Psychiatric Aspects of Pregnancy Termination

10/27/2017 Psychiatric aspects of pregnancy termination - UpToDate
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Psychiatric aspects of pregnancy termination
Authors: Uta Landy, PhD, Philip D Darney, MD, MSc

Section Editors: Jody Steinauer, MD, MAS, Jonathan M Silver, MD
Deputy Editors: Sandy J Falk, MD, FACOG, David Solomon, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2017. | This topic last updated: Sep 14, 2016.
INTRODUCTION — In the United States in 2011, approximately 1 million pregnancies were terminated [1].
Approximately half of all pregnancies were unintended and 40 percent of these were terminated, meaning that 21
percent of all pregnancies were aborted. The number of induced abortions declined by 13 percent between 2008
and 2011, but the number of terminations of intended pregnancies has increased due to advances in prenatal
testing for fetal abnormalities [1-3]. Although the psychological impact of pregnancy termination is controversial,
most studies, especially higher-quality studies, suggest that induced abortion is not associated with an increased
risk of serious mental health disorders [4-10]. It is important to note that the psychological context of pregnancy
termination varies depending upon whether the reason is an unwanted pregnancy, multiple gestation, or fetal
anomalies.
The psychiatric aspects of pregnancy termination are reviewed here. Other issues regarding pregnancy
termination are discussed separately. (See "Overview of pregnancy termination".)
EVIDENCE REGARDING POTENTIAL OUTCOMES — Most reviews have concluded that abortion does not
harm a women’s mental health [4,5,11-13]. However, some of the evidence regarding the psychiatric aspects of
pregnancy termination is of low quality, and study designs are inconsistent [11]. Many studies do not use
validated mental health measures or control for pre-abortion mental status and whether the pregnancy is
planned, and the presence and type of comparison group varies [4]. Specifically, many studies compare women
with unplanned pregnancies to women planning an ongoing pregnancy. The circumstance of an unwanted
pregnancy involves factors that are likely to be associated with emotional distress, such as impaired relationships
and financial difficulties.
In addition, psychological responses to pregnancy termination often vary by social, cultural, religious, or legal
context, so generalizations across populations are difficult to make [14,15]. Emotional responses to abortion
would be expected to differ between environments where induced abortion is permissible and where abortion is
disapproved. If abortion poses risks such as injury, financial ruin, or incarceration, it is difficult to distinguish
psychological responses to abortion from fears of the consequences.
The following sections focus upon mental health outcomes following pregnancy termination for unintended
pregnancy. Psychiatric outcomes of pregnancy termination due to fetal abnormalities are discussed in a separate
section. (See 'Termination for fetal anomalies' below.)
This topic reviews the best evidence rather than all of the evidence, consistent with all UpToDate topics. Thus,
prospective observational studies are favored over retrospective studies, studies with appropriate control groups
are favored over those with inappropriate or no control groups, studies with more events of interest are favored
https://www.uptodate.com/contents/psychiatric-aspects-of-pregnancy-termination/print?source=search_result&search=termination%20of%20pregnan… 1/21
over those with fewer outcomes, studies of longer duration are favored over shorter studies, and studies that
adjust for potential confounders (eg, prepregnancy mental disorders) are favored over studies that did not.
Mental disorders in aggregate — Most studies, especially higher-quality studies, suggest that induced abortion
is not associated with an increased risk of mental health disorders [4-7]. As an example, the primary findings in a
systematic review of 44 studies included the following [11]:
● Among women with unwanted pregnancies who either terminate the pregnancy or give birth, the rate of
mental illness is comparable.
● Unwanted pregnancies are associated with an increased risk for mental illness.
● Postabortion mental illness is most consistently associated with pre-abortion mental illness. Other factors
that may contribute to mental health problems following pregnancy termination include negative attitudes
towards abortion, pressure from a partner to have an abortion, and negative reactions to the abortion
including grief or doubt.
A subsequent retrospective study included adolescents who either had an induced abortion (n = 1041) or gave
birth (n = 394) and were then followed up to age 25 years [10]. Following the abortion or childbirth, the risk of
subsequent psychiatric disorders or episodes of self-harm were comparable. However, educational achievement
was greater among girls who underwent abortion, whereas the girls who gave birth were more likely to receive
income support (welfare).
Some data suggest that the patient population who undergo abortion have a higher baseline rate of mental
health disorders. As an example, national registry study identified females who had no mental disorder and who
either had a first-time first-trimester induced abortion or first childbirth [16]. The study estimated the rates of first
psychiatric contact (either inpatient admission or outpatient visit) for the 12-month period after the abortion or
delivery as compared with the nine-month period preceding the event. The primary findings included the
following:
● Among women who had an abortion (n >84,000), the incidence of first psychiatric contact for the 12 months
after and the nine months preceding the abortion was comparable
● The incidence of psychiatric contact among women (n >280,000) was greater after childbirth than before
● The incidence of mental health problems was greater in the nine months preceding abortion than the nine
months preceding childbirth
A subsequent national registry study identified women who had been hospitalized for mental disorders (eg,
unipolar major depression, schizophrenia, substance use disorder, or personality disorder) and subsequently
became pregnant [17]. Among the women who had a first-time first-trimester induced abortion (n >2800), the risk
of readmission during the 12 months after the abortion or during the nine months prior to the abortion was
comparable (relative risk [RR] 1.1, 95% CI 0.8-1.34). By contrast, in the women who delivered their first child (n
>5200), the risk of readmission was greater during the 12 months after delivery than the nine months prior to
delivery (RR 1.8, 95% CI 1.3-2.4).
Women frequently struggle with decisions to end pregnancies. However, the conflicts and ambivalence regarding
the abortion decision typically occur before the abortion [18]. While unintended pregnancy brings about a crisis
and stress for many women, the pregnancy termination is usually perceived as a resolution of the crisis and
