abortion in women. Multiple logistic regression analyses were employed to examine associations between abortion and lifetime mood, anxiety, substance use, eating, and disruptive behaviour disorders, as well as suicidal ideation and suicide attempts. We calculated the percentage of respondents whose mental disorder came after the first abortion. The role of violence was also explored. Population attributable fractions were calculated for significant associations between abortion and mental disorders.
:Results: After adjusting for sociodemographics, abortion was associated with an increased likelihood of several mental disorders—mood disorders (adjusted odds ratio [AOR] ranging from 1.75 to 1.91), anxiety disorders (AOR ranging from 1.87 to 1.91), substance use disorders (AOR ranging from 3.14 to 4.99), as well as suicidal ideation and suicide attempts (AOR ranging from 1.97 to 2.18). Adjusting for violence weakened some of these associations. For all disorders examined, less than one-half of women reported that their mental disorder had begun after the first abortion. Population attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse).
:Conclusions: Our study confirms a strong association between abortion and mental disorders. Possible mechanisms of this relation are discussed.

'''Abortion and mental health disorders: evidence from a 30-year longitudinal study. Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2008 Dec;193(6):444-51.'''

'''[http://www.uca.edu.ar/uca/common/grupo54/files/new_zealand_abortion_study.pdf Abortion in young women and subsequent mental health.] Fergusson DM, Horwood LJ, Ridder EM. Journal of Child Psychology and Psychiatry 47:1 (2006), pp 16–24'''

:In this 25 year longitudinal study, women who had abortions had significantly higher rates of suicidal ideation than others in the cohort. 50% of those under 18 had suicidal thoughts and about one-fourth of those between the ages of 19 and 25 had suicidal thoughts.

'''[http://www.afterabortion.org/research/DeathsAssociatedWithAbortion.pdf "Deaths Associated with Pregnancy Outcome. A Record Linkage Study of Low Income Women"], DC Reardon et al, Southern Medical Journal 95(8):834, August 2002'''
:A study of 173,279 low income California women who delivered and those who aborted in 1989 were linked to death certificates over an 8 year period following the pregnancy event. Compared to women who delivered, those who had an abortion had a significantly higher age-adjusted risk of death from suicide (2.54) and an increased risk of death from all causes (1.62).

'''[http://www.health.qld.gov.au/caru/networks/qmpqc_publications.asp Queensland Maternal and Perinatal Quality Council Report 2013]''' [http://www.health.qld.gov.au/caru/networks/docs/qmoqc-report-2013-part-2_2.pdf Section 1 Maternal and perinatal mortality]"
:1.2.8 Suicide
::"Suicide is the leading cause of death in women within 42 days after their pregnancy and between 43 days and 365 days after their pregnancy. There appears to be a significant worldwide risk of maternal suicide following termination of pregnancy and, in fact, a higher risk than that following term delivery. The potential for depression and other mental health issues at this time needs to be better
appreciated. Active follow-up of these women needs to happen. Practitioners referring women for termination of pregnancy or undertaking termination of pregnancy should ensure adequate follow up for such women, especially if the procedure is undertaken for mental health concerns."

'''"[http://www.bmj.com/content/313/7070/1431 Suicides after pregnancy in Finland, 1987-94: register linkage study], M. Gissler et. al.. Br. Medical Journal 313: 1431. Dec 7.1996 '''
:A Finnish study of women who committed suicide in 1987-94 within one year of a pregnancy found out that the suicide incidence associated with induced abortion was 34.7 per 100,000 postabortion women compared to 13.1 per 100,000 postmiscarriage women and 5.9 per 100/000 postpartum women and a mean annual suicide rate of 11.3 per 100/000 women generally.

'''Mental health may deteriorate as a direct effect of induced abortion, C Morgan et al, British Medical Journal 314:902, 1997'''

:British researchers studied the frequency of admissions for attempted suicide by pregnancy event in women aged 15-49 in South Glamorgan Health Authority from 1991-1995. The overall frequency of admissions before induced abortion was 5.0 per 1000 and after induced abortion was 8.1 per 1000; The overall frequency of admissions before delivery was 2.9 per 1000 and after delivery was 1.9 per 1000. The authors concluded that, "the increased risk of suicide after an induced abortion may be a consequence of the procedure itself (and) data suggest that a deterioration in mental health may be a consequential side effect of induced abortion."

'''"Suicide and/or abortion. 20th Meeting of the Group for Suicide Research and Prevention: The body and suicide," J. Koperschmitt et al, Psychologie Medicale 21(4): 446, March, 1989 '''
:Abortion can have an important effect on suicidality.

'''[http://www.ncbi.nlm.nih.gov/pubmed/?term=The+Relationship+Between+Suicidal+Thinking+and+Dating+Violence+in+a+Sample+of+Adolescent+Abortion+Patients The relationship between suicidal thinking and dating violence in a sample of adolescent abortion patients.] Ely GE, Nugent WR, Cerel J, Vimbba M. Crisis. 2011;32(5):246-53. doi: 10.1027/0227-5910/a000082.'''

AIMS: This paper highlights a study where the relationship between dating violence and severity of suicidal thinking was examined in a sample of 120 young women ages 14-21 seeking to terminate an unintended pregnancy.
METHODS: The Multidimensional Adolescent Assessment Scale and the Conflict in Adolescent Relationships Scale was used to gather information about psychosocial problems and dating violence so that the relationship between the two problems could be examined, while controlling for the other psychosocial problems.
RESULTS: The results suggest that dating violence was related to severity of suicidal thinking, and that the magnitude of this relationship was moderated by the severity of problems with aggression.
CONCLUSIONS: Specifically, as the severity of participant's general problems with aggression increased, the magnitude of the relationship between dating violence and severity of suicidal thinking increased. Limitations of the study and implications for practice are discussed. Authors recommend pre-abortion screening and assessment.

'''"Psychopathological effects of voluntary termination of pregnancy on the father called up for military service," DuBouis-Bonneford et al, Psychologie Medicale 14(8): 1187-1189, June 1982 '''
:Several case studies are presented of 18-22 year old males who came from disadvantaged backgrounds and were recent military recruits. All had extreme depression and/or attempted suicide brought on by the news of their wives or girlfriends having had a voluntary induced abortion. The men believed that becoming a father would make them more mature or respectable and the abortion brought on feelings of self-recrimination and self-punishment.

'''"Psychiatric Sequelae of Abortion: The Many Faces of Post-Abortion Grief," E. Joanne Angelo, Linacre Quarterly 59:69-80, May 1992. '''
:Three cases of completed suicide following abortion are presented. In one case, a 22 year old woman in the military was referred for psychiatric counseling because of an eating disorder. She had made a suicide attempt two days before her scheduled abortion, feeling unable to go through with the abortion or face the rest of her tour of duty as a single parent. Her psychiatrist had advised going through with the abortion. Following the abortion, her use of cocaine and alcohol escalated and her weight continually dropped. She felt a strong desire to be united with her baby. She made several more suicide attempts and despite continuing therapy it did happen.

:In another case a 23 year old woman was referred for psychiatric counseling after a suicide attempt involving a planned drunk driving incident. She and had two abortions at ages 17 and 18 while in high school. She was the youngest child of a large family and was afraid to tell her parents for fear they would "drop dead of heart attacks." (The parents were in precarious heath.) She suffered alone with the guilt for 6 years. She had planned to tell an uncle, who was a priest, what had happened, but before she could talk with him he suddenly died of a heart attack. Mourning his death as well as her earlier loses, she had planned her own death both to end her pain and to achieve a reunion with her children and her uncle.

:In a third case, an 18 year old male gas station attendant shot himself and died 3 months after his father's unexpected death. Only his closest friend knew that at the time of his suicide he was despondent over his girl friend's abortion. The child had been conceived on the day of his father's death. He had formed a mental image of the child and told his friend he planned to name his son after his father. The loss of the child and what he represented was more than he was able to bear.

'''"Second-Trimester Abortions in the United States," D. Grimes, Family Planning Perspectives 16(6):260, Nov/Dec 1984. '''
:Among the 92 reported deaths of women from second-trimester legal abortion, from 1972-1981, 2 were as a result of suicide.

'''"Physical and Psychological Injury in Women Following Abortion: Akron Pregnancy Services Survey," L.H. Gsellman, Association For Interdisciplinary Research Newsletter 5(4):1-8, Sept/Oct 1993.'''
:(In a survey of 344 post-aborted women receiving services at Akron Pregnancy Services during 1988-1993, 16% reported suicidal impulses, 7% were preoccupied with death and 7% made suicide attempts.

'''"[http://news.google.com/newspapers?id=9P4xAAAAIBAJ&sjid=zYYDAAAAIBAJ&pg=3675,4841318&dq=abortion+and+suicide+attempt&hl=en Adolescent Suicide Attempts Following Elective Abortion]," Carl Tischler, Pediatrics, 68(5):670 (1981). '''
:Case studies of attempted suicide on the anniversary of what would have been the aborted baby's birth.

'''The Psycho-Social Aspects of stress Following Abortion, Anne C. Speckhard, (Kansas City: Sheed and Ward, 1987) '''
:Thirty women stressed by abortion were interviewed 5-10 years since abortion; 65% had suicide ideation; 31% attempted suicide.

'''"Therapeutic Abortion and Psychiatric Disturbance Among Women," E.R. Greenglass, Canadian Psychiatric Association Journal 21:453-459(1976). '''
:Of 188 women interviewed, five attempted suicide about 2.6 months after abortion; there was evidence of other traumatic difficulties in addition to abortion.

'''"Post-Abortive Psychoses," Myre Sim and Robert Neisser, in The Psychological Aspects of Abortion, ed. D. Mall and WF Watts, (Washington D.C.: University Publications of America, 1979). '''
:Fifty-eight women at an Israeli Government hospital volunteered the information that abortion, induced or spontaneous, had led to their referral to the psychiatric unit; seven had made serious attempts at suicide, three others had threatened suicide.

'''Stress. Depression and Suicide: A Study of Adolescents in Minnesota., B Garfinkel, H. Hoberman, J. Parsons and J. Walker (Minneapolis: University of Minnesota Extension Service, 1986). '''
:A teenage girl was about 6 times more likely to have attempted suicide if she had an abortion in the last six months compared to teenagers who had not had an abortion in that period (4% vs. 0.7%). Teenage girls attempting suicide in general were more likely to be depressed, to have recently broken up with their boyfriend, and come from chaotic homes. In an interview announcing the study results Dr. Garfinkel stated that impulsiveness, anger and anxiety are the three most important factors in teenage suicide. Too often abortion is taken as either producing an alleviation of stress or being helpful to young people. I think we need to re-examine the issues. Minnesota Daily, Oct 29,1986, p. 3/16

'''"Mental Disorders After Abortion," B. Jansson, Acta Psychiatrica Scandinavica41:87 (1965) '''
:In a Swedish study of 57 women with prior psychiatric problems who subsequently had induced abortions, three committed suicide as determined by long-term follow-up studies 8-13 years after their abortion. In contrast, of 195 women with previous psychiatric problems who carried their children to term, none committed suicide.

'''[http://afterabortion.org/1999/a-detailed-survey-of-post-abortion-psychological-reactions/ A Detailed Survey of Post-Abortion Psychological Reactions], Reardon DC. Also reprinted in Forbidden Grief, Burke T & Reardon DC.'''

:A survey of 260 women making contact with one of several post-abortion support groups found that 34% reported suicidal feelings after their abortions, and 28% attempted suicide, with 54% of those attempting suicide more than once.

'''Is voluntary abortion a seasonal disorder of mood? Cagnacci A, Volpe A. Human Reproduction 2001, 16(8):1748-52.'''
:An analysis of yearly suicide rates and abortion rates found that the suicide rate of women in Italy peaks in June, one month after the peak in abortion rates, which is in May.
:RESULTS The rate of voluntary abortions showed a seasonal rhythm with an amplitude of 6.1--6.7% and peaked in May (+/-38 days). The national frequency of female suicides, obtained from the same ISTAT database, showed a similar rhythm, with an amplitude of 11.1% and maximal rate in June (+/-37 days).

===Abortion Related Suicide: Case Studies===

:For information regarding a well publicized case of suicide following abortion, see [[Emma Beck - Suicide | Emma Beck]] and also [[Suicide - Case Studies]])

'''[https://www.researchgate.net/profile/Preeti-Gautam-4/publication/379544537_Deaths_among_Women_of_Reproductive_Age_an_Explorative_Case_Study_among_Abortion_Seekers/links/660e986c10ca8679873cd2f0/Deaths-among-Women-of-Reproductive-Age-an-Explorative-Case-Study-among-Abortion-Seekers.pdf Deaths among Women of Reproductive Age: an Explorative Case Study among Abortion Seekers]. Gautam P, Puri MC, Karki S, Foster DG. J Nepal Health Res Counc. 2024 Mar 31;21(4):692-696. doi: 10.33314/jnhrc.v21i4.4871.'''
* In a case series study of 1841 women who sought abortions in Nepal, 83% received abortions and 17% did not. Women were followed for two to three years. Among the 1528 women who had abortions, three committed suicide, for a suicide rate of 196 per 100,000 women, which is nearly 10 times higher than the [https://mhrnepal.org/app/webroot/upload/files/suicide%20in%20nepal%20scoping%20review.pdf 20.0 per 100,000 women reported for general population] of women in Nepal.
* Though all three suicide were among women who had abortions, the authors don't point this out. Instead, they clearly attempt to dismiss such speculation by offering three alternative explanations:
** For instance, one family member of a participant shared that that the participant had epilepsy, but she did not reveal it to her family members after her marriage. She stopped taking medicines used for treatment of epilepsy after marriage and eventually died by suicide.
**One of the women who died by suicide reported that she was facing physical violence (such as getting slapped, punched, being pushed) from her husband during her last follow up interview.
** 22 years old Rita (name changed) was married for four years. She had a son. She had completed 9th grade of education. She received an abortion from an NGO clinic, a 3-hour ride by bus. She took part in the 6 week and 6-month follow up interviews before her death. During her 6-month follow-up interview Rita shared that she frequently felt nervous, anxious, depressed, or unable to stop or control worrying. She also had less interest or pleasure in doing things. We were told that Rita was mistreated by her in-laws during her follow-up interviews. She died by suicide at her home.

Clearly, these vignettes offer another possible explanation, but none of them exclude the possibility that the abortion contributed to these suicides, anywhere from a small to large part.

===Other Suicide Papers of Interest===

[https://www.ncbi.nlm.nih.gov/pubmed/21498972 Suicidal mothers.] J Inj Violence Res. 2011 Jul;3(2):90-7. doi: 10.5249/jivr.v3i2.98. Gentile S.

:BACKGROUND: Epidemiological research has demonstrated that suicidal ideation is a relatively frequent complication of pregnancy in both developed and developing countries. Hence, the aims of this study are: to assess whether or not pregnancy may be considered a period highly susceptible to suicidal acts; to recognize potential contributing factors to suicidal behaviors; to describe the repercussions of suicide attempts on maternal, fetal, and neonatal outcome; to identify a typical profile of women at high risk of suicide during pregnancy.
:METHODS: Medical literature information published in any language since 1950 was identified using MEDLINE/PubMed, Scopus, and Google Scholar databases. Search terms were: "pregnancy", (antenatal) "depression", "suicide". Searches were last updated on 28 September 2010. Forty-six articles assessing the suicidal risk during pregnancy and obstetrical outcome of pregnancies complicated by suicide attempts were analyzed, without methodological limitations.
:RESULTS: Worldwide, frequency of suicidal attempts and the rate of death by suicidal acts are low. Although this clinical event is rare, the consequences of a suicidal attempt are medically and psychologically devastating for the mother-infant pair. We also found that common behaviors exist in women at high risk for suicide during pregnancy. Review data indeed suggest that a characteristic profile can prenatally identify those at highest risk for gestational suicide attempts.
:CONCLUSIONS: Social and health organizations should make all possible efforts to identify women at high suicidal risk, in order to establish specific programs to prevent this tragic event. The available data informs health policy makers with a typical profile to screen women at high risk of suicide during pregnancy. Those women who have a current or past history of psychiatric disorders, are young, unmarried, unemployed, have incurred an unplanned pregnancy (eventually terminated with an induced abortion), are addicted to illicit drugs and/or alcohol, lack effective psychosocial support, have suffered from episodes of sexual or physical violence are particularly vulnerable.

''"Suicide After Ectopic Pregnancy," (letter) J. Farhi et al. New England Journal of Medicine, March 10,1994, p. 714 ''
:A study of Israeli women found that among 160 women treated for ectopic pregnancy 3.75% attempted suicide within one year thereafter and 0.625% committed suicide compared to a matched non-pregnant population rate of 0.04-0.06% and 0.002% respectively.
'''[http://www.ncbi.nlm.nih.gov/pubmed/21969462 Absolute Risk of Suicide After First Hospital Contact in Mental Disorder.] Nordentoft M, Mortensen PB; Pedersen CB. Arch Gen Psychiatry. 2011;68(10):1058-1064.'''

:Participants A total of 176 347 persons born from January 1, 1955, through December 31, 1991, were followed up from their first contact with secondary mental health services after 15 years of age until death, emigration, disappearance, or the end of 2006. For each participant, 5 matched control individuals were included.

:Main Outcome Measures Absolute risk of suicide in percentage of individuals up to 36 years after the first contact.

:Results Among men, the absolute risk of suicide (95% confidence interval [CI]) was highest for bipolar disorder, (7.77%; 6.01%-10.05%), followed by unipolar affective disorder (6.67%; 5.72%-7.78%) and schizophrenia (6.55%; 5.85%-7.34%). Among women, the highest risk was found among women with schizophrenia (4.91%; 95% CI, 4.03%-5.98%), followed by bipolar disorder (4.78%; 3.48%-6.56%). In the nonpsychiatric population, the risk was 0.72% (95% CI, 0.61%-0.86%) for men and 0.26% (0.20%-0.35%) for women. Comorbid substance abuse and comorbid unipolar affective disorder significantly increased the risk. The co-occurrence of deliberate self-harm increased the risk approximately 2-fold. Men with bipolar disorder and deliberate self-harm had the highest risk (17.08%; 95% CI, 11.19%-26.07%).

:Conclusions This is the first analysis of the absolute risk of suicide in a total national cohort of individuals followed up from the first psychiatric contact, and it represents, to our knowledge, the hitherto largest sample with the longest and most complete follow-up. Our estimates are lower than those most often cited, but they are still substantial and indicate the continuous need for prevention of suicide among people with mental disorders.

See also: [http://www.ncbi.nlm.nih.gov/pubmed/15809410 Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers.]

'''[http://www.ncbi.nlm.nih.gov/pubmed/24559792 Suicide attempts and mortality in eating disorders: a follow-up study of eating disorder patients.] Suokas JT1, Suvisaari JM2, Grainger M3, Raevuori A4, Gissler M5, Haukka J6. Gen Hosp Psychiatry. 2014 Jan 13. pii: S0163-8343(14)00005-X. doi: 10.1016/j.genhosppsych.2014.01.002. [Epub ahead of print]'''

:We identified 156 patients with eating disorder (6.3%) and 139 controls (1.4%) who had required hospital treatment for attempted suicide. Of them, 66 (42.3%) and 37 (26.6%) had more than one attempt. The rate ratio (RR) for suicide attempt in patients with eating disorder was 4.70 [95% confidence interval (CI) 1.41-15.74]. In anorexia nervosa, RR was 8.01 (95% CI 5.40-11.87), and in bulimia nervosa, it was 5.08 (95% CI 3.46-7.42). In eating disorder patients with a history of suicide attempt, the risk of death from any cause was 12.8%, suicide being the main cause in 45% of the deaths.
Suicide attempts and repeated attempts are common among patients with eating disorders. Suicidal ideation should be routinely assessed from patients with eating disorders.

==Accidents==

''"Pregnancy-associated deaths in Finland 1987-1994-definition problems and benefits of record linkage," M Gissler et al, Acta Obstet Gynecol Scand 76:651-657, 1997 ''
:A Finnish register linkage study identified all deaths that occurred up to 1 year after an ended pregnancy. The mortality rate was 27 per 100,000 births, and 101 per 100.000 abortions. Compared to women of reproductive age with no pregnancy (1.0), the risk of death from an accident following abortion was 2.08 (1.03-4.20, 95% CI) compared to 0.49 (0.18-1.33, 95% CI) for childbearing women.

''"Suicide Deaths Associated with Pregnancy Outcome: A Record Linkage Study of 173,279 Low Income American Women," D Reardon et al, Clinical Medicine & Health Research clin med/2001 030003 v1 (April 25, 2001) ''
:State funded medical insurance records identifying all paid claims for abortion or delivery in 1989 were linked to the state death certificate registry in a population of low income women in California. Compared to women who delivered (1.0), those who aborted had a significantly higher adjusted risk of dying from accidents (1.82).

''"Sexual Experience and Drinking Among Women in a U.S. National Survey," A Klassen, S Wilsnack, Archives of Sexual Behavior 15(5): 363-392, 1986; "Women's Drinking and Drinking Problems: Patterns from a 1981 U.S. National Survey," R Wilsnack, S Wilsnack, A Klassen, Am J Public Health 74:1231-1238, 1984. ''
:In a random national survey of 917 U.S. women in 1981, 4% of the abstainers and 5% of lighter drinkers reported non-spontaneous abortion compared to 13% for moderate drinkers, 13% for heavier drinkers, and 6% for women who had ever been pregnant. The same survey found that 17% of all women drinkers said they had driven vehicles while drunk or high at least once in the preceding year including 27% of moderate drinkers and 45% of heavier drinkers.

''"Alcohol-Related Relative Risk of Fatal Driver Injuries in Relation to Driver Age and Sex," Paul L Zodor, J Stud Alcohol 52:302-310, 1991. ''
:A study by the Insurance Institute for Highway Safety based on 1986-87 data found that each 0.02% increase in blood alcohol content nearly doubles the risk of being in a single vehicle fatal crash. The risk of a female 21-24 years of age at a blood alcohol level of 0.05%- 0.09% of dying in a single vehicle accident was reported to be 35 times higher compared to a blood level of 0.00%- 0.01%

''"Adolescent Suicide Attempts Following Elective Abortion: A Special Case of Anniversary Reaction," CL Tishler, Pediatrics 68 (5):670-671, 1981''
:A 17 year old upper middle class white girl attempted to kill herself while driving under the influence of alcohol and 29 Bufferin tablets. She smashed her car into a bridge overpass repeatedly, damaging her car beyond repair. She had had an elective abortion approximately seven months prior to the suicide attempt. During the abortion process she calculated the birth date had the fetus been allowed to come to term. The date of the accident was on the perceived birth date of the child.

==Repeat Abortions==

''"Abortion Surveillance-United States, 1997," MMWR Vol 49, No.SS-11, December 8, 2000. ''
:The Centers for Disease Control reported that 48% of U.S. women had repeat abortions in 1997 with 28.4% reporting a second abortion, 12% reporting a third abortion, and 7.6 % reporting a fourth or more abortion.

''"Abortion Surveillance-United States. 1992," L.M. Koonin et. al., MMWR 45, No. 55- 3: 1, May 3,1996 ''
:For 1992,1,359/145 legal abortions were reported to CDC, representing a 2.1% decline overall, from the number reported for 1991. 45.8% of women were repeating abortion with 26.9% reporting a second abortion, 10.8% (third), and 6.4% having 4 or more abortions. The abortion ratio was more than nine times greater for unmarried women than for married women. The abortion rate for white women was 15 per 1000 white women compared to 41 per 1000 black women and 32 per 1000 Hispanic women.

''"The epidemiology of preterm birth," Judith Lumley, Bailliere's Clinical Obstetrics and Gynaecology 7(3): 477, Sept, 1993 ''
:A study of more than 300,000 first singleton births in Victoria, Australia from 1986-1990 found that 6.5 per 1000 births were 20-27 gestational weeks where the woman had one prior induced abortion compared to 10.3 per 1000 births (two prior induced abortions) and 23.1 per 1000 births (three or more prior induced abortions). The rate of preterm births at 32-36 gestational weeks was 54.1 per 1000 births where women had one prior induced abortion, 78.7 per 1000 births where women had two prior induced abortions and 120.1 per 1000 births where women had three or more prior induced abortions. For purposes of analysis women who had experienced both induced and spontaneous abortions were excluded.

''"Pregnancy Decision Making as a Significant Life Event: A Commitment Approach," J. Lydon, et. al. J. Personality and Social Psychology 71(1): 141-151, 1996 ''
:Women with prior abortions were found to be more committed to a current pregnancy compared to women with no prior abortion history. Initial commitment predicted subsequent depression, guilt, and hostility among those who aborted.

''"Post-Abortion Syndrome as a Variant of Post Traumatic Stress Syndrome," Robert C. Erikson, Association for Interdisciplinary Research Newsletter, 3(4) :5-8, Winter, 1991. ''
:Repeat abortion will, to a degree, reflect a re-creation of the social, emotional and relational circumstances present before the initial abortion. Repeat abortions frequently are re-enactments of conflict between drives, and have little to do with ego functions such as learning.

===The compulsion to repeat the trauma. Re-enactment, revictimization, and masochism," PA van der Kolk, Psychiatric Clinics of North America 12(2): 389-411, June, 1989 ''
:Trauma can be repeated in behavioral, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering. Previously traumatized people tend to return to familiar patterns, even if they cause pain.

''"Special Issue on Repeat Abortion,"Association for Interdisciplinary Research Newsletter 2(3): 1-8, Summer 1989. ''
:Review of the literature on the incidence and effects of repeat abortions. It including moral and social deterioration, communication breakdown, decline in religious affiliation, emotional or psychological conflicts, replacement pregnancy, self-punishment, abortion as birth control and the evangelization of abortion.

''"Repeat Abortion: Blaming the Victims," B. Howe, R. Kaplan, and C. English, American Journal Public Health, 69(12):1242-1246, December 1979,''
:Repeaters were found to be more sexually active than first-timers, thus increasing their risk of unwanted pregnancy even though they used contraception more than initial aborters.

''"[http://www.lifeissues.net/writers/air/air_vol5no1_1993.html Women's Health and Abortion. I. Deterioration of Health Among Women Repeating Abortion]," Association for Interdisciplinary Research Newsletter 5(1):1-8, Winter, 1993. ''
:This article identifies 32 areas of social, medical and psychological health that deteriorate as induced abortion is repeated.

''"Repeat Abortion: Is It A Problem?," C. Berger, D. Gold, D. Andres, P. Gillett and R. Kinch, Family Planning Perspectives, 16(2):70-75, March/April 1984,''
:Medical and counseling personnel are troubled by women who come back to their facilities for a repeat abortion. Counseling deficiencies, possible negative media coverage, unclear long-term effects on future child bearing are some of the reasons for concern. This study of Canadian women found that repeaters were more tolerant of abortion than women having a first abortion; they also had intercourse more frequently than first-time abortion patients [average 11 times per month versus 8 times per month]. Women having repeat abortions were slightly more likely to have been using contraceptives at the time they became pregnant. Repeaters described their relationships as being less satisfactory than first-time patients. More repeaters than first-time patients said they had made the decision by themselves [45 percent vs. 33 percent]. Repeaters reported fewer physical complaints but had more difficulty sleeping.

''"Third Time Unlucky: A Study of Women Who Have Had Three or More Legal Abortions," Colin Brewer, Journal Biosocial Science, 9:99-105(1977). ''
:Of 50 women having their third or subsequent legal abortion, 23 were pregnant because they claimed their contraceptive method had failed; 24 because of erratic contraceptive use; and three changed their minds after initially welcoming the pregnancy. The study concluded there was a significant relationship between erratic use and a history of consultation for psychiatric reasons, and suggested that unsettled relationships and low educational status also related to erratic use. There was no evidence that abortion was deliberately used as a method of birth control.

''"Repeaters-Different or Unlucky?," C. Berger and D. Gold, et al., in P. Sechder, ed.. Abortion: Readings and Research. (Toronto: Butterworth Press, 1981). ''

''Proceeding of the Conference on Psycho-Social Factors in Transnational Family Planning Research, W. Pasini and J. Kellerhals (Washington: American Institute for Research, 1970), 44-54.''
:A threefold increase in previous psychiatric consultations was found in women seeking repeat abortions compared with maternity patients.

''Beyond Choice. The Abortion Story No One Is Telling, Don Baker, (Portland: Multonomah Press, 1985). ''
:A powerful narrative true story of a woman who had three abortions. Demonstrates the moral and social deterioration in her life until she commits her life to Jesus Christ. Excerpts reprinted in the April/May 1987 issue of The Christian Reader.

''"The Repeat Abortion Patient," Judith Leach, Family Planning Perspectives, 9(1):37-39, January/February 1977''
:Repeat abortion patients are more often dissatisfied with themselves, more often perceive themselves as victims of bad luck, and more frequently express negative feelings toward the current abortion than women who are obtaining abortions for the first time.

''"Pilot Surveys of Repeated Abortion," E. Szabady and A. Klinger, International Mental Health Res. Newsletter 14:6(1972). ''
:In a study of Hungarian women those women having a repeat abortion were less likely to be in a happy marriage and were more likely to have an abortion independently of their partner.

''"Emotional Distress Patterns Among Women Having First or Repeat Abortions," Ellen Freeman, Obstetrics and Gynecology 55(5):630-636, May 1980 ''
:Repeat abortion patients showed significantly higher distress scores on interpersonal sensitivity, paranoid ideation, phobic anxiety and sleep disturbance, compared with controls. Repeaters also showed a trend in higher scores in somatization, hostility and psychoticism.

''"Repeat Abortions-Why More?," Christopher Tietze, Family Planning Perspectives, 10(5):286-288, September/October 1978, ''
:Repeaters tended to have more frequent intercourseless satisfying relationships, and more difficulty sleeping. They were less likely to live with their partners. (Women with prior abortion were almost 4 times more likely to have repeat abortion compared to women having an abortion for the first time.

''"Women Who Obtain Repeat Abortion: A Study Based Upon Record Linkage," P. Steinhoff, R. Smith, J. Palmore, M. Diamond and C. Chung, Family Planning Perspectives11(1):30-38 Jan/Feb 1979. ''
:Study noted the proportion of induced abortions that are repeat procedures increases over time. Shortcomings in making contraceptives available were cited as the reason. The women's own reporting of repeat abortions was about 20% lower than the actual number determined by record linkage.

''"Abortion Recidivism - A Problem in Preventative Medicine," Joseph Rovinsky, Obstetrics and Gynecology, 39(5) :649-659, May 1972. ''
:There was a lack of contraceptive motivation in repeaters as an etiologic basis for recurrent unwanted pregnancy; the article cites a case of 17 prior abortions.

''"First and Repeat Abortions: A Study of Decision-Making and Delay," M.Bracken and S. Kasi, Journal Biosocial Science, 7:473-491 (1975). ''
:Women having a repeat abortion took less time than those having a first abortion; women repeaters were more likely to report medical problems as a reason for contraceptive failure, compared with first-abortion women who were more likely to admit to carelessness. Women having repeat abortions were more likely to mention problems with the contraceptive, while those having first abortions were more likely to have failed to anticipate intercourse. Fewer women repeaters were pregnant by husbands, and unmarried women having repeat abortions had been in relationships of shorter duration than unmarried women having first abortions. Women having first abortions were generally more concerned with moral and ethical issues, worry over the procedure itself and the possibility of complications than were women having repeat abortions, who generally showed more desire to have children.

''"Characteristics and Contraceptive of Abortion Patients," S. Henshaw, J. Silverman, Family Planning Perspectives 20(4): 158, July/August, 1988. ''
:A national survey of 9/480 women at U.S. abortion facilities in 1987 by the Alan Guttmacher Institute found that 42.9% of those women surveyed had repeat abortions: 26.9% (second abortion); 10.7% (third abortion); 5.3% (fourth abortion or more).

''"Reflections on repeated abortions: The meanings and motivations," Susan Fisher,Journal of Social Work Practice 2(2):70-87, May 1986. ''
:The author, a social worker at a London hospital, interviewed more than 1,000 women with crisis pregnancies. Several in-depth case histories are reported. Repeaters were variously described as "chaotic, childlike" (a woman who had 15 abortions in 23 years); "doll-like" (history of numerous suicide attempts); holding "anxiety, rage and confusion" over mother's mental illness; "a delicate child-woman 16 years old with very little human warmth, depressed"; "cold and detached with little feeling"; "a suicidal woman with a history of three abortions, a first suicide attempt at age 15 and the most recent one at age 27, only six weeks ago/drug overdoses, anorexia nervosa and hospitalization for psychiatric treatment." Women had shallow relationships with putative fathers and seemed to select male partners known to be objectionable to the repeaters' parents. Unconscious conflicts and lack of nurturing in family of origin were typical. Relationships with male partners usually terminated following abortion. Repeaters were irregular in keeping appointments and in completing therapy. Some called their unborn child "monster." The author concluded that repeat abortions are both an individual and social problem with physical and emotional suffering as well as a strain on medical and counseling resources.

''"A Case Study of Reproductive Experience of Women Who Have Had Three or More Induced Abortions," Elizabeth Lincoln, Ph.D. Dissertation, University of Pittsburgh (1982); Dissertation Abstracts International 44(4), October 1983, Order No. DA 8318205. ''
:A study of eight women with three or more abortions found that women had a sex role orientation less modernistic than effective contraceptors, feared health effects, had problematic relationships with partners ,family of origin relationships were characterized by lack of affection and probable subsequent influence on adult relationships, interest in parenting and sexuality. Anger at perceived lack of male interest in contraception combined with poor communication and changing sex role expectations seemed to create conflicts increasing the likelihood of unwanted pregnancy.

''"Incidence of Repeat Abortion. Second-Trimester Abortion. Contraceptive Use and Illness within a Teenage Population," Rena Bobrowsky, Ph.D. Dissertation, University of Southern California (1986); Dissertation Abstracts International 47(9), March 1987. Copies available from Micrographics Dept, Doheny Library, USC, Los Angeles, CA 90069-0182. ''
:In a study of teenage abortion, 404 women were followed through medical records over a five-year period. Some 38% had a previous abortion and 18% had two abortions within the same year. Repeat aborters were found to have less stable relationships with their partners, more likely to show greater use of contraception post-abortion and have more medical problems that might preclude the safe use of more reliable contraceptives.

''"Association of Induced Abortion with Subsequent Pregnancy Loss," A. Levin, S. Schoenbaum, R. Monson, P. Stubbelfield, K. Ryan, JAMA 243:2495(1980). ''
:Women who had two or more induced abortions were 2.7 times more likely to have future first-trimester spontaneous abortions (miscarriage) and 3.2 times more likely to have a second-trimester incomplete abortion than were women with no history of induced abortion.

''"Repeat Abortions Increased Risk of Miscarriage. Premature Births and Low Birth Weight Babies," Family Planning Perspectives, 1(1):39-40, January/February 1979. ''
:Repeated abortion was associated with a 2- to 2.5-fold increase in the rate of low birth weight and short gestation when compared with either one abortion or one live birth.

''"Ectopic Pregnancy and Prior Induced Abortion," A. Levin, S. Schoenbaum, P. Stubblefield, S. Zimicki, R. Monson and K. Ryan, American Journal of Public Health 72(3):253- 256, March 1982. ''
:In a study at Boston Hospital for Women conducted from 1976-1978, the relative risk of ectopic pregnancy was found to be 1.6 for women with one prior abortion and reduced to 1.3 after control of confounding factors. The relative risk for two or more abortions was 4.0 for women with two or more prior induced abortions, which was reduced to 2.6 after control of confounding factors.

''"Patterns of Alcohol and Cigarette Use in Pregnancy," J. Kuzma and D. Kissinger, Neurobehavorial Toxicology and Teratology 3:211-221(1981) ''
:In a California study of more 12,000 women during 1975-1977, of those having a history of two or more abortions, virtually all (98.5%) consumed alcohol throughout the entire 9 months of a subsequent pregnancy and at higher levels, i.e., up to 3 oz. per day than any of the other categories studied.

''"Low Birth Weight in Relation to Multiple Induced Abortions," M.T. Mandelson, C.B. Maden, J.R. Daling, Am.J. Public Health, 82 (3):391-394, March, 1993. ''
:In a Washington State Study of 6541 women who delivered a child between 1984-87, 41.6% of the women smoked during this pregnancy if they had a history of 4 or more induced abortions compared with 31.0% smokers (2 prior abortions), 28.1% smokers (1 prior abortion), or 18.0% smokers (no prior abortions).

''"The Concept of the Repetition Compulsion," E. Bibring, Psychoanalytic Quarterly12: 486,507 (1943). ''
:"Perhaps the most frequent way of taking the compulsive repetition into the personality is through sexualization when the repetition compulsion becomes linked with masochistic drives."

''"Repeat Abortion: Is it a Problem?," C. Berger, D. Gold, D. Andres, P. Gillett and R. Kinch, Family Planning Perspectives 16(2):70-75, March/April 1985. ''
:Interviews with medical and counseling personnel at abortion facilities regarding women who return for repeat abortions reveal counseling deficiencies, possible negative media coverage and unclear long-term effects on childbearing as some of the reasons for concern.

''"Abortion Work: A Study of the Relationship Between Private Troubles and Public," Kathleen Marie Roe, Ph.D. Dissertation, University of California, Berkeley (1985). ''
:In a study of 90 abortion facility workers in the San Francisco area, over 95% expressed discomfort and surprise at repeaters.

''"Contraception and repeat abortion," M. Shepard and M. Bracken, Journal of Biosocial Science 11:289-302 (1979). ''
:In a study of women at Yale-New Haven Hospital during 1974-1975, women having repeat abortions were significantly more likely to be divorced than women having first abortions. Women having repeat abortions were more likely to be on public welfare than women having first abortions (38% vs. 25%).

''"Dysphoric reactions in women after abortion," K. Franco, M. Tamburrino, N. Campbell, J. Pentz and S. Jurs, J. of the American Medical Women's Association 44(4): 113, July/August 1989. ''
:Women reporting multiple abortions had more often considered suicide and scored higher on borderline personality pathology and depression. Some 40% of the 71, women studied reported anniversary reactions. None of the women aborting sought psychotherapy after the procedure.

''"The First Abortion And The Last? A Study of the Personality Factors Underlying Failure of Contraception," P. Niemela, P. Lehtinen, L. Rauramo, R. Hermansson, R. Karjalienen, H. Maki and C-A Stora, International Journal of Gynaecol. Obstet. 19:93- 200(1981). ''
:A Finnish study compared women seeking their second abortion to women who had successfully contracepted after their first abortion Repeaters rated lower in control of impulsivity, emotional balance/realism, self-esteem and stability of life as well as reflecting a lesser capacity for integrated personal relationships. Repeating women more often had a history of broken legalized or non-legalized partner relationships. Partners of repeaters took less responsibility for contraception even though the women had left them greater responsibility in this respect. Solidarity with partners was weaker in the repeaters even though the women felt greater admiration for their partners. Repeating women were less mature and more impulsive, indicating a "split" mechanism and immaturity of ego development which verged on a borderline level disturbance.

''"Single and repeated elective abortions in Japan: a psychosocial study," T Kitamura et al, J Psychosom Obstet Gynecol 19:126-134, 1998. ''
:A Japanese study found that women with two or more abortions had a longer dating period, were likely to have a non-arranged marriage, smoked more cigarettes, had an early maternal loss experience or a lower level of maternal care during childhood compared to women with women with a first abortion.

''"Mourning and Guilt Among Greek Women Having Repeated Abortions," D. Naziri, A. Tzararas, Omega 26(2): 137-144,1992-93 ''
:In a clinical study of the bereavement process of Greek women following one or more induced abortions, it was concluded that strong identifications with both father and mother images were present in the women. It was concluded that abortion might be a replacement/displacement of a reparatory character in relation to the "family romance" of each woman. In several cases of repeated abortion, mourning and guilt not only refer to a murdered and lost person of the fetus, but also principally to the death and loss of an object of ambiguous desire.

''"The Repeat Abortion Patient," Judith Leach, Family Planning Perspectives 9(1):37, January/February 1977. ''
:In a study of repeat abortion patients in the Atlanta area, 21% of the repeat aborters vs. 8% of the first-time aborters reported they had no religious affiliation. The disparity was especially striking in the private clinic population, among whom eight times as many repeat abortion patients as first-time aborters said they had no religious affiliation (20% vs. 2.5%).

''"Risk of Admission to Psychiatric Institutions Among Danish Women Who Experienced Induced Abortion: An Analysis Based Upon Record Linkage," Ronald Somers, Ph.D. Dissertation, University of California, Los Angeles (1979), Dissertation Abstracts International, Order No. 7926066. ''
:A study of the Danish Central Psychiatric Register of all women who had been admitted between April 1,1973 and December 31/1975 found that psychiatric admissions increased with the self-reported number of past abortions (no abortions, 1.90%; one abortion, 3.4%; two abortions, 4.0%; three abortions, 6.0%). No increase was observed as number of live births increased; women aged 35-39 with two or more abortions had higher rates of psychiatric admission than younger women with two or more abortions.

''"Increased Reporting of Menstrual Symptoms Among Women Who Used Induced Abortion," L.H. Roht, M.A. Fanner, H. Aoyama and E. Fonner, Am. Journal of Obstetrics and Gynecology 127:356-362, February 15,1977. ''
:A study of 3,222 female residents in Southern Japan in 1971, based upon a mailed questionnaire, found that women perceived menses to occur more frequently and be of shorter duration as the number of reported prior abortions increased. "Nervousness" increased as number of prior abortions increased: 150/1,000 women (no prior abortion); 228/1,000 (one prior abortion); 256/1/000 (two or more prior abortions).

''"Induced Terminations of Pregnancy: Reporting States," 1988, K. Kochanek, Monthly Vital Statistics Report 39(12): 1-32 (Suppl.), April 30,1991, Table 9, p. 20 ''
:In 1988 among the 14 reporting states, 297,251 induced abortions were performed. Some 25.5% had a second abortion, 9.0% had a third abortion and 8.7% had a fourth abortion or more. Overall, 44.1% were repeating abortion, 39.6% of white women were repeating abortion vs. 53.0% of black women.

''"The Social and Economic Correlates of Pregnancy Resolution Among Adolescents in New York by Race and Ethnicity: A Multivariate Analysis," Theodore Joyce, Am. J. Public Health78(6):626-63, (1988). ''
:Teenagers who experienced one prior abortion were approximately four times more likely to terminate a current pregnancy by abortion compared to teenagers with no prior abortion history. Medicaid tended to increase the likelihood of carrying pregnancies to term. Married adolescents were more likely to carry a pregnancy to term than unmarried adolescents.

==Eating Disorders==

''"Self-Induced Abortion in a Bulimic Woman," C.M. Bulik et. al., Int'l J. Eating Disorders 15(3): 297-299,1994. ''
:A case of a woman was presented who deliberately induced abortion via self-imposed starvation and vigorous exercise. She had a history of severe obsessive-compulsive and narcissistic personality disorders as well as a lifelong pattern of denial of affect and illness.

