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Impact of Abortion On Others

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==Men And Abortion==

'''[https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2818118 Adverse Pregnancy Outcomes and Subsequent First-Time Use of Psychiatric Treatment Among Fathers in Denmark.] Christiansen F, Petersen J, Thorius IH, et al. ''JAMA Netw Open.'' 2024;7(5):e249291. doi:10.1001/jamanetworkopen.2024.9291'''

* Of the 192 455 fathers included (median age, 30.0 [IQR, 27.0-34.0] years), 31.1% experienced an adverse pregnancy outcome. Most of the fathers in the study had a vocational educational level (37.1%). Fathers experiencing a stillbirth had a significantly increased risk of initiating nonpharmacological psychiatric treatment (adjusted hazard ratio [AHR], 23.10 [95% CI, 18.30-29.20]) and treatment with hypnotics (AHR, 9.08 [95% CI, 5.52-14.90]). Moreover, fathers experiencing an early induced abortion (≤12 wk) had an increased risk of initiating treatment with hypnotics (AHR, 1.74 [95% CI, 1.33-2.29]) and anxiolytics (AHR, 1.79 [95% CI, 1.18-2.73]). Additionally, late induced abortion (>12 wk) (AHR, 4.46 [95% CI, 3.13-6.38]) and major congenital malformation (AHR, 1.36 [95% CI, 1.05-1.74]) were associated with increased risk of nonpharmacological treatment. In contrast, fathers having an offspring being born preterm, SGA, or with a minor congenital malformation did not have a significantly increased risk of any of the outcomes.

''[http://www.menandabortion.net/MAN/pdf/NOV_Coyle_Rue_2010.pdf Men’s Experience of Elective Abortion: A Mixed Methods Study of Loss.] Coyle, C.T. & Rue, V.M. . The Journal of Pastoral Counseling, (2010) XLV, 4-31.''
:In-depth interviews were conducted with 10 men to explore the men’s experience with abortion. In addition, clinical assessments of anger, anxiety, and grief were administered. The men’s ages were 21 to 43 years. The time lapse between the abortion and the first interview ranged from 6 months to 22 years. Half of the men were opposed to their partners’ abortions. One man was supportive of the abortion initially and one was not told of the abortion until after it occurred. The rest of the men deferred the decision to their partners.

:The predominant theme identified in the interviews was that of profound loss and this was further evident in several subthemes including relationship problems, helplessness, grief, and guilt. Each of the men’s relationships with their partners ended and the men unanimously identified the abortion experience as the cause of relationship failure. All of the men reported feelings of helplessness and grief and a majority of men experienced guilt as well. Clinical assessments revealed clinically significant levels of anxiety and intense grief.

''[http://www.rachelsvineyard.org/PDF/Articles/Coyle%20Coleman%20%20Rue%20(2009).pdf Inadequate Pre-abortion Counseling and Decision Conflict as Predictors of Subsequent Relationship Difficulties and Psychological Stress in Men and Women.] Coyle, C., et al. (2010). Traumatology: An International Journal, International Journal, 16, 16-30.''
: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.ncbi.nlm.nih.gov/pubmed/17559016 Man’s involvement in the experience of abortion and the dynamic of the couple’s relationship: A Clinical Report.] Naziri, D. (2007). The European Journal of Contraception and Reproductive Health Care, 12 (2), 168-174.''
:OBJECTIVES: To investigate the way men experience abortion from a psychodynamic perspective in order to understand better the impact of this experience on their own image as men and on the couple's relationship.
:METHODS: In-depth semi-structured interviews with 16 men in Belgium and 14 men in Greece.
:RESULTS: Intrapsychic factors seem to play for men an important role in their experience of abortion, whatever their cultural context and contraceptive practices. Two-thirds of the men who agreed to participate in the research disagreed with their partner's decision to have an abortion. Such men may feel that it is impossible for them to fulfill themselves, in particular as potential fathers. This impossibility is, according to men, linked to women's attitudes, but may also be related to their own difficult identification with parental images and to socio-professional concerns.
:CONCLUSIONS: Abortion can create tensions and/or conflicts between partners by revealing their contradictory desires. It is suggested that institutions where men and women are heard can help both partners to outlive this experience as a constructive step in their personal psychosocial evolution and in their relationship.

''[http://www.menandabortion.net/MAN/articles/IPAS_11-09.htm A Critical Response to Exploring Men’s Roles in Women’s Decisionsto End Pregnancies: A Literature Review with Suggestions for Action.] (Ipas Working Paper, 2009)''
:An excellent review of the literature

''[http://www.standapart.org/index.php?route=information/information&information_id=8 Bibliographies and Review Articles Regarding Men and Abortion]'' Alliance for Post-Abortion Research & Training. (2014)

:*[http://www.standapart.org/index.php?route=information/information&information_id=8 Men and Abortion Fact Sheet] (Summary of observations and findings from the scientific literature concerning men and abortion.)

:*[http://www.standapart.org/index.php?route=information/information&information_id=8 Men and Abortion: A Table of Scholarly Papers] (Table of studies, scholarly papers, and reviews concerning men's experience of elective abortion that have been published since 1973)

:*[http://www.standapart.org/index.php?route=information/information&information_id=8 Publications concerning Men and Abortion.] (List of academic papers, books, and articles concerning men and abortion.)

''The Effects of Abortion on Men. Rue VM. Ethics and Medics. 21(4):3, 1996.''

''"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.

''"Emotional distress among couples involved in first-trimester induced abortions," P Lauzon et al, Canadian Family Physician 46:2033-2040, Oct 2000 ''
:A study of short term distress reactions following abortion found that many men were highly distressed with both men and women having similar reactions.

''"Early Adult Psychological Consequences for Males of Adolescent Pregnancy and Its Resolution," M. Buchanan, C. Robbins, J. Youth and Adolescence 19(4): 413, 1990.''
:In a Texas study of 2522 young men who were first surveyed as 7th grade students in 1971, 15% had been involved in a non-marital pregnancy by age 21. 56% of black men had girlfriends who had the child but did not marry or cohabitate, while 28% married and had the child while 16% were ended by abortion. White adolescent males tended to end non-marital adolescent pregnancies by abortion (58%) and 34% chose to marry or cohabitate. Although numbers were small, 55% of Hispanic men married or cohabitated as a result of an adolescent pregnancy. Men whose girlfriends had abortions were more distressed than the men whose girlfriends continued the pregnancy to term.

''"Portraits of Post-Abortive Fathers Devastated by the Abortion Experience," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change 7(3): 1- 8, Nov/Dec 1994.''
:Grief patterns, repressed feelings and emotions, loss of manhood or fatherhood, substance abuse, guilt, suicidal behavior and loss of relationships are described by men following abortion of the child they fathered.

''"Abortion Attitudes and Experiences in a Group of Male Prisoners," Lindy A. Pierce, Association for Interdisciplinary Research in Values and Social Change 6(2): 1-8, Jan/Feb, 1994 ''
:This study is based on interviews during 1987-1988 of men in a Kentucky prison. The men were predominantly pro-life. 62% opposed abortion without stating any exceptions; 14% opposed abortion except for health, rape, or incest; and 24% said they would permit abortion more generally but still had reservations.

''"Adolescent Males' Abortion Attitudes: Data from a National Survey, W," Marsiglio, C.L. Shehan, Family Planning Perspectives 25(4): 162, July/Aug, 1993 ''
:A national survey of 1880 males aged 15-19 found that a majority of males disagreed with abortion if the woman couldn't afford to care for the child, if the man would not support the child, if the woman wanted the abortion for any reason, and if the woman wanted an abortion but the man did not.

''"Restoring Fatherhood Lost," Warren Williams; "Remembering Thomas: Case Study," Phil McCombs; "Forgotten Fathers and Their Unforgettable Children," David Reardon; "Men and Abortion, Grief and Healing," W.F. Brauning, Post-Abortion Review 4(4): 1-8, Fall, 1996.''
:Valuable collection of brief articles.

''Post-Abortion Trauma: 9 Steps To Recovery, Jeanette Vought, (Grand Rapids: Zondervan, 1991) 131-143. ''
:Describes anecdotal reports of men in postabortion counseling who feel extreme anger and helplessness in not having a voice in the abortion decision. The anger may turn inward and lead to depression which further damages relationships and creates isolation.

''"Husband mourns outcome of wife's painful decision," R. Christopher Moore, American Medical News, October 24, 1991, p.24. ''
:The husband was a medical doctor, his wife a lawyer. The wife decided on an abortion over the husband's objections. He said, "Even though I was the father and wanted to care for my child, I couldn't unless my wife wanted to have it. She controlled new life, our child's life and my life. I controlled nothing."

''"Men and Abortion," Wayne Brauning, address to Healing Visions VI Conference, June 1992, National Office Post-Abortion Reconciliation and Healing, P.O. Box 07477, Milwaukee, Wl, 53207. ''
:In counseling men whose partners aborted, rage, powerlessness and isolation have been predominant.

''"Many in Survey Who Had Abortion Cite Guilt Feelings," G. Skelton, Los Angeles Times, March 19, 1989, p.28. ''
:In a random telephone survey conducted in March, 1989 by the Los Angeles Times, 7 % of the 1050 men interviewed acknowledged as having been the father of an aborted child. Guilt was felt by almost two-thirds and regret by more than one-third.

''"Fathers and Fetuses," George W. Harris, Ethics 96:594-603, April 1986. ''
:Conspicuously absent from most discussions of the abortion issue are considerations of third-party interests, especially those of the father. A survey of the literature reveals an implicit assumption by most writers that the issue is to be viewed as a two-party conflict- the rights of the fetus versus the rights of the mother-and that an adequate analysis of the balance of these rights is sufficient to determine the conditions under which abortion is morally permissible.

''"Men's reactions to their partner's elective abortions," A.A. Rothstein, American Journal of Obstetrics and Gynecology 128:831-837, August 15, 1977. ''
:In a study of 60 men who accompanied their wives or girl friends for elective abortion, less than half knew the type of abortion their partners were having. When asked what they knew, just over one third who claimed understanding were able to give fully accurate explanations of the procedure.

''"Adolescent Males. Fatherhood and Abortion," A.A. Rothstein, Journal of Youth and Adolescence 7(2):203-204 (1978). ''
:In a study of 35 adolescent males, most prominent were regressive wishes for nurturance, competition with one's own father, and efforts to meet paternal ego ideals of maturity and responsibility. Cases examined in detail revealed rage, fear of abandonment and total despair.

''"Doesn't a Man Have Any Say? Fathers Go to Court to Stop Abortions," Newsweek,May 23, 1988 p. 74. ''
:Thwarted fathers in unhappy relationships are more likely to go to court to attempt to stop abortions.

''"How Abortion Affects Fathers," Regis Wailing, Liguorian, Liguori Publications, Box 701, Liguori, MO 63057, January 1988, pp. 26-31. ''
:The article describes a university psychology class viewing a film on pre-natal development when suddenly a young male student rushed from the room and leaned against the wall outside, sobbing, and said, "I didn't know it was a baby. I never would have paid for it if I had known it was a baby.' Another man was described as a former seminarian who left the seminary in the late 1960's and had a hard time adjusting. When his girl friend became pregnant, he pleaded in vain with her not to have an abortion. He has had a major alcohol problem ever since.

''"Pregnancy Termination for Genetic Indications: The Impact on Families," R. Furlong and R. Black, Social Work in Health Care 10(1): 17-34, Fall 1984. ''
:Fathers were particularly adversely impacted by genetic abortion and many would not even talk about it.

''"Abortion and Men." Linda Bird Francke, Esquire, September 1978, pp. 58-60. ''
:The article cites several ways in which repressed emotions in men following induced abortion will reveal themselves in various ways: one man feared that a living son would be sacrificed for the aborted one; another felt sadness when he heard a certain song; another experienced periodic impotence and depression. The author concludes, "Abortion is a far greater dilemma for men than researchers, counselors, and women have even begun to realize ... and [men] sometimes have more trouble dealing with abortion than women."

''"Abortion as Fatherhood Lost: Problems and Reforms," Arthur Shostak, The Family Coordinator 28:569-574(1979). ''
:In a study of the impact of abortion on males many relationships between unmarried partners appeared unable to survive the strains inherent in the abortion experience. A sizable minority reported the persistence of day or night dreams about the chiild-that- never-was, and some represented these moments as times of guilt, sadness and remorse.

''"Whose Freedom of Choice? Sometimes it takes two to untangle," Judith Paterson, The Progressive 46(l):42-45, April 1982. ''
:Article includes case histories of men adversely impacted by abortion and also has an extensive discussion by professional psychologists and psychiatrists who have counseled men on the after-effects of abortion. The article quotes Andre Watson, health educator for the Men's Center of Planned Parenthood in Washington, who like many others in his field thinks conflict over abortion often affects a relationship and sometimes destroys it. "For better or for worse, an abortion brings out the stark, naked truth of a relationship." Psychologist Arnold Medvene was quoted as saying, "Abortion is undeniably a death experience, a loss experience with immense reverberations for everybody. If all of that gets blocked, it is bound to have a dramatic and destructive impact on the relationship." Dr. Neil Bernstein, a clinical psychologist, emphasizes the effect of "denial and distancing." Psychiatrist Richard Epstein says that abortion evokes powerful and complex feelings in men as well as women, and that the individuals react in accord with the psychological level at which they experience the abortion. The article notes that many women handle the implications of abortion alone, while men repress them to a dangerous degree.

:One man worried about the negative spiritual consequences and thought women have trivialized the issue by emphasizing the right to control their own bodies. Another was amazed at the intensity of his objections to the destruction of his offspring and surprised at the rift between his political posture and his paternal feelings. A black man expressed a sense of heritage and importance of perpetuating himself.

''"Abortion: How Men Feel About One of Biggest Issues in a Woman's Life," James L. Collier, Glamour Magazine, February 1980, pp. 164-165, 243-244. ''
:The article quotes Uta Landy of the National Abortion Federation: "They [men] behave much differently from the women who call in too. They'll never admit they're directly involved. It's always "this girl, ' never 'my girl friend.' And they're mainly concerned about safety. Frequently, women ignore what you tell them about the guidelines, they're so anxious to get the abortion over with, but men will pay strict attention. Many take down what you tell them word for word." The National Abortion Federation was quoted as saying that 40% of the calls on their hotline are from males. Clinical psychologists who studied male reactions to abortion concluded men had even stronger guilt feelings than women. Men wanted to be present or even go through the abortion themselves.

''"Abortion: Are Men There When Women Need Them Most?," Carol Lynn Mithers, Mademoiselle, April 1981, p. 231. ''
:The author notes that about 3 million people had abortions last year. Only half of them were women. A program director for family planning clinics observed, "Abortion is a difficult experience for everyone concerned. That includes men. A man may escape the physical trauma, but it's unlikely he'll come through unscathed." A woman, in describing a boyfriend's reaction to abortion, said it "freaked him out."

:A macho 29-year-old male said, "Yeah, I still think about it. Not often but sometimes My brother and his wife are having a baby in the next few months and that brings it to mind- they're having a kid. I'm not."

:A 34-year-old man: "I wasn't broken up by the experience. I was saddened though. Even if you have no set moral or philosophical problems with abortion, it's still taking something away from both of you." A 28-year-old said, "I thought. What a shame! This is the combination of her and me and would be such a beautiful child."

:Another 28-year-old expressed a lack of empathy and said, "I thought I knew all about abortion and I thought it was a real routine procedure but it didn't hit me till afterward that it's also very emotionally distressing. I'm more sympathetic about that now. Maybe I would have been before if I'd known what to expect."

:A casual relationship broke up following abortion. A 28-year-old male said, "I was 22, she was 17. We had only been casual lovers. When she discovered she was pregnant I first tried to deny it. I feared I might be trapped into marriage. She said she wanted the child but I insisted abortion was the best idea. I didn't even like her very much."

:A 28-year-old man: "We were students; our biggest problem was where to go for dinner. Afterward, there was a loss of freedom. We were more sober. After the abortion there was no way that relationship was going to work. That's what makes me so sad, because in many ways it was the nicest one I'll ever have."

:A 29-year-old businessman whose girlfriend began seeing another man after her abortion: "The whole experience was like being hit by an emotional battering ram. It broke her down where she was in a real weak and vulnerable condition. I wasn't there for her."

''"How abortion affects men," John Stanhope, Faith Today, May/June 1988, pp. 26- 27. ''
:The article quotes abortionist Henry Morgentaler as saying abortion is a silent agony for many men. There is still little information on the subject. From what is available, there seems to be some indication that men go through the same grief, remorse and sadness that characterize post-abortion syndrome in women.

''The Anatomy of Bereavement, Beverly Raphael, (New York: Basic Books, 1983) 240. ''
:Some fathers will feel angry and cheated by the women's decision to terminate their child, whether or not they would be prepared to care for it as a father. Many men involved in the termination of a pregnancy they have fathered will experience grief too and may need recognition of mourning for the lost child.

''"Psychiatric Sequelae of Abortion: The Many Faces of Post-Abortion Grief, E," Joanne Angelo, Linacre Quarterly 59:69-80, May, 1992. ''
:In a clinical 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.

''"The Effects of Abortion on a Marriages," Janet Mattinson, Abortion: Medical Progress and Social Implications, Ciba Foundation Symposium 115, 1985, pp. 165-177. ''
:Marriage problems involving adverse reactions of men to induced abortion are reported in a British study of several case histories at Tavistock Clinic. Inability to conceive, withdrawal, inability to function to seek employment, sexual and interpersonal conflicts, extramarital affairs, loss of trust, seeking abortion as a form of punishment for a spouse and a heightened sense of inferiority were identified.

''"A Program of Group Counseling for Men Who Accompany Women Seeking Legal Abortions," Robert A. Gordon and Cheryl Kilpatrick, Community Mental Health Journal 13(4):291- 295 (1977). ''
:In a program of group counseling for men developed at a Wisconsin abortion clinic, men expressed anxiety, helplessness, guilt, self-blame and regret. Men used denial, intellectualization, rationalization and withdrawal in an attempt to cope with stress. Men often attempted to be invulnerable, a "real man" by denying any expression of feelings. Many men said they did not express their feelings to their partners and instead felt the need to be a source of support by presenting a strong front. Themes of discussion included (a) issues of right and wrong, particularly in connection with religious beliefs; (b) viewing fetal material as non-human; (c) disinterest in bringing a child into such a "troubled" world.

''Men and Abortion. Lessons. Losses and Love, Arthur Shostak and Gary McLouth, (New York: Praeger, 1984). ''
:In follow-up of 75 post-abortion men 25% had broken up with their partner although only 3% had stated on the day of the abortion that abortion was contributing to the breakup. Unexpected guilt and remorse, relief from tension, anger at the woman, were cited as some of the reasons for breaking up. Sex relations and contraceptive questions caused new stress immediately after the abortion. This study involved people in committed relationships (only 4% were casual).

''"Psychological Factors That Predict Reaction to Abortion," D.T. Moseley, Journal of Clinical Psychology 37(2):276-279, April 1981. ''
:A woman's relationship with her partner was determined as a crucial factor in her post- abortion adjustment. Liberated women tended to devalue the significance of the partner in conception.

''"Fatherhood and Abortion: Psychological and Psychopathological Reactions," P Benvenuti, P. Borri, P. Buzzoni, L. Clerici and M.R. Monti, Rivista di Patologica Nervosa e Mentale104:255-268(1983). ''
:Despite the scant psychological and medical interest in the reactions of men to abortion, there is considerable emotional involvement in lost parenthood both for the man and the woman. The involvement by men may manifest itself in persecutory or depressive anxiety and psychosomatic symptoms. Rarely, psychopathological symptoms such as depression and behavioral disorders may appear. The appearance of these reactions is linked to problems and conflicts aroused by prospective fatherhood leading to a comparison between fulfilled fatherhood and fatherhood lost.

''"Adolescent Males: Fatherhood and Abortion," A.A. Rothstein, Journal of Youth and Adolescence 7(2):203-204 (1978). ''
:A study of 35 adolescent males whose sexual partners were undergoing abortion at Bronx Municipal Hospital found that males had regressive wishes for nurturance, competition with one's own father, and efforts to meet parental ego ideals of maturity and responsibility. In the cases examined in detail rage, fear of abandonment and total despair were observed. Little is known about the reaction or developmental difficulties of adolescent males as a result of their implication in abortion. This is one of the few studies on the subject.

==Abortion's Impact on Siblings==

''[http://www.medicalnewstoday.com/articles/242564.php Slow Brain Growth In Babies Linked To Depression During Pregnancy]'' 2012.

A study by Hanan El Marroun published in Archives of General Psychiatry reports that babies whose mothers are depressed during pregnancy have a greater chance of retarded growth. Antidepressants may also increase the risk of slow growth of the child's brain.

''[http://www.ncbi.nlm.nih.gov/pubmed/16299880 Associations between voluntary and involuntary forms of perinatal loss and child maltreatment among low-income mothers.] Coleman PK, Maxey CD, Rue VM, Coyle CT. Acta Pædiatrica, 2005; 94.''

:Compared to women with no history of perinatal loss, those with one loss (voluntary or involuntary) had a 99% higher risk for child physical abuse, and women with multiple losses were 189% more likely to physically abuse their children. Compared to women with no history of induced abortion, those with one prior abortion had a 144% higher risk for child physical abuse. Finally, maternal history of multiple miscarriages and/or stillbirths compared to no history was associated with a 1237% increased risk of physical abuse and a 605% increased risk of neglect. Perinatal loss may be a marker for elevated risk of child physical abuse, and this information is potentially useful to child maltreatment prevention and intervention efforts. http://journalsonline.tandf.co.uk/link.asp?id=xr05355225rk21wk
''[http://birthpsychology.com/journal-article/post-abortion-survivor-syndrome-signs-and-symptoms Post-Abortion Survivor Syndrome: Signs And Symptoms.] Ney PG, Sheils CK, Gajowy M. Journal of Prenatal and Perinatal Psychology 2010;26:107-129.
:Clinical observations indicated that those psychiatric patients who survived when a preborn sibling died were adversely affected by the experience. It seemed that being a survivor of a pregnancy loss, particularly abortion, contributed to psychiatric illnesses. Data was collected from a sample of 293 adults - 98 patients and 195 counseling trainees. A self-report questionnaire with visual analogue, rating, and descriptive questions was used to ascertain the extent of common psychiatric symptoms. These were analyzed to determine if there were any significant associations with various types of pregnancy outcome. Correlations and stepwise regression analyses demonstrated a cluster of existential symptoms for those surviving when their preborn siblings were aborted. The symptom expressed by the subjects in the study that was most closely associated with abortions in the first pregnancy of their mothers was, “I feel I don’t deserve to be alive.” There were different and more loosely clustered symptoms found in patients whose mother miscarried. Conclusion: there is a reasonably definable syndrome of symptoms in patients associated with the abortion of their sibling, which we have termed, the Post Abortion Survivor Syndrome.

''[http://www.abortionrisks.org/Ney2012/PASS.pdf Post-Abortion Survivor Syndrome: Signs And Symptoms Revisited.] Ney PG, Sheils CK. [http://www.abortionrisks.org/Ney2012/PASS.pdf http://www.abortionrisks.org/Ney2012/PASS.pdf] 2012.
:This is an expanded form of the above 2010 study published in the Journal of Prenatal and Perinatal Psychology.

''"Obstetric Complications and Risk for Severe Psychopathology in Childhood" J Autism and Developmental Disorders (2001;31:279-285 ) Eaton WW, Mortensen PB, Thomsen PH, Frydenberg M.''

:Children born to women with prior history of induced abortion had 72% higher relative risk of later being diagnosed as mentally retarded, and a 40% greater risk of being diagnosed with a learning disorder, and a 47% risk of being diagnosed with some other psychological disorder.

''[http://www.ncbi.nlm.nih.gov/pubmed/10732302 Prenatal and perinatal risk factors for autism.] J Perinat Med. 1999;27(6):441-50. Burd L, Severud R, Kerbeshian J, Klug MG.''

:Abortion and low birth weight are significantly associated with increased risk of autism in subsequent born children.

''[http://www.thefreelibrary.com/Post+Abortion+Survivor+Syndrome+%28PASS%29%3a+signs+and+symptoms-a0158397011 Post abortion survivor syndrome (PASS): signs and symptoms.]'' Ney PG, Sheils C, Gajowy MA Southern Medical Journal 99:1405-1406, 2000

:Data from a sample of 293 adults indicates those whose mother had an abortion were significantly more likely to experience depression and other symptoms which may be associated with a post-abortion survivor syndrome. According to the authors:
::If the data and clinical impressions are correct, there appears to be a definable and diagnosable syndrome of symptoms and problems that arise in people whose parents have aborted their unborn siblings: the Post Abortion Survivor Syndrome (PASS). This constellation of existential guilt, risk-taking behaviors, sense of impending doom and prepsychotic terror appears to be distinct from symptoms that may arise in other types of pregnancy-loss survival situations, from childhood mistreatment, or from an abortion experienced by the individual or the individual's partner. (5) These symptoms are specific enough to point to a likely cause being the loss of a sibling by abortion. Unless the conflicts behind this existential dilemma are addressed, it is unlikely that the expression of these, ie, the need for psychiatric admission, or repeat depressions, are likely to be successfully treated by any other modality.

''"Children's Disturbed Reactions to their Mother's Miscarriage," A.C. Cain et al Psychosomatic Medicine 26:58-66(1964). ''
:Important background article on the subject.

''"Effects of Sibling Death on the Surviving Child: A Family Perspective," R. Krell and L. Rabkin, Family Process 18:471-477, December 1979. ''
:Describes such family maneuvers as conspiracy of guilt, survivor reactions, substitution for the lost child, the haunted child (silence), the resurrected child (substitution). Therapy with survivor families is described as a difficult task involving the working through of short- circuited and unresolved grief reactions, unraveling of multiple distortions of identity and clarifying of mystifying communication.

''"A Consideration of Abortion Survivors." Philip G. Hey, Child Psychiatry and Human Development 13(3): 168-178, Spring 1983. ''
:It is hypothesized that approximately 50% of the children in the Western world are or soon will be abortion survivors, i.e., they are children who have had siblings terminated by induced abortion.

''"The Surviving Sibling: Another Victim of Abortion," National Right to Life News[Washington D.C.], September 25, 1986. ''
:The article quotes Dr. Edward Sheridan of Georgetown University Hospital who observed that children may become aware of an induced abortion through overheard conversations or by being directly told by their parents. Frequently, even a very young child will "sense", the mother's pregnancy and then become confused when the anticipated brother or sister does not materialize. If no explanation is given, this confusion may lead the child to somehow feel responsible for the loss. If the child becomes aware that the mother actively chose to "get rid" of the sibling, the survivor may begin to fear her. The mother becomes the agent of death instead of life.

''"The Survivor Syndrome: Siblings and Abortion," National Right to Life News[Washington D.C.], January 15, 1987, p. 19. ''
:The article quotes Dr. E. Joanne Angelo, a practicing psychiatrist and assistant clinical professor at Tufts University School of Medicine, who observed that siblings of aborted children may be children who are having trouble going to school and being separated from their parents. The children are "replacement children", born after their parents suffered the loss of another child through sudden infant death syndrome, miscarriage or abortion. The children picked up their fears from their parents, not from outside the home. If abortion was the catalyst for the "replacement child, " the child may also suffer from the mother's often unresolved, and perhaps unacknowledged, grief over the loss of the unborn child.

''"The Aborted Sibling Factor: A Case Study," A.H. Weiner and E.C. Weiner, Clinical Social Casework Journal, Human Services Press (1984), pp. 209-215. ''
:Case study of 5-year-old girl whose mother had multiple abortions. The girl was very frightened of her mother, dreamed of being killed and tore her doll's head and arms off.

''"Child's Reaction to Mother's Abortion: Case Report," J.O. Cavenar, J.G. Spaulding and J.L. Sullivan, Military Medicine 144(6):412-413 (1979). ''
:A five-year-old boy was referred for psychiatric evaluation because of aggressive behavior toward his sister, poor peer relationships and multiple tics. He learned of his mother's abortion when he was only slightly over 2 years old. He thought he had undergone mutilative surgery as punishment for his aggressive and hostile impulses and via identification with his mother viewed himself as mutilated and castrated.

''"Ritual Mourning for Unresolved Grief After Abortion," K. McAll and W. Wilson, Southern Medical Journal 80(7):817-821, July 1987. ''
:Includes several case studies drawn from the experience of the authors with the effects of induced abortion or miscarriage on over 400 people with whom they have counseled. A report is given of a 7-year-old girl initially diagnosed as epileptic. She had unpredictable episodes of shouting at her parents, stamping her feet and falling unconscious. She often hurt herself when she fell. Drugs were of no help to her. When in counseling with her parents she added the name of a sibling who she said was her best friend. When her parents attempted to correct her she called her mother a murderer who had thrown her sister away. The mother then admitted to a pregnancy where the doctor gave her a rough examination and she lost the baby. Following prayer and mourning for the lost child the family was helped to recover.

''"Infant Abortion and Child Abuse," Philip G. Ney in The Psychological Aspects ofInfant Abortion and Child Abuse, eds. D. Mall and W.F. Watts, (Washington D.C.: University Publications of America, 1979) 33. ''
:Describes a case of severe child neglect where the mother was depressed as a result of an earlier coerced abortion and the father had rejected the child and had left the family.

''"Ritual Mourning in Anorexia Nervosa," RK McAll and FM McAll, The Lancet, August 16, 1980, p. 368. ''
:The authors report on 18 patients who were treated in a hospital without initial improvement. Fifteen experienced a total relief of symptoms after ritual mourning. Two patients were male. In 17 of the cases, family histories revealed a total of two 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 who had anorexia nervosa since 14 and had been hospitalized three times. Her mother had an earlier pregnancy aborted. She admitted the existence of her unborn "sister" but had not mentioned it for fear of being locked up in a mental hospital.

''"Parental high concern and adolescent-onset anorexia nervosa," . A case-control study to investigate direction of causality, P Stonebridge, SG Gowers, Br J Psychiatry 176:132- 137, 2000 ''
:Mothers of adolescent girls who had anorexia nervosa were found to have a history of second trimester abortion as well as other identified pregnancy losses.

''"Pregnancy Termination for Genetic Indications: The Impact on Families," R. Furlong and R. Black, Social Work in Health Care 10(1): 17-34, Fall 1984. ''
:A study was made of 22 children whose mothers had undergone induced abortion because of a serious fetal defect. Nineteen of the 22 exhibited some adverse reaction according to observations of the parents. The children included several adult children and reactions ranged from mild to severe. Of four young children who supposedly knew nothing about the abortion, three exhibited some adverse reaction including sleep walking, regression in motor behavior and searching for the baby by touching the mothers stomach. Sadness, guilt and separation anxiety were noted. A 7-year-old girl who was given a full explanation exhibited a severe reaction of horror, had trouble sleeping, refused close physical contact with the mother, had a morbid interest in the abortion procedure raising questions about her attitude about future childbearing.

''"Ritual Mourning for Unresolved Grief After Abortion," K. McAll and W. Wilson, Southern Medical Journal 80(7):817-821, July 1987. ''
:A professional man had conducted a long search for therapists on behalf of his 26-year- old daughter who was sexually promiscuous with men about 30 years older. She was the cause of much gossip, impeded the attainment of his goals and the cause of violent arguments in the family. The woman's mother had undergone an abortion several years before the marriage to the father and the mother's life prior to her marriage had many parallels to her daughter's. After the mother mourned for the aborted child and expressed her love for it, the problems of the daughter ceased.

''[http://www.amazon.com/Healing-Family-Tree-Classics-Edition/dp/0281069611/ref=dp_ob_title_bk Healing the Family Tree.] by K. McAll''
This is a more detailed book by Dr. McAll on his observations and efforts to heal inter-generational losses.

''"Psychiatric Sequelae of Therapeutic Abortions," Jesse O. Cavenar, A.A. Maltbie and J.L. Sullivan, North Carolina Medical Journal 39:101-104, February 1978. ''
:A 28-year-old professional man who had entered psychoanalysis for anxiety, career indecisiveness, and inability to become emotionally involved with a woman. He visited his mother to ask about various memories he had recovered in analysis. His mother confessed to an abortion when she was 17 and pressured her son to marry and provide her with grandchildren apparently as an attempt to atone for or undo her own abortion. The authors concluded that abortion may have a profound emotional effect on other family members and permanently alter intrafamilial relationships.

