# data[].attributes.body
"After accounting for confounding factors, abortion was not a statistically significant predictor of subsequent anxiety, mood, impulse-control, and eating disorders or suicidal ideation" (Steinberg, McCulloch, Adler).

"before their pregnancy, women who had abortions had significantly more mental health disorders overall, and were significantly more likely to have had an anxiety disorder, mood disorder, substance use disorder, and suicidal ideation, and marginally more likely to have had an impulse-control disorder, than women in the childbirth group" (Steinberg, McCulloch, Adler).

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Abstract

Objective

To examine whether a first abortion increases risk of mental health disorders compared to a first childbirth, with and without considering prepregnancy mental health and adverse exposures, childhood economic status, miscarriage history, age at first abortion or childbirth, and race or ethnicity.

Methods

A cohort study compared rates of mental disorders (anxiety, mood, impulse-control, substance use, eating disorders, and suicidal ideation) among 259 women postabortion and 677 women postchildbirth aged 18 to 42 at the time of interview from The National Comorbidity Survey-Replication

Results

The percentage of women with no, one, two, and three or more mental health disorders before their first abortion was 37.8%, 19.7%, 15.2% and 27.3%, and before their first childbirth was 57.9%, 19.6%, 9.2%, and 13.3% respectively, indicating that women in the abortion group had more prior mental health disorders than women in the childbirth group, p < .001. Although in unadjusted Cox proportional hazard models, abortion compared to childbirth was associated with statistically significant higher hazards of postpregnancy mental health disorders, associations were reduced and became nonstatistically significant for five disorders after adjusting for the aforementioned factors. Hazard ratios (HR) and associated 95% confidence intervals dropped from 1.52 (1.08-2.15) to 1.12 (0.87-1.46) for any anxiety disorder; from 1.56 (1.23-1.98) to 1.18 (0.88-1.56) for mood disorders; from 1.62 (1.02-2.57) to 1.10 (0.75-1.62) for impulse-control disorders; from 2.53 (1.09-5.86) to 1.82 (0.63-5.25) for eating disorders; and from 1.62 (1.09-2.40) to 1.25 (0.88-1.78) for suicidal ideation. Only abortion and substance use disorders remained statistically significant, although the HR dropped from 3.05 (1.94-4.79) to 2.30 (1.35-3.92).

Conclusions

After accounting for confounding factors, abortion was not a statistically significant predictor of subsequent anxiety, mood, impulse-control, and eating disorders or suicidal ideation.

Introduction

Thirty percent of U.S. women will have an abortion by the time they are age 451. Understanding whether such a common procedure causes mental health problems is important for clinical practice and policy. Conflicting findings currently exist in the literature; these reflect limitations of available data and variations in methodological rigor allowing for control over confounding factors. Some of the strongest evidence has come from research linking Danish population registries reporting reproductive events and those reporting inpatient and outpatient psychiatric admissions. While analyses using these registries found higher rates of psychiatric admissions in the 12-months following abortion compared to the 12-months following birth, rates of these disorders were also higher during the 9 months before abortion compared to the 9 months before birth2.

It also addresses shortcomings in existing U.S. studies, including inappropriate comparison groups, inadequate measurement of mental health outcomes, and failure to control for confounding factors3-5. The study reported here tests whether women's risk of having clinical mental health problems, assessed by structured psychiatric interviews, is higher after a first abortion compared with after a first childbirth, contrasting findings with and without adjustment for possible confounding factors. Moreover, the study here also contrasts findings with another study using the same data set that examined the association between lifetime abortion (compared with no abortion) and lifetime mental health outcomes6, which means it did not assess when the mental health outcomes occurred relative to the abortion. The current study extends this research by using a U.S. national sample on which psychiatric disorders meeting DSM-IV criteria were assessed. This provides an evaluation of actual incidence of disorders that is not biased by health care utilization.

Methods

The National Comorbidity Survey-Replication was designed to be representative of English-speaking adults ages 18 or older living in the non-institutionalized civilian household population of the continental U.S.7 It was administered by trained lay interviewers using laptop computer-assisted personal interview (CAPI) methods between February 2001 and April 2003. National Comorbidity Survey-Replication data assess the prevalence of DSM-IV mental health disorders in the U.S. and their correlates7 and is the most recent cohort of the National Comorbidity Surveys. More specific details on study design and measures may be found elsewhere7,8.

The National Comorbidity Survey-Replication interview had two parts. Part 1 assessed presence and past history of mental health disorders and suicidal behaviors. Part 2 assessed potential correlates of these disorders among a sub-sample of Part 1 respondents, consisting of those who screened positive for a mental health disorder in Part 1 supplemented by a probability subsample of other respondents. Since questions pertaining to pregnancy history and adverse exposures were administered in Part 2, the sample consisted of women who were administered both Parts 1 and 2. Of these, only those who were 13 or younger in 1973, when Roe v. Wade 9 legalized having an abortion in the U.S (n = 1633), were included to ensure women's entire reproductive lifespans occurred during the time when abortion was legal. Eighty-nine who reported not having had had sex, 124 missing on pregnancy history information necessary for this study, and 484 who reported having had no children and no abortions were excluded, leaving 936 women aged 18 to 42 for analysis (see Appendix 1, available online at http://links.lww.com/xxx for flow diagram of sample). This research was exempt from the UCSF Committee on Human Research approval because data were de-identified.

Women were asked questions about previous abortions, childbirths, and miscarriages. Women were coded as having had an abortion if they reported having had an abortion, the number they had, and the age at their first abortion. Of the 986 women, 259 reported having had an abortion (191 only one and 68 more than one abortion). Women reporting an abortion were asked their age at first abortion, which was used to code when mental health problems occurred relative to a woman's first abortion.

Women reported the total number of children to which they ever gave birth and the current age of their biological children in three ranges up to 17 years old. Because no ranges went beyond 17 years old, we did not have age ranges for 110 women who had childbirths and no abortions and whose oldest child was 18 or older. Women were coded as having had a delivery if they reported having had no abortions and had all children aged 17 or younger. Women's exact age at first childbirth was not elicited. For those whose children were all aged 17 or younger, age at first birth can be bracketed to within a range based on the age of the respondent at the time of the interview and the age range (0-4 years, 5-12 years, or 13-17 years) within which the oldest biological child falls. This allowed us to compute a possible range for a woman's age at first childbirth to determine when mental health problems occurred relative to her first childbirth. Those who had children 18 or older (n = 110) were exclude from analyses. The analyses presented below used the youngest possible age within the range because this attributes the maximum number of mental health disorders to be in the postpregnancy period and the mean age at first childbirth using the youngest possible age was the same as the mean age at first abortion. In Appendix 2, available online at http://links.lww.com/xxx, we explore sensitivity analyses to assess the affect of this choice.

Based on prior research with this data10-12, 20 mental health disorders that met the Diagnostic and Statistical Manual of Mental Disorders 4 th edition, text revision13 criteria and 3 suicidal behaviors were grouped into the following categories: anxiety disorders (panic disorder, agoraphobia, specific phobia, social phobia, generalized anxiety disorder, and post-traumatic stress disorder), mood disorders (major depression, bipolar disorder, and dysthymia), impulse-control disorders (attention deficit disorder, conduct disorder, oppositional defiant disorder, and intermittent explosive disorder), substance use disorders (alcohol abuse without dependence, alcohol dependence, drug abuse without dependence, drug dependence), eating disorders (anorexia, bulimia, and any binge eating disorder), and suicidal behaviors (thinking about suicide, making plans for suicide, attempt suicide).

For each category we computed whether a woman experienced a disorder postpregnancy and, if so, the number of years postpregnancy that the first disorder of that type occurred. The reported age of onset and most recent occurrence were linked to the woman's age at first abortion or age at first childbirth to determine whether mental health disorders occurred before or after her pregnancy outcome. If the disorder was recorded at exactly the age of the woman's first abortion or first childbirth, this was coded as occurring postpregnancy (at 0.5 months so it would be included in analyses). If a disorder occurred after a woman's first abortion or first childbirth, the number of years after this event that the disorder occurred was computed. Findings did not differ if we coded mental health disorders that occurred at the age of the woman's first abortion or childbirth as occurring before the pregnancy. Here we present findings with mental health outcomes as occurring at the same age as the pregnancy coded as occurring postpregnancy.

Control factors

We examined factors that have been shown to differ between women who have abortions compared with women who do not14-21: number of pre-first abortion or pre-first childbirth (henceforth pre-pregnancy) mental health problems, number of pre-pregnancy adverse exposures, pre-pregnancy miscarriage history, age at first pregnancy, race or ethnicity, and childhood economic status (low compared with not low). Number of pre-pregnancy mental health problems was determined by assessing whether each of the mental health disorders occurred before women's first abortion (if having had an abortion) or first childbirth (if having had no abortions). The number occurring beforehand was then coded into none, one, two, and three or more mental health problems pre-pregnancy. Number of pre-pregnancy adversities was computed by summing the number of the following experiences that occurred to the women in the sample, before their first abortion or childbirth: any parental loss (parental death, parental divorce, or the woman going away for 6 months or longer to foster care or to live with other relatives), any parental mental illness (depression, anxiety, or substance use disorder), parental criminal behavior, parental violent conflict, physical abuse, sexual abuse, childhood neglect, any personal safety threat, and intimate partner violence. Number of pre-pregnancy adversities was then coded into none, one, or two or more. Sociodemographic factors we included were: age at pregnancy event, race/ethnicity (non-Hispanic white, African American, Hispanic, Other) and childhood economic status (low compared with not low). Similar to another study with this dataset22, childhood economic status was coded as low if women reported growing up in a family which received government assistance for 6 months or more during childhood. In addition, if women reported living with only one parental figure and that parent had less than a high school education, reported living with two parental figures, both of whom had less than a high school education, or reported living with no parental figures. For 58 women who did not have information on parental education, we followed Green and colleagues' definition22 in which women who grew up with both a male and female parental figure or in single-parent homes where the parent worked "most or all of the time" were coded as not growing up in low childhood economic status. We did not have information on respondent's marital status or education level at the time of the pregnancy event.

Survival analyses for each of the six categories of mental health problem were conducted using Cox proportional hazard models. The age at first abortion or childbirth was considered the entry point into the study and we analyzed time from then until a first mental health problem in that category, or if no mental health problem until their age at the time of interview. Following recommendations23, we checked that the proportional hazard assumption was met for the abortion compared with childbirth coefficient.

We considered several models with various levels of adjustment for confounding. Model 1 tested the relationship between first abortion compared with first delivery and time until postpregnancy onset of a mental health problem in an unadjusted Cox proportional hazards model. Model 2 adjusted for pre-pregnancy mental health only. Model 3 adjusted for pre-pregnancy adversities, pre-pregnancy miscarriage, age at time of pregnancy, and childhood economic status; and Model 4 controlled for all the factors in Models 2 and 3. The data were collected using a multi-stage cluster probability area sample, which requires special analytic care. Using Stata 10.1, we incorporated sampling weights for the Part 2 subsample to guarantee national representativeness and clusters and strata to correctly calculate standard errors with this design.

Results

Women in the abortion group were more likely to have never been married, p = .001, to have had more prior adverse experiences, p = .049, and to have had a pre-pregnancy miscarriage, p = .044, than women in the childbirth group ( Table 1 ). In addition, before their pregnancy, women who had abortions had significantly more mental health disorders overall, p < .001, and were significantly more likely to have had an anxiety disorder, p = .004, mood disorder, p < .001, substance use disorder, p < .001, and suicidal ideation, p < .001, and marginally more likely to have had an impulse-control disorder, p = .059, than women in the childbirth group ( Table 2 ).

Table 1

Childbirth Group

Abortion Group

P

Table 2

Prepregnancy

Postpregnancy

Birth
Group

Abortion
Group

Birth
Group

Abortion
Group

Any eating disorder

1.5

2.9

2.3 †

5.7 †

Number of disorders and
suicidal behaviors

*

*

*

*

The total follow-up time for women was 8,095 years for anxiety disorders, 8,437 years for mood disorders, 8,909 years for impulse-control disorders, 8,923 years for substance use disorders, 9,645 years for eating disorders, and 8,920 years for suicidal ideation. In addition, 50% of women contributed 9 or more years for anxiety disorders, 10 or more years for mood disorders, 12 or more years for impulse-control disorders, 12 or more years for substance use disorders, 12 or more years for eating disorders, and 13 or more years for suicidal ideation. Women who had abortions were more likely to have more mental health problems postpregnancy than women in the childbirth group, p < .001 and to have each type of disorder or suicidal ideation at some point postpregnancy, all p-values < .045 ( Table 2 ). This is reflected in hazard ratios presented in Table 3 , which shows that women who had an abortion had an increased hazard of having a postpregnancy anxiety disorder (HR = 1.52, 95% CI: 1.08-2.15), mood disorder (HR = 1.56, 95% CI: 1.23-1.98), impulse-control disorder (HR = 1.62, 95% CI: 1.02-2.57), substance use disorder (HR = 3.05, 95% CI: 1.94-4.79), eating disorder (HR = 2.53, 95% CI: 1.09-5.86), and suicidal ideation (HR = 1.62, 95% CIP: 1.09-2.40) compared to women in the childbirth group, when no factors were considered in analyses (Model 1).

Table 3

Type of Disorder

Model 1

Model 2

Model 3

Model 4

Anxiety disorders

1.52 †
(1.08-2.15)

1.12
(0.86-1.46)

1.50 †
(1.08-2.09)

1.12
(0.87-1.46)

Mood disorders

1.56*
(1.23-1.98)

1.18
(0.91-1.52)

1.53 †
(1.19-1.95)

1.18
(0.88-1.56)

Impulse-control disorders

1.62 †
(1.02-2.57)

1.10
(0.74-1.65)

1.51
(0.99-2.31)

1.10
(0.75-1.62)

Substance use

3.05*
(1.94-4.79)

2.25*
(1.35-3.78)

2.86*
(1.86-4.39)

2.30*
(1.35-3.92)

Eating disorders

2.53 †
(1.09-5.86)

1.79
(0.68-4.73)

2.39
(0.92-6.19)

1.82
(0.63-5.25)

Suicidal ideation

1.62 †
(1.09-2.40)

1.25
(0.87-1.79)

1.52 †
(1.05-2.19)

1.25
(0.88-1.78)

Adjustment for number of pre-pregnancy mental health disorders markedly attenuated the hazard ratios (Model 2). However, the hazard ratios for all of the psychiatric disorders remained significant after adjustment for pre-pregnancy adversities, pre-pregnancy miscarriage, age at time of pregnancy and childhood economic situation (Model 3). Adjustment for pre-pregnancy mental health and the factors included in Model 3 (Model 4) revealed hazard ratios similar to Model 2. Once pre-pregnancy mental health is included, none of the hazard ratios except for substance use disorders remained significant: anxiety disorders HR = 1.12, 95% CI: 0.87-1.46; mood disorders HR = 1.18, 95% CI: 0.88-1.56; impulse-control disorders HR = 1.10, 95% CI: 0.75-1.62; substance use disorders HR = 2.30, 95% CI: 1.35-3.92; eating disorders HR = 1.82, 95% CI: 0.63-5.25; suicidal ideation HR = 1.25, 95% CI: 0.88-1.78.

Appendix 3 (available online at http://links.lww.com/xxx) presents the hazard ratios of all factors in Model 4. Having three or more mental health problems compared to none before the pregnancy event significantly increased women's hazards of having postpregnancy mental health disorders, all p-values < .005. In addition, women who were younger at the time of their pregnancy event were more likely to have postpregnancy mental health problems for all disorders except mood and eating disorders, all p-values < .011.

To make the findings more concrete, Table 4 presents descriptive analyses giving the predicted probability of having a first postpregnancy mental health problem by 5 years postpregnancy for each of the 6 mental health outcomes for various prototypical women. For all outcomes, with the exception of substance use disorders, the likelihood of having a disorder was not statistically different between the abortion and childbirth groups (see Table 3 ). For instance, for a woman who is 20 at the time of her pregnancy, the predicted probability of having a mood disorder by 5 years postpregnancy for a woman with no pre-pregnancy mental health problems is .05 for both the abortion and childbirth groups.

Table 4

No Prior Mental
Health Problems

One Prior Mental
Health Problem

Three or More Prior
Mental Health Problems

Abortion

Childbirth

Abortion

Childbirth

Abortion

Childbirth

Age 20 at Time of
Abortion/Childbirt
h

Age 30 at time of
abortion/childbirth

Results from the sensitivity analysis, presented in Appendixes 4 and 5 (available online at http://links.lww.com/xxx), yielded findings consistent with the findings presented above. One difference, however, should be noted. When using the oldest possible age at first childbirth for the childbirth group, there was no statistically significant association between abortion and subsequent substance use disorders in Model 4, HR = 1.53, 95% CI: 0.91-2.56.

Discussion

The current research adds to the literature by using a nationally representative U.S. sample, examining clinical-level mental health disorders, comparing women who abort to women who give birth, and controlling for a range of mental health disorders occurring prior to the pregnancy. We found that while abortion compared with childbirth was associated with all six categories of disorders in unadjusted models, in models adjusted for pre-pregnancy mental health, the associations between abortion and subsequent anxiety, mood, impulse, and eating disorders and suicidal ideation were markedly attenuated and non-significant while substance abuse remained elevated. In addition, pre-pregnancy mental health was a strong predictor of postpregnancy mental health. These results, along with our findings that women having abortions had a higher number of pre-pregnancy mental health disorders lend support to the perspective that the link between abortion and subsequent mental health link may be driven by other factors-in this case prior mental health3,24. They also support other research showing that pre-pregnancy mental health is a strong predictor of postpregnancy mental health3-5,13-16,19,24,25 and having abortions15,16,24.

Unlike the other disorders, the association between abortion and substance use disorders remained significant, though it was reduced, after controlling for pre-pregnancy mental health problems. This may reflect an actual association between abortion and substance use or merely inadequate control for all factors specifically related to substance use disorders such as women's risk-taking tendencies. Such risk-taking tendencies may be manifested by substance use and sexual behaviors that lead to having unwanted pregnancies (and abortions). Therefore, the association between abortion and substance use may have remained significant because we did not control for risk-taking tendencies. Alternatively, subthreshold substance use problems, which were not controlled for in analyses, are likely related to having both unwanted pregnancies and subsequent substance use disorders. It could also be that both the internal motivation and social pressure for women to avoid substance use during pregnancy carries over to the period of motherhood and contributes to a lower risk of substance use disorders after a childbirth relative to after an abortion. It should also be noted that this association was not statistically significant in supplementary analyses when oldest possible age at first childbirth was used (see Appendix 5, http://links.lww.com/xxx) and all factors were included, suggesting it may not be reliable.

These results differ from a prior analysis with the National Comorbidity Survey-Replication data which reported a significant association between lifetime abortion and lifetime mood disorders, anxiety disorders, substance use disorders, and suicidal ideation. Although the researchers controlled for age at interview, marital status, race, education, income, and violence experience6, they did not differentiate pre-pregnancy from postpregnancy mental disorders. By using lifetime mental health as the outcome, they could not determine if the mental health disorder occurred before or after the abortion. The current analysis coded mental health post-abortion or post-childbirth, illustrating the importance of considering timing of abortion relative to the mental health problem and controlling for prior mental health.

Although the birth group in the current study is better-matched to the abortion group than in other prior research, they are likely to differ in substantial ways, only some of which can be adequately adjusted. In the U.S., 95% of abortions and 37% of births are the result of unintended pregnancies25,26. Limiting the birth group to women who had delivered at least one child and reported no abortions meant that many women in the comparison group had successfully avoided unintended pregnancies and were thus less likely to have some of the risk factors for mental health disorders which are also risk factors for unintended pregnancy. That we found no significant association between abortion and subsequent mental health after accounting for pre-pregnancy mental health for five outcomes even with this differential selection provides strong evidence against the claim that abortion significantly harms women's mental health.

The use of the National Comorbidity Survey-Replication has both advantages and disadvantages. While data are representative of English-speaking non-institutionalized women living in the continental U.S., they are not representative of those living in Hawaii or Alaska or who are not fluent in English. In addition, while clinical mental health disorders are assessed according to DSM-IV criteria, data are based on self-report and recall of life events. Although care was taken to maximize accuracy of reporting and diagnoses, some mental health inaccuracy in diagnoses and abortion underreporting are likely27,28. For instance, in a similar sample from the National Comorbidity Survey-Replication, we found that only 44% of abortions were reported21; this is similar to the level of underreporting of abortion from other national datasets28,29. It is not known how inaccuracy of mental health diagnoses or reporting of abortion influence the findings. Nevertheless, these findings support previous prospective research which has compared women who abort to women who give birth2,30,31. For instance, in a reanalysis of a sample from New Zealand, Fergusson and colleagues30 found that, compared to women who gave birth to unwanted pregnancies, women who had abortions were not at a significant increased risk of subsequent anxiety disorders, depressive disorders, substance use disorders, and suicidal ideation when mental health at age 15, childhood adversities, and family environment were controlled in analyses. In addition, research using Danish registries data has found support for the notion that mental health problems around the time of abortion are driven by factors other than the abortion2,31.

Groups opposed to abortion have used studies showing associations between abortion and mental disorders to advocate for restrictive policies. The results reported here show that policies which require women be told that abortion increases their risk of anxiety, depression, and suicide32,33 lack an evidence base. In this study, it was not abortion that increased women's risk of these mental health problems, but rather prior mental health problems that increased women's risk for both abortion and subsequent mental health disorders, and suicidal behaviors. This does not mean that abortion care settings should ignore mental health risk. Women seeking abortions may be at higher risk of prior mental health disorders and the abortion care setting may be an important intervention point for mental health screening and referrals.

Supplementary Material

Supplemental Digital Content

Acknowledgments

Supported by an NICHD/NIH Building Interdisciplinary Research Careers in Women's Health (BIRCWH) K12 award and a Robert Wood Johnson Health and Society seed award (to J.R.S.).

Footnotes

Financial Disclosure: The authors did not report any potential conflicts of interest.

References

4. National Collaborating Centre for Mental Health . Induced Abortion and Mental Health: A systematic review of the mental health outcomes of induced abortion, including their prevalence and associated factors. Academy of Medical Royal Colleges; London, UK: 2011. [ Google Scholar]

13. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders-IV-TR. Author; Washington, DC: 2000. [ Google Scholar]

23. Vittinghoff E, Glidden DV, Shiboski SC, McCulloch CE. Chapter 6: Survival analysis. In: Vittinghoff E, Glidden D, Shiboski S, McCulloch C, editors. Regression Methods in Biostatistics: Linear, Logistic, Survival, and Repeated Measures Models. 2nd Edition Springer; New York: 2012. pp. 203-259. [ Google Scholar]

27. Mosher WD, Jones J, Abma JC. National Health Statistics Reports. no 55. National Center for Health Statistics; Hyattsville, MD: 2012. Intended and unintended births in the United States: 1982-2010. [[ PubMed] Google Scholar]

30. Fergusson DM, Horwood LJ, Boden JM. Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A reappraisal of the evidence. Australian & New Zealand Journal of Psychiatry. In press. [[ PubMed] Google Scholar]

32. Planned Parenthood v. Rounds. 686 F. 3d 889 (8 th Circuit 2012)

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Abortion and Mental Health: Findings From the National Comorbidity Survey-Replication

# data[].attributes.attachment_link.description
To examine whether a first abortion increases risk of mental health disorders compared to a first childbirth, with and without considering prepregnancy mental health and adverse exposures, childhood economic status, miscarriage history, age at first abortion ...