brings a sense of relief [19,20].
Although a meta-analysis of 22 observational studies (n >870,000 subjects, including more than 160,000 who
had an abortion) found an 81 percent increased risk of mental health problems (eg, depression, anxiety, and/or
substance use disorders) among women who had a prior abortion [12], this analysis has been widely criticized
because of several methodologic problems [4,5,13,21]. As an example, half of the studies included in the meta-
analysis were conducted by the same investigator who performed the meta-analysis, which raised concerns
about selection bias; in addition, the meta-analysis did not assess the quality of studies that were included and
did not control for mental illness prior to the induced abortion.
Suicide — There is no convincing evidence that induced abortion increases the risk of suicidal ideation or
behavior:
● A retrospective study examined women in a nationally representative sample who had their first induced
abortion (n = 218) or childbirth (n = 1547); analyses that controlled for prepregnancy mental disorders and
prepregnancy violence (eg, childhood physical abuse, rape, or being threatened with a weapon) found that
the probability of suicidal ideation or behavior was comparable for the two groups.
● A second retrospective study examined women in a nationally representative sample who had their first
induced abortion (n = 259) or had no abortions and their first childbirth (n = 677); analyses that controlled for
prepregnancy mental disorders found that the probability of suicidal ideation or behavior was comparable for
the two groups [22].
● In a systematic review that assessed study quality, no high- or fair-quality studies have found an increased
risk of completed suicide associated with pregnancy termination [6]. However, two poor-quality studies found
an association between pregnancy termination and completed suicide. In addition, a study not included in
the review also found an association between termination of pregnancy and deliberate self harm (suicide
attempt), but the investigators concluded that the finding was probably confounded by factors such as
psychological and social difficulties [23].
Psychosis — Induced abortion does not appear to be associated with an increased risk of psychosis; however,
few studies have examined this issue. One prospective observational study found that among women with an
unplanned pregnancy and no history of mental illness, the risk of psychosis was 70 percent lower in women who
terminated their pregnancy than women who delivered [23]. However, the incidence of psychosis leading to
hospitalization appeared to be comparable for the two groups.
Depression — Although there are conflicting data regarding the association of pregnancy termination with the
long-term risk of various types of depression, higher-quality studies (eg, prospective and/or well-controlled) have
generally found that induced abortion is not associated with an increased risk of depression [11]. As an example
[22,24]:
● A three-year prospective study (the Turnaway Study) followed women who received a first trimester abortion
(n = 254), women who received an abortion near the limit of the facility's gestational limit (n = 413), and
women who were denied an abortion and gave birth because they presented after the facility's gestational
limit (n = 160) [8]. After controlling for potential confounding factors (eg, age, parity, marital status, and
history of child abuse and/or substance use disorders), the analyses found that baseline (assessed eight
days after their visit to the abortion clinic) rates of clinical depression were comparable for the three groups,
as were cumulative rates during follow-up (approximately 10 percent in each group).
● In a prospective study, women were followed from birth and assessed at age 21 years; the cohort included
women with a recent or remote history of either an induced abortion (n = 101) or miscarriage (n = 82) [25].
Analyses that adjusted for early life and family factors, adolescent behaviors, and sociodemographic factors
showed that the lifetime risk for mood disorders (unipolar major depression, persistent depressive disorder,
and bipolar disorder) was comparable for the two groups.
● A retrospective study examined women in a nationally representative sample aged 14 to 21 years in 1979,
who had unplanned first pregnancies and either had an induced abortion (n = 479) or carried the pregnancy
to term (n = 768) [26]. The incidence of depression following abortion or delivery was comparable (25 and 29
percent). In addition, an analysis of a subgroup who had an abortion (n = 225) or delivery (n = 310) before
1980 found that depression occurred in fewer women who terminated the pregnancy than delivered (26
versus 35). Although a prior study using the same dataset found that the risk of depression was greater
among women who had abortions than women who delivered [27], multiple reviews have concluded that this
study was of poor quality because of several methodologic flaws such as selection bias [6,7].
Following the diagnosis of pregnancy and prior to termination, depression occurs in approximately 20 percent of
women [28]. Following induced abortion, the prevalence of depression is also about 20 percent [11].
Anxiety — Many women experience anxiety just prior to pregnancy termination, but the long-term risk of anxiety
disorders after abortion is not elevated [11,22,29]:
● A review of 24 studies found that in good-quality studies, significant levels of anxiety prior to abortion
occurred in 40 to 45 percent of women [28]. Most studies found that in the month following pregnancy
termination, the prevalence of anxiety had decreased. In one study, the factor most commonly associated
with pre-abortion anxiety was anticipation of pain [30].
● A three-year prospective study (the Turnaway Study) followed women who received a first trimester abortion
limit (n = 160) [8]. After controlling for potential confounding factors (eg, age, parity, marital status, and
history of child abuse and/or substance use disorders), the analyses found that baseline (assessed eight
days after their visit to an abortion clinic) rates of clinical anxiety were comparable for the three groups, as
were cumulative rates during follow-up (ranging from 10 to 16 percent among the groups).
● A retrospective study of women with an unintended first pregnancy who had an induced abortion (n = 1167)
or carried the pregnancy to term (n = 2315), analyses that controlled for potential confounders (including
prepregnancy anxiety and rape) showed that the rate of postpregnancy anxiety symptoms lasting at least six
months was comparable [29].
Posttraumatic stress disorder — Pregnancy termination does not appear to be associated with posttraumatic
stress disorder (PTSD) [29]. As an example:
● A prospective study of women who requested an induced abortion for a first-trimester pregnancy (n = 1402)
included assessments at baseline after diagnosis of the pregnancy and prior to the abortion, and again six
