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Predicting the psychological consequences of abortion
"Sot. Sci. & Med., Vol. /3A, pp. 683 to 689 Pergamon Press Lid t979. Printed in Great Britain
PREDICTING THE PSYCHOLOGICAL CONSEQUENCES O F ABORTION LISA ROSEMAN SHUSTERMAN Northwestern University now at Community Hospital, 1500 North River Avenue, Indianapolis, IN 46219, U.S.A.
Abstract--The study investigated the psychosocial factors of the abortion experience from conception to three weeks after the abortion. The two major parts of the study were: (Part I) to arrive at a picture of the typical abortion patient and her experience, and (Part II) to determine predictors of the psychological sequelae of abortion. A sample of 393 women were randomly selected from patients using two abortion clinics. Structured interviews, given before the operation, and telephone interviews, given two weeks after the operation, were planned for each woman. Almost 75~/o of the women were employed or attending school, thus, not in roles easily suited for child care. Many of the women. belonged to conservative or fundamentalist religions. The majority of patients tended to be involved in positive relationships with their male partner, to confide in him about the abortion, and to receive support from him for the abortion. Two major types of women were found---younger, single, primigravidae women and older, married, multiparous women. The former group was more likely to attribute the pregnancy to their irresponsibility about birth control and to abort because they did not feel equipped or ready to care for a child. The latter group tended to attribute the pregnancy to birth control failure, and to abort because they had completed their families. Very few women suffered negative psychological after-effects. The three variables which were found to account for, on the average, 39~o of the variance in emotional reaction were: (1) the women's overall satisfaction with her decision to abort, (2) the degree of intimacy between the woman and her male partner and whether he participated in the experience, and (3) how anxious or angry the woman became when she first suspected she was pregnant. A cross-validation indicated that the variables had predictive validity in both samples. There was an unusually high agreement between the two predictive equations (R = 0.472, R = 0.453).
The present exploratory study investigates the psychosocial factors of abortion. The major purpose of Part I of the study is to investigate elements of the psychological experience of abortion. Th~ following factors are examined:
present study examines the 23 reasons which were endorsed by at least 4~o of Miller's sample. Also in earlier studies a substantial number of women have reported contraceptive failure [-14, 15] and use of ineffective contraceptive methods [8, 16, 17].
(1) Demographic variables
(4) Immediate response to pregnancy
Previous studies [1-9] have found that the majority of patients obtaining abortions are young, unmarried, educated w o m e n - - w o r k i n g or in school--terminating their first pregnancy. Race and income have been reported to vary with the local population [-3, 10-12]. Because religious groups have taken stands regarding public policy toward abortion, the conservatism/liberalism of the women's religion is evaluated using the Dagenais and Marascuilo [13] criteria. Reliogisity is also considered.
Previous studies have not asked aborting women how they felt (e.g. happy, angry, worried, etc.) when they first suspected they were pregnant. (5) Motivations for seeking abortion Motivation for abortion is a key element in the psychological experience of abortion. According to previous studies [-1, 9, 18] women decide to terminate their pregnancies because they feel unprepared to adequately provide for a child. Part II of the study is to determine predictors of the psychological sequelae of abortion. By analyzing the above antecedent factors and post-abortion reactions, it is hoped that an "at risk" population, i.e. those women who are likely to react negatively to abortion, can be identified. Determination of an "at risk" population will be valuable to counselors in identifying women with a high likelihood of responding adversely to the procedure. So far, studies have been only partially successful in determining what differentiates women who respond negatively to abortion from those who respond favorably or neutrally [7, 14, 18, 19]. These studies have generally found the abortion is a relatively benign procedure except when there is pre-abortion psychopathology in the woman.
(2) Support variables Degree of support from others often influence a person's reactions to potential stress. Two studies [8, 9] indicate that over half of the aborting women are involved in a continuing relationship with a man. Other factors, such as amount of support the women receive from the male involved in the pregnancy, have not been researched previously. (3) Reasons abortin9 women have unwanted pregnan-
cies The main reasons found by Miller [1] were "retrospective rhythm", birth control failure, fear of or incorrect birth control methods, and denial of fertility. The 683
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Subjects The sample consisted of 393 women randomly selected from patients using two abortion clinics (A and B) in downtown Chicago. The women had had at least 41 days and no more than 84 days since the first day of their last menstrual cycle.
Setting The two out-patient abortion clinics terminate pregnancies by the vacuum aspiration method. All patients are given a pregnancy test, blood typing, group counseling, individual counseling and a pelvic exam. The women visit the clinic only once and spend 3-4 hr there. Women may be referred to the clinics by various pregnancy counseling agencies, private physicians or women's groups. Many patients are selfreferred, learning about the clinics from newspaper advertisements or other women. Both clinics have relatively scandal-free reputations. Although the abortion procedure and patient flow is identical in the two clinics, the clinics differ in several ways. First, Clinic A is a non-profit organization whereas Clinic B is run for profit; neither is hospital-affiliated. Second, in Clinic B, but not in Clinic A, the women and staff are surgically gowned for the operation, the women are routinely given Novocaine to ease the pain from dilation of the cervix, and the Operation area is sterile.
