A prospective study on the psychological effects of therapeutic abortion

A Prospective Study on the Psychological Effects of Therapeutic Abortion Douglas Jacobs,

Celso-Ramon

Garcia,

Karl Rickels,

and Robert W. Preucel

A

LTHOUGH it is still surrounded by controversy, abortion is now a common medical intervention. The country seems to be following the recommendation “that abortion when performed by a licensed physician be entirely removed from the domain of criminal law. We believe that a woman should have the right to abort or not just as she has the right to marry or not.“’ Opposition to this liberal attitude toward abortion seems to fall into two categories: religious and psychological. This paper will comment on the psychological aspects of therapeutic abortion. Previously, physicians and others have emphasized the psychological scars that women sustain from therapeutic abortion; however, recent studies have contradicted that assumption. In a comprehensive review article, Simon and Senturia2 state that psychiatric sequelae of therapeutic abortion are rare. The studies they cite involved abortions performed for psychological, medical, or fetal indications. One question that has arisen with the liberalization of the abortion law concerns the psycho-social sequelae of the procedure, A recent report concluded that some women show a decline in emotional functioning from previous adequate levels.3 Since the study was not prospective, the comparison is questionable. This paper attempts to look at the question in a prospective manner. The focus will be on the general psychological sequelae of “abortion on demand” rather than on specific areas of emotional decline in poor-risk, psychologically impaired’ patients. Our hypothesis is that for the majority of patients, psychiatric sequelae of abortion do not occur when abortion is performed in a permissive atmosphere. METHOD

Population Included in the study were 57 unmarried women who requested termination of pregnancy through the outpatient facilities of the hospital of the University of Pennsylvania (HUP). An appointment in the OB-GYN clinic followed. After being screened for pregnancy by an obstetrician, each patient was seen by a social worker and a family-planning staff worker, who explored the patient’s attitudes.,and reviewed alternatives to abortion. Over a IO-week period, 57 consecutive unmarried patients, with the exception of a small number of women seen when the study interviewer could not be present, were

From the Department of Obstetrics and Gynecology and the Department School of Medicine, University of Pennsylvania, Philadelphia, Pa. Douglas Jacobs, M.D.: Fellow in Psychiatry, Massachusetts Mental Health Garcia, M.D.: William Shippen, Jr.. Professor of Human Reproduction; Professor of Psychiatry; Robert W. Preucel, M.D.: Associate Professor of cology; School of Medicine. University of Pennsylvania. This work was supported in part by USPHSgrant MH-08957-8. Reprint requests should be sent to Celso-Ramon Garcia, M.D., lo6 Dulles the University of Pennsylvania, Philadelphia, Pa. 19104. o 1974 by Grune & Stratton, Inc.

Comprehensive Psychietry, Vol. 15. No. 5 (September/October),

1974

of Psychiatry

of the

Center. Celso-Ramon

Karl Rickels, M.D.: Obstetrics

and Gyne-

Building, Hospital

of

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then asked to participate in the study on a voluntary basis. None of the women refused. A pre-abortion questionnaire and several psychometric evaluation instruments were subsequently administered to them by the interviewer. Subsequent to the initial examination and interviews, the Therapeutic Abortion Committee, consisting of three obstetricians, reviewed each patient’s medical situation. Termination of pregnancy was granted when the committee believed that the patient’s physical, mental, or social well-being would be impaired by continuing the pregnancy. Of the present study population, 1patient was denied abortion because of length of gestation (greater than 4 months*), 6 patients decided against having the abortion, and 2 patients were later found not to be pregnant. At a follow-up visit, the study interviewer administered a post-abortion questionnaire and several other evaluation instruments to 43 of the 48 patients who underwent abortion. Of the 5 patients unavailable for follow-up, 1 had moved out of the Philadelphia area, 2 did not respond to repeated attempts at communication, and 2 could not be located. For most patients (56%) the second interview took place approximately 30 days after the abortion, during a previously scheduled clinic visit. One patient was noted to be pregnant again at the time of interview. Since no significant statistical differences in outcome were observed as a function of the type of procedure employed (i.e., vacuum curettage for 21 patients, hysterotomy or tubal ligation for 5 patients, and saline induction for 17 patients), all data are presented for the total study population.