months after the abortion [31]. The prevalence of current PTSD at baseline and six months later was 4 and 2
percent. In addition, the majority of women who did not have PTSD at baseline but developed it after the
abortion did so because of traumatic experiences unrelated to the abortion.
● Another prospective study included women who had an induced abortion of a first-trimester unintended
pregnancy and were assessed two years later (n = 442) [32]. The incidence of PTSD was 1 percent, which
was lower than the rate of PTSD in the general population.
● A four-year prospective study (the Turnaway Study) followed women who received a first trimester abortion
limit (n = 157) [9]. After controlling for potential confounding factors (eg, age, marital status, and history of
child abuse, sexual assault, and/or psychiatric disorders), the analyses found that the baseline (assessed
eight days after their visit to an abortion clinic) risk of screening positive for PTSD was comparable for the
three groups, as was the risk during follow-up.
Although some studies have found an elevated risk of PTSD after pregnancy termination [33,34], it appears that
there are methodological flaws in these studies, and thus it is not possible to know if the association is due to
confounding factors that are frequently present in women who suffer PTSD and women who terminate their
pregnancy [35-38]. Potential confounders include a history of having been a victim of violence and a prior history
of mental disorders.
Substance abuse — Prospective studies suggest that induced abortion is not associated with an increased risk
of subsequent substance use disorders:
● In one study, women were followed from birth and assessed periodically, through age 21 years; the cohort
included women with a history of an induced abortion (n = 101) or miscarriage (n = 82) [25]. Analyses that
adjusted for early life and family factors, adolescent behaviors, and sociodemographic factors showed that
the lifetime risk for alcohol use disorder, cannabis use disorder, or other illicit substance use disorder (eg,
amphetamines, cocaine or opioids) was comparable for the two groups.
● A two-year prospective study included women with unwanted pregnancies who had a first-trimester abortion
(n = 273), a second-trimester abortion (n = 452), or who delivered because they were denied an abortion
(they presented just beyond the gestational age limit; n = 161) [37]. Illicit drug use (eg, cannabis, cocaine, or
prescription drug misuse) was comparable for the three groups (11, 9, and 10 percent).
Eating disorders — Termination of pregnancy does not appear to increase the risk of eating disorders; however,
few studies have examined this issue. One retrospective study examined women in a nationally representative
sample who had their first induced abortion (n = 259) or childbirth (n = 677), and were assessed for the presence
of anorexia nervosa, bulimia nervosa, or binge eating disorder [22]. After adjusting for prepregnancy mental
disorders, the probability of suffering a postpregnancy eating disorder was comparable for the two groups.
In addition, it appears that women with an eating disorder who become pregnant are more likely to have an
unplanned pregnancy than women without an eating disorder. As an example, a prospective observational study
identified women with anorexia nervosa (n = 62) who became pregnant and women with no eating disorder who
became pregnant (n = 61,998) [38]. Unplanned pregnancies were more frequent in women with anorexia
nervosa than women with no eating disorder (50 versus 19 percent).
Regret — Studies of regret in women who have abortions do not always clarify the question “If you could go
back in time with what you know now, would you make a different decision?” In addition, many women regret that
they had to deal with an undesired pregnancy. When the types of regret are analyzed in detail, few women
reported true decisional regret [39]. Specifically, most women do not regret the decision to have an abortion [40],
and when they do, often have simultaneous feelings of relief. One prospective study included women who had
an induced abortion of a first-trimester unintended pregnancy and were assessed two years later (n = 441).
When asked if they would make the same decision to have the abortion, responses were as follows [32]:
● Yes – 69 percent
● No – 19 percent
● Undecided – 12 percent
Women who regretted the abortion tended to have a prepregnancy history of depression.
Another prospective study (the Turnaway Study) examined the consequences of receiving or being denied an
abortion. Among women who received an abortion for an unwanted pregnancy (n = 665) and were asked one
week later if it was the correct decision, 95 percent replied yes [41]. In the subset of women who received an
abortion just prior to the clinic’s gestational age limit (n = 411), 41 percent felt regret, but among those feeling
regret, 87 percent also felt relief. In addition, women who were turned away because they exceeded the
gestational age limit at that clinic (n = 178) were more likely to experience regret (regarding their ongoing
pregnancy) than women who were still eligible and received an abortion.
Women in the Turnaway Study who terminated their pregnancy (n = 667) were assessed every six months for
three years; at each follow-up interview, approximately 95 percent thought it was the right decision [42]. In a
multivariate model controlling for a variety of factors, the probability that the average study subject would report
that getting an abortion was the right decision was >99 percent. Regret and other negative emotions (anger,
guilt, and sadness) were uncommon and were more likely to be reported by women who had terminated planned
pregnancies; however, the intensity of these negative emotions diminished over time, as did positive feelings of
relief and happiness.
Stigma — Concern about social stigma is another psychological aspect of pregnancy termination [41,43,44].
Fear of abortion stigma can lead women to make decisions that increase the risks of abortion, both physically
and mentally [44]. In a study of women followed prospectively for two years after pregnancy termination (n =
442), 47 percent reported that others would disapprove of them as a result of their abortion and 44 percent felt
they needed to keep the abortion a secret from family and/or friends [45]. Stigma may contribute to the
internalization of negative perceptions of self, as well as negatively influence patient perception of the abortion
experience [45,46]. A three-year prospective study of women who terminated a pregnancy (n = 667) found that
women who perceived greater community stigma about abortion reported more negative emotions (regret, guilt,
sadness, and/or anger) following an abortion [42].
POTENTIAL MODIFYING FACTORS — The following factors appear to be associated with the degree of
emotional distress that occurs in response to pregnancy termination:
● Mental disorders prior to abortion

