Predictive Risk Factors of Post-Abortion Injury:Clinical, Legal and Ethical Implications

David C. Reardon, Ph.D.


Poster Presentation at the 
First World Congress on Women's Mental Health 
Berlin, March 27-31, 2001 

Abstract

A substantial body of literature exists that has identified characteristics and situational factors that are predictive of psychological maladjustment after an abortion. A schema for identifying and organizing these risk factors, as identified in over thirty statistically validated studies, is presented. In most cases, risk factors have been verified by multiple investigators. 

A summary list of major risk factors includes: moral ambivalence, conflicting maternal desires, abortion to preserve the life of the mother, abortion for fetal indications, second- or third-trimester abortion, feeling pressured to abort by others, feeling the decision is not one's own or is one's "only choice," feeling rushed to make a decision, biased pre-abortion counseling, adolescence or immaturity, prior emotional or psychological problems, poorly developed coping skills, low expectations of coping well, a history of childhood sexual abuse, a history of unresolved trauma, social isolation, accompaniment to the abortion by the male partner, and a history of prior abortion. 

Examination of the full the constellation of risk factors provides insights into understanding of why a minority of women have severe psychological reactions to abortion. Prior psychological problems, developmental limitations, and compromised decision making are the principle organizing themes for understanding negative reactions. 

Negative reactions can be mild or severe. A recent two-year follow up study of 442 aborting women found that 1.4% experienced post-traumatic stress disorder directly attributed to their abortions. Since predictive risk factors have been well documented, these factors define specific ethical and legal duties that therapists, counselors, and attending physicians owe to their patients. Attention is paid to the special issues raised in counseling a patient who is at heightened risk compared to the "normal" client. A knowledge of risk factors may also be beneficial to therapists who are counseling women who are struggling with unresolved issues regarding a past abortion since identification of risk factors will frequently expose core issues underlying the adverse reaction. 
 

Background

Research regarding the psychological effects of abortion exceptionally complex. Most studies in this field are limited by major methodological problems. It would be extremely difficult, if not impossible, to complete a study in this field that would be generally conclusive and above reproach. Researchers are faced with four major obstacles: 
 

Drop-Out and Concealment -- In longitudinal and retrospective studies, approximately 50 percent of women who have had an abortion will conceal their past abortion[s] from interviewers.(1) Even in short-term follow-up studies, there are high sample attrition rates, typically in the range of 20 to 60 percent. Demographic comparisons of those who initially consent to follow-up and subsequently refuse to be interviewed indicate that those who exclude themselves from the final sample are more likely to match the profile of women who report the greatest post-abortion distress.(2)
 

Multiple Symptoms-- Women have reported an extraordinarily large variety of negative emotional symptoms that they attribute to their abortions. There is no agreement among researchers regarding which symptoms they should attempt to quantify (relief, depression, impacted grieving, intrusive recollections, self-destructive behavior, etc.) nor what degree of each symptoms should be considered significant. Some abortion reactions may fit into the model of complicated bereavement or pathological grief.(3) In other cases, clinicians have reported that at least some women exhibit symptoms that fall within the diagnostic criteria for post-traumatic stress disorder (PTSD).(4) Still other therapists may offer different schemas for categorizing and understanding post-abortion reactions. 
 

Variations over Time-- Reactions to abortion vary over time.(5) Women who are initially filled with grief and self-reproach may subsequently find emotional healing, whereas women who initially coped well may subsequently find themselves emotionally shattered. Research shows that negative emotions and regret tend to increase over at least the first two years following an abortion.(6) In one study of 260 women who reported negative post-abortion reactions, 63 to 76 percent claimed there was a period of time during which they would have denied any negative feelings connected to their abortions. The average period of denial reported by the survey population was 63 months.(7)
 

Inadequacy of Survey Instruments-- The effectiveness of standardized questionnaires regarding adjustment to abortion have been called into doubt by research indicating that abortion may involve repressed feelings that are not readily revealed, at least in response to a questionnaire.(8) Kent reports that in the course of psychotherapy for 50 women, none of whom were originally seeking treatment for abortion-related problems, deep feelings of pain and bereavement about a prior abortion emerged during the time the patient was recovering from the presenting problem.(9) Kent's subsequent research with women who were not in psychotherapy led him to conclude that an initial reaction of emotional numbness may distort questionnaire based studies. He concluded that an underlying sense of loss and pain can only be reliably identified in a clinical setting.(10)
 

Given such complexities, it is understandable that Surgeon General C. Everett Koop concluded, in 1987, that the research in this field is entirely inadequate for drawing any general conclusions about either the efficacy or the dangers of induced abortion.(11)

Predictive Factors of Post-abortion Sequelae

Despite the limitations on existing research, Gregory Wilmoth, editor of a special issue of the Journal of Social Issues dedicated entirely to research relating to the psychological effects of elective abortion, has stated: "There is now virtually no disagreement among researchers that some women experience negative psychological reactions postabortion. Instead the disagreement concerns the following: (1) The prevalence of women who have these experiences . . . , (2) The severity of these negative reactions . . . , (3) The definition of what severity of negative reactions constitutes a public health or mental health problem . . . , [and] (4) The classification of severe reactions . . . "(12)

There are no clear answers to many of the issues identified by Wilmoth. Opinions, especially regarding the severity and prevalence of post-abortion maladjustments, tend to be divided along ideological lines. Fortunately, however, there is one area of post-abortion research in which there considerable certainty: predictive factors of post-abortion sequelae. 

In short, while most of the existing studies are inadequate for drawing incontrovertible conclusions regarding the overall incidence of post-abortion reactions over time, they have proven to be very effective in identifying the factors that place women at higher risk of a negative reaction, at least within the scope of the time and reactions studied. This is due to the fact that researchers have consistently found that some portion of women, usually a minority, report negative symptoms within the time frame of their studies. In an attempt to understand why and how these women react differently from those who do not report the difficulties under study, the researchers have naturally attempted to identify the individual characteristics or situational factors that are statistically associated with negative post-abortion reactions. 

While research continues to identify and refine our understanding of risk factors for post-abortion maladjustment, there is general agreement regarding ten to fifteen key areas. For example, as shown in Table 1, compilations of risk factors by three expert sources reveal considerable overlap in most major areas, and even their differences may be largely explained by variations in their ways of summarizing or delineating related risk factors. 
 

A More Systematic Outline of Risk Factors 

While these and other summaries of risk factors have been useful, these listings are generally not the focus of these various authors' works. Instead, these informal listings have been offered as an incidental summary of these authors' observations from the literature. 

Table 2 represents an attempt to more completely and systematically classify and summarize the predictive risk factors of post-abortion emotional sequelae as reported in the literature. This list may still be incomplete, but it does include all the most widely reported risk factors as well as several less frequently cited risk factors. In addition, it will be observed that with additional research some of the risk factors that are listed separately might collapsed into a single category. I have already done this in regard to studies that use different measures that appear to overlap, but in many cases, where the distinction between two risk factors appears to include subtleties which may involve distinct differences between the risk factors or the related reaction, I have left these as separate items. 

