Psychiatric aspects of pregnancy termination
- Uta Landy, PhD
Uta Landy, PhD
- National Director
- Ryan Residency Training Program
- Fellowship in Family Planning
- University of California, San Francisco
- Philip D Darney, MD, MSc
Philip D Darney, MD, MSc
- University of California, San Francisco
- Section Editors
- Jody Steinauer, MD, MAS
Jody Steinauer, MD, MAS
- Section Editor — Family Planning
- Associate Professor
- Obstetrics, Gynecology and Reproductive Sciences
- University of California, San Francisco
- Jonathan M Silver, MD
Jonathan M Silver, MD
- Section Editor — Mental and Medical Disorders
- Clinical Professor of Psychiatry
- New York University School of Medicine
- Deputy Editors
- Sandy J Falk, MD, FACOG
Sandy J Falk, MD, FACOG
- Director, Editorial Relations — UpToDate
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Instructor of Obstetrics, Gynecology and Reproductive Biology, Part-time
- Harvard Medical School
- David Solomon, MD
David Solomon, MD
- Deputy Editor — Psychiatry
- Clinical Associate Professor
- Brown University School of Medicine
In the United States in 2011, approximately 1 million pregnancies were terminated . Approximately half of all pregnancies were unintended and 40 percent of these were terminated, meaning that 21 percent of all pregnancies were aborted. The number of induced abortions declined by 13 percent between 2008 and 2011, but the number of terminations of intended pregnancies has increased due to advances in prenatal testing for fetal abnormalities [1-3]. Although the psychological impact of pregnancy termination is controversial, most studies, especially higher-quality studies, suggest that induced abortion is not associated with an increased risk of serious mental health disorders [4-10]. It is important to note that the psychological context of pregnancy termination varies depending upon whether the reason is an unwanted pregnancy, multiple gestation, or fetal anomalies.
The psychiatric aspects of pregnancy termination are reviewed here. Other issues regarding pregnancy termination are discussed separately. (See "Overview of pregnancy termination".)
EVIDENCE REGARDING POTENTIAL OUTCOMES
Most reviews have concluded that abortion does not harm a women’s mental health [4,5,11-13]. However, some of the evidence regarding the psychiatric aspects of pregnancy termination is of low quality, and study designs are inconsistent . Many studies do not use validated mental health measures or control for pre-abortion mental status and whether the pregnancy is planned, and the presence and type of comparison group varies . Specifically, many studies compare women with unplanned pregnancies to women planning an ongoing pregnancy. The circumstance of an unwanted pregnancy involves factors that are likely to be associated with emotional distress, such as impaired relationships and financial difficulties.
In addition, psychological responses to pregnancy termination often vary by social, cultural, religious, or legal context, so generalizations across populations are difficult to make [14,15]. Emotional responses to abortion would be expected to differ between environments where induced abortion is permissible and where abortion is disapproved. If abortion poses risks such as injury, financial ruin, or incarceration, it is difficult to distinguish psychological responses to abortion from fears of the consequences.
The following sections focus upon mental health outcomes following pregnancy termination for unintended pregnancy. Psychiatric outcomes of pregnancy termination due to fetal abnormalities are discussed in a separate section. (See 'Termination for fetal anomalies' below.)
- Jones RK, Jerman J. Abortion incidence and service availability in the United States, 2011. Perspect Sex Reprod Health 2014; 46:3.
- Salvesen KA, Oyen L, Schmidt N, et al. Comparison of long-term psychological responses of women after pregnancy termination due to fetal anomalies and after perinatal loss. Ultrasound Obstet Gynecol 1997; 9:80.
- Davies V, Gledhill J, McFadyen A, et al. Psychological outcome in women undergoing termination of pregnancy for ultrasound-detected fetal anomaly in the first and second trimesters: a pilot study. Ultrasound Obstet Gynecol 2005; 25:389.
- Kendall T, Bird V, Cantwell R, Taylor C. To meta-analyse or not to meta-analyse: abortion, birth and mental health. Br J Psychiatry 2012; 200:12.
- http://www.apa.org/pi/women/programs/abortion/mental-health.pdf (Accessed on April 18, 2012).
- Charles VE, Polis CB, Sridhara SK, Blum RW. Abortion and long-term mental health outcomes: a systematic review of the evidence. Contraception 2008; 78:436.
