1. Women’s Mental Health after Abortion Prepared for MWIA 2013 August 1, 2013 Presented to GYN-OB, August 3, 2013

2. Dr. Martha Shuping, M.D. martha.shuping@gmail.com Psychiatrist

3. Disclosures As an undergraduate student, I worked as a volunteer abortion counselor at a clinic that helped women to obtain abortions. I have done volunteer work for both pro- choice and pro-life NGO’s. There are no financial conflicts regarding this presentation.

4. Researchers on both sides agree: Researchers on both sides of the abortion issue agree that there are specific subgroups of women who are at increased risk for mental health problems after abortion.

5. APA 2008 Report Identified at least 17 risk factors, indicating subgroups of women at increased risk for problems after abortion, due to pre-existing characteristics of the women or their social situation.

6. Two Case Reports: Melody & Donna Today’s presentation will focus on two case reports of women who experienced mental health problems after abortion and examine relevant risk factors pertaining to these cases.

7. Case Report: Melody Married, mother of two children. Financially secure; able to stay home with children. No prior psychiatric history. Pregnant for third time. Pregnancy was wanted and meaningful to her. Husband said to terminate—he did not have the energy for one more child.

8. Case Report: Melody Minister of their church said Melody should honor husband’s wishes. Melody terminated the pregnancy. But she believed she had committed the unforgiveable sin. She felt unable to pray, which has always been important to her. She was unable to function in her roles as mother, homemaker, and wife.

9. Case Report: Melody Major Depressive Episode. Suicidal. Hospitalized and given antidepressant medication. Helped by “peer counselor” to resolve problems she experienced regarding conflict with her personal and religious beliefs. Episode resolved.

10. Case Report: Donna 17 years old. Engaged to be married. Fiancee away due to job training. Pregnant & happy about pregnancy. Pregnancy was wanted and meaningful to her. Concealed the pregnancy from mother.

11. Case Report: Donna Mother: Discovered the pregnancy. Said: “You can’t live at home and have the baby.” Wanted to keep the pregnancy a secret due to mother’s shame; did not want others to find out about the pregnancy. Wanted Donna to have an abortion. Made appointment at the abortion clinic.

12. Case Report: Donna Donna: senior in high school with no job and no money. had religious beliefs against abortion. expressed commitment to the pregnancy. sought help from pro-life pregnancy resource center to live away from mother’s home, but housing could not be found in time.

13. Case Report: Donna Mother took Donna to clinic. Donna intended to refuse the abortion. Donna told the doctor and the nurse: “I do not consent to this abortion; I want my baby.” Donna was sedated and restrained and the pregnancy was terminated without her consent. This was a second trimester abortion.

14. Case Report: Donna Forced abortion took place in the mistaken belief that because Donna was not of legal age, she did not have the right to make her own choice. But, in the U.S., in all 50 states, it is illegal to force anyone to have an abortion against their wishes, even young women in their teens.

15. Case Report: Donna For 12 years after the abortion, Donna experienced panic attacks associated with: Tachycardia Chest pain Nausea Vomiting Diarrhea Feelings of panic

16. Case Report: Donna The panic episodes were very disruptive to her life and frequently: prevented her from working. prevented her from keeping appointments for social activities. caused her to go to the hospital Emergency Dept. many times because she thought she may be having heart attack.

17. Case Report: Donna Depressive symptoms included: Depressed & irritable mood. Frequent crying spells. Lack of interest & lack of enjoyment. Excessive guilt. Concentration problems. Low energy.

18. Donna’s PTSD symptoms Feeling alienated from others (e.g., detachment or estrangement). -She married her fiancee but the marriage ended in divorce. -She had problems bonding with her children, with father given custody of children. -She was estranged from her mother for 12 years.

19. Donna’s PTSD symptoms Intense distress after exposure to traumatic reminders. - When she saw television advertisements in which pro-choice views were expressed, she became very distressed and had crying spells. She said, “It wasn’t a choice for me.”

20. Donna’s PTSD symptoms Avoidance of Trauma-related external reminders: - She avoided driving on the street where the abortion clinic was located, and would go out of her way to avoid driving past the clinic.

21. Donna’s PTSD symptoms Persistent negative trauma-related emotions (e.g., fear, anger, guilt, shame). Markedly diminished interest in (pretraumatic) significant activities. Irritable Behavior Concentration problems

22. Donna: Resolution Treated with sertraline (antidepressant medication) with only partial benefit. Invested much time and energy in useless cardiac evaluations because panic symptoms caused her think she was having cardiac problems. Attended a faith-based abortion recovery weekend with resolution of symptoms afterward.

