Mental Health Implications of Abortion and Abortion Restriction: A Brief Narrative Review of U.S. Longitudinal Studies
Publication: American Journal of Psychiatry Residents' Journal
Abstract
This review provides a brief overview of mental health outcomes after abortion and denial of abortion. PubMed and PsycInfo databases were searched for longitudinal epidemiological studies performed in the United States. The literature suggests that women who obtain abortions do not have worse mental health outcomes related directly to abortion and that those denied access to abortion have worse initial adverse psychological outcomes. Given restricted abortion access in many states as a result of the recent overturning of Roe v. Wade, mental health implications surrounding abortion and abortion denial are critical to understand; women with mental illness may face disproportionately restricted access to abortion.
Roe v. Wade is a landmark case that legalized abortion in the United States in 1973 and was overturned by the Supreme Court in 2022, generating significant controversy. The mental health repercussions following abortion have long been debated and used to guide policy making. Although randomized controlled trials to assess causal relationships between abortion and mental health cannot be conducted, multiple theoretical frameworks have been developed to understand a variety of reported responses following abortion (1).
Previous systematic reviews have consolidated the literature regarding mental health following abortion (1, 2). The aim of the present review was to provide a brief overview of the mental health outcomes of either having an abortion or being denied access to abortion in the United States, the latter of which has not been included in recent reviews. Given the recent change in policy, an understanding of the mental health outcomes of abortion and abortion denial becomes essential to the psychiatrist in training.
Methods
A medical librarian was consulted, and PubMed and PsycINFO databases were searched. PsychInfo was searched for the terms “mental health” and “abortion,” which resulted in 1,956 articles. Articles were filtered by peer-reviewed longitudinal studies, which resulted in 109 articles. PubMed was searched for the following terms: “Mental health”[MeSH] OR “Health, Mental”[tw] OR “depression”[tw] OR “anxiety”[tw] OR “suicidal ideation”[tw] OR “posttraumatic stress disorder”[tw] AND “abortion applicants”[MeSH] OR “Abortion Applicant”[tw] OR “Applicant, Abortion”[tw] OR “Abortion Seekers”[tw] OR “Abortion Seeker”[tw] OR “Seekers, Abortion”[tw]. The PubMed search resulted in 76 articles. Studies were included if they were longitudinal epidemiological studies, examined the U.S. population, included women requesting voluntary abortion, and included surveillance of mental health and psychological symptoms after abortion. Studies were excluded if they included only unplanned pregnancy loss or if updated versions of the study had been published.
Results
Mental Health After Abortion
This review includes seven studies that examined various mental health symptoms among women after obtaining an abortion (Table 1). Quinley et al. found that women fared well psychologically in the 1- to 3-day period after the procedure, as evidenced by an overall improvement in their psychological coping score (3). In a study by Payne et al., abortion was not found to be a psychological trauma in and of itself, and most women did not have prolonged emotional conflict; interpersonal and socioenvironmental factors appeared to be more central in determining a woman’s response to abortion (4). When data from the National Comorbidity Survey were analyzed, several structural, psychological, and sociodemographic risk factors were thought to drive the relationship between adverse mental health outcomes and abortion; when the authors controlled for these factors, the relationship between abortion and subsequent adverse mental health outcomes was not clinically significant (5).