Procedure Two structured interviews were planned for each woman: a pre-abortion face-to-face interview conducted before the operation, and a post-abortion telephone interview conducted two to three weeks afterwards. The two interviews were almost always conducted by the same person. The names of patients who refused to participate and their reasons for refusing were recorded. The pre-abortion interview included items assessing demographic variables, reasons for conceiving, immediate response to the pregnancy, support variables, motivations for seeking the abortion, and satisfaction with the decision to abort. Twenty-three separate reasons for conceiving were listed. For each item, a woman could check "definitely not a reason", "probably not a reason", "probably a reason", or "definitely a reason." Some of the reasons listed were: "I didn't think I was fertile", :'I loved him and nothing else mattered", "He was supposed to withdraw but he didn't", and "I was embarrassed or afraid to see a doctor about contraception". The woman described her immediate response to pregnancy by indicating on four-point scales the degree to which she felt each of eight emotions, such as "anger", "happiness" and "guilt". In addition, the woman was asked if she had considered alternatives to abortion. Support variables measured the length and quality of the woman's relationship with her male partner, the male's knowledge of and support for the abortion, and parents' and friends' knowledge and opinion of the abortion. Thirteen motivations for ending the pregnancy were listed. The woman could indicate the degree to
which each reason was applicable on a four-point scale. Several examples of the motivations listed are: °'I am too old to have a child", "I can't afford a child at this time", "Someone else is making me end the pregnancy", and "I do not want to start off a marriage being pregnant". Satisfaction with the decision to end the pregnancy and anxiety about the procedure were assessed by four-point scales. After the interview, the interviewer rated the woman's comfort with her decision to abort, the extent of the woman's anxiety during the interview, how cooperative the woman was during the interview, and how well the woman understood the interview. In the post-abortion interview, the woman indicated whether in the two weeks following the abortion she had had any of five physical problems, such as, "minor bleeding", "infection" and "discomfort". In order to determine the psychological sequelae of abortion, women were asked to rate, on four-point scales, the extent to which they had felt any of 14 reactions. They rated, for example, "regret", "guilt", "relief" and "satisfaction". Additionally, the women were asked about their current relationship with their male partner, their future parity plans, and whether or not they felt that they had made the right decision in aborting the pregnancy. Lastly, women were asked to evaluate the treatment they received at the clinic. Four independent raters judged each item on the post-abortion questionnaire to determine whether it indicated a favorable or unfavorable emotional response to abortion. Several items were eliminated from the total psychological sequelae score because they were judged inappropriate for indicating a favorable or unfavorable emotional response. The four raters agreed completely that certain items should be included and that they should be scored in a particular direction. Both the pre-abortion and the post-abortion questionnaires were finalized on the basis of open-ended interviews conducted during the pilot phase of the study. Mature, emphatic female interviewers were used in order to deal with the possible stress of the interview. All women who began the interview completed it.
RESULTS
The pre-abortion interview was given to 393 patients, but 39 were eliminated for physical reasons. Thus, a total of 345 pre-abortion interviews, 178 from Clinic A and 167 from Clinic B, were analyzed. Four women from Clinic A and two from Clinic B refused to be interviewed. An examination of the clinics' medical records did not reveal any demographic differences between those who participated and those who did not. According to the interviewers' ratings, 97% of the women were moderately or very cooperative during the interview, and 93% understood the interview moderately or very well. Follow up interviews were obtained from 289 women (84% of the pre-abortion sample). The majority of the follow up interviews (91%) were obtained between 2 and 3 weeks after the abortion.
Predicting the psychological consequences of abortion A series of analysis of variance indicated no differences between those women who were contacted and those who were not.
Part I Demographic characteristics. Three-fourths of the sample (77~o) were Caucasian, the rest (23~o) were Negro, roughly similar to the racial distribution of the Chicago metropolitan area (1970 Census). As in other studies, [1-5, 7, 8, 19] over half the women were under 25 years old (,~ = 23.5 years). Thirty-five percent of the women were single, 28~o married, 18~o engaged, 5~o living with a man but not married and 14~ separated, divorced or widowed. Most of the women were high school graduates. Half were employed and the rest were evenly divided between students and unemployed women or housewives. Consistent with other investigations, [1, 20] the financial position of the women basically reflected the general population. For many women (46~o) the abortion terminated their first pregnancy, although the sample differed from other samples [19, 20] in that slightly more than half of the women were parous. Fifteen percent of the sample had had a previous abortion. A significant univariate analysis of previous abortions across marital status groups (F = 2.33*) showed that women living with a man, but not married, had the highest number of previous abortions. Contrary to prediction, liberalism of religion was not related to proportion of women seeking abortion. In fact, over half of the women (60~o) belonged to conservative or fundamentalist religions. One-third of the women were Catholic. No relationship was found between religiosity and use of abortion. Support variables. A majority of the women said that they had better-than average, long term (52~ over 1 year) relationships with their~male partner. Most of the men knew that the woman suspected that she was pregnant (87~o) and that she was aborting the pregnancy (81~). And, when the men knew, they overwhelmingly supported the decision to abort. As might be expected, as the intimacy of the relationship with the male increased, and as the quality of the relationship improved, the male was more likely to know of the pregnancy (r = 0.275#, r < 0.257t), more likely to know about the abortion (r = 0.298t, r = 0.311~) and more likely to support the termination of the pregnancy (r = 121t, r = 0.203t). It is interesting, however, that women involved in a particular sexual relationship for a short time received no less support from the male than women involved in longer term relationships (r = 0.032). An analysis of variance indicated that the woman's view of the intimacy of the relationship and the quality of the relationship differed across racial groups (F = 2.36t, F = 3.04t, respectively). Oriental women claimed the most intimate and positive relationships, while Negro women claimed the least intimate and least positive relationships. A further analysis showed that racial groups also differed significantly as to whether or not the man knew of the pregnancy and abortion (F = 5.63t, F = 6.73t, respectively). Orien* Significant to P < 0.05 level. t Significant to P < 0.01 level.