''"The Impulsivist: a multi-impulsive personality disorder," J.H. Lacey et. al., Br. J. Addiction 81: 641-649,1986. ''
:There are strong associations between eating disorders, substance abuse, impulse control, self-harm and personality disorders.

''Post-Abortion Trauma: 9 Steps to Recovery, Jeanette Vought, (Grand Rapids: Zondervan, 1991) 110. ''
:In a 1990 study of 68 religiously oriented (primarily Evangelical and Lutheran) 10-15 years post-abortion, found 8.8% of the women identified themselves as having suffered from eating disorders (bulimia and anorexia). Of these women, 66.7% had increased problems with their eating disorder after their abortion. And additional 51.5% indicated they had problems with overeating and 23.5% expressed problems of under eating. Overeating behavior increased 54.3% following their abortion and under eating behavior increased 50.1% after their abortion.)

''"Pregnancy : Outcome and Impact on Symptomatology in a Cohort of Eating- Disordered Women," MA Blais et al, Int J Eat Disord 27:140-149, 2000 ''
: There was an elevated incidence of eating disorders among women with therapeutic abortions which was not found among women with live births or spontaneous abortions.

''"Recurrent Abortions in a Bulimic: Implications Regarding Pathogenesis," R.S. El- Mallakh, A.Tasman, Intl. J. Eating Disorders 10(2):215-219,1991. ''
:A woman with severe bulimia used repeated pregnancies and abortions to achieve the same calming function as repeated binge eating and vomiting. It was suggested that her behavior was compatible with the view that bulimics use their own bodies as transitional objects and that the cycle of incorporation and expulsion is central to affect regulation. The woman was suicidal and preoccupied with death.

''The Psycho-Social Aspects of Stress Following Abortion, Anne C. Speckhard, (Sheed and Ward: Kansas City, 1987) ''
:In a study of 30 women who were stressed by abortion, 23 percent reported extreme weight gain, generally defined by the subjects as a 20-pound weight gain or more. Extreme weight gain was usually attributed to increased eating to calm oneself. Extreme weight loss was reported by 30 percent of the sample; 23 percent classified themselves as experiencing a period of anorexia nervosa. This was self defined, although many subjects reporting anorexia included evidence such as loss of 25 percent of body weight, cessation of menses, hospitalization and/or clinical diagnosis of anorexia nervosa.

''Aborted Women: Silent No More, David C. Reardon, (Chicago: Loyola Press, 1987) 24. ''
:In a study of 252 women who were members of Women Exploited by Abortion, two women were reported to suffer from anorexia nervosa which they attributed to their abortions. At least one woman suffered from excessive weight gain after her abortion, as she tried to bury her guilt in food.

''"Ritual Mourning in Anorexia Nervosa," R.K. McAll and F.M. McAll, The Lancet,August 16,1980, p. 368. ''
:Of 18 patients with anorexia nervosa treated in the hospital without improvement, 15 experienced total relief of symptoms following a process of ritual mourning for deceased family members who had not previously been mourned. Two patients were male. In 17 of the cases, family histories revealed a total of 25 violent deaths or deaths by suicide, five terminations of pregnancy for non-medical reasons and eight miscarriages. In one case a 17-year-old girl had anorexia nervosa since age 14 and had been hospitalized three times. At the time of referral she was unable to get out of bed. Her mother had an earlier pregnancy aborted. Without the knowledge of the patient, who was considered too ill to be involved/the parents went through a form of service in a church for the aborted child. When the patient was later told about this she admitted an awareness of the existence of her unborn "sister" but said she had not mentioned this for fear of being locked up in a mental hospital. She was immediately able to get up and in a very short time was successfully attending a college. In another case, a man of 41, had first been diagnosed as having anorexia at age 22. At the time of the examination he was not only anorectic but also severely depressed. On close questioning he admitted to having precipitated the abortion of his wife's first child. Within a week of his admission, and after following through with a process of mourning for and committal of the child, he was no longer depressed and was eating normally. The authors suggest that "hidden guilt, either in the patient or in a close member of the family, or lack of adequate recognition for a lost member of the family may be a causative factor. Providing a means of repentance, mourning for and committal of the dead can lead to dramatic relief of symptoms in the affected person, in addition to the emotional release experienced by other involved members of the family."

''"Value of Family Background and Clinical Features as Predictors of Long Term Outcome in Anorexia Nervosa," H. Morgan and G.F.M. Russell, Psychological Medicine 5:355-37, (1975). ''
:A disturbed relationship between the patient and other members of the family, and premorbid personality difficulties are predictors of unfavorable outcome.

''"Diseases of the Nervous System," Asbury, McKhana, McDonald, Vol. 1(Philadelphia: WB Saunders, 1986)''
:Anorexia nervosa is a disorder usually affecting affluent young women 14-17 years of age but occasionally found even earlier or even up to age 40-50. The person is preoccupied with body weight, under eats even to possible starvation or self-destruction, and becomes depressed, very impatient and irritable. Anorexia nervosa is frequently associated with distressed and disturbed family relationships, suggesting a psychogenic aspect. Some have suggested that anorexia nervosa represents an aspect of affective disorder. Extreme perfectionism and self-criticism are often common traits. Mortality rates range from 4-16 percent depending on the study.

''"A Study of 56 Families with Anorexia Nervosa," R.S. Kalucy, British Journal of Medical Psychology 50:381-395(1977). ''
:A central feature was the threat to family values and stability which such events posed. Deaths and illnesses often involved waiting and then mechanisms of identification seemed important. For example/a daughter's illness was preceded by identification with the loss of another sister from leukemia; in another a father's wasting from achalasis.

''"Avoidance of Anxiety and Eating Disorders," J. Keck and M. Fiebert, Psychological Reports 58: 432-434 (1986) ''
:Female patients with eating disorders appeared to use an obsession with food and weight as a form of escape.

[http://www.ncbi.nlm.nih.gov/pubmed/24559792 Suicide attempts and mortality in eating disorders: a follow-up study of eating disorder patients.] Suokas JT1, Suvisaari JM2, Grainger M3, Raevuori A4, Gissler M5, Haukka J6. Gen Hosp Psychiatry. 2014 Jan 13. pii: S0163-8343(14)00005-X. doi: 10.1016/j.genhosppsych.2014.01.002. [Epub ahead of print]

We identified 156 patients with eating disorder (6.3%) and 139 controls (1.4%) who had required hospital treatment for attempted suicide. Of them, 66 (42.3%) and 37 (26.6%) had more than one attempt. The rate ratio (RR) for suicide attempt in patients with eating disorder was 4.70 [95% confidence interval (CI) 1.41-15.74]. In anorexia nervosa, RR was 8.01 (95% CI 5.40-11.87), and in bulimia nervosa, it was 5.08 (95% CI 3.46-7.42). In eating disorder patients with a history of suicide attempt, the risk of death from any cause was 12.8%, suicide being the main cause in 45% of the deaths.
Suicide attempts and repeated attempts are common among patients with eating disorders. Suicidal ideation should be routinely assessed from patients with eating disorders.

[http://www.ncbi.nlm.nih.gov/pubmed/23996114 Reproductive health outcomes in eating disorders.] Linna S, Raevuori A, Haukka J, Suvisaari JM, Suokas JT, Gissler M. Int J Eat Disord. 2013 Dec;46(8):826-33. doi: 10.1002/eat.22179. Epub 2013 Sep 2.

OBJECTIVE:
Eating disorders are common psychiatric disorders in women at childbearing age. Previous research suggests that eating disorders are associated with fertility problems, unplanned pregnancies, and increased risk of induced abortions and miscarriages. The purpose of this study was to assess how eating disorders are related to reproductive health outcomes in a representative patient population.
METHOD:
Female patients (N = 2,257) treated at the eating disorder clinic of Helsinki University Central Hospital during 1995-2010 were compared with matched controls identified from the Central Population Register (N = 9,028). Patients had been diagnosed (ICD-10) with anorexia nervosa (AN), atypical AN, bulimia nervosa (BN), atypical BN, or binge eating disorder (BED, according to DSM-IV research criteria). Register-based data on number of children, pregnancies, childbirths, induced abortions, miscarriages, and infertility treatments were used to measure reproductive health outcomes.
RESULTS:
Patients were more likely to be childless than controls [odds ratio (OR) 1.86; 95% confidence interval (CI) 1.62-2.13, p < .001]. Pregnancy and childbirth rates were lower among patients than among controls. BN was associated with increased risk of induced abortion compared to controls (OR 1.85; 95% CI 1.43-2.38, p < .001), whereas BED was associated with elevated risk of miscarriage (OR 3.18; 95% CI 1.52-6.66, p = .002).
DISCUSSION:
Reproductive health outcomes are compromised in women with a history of eating disorders across all eating disorder types. Our findings emphasize the importance of reproductive health counseling and monitoring among women with eating disorders.

[http://archpsyc.jamanetwork.com/article.aspx?articleID=1904804&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMAPsychiatry%3AOnlineFirst09%2F17%2F2014 Posttraumatic Stress Disorder Symptoms and Food Addiction in Women by Timing and Type of Trauma Exposure]
Susan M. Mason, PhD, Alan J. Flint, DPH, MD, Andrea L. Roberts, PhD, et al. JAMA Psychiatry. Published online September 17, 2014. doi:10.1001/jamapsychiatry.2014.1208

:While this study did not report on abortion, it did find that "The prevalence of food addiction increased with the number of lifetime PTSD symptoms, and women with the greatest number of PTSD symptoms (6-7 symptoms) had more than twice the prevalence of food addiction as women with neither PTSD symptoms nor trauma histories (prevalence ratio, 2.68; 95% CI, 2.41-2.97). Symptoms of PTSD were more strongly related to food addiction when symptom onset occurred at an earlier age."

==Sexual Promiscuity and Casual Sex==

See also [http://abortionrisks.org/index.php?title=Impact_of_Abortion_On_Others#Impact_of_Abortion_on_Relationships_and_Sexual_Behavior Impact of Abortion on Relationships and SexualBehavior]

''"Abortion and the sexual lives of men and women: Is casual sexual behavior more appealing and
more common after abortion?" Coleman PK, Rue VM, Spense M, Coyle CT. Int J Clin Health Psychol, Vol. 8, Nº 1, 2008
:ABSTRACT. Previous research indicates that abortion increases risk for experiencing difficulties maintaining committed relationships, sexual dysfunction, and psychological prooblems. In the present descriptive study, associations between abortion and attitudes and behaviors associated with casual sexual activity were examined after controlling for family of origin, socio-demographic, reproductive history, and sexual history variables. The National Health and Social Life Survey (NHSLS), a multistage probability sample of 3,432 men and women between the ages of 18 and 59 was the data source. Among women, abortion was associated with more positive attitudes toward sex with strangers and with being forced to have sex; whereas the male experience of a partner abortion was correlated with attitudes endorsing sex with more than one partner and with strangers. Abortion among men and women predicted disagreement relative to restricting sexual activity to love relations, more sex partners in the last year, and endorsement for having sex with an acquaintance. Male experience of a partner abortion also increased the likelihood of having sex with a friend. Finally, abortion predicted engagement in various impersonal sexual behaviors over the previous 12 months among males and females. Strengths of the study include the large nationally representative data source and employment of a variety of control variables.

National Study of Family Growth-1995, Cycle V, U.S. Department of Health and Human Services, National Center for Health Statistics, 1997

:A national U.S. study of ever-pregnant women over age 35 found that women with no history of abortion had fewer sex partners before marriage (3.4 v. 9.2), and fewer lifetime sex partners (4.4 v. 12.7) compared to women with a history of abortion. Excluding women who had no sex partners before marriage, women with two or more abortions were likely to have more sex partners after marriage, (5.0), compared to women with a single abortion (2.0), or women with no history of abortion (2.0).

''Forbidden Grief.The Unspoken Pain of Abortion,'' Theresa Burke and David Reardon, Springfield, IL:Acorn Books, 2002.

:In an Elliot Institute survey of 260 women who were involved in faith-based postabortion counseling or advocacy groups, 42.7% said they became promiscuous within one month following their abortion; 51.6% said they became promiscuous within 6 months following their abortion; 46.6% said they developed an aversion to sex or became sexually unresponsive within one month, and 38.5% said they developed an aversion to sex or became sexually unresponsive within 6 months following their abortion.

''Psychosocial Sequelae of Therapeutic Abortion in Young Unmarried Women,'' Judith Wallerstein et al, Arch Gen Psychiatry 27:828, 1972.

:In-depth interviews of 22 women under 22 years of age who had an abortion At a Planned Parenthood facility in northern California in 1969-1970 at 5-7 months postabortion, 9 reported a newly begun promiscuous pattern in relationships with men following their abortion.

''Physical and Psychological Injury in Women Following Abortion: Akron Pregnancy Services Survey'', L Gsellman, Association for Interdisciplinary Research in Values and Social Change Newsletter 5(4) 1-8, 1993.

:In a self-reported questionnaire survey of 344 postabortion women with a mean age of approximately 18 years at the time of their abortion and who were receiving general pregnancy related services (including 28% who had presented for post abortion counseling) , 9% of the women reported sexual promiscuity, 14% reported frigidity, and 23% reported a desire to get pregnant again as postabortion psychological complaints.

''Psycho-Social Stress Following Abortion,'' Anne Speckhard, Kansas City: Sheed & Ward, 1987.

:A study of 30 women who reported long term stress from abortion, 31% reported sexual promiscuity, 35% reported feelings of sexual anxiety, 35% reported a deter- ioration of their sexual relationship, and 69% reported feelings of sexual inhibition.

''Health issues associated with increasing "crack" use among female sex workers, in London'', H Ward et al, Sex Transm Infect 76(4):292,

:Thirty-four percent of female sex workers reported using "crack" cocaine in 1995- 1996. Crack cocaine use was associated with abortion and hepatitis C infection.

''What have we learned from adolescent prostitutes in the Caribbean that adult prostitutes did not tell us?'', M Alegria et al, Int Conf AIDS, June, 1993; 9(1)89 (Abstract No. WS-CO8-2).

:Prostitution for adolescents begins with family or academic problems leading to early sexual experience with boyfriend followed by pregnancy and abortion which leads to economic/emotional despair followed by prostitution and then drug use.

''HIV risk relevant behaviors of Japanese adolescents'', T Munkata and K Fujisawa, Int Conf AIDS 11(1) 385, July, 1996 (Abstract No. Tu.D.27012)

:A mail survey to 10,000 Japanese adolescents age 13-24 in 1995 found that casual sex experiences were significantly influenced by self- or partners' abortion experience. Casual sex included having "first time" sex where partners were "sexually excited without love", "curiosity", "can't say No", or "nothing in particular".

''Pregnancy outcome after ecstasy use; 43 cases followed by the Teratology Information Service of the National Institute for Public Health and Environment'', MM van-Tonninger-van Driel et al, Ned Tijdschr Geneeskd 2;143(1): 27-31, 1999 (English Abstract).

:A Dutch study of 43 women who used ecstacy during pregnancy reported that pregnancies were often unplanned and previous pregnancies had often been terminated. Besides ecstacy, mothers frequently also used other substances potentially harmful to the pregnancy and child.

''Repeat Abortion: Blaming the Victims'', B Howe et al, Am J Public Health 69(12):70, 1979.

:Women who repeated abortion were found to be more sexually active compared to women with first abortions even though they used contraception more than women with one abortion.

''Repeat Abortion: Is It a Problem?'', C Berger et al, Family Planning Perspectives 16(2): 70, 1984.

:A Canadian study found that women who repeated abortion had more frequent itercourse, less satisfying relations with their partner, had more difficulty sleeping, and were less likely to live with their partner compared to women with a single abortion.

Self-Destructive Behavior

2025-10-07T20:30:22Z

Barb: /* Abortion Related Suicide: Case Studies */

{{DEA}}
{{PsychIndex}}[[Category:Suicide]]

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See also [[Substance Abuse]]

==Suicide Associated with Abortion==

===Specific Cases of Abortion Related Suicide===

See [[Suicide - Case Studies]]

===Statistically Significant Studies===
'''[https://pubmed.ncbi.nlm.nih.gov/34773878/ Premature mortality after pregnancy loss: Trends at 1, 5, 10 years, and beyond.] Auger N, Ghadirian M, Low N, Healy-Profitós J, Wei SQ. Eur J Obstet Gynecol Reprod Biol. 2021 Dec;267:155-160. doi: 10.1016/j.ejogrb.2021.10.033. Epub 2021 Nov 1. PMID: 34773878.'''

'''Objective:''' Little is known on the long-term risk of mortality following pregnancy loss. We assessed risks of premature mortality up to three decades after miscarriage, induced abortion, ectopic or molar pregnancy, and stillbirth relative to live birth.

'''Study design:''' We carried out a longitudinal cohort study of 1,293,640 pregnant women with 18,896,737 person-years of follow-up in Quebec, Canada, from 1989 to 2018. We followed the women up to 29 years after their last pregnancy event to determine the time and cause of future in-hospital deaths before age 75 years. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of miscarriage, induced abortion, ectopic pregnancy, molar pregnancy, and stillbirth with premature mortality, compared with live birth.

'''Results:''' Premature mortality rates were higher for most types of pregnancy loss than live birth. Compared with live birth, pregnancy loss was associated with an elevated risk of premature mortality (HRmiscarriage 1.48, 95% CI 1.33, 1.65; HRinduced abortion 1.50, 95% CI 1.39, 1.62; HRectopic 1.55, 95% CI 1.35, 1.79; and HRstillbirth 1.68, 95%. CI 1.17, 2.41). Molar pregnancy was not associated with premature mortality (HR 0.87, 95% CI 0.33, 2.32). Miscarriage and induced abortion were associated with most causes of death, whereas ectopic pregnancy was associated with cardiovascular (HR 2.18, 95 % CI 1.39, 3.42), cancer (HR 1.38, 95 % CI 1.11, 1.73), and suicide-related mortality (HR 4.94, 95 % CI 2.29, 10.68). Stillbirth was associated with cardiovascular mortality (HR 4.91, 95 % CI 2.33, 10.36).

'''Conclusion:''' Pregnancy loss is associated with an elevated risk of premature mortality up to three decades later, particularly cardiovascular, cancer, and suicide-related deaths.

'''Suicide Specific Results:''' HR Induced Abortion HR 2.41 (1.37 to 4.22) Miscarriage 2.79 (1.29, 6.04); HR Unspecified Abortion 3.31 (1.44, 7.58) Hazard ratio for pregnancy loss relative to live birth, adjusted for maternal age, gravidity, preexisting comorbidity, socioeconomic deprivation, rurality, Aboriginal region, and time period

'''[https://pubmed.ncbi.nlm.nih.gov/40408979/ Induced abortion and implications for long-term mental health: a cohort study of 1.2 million pregnancies.] Auger N, Healy-Profitós J, Ayoub A, Lewin A, Low N. J Psychiatr Res. 2025 Jul;187:304-310. doi: 10.1016/j.jpsychires.2025.05.031. Epub 2025 May 16. PMID: 40408979.'''<blockquote>'''Background:''' The relationship between induced abortion and long-term mental health is not clear. We assessed whether having an induced abortion was associated with an increase in the long-term risk of mental health hospitalization.

'''Methods:''' We carried out a retrospective cohort study of 28,721 induced abortions and 1,228,807 births in hospitals of Quebec, Canada, between 2006 and 2022. The exposure was induced abortion compared with other pregnancies, and the outcome was hospitalization for a psychiatric disorder, substance use disorder, or suicide attempt over time. We followed patients up to 17 years after the end of pregnancy to identify mental health-related hospitalizations. We calculated hazard ratios (HR) and 95 % confidence intervals (CI) for the association between induced abortion and mental health hospitalization, adjusted for pregnancy characteristics.

'''Results:''' Rates of mental health-related hospitalization were higher following induced abortions than other pregnancies (104.0 vs. 42.0 per 10,000 person-years). Abortion was associated with hospitalization for psychiatric disorders (HR 1.81, 95 % CI 1.72-1.90), substance use disorders (HR 2.57, 95 % CI 2.41-2.75), and suicide attempts (HR 2.16, 95 % CI 1.91-2.43) compared with other pregnancies. The associations were greater for patients who had preexisting mental illness or were aged less than 25 years at the time of the abortion. Abortion was strongly associated with mental health hospitalization within five years but risks waned over time.

'''Conclusion:''' Induced abortion is associated with an increased risk of mental health-related hospitalization in the long term but the association weakens with time.

'''Note:''' The supplementary Table S2, compared to live birth, '''the suicide attempts were twice as likely after an abortion (HR=2.16 95% CI 1.92-2.43)'''</blockquote>'''Reardon DC. [https://www.tandfonline.com/doi/full/10.1080/0167482X.2025.2455086 Suicide risks associated with pregnancy outcomes: a national cross-sectional survey of American females 41-45 years of age.] J Psychosom Obstet Gynaecol. 2025 Dec;46(1):2455086.'''<blockquote>'''Objective:''' Numerous studies have linked abortion to an elevated risk of suicide. One hypothesis is that this association is entirely incidental and most likely fully explained by preexisting mental illness. This hypothesis can be tested by examining women’s own self-assessments of the degree, if any, that abortion and other pregnancy outcomes contributed to suicidal thoughts and behaviors.

'''Methods:''' A topic blind survey was distributed to 2829 American females 41–45years of age. Respondents were asked about any history of attempted suicide(s) and reproductive histories. Grouped by reproductive history, respondents were then asked to rank on visual analog scales the degree, if any, to which their pregnancy outcome contributed to suicidal thoughts, self-destructive behaviors, and any attempted suicides.

'''Results:''' Aborting women were twice as likely to have attempted suicide compared to other women. Aborting women, especially those who underwent coerced or unwanted abortions, were significantly more likely to say their pregnancy outcomes directly contributed to suicidal thoughts and behaviors compared to women in all other groups.

'''Conclusions:''' The hypothesis that higher rates of suicide following abortion can be entirely explained by preexisting mental health problems is inconsistent with women’s own self-assessments of the degree their abortions directly contributed to suicidal and self-destructive behaviors.</blockquote>'''[https://pubmed.ncbi.nlm.nih.gov/36808811/ Hospitalisation for non-lethal self-harm and premature mortality in the 3 years following adolescent pregnancy: Population-based nationwide cohort study.] Goueslard K, Jollant F, Cottenet J, Bechraoui-Quantin S, Rozenberg P, Simon E, Quantin C. BJOG. 2023 Aug;130(9):1016-1027. doi: 10.1111/1471-0528.17432. Epub 2023 Mar 16. PMID: 36808811.'''<blockquote>'''Objective:''' To evaluate the risk of non-lethal self-harm and mortality related to adolescent pregnancy.

'''Design:''' Nationwide population-based retrospective cohort.

'''Setting:''' Data were extracted from the French national health data system.

'''Population:''' We included all adolescents aged 12-18 years with an International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) code for pregnancy in 2013-2014.

'''Methods:''' Pregnant adolescents were compared with age-matched non-pregnant adolescents and with first-time pregnant women aged 19-25 years.

'''Main outcome measures:''' Any hospitalisation for non-lethal self-harm and mortality during a 3-year follow-up period. Adjustment variables were age, a history of hospitalisation for physical diseases, psychiatric disorders, self-harm and reimbursed psychotropic drugs. Cox proportional hazards regression models were used.

'''Results:''' In 2013-2014, 35 449 adolescent pregnancies were recorded in France. After adjustment, pregnant adolescents had an increased risk of subsequent hospitalisation for non-lethal self-harm in comparison with both non-pregnant adolescents (n = 70 898) (1.3% vs 0.2%, HR 3.06, 95% CI 2.57-3.66) and pregnant young women (n = 233 406) (0.5%, HR 2.41, 95% CI 2.14-2.71). Rates of hospitalisation for non-lethal self-harm were lower during pregnancy and higher between 12 and 8 months pre-delivery, 3-7 months postpartum and in the month following abortion. Mortality was significantly higher in pregnant adolescents (0.7‰) versus pregnant young women (0.4‰, HR 1.74, 95% CI 1.12-2.72), but not versus non-pregnant adolescents (0.4‰, HR 1.61, 95% CI 0.92-2.83). {'''The risk of hospitalization for nonlethal self-harm among teenagers was highest after induced abortion (HR, 3.5 [95% CI, 2.9-4.2])).'''

'''Conclusions:''' Adolescent pregnancy is associated with an increased risk of hospitalisation for non-lethal self-harm and premature death. Careful psychological evaluation and support should be systematically implemented for adolescents who are pregnant.</blockquote>'''[https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2816198 Teen Pregnancy and Risk of Premature Mortality.] ''Ray JG, Fu L, Austin PC, et al. JAMA Netw Open.'' 2024;7(3):e241833. doi:10.1001/jamanetworkopen.2024.1833'''<blockquote>'''Objective''' To evaluate the risk of premature mortality from 12 years of age onward in association with number of teen pregnancies and age at pregnancy.

'''Design, Setting, and Participants''' This population-based cohort study was conducted among all females alive at 12 years of age from April 1, 1991, to March 31, 2021, in Ontario, Canada (the most populous province, which has universal health care and data collection). The study period ended March 31, 2022.

'''Exposures''' The main exposure was number of teen pregnancies between 12 and 19 years of age (0, 1, or ≥2). Secondary exposures included how the teen pregnancy ended (birth or miscarriage vs induced abortion) and age at first teen pregnancy.

'''Main Outcomes and Measures''' The main outcome was all-cause mortality starting at 12 years of age. Hazard ratios (HRs) were adjusted for year of birth, comorbidities at 9 to 11 years of age, and area-level education, income level, and rurality.

'''Results''' Of 2 242 929 teenagers, 163 124 (7.3%) experienced a pregnancy at a median age of 18 years (IQR, 17-19 years). Of those with a teen pregnancy, 60 037 (36.8%) ended in a birth (of which 59 485 [99.1%] were live births), and 106 135 (65.1%) ended in induced abortion. The median age at the end of follow-up was 25 years (IQR, 18-32 years) for those without a teen pregnancy and 31 years (IQR, 25-36 years) for those with a teen pregnancy. There were 6030 deaths (1.9 per 10 000 person-years [95% CI, 1.9-2.0 per 10 000 person-years]) among those without a teen pregnancy, 701 deaths (4.1 per 10 000 person-years [95% CI, 3.8-4.5 per 10 000 person-years]) among those with 1 teen pregnancy, and 345 deaths (6.1 per 10 000 person-years [95% CI, 5.5-6.8 per 10 000 person-years]) among those with 2 or more teen pregnancies; adjusted HRs (AHRs) were 1.51 (95% CI, 1.39-1.63) for those with 1 pregnancy and 2.14 (95% CI, 1.92-2.39) for those with 2 or more pregnancies. Comparing those with vs without a teen pregnancy, the AHR for premature death was 1.25 (95% CI, 1.12-1.40) from noninjury, 2.06 (95% CI, 1.75-2.43) from unintentional injury, and 2.02 (95% CI, 1.54-2.65) from intentional injury.

'''Conclusions and Relevance''' In this population-based cohort study of 2.2 million female teenagers, teen pregnancy was associated with future premature mortality. It should be assessed whether supports for female teenagers who experience a pregnancy can enhance the prevention of subsequent premature mortality in young and middle adulthood.</blockquote>

'''Premature mortality after pregnancy loss: Trends at 1, 5, 10 years, and beyond. Auger N, Ghadirian M, Low N, Healy-Profitós J, Wei SQ. Eur J Obstet Gynecol Reprod Biol. 2021 Dec;267:155-160. doi: 10.1016/j.ejogrb.2021.10.033. Epub 2021 Nov 1. PMID: 34773878.'''<blockquote>'''Objective:''' Little is known on the long-term risk of mortality following pregnancy loss. We assessed risks of premature mortality up to three decades after miscarriage, induced abortion, ectopic or molar pregnancy, and stillbirth relative to live birth.

'''Study design:''' We carried out a longitudinal cohort study of 1,293,640 pregnant women with 18,896,737 person-years of follow-up in Quebec, Canada, from 1989 to 2018. We followed the women up to 29 years after their last pregnancy event to determine the time and cause of future in-hospital deaths before age 75 years. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of miscarriage, induced abortion, ectopic pregnancy, molar pregnancy, and stillbirth with premature mortality, compared with live birth.

'''Results:''' Premature mortality rates were higher for most types of pregnancy loss than live birth. Compared with live birth, pregnancy loss was associated with an elevated risk of premature mortality (HRmiscarriage 1.48, 95% CI 1.33, 1.65; HRinduced abortion 1.50, 95% CI 1.39, 1.62; HRectopic 1.55, 95% CI 1.35, 1.79; and HRstillbirth 1.68, 95%. CI 1.17, 2.41). Molar pregnancy was not associated with premature mortality (HR 0.87, 95% CI 0.33, 2.32). '''Miscarriage and induced abortion were associated with most causes of death,''' whereas ectopic pregnancy was associated with cardiovascular (HR 2.18, 95 % CI 1.39, 3.42), cancer (HR 1.38, 95 % CI 1.11, 1.73), and suicide-related mortality (HR 4.94, 95 % CI 2.29, 10.68). Stillbirth was associated with cardiovascular mortality (HR 4.91, 95 % CI 2.33, 10.36).

'''Conclusion:''' Pregnancy loss is associated with an elevated risk of premature mortality up to three decades later, particularly cardiovascular, cancer, and suicide-related deaths.</blockquote>

'''[https://www.mdpi.com/1010-660X/55/11/741 Affective and Substance Abuse Disorders Following Abortion by Pregnancy Intention in the United States: A Longitudinal Cohort Study.] Sullins DP. Medicina (Kaunas). 2019 Nov 15;55(11). pii: E741. doi: 10.3390/medicina55110741.'''

:'''Background and Objectives:''' Psychological outcomes following termination of wanted pregnancies have not previously been studied. Does excluding such abortions affect estimates of psychological distress following abortion? To address this question this study examines long-term psychological outcomes by pregnancy intention (wanted or unwanted) following induced abortion relative to childbirth in the United States.

:'''Materials and Methods:''' Panel data on a nationally-representative cohort of 3935 ever-pregnant women assessed at mean age of 15, 22, and 28 years were examined from the National Longitudinal Survey of Adolescent to Adult Health (Add Health). Relative risk (RR) and incident rate ratios (IRR) for time-dynamic mental health outcomes, conditioned by pregnancy intention and abortion exposure, were estimated from population-averaged longitudinal logistic and Poisson regression models, with extensive adjustment for sociodemographic differences, pregnancy and mental health history, and other confounding factors. Outcomes were assessed using the Diagnostic and Statistical Manual, Version 4, American Psychiatric Association (DSM-IV) diagnostic criteria or another validated index for suicidal ideation, depression, and anxiety (affective problems); drug abuse, opioid abuse, alcohol abuse, and cannabis abuse (substance abuse problems); and summary total disorders.

:'''Results:''' Women who terminated one or more wanted pregnancies experienced a 43% higher risk of affective problems (RR 1.69, 95% CI 1.3-2.2) relative to childbirth, compared to women terminating only unwanted pregnancies (RR 1.18, 95% CI 1.0-1.4). Risks of depression (RR 2.22, 95% CI 1.3-3.8) and suicidality (RR 3.44 95% CI 1.5-7.7) were especially elevated with wanted pregnancy abortion. Relative risk of substance abuse disorders with any abortion was high, at about 2.0, but unaffected by pregnancy intention. Excluding wanted pregnancies artifactually reduced estimates of affective disorders by 72% from unity, substance abuse disorders by 11% from unity, and total disorders by 21% from unity.

:'''Conclusions:''' Excluding wanted pregnancies moderately understates overall risk and strongly understates affective risk of mental health difficulties for women following abortion. Compared to corresponding births, abortions of wanted pregnancies are associated with a greater risk of negative psychological affect, particularly depression and suicide ideation, but not greater risk of substance abuse, than are abortions of unwanted pregnancies. Clinical, research, and policy implications are discussed briefly.

[https://www.ncbi.nlm.nih.gov/pubmed/31104119 Maternal suicide in Italy.] Lega I, Maraschini A, D'Aloja P, Andreozzi S, Spettoli D, Giangreco M, Vichi M, Loghi M, Donati S; Regional maternal mortality working group. Arch Womens Ment Health. 2019 May 18. doi: 10.1007/s00737-019-00977-1.

:Abstract: Suicide has been identified as one of the most common causes of death among women within 1 year after the end of pregnancy in several high-income countries. The aim of this study was to provide the first estimate of the maternal suicide ratio and a description of the characteristics of women who died by suicide during pregnancy or within 1 year after giving birth, induced abortion or miscarriage (i.e., maternal suicide) in 10 Italian regions, covering 77% of total national births. Maternal suicides were identified through the linkage between regional death registries and hospital discharge databases. Background population data was collected from the national hospital discharge, abortion and mortality databases. The previous psychiatric history of the women who died by maternal suicide was retrieved from the regionally available data sources. A total of 67 cases of maternal suicide were identified, corresponding to a maternal suicide ratio of 2.30 per 100,000 live births in 2006-2012. The suicide rate was 1.18 per 100,000 after giving birth (n = 2,876,193), 2.77 after an induced abortion (n = 650,549) and 2.90 after a miscarriage (n = 379,583). The majority of the women who died by maternal suicide (34/57) had a previous psychiatric history; 15/18 previously diagnosed mental disorders were not registered along with the index pregnancy obstetric records. Suicide is a relevant cause of maternal death in Italy. The continuity of care between primary, mental health and maternity care were found to be critical. Clinicians should be aware of the issue, as they may play an important role in preventing suicide in their patients.

'''[https://www.sciencedirect.com/science/article/pii/S1028455918303024 The association between abortion experience and postmenopausal suicidal ideation and mental health: Results from the 5th Korean National Health and Nutrition Examination Survey.] Jeong Ha Wie, Su Kyung Nam, Hyun Sun Ko, Jong Chul Shin, In Yang Park, Young Lee. Taiwanese Journal of Obstetrics and Gynecology Volume 58, Issue 1, January 2019, Pages 153-158'''

:Objective:The association between abortion and postmenopausal mental health has not been clearly established in Asian women. The objective of this study was to evaluate the effect of abortion experiences on suicidal ideation and mental health in Korean postmenopausal women.

:Materials and methods: This study included 5133 postmenopausal women registered in the Korean National Health and Nutrition Examination Survey between 2010 and 2012. Difference in suicidal ideation according to type and number of abortions was analyzed. We used survey multiple logistic regression analysis to evaluate the effect of abortion experiences on the risk for suicidal ideation expressed as adjusted odd ratios (ORs) with 95% confidence intervals (95%CIs).

:Results: The risk of suicidal ideation was significantly higher in women who experienced more than three abortions (27.9%). While the incidence of suicidal ideation was not significantly affected by the number of spontaneous abortions (p = 0.718), suicidal ideation was significantly more frequent in women who had undergone ≥ three abortions (p = 0.003). After adjusting for demographic confounding factors, women who underwent ≥ three induced abortions had higher risk for suicidal ideation (OR: 1.510; 95% CI: 1.189–1.919; p = 0.031). This risk remained elevated even after controlling for depression (OR: 1.391; 95% CI: 1.1086–1.871, p = 0.002). Moreover, the risk of experiencing a depressive mood in daily life was also increased with increasing number of induced abortions even after controlling for depression (OR: 1.657; 95% CI: 1.274–2.156, p = 0.002).

:Conclusion: Undergoing three or more induced abortions during reproductive age was associated with postmenopausal suicidal ideation, stress, and depression. However, such association was not noted in those with spontaneous abortion, even in women with more miscarriages. Thus, clinicians should evaluate depression and suicidal ideation in women with multiple induced abortions.

'''[[https://www.ncbi.nlm.nih.gov/pubmed/29266732 Do stillbirth, miscarriage, and termination of pregnancy increase risks of attempted and completed suicide within a year? A population-based nested case-control study.]] Weng SC, Chang JC, Yeh MK, Wang SM, Lee CS, Chen YH. BJOG. 2018 Jul;125(8):983-990. doi: 10.1111/1471-0528.15105. Epub 2018 Feb 7.'''

:OBJECTIVE: To investigate the risks of attempted and completed suicide in women who experienced a stillbirth, miscarriage, or termination of pregnancy within 1 year postnatally and compare this risk with that in women who experienced a live birth.

:SETTING: Linking three nationwide population-based data sets in Taiwan: the National Health Insurance Research Database, the National Birth Registry and the National Death Registry.

:SAMPLE: In all, 485 and 350 cases of attempted and completed suicide, respectively, were identified during 2001-11; for each case, ten controls were randomly selected and matched to the cases according to the age and year of delivery.

:MAIN OUTCOME MEASURES: Attempted and completed suicidal statuses were determined.

:RESULTS: The rates of attempted suicide increased in the women who experienced fetal loss. The risk of completed suicide was higher in women who experienced a stillbirth [adjusted odds ratio (aOR) 5.2; 95% CI 1.77-15.32], miscarriage (aOR 3.81; 95% CI 2.81-5.15), or termination of pregnancy (aOR 3.12; 95% CI 1.77-5.5) than in those who had a live birth. Furthermore, the risk of attempted suicide was significantly higher in women who experienced a miscarriage (aOR 2.1; 95% CI 1.66-2.65) or termination of pregnancy (aOR 2.5; 95% CI 1.63-3.82). In addition to marital and educational statuses, psychological illness increased the risk of suicidal behaviour.

:CONCLUSIONS: The risk of suicide might increase in women who experience fetal loss within 1 year postnatally. Healthcare professionals and family members should enhance their sensitivity to care for possible mental distress, particularly for women who have experienced a stillbirth.

'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5952593/ Association between induced abortion and suicidal ideation among unmarried female migrant workers in three metropolitan cities in China: a cross-sectional study.] Luo M, Jiang X, Wang Y, Wang Z, Shen Q, Li R, Cai Y. ''BMC Public Health''. 2018 May 15;18(1):625. doi: 10.1186/s12889-018-5527-1.'''

:BACKGROUND: Despite reports of mental health issues, suicidality has not been closely examined among the migrant population. The association between induced abortion and suicidal ideation is unknown among unmarried female migrant workers of reproductive age in China. This study aims to examine induced abortion and suicidality among the Chinese migrant population.

:METHODS: We recruited 5115 unmarried female migrant workers during 2015 to 2016 from Shanghai, Beijing and Guangzhou, and collected demographic, psychosocial, reproductive and mental health information using structured questionnaires. We used logistic regression models to examine the association between lifetime induced abortion and suicidal ideation during the past year among the subjects.

:RESULTS: Overall, 8.2% of the subjects had suicidal ideation during the past year, and 15.5% of the subjects experienced induced abortion. Induced abortion was associated with nearly twice the odds of having past-year suicidal ideation (Odds ratio, OR = 1.89; 95% confidence interval, CI: 1.46, 2.44) after adjusting for age, education, years in the working place, tobacco use, alcohol consumption, daily internet use, attitude towards premarital pregnancy, multiple induced abortion, self-esteem, loneliness, depression, and anxiety disorders. The association was stronger in those aged > 25 (OR = 3.37, 95% CI = 2.16, 5.28), with > 5 years of stay in the working place (OR = 2.98, 95% CI = 2.02, 4.39), the non-anxiety group (OR = 2.28, 95% CI = 1.74, 3.00), and the non-depression group (OR = 2.94, 95% CI = 2.08, 4.15).

:CONCLUSIONS: Induced abortion was associated with increased odds for suicidal ideation among the unmarried female migrant workers in urban cities in China. More attention should be paid to the mental health of the population.

''' [http://smo.sagepub.com/content/4/2050312116665997.full Abortion, substance abuse and mental health in early adulthood: Thirteen-year longitudinal evidence from the United States.] Sullins DP. SAGE Open Medicine 2016 vol: 4 (0) pp: 2050312116665997'''

:'''Objective:''' To examine the links between pregnancy outcomes (birth, abortion, or involuntary pregnancy loss) and mental health outcomes for US women during the transition into adulthood to determine the extent of increased risk, if any, associated with exposure to induced abortion.

:'''Method:''' Panel data on pregnancy history and mental health history for a nationally representative cohort of 8005 women at (average) ages 15, 22, and 28 years from the National Longitudinal Study of Adolescent to Adult Health were examined for risk of depression, anxiety, suicidal ideation, alcohol abuse, drug abuse, cannabis abuse, and nicotine dependence by pregnancy outcome (birth, abortion, and involuntary pregnancy loss). Risk ratios were estimated for time-dynamic outcomes from population-averaged longitudinal logistic and Poisson regression models.

:'''Results''': After extensive adjustment for confounding, other pregnancy outcomes, and sociodemographic differences, abortion was consistently associated with increased risk of mental health disorder. Overall risk was elevated 45% (risk ratio, 1.45; 95% confidence interval, 1.30–1.62; p < 0.0001). Risk of mental health disorder with pregnancy loss was mixed, but also elevated 24% (risk ratio, 1.24; 95% confidence interval, 1.13–1.37; p < 0.0001) overall. Birth was weakly associated with reduced mental disorders. One-eleventh (8.7%; 95% confidence interval, 6.0–11.3) of the prevalence of mental disorders examined over the period were attributable to abortion.

:'''Conclusion''': Evidence from the United States confirms previous findings from Norway and New Zealand that, unlike other pregnancy outcomes, abortion is consistently associated with a moderate increase in risk of mental health disorders during late adolescence and early adulthood.

:Note: Adjusted odds ratio for suicidal ideation was 1.69 (95% CI 1.28-2.22)

'''[http://papers.ssrn.com/sol3/papers.cfm?abstract_id=821304 "Mandatory Waiting Periods for Abortions and Female Mental Health."] J Klick. Health Matrix: Journal of Law-Medicine, Vol. 16, p. 183, 2006.'''
:Panel data analyses suggests mandatory waiting periods prior to an abortion reduce suicide rates between 10 and 30 percent. These findings are statistically significant and appear to be robust in that the trend in findings remains the same after various attempts to control for other factors.

'''[http://www.ncbi.nlm.nih.gov/pubmed/25420710 Decreased suicide rate after induced abortion, after the Current Care Guidelines in Finland 1987 - 2012.] Gissler M, Karalis E, Ulander VM. Scand J Public Health. 2014 Nov 24. pii: 1403494814560844.'''

:Abstract

:Aim: Women with a recent induced abortion have a 3-fold risk for suicide, compared to non-pregnant women. The increased risk was recognised in unofficial guidelines (1996) and Current Care Guidelines (2001) on abortion treatment, highlighting the importance of a check-up 2 - 3 weeks after the termination, to monitor for mental health disorders. We studied the suicide trends after induced abortion in 1987 - 2012 in Finland.

:Methods: We linked the Register on Induced Abortions (N = 284,751) and Cause-of-Death Register (N = 3798 suicides) to identify women who had committed suicide within 1 year after an induced abortion (N = 79). The abortion rates per 100,000 person-years were calculated for 1987 - 1996 (period with no guidelines), 1997 - 2001 (with unofficial guidelines) and 2002 - 2012 (with Current Care Guidelines).