''"Great Joy for All-Praise Reports," newsletter of Pastor and Mrs. Timothy D. Hansen, Igreja Evangelica da Renovaqao, Brazil, December 1, 1987. ''
:A woman was married for a number of years but was apparently unable to bear children. Upon prayer with the woman it was discerned that the woman's mother had been involved in deep sin. When mentioned to the woman she began to weep and weep and said, "Yes, my mother is a prostitute and has had 29 abortions." After prayer for the woman she forgave her mother. The missionaries reported, "That was five months ago. We have just learned [the woman] is five months pregnant." Ed. Note: This is the highest number of abortions known to us.

==Abortion's Impact on Subsequent Pregnancies==

[http://www.ncbi.nlm.nih.gov/pubmed/?term=Previous+pregnancy+loss+has+an+adverse+impact+on+distress+and+behaviour+in+subsequent+pregnancy Previous pregnancy loss has an adverse impact on distress and behaviour in subsequent pregnancy.] McCarthy F, et al. BJOG. 2015 Jan 6. 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. Healthy nulliparous women with singleton pregnancies.

:METHODS: Outcomes were recorded at 15 and 20 weeks of gestation. 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, OR 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.

::'''EDITOR's NOTES:''' The number of abortions reported in this study are half of what should have been reported in New Zealand. In the year 2012, New Zealand's Abortion Supervisory Committee report shows there was a total of 14,745 induced abortions and from this number 3,648 (24.7%) had one previous abortion and 1,937 (13.1%) had 2 or more previous abortions. The abortion ratio was 193/1000 (rate of abortion/known pregnancies, not counting miscarriages; 19.3%). Therefore, in the above study of 5,495 pregnant woman there should have been approximately 1060 abortions (rather than 415) with 139 (rather than 66) having had 2 or more previous abortions. All of this suggests that many women participating in the study chose to not disclose their abortion history. If non-disclosers had more emotional problems related to their abortions (which is why they may have been unwilling to disclose their abortions) this would mean the results under estimate the mental health problems associated with abortion.

==Impact of Abortion on Relationships, Sexual Behavior, and Sexual Dysfunction==

'''[https://pubmed.ncbi.nlm.nih.gov/28635530/ The effect of voluntary termination of pregnancy on female sexual and emotional well-being in different age groups] Limoncin E, D’Alfonso A, Corallino C et al. Journal of Psychosomatic Obstetrics and Gynecology (2017) 38(4) 310-316'''

:Introduction: To evaluate the impact of voluntary termination of pregnancy (VTOP) on the psycho-sexological well-being of females before/six months after the abortion.

:Methods: A sample of 194 women was recruited from three obstetrics and gynaecological divisions. The women were evaluated for the variables "sexual functioning" with the Female Sexual Function Index (FSFI), "depression" with the Beck Depression Inventory (BDI-II), and "anxiety state" with the Self-Rating Anxiety Scale (SAS) at time 0 (the beginning of the abortion procedure) and time 1 (six months after the abortion). Since 24 women refused to fill out the questionnaires, the final sample was composed of 170 women.

:Results: The women showed a slight although significant improvement in the mean FSFI score from time 0 (16.7 ± 12.9) to time 1 (20.9 ± 13.8) (p < 0.001) which paralleled with a slight decrease in the incidence of clinically significant sexual dysfunction [49% (84/170) (time 0) versus 34.1% (58/170) (time 1)], (McNemar's test; p = 0.0241). The sub-group of younger women (18-25) showed a lesser increase in FSFI score from time 0 to time 1. In addition, both depression (p = 0.048) and anxiety (p < 0.001) significantly decreased over time. However, the female sexuality remained impaired since more than two thirds (69.5%) of women were sexually dysfunctional six months after VTOP.

:Discussion: Voluntary TOP may influence the sexuality of younger females differently from how it influences that of older women. Hence, the sexuality of younger female should be regularly supervised in follow-up examinations.

''[http://www.standapart.org/index.php?route=information/information&information_id=8 Abortion and Partner Relationships.] Alliance for Post-Abortion Research & Training. 2014.
: An excellent summary of research findings concerning elective abortion and partner relationships.

''[http://www.standapart.org/index.php?route=information/information&information_id=8 Publications concerning Abortion and Relationships.] Alliance for Post-Abortion Research & Training. 2014.
:List of academic papers and articles concerning abortion and relationships.

See also [http://abortionrisks.org/index.php?title=Self-Destructive_Behavior#Sexual_Promiscuity_and_Casual_Sex Sexual Promiscuity and Casual Sex]

''"Intrapersonal Processes and Post-Abortion Relationship Challenges: A Review and Consolidation of Relevant Literature" Coleman PK, Rue VM, Spence M. The Internet Journal of Mental Health. 2007; Volume 4, Number 2.''
:(Abstract) While the study of the psychological effects of abortion has received increased research attention over the past few decades, scholarship devoted to the topic of post-abortion partner relationship quality has been minimal. In this report, existing empirical work on abortion and intimate relationships is analyzed in the context of related research and theory. Evidence indicating possible adverse effects of abortion on the quality of relationships is initially reviewed. Then several logical intrapersonal mediators of associations between abortion experience and relationship outcomes are explored. Finally, adult attachment dynamics are described as a theoretically plausible moderator of associations between abortion experiences and relationship difficulties. Throughout the paper, the most salient gaps in the literature on abortion and relationship quality are highlighted with suggestions for future research provided.

''"Abortion and the sexual lives of men and women: Is casual sexual behavior more appealing and more common after abortion?" Coleman PK, Rue VM, Spence M, Coyle CT. Int J Clin Health Psychol, Vol. 8, Nº 1''
:(ABSTRACT) Previous research indicates that abortion increases risk for experiencing difficulties maintaining committed relationships, sexual dysfunction, and psychological problems. 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.

''[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.''

:Seventy nine percent of those interviewed had decreased libido following their abortions.
''[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.

''Burke T, Reardon D. Forbidden Grief (Acorn Books)''

:A [http://afterabortion.org/1999/a-detailed-survey-of-post-abortion-psychological-reactions/ survey reported in an appendix to this book], revealed that following their abortions, 58% reported pain in the cervix or abdomen, 33% reported increased pain during intercourse, 59% reported loss of pleasure from intercourse, 47% developed an aversion to intercourse or became unresponsive, 43% reported becoming promiscuous, 49% had greater fear regarding becoming pregnant when waiting for each period to begin, and 9% had themselves sterilized to avoid another abortion.

''[https://wce.confex.com/wce/2014/webprogram/Paper2062.html SEXUAL DISFUNCTION AND QUALITY OF LIFE IN PATIENTS WITH BREAST CANCER: A CASE-CONTROL STUDY] S de Paula, PS Carneiro, CM de Lucena, CM Antunes. IEA World Congress of Epidemiology. August 17, 2014.

:INTRODUCTION: Breast cancer is the most prevalent neoplasia among women, responsible for 20% of deaths in this population. The treatment (mastectomy) always alters patients self-image, perception about their own body and their self-esteem. The objective of this case-control study, is to evaluate the quality of life using World Health Organization Quality of Life abbreviated, WHOQoL-bref and the sexual dysfunction using Female Sexual Function Index, FSFI questionnaires.

:METHODS: Women with breast cancer (cases) and women without this disease (controls), identified at Santa Casa de Belo Horizonte, were included. Social demographic, anthropometric and clinical information were also obtained. Multivariate statistical analysis (ordinal regression) was conducted; two models were implemented: (a) the scores of each WHOQoL-bref domain as response variable and (b) the scores of each FSFI domain, as well as the total score, as response variables.

:RESULTS: Breast cancer diagnosis and treatment are associated to sexual dysfunction Regarding quality of life, this same association was not detected. Age, report of using hormonal oral contraceptive and '''abortion history were the other independent risk factors associated to sexual dysfunction.''' Age at last parity, although not being associated to sexual dysfunction, could not be removed from the final model; this seems to indicate a possible effect modification. In reference to individual domains, results showed that breast cancer is associated to desire, excitation and satisfaction lower scores and not associated to lubrication, orgasm and pain. Age is inversely associated to scores in all domains, except satisfaction. History of abortion inversely associated to desire and excitation. Use of oral contraceptive (inverse association) and education (direct association) to excitation and satisfaction, respectively. Age at last parity, as observed in the total model, have to be kept in the models of all individual domains.

:CONCLUSIONS: Breast cancer diagnosis and treatment, age, report of using hormonal oral contraceptive and abortion history are associated to sexual dysfunction.

==Impact of Abortion on Marriage, Family, and Parenting==

''[http://www.standapart.org/index.php?route=information/information&information_id=8 Abortion and Parenting Fact Sheet. Alliance for Post-Abortion Research & Training. 2014.
:Overview of research on associations between abortion and compromised parenting with exploration of reasons why abortion may increase risk of parenting problems.

''Depression associated with abortion and childbirth: a long-term analysis of the NLSY cohort. Med Sci Monit. 2003 Apr;9(4):CR105-12. Cougle JR, Reardon DC, Coleman PK.''
:Women with a history of abortion were significantly more likely to have a subsequent divorce.

''"[http://www.bentham.org/cwhr/contabs/cwhr5-2.htm#4 The Psychological Pain of Perinatal Loss and Subsequent Parenting Risks: Could Induced Abortion be more Problematic than Other Forms of Loss]" Coleman PK. Current Women’s Health Reviews, 2009, 5, 88-99''

:(ABSTRACT) This dual purpose of this review was to organize and synthesize what is known about women’s psychological and behavioral responses to perinatal loss and examine perinatal loss as a predictor of compromised parenting. The conditions surrounding distinct losses (miscarriage, relinquishment of a child for adoption, and abortion) are highly variable necessitating examination of the differential impact of the various forms of loss on women’s mental health and parenting. Preliminary assessment of relevant literature suggests the psychological experience and the cultural context of abortion may render this form of perinatal loss particularly damaging to the parenting process.

''[http://www.ncbi.nlm.nih.gov/pubmed/16299880 Associations between voluntary and involuntary forms of perinatal loss and child maltreatment among low-income mothers.] Coleman PK, Maxey CD, Rue VM, Coyle CT. Acta Pædiatrica, 2005; 94.''

:Compared to women with no history of perinatal loss, those with one loss (voluntary or involuntary) had a 99% higher risk for child physical abuse, and women with multiple losses were 189% more likely to physically abuse their children. Compared to women with no history of induced abortion, those with one prior abortion had a 144% higher risk for child physical abuse. Finally, maternal history of multiple miscarriages and/or stillbirths compared to no history was associated with a 1237% increased risk of physical abuse and a 605% increased risk of neglect. Perinatal loss may be a marker for elevated risk of child physical abuse, and this information is potentially useful to child maltreatment prevention and intervention efforts. http://journalsonline.tandf.co.uk/link.asp?id=xr05355225rk21wk

"The quality of the caregiving environment and child developmental outcomes associated with maternal history of abortion using the NLSY data." Coleman PK, Reardon DC, Cougle J. J Child Psychol Psychiatry 2002; 43: 743-58.

:(ABSTRACT)BACKGROUND: Studies suggest that experiencing a perinatal loss may leave women vulnerable to mental health problems and may compromise parenting. Unfortunately, compared to miscarriages and stillbirths, very little research has examined the potential for grief and feelings of loss associated with elective abortion. Therefore, the aim of this study was to compare the quality of the childcare environment and children's development among children of mothers with a history of abortion prior to childbirth (n = 672) and children of non post-abortive women (n= 4,172). METHOD: Data were derived from the National Longitudinal Survey of Youth (NLSY), with comparisons based on two assessments of the caregiving environment and scores on four child outcome variables. The sample was divided into three child age categories: 1-4 years (n = 1,502), 5-9 years (n = 2,121), and 10-13 years (n = 1,524). RESULTS: After controlling for numerous potentially confounding socio-demographic variables, lower scores were observed for the post-abortion group relative to the level of emotional support in the home among first-born children in the youngest age category. Further, among 5-9-year-olds, more behavior problems were revealed for the children of women with a history of abortion. Finally, no main effects were detected between the abortion history groups relative to the level of cognitive stimulation in the home. CONCLUSION: Although it is widely recognized that at least 10% of post-abortive women experience negative psychological consequences, the potential effects of negative subjective experiences on parenting need more systematic attention.

''"[http://ispub.com/IJPN/6/2/9364 Induced abortion and child-directed aggressive behaviors among mothers of children who have been maltreated.]" Coleman PK, Rue V, Coyle C, Maxey DC. Int J Pediatr Neonatol 2007.''
:Background: The purpose of this study was to explore the relationship between maternal history of induced abortion and subsequent frequency of child-directed aggressive behavior in a sample of mothers of children who have been abused or neglected. The mothers were either the perpetrators of the maltreatment or they allowed someone else to mistreat their children.
:Methods: The participants were 237 mothers who were residents of Baltimore and were receiving Aid to Families with Dependent Children (AFDC) at the time interviews were conducted in the 1980s. Women with and without a history of abortion were compared relative to child-directed physical aggression after controlling for the experience of a non-voluntary perinatal loss as well as socio-demographic, family of origin, and partner aggression variables associated with the choice to abort.
:Results: Abortion history was associated with more frequently maternal slapping, hitting, kicking or biting, beating, and use of physical punishment in general.
Conclusion: In addition to contributing to the literature on factors related to the frequency of engaging in physically aggressive behaviors, this study adds to our knowledge of variables associated with the choice to abort.

''"Associations between voluntary and involuntary forms of perinatal loss and child maltreatment among low income, single mothers." Coleman PK, Maxey DC, Coyle C, Rue V. Acta Paediatr 2005; 94.''
:AIM: This study explored maternal history of perinatal loss relative to risk of child physical abuse and neglect. METHODS: The 518 study participants included 118 abusive mothers, 119 neglecting mothers, and 281 mothers with no known history of child maltreatment. Interviews and observations were conducted in the participants' homes, and comparisons were made between women without a history of perinatal loss and women with one and multiple losses relative to risk for child maltreatment. RESULTS: Compared to women with no history of perinatal loss, those with one loss (voluntary or involuntary) had a 99% higher risk for child physical abuse, and women with multiple losses were 189% more likely to physically abuse their children. Compared to women with no history of induced abortion, those with one prior abortion had a 144% higher risk for child physical abuse. Finally, maternal history of multiple miscarriages and/or stillbirths compared to no history was associated with a 1237% increased risk of physical abuse and a 605% increased risk of neglect. CONCLUSION: Perinatal loss may be a marker for elevated risk of child physical abuse, and this information is potentially useful to child maltreatment prevention and intervention efforts.

''"The Effects of Abortion on Marriage and Other Committed Relationships," Teri Reisser, Association for Interdisciplinary Research in Values and Social Change 6(4): 1-8, May/June 1994 ''
:Anecdotal reports include breakup of relationships, communication problems, threats to family loyalty, increased isolation, loss of self-concept, sexual dysfunction, and interference with relationships to existing or future children as problems related to induced abortion.

''"[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595109/ The Impact of Previous Perinatal Loss on Subsequent Pregnancy and Parenting]" Lamb E. J Perinat Educ. 2002 Spring; 11(2): 33–40.''

''"Post-Traumatic Stress Disorders in Women Following Abortion: Some Considerations and Implications for Marital/Couple Therapy," Dennis A. Bagarozzi, Int'l Journal of Family and Marriage (Dehli, India) Vol. I, No. 2: 51-68, 1993 ''
:A clinical study of 18 women referred for sexual/marital therapy found that the women suffered from post-traumatic stress disorder although women denied that the abortion was a traumatic experience. Impacted grief, guilt, and unresolved mourning were primary issues. See also "Identification, Assessment and Treatment of Women Suffering from Post-Traumatic Stress After Abortion." Dennis A. Bagarozzi, Journal of Family Psychotherapy 5(3): 25,1994.

''"Post-Abortion Survivors Syndrome," (letter), Philip G. Ney, Canadian Journal of Psychiatry 38 (8): 577-578, Oct., 1993. ''
:Post-Abortion survivors syndrome is found in children and adults. It consists of symptoms stemming from deep conflicts because they may have been aborted. All have existential guilt, a sense of worthlessness, and a feeling of impending disaster. Eight types of abortion survivors syndromes are described.

''Invisible Loyalties, I. Boszormeny and G. Spark (New York: Harper and Row, 1973) 149. ''
:Until the post-Victorian age the issues of family loyalty were largely unformulated because they were taken for granted. Our age, on the other hand, denies these issues with the help of myths of individual material success and the endless struggle against the threat of authority.

:From earliest times great playwrights and novelists have always pictured man as part of a relational motivation system. Autonomy purchased through outwardly complete separation and denial of relatedness tends to be offset inwardly by the accumulation of guilt and responsibility.

''"Childbirth is A Family Experience," John G. Howells in Modern Perspectives in Psycho-Obstetrics (1980) 127-149 ''
:The family is a complete organism, a unity in its own right, as well as an individual. The individual is an organized system; so too is the family. The family has a structure, paths of communication, characteristics, elements as any organized system. Like an individual, it has a psyche-the family group psyche. Any event in every part of this organized system impinges on every part of the rest of the system. Every experience within the organized system belongs to the system. Thus, childbirth and its attendant pregnancy is an experience that belongs to the family as a whole.

''"Social Stresses on the Family," Reuben Hill, Social Casework 39:139-150(1958). ''
:Stressor events must be seen as a variable rather than as a constant in family crisis research. Family crises can be classified as dismemberment, accession or demoralization. Various stages of adjustment include [1] attempts to deny the problem; [2] attempts to eliminate the problem; (3] disorganization; (4] attempts to reorganize in spite of the problem; [5] efforts to escape the problem; [6] reorganization of the family without the missing member; (7] reorganization of the entire family. These stages parallel closely the stages of adjustment and recovery to bereavement.
:The sexual area is one of the most sensitive areas of family life. In crises involving interpersonal recriminations, where the crisis is regarded as the fault of any one member, the position of that member is greatly devalued. Intrafamily events such as illegitimacy, nonsupport, mental breakdown, infidelity, suicide and alcoholism are usually more disorganizing to the family because they arise from troubles that reflect poorly on the family's internal adequacy.

''"Family Boundary Ambiguity: A New Variable in Family Stress Theory," Pauline Boss and Jan Greenberg, Family Process 23:535-546(1984). ''
:Boundary ambiguity is defined as the family not knowing who is in and who is out of the system. The family may perceive a physically absent member as psychologically present or a physically present member as psychologically absent. The culture can support the denial of a physical loss and thereby make it more difficult for the family to grieve and close out the missing member. An example is given in regard to stillbirth where the belief system only accorded viable babies mourning rites.

''"The Fund of Sociability," Robert S. Weiss, Trans-Action, July/August 1969, pp 36- 43. ''
:Relationships with other people are essential and their loss can be traumatic. Relational functions necessary for well-being are intimacy, social integration, opportunity for nurturant behavior, reassurance of worth, assistance or guidance.

''"The Effects of Abortion on a Marriage," Janet Mattinson, in Abortion: Medical Progress and Social Implications, Pitman (London: Ciba Foundation Symposium, 1985)165-177. ''
:Patients seeking help for troubled marriages may have a past abortion experience for which they have been unable to mourn at the time of the abortion and they may show a delayed grief reaction. It may be mild or persistent or may occur in more extreme form many years later. Sometimes husbands are more affected than wives. Examples of counseling issues included inability to function, sexual and interpersonal conflict, compulsive sexual affairs outside marriage, development of inferiority feelings, inability to conceive.

''"Predictive Factors in emotional Response to Abortion: Kind's Termination Study- IV," E.M. Belsey, H. Green, S. Lal, S. Lewis and R.W. Beard, Social Science and Medicine (2) 71- 82(1977) ''
:In a British study of marital adjustment 3 months post abortion, 42% of the women said they were less close to their sexual partners vs. 22% who said they were more close. Unsatisfactory or mediocre marital adjustment before the abortion increased the likelihood of marital or sexual adjustment problems following the abortion.

''"Induced abortion and psychosexuality," F Bianchi-Demicheli et al, J Psychosom Obstet Gynecol 21(4): 213-217, 2000 ''
:Reviews the limited published literature on the subject. Sexual dysfunction was reported in up to 30% of women after abortion.

''"Sexuality, partner relations and contraceptive practices after termination of pregnancy," F Bianchi-Demicheli et al, J Psychosom Obstet Gynecol 22(2): 83-90, 2001 ''
:A Swiss study interviewed women before abortion and 6 months postabortion. 18% reported a decrease in sexual desire, and 17% reported orgasmic disorders.

''"Sexual Dysfunction Related to Induced Abortion," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change Research Bulletin 11 (4): 1-8, Sept/ Oct, 1997 ''
:Various studies and anecdotal reports reveal that both men and women may have sexual impotency, aversion to sex, loss of intimacy, unexpected guilt, and extra-martial affairs as a result of induced abortion.

''"The Hostility of Parents to Children: Some Notes on Infertility. Child Abuse and Abortion," Victor Calef, International Journal of Psychoanalytic Psychotherapy l(l):76, February 1972. ''
:A case report by psychiatrist Victor Calef of marital difficulty following induced abortion included anxiety, sexual dissatisfaction, husband's lack of interest in wife and in sex. The wife said she had no guilt over the abortion. The psychiatrist concluded that the guilt over the abortion was displaced onto the doctor who performed the abortion, while guilt over the pregnancy was displaced onto the husband. It was concluded that the woman experiences the request and permission for abortion as a rejection of her sexuality.

''"Abortion As A Stigma: In the Eyes of the Beholder," Gerdi Weidner and William Griffitt, Journal of Research in Personality 18:359-371(1984). ''
:A recent study among university students in an introductory psychology course at a large midwestern U.S. university revealed that involvement in an abortion has a stigmatizing effect for both men and women. Abortion involvement produced a negative perception in members of the opposite sex who considered them less desirable partners to date or marry. Males involved in abortion received strong ratings of rejection only from female subjects , and females involved in abortion were rejected only by male subjects.

''"Low Birth Weight in Relation to Multiple Induced Abortions," M.T. Mandelson, C.B. Madden, J.R. Daling, Am.J. Public Health, 82(3): 391, March, 1992. ''
:In a Washington State Study of 6541 white women who gave birth to their first child between 1984-87, 33.5% of the women reported 4 or more abortions were unmarried compared to 27.5% of women (2 abortions), 24.0% of women (1 abortion) and 20.5% of women (no abortions).

''"The Rights and Responsibilities of Men in Abortion Situations," Shirley Rosenwasser, L.S. Wright and R.B. Barber, Journal of Sex Research 23:97-105, February 1987. ''
:Abortion adversely impacts upon the parental attitude towards the legal obligation of a parent to provide for the care and support of a child. In a study conducted at a state supported university in Texas, male and female students were asked whether or not a woman should be able to legally sue the father for child support if he was willing to pay for an abortion and the woman decided to keep the child. Some 59% of the men and 40% of the women thought the woman should not be able to sue for child support under those circumstances.

''Men and Abortion. Lessons. Losses and Love, Arthur Shostak and Gary McLouth, (New York: Praeger, 1984). ''
:In a study of 1,000 men who accompanied women to abortion clinics in the U.S., 48% of the males did not think a man should be required to pay child support as at present-if the woman refused his request that she have an abortion.

''"Emotional Distress Patterns Among Women Having First or Repeat Abortions," Ellen Freeman, K. Rickels, G. Huggins, C. Garcia and I. Palin, Obstetrics and Gynecology55(5):630-636, May 1980. ''
:Lack of communication by partners following induced abortion is reported. In a study on emotional distress patterns among women following induced abortion it was observed that "repeat aborters continued to have significantly higher emotional distress scores in dimensions relating to interpersonal relationships." In other words, they had trouble getting along with others.

''"Psychological Problems of Abortion for the Unwed Teenage Girl," Cynthia D. Martin, Genetic Psychology Monographs, 88:23-110(1973) ''
:In a San Diego study of unmarried adolescents who obtained abortions for mental health reasons two out of three had poor relationships with both parents prior to the abortion which tended to further deteriorate following the abortion.

''"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. ''
:In a study comparing first-time aborters with repeaters, 45% of the repeaters said they made the decision by themselves compared with 33% of the first-time aborters.

''"Pilot Surveys of Repeated Abortion," E. Szabady and A. Klinger, International Mental Health Res. Letter 14:6(1972). ''
:In a Hungarian study, those women having a repeat abortion were less likely to be in a happy marriage and were more likely to have an abortion independent of their partner.

''"First and Repeat Abortions: A Study of Decision-Making and Delay," M Bracken and S. Kasl, Journal of Biosocial Science 7:473-491(1975). ''
:A 1975 report of social relationships of women following induced abortion concluded that women having repeat abortions are in less stable social situations compared with women who seek abortion for the first time. Their relationships were of shorter duration than unmarried women having first abortions.

''"Maternal Perinatal Risk Factors and Child Abuse," M. Benedict, R. White, and P. Comely, Child Abuse and Neglect, 9:217-224(1985). ''
:A study of 532 Baltimore mothers (two thirds black) found that mothers who maltreated their children were significantly more likely to have had a prior stillbirth or reported abortion (18.2% vs. 12.4%). With two prior stillbirths or abortions or combination thereof, the abuse rate was nearly doubled (4.3% vs. 2.4%). It was concluded that reproductive history may provide important clues in eliciting more precisely what family dynamics may be related to subsequent maltreatment.

''"Motivation of Surrogate Mothers: Initial Findings," Philip Parker, American Journal of Psychiatry 140(1): 117-118, January 1983. ''
:In a Michigan study of 125 women who applied to be commercial surrogates, 35% either had a voluntary prior abortion (26%) or had relinquished a child for adoption (9%). Women felt, often unconsciously, that surrogate motherhood would help them master unresolved feelings through previous voluntary loss. Women stated, "It would be their baby, not mine"; "I'd be nest watching"; and,"I'll attach myself in a different way-hoping its healthy."

''Living Through Personal Crisis, Ann Kaiser Steams (New York: Ballantine Books, 1984). ''
:Describes a delayed reaction in a woman who became pregnant and underwent an abortion. Her relationship with the man who got her pregnant had ended without his being able to share in her troubled feelings over the abortion. Later, when she fell in love again, she found herself mistrusting her new lover and men in general. She also had a renewed sadness over the prior abortion. (Illustrates how abortion circumstances may impair new attachments.)

''Taking Chances: Abortion and the Decision Not to Contracept, K. Luker (Berkeley: University of California Press, 1975). ''
:A study based upon interviews with 50 predominantly unmarried women who had repeat abortions found that many had become pregnant to either test their partners' commitment to the relationship, or to hurry it along to a marriage. When their partners did not commit, the women resorted to abortion.

''"Psychiatric Sequelae of Therapeutic Abortions," Jesse O. Cavenar, A.A. Maltbie and J.L. Sullivan, North Carolina Medical Journal 39:101-104, February 1978.''
:(Grief in a grandmother over a lost grandchild is reported; a 28-year-old professional man who had entered psychoanalysis for anxiety,career indecisiveness and inability to become involved emotionally with a woman visited his mother to ask about various memories he had recovered in analysis. His mother confessed to [having] an abortion when she was 17 and pressured her son to marry and provide her with grandchildren apparently as an attempt to atone for or undo her own abortion. The authors conclude abortion may have a profound emotional effect on other family members and permanently alter intrafamilial relationships.

''"Therapeutic Abortion. Clinical Aspects," Edward Senay, Archives of General Psychiatry 23:408-415, November 1970. ''
:Patients who mention problems following induced abortion almost invariably want help for long-term marital problems. Rarely do they talk about the abortion spontaneously.

''Rachel Weeping: The Case Against Abortion, James Burtchaell (San Francisco: Harper and Row, 1982,1984) 13 ''
:There seems to be some hostility at work which alienates women choosing abortion from even the helpful enjoyment of whatever intimate trust they had previously (and possibly unrealistically) thought they shared with their kinfolk and mates. A decision is produced- apparently the result of freshly independent and straightforward deliberation-yet shadowed by much unspoken and undigested thought. Then it is rushed to completion without the sharing of minds and hearts one would hope for even in matters of far less importance.

''"The Family at Bay," Donald DeMarco, Human Life Review 8(4):44-54, Fall 1982.''
:The family as the fundamental unit of society is the reality. But legislators and judges, knowingly or unknowingly, can and do ignore this reality. A great deal of judicial thinking in recent years has been grounded in the premise that the individual is the fundamental social unit. A prime example of a woman's newly created "right" to individual privacy in the matter of abortion... Once the mother was legally relieved of the duty to care for her unborn child and was given the liberty of destruction, the stage was set for the severing of every other family relationship.

''"The Abortion Experience in Private Practice," David H. Sherman et al in Women and Loss: Psychobiological Perspectives, ed. William F. Finn et al., The Foundation of Thanatology Series, Volume 3, (New York: Praeger Publ., 1985) 98-107. ''
:In a study of 100 women at a private clinic at Mount Sinai School of Medicine, 75% of the women were married or had long-term ongoing relationships. All had knowledge about contraception and had easy access to medical care; 66% had at least a college degree; 71% were employed full-time; 57% had incomes over $20,000 per year; 81% had one abortion, 14% two) and 5% (three); one-third had a pregnancy before abortion, one-third had a child since aborting, and for one-third the abortion was their sole obstetrical history. Some 46% agreed that the abortion was a major crisis in their lives. Most women experienced loss and grief rather than joy and freedom. Relationships were suddenly and unexpectedly shaken. Some 48% believed their relationship with their male partner was significantly altered (approximately equally split positive and negative); 33% felt their sexual life was negatively affected to some degree; 52% were reluctant to tell people they had an abortion. Sadness, a sense of loss or emptiness, guilt, anger, anxiety and/or confusion was recalled by many. None ever expressed joy. Residual emotions diminished with time. Women with Catholic backgrounds and those with previous abortions more frequently expressed abortion as a form of infanticide.

''"Personal Communication," (letter from Sarah J.O. Ricketts to Thomas W. Strahan), April 3,1989. ''
:In working with post-abortion support groups involving women who are seeking counseling and healing, usually one third to one half of the women are siblings of those who had been aborted as well as having had abortions themselves. They frequently report a generational abortion pattern in the family, including grandmother, aunts, uncles, brothers, sisters. These women appear to have a more impenetrable denial (numbness) of emotions of grief following their own abortions.

''"Ethical Issues in Clinical Obstetrics and Gynecology," Benjamin Freedman, Current Problems in Obstetrics, Gynecology and Fertility, 8(3): 1-47, March 1985. ''
:Obstetrics and gynecology is among several medical specialties... that are especially likely to perceive the family unit, rather than a single patient, as the proper focus of primary health care.

''"The Post-Abortion Experience-Abortion's Secondary Victims," National Right to Life News, January 15,1987. ''
:Includes articles on The Survivor Syndrome: Siblings and Abortion, Men and Abortion,and A Grandmother Grieves for Her Lost Grandchild.

''"The Aborted Sibling Factor: A Case Study," A. Weiner and E. Weiner, Clinical Social Work Journal, 1984, pp. 209-215. ''
:A 5-year-old girl tore her doll apart and drew a picture of a child falling down the stairs following her mother's induced abortion.

''"Child's Reaction to Mother's Abortion: A Case Report," Jesse O. Cavenar, J.E. Spaulding and J.L. Sullivan, Military Medicine 144(6): 412A13 (1979). ''

''"A Consideration of Abortion Survivors," Philip Ney, Child Psychiatry and Human Development 13(3): 168-169, Spring 1983. ''
:Argues that since approximately 50% of Western children are abortion survivors, there is a need to analyze their individual and collective responses.

''"Ritual Mourning in Anorexia Nervosa," R.K. McAll and F.M. McAll, The Lancet, August 16,1980, p. 368. ''
:Concludes that hidden guilt, either in the patient or in a close member of the family, or lack of adequate recognition or mourning for a lost family member may be a causative factor in anorexia nervosa-the article includes two abortion related examples involving family members.

''"Seesaw Response of a Young Unmarried Couple to Therapeutic Abortion. I," Wallerstein and M. Bar-Din, Archives of General Psychiatry 27:251-254 (1972) ''

''"Men's Reactions to Their Partner's Elective Abortion," A.A. Rothstein, American Journal of Obstetrics and Gynecology 128:831-837 (1977) ''

''"Out of Wedlock Abortion and Delivery: The Importance of the Male Partner," James M. Robbins, Social Problems 31(3):334-350 February 1984 ''
:Women who aborted tended to be less strongly tied to their partners following abortion.