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tals were the most likely to inform the father, whereas Negroes were the least likely to inform him. A univariate analysis of amount of male support for the pregnancy termination by race also revealed significant difference (F = 10.74t). Negro women received the least amount of male support for the abortion. Although patients rarely Confided in their parents (19~o), they often confided in their friends (63~) who, for the most part were very sympathetic and helpful. Older women and women involved in more intimate heterosexual relationships, however, were not as likely as younger women and women in more casual relationships to inform their friends of the pregnancy and the abortion (r = 190t, r = 0.189?). Married women were significantly less likely than single women to tell friends (F = 5.13t). One other group that was not likely to enlist the help of friends were women with previous abortions (r = 0.226t). Reasons abortin9 women have unwanted pregnancies. Fear of the side effects of certain contraceptives was endorsed by 47~o of the women as a reason for their pregnancy. No other reason or factor drew such frequent positive responses. Eleven percent of the women reported that they wanted to conceive at the time of intercourse. Irresponsibility about birth control, which accounted for 11~ of the variance, was one major reason why aborting women got pregnant. Even though such women were aware of the possibility of conceiving, they did not like to plan for sexual intercourse, they never got around to obtaining birth control, and they decided during intercourse to trust good luck or faith to prevent conception. Other factors included the male's failure to take precautions (8~ of the variance), denial of fertility (7.73~o), impulsivity and lack of control (7.36~), fear of obtaining or of disclosing the use of birth control (7.15~o), and birth control failure (6.07~). Whereas older, married women became pregnant despite their contraceptive efforts, y o u n g e r , single women became pregnant because they were unprepared for sexual intercourse. As in Miller's [13] reports, older women, women with higher education, and women with more previous abortions were more likely to blame birth control failure (r = 0.138t, r = 0.210t, r = 0.172t). And, those who had more previous abortions were less likely than others to explain their pregnancy by retrospective rhythm or denial (r = 0.158t). Younger women were more likely to say that the pregnancy was due to their own irresponsibility about birth control (r = -0.186t), or the male's failure to take adequate precautions (r = - 0 . 1 8 I t ) . Further, women who attributed their pregnancy to contraceptive irresponsibility tended to have had a sexual relationship with the male partner for a shorter period of time (r = -0.137t), and those who attributed it to impulsivity of the moment tended to be involved in less intimate and less positive heterosexual relationships (r = -0.246"~, r = -0.157t). Marital status groups differed significantly in attributing the pregnancy to irresponsibility (F = .4.992t); married women were the least likely to endorse irresponsibility reasons, whereas single and engaged women were the most likely to do so. Also, the less education a woman had and the more conservative her religion, tl'ie m o r e l i k e l y she was to blame the
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man for the conception (r = -0.142t, r = -0.1527). Immediate response to pregnancy. A factor analysis of emotional reaction to the pregnancy was performed. Three factors emerged: (1) anxiety, i.e. the extent to which the woman felt worried, confused, trapped or guilty, (22~ of the variance); (2) disbelief, i.e. the extent to which the woman felt shocked or surprised, (17~o of the variance); and (3) anger-happiness, i.e. the extent to which the woman felt hostile or elated (19~o of the variance). The formation of an anger-happiness factor is puzzling. Osofsky and Osofsky [21] used a unidimensional anger-happiness scale to assess post-abortion reaction, although they do not report whether the scale was constructed on the basis of a statistical relationship or on the basis of an assumed a priori relationship. The mean factor scores indicate that when aborting women became fairly certain of their pregnancy, they reacted with slight to moderate anxiety, little or no disbelief, and slight anger. Immediate response to pregnancy is significantly correlated with several other antecedent variables. For example, as feelings of anxiety increase, the following variables decrease: education (r = -0.136t), intimacy of the relationship with the male partner (r = -0.147t), quality of the relationship (r = - 0 . 1 6 2 t ) , length of the sexual relationship (r = - 0 . 1 7 9 t ) , and regular use of birth control (r = - 0 . 1 9 4 7 ) . Disbelief was significantly positively related to conservatism of religion (r = 0.167?), and significantly negatively related to the number of previous abortions (r = - 0 . 1 3 t t ) . Motivation for seeking abortion. In the assessment of why women seek to end a pregnancy, the most typical reasons were: "I would not be able to give a child a fair chance at this time" (82~o), "A child at this time would interfere with my career, education, or personal freedom" (75~), "I can'~/~afford a child at this time" (72~o) and "I do not want to start off a marriage being pregnant" (44~o). The least endorsed reasons were: "Someone else is making me end the pregnancy" (4~), "I never want children" (6~o) and "I would not like a child by this man" (10~o). A factor analysis of why women have abortions produced four major factors: completion of family (14~o of the variance), i.e. many women felt that they were too old to bear a child and that they did not want any more children; single marital status (13~); not feeling equipped to handle the responsibilities of a child (13~); and feeling that children would interfere with long or short term personal goals (11~o). There seen to be several types of women, each of whom have different reasons for ending their pregnancy. First, those who abort because they have completed their families tend to be older (r = 0.690?), parous (r = 0.693?) women involved in longer term (r = 0.342?) and more intimate (r = 0.304t) relationships with their male partner. A different type of w o m a n - - y o u n g e r and with no previous pregnancies--is more likely to abort because she does not feel equipped to handle childcare responsibilities (r = - 0 . 2 9 4 t , r = - 0 . 1 9 5 7 ) . Women who endorse the "not equipped" reason are also more likely to have gotten pregnant because of impulsivity t Significant to P < 0.01 level.
or lack of control during the sexual encounter (r = 0.200?). These women are likely to feel that being single is a reason for the abortion (r = -0.431t), and to feel that children would interfere with present and/or future goals (r = 0.428?). Satisfaction with abortion decision. As a group, the women were moderately to very satisfied with their decision to abort. Women who were more likely to feel satisfied were more likely to have support from their male partner (r = 0.133t) and from their friends (r = 0.200?). In general, the women were moderately nervous about the medical procedure (X = 2.84, possible low score =1, possible high score =4). As might be expected, women who had previous abortions were the least nervous (r = - 0 . 1 3 7 t ) . Those who were more nervous had considered other possibilities for handling the pregnancy (r = 0.149t).