:Results: The suicide rate after induced abortion declined by 24%, from 32.4/100,000 in 1987 - 1996 to 24.3/100,000 in 1997 - 2001 and then 24.8/100,000 in 2002 - 2012. The age-adjusted suicide rate among women aged 15 - 49 decreased by 13%; from 11.4/100,000 to 10.4/100,000 and 9.9/100,000, respectively. After induced abortions, the suicide rate increased by 30% among teenagers (to 25/100,000), stagnated for women aged 20 - 24 (at 32/100,000), but decreased by 43% (to 21/100,000) for women aged 25 - 49.

:Conclusions: The excess risk for suicide after induced abortion decreased, but the change was not statistically significant. Women with a recent induced abortion still have a 2-fold suicide risk. A mandatory check-up may decrease this risk. The causes for the increased suicide risk, including mental health prior to pregnancy and the social circumstances, should be investigated further.

'''[http://www.ncbi.nlm.nih.gov/pubmed/24562317 Parental bonding and suicidality in pregnant teenagers: a population-based study in southern Brazil.] Coelho FM1, Pinheiro RT, Silva RA, de Ávila Quevedo L, de Mattos Souza LD, de Matos MB, Castelli RD, Pinheiro KA. Soc Psychiatry Psychiatr Epidemiol. 2014 Feb 22. [Epub ahead of print]'''
:A cross-sectional study of 828 pregnant teenagers revealed that prior abortion was a risk factor for a history of suicide attempts among 18 and 19 year olds, with attempted suicide rates 2.76 times higher.

'''Associations Between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample. Mota NP, Burnett M, Sareen J. The Canadian Journal of Psychiatry, Vol 55, No 4, April 2010 '''
:Methods: Data came from the National Comorbidity Survey Replication (n = 3310 women, aged 18 years and older). The World Health Organization–Composite International Diagnostic Interview was used to assess mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and lifetime abortion in women. Multiple logistic regression analyses were employed to examine associations between abortion and lifetime mood, anxiety, substance use, eating, and disruptive behaviour disorders, as well as suicidal ideation and suicide attempts. We calculated the percentage of respondents whose mental disorder came after the first abortion. The role of violence was also explored. Population attributable fractions were calculated for significant associations between abortion and mental disorders.
:Results: After adjusting for sociodemographics, abortion was associated with an increased likelihood of several mental disorders—mood disorders (adjusted odds ratio [AOR] ranging from 1.75 to 1.91), anxiety disorders (AOR ranging from 1.87 to 1.91), substance use disorders (AOR ranging from 3.14 to 4.99), as well as suicidal ideation and suicide attempts (AOR ranging from 1.97 to 2.18). Adjusting for violence weakened some of these associations. For all disorders examined, less than one-half of women reported that their mental disorder had begun after the first abortion. Population attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse).
:Conclusions: Our study confirms a strong association between abortion and mental disorders. Possible mechanisms of this relation are discussed.

'''Abortion and mental health disorders: evidence from a 30-year longitudinal study. Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2008 Dec;193(6):444-51.'''

'''[http://www.uca.edu.ar/uca/common/grupo54/files/new_zealand_abortion_study.pdf Abortion in young women and subsequent mental health.] Fergusson DM, Horwood LJ, Ridder EM. Journal of Child Psychology and Psychiatry 47:1 (2006), pp 16–24'''

:In this 25 year longitudinal study, women who had abortions had significantly higher rates of suicidal ideation than others in the cohort. 50% of those under 18 had suicidal thoughts and about one-fourth of those between the ages of 19 and 25 had suicidal thoughts.

'''[http://www.afterabortion.org/research/DeathsAssociatedWithAbortion.pdf "Deaths Associated with Pregnancy Outcome. A Record Linkage Study of Low Income Women"], DC Reardon et al, Southern Medical Journal 95(8):834, August 2002'''
:A study of 173,279 low income California women who delivered and those who aborted in 1989 were linked to death certificates over an 8 year period following the pregnancy event. Compared to women who delivered, those who had an abortion had a significantly higher age-adjusted risk of death from suicide (2.54) and an increased risk of death from all causes (1.62).

'''[http://www.health.qld.gov.au/caru/networks/qmpqc_publications.asp Queensland Maternal and Perinatal Quality Council Report 2013]''' [http://www.health.qld.gov.au/caru/networks/docs/qmoqc-report-2013-part-2_2.pdf Section 1 Maternal and perinatal mortality]"
:1.2.8 Suicide
::"Suicide is the leading cause of death in women within 42 days after their pregnancy and between 43 days and 365 days after their pregnancy. There appears to be a significant worldwide risk of maternal suicide following termination of pregnancy and, in fact, a higher risk than that following term delivery. The potential for depression and other mental health issues at this time needs to be better
appreciated. Active follow-up of these women needs to happen. Practitioners referring women for termination of pregnancy or undertaking termination of pregnancy should ensure adequate follow up for such women, especially if the procedure is undertaken for mental health concerns."

'''"[http://www.bmj.com/content/313/7070/1431 Suicides after pregnancy in Finland, 1987-94: register linkage study], M. Gissler et. al.. Br. Medical Journal 313: 1431. Dec 7.1996 '''
:A Finnish study of women who committed suicide in 1987-94 within one year of a pregnancy found out that the suicide incidence associated with induced abortion was 34.7 per 100,000 postabortion women compared to 13.1 per 100,000 postmiscarriage women and 5.9 per 100/000 postpartum women and a mean annual suicide rate of 11.3 per 100/000 women generally.

'''Mental health may deteriorate as a direct effect of induced abortion, C Morgan et al, British Medical Journal 314:902, 1997'''

:British researchers studied the frequency of admissions for attempted suicide by pregnancy event in women aged 15-49 in South Glamorgan Health Authority from 1991-1995. The overall frequency of admissions before induced abortion was 5.0 per 1000 and after induced abortion was 8.1 per 1000; The overall frequency of admissions before delivery was 2.9 per 1000 and after delivery was 1.9 per 1000. The authors concluded that, "the increased risk of suicide after an induced abortion may be a consequence of the procedure itself (and) data suggest that a deterioration in mental health may be a consequential side effect of induced abortion."

'''"Suicide and/or abortion. 20th Meeting of the Group for Suicide Research and Prevention: The body and suicide," J. Koperschmitt et al, Psychologie Medicale 21(4): 446, March, 1989 '''
:Abortion can have an important effect on suicidality.

'''[http://www.ncbi.nlm.nih.gov/pubmed/?term=The+Relationship+Between+Suicidal+Thinking+and+Dating+Violence+in+a+Sample+of+Adolescent+Abortion+Patients The relationship between suicidal thinking and dating violence in a sample of adolescent abortion patients.] Ely GE, Nugent WR, Cerel J, Vimbba M. Crisis. 2011;32(5):246-53. doi: 10.1027/0227-5910/a000082.'''

AIMS: This paper highlights a study where the relationship between dating violence and severity of suicidal thinking was examined in a sample of 120 young women ages 14-21 seeking to terminate an unintended pregnancy.
METHODS: The Multidimensional Adolescent Assessment Scale and the Conflict in Adolescent Relationships Scale was used to gather information about psychosocial problems and dating violence so that the relationship between the two problems could be examined, while controlling for the other psychosocial problems.
RESULTS: The results suggest that dating violence was related to severity of suicidal thinking, and that the magnitude of this relationship was moderated by the severity of problems with aggression.
CONCLUSIONS: Specifically, as the severity of participant's general problems with aggression increased, the magnitude of the relationship between dating violence and severity of suicidal thinking increased. Limitations of the study and implications for practice are discussed. Authors recommend pre-abortion screening and assessment.

'''"Psychopathological effects of voluntary termination of pregnancy on the father called up for military service," DuBouis-Bonneford et al, Psychologie Medicale 14(8): 1187-1189, June 1982 '''
:Several case studies are presented of 18-22 year old males who came from disadvantaged backgrounds and were recent military recruits. All had extreme depression and/or attempted suicide brought on by the news of their wives or girlfriends having had a voluntary induced abortion. The men believed that becoming a father would make them more mature or respectable and the abortion brought on feelings of self-recrimination and self-punishment.

'''"Psychiatric Sequelae of Abortion: The Many Faces of Post-Abortion Grief," E. Joanne Angelo, Linacre Quarterly 59:69-80, May 1992. '''
:Three cases of completed suicide following abortion are presented. In one case, a 22 year old woman in the military was referred for psychiatric counseling because of an eating disorder. She had made a suicide attempt two days before her scheduled abortion, feeling unable to go through with the abortion or face the rest of her tour of duty as a single parent. Her psychiatrist had advised going through with the abortion. Following the abortion, her use of cocaine and alcohol escalated and her weight continually dropped. She felt a strong desire to be united with her baby. She made several more suicide attempts and despite continuing therapy it did happen.

:In another case a 23 year old woman was referred for psychiatric counseling after a suicide attempt involving a planned drunk driving incident. She and had two abortions at ages 17 and 18 while in high school. She was the youngest child of a large family and was afraid to tell her parents for fear they would "drop dead of heart attacks." (The parents were in precarious heath.) She suffered alone with the guilt for 6 years. She had planned to tell an uncle, who was a priest, what had happened, but before she could talk with him he suddenly died of a heart attack. Mourning his death as well as her earlier loses, she had planned her own death both to end her pain and to achieve a reunion with her children and her uncle.

:In a third case, an 18 year old male gas station attendant shot himself and died 3 months after his father's unexpected death. Only his closest friend knew that at the time of his suicide he was despondent over his girl friend's abortion. The child had been conceived on the day of his father's death. He had formed a mental image of the child and told his friend he planned to name his son after his father. The loss of the child and what he represented was more than he was able to bear.

'''"Second-Trimester Abortions in the United States," D. Grimes, Family Planning Perspectives 16(6):260, Nov/Dec 1984. '''
:Among the 92 reported deaths of women from second-trimester legal abortion, from 1972-1981, 2 were as a result of suicide.

'''"Physical and Psychological Injury in Women Following Abortion: Akron Pregnancy Services Survey," L.H. Gsellman, Association For Interdisciplinary Research Newsletter 5(4):1-8, Sept/Oct 1993.'''
:(In a survey of 344 post-aborted women receiving services at Akron Pregnancy Services during 1988-1993, 16% reported suicidal impulses, 7% were preoccupied with death and 7% made suicide attempts.

'''"[http://news.google.com/newspapers?id=9P4xAAAAIBAJ&sjid=zYYDAAAAIBAJ&pg=3675,4841318&dq=abortion+and+suicide+attempt&hl=en Adolescent Suicide Attempts Following Elective Abortion]," Carl Tischler, Pediatrics, 68(5):670 (1981). '''
:Case studies of attempted suicide on the anniversary of what would have been the aborted baby's birth.

'''The Psycho-Social Aspects of stress Following Abortion, Anne C. Speckhard, (Kansas City: Sheed and Ward, 1987) '''
:Thirty women stressed by abortion were interviewed 5-10 years since abortion; 65% had suicide ideation; 31% attempted suicide.

'''"Therapeutic Abortion and Psychiatric Disturbance Among Women," E.R. Greenglass, Canadian Psychiatric Association Journal 21:453-459(1976). '''
:Of 188 women interviewed, five attempted suicide about 2.6 months after abortion; there was evidence of other traumatic difficulties in addition to abortion.

'''"Post-Abortive Psychoses," Myre Sim and Robert Neisser, in The Psychological Aspects of Abortion, ed. D. Mall and WF Watts, (Washington D.C.: University Publications of America, 1979). '''
:Fifty-eight women at an Israeli Government hospital volunteered the information that abortion, induced or spontaneous, had led to their referral to the psychiatric unit; seven had made serious attempts at suicide, three others had threatened suicide.

'''Stress. Depression and Suicide: A Study of Adolescents in Minnesota., B Garfinkel, H. Hoberman, J. Parsons and J. Walker (Minneapolis: University of Minnesota Extension Service, 1986). '''
:A teenage girl was about 6 times more likely to have attempted suicide if she had an abortion in the last six months compared to teenagers who had not had an abortion in that period (4% vs. 0.7%). Teenage girls attempting suicide in general were more likely to be depressed, to have recently broken up with their boyfriend, and come from chaotic homes. In an interview announcing the study results Dr. Garfinkel stated that impulsiveness, anger and anxiety are the three most important factors in teenage suicide. Too often abortion is taken as either producing an alleviation of stress or being helpful to young people. I think we need to re-examine the issues. Minnesota Daily, Oct 29,1986, p. 3/16

'''"Mental Disorders After Abortion," B. Jansson, Acta Psychiatrica Scandinavica41:87 (1965) '''
:In a Swedish study of 57 women with prior psychiatric problems who subsequently had induced abortions, three committed suicide as determined by long-term follow-up studies 8-13 years after their abortion. In contrast, of 195 women with previous psychiatric problems who carried their children to term, none committed suicide.

'''[http://afterabortion.org/1999/a-detailed-survey-of-post-abortion-psychological-reactions/ A Detailed Survey of Post-Abortion Psychological Reactions], Reardon DC. Also reprinted in Forbidden Grief, Burke T & Reardon DC.'''

:A survey of 260 women making contact with one of several post-abortion support groups found that 34% reported suicidal feelings after their abortions, and 28% attempted suicide, with 54% of those attempting suicide more than once.

'''Is voluntary abortion a seasonal disorder of mood? Cagnacci A, Volpe A. Human Reproduction 2001, 16(8):1748-52.'''
:An analysis of yearly suicide rates and abortion rates found that the suicide rate of women in Italy peaks in June, one month after the peak in abortion rates, which is in May.
:RESULTS The rate of voluntary abortions showed a seasonal rhythm with an amplitude of 6.1--6.7% and peaked in May (+/-38 days). The national frequency of female suicides, obtained from the same ISTAT database, showed a similar rhythm, with an amplitude of 11.1% and maximal rate in June (+/-37 days).

===Abortion Related Suicide: Case Studies===

:For information regarding a well publicized case of suicide following abortion, see [[Emma Beck - Suicide | Emma Beck]] and also [[Suicide - Case Studies]])

* '''[https://www.researchgate.net/profile/Preeti-Gautam-4/publication/379544537_Deaths_among_Women_of_Reproductive_Age_an_Explorative_Case_Study_among_Abortion_Seekers/links/660e986c10ca8679873cd2f0/Deaths-among-Women-of-Reproductive-Age-an-Explorative-Case-Study-among-Abortion-Seekers.pdf Deaths among Women of Reproductive Age: an Explorative Case Study among Abortion Seekers]. Gautam P, Puri MC, Karki S, Foster DG. J Nepal Health Res Counc. 2024 Mar 31;21(4):692-696. doi: 10.33314/jnhrc.v21i4.4871.'''
** In a case series study of 1841 women who sought abortions in Nepal, 83% received abortions and 17% did not. Women were followed for two to three years. Among the 1528 women who had abortions, three committed suicide, for a suicide rate of 196 per 100,000 women, which is nearly 10 times higher than the [https://mhrnepal.org/app/webroot/upload/files/suicide%20in%20nepal%20scoping%20review.pdf 20.0 per 100,000 women reported for general population] of women in Nepal.
** Though all three suicide were among women who had abortions, the authors don't point this out. Instead, they clearly attempt to dismiss such speculation by offering three alternative explanations:<blockquote>
# For instance, one family member of a participant shared that that the participant had epilepsy, but she did not reveal it to her family members after her marriage. She stopped taking medicines used for treatment of epilepsy after marriage and eventually died by suicide.
# One of the women who died by suicide reported that she was facing physical violence (such as getting slapped, punched, being pushed) from her husband during her last follow up interview.
# 22 years old Rita (name changed) was married for four years. She had a son. She had completed 9th grade of education. She received an abortion from an NGO clinic, a 3-hour ride by bus. She took part in the 6 week and 6-month follow up interviews before her death. During her 6-month follow-up interview Rita shared that she frequently felt nervous, anxious, depressed, or unable to stop or control worrying. She also had less interest or pleasure in doing things. We were told that Rita was mistreated by her in-laws during her follow-up interviews. She died by suicide at her home. </blockquote>Clearly, these vignettes offer another possible explanation, but none of them exclude the possibility that the abortion contributed to these suicides, anywhere from a small to large part.

===Other Suicide Papers of Interest===

[https://www.ncbi.nlm.nih.gov/pubmed/21498972 Suicidal mothers.] J Inj Violence Res. 2011 Jul;3(2):90-7. doi: 10.5249/jivr.v3i2.98. Gentile S.

:BACKGROUND: Epidemiological research has demonstrated that suicidal ideation is a relatively frequent complication of pregnancy in both developed and developing countries. Hence, the aims of this study are: to assess whether or not pregnancy may be considered a period highly susceptible to suicidal acts; to recognize potential contributing factors to suicidal behaviors; to describe the repercussions of suicide attempts on maternal, fetal, and neonatal outcome; to identify a typical profile of women at high risk of suicide during pregnancy.
:METHODS: Medical literature information published in any language since 1950 was identified using MEDLINE/PubMed, Scopus, and Google Scholar databases. Search terms were: "pregnancy", (antenatal) "depression", "suicide". Searches were last updated on 28 September 2010. Forty-six articles assessing the suicidal risk during pregnancy and obstetrical outcome of pregnancies complicated by suicide attempts were analyzed, without methodological limitations.
:RESULTS: Worldwide, frequency of suicidal attempts and the rate of death by suicidal acts are low. Although this clinical event is rare, the consequences of a suicidal attempt are medically and psychologically devastating for the mother-infant pair. We also found that common behaviors exist in women at high risk for suicide during pregnancy. Review data indeed suggest that a characteristic profile can prenatally identify those at highest risk for gestational suicide attempts.
:CONCLUSIONS: Social and health organizations should make all possible efforts to identify women at high suicidal risk, in order to establish specific programs to prevent this tragic event. The available data informs health policy makers with a typical profile to screen women at high risk of suicide during pregnancy. Those women who have a current or past history of psychiatric disorders, are young, unmarried, unemployed, have incurred an unplanned pregnancy (eventually terminated with an induced abortion), are addicted to illicit drugs and/or alcohol, lack effective psychosocial support, have suffered from episodes of sexual or physical violence are particularly vulnerable.

''"Suicide After Ectopic Pregnancy," (letter) J. Farhi et al. New England Journal of Medicine, March 10,1994, p. 714 ''
:A study of Israeli women found that among 160 women treated for ectopic pregnancy 3.75% attempted suicide within one year thereafter and 0.625% committed suicide compared to a matched non-pregnant population rate of 0.04-0.06% and 0.002% respectively.
'''[http://www.ncbi.nlm.nih.gov/pubmed/21969462 Absolute Risk of Suicide After First Hospital Contact in Mental Disorder.] Nordentoft M, Mortensen PB; Pedersen CB. Arch Gen Psychiatry. 2011;68(10):1058-1064.'''

:Participants A total of 176 347 persons born from January 1, 1955, through December 31, 1991, were followed up from their first contact with secondary mental health services after 15 years of age until death, emigration, disappearance, or the end of 2006. For each participant, 5 matched control individuals were included.

:Main Outcome Measures Absolute risk of suicide in percentage of individuals up to 36 years after the first contact.

:Results Among men, the absolute risk of suicide (95% confidence interval [CI]) was highest for bipolar disorder, (7.77%; 6.01%-10.05%), followed by unipolar affective disorder (6.67%; 5.72%-7.78%) and schizophrenia (6.55%; 5.85%-7.34%). Among women, the highest risk was found among women with schizophrenia (4.91%; 95% CI, 4.03%-5.98%), followed by bipolar disorder (4.78%; 3.48%-6.56%). In the nonpsychiatric population, the risk was 0.72% (95% CI, 0.61%-0.86%) for men and 0.26% (0.20%-0.35%) for women. Comorbid substance abuse and comorbid unipolar affective disorder significantly increased the risk. The co-occurrence of deliberate self-harm increased the risk approximately 2-fold. Men with bipolar disorder and deliberate self-harm had the highest risk (17.08%; 95% CI, 11.19%-26.07%).

:Conclusions This is the first analysis of the absolute risk of suicide in a total national cohort of individuals followed up from the first psychiatric contact, and it represents, to our knowledge, the hitherto largest sample with the longest and most complete follow-up. Our estimates are lower than those most often cited, but they are still substantial and indicate the continuous need for prevention of suicide among people with mental disorders.

See also: [http://www.ncbi.nlm.nih.gov/pubmed/15809410 Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers.]

'''[http://www.ncbi.nlm.nih.gov/pubmed/24559792 Suicide attempts and mortality in eating disorders: a follow-up study of eating disorder patients.] Suokas JT1, Suvisaari JM2, Grainger M3, Raevuori A4, Gissler M5, Haukka J6. Gen Hosp Psychiatry. 2014 Jan 13. pii: S0163-8343(14)00005-X. doi: 10.1016/j.genhosppsych.2014.01.002. [Epub ahead of print]'''

:We identified 156 patients with eating disorder (6.3%) and 139 controls (1.4%) who had required hospital treatment for attempted suicide. Of them, 66 (42.3%) and 37 (26.6%) had more than one attempt. The rate ratio (RR) for suicide attempt in patients with eating disorder was 4.70 [95% confidence interval (CI) 1.41-15.74]. In anorexia nervosa, RR was 8.01 (95% CI 5.40-11.87), and in bulimia nervosa, it was 5.08 (95% CI 3.46-7.42). In eating disorder patients with a history of suicide attempt, the risk of death from any cause was 12.8%, suicide being the main cause in 45% of the deaths.
Suicide attempts and repeated attempts are common among patients with eating disorders. Suicidal ideation should be routinely assessed from patients with eating disorders.

==Accidents==

''"Pregnancy-associated deaths in Finland 1987-1994-definition problems and benefits of record linkage," M Gissler et al, Acta Obstet Gynecol Scand 76:651-657, 1997 ''
:A Finnish register linkage study identified all deaths that occurred up to 1 year after an ended pregnancy. The mortality rate was 27 per 100,000 births, and 101 per 100.000 abortions. Compared to women of reproductive age with no pregnancy (1.0), the risk of death from an accident following abortion was 2.08 (1.03-4.20, 95% CI) compared to 0.49 (0.18-1.33, 95% CI) for childbearing women.

''"Suicide Deaths Associated with Pregnancy Outcome: A Record Linkage Study of 173,279 Low Income American Women," D Reardon et al, Clinical Medicine & Health Research clin med/2001 030003 v1 (April 25, 2001) ''
:State funded medical insurance records identifying all paid claims for abortion or delivery in 1989 were linked to the state death certificate registry in a population of low income women in California. Compared to women who delivered (1.0), those who aborted had a significantly higher adjusted risk of dying from accidents (1.82).

''"Sexual Experience and Drinking Among Women in a U.S. National Survey," A Klassen, S Wilsnack, Archives of Sexual Behavior 15(5): 363-392, 1986; "Women's Drinking and Drinking Problems: Patterns from a 1981 U.S. National Survey," R Wilsnack, S Wilsnack, A Klassen, Am J Public Health 74:1231-1238, 1984. ''
:In a random national survey of 917 U.S. women in 1981, 4% of the abstainers and 5% of lighter drinkers reported non-spontaneous abortion compared to 13% for moderate drinkers, 13% for heavier drinkers, and 6% for women who had ever been pregnant. The same survey found that 17% of all women drinkers said they had driven vehicles while drunk or high at least once in the preceding year including 27% of moderate drinkers and 45% of heavier drinkers.

''"Alcohol-Related Relative Risk of Fatal Driver Injuries in Relation to Driver Age and Sex," Paul L Zodor, J Stud Alcohol 52:302-310, 1991. ''
:A study by the Insurance Institute for Highway Safety based on 1986-87 data found that each 0.02% increase in blood alcohol content nearly doubles the risk of being in a single vehicle fatal crash. The risk of a female 21-24 years of age at a blood alcohol level of 0.05%- 0.09% of dying in a single vehicle accident was reported to be 35 times higher compared to a blood level of 0.00%- 0.01%

''"Adolescent Suicide Attempts Following Elective Abortion: A Special Case of Anniversary Reaction," CL Tishler, Pediatrics 68 (5):670-671, 1981''
:A 17 year old upper middle class white girl attempted to kill herself while driving under the influence of alcohol and 29 Bufferin tablets. She smashed her car into a bridge overpass repeatedly, damaging her car beyond repair. She had had an elective abortion approximately seven months prior to the suicide attempt. During the abortion process she calculated the birth date had the fetus been allowed to come to term. The date of the accident was on the perceived birth date of the child.

==Repeat Abortions==

''"Abortion Surveillance-United States, 1997," MMWR Vol 49, No.SS-11, December 8, 2000. ''
:The Centers for Disease Control reported that 48% of U.S. women had repeat abortions in 1997 with 28.4% reporting a second abortion, 12% reporting a third abortion, and 7.6 % reporting a fourth or more abortion.

''"Abortion Surveillance-United States. 1992," L.M. Koonin et. al., MMWR 45, No. 55- 3: 1, May 3,1996 ''
:For 1992,1,359/145 legal abortions were reported to CDC, representing a 2.1% decline overall, from the number reported for 1991. 45.8% of women were repeating abortion with 26.9% reporting a second abortion, 10.8% (third), and 6.4% having 4 or more abortions. The abortion ratio was more than nine times greater for unmarried women than for married women. The abortion rate for white women was 15 per 1000 white women compared to 41 per 1000 black women and 32 per 1000 Hispanic women.

''"The epidemiology of preterm birth," Judith Lumley, Bailliere's Clinical Obstetrics and Gynaecology 7(3): 477, Sept, 1993 ''
:A study of more than 300,000 first singleton births in Victoria, Australia from 1986-1990 found that 6.5 per 1000 births were 20-27 gestational weeks where the woman had one prior induced abortion compared to 10.3 per 1000 births (two prior induced abortions) and 23.1 per 1000 births (three or more prior induced abortions). The rate of preterm births at 32-36 gestational weeks was 54.1 per 1000 births where women had one prior induced abortion, 78.7 per 1000 births where women had two prior induced abortions and 120.1 per 1000 births where women had three or more prior induced abortions. For purposes of analysis women who had experienced both induced and spontaneous abortions were excluded.

''"Pregnancy Decision Making as a Significant Life Event: A Commitment Approach," J. Lydon, et. al. J. Personality and Social Psychology 71(1): 141-151, 1996 ''
:Women with prior abortions were found to be more committed to a current pregnancy compared to women with no prior abortion history. Initial commitment predicted subsequent depression, guilt, and hostility among those who aborted.

''"Post-Abortion Syndrome as a Variant of Post Traumatic Stress Syndrome," Robert C. Erikson, Association for Interdisciplinary Research Newsletter, 3(4) :5-8, Winter, 1991. ''
:Repeat abortion will, to a degree, reflect a re-creation of the social, emotional and relational circumstances present before the initial abortion. Repeat abortions frequently are re-enactments of conflict between drives, and have little to do with ego functions such as learning.

===The compulsion to repeat the trauma. Re-enactment, revictimization, and masochism," PA van der Kolk, Psychiatric Clinics of North America 12(2): 389-411, June, 1989 ''
:Trauma can be repeated in behavioral, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering. Previously traumatized people tend to return to familiar patterns, even if they cause pain.

''"Special Issue on Repeat Abortion,"Association for Interdisciplinary Research Newsletter 2(3): 1-8, Summer 1989. ''
:Review of the literature on the incidence and effects of repeat abortions. It including moral and social deterioration, communication breakdown, decline in religious affiliation, emotional or psychological conflicts, replacement pregnancy, self-punishment, abortion as birth control and the evangelization of abortion.

''"Repeat Abortion: Blaming the Victims," B. Howe, R. Kaplan, and C. English, American Journal Public Health, 69(12):1242-1246, December 1979,''
:Repeaters were found to be more sexually active than first-timers, thus increasing their risk of unwanted pregnancy even though they used contraception more than initial aborters.

''"[http://www.lifeissues.net/writers/air/air_vol5no1_1993.html Women's Health and Abortion. I. Deterioration of Health Among Women Repeating Abortion]," Association for Interdisciplinary Research Newsletter 5(1):1-8, Winter, 1993. ''
:This article identifies 32 areas of social, medical and psychological health that deteriorate as induced abortion is repeated.

''"Repeat Abortion: Is It A Problem?," C. Berger, D. Gold, D. Andres, P. Gillett and R. Kinch, Family Planning Perspectives, 16(2):70-75, March/April 1984,''
:Medical and counseling personnel are troubled by women who come back to their facilities for a repeat abortion. Counseling deficiencies, possible negative media coverage, unclear long-term effects on future child bearing are some of the reasons for concern. This study of Canadian women found that repeaters were more tolerant of abortion than women having a first abortion; they also had intercourse more frequently than first-time abortion patients [average 11 times per month versus 8 times per month]. Women having repeat abortions were slightly more likely to have been using contraceptives at the time they became pregnant. Repeaters described their relationships as being less satisfactory than first-time patients. More repeaters than first-time patients said they had made the decision by themselves [45 percent vs. 33 percent]. Repeaters reported fewer physical complaints but had more difficulty sleeping.

''"Third Time Unlucky: A Study of Women Who Have Had Three or More Legal Abortions," Colin Brewer, Journal Biosocial Science, 9:99-105(1977). ''
:Of 50 women having their third or subsequent legal abortion, 23 were pregnant because they claimed their contraceptive method had failed; 24 because of erratic contraceptive use; and three changed their minds after initially welcoming the pregnancy. The study concluded there was a significant relationship between erratic use and a history of consultation for psychiatric reasons, and suggested that unsettled relationships and low educational status also related to erratic use. There was no evidence that abortion was deliberately used as a method of birth control.

''"Repeaters-Different or Unlucky?," C. Berger and D. Gold, et al., in P. Sechder, ed.. Abortion: Readings and Research. (Toronto: Butterworth Press, 1981). ''

''Proceeding of the Conference on Psycho-Social Factors in Transnational Family Planning Research, W. Pasini and J. Kellerhals (Washington: American Institute for Research, 1970), 44-54.''
:A threefold increase in previous psychiatric consultations was found in women seeking repeat abortions compared with maternity patients.

''Beyond Choice. The Abortion Story No One Is Telling, Don Baker, (Portland: Multonomah Press, 1985). ''
:A powerful narrative true story of a woman who had three abortions. Demonstrates the moral and social deterioration in her life until she commits her life to Jesus Christ. Excerpts reprinted in the April/May 1987 issue of The Christian Reader.

''"The Repeat Abortion Patient," Judith Leach, Family Planning Perspectives, 9(1):37-39, January/February 1977''
:Repeat abortion patients are more often dissatisfied with themselves, more often perceive themselves as victims of bad luck, and more frequently express negative feelings toward the current abortion than women who are obtaining abortions for the first time.

''"Pilot Surveys of Repeated Abortion," E. Szabady and A. Klinger, International Mental Health Res. Newsletter 14:6(1972). ''
:In a study of Hungarian women those women having a repeat abortion were less likely to be in a happy marriage and were more likely to have an abortion independently of their partner.

''"Emotional Distress Patterns Among Women Having First or Repeat Abortions," Ellen Freeman, Obstetrics and Gynecology 55(5):630-636, May 1980 ''
:Repeat abortion patients showed significantly higher distress scores on interpersonal sensitivity, paranoid ideation, phobic anxiety and sleep disturbance, compared with controls. Repeaters also showed a trend in higher scores in somatization, hostility and psychoticism.

''"Repeat Abortions-Why More?," Christopher Tietze, Family Planning Perspectives, 10(5):286-288, September/October 1978, ''
:Repeaters tended to have more frequent intercourseless satisfying relationships, and more difficulty sleeping. They were less likely to live with their partners. (Women with prior abortion were almost 4 times more likely to have repeat abortion compared to women having an abortion for the first time.

''"Women Who Obtain Repeat Abortion: A Study Based Upon Record Linkage," P. Steinhoff, R. Smith, J. Palmore, M. Diamond and C. Chung, Family Planning Perspectives11(1):30-38 Jan/Feb 1979. ''
:Study noted the proportion of induced abortions that are repeat procedures increases over time. Shortcomings in making contraceptives available were cited as the reason. The women's own reporting of repeat abortions was about 20% lower than the actual number determined by record linkage.

''"Abortion Recidivism - A Problem in Preventative Medicine," Joseph Rovinsky, Obstetrics and Gynecology, 39(5) :649-659, May 1972. ''
:There was a lack of contraceptive motivation in repeaters as an etiologic basis for recurrent unwanted pregnancy; the article cites a case of 17 prior abortions.

''"First and Repeat Abortions: A Study of Decision-Making and Delay," M.Bracken and S. Kasi, Journal Biosocial Science, 7:473-491 (1975). ''
:Women having a repeat abortion took less time than those having a first abortion; women repeaters were more likely to report medical problems as a reason for contraceptive failure, compared with first-abortion women who were more likely to admit to carelessness. Women having repeat abortions were more likely to mention problems with the contraceptive, while those having first abortions were more likely to have failed to anticipate intercourse. Fewer women repeaters were pregnant by husbands, and unmarried women having repeat abortions had been in relationships of shorter duration than unmarried women having first abortions. Women having first abortions were generally more concerned with moral and ethical issues, worry over the procedure itself and the possibility of complications than were women having repeat abortions, who generally showed more desire to have children.

''"Characteristics and Contraceptive of Abortion Patients," S. Henshaw, J. Silverman, Family Planning Perspectives 20(4): 158, July/August, 1988. ''
:A national survey of 9/480 women at U.S. abortion facilities in 1987 by the Alan Guttmacher Institute found that 42.9% of those women surveyed had repeat abortions: 26.9% (second abortion); 10.7% (third abortion); 5.3% (fourth abortion or more).

''"Reflections on repeated abortions: The meanings and motivations," Susan Fisher,Journal of Social Work Practice 2(2):70-87, May 1986. ''
:The author, a social worker at a London hospital, interviewed more than 1,000 women with crisis pregnancies. Several in-depth case histories are reported. Repeaters were variously described as "chaotic, childlike" (a woman who had 15 abortions in 23 years); "doll-like" (history of numerous suicide attempts); holding "anxiety, rage and confusion" over mother's mental illness; "a delicate child-woman 16 years old with very little human warmth, depressed"; "cold and detached with little feeling"; "a suicidal woman with a history of three abortions, a first suicide attempt at age 15 and the most recent one at age 27, only six weeks ago/drug overdoses, anorexia nervosa and hospitalization for psychiatric treatment." Women had shallow relationships with putative fathers and seemed to select male partners known to be objectionable to the repeaters' parents. Unconscious conflicts and lack of nurturing in family of origin were typical. Relationships with male partners usually terminated following abortion. Repeaters were irregular in keeping appointments and in completing therapy. Some called their unborn child "monster." The author concluded that repeat abortions are both an individual and social problem with physical and emotional suffering as well as a strain on medical and counseling resources.

''"A Case Study of Reproductive Experience of Women Who Have Had Three or More Induced Abortions," Elizabeth Lincoln, Ph.D. Dissertation, University of Pittsburgh (1982); Dissertation Abstracts International 44(4), October 1983, Order No. DA 8318205. ''
:A study of eight women with three or more abortions found that women had a sex role orientation less modernistic than effective contraceptors, feared health effects, had problematic relationships with partners ,family of origin relationships were characterized by lack of affection and probable subsequent influence on adult relationships, interest in parenting and sexuality. Anger at perceived lack of male interest in contraception combined with poor communication and changing sex role expectations seemed to create conflicts increasing the likelihood of unwanted pregnancy.

''"Incidence of Repeat Abortion. Second-Trimester Abortion. Contraceptive Use and Illness within a Teenage Population," Rena Bobrowsky, Ph.D. Dissertation, University of Southern California (1986); Dissertation Abstracts International 47(9), March 1987. Copies available from Micrographics Dept, Doheny Library, USC, Los Angeles, CA 90069-0182. ''
:In a study of teenage abortion, 404 women were followed through medical records over a five-year period. Some 38% had a previous abortion and 18% had two abortions within the same year. Repeat aborters were found to have less stable relationships with their partners, more likely to show greater use of contraception post-abortion and have more medical problems that might preclude the safe use of more reliable contraceptives.

''"Association of Induced Abortion with Subsequent Pregnancy Loss," A. Levin, S. Schoenbaum, R. Monson, P. Stubbelfield, K. Ryan, JAMA 243:2495(1980). ''
:Women who had two or more induced abortions were 2.7 times more likely to have future first-trimester spontaneous abortions (miscarriage) and 3.2 times more likely to have a second-trimester incomplete abortion than were women with no history of induced abortion.

''"Repeat Abortions Increased Risk of Miscarriage. Premature Births and Low Birth Weight Babies," Family Planning Perspectives, 1(1):39-40, January/February 1979. ''
:Repeated abortion was associated with a 2- to 2.5-fold increase in the rate of low birth weight and short gestation when compared with either one abortion or one live birth.

''"Ectopic Pregnancy and Prior Induced Abortion," A. Levin, S. Schoenbaum, P. Stubblefield, S. Zimicki, R. Monson and K. Ryan, American Journal of Public Health 72(3):253- 256, March 1982. ''
:In a study at Boston Hospital for Women conducted from 1976-1978, the relative risk of ectopic pregnancy was found to be 1.6 for women with one prior abortion and reduced to 1.3 after control of confounding factors. The relative risk for two or more abortions was 4.0 for women with two or more prior induced abortions, which was reduced to 2.6 after control of confounding factors.

''"Patterns of Alcohol and Cigarette Use in Pregnancy," J. Kuzma and D. Kissinger, Neurobehavorial Toxicology and Teratology 3:211-221(1981) ''
:In a California study of more 12,000 women during 1975-1977, of those having a history of two or more abortions, virtually all (98.5%) consumed alcohol throughout the entire 9 months of a subsequent pregnancy and at higher levels, i.e., up to 3 oz. per day than any of the other categories studied.

''"Low Birth Weight in Relation to Multiple Induced Abortions," M.T. Mandelson, C.B. Maden, J.R. Daling, Am.J. Public Health, 82 (3):391-394, March, 1993. ''
:In a Washington State Study of 6541 women who delivered a child between 1984-87, 41.6% of the women smoked during this pregnancy if they had a history of 4 or more induced abortions compared with 31.0% smokers (2 prior abortions), 28.1% smokers (1 prior abortion), or 18.0% smokers (no prior abortions).

''"The Concept of the Repetition Compulsion," E. Bibring, Psychoanalytic Quarterly12: 486,507 (1943). ''
:"Perhaps the most frequent way of taking the compulsive repetition into the personality is through sexualization when the repetition compulsion becomes linked with masochistic drives."

''"Repeat Abortion: Is it a Problem?," C. Berger, D. Gold, D. Andres, P. Gillett and R. Kinch, Family Planning Perspectives 16(2):70-75, March/April 1985. ''
:Interviews with medical and counseling personnel at abortion facilities regarding women who return for repeat abortions reveal counseling deficiencies, possible negative media coverage and unclear long-term effects on childbearing as some of the reasons for concern.

''"Abortion Work: A Study of the Relationship Between Private Troubles and Public," Kathleen Marie Roe, Ph.D. Dissertation, University of California, Berkeley (1985). ''
:In a study of 90 abortion facility workers in the San Francisco area, over 95% expressed discomfort and surprise at repeaters.

''"Contraception and repeat abortion," M. Shepard and M. Bracken, Journal of Biosocial Science 11:289-302 (1979). ''
:In a study of women at Yale-New Haven Hospital during 1974-1975, women having repeat abortions were significantly more likely to be divorced than women having first abortions. Women having repeat abortions were more likely to be on public welfare than women having first abortions (38% vs. 25%).

''"Dysphoric reactions in women after abortion," K. Franco, M. Tamburrino, N. Campbell, J. Pentz and S. Jurs, J. of the American Medical Women's Association 44(4): 113, July/August 1989. ''
:Women reporting multiple abortions had more often considered suicide and scored higher on borderline personality pathology and depression. Some 40% of the 71, women studied reported anniversary reactions. None of the women aborting sought psychotherapy after the procedure.

''"The First Abortion And The Last? A Study of the Personality Factors Underlying Failure of Contraception," P. Niemela, P. Lehtinen, L. Rauramo, R. Hermansson, R. Karjalienen, H. Maki and C-A Stora, International Journal of Gynaecol. Obstet. 19:93- 200(1981). ''
:A Finnish study compared women seeking their second abortion to women who had successfully contracepted after their first abortion Repeaters rated lower in control of impulsivity, emotional balance/realism, self-esteem and stability of life as well as reflecting a lesser capacity for integrated personal relationships. Repeating women more often had a history of broken legalized or non-legalized partner relationships. Partners of repeaters took less responsibility for contraception even though the women had left them greater responsibility in this respect. Solidarity with partners was weaker in the repeaters even though the women felt greater admiration for their partners. Repeating women were less mature and more impulsive, indicating a "split" mechanism and immaturity of ego development which verged on a borderline level disturbance.

''"Single and repeated elective abortions in Japan: a psychosocial study," T Kitamura et al, J Psychosom Obstet Gynecol 19:126-134, 1998. ''
:A Japanese study found that women with two or more abortions had a longer dating period, were likely to have a non-arranged marriage, smoked more cigarettes, had an early maternal loss experience or a lower level of maternal care during childhood compared to women with women with a first abortion.

''"Mourning and Guilt Among Greek Women Having Repeated Abortions," D. Naziri, A. Tzararas, Omega 26(2): 137-144,1992-93 ''
:In a clinical study of the bereavement process of Greek women following one or more induced abortions, it was concluded that strong identifications with both father and mother images were present in the women. It was concluded that abortion might be a replacement/displacement of a reparatory character in relation to the "family romance" of each woman. In several cases of repeated abortion, mourning and guilt not only refer to a murdered and lost person of the fetus, but also principally to the death and loss of an object of ambiguous desire.

''"The Repeat Abortion Patient," Judith Leach, Family Planning Perspectives 9(1):37, January/February 1977. ''
:In a study of repeat abortion patients in the Atlanta area, 21% of the repeat aborters vs. 8% of the first-time aborters reported they had no religious affiliation. The disparity was especially striking in the private clinic population, among whom eight times as many repeat abortion patients as first-time aborters said they had no religious affiliation (20% vs. 2.5%).

''"Risk of Admission to Psychiatric Institutions Among Danish Women Who Experienced Induced Abortion: An Analysis Based Upon Record Linkage," Ronald Somers, Ph.D. Dissertation, University of California, Los Angeles (1979), Dissertation Abstracts International, Order No. 7926066. ''
:A study of the Danish Central Psychiatric Register of all women who had been admitted between April 1,1973 and December 31/1975 found that psychiatric admissions increased with the self-reported number of past abortions (no abortions, 1.90%; one abortion, 3.4%; two abortions, 4.0%; three abortions, 6.0%). No increase was observed as number of live births increased; women aged 35-39 with two or more abortions had higher rates of psychiatric admission than younger women with two or more abortions.

