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Abortion should be removed from the criminal law and 21st century women trusted to make their own decisions about their pregnancies, a campaign launched by the British Pregnancy Advisory Service (bpas) urges today.
* Across the UK, a woman who ends her own pregnancy at any gestation can be sentenced to life imprisonment under laws created before women could vote.

* Two women currently being prosecuted in Northern Ireland for abortion offences and one woman jailed in England in 2015.

* We Trust Women campaign to decriminalise abortion supported by range of women's organisations including Fawcett Society, Royal College of Midwives, End Violence Against Women Coalition, and Women's Aid.

* Humans actress Gemma Chan voices film charting the 150-year fight for gender equality to launch We Trust Women campaign.

Women's organisations have today backed calls for Victorian-era legislation criminalising abortion to be scrapped and for the procedure to be regulated in the same way as all other women's healthcare. In every country in the UK today, a woman who ends her own pregnancy without legal authorisation can be sentenced to life in prison.

The 1861 Offences Against the Person Act (and equivalent common law offences in Scotland) - passed before women could vote - threatens the harshest punishments for self-induced abortion imposed by any country in Europe today, with the exception of the Republic of Ireland.

The 1967 Abortion Act did not overturn this law, but made abortion lawful if 2 doctors agreed a woman's mental or physical health would suffer if forced to continue her pregnancy. It did not extend to Northern Ireland. But even where it applies, abortion is not a choice a woman can make for herself, but a decision which must be made on her behalf by doctors.

In Northern Ireland, two women are currently facing imprisonment under the 1861 Offences Against the Persons Act for buying abortion medication online, one for inducing her own abortion and a mother who wanted to help her daughter. Last year in Durham, England, a young mother was imprisoned for two-and-a-half-year s for inducing a miscarriage in the third trimester also using medication bought online. The increasing availability and knowledge of these pills means more women are likely to put themselves at risk of prosecution.

A film to accompany the campaign, narrated by Humans actress Gemma Chan, charts the history of women's struggle for equal rights and firmly situates the fight to overturn this legislation as one of the final legal hurdles to equality remaining for women today.
Abortion cannot be provided solely on the request of a woman anywhere in the UK today, and a doctor, midwife or nurse who provided safe abortion care on her request alone could face prison. Why we need decriminalisation
* Current abortion legislation is not in keeping with principles of women's rights, bodily autonomy, and patient-centred care

* The threat of prosecution puts doctors off training in this field and providing care. Today, even where the 1967 Act applies, women are compelled to continue pregnancies because they cannot find doctors willing or able to treat them

* In requiring women obtain the permission of 2 doctors, the current law can delay those who are sure of their decision. It has also prevented developments in clinical practice that have facilitated the safe and effective treatment of women in other countries

* As safe and effective medications to induce abortion become readily available online, more women are at risk of prosecution. Even countries such as Poland, where abortion is highly restricted, do not prosecute women for self-inducing abortion

* The UK trails behind Canada and Australia where abortion has been decriminalised

Ann Furedi, Chief Executive of the British Pregnancy Advisory Service, said:
"One in three women will have an abortion in their lifetime in the UK. The ability to end a pregnancy has enabled women to live their lives in the way that they see fit and bear children at the time they think is right. It is high time we recognised this by taking abortion out of the criminal law, and making clear that we trust women to make their own decisions about their own lives and bodies."
Supporters of the campaign include the Royal College of Midwives, Fawcett Society, the Family Planning Association, Women's Aid, Maternity Action and End Violence Against Women, as well as pioneering women's rights activists who campaigned for the 1967 Abortion Act.

Sam Smethers, Chief Executive of the Fawcett Society, said:
"Safe, early, medical abortions are readily available but our outdated abortion laws hinder women's access to them. It makes no sense to force women to delay the termination of a pregnancy when that is their decision. "We need modern abortion legislation fit for 21st Century."
Goretti Horgan, Alliance for Choice Northern Ireland:
"The two women currently on trial in Northern Ireland are facing the sharp end of the criminalisation of abortion in the UK. They are on trial essentially because they could not afford to travel to Britain and pay for a private abortion. If the mother who faces prison for getting abortion pills for her teenage daughter lived in England, her daughter would have been fast-tracked for an abortion if that's what she wanted. A 21-year old is facing life imprisonment for taking pills that she would have got on the NHS had she lived in Britain. This should not be happening in the 21st century."
Diane Munday, the former general secretary of the Abortion Law Reform Association (ALRA) in the 1960s, said:
"If in 1967 - on the day I celebrated that parliament had put Britain in the vanguard for women's reproductive rights - anybody had told me that nearly half a century later we would be lagging behind most of Europe I would have called them deluded. But they would have been right. In the past 50 years, technology and medicine have moved forward beyond belief, yet abortion remains hedged with the same red tape as it did in the 1960s. The anachronistic legal need for two doctors who know nothing about the pregnant woman, her life and her circumstances still stands. Jurisdictions including Canada and Australia have decriminalised abortion and the skies have not fallen in - and neither have rates of abortion risen. In 2016, it is time for Britain to catch up and to acknowledge that women know what is best for themselves and their families."
ENDS

For more information and background to the campaign please visit http://www.wetrustwomen.org.uk/ or contact the bpas press office on 0207 061 3377 or 07788 725185 or email press@bpas.org

About bpas

bpas is a charity which sees more than 70,000 women a year and provides reproductive healthcare services including pregnancy counselling, abortion care, miscarriage management and contraception, at clinics across the UK. It supports and advocates for reproductive choice. More information can be found at bpas.org.

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Abortion should be removed from the criminal law and 21st century women trusted to make their own decisions about their pregnancies, a campaign launched by the British Pregnancy Advisory Service (bpas) urges today. * Across the UK, a woman who ends her own pregnancy at any gestation can be sentenced to life imprisonment under laws created before women could vote.

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This factsheet covers law, policy, guidance and key statistics on abortion in the United Kingdom (England, Wales, Scotland, Northern Ireland).

Data for each country may not be strictly comparable due to the differences in methods of data collection and analysis.

Contents

The law in Great Britain (England, Wales, Scotland)

Abortions in Great Britain are carried out in accordance with the Abortion Act 1967 (1), which was amended by the Human Fertilisation and Embryology Act 1990 (2).

Before 1967, abortion was illegal under the Offences Against the Person Act 1861 in England and Wales and under common law in Scotland. The 1967 Act provided exceptions to the previous legislation, giving circumstances in which abortion could be carried out legally.

Two registered medical practitioners must agree that:

Up to 24 weeks:

the continuance of the pregnancy would involve risk, greater than if the pregnancy was terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family.

The woman's actual or reasonably foreseeable future environment may be taken into account.

With no time limits:

the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman

there is a risk to the life of the pregnant woman, greater than if the pregnancy were terminated

there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

Access for under 16s

A woman aged under 16 may have an abortion without parental knowledge or consent if both the required doctors agree that she has sufficient maturity and understanding to appreciate what is involved.

Health professionals are trained to work within the Fraser guidelines, which cover the provision of contraception, abortion and other sexual health services to under 16s ( 3, 4).

Conscientious objection

Health professionals are not obliged to perform or participate in an abortion to which they have a conscientious objection, but they still have a duty to participate in treatment which is necessary to save the life of or to prevent grave permanent injury to a woman. Any doctor or nurse who feels unable to give information or counselling to a woman seeking an abortion, because of conscientious objection, should refer her to another doctor without delay ( 5, 6).

The role of nurses in providing abortion services was examined by the Supreme Court, which ruled in 2014 that a nurse does not have the right to avoid supervising other nurses involved in abortion procedures ( 7).

Responses to the law

In 2007, the government's Science and Technology Committee carried out a review of scientific developments since the passing of the 1967 Act. It made several recommendations, including that the latest evidence on fetal viability supported maintaining the 24-week time limit, that nurses could safely carry out some types of abortion and that the requirement for two doctors, rather than one, to approve an abortion should be removed ( 8).

There have been various attempts to amend the 1967 Act, including proposed amendments to the Human Fertilisation and Embryology (HFE) Bill in 2008, to reduce the legal time limit, and to the Serious Crime Bill in 2015, to specify that abortion on grounds of gender alone is illegal. Both were rejected. A number of amendments to the HFE Bill that would have modernised abortion law were also tabled but were never debated or voted on.

British Medical Association (BMA) policy opposes any change to the current time limit for abortion. In 2007 the BMA also made it policy that in the first trimester of pregnancy it should not be a requirement for a woman to meet specified medical criteria or for two doctors to approve an abortion, so that abortion in the first trimester is available on the same basis of informed consent as other treatments ( 9).

Policy and guidance

Governments in England ( 10, 11) Wales ( 12) and Scotland ( 13) have published policy and guidance documents which address sexual health issues and services. These include recommendations for improving abortion services, and ensuring equitable access and minimum waiting times between the initial referral and the abortion.

Detailed guidance from the Royal College of Obstetricians and Gynaecologists ( 14) aims to ensure that all women considering abortion have access to a service of uniformly high quality. This guidance should be used as the basis for the development of local protocols or guidelines in the United Kingdom.

Abortion services are also included in broader recommended standards for sexual health services from the Medical Foundation for AIDS and Sexual Health ( 15). Although specifically intended to support the implementation of the government's sexual health policy in England, they can be applied elsewhere.

Northern Ireland

The1967 Abortion Act was not extended to Northern Ireland. Abortion is governed by the Offences Against the Person Act 1861, as well as the Criminal Justice Act (Northern Ireland) 1945.

Abortions can be carried out legally in very restricted circumstances - when the pregnancy is a threat to the woman's life or there is a risk of a real and serious, permanent or long-term adverse effect on her mental or physical health.

Abortion law in Northern Ireland falls within the scope of the criminal justice and policing powers, which were devolved to Northern Ireland's Assembly in 2010.

Women from Northern Ireland are not currently entitled to an NHS abortion in Great Britain, although a current court case (2016) is seeking to challenge this.

See our Northern Ireland abortion factsheet (PDF) for further information about abortion law and policy in Northern Ireland.

Statistics England and Wales (resident women)

The total number of abortions was 185,824, 0.7% more than in 2014 (184,571) and 0.3% less than in 2005.

The abortion rate was 16 per 1,000 women aged 15-44, 0.6% higher than in 2014 (15.9) and 6.4% lower than in 2005 (17.1).

The abortion rate of women under 16 was 2 per 1,000 women, down from 2.5 per 1,000 in 2014 and 3.7 per 1,000 in 2005. There were 1,853 abortions to women aged under 16 - 509 aged under 15 and 79 under 14.

The abortion rate for women under 18 was 9.9 per 1,000 women, down from 11.1 in 2014 and 17.8 in 2005.

The highest abortion rate (at 28.7 per 1,000) was among women aged 21; in 2014 it was women aged 22 (28.5 per 1,000).

730 abortions were carried out among women aged 45 or over.

92% of abortions were carried out at under 13 weeks gestation.

80% of abortions were carried out at under 10 weeks gestation, the same as in 2014, and compared to 67% in 2014. There has been a continuing increase in the proportion of abortions that are performed under 10 weeks since 2005.

There were regional variations in abortions carried out under 10 weeks, from 60% in the Vale of Glamorgan to 88% in NHS Trafford.

98% of abortions were funded by the NHS. Of these, 68% took place in the independent sector under NHS contract, up from 67% in 2014.

Medical abortion accounted for 55% of all abortions. This was higher than in 2014 (51%), and more than double the proportion in 2005 (24%).

Abortions beyond 24 weeks gestation accounted for less than 0.1% (230) of the total.

Grounds for abortion

In 2015:

The vast majority of abortions (98%) were carried out under ground C (pregnancy not exceeded 24th week and continuance of pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnancy woman).

3,213 abortions (2%) were carried out under ground E - substantial risk the child would be born seriously handicapped.

Ethnicity

Of women whose ethnicity was recorded in 2015, 77% were white, 9% were Asian or Asian British and 8% were black or black British.

Statistics Scotland

The total number of abortions was 12,082, compared to 11,776 in 2014, a 2.6% increase.

Abortion rates continued to decline in women under 20 years but increased among older women, particularly those aged 35-39.

The rate was 11.6 per 1,000 women aged 15-44.

Historically the lowest abortion rates have been in the 40+ age group but in 2015 it was among those under 16 (1.6 per 1,000 women aged 13-15). Among women aged over 40 it was 2.5 per 1,000 women aged 40-44, which has remained the same since 2012.

The biggest increase from 2014 was in the 35-39 age group, rising from 6.9 per 1,000 women aged 35-39 to 8.1, a 17.5% increase.

The abortion rate was highest for women aged 20-24, accounting for 30% of all abortions.

72.5% of abortions were carried out under nine weeks' gestation, up from 71.9% in 2014.

81.1% of abortions were medical, accounting for 88.4% of abortions carried out under nine weeks. This was a much higher proportion than in England and Wales (55%).

The rate of abortion was highest in NHS Tayside (13.9 per 1,000) and the lowest was the Island boards, which includes NHS Orkney, Shetland and Western Isles (4.4 per 1,000).