Consequent variables Physical sequelae. A total physical sequelae score (Hoyt r = 0.47) was obtained for each woman by adding up the number of symptoms she had during the follow-up period. Very few women suffered adverse physical consequences of the abortion (.~ = 8.77 for five items, when yes = 1 and no = 2). Many women (71~o) experienced minor spotting or bleeding which is considered a normal symptom. Psychological reaction. A total psychological sequelae score (Hoyt r = 0.76) was obtained for each woman. The general emotional response to abortion was moderately favorable (X = 46, !owest possible score---negative reaction = 15, highest possible score --positive reaction =60). As a group, the women felt quite relieved, moderately satisfied, and slightly t o moderately happy at follow-up. They did not feel resentful, guilty or sorry that they had had the abortion, and almost all said that if they had the decision to make over again, that they would definitely decide to abort. The women reported that they were somewhat open about talking about the abortion to others, and had only a slight tendency to p u s h the whole experience out of their minds. In general, the relationship with the male partner was reported to be average or better-than-average, not significantly different from the pre-abortion judgement of the quality of the relationship. Overall, the women felt that the abortion had not really interfered, or at worst had only slightly interfered, with their everyday activities. Psychological reaction is significantly negatively correlated with physical reaction (r = -0.286t). A stepwise regression analysis was performed using most of the antecedent variables as possible predictors of the post-abortion psychological reaction. Antecedent variables which had little or nor variance, or which had a small number of responses were eliminated from the stepwise regression analysis. The data were split into two samples by clinic. For clinic A, 32 of the variables accounted for 62)/0 of the variance in psychological reaction, with 3 variables accounting for 39)/0 of the variance. The three most important antecedent variables, in order of their ability to predict, were: (1) how angry or happy was the woman's immediate response to the pregnancy, (2) how satisfied was the woman with her decision
Predicting the psychological consequences of abortion to terminate the pregnancy, and (3) how positive was the woman's relationship with her male partner. For clinic B, 31 of the variables accounted for 41~ of the variance in psychological reaction, with 3 variables accounting for 28~o of the variance. The three most important antecedent variables, in order of their ability to predict, were: (1) how satisfied was the woman with her decision to terminate the pregnancy, (2) whether or not the male partner knew of the abortion, and (3) how anxious or worried was the woman's immediate response to the pregnancy. Therefore, the woman's satiafaction with the decision to abort was an important predictor of psychological response in both samples. Also, the angryhappy reaction (Clinic A, variable 1) is highly correlated with the anxiety reaction (Clinic B, variable 3) (r = 0.481t), and whether or not the man knows of the abortion (Clinic B, variable 3) is highly correlated with the quality of the woman's relationship with him (Clinic A, variable 3) (r = 0.3117). Even though the latter variables do not appear in both regression equations, it is not because they are not important in both, but rather because the stepwise regression • analysis eliminates highly correlated variables. Thus, although minor sample variations produced the different equations, in content the predictors are very similar. In order to test the generalizability of the two equations, a cross-validation procedure was employed. The Beta weights from each sample were tested for their ability to predict on the other sample. On the average, each equation accounted for about 21~ of the psychological reaction variance in other sample (RZ= 0.205, R 2 = 0.223). There was considerable agreement between the two equations (R--0.472, R = 0.453). These results indicate that women who do not become very upset when they first think ~hat they are pregnant, who share the abortion experience with their male partner, or who are satisfied prior to the abortion with the decision to terminate the pregnancy are more likely to have favorable emotional reactions, whereas those who do become upset, who do not share the abortion experience with their partner, or who are not satisfied prior to the abortion with the decision to terminate the pregnancy are more likely to have unfavorable emotional reactions. DISCUSSION The main purpose of Part I of the study was to describe the abortion population and the psychological elements of the abortion experience. Almost 75~o of the aborting women were employed o r were attending school. The occupational status of the sample is consistent with other observations I-9] that most abortion patients are not in roles convenient for child care. It is surprising that many of the women belonged to conservative or fundamentalist religious faiths. There are several possible explanations as to why such women terminate their pregnancy even though •their religions are very anti-abortion. First, it may
t Significant to P < 0.01 level.
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be that although the church organizations and spokespeople espouse anti-abortion views, such views are not shared, or not shared as strongly, by church members. Second, it may be that although most of the church members are against abortion, the women who do abort are an especially liberal group of women within the church. Or, third, it may be that aborting women too are anti-abortion, but when they are faced with an actual pregnancy that they do not want, they end the pregnancy because their desire to get rid of it is greater than their anti-abortion attitude. It could also be that conservative or fundamentalist churches are often opposed to contraception as well as to abortion. Women raised in these faiths may experience psychological obstacles to the use of contraception and, therefore, run a greater risk of becoming unintentionally pregnant than adherents of more liberal churches; because they have more unwanted pregnancies they need abortion more often. One issue for future research would be to determine why women whose attitudes would seem to be very much against induced abortion, make up much of the abortion population. The majority of the abortion patients tended to be involved in positive relationships with their male partner; they tended to confide in him about the pregnancy and the abortion, and they tended to receive much support from him for the decision to abort. Even in recent relationships, women viewed the interaction positively and the male was involved in the abortion decision. These findings dispel the myth that aborting women are promiscuous, casual about sex, and involved in unstable relationships. Two major types of women with very different abortion experiences were found. The first group consisted of young, primagravidae, single women living with their parents, while the second group consisted of older, parous married woman. Younger, primagravida¢, single women were more likely to say that the pregnancy was due to their irresponsibility or the male's irresponsibility about contraception. Part of the reason they were not prepared for intercourse is that they were afraid or embarrassed to see a physician about birth control and that they did not want others (probably their parents) to know that they were engaging in sexual intercourse. Irresponsibility aboutcontraception seems to be one reason for un• wanted pregnancy that could be influenced. What is needed may be more or improved means of public sex education, more easily available birth control, or better doctor-patient interaction. This type of patient decided to abort because they did not feel equipped to handle child-care responsibilities, because they did not want to bear a child while single, and because a child would interfere with their present goals. The second type of abortion patient, the older, parous, married woman was likely to say that the pregnancy was due to birth control failure. The older, parous, married patients decided to abort because they had completed their families and/or they felt that they were too old. to bear a. child. When aborting women first suspected that they were pregnant, their emotional response tended to be realistic and healthy, i.e. they were worried about how they would handle the pregnancy, but they were not hostile nor did they deny the reality of the pregnancy.
