Psychological Reactions to Second and Third Trimester Abortion

Thomas W. Strahan Memorial Library
Index
Standard of Care for Abortion
Abortion Decision-Making
Psychological Effects of Abortion
Social Effects and Implications
Physical Effects of Abortion
Abortion and Maternal Mortality
Adolescents and Abortion
Definition of Terms
Women's Health After Abortion
Material Yet to be Cataloged
Strahan Summary Articles

Sub-Index
Psychological Effects
Validity of Studies
Reviews
Risk Factors
PTSD
Grief and Loss
Guilt
Ambivalence or Inner Conflict
Anxiety
Intrusion / Avoidance / Nightmares
Denial
Dissociation
Narcissism
Self-Image
Self Punishment
Depression
Psychiatric Treatment
Self-Destructive Behavior
Substance Abuse
Long-Terms Effects of Abortion
Replacement Pregnancies
Sterilization
Impact of Abortion On Others
Violence
Rape, Incest, Sexual Assault
After Late Term Abortion

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This section includes studies related to eugenic abortions and therapeutic abortions.

Later Abortions and Mental Health: Psychological Experiences of Women Having Later Abortions—A Critical Review of Research. Steinberg JR. Womens Health Issues. 2011 May-Jun;21(3 Suppl):S44-8. doi: 10.1016/j.whi.2011.02.002.

BACKGROUND: Some abortion policies in the U.S. are based on the notion that abortion harms women's mental health. The American Psychological Association (APA) Task Force on Abortion and Mental Health concluded that first-trimester abortions do not harm women's mental health. However, the APA task force does not make conclusions regarding later abortions (second trimester or beyond) and mental health. This paper critically evaluates studies on later abortion and mental health in order to inform both policy and practice.

METHOD: Using guidelines outlined by Steinberg and Russo (2009), post 1989 quantitative studies on later abortion and mental health were evaluated on the following qualities: 1) composition of comparison groups, 2) how prior mental health was assessed, and 3) whether common risk factors were controlled for in analyses if a significant relationship between abortion and mental health was found. Studies were evaluated with respect to the claim that later abortions harm women's mental health.

RESULTS: Eleven quantitative studies that compared the mental health of women having later abortions (for reasons of fetal anomaly) with other groups were evaluated. Findings differed depending on the comparison group. No studies considered the role of prepregnancy mental health, and one study considered whether factors common among women having later abortions and mental health problems drove the association between later abortion and mental health.

CONCLUSION: Policies based on the notion that later abortions (because of fetal anomaly) harm women's mental health are unwarranted. Because research suggests that most women who have later abortions do so for reasons other than fetal anomaly, future investigations should examine women's psychological experiences around later abortions.

Grief after second-trimester termination for fetal anomaly: a qualitative study. Maguire M, Light A, Kuppermann M, Dalton VK, Steinauer JE, Kerns JL. Contraception. 2015 Mar;91(3):234-9. doi: 10.1016/j.contraception.2014.11.015. Epub 2014 Dec 12.

OBJECTIVES: We aimed to qualitatively evaluate factors that contribute to and alleviate grief associated with termination of a pregnancy for a fetal anomaly and how that grief changes over time.

STUDY DESIGN: We conducted a longitudinal qualitative study of decision satisfaction, grief and coping among women undergoing termination (dilation and evacuation or induction termination) for fetal anomalies and other complications. We conducted three post-procedure interviews at 1-3 weeks, 3 months and 1 year. We used a generative thematic approach to analyze themes related to grief using NVivo software program.

RESULTS: Of the 19 women in the overall study, 13 women's interviews were eligible for analysis of the grief experience. Eleven women completed all three interviews, and two completed only the first interview. Themes that contributed to grief include self-blame for the diagnosis, guilt around the termination decision, social isolation related to discomfort with abortion and grief triggered by reminders of pregnancy. Social support and time are mechanisms that serve to alleviate grief.

CONCLUSIONS: Pregnancy termination in this context is experienced as a significant loss similar to other types of pregnancy loss and is also associated with real and perceived stigma. Women choosing termination for fetal anomalies may benefit from tailored counseling that includes dispelling misconceptions about cause of the anomaly. In addition, efforts to decrease abortion stigma and increase social support may improve women's experiences and lessen their grief response.

IMPLICATIONS: The nature and course of grief after second-trimester termination for fetal anomaly are, as of yet, poorly understood. With improved understanding of how women grieve over time, clinicians can better recognize the significance of their patients' suffering and offer tools to direct their grief toward positive coping.

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.

