O&G Magazine

ABORTION
Vol. 20 No 2 | Winter 2018
FEATURE
Psychological effects of abortion
Dr Brett Daniels

BSc, PhD, MBBS, FRANZCOG

This article is 3 years old and may no longer reflect current clinical practice.

A few years ago, I started offering abortion in my obstetric and gynaecology practice. As the
service gradually became more well-known, I met women in many different circumstances. I
have found my perceptions regarding abortion have changed, as these women have told me of
their experiences. Perhaps the most salient insight is that there is no single psychological
response to abortion. It is not only that an unwanted pregnancy is an emotionally charged
situation. As doctors, we are educated on how to communicate with people in difficult
circumstances. Concepts such as ‘breaking bad news’ and the five stages of grief are part of our
training and serve us well. In obstetrics and gynaecology, we understand that miscarriage or
stillbirth is, for most women, an unalloyed sadness, and this guides us in how to respond.
Unplanned pregnancy and the decision to terminate is complex. Doubt, guilt, grief and regret can
be tempered by relief, empowerment and determination.

Research on psychological effects

Inherent difficulties with researching the psychological effects of abortion include defining
appropriate comparison groups and the extremely emotive nature of the research topic. A meta-
analysis of 22 studies with more than 800,000 participants concluded that there was an 80 per
cent increased risk in mental health problems, with 10 per cent of this risk attributable to the
termination.1 The strongest psychological effects were observed when women who had an
abortion were compared with women who had carried a pregnancy (not necessarily unwanted) to
term, and when the outcomes measured related to substance use and suicidal behaviour. The
effects were reported lower in comparison groups who had wanted, but not received an abortion,
and in women who had not been pregnant at all. At the time of publication, there was
considerable debate regarding the nature of this meta-analysis, study selection and choice of
comparison groups, reflecting the controversial nature of this research.

Conversely, it has been suggested that abortion may have some mental health benefits compared
to continuing with an unwanted pregnancy. A 2013 meta-analysis of eight studies found there
was no evidence that abortion reduced the risk of mental health disorders, but was associated
with small to moderate increases in anxiety, substance abuse and suicide.2

Once women realise they are unexpectedly pregnant, appropriate comparison groups for studies
of abortion may be women who choose to continue with unplanned pregnancy, or women who
are unable to access abortion. The Turnaway Study reported on 956 women approaching clinics
in the US for an elective first-trimester abortion, with no known fetal anomalies or fatal demise,
and no maternal health indications for termination.3 Women were split into three groups: women
up to two weeks before the gestational limit who had an abortion (near limit group); those up to
three weeks beyond the gestational limit who did not have an abortion (Turnaway group); and
those who received an abortion in the first trimester. Two-thirds of women in the Turnaway
group eventually had a live birth, while one-third either miscarried or terminated the pregnancy
elsewhere. The study was conducted across 31 clinics with gestational limits from 10 weeks until
the end of the second trimester. There was, therefore, some overlap of gestation across the three
groups.

Women enrolled in the Turnaway Study were initially interviewed eight days after receiving or
being denied an abortion and then every six months for five years. Study outcomes included six
measures of mental health and well-being: two measures of depression, two measures of anxiety,
as well as self-esteem, and life satisfaction. The results showed that women who were unable to
have an abortion, in particular, those who later miscarried or had an abortion elsewhere, had the
most elevated levels of anxiety, and lowest self-esteem and life satisfaction one week after being
denied a termination, which quickly improved to levels similar to those in the other groups by 6–
12 months. In general, the authors concluded that, while there were some negative psychological
consequences of being unable to access an abortion, these differences converged after 6–12
months and there was no difference after five years. The women who had to proceed with
unplanned pregnancy after initially seeking an abortion did not differ from other groups. There
was no group of women who decided to proceed with an unplanned pregnancy.

A large Danish record linkage study compared risk of psychiatric contact in the nine months
before and after first-time abortion, with the risk before and after a desired first childbirth. Using
data from 84,000 abortions and 280,000 births, they found there was no increase in psychiatric
treatment associated with first-trimester abortion, while there was a significant increase in
treatment associated with birth of a first child.4 The wide range of results highlights the
difficulties in researching the psychological effects of abortion. It seems reasonable to conclude
that there are negative psychological consequences of unplanned pregnancy and abortion, but
that these may subside over time. It does not seem that abortion is psychologically protective, but
childbirth itself is also associated with significant psychological risk for some women. Given that
women terminating a pregnancy may have a wide range of psychological stressors prior to and
after their unplanned pregnancy, it is important that every case be considered individually.