Psychological Effects Of Abortion On Women: A Review Of .

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Crisis Pregnancy Agency Report No. 20Psychological Effects of Abortion on Women:A Review of the LiteratureMargret Fine-Davis, PhDSchool of Social Sciences and PhilosophyTrinity College Dublintel: 353 1 814 6292fax: 353 1 814 6282email: info@crisispregnancy.ieweb: www.crisispregnancy.ieRESEARCHDEC 2007ISBN: 1-905199-20-1Crisis Pregnancy Agency Report No. 20Crisis Pregnancy Agency4th Floor89 - 94 Capel StreetDublin 1

Psychological Effects of Abortion on Women:A Review of the LiteraturePsychological Effects of Abortion on Women:A Review of the LiteratureMargret Fine-DavisISBN: 1-905199-20-1PAGE

PAGE Psychological Effects of Abortion on Women:A Review of the LiteratureAbout the authorMargret Fine-Davis, a social psychologist, is Senior Research Fellow and Director ofthe Social Attitude and Policy Research Group in the School of Social Sciences andPhilosophy, Trinity College Dublin. She specialises in survey research and attitudemeasurement and has carried out numerous studies on Irish and cross-nationalsamples.Her primary research interests are changing gender-role attitudes and behaviour, socialpsychological aspects of women’s employment and related social policy issues, includingmental health, work-life balance and childcare.Her recent book, Fathers and Mothers: Dilemmas of the Work-Life Balance, reportedresults of a collaborative cross-cultural study concerning reconciliation of work andfamily life among working parents in four European countries.Dr Fine-Davis is a member of the Board of the Coombe Women and Infants UniversityHospital and the International Editorial Board of the European Journal of Women’sStudies.AcknowledgementsI would like to acknowledge with thanks the contribution to this review made by Dr.Florence Craven, Post-doctoral Research Fellow, Social Attitude and Policy ResearchGroup, School of Social Sciences and Philosophy, Trinity College, who carried out theliterature search. We were assisted in this search by Elizabeth Gleeson of the BerkeleyLibrary, Trinity College. Appreciation is also expressed to Amanda Holzworth whoprepared the graphs.I am also grateful to Dr. Patricia Kennedy, University College Dublin, for access to anearlier manuscript prepared by her for the Crisis Pregnancy Agency on this topic.I would like to express my appreciation to the Crisis Pregnancy Agency for providing mewith much of the key literature in this field, and to Dr. Stephanie O’Keeffe, Research andPolicy Manager, for her most helpful advice during the course of the review. Finally, Iwould like to express my gratitude to the reviewers of the manuscript on the CPA Boardand Research and Policy Subcommittee for their valuable comments.Margret Fine-DavisDecember 2007

Psychological Effects of Abortion on Women:A Review of the LiteratureForewordI am pleased to present this review of research on the psychological effects of abortion.Our aim in commissioning this study was to give a sense of the nature and type ofresearch that has been carried out in this area and, if possible, to draw conclusions toinform the work of the Crisis Pregnancy Agency and the services it funds.The Agency is mandated to provide support to women after crisis pregnancy, includingthe 15% of women experiencing crisis pregnancy who have an abortion. The Agencyis achieving this through the development and improvement of crisis pregnancycounselling services. Our work in this area has been informed by Agency-commissionedresearch examining supports required by women and their families when they choose toparent following a crisis pregnancy and when they choose to place a baby for adoption.The current review of abortion literature will complement this body of research, whichinforms the development of supports for women in a crisis pregnancy situation.Knowledge about how a woman may respond to making a decision to have an abortion isan important part of a counsellor’s work, and yet it can be difficult for service providersand women themselves to make sense of the sometimes seemingly contradictoryfindings on the effects of abortion. In order to standardise and assure the quality of caregiven to a woman in a crisis pregnancy situation, it is vital that clarity be brought tobear on this issue. In commissioning this review the Agency aimed to provide a clearoverview of research conducted in this area, and to synthesise findings where possible.The review provides a comprehensive analysis of the research that exists on this subject,the main findings and the methodological limitations that have been a feature of muchof the research in this area. I commend the author, Dr Margret Fine-Davis, for engagingso comprehensively with a large body of work and producing a report that succinctlysummarises the main issues and findings.The methodological limitations in much of the literature mean that it is difficult to drawfirm conclusions about the psychological effects of abortion - especially in the Irishcontext, where there is very little research. Even the most robust studies reviewed inthis report have limitations in their study design; as a consequence external factors andinfluences could have affected the reliability of the findings. In spite of the limitations,broad consensus does exist within the literature on some issues. The first findingcommon to most studies and reviews is that for most women abortion has no seriouslasting negative psychological effects. Some studies put the figure for the proportionof women likely to experience negative psychological effects at around 20%. Manystudies were also able to identify common factors that seemed to pre-dispose women tonegative psychological effects, although the studies differed in how they defined negativepsychological effects, with some studies speaking of mild symptoms, such as anxiety,and others describing more serious mental health problems, such as depression.PAGE

