Identifying High Risk Abortion Patients

While there is intense controversy regarding how many women experience post-abortion psychological problems, even pro-abortion researchers admit that at least some women are negatively effected. Moreover, according to the American Psychological Association’s 2008 Task Force on Mental Health and Abortion there are at least 15 risk factors that identify the women at greatest risk of psychological problems after an abortion:

1. terminating a pregnancy that is wanted or meaningful
2. perceived pressure from others to terminate a pregnancy
3. perceived opposition to the abortion from partners, family, and/or friends
4. lack of perceived social support from others
5. various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life)
6. a history of mental health problems prior to the pregnancy
7. feelings of stigma
8. perceived need for secrecy
9. exposure to antiabortion picketing
10. use of avoidance and denial coping strategies
11. Feelings of commitment to the pregnancy
12. ambivalence about the abortion decision
13. low perceived ability to cope with the abortion
14. history of prior abortion
15. late term abortion

Because the existence of post-abortion trauma is now almost universally accepted, many researchers are now focusing on the factors which may identify which women are at higher risk. From a political viewpoint, researchers who favor abortion on demand are hoping to show that the “few” women who do report negative post-abortion reactions were actually emotionally “unbalanced” prior to the abortion. If this is true, they argue, then it is possible that the abortion itself is not the cause of psychological injury, but instead women who were previously “unbalanced” are unfairly blaming their problems on abortion.

Blaming the Victim

This “politically correct” view of post-abortion trauma includes a kernel of truth surrounded by a lot of “blaming the victim.” It is certainly true that women who are suffering from mental disorders or have previously suffered psychological trauma are more likely to subsequently report more severe negative post-abortion reactions. Indeed, if one thing is clear from post-abortion research over the last forty years, it is that abortion is contraindicated when a woman has mental health problems.

This is true because abortion is always stressful. How well a person copes with this stress depends on the individual’s resiliency and the conditions under which the stress occurs. When a woman’s psychological state is already fragile, the stress of an abortion can more easily overwhelm her. But the fact that she was more vulnerable to stress than others does not mean that the abortion is not the cause of her psychological injuries.

If a glass plate and a plastic plate are both dropped, the glass plate is likely to shatter, while the same stress may cause the plastic plate to only crack or chip. In either case, the damage cannot be blamed on the material; it must be blamed on the fall. While the extent of the damage is related to the nature of the material, the fall itself is the direct cause of the damage.

In the same way, while the nature of an individual psyche determines the extent of post-abortion injuries, it is the abortion itself which is the direct cause of these injuries.

This “blame the victim” strategy which is being employed by some pro-abortion researchers is not new. It is identical to the type of reasoning used during World War I when veterans suffering from “shell shock” were diagnosed by military psychiatrists as “malingerers” or even cowards. In an age when fighting for one’s country was romantically idealized as adventurous passage into manhood, this “politically correct” diagnosis was necessary to deflect attention away from the fact that modern warfare was often more traumatic than ennobling. Military officials therefore attempted to suppress reports of psychiatric casualties because accurate reports would have had a demoralizing effect on the public.

In the same way, when pro-abortion researchers are confronted with women who suffer from post-abortion trauma, there is a tendency to blame the woman for being “whiners” or “dysfunctional,” since it is common knowledge in pro-abortion circles that abortion normally “empowers” women. Some pro-abortion researchers even argue that women should not be told of the psychological risks associated with abortion because such “demoralizing” information may make them even more prone to an adverse outcome. It is better, they would claim, to be ignorantly optimistic about the future than informed and worried.

Women At Risk

The comments above are useful for understanding the impetus behind much of the recent efforts of pro-abortion researchers. With this in mind, we can now look at some of the very useful findings which these same researchers have made in the area of cataloging pre-identifying factors which can be used to predict post-abortion psychological sequelae.

The risk factors for post-abortion psychological maladjustments can be divided into two general categories. The first category includes women for whom there exists significant emotional, social, or moral conflicts regarding the contemplated abortion. The second category includes women for whom there are developmental problems, including immaturity, or pre-existing and unresolved psychological problems. Women with characteristics in either or both of these categories would properly be classified as high risk patients.

Conversely, a low risk patient can be described as a woman who has maturely, thoughtfully, and freely arrived at her abortion decision and has no emotional, social, or moral conflicts which challenge that decision.

The following outline summarizes the major risk factors and includes pre-identifying characteristics upon which women can be screened for these risk factors.

