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Mental Health Outcomes of Abortion and Its Alternatives

Implications for Future Policy
      Since abortion's legalization in 1973, there have been vocal movements by conservative political and right wing religious groups to ban the procedure. Pro-life or “anti-choice” activists specify that abortion is harmful for many reasons, including that it can cause detrimental effects to the mental and emotional health of the pregnant woman, resulting in a “post-abortion syndrome.” Critics became so vocal that during the Reagan administration, Surgeon General C. Everett Koop was asked to prepare a report about the negative mental health sequelae of abortion for the women who undergo them. Koop's report found no evidence to support the assertion that women suffer from poor mental health outcomes after having an elective abortion (

      Koop, C.E. (1989 Mar. 21). Surgeon General's report: the public health effects of abortion. Congressional Record. 101st Cong, 1st Sess. p. E906–E909

      ). Despite this and other more recent scientific evidence citing similar findings, the U.S. Supreme Court referenced maternal mental health in its decision to uphold a ban on late-term abortions (Gonzales v. Carhart). Specifically, the Supreme Court stated that women may experience “regret, . . . severe depression and loss of esteem” while simultaneously acknowledging that “we find no reliable data to measure the phenomenon” (

      Carhart, 127 S. Ct. at 1634. (2006). (Citing Brief of Sandra Cano, the Former “Mary Doe” of Doe v. Bolton, and 180 Women Injured by Abortion as Amici Curiae Supporting Petitioner at 22-24, Carhart, 127 S. Ct. 1610(No. 05-380), 2006 WL 1436684).

      ). Similarly, legislators in South Dakota used this same rationale in developing a new law that compels physicians to inform women seeking abortions that they will be putting themselves at risk for emotional distress and suicide (
      • Simon S.
      New front in abortion battle: Both sides await report that charts the effects of mental health.
      ). The existing empirical evidence, presented below, has not been accepted by opponents of elective abortions in the United States; many still believe that abortion can be harmful to women's mental health and cite adoption as the preferred alternative. If the mental health of the pregnant woman is paramount, this raises the question as to whether adoption can be recommended as an alternative to elective abortion if there is no evidence to support that it results in more favorable outcomes for maternal mental health. In addition to highlighting the key research showing that abortion does not routinely result in mental health disorders in the women who undergo them, this brief review discusses the mental health outcomes of alternatives to abortions. Specifically, the less acknowledged negative mental health sequelae of mothers who give up their children for adoption and those who raise the child of an unwanted pregnancy are discussed below, as well as the challenges to conducting research on such women. Conclusions are made suggesting that these alternatives may not improve outcomes for women and may in fact hold a worse fate for maternal mental health than a legal, elective abortion.