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“it is clear that some women do experience sadness, grief, and feelings of loss following termination of a pregnancy, and some experience clinically significant disorders, including depression and anxiety.” - (The 2008 report of the American Psychological Association’s (APA) Task Force on Mental Health and Abortion (TFMHA))

1.5% of the remaining 38% of 1177 eligible women after drop-outs had "all the symptoms for abortion-specific post-traumatic stress disorder (PTSD)" (Reardon).

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Abstract

The abortion and mental health controversy is driven by two different perspectives regarding how best to interpret accepted facts. When interpreting the data, abortion and mental health proponents are inclined to emphasize risks associated with abortion, whereas abortion and mental health minimalists emphasize pre-existing risk factors as the primary explanation for the correlations with more negative outcomes. Still, both sides agree that (a) abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; (b) the abortion experience directly contributes to mental health problems for at least some women; (c) there are risk factors, such as pre-existing mental illness, that identify women at greatest risk of mental health problems after an abortion; and (d) it is impossible to conduct research in this field in a manner that can definitively identify the extent to which any mental illnesses following abortion can be reliably attributed to abortion in and of itself. The areas of disagreement, which are more nuanced, are addressed at length. Obstacles in the way of research and further consensus include (a) multiple pathways for abortion and mental health risks, (b) concurrent positive and negative reactions, (c) indeterminate time frames and degrees of reactions, (d) poorly defined terms, (e) multiple factors of causation, and (f) inherent preconceptions based on ideology and disproportionate exposure to different types of women. Recommendations for collaboration include (a) mixed research teams, (b) co-design of national longitudinal prospective studies accessible to any researcher, (c) better adherence to data sharing and re-analysis standards, and (d) attention to a broader list of research questions.

Keywords: Abortion mental health, abortion, reproductive health, post-abortion trauma, research bias, complicated grief, ambiguous loss, bereavement, post-traumatic stress disorder, pregnancy loss

Introduction

In 1992, the Journal of Social Issues dedicated an entire issue to the psychological effects of induced abortion. In an overview of the contributors' papers, the editor, Dr Gregory Wilmoth, concluded,

There is now virtually no disagreement among researchers that some women experience negative psychological reactions postabortion. Instead the disagreement concerns the following: (1) The prevalence of women who have these experiences ..., (2) The severity of these negative reactions ..., (3) The definition of what severity of negative reactions constitutes a public health or mental health problem ..., [and] (4) The classification of severe reactions ...1

Twenty-six years later, the body of literature has grown. Today, there are many additional areas of agreement, but the areas of disagreement have also grown.

As with most controversies, the abortion and mental health (AMH) controversy is driven by at least two different perspectives regarding how best to interpret accepted facts. A useful parallel is found in the debate over climate change. On the fringes of the climate change controversy are non-experts who hold an extreme position of either total denial or total credulity. But it is far more common for skeptics to acknowledge that fossil fuels make some contribution to global warming while still arguing that these effects are not as extreme global warming proponents contend.2 This group may be described as global warming minimalists. Their normal pattern is to interpret the data in a way that minimizes the potential threat. By contrast, global warming proponents may be more likely to interpret the data in ways that emphasize the potential risks.

Similarly, in regard to the AMH controversy, there are both AMH minimalists and AMH proponents. The experts from both groups can report similar findings from the same data but will do so in ways that seem to either minimize or emphasize the negative outcomes associated with abortion. It should be carefully noted that there is actually a broad spectrum of expert views regarding the AMH link.3 While each researcher and expert has likely developed carefully considered and nuanced opinions, these have not been completely disclosed and cannot be cataloged in regard to every issue discussed herein. Still, broadly speaking, it is evident that both expert reviews and the authors of individual studies appear to generally support either the view that (a) the mental health effects associated with abortion are minimal and within the expected range for the women seeking abortions4-10 or (b) the effects are significant enough to justify more research dollars, and better screening and counseling in order to reduce the number of adverse outcomes.11-19 In addressing this conflict, it is not my intention to pigeonhole any particular expert's viewpoint at any location on the spectrum of views regarding AMH.

In writing this review, I have tried to be as objective and fair as possible. Yet, as discussed later, since my own informed opinion is also influenced by my own experiences and preconceptions, full disclosure requires that I acknowledge at the outset that I fit most closely under the category of an AMH proponent. That said, my goal is not to dismiss or disprove the viewpoint of "the other side," but rather to understand and engage with it in a manner that will contribute to a respectful "transformational dialogue" that will help to "crystalize the areas of agreement and disagreement along with opportunities for collaboration."20 In this regard, it is my great hope that those who disagree with my analysis and conclusions herein will use the publication of this review as an opportunity to publish responses and reviews that address the issues raised with additional depth from their perspectives.

The method I used for this review was to carefully examine previous literature reviews regarding mental health effects associated with legal abortion that have been published since 2005.4-10,12-19,21,22 In that sense, this article may be considered a review of reviews of the literature on AMH. In addition, I studied the references cited in these various reviews in order to further my effort to more completely identify (a) areas of agreement and disagreement, (b) the underlying reasons for disagreements, and (c) opportunities to collaborate in light of the current literature.

This undertaking is intended to advance more than just an academic discussion, however. Research has shown that women considering abortion have a high degree of desire for information on "all possible complications," including rare risks.23 Therefore, an updated and more complete understanding of the literature can and should better prepare physicians and mental healthcare providers with more accurate and helpful information for advising and counseling women before or after an abortion. For example, better screening for risk factors should help to identify women who may benefit from additional pre- or post-abortion counseling24-38 and may also help to prevent cases of women being pressured into unwanted abortions. In addition, more complete insights may help mental health counselors to be more aware and sensitive to providing the counseling services that women want and need.

This review is organized into three sections. The first examines major areas of agreement and offers a synthesis of the findings from major studies. The second section investigates the obstacles to building a consensus between AMH minimalists and AMH proponents, including institutional and ideological biases, research obstacles, poorly defined terms, and similar issues that contribute to the disparity in the conclusions most emphasized by each side. The third section provides recommendations for collaborative research based on the insights gained from the first two sections, addressing such issues as data sharing, mixed research teams, and how to maximize the value of longitudinal prospective studies.

Areas of agreement

Abortion contributes to negative outcomes for at least some women

The 2008 report of the American Psychological Association's (APA) Task Force on Mental Health and Abortion (TFMHA) concluded that "it is clear that some women do experience sadness, grief, and feelings of loss following termination of a pregnancy, and some experience clinically significant disorders, including depression and anxiety."4 Indeed, task force chair Brenda Major et al.'s39 own research had reported that 2 years after their abortions, 1.5% of the remnant participating in her case series (38% of the 1177 eligible women, after dropouts) had all the symptoms for abortion-specific post-traumatic stress disorder (PTSD). In addition, she found that compared to their 1-month post-abortion assessments, at 2 years the participating remnant had significantly rising rates of depression and negative reactions and lowering rates of positive reactions, relief, and decision satisfaction.39

The fact that some women do have maladjustments is most specifically documented in case studies developed by post-abortion counselors successfully treating women with maladjustments, including counselors working from a pro-choice perspective as well as from those working from a pro-life perspective.

Some groups of women are predictably at greater risk of negative outcomes

There is a strong research-based consensus that there are numerous risk factors that can be used to identify which women are at greatest risk of negative psychological outcomes following one or more abortions. Indeed, the TFMHA concluded that one of the few areas of research which can be most effectively studied is in regard to efforts to "identify those women who might be more or less likely than others to show adverse or positive psychological outcomes following an abortion."4

The TFMHA itself identified at least 15 risk factors for increased risk of negative reactions. While the TFMHA did not report on the percentage of women exhibiting each risk factor, Table 1 provides ranges of the incidence of each TFMHA risk factor as reported in the literature. The incidence rates shown in Table 1 clearly suggest that the majority of women seeking abortion have one or more of the TFMHA identified risk factors. Since exposure to multiple abortions is one of the risk factors, that risk factor alone applies to approximately half of all women having abortions, at least in the United States.64

Table 1.

TFMHA identified risk factors

Percentage of women at risk

Perceived pressure from others to terminate a pregnancy

20%;48 23%;38 32%;49 64%50

Terminating a pregnancy that is wanted or meaningful

30%-63%;48 26%-39%;38 11%-56%;51 25% fetus human, taking life;52 50.7% morally wrong50

Low perceived or anticipated social support for the abortion decision

Percent at risk not reported55,56

Use of avoidance and denial coping strategies

19%-51%;58 17%;59 75%60

Feelings of commitment to the pregnancy

15%-18%;50 30%48

Ambivalence about the abortion decision

38%-54%;50 30%-44%;61 65%; 6222%; 6311%-29%;38 35%48

Low perceived ability to cope with the abortion prior to its occurrence

36%;38 40%51

Notably, the TFMHA list used here is one of the shortest that has been developed. A similar, but longer list is published in the text book on abortion most highly recommended by the National Abortion Federation.66 A more recent systematic search of the literature for risk factors associated with elevated rates of psychological problems after abortion cataloged 119 peer reviewed studies identifying 146 individual risk factors which the author grouped into 12 clusters.35 Yet another major review of risk factors identified risk factors from 63 studies which were grouped into two major categories.25 The first category includes 22 risk factors related to conflicts or defects in the decision-making process, for example, feeling pressured to abort, conflicting maternal desires and moral beliefs, and inadequate pre-abortion counseling. The second category contains 25 risk factors related to psychological or developmental limitations, such as pre-existing mental health issues, lack of social support, and prior pregnancy loss.25

The ability to identify women who are at greater risk of negative reactions has resulted in numerous recommendations for abortion providers to screen for these risk factors in order to provide additional counseling both before an abortion, including decision-making counseling, and after an abortion.

Notably, while there is no dispute regarding the abundance of research identifying risk factors, there is little if any research identifying which women, if any, acquire any mental health benefits from abortion compared to carrying a pregnancy to term, even if the pregnancy was unintended or unwanted.17

All AMH studies have inherent limitations

It is impossible to conduct randomized double-blind studies to investigate abortion-associated outcomes. Such studies would require random selection of women to have abortions.

Notably, the very same fact that would make such a study unethical-forcing a group of women to have abortions-actually occurs in the real world wherein some women feel pressured or even forced into unwanted abortions by their partners, parents, employers, doctors, or other significant persons.25,45 This problem with coerced abortions highlights one of the major difficulties involved in AMH research: any sample based entirely on self-selection (voluntary participation) no longer represents the full population of women actually having abortions. Indeed, since feeling pressured to abort is a major risk factor, the practice of excluding women aborting intended pregnancies from AMH studies39,69 makes the results from such studies less generalizable to the actual population of all women having abortions.

This is just one of many difficulties which makes it truly impossible to conduct any AMH study that does not have significant methodological weaknesses. As a result, the "true prevalence" and intensity of the negative effects associated with abortion can never be known with any great certainty. Noting this problem, the TFMHA review concurred with the view that the complexity of this field "raises the question of whether empirical science is capable of informing understanding of the mental health implications of and public policy related to abortion," admitting that many research "questions cannot be definitively answered through empirical research because they are not pragmatically or ethically possible."4

Despite study limitations, statistically significant risks are regularly identified

While every observational study can be criticized for methodological weaknesses, it is also nonetheless true that is still possible to discover meaningful and actionable results. For example, research demonstrating elevated rates of mental health problems among women who feel pressured to abort contrary to their moral beliefs is generalizable to that specific subset of women. So while it is important to never generalize to all women who have abortions, insights can be gained from nearly any study when the results are properly narrowed to the limits of the population studied.70

Figure 1 shows the odds ratios (ORs) and 95% confidence interval (95% CI) for risks associated with abortion in all major studies published since 1995 organized by class of symptoms.

While there are disagreements on how to best interpret these findings (to be discussed later), the findings themselves are not disputed. The results are organized into six sets: all classes of symptoms (segregated by inpatient and outpatient treatments when separately reported); depression and depression-related symptoms such as bipolar disorder; anxiety; substance use disorders (segregated by type of substance use when identified); and other disorders. Each row identifies the study reporting the results; the numeric relative risk (or OR) and CIs (also shown as a range in the forest plot); the participation rate of eligible women (after deducting refusals and dropouts) when identifiable; the group to whom the aborting women are being compared in the study; the forest plot; and an abbreviated description of the specific outcome, symptom, diagnostic scale, and/or time frame to which the statistic applies. Comparison groups include women carrying an unintended pregnancy to term, women delivering a child, women delivering a first pregnancy, women with no known history of abortion, women with any other pregnancy outcome other than abortion, and women not pregnant during the period studied.

What is most notable from Figure 1 is that the trend in results, including those reported by questionnaire and record linkage studies, is consistent. All but three odds ratios are above 1. In most cases, the lower 95% CI is also above 1, signifying statistical significance. Moreover, even among studies showing no significant difference (when the lower 95% CI is less than 1.0), the upper 95% CI is always above 1 and overlaps the statistically significant CIs of other studies.

This overlap is very important. For example, as can be seen in the depression grouping in Figure 1 , the overlap of the 95% CIs in the findings of Schmiege & Russo 2005 and Cougle 2003 (both using different sampling rules for the same data set) demonstrates that there is no actual contradiction in the findings of these two studies. Whenever there is overlap in the CIs, this tells us that the variation in the respective relative risks reported by each study is within the expected range of variation given the limits of each study's statistical power. Since findings only contradict each other when there is no overlap in the CIs, it is clear from Figure 1 that the minority of studies without statistically significant findings do not contradict the findings of studies with statistically significant findings. Claims to the contrary69 ignore the relevance of CIs and also the fact that studies with low statistical power are easily prone to Type II errors resulting in false negatives.

The risk of such false negatives is increased when there is also any risk of sample bias. In regard to abortion research, the risk of sample bias is especially high since questions about abortion are frequently associated with feelings of shame.22,59 The resulting selection bias due to self-censure and the high dropout rates of women at greatest risk of negative reactions also contributes to the misclassification of women concealing a history of abortion as non-aborters. In addition, some researchers choose to exclude groups such as women who abort wanted pregnancies,69 have later term abortions, or have other risk factors for more negative reactions ( Table 1 ) and these methodological choices will also tend to shift results below statistical significance.

Despite these problems, the trend in findings, as shown in Figure 1 , is very clear. Women who abort are at higher risk of many mental health problems.

This conclusion is strengthened by the variety of the study designs that have been conducted. Collectively, these studies examine a wide variety of different comparison groups, explore a diverse set of outcome variables, employ a large variety of control variables, and report on numerous outcomes over different time frames and/or at a variety of cross sections of time. Collectively, they reveal the following:

(a) There are no findings of mental health benefits associated with abortion. (These would be signified by the entire 95% confidence line being below 1.0.)

(b) The association between abortion and higher rates of anxiety, depression, substance use, traumatic symptoms, sleep disorders, and other negative outcomes is statistically significant in most analyses.

(c) The minority of analyses that do not show statistically significant higher rates of negative outcomes do not contradict those that do. (Shown by the upper bound of the 95% confidence overlapping the lower 95% CI of the statistically significant studies.)

A number of recent studies have also reported the population attributable risk (PAR) associated with abortion. This statistic estimates the percentage of an outcome that may be attributed to exposure to an abortion experience after statistically removing the effects associated with the available control variables.

Fergusson was the first to report PARs identified in a prospective longitudinal cohort studied from birth to 30 years of age in New Zealand. He reported that the attributable risk ranged from 1.5% to 5.5%, but did not identify the PAR of specific mental health effects nor provide the CIs.75 Specific outcome PAR risks were also calculated by Coleman15 in her meta-analysis, but these were reported without CIs. These are shown in Figure 2 along with PAR estimates with 95% CIs that have been reported in three other studies.

Of particular interest is a 2016 study by Sullins using the National Longitudinal Study of Adolescent to Adult Health that provided three models of analyses, including controls for 25 confounding factors. In addition, he conducted a fixed-effects regression analysis controlling for within-person variations to control "for all unobserved or unmeasured variance that may covary with abortion and/or mental health."94 Sullins' lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. He also identified a dose effect, with each exposure to abortion (up to the four) associated with a 23 percent (95% CI, 1.16-1.30) increased of relative risk of subsequent mental disorders.

Collectively, the findings shown in Figure 2 suggest that substance use disorders appear to be most strongly attributable to abortion. Put another way, assessments of substance use (perhaps indicating self-medicating behavior) may be one of the more sensitive measures of difficulties adjusting to post-abortion.96 Conversely, at least some research has shown that other outcomes, such as variations in self-esteem, may be unaffected, or only weakly associated with abortion.38 Alternatively, some outcomes may appear to be less strongly associated with abortion because women are receiving successful treatment, such as medication for depression or anxiety, that would obviously suppress these associations with abortion.

Prior mental health and co-occurring factors explain at least part of the effects

As shown in Table 1 , a history of mental health problems is a risk factor for higher rates of mental health problems following abortion as compared to women without a history of mental health problems. This association has been known since at least 1973 when a case series identified several pre-existing mental health factors that could be used to identify the women who were most likely to experience subsequent psychopathology.32 The authors of that study recommended that a low-cost computer scored Minnesota Multiphasic Personality Inventory assessment could effectively identify women who could benefit from additional pre- and post-abortion counseling.

Both AMH proponents and AMH minimalists agree that prior health is a major factor in explaining the negative reactions observed post-abortion. There are differences, however, in how proponents and minimalists distinguish, interpret, and emphasize the interactions between prior mental health, the abortion experience, and subsequent mental health.

AMH proponents see poor prior mental health as contributing to the risk that a woman (a) may become pregnant in problematic circumstances; (b) may be more vulnerable to pressure or manipulation to have an abortion contrary to personal preference, maternal desires, or moral ideals; and (c) may have fewer or weakened coping skills with which to process post-abortion stresses. In addition, from the perspective of abortion as a potential stressor, women exposed to prior traumatic experiences may be more predisposed to experiencing abortion as another traumatic experience.

In contrast, AMH minimalists tend to interpret the evidence that a high percentage of women having abortions have prior mental health issues as the primary explanation for higher rates of mental illness observed after abortion. From this perspective, women with mental health problems are more likely to engage in risk-taking behavior and to experience more problematic pregnancies and are more likely to choose abortion. It is also hypothesized that pregnant women with pre-existing mental health problems may be more inclined to choose abortion because they recognize that they are likely to fare worse if they deliver and try to raise an unplanned child.106,107 The higher rates of mental health issues following abortion, therefore, may be mostly explained as just a continuation of pre-existing mental health problems rather than a direct and independent cause of mental illness. While a few minimalists suggest that the underlying cause of mental health problems observed after abortion can be entirely explained by prior mental health defects or co-occurring stressors,30,82 I have been unable to find any researchers who have denied that abortion can contribute to mental health problems.

The differences between AMH minimalists and proponents on these issues will be more thoroughly discussed later. At this point, it is sufficient to note that both sides agree that poor prior mental health is a major predictor of higher rates of mental health problems after an abortion. Moreover, both sides agree that there should be mental health screening of women seeking abortion precisely because the "abortion care setting may be an important intervention point for mental health screening and referrals"30 due to the higher concentration of women with previous and subsequent mental health issues. At the very least, a history of abortion is a useful marker for identifying women at greater risk of mental health problems and a corresponding elevated risk of a variety of related chronic illnesses111 and reduced longevity.112,113

A summary of agreements with difference in emphasis

Table 2 summarizes specific factual propositions to which the vast majority of both AMH minimalists and AMH proponents would agree. As indicated in the table, each side may typically emphasize some points over others and might underemphasize, reluctantly admit, or even evade discussion of some of these propositions. Still, while some may quibble over the exact formulation of any particular proposition in Table 2 , the underlying consensus relative to each proposition is easily discernible in the body of references by both sides cited in this review.

Table 2.

Propositions regarding agreed upon facts

AMH minimalists

AMH proponents

In summary, the consensus of expert opinion, including that of both AMH proponents and minimalists, is that (a) a history of abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; (b) the abortion experience can directly contribute to mental health problems in some women; (c) there are risk factors, including pre-existing vulnerability to mental illness, which can be used to identify the women who are at greatest risk of mental health problems following an abortion; and (d) it is impossible to conduct research in this field in a manner that can definitively identify the extent of any mental illnesses following abortion, much less than the proportion of disorders that can be reliably attributed solely to abortion itself.

Obstacles in the way of research, understanding, and consensus

Facts are facts. But there is plenty of room for disagreement regarding which facts are generalizable, much less on how to best synthesize and interpret sets of facts, especially when there are flaws in the research and gaps in what one would want to know. Indeed, the greater the ideological differences between people regarding any question, the easier it is to disagree about what the available evidence really means. As shown in Table 2 , even areas around which there is a fundamental agreement by experts under sworn testimony may appear muddied by shifts of emphasis and the insertion of nuances that may be technically true but misleading to non-experts who imagine there are simple, global answers.

For example, the same APA task force which produced the list of risk factors shown in Table 1 did not highlight these findings in their press releases with a recommendation for screening. Instead, the centerpiece of their press release114 was the report's conclusion that "the relative risk of mental health problems among adult women who have a single, legal, first-trimester abortion of an unwanted pregnancy for nontherapeutic reasons is no greater than the risk among women who deliver an unwanted pregnancy"7 (italics added).

This statement was widely reported as the APA officially concluding that abortion has no mental health risks. But as shown in Table 1 , this reassuring conclusion was actually couched in nuances which make it applicable to only a minority of women undergoing abortions on any given day. It excludes the 48%-52% of women who already have a history of one or more abortions,64 the 18% of abortion patients who are minors,115 the 11% of patients beyond the first trimester,116 the 7% aborting for therapeutic reasons regarding their own health or concerns about the health of the fetus,117 and the 11%-64% whose pregnancies are wanted, were planned, or for which women developed an attachment despite their problematic circumstances.38,50,51

The above example demonstrates that the same set of facts, presented and interpreted by AMH minimalists in a way that suggests that few women face any risk of negative reactions to abortion, could also have been worded by AMH proponents in a way that would have underscored a conclusion that most women having abortions are at greater risk compared to the minority who have no risk factors.

This points to one of the greatest hindrances in the advance of knowledge: the tendency to use nuances to dodge direct engagement with the ideas, evidence, and arguments which threaten one's own preconceptions.

Therefore, one of the purposes of the following discussion is to invite direct engagement and thoughtful responses to the specific obstacles identified below.

Intrinsic biases in the assessment of evidence are nearly impossible to avoid

Everyone, even the most "objective" scholar, has developed shortcuts in their thinking and beliefs. These shortcuts (or biases) help us to (a) be more efficient in drawing conclusions and making decisions and also (b) be more consistent in how we perceive ourselves and reality, or conversely, to avoid the stress of cognitive dissonance which occurs when some fact or experience clashes with our core beliefs and values.