Outline of Risk Factors Predictive of Greater Post-abortion Psychological Sequelae with Citations to Authorities

I.    CONFLICTED DECISION

A.  Difficulty making the decision, ambivalence, unresolved doubts^{1,2,3,10,13,14,18,23,25,29,34,37,38,40,46,49,52,53,55,56,57,61}

1.   Moral beliefs against abortion⁶¹

a.   Religious or conservative values^{1,2,5,23,34,39,40,48,49,54,56,58,59}

b.   Negative attitudes toward abortion^1,8,27,57

c.   Feelings of shame or social stigma attached to abortion^2,61

d.   Strong concerns about secrecy⁵⁰

2.   Conflicting maternal desires^{1,,29,30,33,34,46,51}

a.  Originally wanted or planned pregnancy^{1,13,23,27,29,53,57,59,61}

b.   Abortion of wanted child due to fetal abnormalities^{3,7,13,18,19,20,26,27,28,41,61}

c.   Therapeutic abortion of wanted pregnancy due to maternal health risk^{3,13,15,18,20,26,27,37,42,49,54,55,61}

d.   Strong maternal orientation^34,48

e.   Being married^{1, 10}

f.    Prior children^{25,48,54,58,60}

g.   Failure to take contraceptive precautions, which may indicate an ambivalent desire to become pregnant⁶

h.      Preoccupation with fantasies of fetus, including sex and awareness of due dateh.   Delay in seeking an abortion^1,2,26

 

3.   Second or third trimester abortion^{1,20,26,27,39,42,49}

4.   Low coping expectancy^1,27,29,30

B.   Feels pressured or coerced^{13,16,18,27,34,43,45,48,49,53,51,52,55,61}

1.   Feels decision is not her own, or is “her only choice”^14,,18

2.   Feels pressured to choose too quickly^17,24

C.  Decision is made with biased, inaccurate, or inadequate information^17,48,49

 

II. PSYCHOLOGICAL OR  DEVELOPMENTAL LIMITATIONS

A.  Adolescence, emotional immaturity^{1,4,9,11,15,16,17,27,29,32,33,42,48,50,54}

B.   Prior emotional or psychiatric problems^{3,5,6,13,15,18,20,22,23,25,26,34,37,40,42,47,51,54,57,61,63}

1.   Poor use of psychological coping mechanisms^2,29,34,61

2.   Prior low self-image^{33,34,43,48,52,61,63}

3.   Poor work pattern or dissatisfied with job^6,52

4.   Prior unresolved trauma or unresolved grief^48,51

5.   A history of sexual abuse or sexual assault.^23,31,51,61

6.   Blames pregnancy on her own character flaws, rather than on chance, others, or on correctable mistakes in behavior^29,30,36

7.   Avoidance and denial prior to abortion^12,27

8.   Unsatisfactory or mediocre marital adjustment⁶

9.   Past negative relationship with mother^5,40

C.  Lack of social support^{1,9,27,33,46,54,55,56,58,61,62, 63}

1.   Few friends, unsatisfactory interpersonal relations^6,52

2.   Made decision alone, without assistance from partner³⁵

3.   A poor or unstable relationship with male partner^{6,25,34,40,43,53}

4.   Single and nulliparous⁹

5.   Separated, divorced, or widowed^{14, 62}

6.   Lack of support from parents and family^{2,8,9,18,27,29,33,35,52,56}

– either to have baby or to have abortion

7.   Lack of support from male partner^{2,6,8,9,18,25,27,29,33,34,35,42,46,52,53}

– either to have baby or to have abortion

8.   Accompanied to abortion by male partner^21,30

9.   Living alone⁵⁶

10. High alienation⁶³

D. Prior abortion(s)^{13,37,43,48,52,58}

E. Prior miscarriage ⁵⁸

F. Less education ⁵⁸

The Role of the Male

The attitude of the male partner toward the pregnancy is an important factor in a woman’s abortion decision and is also significantly related to how she will adjust after the abortion. Because numerous studies have found support from the partner to be an important predictor of good post-abortion adjustment, researchers were recently startled by the finding that accompaniment to the abortion by the male partner was actually a predictor of greater post-abortion depression.