23. Donna: Resolution Started course of study at technical college and trained for career she now enjoys. After one year moved out of area but was doing well at last contact.

24. 1999

25. A Clinician’s Guide to Medical & Surgical Abortion This is a textbook to teach medical doctors how to perform abortions. It is written by abortion providers for abortion providers. This book lists 13 risk factors for mental health problems after abortion, identifying subgroups of women who are at increased risk for problems after abortion.

26. A Clinician’s Guide, Chapter 3 Baker A, Beresford T, Halvorson-Boyd G, Garrity JM. Chapter 3, Informed consent, counseling, and patient preparation. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, and Stubblefield PG, eds. A Clinician’s Guide to Medical and Surgical Abortion. Philadelphia, PA: Churchill Livingston; 1999:28-29.

27. 2009

28. Management of unintended and abnormal pregnancy: Comprehensive Abortion Care Maureen Paul, E. Steve Lichtenberg, Lynn Borgatta, David A. Grimes, Phillip G. Stubblefield, Mitchell D. Creinin This textbook now lists 18 risk factors for mental health problems after abortion. Note: on the cover of this book is the logo of the National Abortion Federation

29. Baker A, Beresford T. Chapter 5, Informed consent, patient education and counseling. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, Creinin MD, eds. Management of Unintended and Abnormal Pregnancy. Chichester, UK: Wiley-Blackwell. 2009:51.

30. APA Report, 2008 American Psychological Association Task Force on Mental Health and Abortion. Report of the Task Force on Mental Health and Abortion. Washington, DC. American Psychological Association; 2008. www.apa/org/pi/wpo/mental-health- abortion-report.pdf

31. APA Report, 2008 Identified at least 17 risk factors, indicating subgroups of women at increased risk for problems after abortion, due to pre-existing characteristics of the women or their social situation.

32. Risk Factors that apply to Donna and/or Melody We will now review the particular risk factors from these two textbooks and other sources that specifically apply to Donna and/or Melody.

33. Researchers from Both Sides Agree: Women who are committed to the pregnancy or who prefer to carry the child to term are at risk for mental health problems after abortion. Clinician’s Guide (1999). Comprehensive Abortion Care (2009). At least 7 studies to date. APA 2008 report.

34. Clinician’s Guide, 1999 “Commitment to the pregnancy” is listed as a risk factor for problems after abortion.”

35. Comprehensive Abortion Care, 2009 “Commitment and attachment to the pregnancy” is listed as a risk factor for negative emotional reactions after abortion.

36. Researchers from Both Sides Agree: Women who are coerced or pressured are at increased risk for mental health problems after abortion. Clinician’s Guide & Comprehensive Abortion Care At least 13 studies to date APA 2008 Report Council on Scientific Affairs of the AMA

37. 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).

38. Researchers on Both Sides Agree: Lack of emotional / social support and receiving criticism from significant people in their lives is a risk factor for mental health problems after abortion. Clinician’s Guide (1999) Comprehensive Abortion Care (2009) APA 2008 Report At least 20 studies to date

39. Researchers on Both Sides Agree: Advanced stage of pregnancy (late term abortion, after first trimester) is a risk factor for negative emotional sequelae” after abortion. Comprehensive Abortion Care (2009) APA 2008 Report

40. Researchers on Both Sides Agree: Perceived need for secrecy is a risk factor for mental health problems after abortion. Comprehensive Abortion Care (2009) APA 2008 Report

41. Researchers on Both Sides Agree: Adolescence is a risk factor for increased mental health problems after abortion. APA 2008 Report Planned Parenthood 1993 Fact Sheet Multiple studies indicating adolescence as a risk factor, some including young adults or “young women.”

42. Recap of APA 2008, Risk Factors that apply to Donna and Melody 1.Terminating a pregnancy that is wanted or meaningful. 2.Feelings of commitment to the pregnancy 3.Perceived pressure from others to terminate a pregnancy.

43. APA 2008, Risk Factors Applying to Donna 4. Lack of perceived social support from others 5. Perceived need for secrecy 6. Feelings of commitment to the pregnancy 7. Late term (other than 1 st trimester) abortion 8. Being an adolescent (not an adult)

44. Religious Beliefs as Risk Factor Having strong religious convictions against abortion, or believing that one is acting against one’s own values, is a risk factor. Planned Parenthood 1993 Fact Sheet At least 10 studies to date.