Our biases are not just personal. They also have a communal element. We tend to adopt the biases of our peers for several practical reasons. First, by adopting the opinion of our peers as our own, we are embracing a collective wisdom that frees us from the need to deeply research and consider every idea on our own. Second, the more completely our beliefs are aligned within our community of peers, the less we will face conflict and suspicion. Obviously, there is never perfect alignment or cessation of independent thinking. But the tendency to accept the "conventional truths" of one's peers as "fact" is a very real phenomenon.

The impact of biases among academics on the interpretation of data and suppression of contrary opinions has been well documented. For example, identical studies, for which the results are the only difference, are more likely to be lauded or condemned by peer reviewers when the results confirm or conflict with the reviewer's own biases. In the fields of psychology and psychiatry, such confirmatory bias may contribute to the promotion or suppression of research findings that favor liberal causes. In one study, only one-fourth of reviewers noted a major methodological problem in a fake study that agreed with their preconceptions, while 72% quickly raised an objection about the problem when presented with a nearly identical fake study in which the results challenged their preconceptions.123 The only way to eliminate result-based bias, the author suggests, would be to solicit reviews only on the relevance of a study's methodology, withholding the actual results and discussion of results, since the latter are the actual drivers of confirmatory bias.123

While much of the confirmatory bias observed in peer reviewers may be unconscious,129 at least one survey of 800 research psychologists found high rates of admissions that they or their colleagues would openly and knowingly discriminate against conservative views when providing peer review (34.2%), awarding grants (37.9%), or making hiring decisions (44.1%).130 The authors noted that this admission of conscious ideological bias was likely just the tip of the iceberg compared to confirmatory bias since "[i]t is easier to detect bias in materials that oppose one's beliefs than in material that supports it.124 Work that supports liberal politics may thus seem unremarkable, whereas work that supports conservatism is seen as improperly ideological."130

Social psychologist Jonathan Haidt, a self-proclaimed liberal specializing in the foundations of morality and ideology, has argued that that the vast majority of psychologists are united by the "sacred values" of a "tribal-moral community" which is politically aligned with the liberal left.134 This shared moral superiority,129 he says, both "binds and blinds" their community.134 The risk of "blindness" occurs because the lack of sufficient political diversity predisposes the community of psychologists to "embrace science whenever it supports their sacred values, but they'll ditch it or distort it as soon as it threatens a sacred value."134

An excellent example of this result-based bias was the four rejections reported by David Fergusson, former director of the Christchurch Health and Development Study, which followed 1265 children born in Christchurch, New Zealand, for over 30 years.137 Fergusson, a self-proclaimed pro-choice atheist, believed that his data would help to prove that AMH proponents were wrong.137 But when he ran his analyses, he found that even after controlling for numerous factors, abortion was indeed independently associated with a two-to threefold increased risk of depression, anxiety, suicidal behaviors, and substance abuse disorders.17,138 Though his findings were opposite to his preconceptions, he submitted them for pubication anyway. It was then that he ran into a wall of ideologically driven rejections and was even asked by the New Zealand government's Abortion Supervisory Committee to withhold the results.137

Similarly, Ann Speckhard,139 another pro-choice AMH proponent and an associate professor of psychiatry at Georgetown University Medical School, has complained,

Politics have also stood in the way of good research being conducted to examine psychological responses in a nationally representative sample to all pregnancy outcomes: live birth, miscarriage, induced abortion, and stillbirth (and perhaps even including adoption). I offered in 1987 to our National Center for Health Statistics a simple mechanism for collecting such data via a short interview to be attached to an already existing survey-but fear of the answers-on both sides of the issue staunchly squelched the idea.

The problem is that even trained scientists struggle with being purely objective-especially regarding issues that may touch one's own core beliefs, values, and experiences. What makes Fergusson's experience particularly unique is that he chose to publish his findings even though they contradicted his own worldview. How many other researchers, expecting to prove mental health benefits from abortion but finding the opposite, might be tempted to withhold their findings, or worse, to redesign their study in ways that would obfuscate their results in order to declare that a lack of statistically significant results "proved" that there was no need to look further? This concern is heightened by the refusal of AMH minimalists to allow examination of their data by AMH proponents,140 as will be discussed in more detail later.

There are different rates of exposure to the highest risk and lowest risk archetypes

This leads us to an important and perhaps closely related observation. It is not only political, philosophical, or ideological beliefs that contribute to the AMH controversy. Conflicts in the perceiving AMH controversy are also colored by direct and indirect personal experiences. The fact that pro-choice feminists are more focused on feelings of relief and other liberating aspects of having a right to abortion3 may be accurately representing their own positive personal experiences. Conversely, anti-abortion conservatives, who presume that AMH problems are common, may be accurately representing their own relative rate of exposure to negative experiences.3

It is reasonable to assume that friends and associates of highly educated research psychologists are more likely to be skewed toward the "affiliated" than the "disaffiliated." If so, the personal experience of such AMH skeptics may be dominated by the observation that they and their closest friends have generally coped well with any exposure to abortions.

In short, applying the general rule that people (including scientists) tend to look for and believe data that confirm their preconceptions, and are disproportionately skeptical of data that conflict with their preconceptions, both AMH skeptics and AMH proponents are at risk of preferentially interpreting their personal exposure to abortion's risks and benefits as applicable to the general population.

While women having abortions will fall across the entire spectrum of risk factors, it is useful for this review to consider two hypothetical women at opposite ends of any risk-benefits analysis: (a) "Allie All-Risks," the worst possible candidate for an abortion and (b) "Betsy Best-Case," with no known risk factors:

"Allie All-Risks" is 15 years old. A victim of verbal, emotional, and physical abuse, including three incidents of sexual molestation, she has low self-esteem with bouts of anxiety, depression, and suicidal ideation. While her parents are not regular churchgoers, she attended a Catholic grade school, believes in God, and believes abortion is the killing of a baby. She is not a good student and has no concrete career goals. She has always wanted to be a mother, loves babies, and fantasizes about how she will find fulfillment in giving the love to her children that she never received from her own mother. Given Allie's yearnings for escape, acceptance, and true love, she is vulnerable to the seductions of a 22-year-old womanizer with whom she falls madly in love and aspires to a happy future. When she learns she is pregnant, her initial reaction is excitement. While not planned, the pregnancy is welcomed. She believes she can now start building a family with her lover. But this fantasy is immediately crushed when he tells her that they can't afford it, that neither of them are ready for it, and that if she decides to continue the pregnancy, he will leave her. She feels she has no choice. She can't imagine losing him. In addition, her parents would be furious and insist on an abortion, too. Allie's initial excitement at being pregnant is replaced by despair. Indeed, given her need to please others, she gives in with barely a complaint. Her mild protests about "their choice" go unnoticed. The day of the abortion she whispers: "Good bye. I don't want to do this to you. But I don't have a choice." Immediately after the abortion, Allie feels a mild relief that the dreaded procedure is now behind her and hopes her boyfriend will be content, but alongside that relief are feelings of emptiness and loss that seem to grow stronger with every passing week. She begins to have obsessive thoughts. Her baby is no longer in her body, but it is constantly in her thoughts.

"Betsy Best-Case" is 32 years old. She has no history of mental illness and has a good family life. Her parents were both well-educated secularists. They preach education, hard work, and honest success as the only ethical standards Betsy needs to guide her. Betsy is popular, has many friends, and has always had high career aspirations, toward which, with grit, she has proudly made good progress. Even as a child, Betsy had little or no interest in being a mother. Married to her career, she now has even less interest in maternity. Having successfully used birth control since she was 15, when her mother got her an IUD, Betsy is shocked when she realizes she is pregnant. But contraceptive failures happen. Her decision to abort is immediate and made without any emotional conflict. When she flips through the state mandated informed consent booklet given to her at the abortion clinic, the pictures of developing fetuses have no effect. Betsy has seen similar photos many times in the past. She has a strong philosophical belief, based on years of engagement in minor abortion debates, that the value of being a "person" is not based on biological features but rather on the development of a psychological, purpose-filled, self-actualized human being far beyond anything to which a 9-week-old fetus could yet lay claim. Betsy is not surprised when her abortion is completed without drama or even a tinge of angst. She thinks of it rarely. The only negative feelings ever associated with it come when she hears the right of women to choose abortion attacked by self-righteous busybodies who should know better.

Hopefully, any reader can see and respect that the Allie and Betsy's abortion experiences are very different. One is focused on her loss and the other on how her abortion helped her to avoid any loss. Given these differences, it would be unfair to them try to interpret their abortion experiences from within a single ideological framework. Similarly, the women who reside at different places along the wide spectrum between the extreme poles of Allie and Betsy are also very different and unique.

We will employ Allie and Betsy in our discussion later in this review. But for now, let them simply stand as examples of why AMH skeptics may, from personal experience, presume that Betsy is "typical" of abortion patients, while AMH proponents may presume that Allie is more "typical." This difference in regard to how each side of the AMH controversy views the "typical" abortion patient is likely to impact how they interpret AMH research in their efforts to describe the experience of "most" women.

There are multiple pathways for AMH risks

Despite the convenience of standard diagnostic criteria, mental illnesses do not necessarily fit into neat, single classifications with distinct and exclusive symptoms arising from a single cause for each illness.147 As noted in one review of the psychiatric complications of abortion,

A psychiatric complication is a disturbance that occurs as an outcome that is precipitated or at least favored by a previous event .... Every psychiatric outcome is of a multi-factorial origin. Predisposing factors including polygenic influence and precipitating factors such as stressful events are involved in this outcome; in addition, there are modulating, both risk and protective, factors. The impact of the events depends on how they are perceived, on psychological defense mechanisms put into action (unconscious to a great extent) and on the coping style.18 (Emphasis added)

An abortion does not occur in isolation from interrelated personal, familial, and social conditions that influence the experience of becoming pregnant, the reaction to discovery of the pregnancy, and the abortion decision. These factors will also affect women's post-abortion adjustments, including adjusting to the memory of the abortion itself, potential changes in relationships associated with the abortion, and whether this experience can be shared or must be kept secret. These are all parts of the abortion experience. Therefore, the mental health effects of abortion cannot be properly limited to the day on which the surgical or medical abortion takes place. The entirety of the abortion experience, including the weeks before and after it, must be considered.

Moreover, there is no reason to believe that there is a single model for understanding, much less predicting, all of the psychological reactions to the abortion experience. Miller alone identified and tested six models for interpreting psychological responses to abortion and concluded that

theoretical approaches that emphasize unitary affective responses to abortion, such as feelings of shame or guilt, loss or depression, and relief may be missing an important broader picture. To some extent what appears to happen following abortion involves not so much a unitary as a broad, multidimensional affective response.148

The APA's TFMHA proposed four models: (a) abortion as a traumatic experience, (b) abortion within a stress and coping perspective, (c) abortion within a socio-cultural context, and (d) abortion as associated with co-occurring risk factors.7 Additional models could be built on biological responses,149,150 attachment theory, bereavement, complicated, prolonged or impacted grief,ambiguous loss, or within a paradigm of psychological responses to miscarriage.

The complexity of considering so many models, or pathways, combined with the multiplicity of symptoms women attribute to their abortions,45 contributes to discord in the literature produced by AMH proponents and AMH minimalists.

When there is no agreement on what outcomes are relevant or what theoretical pathways should be investigated, there are countless reasons to disagree about both (a) the adequacy of any specific studies and (b) how any specific set of findings should be best interpreted.

Women may simultaneously experience both positive and negative reactions

The act of undergoing an abortion can be both a stress reliever and a stress inducer.171 It may relieve one's immediate pressures and concerns while also leaving behind issues that may require attention immediately or at a future date. Positive and negative feelings can co-exist and frequently do.

In one study,

Almost one-half also had parallel feelings of guilt, as they regarded the abortion as a violation of their ethical values. The majority of the sample expressed relief while simultaneously experiencing the termination of the pregnancy as a loss coupled with feelings of grief/emptiness.166

Another study found that 56% of women chose both positive and negative words to describe their upcoming abortion, 33% chose only negative words, and only 11% chose only positive words.62 The women at greatest risk of experiencing negative reactions immediately and in the short term following an abortion are those who feel most conflicted about the decision to abort or have other pre-existing risk factors.

Applying this insight to our polar extremes, Annie All-Risks would be more likely to experience strong negative feelings more profoundly than her feelings of relief, whereas Betsy Best-Case would be more likely to focus on her relief than any doubts or reservations. Moreover, because Annie has low expectations for coping well (itself a TFMHA risk factor), she may be less likely to agree to participate in a follow-up study. The faster she can get out of the abortion clinic without talking to anyone, the better. Conversely, Betsy is confident that her decision is right and will improve her life and is therefore much more likely to participate.

What "most women" experience cannot be reliably measured

As will be further discussed later, the fact that positive and negative feelings can co-exist makes it difficult, and potentially misleading, to describe any single reaction to abortion as the "most common," given the fact that (a) it is very rare for women to have a single reaction and (b) typically, over half of women asked to participate surveys regarding their abortion experiences refuse or drop out. Obviously, it is impossible to know what the most common reaction of women is based on surveys of only a minority of self-selected women.

This insight also underscores the difficulty of making any generalizations regarding prevalence rates from any study involving volunteer participation or questionnaires. Broadly speaking, there are three groups of women: (a) those with no regrets or negative feelings, (b) those with deep regrets and profound negative feelings, and (c) those with a mix of feelings, including contradictory feelings. As discussed above, the best evidence indicates that women with the most negative feelings are least likely to agree to participate in studies initiated at abortion clinics. But it also follows that women with no regrets are unlikely to be represented in studies of women seeking post-abortion counseling. Both of these factors underscore that it is impossible to accurately measure how "most" women react to their abortion experience when participation in research is voluntary.

The degree of reactions can widely vary and there is no reasonable cutoff for concern

Not all negative emotions constitute a diagnosable mental illness. Therefore, the fact that only a minority of women have diagnosable mental illnesses following abortion does not preclude the possibility that a majority experience negative emotional reactions.

The opinion that negative reactions are experienced by the majority of abortion patients is also shared by a number of abortion providers, such as Poppemna and Henderson:175

Sorrow, quite apart from the sense of shame, is exhibited in some way by virtually every woman for whom I've performed an abortion, and that's 20,000 as of 1995. The sorrow is revealed by the fact that most women cry at some point during the experience .... The grieving process may last from several days to several years.

Similarly, Julius Fogel, who as both a psychiatrist and OB-GYN and as a pioneer of abortion rights performed tens of thousands of abortion, testified that while abortion may be necessary and generally beneficial, it always exacts a psychological price:

Every woman-whatever her age, background or sexuality-has a trauma at destroying a pregnancy. A level of humanness is touched. This is a part of her own life. When she destroys a pregnancy, she is destroying herself. There is no way it can be innocuous. One is dealing with the life force. It is totally beside the point whether or not you think a life is there. You cannot deny that something is being created and that this creation is physically happening ...

Often the trauma may sink into the unconscious and never surface in the woman's lifetime. But it is not as harmless and casual an event as many in the pro-abortion crowd insist. A psychological price is paid. It may be alienation; it may be a pushing away from human warmth, perhaps a hardening of the maternal instinct. Something happens on the deeper levels of a woman's consciousness when she destroys a pregnancy. I know that as a psychiatrist.176,177

This distinction between negative reactions and diagnosable mental illness is another important reason why AMH proponents and minimalists appear to disagree more than they really do. When AMH proponents make statements about "most women" which imply that negative reactions are common, they are including women who attribute any negative reactions to their abortions even if the reactions fall short of fitting a standard diagnosable illness.45 Conversely, when AMH minimalists insist that "most women" do not experience mental illness due to their abortions, they are excluding the women who have negative feelings, even if unresolved and disturbing, on the grounds that (a) the symptoms do not rise above the threshold necessary to diagnose a clinically significant mental illness and (b) the symptoms cannot be strictly attributed to the abortion experience alone.7

In short, if pressed, both sides would agree that the best evidence indicates that most women do experience at least some negative feelings related to their abortion experiences. Yet at the same time, the majority do not experience mental illnesses (as defined by standard diagnostic criteria) that can be solely attributed to their abortions.

Even if it could be proven that 99% of women who had abortions experienced more benefit than harm, that would still not justify ignoring the 1% who experienced more harm than good. Majorities matter in elections. But in regard to medical ethics and public policy, negative reactions are important among even a minority of patients ... especially when it is possible to screen for risk factors that identify the patients at greatest risk of adverse reactions.

Negative reactions may manifest themselves over a very long time frame

For example, in a study led by TFMHA chair Brenda Major, volunteers interviewed at an abortion clinic reported a significant decline in their Brief Symptom Inventory Depression scores 1-2 h after their abortions (T2, 62% decline) compared to their scores an hour before their abortions (T1, asking women to rate their depression for the month prior to the abortion). But at the 1-month follow-up (T3), depression scores rose 91% above their post-abortion (T2) score and continued to get higher, up to 118% at the 2-year follow-up (T4).39 Notably, this study had a 30% dropout at the 1-month follow-up (T3) and a 50% dropout at the 2-year follow-up (T4). In addition, the self-selection bias of this volunteer sample was further magnified by the study protocol that also excluded women aborting an intended pregnancy or a second trimester pregnancy, two of the risk categories for elevated risk of negative reactions.

It is likely that there are patterns relative to which women are at greater risk of experiencing early negative reactions and those who are likely to experience later reactions. Zimmerman, for example, found that 74% of "disaffiliated" women were struggling with negative thoughts about their abortions, three times the rate reported by "affiliated" women.48 Thus, it is easy to predict that our archetype Annie All-Risks would likely be among those who would have immediate negative reactions. After all, she felt coerced into aborting an unplanned but welcomed pregnancy against her maternal preferences and moral beliefs. In addition, given her history of abuse and psychological problems, her coping skills were already stretched to the limit prior to her abortion.

Similarly, it is also easy to imagine that Betsy Best-Case would cope well in the immediate hours, days, months, and even years after her abortion. She freely chose to abort a pregnancy that was both unintended and unwanted for rational reasons. She also had strong coping skills and could easily compartmentalize any "socially induced" doubts into the "deeper levels" of her consciousness.

Clinical experience indicates, however, that there is no certainty that Betsy will always remain symptom free. Subsequent reproductive events such as miscarriage, infertility, or even a wanted birth may unexpectedly trigger existential crises deeply intertwined with a nearly forgotten abortion experience. Similarly, life events that trigger introspection such as the death of a loved one, or a later religious conversion, may trigger a redefinition of past choices and experiences in a way that may include obsessive guilt and self-condemnation.45 An example of a "perfect decision" being reinterpreted as a woman's worst decision is found in this posting at a post-abortion counseling site:

I had an abortion when I was 22 years old. Now it is haunting me. I think about it every day of my life. I have so much regret. I wish I could turn the clock and undo my mistakes. I am not coping. The guilt is too much. At that time the decision was perfect. But now it kills me day by day. Please help me. I don't trust anyone with this secret.

AMH minimalists might reasonably argue that it is the subsequent trigger, the miscarriage, or religious conversion, that is the "true cause" of later distress. But efforts to apportion blame for the "true cause" of distress over a prior abortion simply disrespects the real experience of women who seek, desire, or need post-abortion counseling. Whatever the trigger, whatever the contributing factors, the internal turmoil over a past abortion is centered on, or at least intertwines with, the abortion and will not be resolved by pretending the abortion is not part of the problem.

Based on reports of clinical experience, we would hypothesize that delayed reactions are most frequently triggered by (a) subsequent reproductive experiences, including reproductive difficulties and (b) experiences that lead to introspection and reevaluation of one's overall life course or moral integrity.45 Conversely, the more risk factors that are present, especially feelings of coercion and attachment combined with weakened coping skills, are predictive of more immediate negative reactions.

In short, questionnaires which lack abortion-specific retrospective questions such as "Did you ever experience significant negative feelings about a past abortion?" followed by questions regarding the timeline for each type of mental health outcome being studied are simply capturing cross-sectional data. Cross-sectional data regarding current symptoms will simply miss symptoms that have ceased, either due to medication, counseling, or by the healing effects of time or a replacement pregnancy. It will also miss symptoms that may be delayed beyond the date of the assessment. As a result, data from general prospective studies like the NLSY simply cannot tell us anything about the "true prevalence rate" of depression associated with abortion.

The weakness of such general purpose prospective studies also explains why AMH proponents and AMH minimalists can look at the same data and come to different conclusions. For example, the first analysis of NLSY CES-D scores relative to women with a history of abortion found that depression was highest among married women with a history of abortion (OR = 1.92; 95% CI = 1.24-2.97) and among women in their first marriage in particular (OR = 2.23; 95% CI = 1.36-3.74).184 Since CES-D scores did not significantly vary among unmarried women, the combined results for all women (OR = 1.39; 95% CI = 1.02-1.90) were barely significant.184 The significance of marital status may indicate that abortion-related depression after an average of 8 years may be triggered by subsequent pregnancies in marriage. In any event, given the weakness of this data set, it was a trivial matter for AMH minimalists69 to use different selection criteria, excluding a subgroup of women at greatest risk of negative reactions to abortion, in order to shift the lower 95% CI for all women below 1 (OR = 1.19; 95% CI: 0.85-1.66) in their reanalysis of the NLSY data. Notably, their analysis also excluded results segregated by marital status, the finding most significant in the earlier study. Based on these weaknesses, it was simply misleading for Schmiege and Russo69 to interpret their reanalysis as conclusive evidence that abortion does not contribute to the risk of depression in some women. Their overreaching conclusions were particularly unjustified in light of the fact that the NLSY data set was also tainted with a 60% concealment rate regarding past abortions185 and the CES-D scale inquired about only depression in the prior week and was administered in only once, an average of 8 years after the abortions.

In summary, the efforts to estimate the prevalence rate of negative reactions to abortion are complicated by (a) the wide variety of reactions, (b) the existence of both early and delayed reactions, (c) a wide variety of triggers for delayed reactions, and (d) the prospect that in any assessment years after the abortion, a number of women who previously had significant reactions may have experienced full or partial recovery by the time of that assessment. Each of these factors would tend to skew the results of any prevalence estimates based on questionnaires toward underestimating the total lifetime risks.

Self-censure and defense mechanisms contribute to underreporting of sequelae

Data collected to investigate reactions to abortion may also be distorted by any number of defense mechanisms. Avoidance, denial, repression, suppression, intellectualization, rationalization, projection, splitting, and reaction formation may all contribute to the conscious or unconscious underreporting of symptoms attributable to unresolved abortion issues.

In case series studies, where women are first contacted while at the abortion provider and asked to participate in a follow-up evaluation, both the initial refusal and subsequent dropouts usually exceed 50%.39,187 In the Turnaway study, for example, only 37.5% of women asked to participate agreed, and of those who agreed 15% immediately dropped out before the first baseline interview, approximately 8 days after the abortion.179 The study continued with phone interviews every 6 months for 5 years. Women were rewarded with a US$50 gift card each time they completed an interview. But despite this motivation, by the end of the 3 years, only 27% of the eligible women were participating, and this dropped to only 18% at the 5-year assessment.188 Given this high rate of self-censure, the researchers' conclusion that "Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years"179 clearly overstates what the Turnaway data can actually reveal. Unfortunately, the authors' overgeneralized conclusion inspired many newspaper headlines which definitively proclaimed that the overwhelming majority of women are glad they had their abortions.178,189 But if the researchers' conclusions had been more accurately narrowed to describe their actual pool of respondents, the abstract should have read, "Of the 27% of eligible women participating at a three year assessment, the overwhelming majority felt that termination was the right decision for them." That single clarification would have helped even the most pro-choice reporter to recognize that the views of a self-selected minority of volunteers (27%) simply cannot tell us what the "majority of women" feel and think. What "most women" experience is simply unknown when the majority of women are refusing to share their thoughts and feelings at any given time.