''"Increased Reporting of Menstrual Symptoms Among Women Who Used Induced Abortion," L.H. Roht, M.A. Fanner, H. Aoyama and E. Fonner, Am. Journal of Obstetrics and Gynecology 127:356-362, February 15,1977. ''
:A study of 3,222 female residents in Southern Japan in 1971, based upon a mailed questionnaire, found that women perceived menses to occur more frequently and be of shorter duration as the number of reported prior abortions increased. "Nervousness" increased as number of prior abortions increased: 150/1,000 women (no prior abortion); 228/1,000 (one prior abortion); 256/1/000 (two or more prior abortions).

''"Induced Terminations of Pregnancy: Reporting States," 1988, K. Kochanek, Monthly Vital Statistics Report 39(12): 1-32 (Suppl.), April 30,1991, Table 9, p. 20 ''
:In 1988 among the 14 reporting states, 297,251 induced abortions were performed. Some 25.5% had a second abortion, 9.0% had a third abortion and 8.7% had a fourth abortion or more. Overall, 44.1% were repeating abortion, 39.6% of white women were repeating abortion vs. 53.0% of black women.

''"The Social and Economic Correlates of Pregnancy Resolution Among Adolescents in New York by Race and Ethnicity: A Multivariate Analysis," Theodore Joyce, Am. J. Public Health78(6):626-63, (1988). ''
:Teenagers who experienced one prior abortion were approximately four times more likely to terminate a current pregnancy by abortion compared to teenagers with no prior abortion history. Medicaid tended to increase the likelihood of carrying pregnancies to term. Married adolescents were more likely to carry a pregnancy to term than unmarried adolescents.

==Eating Disorders==

''"Self-Induced Abortion in a Bulimic Woman," C.M. Bulik et. al., Int'l J. Eating Disorders 15(3): 297-299,1994. ''
:A case of a woman was presented who deliberately induced abortion via self-imposed starvation and vigorous exercise. She had a history of severe obsessive-compulsive and narcissistic personality disorders as well as a lifelong pattern of denial of affect and illness.

''"The Impulsivist: a multi-impulsive personality disorder," J.H. Lacey et. al., Br. J. Addiction 81: 641-649,1986. ''
:There are strong associations between eating disorders, substance abuse, impulse control, self-harm and personality disorders.

''Post-Abortion Trauma: 9 Steps to Recovery, Jeanette Vought, (Grand Rapids: Zondervan, 1991) 110. ''
:In a 1990 study of 68 religiously oriented (primarily Evangelical and Lutheran) 10-15 years post-abortion, found 8.8% of the women identified themselves as having suffered from eating disorders (bulimia and anorexia). Of these women, 66.7% had increased problems with their eating disorder after their abortion. And additional 51.5% indicated they had problems with overeating and 23.5% expressed problems of under eating. Overeating behavior increased 54.3% following their abortion and under eating behavior increased 50.1% after their abortion.)

''"Pregnancy : Outcome and Impact on Symptomatology in a Cohort of Eating- Disordered Women," MA Blais et al, Int J Eat Disord 27:140-149, 2000 ''
: There was an elevated incidence of eating disorders among women with therapeutic abortions which was not found among women with live births or spontaneous abortions.

''"Recurrent Abortions in a Bulimic: Implications Regarding Pathogenesis," R.S. El- Mallakh, A.Tasman, Intl. J. Eating Disorders 10(2):215-219,1991. ''
:A woman with severe bulimia used repeated pregnancies and abortions to achieve the same calming function as repeated binge eating and vomiting. It was suggested that her behavior was compatible with the view that bulimics use their own bodies as transitional objects and that the cycle of incorporation and expulsion is central to affect regulation. The woman was suicidal and preoccupied with death.

''The Psycho-Social Aspects of Stress Following Abortion, Anne C. Speckhard, (Sheed and Ward: Kansas City, 1987) ''
:In a study of 30 women who were stressed by abortion, 23 percent reported extreme weight gain, generally defined by the subjects as a 20-pound weight gain or more. Extreme weight gain was usually attributed to increased eating to calm oneself. Extreme weight loss was reported by 30 percent of the sample; 23 percent classified themselves as experiencing a period of anorexia nervosa. This was self defined, although many subjects reporting anorexia included evidence such as loss of 25 percent of body weight, cessation of menses, hospitalization and/or clinical diagnosis of anorexia nervosa.

''Aborted Women: Silent No More, David C. Reardon, (Chicago: Loyola Press, 1987) 24. ''
:In a study of 252 women who were members of Women Exploited by Abortion, two women were reported to suffer from anorexia nervosa which they attributed to their abortions. At least one woman suffered from excessive weight gain after her abortion, as she tried to bury her guilt in food.

''"Ritual Mourning in Anorexia Nervosa," R.K. McAll and F.M. McAll, The Lancet,August 16,1980, p. 368. ''
:Of 18 patients with anorexia nervosa treated in the hospital without improvement, 15 experienced total relief of symptoms following a process of ritual mourning for deceased family members who had not previously been mourned. Two patients were male. In 17 of the cases, family histories revealed a total of 25 violent deaths or deaths by suicide, five terminations of pregnancy for non-medical reasons and eight miscarriages. In one case a 17-year-old girl had anorexia nervosa since age 14 and had been hospitalized three times. At the time of referral she was unable to get out of bed. Her mother had an earlier pregnancy aborted. Without the knowledge of the patient, who was considered too ill to be involved/the parents went through a form of service in a church for the aborted child. When the patient was later told about this she admitted an awareness of the existence of her unborn "sister" but said she had not mentioned this for fear of being locked up in a mental hospital. She was immediately able to get up and in a very short time was successfully attending a college. In another case, a man of 41, had first been diagnosed as having anorexia at age 22. At the time of the examination he was not only anorectic but also severely depressed. On close questioning he admitted to having precipitated the abortion of his wife's first child. Within a week of his admission, and after following through with a process of mourning for and committal of the child, he was no longer depressed and was eating normally. The authors suggest that "hidden guilt, either in the patient or in a close member of the family, or lack of adequate recognition for a lost member of the family may be a causative factor. Providing a means of repentance, mourning for and committal of the dead can lead to dramatic relief of symptoms in the affected person, in addition to the emotional release experienced by other involved members of the family."

''"Value of Family Background and Clinical Features as Predictors of Long Term Outcome in Anorexia Nervosa," H. Morgan and G.F.M. Russell, Psychological Medicine 5:355-37, (1975). ''
:A disturbed relationship between the patient and other members of the family, and premorbid personality difficulties are predictors of unfavorable outcome.

''"Diseases of the Nervous System," Asbury, McKhana, McDonald, Vol. 1(Philadelphia: WB Saunders, 1986)''
:Anorexia nervosa is a disorder usually affecting affluent young women 14-17 years of age but occasionally found even earlier or even up to age 40-50. The person is preoccupied with body weight, under eats even to possible starvation or self-destruction, and becomes depressed, very impatient and irritable. Anorexia nervosa is frequently associated with distressed and disturbed family relationships, suggesting a psychogenic aspect. Some have suggested that anorexia nervosa represents an aspect of affective disorder. Extreme perfectionism and self-criticism are often common traits. Mortality rates range from 4-16 percent depending on the study.

''"A Study of 56 Families with Anorexia Nervosa," R.S. Kalucy, British Journal of Medical Psychology 50:381-395(1977). ''
:A central feature was the threat to family values and stability which such events posed. Deaths and illnesses often involved waiting and then mechanisms of identification seemed important. For example/a daughter's illness was preceded by identification with the loss of another sister from leukemia; in another a father's wasting from achalasis.

''"Avoidance of Anxiety and Eating Disorders," J. Keck and M. Fiebert, Psychological Reports 58: 432-434 (1986) ''
:Female patients with eating disorders appeared to use an obsession with food and weight as a form of escape.

[http://www.ncbi.nlm.nih.gov/pubmed/24559792 Suicide attempts and mortality in eating disorders: a follow-up study of eating disorder patients.] Suokas JT1, Suvisaari JM2, Grainger M3, Raevuori A4, Gissler M5, Haukka J6. Gen Hosp Psychiatry. 2014 Jan 13. pii: S0163-8343(14)00005-X. doi: 10.1016/j.genhosppsych.2014.01.002. [Epub ahead of print]

We identified 156 patients with eating disorder (6.3%) and 139 controls (1.4%) who had required hospital treatment for attempted suicide. Of them, 66 (42.3%) and 37 (26.6%) had more than one attempt. The rate ratio (RR) for suicide attempt in patients with eating disorder was 4.70 [95% confidence interval (CI) 1.41-15.74]. In anorexia nervosa, RR was 8.01 (95% CI 5.40-11.87), and in bulimia nervosa, it was 5.08 (95% CI 3.46-7.42). In eating disorder patients with a history of suicide attempt, the risk of death from any cause was 12.8%, suicide being the main cause in 45% of the deaths.
Suicide attempts and repeated attempts are common among patients with eating disorders. Suicidal ideation should be routinely assessed from patients with eating disorders.

[http://www.ncbi.nlm.nih.gov/pubmed/23996114 Reproductive health outcomes in eating disorders.] Linna S, Raevuori A, Haukka J, Suvisaari JM, Suokas JT, Gissler M. Int J Eat Disord. 2013 Dec;46(8):826-33. doi: 10.1002/eat.22179. Epub 2013 Sep 2.

OBJECTIVE:
Eating disorders are common psychiatric disorders in women at childbearing age. Previous research suggests that eating disorders are associated with fertility problems, unplanned pregnancies, and increased risk of induced abortions and miscarriages. The purpose of this study was to assess how eating disorders are related to reproductive health outcomes in a representative patient population.
METHOD:
Female patients (N = 2,257) treated at the eating disorder clinic of Helsinki University Central Hospital during 1995-2010 were compared with matched controls identified from the Central Population Register (N = 9,028). Patients had been diagnosed (ICD-10) with anorexia nervosa (AN), atypical AN, bulimia nervosa (BN), atypical BN, or binge eating disorder (BED, according to DSM-IV research criteria). Register-based data on number of children, pregnancies, childbirths, induced abortions, miscarriages, and infertility treatments were used to measure reproductive health outcomes.
RESULTS:
Patients were more likely to be childless than controls [odds ratio (OR) 1.86; 95% confidence interval (CI) 1.62-2.13, p < .001]. Pregnancy and childbirth rates were lower among patients than among controls. BN was associated with increased risk of induced abortion compared to controls (OR 1.85; 95% CI 1.43-2.38, p < .001), whereas BED was associated with elevated risk of miscarriage (OR 3.18; 95% CI 1.52-6.66, p = .002).
DISCUSSION:
Reproductive health outcomes are compromised in women with a history of eating disorders across all eating disorder types. Our findings emphasize the importance of reproductive health counseling and monitoring among women with eating disorders.

[http://archpsyc.jamanetwork.com/article.aspx?articleID=1904804&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMAPsychiatry%3AOnlineFirst09%2F17%2F2014 Posttraumatic Stress Disorder Symptoms and Food Addiction in Women by Timing and Type of Trauma Exposure]
Susan M. Mason, PhD, Alan J. Flint, DPH, MD, Andrea L. Roberts, PhD, et al. JAMA Psychiatry. Published online September 17, 2014. doi:10.1001/jamapsychiatry.2014.1208

:While this study did not report on abortion, it did find that "The prevalence of food addiction increased with the number of lifetime PTSD symptoms, and women with the greatest number of PTSD symptoms (6-7 symptoms) had more than twice the prevalence of food addiction as women with neither PTSD symptoms nor trauma histories (prevalence ratio, 2.68; 95% CI, 2.41-2.97). Symptoms of PTSD were more strongly related to food addiction when symptom onset occurred at an earlier age."

==Sexual Promiscuity and Casual Sex==

See also [http://abortionrisks.org/index.php?title=Impact_of_Abortion_On_Others#Impact_of_Abortion_on_Relationships_and_Sexual_Behavior Impact of Abortion on Relationships and SexualBehavior]

''"Abortion and the sexual lives of men and women: Is casual sexual behavior more appealing and
more common after abortion?" Coleman PK, Rue VM, Spense M, Coyle CT. Int J Clin Health Psychol, Vol. 8, Nº 1, 2008
:ABSTRACT. Previous research indicates that abortion increases risk for experiencing difficulties maintaining committed relationships, sexual dysfunction, and psychological prooblems. In the present descriptive study, associations between abortion and attitudes and behaviors associated with casual sexual activity were examined after controlling for family of origin, socio-demographic, reproductive history, and sexual history variables. The National Health and Social Life Survey (NHSLS), a multistage probability sample of 3,432 men and women between the ages of 18 and 59 was the data source. Among women, abortion was associated with more positive attitudes toward sex with strangers and with being forced to have sex; whereas the male experience of a partner abortion was correlated with attitudes endorsing sex with more than one partner and with strangers. Abortion among men and women predicted disagreement relative to restricting sexual activity to love relations, more sex partners in the last year, and endorsement for having sex with an acquaintance. Male experience of a partner abortion also increased the likelihood of having sex with a friend. Finally, abortion predicted engagement in various impersonal sexual behaviors over the previous 12 months among males and females. Strengths of the study include the large nationally representative data source and employment of a variety of control variables.

National Study of Family Growth-1995, Cycle V, U.S. Department of Health and Human Services, National Center for Health Statistics, 1997

:A national U.S. study of ever-pregnant women over age 35 found that women with no history of abortion had fewer sex partners before marriage (3.4 v. 9.2), and fewer lifetime sex partners (4.4 v. 12.7) compared to women with a history of abortion. Excluding women who had no sex partners before marriage, women with two or more abortions were likely to have more sex partners after marriage, (5.0), compared to women with a single abortion (2.0), or women with no history of abortion (2.0).

''Forbidden Grief.The Unspoken Pain of Abortion,'' Theresa Burke and David Reardon, Springfield, IL:Acorn Books, 2002.

:In an Elliot Institute survey of 260 women who were involved in faith-based postabortion counseling or advocacy groups, 42.7% said they became promiscuous within one month following their abortion; 51.6% said they became promiscuous within 6 months following their abortion; 46.6% said they developed an aversion to sex or became sexually unresponsive within one month, and 38.5% said they developed an aversion to sex or became sexually unresponsive within 6 months following their abortion.

''Psychosocial Sequelae of Therapeutic Abortion in Young Unmarried Women,'' Judith Wallerstein et al, Arch Gen Psychiatry 27:828, 1972.

:In-depth interviews of 22 women under 22 years of age who had an abortion At a Planned Parenthood facility in northern California in 1969-1970 at 5-7 months postabortion, 9 reported a newly begun promiscuous pattern in relationships with men following their abortion.

''Physical and Psychological Injury in Women Following Abortion: Akron Pregnancy Services Survey'', L Gsellman, Association for Interdisciplinary Research in Values and Social Change Newsletter 5(4) 1-8, 1993.

:In a self-reported questionnaire survey of 344 postabortion women with a mean age of approximately 18 years at the time of their abortion and who were receiving general pregnancy related services (including 28% who had presented for post abortion counseling) , 9% of the women reported sexual promiscuity, 14% reported frigidity, and 23% reported a desire to get pregnant again as postabortion psychological complaints.

''Psycho-Social Stress Following Abortion,'' Anne Speckhard, Kansas City: Sheed & Ward, 1987.

:A study of 30 women who reported long term stress from abortion, 31% reported sexual promiscuity, 35% reported feelings of sexual anxiety, 35% reported a deter- ioration of their sexual relationship, and 69% reported feelings of sexual inhibition.

''Health issues associated with increasing "crack" use among female sex workers, in London'', H Ward et al, Sex Transm Infect 76(4):292,

:Thirty-four percent of female sex workers reported using "crack" cocaine in 1995- 1996. Crack cocaine use was associated with abortion and hepatitis C infection.

''What have we learned from adolescent prostitutes in the Caribbean that adult prostitutes did not tell us?'', M Alegria et al, Int Conf AIDS, June, 1993; 9(1)89 (Abstract No. WS-CO8-2).

:Prostitution for adolescents begins with family or academic problems leading to early sexual experience with boyfriend followed by pregnancy and abortion which leads to economic/emotional despair followed by prostitution and then drug use.

''HIV risk relevant behaviors of Japanese adolescents'', T Munkata and K Fujisawa, Int Conf AIDS 11(1) 385, July, 1996 (Abstract No. Tu.D.27012)

:A mail survey to 10,000 Japanese adolescents age 13-24 in 1995 found that casual sex experiences were significantly influenced by self- or partners' abortion experience. Casual sex included having "first time" sex where partners were "sexually excited without love", "curiosity", "can't say No", or "nothing in particular".

''Pregnancy outcome after ecstasy use; 43 cases followed by the Teratology Information Service of the National Institute for Public Health and Environment'', MM van-Tonninger-van Driel et al, Ned Tijdschr Geneeskd 2;143(1): 27-31, 1999 (English Abstract).

:A Dutch study of 43 women who used ecstacy during pregnancy reported that pregnancies were often unplanned and previous pregnancies had often been terminated. Besides ecstacy, mothers frequently also used other substances potentially harmful to the pregnancy and child.

''Repeat Abortion: Blaming the Victims'', B Howe et al, Am J Public Health 69(12):70, 1979.

:Women who repeated abortion were found to be more sexually active compared to women with first abortions even though they used contraception more than women with one abortion.

''Repeat Abortion: Is It a Problem?'', C Berger et al, Family Planning Perspectives 16(2): 70, 1984.

:A Canadian study found that women who repeated abortion had more frequent itercourse, less satisfying relations with their partner, had more difficulty sleeping, and were less likely to live with their partner compared to women with a single abortion.

New Summary of Evidence Linking Abortion to Mental Health Problems

2025-10-06T21:12:19Z

Barb: /* Cross-Sectional and Regional Studies */

=== Overview ===
Peer-reviewed research published after 2010 has explored potential negative mental health effects associated with induced abortion, often through systematic reviews, cohort studies, and cross-sectional analyses. While the broader literature includes debates and studies finding no causal links, the following summarizes key publications that specifically report negative associations, such as increased risks of depression, anxiety, substance use disorders, and other mental health issues. These findings are drawn from diverse populations and methodologies, with some highlighting factors like pre-existing conditions or unwanted pregnancies as moderators. Prevalence rates and risks vary, and many studies note limitations like self-reporting biases or heterogeneity in data.

=== Systematic Reviews and Meta-Analyses ===
A 2011 quantitative synthesis analyzed 22 studies (published 1995–2009, but the review itself post-2010) involving over 877,000 participants, finding that women with a history of abortion had an 81% increased risk of mental health problems overall, including 37% higher risk of depression, 110% higher risk of alcohol misuse, and 155% higher risk of suicidal behaviors.<ref>Coleman PK. [https://pubmed.ncbi.nlm.nih.gov/21881096/ Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009]. Br J Psychiatry. 2011 Sep;199(3):180-6. doi: 10.1192/bjp.bp.110.077230. PMID: 21881096.</ref> The analysis controlled for variables like prior mental health but faced criticism for methodological flaws in subsequent critiques.

A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior. Anxiety risks were higher but not statistically significant.

The 2018 comprehensive literature review by Reardon examined the abortion and mental health controversy, identifying common ground and disagreements. It noted that abortion is consistently associated with elevated rates of mental illness compared to women without an abortion history, and that the abortion experience directly contributes to mental health problems for at least some women. Risk factors such as pre-existing mental illness were highlighted as predictors of greater vulnerability. The review emphasized obstacles like multiple causation pathways, indeterminate reaction timelines, and ideological biases in research. It reported relative risks from various studies, with abortion linked to higher mental health risks (e.g., relative risk ratios from 1.5 to 5.5 for conditions like depression and anxiety across datasets). Population attributable risks were estimated at 8-28% for mental illnesses post-abortion. Recommendations included mixed research teams and better data sharing to address biases. Figures included relative risk comparisons and population attributable fractions for suicide attempts and other outcomes.

A 2023 systematic review and meta-analysis estimated the global prevalence of post-abortion depression at 34.5% (95% CI: 23.34–45.68) based on 15 observational studies involving 18,207 participants, primarily published between 2010 and 2023.<ref>Gebeyehu, N.A., Tegegne, K.D., Abebe, K. ''et al.'' Global prevalence of post-abortion depression: systematic review and Meta-analysis. ''BMC Psychiatry'' 23, 786 (2023). <nowiki>https://doi.org/10.1186/s12888-023-05278-7</nowiki>https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-023-05278-7</ref> The studies were mainly cross-sectional or cohort designs from regions including Asia, Europe, Africa, and Australia, with higher prevalence in lower-middle-income countries (42.91%) and Asia (37.5%). Associated factors included socioeconomic status, geographical location, and screening tools used (e.g., higher rates with the Center for Epidemiological Studies Depression Scale). Limitations included publication bias, lack of representation from some continents, and inconsistent diagnostic criteria.

=== Cohort and Longitudinal Studies ===
A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior.<ref>Kheriaty, Aaron. [https://issuesinlawandmedicine.com/wp-content/uploads/2025/04/ILM_V40n1_2025_full_issue.pdf#page=7 Abortion and Mental Health: What Can We Conclude?]. ''Issues L. & Med.'' 40 (2025): 3.</ref> Anxiety risks were higher but not statistically significant.

In a 2016 U.S. longitudinal study using National Longitudinal Study of Adolescent to Adult Health data (Sullins), abortion was linked to a 54% increased risk of mental health disorders in late adolescence and early adulthood, with additive effects for multiple abortions.<ref>D. P. Sullins, “Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States,” SAGE Open Med 4 (2016)</ref> The study suggested emotional distress from the abortion experience itself contributed to these outcomes.

A 2017 prospective cohort study in the Netherlands (van Ditzhuijzen et al.) reported increased recurrence of common mental disorders post-abortion among women with prior mental health histories, identifying pre-existing conditions as a key risk factor.<ref>J. van Ditzhuijzen et al., “Incidence and Recurrence of Common Mental Disorders after Abortion: Results from a Prospective Cohort Study,” J Psychiatr Res 84 (2017).</ref>

A 2023 cohort study by Studnicki et al. followed 4,848 continuously eligible Medicaid beneficiaries (aged 16 in 1999) through 2015, comparing first-pregnancy abortion (n=1,331) to birth (n=3,517) cohorts. Women with abortions had higher risks post-pregnancy outcome: outpatient visits (RR 2.10, 95% CI 2.08-2.12; OR 3.36, 95% CI 3.29-3.42), inpatient admissions (RR 2.75, 95% CI 2.38-3.18; OR 5.67, 95% CI 4.39-7.32), and inpatient days of stay (RR 7.38, 95% CI 6.83-7.97; OR 19.64, 95% CI 17.70-21.78). Abortion cohort women had shorter pre-outcome exposure (6.43 vs. 7.80 years) but longer post-outcome (10.57 vs. 9.20 years). Pre-outcome utilization was higher in the birth cohort, challenging the notion that pre-existing conditions fully explain post-abortion effects. Figures showed utilization rates per patient per year for outpatient visits, inpatient admissions, and days of stay. No conflicts of interest were reported.

A 2025 retrospective cohort study by Auger et al. analyzed 1,257,528 pregnancies (28,721 induced abortions and 1,228,807 births) in Quebec, Canada, from 2006 to 2022, following participants up to 17 years post-pregnancy. Hazard ratios were calculated after adjusting for age and time period at the time of the pregnancy, preexisting mental illnesses, comorbidity (obesity, hypertension, diabetes mellitus, dyslipidemia), socioeconomic status, education, employment, rural/urban residence. Rates of mental health-related hospitalizations were higher following induced abortions (104.0 per 10,000 person-years) than other pregnancies (42.0 per 10,000 person-years). Induced abortion was associated with increased risks of hospitalization for psychiatric disorders (HR 1.81, 95% CI 1.72-1.90), substance use disorders (HR 2.57, 95% CI 2.41-2.75), and suicide attempts (HR 2.16, 95% CI 1.91-2.43). Associations were stronger for women with pre-existing mental illness or those under 25 years old, and risks were elevated within five years post-abortion but decreased over time. The study adjusted for pregnancy characteristics but did not explicitly detail limitations in the abstract. The adjusted population attributable risk (PAR) calculations suggest that 2.0% of all psychiatric admissions, 2.2% of suicide attempts and 2.6% of substance use disorders are attributable to abortion. The PAF estimates the fraction of each disease in the population that would be eliminated if the exposure were removed, assuming the adjusted HR represents a causal effect and that all confounders have been adequately measured and controlled for. Notably, among women with prior mental health issues, psychiatric hospitalization was nine times more likely for those who had abortions. In contrast, among women without prior mental health issues, abortion was linked to only a 50% increased risk of psychiatric hospitalization. The risk of psychiatric admissions generally declined over time, nearly disappearing after twelve years. The exception was for substance use disorders, which while declining remained significantly elevated throughout the sixteen years examined by the research team. The study also observed that the risk of psychiatric treatment increased with the number of abortions women experienced. This is a “dose effect.” It means each abortion exposure increased the risk of a mental health disorder requiring hospitalization. Observation of a dose effect is generally considered to be strong evidence of a direct causal pathway between a risk factor (abortion) and a statistically associated outcome (hospitalization for mental health).

=== '''Differences in Mental Health Outcomes Reported by Auger (2025)''' ===
{| class="wikitable"
|'''Outcome'''
|'''Adjusted Hazard Ratio (HR)'''
|'''Adjusted PAF (Using HR)'''
|'''Unadjusted PAF (Using Raw Rates)'''
|-
|'''Any Mental Health Admission'''
|1.91
|2.02%
|3.27%
|-
|'''Psychiatric Disorder'''
|1.81
|1.81%
|2.99%
|-
|Bipolar Disorder
|1.45
|1.01%
|2.27%
|-
|Depression
|1.64
|1.43%
|2.86%
|-
|Anxiety and Stress
|1.81
|1.81%
|3.20%
|-
|Eating Disorders
|2.25
|2.78%
|5.28%
|-
|Psychosis
|2.06
|2.38%
|4.71%
|-
|Personality Disorders
|2.25
|2.78%
|5.62%
|-
|'''Substance Use Disorder'''
|2.57
|3.47%
|5.97%
|-
|Alcohol Use Disorder
|2.49
|3.30%
|5.43%
|-
|Opioids Use Disorder
|3.25
|4.89%
|7.27%
|-
|Cannabis Use Disorder
|2.57
|3.47%
|5.97%
|-
|Cocaine Use Disorder
|3.46
|5.31%
|8.44%
|-
|Stimulant Use Disorder
|2.77
|3.89%
|6.69%
|-
|Hallucinogen Use Disorder
|5.15
|8.66%
|15.38%
|-
|Sedative Use Disorder
|2.85
|4.05%
|6.54%
|-
|Other Illicit Substance Use Disorder
|5.39
|9.11%
|16.67%
|-
|'''Suicide Attempt'''
|2.16
|2.58%
|5.07%
|}

=== Cross-Sectional and Regional Studies ===
A 2012 cross-sectional study in Tehran, Iran (Dadkhah et al.), involving 261 women seeking post-abortion care, found that over one-third experienced psychological side effects, including depression (60.5%), worry about future conception (53.6%), abnormal eating behaviors (48.7%), decreased self-esteem (43.7%), nightmares (39.5%), guilt (37.5%), and regret (33.3%).<ref>Pourreza A, Batebi A. Psychological Consequences of Abortion among the Post Abortion Care Seeking Women in Tehran. Iran J Psychiatry. 2011 Winter;6(1):31-6. PMID: 22952518; PMCID: PMC3395931.</ref> Less common were suicide attempts (4.7%), smoking (2.7%), and drug abuse (1.5%). The study highlighted cultural stigmas exacerbating these effects.

The best data on American women is found in a 2016 study using the National Longitudinal Study of Adolescent to Adult Health (Add Health) that provided three models of analyses, including controls for eight confounding factors.<ref name=":0">Donald Paul Sullins, ''Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States'', 4 SAGE Open Med. 6 (2016).</ref> In addition, the author conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” These lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. This study also identified a dose effect, with ''each exposure to abortion'' (up to four) associated with a 23 percent increase of relative risk of subsequent mental disorders.<ref name=":0" /> In addition, a subsequent 2019 analysis using the same data set revealed that approximately 20% of the women having abortions reported wanting the child.<ref>Donald Paul Sullins, ''Affective and Substance Abuse Disorders Following Abortion by Pregnancy Intention in the United States : A Longitudinal Cohort Study'', 55 Medicina (Mex.) 2 (2019).</ref> Unsurprisingly, the women who aborted wanted children experienced 122% higher rate of depression and a 244% higher rate of suicidality. In addition, the author conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” These lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. The study also identified a dose effect, with each exposure to abortion (up to four) associated with a 23 percent (95% CI, 1.16–1.30) increase of relative risk of subsequent mental disorders. In addition, a subsequent 2019 analysis using the same data set revealed that approximately 20% of the women having abortions reported wanting the child.[81] Unsurprisingly, the women who aborted wanted children experienced higher rates of depression (RR 2.22, 95% CI 1.3–3.8) and suicidality (RR 3.44 95% CI 1.5–7.7). Notably, no refutation of these findings has been published. They are undisputed.

A 2025 cross-sectional survey by Reardon involved 2,829 American females aged 41-45, examining suicide risks by pregnancy outcomes. Aborting women were twice as likely to have attempted suicide compared to others. Those with abortions, especially coerced or unwanted ones, reported higher self-assessed contributions of the abortion to suicidal thoughts, self-destructive behaviors, and attempts (measured via visual analog scales). The study challenged the hypothesis that pre-existing mental health fully explains elevated suicide rates post-abortion, as women's self-reports indicated direct contributions from the abortion experience. No conflicts were noted.

=== Additional Context from Reviews ===
The literature published since 2010 has focused on controlling for the effects of prior mental health and has revealed links between abortion and worsened mental health for some women.

'''References'''
<references />

New Summary of Evidence Linking Abortion to Mental Health Problems

2025-10-06T21:07:26Z

Barb: /* Cross-Sectional and Regional Studies */

=== Overview ===
Peer-reviewed research published after 2010 has explored potential negative mental health effects associated with induced abortion, often through systematic reviews, cohort studies, and cross-sectional analyses. While the broader literature includes debates and studies finding no causal links, the following summarizes key publications that specifically report negative associations, such as increased risks of depression, anxiety, substance use disorders, and other mental health issues. These findings are drawn from diverse populations and methodologies, with some highlighting factors like pre-existing conditions or unwanted pregnancies as moderators. Prevalence rates and risks vary, and many studies note limitations like self-reporting biases or heterogeneity in data.

=== Systematic Reviews and Meta-Analyses ===
A 2011 quantitative synthesis analyzed 22 studies (published 1995–2009, but the review itself post-2010) involving over 877,000 participants, finding that women with a history of abortion had an 81% increased risk of mental health problems overall, including 37% higher risk of depression, 110% higher risk of alcohol misuse, and 155% higher risk of suicidal behaviors.<ref>Coleman PK. [https://pubmed.ncbi.nlm.nih.gov/21881096/ Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009]. Br J Psychiatry. 2011 Sep;199(3):180-6. doi: 10.1192/bjp.bp.110.077230. PMID: 21881096.</ref> The analysis controlled for variables like prior mental health but faced criticism for methodological flaws in subsequent critiques.

A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior. Anxiety risks were higher but not statistically significant.

The 2018 comprehensive literature review by Reardon examined the abortion and mental health controversy, identifying common ground and disagreements. It noted that abortion is consistently associated with elevated rates of mental illness compared to women without an abortion history, and that the abortion experience directly contributes to mental health problems for at least some women. Risk factors such as pre-existing mental illness were highlighted as predictors of greater vulnerability. The review emphasized obstacles like multiple causation pathways, indeterminate reaction timelines, and ideological biases in research. It reported relative risks from various studies, with abortion linked to higher mental health risks (e.g., relative risk ratios from 1.5 to 5.5 for conditions like depression and anxiety across datasets). Population attributable risks were estimated at 8-28% for mental illnesses post-abortion. Recommendations included mixed research teams and better data sharing to address biases. Figures included relative risk comparisons and population attributable fractions for suicide attempts and other outcomes.

A 2023 systematic review and meta-analysis estimated the global prevalence of post-abortion depression at 34.5% (95% CI: 23.34–45.68) based on 15 observational studies involving 18,207 participants, primarily published between 2010 and 2023.<ref>Gebeyehu, N.A., Tegegne, K.D., Abebe, K. ''et al.'' Global prevalence of post-abortion depression: systematic review and Meta-analysis. ''BMC Psychiatry'' 23, 786 (2023). <nowiki>https://doi.org/10.1186/s12888-023-05278-7</nowiki>https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-023-05278-7</ref> The studies were mainly cross-sectional or cohort designs from regions including Asia, Europe, Africa, and Australia, with higher prevalence in lower-middle-income countries (42.91%) and Asia (37.5%). Associated factors included socioeconomic status, geographical location, and screening tools used (e.g., higher rates with the Center for Epidemiological Studies Depression Scale). Limitations included publication bias, lack of representation from some continents, and inconsistent diagnostic criteria.

=== Cohort and Longitudinal Studies ===
A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior.<ref>Kheriaty, Aaron. [https://issuesinlawandmedicine.com/wp-content/uploads/2025/04/ILM_V40n1_2025_full_issue.pdf#page=7 Abortion and Mental Health: What Can We Conclude?]. ''Issues L. & Med.'' 40 (2025): 3.</ref> Anxiety risks were higher but not statistically significant.

In a 2016 U.S. longitudinal study using National Longitudinal Study of Adolescent to Adult Health data (Sullins), abortion was linked to a 54% increased risk of mental health disorders in late adolescence and early adulthood, with additive effects for multiple abortions.<ref>D. P. Sullins, “Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States,” SAGE Open Med 4 (2016)</ref> The study suggested emotional distress from the abortion experience itself contributed to these outcomes.

A 2017 prospective cohort study in the Netherlands (van Ditzhuijzen et al.) reported increased recurrence of common mental disorders post-abortion among women with prior mental health histories, identifying pre-existing conditions as a key risk factor.<ref>J. van Ditzhuijzen et al., “Incidence and Recurrence of Common Mental Disorders after Abortion: Results from a Prospective Cohort Study,” J Psychiatr Res 84 (2017).</ref>

A 2023 cohort study by Studnicki et al. followed 4,848 continuously eligible Medicaid beneficiaries (aged 16 in 1999) through 2015, comparing first-pregnancy abortion (n=1,331) to birth (n=3,517) cohorts. Women with abortions had higher risks post-pregnancy outcome: outpatient visits (RR 2.10, 95% CI 2.08-2.12; OR 3.36, 95% CI 3.29-3.42), inpatient admissions (RR 2.75, 95% CI 2.38-3.18; OR 5.67, 95% CI 4.39-7.32), and inpatient days of stay (RR 7.38, 95% CI 6.83-7.97; OR 19.64, 95% CI 17.70-21.78). Abortion cohort women had shorter pre-outcome exposure (6.43 vs. 7.80 years) but longer post-outcome (10.57 vs. 9.20 years). Pre-outcome utilization was higher in the birth cohort, challenging the notion that pre-existing conditions fully explain post-abortion effects. Figures showed utilization rates per patient per year for outpatient visits, inpatient admissions, and days of stay. No conflicts of interest were reported.

A 2025 retrospective cohort study by Auger et al. analyzed 1,257,528 pregnancies (28,721 induced abortions and 1,228,807 births) in Quebec, Canada, from 2006 to 2022, following participants up to 17 years post-pregnancy. Hazard ratios were calculated after adjusting for age and time period at the time of the pregnancy, preexisting mental illnesses, comorbidity (obesity, hypertension, diabetes mellitus, dyslipidemia), socioeconomic status, education, employment, rural/urban residence. Rates of mental health-related hospitalizations were higher following induced abortions (104.0 per 10,000 person-years) than other pregnancies (42.0 per 10,000 person-years). Induced abortion was associated with increased risks of hospitalization for psychiatric disorders (HR 1.81, 95% CI 1.72-1.90), substance use disorders (HR 2.57, 95% CI 2.41-2.75), and suicide attempts (HR 2.16, 95% CI 1.91-2.43). Associations were stronger for women with pre-existing mental illness or those under 25 years old, and risks were elevated within five years post-abortion but decreased over time. The study adjusted for pregnancy characteristics but did not explicitly detail limitations in the abstract. The adjusted population attributable risk (PAR) calculations suggest that 2.0% of all psychiatric admissions, 2.2% of suicide attempts and 2.6% of substance use disorders are attributable to abortion. The PAF estimates the fraction of each disease in the population that would be eliminated if the exposure were removed, assuming the adjusted HR represents a causal effect and that all confounders have been adequately measured and controlled for.

=== '''Differences in Mental Health Outcomes Reported by Auger (2025)''' ===
{| class="wikitable"
|'''Outcome'''
|'''Adjusted Hazard Ratio (HR)'''
|'''Adjusted PAF (Using HR)'''
|'''Unadjusted PAF (Using Raw Rates)'''
|-
|'''Any Mental Health Admission'''
|1.91
|2.02%
|3.27%
|-
|'''Psychiatric Disorder'''
|1.81
|1.81%
|2.99%
|-
|Bipolar Disorder
|1.45
|1.01%
|2.27%
|-
|Depression
|1.64
|1.43%
|2.86%
|-
|Anxiety and Stress
|1.81
|1.81%
|3.20%
|-
|Eating Disorders
|2.25
|2.78%
|5.28%
|-
|Psychosis
|2.06
|2.38%
|4.71%
|-
|Personality Disorders
|2.25
|2.78%
|5.62%
|-
|'''Substance Use Disorder'''
|2.57
|3.47%
|5.97%
|-
|Alcohol Use Disorder
|2.49
|3.30%
|5.43%
|-
|Opioids Use Disorder
|3.25
|4.89%
|7.27%
|-
|Cannabis Use Disorder
|2.57
|3.47%
|5.97%
|-
|Cocaine Use Disorder
|3.46
|5.31%
|8.44%
|-
|Stimulant Use Disorder
|2.77
|3.89%
|6.69%
|-
|Hallucinogen Use Disorder
|5.15
|8.66%
|15.38%
|-
|Sedative Use Disorder
|2.85
|4.05%
|6.54%
|-
|Other Illicit Substance Use Disorder
|5.39
|9.11%
|16.67%
|-
|'''Suicide Attempt'''
|2.16
|2.58%
|5.07%
|}

=== Cross-Sectional and Regional Studies ===
A 2012 cross-sectional study in Tehran, Iran (Dadkhah et al.), involving 261 women seeking post-abortion care, found that over one-third experienced psychological side effects, including depression (60.5%), worry about future conception (53.6%), abnormal eating behaviors (48.7%), decreased self-esteem (43.7%), nightmares (39.5%), guilt (37.5%), and regret (33.3%).<ref>Pourreza A, Batebi A. Psychological Consequences of Abortion among the Post Abortion Care Seeking Women in Tehran. Iran J Psychiatry. 2011 Winter;6(1):31-6. PMID: 22952518; PMCID: PMC3395931.</ref> Less common were suicide attempts (4.7%), smoking (2.7%), and drug abuse (1.5%). The study highlighted cultural stigmas exacerbating these effects.

The best data on American women is found in a 2016 study using the National Longitudinal Study of Adolescent to Adult Health (Add Health) that provided three models of analyses, including controls for eight confounding factors.<ref name=":0">Donald Paul Sullins, ''Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States'', 4 SAGE Open Med. 6 (2016).</ref> In addition, the author conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” These lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders.

This study also identified a dose effect, with ''each exposure to abortion'' (up to four) associated with a 23 percent increase of relative risk of subsequent mental disorders.<ref name=":0" /> In addition, a subsequent 2019 analysis using the same data set revealed that approximately 20% of the women having abortions reported wanting the child.<ref>Donald Paul Sullins, ''Affective and Substance Abuse Disorders Following Abortion by Pregnancy Intention in the United States : A Longitudinal Cohort Study'', 55 Medicina (Mex.) 2 (2019).</ref> Unsurprisingly, the women who aborted wanted children experienced 122% higher rate of depression and a 244% higher rate of suicidality.

A 2025 cross-sectional survey by Reardon involved 2,829 American females aged 41-45, examining suicide risks by pregnancy outcomes. Aborting women were twice as likely to have attempted suicide compared to others. Those with abortions, especially coerced or unwanted ones, reported higher self-assessed contributions of the abortion to suicidal thoughts, self-destructive behaviors, and attempts (measured via visual analog scales). The study challenged the hypothesis that pre-existing mental health fully explains elevated suicide rates post-abortion, as women's self-reports indicated direct contributions from the abortion experience. No conflicts were noted.

=== Additional Context from Reviews ===
The literature published since 2010 has focused on controlling for the effects of prior mental health and has revealed links between abortion and worsened mental health for some women.

'''References'''
<references />

New Summary of Evidence Linking Abortion to Mental Health Problems

2025-10-03T16:43:49Z

Barb: /* Differences in Mental Health Outcomes Reported by Auger (2025) */

=== Overview ===
Peer-reviewed research published after 2010 has explored potential negative mental health effects associated with induced abortion, often through systematic reviews, cohort studies, and cross-sectional analyses. While the broader literature includes debates and studies finding no causal links, the following summarizes key publications that specifically report negative associations, such as increased risks of depression, anxiety, substance use disorders, and other mental health issues. These findings are drawn from diverse populations and methodologies, with some highlighting factors like pre-existing conditions or unwanted pregnancies as moderators. Prevalence rates and risks vary, and many studies note limitations like self-reporting biases or heterogeneity in data.

=== Systematic Reviews and Meta-Analyses ===
A 2011 quantitative synthesis analyzed 22 studies (published 1995–2009, but the review itself post-2010) involving over 877,000 participants, finding that women with a history of abortion had an 81% increased risk of mental health problems overall, including 37% higher risk of depression, 110% higher risk of alcohol misuse, and 155% higher risk of suicidal behaviors.<ref>Coleman PK. [https://pubmed.ncbi.nlm.nih.gov/21881096/ Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009]. Br J Psychiatry. 2011 Sep;199(3):180-6. doi: 10.1192/bjp.bp.110.077230. PMID: 21881096.</ref> The analysis controlled for variables like prior mental health but faced criticism for methodological flaws in subsequent critiques.

A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior. Anxiety risks were higher but not statistically significant.

The 2018 comprehensive literature review by Reardon examined the abortion and mental health controversy, identifying common ground and disagreements. It noted that abortion is consistently associated with elevated rates of mental illness compared to women without an abortion history, and that the abortion experience directly contributes to mental health problems for at least some women. Risk factors such as pre-existing mental illness were highlighted as predictors of greater vulnerability. The review emphasized obstacles like multiple causation pathways, indeterminate reaction timelines, and ideological biases in research. It reported relative risks from various studies, with abortion linked to higher mental health risks (e.g., relative risk ratios from 1.5 to 5.5 for conditions like depression and anxiety across datasets). Population attributable risks were estimated at 8-28% for mental illnesses post-abortion. Recommendations included mixed research teams and better data sharing to address biases. Figures included relative risk comparisons and population attributable fractions for suicide attempts and other outcomes.