There continued to be a strong link between abortion rates and deprivation. In areas of high deprivation the rate was 15.4 per 1,000 women aged 15-44, 1.8 times higher than the rate of 8.7 per 1,000 in the least deprived areas.

3,787 abortions (31.3%) were to women who had previously had at least one abortion, similar to 31.7% in 2014.

Grounds for abortion

In 2015:

The majority of abortions (98.3%) were carried out under Ground C (pregnancy not exceeded 24th week and continuance of pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnancy woman).

1.5% of abortions were carried out under Ground E (substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped).

Statistics Northern Ireland

833 women from Northern Ireland travelled to England or Wales for an abortion (this figure is given based on the addresses provided by clients and is likely to be an underestimate).

36% were aged under 25 and 12% were under 20.

88% of abortions were carried out under 13 weeks of gestation and 73% under 10 weeks.

See our Northern Ireland abortion factsheet (PDF) for abortion statistics from within Northern Ireland.
References

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This factsheet covers law, policy, guidance and key statistics on abortion in the United Kingdom (England, Wales, Scotland, Northern Ireland). Data for each country may not be strictly comparable due to the differences in methods of data collection and analysis.

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Epidemiological Data of Conception and Abortion rates

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Conceptions in England and Wales - Office for National Statistics

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Pregnancies leading to a birth or legal termination by age group, including women aged under 18 years.

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Ethical Considerations

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RCN nursing framework for termination of pregnancy

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Department of health abortion guidance.

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It is acknowledged that the MDT, including nurses and counsellors (it is possible that the MDT would include a midwife where a congenital abnormality has been diagnosed antenatal) plays an important role in supporting women seeking an abortion and in obtaining information from women.  RMPs can rely on information obtained by members of the MDT but it is DH’s interpretation of the law that the RMPs should themselves review the information before reaching an opinion, for example by considering the paperwork or speaking to members of the team.  The RMP must be satisfied that they can justify how they reached their decision in good faith if later challenged.  The opinions required under the Act are clearly those of the RMP, not of any other member of an MDT, however experienced or trusted.  DH does not think that the Act can be read to enable the opinion required to be that of another person entirely, or the opinion of a team as a whole.  An RMP may, of course, take into account the opinions and views of colleagues in forming an opinion and it is often important to do so, but the opinion provided must be their own (GOV, .

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Abortion Review: The role of nurses in abortion services

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The Family Planning Association reports that nearly one in five young women say they have had sex before the age of 16 (Maner and Rees, 1998). Much of this activity is risky, contraceptive use is often erratic and may result in unwanted pregnancies. In a few instances, sexual activity is forced (World Health Organization, 2000).

Within Western Europe, the UK stands out as having the highest teenage birth rate (Fig 1). It is twice that of Germany, three times that of France and six times that of The Netherlands (Brennan, 2002). The National Assembly for Wales (2003) has published statistics showing that Wales has a consistently higher teenage birth rates than England. In 2000, the conception rate in Wales for under-18s was 47.3 per 1,000 females. Although the rate fluctuates from year to year, the latest figures are below the peak 1998 level.

Unwanted teenage pregnancy is clearly a health problem for Wales. Tables 1 and 2 illustrate the number of abortions performed in Wales by age and area of residence during 2000.

Abortion remains a common approach to handling unwanted pregnancies, which is ideally performed in the first trimester, when an abortion is considered less traumatic. Perioperative nurses are frequently involved in caring for teenagers undergoing surgical termination of pregnancy. At the time of writing, I am a senior staff nurse working in the education department of a busy operating theatre suite comprising 11 theatres, which includes a day surgical unit and obstetric unit.

In 1946, the WHO (2002) defined health as 'a state of physical, mental and social well-being and not merely the absence of disease or infirmity'. In other words, health is not simply about physiological parameters but also about how the person feels.

Medical practice is largely guided by a biomedical model of disease, which assumes that the condition can be fully accounted for by deviations from the norm of measurable biologic variables. Novack (1981) suggests that this model has outlived its usefulness and that a biopsychosocial model offers greater understanding of the illness process.

Most disease prevention focuses on the physiological aspects of health as illustrated by the biomedical model, but Engel (1981) developed a biopsychosocial model of health and illness integrating the psychological and social aspects of health into the more traditional biomedical model (Ogden, 2000). Reiser (1980) confirms that the biopsychosocial model forces realisation that states of health and illness can be fully understood in terms of their biological, psychological and social parameters only. Engel's (1981) biopsychosocial model contains five elements that underpin the psychological aspects of health. These are:

- Behaviour;

- Beliefs;

- Coping;

- Stress;

- Pain.

The health needs of adolescents differ significantly from that of adults, with social and environmental factors playing a strong influence (Blackie et al, 1998). Adolescence is a time of transition from childhood to adulthood, a time when young people experience changes following puberty but do not immediately assume the roles, privileges and responsibilities of adulthood (WHO, 2002). Even as a purely biological phenomenon, puberty is far from being a simple, straightforward process (Gross, 2001).

Behaviour and beliefs

It is possible to argue that if young people were given more information and advice before they became sexually active then the incidence of teenage pregnancy and abortion would fall. This would suggest that young people are ignorant about contraception, proof of which comes from Quinn's study (1999), which found that 70 per cent of women seeking termination of pregnancy said that they would have used emergency contraception had they known about it and where to obtain it.

Sexual health promotion in nursing practice has traditionally been equated with prevention at school level. However, practitioners face increasing demands to address the psychosocial aspects of sexual health, adapt theoretical paradigms from the behavioural sciences and increase the use of counselling skills (Irwin, 1997).

Although adolescents are enjoying greater freedom at a younger age, this brings more risks and greater costs when errors of judgements are made. Teenage pregnancy and abortion is one price some teenage girls pay for this extended freedom (Gross, 2001).

There are many biological, psychological and social reasons why women opt to terminate a pregnancy - this may include cultural, psychological, socioeconomic, education, career and genetic reasons. In some sociocultural settings, premarital sexual activity is taboo, using contraception is forbidden among unmarried youth, and abortion is viewed as the only solution to premarital pregnancy (WHO, 2002).

Adolescent pregnancy and abortion create a significant challenge for health care professionals, while social deprivation compounds the problems - the incidence has been shown to be inversely related to social class and educational attainment (Little, 1997).

In the 1960s teenage pregnancy began to be redefined as a social problem amenable to scientific scrutiny and intervention, rather than a moral problem of sexual transgression (Smith-Battle, 1998). The recommendations of the 1980 Black Report (Black, 1980), promoting sexual health in young people, was aimed at reducing unwanted teenage pregnancy and improving access to contraceptive services. Considering that this report was published almost a quarter of a century ago, the teenage conception rates in Wales remain high (Table 1).

The reasons why there is a high rate of unwanted teenage pregnancies in Wales could be attributed to a range of predisposing factors, which may include living in a challenging social environment, coming from a socially deprived area, low social class, lack of good-quality health care, high unemployment rates, and the effects of family background.

Smith-Battle (1998) believes that middle-class teenagers who become pregnant are more likely to choose abortion for educational and career reasons. However, Jolly (2002) believes that sexual health must depend on an understanding of why teenagers engage in unprotected sex, and stresses the need to recognise that social disadvantage and poverty are associated with increased risk-taking.

Therapeutic abortion

When the 1967 Abortion Act came into being, it defined therapeutic termination as one undertaken before the gestational age of 28 weeks. However, advances in technology have greatly improved the chances of survival for premature babies, and a reduction to 24 weeks was approved by parliament in 1990.

The Abortion Act made it possible for a woman to have an abortion legally, provided two doctors independently agreed that the termination was necessary to prevent:

- The likelihood of the woman's death;

- Permanent illness - physical or psychological;

- Damage to a woman's existing children;

- Prevent abnormality in the woman's coming child.

Although this legislation extended the conditions under which a woman might be allowed to have an abortion, it stopped far short of endorsing the idea that a woman had an absolute right to control her body. Practically, therefore, the law relies on individual doctors exercising discretion as to who qualifies for an abortion (Timpson, 1996).

Biopsychosocial complications

A pregnancy can be terminated by medical or surgical means and, although complications following termination are uncommon, there can be short and long-term complications (Liu and Lachelin, 1989). Women requesting termination should be made aware of these before the procedure is carried out.

There is evidence to suggest that a small percentage of women are affected by postnatal depression after abortion or miscarriage. Women's reactions to abortion can vary from extreme relief to extreme distress (Gilchrist, 1995).

Having strategies to help patients cope with anxiety, stress, pain, anger, isolation, confusion and depression requires maturity, experience and a working knowledge of underlying theories of human behaviour (Kitson, 1999). Pre and postoperative visiting by a perioperative nurse can provide emotional support to teenagers choosing abortion, although nurses' attitudes and behaviours also vary greatly.

McQueen (1997) demonstrates this in her qualitative study, which highlights situations when the use of 'professional empathy' may be incorporated in nurses' behaviour. She reports that when caring for patients undergoing a termination, nurses show an appreciation of the mental turmoil that can precede the event and the possible emotional responses that can follow it. McQueen demonstrates that they tried to meet the needs of patients irrespective of their personal views on abortion.

There is, however, an opt-out clause. The Abortion Act states that 'no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this act to which he has a conscientious objection'.

Overcoming the effects of stress

Stress can mean many different things. Psychologists define it as involving biochemical, physiological, behavioural and psychological changes (Ogden, 2000). Selye (1956) defined it as 'a non-specific response of the body to any demand made on it'. His general adaptation syndrome hypothesised that the stress response was the body enhancing the function of the system best able to cope with it. He concluded that stress could be mild and controlled - and promote growth - or severe and prolonged - and the precursor of psychological and physical disturbances that disrupt health.

Usually the effects of stress are short-lived, and when the pressure recedes, the individual rapidly resumes normal life. However, where pressures are intense and sustained, stress can lead to long-term psychological and physical ill health (Harris, 2001).

Adolescents facing abortion are subject to many stresses. However, there is evidence to show that their psychological state improves postoperatively (Gilchrist, 1995). Studies on psychological response to abortion suggest that, although there may be sensations of regret, sadness and guilt, severe negative reactions are infrequent in the immediate and short-term aftermath of a first-trimester termination (Zolese and Blacker, 1992).

Anxiety can be the response to, or the cause of, stress, which is a biophysiological event. Adolescents undergoing surgical termination of pregnancy are often anxious and frightened, and for the majority it will be their first operating-theatre encounter.

The role of the perioperative nurse is to reduce anxiety and provide a sufficient explanation appropriate to the individual by means of biological and psychological care. Prolonged anxiety levels delay recovery and increase the risk of physiological complications.

Pain

The majority of patients require mild analgesia only following a termination. Physical recovery time from first-trimester abortion is short, although some patients may suffer mild abdominal cramps and post-procedural bleeding similar to a menstrual period.

Conclusion

There is mounting evidence to suggest that education is a large part of the solution to tackling and improving teenage sexual health. Young people need sex education at an appropriate age to teach them the facts about sexual development, pregnancy and contraception.

When caring for adolescents undergoing abortion, perioperative nurses can alleviate anxiety and pain by providing essential preoperative information, sensitive to the needs of the individual young person. They can provide holistic care that will take into account an adolescent's biological and psychological requirements.

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The biopsychosocial aspects of unwanted teenage pregnancy

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The Family Planning Association reports that nearly one in five young women say they have had sex before the age of 16 (Maner and Rees, 1998). Much of this activity is risky, contraceptive use is often erratic and may result in unwanted pregnancies. In a few instances, sexual activity is forced (World Health Organization, 2000).

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Abstract

Background:

Ethical values offer a framework for behavior assessment, and nursing values influence nurses' goals, strategies, and actions. A literature review was adopted in order to determine and define ethical values for nurses.

Materials and Methods:

This literature review was conducted based on the Centre for Reviews and Dissemination guidelines. The key words used to search relevant sources were nursing, ethics, ethical values, and nursing values. The search of articles in English was carried out in Medline, CINAHL, PubMed, Scopus, Ovid, and Proquest databases. The search of articles in Persian was conducted in databases of Magiran, SID, and Irandoc publications. After assessing and analyzing the obtained data, 17 articles which had a distinct definition of ethical values were chosen and subjected to a thorough study.

Results:

The search yielded 10 nursing ethical values: Human dignity, privacy, justice, autonomy in decision making, precision and accuracy in caring, commitment, human relationship, sympathy, honesty, and individual and professional competency.

Conclusions:

This study showed that common ethical values are generally shared within the global community. However, in several areas, influences of social, cultural, and economical status and religious beliefs on values result in a different definition of these values. This study revealed that based on humanistic nature of nursing, common values in nursing protect human dignity and respect to the patients. Recognizing and definition of ethical values can help to improve nursing practice and develop codes of ethics.