Evaluation Instrumentst Pre-abortion questionnaire, on which the interviewer recorded demographic characteristics, obstetrical history, reasons for and attitudes toward forthcoming abortion, sexual history, and brief medical and psychiatric history. Minnesota Mulriphasic Personaliry Invenrory (MMPI). a 566-item inventory yielding 3 scales assessing the validity of the test: he factor (L), validity factor (F), and correction factor (K); and 10 clinical scales representing various psychiatric entities: hypochondriasis (Hs), depression (D), hysteria (Hy), psychopathic deviate (Pd), masculinity-femininity (Mf), paranoia (Pa), psychasthenia (Pt), schizophrenia (SC), hypomania (Ma), and social introversion (Si). Normalized T scores are set at 50 for all scales; by convention, T scores above 70 are considered abnormal or deviant4 Patient symptom checklist (SCL). a 64-item checklist of common psychoneurotic complaints based on a scale developed by Parloff et aLs and completed by the patient on scales ranging from I (no symptom distress) to 4 (extreme distress). Its total score and several factor9 were used as outcome criteria. Zung self-raring depression scale (SDS). a 20-item checklist of depressive complaints developed by Zung,’ rated on scales ranging from 1 (no or minimal distress) to 4 (extreme distress), and providing a total score. Clyde mood scale (CMS), a 48-item checklist designed by Clyde8 yielding six factors (i.e., friendly, aggressive, clear-thinking, sleepy, unhappy, dizzy). A higher score on a factor indicates it to be present to a greater extent in the patient. Post-abortion quesrionnaire. on which the interviewer recorded such information as type of abortion procedure used; medical complications; effects of the abortion on the patient’s attitudes toward sex, marriage, pregnancy, and contraception; and the patient’s emotional reaction to the abortion. The SCL, SDS, and CMS were completed at both the pre-study and follow-up visits. The MMPI, however, was given to the patient only at the pre-study visit, with instructions to complete it at home prior to the abortion and return it to the interviewer; it was completed bv 48 patients.

RESULTS

Pre-Abortion

AND

DISCUSSION

Period

Description ofpopulation. Table 1 describes the total population in terms of several variables recorded on the pre-abortion questionnaire. Patients ranged in

*Departmental

consensus about fetal viability.

+Forms are available on request.

PSYCHOLOGICAL EFFECTS OF ABORTION

425

Table 1. Description of Population Variables

Variables

%

Age (in years):

%

Main source of support:

12-14

5

Public assistance

45

15-19

27

Family

23

20-30

59

The patient

25

31-36

9

Other

Race:

7

Education:

Black

86

< 12 years

35

White

14

High-school graduate

37

> 12 years

28

Religion: Protestant

68

Catholic

21

Other

8

None

5

Parity:

Marital status:

1st pregnancy

35

2nd pregnancy

23

3rd-8th

42

pregnancy

Previous miscarriage:

Single

65

Yes

21

Separated

26

No

79

Divorced, widowed

9

Family type: Parental Relatives Friends

36 9 9

Lives alone

11

Lives alone with children

35

age from 12 to 36, and were predominantly black, protestant, of lower socioeconomic status, and multipara. Every patient in the group stated that she did not wish to be pregnant. All patients claimed knowledge of birth control. Yet, only 65% were using some method of contraception (Table 2). Still, this figure represents greater contraceptive use than might be expected; Pion et a1.,g for example, found in a study of 1,122 women that only 19% had been using some method of contraception. It should be noted that our patients had a high incidence of ineffective use of contraception. Of the 20 women (35% of the total) who did not use contraception, 6 stated that they had abstained because of fear of contraceptive hazards. Table 2 also illustrates the fact that only 23% of the patients were using the pill and the IUD prior to their abortions, while 87% chose one of these methods after their abortions had been performed. The majority of sexual partners did not object to the use of contraception, but Table 2. Use of Contraception Pre-abortion IN = 57)

Post-abortion (N = 43)

None

35%

5%

Pill

21%

74%

IUD

2%

13%

Diaphragm

5%

0

Rhythm

14%

Foam

19%

Condom

4%

3% 5% 0

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Table 3. Sexuel History-First

Percent

Age

ET AL.

