Emotional response to abortion: a critical review of the literature

Anti-abortion groups in the US cite the existence of a post-abortion syndrome--a sense of loss, emptiness, and grief similar to that reported by trauma survivors. Although research on the longterm effects of induced abortion is marred by methodological errors, most studies have found no adverse psychological sequelae; rather, there appears to be a sense of relief and opportunity for personal growth. Nevertheless, there is a small group of women who do experience emotional distress after abortion and it is important to identify the demographic, social, and psychological factors that place women at risk of such a reaction. In terms of demographic factors, young age (adolescence), low or nulliparity, 2nd-trimester procedures, and Catholicism have been characteristics of women who suffered post-abortion depression. Of the social variables that have been examined, a lack of support from significant others (parents or partner) has been linked in some studies to emotional distress after abortion. A relatively consistent finding is that women who feel coerced to abort or are ambivalent about their decision at the time of the procedure are most likely to experience regret, depression, and anger. Women whose coping style involves avoiding responsibility are also prone to post-abortion distress. As noted, the literature does not support the contention that abortion causes longterm trauma. On the other hand, given the fact that 1.5 million abortions take place each year in the US, the existence of some post-abortion distress in even as small percentage of acceptors is enough to indicate a need for pre- and post-abortion counseling to help women determine the meaning of the experience and own their decisions.     

Legal abortion worldwide: incidence and recent trends

CONTEXT: Information on abortion levels and trends can inform research and policies affecting maternal and reproductive health, but the incidence of legal abortion has not been assessed in nearly a decade. METHODS: Statistics on legal abortions in 2003 were compiled for 60 countries in which the procedure is broadly legal, and trends were assessed where possible. Data sources included published and unpublished reports from official national reporting systems, questionnaires sent to government agencies and nationally representative population surveys. The completeness of country estimates was assessed by officials involved in data collection and by in-country and regional experts. RESULTS: In recent years, more countries experienced a decline in legal abortion rates than an increase, among those for which statistics are complete and trend data are available. The most dramatic declines were in Eastern Europe and Central Asia, where rates remained among the highest in the world. The highest estimated levels were in Armenia, Azerbaijan and Georgia, where surveys indicate that women will have close to three abortions each on average in their lifetimes. The U.S. abortion rate dropped by 8% between 1996 and 2003, but remained higher than rates in many Northern and Western European countries. Rates increased in the Netherlands and New Zealand. The official abortion rate declined by 21% over seven years in China, which accounted for a third of the world's legal abortions in 1996. Trends in the abortion rate differed across age-groups in some countries. CONCLUSIONS: The abortion rate varies widely across the countries in which legal abortion is generally available and has declined in many countries since the mid-1990s.     

The psychosocial factors of the abortion experience: a critical review

The literature on the psychosocial factors of abortion is critically reviewed. It is concluded that due to faulty methodology no general statements can be made about these factors for women receiving illegal abortions. It appears that the data showing that women receiving therapeutic abortions experienced favor- able psychological conseuqences are stronger than the data indicating negative consequences. Studies of abortion on request, which, for the most part, have been methodologically sound, indicate that the new abortion patients are mostly young, unmarried women who are not in a social position to bear and care for a child. They tend to end their pregnancies for social and economic reasons. Further, they are either not aware of or not concerned about the possibility of getting pregnant at the time of intercourse, or they have a contraceptive failure. Finally, the psychological consequences of abortion on request appear to be most1 y benign.     

Antiabortion Rhetoric and the Undermining of Choice: Women's Agency as Causing “Psychological Trauma” Following the Termination of a Pregnancy

Historically the antiabortion movement has opposed abortions through reference to the fetus' human status. However, recently there has been a rhetorical shift whereby abortion is criticized based on its alleged negative psychological impact on women, with some authors voicing concerns related to this medicalized repertoire undermining women's capacity to act as rational decision-makers. However, no research to date has systematically analyzed how women's agency over their abortions features in antiabortion rhetoric. In this article, through a discourse analysis of interviews with 15 antiabortion supporters, I explore how psychological concepts are employed to indirectly undermine women's agency to abort. Participants construct the termination of a pregnancy as psychologically damaging when women's agency is evident (e.g., in abortions or rape-pregnancy abortions). Women's choice also appears as enforced by society, victimizing them and removing accountability over it. However, unintentional termination (e.g., miscarriage) is constructed as “natural” and psychologically harmless due to the lack of agency. Overall, the pathologization of abortion through reference to psychological trauma stemming from the exercise of agency allows antiabortionists to naturalize motherhood and oppose abortions in an “objective,” depoliticized, nonrestrictive, and prowoman manner, without explicitly disregarding women's ability to choose or breaching Western norms of autonomy and freedom of choice.     