''Parental Loss of a Child, ed. Therese A. Rando, esp. chapter on "Induced Abortion." Betty Harris, (Champaign, Ill: Research Press Co., 1986) ''

''"The Effects of Abortion on a Marriage," Janet Mattinson, 1985; Abortion: Medical Progress and Social Implications, Pitman, (London: Ciba Foundation Symposium 115), pp. 165- 177. ''
:Patients apparently unable to mourn the loss of a child at the time of the abortion may show a delayed grief reaction. Therapeutic work needs to concern itself with the earlier loss. Sometimes husbands are more affected than wives. Husbands and fathers are much neglected in the British follow-up studies of abortion, except [rarely] through the subjective reports of the women.

''Men and Abortion. Lessons. Losses and Love, Arthur B. Shostak, (New York: Praeger Publishers 1984) xiv. ''
:Men are seriously affected by their abortion experiences, and their memories are extremely sharp and cogent when recalling these experiences.

''"The Psychological Sequelae of Abortion Performed for a Genetic Indication, B," Blumberg, M. Golbus and K. Hanson, American Journal of Obstetrics and Gynecology122(7):799-808, August 1,1975. ''
:Stresses attendant to selective abortion produce undesirable marital consequences. Two families out of 13 experienced separation during the pregnancy, even prior to the performance of amniocentesis; in each case the separation was related to problems engendered by their genetic circumstances. Separation occurred in two families after the selective abortion; although the separations were for less than six weeks, they produced repercussions which threatened marital stability for many months or years afterward.

''"Repeat Abortion: Is It a Problem?," C. Berger, D. Gold, D. Andress, P. Gillett and R. Kinch, Family Planning Perspectives 16(2):70-75, March/April 1984. ''
:Repeaters described their relationships as being less satisfactory than first-time abortion patients; more repeaters than first-timers said they had made the decision by themselves [45% vs. 33%]. Abortion tends to be communication restricting rather than communication enhancing.

''"Abortion: Predicting the Complexity of the Decision-Making Process. M," Friedlander, T. Kaul and C. Stimel, Women and Health 9(1):43-53, Spring 1984. ''
:Observes that "women experience difficulties in decision-making which exceed immediate concern and may include moral dilemmas, problems in relationships, role conflicts and career decisions, among others."

''"First and Repeat Abortions: A Study of Decision-Making and Delay. M," Bracken and S. Kasi, Journal Biosocial Science 7:473-491 (1975). ''
: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.

''Rachael Weeping: The Case Against Abortion, James Burtchaell, (San Francisco: Harper and Row, 1982,1984) 8. ''
:One has the impression that the pregnancy crisis and abortion disclosed rather than caused the falling away of friends and mates. In case after case there seem to have been no previous bonds generous and giving enough - despite the frequency with which they were anointed as "caring" and "loving -to sustain much claim on either good sense or energetic support. In many instances, the women simply woke up to find that they had been on their own all along, despite the couplings. When the emergency erupts, bonds that have long been frayed and rotted simply snap. Comments on case histories of abortion circumstances described in The Ambivalence of Abortion, Linda Bird Francke (1978).

''"Therapeutic Abortion. Clinical Aspects," Edward Senay, Archives of General Psychiatry 23: 408-415, November 1970. ''
:Alter some months most patients appear either to have resolved the abortion crisis completely or to have successfully repressed it, for they report not having thought about the experience in some time. Patients who mention problems almost invariably want help for long-term marital problems. Rarely do they talk about the abortion spontaneously.

''"Abortion in Relationship Context," Vincent M. Rue, International Review of Natural Family Planning, 9:95-121, Summer 1985''
:Like the Trojan horse, abortion is only beginning to be seen for what it truly is and does. There is evidence to suggest that induced abortion promoted "mystification and masking" within the family, which is dysfunctional for the individual. In relationships abortion provides "pseudo-homeostasis," that is, a stability through non-adjustment which promotes even more serious relational disequilibrium. For men it increases masculine insecurity and provides alienation, role conflict, and for some, limited relief. For women it provides relief, but also induces a heavy burden of guilt, secrecy and intra-psychic conflict. Clinically, if an unwanted pregnancy is a mistake or problem, then abortion becomes a denial of the problem. Psychologically, then, abortion reinforces defective problem-solving behavior. The article concludes that abortion exists for women, yet it is against women, men and children. Like an anesthetic, abortion comfortably numbs all from experiencing the burden of pregnancy. Abortion has become a social eraser of choice, individually, quickly/and secretly eliminating all traces of the pregnancy problem. And yet, traces always remain. Within the depths of male-female relations, the indelible marks of violation reappear.

''"A Report on 1.000 Men and the Impact of Abortion on Their Family Life," Arthur Shostak, presented at the 1984 meeting of the American Sociological Society ,San Antonio, Texas, August 29,1984. ''
:The author interviewed 1,000 men in the waiting room of abortion clinics and gave a report on his findings. He describes his own waiting room experience as a "bruising experience." Males spoke with relief of the rapidity and resoluteness of the decision- making process, the insignificance of the cost challenge and their firm conviction that power here belonged exclusively to their sex partner. They were not entirely without discontent. Specifically, a minority worried about the moral character of abortion. Many were bitter about the treatment they received from the abortion clinic, and quite a few had objections to their status in current abortion law. Sixty-eight per cent felt males involved in abortions did not have an easy time of it; 47% worried that such individuals generally had disturbing thoughts about it afterwards [39% were uncertain about this prospect]; 52% had "occasional" and 29% "frequent" thoughts of the fetus prior to the abortion. Thirty-nine per cent thought a fetus was a person; 26% felt abortion was the killing of a child; 17% thought the act they were involved in was immoral; 10% recalled urging adoption as an option; 17% recommended childbirth followed by single parenthood which they would support financially and emotionally; 45% recalled urging abortion.

''"Families. Sex and the Liberal Agenda," Allan C. Carlson, The Public Interest,Winter 1980 p. 77 ''
:In place of the nuclear family, dominant voices in sociology and family counseling journals are now describing the emergence of new normative concepts. There should be no bias towards marriage and children. Everything is open. All habitual and cultural attitudes may be questioned. All values are on trial. Uninhibited Sexuality-Sexual gratification represents one of life's ultimate values. Access to regular sexual satisfaction should be viewed as a basic human right. The Problem of Children-Sexuality should be totally separated from procreation. Parenting should be undertaken only after a careful weighing of social, cultural and economic costs. ... Unwanted pregnancies should be aborted.

==Parents / Grandparents==

Self-Destructive Behavior

2024-05-06T16:43:46Z

WikiSysop: /* Abortion Related Suicide: Case Studies */

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{{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://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, nine committed suicide, for a suicide rate of 589 per 100,000 women, which is nearly 30 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.

===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.

Munk-Olsen et al

2024-04-17T13:32:08Z

WikiSysop: /* Criticisms */

==Risk of First Time use of Anti-Depressants after First Abortion or Delivery (2018)==

'''''[https://www.ncbi.nlm.nih.gov/pubmed/?term=Examining+the+Association+of+Antidepressant+Prescriptions+With+First+Abortion+and+First+Childbirth Examining the Association of Antidepressant Prescriptions With First Abortion and First Childbirth.'''''] Steinberg JR, Laursen TM, Adler NE, Gasse C, Agerbo E, Munk-Olsen T. JAMA Psychiatry. 2018 May 30.

Abstract:
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 of women from Danish population registries who were born in Denmark between January 1, 1980, and December 30, 1994. Overall, 396 397 women were included in this study; of these women, 30 834 had a first-trimester first abortion and 85 592 had a first childbirth.

MAIN OUTCOMES AND MEASURE: First-time antidepressant prescription redemptions were 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 59 465 (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.

====Criticisms====
# When the data is reanalyzed to examine the effects over nine to twelve months, the elevated rates of psychiatric treatments following abortion are significantly higher than those prior to the abortion. [https://zenodo.org/records/10786350 This finding was hidden by the authors] by applying their comparisons to only monthly rates instead of cumulative rates.
# The study was funded by the Susan Thompson Buffett Foundation, which has a principle interest in [https://www.philanthropyroundtable.org/almanac/buffett-billions-for-abortion/ expanding abortion for purposes of population control].
# The opening paragraph and last sentence of the abstract underscore that the goal of this study is is to influence abortion politics. This, itself, is a forewarning that the conclusions are overly broad and exceed what is actually reported in the analyses.
# The study is flawed by the lack of any analysis relative to exposure to miscarriage and other unintended pregnancy losses. Numerous other studies have shown that spontaneous abortion is important bench mark for comparison of outcomes relative to induced abortion.
# The study is fundamentally flawed by the lack of any analyses regarding the dose effects associated with exposure to multiple abortions . . . and even multiple natural pregnancy losses. Both repeat abortions and miscarriages are associated with higher incidence rates of adverse outcomes. This omission is especially important in regard to longer term analyses, which this study purports to offer by examining first time antidepressant use over five years after a first pregnancy outcome. For example, women who carried a first pregnancy to term, for example, but then had two or three pregnancy losses in the subsequent years, are presented and analyzed as if they had only one pregnancy outcome.
# Another fundamental flaw is that the study examines only first time antidepressant use. Clearly, an analysis of how long antidepressants were used, once they began to be used, would provide a better understanding of the duration of depressive symptoms before and after a pregnancy outcome. Such an analysis would be especially important to examine the effects of pregnancy (abortion or delivery) one women whose first use of antidepressants was prior to the abortion or delivery. One would hypothesize that if pregnancy outcome has an effect on mental health, than those who already have depression prior to a pregnancy outcome should be analyzed separately to investigate if their symptoms persist for a longer or shorter period, following the pregnancy outcome.
# The main finding of this paper is that among women without a history of using antidepressants, those who have abortions are over twice as likely to begin using antidepressants in the year following an abortion compared to both women who had no pregnancy and to women who carry a first pregnancy to term. This finding clearly ''confirms'' that abortion is a risk factor for higher rates of depression.
# The rest of the paper is nothing more than an effort to explain away this key finding. The discussion and conclusion of this paper are more focused on speculations to explain away the results than on the results themselves. This demonstrates the clear bias of the authors. Not only do they avoid doing the more in-depth analyses discussed above, but their main finding is essentially dismissed as misleading based on the authors' speculation that the true cause of higher depression rates following an abortion is pre-existing problems that are unrelated to the women's abortions.
# The authors frequently misstate facts in order to advance false conclusions. For example, they state that among women who have abortions "the increased risk of depression did not change from the year before to the year after an abortion." But their study did not measure depression. It did not measure depression scores among women at multiple times before and after their abortions. They measured only first-time use of an anti-depressant. They do not know if women who first used an anti-depressant prior to abortion got better or worse following their abortions. They do know that if they had done an analysis excluding women with a prior history of depression, those who had abortions were twice as likely to begin using anti-depressants than other women (both never pregnant and those who deliver), but that finding is essentially ignored in favor of the assumption that all women who have abortions are more mentally ill to begin with.
# The crux of the author's dismissal of their own findings is their argument that "it is possible that mental health problems may lead women to have unintended pregnancies and abortions." In other words, they are claiming that their study proves that women who have abortions are already mentally ill before they have their abortions, which then entirely explains the higher rates of mental illness after abortion. To support this argument, they point to a finding that among women who had abortions the first time use of anti-depressants in the year prior to their abortions was already higher than that for never pregnant women and women who gave birth. But this is a superficial analysis. It assumes that all women who have abortions fit into the same mental health profile. But clearly, first time use of anti-depressants is a very limited measure of mental health. It tells us nothing about the severity, duration, or recurrence of previous or subsequent mental health problems, even of depression. It is limited to "first time antidepressant use," a useful marker but clearly nothing more than a starting point...and the fact that they look no deeper than this starting point, and so quickly dismiss their own findings suggests that a deeper look would undermine their overly broad conclusions, not support them.
#The study design inappropriately collapses pre- and post- mental health events. The women who had first use of antidepressant prior to their abortion or childbirth should have been analyzed as a separate group to identify if they had an increase or decrease in how long they used antidepressants or had other treatments, such as counseling, in order to measure the relative severity, duration, and recurrence of problems between these two groups. Similarly, women who had a first time use of antidepressants following their first pregnancy outcome should also have been analyzed in a separate comparison to investigate the relative severity, duration, and recurrence of depression and other mental health symptoms.
# The decline in first-time use beyond several years may be explained by subsequent deliveries (which may heal some portion of the depressive effects) or by the increase in drug or alcohol use following abortion which is well documented. This underscores the weakness of looking at a single variable, such as first time use of antidepressants, in an effort to estimate the overall contribution of abortion to mental health issues.
# The longer term analysis (beyond one year) of first time antidepressant use, is deeply flawed by the failure to examine the effects of other pregnancy outcomes, subsequent births, abortions, and miscarriages. The whole premise is to investigate the effects of pregnancy outcomes, but women's experiences are not limited to a first pregnancy outcome. Surely, many women who aborted a first pregnancy may have subsequently carried to term, indeed many will have sought out a replacement pregnancy which may have reduced their risk of using antidepressants. Similarly, many women who gave birth may have experienced subsequent miscarriages or abortions, which may have increased their risk of using antidepressants. This demonstrates the superficial nature of these authors' investigation, which was clearly intended to be limited its scope to the point of demonstrating that among the entire population of women having abortions a disproportionate number have a prior history of using antidepressants. That's an interesting fact, but it simply does not prove that abortion doesn't contribute to depression, despite the authors' arguments to that effect.
# As with prior studies by Munk-Olsen, the author's use one year prior to the pregnancy outcome as a measure which include nine months of pregnancy for women who delivered and just one to three months for women who had abortions. In other record linkage studies, data on pre-pregnancy mental health was examined for one year prior to the estimated date of conception. That same standard should be applied to the analyses of this data set as it would be a better comparison of the women prior to conception.
# The study was limited to first trimester abortions. Approximately 10% of abortions occur after the first trimester, and it is important to investigate and report on the mental health of later term abortions. The most likely explanation for not including a subset in the analysis for later abortions is that the results for women who aborted were even more negative.
# There is no breakdown showing the relative risks relative to age groups. Even more notably, the authors excluded women (or at least women's pregnancies) that occurred prior to their 18th birthday. Since there is evidence that younger women have more negative emotional reactions to abortion, this may have been done in order to reduce the number of women in the entire sample who had first antidepressant use after an abortion.
# The study also excluded women who used antidepressants more than a year prior to their first pregnancy outcome. As previously mentioned, a better design would have been to include women with a history of antidepressant use (any any mental health treatment) into a separate, segregated analysis to investigate whether abortion or childbirth contributed to or reduced the duration of antidepressant use in subsequent years. A count of the number of antidepressants prescriptions filled for each period of time examined, for example, would be a good indicator of whether or not women with prior mental health problems experience more or less depression following abortion or delivery (or miscarriage, which should also have been examined.)
# Clearly, the question of whether abortion contributes to an increase or decrease in subsequent mental health issues, especially for women with a prior history of mental health issues, is an important one. It is also a question these authors carefully avoid. This is why segregated analyses are necessary for the following groups (a) women with a history of mental illness prior to conception of their first pregnancy, (b) women with no history of mental illness, and (c) all women.
# In the methods, the authors state that computed a general mental health score using the Charlson Comorbidity Index (CCI) and also compiled three other measures of mental health history based on (a) prior inpatient and outpatient admissions (b) prior use of anypsychotic medications, and prior use of anti-anxiety medications. These same measures could and should have been used to access the subsequent mental health of women in order to identify any change in severity, duration, or new symptoms following pregnancy outcomes. Instead, they limited their use of these measures to only the pre-pregnancy outcome period in order to blame all subsequent mental health problems on pre-pregnancy mental illness.
# In Table 2, the authors report that across all women (never pregnant, aborting, and delivering) the strongest predictors of first time antidepressant use were a history of psychiatric counseling, a history of taking antianxiety or antipsychotic medications. Notably, they authors did not give a break down of the for each subgroup of women (never pregnant, aborting, and delivering). Instead, we are left to presume that these reported rates applied equally to each subgroup of women, which is highly unlikely. Similarly, the CCI score is reported to show that a higher CCI score is associated with a higher risk of first time use of an antidepressant, but again there is no break down of what these scores were for each group, much less a report of how these CCI scores changed over time following a pregnancy outcome. Again, a prime opportunity was missed (or suppressed) which would have given us a better understanding of the degree of mental illness following abortion or childbirth, especially in women with a prior history of mental illness.
# A major premise of the authors' analysis is that women neatly fit into two categories: those who abort, those who give birth. More specifically, all women who have abortions are cut from the same cloth. Therefore, a finding of higher first use of antidepressants in the group of women in the year prior to having abortions "proves" that all women having abortions are more prone to depression whether or not they get pregnant and abort. More specifically, the authors are arguing that the elevated rate of first antidepressant use in the first year after an abortion (compared to non-pregnant and delivering women) is entirely explained by pre-existing mental health troubles among women who have abortions. But clearly, this is stretching one small data point into an over generalization. These women are individuals. For example, Ruth and Beth both had abortions. If Ruth first used an antidepressant eight months before her abortion, that tells us nothing about Beth. It certainly doesn't prove that if Beth seeks an antidepressant specifically because she is struggling with unwanted thoughts about her abortion that she is wrong...it is likely she would have sought antidepressants for some other reason because that is the "type of women," like Ruth, that she is. This study is simply too shallow. The analysis would be much more convincing if instead of using a single pre-pregnancy measure (first time use of antidepressants) the authors had used ''all of their mental health measures'', including the CCI score and the annual number of antidepressant prescriptions, to show that while Ruth and Beth had a different start date for their first use of an antidepressant, they had similar CCI scores, for example, and a similar duration for using antidepressants. Even better, the author's should have provided data showing how all of these mental health variables changed over time following each pregnancy outcome (not just first pregnancy outcome, but all subsequent combinations of pregnancy outcomes) in order to help us better judge the duration, complexity, and intensity of subsequent mental health problems associated with pregnancy outcomes.
# In their discussion, the authors state: "...the risk of depression decreased as more time elapsed after the abortion." In fact, their data only showed a decline in the first time use of antidepressants the farther out one looks from the abortion. But this tells us nothing about the risk of depression over time. If all the women who start using antidepressants following an abortion continue to have depression over two, five or ten years, it is false to assert that "...the risk of depression decreased as more time elapsed after the abortion." In fact, the cumulative number of women who have experienced depression would be always increasing. Only the rate of new cases would be declining, which is quite a different matter. Moreover, it is likely that only a limited percentage of women would be open to taking antidepressants. And others may self medicate with alcohol or drugs. At some point the number of new cases must necessarily decline, but this tells us nothing about he overall incidence rate. That problem could have been easily corrected if the authors had instead used as their outcome variable the number of antidepressants taken per year (or even a measure of dose levels as a proxy for severity). In other words, do women who have a history of abortions take more antidepressant medications per year, on average, (a) compared to women with no history of pregnancy, (b) women who have delivered with no history of abortion, (c) women with a history of miscarriage, and (d) women who have a history of childbirth, abortion, and miscarriage in every combination.
# The authors claim: "A close look at the data, however, suggests that the higher rates of antidepressant use had less to do with having an abortion than with other risk factors for depression among women who had an abortion." Again, the data that they have selectively chosen to report does reveal that prior psychiatric illness is a predictor for first time use of antidepressants, but it hardly proves that abortion itself does not also contribute to depression. The plain and evident truth is that their own data proves that women who have abortions will begin to use antidepressants at a much higher rate than women who carry to term and compared to women who did not become pregnant. This finding supports the conclusion that abortion ''may contribute'' to depression rates. Does it prove that abortion is the sole cause of depression in any specific number of case? No. Are other factors, such as prior psychiatric history, likely to be important? Yes. But it is illogical to argue that just because prior psychiatric history is the strongest predictor of first time antidepressant use that abortion never contributes to the onset, duration, or intensity of depression.
# The authors also claim: "Taking all of these results together, it is possible that mental health problems may lead women to have unintended pregnancies and abortions, as other research has found," citing two studies, neither of which actually prove that the reason women have unintended pregnancies and abortions is due to pre-existing mental health problems. Again, this is a harsh characterization and overgeneralization of the mental health of women seeking abortions. But even if mental health problems contribute to why some women have abortions, these findings do not even begin to address the critical question of whether or not a mentally ill woman who has an abortion is more likely to improve, get worse, or stay the same, much less whether the abortion itself contributes to any positive or negative trends in mental health.
# The authors also assert that the protective effects of childbirth do not last, noting that the decline in first use of antidepressants in the year following a first delivery disappears in the span between the second and fifth year and beyond. That's an interesting finding, but to be expected. But also, it underscores another weakness in the study, since their analyses do not include subsequent exposure to abortions or miscarriage. Since their own study shows a doubling of the risk of antidepressant use following an abortion, one would expect women who carried a first pregnancy to term but later had an abortion to have an elevated rate of antidepressant use.
# In their conclusions, the authors write:"if having an abortion is causally related to depression, one would expect a higher rate of first antidepressant use after the procedure than before the procedure, yet rates of antidepressant use were no higher in the year after having an abortion than in the year before an abortion." Actually, since prior mental health problems are common, a better hypothesis would be to expect the rate, duration, and intensity of depressive symptoms to increase after an abortion. But none of these are reported in the authors' study (even though they had relevant data). Instead, they limited their analyses to first time use of antidepressant, severely limiting the scope of any conclusions that can be made.
# Additionally they conclude: "if there are lagged effects of abortion, one would expect an increase in the rate of depression over time, but rates of antidepressant use decreased as more time elapsed." Here they seriously misrepresent their own findings. The rate of ''first time antidepressant'' use declined. They could have, and should have, reported on the actual rate of antidepressant use (number of doses per year per thousand women exposed to abortion, for example) but they did not.
# They then write: "Finally, the differences in rates of antidepressant use between women who had an abortion and women who did not have an abortion were substantially reduced when adjusted for earlier mental health conditions, parental mental health conditions, parental educational level, and physical health. This suggests that, compared with women who do not have an abortion, women who have an abortion may be at higher risk of depression after undergoing the procedure because they were at higher risk to begin with." Again, their study was limited to only first time use of antidepressants. But more importantly, even if women having abortions are more prone to experiencing depression due to pre-existing reasons, this does not exclude the possibility, nor justify ignoring the probability, that abortion can trigger, complicate, or prolong mental health issues.
# Their last word: "Consequently, policies based on the notion that having an abortion harms women’s mental health may be misinformed." Here, the verb "may" is misplaced. The "the notion that having an abortion ''may'' harm women's mental health" is actually supported by the very limited data reported in this study. This study verifies that women who have abortions experience higher rates of depression compared to delivering and non-pregnant women. Due to the superficial nature of this study, looking at first time antidepressants alone and lacking any breakdown of subsequent mental health changes among the women who did have pre-existing mental health issues, it sheds no light at all on how much abortion may contribute to the increased risk of mental health problems observed following abortion. Indeed, given the incorrect statements made in the conclusion of this paper, and the poor study design, the assertions made by the authors are clearly misleading or misinformed.
# Notably, the authors cite only two references with data or arguments favoring an association between abortion and depression. One is a metanalysis that is broadly focused and the other is a 1992 paper that obviously did not have access to any of the studies published since 1992. In short, the authors fail to fairly present their study in light of the existing literature and simply ignore evidence that would underscore that their methodology and conclusions are superficial and misleading.

==Induced First-Trimester Abortion and Risk of Mental Disorder.==

'''''[http://www.nejm.org/doi/full/10.1056/NEJMoa0905882 Induced First-Trimester Abortion and Risk of Mental Disorder.]  ''''' Munk-Olsen, T, Laursen TM, Pedersen CB, Lidegaard Ø, Mortensen PB. ''N Engl J Med'' 2011;364:332-9.

==== Abstract ====

'''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. (Funded by the Susan Thompson Buffett Foundation and the Danish Medical Research Council.) 

==== Key Findings ====

#Abortion is not associated with any improvement in mental health.  This finding is consistent with previous studies. 
#The year following abortion was associated with a higher rate of treatment for some mental health conditions compared to the nine months prior to the abortion, including 1 to 3 months while pregnant. Specifically, relative risk for psychiatric visits involving neurotic, stress-related, or somatoform disorders was 47% and 37% higher for women post-abortion compared to pre-abortion at 2 and 3 months respectively. In addition, psychiatric contact for personality or behavioral disorders was 56%, 45%, 31%, and 55% higher at 3, 4-6, 7-9, and 10-12 months respectively. 
#The rate of mental health treatments following a first abortion is significantly higher than the rate of mental health treatments following a first delivery. However, the rate of mental health treatment in the nine months prior to abortion (including up to three months coping with pre-abortion stresses) was also higher than the rate of mental health treatments before and after a live birth.
#Women who have abortions have higher rates of psychiatric treatment (15.2 per 1000 person years) than women who have not been pregnant (8.2 per 1000 person years) and women who deliver their first pregnancy (6.7 per 1000 person years).
#The findings of this study indicate that compared to other women, the elevated rates of mental health problems associated with abortion occur both before the abortion (during the nine months preceding the date of the abortion) and after the abortion.
#Because of differences in study design, and because the study did find elevated rates of psychological problems associated with abortion compared to delivering and non-pregnant women, the findings of this study clearly do not contradict previous studies linking abortion to elevated rates of psychological problems. The study does contribute to the literature, however, in that it provides evidence that some mental health problems associated with abortion may arise from pre-abortion stresses, during the time frame of discovering an unintended pregnancy, facing the pressures and concerns associated with making the abortion decision, and undertaking the abortion itself.
#Clinicians should be alert to the fact that there are higher rates of mental health treatments are sought by women in the year following a first abortion compared to the year following a first delivery.
#The researchers in this study conclude that the higher rates of mental health treatments provided to women who have abortions is not causally due to abortion, but rather due to a self-selection bias causing women with a propensity to require higher rates of mental health care to be more likely to have abortions.  (This conclusion is a good bit at odds with the study's design since it actually excluded women with a history of inpatient care prior to their first pregnancy, in other words, it was designed to look at the most mentally healthy set of women).  Even if this speculation were confirmed, it raises the interesting question: Is abortion "attractive" to the mentally unstable as an act of healing or as an act of self-destruction?  The lack of any evidence of benefit and the abundance of evidence of continued or increased mental health problems after an abortion suggest that it is not an act of healing. 

==== Limitations ====
#Although the researchers asserted that they were comparing women having a first trimester abortion to women giving birth, the study actually mixed the groups. Delivering women who had a previous abortion were included in both the birth group and abortion group. Similarly, women who gave birth to one or more children and then had a subsequent abortion were also included in both groups. The design necessarily dilutes all effects by mixing aborting women and delivering women. In all similar record linkage studies, women with both abortion and childbirth experiences as a third group, one which can be then be compared to both the group of women having only a history of abortion and those having only a history of childbirth.
#:a) Several other other studies have already shown that a history of abortion increases the risk of psychiatric problems during subsequent pregnancies that are delivered. For women with a history of abortion, preparing to give birth to a first live born child can itself trigger unresolved emotional issues regarding a prior abortion.
#:b)Munk-Olsen's failure to segregate the delivering women in this study who previously had abortions would necessarily increase the overall average of psychiatric issues attributed to childbirth even though a significant portion of the effects may actually have been due to the prior abortions.
#The pre-event (abortion or childbirth) measure of mental health was limited to only 9 months.  This period was chosen to include (on average) only the time that a delivering woman was pregnant.  It therefore totally ignores the pre-pregnancy mental health of delivering women. By contrast, for women who had abortions this nine month pre-event window includes six to eight pre-pregnant months plus one to three months during which the woman discovered she was faced with an unintended pregnancy and was deciding on an abortion.
#The sample included women with outpatient psychiatric care, but excluded women with a prior history of inpatient psychiatric care. That would be fine, but it then in regard to the outcome variable, it treats both first time outpatient and inpatient psychiatric care as identical. That is inconsistent. The results should have been reported to show first time outpatient and first time inpatient results both separately and combined. It would also have been preferable to report results separately for women with no prior history of outpatient psychiatric care and those with various levels of outpatient care . . . since clearly women with a history of 40 or more outpatient treatments are different than women with no history of outpatient treatments, but for the sake of this study they are treated the same with no effort to account for these differences.
#While it is important to control for prior mental health, it would have been far preferable to use the the full life history of psychiatric treatments for women in both groups, or at least a five year history prior to the pregnancy. Such far more complete data exists in the Danish database. It was available to the researchers.  Why it was not used is unclear.
#At the very least, the control period should have been based on a period of time estimated to have been before the women in both groups became pregnant, as was done in the [http://www.cmaj.ca/cgi/content/full/168/10/1253 Reardon(2003) analysis] of California medical records, which Munk-Olsen was seeking to replicate and refute. Furthermore, while the researchers did exclude women who had any prior history of inpatient psychiatric care, they did not control for prior history of outpatient psychiatric care.  In other words, we do not know if there were any differences in the rates of outpatient treatment between the two groups.
# The study excluded women who died (including death from suicide) prior to the end of the 12 month follow-up. Given numerous studies showing higher rates of suicide and deaths from accidents following abortion, this design decision may skew the results.
# The study considered only a single psychiatric treatment.  It did not measure or weight repeated treatments, which might be used as a measure of the severity and duration of mental health problems.
#  The study put women in both categories.  Women who had both an abortion and delivery appeared in both groups.  This may have confounding effects.  To eliminate these confounding effects the authors should have limited the study to first pregnancy outcome, and included miscarriage and other natural losses as a third group.
# Curiously the researchers did not follow the research approach used in previous Danish Study [http://www.nejm.org/doi/full/10.1056/NEJMoa033160 Hospitalization for Mental Illness among Parents after the Death of a Child] which examined mental health over a much longer period than just 12 months. Nor did they use a one year exclusion of women with prior hospitalization as was done in the record based study of [http://abortionrisks.org/index.php?title=Psychiatric_or_Psychological_Hospitalization_or_Consultation low income women in California]. This tendency to vary from prior research methods, using arbitrary periods like nine months arouses suspicion that selection criteria were chosen to magnify, or diminish, results in a fashion that best supported the authors' hypothesis.
#The authors controlled for "presence or absence of a history of mental disorders in the parents" of the pregnant girls or women. No justification was given for this. Without showing the results before and after this control, the effect is unclear.
#The paper failed to cite the only previous record linkage studies on abortion and mental health, a study of 56,741 low income women in California, all of which found significantly higher rates of treatments for mental health and sleep disorders following abortion.<ref>Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low income women following abortion and childbirth. Can Med Assoc J. 2003; 168(10):1253-7</ref><ref>Coleman PK, Reardon DC, Rue VM, Cougle J. State-funded abortions versus deliveries: a comparison of outpatient mental health claims over 4 years. Am J Orthopsychiatry. 2002 Jan;72(1):141-52.</ref> <ref>Reardon DC, Coleman PK. Relative treatment rates for sleep disorders and sleep disturbances following abortion and childbirth: a prospective record-based study.Sleep. 2006 Jan;29(1):105-6.</ref> This is very significant since these are the best studies with which to compare results and also the ones which should have informed study design; specifically, Munk-Olsen should have equaled or exceeded the methodological approach previously employed. Instead, she chose an inferior approach, controlling for less time prior to the pregnancy outcome and examining psychiatric outcomes for a shorter period following pregnancy outcomes.
#In addition to ignoring previous record linkage studies, the author's discussion merely compared their results to previous interview based studies, in what was clearly an attempt to suggest that "all" previous studies suffered from selection bias and that, therefore, their record linkage study was superior to all the previous literature (even though they were actually avoiding the comparison of their results the three record linkage studies described above).
#Bottom line: the control for prior mental health history in this study is very weak and may even lead to misleading results. Additional problems associated with this choice to limit prior mental health issues to this nine-month window prior to pregnancy outcome are detailed below:
#*For women carrying to term, the nine month window does not include any pre-pregnancy time. Women who are excited about having a baby may be less likely to seek mental health.  This may is why the incidence rate is so low 3.9%.  With only a nine-month pre-event window, the authors are even excluding those women who may have been experiencing anxiety or other problems as they struggled to become pregnant.  So this measure of mental health during a first pregnancy is a poor indicator of mental health prior to a first delivery, much less prior to first pregnancy.
#*Given the lack of more complete controls for mental health history suggested above, we must assume that since both groups had no prior history of outpatient mental health care prior to their first pregnancies, the mental health of both groups was very similar prior to becoming pregnant.  The three fold increase in mental health treatments prior to abortion (14.6 per 1000 yrs) compared to women who gave birth (3.9 per 1000 yrs) would therefore appear to be most likely explained by stress these women faced discovering they were faced with an unplanned pregnancy and, in many cases, the concurrent disruption of relationships with male partners, parents, employers and others.  In addition, abortion women were more likely to involved in unstable and possibly abusive relationships prior to their pregnancies.  It is not surprising, then, that many of these women facing the stress of abortion decision-making sought psychiatric advise at a much more elevated rate than they had in the past.
#*It is a common failure in abortion research to fail to identify the difference between pre-pregnancy mental health and pre-abortion mental health. Proponents of the abortion and mental health (AMH) connection generally support the view that abortion experience includes pre-abortion mental health stressors occur between the impregnation and abortion.  Discovery of the pregnancy, negative interactions with loved ones over the pregnancy, moral struggles, maternal stress, morning sickness, stress related to career and education decisions, and numerous other factors associated with the pregnancy can all contribute to escalating levels of stress.  Indeed, AMH proponents often describe abortion as both a stress reliever (because it resolves some of these pre-abortion stresses) and a stress inducer (because it creates new stresses or calcifies existing stresses).  This study's failure to distinguish between pre-pregnancy mental health history and post-conception/pre-abortion mental health history prevents any application of the findings to the more central question of when, if ever, an abortion to be beneficial.
#*AMH deniers often suggest that higher rates of post-abortion mental health problems, which are consistently found in the literature, are due to higher rates of pre-existing mental health problems unrelated to the abortion or the unintended pregnancy.  This hypothesis has not yet been tested due to the failure to distinguish between pre-pregnancy mental health and pre-abortion mental health.  This study, again, fails to make that distinction, which is especially unfortunate since, being a record based study, the necessary data was available to the researchers.  <blockquote></blockquote>
# The only confounding variables for which the authors use controls are age and number of pregnancies. Controls for marital status and socioeconomic status are missing, even though such data is generally available in record based studies.
# All women who had a history of psychiatric inpatient treatment more than 9 months prior to the abortion were excluded from the study. Many studies suggest that these women are at heightened risk for post-abortion mental health problems. Additional research should be done to look only at this subset of women to determine if women with a prior history of significant mental health problems (pre-pregnancy) are likely to have a lower or higher rate of mental health problems after abortion or after childbirth.
# Women who experience repeat abortions are likewise not considered. Approximately half of all abortions, at least in the United States, are for women with a prior history of abortion. Numerous studies indicate an elevated risk of mental health problems associated with multiple abortions. This study fails to shed any light on this important issue. In fact, by including women with a history of multiple abortions in the comparison group of women at the time of their first pregnancy, it is likely this inflated the psychiatric contact rate of women giving birth. In short, the failure to examine psychiatric contact rates associated with repeat abortions means the conclusions cannot be applied to women having multiple abortions.
# The limited follow-up to just one year after the pregnancy outcome is also an unfortunate limitation. There is evidence that elevated rates of post-abortion reactions persist for at least four years. Conversely, post-partum reactions tend to occur within the first few months following a delivery and the mental health benefits of childbirth may therefore be underestimated by examining treatment rates within only one year.
# The study did not examine whether the individual women who had psychiatric treatment prior to the abortion were at higher or lower risk of additional psychiatric treatment after the abortion.  For example, did pre-abortion mental health screening/counseling help to reduce subsequent risk of mental health treatment?  Or was it a predictor of higher rates of subsequent mental health treatment?  This is an important issue not answered by the study.
# The authors' conclusions are not consistent with the data. Specifically, the authors conclude: "our study shows that the rates of a first-time psychiatric contact before and after a first-trimester induced abortion are similar."  The identification of ''some "similar" rates,'' however, does not change the fact that their data also showed ''several statistically significant higher rates'' for specific mental disorders following abortion (see table 1). It would have been reasonable for their main conclusion to have been "our study shows higher rates of treatment for psychological illness  Additional study, and better controls, may reveal even more significant differences.  In addition, the authors statement that "This finding does not support the hypothesis that there is an overall increased risk of mental disorders after first-trimester induced abortion," oversimplifies and misrepresents the hypotheses presented by AMH proponents.  Even more importantly, the findings of this study do not ''contradict ''even this oversimplified hypothesis.  Instead, the conclusion seems crafted to be a sound-bite that obfuscates rather than clarifies the issues of concern.
#The study results are slanted by the exclusion of women most likely to have the most severe reactions to abortion, namely (a) women aborting after the first trimester, (b) those with a prior history of psychiatric hospitalization, and (c) women who died from suicide or accidents (elevated risk taking behavior or unrecognized suicide) within the year following their pregnancies.
# The Danish records are so complete that nearly all of these problems could have been addressed through better analyses. The fact that the researchers did not attempt to replicate the better design found in previous studies, but instead incorporated these methodological problems into their study design suggests that they did so in order to slant their result toward their intended conclusions.
#The study was funded by a grant from the [http://www.insidephilanthropy.com/home/2014/2/4/whos-who-at-the-secretive-susan-thompson-buffett-foundation.html Susan Thompson Buffet Foundation] which is primarily focused on funding population control efforts with funding of Planned Parenthood International and other groups promoting abortion in developing countries.