Keywords: Ethics, literature review, nursing, professional values, values

INTRODUCTION

Nurses as one of the health service providers and members in health system who are responsible for giving care to the clients and patients based on ethical issues.[ 1] They need ethical knowledge to conduct their appropriate function to manage situations and to give safe and proper legal and ethical care in today's changing world.[ 2] With regard to practical care, they always try to answer the question of "What can I do?," whereas they should try to answer what is essential to be done for the patients in the context of ethical principles.[ 3] Ethics seek the best way of taking care of the patients as well as the best nursing function.[ 4]

Nurses are responsible for their clinical function, and their main responsibility is to take care of the clients and patients who deserve appropriate and safe care.[ 5] They act based on the values they have selected. These values form a framework to evaluate their activities influencing their goals, strategies, and function.[ 6] These values can also be counted as a resource for nurses' conduct toward clinical ethical competency and their confrontation with contemporary ethical concerns. Values conduct human life priorities and form the world we live in. They act as one of the most basic parts of human life. Ethical values are inseparable components of the society and, as a result, nursing profession.[ 7, 8]

Discovery of basic values and reaching an agreement on clinical ethical values are essential with regard to constant changes in nurses' social class and role.[ 9] Nurses' awareness of their values and the effect of these values on their behavior is a core part of humanistic nursing care.[ 10] They need to tailor their function to the value system and cultural beliefs of their service recipients.[ 11] Values originate from cultural environment, social groups, religion, lived experiences, and the past. Social, cultural, religious, political, and economic considerations influence individuals and their value system,[ 6] and ultimately, health, education, social strategies, and patients' care. Numerous documents have been prepared in nursing texts and literature concerning these values and clarification of their traits.[ 7, 9, 12, 13, 14, 15, 16]

Recognition and definition of nursing ethical values in various communities can help nurses have mutual understanding in international level. It can also bring nurses closer to reach a common meaning of care in patients with different cultures. However, there is a paucity of research particularly in the Iranian context to deeply explore nursing ethical values. Therefore, in the first step, the main aim of the study was to identify and explore nursing ethical values reflected in nursing texts. This search was then used to prepare code of ethics and clinical guidelines for Iranian nurses, along with other documents and evidences. Results of other aspects of the study have been reported in other articles from the researchers.

MATERIALS AND METHODS

This study is a part of a bigger study conducted in the Isfahan University of Medical Sciences. A literature review was carried out in 2010 to determine ethical values and related definitions in nursing systems of various countries.

In this literature review, the York University four-step approach was applied. These steps are as follows: Forming questions and determining search strategies, extracting synthesis, providing quality assessments and applying study evaluation tools, and suggesting methods to analyze and data synthesis.[ 17]

Search strategy

The study tried to answer the following questions:

What nursing ethical values are determined and offered in this study?

What is the definition of each value?

In this literature review, all published articles in English language from 1995 to 2010, as well as articles in Persian from 1996 to 2010 were searched by separated keywords and then keywords in combination, respectively. AND/OR was used combination and collection of various key words together. A manual search was also adopted and the references of the articles were studied as well. The search yielded about 82 articles whose titles and abstracts were studied. The articles not meeting the inclusion criteria were left out. Inclusion criteria were: Articles published in English or Persian and those articles on nursing ethical values in patients' care. At this stage, 37 articles were excluded and 45 were selected and comprehensively reviewed. In the next stage, the articles were completely studied with regard to inclusion criteria and their answers to the questions of the present study.

Finally, 17 related articles were selected and considered for the study. Data were extracted through firstly writing down the detected values and their definitions in the related articles. Then, the research team compared the findings and recorded them in a table, and selected the best definition of each value among the suggested definitions. Finally, after comparison of the names and words, a unique definition for each value was achieved based on the trait of definition.

Research team checked all selected articles concerning assessment of quality based on criteria of study quality evaluation tool. This tool was designed by the research team with regard to the study goal. Two questions were considered with respect to the various research methods employed in the selected articles. The questions were as follows:

Does the article express nursing ethical values?

Does the article contain a clear and specific definition for the expressed ethical values?

In order to increase study credibility, the abstracts were studied by researchers individually and the obscure points were discussed by the research team. In case of a disagreement to include an article in the study, a third member of the research team conducted further investigations, the obscure points were discussed in the group, and a final decision was made.

In the stage of data combination, all textual obtained data from the selected articles were classified and completely described. After textual data had been extracted and studied critically, the traits were separated and finalized based on the obtained definition for each value or ethical concept and finally a unique definition was obtained. Each obtained defined value has been explained in the section "Discussion." These defined values suggested appropriate answers to literature review questions.

Articles methodological traits

The articles were from 12 countries: Four from US, two from Canada, five from European countries (Belgium, England, Finland), and six from Asian countries (Iran, Japan, China, Thailand, and Taiwan).

Reviewed articles included two quantitative studies, eight qualitative studies, three literature reviews, two philosophical inquiries, and two action research philosophical methods. Various sampling methods had been precisely employed in these studies. 1360 subjects comprised the recruited subjects in these 17 articles. In two quantitative descriptive studies, 922 clinical nurses and nursing students had been randomly selected through census sampling. In qualitative researches, the participants comprised 438, randomly selected through purposive sampling. The number of participants ranged between 20 and 300 individuals. In most of these qualitative studies, the participants included clinical nurses accompanied by nurse educators.[ 9, 18, 19, 20] In one study, the participants were just clinical nurses, and in another,[ 21] they were just nursing students.[ 22]

The data were mostly collected through individual interviews which were, in some cases, the only source of data and in some other cases accompanied by other methods. The data had been collected by different methods: One by individual interviews and group discussion,[ 20] one by individual interview and observation,[ 18] one by narration and individual interview,[ 19] one by group discussion and narration,[ 22] and finally, in only one by group discussion.[ 9] In two studies, data had been collected through literature content analysis;[ 10, 13] in two, by applying intervention;[ 16, 23] in two other, through literature review;[ 7, 24] and finally, in two studies, the data had been collected through philosophical inquiries.[ 6, 25]

In two quantitative studies adopted to collect data, standard tools had been employed. In the study of Weis (2000), Nurses' Professional Values Scale (NPVS) with confirmed reliability and validity had been utilized.[ 26] Rassin (2008) used nursing code of ethics related to International Nursing Association to evaluate nurses' professional values as well as the Rokeach Values Survey with confirmed reliability and content validity to assess nurses' personal values.[ 15]

Quality appraisal

The selected articles were reviewed concerning their quality. Application of a systematic literature scientific method in the present literature review study let the research review the articles based on research questions, research project, data collection method, data analysis method, data credibility, ethical considerations, and the results.

In quantitative studies reviewed, standard questionnaires had been adopted for data collection, data analysis method had been clearly defined, and the necessary permissions had been obtained from university and other needed institutes to respect ethical considerations. The results were also in the direction of research questions.

In qualitative studies, research methodology and data analysis had been clearly stated, and participants' consents had been obtained to respect ethical considerations. Various methods had been employed for credibility: Data collection from various methods,[ 19, 20, 22] precise transcription, and data recheck and conformability with participants and colleagues.[ 18, 19, 20]

Data analysis methods of the studies, conducted based on philosophical research methodology and action research, had not been clearly mentioned, but their results were related.

General traits of reviewed studies

General traits of reviewed studies in the context of nursing ethical values have been presented in Table 1 . The reviewed articles had investigated nurses' ethical values from different aspects.

Table 1

RESULTS

In various studies, the values had been differently introduced and defined. Most of the reviewed articles had focused on common nursing ethical values.[ 22] In some, several values and in some other, only one value had been introduced and defined. Konishi (2009) had only studied the value of harmony in nursing and had suggested that as one of the most fundamental values in Japan.[ 13] Verpeet (2003) had defined values as nurses' responsibility against their patients, profession, other health team members, and society.[ 10] Naden (2004) in his study to define components of human dignity indicated braveness, responsibility, respect, commitment, and ethical desires.[ 18] Wros (2004) reported a significant difference in ethical value of decision making among the nurses in two countries.[ 19] Trailer (2004) claims that respect to the patients has the highest priority among codes of ethics and acts as a basic value to design the nursing ethical codes which include three main elements of respect, reliability, and mutuality.[ 25]

Shih (2009) reported that 75% of the participants had indicated taking care of the patients and their related individuals and altruism as the most common nursing values. Other values in his study were provision of holistic professional and appropriate care, promotion of personal and professional competency, disease prevention, health promotion, promotion of interpersonal communication skills, and receiving fair reward.[ 9]

Weis (2000), through factor analysis, introduced eight factors for professional values of which the most important one was nurses' role in care and dimension of commitment.[ 26] Pang (2009) stated nursing professional values in seven themes of altruism, care, respecting the dignity, trust, accountability, independency, and justice.[ 20] Mahmoodi (2008) indicated responsibility, having mental and emotional communication, value, and ethics criteria such as honesty in work, mutual respect, religious margins and confidentiality, justice and fairness.[ 21] Shaw (2008) and Fahrenwald (2005) in our studies, in a different way, investigated application of five nursing professional values in nursing education, including altruism, independency, respect to dignity, nursing interventions' integrity, and social justice.[ 16, 23] Horton (2007) stated that personal and organizational values have effects on nursing and introduced values such as responsibility, honesty, patients' participation, integrity and humanity protection, patients' independency, deep humanistic relationship, dignity, hope, passion, teamwork, differentiation, versatility, altruism, nurturing, integrity and support, reciprocal trust, sound knowledge, clinical competence, communications, unity, homogeneity, coordination, self-sacrifice and devotion, self-protection, privacy preservation, creativity, aesthetics, management, economizing, braveness, commitment, ethical attitude, personal orientation, judgment, freedom, individualism, acknowledgment, and personal success.[ 7] Two studies had stated detection of ethical values as the basis for collection of codes of ethics.[ 24, 27]

DISCUSSION

In all of the articles studied in the present literature review, patients' dignity and respect had been stated as the most frequent value indicated in 12 articles, equality and justice in 8 articles, and altruism and precise care and making appropriate relationships were indicated in 6 articles, respectively.

Comparison and finalization of the obtained data concerning nursing ethical values in patients' care yielded 10 values mostly indicated in the articles: Human dignity, altruism, social justice, autonomy in decision making, precision and accuracy in caring, responsibility, human relationship, individual and professional competency, sympathy, and trust. The 10 obtained values in this literature review and their definitional traits are presented subsequently.

Human dignity

Respecting human dignity was the most common value indicated in the reviewed articles. Respect to individuals including the persons, their families, and the society has been mentioned as an important nursing ethical value. Dignity respect has been defined with definitional traits as consideration of human innate values, respecting patient's beliefs and preservation of their dignity and privacy during clinical procedures, and communication with the patients, and contains understanding the patients and devoting to fulfill clients' needs.[ 15, 16, 18, 20, 22, 23, 24, 27] Pang (2009) argues that nurses should accept that people deserve respect and dignity in action. They should practically cover patients' body parts if exposed and keep patients' secrets confidential.[ 20]

This value has been suggested in most of the articles possibly as a result of humanistic nature of nursing profession in helping others. This value had been emphasized in all articles of Asian countries, reflecting cultural similarities in these countries. This value has also been indicated in most of the codes of ethics in various countries all over the world.

Social justice

Justice is an ethical value suggested in nursing literatures. Social justice has been defined by the traits which, in addition to consideration of individuals' dignity and respect, focus on equal access to health services and the right of being fairly treated and cared free of economic, social, and cultural status.[ 9, 10, 15, 16, 20, 21, 23] Social justice had been the indication in most of the countries and had been defined as fair distribution of resources and provision of individuals' equal treatment and care.

Verpeet (2003) stated that equality means access of all individuals to health services. She claims every individual in Belgium is supposed to have equal right of receiving equal nursing care.[ 10]

Altruism

Altruism is a common nursing value in various countries. It has been defined with traits of consideration of human as the axis of attention and focus in nursing, helping others and provision of the utmost health and welfare for the clients, their families, and the society, selflessness, and self-devotion.[ 6, 9, 13, 15, 16, 18, 22, 23, 27] Therefore, altruism is defined as focusing on clients as a human and struggling to preserve their health and well-being. Pang (2009) debated that based on the principle of altruism, nurses should have spirit of selflessness and helpfulness toward others.[ 20]

Autonomy in decision making

Independency in decision making is a value suggested in some studies as a nursing ethical value. Nurses have defined its traits as having right of independency in decision making, right to accept or reject suggested treatments, interventions, or care. In addition, autonomy in decision making necessitates giving appropriate and adequate information to the clients and, if necessary, to their families.[ 13, 15, 23] So, autonomy in decision making occurs when nurses let patients be informed, free, and independent to decide on the diagnosis, treatment, and prevention through giving them appropriate information.