Coital Experience Relationship

Percent

514

21%

Casual

37%

15-19

67%

Serious

55%

20-23

12%

Husband

8%

40% of the partners either did not care or did not discuss the matter. The relationships in the majority of instances were considered by the patients to be “serious,” in the sense of involving some degree of emotional commitment. Prior to their abortions, 40% thought that their partners would terminate their relationships upon learning of their pregnancy. After their abortions, 37% actually terminated their relationships. Most of the patients’ partners and families who knew that abortion was contemplated approved of it. However, 49% of the families involved were not aware that the patient was pregnant. Table 3 shows that the patients in this study had been sexually active at an early age. The majority of patients believed that abortion would have no effect on their attitudes toward sex (58%), marriage (91%), or having children (86%). As is seen in Table 4, the major reason expressed for seeking abortion was socioeconomic affecting health. This is understandable, since 45% of all patients were on public assistance. The finding that psycho-social indications encompassed 98% of the total is consistent with the permissive atmosphere under which pregnancy was terminated. Sixty-three percent of the women had been subject to previous hospitalization for medical, surgical, or psychiatric reasons, and 21% had had previous minor gynecological surgery. Nineteen percent of the total had some previous psychiatric intervention, with treatment ranging from a single consultation to inpatient hospitalization. There was no history of excessive alcohol intake or drug abuse in this study group. A majority of the women knew that they were pregnant at the end of 1 month, and a majority considered abortion as their best solution. Eighteen percent considered completing the pregnancy, and 21% had doubts about having an abortion. MMPZ. In Table 5, the mean T scores obtained by patients in the present study are compared with those reported in a study by Ford et aLlo for 30 patients receiving therapeutic abortion on the basis of “substantial risk to the woman’s mental health if the pregnancy were allowed to continue.” In view of the use of this criterion, it is not surprising that the pre-abortion T scores of the patients studied by Ford et al. revealed greater abnormality in all clinical scales than those Table 4.

Health Indications for Abortion

Mental

30%

Emotional

18%

Interpersonal relationship Social well-being

12% 68%

Socioeconomic

47%

Unwanted

21%

pregnancy

Physical Renal vascular disease

2% 2%

PSYCHOLOGICAL

EFFECTS OF ABORTION

Table 5.

427

Results of Pre-abortion

MMPl’s

Average 1 Scores % of Present Present study

Patients with

(N =30)

(N = 481

T Scores > 70

L

47.5

51.2

0

F

71.0

60.6

19

Ford et al. Scales

K

48.5

51.3

0

1

0-k)

70.0

58.4

17

2

0)

77.5

62.1

29

3 (HY)

77.5

60.5

21

4 (Pd)

77.0

67.7

35

5 (Mfl

46.5

53.5

4

6 (Pa)

67.5

61.8

29

7 (Pt)

70.0

59.3

17

8 (Se)

71.0

64.2

31

9 (Ma)

60.5

59.8

14

59.5

56.7

6

10 (Si)

of patients in the present study.* Six of the clinical scales in their study, and none in ours, reached mean T scores of 70 or above. It is worth noting that those clinical scales in which at least 20% of our patients achieved T scores above 70 were generally the same scales in which the patients of Ford et al. had mean T scores greater than 70 (i.e., the psychopathic deviate, schizophrenia, depression, and hysteria scales). It should be added here that patients in the study of Ford et al. were somewhat similar to our patients in terms of demographic characteristics (e.g., 37% were members of racial minorities, 40% received public assistance), but, as might be expected, a larger percentage of patients in their study (47%) than in ours (19%) had received previous psychiatric treatment. Results obtained with the symptom Measures of emotional distress. checklist (SCL), Zung depression scale (SDS), and Clyde mood scale (CMS) are presented in Table 6. Of considerable interest is the fact that the mean pre-abortion scores of these patients place them about midway between normal and neurotic patients. This is illustrated graphically for the SCL total score in Fig. 1, which compares abortion patients to a group of “normal” private gynecology patients, primarily middle socioeconomic class, and to a comparable group of female neurotic anxious outpatients. In a recent paper reporting on these two groups of patients, Rickels et al.” suggested that a total SCL score greater than 1.55 indicates measurable symptom distress, while scores of 1.55 or below probably do not. About half of the abortion patients (5 1%) received scores of 1.55 or lower, while 82% of the normal gynecologic and only 16% of the neurotic anxious patients did so. For the SDS total score, Zung gives a mean of 1.30, with a range of 1.00-1.70, for normal controls;12 and in a representative clinical drug trial13 neurotic depressed outpatients, primarily female, had a mean initial SDS total of 2.64. Abortion patients, with a mean of 2.17, are again seen to be between normals and neurotics; in fact, here they appear somewhat closer to the depressed neurotic *A lower score in the Mf scale represents greater abnormality

in these patient

groups.

