Psychological Aspects of Abortion

In June 1996, an 18 year-old high school senior took a break from her senior prom, went in to a bathroom stall, delivered her baby boy, and left him dead in a garbage can. She returned to the prom and continued to socialize until later in the evening when janitors, cleaning blood off the walls of her delivery stall, discovered the tiny corpse wrapped in a plastic bag in the garbage can, whereupon teachers and paramedics made frantic efforts to resuscitate the baby.¹ In November 1996, two young college sweethearts delivered their unplanned baby in a motel room, allegedly killed him, and left his small body in a nearby dumpster.²

The powerful defense of denial coupled with the social stigma of an illegitimate birth undoubtedly contributed to these tragic circumstances. These cases and many others like them tug at our heart-strings and pose complex questions regarding unwanted pregnancies. Clearly, no two situations are exactly alike, and these gruesome tales are the exception and not the rule.

When a woman conceives unexpectedly, she faces a myriad of challenges—personal, relational and social. Her own ability and desire to parent, the impact of a child on her current life circumstances and relationships, the interest and capacity of her partner to parent, and the social and occupational context in which the pregnancy occurs are all critical considerations. The woman's psychological constitution, religious and political beliefs, and social and financial circumstances guide her decision-making at this juncture in her life.

Caregivers serve an essential role in this process, ideally providing education, support, and practical assistance in a nonjudgmental manner. This chapter presents the psychological aspects of pregnancy and abortion and is intended to guide caregivers in their management of patients who are considering or undergoing pregnancy termination.

Surgical abortion before quickening was not prohibited until 1829, when a section of the New York Revised Statutes did so, excepting the “therapeutic abortion” (i.e. an abortion performed in order to preserve the mother's life). It is thought that this legislation was enacted to protect women from unsafe abortion practices in an age when the control of infection and bleeding was primitive.³

In the mid 1800s, with the end of the Civil War and the professionalization of medicine with the establishment of the American Medical Association, an antiabortion movement began. In 1869, Pope Pius IX eliminated any distinction between a formed and unformed fetus in meting out the penalty of excommunication for abortion, even to save the mother's life.³ By 1900, abortion had been outlawed in America. Women seeking abortion turned to illegal and unsafe options, placing themselves at risk for loss of future fertility and life.

The Roe v Wade controversy in 1973 was the next milestone in the evolution of abortion legislation in the United States. The US Supreme Court ruled that unwanted first-trimester pregnancies could be terminated if the patient and her physician decided to do so. The past 35 years have been fraught with controversy over the availability of abortion, its ethical and moral implications, its impact on attitudes about sexual promiscuity and family values, and its association with a market for 'designer babies'. The abortion issue continues to place obstetricians in a pivotal psychosocial role with patients, taxing their broad skills as caregivers and involving them with surgical techniques and procedures they may or may not be comfortable with.

In December 1978, the American Psychiatric Association approved the following Position Statement on Abortion, which it continues to endorse today:⁴

The emotional consequences of unwanted pregnancy on parents and their offspring may to lead to long-standing life distress and disability, and the children of unwanted pregnancies are at high risk for abuse, neglect, mental illness, and deprivation of the quality of life. Pregnancy that results from undue coercion, rape, or incest creates even greater potential distress or disability in the child and the parent. The adolescent most vulnerable to early pregnancy is the product of adverse sociocultural conditions involving poverty, discrimination, and family disorganization, and statistics indicate that the resulting pregnancy is laden with medical complications which threaten the well-being of mother and fetus. The delivery that ensues from teenage pregnancy is prone to prematurity and major threats to the health of mother and child, and the resulting newborns have a higher percentage of birth defects, developmental difficulties, and a poorer life and health expectancy than the average for our society. Such children are often not released for adoption and thus get caught in the web of foster care and welfare systems, possibly entering lifetimes of dependency and costly social interventions. The tendency of this pattern to pass from generation to generation is very marked and thus serves to perpetuate a cycle of social and educational failure, mental and physical illness, and serious delinquency.

Because of these considerations, and in the interest of public welfare, the American Psychiatric Association(1) opposes all constitutional amendments, legislation, and regulation curtailing family planning and abortion services to any segment of the population; (2) reaffirms its position that abortion is a medical procedure in which physicians should respect the patient's right to freedom of choice—psychiatrists may be called on as consultants to the patient or physician in those cases in which the patient or physician requests such consultation to expand mutual appreciation of motivation and consequences; and (3) affirms that the freedom to act to interrupt pregnancy must be considered a mental health imperative with major social and mental health implications.