● Social support
● Relationship violence
● Attitude toward pregnancy termination
● Current family size
● Termination for a fetal anomaly
By contrast, the following factors do not appear to be related to emotional distress following pregnancy
termination:
● Gestational age
● History of pregnancy termination
● Pregnancy termination technique
● Socioeconomic status
● Adolescence
● Multifetal pregnancy reduction
Factors that may increase risk of postabortion psychiatric problems
Mental disorders prior to abortion — Mental health prior to pregnancy termination is the most important risk
factor for psychiatric symptoms or diagnoses after induced abortions [5,11,36,47]. Studies that account for
prepregnancy mental disorders generally find that induced abortion is not associated with postpregnancy mental
disorders [22,24]. Conversely, several studies that have found an association between induced pregnancy and
mental disorders did not account for prepregnancy mental disorders [12,48].
Among pregnant women who either have an induced abortion or carry the pregnancy to term, the rate of mental
disorders preceding induced abortion appears to be greater than the rate preceding delivery [16]. A nationally
representative survey identified women who had their first induced abortion (n = 259) or first childbirth (n = 677),
and assessed the presence of mental disorders (eg, anxiety disorder, mood disorder, or substance use disorder)
prior to pregnancy [22]. Prepregnancy mental disorders were more common in the abortion group than the birth
group (62 versus 42 percent).
Social support — The psychological support available to women before and after pregnancy termination
affects their perception, experience, and postpregnancy feelings about abortion. Studies have found that low
perceived or anticipated social support is associated with an increased rate of negative emotion following
pregnancy termination [5,11]. In addition, relationship health, rather than marital status, appears to affect
emotional response to abortion; most studies have found that partner support is a key factor in reducing the risk
of emotional distress [11,40,49]. Conversely, women who report pressure from a partner or friends as the reason
for terminating the pregnancy may be more likely to feel distress, such as symptoms of posttraumatic stress
disorder (PTSD) [33,50].
Emotional support may be provided by the woman’s partner or other family, friends, or clinicians or counselors
[39]. (See 'Counseling' below.)
Violence victimization — A current or past history of having been a victim of violence (eg, childhood physical
and sexual abuse, partner violence, rape, or being threatened with a weapon) is associated with pregnancy
termination as well as mental disorders:
● A prospective study of women (n >9000) found that the effect of intimate partner violence upon the incidence
of depressive symptoms was fourfold greater than the effect of pregnancy termination or giving birth [51].
● A retrospective study that examined women in a nationally representative sample found that in analyses that
controlled for prepregnancy violence, abortion was not related to depression [24]. In addition, the study
found that prepregnancy rape or molestation predicted postpregnancy depression and suicidal ideation and
behavior.
● In another retrospective study of women (n >2000), analyses that controlled for history of violence and
sociodemographic factors found that abortion was not correlated with depression, anxiety, or suicidal
thoughts [52].
In addition, a history of intimate partner violence, rape, and/or sexual abuse is more common among women who
undergo multiple induced abortions, compared with women who undergo one abortion [53].
Identifying, supporting, and referring women experiencing relationship violence can be an effective intervention
against further psychological consequences of that violence [54]. Termination counseling provides an opportune
time to intervene. (See "Intimate partner violence: Diagnosis and screening" and "Intimate partner violence:
Intervention and patient management".)
Attitude toward pregnancy termination — Baseline ambivalence and negative attitudes toward abortion
may be associated with negative emotional responses postabortion. In a retrospective study, adverse attitudes
about abortion prior to the procedure were present in more women who suffered postabortion emotional distress
(n = 74) than women who did not (n = 72) (46 versus 10 percent) [40].
A woman may feel compelled to terminate an unintended pregnancy, despite a negative personal attitude toward
pregnancy termination; this may make it difficult for her to accept her decision without anxiety and distress. In
addition, attitudes about abortion may be influenced by religious or legal factors [55].
Current family size — Women with greater numbers of children appear to have more positive attitudes
towards abortion [56] and better psychological responses two years postprocedure than women with fewer or no
children [50].
Termination for fetal anomalies — Advances in techniques for prenatal testing now enable clinicians to
diagnose many fetal abnormalities during pregnancy. Women and their partners who receive a diagnosis of a
fetal abnormality must make a challenging decision regarding pregnancy termination or continuing the
pregnancy. In addition, women with a multiple gestation may undergo selective termination if one fetus has an
abnormality. (See "Multifetal pregnancy reduction and selective termination", section on 'Selective termination'.)
Studies have found that women who terminate a pregnancy because of a fetal abnormality are likely to
experience significant emotional distress. The level of distress is generally comparable to that for women who
have pregnancy loss (miscarriage, stillbirth, or neonatal death) during the second trimester or later [57]. In one
study of women who terminated their pregnancy because of fetal anomalies (n = 147), assessments conducted
four months after termination found that clinically significant symptoms of PTSD or depression occurred in 46
and 28 percent [58]. At the 16-month follow-up, symptoms of posttraumatic stress or depression were present in
21 and 13 percent.
Prenatal diagnostic testing is available for some conditions during the first trimester, but most fetal abnormalities
are diagnosed in the second trimester. One study found that women who underwent pregnancy termination for a
fetal anomaly in the second trimester were more likely to have posttraumatic stress symptoms than those who
had a first-trimester termination [3].