Differential impact of abortion on adolescents and adults.

The purpose of this study was to compare adolescent and adult reactions to abortion. A sample of 252 women from 42 states was obtained from a national survey of organizations serving as support groups for women who have had negative reactions to abortion. The age analysis was run using t-tests. Results indicated that the adolescents were significantly more likely to be dissatisfied with the choice of abortion than were the older subjects, to have abortions later in the gestational period, to be dissatisfied with services at the time of the abortion, to feel forced by circumstances to have the abortion, to report being misinformed at the time of the abortion, and to report greater severity of psychological stress. The conclusions suggest that the adolescents' problems may be due to a combination of developmental limitations and the nature of counseling at the time of the abortion.     

Emotional sequelae of abortion: implications for clinical practice

For women in therapy who have had abortions, an exploration of the context and aftermath of each abortion has been suggested. This inquiry should include: characteristics of the woman herself before and at the time of the abortion, the nature of the interpersonal and cultural milieu at the time, characteristics of the medical environment and procedure, and any events subsequent to the abortion that may evoke regrets about the earlier decision.
Whether or not such an inquiry results in the identification of unresolved issues surrounding the abortion, it is likely to enhance one's general understanding of the client. Exploring a woman's decision to have an abortion can bring into relief developmental and family issues, relationship conflicts, and her aspirations for education, work, and family. A woman's approach to establishing and asserting her priorities and values in making difficult personal decisions becomes clear as does her ability to tolerate and resolve the ambivalence inherent in making difficult decisions.
In psychotherapy, it is important to understand and address those aspects of experience that women have difficulty resolving. Hence, the emphasis on categories of experience that may have a negative impact on a woman's emotional well-being after abortion. Nevertheless, the clinician should remember that even women who report negative post-abortion sequelae overwhelmingly report that they feel that the decision was the right one for them. Having ambivalent feelings to resolve does not necessarily mean that one has made a wrong choice, only that one has made an emotionally significant choice with far-reaching personal implications, in a sociocultural environment that reinforces the ambivalence inherent in such decisions.     

Abortion among adolescents

In most countries, adolescents' access to abortion is limited by restrictions on legal abortion. Abortion is legal in the United States, but many states require parental consent or notification. Legislation mandating parental consent has been justified by several assumptions, including high risk of psychological harm from abortion, adolescents' inability to make an adequately informed decision, and benefits of parental involvement. Empirical data raise questions about the first 2 assumptions: Studies suggest a relatively low risk associated with abortion, and adolescents seeking abortion appear to make an informed choice. Less is known about effects of parental involvement. The authors review available research and discuss policy debates over parental consent in the United States and the international context.     

An Ecological Analysis of the Impact of the U.S. Supreme Court's 1973 Abortion Decision

The ecological characteristics of states were correlated with measures of the distribution of abortions among states before and after the Supreme Court's abortion decision. Techniques of path analysis were used to separate these conelations into direct effects and effects mediated through state abortion laws. The Court decision produced a gradual decrease in the effect of abortion laws on the distribution of abortions, and in the indirect effects of ecological variables. The major trend in the direct effects of ecological variables was a gradual increase in the relationship between population size and number of abortions. Differences reflected in state laws continued to influence abortion rates per 1,000 women of reproductive age and abortion ratios per 1,000 live births.     

Abortion in adolescence

Sexual attitudes and behavior of adolescent females have been the topic of much interest over the past decade. Feelings about contraception, conception, and abortion have been described in relation to the adolescents' beliefs about the possibility of becoming pregnant, who will or will not "protect" them, and the influence of significant others on their decision making. This study explores differences in 35 women who had abortions during their teenage years with 36 women whose abortions occurred after the age of twenty. A demographic questionnaire, the Millon Clinical Multiaxial Inventory, and the Beck Depression Inventory were completed by women who were members of a patient-led support group. Premorbid psychiatric histories, the decision-making process itself, and distressing symptoms postabortion are reported. Specific differences in perceptions of coercion, preabortion suicidal ideation, and nightmares post-abortion were found in the adolescent group. Antisocial and paranoid personality disorders as well as drug abuse and psychotic delusions were found to be significantly higher in the group who aborted as teenagers. Hypotheses regarding the influences of adolescent development on mother/child relationships, power struggles, and the use of fantasy as a coping device are explored.     