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ET AL

Table 6. Change in Measures of Emotional Distress (N = 43) Pre-abortion

Post-abortlon Student’s

Measures

of Emotional

Distress

Mean’

SD

Meall’

SD

T Test

Symptom checklist factors: I. General neurotic feeling

1.79

0.53

1.60

0.54

2.441

Il. Somatization

1.46

0.44

1.25

0.29

4.075

III. Performance difficulty

1.52

0.43

1.49

0.51

0.41

IV. Fear-anxiety

1.66

0.57

1.48

0.46

2.211

V. Depression

1.86

0.58

1.55

0.48

3.618

1.64

0.40

1.45

0.38

3.64s

2.17

0.53

1.86

0.44

4.323

Symptom checklist total score Zung depression scale total score Clyde mood scale factors:

t

Aggressive

52.07

7.02

50.50

5.49

1.85

Sleepy

55.98

10.38

49.24

6.78

3.958

Dizzy

57.93

13.98

47.93

6.08

5.063

‘Lower mean represents less distress. tp<0.10:~p<0.05;~p<0.01.

2.s I-

2.2: i-

2.00

1.75

1.50

1.2 5

1.00 “NORMAL”

GYNECOLOGIC PATIENTS (N=l35)

PRE-

POST-

ABORTION PATIENTS (N=43)

NEUROTIC

ANXIOUS PATIENTS (N=l44)

Fig. 1. Emotional distress in gynecologic, abortion, and anxious patients: Symptom checklist total Score.

PSYCHOLOGICAL

EFFECTS OF ABORTION

429

patients. This is not surprising when one considers that: (1) the highest initial score for abortion patients in the SCL occurred in the depression factor (1.86); (2) 29% of abortion patients had abnormally high scores in the depression scale of the MMPI. Post-Abortion Period Changes in emotional distress. As is indicated in Fig. 1, patients in the present study were observed to be slightly more disturbed than normal patients, even after abortion. More important, however, is the observation that a significant reduction in distress occurred in most outcome measures. In all but one of the SCL factors, in the SCL and SDS total scores, and in three of the six CMS factors, Student’s t tests for correlated data demonstrated significant differences in changes between pre- and post-abortion scores (Table 6). Symptom reduction is particularly marked (p < 0.01) in the following areas: dizzy factor of the CMS, which loads most highly on “sick to the stomach”; the SDS total score; the SCL somatization factor, which includes such items as “soreness of muscles,” “ faintness or dizziness,” and “pains in lower part of back”; the CMS sleepy factor, loading highly on “sleepy” and “fatigue”; and the SCL total score and depression factor. We also tested for change in the 64 individual items of the SCL. Table 7 presents the 13 items in which patients reported symptom reduction significant at the 1% level; it should be mentioned that 9 additional items revealed change significant at the 5% level. As might be expected, greatest reduction (mean change of 0.50 or better) was observed in 5 items indicated by gynecologists to represent symptoms commonly experienced during the early months of pregnancy, i.e., physiological items. Since several of these physiological items are found in the SCL somatization factor, the marked change in this measure is explainable. The large reduction in items involving nausea and fatigue is also consistent with the significant change observed in the CMS dizzy and sleepy factors. In regard to items considered to be emotional, the greatest change occurred in two Table 7.

Individual SCL Items Demonstrating

Significant’ Mean

Change (N = 43)

Change

T Test

Physiological items Nausea or upset stomach

1 19

7.92

Feeling low in energy or slowed down

0.86

6.17

Tired or fatigued during the day

0.65

5.25

Sleepy during the day

0.72

4.69

Pains or butterflies in stomach

0.54

4.40

Faintness or dizziness

0.37

2.99

Pains in lower part of back

0.42

2.95

Emotional items

‘p <

Feeling caught or trapped

0.42

3.46

Feeling fearful

0.40

3.05

Weakness in parts of body

0.26

2.89

Dry mouth

0.35

2.81

Loss of sexual interest or pleasure

0.40

2.79

Trouble getting breath

0.19

2.71

0.01.