| Study | Type | N | Design | Measures | Key findings |
|---|---|---|---|---|---|
| Payne et al. (4) | Longitudinal prospective cohort study | 102 | Women were assessed before and 24 hours, 6 weeks, and 6 months after abortion by the same psychiatrist. | Anxiety, depression, anger, guilt, and shame assessed with the MMPI, POMS, and SRS. | Abortion did not appear to be a serious psychological trauma. Most women did not have prolonged emotional conflict following induced abortion. |
| Major et al. (8) | Longitudinal prospective cohort study | 442 | Women with first-trimester unwanted pregnancies were surveyed 1 hour before abortion and 1 hour, 1 month, and 2 years after abortion. | Depression, PTSD, self-esteem, decision satisfaction, perceived harm and benefit, and positive and negative emotions assessed with the BSI, DSM-III-R, and Rosenberg Self-Esteem scale. | Depression decreased and self-esteem increased at 2 years after abortion, and negative emotions increased. Only 1% of women experienced PTSD, 72% were satisfied with their decision, 69% reported that they would have another abortion, and 72% reported more benefit than harm. |
| Schmiege and Russo (7) | Longitudinal retrospective cohort study | 1,247 | U.S. National Longitudinal Survey of Youth included data from women who indicated outcomes of first pregnancy in 1984, followed by interviews that year and every 2 years after. | Depression assessed with the CES-D. | Rates of depression were similar between women with an unwanted first pregnancy who delivered and those who terminated their pregnancy. |
| Hamama et al. (9) | Longitudinal retrospective cohort study | 1,581 | Psychobiology of PTSD and Adverse Outcomes of Childbearing study included prenatal structured telephone surveys of obstetric patients (including women at less than 28 weeks gestation) from three health systems in Midwestern states. | History of trauma, diagnosis of PTSD at the time of the early pregnancy, diagnosis of major depression in the past year, use of prayer, and demographic information. | Elective abortion or spontaneous abortion was not predictive of either PTSD or depression. Women’s labeling of their elective or spontaneous abortion experience as a “hard time” was related to trauma history and was a significant predictor of both PTSD and depression. |
| Steinberg and Finer (5) | Longitudinal retrospective cohort study | 2,888 and 2,065 | The National Comorbidity Survey included data from structured psychiatric interviews administered to a nationally representative sample of the U.S. population. Two analyses were performed. | Mental health outcomes determined by DSM-III-R diagnoses with the CIDI; mental health outcomes grouped as mood, anxiety, and substance use disorders | The strongest predictor of mental health at interview was history of mental health problems or experience of violence. The only significant finding was that women who had multiple abortions were more likely to have a substance use disorder. |
| Quinley et al. (3) | Longitudinal prospective cohort study | 62 | A needs assessment questionnaire was used to determine psychological coping scores before, immediately after, and 1–3 days after abortion. | Psychological coping outcomes | A statistically significant 44% improvement was found in reported psychological outcomes immediately after abortion when compared with psychological coping before the procedure. |
| Gomez (6) | Longitudinal retrospective cohort study | 848 and 438 | The National Longitudinal Study of Adolescent Health data included survey assessments of adolescents in an initial survey and in surveys 1 year, 5 years, and 11 years later. | Depression assessed with the CES-D, and self-esteem assessed with the Rosenberg Self-Esteem scale. | No relationship between having an abortion and subsequent depressive symptoms was found. The strongest indication of depressive symptoms was having depressive symptoms previously. |
a
BSI=Brief Symptom Inventory; CES-D=Center for Epidemiologic Studies Depression scale; CIDI=Composite International Diagnostic Interview; DSM-III-R=Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition–Revised; MMPI=Minnesota Multiphasic Personality Inventory; POMS=Profile of Mood States; PTSD=posttraumatic stress disorder; SRS=Symptom Rating Scale.
Studies that analyzed various U.S. population data sets, such as the National Longitudinal Study of Adolescent Health and the National Longitudinal Survey of Youth, found no significant increases in depressive symptoms as a result of abortion (6, 7). Major et al. found that negative emotions may increase after abortion, but depression decreased and self-esteem increased in the 2 years following abortion, with only 1% of women developing posttraumatic stress disorder (PTSD) (8). Hamama et al. found that neither spontaneous nor elective abortion was predictive of PTSD or depression in subsequent pregnancies; however, previous trauma history influenced women’s negative appraisal of abortion, which was a predictor for both outcomes, demonstrating the impact of previous history on a woman’s psychological response (9).
