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Factors associated with post-abortion adjustment problems: implications for triage.

Key words. Therapeutic abortion Psychological sequelae of abortion

Pre-abortion assessment

Acknowledgements: Work on this report was supported by research grants from the U.S. National Institutes of Health, Health Canada, and Janssen-Ortho Inc. to William A. Fisher, Department of Psychology and Department of Obstetrics and Gynecology, University of Western Ontario, London, Ontario. This paper was originally presented at the 1996 Canadian Sex Research Forum in Montreal, Quebec.


Recent reviews of the literature concerning psychological sequelae of abortion have concluded that the legal abortion of an unwanted pregnancy during the first-trimester does not pose a significant short-term psychological risk for the vast majority of women (see Adler, David, Major, Roth, Russo, & Wyatt, 1990; 1992). Most women report positive emotional responses, such as relief and happiness, after undergoing a first-trimester abortion (Illsey & Hall, 1976; Lazarus, 1985; Osofsky & Osofsky, 1972; Osofsky, Osofsky, & Rajan, 1971), although a small minority of women are consistently found to experience lingering post-abortion feelings of: sadness, guilt, regret, and depression (Adler et al., 1991; 1992). In response to the need to identify women at risk of these negative psychological sequelae, researchers have begun to explore factors that are associated with post-abortion adjustment problems.

Limitations of the Research Before considering the literature concerning post-abortion adjustment problems, it is important to recognize certain limitations inherent in this work. First, the actual prevalence of post-abortion psychological sequelae has not been established (see Wilmoth, de Alteriis, & Bussell, 1992, for a comprehensive discussion of this problem). Reported estimates of negative sequelae range from less than 10% to almost 50% of all abortions, depending upon how "negative sequelae" were defined and measured, and how the sample was identified and recruited (Lodl, McGettigan, & Bucy, 1984-1985). For the most part, however, higher estimates tend to reflect loosely defined, transient negative states; whereas, lower estimates tend to reflect more precisely defined, reliably measured, clinically significant sequelae (Lemkau, 1988). The low base rate of clinically significant after-effects of abortion, however, makes it difficult to determine the predictive strength of potential risk factors, since very large sample sizes would be needed to provide sufficient statistical power. As a result, the relative predictive accuracy of the various risk factors identified in the literature is not known.

Another important limitation of the literature is that post-abortion follow-up periods, during which negative psychological sequelae are tracked, are typically no longer than several weeks duration. This is particularly problematic given the recent debate concerning "post-abortion syndrome", a proposed syndrome similar to Post-Traumatic Stress Disorder, the clinical features of which may not appear in women until months or years after an abortion (see Speckhard & Rue, 1992, for a discussion of this issue). The existence of such a syndrome remains to be established empirically (Stotland, 1992; Wilmoth et al., 1992). Given its supposedly delayed appearance, currently available prospective studies are of questionable use for identifying women at risk.

Other frequently cited limitations of studies in this area are high attrition rates, reliance on correlational, descriptive data and anecdotal case reports, nonstandardized measures, the absence of relevant comparison groups, and the failure to report on the clinical significance of results (see Wilmoth et al., 1992, for a critique of the literature). In addition, many of the more frequently cited studies on post-abortion sequelae were conducted during the 1970s when women faced broader social opposition to abortion than is currently the case. We may ask whether these earlier findings remain valid for women undergoing abortion in the 1990s.


The nine factors described below have been found to be correlated with post-abortion adjustment problems.

(1) Demographic characteristics of women reporting post-abortion distress

Research on the demographic characteristics of women who report feelings of distress after an abortion indicates that they are primarily adolescents or young adults (Adler, 1975; Bracken, Hachamovitz, & Grossman, 1974; Margolis, Davison, Hanson, Loos, & Mikkelsen, 1971; Osofsky & Osofsky, 1972; Smith, 1973) who are unmarried (Miller, 1992) and who have no children (Adler, 1975). However, these characteristics not only describe women at risk, they also describe the typical profile of women seeking abortion (Koonin, Smith, & Green, 1996). Women at risk for negative psychological sequelae are also more likely to be Catholic (Miller, 1992; Adler, 1975) and to hold religious beliefs that are contrary to abortion (Adler, 1975; Bracken et al., 1978; Osofsky & Osofsky, 1972). There is some evidence that women who have received previous care for a diagnosed psychiatric illness may also be at greater risk (Ewing & Rouse, 1973; Frank, Kay, Winsgrave, Lewis, Osborne, & Newll, 1985; Greer, Lal, Lewis, Belsey, & Beard, 1976). The use of demographic information to predict profiles of women at risk for negative post-abortion sequelae may be enhanced by consideration of several psychosocial factors that have been found to influence post-abortion adjustment.