This position was not met with unanimous approval by the American Psychiatric Association's membership of 34,000 psychiatrists, although it followed the legal decision to permit abortion within the next five years.

In 1989, in the wake of a challenge to Roe v Wade, the trimester framework was eliminated, leaving specific legislation regarding abortion in the hands of each individual state. Although most abortions (90%) occur within the first trimester, ambiguity and conflict persist regarding second-trimester abortions (late abortions with extenuating circumstances such as rape, incest, fetal anomalies, and maternal distress, and partial birth abortions). The right of minors to consent to abortion without parental knowledge is another unresolved issue.^{5, 6}

Overall, the number and rate of legal abortions have steadily declined in the United States in the past 15 years.  A study published in Morbidity and Mortality Weekly Report in August 1997 revealed that 1.27 million abortions were reported to the CDC in 1994.⁷ In 2004, the number had dropped to 839,226. At that time, women aged 15 and younger continued to have the highest abortion ratios of 762 per 1000 live births. Women aged 30–34 had rates of 143 per 1000 and women aged greater than 40 had rates of 3 per 1000. The majority of abortions, 88%, were performed during the first trimester, and 61% were performed at less than eight weeks' gestation.⁸

Pregnancy is a culminating event in a woman's young adult development that integrates femininity, sexuality, generativity, maturity, and future orientation. It establishes gender identity and alters the course of a woman's life irreversibly, even if she chooses to terminate the pregnancy.⁹ Depending on underlying personality and predisposition, the normal psychological challenges of pregnancy can evoke a spectrum of responses, from maturation and resolution of old conflicts to decompensation and exacerbation of those conflicts (Table 1).

Table 1. Normative psychological changes during pregnancy

  Increased introspection
  Preoccupation with the pregnancy
  Decreased emotional investment in the external world
  Heightened dependency needs
  Regression (shift to more primitive defenses)
  Altered body image

Psychoanalytic thinkers have absorbed themselves in exploring the wealth of psychological material pregnancy affords. Sigmund Freud understood a girl's wish for a child as a 'substitution' for the wish for a penis, present in pre-oedipal stages of development. As the girl realizes she is 'castrated', her disappointment in her mother's inability to correct this deficiency leads her to her father to repair this mistake. In this classic view, pregnancy itself serves a healing function, representing the ultimate fulfillment. Later, longitudinal studies of pregnant women found that pregnancy reactivates feelings about the original mother-daughter relationship and can be regressive, yet 'pregnant' with opportunity for personal and interpersonal growth.⁹

Freud's notion of pregnancy as healing or repairing a deficiency has been softened and augmented by a more modern conception of pregnancy as a developmental phase that facilitates the transition to motherhood.¹⁰ Pregnancy is neither a meaningless hurdle nor primally curative. It is fraught with complexity and opportunity. The commercially portrayed blissful state of pregnancy is in dynamic tension with an inevitable sense of ambivalence and upheaval.¹¹

As modern people, we align ourselves politically into 'pro-choice' and 'pro-life' camps, but none of us are 'pro-abortion'. Although some perceive women seeking abortion as selfish and irresponsible, too preoccupied with their immediate sexual pleasure to bother with contraception, others consider these women to be driven by a strong awareness of and respect for the duties and responsibilities of motherhood and their ability to meet that challenge.¹²

A woman considering termination of an unwanted or unanticipated pregnancy is in turmoil. Her decision is made in the context of broader social, financial, and cultural issues. The presence of a partner and the quality of that relationship, the presence of other children, and the attitudes of significant others and of caregivers converge to influence this complex decision.¹³

In a study by Freeman¹⁴ of 106 women who underwent elective pregnancy termination, several issues emerged that corroborate the notion that the abortion decision is not a simple or casual one. Thirty-seven percent of the women studied stated they would never have considered aborting a pregnancy before their own pregnancy. Most women expressed ambivalence about the decision. Many found the finality of the decision and the time constraints stressful and felt isolated emotionally, unable to share their concerns openly with family and friends.¹⁴

A review of the literature on psychological sequelae of abortion showed that when abortion is voluntarily chosen as a solution to an unwanted pregnancy, there is little evidence for long-term adverse outcomes. A transient period of guilt, anxiety, and depressed mood may occur, commingled with relief. These negative affects are believed to be a response to violating social norms and facing disapproval combined with a sense of loss, both real and fantasied.¹⁵