- Major B, Appelbaum M, Beckman L, et al. Abortion and mental health: Evaluating the evidence. Am Psychol 2009; 64:863.
- Biggs MA, Neuhaus JM, Foster DG. Mental Health Diagnoses 3 Years After Receiving or Being Denied an Abortion in the United States. Am J Public Health 2015; 105:2557.
- Biggs MA, Rowland B, McCulloch CE, Foster DG. Does abortion increase women's risk for post-traumatic stress? Findings from a prospective longitudinal cohort study. BMJ Open 2016; 6:e009698.
- Leppälahti S, Heikinheimo O, Kalliala I, et al. Is underage abortion associated with adverse outcomes in early adulthood? A longitudinal birth cohort study up to 25 years of age. Hum Reprod 2016; 31:2142.
- National Collaborating Center for Mental Health. Induced abortion and mental health: A systematic review of the mental health outcomes of induced abortion, including their prevalence and associated factors. December, 2011. http://www.nccmh.org.uk/publications_SR_abortion_in_MH.html (Accessed on May 30, 2014).
- Coleman PK. Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009. Br J Psychiatry 2011; 199:180.
- Steinberg JR, Trussell J, Hall KS, Guthrie K. Fatal flaws in a recent meta-analysis on abortion and mental health. Contraception 2012; 86:430.
- Thorp JM Jr, Hartmann KE, Shadigian E. Long-term physical and psychological health consequences of induced abortion: review of the evidence. Obstet Gynecol Surv 2003; 58:67.
- Cameron S. Induced abortion and psychological sequelae. Best Pract Res Clin Obstet Gynaecol 2010; 24:657.
- Munk-Olsen T, Laursen TM, Pedersen CB, et al. Induced first-trimester abortion and risk of mental disorder. N Engl J Med 2011; 364:332.
- Munk-Olsen T, Laursen TM, Pedersen CB, et al. First-time first-trimester induced abortion and risk of readmission to a psychiatric hospital in women with a history of treated mental disorder. Arch Gen Psychiatry 2012; 69:159.
- Harris AA. Supportive counseling before and after elective pregnancy termination. J Midwifery Womens Health 2004; 49:105.
- Adler NE, David HP, Major BN, et al. Psychological factors in abortion. A review. Am Psychol 1992; 47:1194.
- Hemmerling A, Siedentopf F, Kentenich H. Emotional impact and acceptability of medical abortion with mifepristone: a German experience. J Psychosom Obstet Gynaecol 2005; 26:23.
- Howard LM, Rowe M, Trevillion K, et al. Abortion and mental health: guidelines for proper scientific conduct ignored. Br J Psychiatry 2012; 200:74; discussion 78.
- Steinberg JR, McCulloch CE, Adler NE. Abortion and mental health: findings from The National Comorbidity Survey-Replication. Obstet Gynecol 2014; 123:263.
- Gilchrist AC, Hannaford PC, Frank P, Kay CR. Termination of pregnancy and psychiatric morbidity. Br J Psychiatry 1995; 167:243.
- Steinberg JR, Becker D, Henderson JT. Does the outcome of a first pregnancy predict depression, suicidal ideation, or lower self-esteem? Data from the National Comorbidity Survey. Am J Orthopsychiatry 2011; 81:193.
- Dingle K, Alati R, Clavarino A, et al. Pregnancy loss and psychiatric disorders in young women: an Australian birth cohort study. Br J Psychiatry 2008; 193:455.
- Schmiege S, Russo NF. Depression and unwanted first pregnancy: longitudinal cohort study. BMJ 2005; 331:1303.
- Reardon DC, Cougle JR. Depression and unintended pregnancy in the National Longitudinal Survey of Youth: a cohort study. BMJ 2002; 324:151.
- Bradshaw Z, Slade P. The effects of induced abortion on emotional experiences and relationships: a critical review of the literature. Clin Psychol Rev 2003; 23:929.
- Steinberg JR, Russo NF. Abortion and anxiety: what's the relationship? Soc Sci Med 2008; 67:238.
- Lauzon P, Roger-Achim D, Achim A, Boyer R. Emotional distress among couples involved in first-trimester induced abortions. Can Fam Physician 2000; 46:2033.