METHODS: Medical TOP (MTOP) using mifepristone and misoprostol or surgical TOP (STOP) by vacuum aspiration at <15 weeks of gestation, and by dilatation and evacuation at 15 or more weeks of gestation.

MAIN OUTCOME MEASURES: Distress 2 weeks after TOP, measured by the impact of events scale (IES), and acceptability, measured by the proportion of women who would opt for the same procedure again.

RESULTS: One hundred and twenty two women were randomised: 60 to the MTOP group and 62 to the STOP group. Twelve women opted to continue their pregnancy. Follow-up rates were low (n=66/110; 60%). At 2 weeks post-procedure there was no difference in total IES score between groups. However, compared with women undergoing STOP, women undergoing MTOP had a higher score on the IES intrusion subscale (mean difference 6.6; 95% CI 1.4-11.8), and a higher score on the general health questionnaire (GHQ) (P=0.033). Women found STOP more acceptable: compared with MTOP, more women would opt for the same procedure again (100% versus 53%, P≤0.001), and fewer women found the experience to be worse than expected (0% versus 53%, P=0.001). Women who had MTOP experienced more bleeding (P=0.003), more pain on the day of the procedure (P=0.008), and more days of pain (P=0.020). Of the 107 women who declined to participate, 58 (67%) preferred a STOP.

CONCLUSIONS: Randomised trials of women requesting midtrimester TOP are challenging. Women found STOP less painful and more acceptable than MTOP.

Editor Comments: The closer a woman comes to "experiencing" versus "submitting" to an abortion, the more likely she is to readily experience intrusive symptoms characteristic of posttraumatic stress. One large French abortion clinic director put it this way:

"The difference between a surgical and a medical abortion is the difference between experiencing and submitting (un avortement médical est vécu; un avortement chirugical est subi). With a medical abortion, the woman usually experiences contractions, bleeding, waiting, and finally the sight of the expulsion. She participates, whereas with a surgical abortion it's over in two minutes and she has done nothing but submit to the physician . . ." 1

Also, the study is important to be aware of since there is a major transformation occurring both here and worldwide from surgical to medical abortions. Consider the following:

"Medical termination of pregnancy with mifepristone was approved in the United States in 2000 and is used in 31 countries worldwide. Approximately half of all abortions are performed with this method."2

The average IES scores reported for both surgical abortion (30.1) and medical abortion (36.8) indicate a significant likelihood of PTSD. An IES score over 26 is considered a "Powerful Impact Event—you are certainly affected."1 for which there is a 75% chance of PTSD.1

An IES score over 33 is considered a good cutoff score for probable PTSD.[1

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.

Neural Activation Underlying Acute Grief in Women After the Loss of an Unborn Child' Kersting A., et al. Am J Psychiatry. 2009 Dec;166(12):1402-10. Epub 2009 Nov 2.

OBJECTIVE: The traumatic loss of an unborn child by induced termination of pregnancy because of fetal malformation is a major life event that causes intense maternal grief. Increasing evidence supports the hypothesis that the same neural structures involved in the experience of physical pain are involved in the experience of social pain and loss. METHOD: To investigate neural activation patterns related to acute grief, the authors conducted a functional MRI study of 12 post-termination women and 12 noninduced women who delivered a healthy child. Brain activation was measured while participants viewed pictures of happy baby, happy adult, and neutral adult faces. RESULTS: Relative to comparison women, post-termination women showed greater activation in the middle and posterior cingulate gyrus, the inferior frontal gyrus, the middle temporal gyrus, the thalamus, and the brainstem in response to viewing happy baby faces. Functional connectivity between the cingulate gyrus and the thalamus during the processing of happy baby faces was significantly stronger in post-termination women. CONCLUSIONS: Overall, acute grief after the loss of an unborn child was closely related to the activation of the physical pain network encompassing the cingulate gyrus, the inferior frontal gyrus, the thalamus, and the brainstem. To the authors’ knowledge, the stronger functional thalamocingulate connectivity in post-termination women is the first in vivo demonstration of an involvement of the neural maternal attachment network in grief after the loss of an unborn child.

"Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth--a 14-month follow up study." Kersting A, Kroker K, Steinhard J, Hoernig-Franz I, Wesselmann U, Luedorff K, Ohrmann P, Arolt V, Suslow T. Arch Womens Ment Health. 2009 Aug;12(4):193-201. Epub 2009 Mar 6.

"The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting psychological impact."

Older Studies

A prospective study on parental coping 4 months after termination of pregnancy for fetal anomalies. Korenromp MJ et al.Prenat Diagn. 2007 Aug;27(8):709-16.

