Posttraumatic Stress Among Women After Induced Abortion
Posttraumatic Stress Among Women After Induced Abortion
The major finding of the present study was that only a small fraction of women who have an induced abortion developed PTSD or PTSS. In addition, the majority of women who in fact developed PTSD or PTSS within a six- month period of the induced abortion did so because of trauma experiences unrelated to the induced abortion.
The lifetime prevalence of PTSD was 7.2% at the baseline assessment, which is somewhat lower than the 10.4% reported from the United States by Kessler and co-workers. The result, however, is in accordance with the earlier reported population figure of 7.4% in Swedish women, indicating that women who request induced abortion do not suffer different rates of PTSD to the general population. There were two major reasons why lifetime prevalence of PTSD decreased over time, the most obvious reason was that a greater proportion of women with lifetime PTSD at baseline dropped out from the study. It should also be noted that lifetime PTSD was assessed by a questionnaire, not a structured psychiatric interview, and women may be inconsistent in their responses over time. The rates of ongoing PTSD at three and six-months after the induced abortion were 2.0% and 1.9%, respectively. This is in the lower end of what has been reported after childbirth, where PTSD prevalence rates of 1.3–6.9% have been found. Although the rates reported in this study could be underestimated, still only a minority of those who reported a traumatic experience did so in relation to the abortion. The small number of women who developed PTSD or PTSS were more likely to be younger, less well educated, have high levels of anxiety and depression and in need of more counselling than the comparison group. Only 14 women, among whom 11 developed PTSD or PTSS, had trauma experiences related to the abortion, which suggests that women in general do not develop PTSD or PTSS following abortion.
Of 720 women, 51 developed PTSD or PTSS after the abortion, and they had a higher level of depression and anxiety, and needed counselling more often before the abortion than the comparison group. Ambivalence about the decision, strong maternal feelings, poor social support, moral and religious objections to abortion, coerced abortion, intimate partner violence and young age are all risk factors associated with adverse reactions after abortion. In the present study, we have not explored the underlying causes for the women's decision for the termination of the pregnancy because it was not a study aim. Also, in Sweden it is common practice not to ask women why they desire an induced abortion. However, mixed feelings are common as a natural reaction among women applying for abortion. Feelings of guilt, sadness and regret only occur in a relatively small group of women and these feelings commonly arise in those who are ambivalent about the termination. In addition, a previous study investigated the association of past elective or spontaneous abortions and mental health status during the subsequent pregnancy, suggesting that it is not the procedure of the abortion itself that increases the risk of PTSD but rather the women's appraisal of the abortion.
In a Swedish longitudinal abortion study, 12 of 58 women reported in the four month follow- up that they had been in a crisis post abortion, while at the one-year follow- up, only two women still expressed feelings in relations to the abortion in terms of a crisis. Those in the study who reported only painful feelings at the time of the abortion decreased from 30% to 3% at one-year follow-up, while those who only reported positive feelings increased from 16% to 47%. These results might be interpreted as resilience for self-healing and it is possible that women in the present study who reported mental disturbance may at one-year follow-up be healthier and report less disturbance.
In the present study, one-third of all women met criteria for PTSD or PTSS at least once during the observation period. Irrespective of whether their symptoms developed, recovered or were unchanged, these women displayed distinctly higher rates of anxiety and depressive symptoms than the comparison group did. This finding highlights how important it is that health care providers are responsive to women's needs for support. Finally, all women who have PTSD at the time of the abortion as well as those who develop PTSD following the abortion need support. If these women can be identified in advance at the abortion clinics, they could be offered extra support and counselling before the abortion and this could be followed up by extra visits or telephone support after the abortion.
The main limitations for the interpretation of this study are the high rate of dropouts and their sociodemographic characteristics, which ultimately may suggest that they have an increased susceptibility to develop PTSD. The dropouts were younger than the responders, they had a lower level of education, displayed more anxiety and depression symptoms, were more often using antidepressant treatment, and were to a greater extent tobacco users. As expected, the social gradients of the dropouts are in line with earlier findings. Indeed, the poorer mental health among the dropouts, including a higher baseline prevalence of PTSD, is a likely explanation for their decision not to participate further in the study. As the sociodemographic characteristics of the dropouts all are of importance for PTSD, it thus possible that the rates of PTSD and PTSS after induced abortion may be underestimated in this study. However, the rate of lifetime PTSD (9.4%) among dropouts was not higher than the population figure for American women (10.4%). Importantly, our findings are also in line with a number of studies suggesting that induced abortion is not associated with mental health problems. Although some researchers support the view that induced abortion is associated with an increased risk for mental health problems, the research supporting this view has been criticised for methodological errors, particularly in a recent meta-analysis. Most studies report that women cope well with an induced abortion and that psychological sequelae are rare. In fact, a recent review further establishes that the most consistent predictor for mental disorders after induced abortion is the woman's mental health prior to the abortion.
The study design also had several strengths such as the size of the study population and the multi-centre nationwide design, which allowed us to approach all women who requested an induced abortion at out-patient clinics representative of large and middle-sized cities all across the country. The comparison group of the present study had also undergone induced abortion, which is in contrast with many other studies in the field. Another strength of the study is the use of a standardised and validated instrument for assessment of PTSD which takes the trauma experience as well as the trauma symptoms into account. The latter is important as our study suggested that many trauma experiences after the induced abortion were unrelated to the abortion care per se.