      Elective Abortion

      Abortion is a relatively common event in the United States with roughly 2% of women undergoing abortions each year. About half (48%) of these women have already had at least one previous elective abortion (
      • Jones R.K.
      • Darroch J.E.
      • Henshaw S.K.
      Contraceptive use among US women having abortions in 2000-2001.
      ). The reasons most frequently cited were that having a child would interfere with a woman's education, work or ability to care for dependents (74%), that she could not afford a baby now (73%), and that she did not want to be a single mother or was having relationship problems (48%). Nearly 4 in 10 women said they had completed their childbearing, and almost one third were not ready to have a child. Fewer than 1% said their parents' or partners' desire for them to have an abortion was the most important reason. Younger women often reported that they were unprepared for the transition to motherhood, whereas older women regularly cited their responsibility to dependents (
      • Finer L.B.
      • Frohwirth L.F.
      • Dauohinee L.A.
      • Singh S.
      • Moore A.M.
      Reasons U.S. women have abortions: quantitative and qualitative perspectives.
      ).
      In repeated studies performed since the early 1980s, leading experts have concluded that elective abortion does not pose a hazard to women's mental health (
      • Boonstra H.D.
      • Gold R.B.
      • Richards C.
      • Finer L.B.
      Abortion in women's lives.
      ). Despite these findings, there are still articles published citing the opposite (e.g.,
      • Gilchrist A.C.
      • Hannaford P.C.
      • Frank P.
      • Kay C.R.
      Termination of pregnancy and psychiatric morbidity.
      ,
      • Gissler M.
      • Hemminki E.
      • Lonnqvist J.
      Suicides after pregnancy in Finland, 1987-94: Register linkage study.
      ,
      • Reardon D.C.
      • Cougle J.R.
      • Rue V.M.
      • Shuping M.W.
      • Coleman P.K.
      • Ney P.G.
      Psychiatric admissions of low-income women following abortion and childbirth.
      ). Many studies showing poor mental health outcomes for women after an elective abortion are methodologically flawed and may be motivated by the author's political viewpoints. Although some studies do acknowledge that poor mental health outcomes, such as suicide, after an elective abortion may be more likely to be related to the common risk factors of both poor mental health and abortion-seeking behavior (e.g.,
      • Gissler M.
      • Hemminki E.
      • Lonnqvist J.
      Suicides after pregnancy in Finland, 1987-94: Register linkage study.
      ), these same studies often gloss over this, preferring to focus on the facts that suicide followed the abortion, creating the misperception of a causal link that abortion can lead to suicide. Other studies have been criticized for using inappropriate comparison groups (e.g.,
      • Reardon D.C.
      • Cougle J.R.
      • Rue V.M.
      • Shuping M.W.
      • Coleman P.K.
      • Ney P.G.
      Psychiatric admissions of low-income women following abortion and childbirth.
      ). Research comparing the mental health of pregnant women who have sought and obtained abortions with that of pregnant women who have carried their pregnancies to term have been criticized for not taking into account the major differences in stage of life, mental state, and financial ability of women who abort versus women who carry a pregnancy to term (
      • Major B.
      Psychological implications of abortion: Highly charged and rife with misleading research.
      ). According to
      • Major B.
      Psychological implications of abortion: Highly charged and rife with misleading research.
      , women who abort generally do so because the pregnancy was unplanned and unwanted, whereas women who carry a pregnancy to term generally have more positive feelings about the pregnancy. A more appropriate comparison group would be women who were unable to obtain or denied an abortion and therefore carried an unwanted pregnancy to term. A similarly suitable comparison group is women who give their newborns up for adoption; at least this would mimic the same intentions toward the pregnancy. As it is, this type of research on abortion and mental health is extremely difficult to carry out in well-designed, controlled studies because it is highly unethical to consider random assignment to conditions including abortion or unwanted delivery.