A 2023 systematic review and meta-analysis estimated the global prevalence of post-abortion depression at 34.5% (95% CI: 23.34–45.68) based on 15 observational studies involving 18,207 participants, primarily published between 2010 and 2023.<ref>Gebeyehu, N.A., Tegegne, K.D., Abebe, K. ''et al.'' Global prevalence of post-abortion depression: systematic review and Meta-analysis. ''BMC Psychiatry'' 23, 786 (2023). <nowiki>https://doi.org/10.1186/s12888-023-05278-7</nowiki>https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-023-05278-7</ref> The studies were mainly cross-sectional or cohort designs from regions including Asia, Europe, Africa, and Australia, with higher prevalence in lower-middle-income countries (42.91%) and Asia (37.5%). Associated factors included socioeconomic status, geographical location, and screening tools used (e.g., higher rates with the Center for Epidemiological Studies Depression Scale). Limitations included publication bias, lack of representation from some continents, and inconsistent diagnostic criteria.

=== Cohort and Longitudinal Studies ===
A 2013 re-appraisal of New Zealand cohort data (Fergusson et al.) found abortion associated with elevated risks compared to unwanted pregnancy carried to term, including 2.3 times higher risk of alcohol misuse, 3.91 times higher risk of illicit drug use/misuse, and 1.69 times higher risk of suicidal behavior.<ref>Kheriaty, Aaron. [https://issuesinlawandmedicine.com/wp-content/uploads/2025/04/ILM_V40n1_2025_full_issue.pdf#page=7 Abortion and Mental Health: What Can We Conclude?]. ''Issues L. & Med.'' 40 (2025): 3.</ref> Anxiety risks were higher but not statistically significant.

In a 2016 U.S. longitudinal study using National Longitudinal Study of Adolescent to Adult Health data (Sullins), abortion was linked to a 54% increased risk of mental health disorders in late adolescence and early adulthood, with additive effects for multiple abortions.<ref>D. P. Sullins, “Abortion, Substance Abuse and Mental Health in Early Adulthood: Thirteen-Year Longitudinal Evidence from the United States,” SAGE Open Med 4 (2016)</ref> The study suggested emotional distress from the abortion experience itself contributed to these outcomes.

A 2017 prospective cohort study in the Netherlands (van Ditzhuijzen et al.) reported increased recurrence of common mental disorders post-abortion among women with prior mental health histories, identifying pre-existing conditions as a key risk factor.<ref>J. van Ditzhuijzen et al., “Incidence and Recurrence of Common Mental Disorders after Abortion: Results from a Prospective Cohort Study,” J Psychiatr Res 84 (2017).</ref>

A 2023 cohort study by Studnicki et al. followed 4,848 continuously eligible Medicaid beneficiaries (aged 16 in 1999) through 2015, comparing first-pregnancy abortion (n=1,331) to birth (n=3,517) cohorts. Women with abortions had higher risks post-pregnancy outcome: outpatient visits (RR 2.10, 95% CI 2.08-2.12; OR 3.36, 95% CI 3.29-3.42), inpatient admissions (RR 2.75, 95% CI 2.38-3.18; OR 5.67, 95% CI 4.39-7.32), and inpatient days of stay (RR 7.38, 95% CI 6.83-7.97; OR 19.64, 95% CI 17.70-21.78). Abortion cohort women had shorter pre-outcome exposure (6.43 vs. 7.80 years) but longer post-outcome (10.57 vs. 9.20 years). Pre-outcome utilization was higher in the birth cohort, challenging the notion that pre-existing conditions fully explain post-abortion effects. Figures showed utilization rates per patient per year for outpatient visits, inpatient admissions, and days of stay. No conflicts of interest were reported.

A 2025 retrospective cohort study by Auger et al. analyzed 1,257,528 pregnancies (28,721 induced abortions and 1,228,807 births) in Quebec, Canada, from 2006 to 2022, following participants up to 17 years post-pregnancy. Hazard ratios were calculated after adjusting for age and time period at the time of the pregnancy, preexisting mental illnesses, comorbidity (obesity, hypertension, diabetes mellitus, dyslipidemia), socioeconomic status, education, employment, rural/urban residence. Rates of mental health-related hospitalizations were higher following induced abortions (104.0 per 10,000 person-years) than other pregnancies (42.0 per 10,000 person-years). Induced abortion was associated with increased risks of hospitalization for psychiatric disorders (HR 1.81, 95% CI 1.72-1.90), substance use disorders (HR 2.57, 95% CI 2.41-2.75), and suicide attempts (HR 2.16, 95% CI 1.91-2.43). Associations were stronger for women with pre-existing mental illness or those under 25 years old, and risks were elevated within five years post-abortion but decreased over time. The study adjusted for pregnancy characteristics but did not explicitly detail limitations in the abstract. The adjusted population attributable risk (PAR) calculations suggest that 2.0% of all psychiatric admissions, 2.2% of suicide attempts and 2.6% of substance use disorders are attributable to abortion. The PAF estimates the fraction of each disease in the population that would be eliminated if the exposure were removed, assuming the adjusted HR represents a causal effect and that all confounders have been adequately measured and controlled for.

=== '''Differences in Mental Health Outcomes Reported by Auger (2025)''' ===
{| class="wikitable"
|'''Outcome'''
|'''Adjusted Hazard Ratio (HR)'''
|'''Adjusted PAF (Using HR)'''
|'''Unadjusted PAF (Using Raw Rates)'''
|-
|'''Any Mental Health Admission'''
|1.91
|2.02%
|3.27%
|-
|'''Psychiatric Disorder'''
|1.81
|1.81%
|2.99%
|-
|Bipolar Disorder
|1.45
|1.01%
|2.27%
|-
|Depression
|1.64
|1.43%
|2.86%
|-
|Anxiety and Stress
|1.81
|1.81%
|3.20%
|-
|Eating Disorders
|2.25
|2.78%
|5.28%
|-
|Psychosis
|2.06
|2.38%
|4.71%
|-
|Personality Disorders
|2.25
|2.78%
|5.62%
|-
|'''Substance Use Disorder'''
|2.57
|3.47%
|5.97%
|-
|Alcohol Use Disorder
|2.49
|3.30%
|5.43%
|-
|Opioids Use Disorder
|3.25
|4.89%
|7.27%
|-
|Cannabis Use Disorder
|2.57
|3.47%
|5.97%
|-
|Cocaine Use Disorder
|3.46
|5.31%
|8.44%
|-
|Stimulant Use Disorder
|2.77
|3.89%
|6.69%
|-
|Hallucinogen Use Disorder
|5.15
|8.66%
|15.38%
|-
|Sedative Use Disorder
|2.85
|4.05%
|6.54%
|-
|Other Illicit Substance Use Disorder
|5.39
|9.11%
|16.67%
|-
|'''Suicide Attempt'''
|2.16
|2.58%
|5.07%
|}

=== Cross-Sectional and Regional Studies ===
A 2012 cross-sectional study in Tehran, Iran (Dadkhah et al.), involving 261 women seeking post-abortion care, found that over one-third experienced psychological side effects, including depression (60.5%), worry about future conception (53.6%), abnormal eating behaviors (48.7%), decreased self-esteem (43.7%), nightmares (39.5%), guilt (37.5%), and regret (33.3%).<ref>Pourreza A, Batebi A. Psychological Consequences of Abortion among the Post Abortion Care Seeking Women in Tehran. Iran J Psychiatry. 2011 Winter;6(1):31-6. PMID: 22952518; PMCID: PMC3395931.</ref> Less common were suicide attempts (4.7%), smoking (2.7%), and drug abuse (1.5%). The study highlighted cultural stigmas exacerbating these effects.

A 2025 cross-sectional survey by Reardon involved 2,829 American females aged 41-45, examining suicide risks by pregnancy outcomes. Aborting women were twice as likely to have attempted suicide compared to others. Those with abortions, especially coerced or unwanted ones, reported higher self-assessed contributions of the abortion to suicidal thoughts, self-destructive behaviors, and attempts (measured via visual analog scales). The study challenged the hypothesis that pre-existing mental health fully explains elevated suicide rates post-abortion, as women's self-reports indicated direct contributions from the abortion experience. No conflicts were noted.

=== Additional Context from Reviews ===
The literature published since 2010 has focused on controlling for the effects of prior mental health and has revealed links between abortion and worsened mental health for some women.

'''References'''
<references />

New Summary of Evidence Linking Abortion to Mental Health Problems

2025-10-03T16:37:05Z

Barb: /* Differences in Mental Health Outcomes Reported by Auger (2025) */

New Summary of Evidence Linking Abortion to Mental Health Problems

2025-10-03T16:35:10Z

Barb: /* Differences in Mental Health Outcomes Reported by Auger (2025) */

New Summary of Evidence Linking Abortion to Mental Health Problems

2025-10-03T16:26:58Z

Barb: /* Cohort and Longitudinal Studies */

Gilchrist

2025-09-19T23:48:55Z

Barb: /* Low grade under the JBI Critical Appraisal Checklist for Case Series */

Gilchrist AC, Hannaford PC, Frank P, Kay CR. Termination of pregnancy and psychiatric morbidity. ''Br J Psychiatry''. 1995;167:243-248.

Please register and contribute to the development of these notes into a narrative by editing the sections or adding sections.

== Abstract ==

''Gilchrist AC, Hannaford PC, Frank P, Kay CR. [http://archpsyc.ama-assn.org/cgi/ijlink?linkType=ABST&journalCode=bjprcpsych&resid=167/2/243 Termination of pregnancy and psychiatric morbidity.]Br J Psychiatry. 1995;167:243-248.''

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 1'''509 volunteer GPs''' after the conclusion of the pregnancy was compared in four groups: women who had an '''induced abortion (6410)''', women who did not request a termination (6151) for a pregnancy the GP determined '''had not been planned at least 3 months before conception''', women who were '''refused a termination (379)''', and '''321 women''' who changed their minds before the termination was performed.

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.

== Additional Key Findings ==

#The findings confirmed that women with prior psychiatric problems are worse off postabortion
#Women with the most fragile mental health prior to an abortion, i.e., psychosis, were worse off postabortion
#The findings indicated that among women with no prior psychiatric history, significantly higher risks of deliberate self harm were observed both after an abortion and after a refused abortion.

 

== Additional Notes Regarding Population Sample and Methodology ==

#Following screening and risk-benefit analyses, attending physicians refused to peform abortions on 379 women.
#An additional 321 women changed their minds after screening and consultation with their attending physicians.
#British women who do not have abortions were underrepresented in the study. In the study sample 48.3% of the women had abortions, a percentage which is much higher than the abortion rate in the UK. One source reports that only 22.8% of pregnancies in the UK end in abortion.[http://www.mscperu.org/aborto/abortingl/abortos_porcentajepaises.htm]
#All general practitioners reporting were volunteers and were not blind to condition when making their counts. The authors do not disclose the conditions under which volunteers were selected, nor the rate of volunteers among those invited to volunteer, nor any measure or attempts to grade or screen the volunteer physicians relative to age, gender, practice or attitudes regarding abortion, or any other factors which might influence the observer's judgments and reports. This self-selected group of participating physicians may have been biased. Surveys of GP's in Britain find that about 80% report a "pro-choice" perspective which may influence their recommendations for abortion and their subjective interpretation of post-abortion reactions.<ref>Marie Stopes International. General Pracitioners: Attitudes Toward Abortion, 2007. London, UK. www.mariestopes.org.uk</ref> Clearly, those who recommend for abortion would be disinclined to believe that their recommendations were in error. See additional notes below regarding the reluctance of women to return to physicians for follow up care following an abortion.
#GP's reported details every 6 months.
#Data was reported without any actual follow up interviews on the part of the GP. A GP who had not seen a patient in the last six months might therefore simply report that there were no observed psychological problems.
#Information was obtained only from women who volunteered and "agreed to their family doctor supplying anonymous data to the study center." (Research shows that women who expect to deal poorly with an abortion do in fact have more post-abortion problems. Such women might prefer not to be excluded from a follow up study for fear of being exposed to additional stress.)
#Selection bias may have occurred among women volunteers.
#According to the authors, "Had follow-up interviews been required, it is likely that participation would have been greatly reduced; in a pilot survey nearly half of the women who had a termination said that they would refuse to participate if they could not remain anonymous."
#The findings are inconsistent with record based research in Canada which found that 24% of women who had abortions subsequently made visits to psychiatrists compared to 3% in the general population.<ref>''Report of the Committee on the Abortion Law, RF Badgley et al, (Ottawa:Supply and Services, 1977) pp. 313-321''</ref> and record based research in the United States (Reardon, CMAJ).

== Strengths ==

#It was prospective with a large sample size

#The study used four comparison groups

:#those who never requested abortion, including the combination of both those who delivered healthy babies and those who miscarried or had other adverse results;
:#those who had an induced abortion;
:#those who originally requested abortion but changed their minds after consulting with physician; and
:#those who requested termination but for whom physicians refused to perform the abortion after screening and a risk/benefit analysis.

== Weaknesses ==

#This study is not applicable to American experience because British abortion law is much more protective of women's health and requires a level of screening, counseling, and risk benefit analysis not normally found in the United States. In Britain, before an abortion is performed two medical doctors have to evaluate the patient and both agree that the risks of abortion are less than the risk associated with childbirth.<ref>In the United Kingdom, the 1967 abortion act provides that an abortion is legal "if two registered medical practitioners are of the opinion, formed in good faith - a) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or of injury to the physical or mental health of the pregnant woman or any existing children or of her family, greater than if the pregnancy were terminated; or b) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped." The Public General Acts, 1967, p. 2033, (Eng.) (emphasis added)</ref> In the sample used for this study, 700 women (approximately 10% of all those requesting an abortion) did not have an abortion after a risk-benefit screening and consultation with their physicians. It seems apparent that these women were likely at greatest risk of adverse outcomes. Such screening and risk benefit analysis is not typically found in the American context, where instead abortion is generally provided simply on request. As this process of screening by two physicians in Britain may better serve to identify and protect women who are being pressured into unwanted abortions, and would therefore reduce the risk of severe negative psychological reactions among this group of women for whom an unwanted abortion, it is highly likely that British women may be exposed to less psychological trauma associated with unwanted, unsafe, or unnecessary abortions as compared to American women. The potential protective effects of such screening are indicated by research among women who had abortions in the United States in which it was found that 64% reported feeling pressured into the abortion by other people (Rue). In addition to reducing the risk of women being pressured into unwanted abortions by third parties, two physician screening in the UK may also reduce the risk that women will have abortions in violation of their moral views, or their maternal desires, which are two of many statistically validated risk factors for subsequent psychiatric disorders.
#No standardized measures for mental health diagnoses were employed.
#Only the first reported episode of illness was recorded. Though the authors had the data to report on average number of contacts for each illness (a proxy for the duration and degree of the psychological episodes), they did not disclose any measure for duration or severity. The only exception is that they did report psychotic episodes within the first 12 months after delivery or termination...but did not identify prior history of abortion in thise cases. Given the eight year span of the study, the lack of information about when treatments occurred relative to the pregnancy outcome may also have a diluting effect in regard to recency to the stressor.
#The failure to report timing of the first incident of psychiatric illness is underscored by the admission in the discussion that there were indeed "Difference in the timing of admission and the past psychiatric history of women admitted postpartum or post-termination...suggest different underlying mechanisms." If there are indeed "different mechanisms" underlying the difference in timing of psychological illness following pregnancies carried to term versus those aborted, isn't that exactly what should be studied. Instead, they note a difference in timing but don't provide the details. Since proximity to the event supports a casual connection, this is a very serious omission.
#The study spanned, potentially from 1979 thru 1987, with women being introduced into the data set throughout that period. The authors received information about deaths, but they chose not to report deaths . . . which is especially concerning given the elevated rates of suicide attempts and completed suicides among women who abort.
#The study groups are not clearly delineated. Women with a prior history of abortion were mixed into each group. The comparison of women who did not have abortions during the study period, therefore, actually included women with a history of abortion. This is especially important since there is strong evidence that women with a history of abortion have more mental health problems and substance use during and after subsequent pregnancies. It is also unclear what adjustment, if any, was made if women carried to term but subsequently had an abortion.
#By the end of the study, the attrition rate was 65.6% for those had abortions and 57.5% for those who did not (p. 247). Such attrition rates are high and problematic. The fact that they were higher for women who had abortions, which may indicate greater psychological distress, is especially problematic. Those women who are having mental health problems that are trauma-related are precisely the most likely to be in the drop-out pool as they do not wish to go back to a doctor who might bring the incident back to mind. The authors report that "Most loss to follow-up occurred because patients left the practice of the recruiting doctor. Women no longer under observation were slightly younger, of lower parity and higher educational status, and more likely to be single than the original cohort."
#Evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The report of the study itself states: “The major disadvantages of using general practitioners’ reports were the likelihood of under-recognition and an imprecise diagnosis of psychiatric disorder” (p. 247). The authors even remark that the GP's assessments of 'puerperal psychosis' were almost certainly inaccurate.
#The GP's who participated may have also been the same doctors who recommended the abortion to their patients. This involvement may have biased these GP's toward underestimating the negative effects on their patients and overestimating the pre-existing psychological illnesses, which is typically the legal justification for recommending an abortion for social reasons.
#The GPs who participated in this catchment study were volunteers and no attempt was made to control for selection bias. It is possible that many, most, or all volunteered to participate in the study because of a special interest in the issue, and/or because they regularly referred for or performed abortions. The study had no blind or double blind controls and all contributing volunteers were aware of the implications of every judgement they made in preparing their reports. This study therefore falls far short of the objective quality of the record based studies done in Canada, Finland, and the United States, all of which found significantly higher rates of mental health treatments or suicide following abortion. Notably, the authors acknowledge that the risk of errors in diagnostic assessments by recourse to a strong standard of treatment via analysis of "episodes of psychiatric illness leading to hospital admission." In this regard, however, record bases studies are clearly a superior methodology and have clearly shown significantly higher rates of psychiatric hospitalization following abortion compared to delivery and miscarriage.(Reardon, CMAJ)
#Research has indicated that women who have negative abortion reactions are less likely to return to the physician who referred or performed the abortion. For example, a survey of 2,215 abortion patients in 12 abortion clinics in the US found that two out of three women do not return for follow-up appointments at the abortion clinic. (see 'From the Patient’s Perspective - Quality of Abortion Care', Picker Institute. (1999). Boston, MA.) Women embarrassed a past abortion may change providers to avoid facing the stress of seeing the doctor who approved the abortion. In addition, poor followup may result in underestimation of the problem of significant adjustment problems post-abortion. Data in Gilchrist confirms this finding in that by the end of the study, significantly fewer women who aborted. 34.4%, were still under the care of the physician reporting on them comared to 4.4$ of those who did not request an abortion.
#Data regarding prior psychiatric history in this study was reported by a local GP whose may not have had the complete patients’ health records due to lack of comprehensive record linkage in the UK.
#This study had insufficient power to detect significant differences between those women who requested a termination and changed their minds, and those who were refused abortion.
#Only extreme outcomes were measured – drug overdoses rather than substance abuse in general; only diagnosed PTSD but not the more prevalent sub-clinical levels of PTSD or the common practice of PTSD going undiagnosed; psychotic episodes which are rare in the population under either condition.
#There are thousands of case studies of adult women who attribute post-trauma symptoms to their first-trimester abortions, narratives of which are being included in court cases and otherwise publicized. The vast majority of these case studies would not fit into the criteria of extreme problems counted in the Gilchrist 1995 study. Case studies may be inadequate for establishing prevalence or for comparison to the aftermath of other options for dealing with an unplanned pregnancy, but can a statistical study that would exclude those case studies be adequate?
#Women who have miscarriages are known to have higher rates of subsequent psychological distress compared to women who deliver health children. By including women who miscarry with women who carried to term, the study fails to provide a comparison between rates of psychological illness for women who carry to term--which is of course their intent. While miscarriage is an unavoidable risk, the choice women face is between trying to carry to term and having an induced abortion. Therefore, it seems that the comparison between psychological risks of abortion and carrying to term would be relevant to both women and physicians--excluding the risks of psychiatric distress that may follow a miscarriage. While all measures are relevant, the failure to distinguish between successful delivery and miscarriages in this study may have obscured a relative risk of abortion compared to delivery.
#Gilchrist et al. (1995) used outcome-based, convenience sampling (women identified after making a pregnancy decision via selected general practitioners), which prevents estimation of absolute risk in an exposed population; under the criteria of [https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9805a181224c88d888803d906e6c967e2e107829 Dekkers et al. (2012)] this design is more appropriately classified as a case series rather than a cohort study.

{| class="wikitable" style="width:100%;"
! style="width:20%;" | Category
! style="width:50%;" | Key Flaw
! style="width:30%;" | Impact
|-
| '''Study Design'''
| Outcome‑based, post‑decision sampling; convenience GP recruitment
| Cannot calculate absolute risk; not a true cohort
|-
| '''Sampling Bias'''
| Volunteer GPs (~80% pro‑choice); only women consenting to data sharing
| Likely underrepresents distressed women; ideological skew
|-
| '''Attrition'''
| 65.6% loss in abortion group; 57.5% in non‑abortion
| High dropout likely hides adverse outcomes
|-
| '''Diagnosis'''
| GP‑based, no standardized tools; misclassified puerperal psychosis
| Inflated postpartum psychosis; under‑detected other disorders
|-
| '''Data Gaps'''
| No timing of episodes; mortality causes unreported
| Obscures causal links; omits suicide data
|-
| '''Confounding'''
| No control for domestic violence, coercion, moral conflict
| Cannot rule out alternative explanations
|-
| '''Comparisons'''
| Miscarriage lumped with live births; prior abortions in “controls”
| Dilutes differences; masks risks
|-
| '''External Validity'''
| UK’s dual‑physician screening not comparable to US context
| Findings not generalizable
|}

== Table of Claims versus Problems Issues ==

{| class="wikitable" style="width:100%;"
! style="width:40%;" | Gilchrist Claim / Framing
! style="width:60%;" | Critique / Counterpoint
|-
| '''Study is a “prospective cohort” of 13,261 women with unplanned pregnancies'''
| Sampling was ''outcome‑based'' and post‑decision, not exposure‑based. Under Dekkers et al. (2012) criteria, this is a '''case series''', not a true cohort. No inception cohort, no absolute risk calculation possible.
|-
| '''Volunteer GP network ensures broad coverage'''
| 1,509 GPs were self‑selected volunteers; no data on representativeness. Surveys show ~80% of UK GPs are pro‑choice, potentially biasing both referrals and post‑abortion assessments.
|-
| '''Women agreed to anonymous data sharing, ensuring privacy'''
| Self‑selection bias likely — women anticipating distress may have opted out. Those with negative experiences are less likely to return to the referring GP, leading to underreporting.
|-
| '''Follow‑up over years allows long‑term outcome capture'''
| Attrition was extreme: only 34.4% of abortion group and 42.4% of non‑abortion group remained. Dropouts were disproportionately single, educated women — a demographic more likely to abort and potentially more vulnerable to distress.
|-
| '''GP reports capture psychiatric morbidity in the community'''
| Diagnoses made by non‑specialists, without standardized instruments. Authors admit likely over‑diagnosis of puerperal psychosis and under‑recognition of other disorders.
|-
| '''No overall increase in psychiatric morbidity after abortion'''
| Group contamination: “non‑abortion” group included women with prior abortions. Miscarriage cases were lumped with live births, inflating morbidity in the comparison group and masking differences.
|-
| '''Lower risk of psychosis after abortion than postpartum'''
| Inflated postpartum psychosis rates due to misclassification; when hospital admissions are used (a more objective measure), rates are similar.
|-
| '''Higher DSH rates after abortion are due to confounding social factors'''
| No control for key confounders like domestic violence, moral conflict, coercion, or social support. Elevated DSH in women with no prior psychiatric history is a robust finding that cannot be dismissed without data.
|-
| '''Mortality not a focus of the study'''
| Deaths were recorded but causes not reported — omitting suicide data despite known associations in other national datasets (Finland, Canada, US).
|-
| '''Applicable to general abortion–mental health debates'''
| UK’s dual‑physician screening and risk‑benefit analysis likely filter out highest‑risk women. Findings are not generalizable to contexts (e.g., US) where doctors' risks assessments are mandatory.
|-
| '''Large sample size is a strength'''
| Large but non‑representative sample; convenience GP recruitment and patient self‑selection undermine external validity.
|-
| '''Multiple comparison groups improve robustness'''
| Small “refused” and “changed mind” groups lacked statistical power; key differences may have gone undetected.
|}

== Grading of Gilchrist Study ==

=== A Middling Newcastle-Ottawa Scale for Cohort Studies ===
[https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp The Newcastle-Ottawa Scale (NOS)] is commonly used to grade the quality of studies. It is useful for identifying where Gilchrist's study falls short.

The NOQ-Cohort scale evaluation criteria includes three domains; 1) selection of study groups or how well sample represents the target population, (four points); 2) comparability of groups, and account for confounders (two points); and 3) ascertainment of exposure and outcomes, how measured (three points).

In the Case-Control version of the NOS, it is clear that Gilchrist's sample of women, chosen by a group of volunteer general practitioners, is not random nor does it include all eligible cases of women. So it is no representative of all cases. In addition, while women who decided against abortion or were refused abortions, were treated as control groups, NOS requires that "If cases are first occurrence of outcome, then it must explicitly state that controls have no history of this outcome. If cases have new (not necessarily first) occurrence of outcome, then controls with previous occurrences of outcome of interest should not be excluded." But Gilchrist does not control for abortions that may have occurred before or after the index pregnancy event upon which the 1509 volunteer GP's selected and place women into one of the three groups. This means there were at least some women in the two control groups who had prior and/or subsequent abortions.

In the Cohort version NOS, the selection criteria is poor. It is not a representative sample since it relied upon both on volunteer group of GP's and only those women who agreed to have their information shared. As shown in the table below, as judged by this quality index, Gilchrist has a score of 5 out of a possible 9 points.
{| class="wikitable"
|Author
| colspan="4" |Selection
|Comparability
| colspan="3" |Outcome
|Score
|-
|NOQ-Cohort
|Q1
|Q2
|Q3
|Q4
|Q5 & Q6
|Q7
|Q8
|Q9
|
|-
|Gilchrist 1995
|C
|A*
|B*
|B
|A*
|A*
|A*
|C
|5 (max=9)
|}

=== Gilchrist is actually a case series, not a cohort study ===
Although Gilchrist et al. enrolled a non-random, convenience sample of women chosen by a volunteer group GPs who asked a convenience sample of women if they would "agree" to allow their family doctor to provide data to the research team. The GP's ''after'' the women had already sought an abortion and/or from a sample of women they deemed to have not planned their pregnancies at least three months before conceiving.

Because the sampling was from GP's who referred for or provided abortions who non-randomly chose who to invite...and only women who agreed to participate were reported upon (with no data on what percentage of women refused to be reported upon) the study sample is clearly not representative of all women at risk of unplanned pregnancies. Because it does not include sampling at clear inception point (prior to pregnancy, or immediately upon learning one was pregnant) the design is best described as a case series rather than a cohort study.

1) The rule of thumb distinguishing case series from cohort studies: ([https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9805a181224c88d888803d906e6c967e2e107829 Dekkers et a]l.)

* Cohort = sampling based on *exposure* (or a clearly defined inception cohort) wherein participants free of the outcome at baseline, followed over time, so you '''can''' calculate absolute risks or rates. In this case, participants should be identified and followed prior to their becoming pregnant, such as in the example of [https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/abortion-and-mental-health-disorders-evidence-from-a-30year-longitudinal-study/59A90CBF3A58C58B342CBCFFBBFEBD2E Fergusson 2008], a true cohort study which examined mental health effects associated with pregnancy outcomes.
* Case series = sampling based on the *outcome* (or outcome+exposure), so you '''cannot''' calculate an absolute risk for the outcome in an exposed population

2) Why *Gilchrist et al.* is best classified as a **case series**

The subjects utilized were volunteers chosen by a non-random sample of GPs '''after''' they’d already made their pregnancy decision.

* ''Sampling after the decision (outcome-based):'' participants were enrolled *after* the key event (the woman had already decided to terminate or continue). That makes the sampling tied to the outcome/exposure combination and not to a defined exposed population drawn *before* outcomes accrued.
* ''Denominator unclear / no inception cohort:'' because the study did not recruit all women at a defined baseline (e.g., prior to or when a pregnancy was confirmed) you don’t have the full population at risk (the “all exposed” denominator). Without that, you can’t legitimately compute an absolute incidence/risk.
* ''Non-random / convenience GP sampling:'' selecting patients via a non-random set of GPs produces a convenience sample and makes it unlikely the sample represents the population of all women who made each decision — another hallmark of case-series style selection.
* ''What is needed:'' A properly designed study would employ population-based sampling (not convenience GP selection) so the cohort represents the target population. This might be done by using anonymized medical records for an entire population of patients, as has been done in [https://pubmed.ncbi.nlm.nih.gov/14964603/ Coleman 2002], [https://pubmed.ncbi.nlm.nih.gov/12743066/ Reardon 2003], [https://pubmed.ncbi.nlm.nih.gov/37342485/ Studnicki 2023] and [https://pubmed.ncbi.nlm.nih.gov/38771715/ Reardon 2024] and [https://pubmed.ncbi.nlm.nih.gov/39446259/ Studnicki 2024].

3) Why authors (and readers) often misclassify these studies

* ''They see “follow-up” and call it a cohort:'' If subjects are followed for some months after recruitment, many assume “prospective = cohort,” regardless of how recruitment occurred.
* ''Presence of comparison groups is misleading:'' Even if the paper compares women who terminated vs continued, that alone doesn’t make it a cohort — the sampling frame and denominator definition do. Dekkers explicitly notes that a comparison group *doesn’t* define a cohort; sampling method does.
* ''Terminology slippage in clinical journals.'' Words like “prospective consecutive case series” or “cohort” are used loosely.

=== Low grade under the [https://jbi.global/sites/default/files/2021-10/Checklist_for_Case_Series.docx JBI Critical Appraisal Checklist for Case Series] ===
When assessed under the '''Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Series,''' Gilchrist et al. (1995) performs poorly across most domains. The checklist highlights the study’s lack of representativeness, incomplete reporting, and methodological weaknesses.
{| class="wikitable"
|'''JBI Critical Appraisal Item'''
|'''Response (Yes/No/Unclear)'''
|'''Notes informing the Response'''
|-
|1. Were there clear criteria for inclusion in the case series?
|No
|Participants recruited after decision via non-random GP sample; inclusion criteria not systematically applied.
|-
|2. Was the condition measured in a standard, reliable way for all participants?
|Yes
|Psychiatric morbidity assessed using standardized methods (ICD-8 diagnoses)
|-
|3. Were valid methods used for identification of the condition for all participants?
|Unclear
|ICD-8 is a valid classification system, but assessments were made by GPs, not psychiatrists; risk of diagnostic misclassification acknowledged by authors.
|-
|4. Did the case series have consecutive inclusion of participants?
|No
|Recruitment depended on voluntary GP reporting; consecutive inclusion cannot be established
|-
|5. Did the case series have complete inclusion of participants?
|No
|Limited to patients of participating GPs; no attempt to capture a random sample representative of national population.
|-
|6. Was there clear reporting of the demographics of the participants in the study?
|Unclear
|Basic demographics (age, parity, smoking) were used for adjustment but not fully reported in detail.
|-
|7. Was there clear reporting of clinical information of the participants?
|No
|Prior and subsequent abortion history not reported resulting in contamination of the reference groups.
|-
|8. Were the outcomes or follow-up results of cases clearly reported?
|Unclear
|Some outcomes (new psychiatric morbidity) reported, but critical endpoints (timing of events, mortality) and any evaluation of worsening of prior psychiatric morbidity omitted
|-
|9. Was there clear reporting of the presenting site(s) / clinic(s) demographic information?
|No
|No detailed description of GP practice characteristics or catchment areas.
|-
|10. Was statistical analysis appropriate?
|Unclear
|Statistical approach adequate for crude comparisons, but variance estimation, handling of clustering, and small subgroup analyses were methodologically weak.
|}

== Notes that may require further investigation ==

#The study indicates that some dropouts occurred due to death (p 244 col 1), but the authors fail to report the distribution or cause of deaths. Were there for example, an excess number of suicides or accidents among women who had abortions, as has been found in numerous other studies? If so, it appears from the methodology employed that cases of abortion associated suicide would not been included in any of the measure of psychiatric distress. In other words, women who experienced this most sever psychiatric distress would simply have been counted as having no ill effects and as having "dropped out" of the study.
#Ronsmans C, et al. "Mortality in pregnant and nonpregnant women in England and Wales 1997–2002: are pregnant women healthier?" in Lewis G, editor. Why Mothers Die 2000-2002. The Sixth Report of the Confidential Enquiries into Maternal Death in the United Kingdom. London: RCOG Press;2004

:Following the studies of Gissler and Reardon showing lower mortality rates associated with childbirth, the Ronsmans study in Britain confirmed that there is a lower risk of mortality during pregnancy and until one year after birth compared to women without a recent pregnancy. Specifically reporting that:
::"All-cause mortality in women aged 15–44 years was 58.4 deaths per 100,000 women per year.... Surprisingly, however, mortality during pregnancy or within 1 year after birth was between four and five times lower than mortality in women without a recent pregnancy. The rate ratios comparing the pregnancy–42 day and the 43–365 postpartum periods with nonpregnant women were 0.21 and 0.22, respectively."
:Surprisingly, however this government funded inquiry failed to report any data on mortality rates assocaited with abortion. Given the fact that the authors were aware of the findings of Gissler and Reardon, the failure to report an analysis of death rates assocaited with abortion appears to be a deliberate attempt to suppress findings which would confirm previous research.
:While this study fails to report mortality rates relative to pregnancy outcomes, it does report the following citations:
::"In the USA, women who had delivered a live or stillborn infant in the previous year were half as likely to die as women who had not recently delivered." citing Jocums SB, Berg CJ, Entman SS, Mitchell EF. Postdelivery mortality in Tennessee, 1989–1991. Obstet Gynecol 1998; 91: 766–70.
::"In Canada, mortality rates during pregnancy or within 42 days of its termination and between 43 and 225 days postpartum were about half those of nonpregnant women."citing Turner LA, Kramer MS, Liu S. Cause-specific mortality during and after pregnancy and the definition of maternal death. Chronic Dis Can 2002; 23: 1–8.
::"In Finland, the age-adjusted risk of a natural death within a year after birth or a miscarriage was half that of women without a pregnancy." citing Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Pregnancy-associated mortality after birth, spontaneous abortion or induced abortion in Finland, 1987-2000. Am J Ob Gyn 2004; 190:422-427.
::NOT MENTIONED was the following findings from the Gissler 2004 study:
:::The age-adjusted mortality rate for women during pregnancy and within one year of pregnancy termination was 36.7 deaths per 100,000 pregnancies, which was significantly lower than the mortality rate among nonpregnant women 57.0 per 100,000 person-years (RR=0.64, 95% CI 0.58-0.71). '''The mortality was lower after a birth (28.2/100,000) than after a spontaneous (51.9/100,000) or induced abortion (83.1/100,000).''' We observed a significant increase in the risk of death from cerebrovascular diseases after delivery among women aged 15-24 years (RR=4.08, 95% CI 1.58-10.55).

:This three fold higher death rate following abortion is certainly noteworthy and deserving additional investigation. Therefore it is hard to avoid the conclusion that this failure to examine and report on abortion associated deaths in this official British study may reflect a bias in the British research community which may also be reflected in studies regarding the negative pscyhological effects associated with abortion.

== Criticisms by Dr. Philip Ney ==

The study by Gilchrist et al. is based on the concept of an unplanned pregnancy, but the authors make little attempt to define what this is and how it was determined. As every physician knows, people are ambivalent about the inception and conception of almost every pregnancy. There are very few people who actually put much effort into planning a pregnancy, and those are mostly people who use natural family planning methods. Most "plan" only by withdrawing contraception. A recent report of the Alan Guttmacher Institute states that "the proportion of women wanting to become pregnant is extremely low, less than 1 in 5 in industrialised countries."<ref name="gadd">Gadd J. (1995, August 22). Families becoming smaller but many births still unwanted. The Globe and Mail, A8.</ref> If contracepting or not contracepting means whether the pregnancy is planned or not, then there is no basis for making statements about psychiatric sequlae of any pregnancy outcome. Many people change their mind almost in the middle of intercourse about whether they want or plan to have a baby.

The review of the literature is very biased. There are many relevant studies not cited.<ref name="Ney">Ney PG, Fung T, Wickett AR, Beaman_Dodd C. "The Effects of Pregnancy Loss on Women's Health", Social Science and Medicine, 38(9): 1193_1200, 1994.</ref><ref name="Sim">Sim M, Neisser R. "Post_abortive psychosis: a report from two centers. In: The Psychological Aspects of Abortion. Mall D, Watts F (Eds.), University Publications of America, Washington: 1_13, 1979.</ref> Gilchrist et al. do not summarize the references of Doane & Quigley and David et al. correctly.

Since the authors were only using major psychiatric illness classifications, it appears that they did not expect to find or look for the constellation of symptoms and signs now known as the Post_Abortion Syndrome. Post_Abortion Syndrome is now reasonably well recognised and defined, but not included in ICD _ 8.

Although the authors state this study examined a variety of pregnancy outcomes, they did not compare a live birth to a miscarriage or to a stillbirth or to an abortion. They found that the rates of miscarriage were different in the different groups. Miscarriages in the non_abortion group would tend to increase the morbidity because miscarriages do result in higher rates of both physical and psychiatric morbidity. Miscarriages in the abortion group would tend to decrease the apparent morbidity because the effects of the miscarriages are less than the effects of the abortion.

This study relied on general practitioners' assessment of psychiatric morbidity and used the not too precise catagorizations of ICD 8. They diagnosed 225 puerperal psychosis; much higher than the estimated prevalence. The authors found that only 13 of these puerperal psychosis were admitted for treatment, yet almost every case of a puerperal psychosis should be admitted. It seems family physicians were wrong in their diagnosis of puerperal psychosis by a factor of 17. It is likely they were equally out on the other psychiatric diagnosis. The authors did admit that the estimation of puerperal psychosis was too high. The authors found that there is a significantly higher rate of deliberate self_harm (DSH) following an abortion. Eighty_nine (89) % of these were overdoses, which are not difficult to diagnose. If the family physicians were better able to diagnose psychiatric morbidity of other kinds, it is likely that they might have found higher rates in the TOP group.

The authors state that the general practitioners would not have a systematic bias in diagnosing. However, since these general practitioners were referring their patients for TOP, they are less likely to see any adverse effects of a procedure they recommended. Why did the authors not include family physicians who do not make abortion referrals? Physicians of the Christian Medical and Dental Society (CMDS) Canada have a significantly lower rate of abortions and miscarriages in their practices compared to other general practitioners.

The general practitioners' follow up in this study was poor. They lost 65.6% to follow up by the end of the study from the abortion group, and 57.6% from the non_abortion group. The authors state that most of those who were lost to follow up were single, highly educated women. Other studies have shown these women are more likely to have an abortion.

Since those in the refused abortion group were probably refused because of psychiatric problems, psychiatric morbidity in the TOP group should be lower. The authors state that although the DSH was higher in the TOP group, the rates fell more rapidly than in the non_abortion group. They failed to note that the rate the TOP group fell to, i.e. 3.8 was still higher than the baseline group of the non_TOP group, 3.0.

Gilchrist et al. did not show the demographic variables in each group, but state that the data "were indirectly standardised for age, marital status, smoking habit, age at leaving full_time education, gravidity, and previous history of induced abortion at recruitment, since the comparison groups differed on these characteristics." At the end of this article they also state that "the lack of more detailed social information was, however, an important limitation, given the evidence that poor social support increases the risk of psychological morbidity after abortion." They then, to try and explain why DSH is higher in the abortion group, state, "the most likely explanation is that they were at risk because of coexisting social or psychological difficulties associated with both their decision to seek a termination and their subsequent risk of deliberate self_harm." This confusing obfuscation seems to be an attempt to deny the findings that psychiatric morbidity, apart from DSH, was not higher in the group who were refused TOP. The authors state that "risk ratios (RR) were calculated with reference to the group of those who did not request a termination." "The 95% confidence intervals (CI) were calculated using the assumption that the standard deviation of the log of relative risk is equal to the sum of the reciprocals of the observed number of cases in the two groups being compared." This is a questionable assumption, especially in view of the fact that the crude rates for psychosis are; TOP group .1 per 1000, non_TOP group .05 per 1000.

The fact that the psychiatric morbidity of the termination group was not lower than a comparison group of women who requested abortion and changed their minds, effectively demonstrates that abortion is not an effective treatment for psychiatric illness. This study also demonstrates that abortion makes psychiatric conditions of all kinds worse. Yet, without scientific or clinical support, these general practitioners used "previous or anticipated psychiatric illness" as a justification for abortion. This is a practice that the Canadian Psychiatric Association has officially deplored.<ref name="Smith">Smith CM. Canadian Psychiatric Association Bulletin, 13(4): 2_3, Oct. 1981.</ref>

 

== Criticisms by Priscilla Coleman ==
"Incredulously, the Gilchrist et al. (1995) study received a rating of “Good”, when very few controls for confounding 3rd variables were employed, meaning the comparison groups may very well have differed systematically with regard to income, relationship quality including exposure to domestic violence, social support, and other potentially critical factors. Further Gilchrist et al. reported retaining only 34.4% of the termination group and only 43.4% of the group that did not request a termination at the end of the study. No standardized measures for mental health diagnoses were employed and evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The GPs were volunteers and no attempt was made to control for selection bias."

== References ==

  {{reflist}}

Gilchrist

2025-09-19T20:20:37Z

Barb: /* Low grade under the JBI Critical Appraisal Checklist for Case Series */

Gilchrist AC, Hannaford PC, Frank P, Kay CR. Termination of pregnancy and psychiatric morbidity. ''Br J Psychiatry''. 1995;167:243-248.

Please register and contribute to the development of these notes into a narrative by editing the sections or adding sections.

== Abstract ==

''Gilchrist AC, Hannaford PC, Frank P, Kay CR. [http://archpsyc.ama-assn.org/cgi/ijlink?linkType=ABST&journalCode=bjprcpsych&resid=167/2/243 Termination of pregnancy and psychiatric morbidity.]Br J Psychiatry. 1995;167:243-248.''

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 1'''509 volunteer GPs''' after the conclusion of the pregnancy was compared in four groups: women who had an '''induced abortion (6410)''', women who did not request a termination (6151) for a pregnancy the GP determined '''had not been planned at least 3 months before conception''', women who were '''refused a termination (379)''', and '''321 women''' who changed their minds before the termination was performed.

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.

== Additional Key Findings ==

#The findings confirmed that women with prior psychiatric problems are worse off postabortion
#Women with the most fragile mental health prior to an abortion, i.e., psychosis, were worse off postabortion
#The findings indicated that among women with no prior psychiatric history, significantly higher risks of deliberate self harm were observed both after an abortion and after a refused abortion.

