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GENERAL GYNECOLOGY
Adverse childhood experiences and repeat induced abortion
Maria E. Bleil, PhD; Nancy E. Adler, PhD; Lauri A. Pasch, PhD; Barbara Sternfeld, PhD;Renee A. Reijo-Pera, PhD; Marcelle I. Cedars, MD
OBJECTIVE:
The objective of the study was to characterize the back-grounds of women who have repeat abortions.
STUDY DESIGN:
In a cross-sectional study of 259 women (mean age,35.2
Ϯ
5.6 years), the relation between adverse experiences in child-hood and risk of having 2 or more abortions vs 0 or 1 abortion was ex-amined. Self-reported adverse events occurring between the ages of 0and 12 years were summed.
RESULTS:
Independent of confounding factors, women who experi-enced more abuse, personal safety, and total adverse events in child-hood were more likely to have 2 or more abortions vs 0 abortions (oddsratio [OR], 2.56; 95% confidence interval [CI], 1.15–5.71; OR, 2.74;95% CI, 1.29–5.82; and OR, 1.59; 95% CI, 1.21–2.09, respectively)and vs 1 abortion (OR, 5.83; 95% CI, 1.71–19.89; OR, 2.23; 95% CI,1.03–4.81; and OR, 1.37; 95% CI, 1.04–1.81, respectively). Womenwho experienced more family disruption events in childhood were morelikely to have 2 or more abortions vs 0 abortions (OR, 1.75; 95% CI,1.14–2.69) but not vs 1 abortion (OR, 1.16; 95% CI, 0.79–1.70).
CONCLUSION:
Women who have repeat abortions are more likely tohaveexperiencedchildhoodadversitythanthosehaving0or1abortion.
Key words:
contraception, early adversity, life events, repeatabortions
Cite this article as: Bleil ME, Adler NE, Pasch LA, et al. Adverse childhood experiences and repeat induced abortion. Am J Obstet Gynecol 2011;204:122.e1-6.
M
ore abortions are performed inthe United States than in another Western nation.
1
Among Ameri-can women, unintended pregnanciesrepresent almost 50% of all pregnancies,and approximately 40% of all unin-tended pregnancies end in abortion.
2
RepeatabortionsarealsocommonintheUnited States; 47% of women who havean abortion have had 1 or more previousabortions.
2
Incomparison,inCanadaandtheUnitedKingdom,ratesofrepeatabor-tionsare35.5%and32%,respectively.
Theexperienceofhavinganinitialabor-tion provides a powerful opportunity tointervene in preventing subsequent unin-tendedpregnancies.Interventioneffortsinthis population, however, have met withlimitedsuccess.Forexample,inonestudy of 613 women presenting for an inducedabortion,aninterventionusingspecializedcontraceptive counseling and provisioncomparedwithusualcareshowednolong-termimpactonreducingtheoccurrenceof havingasubsequentabortionoverthenext2years.
5
Additionally,althoughtheoverallnumber of abortions in the United Stateshasdeclined,
2
ratesofrepeatabortionsre-mainsteady,
6
suggestingthatwomenwhoare susceptible to recurrent unintendedpregnancies require new interventionapproaches.Interventions to reduce repeat abor-tions will need to target risk factorsfor subsequent unintended pregnancieswith particular emphasis on those fac-tors that are linked to repeat abortions.Previousresearchshowsthat,inadditionto the identification of several socio-demographic characteristics of womenwhohaverepeatabortions(eg,increasedage, nonwhite ethnicity)
experiencesofabuse,includingintimatepartnervio-lence and history of sexual abuse, distin-guishwomenundergoingarepeatvsfirstabortion.
3
Abuse history has also beenlinked to other deleterious reproductivehealth outcomes, including unplannedpregnancy, sexual risk-taking behaviors,pooradherencetocontraception,andhav-ingasexuallytransmittedinfection.
The present study builds on the exist-ing literature by evaluating whetherabuse in childhood relates to the proba-bility of having repeat abortions in ado-lescence and adulthood. Previously re-ported associations between abuse andrepeat abortions examined lifetime his-toryofabuseonly,
3
allowingforpossibleconfounding by experiences of currentabuse. Additionally, given the increasedprevalence of nonabuse compared withabuseevents,thepresentstudyalsoeval-uated whether nonabuse adverse events,such as family difficulties (eg, death of aparent) and issues of personal safety (eg,home robbery) may increase the likeli-hood of having repeat abortions orwhether any associations are limited toabuse-related exposures.The current sample included 259 re-productive-aged women who providedby interview and questionnaire-based
FromtheDepartmentsofPsychiatry(DrsBleil,Adler,andPasch)andObstetrics,Gynecology,andReproductiveSciences(DrCedars),UniversityofCalifornia–SanFranciscoSchoolofMedicine,SanFrancisco;theDivisionofResearch,KaiserPermanente–NorthernCalifornia,Oakland(DrSternfeld);theDepartmentofObstetricsandGynecology,StanfordUniversitySchoolofMedicine,Stanford(DrReijo-Pera),CA.