430

JACOBS

ET AL

items that may well reflect the pre-abortion feelings of many patients, i.e., “feeling caught or trapped” and “feeling fearful.” While we did not find it feasible to include a control group in the present study, we did have available XL data from two previous studies involving gynecology patients. A group of 57 patients participating in placebo-controlled trial of oralcontraceptive medication completed the SCL at their first visit and at a second pre-study visit about a month later. These patients attended the same OB-GYN clinic in which the abortion patients were initially seen, and the two groups were quite similar regarding race, social class, and associated variables. The SCL total score revealed an insignificant change of only -0.04 to have taken place in these patients over 4 weeks. A group of 39 patients seen in a private gynecology practice for miscellaneous complaintsl’ completed the SCL at their first visit and again approximately 6 months later. In these primarily white, middle-class patients, the SCL total score showed an insignificant change of only -0.03. Postabortion patients, however, reported a statistically significant (p < 0.01) change of -0.19 in the SCL total score. Viewed within the context of data on these other gynecology patients, the reduction in emotional distress reported by the present abortion patients seems to represent a clinically meaningful rather than a chance finding. Generalfollow-up. Table 8 demonstrates that a majority of patients reported feeling relieved about the abortion both before (54%) and after (60%) the operation was performed. A larger percentage of patients felt guilty after (23%) than before (13%) the abortion. The percentages of patients reporting no feeling about the abortion were quite similar in the pre-abortion (11%) and post-abortion (12%) periods. When asked in the post-abortion period how they were feeling in general, 60% of patients stated that they felt better, 28% that they felt the same, and only 12% that they felt worse. These subjective statements to the physician seem to support findings made with the objective measures of emotional distress reported earlier. It should be mentioned here that one person with a previous diagnosis of schizophrenia had an exacerbation of symptoms and psychiatric therapy was recommended. Another patient requested psychiatric therapy in the post-abortion period. Consistent with their pre-abortion expectations, most patients found that the abortion had not adversely affected their attitudes toward sex (81’%), marriage (98%), or having children (95%). Seventy-nine percent of patients believed that they had learned from the experience, although 35% stated that they would not go through the procedure again. Within the context of these two stated attitudes, Table 6.

Patient’sFeelings

Reaction to Abortion Pre-abortion (N = 57)

Post-abortion (N = 431

Relieved

54%

Scared Ambivalent

20% -

Guilty

13%

Unhappy Has no feeling

2%

23% -

11%

12%

60% 5%

PSYCHOLOGICAL

EFFECTS OF ABORTION

431

it is interesting to note that fully 95% of patients, as compared to 65% in the preabortion period, chose to use some form of contraception after the abortion. Realizing the importance of following aborted patients for longer than 1 month, we nonetheless decided against patient contact at a later period for various reasons, e.g., nature of the study, mobility of the patient sample. Instead, we conducted an intensive hospital chart review and found that 31 of the 48 patients (65%) who received abortions had returned to the hospital for at least two visits over a period of at least 3 months post-abortion. For 24 of these patients, hospital contact post-abortion continued for 1 to 2 years (mean of 19.2 months), while for 7 patients, hospital charts show contact for 3 to 9 months (mean of 4.4 months). For the remaining 17 patients, only limited chart information, covering less than 1 month, was available. While this information comes from such varied sources as family planning, gynecology, orthopedic, and medical clinics, the emergency room, hospital admission records, and social service reports, we observed a tendency to note emotional problems, when present, in all sources. Of the 24 patients with at least several hospital contacts (mean of six contacts) over 1 to 2 years, two had received subsequent abortions, three had been delivered, and one had been both aborted again and delivered. No emotional problems were noted for 5 of these 6 patients, or for 15 patients whose continued contact with the hospital did not involve abortion or delivery. None of the 7 patients with only two or three hospital contacts from 3 to 9 months post-abortion were noted to have emotional problems, and 1 of these patients was observed to be six months pregnant nine months following abortion. Of the four patients noted in their hospital charts to have emotional problems following abortion, two had been observed by the study interviewer to have problems at the l-month follow-up period. Five months following abortion, the schizophrenic patient with an exacerbation of symptoms at her l-month followup was admitted to the emergency room with a Valium overdose and referred to a community mental health clinic. Three years prior to abortion, this patient had been hospitalized following three suicide attempts. Fourteen months following abortion, when discharged from the hospital after delivery, she was observed to be severely depressed. A second patient, noted by the study interviewer to request psychiatric help at her l-month follow-up, referred herself to the hospital psychiatric clinic 10 months following abortion_ She was diagnosed as having a schizoid personality and referred for outpatient therapy. Two years prior to abortion, this patient had been hospitalized with a diagnosis of depression following a suicide attempt. A third patient was admitted to the emergency room crying and incoherent 13 months following abortion. Suicidal ideation was noted, and the patient was referred for outpatient psychiatric therapy with a diagnosis of hysterical personality. Notes in the hospital chart showed this patient to have been exhibiting numerous psychoneurotic complaints since the death of triplets 4 years prior to abortion, and to have been treated for these complaints for a 3-month period 1 year prior to abortion. Psychiatric intervention was considered unnecessary for a fourth patient, who was observed to have a mild depression and hysterical personality 11 months folldwing abortion, and to be neurotic with many physical and