PAGE Psychological Effects of Abortion on Women:A Review of the LiteratureThe report suggests that women who have more negative responses following abortiontend to be those: who have limited or no partner or family supportwho have psychological problems before the pregnancywho feel coerced to have the abortionwho have an abortion in the second trimester of pregnancywhose own religious beliefs or those of their social environment aredisapproving of abortion live in a cultural context or have a religion that prohibits abortion terminate a wanted pregnancy due to foetal abnormalities or genetic reasons.Since its establishment the Agency has worked to improve women’s access to highquality counselling and support services. As we progress this work, our focus is onquality, and standardising the care given to a woman during and after crisis pregnancy.The planned development of a self-assessment Quality Assurance Framework ofprovision of crisis pregnancy counselling and the accredited training programme toup-skill crisis pregnancy counsellors, which began in November 2007, are importantelements of our strategy to enhance the quality of crisis pregnancy counselling services.The Agency is also in the process of developing a toolkit for the establishment anddelivery of crisis pregnancy counselling services. The findings from this review willinform this work, by enabling us to ensure that all women are given the best informationavailable on the psychological effects of abortion, by supporting counsellors to bemindful of the possible risk factors for negative outcomes and by enhancing referralprocesses, especially for women who may need specialised care.Caroline Spillane,Director,Crisis Pregnancy Agency

PAGE Psychological Effects of Abortion on Women:A Review of the LiteratureTABLE OF CONTENTS1.0Introduction and scope of the review1.1Introduction1.2Scope of review1.3Methodological approach1.4Methodological issues1.5Overview of results1.6Terminology1.6.1Abortion terminology1.6.2Terminology related to the psychological effects of abortion1.7Availability and prevalence of abortion777789999102.0Reviews of the literature2.1Introduction2.2Dagg (1991)2.3Adler, David, Major, Roth, Russo and Wyatt (1992) for theAmerican Psychological Association2.4Clare and Tyrrell (1994)2.5Bonevski and Adams (2001)2.6Thorp, Hartmann and Shadigian (2002)2.7Stotland (1997 and 2001)2.8Bradshaw and Slade (2003)2.9Adler, Ozer and Tschann (2003)1313133.0Individual studies3.1Introduction3.2Adler, David, Major, Russo and colleagues in the U.S.3.3Reardon, Cougle, Coleman and colleagues in the U.S.3.4Fergusson and colleagues, New Zealand3.5Selected Scandinavian studies3.5.1Soderberg, Janzon and Sjoberg (1998) - Sweden3.5.2Kero, Hogberg and Lalos (2004) - Sweden3.5.3Broen, Moum, Bodtker and Ekeberg (2005) - Norway2121212122252527274.0303030323333Views of professional associations and other bodies4.1Introduction4.2Psychological Society of Ireland4.3Royal College of Obstetricians and Gynaecologists (UK)4.4The American Psychological Association (U.S.)4.5The Surgeon General of the United States (U.S.)13151618191919

PAGE Psychological Effects of Abortion on Women:A Review of the Literature5.0Discussion and conclusions5.1Results of research5.2Views of professional associations and other bodies5.3The influence of contextual factors5.3.1Demographic factors5.3.2The effects of support from family and/or partner5.3.3Cultural or religious context5.3.4Foetal abnormalities or genetic reasons5.4Conclusion3535363737373838386.0Policy implications and recommendations for practice and further research6.1Policy implications6.2Recommendations for practice6.3Recommendations for further research404040417.0References43AppendicesAppendix 1: Abortion rates per 1,000 women by country: comparison of1995-1996 and 2003-2006Appendix 2: Glossary of terms4849LIST OF FIGURESFigure 1: Abortion rates per 1,000 women by country: 1995-1996Figure 2: Abortion rates per 1,000 women by country: 2003-20061112