Konishi (2009) debates that conscious adult patients should themselves decide. With regard to nursing profession, nurses should provide the patients with information, explain suggested interventions, and let them free to either accept or reject oncoming procedures so that they and their families can make a decision about their condition.[ 13]

Precision and accuracy in caring

Precise and accurate care has been indicated as a nursing ethical value. Based on this definition, this sort of care is a precise, safe, appropriate, multidimensional, and kind care given to the patients by nurses. This is also thoughtful, based on adequate clinical skills and nursing knowledge to fulfill clients' needs, promote their health, and relieve their pain and suffering. It is also based on standards and results in patients' safety and satisfaction.[ 6, 9, 15, 23, 24, 27] In this regard, Shih (2009) states that holistic and appropriate professional care is to prevent diseases, promote health, and make the feeling of comfort and safety for the patients.[ 9]

Responsibility

Responsibility has been defined as a nursing ethical value. It is defined with traits of commitment, feeling responsible for the duties toward patients, and respecting the patients' rights for decision making.[ 15, 18, 19, 21, 24, 26, 28] Based on this definition, nurses are responsible for giving evidence-based care, best clinical function, and applicable and valid research, and are accountable for their actions and duties. Verpeet (2005) argues that nurses are responsible for promotion of patients' well-being, having a holistic approach toward them and completing their duties.[ 28]

Human relationship

Human relationship has been indicated as a nursing ethical value with traits of mutual respect, trust, and reliance which are accompanied by patients' confidentiality and privacy. It can be verbal or non-verbal and defined through having honesty in words and practice, sympathy and mutual understanding, courtesy, and friendliness.[ 9, 15, 19, 21, 25]

In this regard, giving care is possible only through making humanistic, efficient, and effective relationship, a relationship based on mutual respect and understanding.

Individual and professional competency

Individual and professional competency as a nursing ethical value has been defined with traits of struggling to make nursing as a profession, feeling the need to acquire personal and professional competency so that nurses can grow and develop in the direction of advances and new technology. Personal competency and development of the nurses result in acquiring up-to-date knowledge and promotion of clinical skills and practical abilities, and the ability to give more holistic and comprehensive care. Promotion of personal and professional competency comes true when nurses make a background for the best patients' care by trying to give evidence-based care, and their empowerment for participation in activities in relation with other health team members and interpersonal and inter-professional skills development.[ 7, 9, 15, 20, 24] Pang (2009) debates that participation in continuing professional development suggests that individuals should preserve their competency in their activities and participate in professional continuing education programs throughout their occupational life.[ 20]

Sympathy

Sympathy has been indicated as a nursing ethical value with traits of understanding patients' and their families' needs and giving care based on making a fair communication.[ 6, 19] In some cultures, such as Japanese, nurses share patients' physical and mental pains and sufferings.[ 19]

Trust

Trust has been indicated as a nursing ethical value and is defined by traits of honesty in words and practice. Nurses should gain patients', their families,' and society's trust through understanding patients' situation and status and appropriate conformation with them.[ 15, 20, 23, 24] Based on this definition, gaining clients' trust and reliance comes true when nurses are honest in their words and practice, and gain individuals' trust and reliance by doing their duties appropriately.

CONCLUSION

This study showed that nursing ethical values in patients' and clients' care are similar in many cases due to a common core in humanistic and spiritual approach of nursing profession, which is taking care of a human. Values such as human dignity, kindness and sympathy, altruism, responsibility and commitment, justice and honesty, and personal and professional competency were similar in most of the cultures.

Despite the similarities in ethical and professional values among various countries, it is essential to detect and highlight these values in each country, for example, in Iran, with regard to the prevalent social, cultural, economic, and religious conditions. Detection and declaration of nursing ethical values in each country can be a valuable, scientific, valid, and essential document to design nursing codes of ethics. This search was used to prepare proposed code of ethics and clinical guidelines for Iranian nurses. Findings of this study search must be considered within its limitation. An attempt was made to conduct a search as vast as possible. However, it might be possible that we could not access to all articles available in the period of the search.

ACKNOWLEDGMENT

The authors would also like to acknowledge the Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, for supporting this work.

Footnotes

Source of Support: Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences

Conflict of Interest: None

REFERENCES

1. Jhonstone MJ. 4th ed. Sydney: Churchill Livingstone Publisher; 2004. Bio Ethics: A Nursing perspective; pp. 120-4. [ Google Scholar]

2. Chitty KK, Beth BP. 5th ed. St Louis: Saunders Elsevier; 2007. Professional nursing concepts and challenge; pp. 522-5. [ Google Scholar]

4. Abaszadeh A, Abedi HA, Sharif F, Ghofrani F. A model of develop and assess of nursing ethical performance. Journal of Teb va Tazkieh. 2001;47:59-66. in Persian. [ Google Scholar]

5. London: Nursing and Midwifery Council of England; 2004. England Nursing and Midwifery Council. The NMC code of professional conduct: Standards for conduct, performance and ethics. [ Google Scholar]

8. Tschudin V. Translated by Baligh N. Tehran: Medical Ethics Research Center; 1994. Ethics in Nursing the Caring relationship; p. 242. in Persian. [ Google Scholar]

17. Centre for Reviews and Dissemination, University of York; 2008. Centre for reviews and dissemination. Systematic Reviews CRD's guidance for undertaking reviews in health care. [ Google Scholar]

21. Mahmoodi Shen G, Alhani F, Ahmadi F, Kazemnejad A. A qualitative study: Ethical thematic in nursing life style. Journal on Medical History and Ethics. 2008;2:63-78. in Persian. [ Google Scholar]

22. Macmillan SS. MSN Thesis. University Microfilms International, Florida: Florida Atlantic University; 1994. Nursing values as the basis for practice of graduate students in nursing; p. 75. [ Google Scholar]

27. Ottawa: Canadian Nursing Association; 2008. Canadian Nursing Association. Code of ethic for registered nurse in Canada; p. 64. [ Google Scholar]

Articles from Iranian Journal of Nursing and Midwifery Research are provided here courtesy of Wolters Kluwer -- Medknow Publications

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Nursing ethical values and definitions: A literature review

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Ethical values offer a framework for behavior assessment, and nursing values influence nurses' goals, strategies, and actions. A literature review was adopted in order to determine and define ethical values for nurses.This literature review was ...

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Abortion is regulated by the Abortion Act 1967, which permits a doctor to perform an abortion if two doctors agree that there are medical grounds for it. The Act has rules about the premises where abortions may be conducted and about certifying and registering abortions.
In practice, the Department of Health allows doctors to sanction abortions without genuine medical grounds and seeks to ensure that abortion is provided in every possible case. This policy has led to a total of over 8.4 million abortions since the Act was passed, mostly for social reasons, not medical indications.

The Abortion Act does not apply in Northern Ireland, but pro-abortion groups like Amnesty and Marie Stopes are working strenuously to extend the killing there.

Most abortions in England and Wales now take place in private abortion clinics, often by groups that are registered charities, but which provide abortion on a commercial basis. They are typically funded through NHS contracts. Some abortions in England, and nearly all in Scotland, are performed in NHS hospitals. The NHS finances nearly all abortions in Britain.

Background

Abortion has been regulated by law in the UK for many centuries. Records of several English legal cases show that abortion was certainly regarded as unlawful at common law in 17th-19th centuries, and probably from the 13th century - nearly as far back as legal records go. In 19th century, parliament consolidated the law in the Offences Against the Person Act of 1861. The 1861 Act remains the principal, underlying statute on abortion in England, Wales and Northern Ireland. It does not apply in Scotland, where the legal history is different, and abortion is regarded as subject to common law as well as the 1967 Abortion Act, which applies across Britain.

Legal status of abortion

Abortion remains unlawful in Britain unless the terms of the Abortion Act are fulfilled. Thus abortion is not a "right" as many pro-abortion advocates would wish. However, it is so insistently promoted by health officials that many doctors feel pressure to conform and provide abortions.

The effect of this approach is that abortion on demand is available, and the Department of Health only enforces the law so far as necessary to reduce the risks to women to what they regard as an acceptable level.

Legality of mental health abortions

In 2011 the Department of Health commissioned an independent review of medical evidence on the impact of abortion on women's mental health. This review concluded that: "The rates of mental health problems for women with an unwanted pregnancy were the same whether they had an abortion or gave birth." (This conclusion appears to understate the serious negative effects of abortion on mental health, but even this conclusion challenges the legality of routine abortion for "unwanted pregnancy").

Most abortions (97-98%) are certified by doctors on the grounds that continuing the pregnancy entails greater risk to the mental health of the woman than having an abortion. Often doctors say this simply because of an "unwanted pregnancy".

But the Department of Health will not tell doctors to stop the practice of certifying "unwanted pregnancy" as a mental health risk. The mental health evidence points to the conclusion that there is bad faith on the part of most doctors certifying abortions most of the time. By signing abortion forms based on false opinions, doctors are flouting the rules of the General Medical Council, the statutory regulator upholding standards in medical practice.

Despite the evidence, leading abortion practitioners have declared that an unwanted pregnancy is a threat to a woman's mental health, and that the law therefore permits abortion on the basis of "unwantedness".

SPUC is challenging the Secretary of State for Health to stop this abuse of the law and insist that doctors stop the practice of routinely mis-certifying abortion on mental health grounds. You can read more about this campaign here.

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Abortion is regulated by the Abortion Act 1967, which permits a doctor to perform an abortion if two doctors agree that there are medical grounds for it. The Act has rules about the premises where abortions may be conducted and about certifying and registering abortions.

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Introduction

The Abortion Act 1967, which came into effect on 27 April 1968, permits termination of pregnancy by a registered practitioner subject to certain conditions. In its application to England and Wales, regulations made under the act (The Abortion Regulations 1968, statutory instrument 1968 no 390, as amended by 1969 no 636, 1976 no 15, 1980 no 1724, and 1991 no 499) require any such termination to be notified within seven days, in the form prescribed in schedule 2 of the principal regulation, to the Chief Medical Officer of the Department of Health or to the Chief Medical Officer of the Welsh Office according to where the termination takes place.

Section 37 of the Human Fertilisation and Embryology Act 1990 made changes to the Abortion Act 1967. These changes came into effect on 1 April 1991 and the content of the notification of abortion form (form HSA4) was amended to reflect the changed law.

By arrangement, the Office for National Statistics (ONS) undertakes the statistical processing and analyses of the notifications.

Conditions of the act and statutory grounds

A legally induced abortion must be:

1. performed by a registered medical practitioner,

2. performed, except in an emergency, in a National Health Service (NHS) hospital or in a place for the time being approved for the purpose of the act, and

3. certified by two registered medical practitioners as justified under one or more of the following grounds:

4. the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated;

5. the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;

6. the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman;

7. the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing child(ren) of the family of the pregnant woman;

8. there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped; or in emergency, certified by the operating practitioner as immediately necessary-

9. to save the life of the pregnant woman; or

10. to prevent grave permanent injury to the physical or mental health of the pregnant woman.

The act provides that in relation to grounds C and D the certifying practitioner may take account of the pregnant woman's actual or reasonably foreseeable environment. The changes made to the Abortion Act 1967 by section 37 of the Human Fertilisation and Embryology Act 1990 came into effect on 1 April 1991 and included a time limit of 24 weeks for abortions under statutory grounds C and D. Statutory grounds A, B, and E are without time limit.

Category of premises/purchaser

Except in an emergency, abortion operations may only be carried out in NHS hospitals, in certain approved services' hospitals or in other premises specifically approved by the secretary of state, such as clinics run by the British Pregnancy Advisory Service (BPAS). At the end of 1999 there were 76 such approved places and two services' hospitals.

Abortion statistics

in 1999 there were 173,701 abortions performed on women resident in england and wales.

How the number and rate of abortions has changed

From 1968 to 1973, the annual numbers of legal abortions for women living in England and Wales increased rapidly and then levelled off at about 100,000 a year. Abortion numbers then rose each year until 1991, mainly because the numbers of women in the population aged 15 to 44 (the fertile ages) grew due to a large increase in the birth rate in Britain between 1956 and 1963. There were more abortions between 1975 and 1990 because there were more women to become pregnant. A further factor in the rise in the number of abortions was the fall in the popularity of marriage among young women. Unmarried women are more likely to have an abortion if they have an unplanned pregnancy. The number of abortions has remained stable between 1998 and 1999. Reasons for this new stability could be due to abortion becoming a more acceptable solution than ever before when contraception fails or women fail to use it properly.

Numbers and rates of abortions carried out on residents of England and Wales for the last five years:

The number of abortions in England and Wales declined between 1990 and 1995, and better use of contraception is likely to have been an important factor in this. There was a seven per cent increase in the number of abortions in 1996, largely due to the effects of a Pill scare in 1995 about the safety of certain brands of oral contraceptives. This undermined the confidence of many women in hormonal methods of contraception and decreased their use. The abortion rate has continued to rise, possibly because of continued concern about the safety of contraceptive hormones, especially among young women, and possibly because abortion is seen by more women as an acceptable way to manage an unwanted pregnancy. The increased abortion rate in 1996 was widely publicised and may have educated women that abortion is a legal and safe choice.

Who pays for abortions?

Unlike maternity services when a woman wants to continue a pregnancy, abortions are not automatically available through the NHS. On average, throughout England and Wales the NHS pays for just under three-quarters (74 per cent) of abortions. There are significant differences between regions. In some areas the NHS pays for more than 90 per cent of abortions, in other regions it pays for less than 50 per cent.

At what gestation do most abortions occur?

Almost 90 per cent of abortions are in the first 12 weeks of pregnancy. Just one per cent are after 20 weeks.