==== Data Clarification Request Refused ====

An email request was made to Munk-Olsen on 6/15/2015

:Dear Dr. Munk-Olsen,

:I am studying your 2011 paper "Induced First-Trimester Abortion and Risk of Mental Disorder."

:In your paper you make two statements:

::During the period from 1995 through 2007, a total of 84,620 girls and women had a first-time first-trimester induced abortion. Of these girls and women, 868 (1.0%) had a first psychiatric contact (either inpatient or outpatient psychiatric care) during the 9 months before the abortion, as did 1277 (1.5%) within the 12 months after the abortion.

::During the same study period, a total of 280,930 girls and women gave birth to their first live-born child. Of these girls and women, 790 (0.3%) had a first-time psychiatric contact within the 9 months preceding delivery, as did 1916 (0.7%) from 0 through 12 months post partum.

:It is my understanding that the two above groups include women who had both an abortion and a live birth. Would you please complete the following two statements for those who had first an abortion and then a birth and for those who had first a birth and later an abortion:

::During the same study period, a total of _________ girls and women had a first-time first trimester abortion of their first pregnancy and subsequently gave birth to their first live-born child. Of these girls and women, ___ (___%) had a first psychiatric contact (either inpatient or outpatient psychiatric care) during the 9 months before the abortion, as did ____(___%) within the 12 months after the abortion. Subsequently, of these girls and women, _____ (___%) had a first-time psychiatric contact within the 9 months preceding delivery, as did 1916 (__._%) from 0 through 12 months post partum.

::During the same study period, a total of _________ girls and women gave birth to their first live born child and had no history of prior abortion and also had a first-time first trimester abortion of at least one subsequent pregnancy. Of these girls and women, _____ (___%) had a first-time psychiatric contact within the 9 months preceding delivery, as did 1916 (__._%) from 0 through 12 months post partum. Subsequently, of these girls and women, ___ (___%) had a first psychiatric contact (either inpatient or outpatient psychiatric care) during the 9 months before the abortion, as did ____(___%) within the 12 months after the abortion.

:Thank you for this clarification.

On 7/18/15 Munk Olsen replied:

::Thank you for your email. I am pleased that you find our paper interesting. However, answering your questions would require substantial work from several people here at our center, and for this reason I cannot provide them to you.

::Sincerely,

::Trine Munk-Olsen

Note: Most researchers routinely reply to such requests with the additional details. It literally takes only seconds to run a tabulation like that requested. Munk-Olsen's refusal to provide any details was clearly motivated by a fear of providing data that would lend itself to any interpretation of the data beyond what she has decided to reveal.

==== Critique by David C. Reardon ====

Given the excellence of this data set, it is unfortunate that the researchers failed to consider the methodology employed in prior record based studies of abortion and mental health (for example, [http://www.ncbi.nlm.nih.gov/pubmed/12743066/ Reardon DC, 2003] and [http://www.ncbi.nlm.nih.gov/pubmed/14964603/ Coleman PK, 2002]) and instead made choices which tend to confound rather than clarify the issues at hand.

Perhaps the biggest problem is the failure to examine pre-pregnancy mental health. This was done in prior studies which controlled for psychiatric admissions for at least one year prior to the calculated date of conception ([http://www.ncbi.nlm.nih.gov/pubmed/12743066/ Reardon DC, 2003]). Instead, Munk-Olsen chose as a base line for mental health a nine month period prior to pregnancy outcome, a period covering the entire period of pregnancy for delivering women and approximately three months of pregnancy and six months pre-pregnancy for women who aborted.

This poorly explained decision unfortunately introduces elements of an apples versus oranges comparison.

This is problematic for two key problems. First, it totally ignores the pre-pregnancy mental health of delivering women. Women who are excited about having a baby may be less likely to seek mental health. With only a nine-month pre-event window, the authors are even excluding those women who may have been experiencing anxiety or depression if they were struggling to become pregnant.

Secondly, for aborting women, it includes two to three months of a period in the women's lives which is likely highly stressful since these women are, it must be presumed, facing discovery of an unplanned pregnancy and potential conflicts over this with partners, parents, and others. This nine month window therefore not only fails to provide a base line for mental health prior to the subjects' pregnancy but mixes, several months of pre-pregnancy mental health with one or more months of post-pregnancy, pre-abortion stress.

Third, it is a variation from Munk-Olsen's own prior methodology employed in a [http://jama.jamanetwork.com/article.aspx?articleid=204395 2006 study of mental health problems following childbirth] in which all women who ever had prior history of inpatient treatment were excluded . . . not just those treated within nine months of abortion or delivery. Why this change, unless it was necessary to shift the results in a fashion that would reduce the difference between treatment rates before and after abortion?

These study design criteria are not only unprecedented in similar studies but simply contrary to the stated objective of controlling for prior mental health. This failure in design is even more puzzling given the fact that the available data set included mental health information for the entire life of the women in the study. Given the availability of all prior mental health treatment dates, it seems self evident that the researchers should have created a scale for exposure to prior mental health treatments prior to the estimated conception date of each woman's first pregnancy covering at least one full year, preferably five years, and perhaps for each subject's entire life.

Given the fact that the authors only exclusion criteria was a history of inpatient psychiatric treatment, we must assume that since the mental health of both groups was relatively similar prior to becoming pregnant. The three fold increase in mental health treatments prior to abortion (14.6 per 1000 yrs) compared to women who gave birth (3.9 per 1000 yrs) would therefore appear to be most likely explained by stress these women faced discovering they were faced with an unplanned pregnancy and, in many cases, the concurrent disruption of relationships with male partners, parents, employers and others.

In addition, aborting women were more likely to involved in unstable and possibly abusive relationships prior to their pregnancies. It is not surprising, then, that many of these women facing the stress of abortion decision-making sought psychiatric advise at a much more elevated rate than they had in the past.

The lack of pre-pregnancy mental health measure, in itself, renders it impossible to draw general conclusions regarding from this study. But there are also numerous additional problems with the study design that further confound the results and interpretation:

*The study excluded women who are most likely to have the most severe reactions to an abortion, namely those who already had a prior history of abortion, those with a prior history of inpatient mental health treatment. It also excluded women who died prior to one year after the pregnancy event, thereby excluding women who committed suicide, even though a record linkage study from neighboring Finland found a six fold higher rate of suicide in the year following abortion compared to the year following childbirth ([http://www.ncbi.nlm.nih.gov/pubmed/8973229/ Gissler M, 1996]).

*The study failed to keep women in the two groups separate. Women who had both an abortion and delivery were included in both parts of the analysis groups. This is especially problematic given the evidence women with a prior history of abortion have more stress during and after subsequent pregnancies ([http://www.ncbi.nlm.nih.gov/pubmed/12501082/ Coleman PK, 2002]). As a result, by putting women with a history of abortion in the group of delivering women, the "control" group may be adulterated with the very post-abortion effects this study professes to be exploring. The authors should have limited the study to first pregnancy outcome, and should also have included first pregnancies ending in miscarriage, still birth, and other natural losses as a third group.

*The outcome variable used for this study was limited to only a single psychiatric treatment. It did not measure or give any weight to repeated treatments or multiple mental health problems in an effort to evaluate the severity or duration of mental health problems associated with pregnancy outcomes. It should also be noted that the authors' conclusions are not consistent with their data. Specifically, the authors conclude: "our study shows that the rates of a first-time psychiatric contact before and after a first-trimester induced abortion are similar." The fact that many of the psychiatric contact rates during the nine months preceding an abortion were similar to the contact rates in the year following an abortion were statistically insignificant does not alter the fact that, even with all of the problems in the methodology identified above, their data also showed several statistically significant higher rates for specific mental disorders.

Specifically, as seen in table 1, contact rates for neurotic, stress-related or somatoform disorders were higher in every two month period following an abortion, and was statistically significant in two of the six periods. Similarly, for personality or behavioral disorders, the relative risk was higher for four of the six periods and significantly higher for two of the six periods. In other words, when one actually examines the table of reported findings, the conclusion that "in some cases the rate of a first-time psychiatric contact is significantly higher following an abortion compared to the nine months preceding an abortion" is at least equally true, and arguably more accurate.

Finally, I would note that at least one of the authors, Laursen, was also a co-author of an excellent record linkage study from Denmark examining mental illness among parents of deceased children that was also published in the New England Journal of Medicine.([http://www.ncbi.nlm.nih.gov/pubmed/15788495/ Li J, 2005]) That study design examined long term mental health effects, beyond one year, and controlled for exposure to multiple losses, and had none of the selection bias problems identified in this Munk-Olsen study.

This exact study design could have, and should have, been used simply by plugging the date of exposure to induced abortion into the same fields used for date of exposure to the death of a child. By using a proven study design in this way, Munk-Olsen and Laursen could have avoided the impression (in this case, the very profound impression) that this new study design (with a nine month pre-event control period and intermixing of subjects into both the abortion group and delivery group, et cetera) was artificially constructed precisely to minimize the number of statistically significant findings associating abortion with increased mental health treatments. In conclusion, this study does nothing to impute previous record linkage studies showing elevated rates of psychiatric treatments following induced abortion.

==First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital==

'''[http://archpsyc.jamanetwork.com/article.aspx?articleid=1107446 First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital in women with a history of treated mental disorder.] Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard O, Mortensen PB. Arch Gen Psychiatry. 2012 Feb;69(2):159-65. doi: 10.1001/archgenpsychiatry.2011.153.'''

:Context Mental health problems are associated with women's reproductive decisions and predict poor mental health outcomes after abortion and childbirth.

:Objectives To study whether having a first-trimester induced abortion influenced the risk of psychiatric readmission and compare findings with readmission risk in women with mental disorders giving birth.

:Design Survival analyses were performed in a population-based cohort study merging data from the Danish Civil Registration System, the Danish Psychiatric Central Register, and the Danish National Hospital Register from January 1,1994, to December 31, 2007.

:Setting Denmark.

:Participants: All women born in Denmark between 1962 and 1992 with a record of 1 or more psychiatric admissions at least 9 months before a first-time first-trimester induced abortion or childbirth.

:Main Outcome Measure: Readmission at a psychiatric hospital with any type of mental disorder from 9 months before to 12 months after a first-time first-trimester induced abortion or childbirth.

:Results: Relative risk (RR) for readmission risk 9 to 0 months before a first-trimester induced abortion was 0.95 (95% CI, 0.73-1.23) compared with the first year after the abortion. This contrasts with a reduced risk of readmission before childbirth (RR, 0.56; 95% CI, 0.42-0.75) compared with the first year post partum. Proximity to previous psychiatric admission in particular predicted rehospitalization risks in both the abortion and the childbirth group.

:Conclusions: Risk of readmission is similar before and after first-time first-trimester abortion, contrasting with a marked increased in risk of readmission post partum. We speculate that recent psychiatric episodes may influence women's decisions to have an induced abortion; however, this decision does not appear to influence the illness course in women with a history of treated mental disorders.

''':Comments:'''

*Most of the [[Munk-Olsen_et_al#Limitations | limitations described above]] regarding Munk-Olsen's 2011 study also apply to this extended analysis.
*This study was limited to 2,838 women with a history of having inpatient treatment for psychiatric illness at some time prior to the nine months prior to their abortions. In other words, it is limited to women who most likely have the most mental health problems.
*Why Munk-Olsen does not run the same analyses for women with no prior mental health problems is not explained. While it is certainly relevant to look at how women with pre-existing mental health issues fare following abortion or delivery, it is equally important to look at how women with no pre-existing mental heatlh issues fare after their first pregnancy, whether aborted or delivered. The decision to not publish any results relevant to women without a prior history of mental illness is almost certainly due to the fact that her results showed a difference between aborting and delivering women. Otherwise, she would have published evidence that there was no difference in order to bolster her argument that pre-pregnancy mental health alone explains the higher rates of mental illness among aborting women.
*Her main conclusion is that the rate of women being readmitted for psychiatric care after an abortion is similar to the rate during the nine months before an abortion proves that abortion does not change the rate of psychiatric admissions among women. But in fact, she does not measure the number of readmissions each woman faces, but only whether she is admitted once. Nor does she look to see if the admissions are for longer periods or for any other measure of whether their psychiatric illnesses have become worse or better. Instead, she simply speculates that these women are most likely to have chosen abortions because of their pre-existing psychiatric issues.
*Without any attempt to measure the frequency of subsequent treatments beyond a first time readmission, or any other measure of severity, plus with the limitation to only one year follow-up (and no reporting of suicides), her conclusion that abortion "does not appear to influence the illness course in women with a history of treated mental disorders" is totally unsupported by the very limited evidence she choose to share.

===Letter to Editor By David Reardon Identifying Methodological Problems and Requesting Additional Analyses===

These letters were previously available at the links shown. As of January 2017, it appears that Archives of General Psychiatry have moved the content to a yet to be discovered location.

'''[http://archpsyc.jamanetwork.com/article.aspx?articleid=1107446 Correction of Study Design Problems Would Bring More Clarity to Abortion Mental Health Issue.] Reardon DC. Arch Gen Psychiatry.''' February 23, 2012'''

:As one of the authors of three record linkage studies examining abortion and mental health(1)(2)(3), I applaud the quality of data being accessed by the Munk-Olsen team(4)(5). I am disappointed that their review and discussion ignored our studies. But I’m even more disappointed by their study design decisions which tend to obscure rather than clarify the key issues in this field.

:For example, because negative reactions to abortion increase with time(6) our study examined psychological treatments rates for four years. Munk-Olsen unnecessarily limited follow-up to one year.

:Furthermore, our studies employed a uniform baseline, controlling for any psychiatric admissions prior to conception. By contrast, Munk-Olsen introduces a dissimilar comparison overlaying nine months of pregnancy for delivering women with a nine months mix of pregnancy and no pregnancy for aborting women.

:The weakness of this dissimilar comparison is underscored by the finding that recent admission is the strongest predictor of subsequent readmissions(4). This creates a front loading problem as evidence by 14% of those assigned to the abortion group being readmitted within six months, prior to becoming pregnant. Worse, because the study design censored these cases after their first readmission, the design totally conceals any information about whether this “extra fragile” group (readmitted within 180 days) faced additional readmissions after their abortions.

:It is my hope Munk-Olsen will ameliorate this effect by reporting via a published letter results of a reanalysis restricted to the 429 "reasonably stabilized" women whose previous discharge was at least one year prior to the 21-month period examined.

:Yet another design problem was the decision to include 952 women (13%) into both the abortion and childbirth groups. Since abortion is associated with a higher risk of mental illness during or after subsequent pregnancies,(7)(8)(9)(10) such double assignment of women to both groups would tend to obscure rather than clarify differences.

:This excellent data set can and should be put to better use. Future analyses should show segregated results for women divided into five groups: women with any history of hospitalization for mental health, and women with 0, 1-5, 5-10, and >10 outpatient mental health treatments, either lifetime or within 5 years prior to the estimated conception date of their first pregnancy. With these groupings, analyses should examine inpatient or outpatient treatment rates in the year prior to pregnancy and for one through five years following first pregnancy outcome (including birth, abortion, miscarriage, and other losses). This study design would more clearly identify relative risks of mental illness associated with various pregnancy outcomes for groups of women with various levels of predisposition to mental illness.

:Finally, the opportunity to use these data to provide some definitive answers to questions relating reproductive experiences to mental health would be enhanced by including on the research team experts on both sides of this controversial research field, such as Priscilla Coleman and David Fergusson on one side and Brenda Major and Nancy Russo on the other. Such collaboration would increase confidence in both the study design and the interpretation of results.

:References
:(1) Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low income women following abortion and childbirth. Can Med Assoc J. 2003; 168(10):1253-7.

:(2) Coleman PK, Reardon DC, Rue VM, Cougle JR.State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years. American Journal of Orthopsychiatry, 2002; 72(1):141–52.

:(3) Reardon DC, Coleman PK. Relative treatment rates for sleep disorders and sleep disturbances following abortion and childbirth: a prospective record-based study. Sleep. 2006 Jan;29(1):105-6.

:(4) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard O, Mortensen PB. First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital in women with a history of treated mental disorder. Arch Gen Psychiatry. 2012 Feb;69(2):159-65.

:(5) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard Ø, Mortensen PB. Induced first-trimester abortion and risk of mental disorder. N Engl J Med. 2011 Jan 27;364(4):332-9.

:(6) Major B, Cozzarelli C, Cooper ML, Zubek J, Richards C, Wilhite M, Gramzow RH. Psychological responses of women after first-trimester abortion. Arch Gen Psychiatry. 2000 Aug;57(8):777-84.

:(7) Coleman PK, Reardon DC, Cougle JR. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. Br J Health Psychol. 2005 May;10(Pt 2):255-68.

:(8) Coleman PK, Reardon DC, Rue VM, Cougle J. A history of induced abortion in relation to substance use during subsequent pregnancies carried to term. Am J Obstet Gynecol. 2002 Dec;187(6):1673-8.

:(9) Stotland NL. Abortion: social context, psychodynamic implications. Am J Psychiatry. 1998 Jul;155(7):964-7.

:(10) Burke T, Reardon DC. Forbidden Grief. The Unspoken Pain of Abortion. Springfield, IL: Acorn Books; 2002.

===Munk Olsen's Response===

In her response to Reardon's letter, [http://archpsyc.jamanetwork.com/article.aspx?articleid=1107446 Munk-Olsen made the following responses]

#She admitted that the limitation to a one year follow-up was arbitrary.
#She admitted that the use of nine months prior to pregnancy outcome, rather than nine months prior to pregnancy, meant the two groups "may not be directly compatible across this 9 months period." In this case, "compatible" can only be interpreted to be a synonym for "comparable" meaning the two groups are not properly comparable during this time period as Reardon argued. Obviously, the whole premise of the study is that the design should have comparable measures for each group. Psychiatric treatment rates before the conception dates of women in both groups was available, but not used. This was almost certainly not provided precisely because a proper comparison did not advance Munk-Olsen's preferred outcome.
#In regard to the suggestion that the study should have examined not just first time psychiatric admissions following a birth or abortion among women with prior psychiatric admissions, but instead should have also looked at how many times women were treated following their pregnancy outcomes to determine if abortion might increase the severity or frequency of post-abortion psychiatric episodes, Munk-Olsen rejected this request insisting that "The problem of counting re-admissions is that several psychiatric contacts could be caused by the same psychiatric disease/episode, and that it is difficult to discriminate between several separated events, and several contacts for the same event." If a quick re-analysis of the data had shown that there was no increased frequency of admissions, Munk-Olsen could easily have reported this in her response to disprove Reardon's concern. Instead, she simply defended her dodge, essentially admitting "The evidence may show that their are more frequent re-admissions for psychiatric inpatient treatment for women who have abortions, but since we can't be certain that doesn't mean something else, we choose not to report that data."
#Regarding the problem of mixing women who had both abortions and births into both groups, Munk-Olsen simply declares that it is a fact that some women have both experiences. True. But that does not justify bad research methodology. It is also a fact that it very easy to split women exposed to different pregnancy experiences into more than two group, which is a [http://www.cmaj.ca/content/168/10/1253.full common practice that has been used by many other researchers.] If she had simply used three groups (1. first pregnancy was aborted, 2. first pregnancy was delivered, and 3. one of first two pregnancies aborted and the other delivered) the effects associated with two pregnancies with different outcomes would not distort the effects associated with a single pregnancy outcome. Instead, of providing data from a new analysis showing that Reardon's concerns, if addressed, do not change her results, she instead insists that additional analyses are not necessary (to show to anyone else, I guess). Indeed, she asserts that controlling for parity (number of children born before women's first abortions) somehow remedies the problem, though she give no explanation how or why this should be so.

===Critique by Priscilla Coleman===

The study has numerous problematic elements and the results cannot be trusted for the reasons described below.

1) The sample is limited to women who had a first abortion or birth between 1994 and 2007. The oldest women in the population for whom the investigators had data were born in 1962, and many of the oldest women surely experienced their first abortion or birth well before 1994 (since they would have been 32 at the time), yet they are not included in the analyses and no explanation is provided for their exclusion.

2) There is a serious problem with the structuring of the birth and abortion groups that the authors openly acknowledge: out of the total sample of 8,131 women, 952 (nearly 12%) were in both groups! In order to conduct clean comparisons, these women should absolutely have been removed prior to conducting the analyses.

3) The authors only analyzed a very small fraction of all women with histories of mental illness, the most extreme forms requiring in-patient hospitalization. For every woman hospitalized for a mental illness after abortion, there are potentially 1000s of women suffering from disorders who received out-patient services, were never treated, of self-medicated with substances. The sample is very narrowly constructed.

4) The only control variables employed are age, calendar period, time since previous admission, reproductive history, and parental history of mental disorders. There were no controls for variables demonstrated in previous studies to be associated with the choice to abort and with post-abortion mental illness including marital status, education level, religion, income, relationship history variables including abuse, planning of the pregnancy, reasons women chose to undergo abortion, and pressure to abort, among other variables.

5) The authors conducted correlational analyses and inappropriately made inferences of causality, For example, in the first sentence in the conclusion section of the article they state: “In the present study, we found that first-time first-trimester induced abortion does not influence the risk of readmission to psychiatric facilities.” Such a statement is not permitted with the use of variables that cannot be controlled (like abortion status), particularly when so few control variables are incorporated.

6) Follow-up was limited to 12 months after the pregnancies were resolved. Prospective studies have shown that many women experience mental health problems associated with an abortion years after the procedure. By only measuring readmission for one year, women who have delayed responses, sometimes triggered by a later pregnancy, are not included in the analyses. The data are available in the Danish registries and there is no valid reason for cutting off the follow-up period so early.

== Related Studies Where Munk-Olsen Continues to Reject Requests for Relevant Analyses ==

Munk-Olsen has published a substantial number of subsequent studies related to pregnancy and mental health but has neglected to report on effects associated with abortion . . . when it suits her. When requests have been made for her to report on the effects of abortion or to undertake any additional analyses which might shed further light on the issue, she has refused . . . a position which seems to lend credibility to the concern that she is seeking to conceal results which might reveal shortcomings in her published analyses and conclusions.

==== Perinatal psychiatric episodes: a population-based study on treatment incidence and prevalence. ====
[https://www.ncbi.nlm.nih.gov/pubmed/27754485 Perinatal psychiatric episodes: a population-based study on treatment incidence and prevalence. Munk-Olsen T, Maegbaek ML, Johannsen BM, et al. Transl Psychiatry. 2016;6(10):e919. doi:10.1038/tp.2016.190.]

This is another study in which Munk-Olsen attempts to blame live birth as the primary cause of emotional problems after delivery but chooses to ignore prior pregnancy losses as a significant risk factor. Again, she has refused requests for reanalysis, including the following [https://www.ncbi.nlm.nih.gov/myncbi/david.reardon.1/comments/ submitted to her via PubMed]:

:This analysis of perinatal psychiatric episodes by Munk-Olsen T, 2016(1) is flawed by the decision to ignore the effects of prior pregnancy losses on mental health during and after subsequent pregnancies. This omission reflects a pattern of selective reporting by the lead author and should be corrected by publication of new analyzes.

:Giannandrea SA, 2013 and Gong X, 2013, and others have shown that prior fetal loss increases the risk psychiatric disorders.(2,3) There is even a dose effect. Multiple losses, either from miscarriage or induced abortion, predict elevated rates of postpartum anxiety.(2) History of abortion is associated with higher rates of mental illness(4,5) and a two to tenfold increased risk of alcohol or illegal drug use during subsequent term deliveries.6 Notably, the heightened risk of mental illness following fetal death is confirmed by one of Munk-Olsen’s own studies.(7)

:In light of the literature, Munk-Olsen T, 2016's conclusion that it is not possible to “predict which women will become ill postpartum” is false.(1) Prior fetal loss is risk factor. The data should have been analyzed with attention to this known risk factor. Confirming this effect could motivate improved screening to identify women who may benefit from additional care.

:Sadly, the failure to address fetal loss history does not appear to be an oversight. Rather, in light of Munk-Olsen’s refusal to provide details regarding the impact of abortion history on outcomes reported in several of her studies,(8–10) there appears to be a pattern of obfuscating the effects of pregnancy loss on mental health while overstating the effects of childbirth.

:For example, in her own fetal death study, Munk-Olsen T, 2014 she ignored the precedent of other researchers to report on the effects of both miscarriage and induced abortion.2 Instead, her results show only the effects of miscarriage. Even more oddly, she actually did use induced abortion as a control variable, thereby admitting its relevance,(7) but withheld all statistics showing how abortion effected the results--clearly to deny critics of her previous studies findings that confirm their criticisms.(8,9)

:This pattern of obfuscating methodological choices was also evident in Munk-Olsen's only two abortion studies.(4,5) In those studies, there is no separate analyses given for women without a prior history of mental disorders, exactly the opposite of what she does elsewhere(7,11) in order to eliminate the confounding effects of prior mental illness. The resulting blend of healthy and ill women was further muddied by mixing women who had one or more abortions prior to their first deliveries into the “control group” of women giving birth.(4,5) This cross-adulteration prevented a true comparison of the mental health of women who abort their first pregnancies and those who deliver their first pregnancies–a clean and straight forward comparison such as wad done in Reardon DC, 2003.(12) Moreover, when a colleague requested a simple count of the number of women in the sample who had both abortions and deliveries and the percentage of these who had psychiatric contact, Munk-Olsen emailed the dismissive response: “answering your questions would require substantial work from several people here at our center, and for this reason I cannot provide them to you.”(13)

:Munk-Olsen’s methodology across studies is also inconsistent. In some studies she has shown treatment rates for psychological conditions prior to pregnancy outcome for one(7) or even two years.(11) But in her abortion studies, she used only a nine-month period, covering the entire time women delivering were pregnant while providing a muddy mix of pre-conception time and pregnant time for those who had abortions. In response to criticism on this point, Munk-Olsen admitted this "may not be directly compatible."(5) But isn't the whole point to find methodological choices that make groups "directly comparable"? The precedent of using a period of time prior to conception for the mental health baseline is clearly preferable.(12)

:Despite my concerns regarding selective reporting, it remains my hope that Munk-Olsen will respond to this letter with results, not just excuses, showing the equivalent of Figures 1-31 revised to show treatment rates segregated for (a) women with no history of pregnancy loss, (b) women with history of one miscarriage, (c) women with a history of one abortion, and (d) women with a history of multiple fetal losses.