Mental Health After Abortion Versus After Denial of Abortion
The present review also includes five articles based on data from the Turnaway Study, a 5-year longitudinal study that examined various mental and physical consequences of having an abortion during the first trimester, having an abortion near gestational limits, being turned away from abortion with subsequent birth, or being turned away from abortion with subsequent miscarriage or abortion obtained elsewhere (10) (Table 2).
| Study | Type | N | Design | Measures | Key findings |
|---|---|---|---|---|---|
| Biggs et al. (11) | Longitudinal cohort study | 877 | The four groups of women were surveyed at baseline, 8 days after abortion, and semiannually for 3 years. | Professionally diagnosed anxiety or depressive disorder, including major depression, dysthymia, bipolar disorder, panic disorder, obsessive-compulsive disorder, anxiety disorder, and posttraumatic stress disorder | Self-reported anxiety was greater in the first-trimester abortion group, but no statistically significant difference in professionally diagnosed anxiety or depressive disorder was observed over 3 years. |
| Biggs et al. (12) | Longitudinal cohort study | 877 | The four groups of women were surveyed at baseline, 8 days after abortion, and semiannually for 5 years. | Suicidality assessed with the BSI and the PHQ-9 | No statistically significant differences in suicidality between groups were observed over 5 years. |
| Biggs et al. (10) | Longitudinal cohort study | 877 | The women were surveyed at baseline, 8 days after abortion, and semiannually for 5 years. | Depression and anxiety assessed with BSI subscales; self-esteem and life satisfaction assessed with questionnaires about well-being | Higher initial levels of anxiety and low self-esteem were observed in the two Turnaway groups. Over time, depressive and anxiety symptoms declined in all groups, except the Turnaway-birth group. |
| Rocca et al. (13) | Longitudinal cohort study | 161 | Women who were denied abortions underwent 15 qualitative in-depth interviews 1 year after their abortion denial and semiannually for 5 years. | Positive and negative emotions, including relief, happiness, regret, guilt, sadness, and anger | Women who were denied abortions had greater negative emotions immediately after denial, but negative emotions decreased and positive emotions increased over time. |
| Biggs et al. (14) | Longitudinal cohort study | 928 | Women were surveyed at baseline, 8 days after abortion, and semiannually for 5 years. | Perceived abortion stigma assessed through two questions, and psychological distress measured with the BSI depression and anxiety subscales | Perceived abortion stigma declined significantly in the Turnaway-births and near–gestational age-limit groups. Higher odds of psychological distress among those with high perceived abortion stigma was observed. |
a
The study included four groups of women: those who had a first-trimester abortion, those who had a near–gestational age-limit abortion, those who were denied abortion and gave birth (turnaway births), and those who were denied abortion and did not give birth (turnaway no births). BSI=Brief Symptom Interview; PHQ-9=Patient Health Questionnaire–9.
Biggs et al. conducted multiple studies suggesting that women who had abortions did not have increased levels of depression, anxiety, or suicidality over 5 years compared with those who were denied access (10–12). However, women who were denied abortion and had subsequent births showed a less steep decline in baseline depression or anxiety symptoms than those who did have an abortion (10). Women who were denied abortion access also faced greater initial levels of anxiety, lower self-esteem, and lower life satisfaction (10).
Rocca et al. found that women who were denied abortion access initially reported more negative emotions; however, the overall finding was that women in all groups showed evidence of improved psychological well-being over 5 years (13). In another study, Biggs et al. found that perceived abortion stigma was associated with later psychological distress; however, this perceived abortion stigma declined significantly over time among women who were either denied access or obtained an abortion near gestational limits (14).