Abortions in England and Wales 1999 by gestation (total 173,701):

Later abortions are often for the following reasons: The woman may not have been able to get a hospital appointment earlier in the pregnancy; she may not have realised she was pregnant (this is more common with young women and women approaching the menopause both of whom may have infrequent periods); very young women may feel unable to cope and so hide the pregnancy; sometimes the pregnancy was originally wanted but the woman's circumstances change (perhaps because she is abandoned by her partner or finds that her parents are not willing to provide her with a home or any other support); fetal abnormality is an important reason for late abortion, as many cannot be diagnosed early in pregnancy.

At what age do women have abortions?

Abortions in England and Wales 1999 by age (total 173,701):

The highest number of abortions is among women aged 20-24. However, a great deal of attention has been focused on teenagers because England and Wales has one of the highest teenage pregnancy rates for 15-19 year olds in Western Europe.

One woman in five who has an abortion is married; many others are in stable relationships. Abortion is not only an issue for single women. Forty-seven per cent of women who have abortions have at least one child already.

Why do women from abroad travel to Britain for abortion?

In 1999 almost 10,000 women who lived abroad travelled to England to have an abortion.

Most of these women came from other parts of the British Isles, mainly from Northern Ireland (1,430) and the Irish Republic (6,226). Those from elsewhere in the world came because abortion is available in their countries only up to 12 weeks (France and Italy) or not available at all (the Arab states), or to ensure complete confidentiality.

The numbers have fallen from their peak of 57,000 in 1973 because most other European countries now have abortion laws that are less restrictive than those in Britain.

View Abstract

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The Abortion Act 1967, which came into effect on 27 April 1968, permits termination of pregnancy by a registered practitioner subject to certain conditions.

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The abortion debate asks whether it can be morally right to terminate a pregnancy before normal childbirth.

Some people think that abortion is always wrong. Some think that abortion is right when the mother's life is at risk. Others think that there is a range of circumstances in which abortion is morally acceptable.

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The abortion debate asks whether it can be morally right to terminate a pregnancy before normal childbirth. Some people think that abortion is always wrong. Some think that abortion is right when the mother's life is at risk. Others think that there are a range of circumstances in which abortion is morally acceptable.

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"Having an abortion does not raise risk of mental health problems," according to The Daily Telegraph. The newspaper says that "the world's biggest review of the issue" has found that it makes no difference to a woman's mental health whether she chooses to have an abortion or continue with the pregnancy.

The extensive review behind this news analysed all relevant medical literature available on the matter to help understand whether women with an unwanted pregnancy who undergo an abortion (termination) are at greater risk of mental health problems than if they continue with the pregnancy. Its principle finding is that women who have an unwanted pregnancy are at no higher risk of adverse mental health effects if they have a termination compared to if they continue with the pregnancy. It also found that there were some specific factors associated with increased mental health problems following an abortion, including experiencing negative attitudes towards abortion and the experience of stressful personal circumstances.

The relationship between unwanted pregnancy, abortion or continued pregnancy and mental health are likely to be complex and not answered easily. The authors of this review also caution that there are unavoidable limitations to their analysis due to the variable quality and methods of the underlying research. However, this thorough analysis of the available literature would appear to indicate that for women who have an unwanted pregnancy, the risk of psychological effects is increased whether she chooses to continue with the pregnancy or not, and the researchers rightly call for all such women to have due care and support available to them, whatever their decision.

Where did the story come from?

This review, 'Induced abortion and mental health' was published by The National Collaborating Centre for Mental Health (NCCMH) and funded by the Department of Health.

The news reports generally give the overall message of this review. However, the headline of The Daily Telegraph - "Having an abortion does not raise risk of mental health problems" - is most accurate. The headlines of the Daily Mirror and The Independent, which say that abortion has "no effect" on mental health, could do with further clarity: women with an unwanted pregnancy who have an abortion are at risk of having adverse mental health effects, but this risk is no greater than if they continued with the pregnancy i.e. this mental health risk would appear to result from having an unwanted pregnancy, rather than the abortion itself.

What kind of research was this?

This was a systematic review that aimed to clarify the relationship between planned abortion (termination) and adverse mental health outcomes. The review was focusing upon women who have an abortion for the reason of unwanted pregnancy, rather than for health reasons relating to the mother or problems with the foetus. Related to this they aimed to address three specific questions:

How common are mental health problems in women who have an abortion?

What factors are associated with poor mental health outcomes following an abortion?

Are mental health problems more common in women who have an abortion for an unwanted pregnancy, when compared with women who deliver an unwanted pregnancy?

In the past there has been speculation over whether abortion itself may adversely affect a woman's mental health - despite the fact that many abortions in the UK are performed on the grounds that continuing with an unwanted pregnancy would risk psychological harm to the mother. In 2010 there were almost 190,000 abortions performed in England and Wales, and 98% of these were performed on the grounds that continuing with the pregnancy would risk physical or psychological harm to the woman or child. A third of these abortions were performed for a woman who had already had a previous abortion.

A systematic review is the best way to determine the overall body of evidence available on a particular question. A systematic review looks at the evidence of all relevant studies regardless of their findings, rather than selectively sampling those that support a particular view. Systematic reviews are regarded to be among the most robust sources of evidence.

What did the research involve?

This systematic review builds on the findings of previous systematic reviews, and has pooled the results of previous studies, where possible, into a single analysis (a meta-analysis). Multiple assessors examined the quality of the identified reviews and individual studies to ensure they were robust, and this was followed by a public consultation to obtain comments on the findings and discuss the content of the report.

Three prior systematic reviews were identified, two of which were qualitative (descriptive) reviews only with no quantitative pooling of results. They were:

The APA Task Force on Mental Health and Abortion (2008) systematic review, which included a broad range of studies of variable quality. These featured different periods of post-abortion follow-up, and aimed to address the mental health issues surrounding abortion.

A 2008 US systematic review by Charles and colleagues, which graded a range of relevant studies according to their quality and specifically looked at mental health problems in the longer term (occurring at least 90 days after the abortion).

A 2011 review by Coleman and colleagues, which performed a meta-analysis of the results of studies published between 1995 and 2009. It aimed to compare mental health outcomes for women who did and did not have an abortion.

The present review aimed to address the questions of:

Prevalence of mental health problems in women who have an abortion.

Factors associated with mental health problems in women who have an abortion.

The risks of mental health issues compared to continuing with an unwanted pregnancy.

Medical literature was searched to identify all English language studies published from 1990-2011 that looked at women who had a legal, planned abortion, and examined mental health outcomes occurring at least 90 days after abortion. Eligible studies had to have used validated diagnostic criteria to assess mental health outcomes; have assessed symptoms using validated rating scales; looked at the use of mental health treatments as an outcome; or looked at the outcomes of suicide or substance abuse. Studies had to have included at least 100 participants, and had as a comparison group, women who continued with their unwanted pregnancy. Where possible, meta-analysis was used to combine evidence from the comparative studies e.g. the odds of mental health problems if an abortion was performed compared to if it was not.

The reviewers found that the quality of the studies available varied, and that they had to take a pragmatic approach to decide which studies to include. Restricting the studies to those meeting the ideal quality thresholds would have meant that very few studies were included. For example, cohort studies would be the ideal type of study to assess the effect of abortion on mental health outcomes, but the review decided to also include cross-sectional studies, as long as they provided evidence that they were measuring post-abortion mental health, rather than mental health problems at any point in the women's lives. The decision to exclude or include studies was based on their quality, and not the outcome of their results.

What were the basic results?

The review is extensive, therefore the findings are not reported in depth here. The main findings of the review group on consideration of the broad range of studies available and their limitations were that, on the best evidence available:

An unwanted pregnancy was associated with an increased risk of mental health problems.

For women with an unwanted pregnancy, the rates of mental health problems were the same whether they had an abortion or continued with the pregnancy.

The most reliable predictor of mental health problems after an abortion was having a history of mental health problems before the abortion i.e. those women that had experienced a mental health problem before their pregnancy were more likely to experience one afterwards.

The factors associated with increased rates of mental health problems were similar for women who had an abortion or who continued with the pregnancy.

There were, however, certain factors associated with higher risk of mental health problems that were specifically related to abortion. These included pressure from a partner to have an abortion; the experience of negative attitudes towards abortions in general; and the experience of negative views about the possible effects that having an abortion could have on a woman's mental and emotional health.

The review group also made the following observations:

The rates of mental health problems after an abortion were higher when studies included women with prior mental health problems than in studies that had specifically excluded women with a history of mental health problems (i.e. indicating that prior mental health problems are a confounding factor in this relationships: prior mental health problems are likely to increase the risk of experiencing them after an abortion; it is not abortion itself that can be solely attributed to the outcome).

A negative emotional reaction immediately following an abortion may be an indicator of higher risk of continuing mental health problems.

Although they attempted to combine individual study findings in meta-analyses, they generally considered these pooled results to be of low quality, at significant risk of bias, and providing no greater insight into the issue compared to a well-conducted narrative review on the subject.

They considered that future research should focus on the mental health needs associated with an unwanted pregnancy, rather than the pregnancy outcome - abortion or continuation to birth.

How did the researchers interpret the results?

The review authors conclude that it is important to consider the support needs of a woman with an unwanted pregnancy, because there is a risk of subsequent mental health problems whatever the pregnancy outcome.

If a woman chooses an abortion, they advise that health and social care professionals are aware that she is more likely to be at risk of mental health problems if she has a history of prior mental health problems, has experienced negative attitudes towards abortion, has a negative emotional reaction to the abortion herself, or if she is experiencing stressful life events.

Conclusion

This is a thorough review that highlights that women with an unwanted pregnancy are at risk of adverse mental health effects, but that the decision to have an abortion or keep the pregnancy itself makes little difference to the risk of developing new mental health issues.

The authors acknowledge several important limitations to their review; principally that the included studies and reviews varied in design and quality. These included differences in terms of:

The mental health outcomes examined and how these were assessed.

Variations in the way adjustments were made to account for important confounding factors that might affect results (e.g. the presence of previous mental health problems, partner violence and abuse, etc).

The comparison groups they used; for example, some featured inappropriate comparisons, such as comparing women who had had an abortion with those who had given birth without considering whether or not the pregnancy was wanted.

Their reliance on analysing other sources of data such as national surveys and retrospective studies, which may be a source of some inaccuracy.

The authors also importantly note that some studies were conducted in countries where abortion is available on demand, whereas in other countries abortion was only carried out if it was definitely concluded that continuing with the pregnancy would risk the mental health of the mother. As such, the included study populations in different countries are likely to differ, and may not all reflect the UK situation.

Whether a woman considers her pregnancy 'unwanted' is also clearly a highly subjective feeling and will mean different things to different people. Furthermore, many factors are likely to influence the decision to continue with the pregnancy or not, such as emotional support from a partner, family or other social contacts.

The relationship between unwanted pregnancy, abortion or continued pregnancy and mental health is likely to be complex and not answered easily. However, as the review rightly concludes, for women who have an unwanted pregnancy, the risk of psychological effects is increased whatever the outcome - whether she chooses to continue with the pregnancy or not - and all such women require due care and support.

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Abortion 'does not raise mental health risks'

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"Having an abortion does not raise risk of mental health problems," according to The Daily Telegraph. The newspaper says that "the world's biggest review of the issue" has found that it makes no difference to a woman's mental health whether she chooses to have an abortion or continue with the pregnancy.

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Termination of pregnancy: a review of psychological effects on women

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This study reviews the evidence on the psychological effects of induced abortion.

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Patients respond differently to abortion, some may need with emotional support in coping with the procedure off the and the after effects.

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In 2014, we have reached a situation where in Great Britain each year, about 198,000 women have abortions, which means that roughly one pregnancy in five is terminated.

Many of these women subsequently regret their termination of pregnancy, and they may have sad feelings that last for a long time.

However, in December 2011 a study carried out by the National Collaborating Centre for Mental Health, and funded by the Department of Health, found that the incidence of mental health problems in women who have an unwanted pregnancy was the same whether they had an abortion or not.

Very significantly, the research also found that having an unwanted conception triples the incidence of subsequent anxiety and depression, whether the woman terminates the pregnancy or not.

But sadness is not an inevitable result of having a termination.

Some women are so relieved they don't have to go ahead with the pregnancy, they appear to get over the procedure quite easily. Indeed, plenty of women who have had abortions have not suffered any great distress.

But as a psychotherapist, I sometimes see women who are not coping well after having an abortion. Sometimes, they turn up ready to talk about the termination.

More commonly, they come along and say they are struggling with miserable feelings in general. Only later does it emerge that they've had an abortion in their recent or more distant past.

Mixed emotions

Over the years, I've noticed that a large proportion of women who come for therapy have terminated a pregnancy. As they begin to talk about the abortion, they become very emotional and express feelings of great sorrow and confusion.

Some of these women are astonished that having a termination has affected them so badly, despite believing they were right to halt the pregnancy.

One of my clients went through a period of feeling very angry. She told me that she had always subscribed to the view that it was a woman's right to choose and that women should be in charge of their own bodies.