Severity and cost of unsafe abortion complications treated in Nigerian hospitals

CONTEXT: Each year, thousands of Nigerian women have unintended pregnancies that end in illegal abortion. Many such procedures occur under unsafe conditions, contributing to maternal morbidity and mortality. METHODS: In a 2002-2003 survey of women and their providers in 33 hospitals in eight states across Nigeria, 2,093 patients were identified as being treated for complications of abortion or miscarriage or seeking an abortion. Women's abortion experiences and the health consequences and associated costs were examined through bivariate analysis. Multivariate analysis was used to examine the characteristics of women by type of pregnancy loss and to compare characteristics among three groups of women who had induced abortions in differing circumstances. RESULTS: Among women admitted for abortion-related reasons, 36% had attempted to end the pregnancy before coming to the hospital (including 24% with and 12% without serious complications), 33% obtained an induced abortion at the facility (not withstanding the country's restrictive law) without having made a prior abortion attempt and 32% were treated for complications from a miscarriage. Of women with serious complications, 24% had sepsis, 21% pelvic infection and 11% instrumental injury; 22% required blood transfusion and 10% needed abdominal surgery. The women in this group were poorer and later in gestation than those who sought abortions directly from hospitals. They paid more for treatment (about 13,900 naira) than those who went directly to the hospital for an abortion (3,800 naira) or those treated for miscarriage (5,100 naira). CONCLUSIONS: Policy and program interventions are needed to improve access to contraceptive services and postabortion care in order to reduce abortion-related morbidity and mortality.     

Minors' competence to consent to abortion

In the light of legal restrictions in some states, the psychological evidence for whether adolescents are competent to give informed consent to abortion is reviewed. It would be important to know whether competence to decide on pregnancy outcome reflects maturity to be a parent; further, whether degrees of maturity can be traced throughout adolescence. Research shows that parents, not peers, are major sources of advice for minors' abortion decisions. Younger and less competent minors are more likely to consult parents than older, mature minors. There is no evidence that adolescent issues or developmental tasks influence pregnancy decisions. Decision making competence does not differ from that of adults, except as affected by the living situation of the adolescent. Decision performance does differ: minors are more likely to consider their present family's opinion, and not consider future risks, than are adults. The sparse research available on this problem provides no basis for restricting minors' decision making on the ground of competence alone.     

Sexual assault and stranger aggression on a candian university campus

There is a severe lack of knowledge about sexual assault on Canadian college campuses. This exploratory study of 259 Canadian undergraduate women (mostly white, of British or European heritage, with about half from families of total incomes of over Can $50,000) provides evidence that although Canada generally has a lower crime rate than the United States, sexual aggression against women does not seem to be lower. Further, there is an extraordinary victimization rate for the stranger sexual advances that are legal or barely illegal, but which form a major component of women's fear. Most surveyed women have in the past year been victimized by uncomfortable stranger aggression in public places, while approximately one-third of those who date reported at least one episode of physical, verbal, or psychological sexual coercion. Close to 25% of the women said they had sexual intercourse when they did not want to during the past year.An earlier and substantially different version of this paper was presented at the annual meetings of the Academy of Criminal Justice Sciences, Pittsburgh, March 1992.     

Locus of control and decision to abort

The relationship of locus of control to deciding on an abortion was investigated by administering Rotter's Locus of Control Scale to 118 women immediately prior to abortion and 2 weeks and 3 months following abortion. Subjects' scores were compared across the 3 time periods, and the abortion group's pretest scores were compared with those of a nonpregnant control, group. As hypothesized, the aborting group scored significantly more internal than the general population but no differences in locus of control were found across the 3 time period. The length of delay in deciding to abort an unwanted pregnancy following confirmation was also assessed. Women seeking 1st trimester abortions were divided into internal and external groups on the Rotter Scale and the lengths of delay were compared. The hypothesis that external scores would delay the decision longer than internal ones was confirmed. The results confirm characteristics of the locus of control construct and add information about personality characteristics of women undergoing abortion.     