The references provided for each risk factor include citations for both primary sources and review articles. There are 34 primary sources that rely on statistically validated data. These are indicated in bold type. Sources that reflect clinical experience, case studies, or other "soft data" that is not subject to tests of statistical significance are indicated by italic type. Finally, review articles are indicated in normal type and are included as useful for (1) demonstrating a consensus of authorities who have agreed that the identified risk factor is significant and (2) as references to additional citations. Please note that the references for Table 2 are provided separately from the text references at the end of this paper. 

In the schema presented in Table 2, the risk factors for post-abortion maladjustments have been divided into two general categories. The first category includes risk factors for women for whom there exist significant emotional, social, or moral conflicts regarding the contemplated abortion. The second category includes risk factors relevant to developmental problems, such as immaturity or psychological instability. 

It should be noted that the risk factors in Table 2 must be interpreted in light of the complexity of post-abortion reactions, particularly the existence of multiple symptoms and the time variant experience of negative sequelae. Some of these risk factors are useful for predicting only particular reactions, such as depression or regret. Most often, these risk factors have been identified in studies with a relatively short follow-up period, typically within six months post-abortion. In such cases, the absence of a risk factor should not be interpreted as a reliable predictor that the symptoms at issue will not occur as a delayed effect, for example as part of an anniversary reaction. Finally, it should be noted that characteristics that appear to be opposites (i.e., a teenager versus an older woman with children) may both be risk factors--but for different symptoms. 
 

How Many Women are at Higher Risk?

Examination of Table 2 will immediately suggest the likelihood that a substantial majority of women fall into one or more higher risk categories. This is in part explained by the fact that each risk factor may be associated with a different type of minority reaction. Nor does it necessarily follow that the vast majority of women actually suffer from negative emotional reactions. It only reveals that the majority of women have one or more characteristics that place them at higher risk of a negative reaction as compared to the "ideal" low risk patient who has none of the identified risk factors. Table 3 (a work in progress) provides a listing of the percentage of women, according to demographic variables or case studies, who appear to fall into specific higher risk categories. 

Using just five screening criteria--(1) a history of psychosocial instability, (2) a poor or unstable relationship with the male partner, (3) few friends, (4) a poor work pattern, and (5) failure to take contraceptive precautions--Belsey, et al, determined that 68 percent of the 326 abortion patients she studied were at higher risk of negative reactions and should have been referred for more extensive counseling.(13) Of this high risk group, 72 percent actually did develop negative post-abortion reactions (guilt; regret; disturbance of marital, sexual, or interpersonal relationships; or difficulty in coping with day-to-day activities) during the three-month follow-up period. 

It is noteworthy that the Belsey and her colleagues hold a favorable opinion of elective abortion. The intent of their study was not to justify restrictions of abortion, but merely to identify how women's health could be better served. In this context, the researchers concluded that a simple questionnaire identifying known risk factors could be used to identify women presenting for an abortion who are (1) at higher risk of negative emotional reactions, and conversely, (2) most likely to cope well with an abortion. Though the five criteria resulted in both false negatives (missing 18 percent of the women who did have one or more negative reactions) and false positives (28 percent of the women identified as higher risk did not have any apparent negative reactions at the three month follow up interview) the researchers concluded that appropriate screening could provide a "reasonable forecast of subsequent attitude and emotional reactions."(14) While some women who did not subsequently report problems would have been referred for additional counseling, Belsey argues that "From the clinician's point of view this result can be viewed as erring on the right side, for a [pre-abortion screening] system that tends to select more women for counselling than is actually necessary is preferable to the reverse."(15)

A more recent study by Major and colleagues found that 22 items on a pre-abortion questionnaire were significantly correlated to subsequent distress, and less positive well-being, and less decision satisfaction.(16) As with the Belsey study, the items on this questionnaire could be readily adapted for use in pre-abortion counseling to identify which women are most likely to respond well to an abortion and which are most likely to have negative reactions. As noted by one group of researchers, "Screening procedures to identify such [higher risk abortion] patients could easily and inexpensively be instituted by hospitals and private physicians."(17)
 

The Standard of Care for Proper Screening

The existence of predisposing risk factors naturally suggests that abortion practitioners, abortion counselors, referring physicians, and mental health professionals who consult with a patient who is considering abortion, would all be obligated to screen for these factors, or at least to ensure that proper screening was done by another qualified person.(18) After a proper psychosocial evaluation to screen for known or suspected risk factors, the attending physician or a qualified counselor would reasonably be expected to (1) disclose to the patient the identified risk factors and the post-abortion symptoms to which they may be related; (2) provide additional counseling to explore issues such as maternal or moral ambivalence, to assist the woman in making a decision that is consistent with her fundamental desires and belief system, and/or to resolve issues prior to the abortion so as to reduce the risk of subsequent post-abortion maladjustment; and (3) provide an informed medical recommendation as to the advisability of undergoing an abortion. 

About this last point, it should be noted that the attending physician has a right and duty to recommend against and even to refuse to perform an abortion that is contraindicated.(19) For example, in the case of a minor who is being coerced into an unwanted abortion by domineering parents, the physician is legally and ethically obligated to refuse to perform the involuntary abortion. The proper response in such cases would be (1) to counsel the pressuring parents to explain how a coerced abortion will inflict emotional harm on their daughter and damage their relationship with her, and (2) to refer the parents and daughter to a qualified family counselor. 

Sylvia Stengle, executive director of the National Abortion Federation, which represents numerous abortion clinics, has stated that at least one in five patients is at psychological risk from abortion due to prior philosophical and moral beliefs contrary to abortion. Regarding this "worrisome subset" of patients, she concurs that there may be an ethical obligation for abortion practitioners to refuse to participate in the violation of a woman's conscience.(20)

In evaluating a patient's psychological risks, therapists and abortion counselors should not rely simply on whatever the patient volunteers. Instead, counselors should actively look for "red flags" which would suggest the presence of risk factors. Uta Landy, a former executive director of the National Abortion Federation, encourages counselors to be aware of the fact that: "Some women's feelings about their pregnancy are not simply ambivalent but deeply confused. This confusion is not necessarily expressed in a straightforward manner, but can hide behind such outward behavior as: (1) being uncommunicative, (2) being extremely self-assured, (3) being impatient (how long is this going to take, I have other important things to do), or (4) being hostile (this is an awful place; you are an awful doctor, counselor, nurse; I hate being here)."(21)

Landy has observed that because women seeking abortion are experiencing a time of personal crisis, their decision-making processes can be temporarily impaired. This crisis-related disability may lead them to make poor decisions that may subsequently result in serious feelings of regret. Landy defines four types of defective decision-making observed in abortion clinics. She calls the first defective process the "spontaneous approach," in which the decision is made too quickly, without taking sufficient time to resolve internal conflicts or explore options. A second defective decision-making process is the "rational-analytical approach," which focuses on the practical reasons to terminate the pregnancy (financial problems, single parenthood, etc.) without consideration of emotional needs (attachment to the pregnancy, maternal desires, etc.). A third defective process is the "denying-procrastinating" approach, which is typical of women who have delayed deciding precisely because of the many conflicting feelings they have about keeping the baby. When such a "denying-procrastinator" finally agrees to an abortion, it is likely that she has still not resolved her internal conflicts, but is submitting to the abortion only because she has "run out of time." Fourth, there is the "no-decision-making approach" in which a woman refuses to make her own decision but allows others, such as her male partner, parents, counselors, or physician, to decide for her. 