This finding suggests that an outward show of support, accompaniment to the abortion clinic, is not an accurate measure of the emotional support a woman feels. Instead, accompaniment by the male partner may actually indicate one or more of the following: 1) greater pre-abortion anxiety which led the woman to insist on accompaniment; 2) overt or subtle coercion on the part of the male who is “making sure” she does the “right thing;” or, 3) a more intimate relationship exists between the partners and this greater intimacy is being stressed by the abortion. In this third scenario, the unplanned pregnancy may be perceived by the woman as a “test” of her partner’s commitment to their relationship. She may privately be willing to have the baby, and seal their mutual commitment, if he takes this as opportunity to demonstrate his commitment. Instead, his lack of enthusiasm for, or hostile reaction to, the pregnancy causes her to doubt the depth and endurance of their relationship.

In short, when a woman is accompanied to an abortion by her male partner, the woman is more likely to be choosing abortion because her partner has manipulated her into doing so, or because he has exposed to her a lack of commitment to their relationship. In neither case does she truly feel supported.

Conclusion

While present research is unable to accurately establish what percentage of women suffer from any specific symptom of post-abortion trauma, it is clear that post-abortion psychological disorders do occur. Indeed, the published literature demonstrates that serious emotional and psychological complications following an abortion are probably more common than serious physical complications.

The present literature has also successfully identified statistically significant factors which can be used to pre-identify individuals who are most vulnerable to experiencing post-abortion psychological sequelae. Examination of these risk factors suggests that many, if not most women seeking abortion have one or more of these high risk characteristics.

Based on these findings, most of which have been published by researchers who favor legalized abortion, it would appear reasonable to expect, and demand, that abortion providers: 1) provide pre-consent information about the types of psychological reactions which have been linked to a negative abortion experience and the risk factors associated with these adverse reactions; 2) provide adequate pre-abortion screening using the criteria outlined above to identify women who are at higher risk of negative post-abortion reactions; 3) provide individualized counseling to high risk patients which would more fully explain why the patient is at higher risk along with more detailed information concerning possible post-abortion reactions; and 4) assist women who have pre-identifying high risk factors in evaluating and choosing lower risk solutions to their social, economic, and health needs.

Since these high risk factors have been well established for a considerable period of time, abortion providers who fail to utilize this information in their screening and counseling procedures may incur greater liability for subsequent injuries when malpractice suits are brought on these grounds.

Originally published in The Post-Abortion Review 1(3) Fall 1993. Copyright 1993 Elliot Institute.

Updated Material

For more updated information on Risk Factors, see:

• Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment
• Risk factors 
• Risk Factors Identified by Pro-Choice Sources

In 2008, a task force for the American Psychological Association identified the following list of risk factors which are associated with elevated rates of post-abortion psychological problems:

• terminating a pregnancy that is wanted or meaningful
• perceived pressure from others to terminate a pregnancy
• perceived opposition to the abortion from partners, family, and/or friends
• lack of perceived social support from others
• various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life)
• a history of mental health problems prior to the pregnancy
• feelings of stigma
• perceived need for secrecy
• exposure to antiabortion picketing
• use of avoidance and denial coping strategies
• Feelings of commitment to the pregnancy
• ambivalence about the abortion decision
• low perceived ability to cope with the abortion
• history of prior abortion
• late term abortion

NOTES

(Key for all citations: Normal type = Literature Review or Committee Reports; Italicized = Clinical Experience, Soft Data, Expert Opinion; Bold – Statistically Validated Study.)
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2.   Adler, N.E., et al., “Psychological Responses After Abortion,” Science, 248:41-44 (1990).

3.   Ashton, J.R. “The Psychosocial Outcome of Induced Abortion”,   British Journal of Ob&Gyn., 87:1115-1122 (1980).

4.   Babikian & Goldman, “A Study in Teen-Age Pregnancy,” Am. J. Psychiatry, 755 (1971).

5.   Barnard, C.A., The Long-Term Psychosocial Effects of Abortion (Portsmouth, NH: Institute for Pregnancy Loss, 1990).

6.   Belsey, E.M., et al., “Predictive Factors in Emotional Response to Abortion: King’s Termination Study – IV,” Soc. Sci. & Med., 11:71-82 (1977).

7.   Blumberg,B.D., et al., “The Psychological Sequelae of Abortion Performed for a Genetic Indication,” Am. J. of Obstetrics and Gynecology 122(7):799-808 (1975).

9.   Bracken, M.B., et al., “The Decision to Abort and Psychological Sequelae” Journal of Nervous and Mental Disease, 158:154-162 (1974).