Counseling women who consider termination after diagnosis of fetal anomalies or threat to maternal health
demands special considerations. In such cases, the pregnancy termination typically occurs among women who
initially desired their pregnancies and have not contemplated the need to terminate them. Both factors make the
decision more painful. Helping these women grieve and making referrals to support organizations or
psychotherapists may be helpful.
Factors that do not appear to be related to postabortion mental health
Gestational duration — There are limited data about the impact of gestational age on mental health
outcomes of elective pregnancy termination:
● A two-year prospective study included women with unwanted pregnancies who had a first-trimester abortion
(n = 273), a second-trimester abortion (n = 452), or were denied an abortion because they presented just
beyond the gestational age limit (n = 161) [37]. Drug use (eg, cannabis, cocaine, or prescription drug
misuse) was comparable for the three groups.
● A systematic review identified four studies that compared women who had a later induced abortion (second
trimester or beyond) with women who had other perinatal losses (later miscarriage, stillbirth, or neonatal
death); mental health outcomes for the two groups were comparable [57]. However, the four studies focused
upon women who had induced abortions because of fetal anomalies, and none of the studies controlled for
pre-termination mental health.
History of pregnancy termination — Among women with a history of prior pregnancy termination,
subsequent abortions generally do not appear to be related to postabortion mental disorders. As an example, a
retrospective study examined women in a nationally representative sample who had a history of one induced
abortion (n = 284) or more than one abortion (n = 63) [35]. Analyses that controlled for potential confounders (eg,
history of prior mental disorders or violence experience) found that the rate of mood disorders, anxiety disorders,
and substance use disorders were each comparable in the two groups. Information about the relationship of prior
mental disorders and violence victimization with induced abortion and mental health outcomes is discussed
elsewhere in this topic. (See 'Mental disorders prior to abortion' above and 'Violence victimization' above.)
Pregnancy termination technique — Pregnancies can be terminated using medication or surgery. The
evidence generally suggests that psychiatric sequelae for the two techniques are comparable [20,31,34,59]. As
an example, a randomized trial compared medical termination with surgical termination of pregnancy at less than
14 weeks gestation in 349 women with no preference for termination technique [60]. Anxiety and depression
were each assessed 12 weeks after termination, and the results indicated that emotional responses were
comparable for the two techniques.
Socioeconomic status — The relationship between socioeconomic status and the psychiatric aspects of
pregnancy termination is not clear. Although socioeconomic status is a risk factor for mental health disorders (eg,
depressive disorders, anxiety disorders, and eating disorders) following live births [11], there is little information
about income and occupation and how they affect psychological responses to pregnancy termination. One study
interviewed women one week prior to a first-trimester induced abortion (n = 444), and found that negative
emotional reactions were comparable among different socioeconomic groups [61]. Another study found that
having an abortion for financial reasons was correlated to negative psychological responses after the procedure,
but this study did not compare women of differing socioeconomic status [50]
Adolescence — Adolescents generally do not appear to be at risk for psychiatric problems following induced
abortion [62]. The emotional state of adolescents before their abortions, and the degree to which they feel
pressured to have abortions (by their partners rather than parents), may predict subsequent negative feelings
after pregnancy termination.
A prospective two-year follow-up study of adolescents who sought pregnancy tests found that among the teens
who terminated their pregnancies (n = 141), carried their pregnancy to term (n = 93), or had a negative test (n =
100) [63]:
● Levels of anxiety and other adverse psychological sequelae were lower in adolescents who had an abortion
than the two control groups; among teens who chose to terminate their pregnancy, 95 percent reported no
symptoms of psychological disturbance
● Graduation from or continuation of high school was greater in adolescents who had an abortion, compared
with teens who delivered or had negative tests (90 versus 69 and 79 percent)
● The rate of subsequent pregnancy was lowest in the abortion group, followed by the childbearing and
negative test groups (37 and 47 and 58 percent)
Another study compared emotional responses of adolescents aged 14 to 17 years (n = 23) with adolescents and
young adults aged 18 to 21 years (n = 40) four weeks following pregnancy termination, and found that
depression, regret, doubt, and anger were comparable for the two groups [64].
Multifetal pregnancy reduction — Women with a multiple gestation may choose to terminate one or more of
the fetuses to avoid complications of high-order multiple gestation. The psychological outcomes of this procedure
are discussed separately. (See "Multifetal pregnancy reduction and selective termination", section on
'Psychological outcome'.)
COUNSELING — Counseling before pregnancy termination includes education about the nature and purpose of
the procedure, alternatives, and possible complications and ascertains that the patient is making the decision
voluntarily. It also provides emotional support and helps identify those who require additional emotional support.
Few patients are likely to fall into this latter category. Several approaches to counseling and resources for
clinicians are available [65,66].
Some states in the United States have legal requirements regarding giving patients information about potential
adverse emotional consequences of abortion. Clinicians should consult with their professional organization and
local government authority about these requirements.
Identifying women at risk of adverse outcomes — Women planning pregnancy termination should receive
counseling, and those at risk for mental health issues should be identified. As noted above, risk factors for
postabortion emotional distress or mental health disorders include (see 'Factors that may increase risk of
postabortion psychiatric problems' above):
● Mental disorders prior to abortion