 

== Additional Notes Regarding Population Sample and Methodology ==

#Following screening and risk-benefit analyses, attending physicians refused to peform abortions on 379 women.
#An additional 321 women changed their minds after screening and consultation with their attending physicians.
#British women who do not have abortions were underrepresented in the study. In the study sample 48.3% of the women had abortions, a percentage which is much higher than the abortion rate in the UK. One source reports that only 22.8% of pregnancies in the UK end in abortion.[http://www.mscperu.org/aborto/abortingl/abortos_porcentajepaises.htm]
#All general practitioners reporting were volunteers and were not blind to condition when making their counts. The authors do not disclose the conditions under which volunteers were selected, nor the rate of volunteers among those invited to volunteer, nor any measure or attempts to grade or screen the volunteer physicians relative to age, gender, practice or attitudes regarding abortion, or any other factors which might influence the observer's judgments and reports. This self-selected group of participating physicians may have been biased. Surveys of GP's in Britain find that about 80% report a "pro-choice" perspective which may influence their recommendations for abortion and their subjective interpretation of post-abortion reactions.<ref>Marie Stopes International. General Pracitioners: Attitudes Toward Abortion, 2007. London, UK. www.mariestopes.org.uk</ref> Clearly, those who recommend for abortion would be disinclined to believe that their recommendations were in error. See additional notes below regarding the reluctance of women to return to physicians for follow up care following an abortion.
#GP's reported details every 6 months.
#Data was reported without any actual follow up interviews on the part of the GP. A GP who had not seen a patient in the last six months might therefore simply report that there were no observed psychological problems.
#Information was obtained only from women who volunteered and "agreed to their family doctor supplying anonymous data to the study center." (Research shows that women who expect to deal poorly with an abortion do in fact have more post-abortion problems. Such women might prefer not to be excluded from a follow up study for fear of being exposed to additional stress.)
#Selection bias may have occurred among women volunteers.
#According to the authors, "Had follow-up interviews been required, it is likely that participation would have been greatly reduced; in a pilot survey nearly half of the women who had a termination said that they would refuse to participate if they could not remain anonymous."
#The findings are inconsistent with record based research in Canada which found that 24% of women who had abortions subsequently made visits to psychiatrists compared to 3% in the general population.<ref>''Report of the Committee on the Abortion Law, RF Badgley et al, (Ottawa:Supply and Services, 1977) pp. 313-321''</ref> and record based research in the United States (Reardon, CMAJ).

== Strengths ==

#It was prospective with a large sample size

#The study used four comparison groups

:#those who never requested abortion, including the combination of both those who delivered healthy babies and those who miscarried or had other adverse results;
:#those who had an induced abortion;
:#those who originally requested abortion but changed their minds after consulting with physician; and
:#those who requested termination but for whom physicians refused to perform the abortion after screening and a risk/benefit analysis.

== Weaknesses ==

#This study is not applicable to American experience because British abortion law is much more protective of women's health and requires a level of screening, counseling, and risk benefit analysis not normally found in the United States. In Britain, before an abortion is performed two medical doctors have to evaluate the patient and both agree that the risks of abortion are less than the risk associated with childbirth.<ref>In the United Kingdom, the 1967 abortion act provides that an abortion is legal "if two registered medical practitioners are of the opinion, formed in good faith - a) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or of injury to the physical or mental health of the pregnant woman or any existing children or of her family, greater than if the pregnancy were terminated; or b) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped." The Public General Acts, 1967, p. 2033, (Eng.) (emphasis added)</ref> In the sample used for this study, 700 women (approximately 10% of all those requesting an abortion) did not have an abortion after a risk-benefit screening and consultation with their physicians. It seems apparent that these women were likely at greatest risk of adverse outcomes. Such screening and risk benefit analysis is not typically found in the American context, where instead abortion is generally provided simply on request. As this process of screening by two physicians in Britain may better serve to identify and protect women who are being pressured into unwanted abortions, and would therefore reduce the risk of severe negative psychological reactions among this group of women for whom an unwanted abortion, it is highly likely that British women may be exposed to less psychological trauma associated with unwanted, unsafe, or unnecessary abortions as compared to American women. The potential protective effects of such screening are indicated by research among women who had abortions in the United States in which it was found that 64% reported feeling pressured into the abortion by other people (Rue). In addition to reducing the risk of women being pressured into unwanted abortions by third parties, two physician screening in the UK may also reduce the risk that women will have abortions in violation of their moral views, or their maternal desires, which are two of many statistically validated risk factors for subsequent psychiatric disorders.
#No standardized measures for mental health diagnoses were employed.
#Only the first reported episode of illness was recorded. Though the authors had the data to report on average number of contacts for each illness (a proxy for the duration and degree of the psychological episodes), they did not disclose any measure for duration or severity. The only exception is that they did report psychotic episodes within the first 12 months after delivery or termination...but did not identify prior history of abortion in thise cases. Given the eight year span of the study, the lack of information about when treatments occurred relative to the pregnancy outcome may also have a diluting effect in regard to recency to the stressor.
#The failure to report timing of the first incident of psychiatric illness is underscored by the admission in the discussion that there were indeed "Difference in the timing of admission and the past psychiatric history of women admitted postpartum or post-termination...suggest different underlying mechanisms." If there are indeed "different mechanisms" underlying the difference in timing of psychological illness following pregnancies carried to term versus those aborted, isn't that exactly what should be studied. Instead, they note a difference in timing but don't provide the details. Since proximity to the event supports a casual connection, this is a very serious omission.
#The study spanned, potentially from 1979 thru 1987, with women being introduced into the data set throughout that period. The authors received information about deaths, but they chose not to report deaths . . . which is especially concerning given the elevated rates of suicide attempts and completed suicides among women who abort.
#The study groups are not clearly delineated. Women with a prior history of abortion were mixed into each group. The comparison of women who did not have abortions during the study period, therefore, actually included women with a history of abortion. This is especially important since there is strong evidence that women with a history of abortion have more mental health problems and substance use during and after subsequent pregnancies. It is also unclear what adjustment, if any, was made if women carried to term but subsequently had an abortion.
#By the end of the study, the attrition rate was 65.6% for those had abortions and 57.5% for those who did not (p. 247). Such attrition rates are high and problematic. The fact that they were higher for women who had abortions, which may indicate greater psychological distress, is especially problematic. Those women who are having mental health problems that are trauma-related are precisely the most likely to be in the drop-out pool as they do not wish to go back to a doctor who might bring the incident back to mind. The authors report that "Most loss to follow-up occurred because patients left the practice of the recruiting doctor. Women no longer under observation were slightly younger, of lower parity and higher educational status, and more likely to be single than the original cohort."
#Evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The report of the study itself states: “The major disadvantages of using general practitioners’ reports were the likelihood of under-recognition and an imprecise diagnosis of psychiatric disorder” (p. 247). The authors even remark that the GP's assessments of 'puerperal psychosis' were almost certainly inaccurate.
#The GP's who participated may have also been the same doctors who recommended the abortion to their patients. This involvement may have biased these GP's toward underestimating the negative effects on their patients and overestimating the pre-existing psychological illnesses, which is typically the legal justification for recommending an abortion for social reasons.
#The GPs who participated in this catchment study were volunteers and no attempt was made to control for selection bias. It is possible that many, most, or all volunteered to participate in the study because of a special interest in the issue, and/or because they regularly referred for or performed abortions. The study had no blind or double blind controls and all contributing volunteers were aware of the implications of every judgement they made in preparing their reports. This study therefore falls far short of the objective quality of the record based studies done in Canada, Finland, and the United States, all of which found significantly higher rates of mental health treatments or suicide following abortion. Notably, the authors acknowledge that the risk of errors in diagnostic assessments by recourse to a strong standard of treatment via analysis of "episodes of psychiatric illness leading to hospital admission." In this regard, however, record bases studies are clearly a superior methodology and have clearly shown significantly higher rates of psychiatric hospitalization following abortion compared to delivery and miscarriage.(Reardon, CMAJ)
#Research has indicated that women who have negative abortion reactions are less likely to return to the physician who referred or performed the abortion. For example, a survey of 2,215 abortion patients in 12 abortion clinics in the US found that two out of three women do not return for follow-up appointments at the abortion clinic. (see 'From the Patient’s Perspective - Quality of Abortion Care', Picker Institute. (1999). Boston, MA.) Women embarrassed a past abortion may change providers to avoid facing the stress of seeing the doctor who approved the abortion. In addition, poor followup may result in underestimation of the problem of significant adjustment problems post-abortion. Data in Gilchrist confirms this finding in that by the end of the study, significantly fewer women who aborted. 34.4%, were still under the care of the physician reporting on them comared to 4.4$ of those who did not request an abortion.
#Data regarding prior psychiatric history in this study was reported by a local GP whose may not have had the complete patients’ health records due to lack of comprehensive record linkage in the UK.
#This study had insufficient power to detect significant differences between those women who requested a termination and changed their minds, and those who were refused abortion.
#Only extreme outcomes were measured – drug overdoses rather than substance abuse in general; only diagnosed PTSD but not the more prevalent sub-clinical levels of PTSD or the common practice of PTSD going undiagnosed; psychotic episodes which are rare in the population under either condition.
#There are thousands of case studies of adult women who attribute post-trauma symptoms to their first-trimester abortions, narratives of which are being included in court cases and otherwise publicized. The vast majority of these case studies would not fit into the criteria of extreme problems counted in the Gilchrist 1995 study. Case studies may be inadequate for establishing prevalence or for comparison to the aftermath of other options for dealing with an unplanned pregnancy, but can a statistical study that would exclude those case studies be adequate?
#Women who have miscarriages are known to have higher rates of subsequent psychological distress compared to women who deliver health children. By including women who miscarry with women who carried to term, the study fails to provide a comparison between rates of psychological illness for women who carry to term--which is of course their intent. While miscarriage is an unavoidable risk, the choice women face is between trying to carry to term and having an induced abortion. Therefore, it seems that the comparison between psychological risks of abortion and carrying to term would be relevant to both women and physicians--excluding the risks of psychiatric distress that may follow a miscarriage. While all measures are relevant, the failure to distinguish between successful delivery and miscarriages in this study may have obscured a relative risk of abortion compared to delivery.
#Gilchrist et al. (1995) used outcome-based, convenience sampling (women identified after making a pregnancy decision via selected general practitioners), which prevents estimation of absolute risk in an exposed population; under the criteria of [https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9805a181224c88d888803d906e6c967e2e107829 Dekkers et al. (2012)] this design is more appropriately classified as a case series rather than a cohort study.

{| class="wikitable" style="width:100%;"
! style="width:20%;" | Category
! style="width:50%;" | Key Flaw
! style="width:30%;" | Impact
|-
| '''Study Design'''
| Outcome‑based, post‑decision sampling; convenience GP recruitment
| Cannot calculate absolute risk; not a true cohort
|-
| '''Sampling Bias'''
| Volunteer GPs (~80% pro‑choice); only women consenting to data sharing
| Likely underrepresents distressed women; ideological skew
|-
| '''Attrition'''
| 65.6% loss in abortion group; 57.5% in non‑abortion
| High dropout likely hides adverse outcomes
|-
| '''Diagnosis'''
| GP‑based, no standardized tools; misclassified puerperal psychosis
| Inflated postpartum psychosis; under‑detected other disorders
|-
| '''Data Gaps'''
| No timing of episodes; mortality causes unreported
| Obscures causal links; omits suicide data
|-
| '''Confounding'''
| No control for domestic violence, coercion, moral conflict
| Cannot rule out alternative explanations
|-
| '''Comparisons'''
| Miscarriage lumped with live births; prior abortions in “controls”
| Dilutes differences; masks risks
|-
| '''External Validity'''
| UK’s dual‑physician screening not comparable to US context
| Findings not generalizable
|}

== Table of Claims versus Problems Issues ==

{| class="wikitable" style="width:100%;"
! style="width:40%;" | Gilchrist Claim / Framing
! style="width:60%;" | Critique / Counterpoint
|-
| '''Study is a “prospective cohort” of 13,261 women with unplanned pregnancies'''
| Sampling was ''outcome‑based'' and post‑decision, not exposure‑based. Under Dekkers et al. (2012) criteria, this is a '''case series''', not a true cohort. No inception cohort, no absolute risk calculation possible.
|-
| '''Volunteer GP network ensures broad coverage'''
| 1,509 GPs were self‑selected volunteers; no data on representativeness. Surveys show ~80% of UK GPs are pro‑choice, potentially biasing both referrals and post‑abortion assessments.
|-
| '''Women agreed to anonymous data sharing, ensuring privacy'''
| Self‑selection bias likely — women anticipating distress may have opted out. Those with negative experiences are less likely to return to the referring GP, leading to underreporting.
|-
| '''Follow‑up over years allows long‑term outcome capture'''
| Attrition was extreme: only 34.4% of abortion group and 42.4% of non‑abortion group remained. Dropouts were disproportionately single, educated women — a demographic more likely to abort and potentially more vulnerable to distress.
|-
| '''GP reports capture psychiatric morbidity in the community'''
| Diagnoses made by non‑specialists, without standardized instruments. Authors admit likely over‑diagnosis of puerperal psychosis and under‑recognition of other disorders.
|-
| '''No overall increase in psychiatric morbidity after abortion'''
| Group contamination: “non‑abortion” group included women with prior abortions. Miscarriage cases were lumped with live births, inflating morbidity in the comparison group and masking differences.
|-
| '''Lower risk of psychosis after abortion than postpartum'''
| Inflated postpartum psychosis rates due to misclassification; when hospital admissions are used (a more objective measure), rates are similar.
|-
| '''Higher DSH rates after abortion are due to confounding social factors'''
| No control for key confounders like domestic violence, moral conflict, coercion, or social support. Elevated DSH in women with no prior psychiatric history is a robust finding that cannot be dismissed without data.
|-
| '''Mortality not a focus of the study'''
| Deaths were recorded but causes not reported — omitting suicide data despite known associations in other national datasets (Finland, Canada, US).
|-
| '''Applicable to general abortion–mental health debates'''
| UK’s dual‑physician screening and risk‑benefit analysis likely filter out highest‑risk women. Findings are not generalizable to contexts (e.g., US) where doctors' risks assessments are mandatory.
|-
| '''Large sample size is a strength'''
| Large but non‑representative sample; convenience GP recruitment and patient self‑selection undermine external validity.
|-
| '''Multiple comparison groups improve robustness'''
| Small “refused” and “changed mind” groups lacked statistical power; key differences may have gone undetected.
|}

== Grading of Gilchrist Study ==

=== A Middling Newcastle-Ottawa Scale for Cohort Studies ===
[https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp The Newcastle-Ottawa Scale (NOS)] is commonly used to grade the quality of studies. It is useful for identifying where Gilchrist's study falls short.

The NOQ-Cohort scale evaluation criteria includes three domains; 1) selection of study groups or how well sample represents the target population, (four points); 2) comparability of groups, and account for confounders (two points); and 3) ascertainment of exposure and outcomes, how measured (three points).

In the Case-Control version of the NOS, it is clear that Gilchrist's sample of women, chosen by a group of volunteer general practitioners, is not random nor does it include all eligible cases of women. So it is no representative of all cases. In addition, while women who decided against abortion or were refused abortions, were treated as control groups, NOS requires that "If cases are first occurrence of outcome, then it must explicitly state that controls have no history of this outcome. If cases have new (not necessarily first) occurrence of outcome, then controls with previous occurrences of outcome of interest should not be excluded." But Gilchrist does not control for abortions that may have occurred before or after the index pregnancy event upon which the 1509 volunteer GP's selected and place women into one of the three groups. This means there were at least some women in the two control groups who had prior and/or subsequent abortions.

In the Cohort version NOS, the selection criteria is poor. It is not a representative sample since it relied upon both on volunteer group of GP's and only those women who agreed to have their information shared. As shown in the table below, as judged by this quality index, Gilchrist has a score of 5 out of a possible 9 points.
{| class="wikitable"
|Author
| colspan="4" |Selection
|Comparability
| colspan="3" |Outcome
|Score
|-
|NOQ-Cohort
|Q1
|Q2
|Q3
|Q4
|Q5 & Q6
|Q7
|Q8
|Q9
|
|-
|Gilchrist 1995
|C
|A*
|B*
|B
|A*
|A*
|A*
|C
|5 (max=9)
|}

=== Gilchrist is actually a case series, not a cohort study ===
Although Gilchrist et al. enrolled a non-random, convenience sample of women chosen by a volunteer group GPs who asked a convenience sample of women if they would "agree" to allow their family doctor to provide data to the research team. The GP's ''after'' the women had already sought an abortion and/or from a sample of women they deemed to have not planned their pregnancies at least three months before conceiving.

Because the sampling was from GP's who referred for or provided abortions who non-randomly chose who to invite...and only women who agreed to participate were reported upon (with no data on what percentage of women refused to be reported upon) the study sample is clearly not representative of all women at risk of unplanned pregnancies. Because it does not include sampling at clear inception point (prior to pregnancy, or immediately upon learning one was pregnant) the design is best described as a case series rather than a cohort study.

1) The rule of thumb distinguishing case series from cohort studies: ([https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9805a181224c88d888803d906e6c967e2e107829 Dekkers et a]l.)

* Cohort = sampling based on *exposure* (or a clearly defined inception cohort) wherein participants free of the outcome at baseline, followed over time, so you '''can''' calculate absolute risks or rates. In this case, participants should be identified and followed prior to their becoming pregnant, such as in the example of [https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/abortion-and-mental-health-disorders-evidence-from-a-30year-longitudinal-study/59A90CBF3A58C58B342CBCFFBBFEBD2E Fergusson 2008], a true cohort study which examined mental health effects associated with pregnancy outcomes.
* Case series = sampling based on the *outcome* (or outcome+exposure), so you '''cannot''' calculate an absolute risk for the outcome in an exposed population

2) Why *Gilchrist et al.* is best classified as a **case series**

The subjects utilized were volunteers chosen by a non-random sample of GPs '''after''' they’d already made their pregnancy decision.

* ''Sampling after the decision (outcome-based):'' participants were enrolled *after* the key event (the woman had already decided to terminate or continue). That makes the sampling tied to the outcome/exposure combination and not to a defined exposed population drawn *before* outcomes accrued.
* ''Denominator unclear / no inception cohort:'' because the study did not recruit all women at a defined baseline (e.g., prior to or when a pregnancy was confirmed) you don’t have the full population at risk (the “all exposed” denominator). Without that, you can’t legitimately compute an absolute incidence/risk.
* ''Non-random / convenience GP sampling:'' selecting patients via a non-random set of GPs produces a convenience sample and makes it unlikely the sample represents the population of all women who made each decision — another hallmark of case-series style selection.
* ''What is needed:'' A properly designed study would employ population-based sampling (not convenience GP selection) so the cohort represents the target population. This might be done by using anonymized medical records for an entire population of patients, as has been done in [https://pubmed.ncbi.nlm.nih.gov/14964603/ Coleman 2002], [https://pubmed.ncbi.nlm.nih.gov/12743066/ Reardon 2003], [https://pubmed.ncbi.nlm.nih.gov/37342485/ Studnicki 2023] and [https://pubmed.ncbi.nlm.nih.gov/38771715/ Reardon 2024] and [https://pubmed.ncbi.nlm.nih.gov/39446259/ Studnicki 2024].

3) Why authors (and readers) often misclassify these studies

* ''They see “follow-up” and call it a cohort:'' If subjects are followed for some months after recruitment, many assume “prospective = cohort,” regardless of how recruitment occurred.
* ''Presence of comparison groups is misleading:'' Even if the paper compares women who terminated vs continued, that alone doesn’t make it a cohort — the sampling frame and denominator definition do. Dekkers explicitly notes that a comparison group *doesn’t* define a cohort; sampling method does.
* ''Terminology slippage in clinical journals.'' Words like “prospective consecutive case series” or “cohort” are used loosely.

=== Low grade under the [https://jbi.global/sites/default/files/2021-10/Checklist_for_Case_Series.docx JBI Critical Appraisal Checklist for Case Series] ===
When an appropriate checklist is used to evaluate Gilchrist as a case series study, it becomes increasingly clear that it cannot be rated as a high quality study.
{| class="wikitable"
|'''JBI Critical Appraisal Item'''
|'''Response (Yes/No/Unclear)'''
|'''Notes informing the Response'''
|-
|1. Were there clear criteria for inclusion in the case series?
|No
|Participants recruited after decision via non-random GP sample; inclusion criteria not systematically applied.
|-
|2. Was the condition measured in a standard, reliable way for all participants?
|Yes
|Psychiatric morbidity assessed using standardized methods (ICD-8 diagnoses)
|-
|3. Were valid methods used for identification of the condition for all participants?
|Unclear
|Diagnosis/measurement tools for psychiatric morbidity were valid and appropriate (ICD-8 diagnoses were reported by GP's not psychiatrists)
|-
|4. Did the case series have consecutive inclusion of participants?
|No
|Convenience GP selection precludes consecutive inclusion.
|-
|5. Did the case series have complete inclusion of participants?
|No
|Sample limited to selected GPs; incomplete coverage of all eligible cases.
|-
|6. Was there clear reporting of the demographics of the participants in the study?
|Unclear
|Age, parity, and other sociodemographic characteristics were not reported but were used in calculating adjusted RR.
|-
|7. Was there clear reporting of clinical information of the participants?
|No
|Prior and subsequent abortion history not reported, which may have impacted mental health and adulterated control groups
|-
|8. Were the outcomes or follow-up results of cases clearly reported?
|Unclear
|Reported follow-up outcomes for psychiatric morbidity over the study period.
|-
|9. Was there clear reporting of the presenting site(s) / clinic(s) demographic information?
|No
|No detailed description of GP practice characteristics or catchment areas.
|-
|10. Was statistical analysis appropriate?
|Unclear
|Statistical analysis suitable for descriptive comparisons,. But sample size too small for selfharm analysis
|}

== Notes that may require further investigation ==

#The study indicates that some dropouts occurred due to death (p 244 col 1), but the authors fail to report the distribution or cause of deaths. Were there for example, an excess number of suicides or accidents among women who had abortions, as has been found in numerous other studies? If so, it appears from the methodology employed that cases of abortion associated suicide would not been included in any of the measure of psychiatric distress. In other words, women who experienced this most sever psychiatric distress would simply have been counted as having no ill effects and as having "dropped out" of the study.
#Ronsmans C, et al. "Mortality in pregnant and nonpregnant women in England and Wales 1997–2002: are pregnant women healthier?" in Lewis G, editor. Why Mothers Die 2000-2002. The Sixth Report of the Confidential Enquiries into Maternal Death in the United Kingdom. London: RCOG Press;2004

:Following the studies of Gissler and Reardon showing lower mortality rates associated with childbirth, the Ronsmans study in Britain confirmed that there is a lower risk of mortality during pregnancy and until one year after birth compared to women without a recent pregnancy. Specifically reporting that:
::"All-cause mortality in women aged 15–44 years was 58.4 deaths per 100,000 women per year.... Surprisingly, however, mortality during pregnancy or within 1 year after birth was between four and five times lower than mortality in women without a recent pregnancy. The rate ratios comparing the pregnancy–42 day and the 43–365 postpartum periods with nonpregnant women were 0.21 and 0.22, respectively."
:Surprisingly, however this government funded inquiry failed to report any data on mortality rates assocaited with abortion. Given the fact that the authors were aware of the findings of Gissler and Reardon, the failure to report an analysis of death rates assocaited with abortion appears to be a deliberate attempt to suppress findings which would confirm previous research.
:While this study fails to report mortality rates relative to pregnancy outcomes, it does report the following citations:
::"In the USA, women who had delivered a live or stillborn infant in the previous year were half as likely to die as women who had not recently delivered." citing Jocums SB, Berg CJ, Entman SS, Mitchell EF. Postdelivery mortality in Tennessee, 1989–1991. Obstet Gynecol 1998; 91: 766–70.
::"In Canada, mortality rates during pregnancy or within 42 days of its termination and between 43 and 225 days postpartum were about half those of nonpregnant women."citing Turner LA, Kramer MS, Liu S. Cause-specific mortality during and after pregnancy and the definition of maternal death. Chronic Dis Can 2002; 23: 1–8.
::"In Finland, the age-adjusted risk of a natural death within a year after birth or a miscarriage was half that of women without a pregnancy." citing Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Pregnancy-associated mortality after birth, spontaneous abortion or induced abortion in Finland, 1987-2000. Am J Ob Gyn 2004; 190:422-427.
::NOT MENTIONED was the following findings from the Gissler 2004 study:
:::The age-adjusted mortality rate for women during pregnancy and within one year of pregnancy termination was 36.7 deaths per 100,000 pregnancies, which was significantly lower than the mortality rate among nonpregnant women 57.0 per 100,000 person-years (RR=0.64, 95% CI 0.58-0.71). '''The mortality was lower after a birth (28.2/100,000) than after a spontaneous (51.9/100,000) or induced abortion (83.1/100,000).''' We observed a significant increase in the risk of death from cerebrovascular diseases after delivery among women aged 15-24 years (RR=4.08, 95% CI 1.58-10.55).

:This three fold higher death rate following abortion is certainly noteworthy and deserving additional investigation. Therefore it is hard to avoid the conclusion that this failure to examine and report on abortion associated deaths in this official British study may reflect a bias in the British research community which may also be reflected in studies regarding the negative pscyhological effects associated with abortion.

== Criticisms by Dr. Philip Ney ==

The study by Gilchrist et al. is based on the concept of an unplanned pregnancy, but the authors make little attempt to define what this is and how it was determined. As every physician knows, people are ambivalent about the inception and conception of almost every pregnancy. There are very few people who actually put much effort into planning a pregnancy, and those are mostly people who use natural family planning methods. Most "plan" only by withdrawing contraception. A recent report of the Alan Guttmacher Institute states that "the proportion of women wanting to become pregnant is extremely low, less than 1 in 5 in industrialised countries."<ref name="gadd">Gadd J. (1995, August 22). Families becoming smaller but many births still unwanted. The Globe and Mail, A8.</ref> If contracepting or not contracepting means whether the pregnancy is planned or not, then there is no basis for making statements about psychiatric sequlae of any pregnancy outcome. Many people change their mind almost in the middle of intercourse about whether they want or plan to have a baby.

The review of the literature is very biased. There are many relevant studies not cited.<ref name="Ney">Ney PG, Fung T, Wickett AR, Beaman_Dodd C. "The Effects of Pregnancy Loss on Women's Health", Social Science and Medicine, 38(9): 1193_1200, 1994.</ref><ref name="Sim">Sim M, Neisser R. "Post_abortive psychosis: a report from two centers. In: The Psychological Aspects of Abortion. Mall D, Watts F (Eds.), University Publications of America, Washington: 1_13, 1979.</ref> Gilchrist et al. do not summarize the references of Doane & Quigley and David et al. correctly.

Since the authors were only using major psychiatric illness classifications, it appears that they did not expect to find or look for the constellation of symptoms and signs now known as the Post_Abortion Syndrome. Post_Abortion Syndrome is now reasonably well recognised and defined, but not included in ICD _ 8.

Although the authors state this study examined a variety of pregnancy outcomes, they did not compare a live birth to a miscarriage or to a stillbirth or to an abortion. They found that the rates of miscarriage were different in the different groups. Miscarriages in the non_abortion group would tend to increase the morbidity because miscarriages do result in higher rates of both physical and psychiatric morbidity. Miscarriages in the abortion group would tend to decrease the apparent morbidity because the effects of the miscarriages are less than the effects of the abortion.

This study relied on general practitioners' assessment of psychiatric morbidity and used the not too precise catagorizations of ICD 8. They diagnosed 225 puerperal psychosis; much higher than the estimated prevalence. The authors found that only 13 of these puerperal psychosis were admitted for treatment, yet almost every case of a puerperal psychosis should be admitted. It seems family physicians were wrong in their diagnosis of puerperal psychosis by a factor of 17. It is likely they were equally out on the other psychiatric diagnosis. The authors did admit that the estimation of puerperal psychosis was too high. The authors found that there is a significantly higher rate of deliberate self_harm (DSH) following an abortion. Eighty_nine (89) % of these were overdoses, which are not difficult to diagnose. If the family physicians were better able to diagnose psychiatric morbidity of other kinds, it is likely that they might have found higher rates in the TOP group.

The authors state that the general practitioners would not have a systematic bias in diagnosing. However, since these general practitioners were referring their patients for TOP, they are less likely to see any adverse effects of a procedure they recommended. Why did the authors not include family physicians who do not make abortion referrals? Physicians of the Christian Medical and Dental Society (CMDS) Canada have a significantly lower rate of abortions and miscarriages in their practices compared to other general practitioners.

The general practitioners' follow up in this study was poor. They lost 65.6% to follow up by the end of the study from the abortion group, and 57.6% from the non_abortion group. The authors state that most of those who were lost to follow up were single, highly educated women. Other studies have shown these women are more likely to have an abortion.

Since those in the refused abortion group were probably refused because of psychiatric problems, psychiatric morbidity in the TOP group should be lower. The authors state that although the DSH was higher in the TOP group, the rates fell more rapidly than in the non_abortion group. They failed to note that the rate the TOP group fell to, i.e. 3.8 was still higher than the baseline group of the non_TOP group, 3.0.

Gilchrist et al. did not show the demographic variables in each group, but state that the data "were indirectly standardised for age, marital status, smoking habit, age at leaving full_time education, gravidity, and previous history of induced abortion at recruitment, since the comparison groups differed on these characteristics." At the end of this article they also state that "the lack of more detailed social information was, however, an important limitation, given the evidence that poor social support increases the risk of psychological morbidity after abortion." They then, to try and explain why DSH is higher in the abortion group, state, "the most likely explanation is that they were at risk because of coexisting social or psychological difficulties associated with both their decision to seek a termination and their subsequent risk of deliberate self_harm." This confusing obfuscation seems to be an attempt to deny the findings that psychiatric morbidity, apart from DSH, was not higher in the group who were refused TOP. The authors state that "risk ratios (RR) were calculated with reference to the group of those who did not request a termination." "The 95% confidence intervals (CI) were calculated using the assumption that the standard deviation of the log of relative risk is equal to the sum of the reciprocals of the observed number of cases in the two groups being compared." This is a questionable assumption, especially in view of the fact that the crude rates for psychosis are; TOP group .1 per 1000, non_TOP group .05 per 1000.

The fact that the psychiatric morbidity of the termination group was not lower than a comparison group of women who requested abortion and changed their minds, effectively demonstrates that abortion is not an effective treatment for psychiatric illness. This study also demonstrates that abortion makes psychiatric conditions of all kinds worse. Yet, without scientific or clinical support, these general practitioners used "previous or anticipated psychiatric illness" as a justification for abortion. This is a practice that the Canadian Psychiatric Association has officially deplored.<ref name="Smith">Smith CM. Canadian Psychiatric Association Bulletin, 13(4): 2_3, Oct. 1981.</ref>

 

== Criticisms by Priscilla Coleman ==
"Incredulously, the Gilchrist et al. (1995) study received a rating of “Good”, when very few controls for confounding 3rd variables were employed, meaning the comparison groups may very well have differed systematically with regard to income, relationship quality including exposure to domestic violence, social support, and other potentially critical factors. Further Gilchrist et al. reported retaining only 34.4% of the termination group and only 43.4% of the group that did not request a termination at the end of the study. No standardized measures for mental health diagnoses were employed and evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The GPs were volunteers and no attempt was made to control for selection bias."

== References ==

  {{reflist}}

Gilchrist

2025-09-19T20:17:25Z

Barb: /* A Middling Newcastle-Ottawa Scale for Cohort Studies */

Gilchrist AC, Hannaford PC, Frank P, Kay CR. Termination of pregnancy and psychiatric morbidity. ''Br J Psychiatry''. 1995;167:243-248.

Please register and contribute to the development of these notes into a narrative by editing the sections or adding sections.

== Abstract ==

''Gilchrist AC, Hannaford PC, Frank P, Kay CR. [http://archpsyc.ama-assn.org/cgi/ijlink?linkType=ABST&journalCode=bjprcpsych&resid=167/2/243 Termination of pregnancy and psychiatric morbidity.]Br J Psychiatry. 1995;167:243-248.''

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 1'''509 volunteer GPs''' after the conclusion of the pregnancy was compared in four groups: women who had an '''induced abortion (6410)''', women who did not request a termination (6151) for a pregnancy the GP determined '''had not been planned at least 3 months before conception''', women who were '''refused a termination (379)''', and '''321 women''' who changed their minds before the termination was performed.

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.

== Additional Key Findings ==

#The findings confirmed that women with prior psychiatric problems are worse off postabortion
#Women with the most fragile mental health prior to an abortion, i.e., psychosis, were worse off postabortion
#The findings indicated that among women with no prior psychiatric history, significantly higher risks of deliberate self harm were observed both after an abortion and after a refused abortion.

 

== Additional Notes Regarding Population Sample and Methodology ==

#Following screening and risk-benefit analyses, attending physicians refused to peform abortions on 379 women.
#An additional 321 women changed their minds after screening and consultation with their attending physicians.
#British women who do not have abortions were underrepresented in the study. In the study sample 48.3% of the women had abortions, a percentage which is much higher than the abortion rate in the UK. One source reports that only 22.8% of pregnancies in the UK end in abortion.[http://www.mscperu.org/aborto/abortingl/abortos_porcentajepaises.htm]
#All general practitioners reporting were volunteers and were not blind to condition when making their counts. The authors do not disclose the conditions under which volunteers were selected, nor the rate of volunteers among those invited to volunteer, nor any measure or attempts to grade or screen the volunteer physicians relative to age, gender, practice or attitudes regarding abortion, or any other factors which might influence the observer's judgments and reports. This self-selected group of participating physicians may have been biased. Surveys of GP's in Britain find that about 80% report a "pro-choice" perspective which may influence their recommendations for abortion and their subjective interpretation of post-abortion reactions.<ref>Marie Stopes International. General Pracitioners: Attitudes Toward Abortion, 2007. London, UK. www.mariestopes.org.uk</ref> Clearly, those who recommend for abortion would be disinclined to believe that their recommendations were in error. See additional notes below regarding the reluctance of women to return to physicians for follow up care following an abortion.
#GP's reported details every 6 months.
#Data was reported without any actual follow up interviews on the part of the GP. A GP who had not seen a patient in the last six months might therefore simply report that there were no observed psychological problems.
#Information was obtained only from women who volunteered and "agreed to their family doctor supplying anonymous data to the study center." (Research shows that women who expect to deal poorly with an abortion do in fact have more post-abortion problems. Such women might prefer not to be excluded from a follow up study for fear of being exposed to additional stress.)
#Selection bias may have occurred among women volunteers.
#According to the authors, "Had follow-up interviews been required, it is likely that participation would have been greatly reduced; in a pilot survey nearly half of the women who had a termination said that they would refuse to participate if they could not remain anonymous."
#The findings are inconsistent with record based research in Canada which found that 24% of women who had abortions subsequently made visits to psychiatrists compared to 3% in the general population.<ref>''Report of the Committee on the Abortion Law, RF Badgley et al, (Ottawa:Supply and Services, 1977) pp. 313-321''</ref> and record based research in the United States (Reardon, CMAJ).

== Strengths ==

#It was prospective with a large sample size

#The study used four comparison groups

:#those who never requested abortion, including the combination of both those who delivered healthy babies and those who miscarried or had other adverse results;
:#those who had an induced abortion;
:#those who originally requested abortion but changed their minds after consulting with physician; and
:#those who requested termination but for whom physicians refused to perform the abortion after screening and a risk/benefit analysis.

== Weaknesses ==

#This study is not applicable to American experience because British abortion law is much more protective of women's health and requires a level of screening, counseling, and risk benefit analysis not normally found in the United States. In Britain, before an abortion is performed two medical doctors have to evaluate the patient and both agree that the risks of abortion are less than the risk associated with childbirth.<ref>In the United Kingdom, the 1967 abortion act provides that an abortion is legal "if two registered medical practitioners are of the opinion, formed in good faith - a) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or of injury to the physical or mental health of the pregnant woman or any existing children or of her family, greater than if the pregnancy were terminated; or b) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped." The Public General Acts, 1967, p. 2033, (Eng.) (emphasis added)</ref> In the sample used for this study, 700 women (approximately 10% of all those requesting an abortion) did not have an abortion after a risk-benefit screening and consultation with their physicians. It seems apparent that these women were likely at greatest risk of adverse outcomes. Such screening and risk benefit analysis is not typically found in the American context, where instead abortion is generally provided simply on request. As this process of screening by two physicians in Britain may better serve to identify and protect women who are being pressured into unwanted abortions, and would therefore reduce the risk of severe negative psychological reactions among this group of women for whom an unwanted abortion, it is highly likely that British women may be exposed to less psychological trauma associated with unwanted, unsafe, or unnecessary abortions as compared to American women. The potential protective effects of such screening are indicated by research among women who had abortions in the United States in which it was found that 64% reported feeling pressured into the abortion by other people (Rue). In addition to reducing the risk of women being pressured into unwanted abortions by third parties, two physician screening in the UK may also reduce the risk that women will have abortions in violation of their moral views, or their maternal desires, which are two of many statistically validated risk factors for subsequent psychiatric disorders.
#No standardized measures for mental health diagnoses were employed.
#Only the first reported episode of illness was recorded. Though the authors had the data to report on average number of contacts for each illness (a proxy for the duration and degree of the psychological episodes), they did not disclose any measure for duration or severity. The only exception is that they did report psychotic episodes within the first 12 months after delivery or termination...but did not identify prior history of abortion in thise cases. Given the eight year span of the study, the lack of information about when treatments occurred relative to the pregnancy outcome may also have a diluting effect in regard to recency to the stressor.
#The failure to report timing of the first incident of psychiatric illness is underscored by the admission in the discussion that there were indeed "Difference in the timing of admission and the past psychiatric history of women admitted postpartum or post-termination...suggest different underlying mechanisms." If there are indeed "different mechanisms" underlying the difference in timing of psychological illness following pregnancies carried to term versus those aborted, isn't that exactly what should be studied. Instead, they note a difference in timing but don't provide the details. Since proximity to the event supports a casual connection, this is a very serious omission.
#The study spanned, potentially from 1979 thru 1987, with women being introduced into the data set throughout that period. The authors received information about deaths, but they chose not to report deaths . . . which is especially concerning given the elevated rates of suicide attempts and completed suicides among women who abort.
#The study groups are not clearly delineated. Women with a prior history of abortion were mixed into each group. The comparison of women who did not have abortions during the study period, therefore, actually included women with a history of abortion. This is especially important since there is strong evidence that women with a history of abortion have more mental health problems and substance use during and after subsequent pregnancies. It is also unclear what adjustment, if any, was made if women carried to term but subsequently had an abortion.
#By the end of the study, the attrition rate was 65.6% for those had abortions and 57.5% for those who did not (p. 247). Such attrition rates are high and problematic. The fact that they were higher for women who had abortions, which may indicate greater psychological distress, is especially problematic. Those women who are having mental health problems that are trauma-related are precisely the most likely to be in the drop-out pool as they do not wish to go back to a doctor who might bring the incident back to mind. The authors report that "Most loss to follow-up occurred because patients left the practice of the recruiting doctor. Women no longer under observation were slightly younger, of lower parity and higher educational status, and more likely to be single than the original cohort."
#Evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The report of the study itself states: “The major disadvantages of using general practitioners’ reports were the likelihood of under-recognition and an imprecise diagnosis of psychiatric disorder” (p. 247). The authors even remark that the GP's assessments of 'puerperal psychosis' were almost certainly inaccurate.
#The GP's who participated may have also been the same doctors who recommended the abortion to their patients. This involvement may have biased these GP's toward underestimating the negative effects on their patients and overestimating the pre-existing psychological illnesses, which is typically the legal justification for recommending an abortion for social reasons.
#The GPs who participated in this catchment study were volunteers and no attempt was made to control for selection bias. It is possible that many, most, or all volunteered to participate in the study because of a special interest in the issue, and/or because they regularly referred for or performed abortions. The study had no blind or double blind controls and all contributing volunteers were aware of the implications of every judgement they made in preparing their reports. This study therefore falls far short of the objective quality of the record based studies done in Canada, Finland, and the United States, all of which found significantly higher rates of mental health treatments or suicide following abortion. Notably, the authors acknowledge that the risk of errors in diagnostic assessments by recourse to a strong standard of treatment via analysis of "episodes of psychiatric illness leading to hospital admission." In this regard, however, record bases studies are clearly a superior methodology and have clearly shown significantly higher rates of psychiatric hospitalization following abortion compared to delivery and miscarriage.(Reardon, CMAJ)
#Research has indicated that women who have negative abortion reactions are less likely to return to the physician who referred or performed the abortion. For example, a survey of 2,215 abortion patients in 12 abortion clinics in the US found that two out of three women do not return for follow-up appointments at the abortion clinic. (see 'From the Patient’s Perspective - Quality of Abortion Care', Picker Institute. (1999). Boston, MA.) Women embarrassed a past abortion may change providers to avoid facing the stress of seeing the doctor who approved the abortion. In addition, poor followup may result in underestimation of the problem of significant adjustment problems post-abortion. Data in Gilchrist confirms this finding in that by the end of the study, significantly fewer women who aborted. 34.4%, were still under the care of the physician reporting on them comared to 4.4$ of those who did not request an abortion.
#Data regarding prior psychiatric history in this study was reported by a local GP whose may not have had the complete patients’ health records due to lack of comprehensive record linkage in the UK.
#This study had insufficient power to detect significant differences between those women who requested a termination and changed their minds, and those who were refused abortion.
#Only extreme outcomes were measured – drug overdoses rather than substance abuse in general; only diagnosed PTSD but not the more prevalent sub-clinical levels of PTSD or the common practice of PTSD going undiagnosed; psychotic episodes which are rare in the population under either condition.
#There are thousands of case studies of adult women who attribute post-trauma symptoms to their first-trimester abortions, narratives of which are being included in court cases and otherwise publicized. The vast majority of these case studies would not fit into the criteria of extreme problems counted in the Gilchrist 1995 study. Case studies may be inadequate for establishing prevalence or for comparison to the aftermath of other options for dealing with an unplanned pregnancy, but can a statistical study that would exclude those case studies be adequate?
#Women who have miscarriages are known to have higher rates of subsequent psychological distress compared to women who deliver health children. By including women who miscarry with women who carried to term, the study fails to provide a comparison between rates of psychological illness for women who carry to term--which is of course their intent. While miscarriage is an unavoidable risk, the choice women face is between trying to carry to term and having an induced abortion. Therefore, it seems that the comparison between psychological risks of abortion and carrying to term would be relevant to both women and physicians--excluding the risks of psychiatric distress that may follow a miscarriage. While all measures are relevant, the failure to distinguish between successful delivery and miscarriages in this study may have obscured a relative risk of abortion compared to delivery.
#Gilchrist et al. (1995) used outcome-based, convenience sampling (women identified after making a pregnancy decision via selected general practitioners), which prevents estimation of absolute risk in an exposed population; under the criteria of [https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9805a181224c88d888803d906e6c967e2e107829 Dekkers et al. (2012)] this design is more appropriately classified as a case series rather than a cohort study.