Of special concern are cases in which a woman desires to have her child, but she is under pressure from her male partner, or from his or her parents, to have an unwanted abortion.(22) Patients should be carefully questioned in private to determine if this risk factor is present because the abused or coerced patient may attempt to conceal the abuse out of fear. Abuse or coercion can be either subtle or overt. Sometimes there are blatant threats to withhold financial support or expel a woman from her home unless she "does the right thing." Other times, simply the absence of enthusiasm or emotional support for keeping a pregnancy may be experienced as pressure to choose abortion. Because the pressures to choose abortion can be subtle, or even imagined by the patient, special care must be taken to discover if a woman has moral or maternal feelings contrary to an abortion choice. In such cases, the qualified counselor should work with the patient to determine if she is merely echoing the "practical reasons" to abort that have been projected on her by the desires, needs, or expectations of others. 

Outside pressures that place a woman at higher risk of post-abortion maladjustment are not always interpersonal. Pressure from adverse circumstances, such as financial problems, social problems, or health problems, may also make a woman feel she is being "forced" to accept abortion as her "only choice."(23) If her "only choice" is contrary to her maternal desires and moral conscience, the counselor and attending physician are ethically obligated to assist the woman to find resources or alternatives that would alleviate her adverse circumstances in a way that would not violate her emotional, maternal, or moral needs. 

Insights From Predisposing Risk Factors

Examination of the risk factors shown in Tables 1 and 2 suggests that any decision to abort that compromises a woman's fundamental beliefs and values is problematic. This concern is increased by the fact that society continues to express great moral ambivalence about abortion. Abortion is more likely to be perceived as an "evil necessity" than a great civil right. Polls show that while most adults believe abortion should be legally available, over three-quarters believe abortion is the taking of a human life, with half equating it to "murder."(24) Another major poll has found that 65 percent of those who favor abortion, and 74 percent of women who admit having had an abortion, believe abortion is morally wrong.(25)

Research suggests that most women seeking abortion share this moral ambivalence.(26) In addition, significant percentages of women seeking abortions report having had an initial desire to keep their pregnancies, having strong maternal orientations, or feeling pressured to abort by others or by circumstances outside of their control.(27) Most want to have children at some time in the future. This suggests that for most abortion patients having a child, in and of itself, is not the problem--indeed, having a child is something they anticipate and desire. The problem is that the circumstances with which they are faced make having a child, at that time, problematic. 

These insights suggest that for most women abortion is not a right of passage by which they are able to assert control over their lives; instead, it is an "evil necessity" to which they submit because they "have no choice." Rather than affirming their values, these women feel forced by circumstance or others to compromise their values. Rather than feeling proud of themselves for standing up for their beliefs, especially under difficult circumstances, they see themselves as "compromised." Many report feeling as if they are a "different person" before and after the abortion. 

This conflict between a woman's prior values and her "practical" decision to abort can plant the seeds for a long-lasting internal war between her old self and her new self. On one side are her original moral beliefs and maternal desires. On the other side is the self that seeks to justify her abortion that was contrary to those feelings and to integrate this experience into her life. From this internal warfare, unresolved feelings can unpredictably erupt throughout the woman's life and manifest themselves in a wide variety of psychological illnesses, including self-destructive behaviors. 

Legal Obligations Regarding Screening 

Contrary to popular notions, the laws of most countries do not grant women unrestricted access to abortion, even in the earliest stages of pregnancy. Instead, most governments recognize that abortion is a medical procedure that entails certain risks and that it is the duty and obligation of attending physicians to evaluate the risks and benefits of abortion. For example, in the same decision striking down restrictive abortion laws, the United States Supreme Court rejected arguments for a woman's absolute right to abortion holding instead that that "basic responsibility" for the abortion rests with the physician.(28) While a woman may request an abortion, it is the physician's obligation to determine if the abortion may be dangerous to her well being and to advise her accordingly. If an abortion is contraindicated for medical reasons, which will include physical, psychological, and social reasons(29), the physician has a right and duty to refuse to perform the abortion. 

In many other countries where abortion is liberally practices, such as Great Britain, for example, the law provides for abortion only when it is the reasonable and/or "good faith" opinion of the attending physicians that "the pregnancy would involve risk to the life of the pregnant woman, or of injury to the physical or emotional health of the pregnant woman, or any existing children of her family, greater than if the pregnancy were terminated."(30)

It would appear that under most laws, abortion is still viewed as a medical procedure that requires physicians to make informed medical recommendations. But without comprehensive screening for known and suspected risk factors, it would appear to be impossible for a physician to meet his obligation to provide his patient with an informed medical recommendation. Clearly, adequate screening is a essential, not optional. 
 

Legal & Ethical Obligations Regarding Disclosure

Furthermore, in defining a constitutional right to abortion, the U.S. Supreme Court stated that this judicially granted liberty includes the patient's "imperative" right to "full knowledge of [abortion's] nature and consequences."(31) Since risks may vary substantially in accordance with individual risk factors, it is impossible for a physician to provide an adequate disclosure of risks without prior screening for risk factors. Only in this way can the attending physician explain the risks that are most relevant to each individual given her specific history and circumstance. 

These rights and duties of physicians regarding screening, full disclosure, and alternatives counseling and are widely recognized in medical text books on abortion.(32) In addition, the American College of Obstetricians and Gynecologists(33), the National Abortion Federation(34), the Planned Parenthood Federation of America(35), and the International Planned Parenthood Federation Medical Advisory Panel(36) have all issued documents reaffirming or at least alluding to these duties. 

The U.S. Supreme Court's standard for full disclosure is also in line with the trend in law and medical ethics toward greater patient autonomy and more complete disclosure practices.(37) Yet some have questioned the disclosure of information about the psychological risks of abortion on the basis that such information may increase patient anxiety, lower coping expectations, and thereby increase the risk of subsequent emotional maladjustment.(38) In essence, they raise the question of "therapeutic privilege," the right of a physician to withhold information that in itself "poses such a threat of detriment to the patient as to become unfeasible or contraindicated from a medical point of view."(39) For example, tactlessly disclosing stressful information to a cardiac patient which might make the patient suffer a heart attack is clearly contraindicated. 

But even when a treatment is life-saving, the option of withholding potentially upsetting information from patients, "therapeutic privilege," is very narrow.(40) This option is narrowed even further in the case of an elective procedure, where, by definition, the patient may decline the proposed treatment without dire consequences.(41) Therefore, it seems reasonable that physicians should err on the side of a full and expansive disclosure. 