Our understanding of defense mechanisms also suggests there may be cases where the denial of a link between abortion and abortion-specific symptoms is evidence of both avoidant behavior and an elevated risk of mental illness. It seems likely that defense mechanisms may contribute to a significant underreporting of negative reactions, especially in survey responses. Conversely, questionnaire-based reports may also lead to the exaggerated rating of some positive reactions due to splitting or reaction formation. In these cases, women trying to focus on the positive may respond in ways that may anticipate, or even inflate, the positive feelings they want to feel while "rounding down" negative reactions which they want to escape or deny.

The statistical impact of defense mechanisms is also double edged. First, self-censure, dropouts, and concealment of past abortions are all likely to suppress measurements of the prevalence rate of mental illnesses among those volunteers admitting to a past abortion. Second, comparison groups that include women who conceal their history of abortion (who are most likely to have AMH effects) are likely to have inflated prevalence rates for mental illness due to the misclassification of women with a history of abortion into the comparison group of women who, according to the study design, have not been exposed to abortion.184 Both problems suggest that odd ratios and prevalence rates based on studies relying on voluntary self-reporting of abortions will most likely be skewed toward underestimating the true risks associated with abortion.

It is also worth noting that defense mechanisms may also impede the ability of women to receive good follow-up care. In a survey of women reporting that they sought post-abortion counseling from a psychologist, psychiatrist, social worker, or other professional counselor, 58% reported that the counseling was not helpful.45 Many reported that their therapists simply refused to seriously consider abortions as significant. This phenomenon may be at least partially due to defense mechanisms employed by healthcare professional professionals themselves. Many therapists may have unresolved issues with their own history with abortions; others may be loath to reconsider the wisdom of their advice to previous patients, reassuring them that abortion was a good; still others may have ideological commitments to abortion rights which conflict with their ability to trust their patient's self-assessments, and some may simply have an uncritical confidence in the widely spread, but exaggerated claim, that "there is no evidence that abortion has any mental health risks." This is yet another reason why better research and training regarding how abortion may contribute to problems for " at least some women" is important to prepare healthcare workers to be more sensitive and open to providing informed care.45

There is no perfect control group; yet all comparison groups provide insights

Comparisons have been made to each of the following: the general population of women,77,195 women who have never been pregnant,94 women with no reported history of abortion,74,84,85,91,92,94,95,100,101 women giving birth, women giving birth to a first pregnancy, women having miscarriages or other involuntary losses,81,88,91,94,195-197 women experiencing both births and pregnancy loss (abortions or miscarriages), women giving birth to unintended pregnancies,69,72,75,76,86,90,92,98 and women denied abortions.179,198 Together, these findings show that women with a history of abortion are statistically more likely to experience significantly more mental health issues relative to every comparison group that has been examined.

Notably, most of these comparisons are based on general-purpose longitudinal cohort studies. As discussed previously, due to the temporal limits, cross-sectional data, self-selection bias, concealment, and the misclassification of women with an abortion history into the comparison groups, the results of these studies most certainly skew toward underestimating the true relative risks between the groups compared. Still, while every choice for a comparison group is imperfect,192,193 below we will argue that there are valid insights that can be gained by every comparison. Acting on that premise, many researchers have chosen to simultaneously compare women who abort to multiple other groups whenever the data allow it.

By contrast, Charles et al.,6 have argued that the only "appropriate" comparison group for AMH studies is to women who have "unwanted deliveries." But this argument is weak for three major reasons.

First, the efforts to define and evaluate what constitutes an "unintended" or "unwanted" pregnancy are themselves imprecise, rendering any study based on such a flawed definition imprecise.15,199 Moreover, not intending to become pregnant at a particular time in one's life is very different than not wanting a child. Indeed, over half of unintended pregnancies are carried to term, accounting for approximately 37% of all births.200 Conversely, among women having abortions, the evidence suggests that between 30% and 63% of aborted pregnancies were intended, wanted, welcomed, or involved significant emotional attachment. In short, both groups (women having abortions and women carrying unintended pregnancies to term) encompass a huge variation in intentionality, wantedness, and attachment to their pregnancies.

Second, as Romans192 has convincingly argued, the differences in women who choose to carry an unintended pregnancy to term and those who abort are simply immeasurable. No conceivable comparison between the two groups can control for all the possible variations between them. Still, as both the TFMHA4 and Fergusson et al.193 have argued, even imperfect comparisons have and can continue to yield valuable insights regarding the differences between the women who cope well and those who cope poorly. While such findings cannot tell us what "most women" experience, they can tell us how different subgroups of women compare to each other. These findings are meaningful and actionable since they should be used to guide pre-abortion screening and counseling and post-abortion care25 and for informed consent procedures.23

Third, the argument for discounting studies that lack information on pregnancy intention appears to have been advanced primarily as an excuse to denigrate the majority of studies on AMH. This charge is supported by the fact the "quality scale" created by Charles et al.6 required deducting two of the five possible quality points from any study using any control group other than women carrying unwanted pregnancies to term.

The highly biased and subjective application of Charles et al.'s quality scale is demonstrated by the fact that they rated studies published by AMH minimalists using exactly the same national longitudinal data sets as AMH proponents consistently higher in quality. Moreover, Charles et al.'s quality scale totally ignored the problem of high concealment, misclassification, and drop-out rates in the very same studies they rated as better. Thus, by ignoring issues related to selection bias, the Charles et al. contrived ranking scale identified just four studies as "very good"-even though three of these had concealment rates of 60% or higher,185 and the fourth had a dropout rate of 65%.76 Meanwhile, their skewed scale allowed them to rank as "poor" or "very poor" literally all record linkage studies, which by their nature have no concealment or selection bias, even though these same studies revealed some of the strongest associations between AMH problems.

In response to Charles et al.'s argument that the only appropriate comparison group is to women carrying unintended pregnancies to term, the following arguments are made in defense of other comparison groups. I argue that, while no comparison is perfect, every option for a comparison group can be a useful tool in developing a multidimensional perspective on the complexity of AMH issues.

First, comparisons to women with a history of abortion and the general population of women provide a useful baseline, especially when combined with comparisons to women who miscarry or carry to term. For example, a record linkage in Finland revealed that the age-adjusted risk of death within a year of pregnancy outcome was 5.5 per 100,000 deliveries, 16.5 per 100,000 miscarriages, and 33.8 per 100,000 abortions, compared to 11.8 per 100,000 age-adjusted women years for the general population of women not pregnant in the prior year.196 A similar record linkage study of the population of Denmark revealed a dose effect, with the risk of death increasing by 45%, 114%, and 191% with exposure to one, two, or three abortions, respectively.112 Yet another record linkage study examining attempted suicide rates before and after pregnancies revealed declining rates of suicide attempts after both delivery and miscarriage, but a sharp increase in attempted suicide following abortion, as seen in Figure 3 .81

Another important comparison is between women who have induced abortions and women who miscarry. Both have experienced the effects of pregnancy, which may produce long-lasting changes to the brain, and maternal attachment. While the physiological processes of natural miscarriage and induced abortion are different, there may be similarities in the recovery process. Moreover, this comparison may allow insights into the psychological differences between intentionally choosing the end of a pregnancy versus an unintended loss, both of which may be experienced as a form of disenfranchised grief.45,161 Arguably, examining the differences between miscarriage and abortion may be the most relevant and important comparison.203

Comparisons to women giving birth are also meaningful. Just as a comparison to a never pregnant woman attempts to estimate how closely induced abortion achieves the goal of "turning back the clock" to the point before the woman became pregnant, a comparison to a delivering woman seeks to estimate how a woman's mental health would fare if she chooses to "move into" the group of women giving birth.

While comparisons of first pregnancy outcomes are valuable, it should be noted that it is a very poor methodological choice to include in the group of women experiencing a "first live birth" women who are known to have had one or more abortions before their first live birth or between the birth and the date of the mental health assessment.69,107 Unfortunately, these flawed studies ignore the extensive evidence showing that a history of pregnancy loss (abortion or miscarriage) is associated with higher rates of mental health problems during subsequent pregnancies. By adulterating the "control" group of women having a "first live birth" with women who also have a history of one or more abortion and/or miscarriages, the resulting analyses clearly confound rather than clarify the differences between abortion, miscarriage, and childbirth, shifting the known negative effects associated with prior pregnancy losses into results associated with a first childbirth. Arguably, this confounding methodology has been specifically employed by AMH minimalists precisely with the intent of producing results that obfuscate the mental health effects associated with abortion while inflating the effects associated with childbirth.141,227

Finally, it has been argued that the differences between women who abort and those who do not are so extreme that the only meaningful comparison is between women who abort and women who sought but were denied an abortion.194 While this comparison might be informative, it is clearly not a perfect comparison since the reasons why women may end up being denied an abortion are also likely to make these women significantly different than the average woman seeking and obtaining an abortion. Moreover, since in most countries where abortion is legal, very few women are denied an abortion undertaking such studies may be impractical. Indeed, the only set data set using this control group is the so-called Turnaway Study. Indeed, the argument that this is the only valid comparison group appears to be made in an attempt to dismiss all other research in favor of this single data set. But there are many problems with the Turnaway Study data set.198 The most damning is the problem of self-censure. Over 70% of women approached to participate in this study refused, even after they were promised payments for participating, plus, nearly half of those who did participate subsequently dropped out.198 This high refusal rate alone renders the Turn-Away Study data meaningless in terms of drawing any conclusions regarding the general population of women seeking or having abortions, and that is just one of many major flaws in the Turnaway Study methodology and execution.198

Poorly defined terms produce misleading conclusions: unwanted, relief, and more

Unfortunately, a great deal of the literature on AMH revolves around poorly defined terms. The resulting lack of precision and nuance contribute to AMH minimalists and AMH proponents talking past each other and contributes to overgeneralizations regarding research findings, especially in the press releases and position papers of pro-choice and anti-abortion activists.

As previously discussed, one common overgeneralization is the assertion that abortions typically involve "unwanted" pregnancies. A closer look, however, reveals that many aborted pregnancies, perhaps the majority, occur for planned, partially wanted, or initially welcomed pregnancies. By "welcomed" pregnancies, I mean pregnancies which were not planned in advance but to which the woman was open or naturally inclined to accept and embrace if only she had received the support of her partner, family, or others.

Attempts to define "unwanted" pregnancies are also complicated by the fact that many women report a divide between their emotional and intellectual responses when they first discover they are pregnant. Emotionally, they may be excited that a new life is growing inside them and may fantasize about having the child. But at the same time, their logical side may be immediately convinced that abortion is their only pragmatic choice.45 The pregnancy may therefore be simultaneously "emotionally wanted" and "logically unwanted."

Based on both clinical experience and case series studies,173 we hypothesize that many delayed reactions to abortion stem from the psychological conflicts that arise when emotions are suppressed in favor of pragmatic choices. In such cases, forward-looking women with strong defense mechanisms are likely to cope well with their choice for many years. But if this coping is achieved by suppressed emotions, this may consume energy and may even fuel maladaptive behaviors, like substance use and sleep disorders. Any connection between these symptoms and underlying abortion associated conflicts may not be recognized until some subsequent event or stress compels a reexamination of unresolved maternal attachments or the woman's moral priorities.

One measure of openness to having a child, seldom addressed in AMH studies, is desire for children at some later date. A high level of desire for future children suggests that an aborted pregnancy was most likely problematic due to specific circumstance or lack of sufficient social support. Among a sample of women seeking counseling for post-abortion distress, 64% felt "forced by outside circumstance" to have an abortion and 83% indicated they would have carried to term if significant others in their lives had encouraged delivery.181 While statistics gathered from women contacting post-abortion recovery programs may be not representative of the general population of women, these findings demonstrate that labeling these aborted pregnancies as "unwanted" does not reflect the experience of the women who subsequently do seek post-abortion help.

Given the wide variation in levels of intention or openness to pregnancy, much more extensive data on intention199,228 and attachment207 are required to draw any conclusions regarding the mental health effects of abortion relative to various levels of women's attachment, intention, and outcome preferences.

A second poorly defined variable is "relief." AMH minimalists have frequently asserted that the most common reaction to abortion is relief.4 But "relief" is a very broad term. A woman reporting "relief" may be referring to (a) relief that she will not have a baby, (b) relief that a dreaded medical procedure is now behind her, (c) relief that her parents will not discover she was pregnant, (d) relief that her partner will finally stop harassing her to have an abortion, or (e) any number of other reasons for feeling a reduction in stress.

Similarly, claims that "the most common reaction" to abortion is relief is also misleading because it falsely suggests that a truly representative sample of all women having abortions have been queried about their most prominent and common reactions. But in fact, all the case series studies assessing "relief" have self-censure and dropout rates exceeding 50%.39,59 When only a minority of women agree to report on their reactions to an abortion, these studies cannot reliably tell us anything about the majority of women. This is especially true if the self-selection bias is toward women who expect to feel more relief because their abortion decision is more consistent with their own desires and preferences, while those who refuse to participate anticipate and do experience more negative reactions.

Another misleading factor is that relief is most often reported as a single variable whereas negative reactions are often averaged together. For example, one of the most frequently cited case-series reporting that women felt "more relief than either positive or negative emotions" was based on comparing the results of a single question regarding relief to an average of six scores ("sad," "disappointed," "guilty," "blue," "low," and "feelings of loss") chosen to represent negative emotions and an average of three scores ("happy," "pleased" and "satisfied") chosen to represent positive emotions (excluding relief).39 This methodology was highly problematic.

While it would be interesting to see score distributions for each reaction separately,45 how can a variety of emotions be "averaged" together in any meaningful way? For example, if a score of 1 (corresponding to "not at all" on the Likert-type scale used) is equivalent to 0% of the relevant emotion and a 5 ("a great deal") is 100% of that emotion, averaging six emotion scores together presumes that a rating of 3 (50%) for "disappointed" is truly equivalent to twice a rating of 2 (25%) for "feelings of loss" and half the value of a rating of 5 for "guilty."

But what makes this averaging process even more suspect is that the least common negative reaction ("disappointed," perhaps) would dilute the entire average of negative reactions, concealing the frequency of the more common reactions ("guilty," perhaps). Most importantly, while the most common negative and positive reactions were diluted by this "averaging" process, the "relief" score was not subject to the dilution by averaging with any of the other positive emotions.

Yet another problem with the authors' conclusion39 was their presumption that the six negative reactions they asked about are actually the most common negative reactions. But three of the six negative reactions ("sad," "blue," "low") appear nearly synonymous. The similarity of these three may have been deliberate in order to boost the reliability score for the authors' scale. One of the remaining choices, "disappointed," is simply odd, rather bland, and perhaps disinviting as it is not a term that has been reported in interviews with women reporting negative reactions to abortion. While the assessments of "guilty" and "feelings of loss" were appropriate, it would have been more illuminating to report these separately rather than in an "average" of negative emotions.

In any event, averaging emotion scores is problematic and in this case the choice of the six negative feelings chosen to be averaged together failed to include many of the negative emotions most commonly reported in surveys of the women who seek post-abortion counseling, including sorrow, shame, remorse, emptiness, anger, loneliness, confusion, feigned happiness, loss of confidence, and despair.45

Despite the many limitations regarding the claim that "relief" is more common than negative reactions, it is notable that the same researchers also found that between the 3-month and 2-year post-abortion assessments, both relief scores and positive emotions decreased significantly while the average for negative emotions increased.39 In other words, even with a self-selected sample of women most likely to have more positive reactions, those positive emotions declined and negative emotions increased within the first 2 years. If that trend continued over 20 years, the finding that the "most common reaction" to abortion was relief may not have held up over a longer period of time.

Similar problems apply to the widely reported claim that most women are satisfied with their decisions to abort.179 In this case, the self-selection bias was profound, with only 27% of the eligible women participating at the date of their first assessment. In addition, this "finding" was based on a binary yes or no response to a single question: "Given your situation, was your decision to have an abortion right for you?" This question clearly invited reaction formation and splitting. Additional questions, such as, "If you had received support from others, would you have preferred to have carried to term?" would have provided deeper insight into the participants' true preferences.

Is abortion the sole cause, a contributing cause, or never a cause of mental health problems? Or is this question just a distraction from helping women?

Evidence-based medicine is centered on the idea that there must be real evidence of benefits that outweigh the risks associated with a medical intervention. But there are no statistically validated medical studies showing that women facing any specific disease or fetal anomaly fare better if they have an abortion compared to similar women who allow the pregnancy to continue to a natural outcome. Nor is there evidence of any mental health benefits.17,25 As a result, in approaching a risk-benefits assessment, there are literally no studies to place in the benefits column of an evidence-based risk-benefits analysis. Conversely, there are literally hundreds of studies with statistically significant risks (both physical and mental) associated with abortion which must be considered in weighing abortion's potential risks against the patient's hoped for benefits. See, for example, the references to Table 1 .

In this regard, induced abortion is an anomaly. It is the only medical treatment for which the principles of evidence-based medicine are routinely ignored, not for medical reasons, but by appeals to abortion being a fundamental civil right135 or a public policy tool for population control.25 From these vantage points, there has arisen an a priori premise that abortion should presumed to be safe and beneficial. Therefore, according to defenders of abortion, the burden of proving the safety and efficacy of abortion is no longer on them. Instead, abortion skeptics must prove that abortion is the sole and direct cause of harm to women-and not just a few unfortunate women, but a large proportion of women.

This appellate court's ruling is consistent with idea that "risk," by definition, includes uncertainty-otherwise, it would not be a "risk" but rather a "certainty." Therefore, the question of whether a statistically significant risk is solely due to abortion, partially due to abortion, or only incidentally associated with abortion is itself just another of the uncertainties about the procedure, and therefore a true risk about which patients should be informed.25

The court's decision favoring disclosure of all risks, even when causality is challenged by proponents of the procedure, is in line with the preferences reported by 95% of women considering elective medical procedures, to be informed of "all possible complications."23 From a feminist perspective, the right of each individual woman to evaluate for herself whether a statistically significant risk is incidental or causal would also appear be central to the protection of each woman's personal liberty. Indeed, the United Nation's Fourth World Conference on Women's Declaration and Platform for Action, which specifically addressed the issue of unsafe abortions, urged every government to

Take all appropriate measures to eliminate harmful, medically unnecessary or coercive medical interventions, as well as inappropriate medication and over-medication of women, and ensure that all women are fully informed of their options, including likely benefits and potential side-effects, by properly trained personnel.235 (Emphasis added)

For the reasons above, the claim that the higher incidence rates of mental health problems associated with abortion are most likely "spurious"105 has no bearing on informed consent. Only after full disclosure can each patient judge the relevance of such information for herself.

These challenges are also irrelevant to the obligation of the treating clinician to screen for the risk factors associated with higher rates of negative outcomes associated with abortion.23,25 After all, even if abortion proponents could prove that 100% of all the negative effects associated with abortion are causally due to common risk factors, the finding that abortion is consistently associated with higher rates of mental health problems is still an actionable marker that can and should be used to identify women who may benefit from referrals for additional counseling.26,27,30,32-34,36-39

It should be noted, however, that the Bradford-Hill criteria were developed to evaluate contributing factors for physiological diseases. Bradford-Hill therefore ignored a type of evidence for causality which is unique to psychological diseases, namely, self-aware attribution of causal pathways. For example, the evidence of a woman who says, "After the death of my child, I drank more heavily to dull the pain," is a conscious identification of cause and effect regarding her own mental state and behaviors.

Even though AMH minimalists and proponents approach their research from different perspectives, the results from both sides consistently show that at least a minority of women experience mental health problems that they attribute, at least in part, to their abortions. While not included in the Bradford-Hill criteria, when it comes to mental health issues, the fact that so many intelligent, self-aware women attribute specific patterns of emotional distress to their history of abortion is one of the strongest pieces of evidence that abortion directly contributes to mental health problems. The same is true with regard to mental health associated with miscarriage. The validity of this evidence is further strengthened by the professional assessment of both pro-choice therapists and pro-life therapists who also attest to the causal connection.

As previously noted, self-attribution is not perfect evidence. Defense mechanisms often operate by obscuring the "true cause" of one's mental distress. But we would argue that the bias of defense mechanisms would be toward underreporting of effects truly associated with an abortion rather than toward false attribution of unrelated effects to past abortions.

That is not to say that pre-existing mental health issues cannot become intermingled with an abortion. To the contrary, clinical experience shows that abortion can become such a significant stressor in a woman's life that other pre-existing issues can become enmeshed in the abortion and its aftermath. Pre-existing substance abuse, for example, may become intensified in the abortion aftermath, but it would be a self-deception to blame the abortion entirely for such substance abuse. On the contrary, once the issues become intermeshed, progress in dealing with underlying issues will be hindered by a failure to address the intermingled abortion issues.

Similarly, even in cases where suicide notes specifically attribute a woman's final act of despair to her recent abortion,241 other pre-existing factors may also contribute to these tragedies. In short, while it would be absurd and insulting to deny that abortion at least contributes to such suicides, it would be a mistake to assume that abortion is the sole cause of suicide or any other specific mental illness.

As stated previously, abortion does not occur in isolation from interrelated personal, familial, and social conditions that influence the experience and mental health of each individual. Moreover, there are likely a multiplicity of different pathways for effects to manifest either in the near or longer term.18 In general then, abortion is most likely a contributing factor to the manifestation of problems rather than the sole factor. It may be trigger latent issues, intensify or complicate existing issues, interact with pre-existing issues to create new issues, or contribute in any number of ways unique to any particular individual's susceptibilities and prior and subsequent life stresses.

In summary, there is incontrovertible evidence that abortion contributes to mental health problems, both directly and indirectly. Based on reports of clinical experience, it would appear that abortion can be the primary cause for mental health issues in some women. But it may also trigger, intensify, prolong, or complicate pre-existing mental health issues. Still, for the sake of argument, assuming AMH minimalists are right in their assumption that abortion itself is never the "sole cause" of mental health problems, there is still no reasonable doubt that abortion contributes to mental health issues in some women.

Finally, it should be emphasized that the difficulties involved in proving causality cut both ways. The burden of proving the efficacy and safety of abortion falls on abortion providers. To date, they have failed to provide any evidence, much less proof, that abortion is the sole and direct cause of any health benefits for women in general, or even for specific subgroups of women.193,232 Nor have they shown that the benefits women hope to obtain through abortion are proportionate to or greater than the significantly elevated rates of negative outcomes associated with abortion. In this regard, abortion continues to be an experimental treatment, one for which they hoped for benefits are unproven. And with no proven benefits, the risks-benefits ratio is unknown even for those women without any known risk factors.