:Based on previous research, we expect that such an analysis will support the recommendation that women with a history of fetal loss may benefit from additional counseling services during and after subsequent pregnancies. It is inexplicable why Munk-Olsen would refuse to comply with this request.
:
:References
:(1) Munk-Olsen T, Maegbaek ML, Johannsen BM, Liu X, Howard LM, di Florio A, et al. Perinatal psychiatric episodes: a population-based study on treatment incidence and prevalence. Transl Psychiatry [Internet]. Nature Publishing Group; 2016 Oct 18 [cited 2016 Nov 5];6(10):e919. Available from: http://www.nature.com/doifinder/10.1038/tp.2016.190 PMID: 27754485
:(2) Giannandrea SAM, Cerulli C, Anson E, Chaudron LH. Increased risk for postpartum psychiatric disorders among women with past pregnancy loss. J Womens Health (Larchmt) [Internet]. 2013;22(9):760–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24007380 PMID: 24007380
:(3) Gong X, Hao J, Tao F, Zhang J, Wang H, Xu R, et al. Pregnancy loss and anxiety and depression during subsequent pregnancies: data from the C-ABC study. Eur J Obstet Gynecol Reprod Biol [Internet]. Elsevier; 2013 Jan [cited 2016 Nov 8];166(1):30–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23146315 PMID: 23146315
:(4) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard Ø, Mortensen PB. Induced first-trimester abortion and risk of mental disorder. N Engl J Med. 2011;364(4):332–9. PMID: 22310504
:(5) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard O, Mortensen PB. First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital in women with a history of treated mental disorder. Arch Gen Psychiatry [Internet]. 2012 Feb [cited 2015 Jul 16];69(2):159–65. PMID: 22310504
:(6) Coleman PK, Reardon DC, Rue VM, Cougle J. A history of induced abortion in relation to substance use during subsequent pregnancies carried to term. Am J Obstet Gynecol. 2002;187(6):1673–8. Coleman PK, 2002
:(7) Munk-Olsen T, Bech BH, Vestergaard M, Li J, Olsen J, Laursen TM. Psychiatric disorders following fetal death: a population-based cohort study. BMJ Open. 2014;1–6. < PMID: 24907247>
:(8) Reardon DC. Lack of pregnancy loss history mars depression study. Acta Psychiatr Scand. 2012;126(2):155. PMID: 22616564
:(9) Reardon DC. Postpartum mental health study flawed by fetal loss omission. Scand J Prim Health Care [Internet]. 2015 Oct 2 [cited 2016 Nov 9];33(4):318–9. PMID: 26683289 Available from: http://www.tandfonline.com/doi/full/10.3109/02813432.2015.1111710
:(10) Munk-Olsen T, Laursen TM, Meltzer-Brody S, Mortensen PB, Jones IR. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. 2011;1–7. Available from: http://dx.doi.org/10.1001/archgenpsychiatry.2011.157
:(11) Munk-Olsen T, Pedersen HS, Laursen TM, Fenger-Grøn M, Vedsted P, Vestergaard M. Use of primary health care prior to a postpartum psychiatric episode. Scand J Prim Health Care [Internet]. Informa Healthcare Stockholm; 2015 Jun 24 [cited 2015 Aug 1];33(2):127–33. PMID: 22147807 Available from: http://informahealthcare.com/doi/abs/10.3109/02813432.2015.1041832
:(12) 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(10):1253–6. PMID: 12743066
:(13) Email: Subject:"Question: NEJM Abortion and Risk of Mental Disorder" Dated 7/8/2015

====Bipolar Affective Disorders====

''''[http://archpsyc.jamanetwork.com/article.aspx?articleid=1151054 Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders.] Munk-Olsen T, Laursen TM, Meltzer-Brody S, Mortensen PB, Jones I. Arch Gen Psychiatry. 2012 Apr;69(4):428-34. doi: 10.1001/archgenpsychiatry.2011.157. Epub 2011 Dec 5.''''

:CONTEXT: Childbirth has an important influence on the onset and course of bipolar affective disorder, and it is well established that there may be a delay of many years before receiving a diagnosis of bipolar disorder following an initial episode of psychiatric illness.

:OBJECTIVE: To study to what extent psychiatric disorders with postpartum onset are early manifestations of an underlying bipolar affective disorder.

:DESIGN: Survival analyses were performed in a register-based cohort study linking information from the Danish Civil Registration System and the Danish Psychiatric Central Register.

:PARTICIPANTS: A total of 120,378 women with a first-time psychiatric inpatient or outpatient contact with any type of mental disorder excluding bipolar affective disorder.

:MAIN OUTCOME MEASURES: Each woman was followed up individually from the day of discharge, with the outcome of interest being an inpatient or outpatient contact during the follow-up period with a first-time diagnosis of bipolar affective disorder.

:RESULTS: A total of 3062 women were readmitted or had an outpatient contact with bipolar affective disorder diagnoses. A postpartum onset of symptoms within 0 to 14 days after delivery predicted subsequent conversion to bipolar disorder (relative risk = 4.26; 95% CI =3.11-5.85). Approximately 14% of women with first-time psychiatric contacts during the first postpartum month converted to a bipolar diagnosis within the 15-year follow-up period compared with 4% of women with a first psychiatric contact not related to childbirth. Postpartum inpatient admissions were also associated with higher conversion rates to bipolar disorder than outpatient contacts (relative risk = 2.16; 95% CI = 1.27-3.66).

:CONCLUSIONS: A psychiatric episode in the immediate postpartum period significantly predicted conversion to bipolar affective disorder during the follow-up period. Results indicate that the presentation of mental illness in the early postpartum period is a marker of possible underlying bipolarity.

====='''Request for Additional Analysis (Refused)'''=====

BiPolar Disorder Study Neglects Prior Research and Adequate Controls. Reardon DC.

Dear Editor,

The Munk-Olsen team’s study of elevated risk of bipolar affective disorder following psychiatric illness in the first month after a delivery is potentially important.(1) Unfortunately, the study neglected to control for the effects of prior pregnancy outcomes on bipolarity.

This omission is striking given the fact that Munk-Olsen has used the same data to publish two studies on abortion and subsequent psychiatric treatment.(2)(3). She is also familiar with the three similar record linkage studies we have published in regard to a population of 56,751 low income women in California.(4)(5)(6)

One of these latter studies revealed that women with a history of abortion were three times more likely (OR 3.0, 95% CI 1.5-6.0) to be hospitalized for bipolar disorder than women who carried to term during the four years following pregnancy outcome.(4) Our study also found that women who had abortions were 2.6 times more likely to be hospitalized for psychiatric treatment than were women delivered.(4) Similarly, Munk-Olsen has also found higher rates of psychiatric contact for each of the first 12 months following an abortion compared to delivery.(2) All of these facts have a direct bearing on the present study(1) and should have been addressed in the study design.

It is therefore tremendously baffling . . . if not suspicious . . . that the present study(1) did not include additional analyses relative to other pregnancy outcomes: abortion, miscarriage, and other pregnancy losses. Clearly, a history of pregnancy loss may impact the rates of postpartum depression following a live birth.(7)(8)(9) The failure to consider and control for pregnancy loss history is a major methodological weakness in this new study.

Both the American Psychological Task Force on Abortion and Mental Health and the Royal College of Psychiatry have called for more research regarding abortion and mental health. Yet studies such as this one continue to be published without information about the effects of pregnancy loss on the outcome, even when the researchers have access to complete reproductive histories. Whether investigation of these effects is being neglected due to lack of insight, or whether results are being redacted for ideological reasons, is unclear.

Journal editors and peer reviewers should heed the call for more research on associations between abortion and mental health by requesting that every study regarding reproductive outcomes and mental health should include segregated results allowing for comparisons relative to pregnancy outcome: live birth, miscarriage, abortion, and other losses.

It is my hope that Munk-Olsen will correct this oversight in the near future. Reanalysis should include segregated results allowing comparisons between delivering women with no history of pregnancy loss, women with a history of one abortion, women with a history of two or more abortions, and women with a history of one or more miscarriages.

It is my fear, however, that the politicization of abortion has long caused and continues to perpetuate a trend toward distortions in study design which are intended to either conceal or to obfuscate the associations between abortion and negative mental health outcomes.

'''References'''

(1) Munk-Olsen T, Laursen TM, Meltzer-Brody S, Mortensen PB, Jones I. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. Arch Gen Psychiatry. 2011 Dec 5. [Epub ahead of print]

(2) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard O, Mortensen PB. First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital in women with a history of treated mental disorder. Arch Gen Psychiatry. 2012 Feb;69(2):159-65.

(3) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard Ø, Mortensen PB. Induced first-trimester abortion and risk of mental disorder. N Engl J Med. 2011 Jan 27;364(4):332-9.

(4) Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low income women following abortion and childbirth. Can Med Assoc J. 2003; 168(10):1253-7.

(5) Coleman PK, Reardon DC, Rue VM, Cougle JR.State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years. American Journal of Orthopsychiatry, 2002; 72(1):141–52.

(6) Reardon DC, Coleman PK. Relative treatment rates for sleep disorders and sleep disturbances following abortion and childbirth: a prospective record-based study. Sleep. 2006 Jan;29(1):105-6.

(7) Burke T, Reardon DC. Forbidden Grief. The Unspoken Pain of Abortion. Springfield, IL: Acorn Books; 2002.

(8) Stotland NL. Abortion: social context, psychodynamic implications. Am J Psychiatry. 1998 Jul;155(7):964-7.

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

====='''Oversight of Bipolar Disorder Link to Abortion Demonstrated by Subsequent 2015 Study'''=====

Munk-Olsen's failure to account for prior abortion history in this study is underscored by a new study in the J''ournal of Affective Disorders'', in which researchers found that 42.4 percent of the women with bipolar disorders had a history of abortion compared to only 13.5 percent of the control group, with a relative risk of 1.9778 (95% CI, 1.2660-3.0900). (Marengo E, Martino DJ, Igoa A, Scápola M, Fassi G, Baamonde MU, Strejilevich SA. [http://www.ncbi.nlm.nih.gov/pubmed/25827504 Unplanned pregnancies and reproductive health among women with bipolar disorder.] J Affect Disord. 2015 Jun 1;178:201-5.)

----

====Bipolar Affective Disorders 2====

'''[http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2015.15010124?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis.] Wesseloo R, Kamperman AM, Munk-Olsen T, Pop VJ, Kushner SA, Bergink V. Am J Psychiatry. 2015 Oct 30:appiajp201515010124.'''

:OBJECTIVE: Women with a history of bipolar disorder, postpartum psychosis, or both are at high risk for postpartum relapse. The aim of this meta-analysis was to estimate the risk of postpartum relapse in these three patient groups.

:METHOD: A systematic literature search was conducted in all public medical electronic databases, adhering to the PRISMA guidelines. Studies were included if they reported postpartum relapse in patients diagnosed with bipolar disorder and/or a history of postpartum psychosis or mania according to DSM or ICD criteria or the Research Diagnostic Criteria.

:RESULTS: Thirty-seven articles describing 5,700 deliveries in 4,023 patients were included in the quantitative analyses. The overall postpartum relapse risk was 35% (95% CI=29, 41). Patients with bipolar disorder were significantly less likely to experience severe episodes postpartum (17%, 95% CI=13, 21) than patients with a history of postpartum psychosis (29%, 95% CI=20, 41). Insufficient information was available to determine relapse rates for patients with bipolar disorder and a history of postpartum episodes. In women with bipolar disorder, postpartum relapse rates were significantly higher among those who were medication free during pregnancy (66%, 95% CI=57, 75) than those who used prophylactic medication (23%, 95% CI=14, 37).

:CONCLUSIONS: One-third of women at high risk experience a postpartum relapse. In women with bipolar disorder, continuation of prophylactic medication during pregnancy appears highly protective for maintaining mood stability postpartum. In women with a history of isolated postpartum psychosis, initiation of prophylaxis immediately after delivery offers the opportunity to minimize the risk of relapse while avoiding in utero medication exposure.

----

====Anti-Depressants Study====

'''[http://www.ncbi.nlm.nih.gov/pubmed/22118213 Prevalence of antidepressant use and contacts with psychiatrists and psychologists in pregnant and postpartum women.] Acta Psychiatr Scand. 2012 Apr;125(4):318-24. doi: 10.1111/j.1600-0447.2011.01784.x. Epub 2011 Nov 25. Munk-Olsen T, Gasse C, Laursen TM.'''

:Abstract
:OBJECTIVE: We aimed to study prevalence of antidepressant drug use from 12 months prior childbirth to 12 months postpartum and to compare the prevalences with those in a group of women of similar age who did not give birth. We additionally studied prevalences of contacts with private practicing psychiatrists and psychologists during a similar time period.

:METHOD: Our study population comprised of pregnant women, and their controls were drawn from a 25% sample of the entire Danish population. Information on redeemed prescriptions for antidepressants and referrals to psychiatrists and psychologists was extracted. The outcome measure was period prevalence calculated in 3-month intervals from 12 months before childbirth to 12 months postpartum.

:RESULTS: In the 2-year observation period around childbirth, 2733 (3.17%) women had one or more prescriptions for an antidepressant and 935 (1.18%) and 1399 (1.76%) were referred to consultations with a psychiatrist or psychologist, respectively. Women giving birth had a markedly lower use of antidepressants compared to controls, with the largest observed difference during third trimester of pregnancy (0.6% vs. 2.20%).

:CONCLUSION: We found that the prevalence of redeemed prescriptions for antidepressants decreased during pregnancy and increased postpartum. Similar patterns were observed for contacts with private practicing psychiatrists and psychologists.

:Remarks: This study is deeply flawed by the following major factors: (1) It excludes women under 18; (2) It ignores the effects of multiple abortions; (3) It looks only at first time prescription of antidepressants, thereby failing to investigate the frequency, dosage level, and duration of depressive symptoms, much less how women with a prior history of depression may be made better or worse by exposure to abortion. All it really tells us is that the "type" of woman most likely to have a pregnancy for which she may seek an abortion is more likely than women who do not have abortions to be prone to depression. It does not tell us if abortion worsens or improves her condition. It is only argued (irrationally) that since women who have abortions are more likely to be prone to depression we can ignore the effects of abortion, or more precisely, that abortion therefore CANNOT be a contributing factor to abortion. See additional [[http://abortionrisks.org/index.php?title=Munk-Olsen_et_al#Criticisms detailed listing of problems here.]]

'''Request for Additional Analysis (Refused)'''
[http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.2012.01880.x/abstract;jsessionid=08606AE0A36FC3A0728DF6D0A375F4A5.d01t02 Lack of pregnancy loss history mars depression study.] Reardon DC. Acta Psychiatr Scand. 2012 Aug;126(2):155; author reply 155-6. doi: 10.1111/j.1600-0447.2012.01880.x. Epub 2012 May 23.

:Dear Editor,

:The Munk-Olsen team’s study of antidepressant use and psychological treatments before, during, and after childbirth(1) unfortunately omits any control for the effects of prior pregnancies and any comparison to other pregnancy outcomes.

:A history of pregnancy loss (including induced abortion or miscarriage) can be a stressor that may arouse unresolved feelings during and following subsequent pregnancies.(2)(3)(4) This is also evidenced by findings that women with a history of abortion are significantly more likely to self-medicate with drugs or alcohol during a subsequent pregnancy than women without a history of this pregnancy loss.(5)

:The Munk-Olsen study would have been much more informative if it had included (a) controls for prior pregnancy outcomes, and (b) parallel analyses showing the treatment rates a year before and after other pregnancy outcomes, including abortion, miscarriage, and other natural losses.

:The failure to provide this additional analysis is most striking given the fact that Munk-Olsen has used the same data to publish a much more nuanced comparison of psychiatric treatment rates among women who have abortions and women who carry to terms.

:Both the American Psychological Task Force on Abortion and Mental Health and the Royal College of Psychiatry have called for more research regarding abortion and mental health.

:In a broad sense, efforts to study the interactions between reproductive health and mental health will never be reliable as long as researchers ignore or suppress analyses which fail to encompass the full reproductive history of women, including both voluntary and involuntary pregnancy losses.

:Journal editors and peer reviewers should be alert to this problem and should heed the call for better research by demanding that every study regarding reproductive outcomes and mental health should include segregated results allowing for direct comparison of outcome variables relative to the entire range of pregnancy outcomes: live birth, abortion, miscarriage, and other natural losses. By pressing researchers to address and report on these related pregnancy issues, reviewers and editors will helping to advance more rigorous investigation of all of these issues. Without such requests for more detailed analyses, study designs can easily be fashioned to avoid or minimize the investigation of controversial issues.

:It is my hope that Munk-Olsen will address the research imperatives raised herein by expanding the study design presented in the present paper.(1) Reanalysis should include segregated results allowing comparisons between: (a) delivering women with no history of pregnancy loss, (b) delivering women with a history of one abortion, (c) delivering women with a history of two or more abortions, (d) delivering women with a history of one miscarriages, (e) delivering women with a history of two or more miscarriages, and treatment rates for (f) women with no prior pregnancy whose first pregnancy is aborted, and (g) women with no prior live birth who have two or more abortions or other losses.

:David C. Reardon, Ph.D.
:Elliot Institute

:References

:(1) Munk-Olsen T, Gasse C, Laursen TM. Prevalence of antidepressant use and contacts with psychiatrists and psychologists in pregnant and postpartum women. Acta Psychiatr Scand. 2011 Nov 25. doi: 10.1111/j.1600-0447.2011.01784.x. [Epub ahead of print]
:(2) Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low income women following abortion and childbirth. Can Med Assoc J. 2003; 168(10):1253-7.
:(3) Burke T, Reardon DC. Forbidden Grief. The Unspoken Pain of Abortion. Springfield, IL: Acorn Books; 2002.
:(4) Stotland NL. Abortion: social context, psychodynamic implications. Am J Psychiatry. 1998 Jul;155(7):964-7.
:(5) Coleman PK, Reardon DC, Cougle JR. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. Br J Health Psychol. 2005 May;10(Pt 2):255-68.

----

===Psychiatric disorders following fetal death: a population-based cohort study.===

''[http://www.ncbi.nlm.nih.gov/pubmed/24907247 Psychiatric disorders following fetal death: a population-based cohort study.] Munk-Olsen T, Bech BH, Vestergaard M, Li J, Olsen J, Laursen TM. BMJ Open. 2014 Jun 6;4(6):e005187. doi: 10.1136/bmjopen-2014-005187.''

:OBJECTIVES:Women have increased risks of severe mental disorders after childbirth and death of a child, but it remains unclear whether this association also applies to fetal loss and, if so, to which extent. We studied the risk of any inpatient or outpatient psychiatric treatment during the time period from 12 months before to 12 months after fetal death.

:PARTICIPANTS: A total of 1,112,831 women born in Denmark from 1960 to 1995 were included. In total, 87,687 cases of fetal death (International Classification of Disease-10 codes for spontaneous abortion or stillbirth) were recorded between 1996 and 2010.

:PRIMARY AND SECONDARY OUTCOME MEASURES: The main outcome measures were incidence rate ratios (risk of first psychiatric inpatient or outpatient treatment).

:RESULTS: A total of 1379 women had at least one psychiatric episode during follow-up from the year before fetal death to the year after. Within the first few months after the loss, women had an increased risk of psychiatric contact, IRR: 1.51 (95% CI 1.15 to 1.99). In comparison, no increased risk of psychiatric contact was found for the period before fetal death. The risk of experiencing a psychiatric episode was highest for women with a loss occurring after 20 weeks of gestation (12 month probability: 1.95%, 95% CI 1.50 to 2.39).

:CONCLUSIONS: Fetal death was associated with a transient increased risk of experiencing a first-time episode of a psychiatric disorder, primarily adjustment disorders. The risk of psychiatric episodes tended to increase with increasing gestational age at the time of the loss.

:'''EDITOR'S NOTES:'''
#Once again, even though other researchers have shown that ''abortion and miscarriage are both associated with higher rates'' of subsequent psychiatric disorders. See for example: [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.] Munk-Olsen's team chose to use a different definition of pregnancy loss so as to exclude reporting on the effects associated with induced abortion.
#This analysis actually does indicate that the results were modified by "controlling for induced abortions" but meticulously avoids showing readers how induced abortions impacted the results. This actually involves an amazing dance to avoid disclosure of her findings. Munk-Olsen sees that induced abortion history is a significant factor and needs to be used as an adjustment of the results but she does not want anyone else to see how abortion history is affecting the results. So, not only does she not give results associated with abortion, she simply adds a note at the bottom of the tables indicating that the results were adjusted for numerous factors, including abortion history.
#This study used a 12 month period before the date of fetal death (not 9 months) and also excluded women with psychiatric contact before the pregnancy outcome "as well as women with records of spontaneous abortions and stillbirths prior to the start of the followup period." In other words, unlike her abortion studies, in this study she limited the study to the healthiest set of women to reduce the number of confounding factors. by contrast, in her abortion study, she introduces as many confounding factors as possible.

'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250401/ Does childbirth cause psychiatric disorders? A population-based study paralleling a natural experiment.] Munk-Olsen T, Agerbo E. Epidemiology. 2015;26(1):79-84.
'''
Background: Childbirth is associated with increased risk of first-time psychiatric episodes, and an unwanted pregnancy has been suggested as a possible etiologic contributor. To what extent childbirth causes psychiatric episodes and whether a planned pregnancy reduces the risk of postpartum psychiatric episodes has not been established.

Methods: We conducted a cohort study using data derived from Danish population registers, including all women having in vitro fertilization (IVF) treatment and their partners with recorded information in the IVF register covering fertility treatments in Denmark at all public and private treatment sites from January 1994 to December 2005. We compared parents and childless persons to examine whether childbirth is directly associated with onset of first-time psychiatric episodes, with incidence rate ratios (risk of first psychiatric inpatient or outpatient treatment) as the main outcome measures.

Results: The incidence rate for any type of psychiatric disorder 0-90 days postpartum was 11.3 per 1000 person-years (95% confidence interval = 8.2-15.0), and 3.8 (3.4-4.3) among women not giving birth. IVF-treated mothers had an increased risk of a psychiatric episode postpartum, incidence rate ratio = 2.9 (2.0-4.2) compared with the risk of psychiatric episodes in childless women. Risk of psychiatric episodes from 90 days postpartum and onwards was decreased (incidence rate ratio = 0.9 [0.7-1.0]).

Conclusions: Using a study design paralleling a natural experiment, our results showed that childbirth is associated with first-time psychiatric disorders in new mothers, indicating that a planned pregnancy does not reduce risks of or prevent postpartum psychiatric episodes.

'''NOTES:''' This was a weak study in many respects since IVF mothers may dissimilar to other delivering women in many ways. They may, for example, have a higher rate of prior abortions or miscarriages which are associated with elevated rates of post-partum depression in subsequent pregnancies. Notably, the authors report that they did control for prior history of abortion but they failed to report the rates of abortion or anything about how abortion affected the results . . . thereby concealing the effects of abortion even though the fact that they controlled for abortion signals that it had a significant effect on post-partum treatment rates.

More precisely, while the study found that treatment rates for depression were higher in the first 90 days following IVF deliveries, compared to the rates for not pregnant women, there was no difference beyond the first 90 days.

In the discussion, the authors conclude that since women seeking IVF treatment want their babies, "our results indicate that pregnancy intention does not reduce the risks of having a severe psychiatric episode requiring treatment at a psychiatric facility after a delivery." But if this is true, delivering an intended pregnancy does not reduce the risk of postpartum depression, then this is evidence that delivering an unintended pregnancy does not increase postpartum depression either since intention is not a predictor of postpartum depression.

----

== First Time Psychiatric Hospitalization -- Changing the Yard Stick ==

It's notable that a [http://jama.jamanetwork.com/article.aspx?articleid=204395 2006 study of postpartum psychological illness] done by Munk-Olsen does not match up with the results she reported for women giving birth in her [http://www.nejm.org/doi/full/10.1056/NEJMoa0905882 2011 study published in the New England Journal of Medicine] (NEJM).

In the 2006 study she reports first time psychiatric hospitalization rates for women following a first live birth (table 1) that are much, much lower than what she reported in her 2011 abortion/childbirth study (figure 1).

For example, in the second month after delivery, she reports an admissions rate of 2.87 per 1000 person years in the 2006 study, but a just under 12 per 1000 person years in her 2011 NEJM study (compared to about 18 per 1000 person years for women who had abortions).

What can explain this huge difference when she is supposedly reporting the same statistic for the same group of women in two different studies?

Well, in the 2006 study she excludes all women with a history of inpatient psychiatric care prior to their first delivery. That's a very reasonable approach if you want to measure how childbirth may impact emotionally healthy women. It is the same approach that could have and should have been used in the 2011 study.

But no, in the 2011 study she changes her protocol for unexplained reasons. In the 2011 study she suddenly decides to exclude only those women who had inpatient psychiatric care in the nine months prior to the abortion abortion or delivery which she is charting. She didn't choose one year, but nine months. Moreover, she didn't choose nine months or one year prior to the estimated conception date, but instead, prior to the outcome date...that means delivering women were pregnant almost the entire time and aborting women were pregnant for two to three months of that 9-month period which is pivotal for her comparisons.

Clearly, the exact same protocol use in the 2006 study could have been done. But no, in the 2006 study, she simply decides "pregnancies ending in abortion (both elective abortions and miscarriages) were not included in the study." This itself is very odd, since a well known [http://www.cmaj.ca/content/168/10/1253.long 2003 study by Reardon] looked at psychiatric admissions after not only childbirth, abortion, and miscarriage, but also at combinations of these, for women who experienced both live births and voluntary and involuntary pregnancy losses. Normally, researchers try to build on prior research and improve the methodology employed, not water it down to show fewer results.

In any case, Munk-Olsen not only failed to replicate Reardon's protocol which gives a breakdown by exposure to all the various pregnancy outcomes, but she actually chose to water down her own established protocol to avoid reporting on the healthiest women (those without inpatient psychiatric care prior to their first delivery).

There's only one explanation for this. She needed to shift her approach in order to produce results that were more easily interpreted to advance her preconceived goal of blaming the higher rates of mental health problems following abortion on pre-existing mental health problems. Toward this end, she abandoned her 2006 methodology which employed women with the least compromised prior mental health (no prior inpatient psychiatric history) and instead chose to include women with prior psychiatric inpatient care.

By including women with more prior history of severe mental illness, she could blame the differences observed in the 2011 study on prior mental health problems. At the same time, she could avoid reporting on the psychological effects associated with abortion among women with no known history of prior psychiatric inpatient care (the same control group used in Reardon's 2003 study). Her desire to hide the impact of abortion on women with the least history of severe mental illness is underscored by her second 2011 study, published in [http://abortionrisks.org/index.php?title=Munk-Olsen_et_al#First-time_first-trimester_induced_abortion_and_risk_of_readmission_to_a_psychiatric_hospital Archives of General Psychiatry] in which she specifically focuses on the women with prior history of mental health problems but fails to show how the same analysis applies to women without a prior history of mental health problems.

Notably, in both of her abortion studies, she also ignored all requests to examine whether or not the women with prior mental health problems had '''more frequent''' need for mental health care after their abortions. In other words, she claims that the higher rate of mental health problems following abortion may be entirely explained by higher rates of prior mental health problems among women who abort, but she also refuses to examine if these same women have more frequent or more severe (or less frequent or less severe) mental health issues after their abortions. She simply asserts that abortion has no impact on mental health without measuring the frequency or severity of mental health crises before and after abortions.

===Other Munk-Olsen Studies with Better Methodology===

'''[http://informahealthcare.com/doi/abs/10.3109/02813432.2015.1041832 Use of primary health care prior to a postpartum psychiatric episode.] Munk-Olsen T, Pedersen HS, Laursen TM, Fenger-Grøn M, Vedsted P, Vestergaard M. Scand J Prim Health Care. 2015 Jun;33(2):127-33. doi: 10.3109/02813432.2015.1041832. Epub 2015 Jul 15.A'''

:OBJECTIVE: Childbirth is a strong trigger of psychiatric episodes. Nevertheless, use of primary care before these episodes is not quantified. The aim was to study the use of general practice in Denmark from two years before to one year after childbirth in women who developed postpartum psychiatric disorders.

:DESIGN: A matched cohort study was conducted including women who gave birth in the period 1996-2010. Women were divided into four groups: (i) all mothers with postpartum psychiatric episodes 0-3 months after birth, n = 939; 2: All mothers with a postpartum psychiatric episode 3-12 months after birth, n = 1 436; and (iii) two comparison groups of mothers, total n = 6 630 among 320 620 eligible women.

:SUBJECTS: Women born in Denmark after 1 January 1960, restricting the cohort to women who gave birth to their first singleton child between 1 January 1996 and 20 October 2010.

:MAIN OUTCOME MEASURES: The main outcome measures were consultation rates, consultation rate ratios, and rate differences.

:RESULTS: Women who developed a psychiatric episode after childbirth had higher GP consultation rates before, during, and after the pregnancy. Women with a psychiatric episode 0-3 months postpartum had 6.89 (95% CI 6.60; 7.18) mean number of consultations during pregnancy, corresponding to 1.52 (95% CI 1.22; 1.82) more visits than the comparison group.

:CONCLUSION: Women with a postpartum psychiatric episode had higher use of GP-based primary health care services years before the childbirth, and in this specific group of patients childbirth itself triggered a marked increase in the number of GP contacts postpartum.

''':NOTES:'''
*In this study Munk-Olsen excluded women with any history of prior outpatient or inpatient psychiatric treatment prior to childbirth. This should also have been done in her abortion studies.
*Her analysis did not examine the effects of prior pregnancy loss on post-partum depression, even though research by [http://www.ncbi.nlm.nih.gov/pubmed/24007380 Giannandrea (2013)] has shown that women with a history of miscarriage and/or induced abortion are at higher risk of postpartum psychiatric problems, including depression, anxiety, and PTSD.
*Her analysis included tabulations of the number of average number of consultations women had with their physicians displayed over a monthly basis for over three years. In response to a query for this type of measurement of frequency of contact for psychiatric care after abortion, she had previously claimed it was too hard to do and might be misleading.
*These criticisms were raised in a [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4750743/ letter to the editor which was published]. Munk-Olsen declined the opportunity to respond.

=== Overview of Danish Researchers Avoiding Analyses that Would Shed Light on Abortion ===
A series of studies on post-partum mental health from Denmark have demonstrated diligent efforts to conceal the negative effects of abortion on women's mental health, according to an article published in the ''Scandinavian Journal of Primary Health Care''.

The research team, led by Trine Munk-Olsen, specializes in analyses of Denmark's national medical records, especially pertaining to mental health treatments associated with women's reproductive health. Notably, of over two dozen such studies, in only two does Munk-Olsen report on the mental health treatments associated with induced abortion.

Munk-Olsen's most recent study found that among women receiving psychiatric care after giving birth were more likely to have sought treatment from a primary care provider before, during and after pregnancy. Based on this finding, Munk-Olsen asserts that childbirth is a psychological stressor that can be "a strong trigger of psychiatric episodes."

Notably, this is a frequent assertion made in Munk-Olsen’s studies: childbirth triggers mental health problems. On the other hand, in the only two studies she has published reporting on mental health effects associated with abortion, she has argued that abortion has no impact on mental health.

In a criticism of Munk-Olsen’s latest study [https://www.tandfonline.com/doi/full/10.3109/02813432.2015.1111710 published in the ''Scandinavian Journal of Primary Health Care''], David Reardon, director of the Elliot Institute and one of the most published researchers on abortion and mental health issues, questions the validity of Munk-Olsen's finding. He is especially critical of the manner in which she modifies her research methods to produce results to avoid reporting on the negative effects of abortion.

Reardon points out, for example, that in Munk-Olsen’s most recent study examining medical records of women who had postpartum psychiatric treatments she chose to ignore the effects of prior pregnancy losses, abortions and miscarriages, on treatment rates. At the very least, this was a serious oversight since previous research has shown that women exposed to prior pregnancy losses are at higher risk of post-partum depression and other mental health issues. Reardon asserts that Munk-Olsen was clearly aware of this connection base on her own prior research, much less that of others in the field. By excluding this from her most recent study, Munk-Olsen appears builds a platform to argue that the differences in primary care treatments among women with mental health issues following delivery are due to childbirth alone when in fact a more detailed analysis, as demonstrated by other researchers, is likely to show that the heightened risks are more likely due to prior abortions and miscarriages.

Reardon’s letter goes on to assert that Munk-Olsen has repeatedly altered her research methodology precisely in ways designed to avoid showing the effects of abortion on mental health. For example:

# In a study of bipolar disorders following delivery, Munk-Olsen ignored prior research linking abortion to elevated rates of bipolar disorder, and once again chose to exclude any examination of women’s prior exposure to abortion and miscarriage. When this oversight was called to hear attention, she refused to run additional analyses . . . or at least to report on her results from such analyzes.
# In a study of the [[Munk-Olsen et al#Anti-Depressants Study|rates of anti-depressant use among pregnant and post-partum women]], Munk-Olsen yet again refused a request, published in the same journal, to provide a breakdown of anti-depressant use among the same women relative to their past exposure to abortions.
# In a study of [[Munk-Olsen et al#Psychiatric disorders following fetal death: a population-based cohort study.|psychiatric interventions following miscarriage]], Munk-Olsen revealed in a footnote that she actually did control for prior history of abortion, but once again refused requests to provide any information showing how abortion itself affected the rates of psychiatric treatment.

Munk-Olsen has only reported on mental health treatment rates following abortion in [[Munk-Olsen et al#Induced First-Trimester Abortion and Risk of Mental Disorder.|two studies]], both of which were used to boldly proclaim that abortion has no effect on mental health. But Reardon asserts that Munk-Olsen chose to deviate from her own prior methodology, and that of other researchers in the field, in order to massage her data in a way that would minimize and obscure the effects of abortion on mental health.