432

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ET AL.

psychosomatic complaints 20 months following abortion. This patient had been receiving psychiatric care and medication for anxiety and depression over a period of a year just prior to abortion. Summarizing these hospital-chart data, no emotional problems were found for 20 of the 24 patients for whom information was available for 1 to 2 years, or for any of the 7 patients for whom information was available for 3 to 9 months. All four patients observed to have emotional problems post-abortion were found to have received psychiatric care prior to abortion. They were also noted to have high (above 70) MMPI T scores, particularly in scales pertaining to their area of psychopathology, e.g., SC (schizophrenia) scale scores of 104 and 83 for the patients diagnosed as schizophrenic and schizoid, HY (hysteria) scale score of 77 for the patient with a hysterical personality. Finally, it should be mentioned that no emotional problems 1 to 2 years post-abortion were observed in the hospital charts of 3 patients who had also received psychiatric care prior to abortion, two as outpatients for anxiety and one as an inpatient for depression. CONCLUSION

The present data indicate that our patient group as a whole experienced no significant psychological ill effects from therapeutic abortion. The fact that 2 patients previously hospitalized for psychiatric illness were found to have emotional problems 1 month post-abortion should be recognized as a response to a preexisting illness and not as a de novo effect of the abortion. As Ford et al.‘O have stated, there is a tendency for severely disturbed patients to incorporate their abortions into their illnesses. Also, earlier studies have shown that psychiatric sequelae in previously normal patients are rare, but do occur. In a study of 46 women by Simon et a1.,14only one woman had to be hospitalized for psychiatric illness that was directly related to the abortion. Neither our l-month follow-up of 43 aborted patients nor our 3month to 2-year hospital-chart follow-up of 31 aborted patients indicated that any patients in our study were hospitalized following abortion. Also, none of the four patients found in our follow-up to have emotional problems post-abortion could be considered normal, i.e., all had received psychiatric care before abortion. Furthermore, three patients who had received psychiatric care pre-abortion were observed not to develop emotional problems following abortion. Of greatest interest in this study is the relief that a majority of patients experienced following termination of pregnancy. This was observed both in their statements to an interviewer and in their scores on several psychometric rating instruments. Our findings thus corroborate the statements made by Ford et al.*O with regard to the benefit that “normal” women receive from therapeutic abortion. An excellent review of the literature on abortion2 emphasizes the need for welldesigned studies. We recognize that the present study was biased in that a control group was not used. However, in order to provide an adequate control group, it would have been necessary to reject arbitrarily the requests for abortion of over 50 women. This was not felt to be desirable. We also recognize that the present sample size was fairly small. This was a reality factor; the interviewer (D.J.) was a medical student with a limited time period for the study. Due to the intensive

PSYCHOLOGICAL

EFFECTS OF ABORTION

433

evaluation of each patient who did participate in the study, we believe that the information provided is valuable and relevant to a consideration of the psychological effects of therapeutic abortion, particularly on unmarried women. This study is among the first prospective studies carried out in the United States in a setting with a liberal attitude toward legal abortion. The supporters of a more permissive attitude toward abortion stress the problem of the unwanted pregnancy. As Sloane15 has aptly stated: Unwillingness is a key issue. Should a woman be compelled to carry a pregnancy to term if she does not wish to? If she is single, she is likely to have a continuing poor relation with her child. If she is married and under stress from the burdens of her job and household both she and her children are likely to suffer. In either case if she has emotional symptoms they are likely to be persistent and to influence her abilities as a mother. If she is given an abortion such symptoms usually subside and the procedure itself does not seem to carry adverse psychologic consequence.