OBJECTIVE: To identify short-term factors influencing psychological outcome of termination of pregnancy for fetal anomaly, in order to define those patients most vulnerable to psychopathology.

STUDY DESIGN: A prospective cohort of 217 women and 169 men completed standardized questionnaires 4 months after termination. Psychological adjustment was measured by the Inventory of Complicated Grief (ICG), the Impact of Event Scale (IES), the Edinburgh Postnatal Depression Scale (EPDS), and the Symptom Checklist-90 (SCL-90).

RESULTS: Women and men showed high levels of posttraumatic stress (PTS) symptoms (44 and 22%, respectively) and symptoms of depression (28 and 16%, respectively). Determinants of adverse psychological outcome were the following: high level of doubt in the decision period, inadequate partner support, low self-efficacy, lower parental age, being religious, and advanced gestational age. Whether the condition was Down syndrome or another disability was irrelevant to the outcome. Termination did not have an important effect on future reproductive intentions. Only 2% of women and less than 1% of men regretted the decision to terminate.

CONCLUSION: Termination of pregnancy (TOP) for fetal anomaly affects parents deeply. Four months after termination a considerable part still suffers from posttraumatic stress symptoms and depressive feelings. Patients who are at high risk could benefit from intensified support.

Do women grieve after terminating pregnancies because of fetal anomalies? A controlled investigation. Zeanah CH1, Dailey JV, Rosenblatt MJ, Saller DN Jr. Obstet Gynecol. 1993 Aug;82(2):270-5.

OBJECTIVE: To test the hypothesis that grief responses do not differ between women who terminate their pregnancies for fetal anomalies and women who experience spontaneous perinatal losses.

METHODS: A case-control study was conducted. Twenty-three women who underwent terminations through the genetics service of a tertiary referral obstetric hospital from January 1991 to April 1992 were assessed psychiatrically 2 months after the termination. The grief responses of these women on the Perinatal Grief Scale and the Beck Depression Inventory were compared to a demographically similar group of women assessed 2 months after they experienced spontaneous perinatal loss. Differences between the groups were assessed through one-way analysis of covariance.

RESULTS: After matching women in the two groups, it became clear that women who terminated for fetal anomalies were significantly older than women in the comparison group, and age was inversely correlated with intensity of grief. Therefore, age was covaried in comparing the grief responses of women in the two groups. Neither statistically significant nor clinically meaningful differences were found in symptomatology between the groups. By the time of assessment, four of 23 women (17%) who terminated their pregnancies were diagnosed with a major depression, and five of 23 (22%) had sought psychiatric treatment.

CONCLUSIONS: Women who terminate pregnancies for fetal anomalies experience grief as intense as those who experience spontaneous perinatal loss, and they may require similar clinical management. Diagnosis of a fetal anomaly and subsequent termination may be associated with psychological morbidity.

"Why Do Women Have Abortions?" A Torres and JD Forrest, Family Planning Perspectives 20(4): 169, 1988.

An Alan Guttmacher Institute survey in 1987 who obtained abortions at 16 gestational weeks or later are significantly more likely to be teenagers under the age of 18, black women, unemployed women, or women covered by Medicaid. Abortions at 16 gestational weeks or more were more apt to be performed if the reason was possible fetal health problems, if the woman's parents wanted her to have an abortion, or if the pregnancy resulted from rape or incest. Women were significantly less likely to have an abortion at 16 gestational weeks or later if they were age 30 or older, if they had no religious affiliation, if they were having health problems, or if their husband or partner wanted them to have an abortion.

Induced Terminations of Pregnancy: Reporting States, 1988 KD Kochenek, National Center for Health Statistics, Monthly Vital Statistics Report 39(12) Supplement, April 30, 1991

Twenty-five percent of young women age 14 had abortions at 13 gestational weeks or greater compared to 19% of women age 16, 13.8% of women age 18, and 11.2% of women age 20-24.

Emotional Patterns Related to Delay in Decision to Seek Legal Abortion. N Kaltreider, Cal Med 118:23, 1973.

Women who have abortions in the second trimester are more likely to use the word " baby" to describe what is in her womb compared to women who have abortions in the first trimester who are more likely to use words such as " this pregnancy" or " this condition."

"Abortion Surveillance-United States, 1996," Koonin et al, MMWR 48/No.SS-4, July 30, 1999

11.0% of U.S. white women had abortions at 13 gestational weeks or more compared to 14.2% of black women, and 12.3% of Hispanic women.

"Psychodynamic aspects of delayed abortion decisions," JA Cancelmo et al, Br J Medical Psychology 65:333, 1992.