(2) Decision Process

The process by which the decision to have an abortion was reached and the extent to which a woman reports having had difficulty arriving at this decision are important predictors of post-abortion adjustment. Research examining the relationship between aspects of the abortion decision process and a woman's post-abortion emotional response has consistently found that greater difficulty with the decision to abort is associated with poorer post-abortion adjustment, including greater feelings of guilt (Osofsky & Osofsky, 1972), anxiety (Bracken, 1978), and negative emotions such as regret, depression, and anger (Adler, 1975). Women who abort a pregnancy due to pressure from their partner or parents also tend to exhibit a more negative post-abortion response (Miller, 1992; Perez-Reyes & Falk, 1973; Smith, 1973). In addition, research has consistently found a relationship between ambivalence about abortion and ethnicity: black women have been reported to experience significantly more difficulty deciding to undergo an abortion than white women, evidenced by both self-reported ambivalence (Bracken & Kasl, 1977; Faria, Barrett, & Goodman, 1985) and by a longer delay in seeking an abortion (Bracken & Kasl, 1977; Lynxwiler & Wilson, 1994; Perez-Reyes & Falk, 1973). Explanations offered for this result have included less pro-choice attitudes, less support from important others for the abortion decision, and stronger religiosity among black women. More recent efforts to understand the psychological processes underlying the relationship between decisional conflict and poorer post-abortion adjustment have focused on the meaningfulness that women ascribe to a pregnancy that they have chosen to terminate.

(3) Meaningfulness of the Pregnancy

Not surprisingly, women who abort an intended pregnancy are more likely to experience poorer post-abortion adjustment than women who abort an unintended pregnancy (Adler, 1992). Major, Mueller, and Hildebrandt (1985), for example, found that women who indicated that they had had some; intention to conceive exhibited significantly more symptoms of subclinical depression post-abortion than women who indicated that they had had no intention of becoming pregnant. In the same study, women who rated their pregnancy as "highly meaningful" were also found to cope worse immediately following the abortion than women who described their pregnancy as less meaningful. Unfortunately, it is not clear how meaningfulness was operationally or conceptually defined in this study. Miller (1992) also found that women who indicated that "wanting to have a baby to take care of and love" was an important reason not to have an abortion were more likely to experience post-abortion regret.

Although, as noted by Adler (1992), research has not yet explored the relationship between the degree of wantedness of pregnancies that are terminated and subsequent post-abortion adjustment, Miller (1992) found a strong relationship between the intendedness and wantedness of a pregnancy. The relationship between intendedness and wantedness is not a perfect one, however: while high intendedness has been found to be associated with high wantedness, middle and low intendedness are associated with high, middle, and low wantedness (Miller, 1992). Based on these findings, Adler (1992) has cautioned against confusing the wantedness of a pregnancy with its intendedness, particularly since post-conception circumstances, such as separation from one's partner, may have an impact on the wantedness of an initially intended and wanted pregnancy.

(4) Medical/Genetic Indications

Another factor that appears to be related to post-abortion adjustment is whether the pregnancy was terminated for a medical or genetic reason. Although much of the research is anecdotal, women who undergo abortion because of a medical or genetic indication (e.g., fetal malformation indicated by the results of amniocentesis) are reported to be relatively more likely to experience lingering post-abortion distress (Blumberg, Golbus, & Hanson, 1975; Donnai, Charles, & Harris, 1981). One small study has found that the spouses of women who abort because of a genetic indication also exhibit persistent distress and, in some cases, appear to respond more negatively after the abortion than their wives (Blumberg et al., 1975).

For both women and their partners, post-abortion distress following an abortion for a genetic indication may be partly attributable to the initial wantedness and intendedness of the pregnancy, particularly since genetic fetal anomalies are not usually detected until the second trimester (Donna) et al., 1981) and wantedness has been found to increase over the course of pregnancy (Miller, 1992). In addition, the degree of psychological and physical stress occasioned by an abortion for genetic reasons taking place during the second trimester is likely to be greater as well. A period of grieving, then, is to be expected following pregnancy termination under these circumstances. In the majority of reported cases of medical or genetic termination of pregnancy, women and their spouses have indicated that they would choose to have an abortion again under the same circumstances (Blumberg et al., 1975; Donnai et al., 1981).