Each of the women in the present study presented with an unwanted pregnancy. Prior to the abortion, several psychometric instruments indicated emotional symptoms to be present to a marked degree; scores in these measures generally indicated the group to be about midway between normal and neurotic subjects in their emotional symptomatology. Following abortion, there was a statistically significant reduction in the emotional distress of these patients. Indeed, far from carrying adverse psychological consequence, therapeutic abortion within this group of unmarried clinic patients was followed by marked improvement in psychological parameters. However, the fact that 35% of the women stated that they would not go through the experience again suggests an inherent unpleasantness about the procedure. Our goal should be to prevent unwanted pregnancy, not to abort. Within this context, it is most important to note that only 5% of patients who underwent abortion, as opposed to 35% of patients in the pre-abortion period, chose not to use some form of contraception. This is in agreement with findings in such countries as Poland and Finland that a liberalization of laws permitting abortion does not favor a disregard for contraception. These data, as well as the fact that fully 65% of the women in this study reported having used some form of contraception, clearly indicate the necessity for further contraceptive counseling. Until such time as undesired pregnancies can effectively be prevented, therapeutic abortion remains a humane and valuable treatment for unwanted pregnancy. SUMMARY

This study was conducted to assess the effect of therapeutic abortion on the emotional state of the patient. Prior to abortion, 57 women were interviewed and given several psychometric tests. Patients were unmarried, ranged in age from 12 to 36 years, and were predominantly black, protestant, of lower socioeconomic class, and multipara. Mean pre-abortion scores on the tests placed patients about midway between normal and neurotic patients in their emotional distress. Test scores obtained from 43 patients 4 weeks following abortion revealed statistically significant reduction in distress in most outcome measures. A total of 60% of these patients stated that they felt “relieved” and “better” at this time. We conclude that this patient group did not experience psychological ill effects from abortion. Until unwanted pregnancies can be reduced to their lowest level by

434

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ET AL.

more effective contraceptive counseling, therapeutic abortion remains a humane and valuable treatment for unwanted pregnancy. ACKNOWLEDGMENT The authors wish to express their gratitude to Ms. Ellen Fisher for her statistical and editorial assistance. We are also grateful to the Family Planning and Social Service Department of the OBGYN clinic at the Hospital of the University of Pennsylvania, and to Mrs. Mary Jacobs. REFERENCES 1. Group for the Advancement of Psychiatry: The Right to Abortion: A Psychiatric View. Vol. VII, No. 75, October 1969 2. Simon N, Senturia A: Psychiatric sequelae of therapeutic abortion: A review of the literature, 19351964. Arch Gen Psychiatry 15:378-389,1966 3. Wallerstein JS, Kurtz P, Bar-Din M: Psychosocial sequelae of therapeutic abortion in young, unmarried women. Arch Gen Psychiatry 27:828-832,1972 4. Dahlstrom WG, Welsh GS: An MMPI Handbook: A Guide to Use in Clinical Practice and Research. Minneapolis, University of Minnesota Press, 1960 5. Parlolf MB, Kelman HC, Frank JD: Comfort, effectiveness, and self-awareness as criteria of improvement in psychotherapy. Am J Psychiatry 111:343-351,1954 6. Williams HV, Lipman RS, Rickels K, et al: Relication of symptom distress factors in anxious neurotic outpatients. Mult Behav Res 3:199-212.1968 7. ‘Zung WWK: A self-rating depression scale. Arch Gen Psychiatry 12:63-70,1965

8. Clyde DJ: Manual for the Clyde Mood Scale. Coral Gables, Fla., Biometric Laboratory, University of Miami, 1963 9. Pion RJ, Wagner NN, Butler JC, et al: Abortion request and post-operative response: A Washington community survey. Northwest Med Sept.:693-698,197O 10. Ford CV, Catelnuovo-Tedesco P, Long KD: Abortion: Is it a therapeutic procedure in psychiatry? JAMA 218: 1173-l 178, 1971 II. Rickels K, Garcia C-R, Fisher E: A measure of emotional symptom distress in private gynecologic practice. Obstet Gynecol 38:139-146,197l 12. Zung WWK: Depression in the normal aged. Psychosomatics 8:287-292, I%7 13. Rickels K, Gordon PE, Jenkins BW, et al: Drug treatment in depressive illness: Amitriptyline and chlordiazepoxide in two neurotic populations. Dis Nerv Syst 3 1:30-42, 1970 14. Simon NM, Senturia AG, Rothman D: Psychiatric illness following therapeutic abortion. Am J Psychiatry 12459-65, 1967 15. Sloane RB: The unwanted pregnancy. N Engl J Med 280:1206-1213, 1969