But she felt that the women of the 70s who had blazed the 'termination trail' had failed to tell the next generation that abortion can leave a legacy of misery.

If you're having trouble coming to terms with an abortion, please let me assure you that you're not unusual, even if it happened many years ago.

What can you do to help yourself?

In this country, we seem to be pretty hopeless about matters of life and death.

The rituals we do have are often tied up with organised religion, and many people feel these are not appropriate for them.

My experience is that women who have terminated a pregnancy can feel comforted by some sort of ritual or ceremony.

Some women choose to plant a rose tree or a window box.

Others find it helps to mark certain anniversaries. For example, one of my clients worked out that that had the pregnancy proceeded, the child's birthday would have been around 25 March. So on the 25th of every month she used to light a candle.

One client found some comfort and purpose in sponsoring a child in Africa.

Another way of helping yourself is to write down your feelings about the pregnancy and the termination whenever you feel upset about it. That way you will gradually make sense of it.

Where can I get help?

Many women who are struggling after a termination feel better for having some counselling.

If you are under 25, a good place to get free counselling post-abortion is at a Brook centre.

Another organisation that can help women of all ages is the British Pregnancy Advisory Service .

There are other support organisations such as Care Confidential, which is a Christian organisation.

But some women are so angry and upset after a termination that they don't find it helpful to go to any of the above.

Other psychotherapists and counsellors can help. Under the NHS, such therapy is only available to a limited extent.

If you have the means to do so, you may want to consider having some private therapy. A good way to find a therapist is through the British Association for Counselling and Psychotherapy.

Other people also read:

Abortion: what are the different methods for termination of pregnancy.

Cognitive therapy: will CBT work for you?

Depression therapy on the NHS: what kinds of therapy are there?

Talking to your GP about depression: talking it over.
Last updated

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national collaborating centre for mental health

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british association for counselling and psychotherapy

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Sadness is not an inevitable result of having a termination. Some women are so relieved they don't have to go ahead with the pregnancy, they appear to get over the procedure quite easily. But as a psychotherapist, I frequently see women who are not coping well after having an abortion.

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Knowing the risks and complications through terminations.

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Printable Fact Sheets
Psychological Complications
More articles on abortion complications

Physical Dangers Associated With Abortion

Approximately 10% of women undergoing induced abortion suffer from immediate complications, of which one-fifth (2%) were considered major. ¹⁹ However the majority of complications take time to develop and will not be apparent for days, months or even years.

Negative psychological reactions to abortion are more common than physical complications. These are described in a later section.

The major physical risks and complications of abortion are described below. Citations to the medical literature regarding each danger or risk are included as end notes at the bottom of this page.

ELEVATED RISK OF DEATH

According to the best record based study of deaths following pregnancy and abortion, a 1997 government funded study in Finland, women who abort are approximately four times more likely to die in the following year than women who carry their pregnancies to term. In addition, women who carry to term are only half as likely to die as women who were not pregnant. ¹⁶ ( for more details on this important study.)

The Finland researchers found that compared to women who carried to term, women who aborted in the year prior to their deaths were 60 percent more likely to die of natural causes, seven times more likely to die of suicide, four times more likely to die of injuries related to accidents, and 14 times more likely to die from homicide.

Researchers believe the higher rate of deaths related to accidents and homicide may be linked to higher rates of suicidal or risk-taking behavior. ¹⁶ ( Click here for details on the latest research regarding abortion associated deaths.)

The leading causes of abortion related maternal deaths within a week of the surgery are hemorrhage, infection, embolism, anesthesia, and undiagnosed ectopic pregnancies. Legal abortion is reported as the fifth leading cause of maternal death in the United States, though in fact it is recognized that most abortion-related deaths are not officially reported as such. ² ( for more details on the underreporting of abortion related deaths in the U.S.)

Two studies of the entire population of women in Denmark published in 2012 have shown similar results. The first found that the risk of death following abortion remains higher in each of the first ten years following the abortion. The second found that the risk of death increases with each abortion, 45% after one abortion, 114% after two abortions, and 192 percent after three or more abortions.

For a complete review of the literature see Deaths associated with abortion compared to childbirth: a review of new and old data and the medical and legal implications (2004).

CERVICAL, OVARIAN, AND LIVER CANCER

Women with a history of one abortion face a 2.3 times higher risk of having cervical cancer, compared to women with no history of abortion. Women with two or more abortions face a 4.92 relative risk. Similar elevated risks of subsequent ovarian and liver cancer have also been linked to single and multiple abortions. These increased cancer rates for post-aborted women may be linked to the unnatural disruption of the hormonal changes which accompany pregnancy and untreated cervical damage or to increased stress and the negative impact of stress on the immune system. ⁴

UTERINE PERFORATION

Between 2 and 3% of all abortion patients may suffer perforation of their uterus, yet most of these injuries will remain undiagnosed and untreated unless laparoscopic visualization is performed. ⁵ Such an examination may be useful when beginning an abortion malpractice suit. The risk of uterine perforation is increased for women who have previously given birth and for those who receive general anesthesia at the time of the abortion.(6) Uterine damage may result in complications in later pregnancies and may eventually evolve into problems which require a hysterectomy, which itself may result in a number of additional complications and injuries including osteoporosis.

CERVICAL LACERATIONS

Significant cervical lacerations requiring sutures occur in at least one percent of first trimester abortions. Lesser lacerations, or micro fractures, which would normally not be treated may also result in long term reproductive damage. Latent post-abortion cervical damage may result in subsequent cervical incompetence, premature delivery, and complications of labor. The risk of cervical damage is greater for teenagers, for second trimester abortions, and when practitioners fail to use laminaria for dilation of the cervix. ⁷

PLACENTA PREVIA

Abortion increases the risk of placenta previa in later pregnancies (a life threatening condition for both the mother and her wanted pregnancy) by seven to fifteen fold. Abnormal development of the placenta due to uterine damage increases the risk of fetal malformation, perinatal death, and excessive bleeding during labor. ⁸

SUBSEQUENT PRE-TERM DELIVERIES AND OTHER COMPLICATIONS OF LABOR

Women who had one, two, or more previous induced abortions are, respectively, 1.89, 2.66, or 2.03 times more likely to have a subsequent pre-term delivery, compared to women who carry to term. Prior induced abortion not only increased the risk of premature delivery, it also increased the risk of delayed delivery. Women who had one, two, or more induced abortions are, respectively, 1.89, 2.61, and 2.23 times more likely to have a post-term delivery (over 42 weeks). ¹⁷ Pre-term delivery increases the risk of neonatal death and handicaps.

HANDICAPPED NEWBORNS IN LATER PREGNANCIES

Abortion is associated with cervical and uterine damage which may increase the risk of premature delivery, complications of labor and abnormal development of the placenta in later pregnancies. These reproductive complications are the leading causes of handicaps among newborns. ⁹

ECTOPIC PREGNANCY

Abortion is significantly related to an increased risk of subsequent ectopic pregnancies. Ectopic pregnancies, in turn, are life threatening and may result in reduced fertility. ¹⁰

PELVIC INFLAMMATORY DISEASE (PID)

PID is a potentially life threatening disease which can lead to an increased risk of ectopic pregnancy and reduced fertility. Of patients who have a chlamydia infection at the time of the abortion, 23% will develop PID within 4 weeks. Studies have found that 20 to 27% of patients seeking abortion have a chlamydia infection. Approximately 5% of patients who are not infected by chlamydia develop PID within 4 weeks after a first trimester abortion. It is therefore reasonable to expect that abortion providers should screen for and treat such infections prior to an abortion. ¹¹

ENDOMETRITIS

Endometritis is a post-abortion risk for all women, but especially for teenagers, who are 2.5 times more likely than women 20-29 to acquire endometritis following abortion. ¹²

IMMEDIATE COMPLICATIONS

Approximately 10% of women undergoing elective abortion will suffer immediate complications, of which approximately one-fifth (2%) are considered life threatening. The nine most common major complications which can occur at the time of an abortion are: infection, excessive bleeding, embolism, ripping or perforation of the uterus, anesthesia complications, convulsions, hemorrhage, cervical injury, and endotoxic shock. The most common "minor" complications include: infection, bleeding, fever, second degree burns, chronic abdominal pain, vomiting, gastro-intestinal disturbances, and Rh sensitization. ¹³

INCREASED COMPLICATIONS FOR WOMEN SEEKING MULTIPLE ABORTIONS:

In general, most of the studies cited above reflect risk factors for women who undergo a single abortion. These same studies show that women who have multiple abortions face a much greater risk of experiencing these complications. This point is especially noteworthy since approximately 45% of all abortions are for repeat aborters.

LOWER GENERAL HEALTH:

In a survey of 1428 women researchers found that pregnancy loss, and particularly losses due to induced abortion, was significantly associated with an overall lower health. Multiple abortions correlated to an even lower evaluation of "present health." While miscarriage was detrimental to health, abortion was found to have a greater correlation to poor health. These findings support previous research which reported that during the year following an abortion women visited their family doctors 80% more for all reasons and 180% more for psychosocial reasons. The authors also found that "if a partner is present and not supportive, the miscarriage rate is more than double and the abortion rate is four times greater than if he is present and supportive. If the partner is absent the abortion rate is six times greater." ⁽¹⁵⁾

This finding is supported by a 1984 study that examined the amount of health care sought by women during a year before and a year after their induced abortions. The researchers found that on average, there was an 80 percent increase in the number of doctor visits and a 180 percent increase in doctor visits for psychosocial reasons after abortion. ¹⁸

INCREASED RISK FOR CONTRIBUTING HEALTH RISK FACTORS:

Abortion is significantly linked to behavioral changes such as promiscuity, smoking, drug abuse, and eating disorders which all contribute to increased risks of health problems. For example, promiscuity and abortion are each linked to increased rates of PID and ectopic pregnancies. Which contributes most is unclear, but apportionment may be irrelevant if the promiscuity is itself a reaction to post- abortion trauma or loss of self esteem.

INCREASED DANGERS FROM ABORTION FOR TEENAGERS:

Teenagers, who account for about 30 percent of all abortions, are also at much high risk of suffering many abortion related complications. This is true of both immediate complications, and of long-term reproductive damage. ¹⁴

The most complete listing of physical dangers associated with abortion can be found at at AbortionRisks.org

Psychological Risks Associated with Abortion
Printable Fact Sheets
REQUIREMENT OF PSYCHOLOGICAL TREATMENT
A study of the medical records of 56,741 California medicaid patients revealed that women who had abortions were 160 percent more likely than delivering women to be hospitalized for psychiatric treatment in the first 90 days following abortion or delivery. Rates of psychiatric treatment remained significantly higher for at least four years.

In a study of post-abortion patients only 8 weeks after their abortion, researchers found that 44% complained of nervous disorders, 36% had experienced sleep disturbances, 31% had regrets about their decision, and 11% had been prescribed psychotropic medicine by their family doctor. (2) A 5 year retrospective study in two Canadian provinces found significantly greater use of medical and psychiatric services among women with a history of abortion. Most significant was the finding that 25% of women who had abortions made visits to psychiatrists as compared to 3% of the control group. (3) Women who have had abortions are significantly more likely than others to subsequently require admission to a psychiatric hospital. At especially high risk are teenagers, separated or divorced women, and women with a history of more than one abortion. (4)

Since many post-abortive women use repression as a coping mechanism, there may be a long period of denial before a woman seeks psychiatric care. These repressed feelings may cause psychosomatic illnesses and psychiatric or behavioral in other areas of her life. As a result, some counselors report that unacknowledged post-abortion distress is the causative factor in many of their female patients, even though their patients have come to them seeking therapy for seemingly unrelated problems. (5)

RISK FACTORS

Researchers have identified a large number of statistically significant risk factors that identify which women are at greatest risk of experiencing one or more severe reactions to abortion. The following is list of risk factors identified by the American Psychological Association Task Force on Mental Health and Abortion in their 2008 report:

1. terminating a pregnancy that is wanted or meaningful

2. perceived pressure from others to terminate a pregnancy

3. perceived opposition to the abortion from partners, family, and/or friends

4. lack of perceived social support from others

5. various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life)

6. a history of mental health problems prior to the pregnancy

7. feelings of stigma

8. perceived need for secrecy

9. exposure to antiabortion picketing

10. use of avoidance and denial coping strategies

11. feelings of commitment to the pregnancy

12. ambivalence about the abortion decision

13. low perceived ability to cope with the abortion

14. history of prior abortion

15. late term abortion

16. being an adolescent (not an adult)

17. having a non-elective (therapeutic or coerced) abortion

18. prior history of abortion (having a second or third abortion, or more)

SUICIDAL IDEATION AND SUICIDE ATTEMPTS

Approximately 60 percent of women who experience post-abortion sequelae report suicidal ideation, with 28 percent actually attempting suicide, of which half attempted suicide two or more times.(13)

Researchers in Finland have identified a strong statistical association between abortion and suicide in a records based study (see figure at the right). They found that the mean annual suicide rate for all women was 11.3 per 100,000 but the rate for women following abortion was 34.7 per 100,000, three times higher. The suicide rate associated with birth, by contrast, was half the rate of all women and less than one-sixth the rate of suicide among women who had abortions.(13)