(5) Abortion During the Second Trimester

Women undergoing a second trimester abortion procedure are reported to be at greater risk for an adverse post-abortion response than women undergoing an abortion during the first trimester (Athanasiou, Oppel, Michelson, Unger, & Yager, 1973; Kaltreider, Goldsmith, & Margolis, 1979). A number of factors may contribute to the relatively poorer post-abortion adjustment of women terminating pregnancy beyond twelve weeks gestation. For example, Blumberg et al. (1975) have suggested that second trimester abortions may be experienced as more traumatic than first trimester abortions because the pregnancy is sufficiently advanced for the woman to view the fetus as a "future child", particularly if she has felt fetal movement. Termination of pregnancy at this stage, they suggest, is therefore more likely to be experienced and mourned as a loss. Some of the medical procedures associated with second trimester abortions, particularly those requiring the induction of labour and resulting in the expulsion of a dead fetus (e.g., intrauterine instillation), have themselves been found to be associated with greater post-abortion distress (Kaltreider et al., 1979). Recent reports suggest that the percentage of second trimester abortions performed by intrauterine instillation has decreased substantially (Koonin et al., 1996).

Pre-abortion decisional conflict may also account for the relatively poorer post-abortion adjustment among women undergoing second trimester abortions. For example, in a large sample of women, Osofsky et al. (1973) reported that only 12% of women undergoing a first trimester abortion indicated that the abortion decision was difficult for them; whereas, 51% of women undergoing a second trimester abortion reported similar difficulty. Thus, it may be that conflicted women delay decisions and have later abortions, both of which contribute to poorer post-abortion adjustment. Also, age has been found to be inversely associated with the timing of an abortion, such that teenagers are more likely to obtain an abortion later in gestation than older women. Several factors may be responsible for this finding, including a lack of information about reproductive health (e.g., teenagers not knowing that they are pregnant, not knowing where to seek services such as pregnancy testing or abortion counselling, etc.), delaying disclosure due to the negative social stigma associated with teenage pregnancy, the necessity for parental consent and, in some cases, conflictual relationships with the partner or parents (Adler, 1992; Perez-Reyes & Falk, 1973). Overall then, women who, for a variety of reasons, encounter difficulties reaching the decision to terminate their pregnancy may delay obtaining an abortion until such time as a second trimester procedure remains the only medical option available to them.

(6) Stress and Coping

The most recent research in this area has explored factors associated with post-abortion adjustment from the perspective of the psychology of stress and coping. Attributions for the pregnancy (i.e., whether a woman blames herself or some aspect of her situation for her pregnancy), self-efficacy and coping expectancies (i.e., how well a woman believes she will be able to function post-abortion, particularly in situations that may remind her of her abortion), and perceived social support (e.g., whether her parents and her partner support her decision to terminate this pregnancy) have all been found to be associated with post-abortion adjustment.

(7) Attributions for the Pregnancy

Women who blame their pregnancy on some aspect of their own character (e.g., not being a responsible person) tend to exhibit poorer post-abortion adjustment than women who attribute their pregnancy to some aspect of their behaviour (e.g., something that they did or did not do at the time, such as forgetting to take the birth control pill; Major et al., 1985; Mueller & Major, 1989). Blaming another person for their pregnancy has also been found to be associated with poorer immediate post-abortion adjustment in women (Major et al., 1985; Mueller & Major, 1989).

(8) Coping Expectancies

Women who have low expectations about their ability to cope after their abortion (e.g., they report that they will have difficulty being around young children, watching television shows about abortion, resuming sexual activity, etc.) also exhibit significantly greater post-abortion depression and generally poorer adjustment than women who expect to cope well (Cozzarelli, 1993; Major et al., 1985; 1990; Mueller & Major, 1989). There is some indication, however, that brief interventions aimed at changing maladaptive attributions and raising women's expectations that they can cope successfully with abortion may have some effect on immediate post-abortion adjustment (Mueller & Major, 1989). While the effects of more elaborate interventions on longer-term post-abortion adjustment have not been reported in the literature, this finding is encouraging.

(9) Social Support

Although social support has often been found to be associated with post-abortion adjustment, recent work suggests that this relationship is more complex than was once supposed. In general, however, social support appears to have a stress-buffering effect such that higher levels of perceived social support from a woman's partner (Moseley, Follingstad, Hartley, & Heckel, 1981; Robbins & DeLamater, 1985; Shusterman, 1979) and from her parents (Bracken et al., 1974; Perez-Reyes & Falk, 1973) are related to better post-abortion adjustment. On the other hand, having negative feelings towards one's partner, making the decision to abort alone, and parental opposition to abortion have all been found to be related to pre- and post-abortion emotional distress (Moseley et al., 1981; Perez-Reyes & Falk, 1973). For example, Major, Cozzarelli, Sciacchitano, Cooper, Testa and Mueller (1990) found that women at the highest risk for immediate post-abortion adjustment problems were women who told family members about their abortion and perceived them to respond non-supportively or to be qualified in their support; whereas, those women who told family members and perceived them as completely supportive were least at risk.