● Lack of social support
● Relationship violence
● Negative attitude toward pregnancy termination in general
● Small family size or no children
Numerous validated inventories are available to help assess depression and anxiety pre- and postabortion,
including the following self report instruments that are in the public domain:
● Patient Health Questionnaire – Nine-Item (PHQ-9) (table 1) – The PHQ-9 screens for depression. The two-
item Patient Health Questionnaire (PHQ-2) (form 1) can also be used; this instrument consists of the first
two items from the PHQ-9. The PHQ-2 is briefer and somewhat less accurate than the PHQ-9. (See
"Screening for depression in adults", section on 'Screening instruments'.)
● Generalized Anxiety Disorder – Seven-Item (GAD-7) (table 2) – The GAD-7 screens for anxiety symptoms
(eg, excessive fears and worrying).
For patients who express clinically significant distress, mental health referrals should be made; additional
referrals to further in-clinic counseling, community support organizations, or abortion talk lines may also be
helpful. In the rare circumstance in which a woman might be at risk of self-harm or suicide, she should be
referred to a mental health clinician or hospital emergency department, depending upon the level of acuity.
Counseling before pregnancy termination
Source of counseling — Some women who consider pregnancy termination present directly to abortion
clinics, while others seek the advice of their primary care clinician, gynecologist, midwife, or other clinicians, and
are then referred to an abortion provider or clinic.
Referring clinician — Clinicians who refer patients for induced abortion can play an important role in
counseling patients [18]. Awareness of potential psychiatric outcomes and modifying factors is helpful in
counseling patients. For referring clinicians, a key goal is to identify patients with preexisting mental illness, a
lack of social support, or intimate partner issues (violence or coercion) and help the patient to access appropriate
services.
Referring clinicians should be able to provide contact information for abortion providers (as well as adoption
agencies) and have a general knowledge of different options for pregnancy termination. A referral list based
upon personal knowledge of colleagues and previous experiences of patients is helpful to patients and preferable
to advising a patient to check a printed or online directory.
Clinicians should be aware that it may be difficult for patients to bring up the subject of pregnancy termination
and should approach patients in a manner that puts them at ease and avoids a perception of stigma. Poor
support from the woman’s gynecologist or primary care provider may be associated with emotional distress in
women undergoing abortion.
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Clinicians may have differing personal views of abortion. However, codes of medical ethics require clinicians to
provide impartial information and referrals to patients. Regarding pregnancy termination, the American College of
Obstetricians and Gynecologists advises, “All health care providers must provide accurate and unbiased
information so that patients can make informed decisions” [67].
Clinician performing the termination — Pregnancy termination may be provided in a clinic, hospital, or
clinician’s office. In any of these settings, counseling should be provided before and after the termination, with
the following goals:
● Assist decision-making regarding termination. Although few women who request termination would also
consider carrying a pregnancy to term, counselors should ensure that this alternative is considered either
through parenting or placing for adoption. The risks of abortion versus delivery must be included in the
information to those who require this additional counseling.
● Inform patients about the procedure, including the different types of abortion that are available and details of
the procedure (including risk of complications and post-termination health risks), and follow-up care. Written
information is useful for the patient to review later and share with partners. (See "Overview of pregnancy
termination", section on 'Complications'.)
● Provide emotional support and help the patient identify sources of social support.
● Identify patients with psychiatric symptoms or disorders who require additional psychiatric evaluation or
care; abortion providers should have a list of resources for referrals as needed.
● Provide information about post-termination contraception to avoid a subsequent unplanned pregnancy. (See
"Postpartum contraception: Initiation and methods".)
● Review payment options. Financial aspects of abortion contribute to emotional distress.
Decision-making — It is important for clinicians to acknowledge the individual situation of the patient and
offer support in decision-making if needed. Many private and public family planning and abortion services offer
decision-making counseling and employ staff specifically trained to help women with this process. Several
studies have found that the process of decision-making is a key factor in postabortion reactions [68-70].
Unintended pregnancies are not necessarily unwanted, but financial problems, age and maturity, and lack of a
supportive partner or parents may contribute to the decision to terminate. For women who feel compelled by their
circumstances to have an abortion, reactions may range from welcoming the opportunity to end the pregnancy
safely to feelings of profound ambivalence and disapproval. Ambivalence and disapproval are particularly
common among women who have an anti-abortion perspective or believe that abortion is akin to murder.
Clinicians can help identify the key issues and considerations to facilitate a decision that will mitigate negative
psychological responses in the future. For women who are ambivalent about abortion, feelings of sadness and
grieving are appropriate responses, and women can benefit from the opportunity to express all of their feelings
about the pregnancy and potential parenthood [68]. Women with a great degree of emotional conflict may benefit