The application of these principles to the case of abortion is readily apparent. Since a decision against an elective abortion is, by definition, never life-threatening, the withholding of "upsetting" or "not yet completely proven" information is never justified. This right of women to be fully informed about the nature and risks of abortion is internationally acknowledged(42) because a decision to forego a previously desired elective abortion because of possible risks, even remote ones, is always reasonable, if not wise.(43)

Furthermore, since abortion is an elective procedure, an abortion practitioner's opinion that one or another risk is not yet firmly established, or has not yet been adequately measured, does not relieve him of the responsibility to disclose to the patient that members of the medical community are concerned about this disputed risk. Since it is the patient's right to weigh the evidence for or against a contested abortion complication, candidates for elective abortion are entitled to full disclosure of disputed or even "theoretical" risks, such as would be the case with the use of experimental drugs. When physicians or counselors withhold information because they fear the information will lead to an "unreasonable" choice for childbirth, they are reflecting their own biases on the decision making process, biases that infringes on the rights and autonomy of the patient and expose her to avoidable health risks. 

Counselors and physicians are legally and ethically obligated to respect the rights and autonomy of their patients. They should guard against a tendency to "guide" a woman toward abortion because of financial or personal bias, such as a socioeconomic bias that might suggest that the gravida would be an "unfit" mother or that the child, if born, would be a "burden" on society. The decision to recommend and proceed with an abortion must be based on an informed medical conclusion that an abortion is likely to provide benefits to the patient that outweigh any corresponding risks. This equation should not be tainted by consideration of any purported benefits that abortion may provide to third parties or some eugenic goals. 

The need for full disclosure of suspected risk factors and their associated risks is especially important because many abortion patients, perhaps even the majority, are ambivalent about their choices in the first place. As many as 80 percent, in some surveys, have stated they would have kept their pregnancies under better circumstances or if supported to do so by significant others.(44) Because the initial decision to abort is often tentative, or even made solely to please others, "upsetting" information about risks may be exactly what a woman is looking for as an excuse to keep her child when everyone else is pressuring her into an unwanted abortion. It is often far easier for a reluctant woman to resist her pressuring boyfriend with an exaggerated "The doctor says abortion is dangerous," than "I want this baby, even if you don't." 

Full disclosure is also important because reports of inadequate, inaccurate, or biased counseling are statistically associated with reports of more frequent and more severe negative psychological reactions post-abortion.(45) Proper screening and full disclosure, therefore, are additionally necessary to reduce the risk that patients will subsequently feel that (1) they are "alone" in feeling negative reactions that "no one else feels," (2) they were ill-prepared for the adjustments that must follow an abortion; or (3) they were exploited by "abortion profiteers" in a time of crisis and confusion. 
 

Discussion

Mental health professionals who may be called upon to counsel women with a crisis pregnancy should be familiar with the predictive risk factors in Tables 1 and 2. Women faced with this crisis situation have every reason to expect that professional counselors will be aware of this information and will accurately convey it to them. 

Therapists should be especially alert for patients who are seeking their therapists "approval" of a decision to abort. Women who are morally conflicted over an abortion choice frequently turn to authority figures, such as therapists, school counselors, or religious figures. This need for approval may suggest a deep-rooted ambivalence. In such cases, the woman may be seeking either a "blessing" upon a decision to "bend" her moral beliefs or, conversely, encouragement to follow her "emotional" desire to protect the pregnancy despite all the "rational reasons" to abort. 

From a liability perspective, health professionals should avoid offering support for an abortion decision without first undertaking a proper evaluation of risk factors and providing disclosure of the related risks which a reasonable patient might consider relevant to her decision. Otherwise, if a therapist, for example, proffers an opinion that the client interprets as supportive of her inclination to abort or as an assurance that an abortion will not be emotional harmful to her, the therapist may expose himself to civil liability for improper screening and disclosure. As a licenced counseling professional, he or she may be presumed responsible for screening for these known risk factors and for fully disclosing relevant risk information to the client. 

While there is substantial information about predictive risk factors of post-abortion sequelae, it does not appear that most abortion providers have adequately incorporated this information into their medical practices. Proper screening, full disclosure, and additional counseling for high risk patients, are time-consuming tasks. While the performance of these tasks is imperative with respect to protecting the rights and health of patients, it is also inconvenient in abortion clinic settings where a rapid processing schedule may allow as little as 30 minutes for intake, screening, and counseling of each client. Abortion practitioners who fail to provide proper screening and counseling should, of course, be held accountable for both malpractice and the violation of their patients' civil rights. Only in this way will the standard of care be raised to a level that adequately preserves the rights and welfare of women--both for those women who choose to proceed with an abortion and for those women for whom abortion is unwanted, avoidable, or contraindicated. 

It should also be noted that physicians have the duty to provide their patients with an informed medical recommendation. While a woman may initiate a request for an abortion, it is the duty of the physician to evaluate the patient, identify the factors that make her pregnancy a problem in her life, examine all options that may resolve her problem, and provide her with an informed recommendation.(46) A physician who ignores these duties, and merely provides abortion on request, is guilty of a serious malfeasance of duty. Abortion may eliminate the pregnancy but it may not solve the problems that made the pregnancy problematic. It also clearly introduces the risk of causing new problems--physical, emotional, familial, social, and spiritual--when less intrusive measures, such as family counseling, may better serve a patient's overall health needs with far less risk. 

In forming a medical recommendation for abortion, physicians should not only be aware of predictive risk factors for physical or psychological sequelae, they should also have a sound medical basis for determining in what circumstances an abortion is likely to be beneficial. If a woman has one or more risk factors, and there is no clear evidence that she is likely to benefit from an abortion, it is difficult to see how a physician could justify proceeding with a contraindicated procedure. 

Very little research has been done with regard to identifying situations or characteristics wherein abortion is most likely to improve a woman's life or well-being. There is even less, if any, research that has attempted to quantify such improvements. Instead, there is a widespread and untested presumption that if an abortion does not measurably hurt a woman's life, then it must have benefitted her life. But there is no logical basis for assuming that lack of harm correlates to positive benefit. Humans are extremely adaptable. Some mothers who have been denied abortion will subsequently claim, after having bonded with their children, that they never wanted an abortion in the first place.(47)

Since abortion is sought for a wide variety of reasons, it would seem essential to know in which cases abortion best fulfills the hopes and expectations of patients. Are women who seek abortions because of relationship problems likely to report that their relationships were improved? Or were their relationships hindered? Or did the abortion not make a difference? Are women who abort to protect their educational or career plans more likely to finish school or advance in their careers than women who carry to term and resume their education or career at a later date? Do women who abort in order to avoid embarrassing themselves or their families achieve higher levels of emotional security or family harmony? In the absence of such research demonstrating when abortion is beneficial, it is difficult to understand how physicians can fulfill their obligation to give women considering abortions sound medical advise. Just as the risks of abortion vary by the characteristics of the individual, it is likely that research into any benefits that may be attached to abortion would also indicate that these benefits are most likely to be attained in certain situations or for women meeting certain physical and psycho-social criteria. Until this research is done, proper screening for known and suspected risk factors is even more important to safeguard patients' health. 

Proper screening is clearly necessary to improve the rate at which abortion benefits women's lives without causing offsetting harm. If it cannot be shown that abortion clearly benefits the lives of most patients, the issue of limiting the right of physicians to perform abortions will once again become a major public health issue. 


NOTE: The main text references are separate from the Table 2 references.