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LISA ROSEMANSHUSTERMAN
By the time of the abortion, almost all of the women were very satisfied with their decision. The results showed that women who were certain about the abortion from the first suspicion of pregnancy tended to get more male, friend, and parent support for the abortion, whereas those who were not so certain got less support. In the two weeks following the abortion, few women suffered negative physical or psychological after-effects. Such a finding supports wevious research on the sequelae of legal ~ abortion [8, 15, 18, 21-26]. Women felt relieved and satisfied after the procedure, and said that they would abort again given the same circumstances. It is interesting that psychological sequelae and physical sequelae are significantly negatively correlated. It may be that women who had a negative physical response attributed all negative feelings to the adverse bodily reactions, whereas those who had a positive or neutral physical reaction could only attribute negative feelings to psychological response. The major purpose of Part II of the study was to determine an "at risk" population for negative emotional reaction to abortion. The findings indicated three variables which help predict psychological sequelae. The first variable was the woman's overall preabortion satisfaction with her decision to terminate the pregnancy. If a woman is not satisfied with the decision before the abortion, she will be more likely to feel unhappy, guilty, resentful, etc. afterwards than those who are satisfied with their decision. Satisfied women will have received more preabortion support from their significant others. It is also more likely that the decision to abort will have been theirs, and not forced on them by someone else. The second variable was the degree of intimacy between the woman and her male partner, and whether or not he participated in the abortion experience. Women involved in more intimate, permanent relationships were more likely to have recieved male partner support for the abortion. Thus, if the woman can share her feelings about the abortion with the other person most directly involved in the pregnancy, and can be supported by him in the pregnancy termination, then she is not likely to experience adverse psychological consequences. The third variable that contributed to the prediction of psychological reaction was the woman's emotional response to the suspicion of her pregnancy. If the woman was especially anxious or angry then she will be more likely to have an unfavorable reaction. The findings show that such women were more likely to be involved in less intimate, less permanent and less positive relationships with the male partner and to abort because they do not want to bear that male's child. It may be that such women become upset because they are not involved in a positive, supportive, heterosexual relationship. Or, it may be that for some other reason, not tapped by the present research, such women are the type who tend to react with strong negative emotions to important life situations--pregnancy and abortion. Why such women react negatively should be investigated. The three variables--satisfaction with the abortion decision, whether or not the male shares in the abortion experience, and immediate response to preg-
nancy--account for about one-third of the variance in psychological reaction. The remainder of the variance is unaccounted for. Future studies might investigate whether variables not included in the present study, such as atmosphere of the clinic, the amount of pain experienced during the procedure, the type of pre-abortion counselling, the psychological wellbeing of the women or other variables relate to emotional response to abortion. The findings of Part II of the study have immediately applicable, practical values. The three issues which proved to be the best predictors of emotional response should be explored by abortion counsellors. Although counsellors usually try to ascertain how satisfied the woman is with the decision to abort, they do not necessarily do so systematically. In addition, they rarely question how the male is involved in the abortion or how the woman responded to the pregnancy. Such questions could be used routinely by abortion counsellors to assist them in spotting those who would react unfavorably to the abortion. Several qualifications should be added to the above discussion. First, the study is concerned only with the short-term effects of abortion. From the results, it cannot be determined whether the negative sequelae decrease over time, whether they affect responses to future crises or decision points, or how they compare with sequelae of Other procedures. In addition, the results are not necessarily generalizable to women obtaining abortions in hospital or private settings, at later periods of gestation, or by other methods of abortion. Lastly, the study was conducted shortly after the U.S. Supreme Court decision to legalize abortion. It is possible that changes in the public attitudes toward abortion could affect emotional responses. Further research is needed to answer the remaining questions about the abortion experience. REFERENCES
1. Smith R., Diamond M. and Steinhoff P. Abortion in Hawaii: 1970-1971. Hawaii reed. J. inter-Isl. Nurs. Bull. 32, 213-220, 1973. 2. Duffy E. The Effect of Changes in the State Abortion Laws. Washington, United States Government Printing Office, 1971. 3. Pakter J. and Nelson F. Abortion in New York City: the first nine months. Family Plan. Perspect. 3, 5-12, 1971. 4. Rovinsky J. Abortion in New York City, preliminary experience with a permissive abortion statute. Obstet. Gynec. N.Y. 38, 333-342, 1971. 5. Tietze C. and Lewit S. Joint program for the study of abortion (JSPA): early medical complications of legal abortions. Stud. jam. Plann. 3, 97-122, 1972. 6. Steinhoff P., Diamond D., Palmore J. and Smith R. Who are the new abortion patients. Presented at Abortion Research Workshop, New Orleans, April, I970. 7. Miller W. Psychological antecedents to conception in pregnancies terminated by therapeutic abortion. Unpublished manuscript, Stanford University, 1973. 8. Smith E. A follow up study of women who request abortion. Am. J. Orthopsychiat, 43, 574-585, 1973. 9. Steinhoff P., Smith R. and Diamond M. The Hawaii Pregnancy, Birth Control and Abortion Study: social psychological aspects. Conference Proceedings: Psychological Measurement in the Study of Population Problems. Institute of Personality Assessment and Research, University of California, Berkeley, 33-40, 1972.
Predicting the psychological consequences of abortion 10. Peck A. and Marcus H. Psychiatric sequelae of therapeutic interruption of pregnancy. J. nerv. ment. Dis. 143, 417M25, 1966. 11. Moore-Cavar E. International Inventory of Information on Induced Abortion. Division of Social and Administrative Sciences. Internal Institute for th e Study of Human Reproduction. Columbia University, 1974. 12. Tietze C. Two year's experience with a liberal abortion law: its impact on fertility trends in New York City. Family Plann. Perspect. 5, 36-41, 1973. 13. Dagenais F. and Marascuilo L. The effect of factor scores, Guttman scores, and simple sum scores on the size of F ratios in an analysis of variance design. Multivar. behav. Res. 8, 491-502, 1973. 14. Diamond M., Steinhoff P., Palmore J. Y. and Smith R. Sexuality, birth control and abortion: a decisionmaking sequence. J. Biosoc. Sc. 5, 347-361, 1972. 15. Monsour K. and Stewart B. Abortion and sexual behavior in college women. Am. J. Orthopsych. 43, 804-813, 1973. 16. Kane F., Lachenbruch P. and Lipton M. Motivational factors in abortion patients. Am. J. Psychiat. 130, 290-293, 1973. 17. Ford C, Castelnuova-Tedesco P. and Long K. Women who seek abortion: a comparison with women who complete their pregnancies. Am. J. Psychiat. 129, 546-552, 1972. 18. Osofsky J. and Osofsky H. The psychological reaction of patients to legalized abortion. Am. J. Orthopsychiat. 42, 48-60, 1972.
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I9. Steinhoff P. Background characteristics of abortion patients. In Abortion Experience in the United States (Edited by Osofsky J. and Osofsky H.), pp. 206-236. Harper & Row, New York, 1973. 20. Steinhoff P. Ethnic and social class differences in the use of abortion. Presented at Population Studies Seminar, East-West Center, University of Hawaii, November 1971. 21. Osofsky J., Osofsky H. and Rajah R. Psychological effects of legal abortion. Clin. Obstet. Gynec. 14, 215-234, 1971. 22. Shusterman L. The psychosocial factors of the abortion experience: a review. Psychot Women Q. 1, 79-106, 1976. 23. Athanasious R., Michelson L. and Oppel W. A longitudinal study of sequelae to term birth and therapeutic abortions. Presented at 21st Annual Clinical Meeting of the American College of Obstetricians and Gynecologists, Bal Harbour, May 23, 1973. 24. Adler N. Dimensions underlying emotional responses of women following therapeutic abortion. Presented at American Psychological Association meeting, Montreal, August 30, 1973. 25. Addelson F. Induced abortion: source of guilt or growth? Am. J. Orthopsychiat. 43, 815-823, 1973. 26. Walter G. Psychologic and emotional consequences of elective abortion. Obstet Gynec. 36, 482-487, 1970.