from referral to a psychotherapist.
Women should ideally make the decision of carrying a pregnancy to term or terminating it without coercion and
with the support of their partners, families, and health care providers. Counselors should ask women considering
pregnancy termination whether they feel pressured into making a particular choice, and should provide unbiased
counseling to help a woman arrive at her own decision. For adolescent patients, particular attention should be
paid to possible pressure to terminate or continue the pregnancy by her partner or parents.
Control of decision-making may be an aspect of intimate partner violence. Several studies suggest that women
who experience relationship violence are more likely to have repeat terminations [53,71,72]. This may be due to
partners not allowing the use of contraception. Screening for intimate partner violence should be provided for all
women who present with clinical symptoms or signs listed in the table (table 3), as well as women who present
for an initial visit to primary care clinicians or obstetrician-gynecologists. Screening and management of intimate
partner violence is discussed separately. (See "Intimate partner violence: Diagnosis and screening" and "Intimate
partner violence: Intervention and patient management".)
Emotional support — Studies suggest that counseling support before and after the abortion can have a
positive effect on mental state and perception of the pregnancy termination experience [65].
Clinicians can discuss concerns, feelings, and attitudes that women have about pregnancy termination, and
other issues such as relationship health, which may impact a woman’s emotional response. The discussion may
also identify sources of emotional support beyond the clinician, such as family, friends, support groups, and
therapy. In addition, postabortion support talk lines can provide ongoing emotional support subsequent to an
abortion, particularly benefiting women who experience distress that does not manifest while in the clinic [73].
The clinician can help the woman to identify potential coping mechanisms, especially for women who are
experiencing or anticipating emotional distress. A study of women seeking an abortion (n >5000) found that prior
to the procedure, most women anticipated positive emotions following pregnancy termination [74]. However,
women who anticipated poor coping included adolescents, women with a history of depression, women who
were ambivalent or felt pushed into terminating the pregnancy, women who had spiritual concerns about
abortion, and women terminating pregnancies with fetal anomalies. In an observational study of women who
underwent surgical abortion (n = 114), changes from preoperative anxiety were assessed postoperatively; the
decreases were greater in women who were accompanied in the postoperative recovery room by a support
person, compared with women who were not accompanied [75].
Counseling after pregnancy termination — Although not often routinely performed, counseling after
pregnancy termination presents another opportunity to identify women at risk for significant emotional distress.
Assessment for current symptoms or a prior history of mental health disorders are key components of this
evaluation.
Clinicians should acknowledge feelings of sadness and grief that are expressed; based upon our clinical
experience, discussing these feelings helps women cope following pregnancy termination. Women who need
further postpregnancy termination emotional support should be referred to therapists or organizations that offer
support services, as women rarely return to the abortion provider for postabortion support.
SUMMARY
● Most studies suggest that induced abortion is not associated with an increased risk of mental disorders.
Among women with unwanted pregnancies who either terminate a pregnancy or give birth, the rate of
mental illness is comparable. Postabortion mental illness is most consistently associated with pre-abortion
mental illness. (See 'Evidence regarding potential outcomes' above.)
● Mental health prior to pregnancy termination is the most important risk factor for psychiatric symptoms or
diagnoses after induced abortion. Other factors that appear to modify the degree of emotional distress that
occurs in response to pregnancy termination include social support, violence victimization, attitude toward
pregnancy termination, current family size, and need to terminate for fetal anomaly or health. (See 'Potential
modifying factors' above.)
● Counseling before pregnancy termination facilitates making an informed decision, provides emotional
support, helps to identify women who require additional psychiatric care, and can reduce the likelihood of
negative emotional experiences after an abortion. (See 'Counseling' above.)
● Clinicians referring patients for induced abortions can play an important role in counseling women regarding
pregnancy termination. Awareness of the psychiatric aspects is helpful in counseling patients and identifying
those who may require psychiatric care. (See 'Referring clinician' above.)
● Self-report questionnaires are available to help assess depression (table 1) and anxiety (table 2) pre- and
postabortion. For patients who express clinically significant distress, mental health referrals should be made.
(See 'Identifying women at risk of adverse outcomes' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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Topic 14193 Version 10.0
GRAPHICS
PHQ-9 depression questionnaire
Name: Date:
Over the last two weeks, how often have you been bothered by Not at Several More Nearly
any of the following problems? all days than every
half the day
days
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
Trouble falling or staying asleep, or sleeping too much 0 1 2 3
Feeling tired or having little energy 0 1 2 3
Poor appetite or overeating 0 1 2 3
Feeling bad about yourself, or that you are a failure, or that you 0 1 2 3
have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or 0 1 2 3