For example, in Munk-Olsen’s first abortion study, published in 2011, she compares inpatient and outpatient psychiatric treatments for nine months before the abortion or first childbirth took place and twelve months afterward. But the time frames and inclusion criteria used for this 2011 study were markedly changed from a similar study she had done in [[Munk-Olsen et al#First Time Psychiatric Hospitalization -- Changing the Yard Stick|2006 examining mental health treatment rates following childbirth]]. In the 2006 study she excluded all women with a history of inpatient psychiatric care prior to their first delivery in order to measure how childbirth might impact emotionally healthy women. But in the 2011 study, she excluded only women with a history of inpatient psychiatric care 9 months prior to their abortion or delivery. The only possible explanation for changing her methodology in this way was that it produced results she preferred to present––or concealed results she did not want to present.

An even more serious flaw in her 2011 study was that she included women who had abortions in both groups! Unlike previous researchers who compared women who aborted their first pregnancies to women who gave birth to their first pregnancies, Munk-Olsen included women with prior abortions who later gave birth into the childbirth group. Every researcher knows this mixing would tend dilute the differences between the two groups being compared. It is simply bad technique––but useful if your goal is to obfuscate rather than illuminate.

Despite these study design choices that were clearly meant to minimize findings regarding psychological effects of abortion, her study still showed that women who had abortions Women who have abortions had significantly higher rates of psychiatric treatment (15.2 per 1000 person years) compared to both delivering women (6.7 per 1000 person years) and women who have not been pregnant (8.2 per 1000 person years). It also found that relative risk for psychiatric visits involving neurotic, stress-related, or somatoform disorders was significantly higher for women post-abortion compared to pre-abortion at 2 and 3 months respectively and that treatment for personality or behavioral disorders was 56%, 45%, 31%, and 55% higher at 3, 4-6, 7-9, and 10-12 months respectively.

Indeed, when the data provided is [https://zenodo.org/records/10684720 reanalyzed over the cumulative rates] of first time psychiatric treatment over the full 12 months, the post-abortion treatment rates was significantly higher across all psychiatric diagnoses. The fact that first-time psychiatric contact increased from an odds ratio of 1.12 (95% CI: 1.02 to 1.22) to 1.49 (95% CI: 1.37 to 1.63) for the cumulative post-abortion periods of 9 months and 12 months demonstrates that the effects increase with time. This suggests that Munk-Olsen deliberately chose to analyses the results in one month and three month increments precisely to hide the effects that are evident over longer periods of time. Notably, at 12 months post-abortion, the rates of psychiatric diagnosis were significantly higher across all four diagnostic groupings and most strongly 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).

Despite these findings, Munk-Olsen argues that all of these results can be ignored because, in her view, women with a propensity to mental illness are simply more likely to have abortions, which may, in her view, be a good thing. But [[Munk-Olsen et al#Induced First-Trimester Abortion and Risk of Mental Disorder.|as criticisms of her study have elsewhere noted]], even her selectively reported data does not support this broad assertion.

Munk-Olsen second study of mental health effects associated with abortion was [[Munk-Olsen et al#First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital|even more severely flawed]]. But once again, [[Munk-Olsen et al#Munk Olsen.27s Response|Munk-Olsen refused]] to provide any additional data that would either confirm or refute her selectively reported results.

== References ==
{{reflist|refs=}}

Turn Away Study

2024-03-25T19:07:42Z

WikiSysop: /* Suicidal Thoughts */

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.

=====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.

===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 politicizied 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

2024-03-25T18:57:54Z

WikiSysop: /* 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.

=====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.

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.

===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 politicizied 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.

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://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.

==Sleep Disorders==

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

Munk-Olsen et al

2024-02-22T19:09:23Z

WikiSysop: /* References */

==Risk of First Time use of Anti-Depressants after First Abortion or Delivery (2018)==

'''''[https://www.ncbi.nlm.nih.gov/pubmed/?term=Examining+the+Association+of+Antidepressant+Prescriptions+With+First+Abortion+and+First+Childbirth Examining the Association of Antidepressant Prescriptions With First Abortion and First Childbirth.'''''] Steinberg JR, Laursen TM, Adler NE, Gasse C, Agerbo E, Munk-Olsen T. JAMA Psychiatry. 2018 May 30.

Abstract:
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 of women from Danish population registries who were born in Denmark between January 1, 1980, and December 30, 1994. Overall, 396 397 women were included in this study; of these women, 30 834 had a first-trimester first abortion and 85 592 had a first childbirth.

MAIN OUTCOMES AND MEASURE: First-time antidepressant prescription redemptions were 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 59 465 (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.

====Criticisms====
# The opening paragraph and last sentence of the abstract underscore that the goal of this study is is to influence abortion politics. This, itself, is a forewarning that the conclusions are overly broad and exceed what is actually reported in the analyses.
# The study is flawed by the lack of any analysis relative to exposure to miscarriage and other unintended pregnancy losses. Numerous other studies have shown that spontaneous abortion is important bench mark for comparison of outcomes relative to induced abortion.
# The study is fundamentally flawed by the lack of any analyses regarding the dose effects associated with exposure to multiple abortions . . . and even multiple natural pregnancy losses. Both repeat abortions and miscarriages are associated with higher incidence rates of adverse outcomes. This omission is especially important in regard to longer term analyses, which this study purports to offer by examining first time antidepressant use over five years after a first pregnancy outcome. For example, women who carried a first pregnancy to term, for example, but then had two or three pregnancy losses in the subsequent years, are presented and analyzed as if they had only one pregnancy outcome.
# Another fundamental flaw is that the study examines only first time antidepressant use. Clearly, an analysis of how long antidepressants were used, once they began to be used, would provide a better understanding of the duration of depressive symptoms before and after a pregnancy outcome. Such an analysis would be especially important to examine the effects of pregnancy (abortion or delivery) one women whose first use of antidepressants was prior to the abortion or delivery. One would hypothesize that if pregnancy outcome has an effect on mental health, than those who already have depression prior to a pregnancy outcome should be analyzed separately to investigate if their symptoms persist for a longer or shorter period, following the pregnancy outcome.
# The main finding of this paper is that among women without a history of using antidepressants, those who have abortions are over twice as likely to begin using antidepressants in the year following an abortion compared to both women who had no pregnancy and to women who carry a first pregnancy to term. This finding clearly ''confirms'' that abortion is a risk factor for higher rates of depression.
# The rest of the paper is nothing more than an effort to explain away this key finding. The discussion and conclusion of this paper are more focused on speculations to explain away the results than on the results themselves. This demonstrates the clear bias of the authors. Not only do they avoid doing the more in-depth analyses discussed above, but their main finding is essentially dismissed as misleading based on the authors' speculation that the true cause of higher depression rates following an abortion is pre-existing problems that are unrelated to the women's abortions.
# The authors frequently misstate facts in order to advance false conclusions. For example, they state that among women who have abortions "the increased risk of depression did not change from the year before to the year after an abortion." But their study did not measure depression. It did not measure depression scores among women at multiple times before and after their abortions. They measured only first-time use of an anti-depressant. They do not know if women who first used an anti-depressant prior to abortion got better or worse following their abortions. They do know that if they had done an analysis excluding women with a prior history of depression, those who had abortions were twice as likely to begin using anti-depressants than other women (both never pregnant and those who deliver), but that finding is essentially ignored in favor of the assumption that all women who have abortions are more mentally ill to begin with.
# The crux of the author's dismissal of their own findings is their argument that "it is possible that mental health problems may lead women to have unintended pregnancies and abortions." In other words, they are claiming that their study proves that women who have abortions are already mentally ill before they have their abortions, which then entirely explains the higher rates of mental illness after abortion. To support this argument, they point to a finding that among women who had abortions the first time use of anti-depressants in the year prior to their abortions was already higher than that for never pregnant women and women who gave birth. But this is a superficial analysis. It assumes that all women who have abortions fit into the same mental health profile. But clearly, first time use of anti-depressants is a very limited measure of mental health. It tells us nothing about the severity, duration, or recurrence of previous or subsequent mental health problems, even of depression. It is limited to "first time antidepressant use," a useful marker but clearly nothing more than a starting point...and the fact that they look no deeper than this starting point, and so quickly dismiss their own findings suggests that a deeper look would undermine their overly broad conclusions, not support them.
#The study design inappropriately collapses pre- and post- mental health events. The women who had first use of antidepressant prior to their abortion or childbirth should have been analyzed as a separate group to identify if they had an increase or decrease in how long they used antidepressants or had other treatments, such as counseling, in order to measure the relative severity, duration, and recurrence of problems between these two groups. Similarly, women who had a first time use of antidepressants following their first pregnancy outcome should also have been analyzed in a separate comparison to investigate the relative severity, duration, and recurrence of depression and other mental health symptoms.
# The decline in first-time use beyond several years may be explained by subsequent deliveries (which may heal some portion of the depressive effects) or by the increase in drug or alcohol use following abortion which is well documented. This underscores the weakness of looking at a single variable, such as first time use of antidepressants, in an effort to estimate the overall contribution of abortion to mental health issues.
# The longer term analysis (beyond one year) of first time antidepressant use, is deeply flawed by the failure to examine the effects of other pregnancy outcomes, subsequent births, abortions, and miscarriages. The whole premise is to investigate the effects of pregnancy outcomes, but women's experiences are not limited to a first pregnancy outcome. Surely, many women who aborted a first pregnancy may have subsequently carried to term, indeed many will have sought out a replacement pregnancy which may have reduced their risk of using antidepressants. Similarly, many women who gave birth may have experienced subsequent miscarriages or abortions, which may have increased their risk of using antidepressants. This demonstrates the superficial nature of these authors' investigation, which was clearly intended to be limited its scope to the point of demonstrating that among the entire population of women having abortions a disproportionate number have a prior history of using antidepressants. That's an interesting fact, but it simply does not prove that abortion doesn't contribute to depression, despite the authors' arguments to that effect.
# As with prior studies by Munk-Olsen, the author's use one year prior to the pregnancy outcome as a measure which include nine months of pregnancy for women who delivered and just one to three months for women who had abortions. In other record linkage studies, data on pre-pregnancy mental health was examined for one year prior to the estimated date of conception. That same standard should be applied to the analyses of this data set as it would be a better comparison of the women prior to conception.
# The study was limited to first trimester abortions. Approximately 10% of abortions occur after the first trimester, and it is important to investigate and report on the mental health of later term abortions. The most likely explanation for not including a subset in the analysis for later abortions is that the results for women who aborted were even more negative.
# There is no breakdown showing the relative risks relative to age groups. Even more notably, the authors excluded women (or at least women's pregnancies) that occurred prior to their 18th birthday. Since there is evidence that younger women have more negative emotional reactions to abortion, this may have been done in order to reduce the number of women in the entire sample who had first antidepressant use after an abortion.
# The study also excluded women who used antidepressants more than a year prior to their first pregnancy outcome. As previously mentioned, a better design would have been to include women with a history of antidepressant use (any any mental health treatment) into a separate, segregated analysis to investigate whether abortion or childbirth contributed to or reduced the duration of antidepressant use in subsequent years. A count of the number of antidepressants prescriptions filled for each period of time examined, for example, would be a good indicator of whether or not women with prior mental health problems experience more or less depression following abortion or delivery (or miscarriage, which should also have been examined.)
# Clearly, the question of whether abortion contributes to an increase or decrease in subsequent mental health issues, especially for women with a prior history of mental health issues, is an important one. It is also a question these authors carefully avoid. This is why segregated analyses are necessary for the following groups (a) women with a history of mental illness prior to conception of their first pregnancy, (b) women with no history of mental illness, and (c) all women.
# In the methods, the authors state that computed a general mental health score using the Charlson Comorbidity Index (CCI) and also compiled three other measures of mental health history based on (a) prior inpatient and outpatient admissions (b) prior use of anypsychotic medications, and prior use of anti-anxiety medications. These same measures could and should have been used to access the subsequent mental health of women in order to identify any change in severity, duration, or new symptoms following pregnancy outcomes. Instead, they limited their use of these measures to only the pre-pregnancy outcome period in order to blame all subsequent mental health problems on pre-pregnancy mental illness.
# In Table 2, the authors report that across all women (never pregnant, aborting, and delivering) the strongest predictors of first time antidepressant use were a history of psychiatric counseling, a history of taking antianxiety or antipsychotic medications. Notably, they authors did not give a break down of the for each subgroup of women (never pregnant, aborting, and delivering). Instead, we are left to presume that these reported rates applied equally to each subgroup of women, which is highly unlikely. Similarly, the CCI score is reported to show that a higher CCI score is associated with a higher risk of first time use of an antidepressant, but again there is no break down of what these scores were for each group, much less a report of how these CCI scores changed over time following a pregnancy outcome. Again, a prime opportunity was missed (or suppressed) which would have given us a better understanding of the degree of mental illness following abortion or childbirth, especially in women with a prior history of mental illness.
# A major premise of the authors' analysis is that women neatly fit into two categories: those who abort, those who give birth. More specifically, all women who have abortions are cut from the same cloth. Therefore, a finding of higher first use of antidepressants in the group of women in the year prior to having abortions "proves" that all women having abortions are more prone to depression whether or not they get pregnant and abort. More specifically, the authors are arguing that the elevated rate of first antidepressant use in the first year after an abortion (compared to non-pregnant and delivering women) is entirely explained by pre-existing mental health troubles among women who have abortions. But clearly, this is stretching one small data point into an over generalization. These women are individuals. For example, Ruth and Beth both had abortions. If Ruth first used an antidepressant eight months before her abortion, that tells us nothing about Beth. It certainly doesn't prove that if Beth seeks an antidepressant specifically because she is struggling with unwanted thoughts about her abortion that she is wrong...it is likely she would have sought antidepressants for some other reason because that is the "type of women," like Ruth, that she is. This study is simply too shallow. The analysis would be much more convincing if instead of using a single pre-pregnancy measure (first time use of antidepressants) the authors had used ''all of their mental health measures'', including the CCI score and the annual number of antidepressant prescriptions, to show that while Ruth and Beth had a different start date for their first use of an antidepressant, they had similar CCI scores, for example, and a similar duration for using antidepressants. Even better, the author's should have provided data showing how all of these mental health variables changed over time following each pregnancy outcome (not just first pregnancy outcome, but all subsequent combinations of pregnancy outcomes) in order to help us better judge the duration, complexity, and intensity of subsequent mental health problems associated with pregnancy outcomes.
# In their discussion, the authors state: "...the risk of depression decreased as more time elapsed after the abortion." In fact, their data only showed a decline in the first time use of antidepressants the farther out one looks from the abortion. But this tells us nothing about the risk of depression over time. If all the women who start using antidepressants following an abortion continue to have depression over two, five or ten years, it is false to assert that "...the risk of depression decreased as more time elapsed after the abortion." In fact, the cumulative number of women who have experienced depression would be always increasing. Only the rate of new cases would be declining, which is quite a different matter. Moreover, it is likely that only a limited percentage of women would be open to taking antidepressants. And others may self medicate with alcohol or drugs. At some point the number of new cases must necessarily decline, but this tells us nothing about he overall incidence rate. That problem could have been easily corrected if the authors had instead used as their outcome variable the number of antidepressants taken per year (or even a measure of dose levels as a proxy for severity). In other words, do women who have a history of abortions take more antidepressant medications per year, on average, (a) compared to women with no history of pregnancy, (b) women who have delivered with no history of abortion, (c) women with a history of miscarriage, and (d) women who have a history of childbirth, abortion, and miscarriage in every combination.
# The authors claim: "A close look at the data, however, suggests that the higher rates of antidepressant use had less to do with having an abortion than with other risk factors for depression among women who had an abortion." Again, the data that they have selectively chosen to report does reveal that prior psychiatric illness is a predictor for first time use of antidepressants, but it hardly proves that abortion itself does not also contribute to depression. The plain and evident truth is that their own data proves that women who have abortions will begin to use antidepressants at a much higher rate than women who carry to term and compared to women who did not become pregnant. This finding supports the conclusion that abortion ''may contribute'' to depression rates. Does it prove that abortion is the sole cause of depression in any specific number of case? No. Are other factors, such as prior psychiatric history, likely to be important? Yes. But it is illogical to argue that just because prior psychiatric history is the strongest predictor of first time antidepressant use that abortion never contributes to the onset, duration, or intensity of depression.
# The authors also claim: "Taking all of these results together, it is possible that mental health problems may lead women to have unintended pregnancies and abortions, as other research has found," citing two studies, neither of which actually prove that the reason women have unintended pregnancies and abortions is due to pre-existing mental health problems. Again, this is a harsh characterization and overgeneralization of the mental health of women seeking abortions. But even if mental health problems contribute to why some women have abortions, these findings do not even begin to address the critical question of whether or not a mentally ill woman who has an abortion is more likely to improve, get worse, or stay the same, much less whether the abortion itself contributes to any positive or negative trends in mental health.
# The authors also assert that the protective effects of childbirth do not last, noting that the decline in first use of antidepressants in the year following a first delivery disappears in the span between the second and fifth year and beyond. That's an interesting finding, but to be expected. But also, it underscores another weakness in the study, since their analyses do not include subsequent exposure to abortions or miscarriage. Since their own study shows a doubling of the risk of antidepressant use following an abortion, one would expect women who carried a first pregnancy to term but later had an abortion to have an elevated rate of antidepressant use.
# In their conclusions, the authors write:"if having an abortion is causally related to depression, one would expect a higher rate of first antidepressant use after the procedure than before the procedure, yet rates of antidepressant use were no higher in the year after having an abortion than in the year before an abortion." Actually, since prior mental health problems are common, a better hypothesis would be to expect the rate, duration, and intensity of depressive symptoms to increase after an abortion. But none of these are reported in the authors' study (even though they had relevant data). Instead, they limited their analyses to first time use of antidepressant, severely limiting the scope of any conclusions that can be made.
# Additionally they conclude: "if there are lagged effects of abortion, one would expect an increase in the rate of depression over time, but rates of antidepressant use decreased as more time elapsed." Here they seriously misrepresent their own findings. The rate of ''first time antidepressant'' use declined. They could have, and should have, reported on the actual rate of antidepressant use (number of doses per year per thousand women exposed to abortion, for example) but they did not.
# They then write: "Finally, the differences in rates of antidepressant use between women who had an abortion and women who did not have an abortion were substantially reduced when adjusted for earlier mental health conditions, parental mental health conditions, parental educational level, and physical health. This suggests that, compared with women who do not have an abortion, women who have an abortion may be at higher risk of depression after undergoing the procedure because they were at higher risk to begin with." Again, their study was limited to only first time use of antidepressants. But more importantly, even if women having abortions are more prone to experiencing depression due to pre-existing reasons, this does not exclude the possibility, nor justify ignoring the probability, that abortion can trigger, complicate, or prolong mental health issues.
# Their last word: "Consequently, policies based on the notion that having an abortion harms women’s mental health may be misinformed." Here, the verb "may" is misplaced. The "the notion that having an abortion ''may'' harm women's mental health" is actually supported by the very limited data reported in this study. This study verifies that women who have abortions experience higher rates of depression compared to delivering and non-pregnant women. Due to the superficial nature of this study, looking at first time antidepressants alone and lacking any breakdown of subsequent mental health changes among the women who did have pre-existing mental health issues, it sheds no light at all on how much abortion may contribute to the increased risk of mental health problems observed following abortion. Indeed, given the incorrect statements made in the conclusion of this paper, and the poor study design, the assertions made by the authors are clearly misleading or misinformed.
# Notably, the authors cite only two references with data or arguments favoring an association between abortion and depression. One is a metanalysis that is broadly focused and the other is a 1992 paper that obviously did not have access to any of the studies published since 1992. In short, the authors fail to fairly present their study in light of the existing literature and simply ignore evidence that would underscore that their methodology and conclusions are superficial and misleading.

==Induced First-Trimester Abortion and Risk of Mental Disorder.==

'''''[http://www.nejm.org/doi/full/10.1056/NEJMoa0905882 Induced First-Trimester Abortion and Risk of Mental Disorder.]  ''''' Munk-Olsen, T, Laursen TM, Pedersen CB, Lidegaard Ø, Mortensen PB. ''N Engl J Med'' 2011;364:332-9.

==== Abstract ====

'''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. (Funded by the Susan Thompson Buffett Foundation and the Danish Medical Research Council.) 

==== Key Findings ====

#Abortion is not associated with any improvement in mental health.  This finding is consistent with previous studies. 
#The year following abortion was associated with a higher rate of treatment for some mental health conditions compared to the nine months prior to the abortion, including 1 to 3 months while pregnant. Specifically, relative risk for psychiatric visits involving neurotic, stress-related, or somatoform disorders was 47% and 37% higher for women post-abortion compared to pre-abortion at 2 and 3 months respectively. In addition, psychiatric contact for personality or behavioral disorders was 56%, 45%, 31%, and 55% higher at 3, 4-6, 7-9, and 10-12 months respectively. 
#The rate of mental health treatments following a first abortion is significantly higher than the rate of mental health treatments following a first delivery. However, the rate of mental health treatment in the nine months prior to abortion (including up to three months coping with pre-abortion stresses) was also higher than the rate of mental health treatments before and after a live birth.
#Women who have abortions have higher rates of psychiatric treatment (15.2 per 1000 person years) than women who have not been pregnant (8.2 per 1000 person years) and women who deliver their first pregnancy (6.7 per 1000 person years).
#The findings of this study indicate that compared to other women, the elevated rates of mental health problems associated with abortion occur both before the abortion (during the nine months preceding the date of the abortion) and after the abortion.
#Because of differences in study design, and because the study did find elevated rates of psychological problems associated with abortion compared to delivering and non-pregnant women, the findings of this study clearly do not contradict previous studies linking abortion to elevated rates of psychological problems. The study does contribute to the literature, however, in that it provides evidence that some mental health problems associated with abortion may arise from pre-abortion stresses, during the time frame of discovering an unintended pregnancy, facing the pressures and concerns associated with making the abortion decision, and undertaking the abortion itself.
#Clinicians should be alert to the fact that there are higher rates of mental health treatments are sought by women in the year following a first abortion compared to the year following a first delivery.
#The researchers in this study conclude that the higher rates of mental health treatments provided to women who have abortions is not causally due to abortion, but rather due to a self-selection bias causing women with a propensity to require higher rates of mental health care to be more likely to have abortions.  (This conclusion is a good bit at odds with the study's design since it actually excluded women with a history of inpatient care prior to their first pregnancy, in other words, it was designed to look at the most mentally healthy set of women).  Even if this speculation were confirmed, it raises the interesting question: Is abortion "attractive" to the mentally unstable as an act of healing or as an act of self-destruction?  The lack of any evidence of benefit and the abundance of evidence of continued or increased mental health problems after an abortion suggest that it is not an act of healing. 

==== Limitations ====
#Although the researchers asserted that they were comparing women having a first trimester abortion to women giving birth, the study actually mixed the groups. Delivering women who had a previous abortion were included in both the birth group and abortion group. Similarly, women who gave birth to one or more children and then had a subsequent abortion were also included in both groups. The design necessarily dilutes all effects by mixing aborting women and delivering women. In all similar record linkage studies, women with both abortion and childbirth experiences as a third group, one which can be then be compared to both the group of women having only a history of abortion and those having only a history of childbirth.
#:a) Several other other studies have already shown that a history of abortion increases the risk of psychiatric problems during subsequent pregnancies that are delivered. For women with a history of abortion, preparing to give birth to a first live born child can itself trigger unresolved emotional issues regarding a prior abortion.
#:b)Munk-Olsen's failure to segregate the delivering women in this study who previously had abortions would necessarily increase the overall average of psychiatric issues attributed to childbirth even though a significant portion of the effects may actually have been due to the prior abortions.
#The pre-event (abortion or childbirth) measure of mental health was limited to only 9 months.  This period was chosen to include (on average) only the time that a delivering woman was pregnant.  It therefore totally ignores the pre-pregnancy mental health of delivering women. By contrast, for women who had abortions this nine month pre-event window includes six to eight pre-pregnant months plus one to three months during which the woman discovered she was faced with an unintended pregnancy and was deciding on an abortion.
#The sample included women with outpatient psychiatric care, but excluded women with a prior history of inpatient psychiatric care. That would be fine, but it then in regard to the outcome variable, it treats both first time outpatient and inpatient psychiatric care as identical. That is inconsistent. The results should have been reported to show first time outpatient and first time inpatient results both separately and combined. It would also have been preferable to report results separately for women with no prior history of outpatient psychiatric care and those with various levels of outpatient care . . . since clearly women with a history of 40 or more outpatient treatments are different than women with no history of outpatient treatments, but for the sake of this study they are treated the same with no effort to account for these differences.
#While it is important to control for prior mental health, it would have been far preferable to use the the full life history of psychiatric treatments for women in both groups, or at least a five year history prior to the pregnancy. Such far more complete data exists in the Danish database. It was available to the researchers.  Why it was not used is unclear.
#At the very least, the control period should have been based on a period of time estimated to have been before the women in both groups became pregnant, as was done in the [http://www.cmaj.ca/cgi/content/full/168/10/1253 Reardon(2003) analysis] of California medical records, which Munk-Olsen was seeking to replicate and refute. Furthermore, while the researchers did exclude women who had any prior history of inpatient psychiatric care, they did not control for prior history of outpatient psychiatric care.  In other words, we do not know if there were any differences in the rates of outpatient treatment between the two groups.
# The study excluded women who died (including death from suicide) prior to the end of the 12 month follow-up. Given numerous studies showing higher rates of suicide and deaths from accidents following abortion, this design decision may skew the results.
# The study considered only a single psychiatric treatment.  It did not measure or weight repeated treatments, which might be used as a measure of the severity and duration of mental health problems.
#  The study put women in both categories.  Women who had both an abortion and delivery appeared in both groups.  This may have confounding effects.  To eliminate these confounding effects the authors should have limited the study to first pregnancy outcome, and included miscarriage and other natural losses as a third group.
# Curiously the researchers did not follow the research approach used in previous Danish Study [http://www.nejm.org/doi/full/10.1056/NEJMoa033160 Hospitalization for Mental Illness among Parents after the Death of a Child] which examined mental health over a much longer period than just 12 months. Nor did they use a one year exclusion of women with prior hospitalization as was done in the record based study of [http://abortionrisks.org/index.php?title=Psychiatric_or_Psychological_Hospitalization_or_Consultation low income women in California]. This tendency to vary from prior research methods, using arbitrary periods like nine months arouses suspicion that selection criteria were chosen to magnify, or diminish, results in a fashion that best supported the authors' hypothesis.
#The authors controlled for "presence or absence of a history of mental disorders in the parents" of the pregnant girls or women. No justification was given for this. Without showing the results before and after this control, the effect is unclear.
#The paper failed to cite the only previous record linkage studies on abortion and mental health, a study of 56,741 low income women in California, all of which found significantly higher rates of treatments for mental health and sleep disorders following abortion.<ref>Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low income women following abortion and childbirth. Can Med Assoc J. 2003; 168(10):1253-7</ref><ref>Coleman PK, Reardon DC, Rue VM, Cougle J. State-funded abortions versus deliveries: a comparison of outpatient mental health claims over 4 years. Am J Orthopsychiatry. 2002 Jan;72(1):141-52.</ref> <ref>Reardon DC, Coleman PK. Relative treatment rates for sleep disorders and sleep disturbances following abortion and childbirth: a prospective record-based study.Sleep. 2006 Jan;29(1):105-6.</ref> This is very significant since these are the best studies with which to compare results and also the ones which should have informed study design; specifically, Munk-Olsen should have equaled or exceeded the methodological approach previously employed. Instead, she chose an inferior approach, controlling for less time prior to the pregnancy outcome and examining psychiatric outcomes for a shorter period following pregnancy outcomes.
#In addition to ignoring previous record linkage studies, the author's discussion merely compared their results to previous interview based studies, in what was clearly an attempt to suggest that "all" previous studies suffered from selection bias and that, therefore, their record linkage study was superior to all the previous literature (even though they were actually avoiding the comparison of their results the three record linkage studies described above).
#Bottom line: the control for prior mental health history in this study is very weak and may even lead to misleading results. Additional problems associated with this choice to limit prior mental health issues to this nine-month window prior to pregnancy outcome are detailed below:
#*For women carrying to term, the nine month window does not include any pre-pregnancy time. Women who are excited about having a baby may be less likely to seek mental health.  This may is why the incidence rate is so low 3.9%.  With only a nine-month pre-event window, the authors are even excluding those women who may have been experiencing anxiety or other problems as they struggled to become pregnant.  So this measure of mental health during a first pregnancy is a poor indicator of mental health prior to a first delivery, much less prior to first pregnancy.
#*Given the lack of more complete controls for mental health history suggested above, we must assume that since both groups had no prior history of outpatient mental health care prior to their first pregnancies, the mental health of both groups was very similar prior to becoming pregnant.  The three fold increase in mental health treatments prior to abortion (14.6 per 1000 yrs) compared to women who gave birth (3.9 per 1000 yrs) would therefore appear to be most likely explained by stress these women faced discovering they were faced with an unplanned pregnancy and, in many cases, the concurrent disruption of relationships with male partners, parents, employers and others.  In addition, abortion women were more likely to involved in unstable and possibly abusive relationships prior to their pregnancies.  It is not surprising, then, that many of these women facing the stress of abortion decision-making sought psychiatric advise at a much more elevated rate than they had in the past.
#*It is a common failure in abortion research to fail to identify the difference between pre-pregnancy mental health and pre-abortion mental health. Proponents of the abortion and mental health (AMH) connection generally support the view that abortion experience includes pre-abortion mental health stressors occur between the impregnation and abortion.  Discovery of the pregnancy, negative interactions with loved ones over the pregnancy, moral struggles, maternal stress, morning sickness, stress related to career and education decisions, and numerous other factors associated with the pregnancy can all contribute to escalating levels of stress.  Indeed, AMH proponents often describe abortion as both a stress reliever (because it resolves some of these pre-abortion stresses) and a stress inducer (because it creates new stresses or calcifies existing stresses).  This study's failure to distinguish between pre-pregnancy mental health history and post-conception/pre-abortion mental health history prevents any application of the findings to the more central question of when, if ever, an abortion to be beneficial.
#*AMH deniers often suggest that higher rates of post-abortion mental health problems, which are consistently found in the literature, are due to higher rates of pre-existing mental health problems unrelated to the abortion or the unintended pregnancy.  This hypothesis has not yet been tested due to the failure to distinguish between pre-pregnancy mental health and pre-abortion mental health.  This study, again, fails to make that distinction, which is especially unfortunate since, being a record based study, the necessary data was available to the researchers.  <blockquote></blockquote>
# The only confounding variables for which the authors use controls are age and number of pregnancies. Controls for marital status and socioeconomic status are missing, even though such data is generally available in record based studies.
# All women who had a history of psychiatric inpatient treatment more than 9 months prior to the abortion were excluded from the study. Many studies suggest that these women are at heightened risk for post-abortion mental health problems. Additional research should be done to look only at this subset of women to determine if women with a prior history of significant mental health problems (pre-pregnancy) are likely to have a lower or higher rate of mental health problems after abortion or after childbirth.
# Women who experience repeat abortions are likewise not considered. Approximately half of all abortions, at least in the United States, are for women with a prior history of abortion. Numerous studies indicate an elevated risk of mental health problems associated with multiple abortions. This study fails to shed any light on this important issue. In fact, by including women with a history of multiple abortions in the comparison group of women at the time of their first pregnancy, it is likely this inflated the psychiatric contact rate of women giving birth. In short, the failure to examine psychiatric contact rates associated with repeat abortions means the conclusions cannot be applied to women having multiple abortions.
# The limited follow-up to just one year after the pregnancy outcome is also an unfortunate limitation. There is evidence that elevated rates of post-abortion reactions persist for at least four years. Conversely, post-partum reactions tend to occur within the first few months following a delivery and the mental health benefits of childbirth may therefore be underestimated by examining treatment rates within only one year.
# The study did not examine whether the individual women who had psychiatric treatment prior to the abortion were at higher or lower risk of additional psychiatric treatment after the abortion.  For example, did pre-abortion mental health screening/counseling help to reduce subsequent risk of mental health treatment?  Or was it a predictor of higher rates of subsequent mental health treatment?  This is an important issue not answered by the study.
# The authors' conclusions are not consistent with the data. Specifically, the authors conclude: "our study shows that the rates of a first-time psychiatric contact before and after a first-trimester induced abortion are similar."  The identification of ''some "similar" rates,'' however, does not change the fact that their data also showed ''several statistically significant higher rates'' for specific mental disorders following abortion (see table 1). It would have been reasonable for their main conclusion to have been "our study shows higher rates of treatment for psychological illness  Additional study, and better controls, may reveal even more significant differences.  In addition, the authors statement that "This finding does not support the hypothesis that there is an overall increased risk of mental disorders after first-trimester induced abortion," oversimplifies and misrepresents the hypotheses presented by AMH proponents.  Even more importantly, the findings of this study do not ''contradict ''even this oversimplified hypothesis.  Instead, the conclusion seems crafted to be a sound-bite that obfuscates rather than clarifies the issues of concern.
#The study results are slanted by the exclusion of women most likely to have the most severe reactions to abortion, namely (a) women aborting after the first trimester, (b) those with a prior history of psychiatric hospitalization, and (c) women who died from suicide or accidents (elevated risk taking behavior or unrecognized suicide) within the year following their pregnancies.
# The Danish records are so complete that nearly all of these problems could have been addressed through better analyses. The fact that the researchers did not attempt to replicate the better design found in previous studies, but instead incorporated these methodological problems into their study design suggests that they did so in order to slant their result toward their intended conclusions.
#The study was funded by a grant from the [http://www.insidephilanthropy.com/home/2014/2/4/whos-who-at-the-secretive-susan-thompson-buffett-foundation.html Susan Thompson Buffet Foundation] which is primarily focused on funding population control efforts with funding of Planned Parenthood International and other groups promoting abortion in developing countries.