A study of New York City women found that abortion at later gestational ages was significantly associated with a greater disturbance of the basic sense of self due to gender/sexual conflict and lower levels of internalized striving or ambition.

"Delayed Abortion in an Area of Easy Accessibility," WA Burr, KF Schulz, JAMA 244 (1): 44, 1980.

Women with moral objections to abortion were more likely to have a late abortion compared to an early abortion. These moral conflicts included opposition of the woman to abortion as well as conflicted decisions.

Psycho-Social Stress Following Abortion, Anne Speckhard, (Kansas City, MO: Sheed&Ward, 1987)

A study of women with long term stress reactions following induced abortion had an overrepresentation of women who had abortions in the second trimester.

Post Abortion Trauma: 9 Steps to Recovery, Jeanette Vought, (Grand Rapids: Zondervan, 1991)

A religiously based postabortion recovery group had an overrepresentation of women with second or third trimester abortions.

"Psycho-Social Aspects of Late Term Abortions," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change Research Bulletin 14(4): 108, Jan/Feb 2000

Review Article

"Very and moderate preterm births: are the risk factors different?," Pierre-Yves Ancel et al, Br J Obstet Gynaecol 106: 1162-1170, Nov, 1999.

A study of preterm birth in 15 European countries found that among women with a previous second trimester abortion there was a 3.67 increased relative risk for very preterm birth (22-32 gestational weeks) and a 2.33 increased relative risk for moderate preterm birth (33-36 gestational weeks). Among women with a previous first trimester abortion there was a 1.86 increased relative risk for very preterm birth and a 1.58 increased risk for moderate preterm birth.

"Induced Abortion and Subsequent Pregnancy Duration," W Zhou et al, Obstet Gynecol 94:948-953, 1999.

A Danish study using national registries found that one evacuation had an overall increased relative risk of 2.27 for preterm birth compared to 1.82 for one vacuum aspiration abortion. Two evacuations had an overall increased relative risk of 12.55 for preterm birth compared to 2.45 overall increased relative risk for two vacuum aspirations. Ed Note: evacuations would most likely occur in the second trimester, while vacuum aspirations would occur in the first trimester.

Abortion for Fetal Anomaly

Stigma in the context of pregnancy termination after diagnosis of fetal anomaly: associations with grief, trauma, and depression. Hanschmidt F, Treml J, Klingner J, Stepan H, Kersting A. Arch Womens Ment Health. 2018 Aug;21(4):391-399. doi: 10.1007/s00737-017-0807-9. Epub 2017 Dec 29.

Termination of pregnancy after diagnosis of fetal anomaly (TOPFA) is a contested issue and stigma may negatively impact affected women's psychological reactions. This study examined the influence of perceived and internalized stigma on women's long-term adjustment to a TOPFA. One hundred forty-eight women whose TOPFA dated back 1 to 7 years responded to self-report questionnaires. The associations between perceived stigma at the time of the TOPFA, current internalized stigma and symptoms of grief, trauma and depression were modeled using multiple linear regression. The proportion of participants reporting scores above the cutoffs on the respective scale was 17.6% for grief, 18.9% for posttraumatic stress, and 10.8% for depression. After controlling for time since the TOPFA, pre-TOPFA mental health and obstetric variables, higher levels of current internalized stigma were related to higher levels of grief, trauma, and depression. Mediation analyses suggested that the effect of perceived stigma at the time of the TOPFA on symptoms of grief and trauma was mediated by current internalized stigma, but the cross-sectional design limited causal interpretation of results. Internalized stigma is associated with long-term psychological distress following a TOPFA. Perceived stigma at the time of the TOPFA may contribute to increased trauma and grief symptomatology, but results need to be validated in longitudinal studies. Health care providers and public initiatives should aim at reducing stigma among affected women.

Fetal Anomolies--Better Coping Without Abortion

Pregnancy continuation and organizational religious activity following prenatal diagnosis of a lethal fetal defect are associated with improved psychological outcome. Cope H, Garrett ME, Gregory S, Ashley-Koch A. Prenat Diagn. 2015 Aug;35(8):761-8. doi: 10.1002/pd.4603. Epub 2015 May 26.

OBJECTIVE: The aim of the article is to examine the psychological impact, specifically symptoms of grief, post-traumatic stress and depression, in women and men who either terminated or continued a pregnancy following prenatal diagnosis of a lethal fetal defect.

METHOD: This project investigated a diagnostically homogeneous group composed of 158 women and 109 men who lost a pregnancy to anencephaly, a lethal neural tube defect. Participants completed the Perinatal Grief Scale, Impact of Event Scale - Revised and Beck Depression Inventory-II, which measure symptoms of grief, post-traumatic stress and depression, respectively. Demographics, religiosity and pregnancy choices were also collected. Gender-specific analysis of variance was performed for instrument total scores and subscales.