Suicide attempts appear to be especially prevalent among post-abortion teenagers. Numerous other studies have also revealed higher rates of suicide and suicide attempts associated with abortion.(13)

ALCOHOL AND DRUG ABUSE

Over twenty studies have linked abortion to increased rates of drug and alcohol use. Abortion is significantly linked with a two fold increased risk of alcohol abuse among women.(16) Abortion followed by alcohol abuse is linked to violent behavior, divorce or separation, auto accidents, and job loss.(17) In addition to the psycho-social costs of such abuse, drug abuse is linked with increased exposure to HIV/AIDS infections, congenital malformations, and assaultive behavior. (18)

EATING DISORDERS

For at least some women, post-abortion stress is associated with eating disorders such as binge eating, bulimia, and anorexia nervosa. (19)

SEXUAL DYSFUNCTION

Thirty to fifty percent of the women who experience difficulty adjusting to a past abortion report experiencing sexual dysfunctions, of both short and long duration, beginning immediately after their abortions. These problems may include one or more of the following: loss of pleasure from intercourse, increased pain, an aversion to sex and/or males in general, or the development of a promiscuous life-style. (12)

CHILD NEGLECT OR ABUSE

Abortion is linked with increased depression, violent behavior, alcohol and drug abuse, replacement pregnancies, and reduced maternal bonding with children born subsequently. These factors are closely associated with child abuse and would appear to confirm individual clinical assessments linking post-abortion trauma with subsequent child abuse. (20)

POST-TRAUMATIC STRESS DISORDER (PTSD or PAS)

While psychological reactions to abortion fall into many categories, some women experience all or some of they symptoms of post-traumatic stress disorder (PTSD). The lowest incidence rate of PTSD reported following abortion is 1.5%, which would translate to over 600,000 cases of abortion induced PTSD.Another study found that 14% of American women have all the symptoms of PTSD and attribute them to their abortions, with as many as 65% reporting some, but not all symptoms of PTSD.

Yet another random study found that a minimum of 19% of post-abortion women suffer from diagnosable post-traumatic stress disorder (PTSD). Approximately half had many, but not all, symptoms of PTSD, and 20 to 40 percent showed moderate to high levels of stress and avoidance behavior relative to their abortion experiences. (6)

PTSD is a psychological dysfunction which results from a traumatic experience which overwhelms a person's normal defense mechanisms resulting in intense fear, feelings of helplessness or being trapped, or loss of control. The risk that an experience will be traumatic is increased when the traumatizing event is perceived as including threats of physical injury, sexual violation, or the witnessing of or participation in a violent death. PTSD results when the traumatic event causes the hyperarousal of "flight or fight" defense mechanisms. This hyperarousal causes these defense mechanisms to become disorganized, disconnected from present circumstances, and take on a life of their own resulting in abnormal behavior and major personality disorders. As an example of this disconnection of mental functions, some PTSD victim may experience intense emotion but without clear memory of the event; others may remember every detail but without emotion; still others may reexperience both the event and the emotions in intrusive and overwhelming flashback experiences. (7)

Women may experience abortion as a traumatic event for several reasons. Many are forced into an unwanted abortions by husbands, boyfriends, parents, or others. If the woman has repeatedly been a victim of domineering abuse, such an unwanted abortion may be perceived as the ultimate violation in a life characterized by abuse. Other women, no matter how compelling the reasons they have for seeking an abortion, may still perceive the termination of their pregnancy as the violent killing of their own child. The fear, anxiety, pain, and guilt associated with the procedure are mixed into this perception of grotesque and violent death. Still other women, report that the pain of abortion, inflicted upon them by a masked stranger invading their body, feels identical to rape. (8) Indeed, researchers have found that women with a history of sexual assault may experience greater distress during and after an abortion exactly because of these associations between the two experiences. (9) When the stressor leading to PTSD is abortion, some clinicians refer to this as Post-Abortion Syndrome (PAS).

The major symptoms of PTSD are generally classified under three categories: hyperarousal, intrusion, and constriction.

Hyperarousal is a characteristic of inappropriately and chronically aroused "fight or flight" defense mechanisms. The person is seemingly on permanent alert for threats of danger. Symptoms of hyperarousal include: exaggerated startle responses, anxiety attacks, irritability, outbursts of anger or rage, aggressive behavior, difficulty concentrating, hypervigilence, difficulty falling asleep or staying asleep, or physiological reactions upon exposure to situations that symbolize or resemble an aspect of the traumatic experience (eg. elevated pulse or sweat during a pelvic exam, or upon hearing a vacuum pump sound.)

Intrusion is the reexperience of the traumatic event at unwanted and unexpected times. Symptoms of intrusion in PAS cases include: recurrent and intrusive thoughts about the abortion or aborted child, flashbacks in which the woman momentarily reexperiences an aspect of the abortion experience, nightmares about the abortion or child, or anniversary reactions of intense grief or depression on the due date of the aborted pregnancy or the anniversary date of the abortion.

Constriction is the numbing of emotional resources, or the development of behavioral patterns, so as to avoid stimuli associated with the trauma. It is avoidance behavior; an attempt to deny and avoid negative feelings or people, places, or things which aggravate the negative feelings associated with the trauma. In post-abortion trauma cases, constriction may include: an inability to recall the abortion experience or important parts of it; efforts to avoid activities or situations which may arouse recollections of the abortion; withdrawal from relationships, especially estrangement from those involved in the abortion decision; avoidance of children; efforts to avoid or deny thoughts or feelings about the abortion; restricted range of loving or tender feelings; a sense of a foreshortened future (e.g., does not expect a career, marriage, or children, or a long life.); diminished interest in previously enjoyed activities; drug or alcohol abuse; suicidal thoughts or acts; and other self-destructive tendencies.

As previously mentioned, Barnard's study identified a 19% rate of PTSD among women who had abortions three to five years previously. But in reality the actual rate is probably higher. Like most post-abortion studies, Barnard's study was handicapped by a fifty percent drop out rate. Clinical experience has demonstrated that the women least likely to cooperate in post-abortion research are those for whom the abortion caused the most psychological distress. Research has confirmed this insight, demonstrating that the women who refuse followup evaluation most closely match the demographic characteristics of the women who suffer the most post-abortion distress. (10) The extraordinary high rate of refusal to participate in post-abortion studies may interpreted as evidence of constriction or avoidance behavior (not wanting to think about the abortion) which is a major symptom of PTSD.

For many women, the onset or accurate identification of PTSD symptoms may be delayed for several years. (11) Until a PTSD sufferer has received counseling and achieved adequate recovery, PTSD may result in a psychological disability which would prevent an injured abortion patient from bringing action within the normal statutory period. This disability may, therefore, provide grounds for an extended statutory period.

INCREASED SMOKING WITH CORRESPONDENT NEGATIVE HEALTH EFFECTS

Post-abortion stress is linked with increased cigarette smoking. Women who abort are twice as likely to become heavy smokers and suffer the corresponding health risks. (14) Post-abortion women are also more likely to continue smoking during subsequent wanted pregnancies with increased risk of neonatal death or congenital anomalies. (15)

DIVORCE AND CHRONIC RELATIONSHIP PROBLEMS

For most couples, an abortion causes unforeseen problems in their relationship. Post-abortion couples are more likely to divorce or separate. Many post-abortion women develop a greater difficulty forming lasting bonds with a male partner. This may be due to abortion related reactions such as lowered self-esteem, greater distrust of males, sexual dysfunction, substance abuse, and increased levels of depression, anxiety, and volatile anger. Women who have more than one abortion (representing about 45% of all abortions) are more likely to require public assistance, in part because they are also more likely to become single parents. (21)

REPEAT ABORTIONS

Women who have one abortion are at increased risk of having additional abortions in the future. Women with a prior abortion experience are four times more likely to abort a current pregnancy than those with no prior abortion history. (22)

This increased risk is associated with the prior abortion due to lowered self esteem, a conscious or unconscious desire for a replacement pregnancy, and increased sexual activity post-abortion. Subsequent abortions may occur because of conflicted desires to become pregnant and have a child and continued pressures to abort, such as abandonment by the new male partner. Aspects of self-punishment through repeated abortions are also reported. (23)

Approximately 45% of all abortions are now repeat abortions. The risk of falling into a repeat abortion pattern should be discussed with a patient considering her first abortion. Furthermore, since women who have more than one abortion are at a significantly increased risk of suffering physical and psychological sequelae, these heightened risks should be thoroughly discussed with women seeking abortions.

The most complete listing of psychological problems associated with abortion can be found at at AbortionRisks.org
NOTES Regarding Physical Risks
1. Detrimental Effects of Abortion: An Annotated Bibliography with Commentary (Third Edition) is the most complete review of medical studies relevant to abortion. It includes brief summaries of major finding drawn from medical and psychology journal articles, books, and related materials, divided into major categories of relevant injuries. An online version of the bibliography can be found at www.AbortionRisks.com 2. Kaunitz, "Causes of Maternal Mortality in the United States," Obstetrics and Gynecology, 65(5) May 1985.3. H.L. Howe, et al., "Early Abortion and Breast Cancer Risk Among Women Under Age 40," International Journal of Epidemiology 18(2):300-304 (1989); L.I. Remennick, "Induced Abortion as A Cancer Risk Factor: A Review of Epidemiological Evidence," Journal of Epidemiological Community Health, (1990); M.C. Pike, "Oral Contraceptive Use and Early Abortion as Risk Factors for Breast Cancer in Young Women," British Journal of Cancer 43:72 (1981).4. M-G, Le, et al., "Oral Contraceptive Use and Breast or Cervical Cancer: Preliminary Results of a French Case- Control Study, Hormones and Sexual Factors in Human Cancer Etiology, ed. JP Wolff, et al., Excerpta Medica: New York (1984) pp.139-147; F. Parazzini, et al., "Reproductive Factors and the Risk of Invasive and Intraepithelial Cervical Neoplasia," British Journal of Cancer, 59:805-809 (1989); H.L. Stewart, et al., "Epidemiology of Cancers of the Uterine Cervix and Corpus, Breast and Ovary in Israel and New York City," Journal of the National Cancer Institute 37(1):1-96; I. Fujimoto, et al., "Epidemiologic Study of Carcinoma in Situ of the Cervix," Journal of Reproductive Medicine 30(7):535 (July 1985); N. Weiss, "Events of Reproductive Life and the Incidence of Epithelial Ovarian Cancer," Am. J. of Epidemiology, 117(2):128-139 (1983); V. Beral, et al., "Does Pregnancy Protect Against Ovarian Cancer," The Lancet, May 20, 1978, pp. 1083-1087; C. LaVecchia, et al., "Reproductive Factors and the Risk of Hepatocellular Carcinoma in Women," International Journal of Cancer, 52:351, 1992.

5. S. Kaali, et al., "The Frequency and Management of Uterine Perforations During First-Trimester Abortions," Am. J. Obstetrics and Gynecology 161:406-408, August 1989; M. White, "A Case-Control Study of Uterine Perforations documented at Laparoscopy," Am. J. Obstetrics and Gynecology 129:623 (1977).

6. D. Grimes, et al., "Prevention of uterine perforation During Curettage Abortion," JAMA, 251:2108-2111 (1984); D. Grimes, et al.,"Local versus General Anesthesia: Which is Safer For Performing Suction Abortions?" Am. J. of Obstetrics and Gynecology, 135:1030 (1979).

7. K. Schulz, et al., "Measures to Prevent Cervical Injuries During Suction Curettage Abortion," The Lancet, May 28, 1983, pp 1182-1184; W. Cates, "The Risks Associated with Teenage Abortion," New England Journal of Medicine, 309(11):612-624; R. Castadot, "Pregnancy Termination: Techniques, Risks, and Complications and Their Management," Fertility and Sterility, 45(1):5-16 (1986).

8. Barrett, et al., "Induced Abortion: A Risk Factor for Placenta Previa", American Journal of Ob&Gyn. 141:7 (1981).

9. Hogue, Cates and Tietze, "Impact of Vacuum Aspiration Abortion on Future Childbearing: A Review", Family Planning Perspectives (May-June 1983),vol.15, no.3.. Jacobsson B, Hagberg G, Hagberg B, Ladfors L, Niklasson A, Hagberg A. Cerebral Palsy in preterm infants: a population-based case-control study of antenatal and intrapartal risk factors. Acta Paediatrica 2002;91:946-951. Calhoun BC, Shadigian E, Rooney B. Cost consequences of induced abortion as an attributable risk for preterm birth and informed consent. J Reprod Med 2007;52:929-939.