Table 1. Predisposing Risk Factors for Negative Psychological Reactions as Compiled by Three Authorities
Planned Parenthood Federation of America1 A Clinician's Guide to Medical and Surgical Abortion2 Speckhard and Rue3
adolescence adolescence
emotional instability existing or prior mental illness or disorder prior emotional problems
past childhood sexual abuse unresolved traumatization
unresolved past losses and perception of abortion as a loss
low self-esteem low self-esteem
pressure or coercion to abort perceived coercion pressure or coercion to abort
lack of parental support lack of emotional support and receiving criticism from significant people in their lives lack of support from one's family of origin
lack of partner support lack of relationship support and/or immature interpersonal relationships
unstable living conditions 
commitment to the pregnancy a maternal orientation
prior children
diagnosis of a fetal malformation leading to abortion diagnosis of a fetal malformation or other medical indication diagnosis of a fetal malformation leading to abortion
late term abortion late term abortion
prior abortion
significant ambivalence about decision preabortion ambivalence
strong religious convictions against abortion belief that fetus is same as a child and abortion is murder religious affiliation and religious conservatism
guilt or shame prior to abortion
low expectations for coping well after the abortion expectations of depression, grief, guilt or regret after the abortion
usual coping style is repression or denial
pregnancy as a result of failed contraception Experiencing social stigma and anti-abortion demonstrators biased preabortion counseling
1. Fact Sheet: The Emotional Effects of Induced Abortion" (PPFA Communications Division, FS-A4, revised 1993). 
2. Anne Baker and others, "Informed Consent, Counseling, and Patient Preparation," in A Clinician's Guide to Medical and Surgical Abortion, Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.;Stubblefield, Philip G (New York: Churchhill Livingstone, 1999). 
3. Anne C. Speckhard & Vincent M. Rue, "Postbortion Syndrome: An Emerging Public Health Concern," J. Soc. Issues 48(3): 95-119 (1992) at 114 (citing Vincent M. Rue & Anne C. Speckhard, "Informed Consent and Abortion: Issues in Medicine and Counseling," Med. & Mind 6(1):75-94 (1992). 

Table 2: Risk Factors Predicting Post-abortion Psychological Sequelae  (See Table 2 References)
 

I. CONFLICTED DECISION

A. Difficulty making the decision, ambivalence, unresolved doubts1,2,3,10,13,14,18,23,25,29,34,37,38,40,46,49,52,53,55,56,57,61
1. Moral beliefs against abortion61
a. Religious or conservative values1,2,5,23,34,39,40,48,49,54,56,58,59

b. Negative attitudes toward abortion1,8,27,57

c. Feelings of shame or social stigma attached to abortion2,61

d. Strong concerns about secrecy50

2. Conflicting maternal desires1,29,30,33,34,46,51
a. Originally wanted or planned pregnancy1,13,23,27,29,53,57,59,61

b. Abortion of wanted child due to fetal abnormalities3,7,13,18,19,20,26,27,28,41,61

c. Therapeutic abortion of wanted pregnancy due to maternal health risk3,13,15,18,20,26,27,37,42,49,54,55,61

d. Strong maternal orientation34,48

e. Being married1, 10

f. Prior children25,48,54,58,60

g. Failure to take contraceptive precautions, which may indicate an ambivalent desire to become pregnant6

h. Delay in seeking an abortion1,2,26

3. Second or third trimester abortion1,20,26,27,39,42,49
 

4. Low coping expectancy1,27,29,30

B. Feels pressured or coerced13,16,18,27,34,43,45,48,49,53,51,52,55,61
 
1. Feels decision is not her own, or is "her only choice"14,,18

2. Feels pressured to choose too quickly17,24

C. Decision is made with biased, inaccurate, or inadequate information17,48,49

 

II. PSYCHOLOGICAL OR DEVELOPMENTAL LIMITATIONS
 

A. Adolescence, emotional immaturity1,4,9,11,15,16,17,27,29,32,33,42,48,50,54
B. Prior emotional or psychiatric problems3,5,6,13,15,18,20,22,23,25,26,34,37,40,42,47,51,54,57,61,63
 
1. Poor use of psychological coping mechanisms2,29,34,61

2. Prior low self-image33,34,43,48,52,61,63

3. Poor work pattern or dissatisfied with job6,52

4. Prior unresolved trauma or unresolved grief48,51

5. A history of sexual abuse or sexual assault.23,31,51,61

6. Blames pregnancy on her own character flaws, rather than on chance, others, or on correctable mistakes in behavior29,30,36

7. Avoidance and denial prior to abortion12,27

8. Unsatisfactory or mediocre marital adjustment6

9. Past negative relationship with mother5,40

C. Lack of social support1,9,27,33,46,54,55,56,58,61,62, 63
1. Few friends, unsatisfactory interpersonal relations6,52

2. Made decision alone, without assistance from partner35

3. A poor or unstable relationship with male partner6,25,34,40,43,53

4. Single and nulliparous9

5. Separated, divorced, or widowed14, 62

6. Lack of support from parents and family2,8,9,18,27,29,33,35,52,56

- either to have baby or to have abortion 

7. Lack of support from male partner2,6,8,9,18,25,27,29,33,34,35,42,46,52,53

- either to have baby or to have abortion 

8. Accompanied to abortion by male partner21,30

9. Living alone56

10. High alienation63

D. Prior abortion(s)13,37,43,48,52,58
 

E. Prior miscarriage 58
 

F. Less education 58
 
 


 

Table 3: Percentage of Women Having Abortions Who Possess the Identified Risk Factor
Risk Factor % Women  Source
Low expectation of coping well 40% B. Major, P. Mueller, and K.Hildebrandt "Attributions, Expectations, and Coping With Abortion" J Personality and Social Psychology 48(3):585-599.
Self character blame 47% B. Major, P. Mueller, and K.Hildebrandt "Attributions, Expectations, and Coping With Abortion" J Personality and Social Psychology 48(3):585-599.
High chance blame 52% B. Major, P. Mueller, and K.Hildebrandt "Attributions, Expectations, and Coping With Abortion" J Personality and Social Psychology 48(3):585-599.
High other person blame 35% B. Major, P. Mueller, and K.Hildebrandt "Attributions, Expectations, and Coping With Abortion" J Personality and Social Psychology 48(3):585-599.
High situation blame 50% B. Major, P. Mueller, and K.Hildebrandt "Attributions, Expectations, and Coping With Abortion" J Personality and Social Psychology 48(3):585-599.
Accompanied by partner 33% B. Major, P. Mueller, and K.Hildebrandt "Attributions, Expectations, and Coping With Abortion" J Personality and Social Psychology 48(3):585-599.
Reported a history of physical or sexual abuse 40% Family Planning Perspectives Sept/Oct 1998 reporting on a 1996 survey of 486 abortion patients at an urban clinic; .Herman, JL. Trauma and Recovery(New York: Basic Books, 1992)
Lower education 

(<12 years)

 14% KD Kochaneck, "Induced Terminations of Pregnancy: Reporting States," Monthly VitalStatistics Report, 1998, 39(12), Suppl:1-31, April 30, 1991.
Previous live birth 53% "Abortion Surveillance: Preliminary Data - U.S., 1991" MMWR, 43(3):42-44, Jan 28,1994.
Prior history of abortion 43% SK Henshaw & J Silverman."The Characteristics and Prior Contraceptive Use of U.S. Abortion Patients" Family Planning Perspectives, 20(4):158, July/Aug 1988.
Negative moral view of abortion 60 - 75% Zimmerman, Passage Through Abortion (New York: Praeger Publishers, 1977); Osofsky, eds., The Abortion Experience (New York: Harper and Row, 1973); Reardon, Aborted Women-Silent No More, (Chicago: Loyola University Press, 1987).) Los Angeles Times Poll, March 19, 1989, question 76.
Catholic, Evangelical or conservative Protestant  57% SK Henshaw & J Silverman, "The Characteristics and Prior Contraceptive Use of U.S. Abortion Patients" Family Planning Perspectives, 20(4):158, July/Aug 1988.
Pressured by others 30-60% Zimmerman, Passage Through Abortion (New York: Praeger Publishers, 1977); Reardon, Aborted Women-Silent No More, (Chicago: Loyola University Press, 1987);Callahan, "An Ethical Challenge to Pro-Choice Advocates," Commonweal, Nov. 23. 1990, 684.