watching television
Moving or speaking so slowly that other people could have noticed? 0 1 2 3

Or the opposite, being so fidgety or restless that you have been
moving around a lot more than usual.
Thoughts that you would be better off dead, or of hurting yourself 0 1 2 3

in some way
Total ___ = ___ + ___ + ___ + ___
PHQ-9 score ≥10: Likely major depression
Depression score ranges:
5 to 9: mild
10 to 14: moderate
15 to 19: moderately severe
≥20: severe
If you checked off any problems, how difficult have these Not Somewhat Very Extremely
problems made it for you to do your work, take care of things difficult difficult difficult difficult
at home, or get along with other people? at all ___ ___ ___
___
PHQ: Patient Health Questionnaire.
Developed by Drs. Robert L Spitzer, Janet BW Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer,
Inc. No permission required to reproduce, translate, display or distribute.
Graphic 59307 Version 7.0
Short Patient Health Questionnaire (PHQ-2)
Reference:
1. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item
depression screener. Med Care 2003; 41:1284.
PHQ-2 reproduced with the permission of Pfizer Inc.
GAD-7 anxiety scale
More than
Several Nearly
Not at all half the
days every day
days
Over the last two weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious, or on edge 0 1 2 3
2. Not being able to stop or control 0 1 2 3

worrying
3. Worrying too much about different things 0 1 2 3
4. Trouble relaxing 0 1 2 3
5. Being so restless that it is hard to sit still 0 1 2 3
6. Becoming easily annoyed or irritable 0 1 2 3
7. Feeling afraid as if something awful 0 1 2 3

might happen
Total score* ¶ _____ = Add Columns _____ + _____ + _____
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things
at home, or get along with other people?
Circle one Not difficult at Somewhat Very difficult Extremely

all difficult difficult
* Score: 5 to 9 = mild anxiety; 10 to 14 = moderate anxiety; 15 to 21 = severe anxiety.

¶ This is a form that can be printed out and filled out by hand rather than a calculator that can be filled in online.
Adapted and reproduced with permission from: Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing
generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166:1092. Copyright © 2006 American Medical Association.
All rights reserved.
Patients who should be asked about domestic violence
Female trauma victims
Female emergency room patients
Women with chronic abdominal pain
Women with chronic headaches
Pregnant women, especially with injuries
Women with sexually transmitted diseases
Elders with evidence of neglect
Elders with injuries
Contributor Disclosures
Uta Landy, PhD Nothing to disclose Philip D Darney, MD, MSc Grant/Research/Clinical Trial Support: Meds
360 [Intrauterine contraception (LNg IUD)]; Bayer [Intrauterine contraception (LNg IUD)]. Consultant/Advisory
Boards: Merck [Implant contraception (Etonogestrel implant)]. Jody Steinauer, MD, MAS Nothing to
disclose Jonathan M Silver, MD Nothing to disclose Sandy J Falk, MD, FACOG Nothing to disclose David
Solomon, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
Conflict of interest policy

Psychiatric Aspects of Pregnancy Termination

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Psychiatric aspects of pregnancy termination

Authors: Uta Landy, PhD, Philip D Darney, MD, MSc

● Mental disorders prior to abortion

Factors that may increase risk of postabortion psychiatric problems

Factors that do not appear to be related to postabortion mental health

● Mental disorders prior to abortion

Counseling before pregnancy termination

● Review payment options. Financial aspects of abortion contribute to emotional distress.

negative emotional experiences after an abortion. (See 'Counseling' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 14193 Version 10.0

PHQ-9 depression questionnaire

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

Trouble falling or staying asleep, or sleeping too much 0 1 2 3

Feeling tired or having little energy 0 1 2 3

Poor appetite or overeating 0 1 2 3

Trouble concentrating on things, such as reading the newspaper or 0 1 2 3

Moving or speaking so slowly that other people could have noticed? 0 1 2 3

Thoughts that you would be better off dead, or of hurting yourself 0 1 2 3

Total ___ = ___ + ___ + ___ + ___

PHQ-9 score ≥10: Likely major depression

Depression score ranges:

15 to 19: moderately severe

PHQ: Patient Health Questionnaire.

Graphic 59307 Version 7.0

Short Patient Health Questionnaire (PHQ-2)

Graphic 89663 Version 1.0

GAD-7 anxiety scale

1. Feeling nervous, anxious, or on edge 0 1 2 3

2. Not being able to stop or control 0 1 2 3

3. Worrying too much about different things 0 1 2 3

5. Being so restless that it is hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful 0 1 2 3

Total score* ¶ _____ = Add Columns _____ + _____ + _____

Circle one Not difficult at Somewhat Very difficult Extremely

* Score: 5 to 9 = mild anxiety; 10 to 14 = moderate anxiety; 15 to 21 = severe anxiety.

Graphic 77755 Version 20.0

Patients who should be asked about domestic violence

Female trauma victims

Female emergency room patients

Women with chronic abdominal pain

Women with chronic headaches

Pregnant women, especially with injuries

Women with sexually transmitted diseases

Elders with evidence of neglect

Elders with injuries

Graphic 53373 Version 2.0

Conflict of interest policy

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Total _ = _ + _ + _ + ___

Total score* ¶ ___ = Add Columns _ + _ + ___