Is it reasonable to attribute all negative effects to pre-existing factors?

In courtrooms, this line of arguments is known as the thin skull, or eggshell skull, defense. It asserts that a defendant should not be held accountable for injuries that would not have been suffered if the plaintiff had not been predisposed to injury due to pre-existing physical or emotional defects. Notably, the thin skull defense has been rejected in most legal jurisdictions. Even if the damages of the "frail" plaintiff are greater than they would be for a healthier person, jurists have ruled, the defendant is still liable for the greater damages because

a defendant who negligently inflicts injury on another takes the injured party as he finds her, which means it is not a defense that some other person of greater strength, constitution, or emotional makeup might have been less injured, or differently injured, or quicker to recover.244 (Emphasis added)

Applying the thin skull legal analysis to abortion, this means that a physician who fails to screen for known risk factors, such as prior mental illness, before recommending or performing an abortion is guilty of negligence if the woman suffers any subsequent mental health problems because it is precisely the obligation of the physician to treat the woman "as he finds her."

In short, the argument that negative effects may be mostly due to pre-existing mental health problems simply strengthens the argument for better pre-abortion screening for this and other risk factors. Conversely, it does not at all support the presumption that abortion is safe or likely beneficial to most women, much less all.

Still another AMH minimalist argument is that women with prior mental illness may instinctively know they are less likely to cope well with an unwanted pregnancy, so the higher rate of abortion among women with mental illness is actually a sign of these women choosing abortion wisely.106,107 Again, this is entirely speculation. It ignores the likelihood that mentally ill women, especially those with a history of being abused, may simply be more susceptible to being pressured into unwanted abortions45 like Allie All-Risks. Moreover, it ignores the ethical obligation of caregivers to discourage, rather than enable, patterns of behavior that may be self-destructive.

Moreover, bearing children may actually contribute to mental health improvements through direct biological effect, by expanding and strengthening interpersonal relationships with the child(ren) and others, or by behavioral adaptations that may replace risk-taking with self-improving behaviors. These benefits may also apply to bearing unplanned children. Indeed, given how common unplanned pregnancies are throughout the millennia, it could be argued that female biology has evolved mechanisms in order to adapt and adjust to unexpected pregnancies.

In short, the argument that higher rates of mental illness following abortion are simply due to mentally ill women being wise enough to choose abortion more often is simply not supported by any statistically validated research. Instead, the opposite argument, that giving birth is more likely to produce mental health benefits, is more plausible and better supported by actual data.

It should also be noted that while we are aware of only one record linkage study examining mental health effects for women without any history of mental health issues, that study (by AMH minimalists) revealed that a history of abortion was associated with a significantly increased risk (risk ratio (RR) = 1.18; 95% CI = 1.03-1.37) of postpartum depression after a first live birth.80

Closely related to the pre-existing mental illness issue is the finding that women with a history of abortion also have higher rates of abuse and violence in their lives. According to this argument, violence106,110 or childhood adversities,106 not abortion, are the most likely cause of higher rates of mental illness among women with a history of abortion. This hypothesis is contradicted, however, by studies which have shown that there are higher rates of mental illness associated with abortion even after controlling for violence.94,109 More importantly, it is a mistake to engage in either/or arguments; a both/and approach is both more likely and more productive. Clearly, a history of abuse contributes to a heightened risk of both pregnancy and abortion, especially abortions to satisfy the demands of others. At the same time, clinical experience reveals that issues related to abuse and abortion can become deeply entangled. Efforts to treat based on an either/or attribution are most likely to be frustrated. Progress is most likely to be made when both the abuse and abortion experiences are holistically addressed.45

While it important to study the interactions between exposure to violence and abortion on mental health, it is also important to consider that there may be two-way interactions. Surveys of women entering into post-abortion counseling reveal high percentages reporting elevated feelings of anger (81%), rage (52%), more easily lost temper (59%), and more violent behavior when angered (47%) following their abortions, which can obviously increase incidence rates of subsequent intimate partner violence.45 Moreover, in the same sample, in which 56% reported suicidal feelings and 28% reported attempting suicide (with over half trying more than once), there are case studies of women "pushing the buttons" of a violent partner because they believed they did not "deserve to live."45 This escalation of violence following abortion may help to explain the elevated rate of homicide among women with a history of abortion. For these reasons, given the multiple pathways for interactions between abortion and violence, studies that fail to distinguish between violence before and following abortion are methodologically flawed.110,247

In response, AMH proponents argue that (a) the burden of proving safety and effectiveness is on the proponents of a medical treatment and (b) given the weight of the evidence, it is far more logical to accept that abortion is at least a contributing factor that may work in concert with any number of other contributing factors.

In addition, denying that abortion directly contributes to mental health problems is illogical given the fact that so many of the risk factors identified by AMH minimalists themselves (see Table 1 ) are specifically part of the abortion experience. These include feeling pressured to abort by others; negative moral views of abortion; low expectation of coping well after an abortion; ambivalence about the abortion decision; and feelings of attachment or commitment to a pregnancy that is meaningful or wanted.

In other words, given what we know of the risk factors associated with mental illness after abortion, many of them are directly enmeshed in the abortion experience; they are not fully independent of the pregnancy and abortion experience. Therefore, even to the degree that mental illnesses can be associated with common risk factors for both unintended pregnancy and abortion, such as a history of sexual abuse, the intermeshing of elevated risk for pregnancy, abortion, and mental health issues precludes the conclusion that abortion does not contribute in any way to the observed problems. The only support for that argument comes from ideology, not from any statistically validated studies. For example, an incest victim may be at greater risk of a high school pregnancy with the first boyfriend that she imagines will be able to free her from an abusive step-father.250 She may also be at greater risk to being pressured into an unwanted abortion. While it would be a mistake to blame the abortion for all of her subsequent mental health problems, even if a subsequent suicide note focuses on the abortion, it is ludicrous to assert that her abortion did not contribute to her problems. Moreover, it is also evident that the failure of healthcare providers to identify the risk factors that made her a poor candidate for abortion missed an opportunity to assist her in using her pregnancy to break a cycle of exploitation and trauma.

Finally, it should be noted that AMH minimalists frequently cite studies showing that women who deliver an unintended pregnancy have more subsequent problems than women who only have intended pregnancies.248 From this base of evidence, they argue that since women who deliver unintended pregnancies have more problems, with mental health and otherwise, it follows that access to abortion helps to reduce the problems associated with unintended pregnancies. But this argument falsely presumes that abortion puts women who have unintended pregnancies back into the category of women who have never had an unintended pregnancy, and that all intended pregnancies are carried to term. But there are not just two groups: (a) women with "perfect" reproductive lives and (b) women with a history of unintended pregnancies. There is a third group, (c) women who have had abortions, who may fare worse than either of the other two groups.

While AMH proponents do not dispute that on average women with unintended pregnancies may face more problems than women who have perfect reproductive lives, it appears likely that they still have fewer problems than women who abort. Indeed, as previously discussed, not a single study has found evidence that the mental health of women who deliver an unintended pregnancy is worse than that of women who have abortions.69,72,75,76,86,90,92,98,188 To the contrary, the only statistically significant findings indicate that women who abort are likely to have more mental health problems than those who deliver their unintended pregnancies.17

The controversy over abortion related PTSD is more political than scientific

First, it is notable that all pregnancy outcomes are associated with some PTSD risk. Both vaginal and cesarean deliveries can be experienced as traumatic with a corresponding risk of PTSD. Miscarriage and other natural pregnancy losses are also consistently associated with increased risk of PTSD. It should therefore come as no surprise that induced abortion is also consistently found to be associated with the onset of PTSD symptoms. Notably, a history of induced abortion is also a risk factor for the onset of PTSD following subsequent pregnancy outcomes, so the effects of abortion may not always be immediate but may be triggered by subsequent deliveries or natural losses, or even subsequent non-pregnancy-related events.271 These findings are consistent with the insight that multiple traumas and related life experiences may contribute to the triggering of PTSD symptoms.

The evidence is clear that some women do experience abortion as a trauma. The prevalence rates and pre-existing risk factors may continue to be disputed, but the fact that abortion contributes to PTSD symptoms in at least a small number of women is a settled issue.

Recommendations for research and collaboration

Good research is essential for both healthcare providers and patients. Better information about the risks and benefits associated with abortion should contribute to better screening, better risk-benefit assessments, and better disclosures to patients,23 that will help to shape the expectations of patients and those who advise them. Better information will also improve the identification of at risk patients who may benefit from referrals to post-abortion counseling.

As previously discussed, while the ideological divides between AMH minimalists and proponents will continue to shape how each side interprets the data, these differing viewpoints actually provide an opportunity for improving the collection of useful data, analyses of the available data, and more thorough interpretations of research findings. Therefore, healthcare providers and patients would be better served by AMH minimalists and AMH proponents both bringing their various perspectives to bear on research efforts in a more cooperative fashion.

Whenever possible, research teams should include both AMH minimalists and AMH proponents. Such cooperation would improve methodologies by better addressing the differing concerns of each perspective at the time of the study design. Collaboration in the writing of introductions and conclusions to such studies would also be improved by bringing balance to both perspectives and by reducing the tendency to overgeneralize results of specific analyses.

More specific opportunities for collaboration and better research are discussed below.

Expanding the research goals

A major problem with abortion research and reviews is a failure to address all of the relevant questions which need to be asked, investigated, and answered. For example, the team from the National Collaborating Center for Mental Health (NCCMH) that wrote a review of AMH issues for the Academy of Medical Royal Colleges in 2011 strictly limited their investigation to only three questions: "(1) How prevalent are mental health problems in women who have an induced abortion? (2) What factors are associated with poor mental health outcomes following an induced abortion? (3) Are mental health problems more common in women who have an induced abortion when compared with women who deliver an unwanted pregnancy?"5 Most notably, the NCCMH team chose to ignore the question specifically posed for it to investigate in the 2008 Royal College of Psychiatrists position statement on abortion, namely, "whether there is evidence for psychiatric indications for abortion"272 (emphasis added). Given the lack of any evidence for psychiatric indications for abortion, it seems likely that the NCCMH decided to ignore this question because it echoed previous allegations that UK law was not being followed in regard to limiting abortion to cases where there are therapeutic benefits.273

The following is a list of some key research questions that should be addressed in future studies and reviews. It was developed, in part, by using the NCCMH consultation report as a starting point:274

1. How prevalent are mental health problems in women who carry unplanned pregnancies to term compared to women who deliver wanted pregnancies, to women who have no children, and to women who have abortions?

2. Given that women may experience a range of reactions in the near term and over a period of many years, what are the cumulative rates of negative reactions over a long period of time (including a minimum of 30 years) and what are the temporal, cross-sectional prevalence rates relative to various risk factors that may contribute to these temporal differences?

3. Among women who do experience negative emotional reactions (not limited to mental illness) which they attribute to their abortions, what reactions are reported?

4. What treatments are most effective?

5. What statistically validated indicators predict when the mental health risks of continuing a pregnancy are greater than if the pregnancies were aborted?

6. What statistically validated risk factors predict negative outcomes following one abortion, two abortions, and three or more abortions compared to each available comparison group?

7. What factors, if any, are associated with improved mental health following abortion compared to similar women who carry a similarly problematic pregnancy to term?

8. Among women with pre-existing mental health issues, what factors predict a likelihood that abortion may contribute to a reduction in mental health problems (intensity, duration, and number of mental health issues), and what factors predict a likelihood that abortion may contribute to an increase in mental health problems?

9. Among women without pre-existing mental health issues, what factors predict a likelihood that abortion may protect good mental health, and what factors predict a likelihood that abortion may contribute to subsequent mental health problems?

10. Is presenting for an abortion, or a history of abortion, a meaningful diagnostic marker for higher rates of mental illness and related problems that can be timely addressed by appropriate offers of care?

11. In evaluating the risk-benefits profile of a specific patient, what criteria should be met in order to reach an evidence-based conclusion that the benefits of abortion are most likely to exceed the risks?

12. In cases of pregnancy following rape or incest, what are the short- and long-term mental health effects associated with each of the following outcomes: (a) abortion, (b) miscarriage or stillbirth, (c) childbirth and adoption, and (d) childbirth and raising the child?

13. Is abortion associated with an increase in rapid repeat pregnancies, that is, "replacement pregnancies?" If so, what portion are delivered, aborted, or miscarried?

14. Does a history of abortion contribute to the strengthening or weakening of the woman's relationships with her partner and/or others?

15. What are the mental health effects of the abortion experience, if any, on men?

16. What are the mental health and developmental effects of the abortion experience, if any, on previously born children and/or subsequently born children?

17. Does a history of abortion contribute to or hinder bonding and parenting of previous and/or subsequently born children?

National prospective longitudinal studies specific to reproductive and mental health

We recommend that the value of such longitudinal studies would be vastly increased by expanding the goal of data collection to encompass not just mental health effects associated with abortion but also with all reproductive health issues from first menses to menopause. This would assist in research related to infertility, miscarriage, assisted reproductive technologies, postpartum reactions, premenstrual syndrome, and more. And given the interactions with multiple pregnancy outcomes already seen in AMH research, comprehensive reproductive health histories are needed in any case.

Most importantly, the design and management of such studies should include both AMH minimalists and AMH proponents. An explicit objective should be ensuring that every line of questioning either side considers important is included. When both sides contribute to the design of such studies and have equal access to the same data, concerns about suppressed findings or incomplete analyses will be dramatically reduced ... at least after re-analyses. When both sides have equal access to better data, it is more likely that the areas of consensus will increase.

The value of longitudinal studies would also be enhanced by seeking the consent of participants to link their medical records to their questionnaires. This would be most helpful given the fact that many women are reluctant to reveal abortion information even in responding to a confidential questionnaire. Since women's willingness to share data may vary over time, this request for record linkage should perhaps be offered multiple times over the course of the longitudinal study. While many will likely refuse this option, the refusal to permit record linkage is itself a data point for analyzing patterns associated with concealment and dropout. Along the same lines, at each wave there should be included a query regarding the level of stress associated with completing the questionnaire.183 This may also help to better understand and estimate the effects of women subsequently dropping out.

Finally, it should be noted that it has already been shown that there may be significant differences in women's experiences relative to different cultures and nationalites.50 Therefore, it is highly recommended that longitudinal studies to comprehensively investigate the intersections between mental and reproductive health should be funded in multiple countries.

Data sharing for re-analyses should be rule rather than the exception

It is precisely because data can be selectively analyzed and interpreted to produce slanted results, that data should be made available for re-analyses by third parties.276 Data sharing also reduces the costs of research and magnifies the contribution volunteers make to science by making their non-identifying information accessible to more scientists, which presumably most volunteers would prefer as their participation is generally intended to help science in general, not specific research teams. Most importantly, data sharing enhances confidence in the reliability of research findings, especially when related to controversial issues. Unfortunately, though many publications and professional organizations encourage or require post-publication sharing of data, in practice many researchers across many disciplines evade data sharing.277

Support for data sharing, at least in theory, is found in the APA's ethics rule 8.14, which states that following publication of their results, research psychologists should share the data for reanalysis by others.278 But this principle has been frequently ignored, especially in regard to abortion research. For example, the chair of the APA's own TFMHA, Brenda Major, has repeatedly refused to allow data she collected on abortion patients to be subject to reanalysis by AMH proponents. She even refused to comply with a request for the data from the US Department of Health and Human Services, even though the study was funded by that agency.140

Such data hoarding undermines confidence not only in the published findings of a specific study but also diminishes the value of syntheses or reviews relying on those unverified findings.

Data sharing is especially important when the process of collecting data may be blocked by ideological litmus tests. For example, abortion providers are naturally unlikely to cooperate with studies initiated by AMH proponents who they perceive as opponents of their work. On the contrary, they have frequently cooperated with AMH minimalists-precisely because of their shared ideology. Implicit in granting that cooperation may be the expectation that pro-choice researchers will not report any findings that may contribute to anti-abortion rhetoric. Conversely, many post-abortion counseling programs may also limit their cooperation to AMH proponents whom they perceive as most accepting and supportive of the issues raised by their clientele.88

In both cases, the ideological alignments required to collect data may create biases in the design, analysis, and reporting of results. This does not mean that meaningful results cannot be obtained. But it does mean that such results should always be presumed to reflect sample and investigator biases until the findings have been confirmed in reanalyses conducted by investigators of all perspectives. It is only through equal access to the data that consensus will grow around results which survive reanalyses. It is also through this process that new research objectives will be better identified in response to these reanalyses.

Responsiveness to requests for additional analyses

In many cases, legal restrictions (government or contractual) may bar the sharing of underlying data. In such cases, reasonable requests for additional information, tables, and reanalyses should be honored through personal communication, publication of a response, or, if a major reanalysis is required, in publication of a subsequent paper. Such cooperation is especially important in regard to data sets that have access restrictions, such as those collected by government agencies.

For example, the centralized medical records of Denmark have provided some of the best record linkage studies in the world. However, when it comes to mental health effects associated with abortion, there is strong evidence that significant findings are being suppressed for ideological reasons. The arguments and evidence for this assertion are given below.

Another methodological problem was the decision to include women who had one or more abortions prior to their first delivery into the delivery group. This decision is especially problematic since a history of abortion is significantly associated with higher rates of mental illness during and after subsequent pregnancies. Notably, when Munk-Olsen was asked to provide a simple count of the number of women in her analyses who had both abortions and deliveries and the percentage of those who had psychiatric contact, she refused this and all other requests for more details.227

Before examining the inconsistencies revealed in subsequent Munk-Olsen et al.82 studies, it is relevant to compare her abortion study to three very similar record linkage studies conducted by AMH proponents conducted a decade earlier. These prior studies examined the differences between abortion and delivery in regard to inpatient psychiatric treatments,89 outpatient psychiatric treatments,97 and sleep disorders.87 The designs of those studies were superior to Munk-Olsen's in several respects: (a) in each case, controls for prior psychiatric inpatient treatment were employed for a longer period of time, a 12- to 18-month period prior to the estimated date of conception for each woman; (b) there was complete segregation of women relative to exposure to abortion; (c) mental health outcomes were reported showing variations relative to different age groups; and (d) results were shown over multiple time periods: 0-90 days, 0-180 days, first year, second year, third year, fourth year, and 0-4 years.

Normally, one would expect Munk-Olsen to have at least replicated, if not improved on, the methodology employed in these prior record linkage studies. Instead, the methodological choices she made severely narrowed the range of her investigation. Studies that are narrowly drawn can only support narrow conclusions. This is especially true since Munk-Olsen also excluded any analyses of the effects of multiple abortions, which are known to be associated with even higher rates of negative reactions94,112 and also make up the majority of all abortions being performed.64

Concerns about selective reporting are heighted by the fact that Munk-Olsen subsequently published numerous studies on mental health associated with childbirth in which, once again, she refused requests to supply data for findings associated with abortion. For example, using the same data set, Munk-Olsen published findings that reported

In each of these cases, her analyses and conclusions were flawed by the failure to address the effects of prior fetal loss, which are known to increase the risk of psychiatric disorders during and after subsequent pregnancies.

While in most cases she simply omitted abortion history from her analyses, in two cases she used abortion history as a control variable217,284 but omitted any statistics showing how this control affected the results. Clearly, the only reason to use abortion history as a control is if it has a significant independent effect on mental health outcomes.

The possibility that Munk-Olsen simply overlooked these opportunities to report on effects associated with abortion is disproven by the fact that in each case Munk-Olsen rejected both published141,227 and unpublished requests for details relative to the effects of abortion on the outcomes studied. Even a request for a simple count of the number of women exposed to abortion in each of Munk-Olsen's comparison groups was refused.141

All of the above factors give credence to the concern that there is a selective withholding of results, by Munk-Olsen and other AMH minimalists. Moreover, given the evidence that abortion and miscarriage impacts mental health during subsequent pregnancies, it is clear that every study examining the intersection between mental and reproductive health may be misleading if it fails to include analyses associated with pregnancy loss. Without such analyses, effects associated with pregnancy loss may be wrongly attributed to childbirth.

The combination of Munk-Olsen's failure to publish these results without being asked, combined with her refusal to respond to requests for reanalysis,141,227 strongly suggests a pattern of selective reporting and obfuscation. If the additional analyses requested actually supported her previous assertion that prior mental health fully explains the higher rates of mental illness seen among women who have aborted82,107 it seems clear that she should be rushing to publish these requested analyses precisely to silence skeptics.

In short, whenever either AMH minimalists or AMH proponents refuse to respond to queries for reanalyses of published findings, they are increasing distrust and weakening the credibility of all conclusions based on their previously published research. This creates real obstacles in the advance of evidence-based medicine, informed consent practices, and ultimately in the medical care of women. The advance of scientific investigations into reproductive mental health can only be enhanced by generously responding to requests for details and re-analyses that clarify the interpretation of published findings.

Recommendations for editors and peer reviewers

As previously discussed, there is strong evidence that individual biases may unfairly bias editors and reviewers against findings that challenge their preconceived notions. Biases against "conservative" viewpoints, which may attach to the AMH controversy, are especially common.

Editors should guard against this bias by seeking a mix of peer reviewers, including both AMH minimalists and AMH proponents. For reasons discussed previously, while recognizing that every study in this area will have methodological weaknesses and that no sample can be perfect, editors should be blind to the results and focus their evaluation of peer review comments on the appropriateness and adequacy of the methodology and study sample. Editors should be alert to criticisms that appear to reflect a reviewer's bias against results which support an undesired conclusion, especially when the methodology employed is comparable to studies that would be accepted for publication in any other field of research.

A good test of bias is to simply imagine that the results were flipped,123 with the ORs showing benefits to abortion compared to delivering an unwanted pregnancy, for example. If the reviewer's or editors reactions to the paper would most likely have been in the opposite direction, that reaction is obviously driven by a bias for preferred results.

Editors and peer reviewers should also strive to ensure that all studies relating to the intersection of mental and reproductive health include, whenever possible, analyses that delineate findings relative to exposure to all prior pregnancy outcomes, including both natural pregnancy losses and induced abortions.141,227 This is important for several reasons. First, there is consensus even among AMH minimalists that better data are needed on the effects of pregnancy loss on mental health.4,274 Second, there is clear and convincing evidence that exposure to pregnancy losses (both natural and induced) may have a significant impact on women's health during and after subsequent pregnancies and at other times in women's lives.80,88,94,99,112,170,212,285

Limitations

The purpose of this review of the medical literature on AMH was to examine the areas of agreement and disagreement, the reasons for disagreement, and the opportunities for improved research and collaboration. The method I used began with a review of reviews published since 20054-10,12-19,21,22 and an examination of the studies cited in these reviews.

Given the difficulties previously discussed in conducting any conclusive studies, the breadth of issues examined in this review, and the range of theories and opinions of the authors of the reviews and studies examined, it is out of the scope of this, or any, review to fully address every view or concern. With that limitation in mind, however, this review does catalog a broader range of relevant issues than any previous reviews. In doing so, this review does not offer the last word on the AMH controversy. Instead, it seeks to expand and continue the conversation, inviting more detailed responses, criticism, and elaboration regarding the issues identified herein.