Psychological Effects of Abortion on Women:A Review of the Literature1.0Introduction and scope of the review1.1 IntroductionThe psychological effects of abortion have been the subject of scientific investigation,as well as public debate internationally, for several decades and have generated a greatdeal of discussion, as well as some controversy. Given the importance of this matter forwomen and the significant public health implications resulting from it, it is an importantissue upon which to focus attention from a health policy point of view.1.2 Scope of reviewWhile there is much literature on this topic going back quite a long way (e.g.Shusterman, 1976; Lemkau, 1988), we are focusing in this review on more recentliterature. In general, we are limiting ourselves to peer-reviewed studies that havebeen published in the last 10 years - that is from 1996. The only exception to this is inrelation to review articles, in which case we have included some that go back to the early1990s. We are making this exception since review articles are particularly useful, as theyhave systematically reviewed many other studies and hence are particularly strong andreliable sources. Among the individual studies, we are paying particular attention to thelatest studies, e.g. those carried out in the last five years, since it may be assumed thatthese have benefited from previous research and are taking the topic further.The types of literature to be covered in this review include the following:1. Reviews of literature concerning the psychological effects of abortion on women;2. Individual studies concerning the psychological effects of abortion on women;3. Reports and articles from professional associations and other bodies.In the course of this review, we will also touch upon the contextual issues which bearupon the main issue. These relate to demographic factors and issues of support,including support of family, partner, etc.1.3 Methodological approachOur methodological approach in carrying out this review was to search the psychologicaland related literature, including psychiatric and nursing literature, to locate referencesconcerning the psychological effects of abortion on women. We used the followingTrinity College Library databases to locate peer-reviewed literature dating from the timeperiods noted above:PsychLitPsychArticlesPsychInfoPsychology and Behavioural Sciences CollectionPubMedEmbaseScience Citation IndexCinahlSpringer LinkUMI ProQuest Digital DissertationsPAGE

PAGE Psychological Effects of Abortion on Women:A Review of the LiteratureRelevant articles were located through PsychArticles, Psychology and BehaviouralSciences Collection and PsychInfo simultaneously. Search words used included:Psychology and Abortion, Psychological Effects of Abortion, Human Females andAbortion, Women and Abortion, Partners and Abortion. The databases yielded a largenumber of articles dating back to the 1960s and before. However, with rare exceptions,we have restricted ourselves to those dating from 1996, as noted above.Search words used in the PubMed database were also Psychology and Abortion,Psychological Effects of Abortion, Human Females and Abortion, Women and Abortion,Partners and Abortion. Approximately 500 articles were located, but most of these predated the cut-off point of 1996 to the present. Using ‘Psychology' as a principal searchword also produced articles relating to a partner's experience of abortion.The same search words were applied to a search of Embase. This yielded only 17articles, none of which were relevant to our purposes. A search of Springerlink yielded25 articles, of which 11 were relevant.The same search words were applied to a search of the Science Citation Index, whichyielded 51 results, approximately ten of which were useful.UMI ProQuest Digital Dissertations was also very useful; many of the articles found herecontained a full PDF version as well as brief summaries of dissertations.1.4 Methodological issuesBefore presenting an overview of the findings, it is important to point out that researchin this area is prone to several methodological limitations. Numerous authors haveprefaced their results by referring to these limitations.Stotland (1997) points out that “psychiatric aspects of abortion have been limited bymethodological problems such as the impossibility of randomly assigning women tostudy and control groups, resistance to follow–up, and confounding variables”. Heobserves that a wide range of factors may impact on an unintended pregnancy and thedecision to abort. These include: “Ongoing or past psychiatric illness, poverty, socialchaos, youth and immaturity, abandonment issues, ongoing domestic responsibilities,rape and incest, domestic violence, religion, and contraceptive failure.” He cites therisk factors for post-abortion psychosocial difficulties as being previous or concurrentpsychiatric illness, coercion to abort, genetic or medical indications, lack of socialsupports, ambivalence and increasing length of gestation.Thorp, Hartmann and Shadigian (2002) also refer to the methodological problemsinherent in research on abortion and its effects. They echo Stotland’s (1997) concernthat such research cannot be carried out using experimental designs and randomassignment to groups: “Abortion is an exposure that cannot be assigned to womenby chance as part of an experimental design. Thus, investigators are deprived ofthe powerful tool of randomization to minimize bias in their findings.” They pointout that progress in research must therefore depend on well designed and executedobservational studies.