ReceivedApril15,2010;revisedJuly25,2010;acceptedSept.28,2010.Reprints:MariaE.Bleil,PhD,HealthPsychologyProgram,UniversityofCalifornia,SanFrancisco,3333CaliforniaSt.,Suite465,SanFrancisco,CA94143-0848.maria.bleil@ucsf.edu. ThisstudywassupportedinpartbyNationalInstituteofChildHealthandHumanDevelopment/ NationalInstituteonAgingGrantR01HD044876,NationalInstituteofMentalHealthGrant T32MH019391,andRobertWoodJohnsonFoundationGrant045820.0002-9378/$36.00 • © 2011 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2010.09.029
Research
www.
AJOG
.org 
122.e1
American Journal of Obstetrics
Gynecology
FEBRUARY 2011
 
methodsinformationregardingtheirex-posurestoadverseeventsinchildhoodaswell as their lifetime reproductive medi-cal history. We hypothesized that in-creased exposures to abuse as well asnonabuse adverse events in childhoodwould increase the likelihood of awoman having repeat abortions (ie,
Ն
2)inadolescenceandadulthoodcomparedwith never having had an abortion orhaving only 1 abortion.
M
ATERIALS AND
M
ETHODS
Participants
The current sample was derived from anongoing population-based study of ovarian aging (the OVA Study), whichincludes women belonging to a large in-tegratedhealthcaredeliverysystemserv-ing a wide and generally representativepopulation in northern California.
Se-lection criteria for the OVA Study re-quire that participants be between theagesof25-45years,haveregularmenses,and have their uterus and both ovariesintact.All participants self-identify as being of 1 of 5 different ethnicities: Caucasian, Af-rican American, Latino, Chinese, or Fili-pino and speak/read English, Spanish, orCantonese. Participants are excluded if they report a major medical illness, are onmedications affecting the menstrual cyclewithin the 3 months prior to study partic-ipation,orarepregnantorbreastfeeding.As a part of the OVA Study protocol,womenparticipateinanin-personinter-view,undergoatransvaginalultrasound,and have their blood drawn. Addition-ally, beginning 4 months after the initia-tion of the OVA Study, participants be-gan to also complete a questionnairepacketofself-reportmeasures,includingthe measure of stressful life events usedin the present analysis.The participants considered for inclu-sion in the current sample were thosewomen who enrolled in the study at thetimethequestionnairepacketwasaddedto the study protocol. Over a 1 year pe-riod (June 2007 to May 2008), 295women enrolled in the OVA Study. Of these, 259 (88%) completed the ques-tionnaire packet and are included in thepresent analysis.The study protocol was approved by the University of California, San Fran-cisco, Committee on Human Researchas well as the Kaiser Permanente of Northern California Institutional Re-view Board. Informed, written consentwasobtainedfromallstudyparticipants.
Measures
 Abortion history:
information regardingabortion history was obtained from anin-person medical history interview.Participants underwent a structured in-terviewadministeredbytrainedresearchassociates in which a detailed medicalhistory was obtained. As a part of thisinterview, women were asked to identify eachpregnancytheyexperiencedandtheoutcome of the pregnancy. In cases inwhich a pregnancy was terminated by abortion, other relevant details, includ-ing the age of the participant at the timeoftheabortionandwhethertheabortionwas medically indicated, were ascer-tained. Women were classified as havingno abortion, 1 abortion, or 2 or moreabortions.