PREDICTING THE PSYCHOLOGICAL CONSEQUENCES O F ABORTION LISA ROSEMAN SHUSTERMAN Northwestern University now at Community Hospital, 1500 North River Avenue, Indianapolis, IN 46219, U.S.A.
Abstract--The study investigated the psychosocial factors of the abortion experience from conception to three weeks after the abortion. The two major parts of the study were: (Part I) to arrive at a picture of the typical abortion patient and her experience, and (Part II) to determine predictors of the psychological sequelae of abortion. A sample of 393 women were randomly selected from patients using two abortion clinics. Structured interviews, given before the operation, and telephone interviews, given two weeks after the operation, were planned for each woman. Almost 75~/o of the women were employed or attending school, thus, not in roles easily suited for child care. Many of the women. belonged to conservative or fundamentalist religions. The majority of patients tended to be involved in positive relationships with their male partner, to confide in him about the abortion, and to receive support from him for the abortion. Two major types of women were found---younger, single, primigravidae women and older, married, multiparous women. The former group was more likely to attribute the pregnancy to their irresponsibility about birth control and to abort because they did not feel equipped or ready to care for a child. The latter group tended to attribute the pregnancy to birth control failure, and to abort because they had completed their families. Very few women suffered negative psychological after-effects. The three variables which were found to account for, on the average, 39~o of the variance in emotional reaction were: (1) the women's overall satisfaction with her decision to abort, (2) the degree of intimacy between the woman and her male partner and whether he participated in the experience, and (3) how anxious or angry the woman became when she first suspected she was pregnant. A cross-validation indicated that the variables had predictive validity in both samples. There was an unusually high agreement between the two predictive equations (R = 0.472, R = 0.453).
The present exploratory study investigates the psychosocial factors of abortion. The major purpose of Part I of the study is to investigate elements of the psychological experience of abortion. Th~ following factors are examined:
present study examines the 23 reasons which were endorsed by at least 4~o of Miller's sample. Also in earlier studies a substantial number of women have reported contraceptive failure [-14, 15] and use of ineffective contraceptive methods [8, 16, 17].
(1) Demographic variables
(4) Immediate response to pregnancy
Previous studies [1-9] have found that the majority of patients obtaining abortions are young, unmarried, educated w o m e n - - w o r k i n g or in school--terminating their first pregnancy. Race and income have been reported to vary with the local population [-3, 10-12]. Because religious groups have taken stands regarding public policy toward abortion, the conservatism/liberalism of the women's religion is evaluated using the Dagenais and Marascuilo [13] criteria. Reliogisity is also considered.
Previous studies have not asked aborting women how they felt (e.g. happy, angry, worried, etc.) when they first suspected they were pregnant. (5) Motivations for seeking abortion Motivation for abortion is a key element in the psychological experience of abortion. According to previous studies [-1, 9, 18] women decide to terminate their pregnancies because they feel unprepared to adequately provide for a child. Part II of the study is to determine predictors of the psychological sequelae of abortion. By analyzing the above antecedent factors and post-abortion reactions, it is hoped that an "at risk" population, i.e. those women who are likely to react negatively to abortion, can be identified. Determination of an "at risk" population will be valuable to counselors in identifying women with a high likelihood of responding adversely to the procedure. So far, studies have been only partially successful in determining what differentiates women who respond negatively to abortion from those who respond favorably or neutrally [7, 14, 18, 19]. These studies have generally found the abortion is a relatively benign procedure except when there is pre-abortion psychopathology in the woman.
(2) Support variables Degree of support from others often influence a person's reactions to potential stress. Two studies [8, 9] indicate that over half of the aborting women are involved in a continuing relationship with a man. Other factors, such as amount of support the women receive from the male involved in the pregnancy, have not been researched previously. (3) Reasons abortin9 women have unwanted pregnan-
cies The main reasons found by Miller [1] were "retrospective rhythm", birth control failure, fear of or incorrect birth control methods, and denial of fertility. The 683
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LISA ROSEMAN SHUSTERMAN METHOD
Subjects The sample consisted of 393 women randomly selected from patients using two abortion clinics (A and B) in downtown Chicago. The women had had at least 41 days and no more than 84 days since the first day of their last menstrual cycle.
Setting The two out-patient abortion clinics terminate pregnancies by the vacuum aspiration method. All patients are given a pregnancy test, blood typing, group counseling, individual counseling and a pelvic exam. The women visit the clinic only once and spend 3-4 hr there. Women may be referred to the clinics by various pregnancy counseling agencies, private physicians or women's groups. Many patients are selfreferred, learning about the clinics from newspaper advertisements or other women. Both clinics have relatively scandal-free reputations. Although the abortion procedure and patient flow is identical in the two clinics, the clinics differ in several ways. First, Clinic A is a non-profit organization whereas Clinic B is run for profit; neither is hospital-affiliated. Second, in Clinic B, but not in Clinic A, the women and staff are surgically gowned for the operation, the women are routinely given Novocaine to ease the pain from dilation of the cervix, and the Operation area is sterile.