Conclusion

While there will continue to be differences of opinion between AMH minimalists and AMH proponents, there is sufficient common ground upon which to build future efforts to improve research and meaningful re-analyses. Common ground exists regarding the very basic fact that at least some women do have significant mental health issues that are caused, triggered, aggravated, or complicated by their abortion experience. In many cases, this may be due to feeling pressured into an abortion or choosing an abortion without sufficient attention to maternal desires or moral beliefs that may make it difficult to reconcile one's choice with one's self-identity.

There is also common ground regarding the fact that risk factors identifying women who are at greater risk, including a history of prior mental illness, can be used to identify women who may benefit from more pre-abortion and post-abortion counseling. Additional research regarding risk factors, and indicators identifying when abortion may be most likely to produce the benefits sought by women without negative consequences, can and should be conducted through major longitudinal prospective studies.

Finally, there is common ground on the need for better research. That fact alone is a strong argument for mixed research teams, collaboration in the design of longitudinal studies available for analysis by any researcher (without ideological screenings), data sharing and more responsive cooperation in responding to requests for reanalysis. All of these steps will help to provide healthcare workers with more accurate information for screening, risk-benefits assessments, and for offering better care and information to women both before and after abortion and other reproductive events.

Footnotes

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: D.C.R.'s efforts were funded as part of his regular duties as Director of Research with the Elliot Institute.

ORCID iD: David C Reardon https://orcid.org/0000-0002-4478-6231

References

30. Steinberg JR, McCulloch CE, Adler NE. Abortion and mental health: findings from the national comorbidity survey-replication. Obstet Gynecol 2014; 123(2 Pt 1): 263-270. [[ PubMed] PMC free article] [ Google Scholar]

234. 8th Cir. (en banc). Planned Parenthood Minn., N.D., S.D. v. Rounds, 2012. [ Google Scholar]

Articles from SAGE Open Medicine are provided here courtesy of SAGE Publications

# data[].attributes.attachment_link.title
The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities

# data[].attributes.attachment_link.description
The abortion and mental health controversy is driven by two different perspectives regarding how best to interpret accepted facts. When interpreting the data, abortion and mental health proponents are inclined to emphasize risks associated with abortion, ...

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Texans can get the following support for an alternative to having an abortion:

"-Counseling, mentoring, educational information and classes on pregnancy, parenting, adoption, life skills and employment readiness.

-Material assistance, such as car seats, clothing, diapers and formula.

-Care coordination through referrals to government assistance programs and other social services programs.

-Call center for information and appointment scheduling.

-Housing and support services through maternity homes"

# data[].attributes.attachment_link.readable_text
The statewide Alternatives to Abortion program promotes childbirth and provides support services to pregnant women and their families, adoptive parents, and parents who have experienced miscarriage or the loss of a child.

Services include:

Counseling, mentoring, educational information and classes on pregnancy, parenting, adoption, life skills and employment readiness.

Material assistance, such as car seats, clothing, diapers and formula.

Care coordination through referrals to government assistance programs and other social services programs.

Call center for information and appointment scheduling.

Housing and support services through maternity homes.

Who Is Eligible?

The program is available to any Texas resident who is a U.S. citizen or legal immigrant and is:

The biological mother or father of an unborn child.

The biological mother or father of a child, for up to three years postpartum.

The parent, legal guardian or adult caregiver of a minor who is a program client.

A parent who has experienced miscarriage or loss of a child. These clients are eligible to receive counseling, referrals and other relevant services for up to 90 days after the miscarriage or loss.

An adoptive parent of a child of any age, for up to two years after adoption finalization.

Find Services

Contact one of the following HHS contracted service providers serving people statewide:

Austin LifeCare
512-851-1854

Longview Wellness Center
903-758-2610 or 888-811-6648 (toll-free)

The Pregnancy Network
Operated by the Human Coalition
800-499-4203

Texas Pregnancy Care Network
877-345-7734

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The statewide Alternatives to Abortion program promotes childbirth and provides support services to pregnant women and their families, adoptive parents, and parents who have experienced miscarriage or the loss of a child.

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It may not be emotionally easy for the birth mother to give her child up for adoption, but the resources available, like the ones at Thompson Dove, make the process easy.

"the resources and guidance available to prospective birth mothers means the practical process of placing a child for adoption can be easy. A prospective birth mother never has to go through adoption alone; our adoption professionals are always available to help an expectant mother create an adoption plan that works for her"

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Oxford Languages defines life as:

"the condition that distinguishes animals and plants from inorganic matter, including the capacity for growth, reproduction, functional activity, and continual change preceding death".

A fetus, a baby, has the "capacity for growth", someday will have the ability to reproduce, is continually changing, is not dead, and at a certain point in its development, once its capacity for growth has been exercised, it will have functional activity in its mother's womb.

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National Geographic says:

"A cell is the smallest unit that is typically considered alive and is a fundamental unit of life. All living organisms are composed of cells, from just one (unicellular) to many trillions (multicellular). Cell biology is the study of cells, their physiology, structure, and life cycle."

Following that line of logic, wouldn't an unborn baby be considered life? The "it's just a clump of cells" argument, though true, through the lens of this quote would mean that that "clump of cells" is very much alive

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A cell is the smallest unit that is typically considered alive and is a fundamental unit of life. All living organisms are composed of cells, from just one (unicellular) to many trillions (multicellular). Cell biology is the study of cells, their physiology, structure, and life cycle.

Subjects

Biology, Ecology, Health, Genetics

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A cell is the smallest unit that is typically considered alive and is a fundamental unit of life. All living organisms are composed of cells, from just one (unicellular) to many trillions (multicellular). Cell biology is the study of cells, their physiology, structure, and life cycle.

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PreBorn! is a non-profit, pro-life organization that provides many resources to expecting mothers for free, in the hopes that they won't abort their child.

"offering them free ultrasounds and support, as well as providing Pregnancy Clinics with vital grants for state-of-the-art ultrasound machines, evangelism training, and additional resources.

All services provided to expectant mothers within the PreBorn! Pregnancy Network are offered at no cost, emphasizing our commitment to life."

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Pre-Born! is a pro-life non-profit ministry that connects with life-affirming Pregnancy Clinics across the nation to strategically diminish the grip of the abortion industry by continuing to save babies and souls. With the help of generous donors, Pre-Born!

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"I loved, lived, and slept with whomever I pleased. I keep a Post-it in my wallet that says, “I can do anything I want to.” But the freedoms that come with childlessness are much more profound than the thrill of wild adventure, wild sex or wild precocity. I have the time to think, to be creative, to cultivate a career of my own curation" (Neumann).

A woman without a child is told she can do whatever she wants, and she loves that freedom. If this woman were to get pregnant, she would more than likely have an abortion in order to keep hold of her beloved freedom.

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Last autumn, I fell in love for the first time in at least 20 years.

That enormous feeling overwhelmed me like fall in New England or a natural disaster. I knew I was in serious trouble when I found myself patiently, even blissfully, ironing his shirts. Who the hell am I right now, my besotted self thought. In a flash of recognition, I knew: I was a woman taking care of a man.

Cue my dormant alarm system, long ago set to self-preservation, now rebooted with a scream and a blare. Domestic tasks, particularly those in service of a man, are a well-established signal for me to run as fast as I can the other way. Snap out of it, this is a trap! Care is a woman's most dangerous gateway drug. Pick up the dry-cleaning once and the next thing you know, you're knocked up and wondering where your writing career went.

Just don't get pregnant, is the most salient bit of advice my divorced father ever gave me.

t takes a lot of money, discipline and medical access to not have children. There's also some hell to pay for it, even today: namely, the too-personal inquiries (our female bodies are never our own), the loss of social status (mothers are the moral future of the nation) and the steady blows to our respectability that society gleefully lands.

Childlessness is almost as radical today as it's always been, a fact that belies the numbers: in 2018, 15% of women between 45 and 50 were childless.

As I've aged - I'll turn 52 this year - my appreciation for the liberties I've chosen has only grown. Like a free agent, I've always revelled in my actions without restrictions, my decisions without ramifications. I could move to the other side of the country, then move back; spend three months making sandwiches in a cafe in Alaska; throw all my savings into a furniture store for a short year; then cut and run with a backpack across the African continent for another.

I loved, lived, and slept with whomever I pleased. I keep a Post-it in my wallet that says, "I can do anything I want to."

But the freedoms that come with childlessness are much more profound than the thrill of wild adventure, wild sex or wild precarity. I have the time to think, to be creative, to cultivate a career of my own curation. Now that I am biologically incapable of having children, thanks to menopause, I have a fresh perspective on the nature and possibility of reproductive choice.

When speaking with younger female friends who are struggling with the children question, I rely on different arguments to reassure them that it is absolutely possible to have a satisfying and fulfilling life without children.

Among them: every day I didn't buy diapers, I was sticking it to the man.The American Dream is a corporate wet dream: the house with a two-car garage, white picket fence, and an UPPAbaby Vista stroller for $899.99.

Capitalism is deeply invested in incentivizing the mythical traditional family - even as it impoverishes and undermines actual families. Tax credits benefit married couples and parents - which is great, but these policies leave non-traditional families to fend for themselves. For decades, social conservatives have wrongly seen fatherlessness as a family crisis, bemoaning divorce and out-of-wedlock motherhood, and devising policies that support "traditional" families - as they define them, straight, married and mortgaged to the hilt.

Capitalism is deeply invested in incentivizing the mythical traditional family - even as it impoverishes actual families

Neoliberalism offered little relief, seeing women who were liberated from the kitchen as a new and exploitable sector of the workforce. Paying women less than men - in 2019 women earn 79 cents to every male dollar - serves two nefarious purposes: it provides corporations with discounted labor, and it keeps women dependent on men.

(Let me tell you, ladies, nothing makes it easier to get out of a bad or even violent marriage than having your own money.)

Still, domesticity is a compelling narrative, the story of a life of order, stability and security - and most of all, enduring love.

I've fallen for it a couple of times. Birth control set me free.

y gendering domestic labor - women's work is cleaning, cooking, caring for children, spouses, and increasingly, elders - religious conservatives (and let's be honest, society at large) ensure that male headship and female subservience continue.

Once I figured out that if I didn't dirty the dishes I didn't have to wash them, I was liberated from unfair and unequal domestic responsibilities. It's much harder to get out from under domestic labor when you have children, your husband earns more than you do, and daycare costs more than you would earn at a job.

What's more, women are still told that our value is in our domestic achievements, so we put our all into being good homemakers, mothers and wives. "It's hard for me to understand when cooking became more repression than liberation," Lyz Lenz wrote for Glamour in 2018, "more act of obligation than act of creation. This thing that had sustained me now felt like a prison. And whose fault was it? It certainly wasn't all my husband's." We fool ourselves (and each other) into thinking that if we love the task, we're not oppressed.

If our labor is coded as love and kindness, those most feminine qualities, or even achievement and pleasure, men are free to pursue their own interests without being encumbered with family care. Lenz's husband used to rate her meals, never giving her a five out of five because he didn't want her to stop trying so hard to please him. That's patriarchy, sisters.

There's no way I could do what my sister - the mother of two teenagers, and a homeowner with two part time jobs - does in a day. Nor would I want to.

If time is money, time is also children. Mothers today can have everything - marriage, a career, a beautiful, clean home, health insurance, doting children - but only if they can afford the domestic help doing so requires.

Not having children has allowed me to direct that time and attention to my work and my community. And if the world needs anything right now, it's strong communities.

I spent thousands of dollars and countless time and anxiety trying not to get pregnant during my reproductive years. Two abortions and decades of birth control later, I'm one of the lucky ones.

Around the world and across the US women still struggle to control their own reproductive health. Recent attacks on abortion and birth control are as revanchist as they are destructive to women.

Family planning, studies continuously show, improves the lives of women and children, from better health outcomes to higher education rates. We honor the lives of our sisters by working to preserve access and affordability of reproductive services.

here are other misleading stories that young women are told about not having children. Once and for all, let's dispel them: everyone dies alone and having children will not ensure that someone will sit by your deathbed; nor can we expect our children to financially or emotionally support us (and besides, that's a terrible expectation); women are no better at so-called domestic tasks than men, we've just been scapegoated into cleaning and cooking; sure enough, a mother's children are the most important thing in her life, but if you have no children, well, some other most important thing gets room to be and become.

By some luck of the draw, some DNA hiccup, by the lessons of a hideous childhood and the measure of the lives of my female forebears, I knew early on that I wasn't cut out to be a mother. Or, to put it quite another way, I intuited that I had different priorities - and options! - than my meticulous Mennonite grandmother, who raised four children, kept a one-acre garden, taught preschool at church and cleaned the house, top to bottom, (even behind the refrigerator) the very same day every week for more than six dozen years.

Menopause has only added more nuance to the vital question, who the hell am I right now?

I am a woman who has no regrets about not having children and who knows the clear difference between caring for others and respecting myself. It is our obligation as women to help others understand and embrace this difference. Sometimes an ironed shirt is just an ironed shirt.

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Why I don't have a child: I cherish my freedom

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Last autumn, I fell in love for the first time in at least 20 years. That enormous feeling overwhelmed me like fall in New England or a natural disaster. I knew I was in serious trouble when I found myself patiently, even blissfully, ironing his shirts.

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"The most frequently mentioned effects [of not having children] are distress, raised depression and anxiety levels, lowered self-esteem, feelings of blame and guilt, somatic complaints, and reduced sexual interest" (Balen).

Not having children affects a person's psychological state, in both qualitative and quantitative data.

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Introduction

Approximately 70-80 million couples world wide are currently infertile (Bos et al., 1995; Boivin et al., 2007) and it can be estimated that tens of millions of couples are primary infertile or childless. For most people, having children is immensely important; not being able to have children is a major life problem. There is also a large group of women and men, who have children, possibly form a previous relationship, who desperately wants to have another child. A considerable body of research in Western countries has shown that involuntary childlessness has strong psychological consequences (see for reviews: Greil, 1997; Brokvich and Fisher, 1998). Most of the studies carried out in this domain are quantatitative and some are qualitative. Both kind of studies, point in the same direction: there are various psychological and psychosomatic effects, and especially women are affected. The most frequently mentioned effects are distress, raised depression and anxiety levels, lowered self-esteem, feelings of blame and guilt, somatic complaints, and reduced sexual interest. For a small minority of women and men in the Western world these effects are at a clinical level or can be considered extremely serious (Greil, 1997).

It is interesting that social and cultural consequences are seldom mentioned in the reports on these studies. When these aspects are considered, they are often related to studies about elderly people without children, regardless of the reason for being childless. It is stressed in the reports of these studies that frail old people without children have less social support (cf., Johnson, 2006) and a less robust network for independent living compared to old people with children (cf., Wenger et al., 2009). Wirtberg and co-workers (2007) however, carried out a study that is unique in the sense that it aims at elderly involuntarily childless women. They reported on 14 women, and described that in all cases but one sexual life was affected negatively and that half of these elderly childless women were separated.

Some studies, report the difficulty that childless couples have in communicating with friends who do have children. They describe negative (although sometimes well-meant) remarks within the couples' social worlds, for instance at birthday parties and other social gatherings; however, supportive reactions are also mentioned very often (Greil, 1991; van Balen et al., 1996; Schmidt, 2006). It is possible for childless couples to participate in the 'world of children', especially if couples have good friends or relatives who have children. They are able to participate in the lives and activities of the children of their friends and relatives by, for instance taking care of the children for a part of the week or when the parents are on holiday; taking the children to school, music lessons or sports activities; or going to games or shows in which the children participate. An early study on childlessness found that about ten per cent of couples had chosen this strategy as a way of coming to terms with their childless life (van Balen, 1991) Also, recently Wirtberg and colleagues (2007) described this as typical coping strategy for childlessness. It appears that in the West childless people are not formally excluded from being involved with raising children.

In the 1990s, studies were published about the effects of childlessness in developing countries. The focus of these studies was different from studies carried out in the West. Although psychological effects are described, the main concerns are social and cultural effects (van Balen and Inhorn, 2002). This paper presents a review and an analysis of the results of the studies done to date in poor-resource areas regarding the social and cultural effects of being childless.

Methods

Literature search

To collect the studies, four Internet online databases were searched. These were Web of Science, Academic Search Premier, Science Direct and PiCarta. The following search terms were used on subject areas: 'childless/childlessness' combined with 'consequences/effects' and 'infertile/infertility' combined with 'social consequences/effects'. In addition, chapters were collected from three edited volumes, namely Social Science Research on Childlessness in a Global Perspective (2000), Women and Infertility in sub-Saharan Africa (2001) and Infertility Around the Globe, New Thinking on Childlessness, Gender and Reproductive Technologies (2002). Finally papers that were possibly additional to the Internet search, were collected from special issues of journals on the topic of infertility in poor resource areas, viz: Patient Education and Counseling (1997, 2005), Reproductive Health Matters (2002), Journal of Infant and Reproductive Psychology (2004), Journal of Psychosomatic Obstetrics and Gynaecology (2007). By using the search term infertile/infertility (which may comprise secondary infertility) studies that involved women or men who want to have another child, were included in the database.

Interpretative phenomenological analysis

A method based on interpretative phenomenological analysis ( IPA; Smith and Osborn, 2004) was used to order the results reported in the studies. IPA is especially useful in exploring and ordering new topics (Chapman and Smith, 2002). This method is normally used in empirical studies, in this case however it was adapted for application to a literature review. The adaptation process started from a certain framework of analysing and grouping results, followed by recoding and regrouping of the results, adapting the framework definitions of concepts, and then re-assessing and improving the way the findings of the various studies were ordered so as to establish the final framework and definitions of concepts and to locate the results in the categories and levels. To improve coherence and consistency, the co-author also coded categories, levels and frequency indications of a quarter of the studies and evaluated the concepts and assessed the framework. In this way, the results reported in the various studies were ordered into categories, intensity levels and frequency ranges.

Categories of consequences

Consequences were initially categorized according to four fields in which effects are mentioned in the various reports, namely the social, economic, legal and religious fields. While carrying out the rounds of IPA described above, it appeared more feasible to adapt these four categories. In-law effects were added to the 'economic' category because there were often essential economic effects attached to problems in the relationship with the in-laws. Couple relationships with extended family appeared to be a separate issue from 'within couple effects' which were coined 'marriage effects'. Marriage effects, such as marital instability and possible divorce, often appeared to be associated with other legal effects and were therefore added to the 'legal' category. Social effects were renamed 'community effects', in order to disentangle them from the more general use of the term social (e.g. 'social sciences' or 'social life'). The category 'religious' was augmented with the aspect 'spiritual', because this aspect was mentioned in some of the studies.

Intensity of effects

Several levels of intensity within each category were used to describe the effects. It was convenient to consider four levels for each category and to include in each category effects that have roughly the same intensity.

Community effects (from lowest to most intense level): (i) status loss, including no respect and being a social failure; (ii) ridicule, including insults and verbal abuse; (iii) stigmatization or recognizable marginalization; and (iv) isolation, including exclusion (from ceremonies and social gatherings), rejection, being an outcasts and physical abuse perpetrated by community members.

Economic and in-law effects (from lowest to most intense level): (i) costs of treatment (biomedical or traditional); (ii) no economic security, including no care in old age, no economic support from others, unable to find work, no connections and restricted land use; (iii) harassment, pressure and rejection by in-laws; and (iv) exploitation and abuse perpetrated by in-laws.

Legal and family aspects (from lowest to most intense level): (i) inheritance restrictions, including other legal restrictions such as property rights and burial rights; (ii) marital instability, including fear of the husband taking a second wife or divorcing the childless woman; (iii) the husband actually having a second wife; and (iv) divorce, including also expulsion from the home and physical abuse and violence perpetrated by the partner.

Religious and spiritual effects (from lowest to most intense level): were ordered as follows (i) effects perceived by oneself: not to have children in order to fulfil religious obligations; (ii) diverse forms of witchcraft attributed to the infertile person; (iii) having the 'evil eye' or being a considered a person whom it is better not to touch; and (iv) being considered a person who brings illnesses and disasters to the community.

Frequency of effects

Because most of the studies that were collected were qualitative in character, the effects are often reported in descriptions, like 'almost all', 'common', 'frequently', and 'a few', 'one case'. It appeared most feasible to use three frequency ranges: (1) all, almost all, majority, most; (2) many, frequent, often, common, not uncommon; and (3) some, a few, one (in small samples). In some of the reports clear indications of the frequency of some or all findings are absent. However, it could be deduced from the context whether the effect could be ranked in one of the three levels. Nevertheless, in a considerable number of papers this appeared not possible and therefore the effects were not quantified for these studies.

Results

The studies

Thirty-nine studies into various social effects of childlessness in poor-resource areas were collected. Of these, 19 concerned areas in sub-Saharan Africa, and 13 concerned areas the Indian subcontinent (India, Pakistan, Bangladesh, Sri Lanka). Just two studies were found concerning North-Africa and the Near East and only one concerning a Latin American country.

Some studies were sociological in character, based on a large survey and presented quantatitive data (Sundby 1997/1998; Unisa, 1999; Mulgoankar 2000a/2000b). In one of these (Sundby 1997/98), more sensitive issues were reported, that were collected through in-depth interviews in a smaller subsample. Four studies started with a psychological perspective (Denga, 1982; Fido and Zahid, 2004; Wiersema et al., 2006; Donkor and Sandall, 2007). Donkor and Sandall (2007) and Wiersema and co-workers (2006) used a quantitative methodology to collect psychological and social data, while in the last authors also carried out semi-structured interviews on a subsample regarding socio-cultural aspects. Denga (1982) and Fido and Zahis (2004) reported on social effects but described only the methods used to collect psychological data.

The other studies had an anthropological approach, and employed various qualitative methods, mostly in-depth interviews with infertile people (see table 1). A few of these were based on a limited number of cases. The study by Riessmann (2000a/2002) used narrative analysis on three cases. Hollos (2003) and Hörbst (2008) performed out a qualitative analysis based on six, respectively two life histories. The report by Jenkins (2002) is a case study written in a novel-like style.

In several studies the number of the sample of infertile persons interviewed was absent (Neff, 1994; Boonmongkong, 2000; Feldman-Savelsberg, 2002). Also, in reports that used various sources of information, it is not always clear which source was the origin of the various results (Neff, 1994; Feldman- Savelsberger, 2002; Handwerker, 2002). Furthermore, a number studies were based not on information provided by infertile persons themselves but, for instance, on key-persons and focus group discussions (Okonufua et al., 1997), attitudes in the general population and key Churchpersons (Pearce, 1999) or stories in newspapers and movies (Meyer, 1994). Only a few studies focused specifically on men (Dyer, 2004; Hörbst 2008). In the studies that included men, the focus was mainly on women (Bharadwaj, 2000; Nahar, 2000; Wiersema et al., 2006).

Some papers had a limited perspective to start with and included only some aspects of childlessness, such as marital relational aspects (Denga, 1982), religious and spiritual effects (Meyer, 1994). Other studies were specifically focused on stigma (Apte et al., 2004; Donkor and Sandall, 2007), identity, social construction and meaning (Neff, 1994; Kielman, 1998; Mariano, 2000/2004), treatment technology (Handwerker, 2002) and sexual dysfunction (Nene et al., 2005). Most studies however, were not explicitly limited in focus with respect to the various social effects of childlessness. Sixteen of the reports listed at least effects in three of the social categories of effects, while 11 reports do so in two categories.