Stressful life events:
the original LifeEvents Checklist
was adapted to in-clude 26 items pertaining both to con-ventional life events (eg, parental di-vorce)aswellastraumaticlifeevents(eg,sexual abuse). For each of 14 items rele-vant to childhood, participants wereasked to indicate whether they experi-enced the event and their age(s) at thetime the event occurred. Participantswereassigned1pointforeacheventthey endorsed having experienced in child-hood defined as occurring between theages of 0 and 12. Items were summed tocreate a total score (score range, 0–14).Inaddition,3subscalescoreswerecalcu-lated reflecting abuse history, family dis-ruption, and threats to personal safety.Abuse history (score range, 0–2) con-sisted of 2 items pertaining to physicalabuse and sexual abuse.Family disruption (score range, 0–6)consistedof6itemspertainingtothefol-lowing: (1) death of a parent, (2) separa-tionordivorceofparents,(3)witnessingphysical fights between parents, (4)witnessing frequent arguments betweenparents,(5)livingwitharelativewhohasa serious drinking or drug problem, and(6) living with a relative who has a psy-chiatric illness.Threats to personal safety (scorerange,06)consistedof6itemspertain-ing to the following: (1) being in a life-threateningaccident,(2)sufferingaseri-ous illness or injury, (3) witnessingviolence to another person, (4) experi-encing a home robbery, (5) being in anatural disaster, and (6) being physically assaulted.
Statistical analysis
Allparticipantshadcompletedataonthevariables of primary interest, includingabortion history and stressful life eventsin childhood. Regarding covariates (age,race,childhoodsocioeconomicstatus,andnumber of pregnancies), 8 participants(3.1%)hadmissingdataonmother’sedu-cation; a multiple linear regression proce-dure was used to estimate these 8 missingvalues from 3 predictor variables, includ-ing participant’s age (in years), race (1,Caucasian; 2, nonwhite), and education(inyears).
Comparisonofwomenwithandwith-out missing values on mother educationshowed missingness was unrelated toabortionhistoryorstressfullifeeventsinchildhood (
Ͼ
.05). Seven participants(2.7%) had missing data on father edu-cation and 12 participants (4.6%) indi-cated that they did not have a father orfather-figure present in their lives. Val-ues for missing data on father educationwere not imputed. Mother and fathereducation were then standardized andsummed to create an index of childhoodsocioeconomic status; in cases in whichfather education was missing, mothereducation only was used in the index of childhood socioeconomic status.Among the remaining covariates (age,race, and number of pregnancies), allparticipants had complete data.To compare women who had 0 (n
ϭ
170),1(n
ϭ
46),and2ormore(n
ϭ
43)abortions on sociodemographic factors,reproductive history, and exposures tostressful life events, analysis of variance(ANOVA) was used to examine contin-uousvariablesand
␹ 
2
toexaminedichot-omous variables. For ANOVAs in whichgroup differences reached statistical sig-
 www.AJOG.org 
General Gynecology
Research
FEBRUARY 2011
American Journal of Obstetrics
Gynecology
122.e2
 
nificance, post hoc multiple compari-sons were computed.Stepwise logistic multiple regressionanalyseswereusedtodeterminewhetherexposurestostressfullifeeventsinchild-hood relate to the probability of havingrepeat abortions in later life. In separateregression equations, the total numberof stressful life events, the stressful lifeevents composites (abuse history, family disruption, and threats to personalsafety), and the individual physical andsexual abuse items were entered as inde-pendentvariablesinrelationto3dichot-omized abortion outcomes: having 1abortion (n
ϭ
46) vs 0 abortions (n
ϭ
170); having 2 or more abortions (n
ϭ
43) vs 0 abortions (n
ϭ
170), and having2 or more abortions (n
ϭ
43) vs 1 abor-tion (n
ϭ
46).The following covariates were enteredsimultaneouslyonthefirststepofeachre-gression equation: age (in years), race (1,Caucasian;2,nonwhite),childhoodsocio-economicstatus(indexedbysummingthestandardized values of mother and fathereducation),andnumberofpregnancies.The regression coefficient (B), signifi-cancevalue(
),oddsratio(OR),and95%confidence interval (CI) were derived foreach regression equation; statistical signif-icance was set at
Ͻ
.05. Statistical analy-ses were performed using version 17.0 of SPSS(SPSSInc,Chicago,IL).
ESULTS
Sample characteristics
The sample consisted of 259 women be-tween the ages of 25-45 years (M 35.2
Ϯ
5.6 years). The sample was multiethnic,including 101 (39%) participants whoself-identified as nonwhite: AfricanAmerican(n
ϭ
67,26%),Latino(n
ϭ
13,5%),Chinese(n
ϭ
12,5%),andFilipino(n
ϭ
9, 3%). All participants chose tocomplete the study protocol in English.The majority (70%) of the participantsheld a college or graduate-level degree,whereas 39% of the participants’ moth-ers were college educated or greater.Almosthalfofthesamplehadneverbeenmarried, 42% were currently married,and the remaining 11% were widowed,separated, or divorced. Consistent withprevious research
2
, among the 89 womenreporting having had an abortion, 48.3%ofthemhadhad2ormoreabortions.