Psychological Effects of Abortion on Women:A Review of the LiteratureThorp et al. (2002) also point out that women who choose to have abortions often differin many ways from those who do not. The former are likely to be younger, poorer,and less able to reliably use contraceptives. These authors further emphasise that“dissimilarities in socio-economic status, stress and access to health care and lifestylemay persist across time, and themselves be associated with adverse health events”(p. 68). This introduces risk of uncontrolled confounding of the results concerning therelationship between abortion and long-term outcomes.Adler, David, Major, Roth, Russo and Wyatt (1992) point out that interpretations ofresults may be influenced by bias. For example, they point to a study by Fingerer (1973),who demonstrated that postdoctoral students undergoing psychoanalytic training wereasked to predict responses of women following abortion. The responses predicted by thepostdoctoral psychologists were significantly more negative than those actually reportedby 324 women following their abortions. Thus the bias toward expecting negativeresponses is “inherent in a number of studies” (Adler et al., 1992, p.1197).1.5 Overview of resultsAs noted above, this review of the literature covers three main types of literature: Reviews of the literature concerning psychological effects of abortion on women. Individual studies concerning psychological effects of abortion on women. Reports and articles from professional associations and other bodies.We will present literature systematically under each of these three headings and thenpresent a Discussion and Conclusions section, which will summarise and synthesise thekey findings and main trends that have emerged in the recent literature.1.6 Terminology1.6.1 Abortion terminologyThroughout the report the term ‘abortion’ is used to describe a legally obtained, electiveabortion (i.e. one that is sought by the woman concerned as the chosen response to herpregnancy). The terms ‘induced abortion’, ‘legal abortion’ and ‘elective abortion’ areused when quoting directly from the research. Definitions of these can be found in the‘Glossary of key terms’ in Appendix 2.1.6.2 Terminology related to the psychological effects of abortionA variety of terms are used in the literature to denote that women did display somenegative feelings following an abortion; for example: ‘negative psychological effects’,‘psychiatric sequelae’, ‘emotional problems’, ‘negative psychological outcomes’, ‘mentalhealth problems’, ‘adverse mental health effects’. The level of distress conveyed by theseterms is not always made explicit in the literature; in some studies a negative healthconsequence could be anxiety, regret, guilt or avoiding thinking about the abortion; otherstudies define negative outcomes as serious mental health problems, such as self-harm,suicidal thoughts or depression. Some of the studies reviewed herein used standardisedmeasures to define mental health outcomes and others relied on the respondents’descriptions of how they felt and/or the interviewer’s interpretation of respondents’comments. For these reasons care should be taken when assessing the findings of thestudies under review.PAGE

PAGE 10Psychological Effects of Abortion on Women:A Review of the Literature1.7 Availability and prevalence of abortionBefore presenting research results, it may be useful to present some background data on theavailability and prevalence of abortion in the countries in which the research was carried out.Most of the research we have reviewed was carried out in the United States and theUnited Kingdom. Several studies were also reported from Scandinavia, i.e. Sweden,Norway and Denmark, as well as studies and reviews from Australia and New Zealand.A few studies were reported from Ireland, the Czech Republic and Russia.Abortion has been legal in the United Kingdom (excluding Northern Ireland) since 1967.It has been estimated that one in five pregnancies in England and Wales are terminated(Zolese and Blacker, 1992, as cited in Psychological Society of Ireland, 1992). Most ofthese are by single women.Abortion has been legal in the United States since 1973. About 1.5 million abortions areperformed annually. Most women having abortions are single (Adler et al., 1970, as citedin Psychological Society of Ireland, 1992).The Swedish abortion law of 1975 grants the woman the right to have an a

1.5 Overview of results 9 1.6 Terminology 9 1.6.1 Abortion terminology 9 1.6.2 Terminology related to the psychological effects of abortion 9 1.7 Availability and prevalence of abortion 10 .0 Reviews of the liter

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