Discussion
The major finding of the present study was that only a small fraction of women who have an induced abortion developed PTSD or PTSS. In addition, the majority of women who in fact developed PTSD or PTSS within a six- month period of the induced abortion did so because of trauma experiences unrelated to the induced abortion.
The lifetime prevalence of PTSD was 7.2% at the baseline assessment, which is somewhat lower than the 10.4% reported from the United States by Kessler and co-workers. The result, however, is in accordance with the earlier reported population figure of 7.4% in Swedish women, indicating that women who request induced abortion do not suffer different rates of PTSD to the general population. There were two major reasons why lifetime prevalence of PTSD decreased over time, the most obvious reason was that a greater proportion of women with lifetime PTSD at baseline dropped out from the study. It should also be noted that lifetime PTSD was assessed by a questionnaire, not a structured psychiatric interview, and women may be inconsistent in their responses over time. The rates of ongoing PTSD at three and six-months after the induced abortion were 2.0% and 1.9%, respectively. This is in the lower end of what has been reported after childbirth, where PTSD prevalence rates of 1.3–6.9% have been found. Although the rates reported in this study could be underestimated, still only a minority of those who reported a traumatic experience did so in relation to the abortion. The small number of women who developed PTSD or PTSS were more likely to be younger, less well educated, have high levels of anxiety and depression and in need of more counselling than the comparison group. Only 14 women, among whom 11 developed PTSD or PTSS, had trauma experiences related to the abortion, which suggests that women in general do not develop PTSD or PTSS following abortion.
Of 720 women, 51 developed PTSD or PTSS after the abortion, and they had a higher level of depression and anxiety, and needed counselling more often before the abortion than the comparison group. Ambivalence about the decision, strong maternal feelings, poor social support, moral and religious objections to abortion, coerced abortion, intimate partner violence and young age are all risk factors associated with adverse reactions after abortion. In the present study, we have not explored the underlying causes for the women's decision for the termination of the pregnancy because it was not a study aim. Also, in Sweden it is common practice not to ask women why they desire an induced abortion. However, mixed feelings are common as a natural reaction among women applying for abortion. Feelings of guilt, sadness and regret only occur in a relatively small group of women and these feelings commonly arise in those who are ambivalent about the termination. In addition, a previous study investigated the association of past elective or spontaneous abortions and mental health status during the subsequent pregnancy, suggesting that it is not the procedure of the abortion itself that increases the risk of PTSD but rather the women's appraisal of the abortion.
In a Swedish longitudinal abortion study, 12 of 58 women reported in the four month follow- up that they had been in a crisis post abortion, while at the one-year follow- up, only two women still expressed feelings in relations to the abortion in terms of a crisis. Those in the study who reported only painful feelings at the time of the abortion decreased from 30% to 3% at one-year follow-up, while those who only reported positive feelings increased from 16% to 47%. These results might be interpreted as resilience for self-healing and it is possible that women in the present study who reported mental disturbance may at one-year follow-up be healthier and report less disturbance.
In the present study, one-third of all women met criteria for PTSD or PTSS at least once during the observation period. Irrespective of whether their symptoms developed, recovered or were unchanged, these women displayed distinctly higher rates of anxiety and depressive symptoms than the comparison group did. This finding highlights how important it is that health care providers are responsive to women's needs for support. Finally, all women who have PTSD at the time of the abortion as well as those who develop PTSD following the abortion need support. If these women can be identified in advance at the abortion clinics, they could be offered extra support and counselling before the abortion and this could be followed up by extra visits or telephone support after the abortion.
The main limitations for the interpretation of this study are the high rate of dropouts and their sociodemographic characteristics, which ultimately may suggest that they have an increased susceptibility to develop PTSD. The dropouts were younger than the responders, they had a lower level of education, displayed more anxiety and depression symptoms, were more often using antidepressant treatment, and were to a greater extent tobacco users. As expected, the social gradients of the dropouts are in line with earlier findings. Indeed, the poorer mental health among the dropouts, including a higher baseline prevalence of PTSD, is a likely explanation for their decision not to participate further in the study. As the sociodemographic characteristics of the dropouts all are of importance for PTSD, it thus possible that the rates of PTSD and PTSS after induced abortion may be underestimated in this study. However, the rate of lifetime PTSD (9.4%) among dropouts was not higher than the population figure for American women (10.4%). Importantly, our findings are also in line with a number of studies suggesting that induced abortion is not associated with mental health problems. Although some researchers support the view that induced abortion is associated with an increased risk for mental health problems, the research supporting this view has been criticised for methodological errors, particularly in a recent meta-analysis. Most studies report that women cope well with an induced abortion and that psychological sequelae are rare. In fact, a recent review further establishes that the most consistent predictor for mental disorders after induced abortion is the woman's mental health prior to the abortion.
The study design also had several strengths such as the size of the study population and the multi-centre nationwide design, which allowed us to approach all women who requested an induced abortion at out-patient clinics representative of large and middle-sized cities all across the country. The comparison group of the present study had also undergone induced abortion, which is in contrast with many other studies in the field. Another strength of the study is the use of a standardised and validated instrument for assessment of PTSD which takes the trauma experience as well as the trauma symptoms into account. The latter is important as our study suggested that many trauma experiences after the induced abortion were unrelated to the abortion care per se.
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