Procedure Two structured interviews were planned for each woman: a pre-abortion face-to-face interview conducted before the operation, and a post-abortion telephone interview conducted two to three weeks afterwards. The two interviews were almost always conducted by the same person. The names of patients who refused to participate and their reasons for refusing were recorded. The pre-abortion interview included items assessing demographic variables, reasons for conceiving, immediate response to the pregnancy, support variables, motivations for seeking the abortion, and satisfaction with the decision to abort. Twenty-three separate reasons for conceiving were listed. For each item, a woman could check "definitely not a reason", "probably not a reason", "probably a reason", or "definitely a reason." Some of the reasons listed were: "I didn't think I was fertile", :'I loved him and nothing else mattered", "He was supposed to withdraw but he didn't", and "I was embarrassed or afraid to see a doctor about contraception". The woman described her immediate response to pregnancy by indicating on four-point scales the degree to which she felt each of eight emotions, such as "anger", "happiness" and "guilt". In addition, the woman was asked if she had considered alternatives to abortion. Support variables measured the length and quality of the woman's relationship with her male partner, the male's knowledge of and support for the abortion, and parents' and friends' knowledge and opinion of the abortion. Thirteen motivations for ending the pregnancy were listed. The woman could indicate the degree to
which each reason was applicable on a four-point scale. Several examples of the motivations listed are: °'I am too old to have a child", "I can't afford a child at this time", "Someone else is making me end the pregnancy", and "I do not want to start off a marriage being pregnant". Satisfaction with the decision to end the pregnancy and anxiety about the procedure were assessed by four-point scales. After the interview, the interviewer rated the woman's comfort with her decision to abort, the extent of the woman's anxiety during the interview, how cooperative the woman was during the interview, and how well the woman understood the interview. In the post-abortion interview, the woman indicated whether in the two weeks following the abortion she had had any of five physical problems, such as, "minor bleeding", "infection" and "discomfort". In order to determine the psychological sequelae of abortion, women were asked to rate, on four-point scales, the extent to which they had felt any of 14 reactions. They rated, for example, "regret", "guilt", "relief" and "satisfaction". Additionally, the women were asked about their current relationship with their male partner, their future parity plans, and whether or not they felt that they had made the right decision in aborting the pregnancy. Lastly, women were asked to evaluate the treatment they received at the clinic. Four independent raters judged each item on the post-abortion questionnaire to determine whether it indicated a favorable or unfavorable emotional response to abortion. Several items were eliminated from the total psychological sequelae score because they were judged inappropriate for indicating a favorable or unfavorable emotional response. The four raters agreed completely that certain items should be included and that they should be scored in a particular direction. Both the pre-abortion and the post-abortion questionnaires were finalized on the basis of open-ended interviews conducted during the pilot phase of the study. Mature, emphatic female interviewers were used in order to deal with the possible stress of the interview. All women who began the interview completed it.
RESULTS
The pre-abortion interview was given to 393 patients, but 39 were eliminated for physical reasons. Thus, a total of 345 pre-abortion interviews, 178 from Clinic A and 167 from Clinic B, were analyzed. Four women from Clinic A and two from Clinic B refused to be interviewed. An examination of the clinics' medical records did not reveal any demographic differences between those who participated and those who did not. According to the interviewers' ratings, 97% of the women were moderately or very cooperative during the interview, and 93% understood the interview moderately or very well. Follow up interviews were obtained from 289 women (84% of the pre-abortion sample). The majority of the follow up interviews (91%) were obtained between 2 and 3 weeks after the abortion.
Predicting the psychological consequences of abortion A series of analysis of variance indicated no differences between those women who were contacted and those who were not.
Part I Demographic characteristics. Three-fourths of the sample (77~o) were Caucasian, the rest (23~o) were Negro, roughly similar to the racial distribution of the Chicago metropolitan area (1970 Census). As in other studies, [1-5, 7, 8, 19] over half the women were under 25 years old (,~ = 23.5 years). Thirty-five percent of the women were single, 28~o married, 18~o engaged, 5~o living with a man but not married and 14~ separated, divorced or widowed. Most of the women were high school graduates. Half were employed and the rest were evenly divided between students and unemployed women or housewives. Consistent with other investigations, [1, 20] the financial position of the women basically reflected the general population. For many women (46~o) the abortion terminated their first pregnancy, although the sample differed from other samples [19, 20] in that slightly more than half of the women were parous. Fifteen percent of the sample had had a previous abortion. A significant univariate analysis of previous abortions across marital status groups (F = 2.33*) showed that women living with a man, but not married, had the highest number of previous abortions. Contrary to prediction, liberalism of religion was not related to proportion of women seeking abortion. In fact, over half of the women (60~o) belonged to conservative or fundamentalist religions. One-third of the women were Catholic. No relationship was found between religiosity and use of abortion. Support variables. A majority of the women said that they had better-than average, long term (52~ over 1 year) relationships with their~male partner. Most of the men knew that the woman suspected that she was pregnant (87~o) and that she was aborting the pregnancy (81~). And, when the men knew, they overwhelmingly supported the decision to abort. As might be expected, as the intimacy of the relationship with the male increased, and as the quality of the relationship improved, the male was more likely to know of the pregnancy (r = 0.275#, r < 0.257t), more likely to know about the abortion (r = 0.298t, r = 0.311~) and more likely to support the termination of the pregnancy (r = 121t, r = 0.203t). It is interesting, however, that women involved in a particular sexual relationship for a short time received no less support from the male than women involved in longer term relationships (r = 0.032). An analysis of variance indicated that the woman's view of the intimacy of the relationship and the quality of the relationship differed across racial groups (F = 2.36t, F = 3.04t, respectively). Oriental women claimed the most intimate and positive relationships, while Negro women claimed the least intimate and least positive relationships. A further analysis showed that racial groups also differed significantly as to whether or not the man knew of the pregnancy and abortion (F = 5.63t, F = 6.73t, respectively). Orien* Significant to P < 0.05 level. t Significant to P < 0.01 level.