{| class="wikitable" style="width:100%;"
! style="width:20%;" | Category
! style="width:50%;" | Key Flaw
! style="width:30%;" | Impact
|-
| '''Study Design'''
| Outcome‑based, post‑decision sampling; convenience GP recruitment
| Cannot calculate absolute risk; not a true cohort
|-
| '''Sampling Bias'''
| Volunteer GPs (~80% pro‑choice); only women consenting to data sharing
| Likely underrepresents distressed women; ideological skew
|-
| '''Attrition'''
| 65.6% loss in abortion group; 57.5% in non‑abortion
| High dropout likely hides adverse outcomes
|-
| '''Diagnosis'''
| GP‑based, no standardized tools; misclassified puerperal psychosis
| Inflated postpartum psychosis; under‑detected other disorders
|-
| '''Data Gaps'''
| No timing of episodes; mortality causes unreported
| Obscures causal links; omits suicide data
|-
| '''Confounding'''
| No control for domestic violence, coercion, moral conflict
| Cannot rule out alternative explanations
|-
| '''Comparisons'''
| Miscarriage lumped with live births; prior abortions in “controls”
| Dilutes differences; masks risks
|-
| '''External Validity'''
| UK’s dual‑physician screening not comparable to US context
| Findings not generalizable
|}

== Table of Claims versus Problems Issues ==

{| class="wikitable" style="width:100%;"
! style="width:40%;" | Gilchrist Claim / Framing
! style="width:60%;" | Critique / Counterpoint
|-
| '''Study is a “prospective cohort” of 13,261 women with unplanned pregnancies'''
| Sampling was ''outcome‑based'' and post‑decision, not exposure‑based. Under Dekkers et al. (2012) criteria, this is a '''case series''', not a true cohort. No inception cohort, no absolute risk calculation possible.
|-
| '''Volunteer GP network ensures broad coverage'''
| 1,509 GPs were self‑selected volunteers; no data on representativeness. Surveys show ~80% of UK GPs are pro‑choice, potentially biasing both referrals and post‑abortion assessments.
|-
| '''Women agreed to anonymous data sharing, ensuring privacy'''
| Self‑selection bias likely — women anticipating distress may have opted out. Those with negative experiences are less likely to return to the referring GP, leading to underreporting.
|-
| '''Follow‑up over years allows long‑term outcome capture'''
| Attrition was extreme: only 34.4% of abortion group and 42.4% of non‑abortion group remained. Dropouts were disproportionately single, educated women — a demographic more likely to abort and potentially more vulnerable to distress.
|-
| '''GP reports capture psychiatric morbidity in the community'''
| Diagnoses made by non‑specialists, without standardized instruments. Authors admit likely over‑diagnosis of puerperal psychosis and under‑recognition of other disorders.
|-
| '''No overall increase in psychiatric morbidity after abortion'''
| Group contamination: “non‑abortion” group included women with prior abortions. Miscarriage cases were lumped with live births, inflating morbidity in the comparison group and masking differences.
|-
| '''Lower risk of psychosis after abortion than postpartum'''
| Inflated postpartum psychosis rates due to misclassification; when hospital admissions are used (a more objective measure), rates are similar.
|-
| '''Higher DSH rates after abortion are due to confounding social factors'''
| No control for key confounders like domestic violence, moral conflict, coercion, or social support. Elevated DSH in women with no prior psychiatric history is a robust finding that cannot be dismissed without data.
|-
| '''Mortality not a focus of the study'''
| Deaths were recorded but causes not reported — omitting suicide data despite known associations in other national datasets (Finland, Canada, US).
|-
| '''Applicable to general abortion–mental health debates'''
| UK’s dual‑physician screening and risk‑benefit analysis likely filter out highest‑risk women. Findings are not generalizable to contexts (e.g., US) where doctors' risks assessments are mandatory.
|-
| '''Large sample size is a strength'''
| Large but non‑representative sample; convenience GP recruitment and patient self‑selection undermine external validity.
|-
| '''Multiple comparison groups improve robustness'''
| Small “refused” and “changed mind” groups lacked statistical power; key differences may have gone undetected.
|}

== Grading of Gilchrist Study ==

=== A Middling Newcastle-Ottawa Scale for Cohort Studies ===
[https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp The Newcastle-Ottawa Scale (NOS)] is commonly used to grade the quality of studies. It is useful for identifying where Gilchrist's study falls short.

The NOQ-Cohort scale evaluation criteria includes three domains; 1) selection of study groups or how well sample represents the target population, (four points); 2) comparability of groups, and account for confounders (two points); and 3) ascertainment of exposure and outcomes, how measured (three points).

In the Case-Control version of the NOS, it is clear that Gilchrist's sample of women, chosen by a group of volunteer general practitioners, is not random nor does it include all eligible cases of women. So it is no representative of all cases. In addition, while women who decided against abortion or were refused abortions, were treated as control groups, NOS requires that "If cases are first occurrence of outcome, then it must explicitly state that controls have no history of this outcome. If cases have new (not necessarily first) occurrence of outcome, then controls with previous occurrences of outcome of interest should not be excluded." But Gilchrist does not control for abortions that may have occurred before or after the index pregnancy event upon which the 1509 volunteer GP's selected and place women into one of the three groups. This means there were at least some women in the two control groups who had prior and/or subsequent abortions.

In the Cohort version NOS, the selection criteria is poor. It is not a representative sample since it relied upon both on volunteer group of GP's and only those women who agreed to have their information shared. As shown in the table below, as judged by this quality index, Gilchrist has a score of 5 out of a possible 9 points.
{| class="wikitable"
|Author
| colspan="4" |Selection
|Comparability
| colspan="3" |Outcome
|Score
|-
|NOQ-Cohort
|Q1
|Q2
|Q3
|Q4
|Q5 & Q6
|Q7
|Q8
|Q9
|
|-
|Gilchrist 1995
|C
|A*
|B*
|B
|A*
|A*
|A*
|C
|5 (max=9)
|}

=== Gilchrist is actually a case series, not a cohort study ===
Although Gilchrist et al. enrolled a non-random, convenience sample of women chosen by a volunteer group GPs who asked a convenience sample of women if they would "agree" to allow their family doctor to provide data to the research team. The GP's ''after'' the women had already sought an abortion and/or from a sample of women they deemed to have not planned their pregnancies at least three months before conceiving.

Because the sampling was from GP's who referred for or provided abortions who non-randomly chose who to invite...and only women who agreed to participate were reported upon (with no data on what percentage of women refused to be reported upon) the study sample is clearly not representative of all women at risk of unplanned pregnancies. Because it does not include sampling at clear inception point (prior to pregnancy, or immediately upon learning one was pregnant) the design is best described as a case series rather than a cohort study.

1) The rule of thumb distinguishing case series from cohort studies: ([https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9805a181224c88d888803d906e6c967e2e107829 Dekkers et a]l.)

* Cohort = sampling based on *exposure* (or a clearly defined inception cohort) wherein participants free of the outcome at baseline, followed over time, so you '''can''' calculate absolute risks or rates. In this case, participants should be identified and followed prior to their becoming pregnant, such as in the example of [https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/abortion-and-mental-health-disorders-evidence-from-a-30year-longitudinal-study/59A90CBF3A58C58B342CBCFFBBFEBD2E Fergusson 2008], a true cohort study which examined mental health effects associated with pregnancy outcomes.
* Case series = sampling based on the *outcome* (or outcome+exposure), so you '''cannot''' calculate an absolute risk for the outcome in an exposed population

2) Why *Gilchrist et al.* is best classified as a **case series**

The subjects utilized were volunteers chosen by a non-random sample of GPs '''after''' they’d already made their pregnancy decision.

* ''Sampling after the decision (outcome-based):'' participants were enrolled *after* the key event (the woman had already decided to terminate or continue). That makes the sampling tied to the outcome/exposure combination and not to a defined exposed population drawn *before* outcomes accrued.
* ''Denominator unclear / no inception cohort:'' because the study did not recruit all women at a defined baseline (e.g., prior to or when a pregnancy was confirmed) you don’t have the full population at risk (the “all exposed” denominator). Without that, you can’t legitimately compute an absolute incidence/risk.
* ''Non-random / convenience GP sampling:'' selecting patients via a non-random set of GPs produces a convenience sample and makes it unlikely the sample represents the population of all women who made each decision — another hallmark of case-series style selection.
* ''What is needed:'' A properly designed study would employ population-based sampling (not convenience GP selection) so the cohort represents the target population. This might be done by using anonymized medical records for an entire population of patients, as has been done in [https://pubmed.ncbi.nlm.nih.gov/14964603/ Coleman 2002], [https://pubmed.ncbi.nlm.nih.gov/12743066/ Reardon 2003], [https://pubmed.ncbi.nlm.nih.gov/37342485/ Studnicki 2023] and [https://pubmed.ncbi.nlm.nih.gov/38771715/ Reardon 2024] and [https://pubmed.ncbi.nlm.nih.gov/39446259/ Studnicki 2024].

3) Why authors (and readers) often misclassify these studies

* ''They see “follow-up” and call it a cohort:'' If subjects are followed for some months after recruitment, many assume “prospective = cohort,” regardless of how recruitment occurred.
* ''Presence of comparison groups is misleading:'' Even if the paper compares women who terminated vs continued, that alone doesn’t make it a cohort — the sampling frame and denominator definition do. Dekkers explicitly notes that a comparison group *doesn’t* define a cohort; sampling method does.
* ''Terminology slippage in clinical journals.'' Words like “prospective consecutive case series” or “cohort” are used loosely.

=== Low grade under the [https://jbi.global/sites/default/files/2021-10/Checklist_for_Case_Series.docx JBI Critical Appraisal Checklist for Case Series] ===
{| class="wikitable"
|Item
|Response (Yes/No/Unclear)
|Notes
|-
|1. Were there clear criteria for inclusion in the case series?
|No
|Participants recruited after decision via non-random GP sample; inclusion criteria not systematically applied.
|-
|2. Was the condition measured in a standard, reliable way for all participants?
|Yes
|Psychiatric morbidity assessed using standardized methods (ICD-8 diagnoses)
|-
|3. Were valid methods used for identification of the condition for all participants?
|Unclear
|Diagnosis/measurement tools for psychiatric morbidity were valid and appropriate (ICD-8 diagnoses were reported by GP's not psychiatrists)
|-
|4. Did the case series have consecutive inclusion of participants?
|No
|Convenience GP selection precludes consecutive inclusion.
|-
|5. Did the case series have complete inclusion of participants?
|No
|Sample limited to selected GPs; incomplete coverage of all eligible cases.
|-
|6. Was there clear reporting of the demographics of the participants in the study?
|Unclear
|Age, parity, and other sociodemographic characteristics were not reported but were used in calculating adjusted RR.
|-
|7. Was there clear reporting of clinical information of the participants?
|No
|Prior and subsequent abortion history not reported, which may have impacted mental health and adulterated control groups
|-
|8. Were the outcomes or follow-up results of cases clearly reported?
|Unclear
|Reported follow-up outcomes for psychiatric morbidity over the study period.
|-
|9. Was there clear reporting of the presenting site(s) / clinic(s) demographic information?
|No
|No detailed description of GP practice characteristics or catchment areas.
|-
|10. Was statistical analysis appropriate?
|Unclear
|Statistical analysis suitable for descriptive comparisons,. But sample size too small for selfharm analysis
|}

== Notes that may require further investigation ==

#The study indicates that some dropouts occurred due to death (p 244 col 1), but the authors fail to report the distribution or cause of deaths. Were there for example, an excess number of suicides or accidents among women who had abortions, as has been found in numerous other studies? If so, it appears from the methodology employed that cases of abortion associated suicide would not been included in any of the measure of psychiatric distress. In other words, women who experienced this most sever psychiatric distress would simply have been counted as having no ill effects and as having "dropped out" of the study.
#Ronsmans C, et al. "Mortality in pregnant and nonpregnant women in England and Wales 1997–2002: are pregnant women healthier?" in Lewis G, editor. Why Mothers Die 2000-2002. The Sixth Report of the Confidential Enquiries into Maternal Death in the United Kingdom. London: RCOG Press;2004

:Following the studies of Gissler and Reardon showing lower mortality rates associated with childbirth, the Ronsmans study in Britain confirmed that there is a lower risk of mortality during pregnancy and until one year after birth compared to women without a recent pregnancy. Specifically reporting that:
::"All-cause mortality in women aged 15–44 years was 58.4 deaths per 100,000 women per year.... Surprisingly, however, mortality during pregnancy or within 1 year after birth was between four and five times lower than mortality in women without a recent pregnancy. The rate ratios comparing the pregnancy–42 day and the 43–365 postpartum periods with nonpregnant women were 0.21 and 0.22, respectively."
:Surprisingly, however this government funded inquiry failed to report any data on mortality rates assocaited with abortion. Given the fact that the authors were aware of the findings of Gissler and Reardon, the failure to report an analysis of death rates assocaited with abortion appears to be a deliberate attempt to suppress findings which would confirm previous research.
:While this study fails to report mortality rates relative to pregnancy outcomes, it does report the following citations:
::"In the USA, women who had delivered a live or stillborn infant in the previous year were half as likely to die as women who had not recently delivered." citing Jocums SB, Berg CJ, Entman SS, Mitchell EF. Postdelivery mortality in Tennessee, 1989–1991. Obstet Gynecol 1998; 91: 766–70.
::"In Canada, mortality rates during pregnancy or within 42 days of its termination and between 43 and 225 days postpartum were about half those of nonpregnant women."citing Turner LA, Kramer MS, Liu S. Cause-specific mortality during and after pregnancy and the definition of maternal death. Chronic Dis Can 2002; 23: 1–8.
::"In Finland, the age-adjusted risk of a natural death within a year after birth or a miscarriage was half that of women without a pregnancy." citing Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Pregnancy-associated mortality after birth, spontaneous abortion or induced abortion in Finland, 1987-2000. Am J Ob Gyn 2004; 190:422-427.
::NOT MENTIONED was the following findings from the Gissler 2004 study:
:::The age-adjusted mortality rate for women during pregnancy and within one year of pregnancy termination was 36.7 deaths per 100,000 pregnancies, which was significantly lower than the mortality rate among nonpregnant women 57.0 per 100,000 person-years (RR=0.64, 95% CI 0.58-0.71). '''The mortality was lower after a birth (28.2/100,000) than after a spontaneous (51.9/100,000) or induced abortion (83.1/100,000).''' We observed a significant increase in the risk of death from cerebrovascular diseases after delivery among women aged 15-24 years (RR=4.08, 95% CI 1.58-10.55).

:This three fold higher death rate following abortion is certainly noteworthy and deserving additional investigation. Therefore it is hard to avoid the conclusion that this failure to examine and report on abortion associated deaths in this official British study may reflect a bias in the British research community which may also be reflected in studies regarding the negative pscyhological effects associated with abortion.

== Criticisms by Dr. Philip Ney ==

The study by Gilchrist et al. is based on the concept of an unplanned pregnancy, but the authors make little attempt to define what this is and how it was determined. As every physician knows, people are ambivalent about the inception and conception of almost every pregnancy. There are very few people who actually put much effort into planning a pregnancy, and those are mostly people who use natural family planning methods. Most "plan" only by withdrawing contraception. A recent report of the Alan Guttmacher Institute states that "the proportion of women wanting to become pregnant is extremely low, less than 1 in 5 in industrialised countries."<ref name="gadd">Gadd J. (1995, August 22). Families becoming smaller but many births still unwanted. The Globe and Mail, A8.</ref> If contracepting or not contracepting means whether the pregnancy is planned or not, then there is no basis for making statements about psychiatric sequlae of any pregnancy outcome. Many people change their mind almost in the middle of intercourse about whether they want or plan to have a baby.

The review of the literature is very biased. There are many relevant studies not cited.<ref name="Ney">Ney PG, Fung T, Wickett AR, Beaman_Dodd C. "The Effects of Pregnancy Loss on Women's Health", Social Science and Medicine, 38(9): 1193_1200, 1994.</ref><ref name="Sim">Sim M, Neisser R. "Post_abortive psychosis: a report from two centers. In: The Psychological Aspects of Abortion. Mall D, Watts F (Eds.), University Publications of America, Washington: 1_13, 1979.</ref> Gilchrist et al. do not summarize the references of Doane & Quigley and David et al. correctly.

Since the authors were only using major psychiatric illness classifications, it appears that they did not expect to find or look for the constellation of symptoms and signs now known as the Post_Abortion Syndrome. Post_Abortion Syndrome is now reasonably well recognised and defined, but not included in ICD _ 8.

Although the authors state this study examined a variety of pregnancy outcomes, they did not compare a live birth to a miscarriage or to a stillbirth or to an abortion. They found that the rates of miscarriage were different in the different groups. Miscarriages in the non_abortion group would tend to increase the morbidity because miscarriages do result in higher rates of both physical and psychiatric morbidity. Miscarriages in the abortion group would tend to decrease the apparent morbidity because the effects of the miscarriages are less than the effects of the abortion.

This study relied on general practitioners' assessment of psychiatric morbidity and used the not too precise catagorizations of ICD 8. They diagnosed 225 puerperal psychosis; much higher than the estimated prevalence. The authors found that only 13 of these puerperal psychosis were admitted for treatment, yet almost every case of a puerperal psychosis should be admitted. It seems family physicians were wrong in their diagnosis of puerperal psychosis by a factor of 17. It is likely they were equally out on the other psychiatric diagnosis. The authors did admit that the estimation of puerperal psychosis was too high. The authors found that there is a significantly higher rate of deliberate self_harm (DSH) following an abortion. Eighty_nine (89) % of these were overdoses, which are not difficult to diagnose. If the family physicians were better able to diagnose psychiatric morbidity of other kinds, it is likely that they might have found higher rates in the TOP group.

The authors state that the general practitioners would not have a systematic bias in diagnosing. However, since these general practitioners were referring their patients for TOP, they are less likely to see any adverse effects of a procedure they recommended. Why did the authors not include family physicians who do not make abortion referrals? Physicians of the Christian Medical and Dental Society (CMDS) Canada have a significantly lower rate of abortions and miscarriages in their practices compared to other general practitioners.

The general practitioners' follow up in this study was poor. They lost 65.6% to follow up by the end of the study from the abortion group, and 57.6% from the non_abortion group. The authors state that most of those who were lost to follow up were single, highly educated women. Other studies have shown these women are more likely to have an abortion.

Since those in the refused abortion group were probably refused because of psychiatric problems, psychiatric morbidity in the TOP group should be lower. The authors state that although the DSH was higher in the TOP group, the rates fell more rapidly than in the non_abortion group. They failed to note that the rate the TOP group fell to, i.e. 3.8 was still higher than the baseline group of the non_TOP group, 3.0.

Gilchrist et al. did not show the demographic variables in each group, but state that the data "were indirectly standardised for age, marital status, smoking habit, age at leaving full_time education, gravidity, and previous history of induced abortion at recruitment, since the comparison groups differed on these characteristics." At the end of this article they also state that "the lack of more detailed social information was, however, an important limitation, given the evidence that poor social support increases the risk of psychological morbidity after abortion." They then, to try and explain why DSH is higher in the abortion group, state, "the most likely explanation is that they were at risk because of coexisting social or psychological difficulties associated with both their decision to seek a termination and their subsequent risk of deliberate self_harm." This confusing obfuscation seems to be an attempt to deny the findings that psychiatric morbidity, apart from DSH, was not higher in the group who were refused TOP. The authors state that "risk ratios (RR) were calculated with reference to the group of those who did not request a termination." "The 95% confidence intervals (CI) were calculated using the assumption that the standard deviation of the log of relative risk is equal to the sum of the reciprocals of the observed number of cases in the two groups being compared." This is a questionable assumption, especially in view of the fact that the crude rates for psychosis are; TOP group .1 per 1000, non_TOP group .05 per 1000.

The fact that the psychiatric morbidity of the termination group was not lower than a comparison group of women who requested abortion and changed their minds, effectively demonstrates that abortion is not an effective treatment for psychiatric illness. This study also demonstrates that abortion makes psychiatric conditions of all kinds worse. Yet, without scientific or clinical support, these general practitioners used "previous or anticipated psychiatric illness" as a justification for abortion. This is a practice that the Canadian Psychiatric Association has officially deplored.<ref name="Smith">Smith CM. Canadian Psychiatric Association Bulletin, 13(4): 2_3, Oct. 1981.</ref>

 

== Criticisms by Priscilla Coleman ==
"Incredulously, the Gilchrist et al. (1995) study received a rating of “Good”, when very few controls for confounding 3rd variables were employed, meaning the comparison groups may very well have differed systematically with regard to income, relationship quality including exposure to domestic violence, social support, and other potentially critical factors. Further Gilchrist et al. reported retaining only 34.4% of the termination group and only 43.4% of the group that did not request a termination at the end of the study. No standardized measures for mental health diagnoses were employed and evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The GPs were volunteers and no attempt was made to control for selection bias."

== References ==

  {{reflist}}

Gilchrist

2025-09-19T20:15:33Z

Barb: /* Grading of Gilchrist Study */

Gilchrist AC, Hannaford PC, Frank P, Kay CR. Termination of pregnancy and psychiatric morbidity. ''Br J Psychiatry''. 1995;167:243-248.

Please register and contribute to the development of these notes into a narrative by editing the sections or adding sections.

== Abstract ==

''Gilchrist AC, Hannaford PC, Frank P, Kay CR. [http://archpsyc.ama-assn.org/cgi/ijlink?linkType=ABST&journalCode=bjprcpsych&resid=167/2/243 Termination of pregnancy and psychiatric morbidity.]Br J Psychiatry. 1995;167:243-248.''

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 1'''509 volunteer GPs''' after the conclusion of the pregnancy was compared in four groups: women who had an '''induced abortion (6410)''', women who did not request a termination (6151) for a pregnancy the GP determined '''had not been planned at least 3 months before conception''', women who were '''refused a termination (379)''', and '''321 women''' who changed their minds before the termination was performed.

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.

== Additional Key Findings ==

#The findings confirmed that women with prior psychiatric problems are worse off postabortion
#Women with the most fragile mental health prior to an abortion, i.e., psychosis, were worse off postabortion
#The findings indicated that among women with no prior psychiatric history, significantly higher risks of deliberate self harm were observed both after an abortion and after a refused abortion.

 

== Additional Notes Regarding Population Sample and Methodology ==

#Following screening and risk-benefit analyses, attending physicians refused to peform abortions on 379 women.
#An additional 321 women changed their minds after screening and consultation with their attending physicians.
#British women who do not have abortions were underrepresented in the study. In the study sample 48.3% of the women had abortions, a percentage which is much higher than the abortion rate in the UK. One source reports that only 22.8% of pregnancies in the UK end in abortion.[http://www.mscperu.org/aborto/abortingl/abortos_porcentajepaises.htm]
#All general practitioners reporting were volunteers and were not blind to condition when making their counts. The authors do not disclose the conditions under which volunteers were selected, nor the rate of volunteers among those invited to volunteer, nor any measure or attempts to grade or screen the volunteer physicians relative to age, gender, practice or attitudes regarding abortion, or any other factors which might influence the observer's judgments and reports. This self-selected group of participating physicians may have been biased. Surveys of GP's in Britain find that about 80% report a "pro-choice" perspective which may influence their recommendations for abortion and their subjective interpretation of post-abortion reactions.<ref>Marie Stopes International. General Pracitioners: Attitudes Toward Abortion, 2007. London, UK. www.mariestopes.org.uk</ref> Clearly, those who recommend for abortion would be disinclined to believe that their recommendations were in error. See additional notes below regarding the reluctance of women to return to physicians for follow up care following an abortion.
#GP's reported details every 6 months.
#Data was reported without any actual follow up interviews on the part of the GP. A GP who had not seen a patient in the last six months might therefore simply report that there were no observed psychological problems.
#Information was obtained only from women who volunteered and "agreed to their family doctor supplying anonymous data to the study center." (Research shows that women who expect to deal poorly with an abortion do in fact have more post-abortion problems. Such women might prefer not to be excluded from a follow up study for fear of being exposed to additional stress.)
#Selection bias may have occurred among women volunteers.
#According to the authors, "Had follow-up interviews been required, it is likely that participation would have been greatly reduced; in a pilot survey nearly half of the women who had a termination said that they would refuse to participate if they could not remain anonymous."
#The findings are inconsistent with record based research in Canada which found that 24% of women who had abortions subsequently made visits to psychiatrists compared to 3% in the general population.<ref>''Report of the Committee on the Abortion Law, RF Badgley et al, (Ottawa:Supply and Services, 1977) pp. 313-321''</ref> and record based research in the United States (Reardon, CMAJ).

== Strengths ==

#It was prospective with a large sample size

#The study used four comparison groups

:#those who never requested abortion, including the combination of both those who delivered healthy babies and those who miscarried or had other adverse results;
:#those who had an induced abortion;
:#those who originally requested abortion but changed their minds after consulting with physician; and
:#those who requested termination but for whom physicians refused to perform the abortion after screening and a risk/benefit analysis.

== Weaknesses ==

#This study is not applicable to American experience because British abortion law is much more protective of women's health and requires a level of screening, counseling, and risk benefit analysis not normally found in the United States. In Britain, before an abortion is performed two medical doctors have to evaluate the patient and both agree that the risks of abortion are less than the risk associated with childbirth.<ref>In the United Kingdom, the 1967 abortion act provides that an abortion is legal "if two registered medical practitioners are of the opinion, formed in good faith - a) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or of injury to the physical or mental health of the pregnant woman or any existing children or of her family, greater than if the pregnancy were terminated; or b) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped." The Public General Acts, 1967, p. 2033, (Eng.) (emphasis added)</ref> In the sample used for this study, 700 women (approximately 10% of all those requesting an abortion) did not have an abortion after a risk-benefit screening and consultation with their physicians. It seems apparent that these women were likely at greatest risk of adverse outcomes. Such screening and risk benefit analysis is not typically found in the American context, where instead abortion is generally provided simply on request. As this process of screening by two physicians in Britain may better serve to identify and protect women who are being pressured into unwanted abortions, and would therefore reduce the risk of severe negative psychological reactions among this group of women for whom an unwanted abortion, it is highly likely that British women may be exposed to less psychological trauma associated with unwanted, unsafe, or unnecessary abortions as compared to American women. The potential protective effects of such screening are indicated by research among women who had abortions in the United States in which it was found that 64% reported feeling pressured into the abortion by other people (Rue). In addition to reducing the risk of women being pressured into unwanted abortions by third parties, two physician screening in the UK may also reduce the risk that women will have abortions in violation of their moral views, or their maternal desires, which are two of many statistically validated risk factors for subsequent psychiatric disorders.
#No standardized measures for mental health diagnoses were employed.
#Only the first reported episode of illness was recorded. Though the authors had the data to report on average number of contacts for each illness (a proxy for the duration and degree of the psychological episodes), they did not disclose any measure for duration or severity. The only exception is that they did report psychotic episodes within the first 12 months after delivery or termination...but did not identify prior history of abortion in thise cases. Given the eight year span of the study, the lack of information about when treatments occurred relative to the pregnancy outcome may also have a diluting effect in regard to recency to the stressor.
#The failure to report timing of the first incident of psychiatric illness is underscored by the admission in the discussion that there were indeed "Difference in the timing of admission and the past psychiatric history of women admitted postpartum or post-termination...suggest different underlying mechanisms." If there are indeed "different mechanisms" underlying the difference in timing of psychological illness following pregnancies carried to term versus those aborted, isn't that exactly what should be studied. Instead, they note a difference in timing but don't provide the details. Since proximity to the event supports a casual connection, this is a very serious omission.
#The study spanned, potentially from 1979 thru 1987, with women being introduced into the data set throughout that period. The authors received information about deaths, but they chose not to report deaths . . . which is especially concerning given the elevated rates of suicide attempts and completed suicides among women who abort.
#The study groups are not clearly delineated. Women with a prior history of abortion were mixed into each group. The comparison of women who did not have abortions during the study period, therefore, actually included women with a history of abortion. This is especially important since there is strong evidence that women with a history of abortion have more mental health problems and substance use during and after subsequent pregnancies. It is also unclear what adjustment, if any, was made if women carried to term but subsequently had an abortion.
#By the end of the study, the attrition rate was 65.6% for those had abortions and 57.5% for those who did not (p. 247). Such attrition rates are high and problematic. The fact that they were higher for women who had abortions, which may indicate greater psychological distress, is especially problematic. Those women who are having mental health problems that are trauma-related are precisely the most likely to be in the drop-out pool as they do not wish to go back to a doctor who might bring the incident back to mind. The authors report that "Most loss to follow-up occurred because patients left the practice of the recruiting doctor. Women no longer under observation were slightly younger, of lower parity and higher educational status, and more likely to be single than the original cohort."
#Evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The report of the study itself states: “The major disadvantages of using general practitioners’ reports were the likelihood of under-recognition and an imprecise diagnosis of psychiatric disorder” (p. 247). The authors even remark that the GP's assessments of 'puerperal psychosis' were almost certainly inaccurate.
#The GP's who participated may have also been the same doctors who recommended the abortion to their patients. This involvement may have biased these GP's toward underestimating the negative effects on their patients and overestimating the pre-existing psychological illnesses, which is typically the legal justification for recommending an abortion for social reasons.
#The GPs who participated in this catchment study were volunteers and no attempt was made to control for selection bias. It is possible that many, most, or all volunteered to participate in the study because of a special interest in the issue, and/or because they regularly referred for or performed abortions. The study had no blind or double blind controls and all contributing volunteers were aware of the implications of every judgement they made in preparing their reports. This study therefore falls far short of the objective quality of the record based studies done in Canada, Finland, and the United States, all of which found significantly higher rates of mental health treatments or suicide following abortion. Notably, the authors acknowledge that the risk of errors in diagnostic assessments by recourse to a strong standard of treatment via analysis of "episodes of psychiatric illness leading to hospital admission." In this regard, however, record bases studies are clearly a superior methodology and have clearly shown significantly higher rates of psychiatric hospitalization following abortion compared to delivery and miscarriage.(Reardon, CMAJ)
#Research has indicated that women who have negative abortion reactions are less likely to return to the physician who referred or performed the abortion. For example, a survey of 2,215 abortion patients in 12 abortion clinics in the US found that two out of three women do not return for follow-up appointments at the abortion clinic. (see 'From the Patient’s Perspective - Quality of Abortion Care', Picker Institute. (1999). Boston, MA.) Women embarrassed a past abortion may change providers to avoid facing the stress of seeing the doctor who approved the abortion. In addition, poor followup may result in underestimation of the problem of significant adjustment problems post-abortion. Data in Gilchrist confirms this finding in that by the end of the study, significantly fewer women who aborted. 34.4%, were still under the care of the physician reporting on them comared to 4.4$ of those who did not request an abortion.
#Data regarding prior psychiatric history in this study was reported by a local GP whose may not have had the complete patients’ health records due to lack of comprehensive record linkage in the UK.
#This study had insufficient power to detect significant differences between those women who requested a termination and changed their minds, and those who were refused abortion.
#Only extreme outcomes were measured – drug overdoses rather than substance abuse in general; only diagnosed PTSD but not the more prevalent sub-clinical levels of PTSD or the common practice of PTSD going undiagnosed; psychotic episodes which are rare in the population under either condition.
#There are thousands of case studies of adult women who attribute post-trauma symptoms to their first-trimester abortions, narratives of which are being included in court cases and otherwise publicized. The vast majority of these case studies would not fit into the criteria of extreme problems counted in the Gilchrist 1995 study. Case studies may be inadequate for establishing prevalence or for comparison to the aftermath of other options for dealing with an unplanned pregnancy, but can a statistical study that would exclude those case studies be adequate?
#Women who have miscarriages are known to have higher rates of subsequent psychological distress compared to women who deliver health children. By including women who miscarry with women who carried to term, the study fails to provide a comparison between rates of psychological illness for women who carry to term--which is of course their intent. While miscarriage is an unavoidable risk, the choice women face is between trying to carry to term and having an induced abortion. Therefore, it seems that the comparison between psychological risks of abortion and carrying to term would be relevant to both women and physicians--excluding the risks of psychiatric distress that may follow a miscarriage. While all measures are relevant, the failure to distinguish between successful delivery and miscarriages in this study may have obscured a relative risk of abortion compared to delivery.
#Gilchrist et al. (1995) used outcome-based, convenience sampling (women identified after making a pregnancy decision via selected general practitioners), which prevents estimation of absolute risk in an exposed population; under the criteria of [https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9805a181224c88d888803d906e6c967e2e107829 Dekkers et al. (2012)] this design is more appropriately classified as a case series rather than a cohort study.

{| class="wikitable" style="width:100%;"
! style="width:20%;" | Category
! style="width:50%;" | Key Flaw
! style="width:30%;" | Impact
|-
| '''Study Design'''
| Outcome‑based, post‑decision sampling; convenience GP recruitment
| Cannot calculate absolute risk; not a true cohort
|-
| '''Sampling Bias'''
| Volunteer GPs (~80% pro‑choice); only women consenting to data sharing
| Likely underrepresents distressed women; ideological skew
|-
| '''Attrition'''
| 65.6% loss in abortion group; 57.5% in non‑abortion
| High dropout likely hides adverse outcomes
|-
| '''Diagnosis'''
| GP‑based, no standardized tools; misclassified puerperal psychosis
| Inflated postpartum psychosis; under‑detected other disorders
|-
| '''Data Gaps'''
| No timing of episodes; mortality causes unreported
| Obscures causal links; omits suicide data
|-
| '''Confounding'''
| No control for domestic violence, coercion, moral conflict
| Cannot rule out alternative explanations
|-
| '''Comparisons'''
| Miscarriage lumped with live births; prior abortions in “controls”
| Dilutes differences; masks risks
|-
| '''External Validity'''
| UK’s dual‑physician screening not comparable to US context
| Findings not generalizable
|}

== Table of Claims versus Problems Issues ==

{| class="wikitable" style="width:100%;"
! style="width:40%;" | Gilchrist Claim / Framing
! style="width:60%;" | Critique / Counterpoint
|-
| '''Study is a “prospective cohort” of 13,261 women with unplanned pregnancies'''
| Sampling was ''outcome‑based'' and post‑decision, not exposure‑based. Under Dekkers et al. (2012) criteria, this is a '''case series''', not a true cohort. No inception cohort, no absolute risk calculation possible.
|-
| '''Volunteer GP network ensures broad coverage'''
| 1,509 GPs were self‑selected volunteers; no data on representativeness. Surveys show ~80% of UK GPs are pro‑choice, potentially biasing both referrals and post‑abortion assessments.
|-
| '''Women agreed to anonymous data sharing, ensuring privacy'''
| Self‑selection bias likely — women anticipating distress may have opted out. Those with negative experiences are less likely to return to the referring GP, leading to underreporting.
|-
| '''Follow‑up over years allows long‑term outcome capture'''
| Attrition was extreme: only 34.4% of abortion group and 42.4% of non‑abortion group remained. Dropouts were disproportionately single, educated women — a demographic more likely to abort and potentially more vulnerable to distress.
|-
| '''GP reports capture psychiatric morbidity in the community'''
| Diagnoses made by non‑specialists, without standardized instruments. Authors admit likely over‑diagnosis of puerperal psychosis and under‑recognition of other disorders.
|-
| '''No overall increase in psychiatric morbidity after abortion'''
| Group contamination: “non‑abortion” group included women with prior abortions. Miscarriage cases were lumped with live births, inflating morbidity in the comparison group and masking differences.
|-
| '''Lower risk of psychosis after abortion than postpartum'''
| Inflated postpartum psychosis rates due to misclassification; when hospital admissions are used (a more objective measure), rates are similar.
|-
| '''Higher DSH rates after abortion are due to confounding social factors'''
| No control for key confounders like domestic violence, moral conflict, coercion, or social support. Elevated DSH in women with no prior psychiatric history is a robust finding that cannot be dismissed without data.
|-
| '''Mortality not a focus of the study'''
| Deaths were recorded but causes not reported — omitting suicide data despite known associations in other national datasets (Finland, Canada, US).
|-
| '''Applicable to general abortion–mental health debates'''
| UK’s dual‑physician screening and risk‑benefit analysis likely filter out highest‑risk women. Findings are not generalizable to contexts (e.g., US) where doctors' risks assessments are mandatory.
|-
| '''Large sample size is a strength'''
| Large but non‑representative sample; convenience GP recruitment and patient self‑selection undermine external validity.
|-
| '''Multiple comparison groups improve robustness'''
| Small “refused” and “changed mind” groups lacked statistical power; key differences may have gone undetected.
|}

== Grading of Gilchrist Study ==

=== A Middling Newcastle-Ottawa Scale for Cohort Studies ===
[https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp The Newcastle-Ottawa Scale (NOS)] is commonly used to grade the quality of studies. It is useful for identifying where Gilchrist's study falls short.

The NOQ-Cohort scale evaluation criteria includes three domains; 1) selection of study groups or how well sample represents the target population, (four points); 2) comparability of groups, and account for confounders (two points); and 3) ascertainment of exposure and outcomes, how measured (three points).

In the Case-Control version of the NOS, it is clear that Gilchrist's sample of women, chosen by a group of volunteer general practitioners, is not random nor does it include all eligible cases of women. So it is no representative of all cases. In addition, while women who decided against abortion or were refused abortions, were treated as control groups, NOS requires that "If cases are first occurrence of outcome, then it must explicitly state that controls have no history of this outcome. If cases have new (not necessarily first) occurrence of outcome, then controls with previous occurrences of outcome of interest should not be excluded." But Gilchrist does not control for abortions that may have occurred before or after the index pregnancy event upon which the 1509 volunteer GP's selected and place women into one of the three groups. This means there were at least some women in the two control groups who had prior and/or subsequent abortions.

In the Cohort version NOS, the selection criteria is poor. It is not a representative sample since it relied upon both on volunteer group of GP's and only those women who agreed to have their information shared.
{| class="wikitable"
|Author
| colspan="4" |Selection
|Comparability
| colspan="3" |Outcome
|Score
|-
|NOQ-Cohort
|Q1
|Q2
|Q3
|Q4
|Q5 & Q6
|Q7
|Q8
|Q9
|
|-
|Gilchrist 1995
|C
|A*
|B*
|B
|A*
|A*
|A*
|C
|5 (max=9)
|}

=== Gilchrist is actually a case series, not a cohort study ===
Although Gilchrist et al. enrolled a non-random, convenience sample of women chosen by a volunteer group GPs who asked a convenience sample of women if they would "agree" to allow their family doctor to provide data to the research team. The GP's ''after'' the women had already sought an abortion and/or from a sample of women they deemed to have not planned their pregnancies at least three months before conceiving.

Because the sampling was from GP's who referred for or provided abortions who non-randomly chose who to invite...and only women who agreed to participate were reported upon (with no data on what percentage of women refused to be reported upon) the study sample is clearly not representative of all women at risk of unplanned pregnancies. Because it does not include sampling at clear inception point (prior to pregnancy, or immediately upon learning one was pregnant) the design is best described as a case series rather than a cohort study.

1) The rule of thumb distinguishing case series from cohort studies: ([https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9805a181224c88d888803d906e6c967e2e107829 Dekkers et a]l.)

* Cohort = sampling based on *exposure* (or a clearly defined inception cohort) wherein participants free of the outcome at baseline, followed over time, so you '''can''' calculate absolute risks or rates. In this case, participants should be identified and followed prior to their becoming pregnant, such as in the example of [https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/abortion-and-mental-health-disorders-evidence-from-a-30year-longitudinal-study/59A90CBF3A58C58B342CBCFFBBFEBD2E Fergusson 2008], a true cohort study which examined mental health effects associated with pregnancy outcomes.
* Case series = sampling based on the *outcome* (or outcome+exposure), so you '''cannot''' calculate an absolute risk for the outcome in an exposed population

2) Why *Gilchrist et al.* is best classified as a **case series**

The subjects utilized were volunteers chosen by a non-random sample of GPs '''after''' they’d already made their pregnancy decision.

* ''Sampling after the decision (outcome-based):'' participants were enrolled *after* the key event (the woman had already decided to terminate or continue). That makes the sampling tied to the outcome/exposure combination and not to a defined exposed population drawn *before* outcomes accrued.
* ''Denominator unclear / no inception cohort:'' because the study did not recruit all women at a defined baseline (e.g., prior to or when a pregnancy was confirmed) you don’t have the full population at risk (the “all exposed” denominator). Without that, you can’t legitimately compute an absolute incidence/risk.
* ''Non-random / convenience GP sampling:'' selecting patients via a non-random set of GPs produces a convenience sample and makes it unlikely the sample represents the population of all women who made each decision — another hallmark of case-series style selection.
* ''What is needed:'' A properly designed study would employ population-based sampling (not convenience GP selection) so the cohort represents the target population. This might be done by using anonymized medical records for an entire population of patients, as has been done in [https://pubmed.ncbi.nlm.nih.gov/14964603/ Coleman 2002], [https://pubmed.ncbi.nlm.nih.gov/12743066/ Reardon 2003], [https://pubmed.ncbi.nlm.nih.gov/37342485/ Studnicki 2023] and [https://pubmed.ncbi.nlm.nih.gov/38771715/ Reardon 2024] and [https://pubmed.ncbi.nlm.nih.gov/39446259/ Studnicki 2024].

3) Why authors (and readers) often misclassify these studies

* ''They see “follow-up” and call it a cohort:'' If subjects are followed for some months after recruitment, many assume “prospective = cohort,” regardless of how recruitment occurred.
* ''Presence of comparison groups is misleading:'' Even if the paper compares women who terminated vs continued, that alone doesn’t make it a cohort — the sampling frame and denominator definition do. Dekkers explicitly notes that a comparison group *doesn’t* define a cohort; sampling method does.
* ''Terminology slippage in clinical journals.'' Words like “prospective consecutive case series” or “cohort” are used loosely.