Women at risk for long-term negative reactions are likely to have a history of psychiatric illness; to be young, single, and nulliparous; to have immature or conflicted relationships (notably with their partner and their mother); and to have increased levels of ambivalence about the procedure. Many have undergone abortion in an 'involuntary' manner, namely, for fetal or maternal indications or as a result of family or social pressure (Table 2).^{13, 16, 17, 18} The risk of psychosis in a previously nonpsychotic woman seems to be lower after pregnancy termination than after delivery.^{13, 19}

Table 2. Factors for negative psychological outcome after abortion

  Past psychiatric history
  Young age
  Single
  Nulliparous
  Immature/conflicted relationships with partner and/or mother
  Involuntary procedure (fetal/maternal indications, external pressure)
  Denied abortion
  Medical complications

Conversely, women who desire an abortion and are denied that intervention experience adverse psychological outcomes, especially with multiparity and poor social supports.¹³ Children born under these circumstances experience numerous broadly based difficulties in social and occupational functioning which persist through early adulthood.¹⁷ These include an increased incidence of psychiatric illness, delinquency, low educational levels, criminal behavior, alcoholism and dependence on public aid compared to controls.¹⁸

When compared with data on the psychological impact of unwanted perinatal loss (miscarriage, stillbirth), the benign course after abortion may be related to two factors. First, a woman who chooses to terminate a pregnancy may not fantasize about or become as attached to her unborn child as a woman with a desired pregnancy who experiences a spontaneous loss. Second, a woman who chooses, seeks out, and obtains an abortion has attained some mastery over her circumstances, in contrast to a spontaneous loss, in which the woman is a victim of her circumstances.¹⁶

Although the consensus seems to be that elective abortion has a low incidence of psychiatric morbidity, the psychological implications of different types of abortion procedures have led to studies of the differential effect of medical abortion (induction) versus surgical abortion (vacuum aspiration). In an abortion by vacuum aspiration, the woman under goes a surgical procedure under anesthesia. A medical abortion entails a woman's participation, the perception of labor pain, and an awareness of the products of conception.

In a Scottish study of 363 women undergoing elective terminations, 20% preferred medical abortion, 26% preferred vacuum aspiration, and 54% had no preference. Greater gestational age predicted a preference for vacuum aspiration over medical abortion.²⁰ The women who expressed no preference were randomly assigned to undergo either medical or surgical abortion, and no difference was found between the two groups in postabortal anxiety, depression, or self-esteem. Women with high levels of mood disturbance before the abortion, women who were smokers, and women who experienced medical complications after abortion were at highest risk for postabortal mood disorders.²¹

Although the overall psychological morbidity of abortion may be minimal, several special scenarios are worth noting.

The anniversary date of an abortion or the estimated date of confinement may be a time of emotional upheaval, especially for a woman who has incompletely grieved or acknowledged the loss of the pregnancy. ²¹ Future pregnancies may reactivate feelings of grief, anxiety, and depression, although a Canadian study published in 1984 demonstrated no association between anxiety during pregnancy and a prior abortion. It did, however, find higher levels of depressive affect in the third trimester of pregnancy and after delivery among women with a history of abortion. As a group, women with a previous abortion scored higher on measures of autonomy and nurturance and showed no indications of inadequate maternal functioning, as previous studies have suggested.²²

Infertility after abortion may be completely unrelated to the termination yet may stir up feelings of guilt, remorse, and sadness over the lost opportunity and, at times, a belief that the inability to conceive is punishment or retribution for the abortion. Such reactions must be acknowledged and assessed. Referral to a mental health professional should be made if the symptoms cause persistent distress or impair social or occupational functioning.

The explosion in availability of prenatal testing has dramatically altered decisions about childbearing. Modern technology now informs us not only of the baby's sex, but of genetic defects as well. The futuristic fantasy of 'designer babies' may not be far off, but of more immediate concern is the psychological impact of pregnancy termination for genetic or fetal indications. In a 1975 study of 13 families in which the decision to terminate a pregnancy was made after a genetic defect was found on amniocentesis, the incidence of depression was as high as 92% in women and 82% in men, far greater than the numbers associated with pregnancy loss, stillbirth, or termination for psychosocial reasons.²³ In a more recent study, pathologic grief responses were found to be more common after termination for fetopathic reasons than after other losses, perhaps because of the guilt associated with the decision. Supportive caregivers and the ability to face the loss, even to hold the baby after termination, have been shown to play a significant role in facilitating normal mourning, which takes place even after a planned termination.²⁴