==== Data Clarification Request Refused ====

An email request was made to Munk-Olsen on 6/15/2015

:Dear Dr. Munk-Olsen,

:I am studying your 2011 paper "Induced First-Trimester Abortion and Risk of Mental Disorder."

:In your paper you make two statements:

::During the period from 1995 through 2007, a total of 84,620 girls and women had a first-time first-trimester induced abortion. Of these girls and women, 868 (1.0%) had a first psychiatric contact (either inpatient or outpatient psychiatric care) during the 9 months before the abortion, as did 1277 (1.5%) within the 12 months after the abortion.

::During the same study period, a total of 280,930 girls and women gave birth to their first live-born child. Of these girls and women, 790 (0.3%) had a first-time psychiatric contact within the 9 months preceding delivery, as did 1916 (0.7%) from 0 through 12 months post partum.

:It is my understanding that the two above groups include women who had both an abortion and a live birth. Would you please complete the following two statements for those who had first an abortion and then a birth and for those who had first a birth and later an abortion:

::During the same study period, a total of _________ girls and women had a first-time first trimester abortion of their first pregnancy and subsequently gave birth to their first live-born child. Of these girls and women, ___ (___%) had a first psychiatric contact (either inpatient or outpatient psychiatric care) during the 9 months before the abortion, as did ____(___%) within the 12 months after the abortion. Subsequently, of these girls and women, _____ (___%) had a first-time psychiatric contact within the 9 months preceding delivery, as did 1916 (__._%) from 0 through 12 months post partum.

::During the same study period, a total of _________ girls and women gave birth to their first live born child and had no history of prior abortion and also had a first-time first trimester abortion of at least one subsequent pregnancy. Of these girls and women, _____ (___%) had a first-time psychiatric contact within the 9 months preceding delivery, as did 1916 (__._%) from 0 through 12 months post partum. Subsequently, of these girls and women, ___ (___%) had a first psychiatric contact (either inpatient or outpatient psychiatric care) during the 9 months before the abortion, as did ____(___%) within the 12 months after the abortion.

:Thank you for this clarification.

On 7/18/15 Munk Olsen replied:

::Thank you for your email. I am pleased that you find our paper interesting. However, answering your questions would require substantial work from several people here at our center, and for this reason I cannot provide them to you.

::Sincerely,

::Trine Munk-Olsen

Note: Most researchers routinely reply to such requests with the additional details. It literally takes only seconds to run a tabulation like that requested. Munk-Olsen's refusal to provide any details was clearly motivated by a fear of providing data that would lend itself to any interpretation of the data beyond what she has decided to reveal.

==== Critique by David C. Reardon ====

Given the excellence of this data set, it is unfortunate that the researchers failed to consider the methodology employed in prior record based studies of abortion and mental health (for example, [http://www.ncbi.nlm.nih.gov/pubmed/12743066/ Reardon DC, 2003] and [http://www.ncbi.nlm.nih.gov/pubmed/14964603/ Coleman PK, 2002]) and instead made choices which tend to confound rather than clarify the issues at hand.

Perhaps the biggest problem is the failure to examine pre-pregnancy mental health. This was done in prior studies which controlled for psychiatric admissions for at least one year prior to the calculated date of conception ([http://www.ncbi.nlm.nih.gov/pubmed/12743066/ Reardon DC, 2003]). Instead, Munk-Olsen chose as a base line for mental health a nine month period prior to pregnancy outcome, a period covering the entire period of pregnancy for delivering women and approximately three months of pregnancy and six months pre-pregnancy for women who aborted.

This poorly explained decision unfortunately introduces elements of an apples versus oranges comparison.

This is problematic for two key problems. First, it totally ignores the pre-pregnancy mental health of delivering women. Women who are excited about having a baby may be less likely to seek mental health. With only a nine-month pre-event window, the authors are even excluding those women who may have been experiencing anxiety or depression if they were struggling to become pregnant.

Secondly, for aborting women, it includes two to three months of a period in the women's lives which is likely highly stressful since these women are, it must be presumed, facing discovery of an unplanned pregnancy and potential conflicts over this with partners, parents, and others. This nine month window therefore not only fails to provide a base line for mental health prior to the subjects' pregnancy but mixes, several months of pre-pregnancy mental health with one or more months of post-pregnancy, pre-abortion stress.

Third, it is a variation from Munk-Olsen's own prior methodology employed in a [http://jama.jamanetwork.com/article.aspx?articleid=204395 2006 study of mental health problems following childbirth] in which all women who ever had prior history of inpatient treatment were excluded . . . not just those treated within nine months of abortion or delivery. Why this change, unless it was necessary to shift the results in a fashion that would reduce the difference between treatment rates before and after abortion?

These study design criteria are not only unprecedented in similar studies but simply contrary to the stated objective of controlling for prior mental health. This failure in design is even more puzzling given the fact that the available data set included mental health information for the entire life of the women in the study. Given the availability of all prior mental health treatment dates, it seems self evident that the researchers should have created a scale for exposure to prior mental health treatments prior to the estimated conception date of each woman's first pregnancy covering at least one full year, preferably five years, and perhaps for each subject's entire life.

Given the fact that the authors only exclusion criteria was a history of inpatient psychiatric treatment, we must assume that since the mental health of both groups was relatively similar prior to becoming pregnant. The three fold increase in mental health treatments prior to abortion (14.6 per 1000 yrs) compared to women who gave birth (3.9 per 1000 yrs) would therefore appear to be most likely explained by stress these women faced discovering they were faced with an unplanned pregnancy and, in many cases, the concurrent disruption of relationships with male partners, parents, employers and others.

In addition, aborting women were more likely to involved in unstable and possibly abusive relationships prior to their pregnancies. It is not surprising, then, that many of these women facing the stress of abortion decision-making sought psychiatric advise at a much more elevated rate than they had in the past.

The lack of pre-pregnancy mental health measure, in itself, renders it impossible to draw general conclusions regarding from this study. But there are also numerous additional problems with the study design that further confound the results and interpretation:

*The study excluded women who are most likely to have the most severe reactions to an abortion, namely those who already had a prior history of abortion, those with a prior history of inpatient mental health treatment. It also excluded women who died prior to one year after the pregnancy event, thereby excluding women who committed suicide, even though a record linkage study from neighboring Finland found a six fold higher rate of suicide in the year following abortion compared to the year following childbirth ([http://www.ncbi.nlm.nih.gov/pubmed/8973229/ Gissler M, 1996]).

*The study failed to keep women in the two groups separate. Women who had both an abortion and delivery were included in both parts of the analysis groups. This is especially problematic given the evidence women with a prior history of abortion have more stress during and after subsequent pregnancies ([http://www.ncbi.nlm.nih.gov/pubmed/12501082/ Coleman PK, 2002]). As a result, by putting women with a history of abortion in the group of delivering women, the "control" group may be adulterated with the very post-abortion effects this study professes to be exploring. The authors should have limited the study to first pregnancy outcome, and should also have included first pregnancies ending in miscarriage, still birth, and other natural losses as a third group.

*The outcome variable used for this study was limited to only a single psychiatric treatment. It did not measure or give any weight to repeated treatments or multiple mental health problems in an effort to evaluate the severity or duration of mental health problems associated with pregnancy outcomes. It should also be noted that the authors' conclusions are not consistent with their data. Specifically, the authors conclude: "our study shows that the rates of a first-time psychiatric contact before and after a first-trimester induced abortion are similar." The fact that many of the psychiatric contact rates during the nine months preceding an abortion were similar to the contact rates in the year following an abortion were statistically insignificant does not alter the fact that, even with all of the problems in the methodology identified above, their data also showed several statistically significant higher rates for specific mental disorders.

Specifically, as seen in table 1, contact rates for neurotic, stress-related or somatoform disorders were higher in every two month period following an abortion, and was statistically significant in two of the six periods. Similarly, for personality or behavioral disorders, the relative risk was higher for four of the six periods and significantly higher for two of the six periods. In other words, when one actually examines the table of reported findings, the conclusion that "in some cases the rate of a first-time psychiatric contact is significantly higher following an abortion compared to the nine months preceding an abortion" is at least equally true, and arguably more accurate.

Finally, I would note that at least one of the authors, Laursen, was also a co-author of an excellent record linkage study from Denmark examining mental illness among parents of deceased children that was also published in the New England Journal of Medicine.([http://www.ncbi.nlm.nih.gov/pubmed/15788495/ Li J, 2005]) That study design examined long term mental health effects, beyond one year, and controlled for exposure to multiple losses, and had none of the selection bias problems identified in this Munk-Olsen study.

This exact study design could have, and should have, been used simply by plugging the date of exposure to induced abortion into the same fields used for date of exposure to the death of a child. By using a proven study design in this way, Munk-Olsen and Laursen could have avoided the impression (in this case, the very profound impression) that this new study design (with a nine month pre-event control period and intermixing of subjects into both the abortion group and delivery group, et cetera) was artificially constructed precisely to minimize the number of statistically significant findings associating abortion with increased mental health treatments. In conclusion, this study does nothing to impute previous record linkage studies showing elevated rates of psychiatric treatments following induced abortion.

==First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital==

'''[http://archpsyc.jamanetwork.com/article.aspx?articleid=1107446 First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital in women with a history of treated mental disorder.] Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard O, Mortensen PB. Arch Gen Psychiatry. 2012 Feb;69(2):159-65. doi: 10.1001/archgenpsychiatry.2011.153.'''

:Context Mental health problems are associated with women's reproductive decisions and predict poor mental health outcomes after abortion and childbirth.

:Objectives To study whether having a first-trimester induced abortion influenced the risk of psychiatric readmission and compare findings with readmission risk in women with mental disorders giving birth.

:Design Survival analyses were performed in a population-based cohort study merging data from the Danish Civil Registration System, the Danish Psychiatric Central Register, and the Danish National Hospital Register from January 1,1994, to December 31, 2007.

:Setting Denmark.

:Participants: All women born in Denmark between 1962 and 1992 with a record of 1 or more psychiatric admissions at least 9 months before a first-time first-trimester induced abortion or childbirth.

:Main Outcome Measure: Readmission at a psychiatric hospital with any type of mental disorder from 9 months before to 12 months after a first-time first-trimester induced abortion or childbirth.

:Results: Relative risk (RR) for readmission risk 9 to 0 months before a first-trimester induced abortion was 0.95 (95% CI, 0.73-1.23) compared with the first year after the abortion. This contrasts with a reduced risk of readmission before childbirth (RR, 0.56; 95% CI, 0.42-0.75) compared with the first year post partum. Proximity to previous psychiatric admission in particular predicted rehospitalization risks in both the abortion and the childbirth group.

:Conclusions: Risk of readmission is similar before and after first-time first-trimester abortion, contrasting with a marked increased in risk of readmission post partum. We speculate that recent psychiatric episodes may influence women's decisions to have an induced abortion; however, this decision does not appear to influence the illness course in women with a history of treated mental disorders.

''':Comments:'''

*Most of the [[Munk-Olsen_et_al#Limitations | limitations described above]] regarding Munk-Olsen's 2011 study also apply to this extended analysis.
*This study was limited to 2,838 women with a history of having inpatient treatment for psychiatric illness at some time prior to the nine months prior to their abortions. In other words, it is limited to women who most likely have the most mental health problems.
*Why Munk-Olsen does not run the same analyses for women with no prior mental health problems is not explained. While it is certainly relevant to look at how women with pre-existing mental health issues fare following abortion or delivery, it is equally important to look at how women with no pre-existing mental heatlh issues fare after their first pregnancy, whether aborted or delivered. The decision to not publish any results relevant to women without a prior history of mental illness is almost certainly due to the fact that her results showed a difference between aborting and delivering women. Otherwise, she would have published evidence that there was no difference in order to bolster her argument that pre-pregnancy mental health alone explains the higher rates of mental illness among aborting women.
*Her main conclusion is that the rate of women being readmitted for psychiatric care after an abortion is similar to the rate during the nine months before an abortion proves that abortion does not change the rate of psychiatric admissions among women. But in fact, she does not measure the number of readmissions each woman faces, but only whether she is admitted once. Nor does she look to see if the admissions are for longer periods or for any other measure of whether their psychiatric illnesses have become worse or better. Instead, she simply speculates that these women are most likely to have chosen abortions because of their pre-existing psychiatric issues.
*Without any attempt to measure the frequency of subsequent treatments beyond a first time readmission, or any other measure of severity, plus with the limitation to only one year follow-up (and no reporting of suicides), her conclusion that abortion "does not appear to influence the illness course in women with a history of treated mental disorders" is totally unsupported by the very limited evidence she choose to share.

===Letter to Editor By David Reardon Identifying Methodological Problems and Requesting Additional Analyses===

These letters were previously available at the links shown. As of January 2017, it appears that Archives of General Psychiatry have moved the content to a yet to be discovered location.

'''[http://archpsyc.jamanetwork.com/article.aspx?articleid=1107446 Correction of Study Design Problems Would Bring More Clarity to Abortion Mental Health Issue.] Reardon DC. Arch Gen Psychiatry.''' February 23, 2012'''

:As one of the authors of three record linkage studies examining abortion and mental health(1)(2)(3), I applaud the quality of data being accessed by the Munk-Olsen team(4)(5). I am disappointed that their review and discussion ignored our studies. But I’m even more disappointed by their study design decisions which tend to obscure rather than clarify the key issues in this field.

:For example, because negative reactions to abortion increase with time(6) our study examined psychological treatments rates for four years. Munk-Olsen unnecessarily limited follow-up to one year.

:Furthermore, our studies employed a uniform baseline, controlling for any psychiatric admissions prior to conception. By contrast, Munk-Olsen introduces a dissimilar comparison overlaying nine months of pregnancy for delivering women with a nine months mix of pregnancy and no pregnancy for aborting women.

:The weakness of this dissimilar comparison is underscored by the finding that recent admission is the strongest predictor of subsequent readmissions(4). This creates a front loading problem as evidence by 14% of those assigned to the abortion group being readmitted within six months, prior to becoming pregnant. Worse, because the study design censored these cases after their first readmission, the design totally conceals any information about whether this “extra fragile” group (readmitted within 180 days) faced additional readmissions after their abortions.

:It is my hope Munk-Olsen will ameliorate this effect by reporting via a published letter results of a reanalysis restricted to the 429 "reasonably stabilized" women whose previous discharge was at least one year prior to the 21-month period examined.

:Yet another design problem was the decision to include 952 women (13%) into both the abortion and childbirth groups. Since abortion is associated with a higher risk of mental illness during or after subsequent pregnancies,(7)(8)(9)(10) such double assignment of women to both groups would tend to obscure rather than clarify differences.

:This excellent data set can and should be put to better use. Future analyses should show segregated results for women divided into five groups: women with any history of hospitalization for mental health, and women with 0, 1-5, 5-10, and >10 outpatient mental health treatments, either lifetime or within 5 years prior to the estimated conception date of their first pregnancy. With these groupings, analyses should examine inpatient or outpatient treatment rates in the year prior to pregnancy and for one through five years following first pregnancy outcome (including birth, abortion, miscarriage, and other losses). This study design would more clearly identify relative risks of mental illness associated with various pregnancy outcomes for groups of women with various levels of predisposition to mental illness.

:Finally, the opportunity to use these data to provide some definitive answers to questions relating reproductive experiences to mental health would be enhanced by including on the research team experts on both sides of this controversial research field, such as Priscilla Coleman and David Fergusson on one side and Brenda Major and Nancy Russo on the other. Such collaboration would increase confidence in both the study design and the interpretation of results.

:References
:(1) Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low income women following abortion and childbirth. Can Med Assoc J. 2003; 168(10):1253-7.

:(2) Coleman PK, Reardon DC, Rue VM, Cougle JR.State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years. American Journal of Orthopsychiatry, 2002; 72(1):141–52.

:(3) Reardon DC, Coleman PK. Relative treatment rates for sleep disorders and sleep disturbances following abortion and childbirth: a prospective record-based study. Sleep. 2006 Jan;29(1):105-6.

:(4) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard O, Mortensen PB. First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital in women with a history of treated mental disorder. Arch Gen Psychiatry. 2012 Feb;69(2):159-65.

:(5) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard Ø, Mortensen PB. Induced first-trimester abortion and risk of mental disorder. N Engl J Med. 2011 Jan 27;364(4):332-9.

:(6) Major B, Cozzarelli C, Cooper ML, Zubek J, Richards C, Wilhite M, Gramzow RH. Psychological responses of women after first-trimester abortion. Arch Gen Psychiatry. 2000 Aug;57(8):777-84.

:(7) Coleman PK, Reardon DC, Cougle JR. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. Br J Health Psychol. 2005 May;10(Pt 2):255-68.

:(8) Coleman PK, Reardon DC, Rue VM, Cougle J. A history of induced abortion in relation to substance use during subsequent pregnancies carried to term. Am J Obstet Gynecol. 2002 Dec;187(6):1673-8.

:(9) Stotland NL. Abortion: social context, psychodynamic implications. Am J Psychiatry. 1998 Jul;155(7):964-7.

:(10) Burke T, Reardon DC. Forbidden Grief. The Unspoken Pain of Abortion. Springfield, IL: Acorn Books; 2002.

===Munk Olsen's Response===

In her response to Reardon's letter, [http://archpsyc.jamanetwork.com/article.aspx?articleid=1107446 Munk-Olsen made the following responses]

#She admitted that the limitation to a one year follow-up was arbitrary.
#She admitted that the use of nine months prior to pregnancy outcome, rather than nine months prior to pregnancy, meant the two groups "may not be directly compatible across this 9 months period." In this case, "compatible" can only be interpreted to be a synonym for "comparable" meaning the two groups are not properly comparable during this time period as Reardon argued. Obviously, the whole premise of the study is that the design should have comparable measures for each group. Psychiatric treatment rates before the conception dates of women in both groups was available, but not used. This was almost certainly not provided precisely because a proper comparison did not advance Munk-Olsen's preferred outcome.
#In regard to the suggestion that the study should have examined not just first time psychiatric admissions following a birth or abortion among women with prior psychiatric admissions, but instead should have also looked at how many times women were treated following their pregnancy outcomes to determine if abortion might increase the severity or frequency of post-abortion psychiatric episodes, Munk-Olsen rejected this request insisting that "The problem of counting re-admissions is that several psychiatric contacts could be caused by the same psychiatric disease/episode, and that it is difficult to discriminate between several separated events, and several contacts for the same event." If a quick re-analysis of the data had shown that there was no increased frequency of admissions, Munk-Olsen could easily have reported this in her response to disprove Reardon's concern. Instead, she simply defended her dodge, essentially admitting "The evidence may show that their are more frequent re-admissions for psychiatric inpatient treatment for women who have abortions, but since we can't be certain that doesn't mean something else, we choose not to report that data."
#Regarding the problem of mixing women who had both abortions and births into both groups, Munk-Olsen simply declares that it is a fact that some women have both experiences. True. But that does not justify bad research methodology. It is also a fact that it very easy to split women exposed to different pregnancy experiences into more than two group, which is a [http://www.cmaj.ca/content/168/10/1253.full common practice that has been used by many other researchers.] If she had simply used three groups (1. first pregnancy was aborted, 2. first pregnancy was delivered, and 3. one of first two pregnancies aborted and the other delivered) the effects associated with two pregnancies with different outcomes would not distort the effects associated with a single pregnancy outcome. Instead, of providing data from a new analysis showing that Reardon's concerns, if addressed, do not change her results, she instead insists that additional analyses are not necessary (to show to anyone else, I guess). Indeed, she asserts that controlling for parity (number of children born before women's first abortions) somehow remedies the problem, though she give no explanation how or why this should be so.

===Critique by Priscilla Coleman===

The study has numerous problematic elements and the results cannot be trusted for the reasons described below.

1) The sample is limited to women who had a first abortion or birth between 1994 and 2007. The oldest women in the population for whom the investigators had data were born in 1962, and many of the oldest women surely experienced their first abortion or birth well before 1994 (since they would have been 32 at the time), yet they are not included in the analyses and no explanation is provided for their exclusion.

2) There is a serious problem with the structuring of the birth and abortion groups that the authors openly acknowledge: out of the total sample of 8,131 women, 952 (nearly 12%) were in both groups! In order to conduct clean comparisons, these women should absolutely have been removed prior to conducting the analyses.

3) The authors only analyzed a very small fraction of all women with histories of mental illness, the most extreme forms requiring in-patient hospitalization. For every woman hospitalized for a mental illness after abortion, there are potentially 1000s of women suffering from disorders who received out-patient services, were never treated, of self-medicated with substances. The sample is very narrowly constructed.

4) The only control variables employed are age, calendar period, time since previous admission, reproductive history, and parental history of mental disorders. There were no controls for variables demonstrated in previous studies to be associated with the choice to abort and with post-abortion mental illness including marital status, education level, religion, income, relationship history variables including abuse, planning of the pregnancy, reasons women chose to undergo abortion, and pressure to abort, among other variables.

5) The authors conducted correlational analyses and inappropriately made inferences of causality, For example, in the first sentence in the conclusion section of the article they state: “In the present study, we found that first-time first-trimester induced abortion does not influence the risk of readmission to psychiatric facilities.” Such a statement is not permitted with the use of variables that cannot be controlled (like abortion status), particularly when so few control variables are incorporated.

6) Follow-up was limited to 12 months after the pregnancies were resolved. Prospective studies have shown that many women experience mental health problems associated with an abortion years after the procedure. By only measuring readmission for one year, women who have delayed responses, sometimes triggered by a later pregnancy, are not included in the analyses. The data are available in the Danish registries and there is no valid reason for cutting off the follow-up period so early.

== Related Studies Where Munk-Olsen Continues to Reject Requests for Relevant Analyses ==

Munk-Olsen has published a substantial number of subsequent studies related to pregnancy and mental health but has neglected to report on effects associated with abortion . . . when it suits her. When requests have been made for her to report on the effects of abortion or to undertake any additional analyses which might shed further light on the issue, she has refused . . . a position which seems to lend credibility to the concern that she is seeking to conceal results which might reveal shortcomings in her published analyses and conclusions.

==== Perinatal psychiatric episodes: a population-based study on treatment incidence and prevalence. ====
[https://www.ncbi.nlm.nih.gov/pubmed/27754485 Perinatal psychiatric episodes: a population-based study on treatment incidence and prevalence. Munk-Olsen T, Maegbaek ML, Johannsen BM, et al. Transl Psychiatry. 2016;6(10):e919. doi:10.1038/tp.2016.190.]

This is another study in which Munk-Olsen attempts to blame live birth as the primary cause of emotional problems after delivery but chooses to ignore prior pregnancy losses as a significant risk factor. Again, she has refused requests for reanalysis, including the following [https://www.ncbi.nlm.nih.gov/myncbi/david.reardon.1/comments/ submitted to her via PubMed]:

:This analysis of perinatal psychiatric episodes by Munk-Olsen T, 2016(1) is flawed by the decision to ignore the effects of prior pregnancy losses on mental health during and after subsequent pregnancies. This omission reflects a pattern of selective reporting by the lead author and should be corrected by publication of new analyzes.

:Giannandrea SA, 2013 and Gong X, 2013, and others have shown that prior fetal loss increases the risk psychiatric disorders.(2,3) There is even a dose effect. Multiple losses, either from miscarriage or induced abortion, predict elevated rates of postpartum anxiety.(2) History of abortion is associated with higher rates of mental illness(4,5) and a two to tenfold increased risk of alcohol or illegal drug use during subsequent term deliveries.6 Notably, the heightened risk of mental illness following fetal death is confirmed by one of Munk-Olsen’s own studies.(7)

:In light of the literature, Munk-Olsen T, 2016's conclusion that it is not possible to “predict which women will become ill postpartum” is false.(1) Prior fetal loss is risk factor. The data should have been analyzed with attention to this known risk factor. Confirming this effect could motivate improved screening to identify women who may benefit from additional care.

:Sadly, the failure to address fetal loss history does not appear to be an oversight. Rather, in light of Munk-Olsen’s refusal to provide details regarding the impact of abortion history on outcomes reported in several of her studies,(8–10) there appears to be a pattern of obfuscating the effects of pregnancy loss on mental health while overstating the effects of childbirth.

:For example, in her own fetal death study, Munk-Olsen T, 2014 she ignored the precedent of other researchers to report on the effects of both miscarriage and induced abortion.2 Instead, her results show only the effects of miscarriage. Even more oddly, she actually did use induced abortion as a control variable, thereby admitting its relevance,(7) but withheld all statistics showing how abortion effected the results--clearly to deny critics of her previous studies findings that confirm their criticisms.(8,9)

:This pattern of obfuscating methodological choices was also evident in Munk-Olsen's only two abortion studies.(4,5) In those studies, there is no separate analyses given for women without a prior history of mental disorders, exactly the opposite of what she does elsewhere(7,11) in order to eliminate the confounding effects of prior mental illness. The resulting blend of healthy and ill women was further muddied by mixing women who had one or more abortions prior to their first deliveries into the “control group” of women giving birth.(4,5) This cross-adulteration prevented a true comparison of the mental health of women who abort their first pregnancies and those who deliver their first pregnancies–a clean and straight forward comparison such as wad done in Reardon DC, 2003.(12) Moreover, when a colleague requested a simple count of the number of women in the sample who had both abortions and deliveries and the percentage of these who had psychiatric contact, Munk-Olsen emailed the dismissive response: “answering your questions would require substantial work from several people here at our center, and for this reason I cannot provide them to you.”(13)

:Munk-Olsen’s methodology across studies is also inconsistent. In some studies she has shown treatment rates for psychological conditions prior to pregnancy outcome for one(7) or even two years.(11) But in her abortion studies, she used only a nine-month period, covering the entire time women delivering were pregnant while providing a muddy mix of pre-conception time and pregnant time for those who had abortions. In response to criticism on this point, Munk-Olsen admitted this "may not be directly compatible."(5) But isn't the whole point to find methodological choices that make groups "directly comparable"? The precedent of using a period of time prior to conception for the mental health baseline is clearly preferable.(12)

:Despite my concerns regarding selective reporting, it remains my hope that Munk-Olsen will respond to this letter with results, not just excuses, showing the equivalent of Figures 1-31 revised to show treatment rates segregated for (a) women with no history of pregnancy loss, (b) women with history of one miscarriage, (c) women with a history of one abortion, and (d) women with a history of multiple fetal losses.

:Based on previous research, we expect that such an analysis will support the recommendation that women with a history of fetal loss may benefit from additional counseling services during and after subsequent pregnancies. It is inexplicable why Munk-Olsen would refuse to comply with this request.
:
:References
:(1) Munk-Olsen T, Maegbaek ML, Johannsen BM, Liu X, Howard LM, di Florio A, et al. Perinatal psychiatric episodes: a population-based study on treatment incidence and prevalence. Transl Psychiatry [Internet]. Nature Publishing Group; 2016 Oct 18 [cited 2016 Nov 5];6(10):e919. Available from: http://www.nature.com/doifinder/10.1038/tp.2016.190 PMID: 27754485
:(2) Giannandrea SAM, Cerulli C, Anson E, Chaudron LH. Increased risk for postpartum psychiatric disorders among women with past pregnancy loss. J Womens Health (Larchmt) [Internet]. 2013;22(9):760–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24007380 PMID: 24007380
:(3) Gong X, Hao J, Tao F, Zhang J, Wang H, Xu R, et al. Pregnancy loss and anxiety and depression during subsequent pregnancies: data from the C-ABC study. Eur J Obstet Gynecol Reprod Biol [Internet]. Elsevier; 2013 Jan [cited 2016 Nov 8];166(1):30–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23146315 PMID: 23146315
:(4) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard Ø, Mortensen PB. Induced first-trimester abortion and risk of mental disorder. N Engl J Med. 2011;364(4):332–9. PMID: 22310504
:(5) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard O, Mortensen PB. First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital in women with a history of treated mental disorder. Arch Gen Psychiatry [Internet]. 2012 Feb [cited 2015 Jul 16];69(2):159–65. PMID: 22310504
:(6) Coleman PK, Reardon DC, Rue VM, Cougle J. A history of induced abortion in relation to substance use during subsequent pregnancies carried to term. Am J Obstet Gynecol. 2002;187(6):1673–8. Coleman PK, 2002
:(7) Munk-Olsen T, Bech BH, Vestergaard M, Li J, Olsen J, Laursen TM. Psychiatric disorders following fetal death: a population-based cohort study. BMJ Open. 2014;1–6. < PMID: 24907247>
:(8) Reardon DC. Lack of pregnancy loss history mars depression study. Acta Psychiatr Scand. 2012;126(2):155. PMID: 22616564
:(9) Reardon DC. Postpartum mental health study flawed by fetal loss omission. Scand J Prim Health Care [Internet]. 2015 Oct 2 [cited 2016 Nov 9];33(4):318–9. PMID: 26683289 Available from: http://www.tandfonline.com/doi/full/10.3109/02813432.2015.1111710
:(10) Munk-Olsen T, Laursen TM, Meltzer-Brody S, Mortensen PB, Jones IR. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. 2011;1–7. Available from: http://dx.doi.org/10.1001/archgenpsychiatry.2011.157
:(11) Munk-Olsen T, Pedersen HS, Laursen TM, Fenger-Grøn M, Vedsted P, Vestergaard M. Use of primary health care prior to a postpartum psychiatric episode. Scand J Prim Health Care [Internet]. Informa Healthcare Stockholm; 2015 Jun 24 [cited 2015 Aug 1];33(2):127–33. PMID: 22147807 Available from: http://informahealthcare.com/doi/abs/10.3109/02813432.2015.1041832
:(12) 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(10):1253–6. PMID: 12743066
:(13) Email: Subject:"Question: NEJM Abortion and Risk of Mental Disorder" Dated 7/8/2015

====Bipolar Affective Disorders====

''''[http://archpsyc.jamanetwork.com/article.aspx?articleid=1151054 Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders.] Munk-Olsen T, Laursen TM, Meltzer-Brody S, Mortensen PB, Jones I. Arch Gen Psychiatry. 2012 Apr;69(4):428-34. doi: 10.1001/archgenpsychiatry.2011.157. Epub 2011 Dec 5.''''

:CONTEXT: Childbirth has an important influence on the onset and course of bipolar affective disorder, and it is well established that there may be a delay of many years before receiving a diagnosis of bipolar disorder following an initial episode of psychiatric illness.

:OBJECTIVE: To study to what extent psychiatric disorders with postpartum onset are early manifestations of an underlying bipolar affective disorder.

:DESIGN: Survival analyses were performed in a register-based cohort study linking information from the Danish Civil Registration System and the Danish Psychiatric Central Register.

:PARTICIPANTS: A total of 120,378 women with a first-time psychiatric inpatient or outpatient contact with any type of mental disorder excluding bipolar affective disorder.

:MAIN OUTCOME MEASURES: Each woman was followed up individually from the day of discharge, with the outcome of interest being an inpatient or outpatient contact during the follow-up period with a first-time diagnosis of bipolar affective disorder.

:RESULTS: A total of 3062 women were readmitted or had an outpatient contact with bipolar affective disorder diagnoses. A postpartum onset of symptoms within 0 to 14 days after delivery predicted subsequent conversion to bipolar disorder (relative risk = 4.26; 95% CI =3.11-5.85). Approximately 14% of women with first-time psychiatric contacts during the first postpartum month converted to a bipolar diagnosis within the 15-year follow-up period compared with 4% of women with a first psychiatric contact not related to childbirth. Postpartum inpatient admissions were also associated with higher conversion rates to bipolar disorder than outpatient contacts (relative risk = 2.16; 95% CI = 1.27-3.66).