      The existing literature on the mental health consequences of elective abortion is further flawed by the existence of published case studies, a number of which draw negative conclusions about the effect of abortion on mental health. However, many of these case studies or other studies conducted with very small sample sizes (n=1–11) focus on psychodynamic theories of psychopathology and not criteria set forth by the Diagnostic and Statistical Manual of Mental Disorders (
      American Psychiatric Association
      ). They also tend to draw on qualitative or anecdotal evidence and are not backed up by sound statistical analyses; nor are they well designed or controlled (e.g.,
      • Fischer N.
      Multiple induced abortions: A psychoanalytic case study.
      ).
      Pointing out the flawed research methodology in an effort to correct improper conclusions is not meant to suggest that there are no women who experience negative mental health outcomes after an abortion. The intent is merely to imply that this is not occurring in epidemic proportions. Overall, the literature shows that legal abortion is a medically safe procedure without negative mental health consequences. In fact, the majority of women who undergo elective, legal abortions cite relief and enhanced self-esteem after the procedure (
      • Kero A.
      • Hogberg U.
      • Lalos A.
      Wellbeing and mental growth—Long-term effects of legal abortion.
      ).
      • Steinberg J.
      • Jordan B.
      • Wells E.
      Science prevails: Abortion and mental health.
      also point out that as a result of the focus on negative mental health consequences of elective abortions, little research has been conducted on what may be seen as the potential positive outcomes for mental health. These authors refer to positive feelings that may arise when a women is given the ability to exercise control over her own reproductive decisions, or from the knowledge that her other children will have more opportunities based on her decision. It is also possible that for those women who do experience negative mental health issues after an abortion, these symptoms are less severe than they might have been had the pregnancy been carried to term (
      • Steinberg J.
      • Jordan B.
      • Wells E.
      Science prevails: Abortion and mental health.
      ).
      There are some women who do suffer from depression, anxiety or psychotic episodes after an abortion. In general the risk factors for these outcomes are a prior history of depression (
      • Major B.
      • Cozzarelli C.
      • Cooper M.L.
      • Zubek J.
      • Rickards C.
      • Wilhite M.
      • et al.
      Psychological responses of women after first-trimester abortion.
      ), younger age, first pregnancy, and coercion in the decision making (
      • Andrew J.
      • Boyle J.S.
      African American Adolescents experiences of unplanned pregnancy and elective abortion.
      ). Studies indicate that the psychological outcome of abortion is best when the woman is free to make her own choice about the continuation or termination of her pregnancy and confident that she will be supported in whatever decision she makes (e.g.,
      • Andrew J.
      • Boyle J.S.
      African American Adolescents experiences of unplanned pregnancy and elective abortion.
      ). In fact, the American Psychological Association's Task Force on Mental Health and Abortion recently conducted and released a comprehensive review of literature since 1989 and concluded that, among women who have a single, legal, first-trimester abortion of an unplanned pregnancy for nontherapeutic reasons, the risk of mental health problems is no greater than that among women who deliver unplanned pregnancies (
      • Major B.
      • Appelbaum M.
      • Beckman L.
      • Dutton M.A.
      • Felipe Russo N.
      • West C.
      Report of the APA Task Force on Mental Health and Abortion.
      ;
      • Major B.
      • Appelbaum M.
      • Beckman L.
      • Dutton M.A.
      • Felipe Russo N.
      • West C.
      Abortion and mental health: evaluating the evidence.
      ).