Group comparisonsby abortion history
For descriptive purposes, women whohad 0 (n
ϭ
170), 1 (n
ϭ
46), and 2 ormore(n
ϭ
43)abortionswerecomparedon sociodemographic factors, reproduc-tive history, and exposures to adverseevents(Table1).Regardingwomenwith 2 or more abortions compared withwomen with 0 or 1 abortion, post hocmultiple comparisons of significant dif-ferencesbyANOVAshowedthatwomenwith2ormoreabortionswereolderthanwomen with 0 abortions and were lesseducated than women with 0 or 1abortion.With respect to reproductive history,womenwith2ormoreabortionsexperi-enced more pregnancies than womenwith 0 or 1 abortion and had more livebirths and were younger at their firstpregnancy than women with 0 abor-tions. Results of 
␹ 
2
analyses also showedsignificant differences between whiteand nonwhite women with a greaternumber of nonwhite women belongingto the 2 or more abortion group. Lastly,indescriptiveanalyses,agreaterpercent-age of women with 2 or more abortionscompared with women with 0 or 1 abor-tionwereshowntohaveexperiencedad-verse events in childhood, including35.7% who experienced physical or sex-ual abuse, 50% who experienced 2 ormoreeventsrelatedtofamilydisruption,and 16.7% who experienced 2 or moreeventsrelatedtoissuesofpersonalsafety.
Logistic multiple regression
Results of logistic multiple regressionanalyses are reported inTable 2.Follow- ing adjustment for covariates (age, race,childhood socioeconomic status, andnumberofpregnancies),womenreport-ing a greater overall number of stressfullife events were more likely to have 2 ormore abortions in adolescence/adult-hood vs 0 (OR, 1.59; 95% CI, 1.21–2.09)or 1 abortion (OR, 1.37; 95% CI, 1.04–1.81). Similarly, women reporting agreater number of abuse and personalsafety–related stressful life events weremore likely to have 2 or more abortionsinadolescence/adulthoodvs0(OR,2.56;95%CI,1.15–5.71andOR,2.74;95%CI,1.29–5.82, respectively) or 1 abortion(OR, 5.83; 95% CI, 1.71–19.89 and OR,2.23; 95% CI, 1.03–4.81, respectively).With respect to family disruption–related stressful life events, women re-porting a greater number of events weremore likely to have 2 or more abortionsin adolescence/adulthood comparedwith0(OR,1.75;95%CI,1.14–2.69)butnotcomparedwith1abortion(OR,1.16;95% CI, 0.79–1.70). In contrast, womenreporting more stressful life events werenomorelikelytohave1vs0abortionsinadolescence/adulthood for the overallnumberofstressfullifeevents(OR,1.17;95%CI,0.96–1.44)aswellasabuse,per-sonal safety, and family disruption–re-lated stressful life events (OR, 0.79; 95%CI, 0.35–1.79; OR, 1.30; 95% CI, 0.69–2.42; and OR, 1.34; 95% CI, 1.00–1.79,respectively).As described above, with each 1 unitincrease in abuse-related stressful lifeevents (that is, having never experiencedabuse [coded 0]; vs having experiencedeither physical abuse
or 
sexual abuse[coded 1]; vs having experienced bothphysical and sexual abuse [coded 2]),women were 2.6 times more likely tohave2ormoreabortionscomparedwithhaving 0 abortions (OR, 2.56; 95% CI,1.15–5.71) and almost 6 times morelikely to have 2 or more abortions com-pared with having 1 abortion (OR, 5.83;95% CI, 1.71–19.89). In follow-up anal- yses, the individual physical and sexualabuseitemswereexaminedtodeterminetheir respective associations with abor-tion number.Results showed that whereas womenreporting sexual abuse-related stressfullife events were more likely to have 2 ormore abortions compared with 0 (OR,3.41;95%CI,1.05–11.09)and1abortion(OR,9.12;95%CI,1.70–48.97),womenreporting physical abuse–related stress-ful life event were no more likely to have2 or more compared with 0 (OR, 3.23;95% CI, 0.80–13.12), 2 or more com-pared with 1 (OR, 6.45; 95% CI, 0.87–47.98), or 1 compared with 0 (OR, 0.66;95% CI, 0.13–3.24) abortions.
Research
General Gynecology
www.AJOG.org 
122.e3
American Journal of Obstetrics
Gynecology
FEBRUARY 2011

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