- Wallin Lundell I, Georgsson Öhman S, Frans Ö, et al. Posttraumatic stress among women after induced abortion: a Swedish multi-centre cohort study. BMC Womens Health 2013; 13:52.
- Major B, Cozzarelli C, Cooper ML, et al. Psychological responses of women after first-trimester abortion. Arch Gen Psychiatry 2000; 57:777.
- Rue VM, Coleman PK, Rue JJ, Reardon DC. Induced abortion and traumatic stress: a preliminary comparison of American and Russian women. Med Sci Monit 2004; 10:SR5.
- Rousset C, Brulfert N, Sejourne N, et al.. Posttraumatic stress disorder and psychological distress following medical and surgical abortion. J Reprod Infant Psychol 2011; 29:506.
- Steinberg JR, Finer LB. Examining the association of abortion history and current mental health: A reanalysis of the National Comorbidity Survey using a common-risk-factors model. Soc Sci Med 2011; 72:72.
- Robinson GE, Stotland NL, Russo NF, et al. Is there an "abortion trauma syndrome"? Critiquing the evidence. Harv Rev Psychiatry 2009; 17:268.
- Roberts SC, Rocca CH, Foster DG. Receiving versus being denied an abortion and subsequent drug use. Drug Alcohol Depend 2014; 134:63.
- Bulik CM, Hoffman ER, Von Holle A, et al. Unplanned pregnancy in women with anorexia nervosa. Obstet Gynecol 2010; 116:1136.
- Kimport K, Foster K, Weitz TA. Social sources of women's emotional difficulty after abortion: lessons from women's abortion narratives. Perspect Sex Reprod Health 2011; 43:103.
- Söderberg H, Janzon L, Sjöberg NO. Emotional distress following induced abortion: a study of its incidence and determinants among abortees in Malmö, Sweden. Eur J Obstet Gynecol Reprod Biol 1998; 79:173.
- Rocca CH, Kimport K, Gould H, Foster DG. Women's emotions one week after receiving or being denied an abortion in the United States. Perspect Sex Reprod Health 2013; 45:122.
- Rocca CH, Kimport K, Roberts SC, et al. Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study. PLoS One 2015; 10:e0128832.
- Astbury-Ward E, Parry O, Carnwell R. Stigma, abortion, and disclosure--findings from a qualitative study. J Sex Med 2012; 9:3137.
- Harris LH. Stigma and abortion complications in the United States. Obstet Gynecol 2012; 120:1472.
- Major B, Gramzow RH. Abortion as stigma: cognitive and emotional implications of concealment. J Pers Soc Psychol 1999; 77:735.
- Norris A, Bessett D, Steinberg JR, et al. Abortion stigma: a reconceptualization of constituents, causes, and consequences. Womens Health Issues 2011; 21:S49.
- Broen AN, Moum T, Bödtker AS, Ekeberg O. Predictors of anxiety and depression following pregnancy termination: a longitudinal five-year follow-up study. Acta Obstet Gynecol Scand 2006; 85:317.
- Mota NP, Burnett M, Sareen J. Associations between abortion, mental disorders, and suicidal behaviour in a nationally representative sample. Can J Psychiatry 2010; 55:239.
- Rizzardo R, Novarin S, Forza G, Cosentino M. Personality and psychological distress in legal abortion, threatened miscarriage and normal pregnancy. Psychother Psychosom 1991; 56:227.
- Broen AN, Moum T, Bödtker AS, Ekeberg O. Reasons for induced abortion and their relation to women's emotional distress: a prospective, two-year follow-up study. Gen Hosp Psychiatry 2005; 27:36.
- Taft AJ, Watson LF. Depression and termination of pregnancy (induced abortion) in a national cohort of young Australian women: the confounding effect of women's experience of violence. BMC Public Health 2008; 8:75.
- Russo NF, Denious JE. Violence in the lives of women having abortions: Implications for practice and public policy. Prof Psychol Res Pract 2001; 32:142.
- Fisher WA, Singh SS, Shuper PA, et al. Characteristics of women undergoing repeat induced abortion. CMAJ 2005; 172:637.
- Bacchus LJ, Bewley S, Vitolas CT, et al. Evaluation of a domestic violence intervention in the maternity and sexual health services of a UK hospital. Reprod Health Matters 2010; 18:147.