Psychological and ethical issues naturally spill over into the area of selective reduction in multiple gestations. Clear and careful counseling must be provided for patients undergoing these procedures, and for their families. Any study of the psychological impact of selective reduction must take into account multiple additional factors: the high-tech nature of the pregnancy, patient characteristics (consumer of fertility treatment), the context of multiple caregivers (obstetrician-gynecologist, reproductive endocrinologist, perinatologist), and the 'impossible' choice inherent in the decision. It is not yet clear whether data from other types of terminations can be extrapolated to this population, given the many unusual ethical, medical, and psychological subtleties at play.²⁴

On May 1, 1998, the Chicago Tribune reported that the birth rate among teenagers was dropping dramatically in every state in the nation, which experts attributed to less sex and more birth control. Nonetheless, this chapter would not be complete without a discussion of the special psychological issues of pregnancy and abortion in the teenage population.

Psychodynamic thinkers have described adolescent pregnancy as a symbolic struggle between the desire to mother and the need to be mothered. Unresolved adolescent conflicts are extended and redefined as they embrace the next generation. Research by Schaeffer and Pine²⁵ found that postabortion adjustment was at least in part related to this theory. Adolescents who identified with the infant were more passive, establishing 'regressive ties' with their own mothers by letting their mothers take charge, whereas those who identified with the mothering role were better able to care for themselves, more independent, and more successful in coping with the abortion.²⁵ Such findings carry over into parenting as well.

There may be a significant element of self-selection in populations of adolescents who choose abortion for unplanned pregnancies. In a study examining factors influencing the decisions of 50 pregnant adolescents to terminate or continue their pregnancy, it was found that adolescents choosing abortion viewed themselves as less likely to experience guilt and more likely to finish school easily, to be independent, and to preserve peace in their families because of making that choice. In contrast, those intending to continue pregnancy wanted to take on the responsibility of parenting. They believed that motherhood would result in having someone to love and care for, would enable them to become closer to their boyfriends, and would affect their daily freedom and future plans only minimally. Many more in the latter group came from families characterized by highly conflictual relationships.²⁶

Adolescence can be divided into three stages: early, middle and late. Early adolescents, 12–15 years old, are at the most concrete stages of learning development and respond to pregnancy with denial, often disappearing from medical care after the termination. Abortion may be most troublesome for middle-stage adolescents, 15–18 years old, who are disappointed that the termination did not afford them any greater independence and autonomy. This group is most at risk for a repeat pregnancy and for postabortion depression. Women in the late stage of adolescence, 19–21 years old, have a more positive response to abortion, most similar to that in the general population.²⁵

The psychosocial variables described earlier as being risk factors for adverse psychiatric outcomes in women after abortion can be generalized to the adolescent population—namely, being young and single, having a previous psychiatric history, having immature interpersonal relationships, having an unstable or conflicted relationship with partner or mother, being extremely ambivalent about the abortion, and having a religious or cultural background that opposes abortion.²⁵

A woman seeking an abortion may be in dire psychosocial straits, including ignorance, financial hardship, lack of contraception, strained relationships, physical or sexual abuse, immaturity, impulsivity, and social isolation.¹² She may be highly ambivalent about the pregnancy, failing to explore adequately her attitudes toward herself, her unborn child, and her partner.¹⁴ Clinicians involved with patients considering or undergoing abortion must consider the context of the pregnancy and the motivation for seeking an abortion. A sincere desire to help resolve conflicts or circumstances precipitating this painful decision must be weighed against the intrusion of personal values and paternalism (pretending to know what is 'best for the patient'). Ideally, patients engage in a partnership with their caregivers that is imbued with trust and honesty, both seeking the best possible outcome: an autonomous but supported decision.¹²

From the perspective of physician as healer, the process of obtaining an abortion is in some respects quite atypical. In requesting that a pregnancy be terminated, a woman is asserting her legal right to do so for personal reasons. This places the physician in the role of medical or technical implementor of a woman's decision, in contradistinction to the more traditional role of medical decision maker and caregiver.³ Abortion, perhaps more than any other issue in medicine, has brought this dichotomy to the forefront. Some physicians perform abortions only in cases of maternal indications or rape, others only for known patients; still others perceive abortion as part of their overall responsibility to patients as physicians with expertise in the area of obstetrics and gynecology. In all cases, the patient and the physician have decision-making power, and neither should feel coerced or manipulated.

A careful biopsychosocial assessment must be conducted, identifying high-risk patients and those with active psychiatric illness. Interventions can then approximate the patient's needs more personally, maximizing prevention and minimizing morbidity.