10. Daling,et.al., "Ectopic Pregnancy in Relation to Previous Induced Abortion", JAMA, 253(7):1005-1008 (Feb. 15, 1985); Levin, et.al., "Ectopic Pregnancy and Prior Induced Abortion", American Journal of Public Health (1982), vol.72,p253; C.S. Chung, "Induced Abortion and Ectopic Pregnancy in Subsequent Pregnancies," American Journal of Epidemiology 115(6):879-887 (1982)

11. T. Radberg, et al., "Chlamydia Trachomatis in Relation to Infections Following First Trimester Abortions," Acta Obstricia Gynoecological (Supp. 93), 54:478 (1980); L. Westergaard, "Significance of Cervical Chlamydia Trachomatis Infection in Post-abortal Pelvic Inflammatory Disease," Obstetrics and Gynecology, 60(3):322-325, (1982); M. Chacko, et al., "Chlamydia Trachomatosis Infection in Sexually Active Adolescents: Prevalence and Risk Factors," Pediatrics, 73(6), (1984); M. Barbacci, et al., "Post- Abortal Endometritis and Isolation of Chlamydia Trachomatis," Obstetrics and Gynecology 68(5):668-690, (1986); S. Duthrie, et al., "Morbidity After Termination of Pregnancy in First-Trimester," Genitourinary Medicine 63(3):182-187, (1987).

12. Burkman, et al., "Morbidity Risk Among Young Adolescents Undergoing Elective Abortion" Contraception, 30:99-105 (1984); "Post-Abortal Endometritis and Isolation of Chlamydia Trachomatis," Obstetrics and Gynecology 68(5):668- 690, (1986)

13. Frank, et.al., "Induced Abortion Operations and Their Early Sequelae", Journal of the Royal College of General Practitioners (April 1985),35(73):175-180; Grimes DA, Cates W Jr. Abortion: Methods and complications. In: Hafez ESE, ed. Human reproduction: Conception and contraception (2nd ed). Hagerstown, Maryland: Harper and Row, 1980:796‑813.; M.A. Freedman, "Comparison of complication rates in first trimester abortions performed by physician assistants and physicians," Am. J. Public Health, 76(5):550- 554 (1986).

14. Wadhera, "Legal Abortion Among Teens, 1974-1978", Canadian Medical Association Journal, 122:1386-1389,(June 1980).

15. Ney, et.al., "The Effects of Pregnancy Loss on Women's Health," Soc. Sci. Med. 48(9):1193-1200, 1994; Badgley, Caron, & Powell, Report of the Committee on the Operation of the Abortion Law, Supply and Services, Ottawa, 1977: 319-321.

16. Gissler, M., et. al., "Pregnancy-associated deaths in Finland 1987-1994 - definition problems and benefits of record linkage," Acta Obsetricia et Gynecolgica Scandinavica 76:651-657 (1997).

17. Zhou, Weijin, et. al., "Induced Abortion and Subsequent Pregnancy Duration," Obstetrics & Gynecology 94(6):948-953 (Dec. 1999). Klemetti R, Gissler M, Niinimäki M, Hemminki E. Birth outcomes after induced abortion: a nationwide register-based study of first births in Finland. Hum Reprod 2012 Aug 29. [Epub ahead of print]. Rooney B, Calhoun BC. Induced Abortion and Risk of Later Premature Births. Journal American Physicians & Surgeons 2003;8(2):46-49 Bhattacharya S, Lowit A, Bhattacharya S, Raja EA. -et al. Reproductive outcomes following induced abortion: a national register-based study in Scotland. BMJ OPEN Summer 2012. Swingle HM, Colaizy TT, Zimmerman MB, et al Abortion and the risk of subsequent preterm birth: a systematic review and meta-analysis. J Reproductive Med 2009;54:95-108.

18. D. Berkeley, P.L. Humphreys, and D. Davidson, "Demands Made on General Practice by Women Before and After an Abortion," J. R. Coll. Gen. Pract. 34:310-315, 1984.

19. Frank, et.al., "Induced Abortion Operations and Their Early Sequelae", Journal of the Royal College of General Practitioners (April 1985), vol.35,no.73,pp175-180. and Grimes and Cates, "Abortion: Methods and Complications", Human Reproduction, 2nd ed., 796-813.
NOTES RELATIVE TO SECTION ON PSYCHOLOGICAL RISKS:
1. An excellent resource is Thomas Strahan's Detrimental Effects of Abortion: An Annotated Bibliography with Commentary (Third Edition) This resource includes brief summaries of major finding drawn from medical and psychology journal articles, books, and related materials, divided into major categories of relevant injuries. An online version can be found at AbortionRisks.org

2. Ashton,"They Psychosocial Outcome of Induced Abortion", British Journal of Ob&Gyn., 87:1115-1122, (1980).

3. Badgley, et.al.,Report of the Committee on the Operation of the Abortion Law (Ottawa:Supply and Services, 1977)pp.313-321.

4. R. Somers, "Risk of Admission to Psychiatric Institutions Among Danish Women who Experienced Induced Abortion: An Analysis on National Record Linkage," Dissertation Abstracts International, Public Health 2621-B, Order No. 7926066 (1979); H. David, et al., "Postpartum and Postabortion Psychotic Reactions," Family Planning Perspectives 13:88-91 (1981).

5. Kent, et al., "Bereavement in Post-Abortive Women: A Clinical Report", World Journal of Psychosynthesis (Autumn-Winter 1981), vol.13,nos.3-4.

6. Catherine Barnard, The Long-Term Psychological Effects of Abortion, Portsmouth, N.H.: Institute for Pregnancy Loss, 1990).

7. Herman, Trauma and Recovery, (New York: Basic Books, 1992) 34.

8. Francke, The Ambivalence of Abortion (New York: Random House, 1978) 84-95.

9. Zakus, "Adolescent Abortion Option," Social Work in Health Care, 12(4):87 (1987); Makhorn, "Sexual Assault & Pregnancy," New Perspectives on Human Abortion, Mall & Watts, eds., (Washington, D.C.: University Publications of America, 1981).

10. Adler, "Sample Attrition in Studies of Psycho-social Sequelae of Abortion: How great a problem." Journal of Social Issues, 1979, 35, 100-110.

11. Speckhard, "Postabortion Syndrome: An Emerging Public Health Concern," Journal of Social Issues, 48(3):95-119.

12. Speckhard, Psycho-social Stress Following Abortion, Sheed & Ward, Kansas City: MO, 1987; and Belsey, et al., "Predictive Factors in Emotional Response to Abortion: King's Termination Study - IV," Soc. Sci. & Med., 11:71-82 (1977).

13. Speckhard, Psycho-social Stress Following Abortion, Sheed & Ward, Kansas City: MO, 1987; Gissler, Hemminki & Lonnqvist, "Suicides after pregnancy in Finland, 1987-94: register linkage study," British Journal of Medicine 313:1431-4, 1996.C. Haignere, et al., "HIV/AIDS Prevention and Multiple Risk Behaviors of Gay Male and Runaway Adolescents," Sixth International Conference on AIDS: San Francisco, June 1990; N. Campbell, et al., "Abortion in Adolescence," Adolescence, 23(92):813-823 (1988); H. Vaughan, Canonical Variates of Post-Abortion Syndrome, Portsmouth, NH: Institute for Pregnancy Loss, 1991; B. Garfinkel, "Stress, Depression and Suicide: A Study of Adolescents in Minnesota," Responding to High Risk Youth, Minnesota Extension Service, University of Minnesota (1986).

14. Harlap, "Characteristics of Pregnant Women Reporting Previous Induced Abortions," Bulletin World Health Organization, 52:149 (1975); N. Meirik, "Outcome of First Delivery After 2nd Trimester Two Stage Induced Abortion: A Controlled Cohort Study," Acta Obsetricia et Gynecologica Scandinavia 63(1):45-50(1984); Levin, et al., "Association of Induced Abortion with Subsequent Pregnancy Loss," JAMA, 243:2495-2499, June 27, 1980.

15. Obel, "Pregnancy Complications Following Legally Induced Abortion: An Analysis of the Population with Special Reference to Prematurity," Danish Medical Bulletin, 26:192- 199 (1979); Martin, "An Overview: Maternal Nicotine and Caffeine Consumption and Offspring Outcome," Neurobehavioral Toxicology and Tertology, 4(4):421-427, (1982).

16. Klassen, "Sexual Experience and Drinking Among Women in a U.S. National Survey," Archives of Sexual Behavior, 15(5):363-39 ; M. Plant, Women, Drinking and Pregnancy, Tavistock Pub, London (1985); Kuzma & Kissinger, "Patterns of Alcohol and Cigarette Use in Pregnancy," Neurobehavioral Toxicology and Terotology, 3:211-221 (1981).

17. Morrissey, et al., "Stressful Life Events and Alcohol Problems Among Women Seen at a Detoxification Center," Journal of Studies on Alcohol, 39(9):1159 (1978).

18. Oro, et al., "Perinatal Cocaine and Methamphetamine Exposure Maternal and Neo-Natal Correlates," J. Pediatrics, 111:571- 578 (1978); D.A. Frank, et al., "Cocaine Use During Pregnancy Prevalence and Correlates," Pediatrics, 82(6):888 (1988); H. Amaro, et al., "Drug Use Among Adolescent Mothers: Profile of Risk," Pediatrics 84:144-150, (1989)

19. Speckhard, Psycho-social Stress Following Abortion, Sheed & Ward, Kansas City: MO, 1987; J. Spaulding, et al, "Psychoses Following Therapeutic Abortion, Am. J. of Psychiatry 125(3):364 (1978); R.K. McAll, et al., "Ritual Mourning in Anorexia Nervosa," The Lancet, August 16, 1980, p. 368.

20. Benedict, et al., "Maternal Perinatal Risk Factors and Child Abuse," Child Abuse and Neglect, 9:217-224 (1985); P.G. Ney, "Relationship between Abortion and Child Abuse," Canadian Journal of Psychiatry, 24:610-620, 1979; Reardon, Aborted Women - Silent No More (Chicago: Loyola University Press, 1987), 129-30, describes a case of woman who beat her three year old son to death shortly after an abortion which triggered a "psychotic episode" of grief, guilt, and misplaced anger.

21. Shepard, et al., "Contraceptive Practice and Repeat Induced Abortion: An Epidemiological Investigation," J. Biosocial Science, 11:289-302 (1979); M. Bracken, "First and Repeated Abortions: A Study of Decision-Making and Delay," J. Biosocial Science, 7:473-491 (1975); S. Henshaw, "The Characteristics and Prior Contraceptive Use of U.S. Abortion Patients," Family Planning Perspectives, 20(4):158-168 (1988); D. Sherman, et al., "The Abortion Experience in Private Practice," Women and Loss: Psychobiological Perspectives, ed. W.F. Finn, et al., (New York: Praeger Publ. 1985), pp98-107; E.M. Belsey, et al., "Predictive Factors in Emotional Response to Abortion: King's Termination Study - IV," Social Science and Medicine, 11:71- 82 (1977); E. Freeman, et al., "Emotional Distress Patterns Among Women Having First or Repeat Abortions," Obstetrics and Gynecology, 55(5):630-636 (1980); C. Berger, et al., "Repeat Abortion: Is it a Problem?" Family Planning Perspectives 16(2):70-75 (1984).

22. Joyce, "The Social and Economic Correlates of Pregnancy Resolution Among Adolescents in New York by Race and Ethnicity: A Multivariate Analysis," Am. J. of Public Health, 78(6):626-631 (1988); C. Tietze, "Repeat Abortions - Why More?" Family Planning Perspectives 10(5):286-288, (1978).

23. Leach, "The Repeat Abortion Patient," Family Planning Perspectives, 9(1):37-39 (1977); S. Fischer, "Reflection on Repeated Abortions: The meanings and motivations," Journal of Social Work Practice 2(2):70-87 (1986); B. Howe, et al., "Repeat Abortion, Blaming the Victims," Am. J. of Public Health, 69(12):1242-1246, (1979).

Abortion Risks and Complications, copyright 1997, 2000 Elliot Institute.

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Abortion Risks | Abortion Complications | Abortion Dangers | Abortion Side Effects

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Printable Fact Sheets Psychological Complications More articles on abortion complications Approximately 10% of women undergoing induced abortion suffer from immediate complications, of which one-fifth (2%) were considered major. 19 However the majority of complications take time to develop and will not be apparent for days, months or even years.

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The patient may not be educated in sexual activity and the risk involved,Therefore the staff aproach of judging the patient is not proffesional

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Sex, Etc. | Sex education by teens, for teens

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Sex, Etc. Sex education by teens, for teens. Info on birth control, condoms, HIV/AIDS & STDs, pregnancy and more. Sex, Etc. is published by Answer.

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Contraception advice which is available within the UK, along with how effective they are.  Choosing the right one for you.

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Which method of contraception suits me? - NHS.UK

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There are 15 different methods of contraception currently available in the UK. The type that works best for you will depend on your health and circumstances.

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Support groups for the family through difficult times

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The then Minister for Social Services and Public Health established a Sexual Health Programme Board, chaired by the Chief Medical Officer, to oversee the review with the intent to establish the priorities for sexual health and sexual health services in Wales over the next few years in line with prudent healthcare principals.

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There are many principles in the NMC code that need to be adhered to when dealing with a situation like scenario 5.
2. Listen to people and respond to their preferences and concerns
- recognise when people are anxious or in distress and respond     compassionately and politely.
5. Respect people’s right to privacy and confidentiality.