=== Low grade under the [https://jbi.global/sites/default/files/2021-10/Checklist_for_Case_Series.docx JBI Critical Appraisal Checklist for Case Series] ===
{| class="wikitable"
|Item
|Response (Yes/No/Unclear)
|Notes
|-
|1. Were there clear criteria for inclusion in the case series?
|No
|Participants recruited after decision via non-random GP sample; inclusion criteria not systematically applied.
|-
|2. Was the condition measured in a standard, reliable way for all participants?
|Yes
|Psychiatric morbidity assessed using standardized methods (ICD-8 diagnoses)
|-
|3. Were valid methods used for identification of the condition for all participants?
|Unclear
|Diagnosis/measurement tools for psychiatric morbidity were valid and appropriate (ICD-8 diagnoses were reported by GP's not psychiatrists)
|-
|4. Did the case series have consecutive inclusion of participants?
|No
|Convenience GP selection precludes consecutive inclusion.
|-
|5. Did the case series have complete inclusion of participants?
|No
|Sample limited to selected GPs; incomplete coverage of all eligible cases.
|-
|6. Was there clear reporting of the demographics of the participants in the study?
|Unclear
|Age, parity, and other sociodemographic characteristics were not reported but were used in calculating adjusted RR.
|-
|7. Was there clear reporting of clinical information of the participants?
|No
|Prior and subsequent abortion history not reported, which may have impacted mental health and adulterated control groups
|-
|8. Were the outcomes or follow-up results of cases clearly reported?
|Unclear
|Reported follow-up outcomes for psychiatric morbidity over the study period.
|-
|9. Was there clear reporting of the presenting site(s) / clinic(s) demographic information?
|No
|No detailed description of GP practice characteristics or catchment areas.
|-
|10. Was statistical analysis appropriate?
|Unclear
|Statistical analysis suitable for descriptive comparisons,. But sample size too small for selfharm analysis
|}

== Notes that may require further investigation ==

#The study indicates that some dropouts occurred due to death (p 244 col 1), but the authors fail to report the distribution or cause of deaths. Were there for example, an excess number of suicides or accidents among women who had abortions, as has been found in numerous other studies? If so, it appears from the methodology employed that cases of abortion associated suicide would not been included in any of the measure of psychiatric distress. In other words, women who experienced this most sever psychiatric distress would simply have been counted as having no ill effects and as having "dropped out" of the study.
#Ronsmans C, et al. "Mortality in pregnant and nonpregnant women in England and Wales 1997–2002: are pregnant women healthier?" in Lewis G, editor. Why Mothers Die 2000-2002. The Sixth Report of the Confidential Enquiries into Maternal Death in the United Kingdom. London: RCOG Press;2004

:Following the studies of Gissler and Reardon showing lower mortality rates associated with childbirth, the Ronsmans study in Britain confirmed that there is a lower risk of mortality during pregnancy and until one year after birth compared to women without a recent pregnancy. Specifically reporting that:
::"All-cause mortality in women aged 15–44 years was 58.4 deaths per 100,000 women per year.... Surprisingly, however, mortality during pregnancy or within 1 year after birth was between four and five times lower than mortality in women without a recent pregnancy. The rate ratios comparing the pregnancy–42 day and the 43–365 postpartum periods with nonpregnant women were 0.21 and 0.22, respectively."
:Surprisingly, however this government funded inquiry failed to report any data on mortality rates assocaited with abortion. Given the fact that the authors were aware of the findings of Gissler and Reardon, the failure to report an analysis of death rates assocaited with abortion appears to be a deliberate attempt to suppress findings which would confirm previous research.
:While this study fails to report mortality rates relative to pregnancy outcomes, it does report the following citations:
::"In the USA, women who had delivered a live or stillborn infant in the previous year were half as likely to die as women who had not recently delivered." citing Jocums SB, Berg CJ, Entman SS, Mitchell EF. Postdelivery mortality in Tennessee, 1989–1991. Obstet Gynecol 1998; 91: 766–70.
::"In Canada, mortality rates during pregnancy or within 42 days of its termination and between 43 and 225 days postpartum were about half those of nonpregnant women."citing Turner LA, Kramer MS, Liu S. Cause-specific mortality during and after pregnancy and the definition of maternal death. Chronic Dis Can 2002; 23: 1–8.
::"In Finland, the age-adjusted risk of a natural death within a year after birth or a miscarriage was half that of women without a pregnancy." citing Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Pregnancy-associated mortality after birth, spontaneous abortion or induced abortion in Finland, 1987-2000. Am J Ob Gyn 2004; 190:422-427.
::NOT MENTIONED was the following findings from the Gissler 2004 study:
:::The age-adjusted mortality rate for women during pregnancy and within one year of pregnancy termination was 36.7 deaths per 100,000 pregnancies, which was significantly lower than the mortality rate among nonpregnant women 57.0 per 100,000 person-years (RR=0.64, 95% CI 0.58-0.71). '''The mortality was lower after a birth (28.2/100,000) than after a spontaneous (51.9/100,000) or induced abortion (83.1/100,000).''' We observed a significant increase in the risk of death from cerebrovascular diseases after delivery among women aged 15-24 years (RR=4.08, 95% CI 1.58-10.55).

:This three fold higher death rate following abortion is certainly noteworthy and deserving additional investigation. Therefore it is hard to avoid the conclusion that this failure to examine and report on abortion associated deaths in this official British study may reflect a bias in the British research community which may also be reflected in studies regarding the negative pscyhological effects associated with abortion.

== Criticisms by Dr. Philip Ney ==

The study by Gilchrist et al. is based on the concept of an unplanned pregnancy, but the authors make little attempt to define what this is and how it was determined. As every physician knows, people are ambivalent about the inception and conception of almost every pregnancy. There are very few people who actually put much effort into planning a pregnancy, and those are mostly people who use natural family planning methods. Most "plan" only by withdrawing contraception. A recent report of the Alan Guttmacher Institute states that "the proportion of women wanting to become pregnant is extremely low, less than 1 in 5 in industrialised countries."<ref name="gadd">Gadd J. (1995, August 22). Families becoming smaller but many births still unwanted. The Globe and Mail, A8.</ref> If contracepting or not contracepting means whether the pregnancy is planned or not, then there is no basis for making statements about psychiatric sequlae of any pregnancy outcome. Many people change their mind almost in the middle of intercourse about whether they want or plan to have a baby.

The review of the literature is very biased. There are many relevant studies not cited.<ref name="Ney">Ney PG, Fung T, Wickett AR, Beaman_Dodd C. "The Effects of Pregnancy Loss on Women's Health", Social Science and Medicine, 38(9): 1193_1200, 1994.</ref><ref name="Sim">Sim M, Neisser R. "Post_abortive psychosis: a report from two centers. In: The Psychological Aspects of Abortion. Mall D, Watts F (Eds.), University Publications of America, Washington: 1_13, 1979.</ref> Gilchrist et al. do not summarize the references of Doane & Quigley and David et al. correctly.

Since the authors were only using major psychiatric illness classifications, it appears that they did not expect to find or look for the constellation of symptoms and signs now known as the Post_Abortion Syndrome. Post_Abortion Syndrome is now reasonably well recognised and defined, but not included in ICD _ 8.

Although the authors state this study examined a variety of pregnancy outcomes, they did not compare a live birth to a miscarriage or to a stillbirth or to an abortion. They found that the rates of miscarriage were different in the different groups. Miscarriages in the non_abortion group would tend to increase the morbidity because miscarriages do result in higher rates of both physical and psychiatric morbidity. Miscarriages in the abortion group would tend to decrease the apparent morbidity because the effects of the miscarriages are less than the effects of the abortion.

This study relied on general practitioners' assessment of psychiatric morbidity and used the not too precise catagorizations of ICD 8. They diagnosed 225 puerperal psychosis; much higher than the estimated prevalence. The authors found that only 13 of these puerperal psychosis were admitted for treatment, yet almost every case of a puerperal psychosis should be admitted. It seems family physicians were wrong in their diagnosis of puerperal psychosis by a factor of 17. It is likely they were equally out on the other psychiatric diagnosis. The authors did admit that the estimation of puerperal psychosis was too high. The authors found that there is a significantly higher rate of deliberate self_harm (DSH) following an abortion. Eighty_nine (89) % of these were overdoses, which are not difficult to diagnose. If the family physicians were better able to diagnose psychiatric morbidity of other kinds, it is likely that they might have found higher rates in the TOP group.

The authors state that the general practitioners would not have a systematic bias in diagnosing. However, since these general practitioners were referring their patients for TOP, they are less likely to see any adverse effects of a procedure they recommended. Why did the authors not include family physicians who do not make abortion referrals? Physicians of the Christian Medical and Dental Society (CMDS) Canada have a significantly lower rate of abortions and miscarriages in their practices compared to other general practitioners.

The general practitioners' follow up in this study was poor. They lost 65.6% to follow up by the end of the study from the abortion group, and 57.6% from the non_abortion group. The authors state that most of those who were lost to follow up were single, highly educated women. Other studies have shown these women are more likely to have an abortion.

Since those in the refused abortion group were probably refused because of psychiatric problems, psychiatric morbidity in the TOP group should be lower. The authors state that although the DSH was higher in the TOP group, the rates fell more rapidly than in the non_abortion group. They failed to note that the rate the TOP group fell to, i.e. 3.8 was still higher than the baseline group of the non_TOP group, 3.0.

Gilchrist et al. did not show the demographic variables in each group, but state that the data "were indirectly standardised for age, marital status, smoking habit, age at leaving full_time education, gravidity, and previous history of induced abortion at recruitment, since the comparison groups differed on these characteristics." At the end of this article they also state that "the lack of more detailed social information was, however, an important limitation, given the evidence that poor social support increases the risk of psychological morbidity after abortion." They then, to try and explain why DSH is higher in the abortion group, state, "the most likely explanation is that they were at risk because of coexisting social or psychological difficulties associated with both their decision to seek a termination and their subsequent risk of deliberate self_harm." This confusing obfuscation seems to be an attempt to deny the findings that psychiatric morbidity, apart from DSH, was not higher in the group who were refused TOP. The authors state that "risk ratios (RR) were calculated with reference to the group of those who did not request a termination." "The 95% confidence intervals (CI) were calculated using the assumption that the standard deviation of the log of relative risk is equal to the sum of the reciprocals of the observed number of cases in the two groups being compared." This is a questionable assumption, especially in view of the fact that the crude rates for psychosis are; TOP group .1 per 1000, non_TOP group .05 per 1000.

The fact that the psychiatric morbidity of the termination group was not lower than a comparison group of women who requested abortion and changed their minds, effectively demonstrates that abortion is not an effective treatment for psychiatric illness. This study also demonstrates that abortion makes psychiatric conditions of all kinds worse. Yet, without scientific or clinical support, these general practitioners used "previous or anticipated psychiatric illness" as a justification for abortion. This is a practice that the Canadian Psychiatric Association has officially deplored.<ref name="Smith">Smith CM. Canadian Psychiatric Association Bulletin, 13(4): 2_3, Oct. 1981.</ref>

 

== Criticisms by Priscilla Coleman ==
"Incredulously, the Gilchrist et al. (1995) study received a rating of “Good”, when very few controls for confounding 3rd variables were employed, meaning the comparison groups may very well have differed systematically with regard to income, relationship quality including exposure to domestic violence, social support, and other potentially critical factors. Further Gilchrist et al. reported retaining only 34.4% of the termination group and only 43.4% of the group that did not request a termination at the end of the study. No standardized measures for mental health diagnoses were employed and evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The GPs were volunteers and no attempt was made to control for selection bias."

== References ==

  {{reflist}}

Gilchrist

2025-09-19T20:15:03Z

Barb: /* Grading of Gilchrist Study */

Gilchrist AC, Hannaford PC, Frank P, Kay CR. Termination of pregnancy and psychiatric morbidity. ''Br J Psychiatry''. 1995;167:243-248.

Please register and contribute to the development of these notes into a narrative by editing the sections or adding sections.

== Abstract ==

''Gilchrist AC, Hannaford PC, Frank P, Kay CR. [http://archpsyc.ama-assn.org/cgi/ijlink?linkType=ABST&journalCode=bjprcpsych&resid=167/2/243 Termination of pregnancy and psychiatric morbidity.]Br J Psychiatry. 1995;167:243-248.''

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 1'''509 volunteer GPs''' after the conclusion of the pregnancy was compared in four groups: women who had an '''induced abortion (6410)''', women who did not request a termination (6151) for a pregnancy the GP determined '''had not been planned at least 3 months before conception''', women who were '''refused a termination (379)''', and '''321 women''' who changed their minds before the termination was performed.

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.

== Additional Key Findings ==

#The findings confirmed that women with prior psychiatric problems are worse off postabortion
#Women with the most fragile mental health prior to an abortion, i.e., psychosis, were worse off postabortion
#The findings indicated that among women with no prior psychiatric history, significantly higher risks of deliberate self harm were observed both after an abortion and after a refused abortion.

 

== Additional Notes Regarding Population Sample and Methodology ==

#Following screening and risk-benefit analyses, attending physicians refused to peform abortions on 379 women.
#An additional 321 women changed their minds after screening and consultation with their attending physicians.
#British women who do not have abortions were underrepresented in the study. In the study sample 48.3% of the women had abortions, a percentage which is much higher than the abortion rate in the UK. One source reports that only 22.8% of pregnancies in the UK end in abortion.[http://www.mscperu.org/aborto/abortingl/abortos_porcentajepaises.htm]
#All general practitioners reporting were volunteers and were not blind to condition when making their counts. The authors do not disclose the conditions under which volunteers were selected, nor the rate of volunteers among those invited to volunteer, nor any measure or attempts to grade or screen the volunteer physicians relative to age, gender, practice or attitudes regarding abortion, or any other factors which might influence the observer's judgments and reports. This self-selected group of participating physicians may have been biased. Surveys of GP's in Britain find that about 80% report a "pro-choice" perspective which may influence their recommendations for abortion and their subjective interpretation of post-abortion reactions.<ref>Marie Stopes International. General Pracitioners: Attitudes Toward Abortion, 2007. London, UK. www.mariestopes.org.uk</ref> Clearly, those who recommend for abortion would be disinclined to believe that their recommendations were in error. See additional notes below regarding the reluctance of women to return to physicians for follow up care following an abortion.
#GP's reported details every 6 months.
#Data was reported without any actual follow up interviews on the part of the GP. A GP who had not seen a patient in the last six months might therefore simply report that there were no observed psychological problems.
#Information was obtained only from women who volunteered and "agreed to their family doctor supplying anonymous data to the study center." (Research shows that women who expect to deal poorly with an abortion do in fact have more post-abortion problems. Such women might prefer not to be excluded from a follow up study for fear of being exposed to additional stress.)
#Selection bias may have occurred among women volunteers.
#According to the authors, "Had follow-up interviews been required, it is likely that participation would have been greatly reduced; in a pilot survey nearly half of the women who had a termination said that they would refuse to participate if they could not remain anonymous."
#The findings are inconsistent with record based research in Canada which found that 24% of women who had abortions subsequently made visits to psychiatrists compared to 3% in the general population.<ref>''Report of the Committee on the Abortion Law, RF Badgley et al, (Ottawa:Supply and Services, 1977) pp. 313-321''</ref> and record based research in the United States (Reardon, CMAJ).

== Strengths ==

#It was prospective with a large sample size

#The study used four comparison groups

:#those who never requested abortion, including the combination of both those who delivered healthy babies and those who miscarried or had other adverse results;
:#those who had an induced abortion;
:#those who originally requested abortion but changed their minds after consulting with physician; and
:#those who requested termination but for whom physicians refused to perform the abortion after screening and a risk/benefit analysis.

== Weaknesses ==

#This study is not applicable to American experience because British abortion law is much more protective of women's health and requires a level of screening, counseling, and risk benefit analysis not normally found in the United States. In Britain, before an abortion is performed two medical doctors have to evaluate the patient and both agree that the risks of abortion are less than the risk associated with childbirth.<ref>In the United Kingdom, the 1967 abortion act provides that an abortion is legal "if two registered medical practitioners are of the opinion, formed in good faith - a) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or of injury to the physical or mental health of the pregnant woman or any existing children or of her family, greater than if the pregnancy were terminated; or b) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped." The Public General Acts, 1967, p. 2033, (Eng.) (emphasis added)</ref> In the sample used for this study, 700 women (approximately 10% of all those requesting an abortion) did not have an abortion after a risk-benefit screening and consultation with their physicians. It seems apparent that these women were likely at greatest risk of adverse outcomes. Such screening and risk benefit analysis is not typically found in the American context, where instead abortion is generally provided simply on request. As this process of screening by two physicians in Britain may better serve to identify and protect women who are being pressured into unwanted abortions, and would therefore reduce the risk of severe negative psychological reactions among this group of women for whom an unwanted abortion, it is highly likely that British women may be exposed to less psychological trauma associated with unwanted, unsafe, or unnecessary abortions as compared to American women. The potential protective effects of such screening are indicated by research among women who had abortions in the United States in which it was found that 64% reported feeling pressured into the abortion by other people (Rue). In addition to reducing the risk of women being pressured into unwanted abortions by third parties, two physician screening in the UK may also reduce the risk that women will have abortions in violation of their moral views, or their maternal desires, which are two of many statistically validated risk factors for subsequent psychiatric disorders.
#No standardized measures for mental health diagnoses were employed.
#Only the first reported episode of illness was recorded. Though the authors had the data to report on average number of contacts for each illness (a proxy for the duration and degree of the psychological episodes), they did not disclose any measure for duration or severity. The only exception is that they did report psychotic episodes within the first 12 months after delivery or termination...but did not identify prior history of abortion in thise cases. Given the eight year span of the study, the lack of information about when treatments occurred relative to the pregnancy outcome may also have a diluting effect in regard to recency to the stressor.
#The failure to report timing of the first incident of psychiatric illness is underscored by the admission in the discussion that there were indeed "Difference in the timing of admission and the past psychiatric history of women admitted postpartum or post-termination...suggest different underlying mechanisms." If there are indeed "different mechanisms" underlying the difference in timing of psychological illness following pregnancies carried to term versus those aborted, isn't that exactly what should be studied. Instead, they note a difference in timing but don't provide the details. Since proximity to the event supports a casual connection, this is a very serious omission.
#The study spanned, potentially from 1979 thru 1987, with women being introduced into the data set throughout that period. The authors received information about deaths, but they chose not to report deaths . . . which is especially concerning given the elevated rates of suicide attempts and completed suicides among women who abort.
#The study groups are not clearly delineated. Women with a prior history of abortion were mixed into each group. The comparison of women who did not have abortions during the study period, therefore, actually included women with a history of abortion. This is especially important since there is strong evidence that women with a history of abortion have more mental health problems and substance use during and after subsequent pregnancies. It is also unclear what adjustment, if any, was made if women carried to term but subsequently had an abortion.
#By the end of the study, the attrition rate was 65.6% for those had abortions and 57.5% for those who did not (p. 247). Such attrition rates are high and problematic. The fact that they were higher for women who had abortions, which may indicate greater psychological distress, is especially problematic. Those women who are having mental health problems that are trauma-related are precisely the most likely to be in the drop-out pool as they do not wish to go back to a doctor who might bring the incident back to mind. The authors report that "Most loss to follow-up occurred because patients left the practice of the recruiting doctor. Women no longer under observation were slightly younger, of lower parity and higher educational status, and more likely to be single than the original cohort."
#Evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The report of the study itself states: “The major disadvantages of using general practitioners’ reports were the likelihood of under-recognition and an imprecise diagnosis of psychiatric disorder” (p. 247). The authors even remark that the GP's assessments of 'puerperal psychosis' were almost certainly inaccurate.
#The GP's who participated may have also been the same doctors who recommended the abortion to their patients. This involvement may have biased these GP's toward underestimating the negative effects on their patients and overestimating the pre-existing psychological illnesses, which is typically the legal justification for recommending an abortion for social reasons.
#The GPs who participated in this catchment study were volunteers and no attempt was made to control for selection bias. It is possible that many, most, or all volunteered to participate in the study because of a special interest in the issue, and/or because they regularly referred for or performed abortions. The study had no blind or double blind controls and all contributing volunteers were aware of the implications of every judgement they made in preparing their reports. This study therefore falls far short of the objective quality of the record based studies done in Canada, Finland, and the United States, all of which found significantly higher rates of mental health treatments or suicide following abortion. Notably, the authors acknowledge that the risk of errors in diagnostic assessments by recourse to a strong standard of treatment via analysis of "episodes of psychiatric illness leading to hospital admission." In this regard, however, record bases studies are clearly a superior methodology and have clearly shown significantly higher rates of psychiatric hospitalization following abortion compared to delivery and miscarriage.(Reardon, CMAJ)
#Research has indicated that women who have negative abortion reactions are less likely to return to the physician who referred or performed the abortion. For example, a survey of 2,215 abortion patients in 12 abortion clinics in the US found that two out of three women do not return for follow-up appointments at the abortion clinic. (see 'From the Patient’s Perspective - Quality of Abortion Care', Picker Institute. (1999). Boston, MA.) Women embarrassed a past abortion may change providers to avoid facing the stress of seeing the doctor who approved the abortion. In addition, poor followup may result in underestimation of the problem of significant adjustment problems post-abortion. Data in Gilchrist confirms this finding in that by the end of the study, significantly fewer women who aborted. 34.4%, were still under the care of the physician reporting on them comared to 4.4$ of those who did not request an abortion.
#Data regarding prior psychiatric history in this study was reported by a local GP whose may not have had the complete patients’ health records due to lack of comprehensive record linkage in the UK.
#This study had insufficient power to detect significant differences between those women who requested a termination and changed their minds, and those who were refused abortion.
#Only extreme outcomes were measured – drug overdoses rather than substance abuse in general; only diagnosed PTSD but not the more prevalent sub-clinical levels of PTSD or the common practice of PTSD going undiagnosed; psychotic episodes which are rare in the population under either condition.
#There are thousands of case studies of adult women who attribute post-trauma symptoms to their first-trimester abortions, narratives of which are being included in court cases and otherwise publicized. The vast majority of these case studies would not fit into the criteria of extreme problems counted in the Gilchrist 1995 study. Case studies may be inadequate for establishing prevalence or for comparison to the aftermath of other options for dealing with an unplanned pregnancy, but can a statistical study that would exclude those case studies be adequate?
#Women who have miscarriages are known to have higher rates of subsequent psychological distress compared to women who deliver health children. By including women who miscarry with women who carried to term, the study fails to provide a comparison between rates of psychological illness for women who carry to term--which is of course their intent. While miscarriage is an unavoidable risk, the choice women face is between trying to carry to term and having an induced abortion. Therefore, it seems that the comparison between psychological risks of abortion and carrying to term would be relevant to both women and physicians--excluding the risks of psychiatric distress that may follow a miscarriage. While all measures are relevant, the failure to distinguish between successful delivery and miscarriages in this study may have obscured a relative risk of abortion compared to delivery.
#Gilchrist et al. (1995) used outcome-based, convenience sampling (women identified after making a pregnancy decision via selected general practitioners), which prevents estimation of absolute risk in an exposed population; under the criteria of [https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9805a181224c88d888803d906e6c967e2e107829 Dekkers et al. (2012)] this design is more appropriately classified as a case series rather than a cohort study.

{| class="wikitable" style="width:100%;"
! style="width:20%;" | Category
! style="width:50%;" | Key Flaw
! style="width:30%;" | Impact
|-
| '''Study Design'''
| Outcome‑based, post‑decision sampling; convenience GP recruitment
| Cannot calculate absolute risk; not a true cohort
|-
| '''Sampling Bias'''
| Volunteer GPs (~80% pro‑choice); only women consenting to data sharing
| Likely underrepresents distressed women; ideological skew
|-
| '''Attrition'''
| 65.6% loss in abortion group; 57.5% in non‑abortion
| High dropout likely hides adverse outcomes
|-
| '''Diagnosis'''
| GP‑based, no standardized tools; misclassified puerperal psychosis
| Inflated postpartum psychosis; under‑detected other disorders
|-
| '''Data Gaps'''
| No timing of episodes; mortality causes unreported
| Obscures causal links; omits suicide data
|-
| '''Confounding'''
| No control for domestic violence, coercion, moral conflict
| Cannot rule out alternative explanations
|-
| '''Comparisons'''
| Miscarriage lumped with live births; prior abortions in “controls”
| Dilutes differences; masks risks
|-
| '''External Validity'''
| UK’s dual‑physician screening not comparable to US context
| Findings not generalizable
|}

== Table of Claims versus Problems Issues ==

{| class="wikitable" style="width:100%;"
! style="width:40%;" | Gilchrist Claim / Framing
! style="width:60%;" | Critique / Counterpoint
|-
| '''Study is a “prospective cohort” of 13,261 women with unplanned pregnancies'''
| Sampling was ''outcome‑based'' and post‑decision, not exposure‑based. Under Dekkers et al. (2012) criteria, this is a '''case series''', not a true cohort. No inception cohort, no absolute risk calculation possible.
|-
| '''Volunteer GP network ensures broad coverage'''
| 1,509 GPs were self‑selected volunteers; no data on representativeness. Surveys show ~80% of UK GPs are pro‑choice, potentially biasing both referrals and post‑abortion assessments.
|-
| '''Women agreed to anonymous data sharing, ensuring privacy'''
| Self‑selection bias likely — women anticipating distress may have opted out. Those with negative experiences are less likely to return to the referring GP, leading to underreporting.
|-
| '''Follow‑up over years allows long‑term outcome capture'''
| Attrition was extreme: only 34.4% of abortion group and 42.4% of non‑abortion group remained. Dropouts were disproportionately single, educated women — a demographic more likely to abort and potentially more vulnerable to distress.
|-
| '''GP reports capture psychiatric morbidity in the community'''
| Diagnoses made by non‑specialists, without standardized instruments. Authors admit likely over‑diagnosis of puerperal psychosis and under‑recognition of other disorders.
|-
| '''No overall increase in psychiatric morbidity after abortion'''
| Group contamination: “non‑abortion” group included women with prior abortions. Miscarriage cases were lumped with live births, inflating morbidity in the comparison group and masking differences.
|-
| '''Lower risk of psychosis after abortion than postpartum'''
| Inflated postpartum psychosis rates due to misclassification; when hospital admissions are used (a more objective measure), rates are similar.
|-
| '''Higher DSH rates after abortion are due to confounding social factors'''
| No control for key confounders like domestic violence, moral conflict, coercion, or social support. Elevated DSH in women with no prior psychiatric history is a robust finding that cannot be dismissed without data.
|-
| '''Mortality not a focus of the study'''
| Deaths were recorded but causes not reported — omitting suicide data despite known associations in other national datasets (Finland, Canada, US).
|-
| '''Applicable to general abortion–mental health debates'''
| UK’s dual‑physician screening and risk‑benefit analysis likely filter out highest‑risk women. Findings are not generalizable to contexts (e.g., US) where doctors' risks assessments are mandatory.
|-
| '''Large sample size is a strength'''
| Large but non‑representative sample; convenience GP recruitment and patient self‑selection undermine external validity.
|-
| '''Multiple comparison groups improve robustness'''
| Small “refused” and “changed mind” groups lacked statistical power; key differences may have gone undetected.
|}

== Grading of Gilchrist Study ==

=== A Weal Newcastle-Ottawa Scale for Cohort Studies ===
[https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp The Newcastle-Ottawa Scale (NOS)] is commonly used to grade the quality of studies. It is useful for identifying where Gilchrist's study falls short.

The NOQ-Cohort scale evaluation criteria includes three domains; 1) selection of study groups or how well sample represents the target population, (four points); 2) comparability of groups, and account for confounders (two points); and 3) ascertainment of exposure and outcomes, how measured (three points).

In the Case-Control version of the NOS, it is clear that Gilchrist's sample of women, chosen by a group of volunteer general practitioners, is not random nor does it include all eligible cases of women. So it is no representative of all cases. In addition, while women who decided against abortion or were refused abortions, were treated as control groups, NOS requires that "If cases are first occurrence of outcome, then it must explicitly state that controls have no history of this outcome. If cases have new (not necessarily first) occurrence of outcome, then controls with previous occurrences of outcome of interest should not be excluded." But Gilchrist does not control for abortions that may have occurred before or after the index pregnancy event upon which the 1509 volunteer GP's selected and place women into one of the three groups. This means there were at least some women in the two control groups who had prior and/or subsequent abortions.

In the Cohort version NOS, the selection criteria is poor. It is not a representative sample since it relied upon both on volunteer group of GP's and only those women who agreed to have their information shared.
{| class="wikitable"
|Author
| colspan="4" |Selection
|Comparability
| colspan="3" |Outcome
|Score
|-
|NOQ-Cohort
|Q1
|Q2
|Q3
|Q4
|Q5 & Q6
|Q7
|Q8
|Q9
|
|-
|Gilchrist 1995
|C
|A*
|B*
|B
|A*
|A*
|A*
|C
|5 (max=9)
|}

=== Gilchrist is actually a case series, not a cohort study ===
Although Gilchrist et al. enrolled a non-random, convenience sample of women chosen by a volunteer group GPs who asked a convenience sample of women if they would "agree" to allow their family doctor to provide data to the research team. The GP's ''after'' the women had already sought an abortion and/or from a sample of women they deemed to have not planned their pregnancies at least three months before conceiving.

Because the sampling was from GP's who referred for or provided abortions who non-randomly chose who to invite...and only women who agreed to participate were reported upon (with no data on what percentage of women refused to be reported upon) the study sample is clearly not representative of all women at risk of unplanned pregnancies. Because it does not include sampling at clear inception point (prior to pregnancy, or immediately upon learning one was pregnant) the design is best described as a case series rather than a cohort study.

1) The rule of thumb distinguishing case series from cohort studies: ([https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9805a181224c88d888803d906e6c967e2e107829 Dekkers et a]l.)

* Cohort = sampling based on *exposure* (or a clearly defined inception cohort) wherein participants free of the outcome at baseline, followed over time, so you '''can''' calculate absolute risks or rates. In this case, participants should be identified and followed prior to their becoming pregnant, such as in the example of [https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/abortion-and-mental-health-disorders-evidence-from-a-30year-longitudinal-study/59A90CBF3A58C58B342CBCFFBBFEBD2E Fergusson 2008], a true cohort study which examined mental health effects associated with pregnancy outcomes.
* Case series = sampling based on the *outcome* (or outcome+exposure), so you '''cannot''' calculate an absolute risk for the outcome in an exposed population

2) Why *Gilchrist et al.* is best classified as a **case series**

The subjects utilized were volunteers chosen by a non-random sample of GPs '''after''' they’d already made their pregnancy decision.

* ''Sampling after the decision (outcome-based):'' participants were enrolled *after* the key event (the woman had already decided to terminate or continue). That makes the sampling tied to the outcome/exposure combination and not to a defined exposed population drawn *before* outcomes accrued.
* ''Denominator unclear / no inception cohort:'' because the study did not recruit all women at a defined baseline (e.g., prior to or when a pregnancy was confirmed) you don’t have the full population at risk (the “all exposed” denominator). Without that, you can’t legitimately compute an absolute incidence/risk.
* ''Non-random / convenience GP sampling:'' selecting patients via a non-random set of GPs produces a convenience sample and makes it unlikely the sample represents the population of all women who made each decision — another hallmark of case-series style selection.
* ''What is needed:'' A properly designed study would employ population-based sampling (not convenience GP selection) so the cohort represents the target population. This might be done by using anonymized medical records for an entire population of patients, as has been done in [https://pubmed.ncbi.nlm.nih.gov/14964603/ Coleman 2002], [https://pubmed.ncbi.nlm.nih.gov/12743066/ Reardon 2003], [https://pubmed.ncbi.nlm.nih.gov/37342485/ Studnicki 2023] and [https://pubmed.ncbi.nlm.nih.gov/38771715/ Reardon 2024] and [https://pubmed.ncbi.nlm.nih.gov/39446259/ Studnicki 2024].

3) Why authors (and readers) often misclassify these studies

* ''They see “follow-up” and call it a cohort:'' If subjects are followed for some months after recruitment, many assume “prospective = cohort,” regardless of how recruitment occurred.
* ''Presence of comparison groups is misleading:'' Even if the paper compares women who terminated vs continued, that alone doesn’t make it a cohort — the sampling frame and denominator definition do. Dekkers explicitly notes that a comparison group *doesn’t* define a cohort; sampling method does.
* ''Terminology slippage in clinical journals.'' Words like “prospective consecutive case series” or “cohort” are used loosely.

=== Low grade under the [https://jbi.global/sites/default/files/2021-10/Checklist_for_Case_Series.docx JBI Critical Appraisal Checklist for Case Series] ===
{| class="wikitable"
|Item
|Response (Yes/No/Unclear)
|Notes
|-
|1. Were there clear criteria for inclusion in the case series?
|No
|Participants recruited after decision via non-random GP sample; inclusion criteria not systematically applied.
|-
|2. Was the condition measured in a standard, reliable way for all participants?
|Yes
|Psychiatric morbidity assessed using standardized methods (ICD-8 diagnoses)
|-
|3. Were valid methods used for identification of the condition for all participants?
|Unclear
|Diagnosis/measurement tools for psychiatric morbidity were valid and appropriate (ICD-8 diagnoses were reported by GP's not psychiatrists)
|-
|4. Did the case series have consecutive inclusion of participants?
|No
|Convenience GP selection precludes consecutive inclusion.
|-
|5. Did the case series have complete inclusion of participants?
|No
|Sample limited to selected GPs; incomplete coverage of all eligible cases.
|-
|6. Was there clear reporting of the demographics of the participants in the study?
|Unclear
|Age, parity, and other sociodemographic characteristics were not reported but were used in calculating adjusted RR.
|-
|7. Was there clear reporting of clinical information of the participants?
|No
|Prior and subsequent abortion history not reported, which may have impacted mental health and adulterated control groups
|-
|8. Were the outcomes or follow-up results of cases clearly reported?
|Unclear
|Reported follow-up outcomes for psychiatric morbidity over the study period.
|-
|9. Was there clear reporting of the presenting site(s) / clinic(s) demographic information?
|No
|No detailed description of GP practice characteristics or catchment areas.
|-
|10. Was statistical analysis appropriate?
|Unclear
|Statistical analysis suitable for descriptive comparisons,. But sample size too small for selfharm analysis
|}

== Notes that may require further investigation ==

#The study indicates that some dropouts occurred due to death (p 244 col 1), but the authors fail to report the distribution or cause of deaths. Were there for example, an excess number of suicides or accidents among women who had abortions, as has been found in numerous other studies? If so, it appears from the methodology employed that cases of abortion associated suicide would not been included in any of the measure of psychiatric distress. In other words, women who experienced this most sever psychiatric distress would simply have been counted as having no ill effects and as having "dropped out" of the study.
#Ronsmans C, et al. "Mortality in pregnant and nonpregnant women in England and Wales 1997–2002: are pregnant women healthier?" in Lewis G, editor. Why Mothers Die 2000-2002. The Sixth Report of the Confidential Enquiries into Maternal Death in the United Kingdom. London: RCOG Press;2004

:Following the studies of Gissler and Reardon showing lower mortality rates associated with childbirth, the Ronsmans study in Britain confirmed that there is a lower risk of mortality during pregnancy and until one year after birth compared to women without a recent pregnancy. Specifically reporting that:
::"All-cause mortality in women aged 15–44 years was 58.4 deaths per 100,000 women per year.... Surprisingly, however, mortality during pregnancy or within 1 year after birth was between four and five times lower than mortality in women without a recent pregnancy. The rate ratios comparing the pregnancy–42 day and the 43–365 postpartum periods with nonpregnant women were 0.21 and 0.22, respectively."
:Surprisingly, however this government funded inquiry failed to report any data on mortality rates assocaited with abortion. Given the fact that the authors were aware of the findings of Gissler and Reardon, the failure to report an analysis of death rates assocaited with abortion appears to be a deliberate attempt to suppress findings which would confirm previous research.
:While this study fails to report mortality rates relative to pregnancy outcomes, it does report the following citations:
::"In the USA, women who had delivered a live or stillborn infant in the previous year were half as likely to die as women who had not recently delivered." citing Jocums SB, Berg CJ, Entman SS, Mitchell EF. Postdelivery mortality in Tennessee, 1989–1991. Obstet Gynecol 1998; 91: 766–70.
::"In Canada, mortality rates during pregnancy or within 42 days of its termination and between 43 and 225 days postpartum were about half those of nonpregnant women."citing Turner LA, Kramer MS, Liu S. Cause-specific mortality during and after pregnancy and the definition of maternal death. Chronic Dis Can 2002; 23: 1–8.
::"In Finland, the age-adjusted risk of a natural death within a year after birth or a miscarriage was half that of women without a pregnancy." citing Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Pregnancy-associated mortality after birth, spontaneous abortion or induced abortion in Finland, 1987-2000. Am J Ob Gyn 2004; 190:422-427.
::NOT MENTIONED was the following findings from the Gissler 2004 study:
:::The age-adjusted mortality rate for women during pregnancy and within one year of pregnancy termination was 36.7 deaths per 100,000 pregnancies, which was significantly lower than the mortality rate among nonpregnant women 57.0 per 100,000 person-years (RR=0.64, 95% CI 0.58-0.71). '''The mortality was lower after a birth (28.2/100,000) than after a spontaneous (51.9/100,000) or induced abortion (83.1/100,000).''' We observed a significant increase in the risk of death from cerebrovascular diseases after delivery among women aged 15-24 years (RR=4.08, 95% CI 1.58-10.55).

:This three fold higher death rate following abortion is certainly noteworthy and deserving additional investigation. Therefore it is hard to avoid the conclusion that this failure to examine and report on abortion associated deaths in this official British study may reflect a bias in the British research community which may also be reflected in studies regarding the negative pscyhological effects associated with abortion.

== Criticisms by Dr. Philip Ney ==

The study by Gilchrist et al. is based on the concept of an unplanned pregnancy, but the authors make little attempt to define what this is and how it was determined. As every physician knows, people are ambivalent about the inception and conception of almost every pregnancy. There are very few people who actually put much effort into planning a pregnancy, and those are mostly people who use natural family planning methods. Most "plan" only by withdrawing contraception. A recent report of the Alan Guttmacher Institute states that "the proportion of women wanting to become pregnant is extremely low, less than 1 in 5 in industrialised countries."<ref name="gadd">Gadd J. (1995, August 22). Families becoming smaller but many births still unwanted. The Globe and Mail, A8.</ref> If contracepting or not contracepting means whether the pregnancy is planned or not, then there is no basis for making statements about psychiatric sequlae of any pregnancy outcome. Many people change their mind almost in the middle of intercourse about whether they want or plan to have a baby.

The review of the literature is very biased. There are many relevant studies not cited.<ref name="Ney">Ney PG, Fung T, Wickett AR, Beaman_Dodd C. "The Effects of Pregnancy Loss on Women's Health", Social Science and Medicine, 38(9): 1193_1200, 1994.</ref><ref name="Sim">Sim M, Neisser R. "Post_abortive psychosis: a report from two centers. In: The Psychological Aspects of Abortion. Mall D, Watts F (Eds.), University Publications of America, Washington: 1_13, 1979.</ref> Gilchrist et al. do not summarize the references of Doane & Quigley and David et al. correctly.

Since the authors were only using major psychiatric illness classifications, it appears that they did not expect to find or look for the constellation of symptoms and signs now known as the Post_Abortion Syndrome. Post_Abortion Syndrome is now reasonably well recognised and defined, but not included in ICD _ 8.

Although the authors state this study examined a variety of pregnancy outcomes, they did not compare a live birth to a miscarriage or to a stillbirth or to an abortion. They found that the rates of miscarriage were different in the different groups. Miscarriages in the non_abortion group would tend to increase the morbidity because miscarriages do result in higher rates of both physical and psychiatric morbidity. Miscarriages in the abortion group would tend to decrease the apparent morbidity because the effects of the miscarriages are less than the effects of the abortion.

This study relied on general practitioners' assessment of psychiatric morbidity and used the not too precise catagorizations of ICD 8. They diagnosed 225 puerperal psychosis; much higher than the estimated prevalence. The authors found that only 13 of these puerperal psychosis were admitted for treatment, yet almost every case of a puerperal psychosis should be admitted. It seems family physicians were wrong in their diagnosis of puerperal psychosis by a factor of 17. It is likely they were equally out on the other psychiatric diagnosis. The authors did admit that the estimation of puerperal psychosis was too high. The authors found that there is a significantly higher rate of deliberate self_harm (DSH) following an abortion. Eighty_nine (89) % of these were overdoses, which are not difficult to diagnose. If the family physicians were better able to diagnose psychiatric morbidity of other kinds, it is likely that they might have found higher rates in the TOP group.

The authors state that the general practitioners would not have a systematic bias in diagnosing. However, since these general practitioners were referring their patients for TOP, they are less likely to see any adverse effects of a procedure they recommended. Why did the authors not include family physicians who do not make abortion referrals? Physicians of the Christian Medical and Dental Society (CMDS) Canada have a significantly lower rate of abortions and miscarriages in their practices compared to other general practitioners.

The general practitioners' follow up in this study was poor. They lost 65.6% to follow up by the end of the study from the abortion group, and 57.6% from the non_abortion group. The authors state that most of those who were lost to follow up were single, highly educated women. Other studies have shown these women are more likely to have an abortion.

Since those in the refused abortion group were probably refused because of psychiatric problems, psychiatric morbidity in the TOP group should be lower. The authors state that although the DSH was higher in the TOP group, the rates fell more rapidly than in the non_abortion group. They failed to note that the rate the TOP group fell to, i.e. 3.8 was still higher than the baseline group of the non_TOP group, 3.0.

Gilchrist et al. did not show the demographic variables in each group, but state that the data "were indirectly standardised for age, marital status, smoking habit, age at leaving full_time education, gravidity, and previous history of induced abortion at recruitment, since the comparison groups differed on these characteristics." At the end of this article they also state that "the lack of more detailed social information was, however, an important limitation, given the evidence that poor social support increases the risk of psychological morbidity after abortion." They then, to try and explain why DSH is higher in the abortion group, state, "the most likely explanation is that they were at risk because of coexisting social or psychological difficulties associated with both their decision to seek a termination and their subsequent risk of deliberate self_harm." This confusing obfuscation seems to be an attempt to deny the findings that psychiatric morbidity, apart from DSH, was not higher in the group who were refused TOP. The authors state that "risk ratios (RR) were calculated with reference to the group of those who did not request a termination." "The 95% confidence intervals (CI) were calculated using the assumption that the standard deviation of the log of relative risk is equal to the sum of the reciprocals of the observed number of cases in the two groups being compared." This is a questionable assumption, especially in view of the fact that the crude rates for psychosis are; TOP group .1 per 1000, non_TOP group .05 per 1000.

The fact that the psychiatric morbidity of the termination group was not lower than a comparison group of women who requested abortion and changed their minds, effectively demonstrates that abortion is not an effective treatment for psychiatric illness. This study also demonstrates that abortion makes psychiatric conditions of all kinds worse. Yet, without scientific or clinical support, these general practitioners used "previous or anticipated psychiatric illness" as a justification for abortion. This is a practice that the Canadian Psychiatric Association has officially deplored.<ref name="Smith">Smith CM. Canadian Psychiatric Association Bulletin, 13(4): 2_3, Oct. 1981.</ref>

 

== Criticisms by Priscilla Coleman ==
"Incredulously, the Gilchrist et al. (1995) study received a rating of “Good”, when very few controls for confounding 3rd variables were employed, meaning the comparison groups may very well have differed systematically with regard to income, relationship quality including exposure to domestic violence, social support, and other potentially critical factors. Further Gilchrist et al. reported retaining only 34.4% of the termination group and only 43.4% of the group that did not request a termination at the end of the study. No standardized measures for mental health diagnoses were employed and evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The GPs were volunteers and no attempt was made to control for selection bias."

== References ==

  {{reflist}}