- Tomal A. Parental involvement laws, religion, and abortion rates. Gend Issues 2000; 18:33.
- Moseley DT, Follingstad DR, Harley H, Heckel RV. Psychological factors that predict reaction to abortion. J Clin Psychol 1981; 37:276.
- Steinberg JR. Later abortions and mental health: psychological experiences of women having later abortions--a critical review of research. Womens Health Issues 2011; 21:S44.
- Korenromp MJ, Page-Christiaens GC, van den Bout J, et al. Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months. Am J Obstet Gynecol 2009; 201:160.e1.
- Sit D, Rothschild AJ, Creinin MD, et al. Psychiatric outcomes following medical and surgical abortion. Hum Reprod 2007; 22:878.
- Robson SC, Kelly T, Howel D, et al. Randomised preference trial of medical versus surgical termination of pregnancy less than 14 weeks' gestation (TOPS). Health Technol Assess 2009; 13:1.
- Hamark B, Uddenberg N, Forssman L. The influence of social class on parity and psychological reactions in women coming for induced abortion. Acta Obstet Gynecol Scand 1995; 74:302.
- Stotland NL. Induced abortion and adolescent mental health. Curr Opin Obstet Gynecol 2011; 23:340.
- Zabin LS, Hirsch MB, Emerson MR. When urban adolescents choose abortion: effects on education, psychological status and subsequent pregnancy. Fam Plann Perspect 1989; 21:248.
- Pope LM, Adler NE, Tschann JM. Postabortion psychological adjustment: are minors at increased risk? J Adolesc Health 2001; 29:2.
- Upadhyay UD, Cockrill K, Freedman LR. Informing abortion counseling: an examination of evidence-based practices used in emotional care for other stigmatized and sensitive health issues. Patient Educ Couns 2010; 81:415.
- Perrucci, A. Decision assessment and counseling in abortion care, Rowman & Littlefield, Lanham, Maryland 2012.
- American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 385 November 2007: the limits of conscientious refusal in reproductive medicine. Obstet Gynecol 2007; 110:1203.
- Kero A, Högberg U, Lalos A. Wellbeing and mental growth-long-term effects of legal abortion. Soc Sci Med 2004; 58:2559.
- Turell SC, Armsworth MW, Gaa JP. Emotional response to abortion: a critical review of the literature. Women Ther 1990; 9:49.
- Trost JE. Abortions in relation to age, coital frequency, and fecundity. Arch Sex Behav 1986; 15:505.
- McCloskey LA, Williams CM, Lichter E, et al. Abused women disclose partner interference with health care: an unrecognized form of battering. J Gen Intern Med 2007; 22:1067.
- Roth L, Sheeder J, Teal SB. Predictors of intimate partner violence in women seeking medication abortion. Contraception 2011; 84:76.
- Kimport K, Perrucci A, Weitz TA. Addressing the silence in the noise: how abortion support talklines meet some women's needs for non-political discussion of their experiences. Women Health 2012; 52:88.
- Foster DG, Gould H, Kimport K. How women anticipate coping after an abortion. Contraception 2012; 86:84.
- Veiga MB, Lam M, Gemeinhardt C, et al. Social support in the post-abortion recovery room: evidence from patients, support persons and nurses in a Vancouver clinic. Contraception 2011; 83:268.
- EVIDENCE REGARDING POTENTIAL OUTCOMES
- Mental disorders in aggregate
- Posttraumatic stress disorder
- Substance abuse
- Eating disorders
- POTENTIAL MODIFYING FACTORS
- Factors that may increase risk of postabortion psychiatric problems
- - Mental disorders prior to abortion
- - Social support
- - Violence victimization
- - Attitude toward pregnancy termination
- - Current family size
- - Termination for fetal anomalies
- Factors that do not appear to be related to postabortion mental health
- - Gestational duration
- - History of pregnancy termination
- - Pregnancy termination technique
- - Socioeconomic status
- - Adolescence
- - Multifetal pregnancy reduction
- Identifying women at risk of adverse outcomes
- Counseling before pregnancy termination
- - Source of counseling
- Referring clinician
- Clinician performing the termination
- - Decision-making
- - Emotional support
- Counseling after pregnancy termination