      Unwanted Pregnancy and Childbirth

      If a pregnant woman who does not want the pregnancy is prevented from securing an abortion, she is then compelled to carry this unwanted child to term. Although anti-abortion groups seek to ban the elective abortion procedure citing among many reasons a woman's mental health, it does not seem that these groups have considered the negative outcomes that could result from carrying an unwanted pregnancy to term.
      • Kost K.
      • Landry D.J.
      • Darroch J.E.
      Predicting maternal behaviors during pregnancy: Does intention status matter?.
      found many negative consequences for mothers and children of carrying such a pregnancy to term, including late presentation for prenatal care, a decrease in health promotion behaviors during pregnancy, continued alcohol and nicotine use during pregnancy, premature delivery, low-birth-weight infants, infants that are small for gestational age, inconsistent or no presentation for well-baby care, and a lack of breastfeeding. An unwanted pregnancy increases the likelihood that the infant's health will be compromised (odds ratio, 1.3;
      • Kost K.
      • Landry D.J.
      • Darroch J.E.
      Predicting maternal behaviors during pregnancy: Does intention status matter?.
      ) and it also shows poor outcomes for maternal fetal bonding should the birth mother keep and raise the child (
      • Barber J.S.
      • Axinn W.
      • Thornton A.
      Unwanted childbearing, health and mother-child relationships.
      ). These authors also point out that poor mother–child relationships are not specific to the unwanted child; all of the children in the family suffer when the mother has given birth to a child as a result of an unwanted pregnancy. Many mothers with unwanted pregnancies deliver low or very low birth weight infants (
      • Kost K.
      • Landry D.J.
      • Darroch J.E.
      Predicting maternal behaviors during pregnancy: Does intention status matter?.
      ), which has been associated with higher levels of maternal psychological distress including depression, anxiety, and obsessive compulsive behaviors (
      • Singer L.T.
      • Salvator A.
      • Guo S.
      • Collin M.
      • Lilien L.
      • Baley J.
      Maternal psychological distress and parenting stress after the birth of a very low-birth-weight infant.
      ). Unwanted pregnancy and delivery has also been shown to be associated with postpartum depression (
      • Beck C.T.
      Predictors of postpartum depression: An update.
      ), feelings of powerlessness, increased time pressures, and impaired physical health (
      • Barber J.S.
      • Axinn W.
      • Thornton A.
      Unwanted childbearing, health and mother-child relationships.
      ). Regardless of whether the mother keeps or gives the child up for adoption, she must actually go through the physical act of an unwanted childbirth.
      • Barber J.S.
      • Axinn W.
      • Thornton A.
      Unwanted childbearing, health and mother-child relationships.
      posit that this is likely to lead to significant feelings of powerlessness which has been significantly associated with the development of depression and anxiety, as well as with malaise, physical illness, and alcoholism (e.g.,
      • Bird C.E.
      • Ross C.E.
      Houseworkers and paid workers: Qualities of the work and effects on personal control.
      ;
      • Mirowsky J.
      • Ross C.E.
      Social patterns of distress.
      ).
      The research cited above summarily shows that although there is no evidence for widespread and consistent symptoms of mental health disorders among women after an elective abortion, there may actually be significant negative consequences of unwanted childbearing for the mental health of the mother. This raises the question of whether an unqualified call for adoption is really a better option for maternal mental health. A mother who chooses to give up her child for adoption still has to undergo an unwanted pregnancy and childbirth with all of the poor potential outcomes that this may entail. Consequently, a child with health complications given up for adoption may not be seen as the most desirable candidate for prospective families and may languish in foster care. Additionally, the mental health of women who have given their children up for adoption has not been studied in depth owing to privacy laws that maintain the confidentiality of birth mothers. Most research on adoption has been conducted to determine factors that cause or result in mental health problems for children who have been adopted with the resounding finding being that most adoptees fall within the normal range of psychological functioning (
      • Brodzinsky D.M.
      • Smith D.W.
      • Brodzinsky A.B.
      Children's adjustment to adoption: Developmental and clinical issues.
      ,
      • Wegar K.
      Adoption, family ideology, and social stigma: Bias in community attitudes, adoption research, and practice.
      ). Research that has been conducted on birth mother outcomes after relinquishment of the infant has found evidence supporting poor mental health and adjustment after the adoption.
      • Deykin E.Y.
      • Campbell L.
      • Patti P.
      The postadoption experience of surrendering parents.
      found that having given up a child is perceived by birth mothers as having a long-term negative influence on their lives in the areas of marriage, fertility, and parenting subsequent children. Similarly,
      • Wiley M.O.L.
      • Baden A.L.
      Birth parents in adoption: Research, practice, and counseling psychology.
      found that clinical symptoms for birth parents include unresolved grief, isolation, difficulty with future relationships, and trauma, and
      • Kelly J.
      The trauma of relinquishment: The long-term impact of relinquishment on birthmothers who lost their infants to adoption during the years 1965-1972.
      found evidence for increased rates of depression among birth mothers (51% of respondents endorsed severe depression since relinquishment and 97% endorsed some level of depression [mild, moderate, or severe]). Last, in their review article,
      • Askren H.A.
      • Bloom K.C.
      Postadoptive reactions of the relinquishing mother: A review.
      found a grief reaction unique to birth mothers who had surrendered their children for adoption. This grief reaction consists of the typical features of the normal grief reaction; however, the symptoms persist and often lead to chronic unresolved grief.
      If anti-abortion activists and legislators want to spin their “fetally focused platform” (
      • Steinberg J.
      • Jordan B.
      • Wells E.
      Science prevails: Abortion and mental health.
      ) to one of maternal mental health, then the scientific evidence should be examined from every angle, not solely what supports their claim that elective abortions are bad for women. In so doing, it becomes evident that elective abortions only rarely result in negative mental health outcomes for the mother. Generally, the studies that show widespread poor mental health outcomes make inappropriate causal inferences, use poorly selected control groups, and may be motivated by the authors' political or religious viewpoints. Alternatives to abortion such as giving birth to an unwanted child and relinquishing that child for adoption are often cited as recommended substitutes to preserve the mental health of the mother; however, as referenced, these options may not improve outcomes and may in fact result in no better and perhaps even worse consequences for maternal health and well-being.

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      Biography

      Sara Levine Kornfield will receive her PhD in Clinical Psychology from Drexel University in August 2010. Her recent research has focused on psychosocial factors affecting HIV prevention during pregnancy among low-income minority women.

      Biography

      Dr. Geller is Associate Professor of Psychology and Public Health Drexel University) and Research Associate Professor of Ob/Gyn (Drexel University College of Medicine). Her research focuses on women's reproductive health, particularly medical education and the mental health consequences of pregnancy loss.