10. Bracken, M.B. “A Causal Model of Psychosomatic Reactions to Vacuum Aspiration Abortion,” Social Psychiatry, 13:135-145 (1978).

11. Campbell, N.B., et al., “Abortion in Adolescence,” Adolescence 23:813-823 (1988).

12. Cohen, L. & Roth, S., “Coping With Abortion,” Journal of Human Stress 10:140-145 (1984).

13. Council on Scientific Affairs, American Medical Association, “Induced Termination of Pregnancy Before and After Roe v Wade: Trends in Mortality and Morbidity of Women,” JAMA, 268(22):3231-3239 (1992).

14. David, H.P., “Post-abortion and Post-partum Psychiatric Hosptialization,” 1985 Abortion: Medical Progress and Social Implications (London: Ciba Foundation Symposium 115, 1985) 150-64.

15. De Veber, L.L., et.al., “Post-Abortion Grief: Psychological Sequelae of Induced Abortion,” Humane Medicine,7(3):203-8 (1991).

16. Dunlop, “Counseling of Patients Requesting an Abortion,” The Practitioner, 220:847-852 (1978).

17. Franz, W., Reardon, D., “Differential Impact of Abortion on Adolescents and Adults,” Adolescence, 27(105):161-172 (1992).

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19. Furlong, R. & Black, R., “Pregnancy Termination for Genetic Indications: The Impact on Families,” Social Work in Health Care, 10(1):17 (1984).

20. Lazarus, A., Stern, R., “Psychiatric Aspects of Pregnancy Termination,” Clinics in Obs/Gyn, 13(1):125-134 (1986).

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23. Hern, W. Abortion Practice, (Boulder, CO: Alpenglo Graphics, Inc., 1990).

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25. Lask, B. “Short-term Psychiatric Sequelae to Therapeutic Termination of Pregnancy,” Br J Psychiatry, 126: 173-177 (1975).

26. Lazarus, A. “Psychiatric Sequelae of Legalized Elective First Trimester Abortion”, Journal of Psychosomatic Ob&Gyn 4:141-150 (1985).

27. Lemkau, J.P., “Emotional Sequelae of Abortion,” Psychology of Women Quarterly, 12:461-472 (1988).

28. Lloyd, J. & Laurence, K.M., “Sequelae and Support After Termination of Pregnancy for Fetal Malformation,” British Medical Journal, 290:907-909 (1985).

29. Major, B. & Cozzarelli,C., “Psychosocial Predictors of Adjustment to Abortion,”  Journal of Social Issues, 48(3):121-142 (1992).

30. Major, B., et al., “Attributions, Expectations and Coping with Abortion,” Journal of Personality and Social Psychology, 48:585-599 (1985).

31. Mahkorn, S. K., “Pregnancy & Sexual Assault,” The Psychological Aspects of Abortion, Mall, D., & Watts, W.F., eds., (Washington, D.C.: University Publications of America, 1979) pp.53-72.

32. Margolis, A.J.,et.al., “Therapeutic Abortion Follow-up Study,” Am J Obstet Gynecol, 110:243-9 (1971).

33. Martin, C.D., “Psychological Problems of Abortion for Unwed Teenage Girls,” Genetic Psychology Monographs 88:23-110 (1973).

34. Miller, W.B., “An Empirical Study of the Psychological Antecedents and Consequences of Induced Abortion,” Journal of Social Issues, 48(3):67-93 (1992).

35. Moseley, D.T., et al., “Psychological Factors That Predict Reaction to Abortion,” J. of Clinical Psychology, 37:276-279 (1981).

36. Mueller, P. & Major, B., “Self-blame, Self-efficacy and Adjustment to Abortion,” Journal of Personality and Social Psychology 57:1059-1068 (1989).

37. Ney, P.G. & Wickett, A.R., “Mental Health and Abortion: Review and Analysis,” Psychiatr J Univ Ottawa, 14(4):506-16 (1989).

38. Osofsky J.D. & Osofsky, H.J., “The Psychological Reaction of Patients to Legalized Abortion,” American Journal of Orthopsychiatry, 42:48-60 (1972).

39. Osofsky, J.D., et al., “Psychological Effects of Abortion: with Emphasis upon the Immediate Reactions and Followup,” in H. J. Osofsky & J.D. Osofsky, eds., The Abortion Experience (Hagerstown, MD: Harper & Row, 1973), 189-205.