First, a careful medical, gynecologic, and obstetric history should be taken, with a focus on any complications or adverse sequelae associated with prior conditions. Historic responses to stress and adversity inform caregivers about what may be in store.

Contraceptive use should be explored, assessing technical knowledge as well as psychological and relationship factors. Admonishing remarks are inappropriate and damaging in this setting. Aside from the painful emotional impact of a caregiver's obvious repugnance, such behavior may alienate the patient and cause her to delay the procedure. Such a delay imposes the risk of a termination late in pregnancy or an undesired pregnancy brought to term, with attendant morbidity to both the patient and her unborn child, as described previously.

Next, the patient's psychiatric history and current state should be explored (Table 3). Simple questions such as, “Have you ever seen a psychiatrist or therapist before?” or “Have you ever been treated for a psychiatric illness?” open the door. If the patient responds positively, a more detailed history should be obtained.

Table 3. Psychiatric history

  Nature of illness (symptoms, diagnosis)
  Precipitants (stressors, losses)
  Concurrent substance use
  Suicide attempts
  Dates of illness
  Duration of episode
  Inpatient treatment (length of stay, medications, electroconvulsive therapy, efficacy)
  Pharmacologic treatment (medications, doses, duration, efficacy, side effects)
  Psychotherapy(type, duration, efficacy)

Current psychiatric symptoms should also be assessed, including mood, anxiety or panic, and substance use. If such symptoms appear prominent, they may be powerful factors affecting the decision to terminate the pregnancy. A psychiatric evaluation should be arranged for clinical and consultative purposes. Active suicidality and psychotic symptoms (hallucinations, delusions, thought disorganization) are medical emergencies and should be addressed in a psychiatric emergency room or crisis program.

Finally, the patient's social situation should be assessed, including employment, finances, primary relationship (partner), family support, and social network. Specifically, tension or conflict with partner and parents (mother) is significant, as are familial, social, and religious attitudes toward abortion.

Once a thorough biopsychosocial assessment has been conducted, a checklist of risks for adverse psychological outcome can be completed, and appropriate measures can be taken to address these risks. Some interventions may be relatively simple (e.g. helping sort out insurance coverage), others more complex.

Patient issues that create an ethical dilemma or emotional upheaval for the caregiver prove most challenging. When a clinician feels forced to perform a procedure against his or her better judgment, or to provide care under duress, consultation with a colleague or supervisor is advisable. The experience and support of others in the field can often provide clarification. In extreme circumstances, it may be necessary to ask a patient to seek a second opinion or to seek care elsewhere.

The second component of preabortion counseling is the sharing of information regarding the procedure itself and its follow-up. An attempt should be made to assess and clarify any misconceptions about pregnancy, labor, delivery, and abortion. Medical information should be communicated in layman's terms and repeated for clarification if necessary. A patient's ability to repeat back what has been explained with reasonable comprehension and her awareness of the attendant risks and benefits of the procedure constitute informed consent.

It is important to acknowledge the possibility that the patient may experience transient feelings of sadness, anxiety, and guilt after the procedure, commingled with relief.¹⁵ 'High-risk' patients should be counseled about the possibility of other, more intense symptoms, advised to report such symptoms as soon as they appear, and linked with ancillary mental health services if necessary. In some cases, this linkage is made prophylactically, establishing the resource to bolster psychoeducational input and support, monitor the patient along with the primary caregiver, and, possibly, avert a crisis.

Patients seeking abortion may have a choice of a medical versus a surgical procedure. In addition to providing the information and advice necessary for the patient to make this decision, the physician may note the results of the Scottish study cited earlier.²⁰ In that study, greater gestational age predicted a preference for vacuum aspiration (anesthesia) over medical abortion. The psychological impact of laboring to deliver a nonviable fetus must be weighed against the risk imposed by a surgical intervention.

At the time of the office follow-up, a careful as sessment of psychosocial adjustment should be performed. Again, simple questions such as, “What kind of thoughts or feelings have you had about the abortion?” can open doors. Symptoms of depression and anxiety should be reviewed—specifically, mood, sleep, appetite, irritability, tearfulness, difficulty concentrating, panic attacks, rumination about the procedure, negativism, and hopelessness. The impact of the procedure on the patient's partner and family should be explored, in addition to thoughts or questions about future pregnancies.

In all interactions, empathic listening and a nonjudgmental stance are essential components of the doctor–patient relationship. In the context of trust and mutual respect, honest communication can occur, a thorough evaluation can be performed, and the best possible outcome can be achieved.