RESULTS: Women who terminated reported significantly more despair (p = 0.02), avoidance (p = 0.008) and depression (p = 0.04) than women who continued the pregnancy. Organizational religious activity was associated with a reduction in grief (Perinatal Grief Scale subscales) in both women (p = 0.02, p = 0.04 and p = 0.03) and men (p = 0.047).

CONCLUSION: There appears to be a psychological benefit to women to continue the pregnancy following a lethal fetal diagnosis. Following a lethal fetal diagnosis, the risks and benefits, including psychological effects, of termination and continuation of pregnancy should be discussed in detail with an effort to be as nondirective as possible.

Lack of Benefits from Therapeutic Abortions

There is no statistically validated medical evidence that women facing any specific disease or fetal anomaly fair better if they have an abortion compared to similar women who allow the pregnancy to continue to a natural outcome (delivery, miscarriage, or still birth.)

''Therapeutic abortion: the medical argument. Murphy JF, O'Driscoll K. Irish Medical Journal. 1982 Aug;75(8):304-6.''

Editors note: There is no evidence that abortion can be used to actually reduce maternal mortality rates because there is no evidence that those women at risk of dying during a pregnancy are at less risk of dying from an abortion.

Abstract:This document analyzes all cases of maternal death between 1970-79 at the National Maternity Hospital, Dublin, Ireland, and speculates as to the number of lives which might have been saved by therapeutic abortion. 74,317 births were considered; there were 21 deaths, or a mortality rate of 0.28/1000. 7 women died for reasons that had nothing to do with pregnancy: 3 cases of malignant disease, 2 of cerebrovascular accident, 1 of road accident, and 1 of Weil's disease. Therapeutic abortion would not have altered the outcome of pregnancy in these cases. 11 women died of pregnancy complications, 4 of infection, 3 of embolism, 2 of hemorrhage, 1 of eclampsia, and 1 of liver rupture. These deaths, however, could not have been prevented by therapeutic abortion, since these complications could not have been foreseen. 3 women died of diseases which could be said to have made pregnancy more dangerous. However, in the 1st case no disease was suspected until necropsy demonstrated the lesion; in the 2nd case the fatal outcome was interpreted as the terminal state of a chronic process which would have occurred whether or not the woman had been pregnant. Only in the 3rd instance a reasonable case could have been made in favor of therapeutic abortion. However, the woman in question had purposely sought pregnancy for the 2nd time in 2 years, fully aware of the risk involved; she would not have accepted a therapeutic abortion. Thus, the conclusion seems to be that, in the series presented, therapeutic abortion would not have saved a single life. The most recent publication on therapeutic abortion, bearing on 57,228 deliveries at the Mount Sinai Hospital in New York between 1953-64, indicates that in over 69 cases of therapeutic abortion the degree of risk to the mother's life was debatable.

Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence. Fergusson DM, Horwood LJ, Boden JM. Aust N Z J Psychiatry. 2013 Apr 3. [Epub ahead of print]

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

Abstract

Objective:There have been debates about the linkages between abortion and mental health. Few reviews have considered the extent to which abortion has therapeutic benefits that mitigate the mental health risks of abortion. The aim of this review was to conduct a re-appraisal of the evidence to examine the research hypothesis that abortion reduces rates of mental health problems in women having unwanted or unintended pregnancy.

Methods:Analysis of recent reviews (Coleman, 2011; National Collaborating Centre for Mental Health, 2011) identified eight publications reporting 14 adjusted odds ratios (AORs) spanning five outcome domains: anxiety; depression; alcohol misuse; illicit drug use/misuse; and suicidal behaviour. For each outcome, pooled AORs were estimated using a random-effects model.

Results:There was consistent evidence to show that abortion was not associated with a reduction in rates of mental health problems (p>0.75). Abortion was associated with small to moderate increases in risks of anxiety (AOR 1.28, 95% CI 0.97-1.70; p<0.08), alcohol misuse (AOR 2.34, 95% CI 1.05-5.21; p<0.05), illicit drug use/misuse (AOR 3.91, 95% CI 1.13-13.55; p<0.05), and suicidal behaviour (AOR 1.69, 95% CI 1.12-2.54; p<0.01).

Conclusions:There is no available evidence to suggest that abortion has therapeutic effects in reducing the mental health risks of unwanted or unintended pregnancy. There is suggestive evidence that abortion may be associated with small to moderate increases in risks of some mental health problems.