Regarding the settings, about half of the studies (18) were carried out within a community or were based on surveys in the community or the country. About the same number (15) were carried out in a medical setting or started out from a sample collected through clinics, gynaecologists and other health personnel. Two studies (Bahti et al., 1999; Riessman, 2000b) used samples from a medical as well as a community source. Another report (Boonmongkong, 2000) did not specify the origin of the sample (see table I ).

Table I.

Study

Area/culture/class

Community effects

Economic and in-law relation effects

Legal and marriage effects

Religious/spirit effects

Sample, and Methods

Setting and Focus Limitation (if explicitly mentioned)

SUB-SAHARAN AFRICA

Sundby, 1997/ 1998

The Gambia
Islam
National

Verbal abuse (some)
Stigma (ni)

-

Inheritance restricted (all)
Marital instability (many)
Fear of extra wife (often)
Extra wife (some)
Divorce (some)

-

243 infertile women questionnaire; 17 women and 2 men unstructured interview; 4 women in-depth interviews and keypersons

Countrywide survey
Primary and secondary infertility

Meyer, 1994

Ghana
Christian/spirits

-

-

-

Evil eye (ni)
Witchcraft (ni)

Analysis based on stories in media

Newspapers, magazines and movies
Having no children
Limited to: Spiritual aspects

Donkor and Sandall, 2007

Ghana
Urban and rural

Stigma (majority)

-

-

615 women waiting for treatment; Questionnaire based survey

Medical setting
Primary and secondary infertility
Limited to: Stigma

Denga, 1982

Nigeria
Christian
Urban

-

-

Marital instability (common)
Extra wife (common)
Divorce (common)

-

40 childless women and 40 controls: but no information about collection of social effects

Gynaecologists records
Childless women
Limited to: Marital relationship

Okonofua et al., 1997

Nigeria
Yoruba
Patrilocal

Outcasts (ni)

No economic security (often)

Inheritance restricted (often)
Expulsion of the husbands house (common)
Divorce (common)

Witchcraft (often)

Focus group discussions with key persons

Community setting
Primary and secondary infertility

Koster-Oyekan, 1999

Nigeria
Urban
Patrilocal

Stigma (ni)

Fear of extra wife (ni)
Fear of divorce (ni)
Divorce (some)

Being a witch (ni)

In-depth interviews with 25 women confronted with infertility and several keypersons
Questionnaire of school youths
Semi-structured questionnaire among other women visiting traditional healers

Community-based Childless (barren) women

Pearce, 1999

Nigeria
Yoruba

No respect (many)
Ridicule (many)
Stigma (margin) (many)
Outcast (many)
Exclusion ceremonies (all)

Old age (ni)
No connections (all)

Burial rights (ni)

-

Based on 2 previous break/>studies: attitudes of 104men and women, and interviews and participant observation charismatic churckeypersons

Community break/>attitude about childlessness
Being childless

Hollos, 2003

No economic security (some)

Divorce (all)
No right of residence (expulsion) (all)

-

6 women aged 30-80: life histories

Community based, household survey
Childless (barren) wome

Leonard, 2002

Ridicule (ni)

Rejection by in-laws (ni)

Marital instability (ni)
Divorce (often)

-

Conversations with 21 selfdefined infertile Women

Based on household survey (170 interviews)
Self-defined infertility

Hörbst, 2008

Mali
Urban

Status loss (ni)
Verbal abuse (ni)
Stigma (ni)

-

-

2 males with infertility (results based on one case)
Participant observation and in-depth interviews

Medical setting
Having no child

Feldman-Savelsberg, 2002

Cameroon
Rural poor

Less gifts and less land (ni)

No property after divorce (ni)
Fear of divorce (ni)

Witchcraft (ni)

Participant observation, and interviews with infertile women, husbands and keypersons
No numbers given

Community level and medical personnel
Childless (by implication)

Kielman, 1998

Tanzania
Islam
Villages

-

-

Divorce (often/common)

-

25 interviews with selfdefined infertile women

Based on local health clinics
Self-defined infertility
Limited to: Identity of infertile women

Gijsels et al., 2001

Tanzania
Urban district

No respect (ni)

Old age (ni)
Child labour (ni)

Marital instability (mostly)
Extra wives (few) Divorce (most)

-

30 life histories of infertile women

Medical setting
Primary and secondary infertility

Hollos and Larsen, 2008

Tanzania
Urban

No respect (all)
Verbal abuse (all)
Stigma (all)

Harassment by in-laws (often)

Marital instability (often)

-

25 infertile and 23 fertile women;
In-depth Interviews

Based on household survey
Childless women

Gerrits, 1997/2002

Mozambique
Rural
Matrilineal

Stigma (all)
Isolation (all)
Exclusion (ceremonies) (all)

Lack support old age (almost all)

Fear of divorce (some)

-

Snowball 25 infertile women, 9 cured, 10 fertile, and keypersons;
Semi structured interviews

Snowball starting from community level
Childless women

Mariano, 1999/2004

Mozambique
Rural
Patrilocal

Stigma (fringe) (ni)

-

Fear of divorce (ni)

-

18 infertile women; informal interviews (3 cases reported on)

Community level
Childless women
Limited to: Meaning of childlessness

Upton, 2001

Botswana
Village area

Status loss (ni)
Ridicule (ni)
Islolation (ni)

-

-

-

Participant observation, Interviews and discussion with infertile persons, community leades (no numbers given) and 17 traditional healers.
Two case studes described

Community setting
Primary and secunday infertility

Dyer, 2002

South Africa
Urban

Status loss (some)
Verbal abuse (many)
Stigma (many)

-

-

-

27 men seeking treatment; In-depth interviews

Infertility clinic
Partly women with child (secondary infertility

Dyer, 2002

South Africa
Urban

Ridicule/ verbal abuse (many)
Stigma (many)
Outcasts (many

-

Marital instability (many)
Fear of divorce (many)
Physical abuse by partner (few)

-

30 women seeking treatment; In-depth interviews

Infertility clinic
Partly women with child (secondary infertility)

INDIAN SUB-CONTINENT

Bhatti et al., 1999

Pakistan
Low income Urban

Isolation (one)

Pressure by in-laws (one

-

-

17 infertile women;
In-depth interviews

Clinic and community based
Having no children

Neff, 1994

India
Tribe

Stigma (margin) (ni

-

-

-

Anthropological fieldwork and case study (no numbers mentioned)

Community based
No indication of kind of infertility
Limited to: Social construction of infertility

Bharadwaj, 2000

India
Several big cities

Stigma (almost all) Isolation (ni)

Harassment by in laws (ni)

-

-

45 semi structured interviews in IVF clinics (women and men)

IVF clinics
Primary infertility (by implication)

Mulgoankar, 2000a/2000b

India
Urban slum

Status loss (ni)
Verbal abuse (ni)
Stigma (ni)

Cost of IVF (some)
Harassment by in-laws (ni)

Fear of divorce (ni)

-

225 childless couples semistructured interviews (results based on women's reports)

Community based on household survey
Being childless

Riessman, 2000a/2002

India
Middle class

-

Harassment by in-laws (all)
Exploitation by in-laws (one

Fear of divorce (some)

-

Narrative analysis 3 childless women of upper class; In-depth interviews

Community based
Childless women

Riessman, 2000b

India rural Kerala

Pressure by in-laws (all)

Fear of divorce (some)

-

31 in-depth interviews with infertile women, participant observation

Infertility clinic and village based childless women

Unisa,1999

India Villages

No respect (some) Verbal abuse (some) Stigma (common) Isolation and Exclusion (ceremonies) (frequently)

-

Fear of divorce (few)
Extra wife (some)
Physical abuse husband (some)

-

332 childless women: questionnaires; 60 childless women: semi structured interviews (not reported on)

Community based on household survey Childless women

Apte et al., 2004

India
Sex workers

Stigma (all)

-

-

-

107 childless female sex workers; Interviews and group discussion

Data collected in workplace area (community) Childless women Limited to: Stigma

Meera Guntupalli and Chenchelgudem, 2004

India
Tribe

-

-

Divorce (some)

-

5 infertile, 22 cured and 11 fertile women. Participant observation, in-depth interviews, and informal interviews

Community based
Childless wome

Nene et al., 2005

India Urban

Stigma (distinction) (almost all) Rejection (humiliation at gatherings) (almost all)

Harassment and rejection by in-laws (many) Exploitation by in-laws (very common)

-

-

40 couples with sexual dysfunction; Semi structured and in-depth interviews

Fertility clinic Childless couples with sexual dysfunction

Widge, 2005

India
Middle class
Urban

Verbal abuse (many)
Stigma (many)

Cost of IVF (all)
Rejection in-laws (some)

-

-

4 couples and 18 women in treatment; In-depth interviews

Infertility clinic
Being childless

Nahar, 2000

Bangla Desh
Poor urban

Status loss (many men)
Ridicule (ni)
Stigma (all women)
Physical abuse (ni)
Rejection (all women)

No work (many women)
Rejection by in-laws (some women)
Exploitation by in-laws (some women)

Fear of divorce (frequent women)
Rejection by husband (many)

Not to touch (all women) Responsible for illnesses (one woman)

20 infertile women;
In-depth interviews, and 60 men and women general population

Community based
Being childless

Nahar, 2007

Bangla Desh
Poor rural and middle class big city

Cost treatment (almost all)
Old age (rural: mostly)
Social Support (especially: rural)
Child earnings (rural: mostly);
Rejection in-laws (common

-

Community based and social network
Being childless

OTHER AREAS

Inhorn, 1994

Egypt
Islam
Urban poor

Stigma (ni)
Rejection (ni)
Exclusion (ni)

-

Fear of extra wife (ni)
Fear of divorce (ni)

Evil eye (ni)
Witchcraft (ni)

100 infertile women and 90 fertile women;
Semi structured interviews

Hospital based
Being childless

Fido and Zahid, 2004

Kuwait
Islam
Litterate and Illetrate

Stigma (all)

-

Fear of divorce (some) Fear of violence (some)

-

120 women and 125 controls: but no information on collection of social effects

Hospital based
No indication of kind of infertility
Limited to: Psychological distress

Handwerker, 2002

China
Big cit

Social failure (ni)

-

-

Pious duties (ni)

100 women in treatment by questionnaire, 50 other women and 5 men semi-structured interviews, and interviews with various keypersons

Hospital based
No child (by implication)
Limited to: IVF as a new technology

Pashigian, 2000/2002

Vietnam
Rural

Social failure (no respect) (some)
Insults (some)

Treatment costs (ni)
Old age (ni)
Harassment by in-laws (ni

Fear of divorce (some)
Fear of extra wife (some)

Pious duties (ancestor) (frequently)

39 women in treatment, and 10 women with one child; Ethnographic interviews and life histories

Interviews in hospital
Having no child

Wiersema et al., 2006

Vietnam
Big city

-

Cost of treatment (some)
Old age (many)
Pressure by in-laws (some)

Fear of divorce (frequent)
Marital instability (not uncommon)

-

118 couples questionnaire psychological and medical aspects. Results based on 15 men and 13 women in treatment by semi- structured interviews

Interviews in hospital
Primary infertility

Boonmongkong, 2000

Thailand
Bhoedhism

Stigma (some)

Rejection by In-laws (ni)

Fear of extra wife (all)
Fear of divorce (all)

-

Interviews female
Patients; No numbers give

No information about setting
Primary infertility (by implication)

Jenkins, 2002

Costa Rica
Roman Catholic
Urban

Stigma (ni

-

-

-

One childless couple followed for more than year; Life story

Landlord/lady of researcher
Childless couple

The large majority (28) of studies concerned persons who were childless or primary infertile (never been pregnant). However, this is not always clearly specified in a methods section or the introduction, but could be deduced from the description and the results (or by implication), and in one case based on state politics (Handwerker, 2002). This last mentioned paper was based on interviews with infertile women in China, at a time and in an area where a strict one child policy in force. Seven studies included primary and secondary infertility (having been pregnant before), or people who had a child in the current or previous relationship. Two reports used the concept of self-defined infertility; that is the woman defines her situation as infertile, irrespective of the medical or social definitions (Kielman, 1998; Leonard, 2002). In two papers the term 'infertile' was used without there being sufficient information to decide whether or not this included women with children (Neff, 1994: Fido and Zahid, 2004).

Social effects

Community effects are mentioned in almost all reports (32). Stigma was mentioned the most (in 25 reports), while the highest intensity of community effects (isolation, rejection and exclusion) is mentioned in 14 reports. Status loss, social failure and no respect are also mentioned in 14 reports, as are ridicule and verbal abuse.

Economic and in-law effects are mentioned in most studies (21). In five of these, the effects concern the costs of infertility treatment, by either modern biomedicine or traditional medicine (e.g. healers or herbs). In 11 cases, economic insecurity is mentioned, for example no support in old age, receiving fewer gifts and less land, and having fewer relations. Harassment and feeling rejected by in-laws are mentioned in 15 reports, in four reports this was at the level of exploitation and abuse.

Legal and marriage effects were are reported in 26 of the reports. In five cases, the effects concerned inheritance restrictions and restricted burial rights. Many (21) of the reports mention marital instability, fear of divorce or fear of the husband taking an extra wife. Five of the reports state that husbands had actually taken a second wife. Divorce, expulsion from the home or physical abuse perpetrated by the husband is mentioned in 11 reports.

Religious and spiritual effects are mentioned in a few (8) of the reports. In two reports these had to do with the thoughts and feelings of the infertile person, namely fearing that pious duties could not be carried out after one's death. The other cases concerned accusations of witchcraft: diverse forms of witchcraft were mentioned five times, having the evil eye or being considered a person one had better not touch three times, and considered someone who brings illnesses and disasters to others in one paper (see figure 1 ).

Frequency of incidence

The frequency of incidence of at least one of the social effects of being childless was indicated in 30 of the reports. More than half of these reports mention status loss and ridicule as happening frequently or always. The majority of the papers indicate that stigma and isolation are happening to most of the infertile persons. Several of the other social effects, such as no economic security, harassment by in-laws and marital instability were reported in about half of the papers as happening often. In the papers that mentioned the frequency in which husbands have actually taken a second wife or actually divorced their wives this was described in about equal numbers as happening in a few cases or happening often (see figure 2 ).

Comparison of sub-Saharan Africa and the Indian subcontinent

A comparison was made regarding the two regions in which most of the studies were carried out, namely sub-Saharan Africa (19 studies) and the Indian subcontinent (13 studies). The studies performed in the Indian subcontinent reported the most severe level of community effects (isolation) more frequently than the studies carried out in sub-Saharan Africa (54% vs 32%). Also, stigma was reported more often in the studies performed in the Indian subconinent compared to these in sub-Saharan Africa (77% vs 53%). Harassment (69% vs 16%) and exploitation (23% vs 5%) by in-laws were also reported much more in studies carried out in the Indian subcontinent compared to these performed in sub-Saharan Africa. On the other hand, actual divorce as a consequence of being childless was more frequently reported in sub-Saharan Africa than in the Indian subcontinent (47% vs 15%). Also a a lack of economic security was more often reported in the sub-Saharan studies compared to these in the Indian subcontinent (37% vs 15%) (see further figure 3 ).

Discussion

Over the last decade, a substantial number of papers have been published about the social consequences of being childless in poor resource areas. This subject is thus getting at least some of the attention that was promised in the action plan of the International Conference of Population and Development in Cairo (ICPD, 1994), which for the first time included infertility care in its goals for reproductive health. However, it is remarkable that most of the studies were carried out in sub-Saharan Africa and the Indian subcontinent. Almost no papers have been published about Latin America or North Africa and the Near East. The majority of the studies in sub-Saharan Africa were carried out by Western anthropologists. It can be speculated that sub-Saharan Africa is still a very accessible area for Western anthropological research, and this is helpful in publishing in international (English-language) journals. The studies performed in the Indian subcontinent were mostly undertaken by scientists indigenous to the area. In the Indian subcontinent, in contrast to many other areas, English is both still an official language and language that scientists use to communicate, which is an advantage as regards getting papers published in international journals. These factors may be partly responsible for the relatively large body of papers concerning the two areas that are published in international journals.

Regarding the few papers published about areas in North Africa and the Near East, one can speculate that the rather prominent separation between the world of men and that of women in many Arabian and Islamic areas might hamper research in this field, especially because of the difficulties in getting access to women in the home. Regarding the few studies carried out in Latin America, social consequences of childlessness might be less intense, because of the same cultural and economic forces that might explain the lack of serious social consequences in Western societies. Some cultural researchers state that Latin America has much in common with Western Europe and could possibly be considered a sub-civilization within Western civilization (Huntington, 1997) or is closely linked to Western culture and especially to that of Catholic Europe (Inglehart 1997).

The most frequently mentioned serious consequences of being childless are in the realm of community effects, in-law effects and effects on marriage. These severe effects concern almost exclusively women. This might be partly caused by still prevailing ideas that infertility is a woman's 'fault' or the denial of the existence of male infertility. It is remarkable that the most severe community effect, namely isolation and exclusion, is mentioned in ten reports. This situation creates an extremely difficult life for childless women, especially in communities in which people are well known to each other. But also stigma or being marginalized (mentioned in 24 reports), makes life very difficult in a village or quarter in which community life is the centre of most human interactions. The reactions of in-laws, and especially the mother in-law, also make childlessness difficult to bear: harassment and rejection by in-laws is reported in 14 studies, while exploitation of the childless woman by the in-laws (husbands' family) is reported four times. In addition and often also influenced by in-laws, childlessness may lead to marital instability as described in 20 reports. Five reports state that husbands have actually taken another wife, and 11 state that husbands have divorced their childless wives. These effects on marriage are not so different from those reported by a recent study among elderly involuntary childless women done in the West (Wirtberg et al., 2007). However, positive marriage effects have regularly been reported in studies in Western countries on couples in treatment or during reproductive life (Van Keep et al., 1973; Callan, 1987; Baram et al., 1988; Schmidt et al., 2005). These effects are supposed to be associated with the shared experience of husband and wife of having to adapt to infertility and treatment. In contrast to marriage effects, accusations of witchcraft, including having the evil eye or being responsible for illness, are not mentioned very often (six studies) but this may indicate that community members try to avoid and exclude childless women as much as possible.

In studies carried out in the Indian subcontinent, community effects and especially in-law effects are reported more often than in studies performed in sub-Saharan Africa. This might be explained by the possibly greater importance of in-laws in the lives of married women and their nuclear families, in the areas were the studies have been carried out. Actual divorce is mentioned more in the sub-Saharan studies. Here, a role may be played by local customs related to marriage and divorce that makes dissolution of the marriage easier and more common. However, in describing these differences it is necessary to remark that there are of course large differences in cultural and economic circumstances within both these parts of the world, and this makes overall conclusions very preliminary and rather imprecise. This applies especially to the comparison between sub-Saharan Africa and the Indian subcontinent.

A considerable number of the studies were limited in focus and did not take into consideration all discerned types of social effects, thus effects might be unreported or under-reported. Some of the studies included research among childless persons as well as among women and men who already had a child. Assuming that the effects of not having a child at all are greater than the effects of not being able to have another child, there might be also under-reporting on severity of effects. Furthermore there are some considerable uncertainties in the reports that make the results difficult to interpreter. Some of the studies did not report very well on the numbers of respondents or the frequency of effects. Social effects were sometimes described without revealing the sources of this knowledge. In other cases, in which different methods for information gathering were used, it is not always clear on which source the various results were based. In addition, about half of the studies were based on samples of women or couples who were looking for treatment or were having treatment, and thus those who did not visit hospitals, clinics or other health-care centres were not included. According to the study by Boivin and colleagues (2007), this number might be about half of the infertile populations in the areas concerned.

Most studies were qualitative, used small samples and were very local. Although qualitative research is very useful in exploring new areas and new issues, quantative studies could help to corroborate the findings. Moreover, it would allow for statistical analysis, in particular it would be possible to analyse the relationships between the social effects of childlessness and the socio-economic and cultural variables.

Of course, whether or not one has a child is not the only factor that influences one's status and one's well-being; for instance, Donkor and Sandall (2007) showed that infertile women in Southern Ghana with a relatively high status in the community that is derived from other factors (e.g. education), were less stigmatized than other infertile women. Nahar (2007) also described that childless women from poor rural families suffered much more than childless women from the urban middle class in Dacca. Also, Riessman (2000b) described a lesser ferquency of insults and ridicule among economically priviliged childless women than among poor chidlless women in rural Kerala.

In contrast to most Western studies on childlessness and infertility few studies in poor resource areas have focused on psychological effects. It might be expected that the often intense social consequences described above may exacerbate the psychological consequences (e.g. stress, anxiety, depression and health complaints) much more than in the West. Indeed, a study by Dyer (2005) into the psychological distress of infertile women in a local community of Cape Town showed that women who reported intense social effects (i.e. physical abuse perpetrated by their husbands) suffered considerably more stress than infertile women in non-abusive relationships.

Finally, it can be asked whether economic and social development will ameliorate the often immensely serious consequences of being childless. In the rich Western countries, these social effects are seldom found. It is possible that some of the economic consequences regarding for example, care in old age and lack of economic security will diminish as economies develop further. Couples will be much less dependent on their children for their income. In Western countries, on a lifetime basis children cost more than they deliver. Economists have calculated that in the West a woman who has children will earn about EUR 100,000 less than a woman who does not have children (Mertens et al., 1995; Pott-Butter, 1997). The Dutch 'household budget' institute recently stated that one child costs about 17% of the mean annual family income, and two children about 26% (Nibud, 2009). Across the Atlantic, the US Department of Agriculture stated in an Internet release that to raise a child to the age of 17 costs USD 150,000-300,000, depending on the family's social class (USDA News Release 0023.09). It might be argued that also in developing areas the balance between earnings and costs of having children is changing, because in the last decades the mean number of children per couple in many developing areas has decreased dramatically, especially in Asia, North Africa and the Near East (Population Studies, website 2009). Associated with this it appears that the nuclear family is becoming more and more the ideal family form (Pashigian, 2002; Nahar 2008), which may result in less influence from in-laws, and consequently less harassment by them. Improvements and developments in schooling that lead to more knowledge and information about the causes of infertility may mitigate the negative views of people in the community towards people who do not succeed in having a child and especially towards the end of blaming women for infertility. In this respect, active resilience among some of the childless women as described by Riessman (2000b) and by Nahar (2007) may help to diminish discriminatory behaviour. However, in many areas of the world there is still a pronatalist culture in which, besides the marginalization of involuntarily childless couples, the phenomenon of being voluntarily childless or postponing of having children is not well received (Feldman-Savelsberger, 2002; van Balen and Inhorn, 2002; Kagitbasi and Ataca, 2005). The social acceptance of couples who do not want to have children may be a sign of the disappearance of the stigmatization of being childless. Childless couples will probably continue to suffer negative social consequences as long as under the prevailing cultural forces they are considered less worthy than other couples.