 
 

Main Text References


1. Jones, E.F. & Forrest, J.D., "Underreporting of Abortion in Surveys of U.S. Women: 1976 to 1988," Demography, 29(1):113-126 (1992).

2. Söderberg H, Andersson C, Janzon L, Sjöberg N-O, "Selection bias in a study on how women experienced induced abortion" Eur J Obstet Gynecol Reprod Biol 77(1):67-70 (1998); Adler, N., "Sample Attrition in Studies of Psychosocial Sequelae of Abortion: How Great A Problem?" J Applied Soc Psych, 6(3):240-259 (1976).

3. Angelo, E.J., "Psychiatric Sequelae of Abortion: The Many Faces of Post-Abortion Grief" Linacre Quarterly, 59(2):69-80, 1992; Brown, D., Elkins, T.E., Lardson, D.B., "Prolonged Grieving After Abortion," J Clinical Ethics, 4(2):118-123 (1993).

4. Speckhard, A. & Rue, V., "Postabortion Syndrome: An Emerging Public Health Concern," J Social Issues 42(3):95-119, 1992; Barnard, C.A., The Long-Term Psychosocial Effects of Abortion (Portsmouth, NH: Institute for Pregnancy Loss, 1990).

5. Miller, W.B., Pasta, D.J., Dean, C.L., "Testing a Model of the Psychological Consequences of Abortion" The New Civil War: The Psychology, Culture, and Politics of Abortion, ed. Linda J. Beckman and S. Maria Harvey (American Psychological Assoc., Washington, DC, 1998)

6. Major B., Cozzarelli C., Cooper M. L., Zubek J., Richards C., Wilhite M., & Gramzow R. H. Psychological responses of women after first-trimester abortion. Archives of General Psychiatry ; 57(8), 777-84 (2000).

7. Reardon, D., "Psychological Reactions Reported After Abortion," The Post-Abortion Review, 2(3):4-8 (1994).

8. Lazarus, A. & Stern, R., "Psychiatric Aspects of Pregnancy Termination," Clin Obstet Gynaecol, 13:125-134 (1986).

9. Kent, I., et.al., "Emotional Sequelae of elective Abortion," BC Med J, 20:118-9 (1978).

10. Kent, I. & Nicholls, W., "Bereavement in Post-Abortion Women: A Clinical Report," World J Psychosyn 13:14-17 (1981).

11. Koop, C.E., Letter to President Reagan, January 9, 1989.

12. Wilmoth, G., "Abortion, Public Health Policy, and Informed Consent Legislation," J Social Issues, 48(3):1-17 (1992). 

13. Elizabeth M. Belsey et al., "Predictive Factors in Emotional Response to Abortion: King's Termination Study - IV", Soc. Sci. & Med. 11:71-82 (1977).

14. Id. at 81.

15. Id.

16. B. Major et al., "Personal resilience, cognitive appraisals, and coping: an integrative model of adjustment to abortion." J Pers Soc Psychol. 74:735-752 (1998).

17. Athanasiou R, Oppel W., and I. Michelson, et al. "Psychiatric Sequelae to Term Birth and Induced Early and Late Abortion: a Longitudinal Study." Fam Plann Perspect 5, 4 (1973): 227-231 at 231. In this very early study, several basic risk factors were already identified. The researchers, who strongly favored liberal abortion laws, argued that screening would be beneficial to patients without adding exorbitant costs: "The short form of the MMPI, for example, can be administered in 45 minutes and scored by a nurse in 10 minutes; interpretation is actuarial. The attitude scales used here can be administered and scored in about 15 minutes. For large populations, the MMPI can be computer scored and analyzed at a cost of about 85 cents per patient."

18. Borton, M. "Induced Abortion" Obstetrical Decision Making, Second Edition, E. Friedman, et al., eds. (Philadelphia: B.C. Decker Inc., 1987); Ambulatory Maternal Health Care and Family Planning Services Policies, Principles, Practices, ed. F. Barnes, Committee on Maternal Health Care and Family Planning, Maternal and Child Health Association, American Public Health Association, Interdisciplinary Books and Periodicals for the Professional and Layman (1978).

19. "It is recognized that although an abortion may be requested by a patient or recommended by a physician, the final decision as to performing the abortion must be left to the medical judgment of the pregnant woman's attending physician, in consultation with the patient." American College of Obstetricians and Gynecologists: Committee on Professional Standards, Standard for Obstetric-Gynecological Services (1981). See also Roe v. Wade, 410 U.S. 113, 1973 at 153-154, 165-166.

20. Woo, J., "Abortion Doctor's Patients Broaden Suits," Wall Street Journal, Oct 28, 1994, B12:1.

21. Landy, U., "Abortion Counseling - A New Component of Medical Care," Clinics in Obs/Gyn, 13(1):33-41 (1986).

22. Hern, W., Abortion Practice, (Boulder, CO: Alpenglo Graphics, Inc., 1990), 80,81

23. Reardon, D., Aborted Women, Silent No More (Chicago: Loyola University Press, 1987) 9,10. 

24. Hunter, J.D., Before the Shooting Begins: Searching for Democracy in America's Cultural War (New York: Free Press, 1994) 93.

25. Los Angeles Times Poll, March 19, 1989.

26. Zimmerman, Passage Through Abortion (New York: Praeger Publishers, 1977), 69, 193. 

27. Ibid., 110-112, 122; Miller, W. B., "An Empirical Study of the Psychological Antecedents and Consequences of Induced Abortion," J Social Issues 48(3):67-93 (1992); Reardon, D. Aborted Women, Silent No More, op.cit.

28. Roe v Wade, 410 U.S. 113, 166 (1973). 

29. The decision whether or not to abort should be made "in light of all circumstances - psychological and emotional as well as physical - that might be relevant to the well being of the patient." (Danforth at 66) Family size, financial concerns, mental health, and physical health are all issues in making a medical recommendation for abortion. "All these are factors the woman and her responsible physician necessarily will consider in consultation." (Roe, 153) The duty to evaluate this medical decision is especially weighty, because "Abortion is inherently different from other medical procedures, because no other procedure involves the purposeful termination of potential life." Harris v. McRaie, 448 U.S. 297, 325 (1980).