Discussion
In this brief narrative review, the overwhelming majority of studies demonstrate that women who seek abortion do not face worse mental health outcomes directly related to abortion, which is consistent with previous reviews. Various sociodemographic factors, previous history of mental disorders, as well as perceived experience may play a complex role in women’s psychological well-being after abortion. Schmiege and Russo, Major et al., and Hamama et al. suggest that mental health or trauma before abortion affects the relationship between abortion and subsequent worsening mental health (7–9). Steinberg and Finer showed evidence for a common-risk-factors model, which suggests that worsening mental health after abortion is likely a result of shared, preexisting risk factors between mental health and abortion (5).
The landmark Turnaway Study is the first to directly compare women who have abortions with those who are denied access. The authors found higher levels of psychological distress, including initial anxiety, poor self-esteem, and life satisfaction, immediately after abortion denial. However, over time, even women who were denied access to abortion did have measures of improved psychological coping. Data from the study also support the notion that previous mental health diagnoses and trauma history may affect a woman’s psychological response following abortion and that women with histories of mental disorders may fare worse with abortion denial.
The lack of studies in the United States examining the risk that women with serious mental illness face because of abortion or abortion restriction remains a limitation. It is well documented that women in this population have higher rates of unplanned pregnancies and engage in high-risk sexual activity or coercive sexual practices (15); however, little is known about how women with serious mental illness fare after abortion or denial of abortion, given the ethical limitations in designing such studies. A recent Dutch study found that women with bipolar I disorder had an increase in bipolar episodes after induced abortions and an even higher risk of episodes after live births (16). Given the stringent abortion restrictions in numerous states, these ramifications are important to study further, because women with serious mental illness are more likely to carry pregnancies to term and be vulnerable to significant exacerbation of symptoms.
Furthermore, the larger ethical framework regarding access to abortion is important to consider. Women with previous mental disorders have been found to be more likely to seek abortion, partly because of risk factors influenced by structural inequities that affect both their mental health and their desire for abortion (5, 17). Women with serious mental illness also have a higher likelihood of facing additional obstacles, such as lack of social support or challenges regarding competency with parenting, which adds another layer of complexity to carrying unwanted pregnancies to term (18).
Women with mental illness will not only face threat to their autonomy because of abortion restrictions in certain states but also reproductive injustice because they are likely to be disproportionately affected. Women with serious mental illness not only seek abortion at higher rates, but they will not have the same ability to navigate the barriers to obtaining reproductive care, placing them at inequitable risk (17). Knowledge of the evidence that exists regarding mental health in relation to abortion and abortion denial, as well as increased risks to marginalized groups, is critical to consider when creating policy change.
Conclusions
This review demonstrates that women do not have worse mental health outcomes after abortion when compared with women who carry pregnancies to term or are denied access; women who are denied access have worse initial outcomes. Further research is needed to understand how women with mental illness will be particularly affected by newly restrictive abortion policies because these individuals constitute a historically marginalized population at increased risk.
Key Points/Clinical Pearls
•
Seeking abortion does not appear to be associated with worse mental health outcomes related directly to abortion itself.
•
Sociodemographic factors, history of mental disorders, and perceived experience play a complex role in psychological well-being after abortion.
•
Denial of abortion is associated with worse initial adverse psychological outcomes.
Acknowledgments
The author thanks Rubiahna Vaughn, M.D., M.P.H., for mentorship in the development of this article.
References
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Gomez AM: Abortion and subsequent depressive symptoms: an analysis of the National Longitudinal Study of Adolescent Health. Psychol Med 2018;48:294–304
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Hamama L, Rauch SA, Sperlich M, et al: Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy. Depress Anxiety 2010;27:699–707
10.
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Rocca CH, Moseson H, Gould H, et al: Emotions over five years after denial of abortion in the United States: contextualizing the effects of abortion denial on women’s health and lives. Soc Sci Med 2021;269:113567
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Biggs MA, Brown K, Foster DG: Perceived abortion stigma and psychological well-being over five years after receiving or being denied an abortion. PloS One 2020;15:e0226417
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American Journal of Psychiatry Residents' Journal
Pages: 11 - 15
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Published online: 6 September 2024
Published in print: September 6, 2024
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