:CONCLUSIONS: A psychiatric episode in the immediate postpartum period significantly predicted conversion to bipolar affective disorder during the follow-up period. Results indicate that the presentation of mental illness in the early postpartum period is a marker of possible underlying bipolarity.

====='''Request for Additional Analysis (Refused)'''=====

BiPolar Disorder Study Neglects Prior Research and Adequate Controls. Reardon DC.

Dear Editor,

The Munk-Olsen team’s study of elevated risk of bipolar affective disorder following psychiatric illness in the first month after a delivery is potentially important.(1) Unfortunately, the study neglected to control for the effects of prior pregnancy outcomes on bipolarity.

This omission is striking given the fact that Munk-Olsen has used the same data to publish two studies on abortion and subsequent psychiatric treatment.(2)(3). She is also familiar with the three similar record linkage studies we have published in regard to a population of 56,751 low income women in California.(4)(5)(6)

One of these latter studies revealed that women with a history of abortion were three times more likely (OR 3.0, 95% CI 1.5-6.0) to be hospitalized for bipolar disorder than women who carried to term during the four years following pregnancy outcome.(4) Our study also found that women who had abortions were 2.6 times more likely to be hospitalized for psychiatric treatment than were women delivered.(4) Similarly, Munk-Olsen has also found higher rates of psychiatric contact for each of the first 12 months following an abortion compared to delivery.(2) All of these facts have a direct bearing on the present study(1) and should have been addressed in the study design.

It is therefore tremendously baffling . . . if not suspicious . . . that the present study(1) did not include additional analyses relative to other pregnancy outcomes: abortion, miscarriage, and other pregnancy losses. Clearly, a history of pregnancy loss may impact the rates of postpartum depression following a live birth.(7)(8)(9) The failure to consider and control for pregnancy loss history is a major methodological weakness in this new study.

Both the American Psychological Task Force on Abortion and Mental Health and the Royal College of Psychiatry have called for more research regarding abortion and mental health. Yet studies such as this one continue to be published without information about the effects of pregnancy loss on the outcome, even when the researchers have access to complete reproductive histories. Whether investigation of these effects is being neglected due to lack of insight, or whether results are being redacted for ideological reasons, is unclear.

Journal editors and peer reviewers should heed the call for more research on associations between abortion and mental health by requesting that every study regarding reproductive outcomes and mental health should include segregated results allowing for comparisons relative to pregnancy outcome: live birth, miscarriage, abortion, and other losses.

It is my hope that Munk-Olsen will correct this oversight in the near future. Reanalysis should include segregated results allowing comparisons between delivering women with no history of pregnancy loss, women with a history of one abortion, women with a history of two or more abortions, and women with a history of one or more miscarriages.

It is my fear, however, that the politicization of abortion has long caused and continues to perpetuate a trend toward distortions in study design which are intended to either conceal or to obfuscate the associations between abortion and negative mental health outcomes.

'''References'''

(1) Munk-Olsen T, Laursen TM, Meltzer-Brody S, Mortensen PB, Jones I. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. Arch Gen Psychiatry. 2011 Dec 5. [Epub ahead of print]

(2) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard O, Mortensen PB. First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital in women with a history of treated mental disorder. Arch Gen Psychiatry. 2012 Feb;69(2):159-65.

(3) Munk-Olsen T, Laursen TM, Pedersen CB, Lidegaard Ø, Mortensen PB. Induced first-trimester abortion and risk of mental disorder. N Engl J Med. 2011 Jan 27;364(4):332-9.

(4) Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low income women following abortion and childbirth. Can Med Assoc J. 2003; 168(10):1253-7.

(5) Coleman PK, Reardon DC, Rue VM, Cougle JR.State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years. American Journal of Orthopsychiatry, 2002; 72(1):141–52.

(6) Reardon DC, Coleman PK. Relative treatment rates for sleep disorders and sleep disturbances following abortion and childbirth: a prospective record-based study. Sleep. 2006 Jan;29(1):105-6.

(7) Burke T, Reardon DC. Forbidden Grief. The Unspoken Pain of Abortion. Springfield, IL: Acorn Books; 2002.

(8) Stotland NL. Abortion: social context, psychodynamic implications. Am J Psychiatry. 1998 Jul;155(7):964-7.

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

====='''Oversight of Bipolar Disorder Link to Abortion Demonstrated by Subsequent 2015 Study'''=====

Munk-Olsen's failure to account for prior abortion history in this study is underscored by a new study in the J''ournal of Affective Disorders'', in which researchers found that 42.4 percent of the women with bipolar disorders had a history of abortion compared to only 13.5 percent of the control group, with a relative risk of 1.9778 (95% CI, 1.2660-3.0900). (Marengo E, Martino DJ, Igoa A, Scápola M, Fassi G, Baamonde MU, Strejilevich SA. [http://www.ncbi.nlm.nih.gov/pubmed/25827504 Unplanned pregnancies and reproductive health among women with bipolar disorder.] J Affect Disord. 2015 Jun 1;178:201-5.)

----

====Bipolar Affective Disorders 2====

'''[http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2015.15010124?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis.] Wesseloo R, Kamperman AM, Munk-Olsen T, Pop VJ, Kushner SA, Bergink V. Am J Psychiatry. 2015 Oct 30:appiajp201515010124.'''

:OBJECTIVE: Women with a history of bipolar disorder, postpartum psychosis, or both are at high risk for postpartum relapse. The aim of this meta-analysis was to estimate the risk of postpartum relapse in these three patient groups.

:METHOD: A systematic literature search was conducted in all public medical electronic databases, adhering to the PRISMA guidelines. Studies were included if they reported postpartum relapse in patients diagnosed with bipolar disorder and/or a history of postpartum psychosis or mania according to DSM or ICD criteria or the Research Diagnostic Criteria.

:RESULTS: Thirty-seven articles describing 5,700 deliveries in 4,023 patients were included in the quantitative analyses. The overall postpartum relapse risk was 35% (95% CI=29, 41). Patients with bipolar disorder were significantly less likely to experience severe episodes postpartum (17%, 95% CI=13, 21) than patients with a history of postpartum psychosis (29%, 95% CI=20, 41). Insufficient information was available to determine relapse rates for patients with bipolar disorder and a history of postpartum episodes. In women with bipolar disorder, postpartum relapse rates were significantly higher among those who were medication free during pregnancy (66%, 95% CI=57, 75) than those who used prophylactic medication (23%, 95% CI=14, 37).

:CONCLUSIONS: One-third of women at high risk experience a postpartum relapse. In women with bipolar disorder, continuation of prophylactic medication during pregnancy appears highly protective for maintaining mood stability postpartum. In women with a history of isolated postpartum psychosis, initiation of prophylaxis immediately after delivery offers the opportunity to minimize the risk of relapse while avoiding in utero medication exposure.

----

====Anti-Depressants Study====

'''[http://www.ncbi.nlm.nih.gov/pubmed/22118213 Prevalence of antidepressant use and contacts with psychiatrists and psychologists in pregnant and postpartum women.] Acta Psychiatr Scand. 2012 Apr;125(4):318-24. doi: 10.1111/j.1600-0447.2011.01784.x. Epub 2011 Nov 25. Munk-Olsen T, Gasse C, Laursen TM.'''

:Abstract
:OBJECTIVE: We aimed to study prevalence of antidepressant drug use from 12 months prior childbirth to 12 months postpartum and to compare the prevalences with those in a group of women of similar age who did not give birth. We additionally studied prevalences of contacts with private practicing psychiatrists and psychologists during a similar time period.

:METHOD: Our study population comprised of pregnant women, and their controls were drawn from a 25% sample of the entire Danish population. Information on redeemed prescriptions for antidepressants and referrals to psychiatrists and psychologists was extracted. The outcome measure was period prevalence calculated in 3-month intervals from 12 months before childbirth to 12 months postpartum.

:RESULTS: In the 2-year observation period around childbirth, 2733 (3.17%) women had one or more prescriptions for an antidepressant and 935 (1.18%) and 1399 (1.76%) were referred to consultations with a psychiatrist or psychologist, respectively. Women giving birth had a markedly lower use of antidepressants compared to controls, with the largest observed difference during third trimester of pregnancy (0.6% vs. 2.20%).

:CONCLUSION: We found that the prevalence of redeemed prescriptions for antidepressants decreased during pregnancy and increased postpartum. Similar patterns were observed for contacts with private practicing psychiatrists and psychologists.

:Remarks: This study is deeply flawed by the following major factors: (1) It excludes women under 18; (2) It ignores the effects of multiple abortions; (3) It looks only at first time prescription of antidepressants, thereby failing to investigate the frequency, dosage level, and duration of depressive symptoms, much less how women with a prior history of depression may be made better or worse by exposure to abortion. All it really tells us is that the "type" of woman most likely to have a pregnancy for which she may seek an abortion is more likely than women who do not have abortions to be prone to depression. It does not tell us if abortion worsens or improves her condition. It is only argued (irrationally) that since women who have abortions are more likely to be prone to depression we can ignore the effects of abortion, or more precisely, that abortion therefore CANNOT be a contributing factor to abortion. See additional [[http://abortionrisks.org/index.php?title=Munk-Olsen_et_al#Criticisms detailed listing of problems here.]]

'''Request for Additional Analysis (Refused)'''
[http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.2012.01880.x/abstract;jsessionid=08606AE0A36FC3A0728DF6D0A375F4A5.d01t02 Lack of pregnancy loss history mars depression study.] Reardon DC. Acta Psychiatr Scand. 2012 Aug;126(2):155; author reply 155-6. doi: 10.1111/j.1600-0447.2012.01880.x. Epub 2012 May 23.

:Dear Editor,

:The Munk-Olsen team’s study of antidepressant use and psychological treatments before, during, and after childbirth(1) unfortunately omits any control for the effects of prior pregnancies and any comparison to other pregnancy outcomes.

:A history of pregnancy loss (including induced abortion or miscarriage) can be a stressor that may arouse unresolved feelings during and following subsequent pregnancies.(2)(3)(4) This is also evidenced by findings that women with a history of abortion are significantly more likely to self-medicate with drugs or alcohol during a subsequent pregnancy than women without a history of this pregnancy loss.(5)

:The Munk-Olsen study would have been much more informative if it had included (a) controls for prior pregnancy outcomes, and (b) parallel analyses showing the treatment rates a year before and after other pregnancy outcomes, including abortion, miscarriage, and other natural losses.

:The failure to provide this additional analysis is most striking given the fact that Munk-Olsen has used the same data to publish a much more nuanced comparison of psychiatric treatment rates among women who have abortions and women who carry to terms.

:Both the American Psychological Task Force on Abortion and Mental Health and the Royal College of Psychiatry have called for more research regarding abortion and mental health.

:In a broad sense, efforts to study the interactions between reproductive health and mental health will never be reliable as long as researchers ignore or suppress analyses which fail to encompass the full reproductive history of women, including both voluntary and involuntary pregnancy losses.

:Journal editors and peer reviewers should be alert to this problem and should heed the call for better research by demanding that every study regarding reproductive outcomes and mental health should include segregated results allowing for direct comparison of outcome variables relative to the entire range of pregnancy outcomes: live birth, abortion, miscarriage, and other natural losses. By pressing researchers to address and report on these related pregnancy issues, reviewers and editors will helping to advance more rigorous investigation of all of these issues. Without such requests for more detailed analyses, study designs can easily be fashioned to avoid or minimize the investigation of controversial issues.

:It is my hope that Munk-Olsen will address the research imperatives raised herein by expanding the study design presented in the present paper.(1) Reanalysis should include segregated results allowing comparisons between: (a) delivering women with no history of pregnancy loss, (b) delivering women with a history of one abortion, (c) delivering women with a history of two or more abortions, (d) delivering women with a history of one miscarriages, (e) delivering women with a history of two or more miscarriages, and treatment rates for (f) women with no prior pregnancy whose first pregnancy is aborted, and (g) women with no prior live birth who have two or more abortions or other losses.

:David C. Reardon, Ph.D.
:Elliot Institute

:References

:(1) Munk-Olsen T, Gasse C, Laursen TM. Prevalence of antidepressant use and contacts with psychiatrists and psychologists in pregnant and postpartum women. Acta Psychiatr Scand. 2011 Nov 25. doi: 10.1111/j.1600-0447.2011.01784.x. [Epub ahead of print]
:(2) Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low income women following abortion and childbirth. Can Med Assoc J. 2003; 168(10):1253-7.
:(3) Burke T, Reardon DC. Forbidden Grief. The Unspoken Pain of Abortion. Springfield, IL: Acorn Books; 2002.
:(4) Stotland NL. Abortion: social context, psychodynamic implications. Am J Psychiatry. 1998 Jul;155(7):964-7.
:(5) Coleman PK, Reardon DC, Cougle JR. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. Br J Health Psychol. 2005 May;10(Pt 2):255-68.

----

===Psychiatric disorders following fetal death: a population-based cohort study.===

''[http://www.ncbi.nlm.nih.gov/pubmed/24907247 Psychiatric disorders following fetal death: a population-based cohort study.] Munk-Olsen T, Bech BH, Vestergaard M, Li J, Olsen J, Laursen TM. BMJ Open. 2014 Jun 6;4(6):e005187. doi: 10.1136/bmjopen-2014-005187.''

:OBJECTIVES:Women have increased risks of severe mental disorders after childbirth and death of a child, but it remains unclear whether this association also applies to fetal loss and, if so, to which extent. We studied the risk of any inpatient or outpatient psychiatric treatment during the time period from 12 months before to 12 months after fetal death.

:PARTICIPANTS: A total of 1,112,831 women born in Denmark from 1960 to 1995 were included. In total, 87,687 cases of fetal death (International Classification of Disease-10 codes for spontaneous abortion or stillbirth) were recorded between 1996 and 2010.

:PRIMARY AND SECONDARY OUTCOME MEASURES: The main outcome measures were incidence rate ratios (risk of first psychiatric inpatient or outpatient treatment).

:RESULTS: A total of 1379 women had at least one psychiatric episode during follow-up from the year before fetal death to the year after. Within the first few months after the loss, women had an increased risk of psychiatric contact, IRR: 1.51 (95% CI 1.15 to 1.99). In comparison, no increased risk of psychiatric contact was found for the period before fetal death. The risk of experiencing a psychiatric episode was highest for women with a loss occurring after 20 weeks of gestation (12 month probability: 1.95%, 95% CI 1.50 to 2.39).

:CONCLUSIONS: Fetal death was associated with a transient increased risk of experiencing a first-time episode of a psychiatric disorder, primarily adjustment disorders. The risk of psychiatric episodes tended to increase with increasing gestational age at the time of the loss.

:'''EDITOR'S NOTES:'''
#Once again, even though other researchers have shown that ''abortion and miscarriage are both associated with higher rates'' of subsequent psychiatric disorders. See for example: [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.] Munk-Olsen's team chose to use a different definition of pregnancy loss so as to exclude reporting on the effects associated with induced abortion.
#This analysis actually does indicate that the results were modified by "controlling for induced abortions" but meticulously avoids showing readers how induced abortions impacted the results. This actually involves an amazing dance to avoid disclosure of her findings. Munk-Olsen sees that induced abortion history is a significant factor and needs to be used as an adjustment of the results but she does not want anyone else to see how abortion history is affecting the results. So, not only does she not give results associated with abortion, she simply adds a note at the bottom of the tables indicating that the results were adjusted for numerous factors, including abortion history.
#This study used a 12 month period before the date of fetal death (not 9 months) and also excluded women with psychiatric contact before the pregnancy outcome "as well as women with records of spontaneous abortions and stillbirths prior to the start of the followup period." In other words, unlike her abortion studies, in this study she limited the study to the healthiest set of women to reduce the number of confounding factors. by contrast, in her abortion study, she introduces as many confounding factors as possible.

'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250401/ Does childbirth cause psychiatric disorders? A population-based study paralleling a natural experiment.] Munk-Olsen T, Agerbo E. Epidemiology. 2015;26(1):79-84.
'''
Background: Childbirth is associated with increased risk of first-time psychiatric episodes, and an unwanted pregnancy has been suggested as a possible etiologic contributor. To what extent childbirth causes psychiatric episodes and whether a planned pregnancy reduces the risk of postpartum psychiatric episodes has not been established.

Methods: We conducted a cohort study using data derived from Danish population registers, including all women having in vitro fertilization (IVF) treatment and their partners with recorded information in the IVF register covering fertility treatments in Denmark at all public and private treatment sites from January 1994 to December 2005. We compared parents and childless persons to examine whether childbirth is directly associated with onset of first-time psychiatric episodes, with incidence rate ratios (risk of first psychiatric inpatient or outpatient treatment) as the main outcome measures.

Results: The incidence rate for any type of psychiatric disorder 0-90 days postpartum was 11.3 per 1000 person-years (95% confidence interval = 8.2-15.0), and 3.8 (3.4-4.3) among women not giving birth. IVF-treated mothers had an increased risk of a psychiatric episode postpartum, incidence rate ratio = 2.9 (2.0-4.2) compared with the risk of psychiatric episodes in childless women. Risk of psychiatric episodes from 90 days postpartum and onwards was decreased (incidence rate ratio = 0.9 [0.7-1.0]).

Conclusions: Using a study design paralleling a natural experiment, our results showed that childbirth is associated with first-time psychiatric disorders in new mothers, indicating that a planned pregnancy does not reduce risks of or prevent postpartum psychiatric episodes.

'''NOTES:''' This was a weak study in many respects since IVF mothers may dissimilar to other delivering women in many ways. They may, for example, have a higher rate of prior abortions or miscarriages which are associated with elevated rates of post-partum depression in subsequent pregnancies. Notably, the authors report that they did control for prior history of abortion but they failed to report the rates of abortion or anything about how abortion affected the results . . . thereby concealing the effects of abortion even though the fact that they controlled for abortion signals that it had a significant effect on post-partum treatment rates.

More precisely, while the study found that treatment rates for depression were higher in the first 90 days following IVF deliveries, compared to the rates for not pregnant women, there was no difference beyond the first 90 days.

In the discussion, the authors conclude that since women seeking IVF treatment want their babies, "our results indicate that pregnancy intention does not reduce the risks of having a severe psychiatric episode requiring treatment at a psychiatric facility after a delivery." But if this is true, delivering an intended pregnancy does not reduce the risk of postpartum depression, then this is evidence that delivering an unintended pregnancy does not increase postpartum depression either since intention is not a predictor of postpartum depression.

----

== First Time Psychiatric Hospitalization -- Changing the Yard Stick ==

It's notable that a [http://jama.jamanetwork.com/article.aspx?articleid=204395 2006 study of postpartum psychological illness] done by Munk-Olsen does not match up with the results she reported for women giving birth in her [http://www.nejm.org/doi/full/10.1056/NEJMoa0905882 2011 study published in the New England Journal of Medicine] (NEJM).

In the 2006 study she reports first time psychiatric hospitalization rates for women following a first live birth (table 1) that are much, much lower than what she reported in her 2011 abortion/childbirth study (figure 1).

For example, in the second month after delivery, she reports an admissions rate of 2.87 per 1000 person years in the 2006 study, but a just under 12 per 1000 person years in her 2011 NEJM study (compared to about 18 per 1000 person years for women who had abortions).

What can explain this huge difference when she is supposedly reporting the same statistic for the same group of women in two different studies?

Well, in the 2006 study she excludes all women with a history of inpatient psychiatric care prior to their first delivery. That's a very reasonable approach if you want to measure how childbirth may impact emotionally healthy women. It is the same approach that could have and should have been used in the 2011 study.

But no, in the 2011 study she changes her protocol for unexplained reasons. In the 2011 study she suddenly decides to exclude only those women who had inpatient psychiatric care in the nine months prior to the abortion abortion or delivery which she is charting. She didn't choose one year, but nine months. Moreover, she didn't choose nine months or one year prior to the estimated conception date, but instead, prior to the outcome date...that means delivering women were pregnant almost the entire time and aborting women were pregnant for two to three months of that 9-month period which is pivotal for her comparisons.

Clearly, the exact same protocol use in the 2006 study could have been done. But no, in the 2006 study, she simply decides "pregnancies ending in abortion (both elective abortions and miscarriages) were not included in the study." This itself is very odd, since a well known [http://www.cmaj.ca/content/168/10/1253.long 2003 study by Reardon] looked at psychiatric admissions after not only childbirth, abortion, and miscarriage, but also at combinations of these, for women who experienced both live births and voluntary and involuntary pregnancy losses. Normally, researchers try to build on prior research and improve the methodology employed, not water it down to show fewer results.

In any case, Munk-Olsen not only failed to replicate Reardon's protocol which gives a breakdown by exposure to all the various pregnancy outcomes, but she actually chose to water down her own established protocol to avoid reporting on the healthiest women (those without inpatient psychiatric care prior to their first delivery).

There's only one explanation for this. She needed to shift her approach in order to produce results that were more easily interpreted to advance her preconceived goal of blaming the higher rates of mental health problems following abortion on pre-existing mental health problems. Toward this end, she abandoned her 2006 methodology which employed women with the least compromised prior mental health (no prior inpatient psychiatric history) and instead chose to include women with prior psychiatric inpatient care.

By including women with more prior history of severe mental illness, she could blame the differences observed in the 2011 study on prior mental health problems. At the same time, she could avoid reporting on the psychological effects associated with abortion among women with no known history of prior psychiatric inpatient care (the same control group used in Reardon's 2003 study). Her desire to hide the impact of abortion on women with the least history of severe mental illness is underscored by her second 2011 study, published in [http://abortionrisks.org/index.php?title=Munk-Olsen_et_al#First-time_first-trimester_induced_abortion_and_risk_of_readmission_to_a_psychiatric_hospital Archives of General Psychiatry] in which she specifically focuses on the women with prior history of mental health problems but fails to show how the same analysis applies to women without a prior history of mental health problems.

Notably, in both of her abortion studies, she also ignored all requests to examine whether or not the women with prior mental health problems had '''more frequent''' need for mental health care after their abortions. In other words, she claims that the higher rate of mental health problems following abortion may be entirely explained by higher rates of prior mental health problems among women who abort, but she also refuses to examine if these same women have more frequent or more severe (or less frequent or less severe) mental health issues after their abortions. She simply asserts that abortion has no impact on mental health without measuring the frequency or severity of mental health crises before and after abortions.

===Other Munk-Olsen Studies with Better Methodology===

'''[http://informahealthcare.com/doi/abs/10.3109/02813432.2015.1041832 Use of primary health care prior to a postpartum psychiatric episode.] Munk-Olsen T, Pedersen HS, Laursen TM, Fenger-Grøn M, Vedsted P, Vestergaard M. Scand J Prim Health Care. 2015 Jun;33(2):127-33. doi: 10.3109/02813432.2015.1041832. Epub 2015 Jul 15.A'''

:OBJECTIVE: Childbirth is a strong trigger of psychiatric episodes. Nevertheless, use of primary care before these episodes is not quantified. The aim was to study the use of general practice in Denmark from two years before to one year after childbirth in women who developed postpartum psychiatric disorders.

:DESIGN: A matched cohort study was conducted including women who gave birth in the period 1996-2010. Women were divided into four groups: (i) all mothers with postpartum psychiatric episodes 0-3 months after birth, n = 939; 2: All mothers with a postpartum psychiatric episode 3-12 months after birth, n = 1 436; and (iii) two comparison groups of mothers, total n = 6 630 among 320 620 eligible women.

:SUBJECTS: Women born in Denmark after 1 January 1960, restricting the cohort to women who gave birth to their first singleton child between 1 January 1996 and 20 October 2010.

:MAIN OUTCOME MEASURES: The main outcome measures were consultation rates, consultation rate ratios, and rate differences.

:RESULTS: Women who developed a psychiatric episode after childbirth had higher GP consultation rates before, during, and after the pregnancy. Women with a psychiatric episode 0-3 months postpartum had 6.89 (95% CI 6.60; 7.18) mean number of consultations during pregnancy, corresponding to 1.52 (95% CI 1.22; 1.82) more visits than the comparison group.

:CONCLUSION: Women with a postpartum psychiatric episode had higher use of GP-based primary health care services years before the childbirth, and in this specific group of patients childbirth itself triggered a marked increase in the number of GP contacts postpartum.

''':NOTES:'''
*In this study Munk-Olsen excluded women with any history of prior outpatient or inpatient psychiatric treatment prior to childbirth. This should also have been done in her abortion studies.
*Her analysis did not examine the effects of prior pregnancy loss on post-partum depression, even though research by [http://www.ncbi.nlm.nih.gov/pubmed/24007380 Giannandrea (2013)] has shown that women with a history of miscarriage and/or induced abortion are at higher risk of postpartum psychiatric problems, including depression, anxiety, and PTSD.
*Her analysis included tabulations of the number of average number of consultations women had with their physicians displayed over a monthly basis for over three years. In response to a query for this type of measurement of frequency of contact for psychiatric care after abortion, she had previously claimed it was too hard to do and might be misleading.
*These criticisms were raised in a [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4750743/ letter to the editor which was published]. Munk-Olsen declined the opportunity to respond.

=== Overview of Danish Researchers Avoiding Analyses that Would Shed Light on Abortion ===
A series of studies on post-partum mental health from Denmark have demonstrated diligent efforts to conceal the negative effects of abortion on women's mental health, according to an article published in the ''Scandinavian Journal of Primary Health Care''.

The research team, led by Trine Munk-Olsen, specializes in analyses of Denmark's national medical records, especially pertaining to mental health treatments associated with women's reproductive health. Notably, of over two dozen such studies, in only two does Munk-Olsen report on the mental health treatments associated with induced abortion.

Munk-Olsen's most recent study found that among women receiving psychiatric care after giving birth were more likely to have sought treatment from a primary care provider before, during and after pregnancy. Based on this finding, Munk-Olsen asserts that childbirth is a psychological stressor that can be "a strong trigger of psychiatric episodes."

Notably, this is a frequent assertion made in Munk-Olsen’s studies: childbirth triggers mental health problems. On the other hand, in the only two studies she has published reporting on mental health effects associated with abortion, she has argued that abortion has no impact on mental health.

In a criticism of Munk-Olsen’s latest study [https://www.tandfonline.com/doi/full/10.3109/02813432.2015.1111710 published in the ''Scandinavian Journal of Primary Health Care''], David Reardon, director of the Elliot Institute and one of the most published researchers on abortion and mental health issues, questions the validity of Munk-Olsen's finding. He is especially critical of the manner in which she modifies her research methods to produce results to avoid reporting on the negative effects of abortion.

Reardon points out, for example, that in Munk-Olsen’s most recent study examining medical records of women who had postpartum psychiatric treatments she chose to ignore the effects of prior pregnancy losses, abortions and miscarriages, on treatment rates. At the very least, this was a serious oversight since previous research has shown that women exposed to prior pregnancy losses are at higher risk of post-partum depression and other mental health issues. Reardon asserts that Munk-Olsen was clearly aware of this connection base on her own prior research, much less that of others in the field. By excluding this from her most recent study, Munk-Olsen appears builds a platform to argue that the differences in primary care treatments among women with mental health issues following delivery are due to childbirth alone when in fact a more detailed analysis, as demonstrated by other researchers, is likely to show that the heightened risks are more likely due to prior abortions and miscarriages.

Reardon’s letter goes on to assert that Munk-Olsen has repeatedly altered her research methodology precisely in ways designed to avoid showing the effects of abortion on mental health. For example:

# In a study of bipolar disorders following delivery, Munk-Olsen ignored prior research linking abortion to elevated rates of bipolar disorder, and once again chose to exclude any examination of women’s prior exposure to abortion and miscarriage. When this oversight was called to hear attention, she refused to run additional analyses . . . or at least to report on her results from such analyzes.
# In a study of the [[Munk-Olsen et al#Anti-Depressants Study|rates of anti-depressant use among pregnant and post-partum women]], Munk-Olsen yet again refused a request, published in the same journal, to provide a breakdown of anti-depressant use among the same women relative to their past exposure to abortions.
# In a study of [[Munk-Olsen et al#Psychiatric disorders following fetal death: a population-based cohort study.|psychiatric interventions following miscarriage]], Munk-Olsen revealed in a footnote that she actually did control for prior history of abortion, but once again refused requests to provide any information showing how abortion itself affected the rates of psychiatric treatment.

Munk-Olsen has only reported on mental health treatment rates following abortion in [[Munk-Olsen et al#Induced First-Trimester Abortion and Risk of Mental Disorder.|two studies]], both of which were used to boldly proclaim that abortion has no effect on mental health. But Reardon asserts that Munk-Olsen chose to deviate from her own prior methodology, and that of other researchers in the field, in order to massage her data in a way that would minimize and obscure the effects of abortion on mental health.

For example, in Munk-Olsen’s first abortion study, published in 2011, she compares inpatient and outpatient psychiatric treatments for nine months before the abortion or first childbirth took place and twelve months afterward. But the time frames and inclusion criteria used for this 2011 study were markedly changed from a similar study she had done in [[Munk-Olsen et al#First Time Psychiatric Hospitalization -- Changing the Yard Stick|2006 examining mental health treatment rates following childbirth]]. In the 2006 study she excluded all women with a history of inpatient psychiatric care prior to their first delivery in order to measure how childbirth might impact emotionally healthy women. But in the 2011 study, she excluded only women with a history of inpatient psychiatric care 9 months prior to their abortion or delivery. The only possible explanation for changing her methodology in this way was that it produced results she preferred to present––or concealed results she did not want to present.

An even more serious flaw in her 2011 study was that she included women who had abortions in both groups! Unlike previous researchers who compared women who aborted their first pregnancies to women who gave birth to their first pregnancies, Munk-Olsen included women with prior abortions who later gave birth into the childbirth group. Every researcher knows this mixing would tend dilute the differences between the two groups being compared. It is simply bad technique––but useful if your goal is to obfuscate rather than illuminate.

Despite these study design choices that were clearly meant to minimize findings regarding psychological effects of abortion, her study still showed that women who had abortions Women who have abortions had significantly higher rates of psychiatric treatment (15.2 per 1000 person years) compared to both delivering women (6.7 per 1000 person years) and women who have not been pregnant (8.2 per 1000 person years). It also found that relative risk for psychiatric visits involving neurotic, stress-related, or somatoform disorders was significantly higher for women post-abortion compared to pre-abortion at 2 and 3 months respectively and that treatment for personality or behavioral disorders was 56%, 45%, 31%, and 55% higher at 3, 4-6, 7-9, and 10-12 months respectively.

Indeed, when the data provided is [https://zenodo.org/records/10684720 reanalyzed over the cumulative rates] of first time psychiatric treatment over the full 12 months, the post-abortion treatment rates was significantly higher across all psychiatric diagnoses. The fact that first-time psychiatric contact increased from an odds ratio of 1.12 (95% CI: 1.02 to 1.22) to 1.49 (95% CI: 1.37 to 1.63) for the cumulative post-abortion periods of 9 months and 12 months demonstrates that the effects increase with time. This suggests that Munk-Olsen deliberately chose to analyses the results in one month and three month increments precisely to hide the effects that are evident over longer periods of time. Notably, at 12 months post-abortion, the rates of psychiatric diagnosis were significantly higher across all four diagnostic groupings and most strongly 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).

Despite these findings, Munk-Olsen argues that all of these results can be ignored because, in her view, women with a propensity to mental illness are simply more likely to have abortions, which may, in her view, be a good thing. But [[Munk-Olsen et al#Induced First-Trimester Abortion and Risk of Mental Disorder.|as criticisms of her study have elsewhere noted]], even her selectively reported data does not support this broad assertion.

Munk-Olsen second study of mental health effects associated with abortion was [[Munk-Olsen et al#First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital|even more severely flawed]]. But once again, [[Munk-Olsen et al#Munk Olsen.27s Response|Munk-Olsen refused]] to provide any additional data that would either confirm or refute her selectively reported results.

== References ==
{{reflist|refs=}}

Mifepristone

2024-02-13T14:38:56Z

WikiSysop:

Mifepristone is also known as RU-486, the abortion pill, medical abortion, or chemical 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.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.

Mifepristone

2024-02-13T14:36:23Z

WikiSysop:

Mifepristone is also known as RU-486

'''" 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.

Mifepristone

2024-02-13T14:34:48Z

WikiSysop:

Mifepristone is also known as RU-486

" 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.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.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 ]

[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.

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

2010-06-09T16:03:50Z

Category:Research

2010-06-08T16:30:46Z

WikiSysop:

2010-06-08T16:24:28Z

WikiSysop: Created page with ' '