“I'm Not That Type of Person”: Managing the Stigma of Having an Abortion

Drawing on interviews with U.S. women, this article offers a social–psychological framework for understanding the stigma of having an abortion and identifies the individual stigma management strategies women use to mitigate negative intrapersonal and interpersonal consequences of abortion stigma. We also contribute to contemporary understandings of abortion stigma by theorizing how aspects of abortion stigma—such as its concealability and episodic expression—interfere with women's potential to collectively manage or dismantle abortion stigma. Finally, we discuss how our conceptual framework can be used to inform the development of a measure of the stigma experiences of women who have had an abortion, which can help improve health and well-being outcomes for women.     

Visual evidence

Visual and other demonstrative evidence has become increasingly prevalent in American and other courtrooms in recent years. However, there have been relatively few experimental studies of the effects of this kind of evidence in legal settings. As a consequence, little is known about when and how it affects legal decision making. In this article, I survey the extant research, including studies of photographs, videos, computer animations, and PowerPoint displays. The research shows that visual evidence affects legal decisions in some circumstances but not in others. It also indicates that visual evidence sometimes enhances legal judgment by improving recall and understanding but sometimes impairs judgment by prompting undue emotional responses, cognitive and perceptual biases, and/or peripheral processing. The limitations of the research are discussed, and directions for future research are suggested.     

Autonomous abortions: the inhibiting of women's autonomy through legal ultrasound requirements

Recently, we have seen various proposed laws that would require that women considering abortions be given ultrasounds along with explanations of these ultrasounds. Proponents of these laws could argue that they are assisting with autonomous abortion choices by providing needed information, especially about the ontological status of the fetus. Arguing against these proposed laws, I first claim that their supporters fail to appreciate how personalized an abortion choice must be. Second, I argue that these laws would provide the pregnant woman no control over when and to what extent emotion is inserted into her deliberation. This unjustly inhibits her autonomy, making these ultrasound laws unjustified.     

An editorial overview

Now is an excellent time to be doing research at the intersection of psychology and law. In the last few years, both the legal system and the legal academic community have taken more and more interest in the empirical findings of cognitive and social psychologists. Much of this interest has been provoked by the large number of convicted people who have been exonerated by DNA evidence. Examination of their cases reveals that most are associated with one (or more) of the following problems: bad eyewitness testimony, a false confession, or flawed forensic evidence. These issues are ones that psychologists have been investigating for years. For those of you new to this area, we recommend Elizabeth Loftus’s foundational work on so many areas of memory, Gary Wells’s work on eyewitness identification, Saul Kassin’s work on false confessions, and Reid Hastie’s work on jury decision making. All have written for both psychological and legal audiences.     

Sandra Day O'Connor and the justification of abortion

The recent Supreme Court decision upholding Roe v. Wade and in particular, the dissent by Justice Sandra Day O'Connor, sheds new light on the issue of abortion. Let us consider any stage of a pregnancy when abortion is medically safe for the mother. If at that stage it is also medically viable to save the fetus, is an abortion performed at that stage of pregnancy morally justifiable? For example, if it is, or becomes, medically safe to perform abortions after first trimester of pregnancy and at the same time saving a fetus is, or becomes, medically viable or not unusual during some stage of the second trimester, can abortions during and after that stage of pregnancy be justified? With a number of qualifications I shall argue the thesis that as a general rule, but not an absolute rule, abortion in these instances is not usually justifiable. For if it is, then one will also have to grant the moral justification for a number of other highly questionable medical practices. This thesis is not to be identified with the stronger claim that abortions of viable fetuses can never be performed. There are surely exceptions such as when the life or health of the mother is in danger. But, I shall argue, the justification for making such exceptions is on different grounds than is sometimes claimed because one must weigh the health of the mother against the life of another human being.     

Perceived social support, self-efficacy, and adjustment to abortion

Prior to their having a 1st trimester abortion, women's perceptions of social support from their partner, family, and friends and self-efficacy for coping were assessed. Depression, mood, physical complaints, and anticipation of negative consequences were measured after the 30-min recovery period. As predicted, perceived social support enhanced adjustment indirectly through its effects on self-efficacy. Women who perceived high support from their family, friends, and partners had higher self-efficacy for coping. Higher self-efficacy, in turn, predicted better adjustment on the psychological measures but not on the physical complaint measure. No direct path between social support and adjustment was observed. In addition, women who told close others of their abortion but perceived them as less than completely supportive had poorer postabortion psychological adjustment than either women who did not tell or women who told and perceived complete support.