40. Payne, E.C., et al., “Outcome Following Therapeutic Abortion,” Archives of General Psychiatry, 33:725-33 (1976).

41. Rayburn, W. & Laferla, J.,“Mid-gestational Abortion for Medical or Genetic Indications,” Clin Obstet Gynaecol 13:71-82 (1986).

42. Rosenfeld, J. “Emotional Responses to Therapeutic Abortion,” American Family Physician, 45(1):137-140, (1992).

43. Rue, V. & Speckhard, A., “Informed Consent & Abortion: Issues in Medicine & Counseling,” Medicine & Mind 7:75-95 (1992).

45. Senay, E., “Therapeutic Abortion: Clinical Aspects,” Arch Gen Psychiatry 23:408-15, (1970).

46. Shusterman, L.R., “Predicting the Psychological Consequences of Abortion,” Social Science and Medicine, 13A:683-689 (1979).

47. Sim, M., Neisser, R., “Post-abortive Psychoses: A Report From Two Centers,” The Psychological Aspects of Abortion, Mall, D. and Watts W.F.(eds)(Washington, DC: University Publications of America, 1979).

48. Speckhard, A. & Rue, V., “Postabortion Syndrome: An Emerging Public Health Concern,” Journal of Social Issues, 48(3):95-119 (1992).

49. Vaughan, H.P., Canonical Variates of Post Abortion Syndrome (Portsmouth, NH: Institute for Pregnancy Loss, 1990).

50. Wallerstein, J.S. et.al.,”Psychological Sequelae of Therapuetic Abortion in Young Unmarried Women,” Arch Gen Psychiatry 27:828-32 (1972).

51. Zakus, G. & Wilday, S., “Adolescent Abortion Option,” Social Work in Health Care, 12(4):77-91 (1987).

52. Zimmerman, M., Passage Through Abortion (New York: Praeger Publishers, 1977).

53. Zimmerman, M. “Psychosocial and Emotional Consequences of Elective Abortion: A Literature Review”, in Paul Sachdev, ed., Abortion: Readings and Research (Toronto:Butterworth, 1981).

54. Zolese, G. & Blacker, C.V.R., “The Psychological Complications of Therapeutic Abortion” British J Psych 160:742-749 (1992).

55. Gibbons, M., “Psychiatric Sequelae of Induced Abortion,” J Royal College of General Practitioners 34:146-150 (1984).

56. Hanna Söderberg, Andersson C, Lars Janzon, Nils-Otto Sjöberg, “Emotional distress following induced abortion: A Study of incidence and determinants among abortees in Malmö Sweden” Eur J Obstet Gynecol Reprod Biol 79:173-178 (1998).

57. Miller, W.B., Pasta, D.J., Dean, C.L., “Testing a Model of the Psychological Consequences of Abortion” The New Civil War: The Psychology, Culture, and Politics of Abortion, ed. Linda J. Beckman and S. Maria Harvey (American Psychological Assoc., Washington, DC, 1998)

58. Peppers, L. G.,  “Grief and Elective Abortion: Implications for the Counselor,” Disenfranchised Grief: Recognizing Hidden Sorrow, ed. Kenneth J. Doka (Lexington Books: Lexington MA, 1989), pp.135-146.

59. Lydon, J.,  Duncel-Schetter, C., Cohan, C.L.,  Pierce, T., “Pregnancy Decision Making as a Significant Life Event: A Commitment Approach” Journal of Personality and Social Psychology, 71(1):141-151, 1996.

60. Gail B. Williams, “Induced Elective Abortion and Pre-natal Grief” PhD Thesis, New York Univeristy (1991), Dissertation Abstracts Int’l, Vol 53, No 3, Sept 1992, Order No DA9213205.

61. Anne Baker, et. al., “Informed Consent, Counseling, and Patient Preparation,” A Clinician’s Guide to Medical and Surgical Abortion, ed. Maureen Paul, et. al., (New York: Churchill Livingston, 1999) 29.

62. Gissler M, Hemminki E, Lonnqvist J. Suicides after pregnancy in Finland: 1987‑94: register linkage study. BMJ 1996;313:1431‑4.

63. Athanasiou R, Oppel W., Michelson, I., et al, “Psychiatric sequelae to term birth and induced early and late abortion: a longitudinal study,” Fam Plann Perspect 5:227-231, 1973.

 

 

 

 

Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment

 

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