Articles from Facts, Views & Vision in ObGyn are provided here courtesy of The Walking Egg Foundation

# data[].attributes.attachment_link.title
The social and cultural consequences of being childless in poor-resource areas

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Approximately 70-80 million couples world wide are currently infertile (Bos et al., 1995; Boivin et al., 2007) and it can be estimated that tens of millions of couples are primary infertile or childless. For most people, having children is immensely important; not being able to have children is a major life problem.

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One of the "most frequently cited reasons for having an abortion were socioeconomic concerns" (____).

Socioeconomic concerns, as defined by county health rankings are: (Next article)

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Contraception. Author manuscript; available in PMC 2018 May 17.

Published in final edited form as:

Abstract

Objective

Many reasons inform women's reproductive decision-making. This paper aims to present the reasons women give for obtaining induced abortions in 14 countries.

Study design

We examined nationally representative data from 14 countries collected in official statistics, population-based surveys, and facility-based surveys of abortion patients. In each country, we calculated the percentage distribution of women who have abortions by main reason given for the abortion. We examined these reasons across countries and within countries by women's sociodemographic characteristics (age, marital status, educational attainment, and residence). Where data are available, we also studied the multiple reasons women give for having an abortion.

Results

In most countries, the most frequently cited reasons for having an abortion were socioeconomic concerns or limiting childbearing. With some exceptions, little variation existed in the reasons given by women's sociodemographic characteristics. Data from three countries where multiple reasons could be reported in the survey showed that women often have more than one reason for having an abortion.

Conclusion

This study shows that women have abortions for a variety of reasons, and provides a broad picture of the circumstances that inform women's decisions to have abortions.

Implications

Future research should examine in greater depth the personal, social, economic, and health factors that inform a woman's decision to have an abortion as these reasons may shed light on the potential consequences that unintended births can have on women's lives.

Keywords: Induced abortion, Reasons, Unintended pregnancy, Multiple countries

1. Introduction

A growing body of research has examined the reasons women seek an abortion. Many of these studies are based on convenience samples of women from specific subgroups (i.e. ever-married or students) or women seeking abortions or postabortion care at certain health facilities [ 1- 8]. Thus, findings may not represent all women seeking abortions and may instead reflect women who have access to or require facility-based care. Other studies have examined why women obtain abortions during a particular trimester of pregnancy [ 9, 10]. Women who have abortions after the first trimester, however, may be motivated by different reasons from those seeking first-trimester abortions.

The most recent review of women's reasons for obtaining abortions focused on developed countries [ 8]. Although a prior review included developed and developing countries, that study was conducted almost 20 years ago, and the reasons why women have abortions may have changed [ 7, 8]. This paper attempts to fill this gap in the literature by using more recent data to categorize women's reasons for having abortions. Knowledge of these reasons will provide a broad picture of the circumstances surrounding women's abortion decision-making and demonstrate some of the potential consequences unintended births can have on women's lives.

2. Material and methods

2.1. Data sources

We identified data from 14 countries across three types of data sources ( Table A.1 ): official statistics,1 population-based surveys of reproductive-age women (15-49 years) and facility-based data collected from abortion patients. These countries represent diverse contexts that could inform reasons reported for having an abortion. For each country, we present information on geographic region, income classification, abortion law restrictiveness, total fertility rate, and modern contraceptive prevalence ( Table 1 ).

Table 1

Country and year of survey

Geographic region

Country income classificationa

Circumstances under which abortion is legalb

Total fertility rate (TFR)c

Modern contraceptive prevalence (%)d

Turkey, 2003 a

Central Asia

Lower-middle income

Without restriction as to reason

2.3

42.5

For 11 countries, we had population-based data collected by the Demographic and Health Surveys (DHS) and Reproductive Health Surveys (RHS), standardized surveys designed to collect comparable data across countries. Both are interviewer-administered and conducted in-person. Women who reported an abortion in the 5-year period before the survey were included in analyses; if more than one abortion was reported, only information about the most recent abortion was included. The primary reason for having an abortion was captured using the following close-ended question: "What was the main reason you decided to have this abortion?"2 In Turkey, open-ended responses were collected.

One source of US data was from women obtaining abortions at 11 large providers in 2004 using a self-administered survey [ 12]. The first question, used to determine the main reason for having an abortion, stated: "Please describe briefly why you are choosing to have an abortion now. If you have more than one reason, please list them all, starting with the most important one first." Subsequent close-ended questions, related to specific reasons, were used to code women's multiple reasons for having an abortion.3

We extracted data from two peer-reviewed articles that included data about reasons from self-administered surveys conducted in abortion facilities in Sweden and the US [ 13, 14]. The Swedish data were collected from abortion-seeking patients in 13 urban and rural clinics across the middle one-third of the country. Multiple responses were allowed, but the main reason for having an abortion was not collected. The US data were collected between 2008 and 2010 from abortion patients at 30 facilities in 21 states across all regions. These data are included alongside the 2004 US data to provide a more recent snapshot of women's multiple reasons for seeking an abortion. The US and Swedish data sources are not nationally representative.

2.2. Categories of reasons

Each data source categorized reasons for having an abortion. Although the same categories did not exist across all countries, reasons were similarly enough worded to construct overarching categories. In some cases, we collapsed two or more similar categories into a single category. For analyses of the main reason given, we created seven categories: wants to postpone/space childbearing4, wants no (more) children, socioeconomic concerns, partner-related, too young or parents/others object, risk to maternal health and risk to fetal health. All other reasons were included in the 'other' category. The specific reasons comprising each category are listed by country in Table A.2 .

We were unable to create overarching categories of reasons from the peer-reviewed articles. Combining categories would overestimate the percentage of women reporting a singular reason because some women reported more than one reason.

2.3. Measures

For 13 countries, we calculated the percentage distribution of main reasons given for obtaining an abortion.5 For countries with subgroups of women that had data about reasons for at least 100 women, we presented these data according to women's age at abortion,6 marital status, educational attainment, and residence. Lastly, we extracted or calculated the percentage of women citing each reason in the US and Sweden.

2.4. Analyses

We conducted original data analyses using Stata version 14 and applied survey-specific sample weights where appropriate. For countries without publically available data, we extracted the relevant information from published articles and reports [ 13- 17].

3. Results

3.1. Main reasons for abortion

In six of the 13 countries for which we had data on the main reason, the most commonly reported reason for having an abortion was socioeconomic concerns, cited by a plurality of women (ranging from 27% to 40%) ( Table 3 ). In five countries, limiting childbearing was the most frequently reported reason, ranging from 20% in Nepal to 64% in Azerbaijan. In Belgium, the most frequently cited reasons were partner-related (23%) and socioeconomic concerns (23%), and in Kyrgyz Republic, risk to maternal health was commonly reported (44%).

Table 3

Sweden, 2009

United States, 2004

United States, 2008-2010

3.2. Main reasons for abortion by women's sociodemographic characteristics

We examined the three most frequently cited main reasons cited for having an abortion according to women's sociodemographic characteristics ( Figs. 1 - 4 ). In all countries, except Nepal, we observed minimal variation by age at abortion ( Fig. 1 ). While similar proportions of Nepalese women cited socioeconomic concerns, younger women frequently reported wanting to postpone/space children and partner-related concerns, and older women commonly reported limiting childbearing and other reasons.

In three of the four countries with data on reasons for abortion by marital status, some variation exists in the most frequently cited main reasons ( Fig. 2 ). Across all three African countries, married women were more likely to cite postponing/spacing children while unmarried women were more likely to report being too young or family objections ( Fig. 2 ).

The distribution of the most frequently cited main reasons by educational attainment is similar within countries, except in Nepal and Ghana ( Fig. 3 ). In Nepal, less educated women cited partner-related concerns and more educated women reported postponing/spacing childbearing. In Ghana, less educated women cited partner concerns as a key reason whereas more educated women reported being too young or family objections.

Overall, the most frequently cited main reasons for having an abortion did not vary by residence except in Armenia, Nepal and Kyrgyz Republic ( Fig. 4 ). In Armenia, risk to maternal health and postponing/spacing childbearing were commonly reported in urban and rural areas, respectively, and in Nepal, socioeconomic concerns and other reasons were more frequently cited in urban and rural areas, respectively. Urban women in Kyrgyz Republic more commonly reported partner-related concerns while rural women reported limiting childbearing.

3.3. Multiple reasons for abortion

We examined multiple reasons reported by women seeking abortions in Sweden and the US ( Table 3 ). In the Swedish study, women reported seeking abortions because of a desire to postpone childbearing (60%), partner-related concerns (32%), and not being financially prepared (32%).

In the 2004 US data, 89% of women reported more than one reason for having an abortion; slightly more than half reported at least four reasons. The most frequently cited reasons were lack of financial preparedness (56%), partner-related (55%), and interference with future opportunities (54%). These results were comparable with the findings on women's main reason for having an abortion using data in the same survey ( Table 2 ), in that lack of financial preparedness was also frequently cited as a main reason. While partner-related concerns and interference with future opportunities were frequently reported when multiple reasons were allowed, they were less likely to be cited as the primary reason. The recent US data from 2008-2010, presented in Table 3 , show that the top three motivations for seeking an abortion were not being financially prepared (40%), not the right time for a baby (36%), and partner-related concerns (31%).

Table 2

Country and year of survey

Wants to postpone/space childbearing

Wants no (more) children

Socioeconomic concerns

Partner-related

Too young; parents/others object to pregnancy

Risk to maternal health

Risk to fetal health

Other

Total

N

Russia, 2011

10.0

24.0

33.0

17.0

-

11.0

-

5.0

100
a

Turkey, 2003 b

17.3

30.1

24.3

4.5

-

7.4

7.2

9.1

100

1689

4. Discussion

This study highlights the many personal, social, economic and health factors that inform a woman's decision to have an abortion. Socioeconomic concerns or limiting childbearing were the most frequently cited reasons in most of the countries in our study. Few generalizations can be made about these reasons by women's sociodemographic characteristics, partly because only a handful of countries had sufficient data to examine patterns. Our study echoes prior findings that information on only the main reason may not fully demonstrate the circumstances that surround women's abortion decision-making [ 12- 14].

In many of the countries where socioeconomic concerns or limiting childbearing were most frequently cited, a substantial proportion of abortions occurred among young, unmarried women [ 18, 19]. These women may obtain abortions because they lack the financial means to raise a child or feel that having a child would interfere with future opportunities. In the remaining countries, socioeconomic concerns was still ranked highly as a reason for abortion, emphasizing the widespread influence of financial circumstances in women's reproductive decision-making. In the five countries where limiting childbearing was most frequently cited, prior findings suggest that women begin childbearing early and reach their desired family size at relatively young ages [ 17, 20, 21]. As a result, women may spend more years trying to avoid pregnancy while still fecund, and be at higher risk for unintended pregnancies.

Only three of the included data sources collected information on multiple reasons. Findings from the US, where data existed on both primary and multiple reasons, suggest that many factors influence a woman's decision to have an abortion and collecting data on only one reason may overlook the web of circumstances that contribute to the decision-making process. For example, when asked for their main reason, women may choose to focus on either the distal (financial concerns) or proximal (delay childbearing) drivers for obtaining their abortion. Focusing solely on women's primary reason could result in misleading or simplistic conclusions about their abortion decision-making. Future surveys should ask women to report all or a certain number of reasons (in rank order) or incorporate qualitative approaches to help illuminate women's underlying reasons for having an abortion.

This study contains several limitations. In 11 of the 14 countries, the timeframe for abortions was 5 years prior to the survey, while marital status, educational attainment, and residence were measured at the time of the survey. Thus, women's characteristics at the time of their abortion may differ from those at the time of the survey; this likely affects younger women disproportionately. Moreover, recall bias may affect women's responses, especially for those who obtained an abortion further in the past. Future research should consider using panel data to overcome this limitation.

Differential underreporting of abortions in population- based surveys, especially where abortion is highly restricted [ 22], may bias findings of women's reasons for obtaining abortions. Women who report their abortion might have different reasons for seeking one, compared to those who do not report them. The fact that very few unmarried women reported abortions in Asia suggests that differential underreporting was present in this region.

Our study analyzes data from an array of survey instruments with varying data collection procedures and interviewers, which may have affected the quality of responses. Furthermore, population-level data were collected using face-to-face interviews, which could have prompted socially desirable responses to abortion-related questions. Circumstances surrounding the interview, such as how the questions were asked, respondent's comfort level with the interviewer, and location of the interview, as well as the woman's stage of life (e.g., marital status) could affect responses to these questions. Additionally, the social acceptability of particular reasons may vary across countries, influencing which reasons women are more and less likely to report.

Lastly, our study is a descriptive comparison of the reasons why women have abortions. The categories of reasons are necessarily simplified at two levels - country questionnaire and analysis. Rather than fully reflect the reasons why women have abortions, our findings may reflect the structured response categories listed in the questionnaires and our classification of these categories.

Despite these limitations, the evidence suggests that women have abortions for a variety of reasons, and these appear to vary across countries and, sometimes, within countries by women's sociodemographic characteristics. Cross-country differences may be indicative of varied cultural contexts; access to quality and affordable health care; desired number, timing and spacing of births and levels of social stigma and support for childbearing. These findings provide a broad picture of the circumstances that may influence women's decisions to have an abortion and the potential consequences of unwanted childbearing.

Acknowledgments

The authors gratefully acknowledge data assistance provided by Suzette Audam. Additional support was provided by the Guttmacher Center for Population Research Innovation and Dissemination (NIH grant 5 R24 HD074034). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Appendix A

Table A.1

Country

Coverage

Type of data

Year of data

Data source

Sweden

13 urban and rural abortion clinics in middle-third of Sweden

Facility-based

2009

Makenzius et al., Repeat induced abortion - a matter of individual behavior or societal factors? A cross-sectional study among Swedish Women, The European Journal of Contraception and Reproductive Health Care, 2011, 16:369-377

Table A.2

Country and year of survey

Main reason category

Wants to postpone/space childbearing

Wants no (more) children

Socioeconomic concerns

Partner-related reasons

Too young; parent(s) or other(s) object to pregnancy

Risk to maternal health

Risk to fetal health

Other

Footnotes

¹Belgium is the only country for which we had data from official statistics [ 11].

² There was slight variation in the survey question and response codes used across countries.

³ One of these questions, for example, asked: "Is one reason you are having an abortion because...you can't afford a baby now; having a baby would dramatically change your life in ways you are not ready for; you don't want to be a single mother or because of problems with your relationship with your husband or partner; of some physical problem or problem with your health; of possible problems affecting the health of the fetus; or other reasons?"

⁴ We combined postponing and spacing childbearing into a single category because most countries listed only one of the two reasons as possible response options. See Table A.2 for more details.

⁵ Analyses revealed that very few unmarried women reported an abortion in the Asian countries in our study. Thus, the reasons given for having an abortion predominantly reflect those of married women.

⁶ Georgia lacks data on age at abortion; thus, we used age at the time of the survey.

References

7. Bankole A, Singh S, Haas T. Reasons why women have induced abortions: evidence from 27 countries. Int Fam Plan Perspect. 1998:117-52. [ Google Scholar]

11. Commission Nationale. d'Evaluation Interruption de Grossesse. Rapport bisannuel 2010-2011. 2012 [ Google Scholar]

15. Hacettepe University Institute of Population Studies. Turkey Demo- graphic and Health Survey. Hacettepe University Institute of Population Studies, Ministry of Health General Directorate of Mother and Child Health and Family Planning, State Planning Organization and European Union; Ankara, Turkey: 2003. [ Google Scholar]

16. McFarlane C, Serbanescu F, Durant T, Abisdid M, Edmonson D. Reproductive Health Survey Jamaica 2002: Final report. Atlanta, GA and Kingston, Jamaica: 2005. [ Google Scholar]

17. Division of Reproductive Health, Centers for Disease Control and Prevention (CDC), Georgia Ministry of Labor, Health and Social Affairs, National Center for Disease Control and Public Health (Georgia), National Statistics Office of Georgia. Reproductive Health Survey Georgia 2010: Final Report. 2012 [ Google Scholar]

18. Jones RK, Finer LB, Singh S. Characteristics of US abortion patients, 2008. New York: Guttmacher Institute; pp. 201020101-8. [ Google Scholar]

19. Chae S, Desai S, Crowell M, Sedgh G, Singh S. Characteristics of women obtaining induced abortions in selected low-and middle- income countries. PLoS One. 2017:12e0172976. [[ PMC free article] [ PubMed] Google Scholar]

20. ICF International, Ministry of Health (Armenia), National Statistical Service of the Republic of Armenia. Armenia Demographic and Health Survey 2010. Yerevan, Armenia: ICF International; 2012. [ Google Scholar]

21. Macro International, Inc., State Statistical Committee of Azerbaijan. Azerbaijan Demographic and Health Survey. Baku, Azerbaijan: Macro International, Inc; 2006. [ Google Scholar]

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Reasons why women have induced abortions: a synthesis of findings from 14 countries

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Many reasons inform women's reproductive decision-making. This paper aims to present the reasons women give for obtaining induced abortions in 14 countries.We examined nationally representative data from 14 countries collected in official statistics, ...

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"Social and economic factors include factors such as income, education, employment, community safety and social support. The choices that are available in a community are impacted by social and economic factors. These choices include our abilities to afford medical care and housing and to manage stress"

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About

Social and economic factors affect how well and how long we live. Social and economic factors include factors such as income, education, employment, community safety and social support. The choices that are available in a community are impacted by social and economic factors. These choices include our abilities to afford medical care and housing and to manage stress.

Social and economic opportunities help communities live longer and healthier lives. For example, a living wage shapes opportunities for housing, education, child care, food and medical care.

We do not always think about social and economic factors when we think about health. However, strategies to improve these factors can have a greater impact on health than strategies that target individual behaviors.

Communities that have been cut off from investments or who have experienced discrimination have fewer social and economic opportunities. These gaps disproportionately affect people of color and people living in rural areas. Children may be especially impacted.

Social and Economic Factors include:

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Social and economic factors affect how well and how long we live. Social and economic factors include factors such as income, education, employment, community safety and social support. The choices that are available in a community are impacted by social and economic factors.

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"So, know that when you put a baby up for adoption, it does not go into foster care, but instead into a loving family of your choice. Our adoption specialists are always available to talk in depth with you about how the process of adoption helps your child avoid foster care"

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Sometimes, pregnant women considering adoption wonder, "If I give my baby up for adoption, do they go to foster care?"

The answer is no. By placing your child for adoption with an adoption agency, you are choosing a clear path for the rest of your baby's life, avoiding the possibility of them ending up in foster care. When you work with an adoption agency like American Adoptions, your child will be placed directly in a healthy, happy family that's been thoroughly screened, is 100 percent ready for the commitment of raising a child and is happy to embrace you as the birth mother of your child, speaking of you with joy and love and keeping you a part of your child's life through pictures and letters. So, know that when you put a baby up for adoption, it does not go into foster care, but instead into a loving family of your choice.

Our adoption specialists are always available to talk in depth with you about how the process of adoption helps your child avoid foster care. Even if you're just considering adoption, you can contact us anytime at 1-800-ADOPTION completely for free and with no obligation to choose adoption unless you're ready.

How an Agency Adoption is Different from Foster Care

When you're wondering if by putting a baby up for adoption, it ends up in foster care, know that this is never the case with American Adoptions. In many cases, a foster care placement of a child is not a voluntary decision - but choosing to place your child for adoption is always entirely up to you.

When you choose to place your baby for adoption, you also get to choose the perfect adoptive parents for your baby, and he or she can be placed directly with them - without ever entering the foster care system. Unlike foster care placements, an adoptive placement involves you selecting the family that you want to raise your baby. This is why when you put a baby up for adoption it does not go into foster care - because there is a home waiting for them once you sign your adoption consent. You are the only one who decides which family is best for your baby, and your adoption specialist will help you find the perfect family for your preferences.

In addition to selecting a family and knowing that there will be a home for your baby after you place them for adoption, you can also be reassured that these families will provide the support and love that you want for your baby. All adoptive families go through a lengthy screening process, which includes criminal background checks and a home study review process to ensure they're prepared to raise an adopted child. Therefore, you can know that these families will provide a great home for your baby, and the risk of them ending up in foster care after being placed through our agency is nearly nonexistent.

In adoption, you will also be able to choose the level of contact with your child and their adoptive family before, during and after the adoption process is complete. You will rarely have that opportunity with a foster care placement. With adoption, however, you have the option of staying in contact with your baby's adoptive family in whatever way you desire - whether it's through letters and pictures sent through your adoption agency, direct email and text correspondence or even in-person meetings. Open adoption is important in creating a healthy adoption relationship for all, so when you choose to place your child for adoption, you will likely have a more positive experience that helps you heal from the emotional struggles of placing your child with another family - unlike in foster care, where you have no such guaranteed contact. As a prospective birth mother who chooses adoption, you will always have control of the level of openness you desire in your relationship.

Other Questions You May Have About Adoption and Foster Care

We understand that you, as a pregnant woman considering adoption, have many decisions to make - and you may also have many concerns and questions during this decision process. As mentioned above, we are always ready to answer these questions and help you choose an unplanned pregnancy option that's best for you.

Some questions women commonly have are:
"Can the state make you give up children for adoption?"
If you're concerned about putting a baby up for adoption and having it end up in foster care, it's important to first understand how the foster care system works. Foster care is designed as a safekeeping process for children whose parents need time to improve their circumstances before being reunified; foster care does not mean a child is automatically made available for adoption. In fact, when a child is removed by the state and placed in foster care, parents are given multiple opportunities to complete a reunification plan before the department of child services starts exploring the possibility of adoption and termination of parental rights. If necessary, they will go through a lengthy legal process before potentially terminating parental rights. But, as mentioned before, you will have several opportunities to reunite with your children before then if you're in this situation.

When it comes to the infant adoptions completed by American Adoptions, we will never force you to place your baby for adoption; that's entirely your decision. Know that no one has the power to choose adoption for your baby except you. If you are worried that a state department may force you into a decision that you're not ready for, you can always contact our agency at 1-800-ADOPTION. We can help you obtain an adoption attorney to interact with the state department on your behalf.
"If I don't have an adoptive family lined up, can my baby go to foster care?"
It's never too late to find an adoptive family for your baby and go through the adoption process, avoiding the placement of your child in foster care. If you want to place your baby for adoption but don't yet have an adoptive family chosen, our adoption specialists will help you find the perfect adoptive family, no matter how late you're starting the adoption process. When you work with an adoption agency, your child will never be placed in foster care but instead will go through the normal adoption process with you being in charge every step of the way. If you've given birth at the hospital and are worried about your baby being placed in foster care, call us at 1-800-ADOPTION for the free assistance you need. By choosing adoption, you will have the ability to create an adoption plan that meets your desires, rather than a state department making those important choices for you.

If you're still asking, "If I give a kid up for adoption, will they be in foster care?" or have more questions about the adoption process, we encourage you to reach out to our adoption specialists. They can give you more specific answers to your questions based on your circumstances and help you get the resources you need.

Share to help reach women who may be worried about what happens when you place a child for adoption.

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"If I Give My Baby Up for Adoption, Do They Go to Foster Care?"

# data[].attributes.attachment_link.description
There are many myths about foster care & adoption. If you're considering placing a child for adoption, you should know that adoption with American Adoptions does not mean foster care for your baby.