With respect to perceived support from partners, Major et al. (1990) found that women who did not disclose their abortion to their partner did as well post-abortion as women who told their partner and perceived him as completely supportive. Those who told their partner but perceived him as less than completely supportive evidenced relatively poorer immediate post-abortion adjustment. In addition, Major, Cozzarelli, Testa and Mueller (1992) found that women who expected to cope poorly after an abortion tended to exhibit greater post-abortion depression if their male partner also had low coping expectancies.

These results led Major and her colleagues to examine the relationship between social support, self-efficacy, and post-abortion adjustment more closely. Their most recent findings suggest that perceived social support indirectly influences post-abortion adjustment by increasing a woman's coping expectancies and feelings of self-efficacy (Cozzarelli, 1993; Major et al., 1990).


Existing literature indicates that the vast majority of women undergoing the legal abortion of an unwanted pregnancy during the first trimester do not suffer adverse effects, at least in the short-term. A small minority of women, however, do appear to experience adjustment difficulties following abortion. The actual prevalence of clinically significant negative post-abortion responses has not yet been established. However, the literature identifies several factors that tend to be associated with poor post-abortion adjustment, and suggests some areas that may be foci for pre-abortion assessment and referral of"high risk" clients to counselling and follow-up. These factors are presented in Table 1.

Table 1 Factors Associated with Poor Post-Abortion Adjustment
Demographic * Age < 19
 * Unmarried
 * No children
 * Catholic and/or holding religious
 beliefs contrary to abortion
 * Prior diagnosis for a psychiatric

Decision Process * Difficulty arriving at the decision
 to abort
 * Pressure from parents or partner to

Meaningfulness of * Intention to conceive
the Pregnancy * Pregnancy is described as highly
 * Pregnancy is wanted

Medical/Genetic Indication * A genetic fetal anomaly has been
 * A genetic fetal anomaly was detected
 in later pregnancy, such that the
 abortion must be performed during the
 second trimester

Abortion During * Fetus is viewed as a future child;
the Second Trimester fetal movement has been experienced
 * A procedure that involves inducing
 labour is required

Attributions * Woman blames some aspect of her
for the Pregnancy character for the pregnancy
 * Woman blames another person for the

Coping Expectancies * Woman has low expectations, in
 general, for her ability to cope
 after the abortion
 * Woman has low expectations for her
 ability to cope with situations that
 may remind her of her abortion (e.g.,
 being around young children)

Social Support * Family members are non-supportive or
 qualified in their support for the
 woman's decision to terminate the
 * Partner is non-supportive or
 qualified in his support for the
 woman's decision to terminate the
 pregnancy (note a woman's choosing
 to make the decision to terminate a
 pregnancy on her own is not an
 indicator of risk)
 * Both the woman and her partner have
 low coping expectancies

As the foregoing discussion suggests, risk factors for negative post-abortion psychological sequelae are interdependent. For example, a pregnant teenager who is Catholic and has conflictual relationships with her parents and her partner is likely to experience personal conflict over the decision to have an abortion and to delay disclosure of her pregnancy. Once she does disclose, it is unlikely that her parents will be supportive of an abortion and may also delay giving their consent. She is therefore more likely to have to undergo a second trimester procedure. If she blames some aspect of her character for the abortion and does not expect to cope well afterwards, this further increases her risk for poor post-abortion adjustment.

By employing the risk factors presented in Table 1 as a checklist, it should be possible to identify women who are at greatest risk for negative post-abortion sequelae and to design individualized intervention and follow-up strategies. Using this checklist, it should be possible to design a brief clinical interview or brief self-administered questionnaire that could be integrated with existing intake procedures and validated in prospective research over time. For example, a series of clients could be assessed pre-abortion with respect to these identified risk factors and then followed-up, perhaps with telephone interviews, one month and 6 months later to assess clinically significant post-abortion adjustment problems. Analyses of these data could be used to identify significant predictors of and clinical cut-off points for predicting post-adjustment problems which, in turn, would serve to further enhance assessment procedures in therapeutic abortion settings.


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Correspondence concerning this paper should be addressed to Wendy J. Lewis, Department of Psychology, University of Western Ontario, London, Ontario, N6A 5C2. Tel: (519) 679-2111 ext. 4671; e-mail:
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Author:Lewis, Wendy J.
Publication:The Canadian Journal of Human Sexuality
Date:Mar 22, 1997
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