45. Pre-abortion screening & counseling Comprehensive Abortion Care (2009) has an example of a “needs assessment” form that asks many questions that are based on some of the known risk factors we have discussed, and other risk factors identified in the above sources. (Time does not permit discussion of all risk factors today).

46. Pre-abortion screening & counseling If Melody or Donna had completed this form at the clinic prior to their abortions, they would have answered questions about: Their beliefs about abortion and their religious beliefs Who is pressuring them Do they want the baby instead of abortion

47. Discussion of these risk factors with Donna (and possibly with her mother) and with Melody (and possibly with her husband) could have led to more accurate consideration of the applicable specific risks applicable to their situation, and may have led to a different decision for these women.

48. Prenatal Bonding Comprehensive Abortion Care (2009) stated that the commitment to the pregnancy and attachment to the pregnancy were risk factors. This refers to prenatal bonding that many women experience.

49. Prenatal Bonding Australian researchers Allanson & Astbury (1996) revealed that a significant number of women attending an abortion clinic reported having fantasies about the child and engaging in attachment behaviors. 40% talked to their fetus 30% rubbed their stomach

50. Prenatal Bonding Published studies for more than 60 years have consistently concluded that attachment or bonding between mother and child begins during pregnancy, not at birth. Several authors have demonstrated that the the degree of bonding that is established during pregnancy is predictive of the degree of emotional distress and trauma symptoms that are experienced after the abortion. “

51. Qualitative Study: Women’s Views at Menopause Long term follow-up of emotional experiences after termination of pregnancy: women’s views at menopause, by Kathryn Dykes, et al. Journal of Reproductive and Infant Psychology 2010, 1–20, iFirst Article ISSN 0264-6838 print/ISSN 1469-672X online © 2010 Society for Reproductive and Infant Psychology DOI: 10.1080/02646838.2010.513046 http://www.informaworld.com

52. Women’s Views at Menopause, Looking Back at Past Abortion All women reported that they continued to think about the child they had aborted many years previously, expressing long lasting attachment to the child lost to abortion: Examples: Jenny said, “I’ve always thought of him … wondering how old he’d be, I do wonder about that child.” Elaine also thought about the baby and remembered the expected due date each year, thinking of what age the child would be. Tina also reported “wondering what it would have been like now, how old would it have been.”

53. Women’s Views at Menopause, Looking Back at Past Abortions Women in Dykes’ study (women at age of menopause) had abortions in a culture where abortion has been legal and widely accepted since 1967. But attachment to the fetus still persisted decades later. This study is too small to be generalizable, but the women’s statements are examples of what Comprehensive Abortion Care says can occur and is consistent with other research.

54. United Nations: Beijing Platform for Action The United Nations document, The Beijing Platform for Action, was adopted by international consensus. This document mandates that all women must be fully informed of their reproductive options, including potential side-effects. (It does not mandate that abortion be provided, only that when reproductive health care is provided, side effects must be disclosed.) The document also mandates that, if abortions are performed, women have immediate access to post-abortion counseling.

55. Informed Consent When informing a patient about the risks of abortion and possible side effects that she may experience, it would seem important to discuss all risk factors that may apply to that patient. Considering the data on risk factors, which are well established, it appears appropriate to consider the woman’s specific risks and discuss them openly and fully.

56. Attachment to the pregnancy may be a particularly important risk factor This may be a “common denominator” for women in these risk groups: Women who are committed to the pregnancy. Women for whom the pregnancy is wanted and meaningful. Women who were coerced or pressured. Women having later abortions (and thus longer time period in which attachment may occur.

57. In conclusion: As a practical matter, the needs assessment questionnaire published in Comprehensive Abortion Care (2009), or similar questionnaire can be used to identify subgroups of women in well established risk groups who may benefit from discussion of risks during pre- abortion counseling.

58. In conclusion: I am not recommending abortion, but from the published information available from abortion providers and the sources we have discussed, it can be concluded that screening for risk factors is appropriate and may in some cases prevent harmful effects of abortion by preventing the abortion; women and their families may prefer not to choose abortion if they discover they are in a risk group that is especially vulnerable to negative reactions to abortion.

59. In conclusion: More research needed to elucidate the role of prenatal attachment in development of negative effects in subgroups of women.