30. The Public General Acts, 1967, p2033.

31. Planned Parenthood v. Danforth 428 U.S. 51 (1975) at 67; also Planned Parenthood v. Casey 120 L Ed 2d 674 (1992) at 718.

32. Friedman, E., ed., Obstetrical Decision Making (Second Edition (1987), especially Borton, M., "Induced Abortion" p. 44 and Stewart, P. S., "Psychosocial Assessment" p. 30; Hern, W., Abortion Practice (Boulder, CO: Alpenglo Graphics, Inc. 1990), 86.

33. American College of Obstetricians and Gynecologists: Committee on Professional Standards, Standard for Obstetric-Gynecological Services (1981). Also, ACOG Executive Board, Statement of Policy - Further Ethical Considerations in Induced Abortion, (Washington, DC: ACOG, 1977).

34. Standards for Abortion Care, Rev. (Washington, DC: National Abortion Federation, 1987).

35. Saltzman, L. & Policar, M., The Complete Guide to Pregnancy Testing and Counseling (San Francisco: Planned Parenthood of Alameda/San Francisco, 1985).

36. IPPF International Medical Advisory Panel, "IMAP Statement on Abortion," IPPF Medical Bulletin, 27 (4):1 (1993).

37. See for example, Britain's General Medical Council, "Seeking patient's consent: the ethical considerations." 2000.

38. Russo, N.F., "Abortion, Childbearing, and Women's Well-Being," Professional Psychology, 23(4):296-280 (1992).

39. Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972) at 789.

40. Ibid.

41. Annas, The Rights of Hospital Patients: The Basic ACLU Guide to a Hospital Patient's Rights, (New York: Discus Books, 1975) 68.

42. "The woman should be fully informed of the procedures to be performed, including anaesthesia. Their safety and their possible immediate and future side-effects and complications should be discussed... It may be advantageous to allow, wherever possible, an interval of at least 24 hours to elapse between counseling and the performance of the abortion....While counseling on contraception, the subject of repeat abortion and its undesirability should be discussed... Pregnant adolescents seeking abortion require special care and attention during counseling." IPPF International Medical Advisory Panel, "IMAP Statement on Abortion," IPPF Medical Bulletin, 27(4):1 (1993).

43. "The very foundation of the doctrine of informed consent is every man's right to forego treatment or even cure if it entails what for him are intolerable consequences or risks, however warped or perverted his sense of values may be in the eyes of the medical profession, or even of the community, so long as any distortion falls short of what the law regards as competency. Individual freedom here is guaranteed only if people are given the right to make choices which would generally be regarded as foolish." Harper & James, The Law of Torts (1968 Supp.) section 17.1 at 61.

44. Zimmerman, Passage Through Abortion (New York: Praeger Publishers, 1977), 110-112,143; Reardon, Aborted Women - Silent No More, (Chicago: Loyola University Press, 1987), 11-20.

45. Franz, W. & Reardon, D., "Differential Impact of Abortion on Adolescents and Adults," Adolescence, 27(105):161-172 (1992); Steinberg, "Abortion Counseling: To Benefit Maternal Health," American Journal of Law & Medicine 15:4, 483-517 (1989); Vaughan, Canonical Variates of Post Abortion Syndrome (Portsmouth, NH: Institute for Pregnancy Loss, 1990). 

46. "In responding to the patient's expressed wish for termination of her pregnancy, there may be a tendency for the physician to act solely as a technician. Such action denies the physician's traditional role as a counselor and advisor. Physicians have an ethical responsibility to assure quality counseling is provided by them or others." ACOG Executive Board, Statement of Policy - Further Ethical Considerations in Induced Abortion, (Washington, DC: ACOG, 1977), 2.

47. David, H., et.al., Born Unwanted: Developmental Effects of Denied Abortion (New York: Springer Pub. Co., 1988).
 
 
 

Table 2 References

(Reference Key: Bold - Statistically Validated Study; Italicized = Clinical Experience, Soft Data, Expert Opinion; Normal type = Literature Review or Committee Reports) 
1. Adler, N.E., et al., "Psychological Factors in Abortion: A Review" American Psychologist 47(10):1194-1204 (1992). 

2. Adler, N.E., et al., "Psychological Responses After Abortion," Science, 248:41-44 (1990). 

3. Ashton, J.R. "The Psychosocial Outcome of Induced Abortion", British Journal of Ob&Gyn., 87:1115-1122 (1980).

4. Babikian & Goldman, "A Study in Teen-Age Pregnancy," Am. J. Psychiatry, 755 (1971).

5. Barnard, C.A., The Long-Term Psychosocial Effects of Abortion (Portsmouth, NH: Institute for Pregnancy Loss, 1990).

6. Belsey, E.M., et al., "Predictive Factors in Emotional Response to Abortion: King's Termination Study - IV," Soc. Sci. & Med., 11:71-82 (1977).

7. Blumberg,B.D., et al., "The Psychological Sequelae of Abortion Performed for a Genetic Indication," Am. J. of Obstetrics and Gynecology 122(7):799-808 (1975).

9. Bracken, M.B., et al., "The Decision to Abort and Psychological Sequelae" Journal of Nervous and Mental Disease, 158:154-162 (1974).

10. Bracken, M.B. "A Causal Model of Psychosomatic Reactions to Vacuum Aspiration Abortion," Social Psychiatry, 13:135-145 (1978).

11. Campbell, N.B., et al., "Abortion in Adolescence," Adolescence23:813-823 (1988).

12. Cohen, L. & Roth, S., "Coping With Abortion," Journal of Human Stress 10:140-145 (1984).

13. Council on Scientific Affairs, American Medical Association, "Induced Termination of Pregnancy Before and After Roe v Wade: Trends in Mortality and Morbidity of Women," JAMA, 268(22):3231-3239 (1992). 

14. David, H.P., "Post-abortion and Post-partum Psychiatric Hosptialization," 1985 Abortion: Medical Progress and Social Implications (London: Ciba Foundation Symposium 115, 1985) 150-64.

15. De Veber, L.L., et.al., "Post-Abortion Grief: Psychological Sequelae of Induced Abortion," Humane Medicine,7(3):203-8 (1991). 

16. Dunlop, "Counseling of Patients Requesting an Abortion," The Practitioner, 220:847-852 (1978).

17. Franz, W., Reardon, D., "Differential Impact of Abortion on Adolescents and Adults," Adolescence, 27(105):161-172 (1992).

18. Friedman, C.M. et al., "The Decision-Making Process and the Outcome of Therapeutic Abortion," Am J of Psychiatry, 131(12):1332-1337 (1974).

19. Furlong, R. & Black, R., "Pregnancy Termination for Genetic Indications: The Impact on Families," Social Work in Health Care, 10(1):17 (1984).

20. Lazarus, A., Stern, R., "Psychiatric Aspects of Pregnancy Termination," Clinics in Obs/Gyn, 13(1):125-134 (1986). 

21. Gold, D., et.al., The Abortion Choice: Psychological Determinants and Consequences (Montreal: Concordia University Department of Psychology, 1984). 

22. Heath, D.S., "Psychiatry and Abortion," Can Psychiatr Assoc J, 16:55-63 (1971). 

23. Hern, W. Abortion Practice, (Boulder, CO: Alpenglo Graphics, Inc., 1990).

24. Landy, U. "Abortion Counseling - A New Component of Medical Care," Clinics in Obs/Gyn, 13(1):33-41 (1986).

25. Lask, B. "Short-term Psychiatric Sequelae to Therapeutic Termination of Pregnancy," Br J Psychiatry, 126: 173-177 (1975).

26. Lazarus, A. "Psychiatric Sequelae of Legalized Elective First Trimester Abortion", Journal of Psychosomatic Ob&Gyn 4:141-150 (1985).

27. Lemkau, J.P., "Emotional Sequelae of Abortion," Psychology of Women Quarterly, 12:461-472 (1988). 

28. Lloyd, J. & Laurence, K.M., "Sequelae and Support After Termination of Pregnancy for Fetal Malformation," British Medical Journal, 290:907-909 (1985).

29. Major, B. & Cozzarelli,C., "Psychosocial Predictors of Adjustment to Abortion," Journal of Social Issues, 48(3):121-142 (1992).

30. Major, B., et al., "Attributions, Expectations and Coping with Abortion," Journal of Personality and Social Psychology, 48:585-599 (1985).

31. Mahkorn, S. K., "Pregnancy & Sexual Assault," The Psychological Aspects of Abortion, Mall, D., & Watts, W.F., eds., (Washington, D.C.: University Publications of America, 1979) pp.53-72.

32. Margolis, A.J.,et.al., "Therapeutic Abortion Follow-up Study," Am J Obstet Gynecol, 110:243-9 (1971).

33. Martin, C.D., "Psychological Problems of Abortion for Unwed Teenage Girls," Genetic Psychology Monographs 88:23-110 (1973).

34. Miller, W.B., "An Empirical Study of the Psychological Antecedents and Consequences of Induced Abortion," Journal of Social Issues, 48(3):67-93 (1992).

35. Moseley, D.T., et al., "Psychological Factors That Predict Reaction to Abortion," J. of Clinical Psychology, 37:276-279 (1981).

36. Mueller, P. & Major, B., "Self-blame, Self-efficacy and Adjustment to Abortion," Journal of Personality and Social Psychology 57:1059-1068 (1989).

37. Ney, P.G. & Wickett, A.R., "Mental Health and Abortion: Review and Analysis," Psychiatr J Univ Ottawa, 14(4):506-16 (1989). 

38. Osofsky J.D. & Osofsky, H.J., "The Psychological Reaction of Patients to Legalized Abortion," American Journal of Orthopsychiatry, 42:48-60 (1972).

39. Osofsky, J.D., et al., "Psychological Effects of Abortion: with Emphasis upon the Immediate Reactions and Followup," in H. J. Osofsky & J.D. Osofsky, eds., The Abortion Experience (Hagerstown, MD: Harper & Row, 1973), 189-205.

40. Payne, E.C., et al., "Outcome Following Therapeutic Abortion," Archives of General Psychiatry, 33:725-33 (1976).

41. Rayburn, W. & Laferla, J.,"Mid-gestational Abortion for Medical or Genetic Indications," Clin Obstet Gynaecol 13:71-82 (1986).

42. Rosenfeld, J. "Emotional Responses to Therapeutic Abortion," American Family Physician, 45(1):137-140, (1992). 

43. Rue, V. & Speckhard, A., "Informed Consent & Abortion: Issues in Medicine & Counseling," Medicine & Mind 7:75-95 (1992).

45. Senay, E., "Therapeutic Abortion: Clinical Aspects," Arch Gen Psychiatry 23:408-15, (1970).

46. Shusterman, L.R., "Predicting the Psychological Consequences of Abortion," Social Science and Medicine, 13A:683-689 (1979).

47. Sim, M., Neisser, R., "Post-abortive Psychoses: A Report From Two Centers," The Psychological Aspects of Abortion, Mall, D. and Watts W.F.(eds)(Washington, DC: University Publications of America, 1979).

48. Speckhard, A. & Rue, V., "Postabortion Syndrome: An Emerging Public Health Concern," Journal of Social Issues, 48(3):95-119 (1992).

49. Vaughan, H.P., Canonical Variates of Post Abortion Syndrome (Portsmouth, NH: Institute for Pregnancy Loss, 1990).

50. Wallerstein, J.S. et.al.,"Psychological Sequelae of Therapuetic Abortion in Young Unmarried Women," Arch Gen Psychiatry 27:828-32 (1972). 

51. Zakus, G. & Wilday, S., "Adolescent Abortion Option," Social Work in Health Care, 12(4):77-91 (1987).

52. Zimmerman, M., Passage Through Abortion (New York: Praeger Publishers, 1977).

53. Zimmerman, M. "Psychosocial and Emotional Consequences of Elective Abortion: A Literature Review", in Paul Sachdev, ed., Abortion: Readings and Research (Toronto:Butterworth, 1981). 

54. Zolese, G. & Blacker, C.V.R., "The Psychological Complications of Therapeutic Abortion" British J Psych 160:742-749 (1992). 

55. Gibbons, M., "Psychiatric Sequelae of Induced Abortion," J Royal College of General Practitioners 34:146-150 (1984). 

56. Hanna Söderberg, Andersson C, Lars Janzon, Nils-Otto Sjöberg, "Emotional distress following induced abortion: A Study of incidence and determinants among abortees in Malmö Sweden" Eur J Obstet Gynecol Reprod Biol 79:173-178 (1998).

57. Miller, W.B., Pasta, D.J., Dean, C.L., "Testing a Model of the Psychological Consequences of Abortion" The New Civil War: The Psychology, Culture, and Politics of Abortion, ed. Linda J. Beckman and S. Maria Harvey (American Psychological Assoc., Washington, DC, 1998)

58. Peppers, L. G., "Grief and Elective Abortion: Implications for the Counselor," Disenfranchised Grief: Recognizing Hidden Sorrow, ed. Kenneth J. Doka (Lexington Books: Lexington MA, 1989), pp.135-146.

59. Lydon, J., Duncel-Schetter, C., Cohan, C.L., Pierce, T., "Pregnancy Decision Making as a Significant Life Event: A Commitment Approach" Journal of Personality and Social Psychology, 71(1):141-151, 1996.

60. Gail B. Williams, "Induced Elective Abortion and Pre-natal Grief" PhD Thesis, New York Univeristy (1991), Dissertation Abstracts Int'l, Vol 53, No 3, Sept 1992, Order No DA9213205.

61. Anne Baker, et. al., "Informed Consent, Counseling, and Patient Preparation," A Clinician's Guide to Medical and Surgical Abortion, ed. Maureen Paul, et. al., (New York: Churchill Livingston, 1999) 29. 

62. Gissler M, Hemminki E, Lonnqvist J. Suicides after pregnancy in Finland: 1987-94: register linkage study. BMJ 1996;313:1431-4. 

63. Athanasiou R, Oppel W., Michelson, I., et al, "Psychiatric sequelae to term birth and induced early and late abortion: a longitudinal study," Fam Plann Perspect 5:227-231, 1973.