685
tals were the most likely to inform the father, whereas Negroes were the least likely to inform him. A univariate analysis of amount of male support for the pregnancy termination by race also revealed significant difference (F = 10.74t). Negro women received the least amount of male support for the abortion. Although patients rarely Confided in their parents (19~o), they often confided in their friends (63~) who, for the most part were very sympathetic and helpful. Older women and women involved in more intimate heterosexual relationships, however, were not as likely as younger women and women in more casual relationships to inform their friends of the pregnancy and the abortion (r = 190t, r = 0.189?). Married women were significantly less likely than single women to tell friends (F = 5.13t). One other group that was not likely to enlist the help of friends were women with previous abortions (r = 0.226t). Reasons abortin9 women have unwanted pregnancies. Fear of the side effects of certain contraceptives was endorsed by 47~o of the women as a reason for their pregnancy. No other reason or factor drew such frequent positive responses. Eleven percent of the women reported that they wanted to conceive at the time of intercourse. Irresponsibility about birth control, which accounted for 11~ of the variance, was one major reason why aborting women got pregnant. Even though such women were aware of the possibility of conceiving, they did not like to plan for sexual intercourse, they never got around to obtaining birth control, and they decided during intercourse to trust good luck or faith to prevent conception. Other factors included the male's failure to take precautions (8~ of the variance), denial of fertility (7.73~o), impulsivity and lack of control (7.36~), fear of obtaining or of disclosing the use of birth control (7.15~o), and birth control failure (6.07~). Whereas older, married women became pregnant despite their contraceptive efforts, y o u n g e r , single women became pregnant because they were unprepared for sexual intercourse. As in Miller's [13] reports, older women, women with higher education, and women with more previous abortions were more likely to blame birth control failure (r = 0.138t, r = 0.210t, r = 0.172t). And, those who had more previous abortions were less likely than others to explain their pregnancy by retrospective rhythm or denial (r = 0.158t). Younger women were more likely to say that the pregnancy was due to their own irresponsibility about birth control (r = -0.186t), or the male's failure to take adequate precautions (r = - 0 . 1 8 I t ) . Further, women who attributed their pregnancy to contraceptive irresponsibility tended to have had a sexual relationship with the male partner for a shorter period of time (r = -0.137t), and those who attributed it to impulsivity of the moment tended to be involved in less intimate and less positive heterosexual relationships (r = -0.246"~, r = -0.157t). Marital status groups differed significantly in attributing the pregnancy to irresponsibility (F = .4.992t); married women were the least likely to endorse irresponsibility reasons, whereas single and engaged women were the most likely to do so. Also, the less education a woman had and the more conservative her religion, tl'ie m o r e l i k e l y she was to blame the
686
LISA ROSEMAN SHUSTERMAN
man for the conception (r = -0.142t, r = -0.1527). Immediate response to pregnancy. A factor analysis of emotional reaction to the pregnancy was performed. Three factors emerged: (1) anxiety, i.e. the extent to which the woman felt worried, confused, trapped or guilty, (22~ of the variance); (2) disbelief, i.e. the extent to which the woman felt shocked or surprised, (17~o of the variance); and (3) anger-happiness, i.e. the extent to which the woman felt hostile or elated (19~o of the variance). The formation of an anger-happiness factor is puzzling. Osofsky and Osofsky [21] used a unidimensional anger-happiness scale to assess post-abortion reaction, although they do not report whether the scale was constructed on the basis of a statistical relationship or on the basis of an assumed a priori relationship. The mean factor scores indicate that when aborting women became fairly certain of their pregnancy, they reacted with slight to moderate anxiety, little or no disbelief, and slight anger. Immediate response to pregnancy is significantly correlated with several other antecedent variables. For example, as feelings of anxiety increase, the following variables decrease: education (r = -0.136t), intimacy of the relationship with the male partner (r = -0.147t), quality of the relationship (r = - 0 . 1 6 2 t ) , length of the sexual relationship (r = - 0 . 1 7 9 t ) , and regular use of birth control (r = - 0 . 1 9 4 7 ) . Disbelief was significantly positively related to conservatism of religion (r = 0.167?), and significantly negatively related to the number of previous abortions (r = - 0 . 1 3 t t ) . Motivation for seeking abortion. In the assessment of why women seek to end a pregnancy, the most typical reasons were: "I would not be able to give a child a fair chance at this time" (82~o), "A child at this time would interfere with my career, education, or personal freedom" (75~), "I can'~/~afford a child at this time" (72~o) and "I do not want to start off a marriage being pregnant" (44~o). The least endorsed reasons were: "Someone else is making me end the pregnancy" (4~), "I never want children" (6~o) and "I would not like a child by this man" (10~o). A factor analysis of why women have abortions produced four major factors: completion of family (14~o of the variance), i.e. many women felt that they were too old to bear a child and that they did not want any more children; single marital status (13~); not feeling equipped to handle the responsibilities of a child (13~); and feeling that children would interfere with long or short term personal goals (11~o). There seen to be several types of women, each of whom have different reasons for ending their pregnancy. First, those who abort because they have completed their families tend to be older (r = 0.690?), parous (r = 0.693?) women involved in longer term (r = 0.342?) and more intimate (r = 0.304t) relationships with their male partner. A different type of w o m a n - - y o u n g e r and with no previous pregnancies--is more likely to abort because she does not feel equipped to handle childcare responsibilities (r = - 0 . 2 9 4 t , r = - 0 . 1 9 5 7 ) . Women who endorse the "not equipped" reason are also more likely to have gotten pregnant because of impulsivity t Significant to P < 0.01 level.
or lack of control during the sexual encounter (r = 0.200?). These women are likely to feel that being single is a reason for the abortion (r = -0.431t), and to feel that children would interfere with present and/or future goals (r = 0.428?). Satisfaction with abortion decision. As a group, the women were moderately to very satisfied with their decision to abort. Women who were more likely to feel satisfied were more likely to have support from their male partner (r = 0.133t) and from their friends (r = 0.200?). In general, the women were moderately nervous about the medical procedure (X = 2.84, possible low score =1, possible high score =4). As might be expected, women who had previous abortions were the least nervous (r = - 0 . 1 3 7 t ) . Those who were more nervous had considered other possibilities for handling the pregnancy (r = 0.149t).
Consequent variables Physical sequelae. A total physical sequelae score (Hoyt r = 0.47) was obtained for each woman by adding up the number of symptoms she had during the follow-up period. Very few women suffered adverse physical consequences of the abortion (.~ = 8.77 for five items, when yes = 1 and no = 2). Many women (71~o) experienced minor spotting or bleeding which is considered a normal symptom. Psychological reaction. A total psychological sequelae score (Hoyt r = 0.76) was obtained for each woman. The general emotional response to abortion was moderately favorable (X = 46, !owest possible score---negative reaction = 15, highest possible score --positive reaction =60). As a group, the women felt quite relieved, moderately satisfied, and slightly t o moderately happy at follow-up. They did not feel resentful, guilty or sorry that they had had the abortion, and almost all said that if they had the decision to make over again, that they would definitely decide to abort. The women reported that they were somewhat open about talking about the abortion to others, and had only a slight tendency to p u s h the whole experience out of their minds. In general, the relationship with the male partner was reported to be average or better-than-average, not significantly different from the pre-abortion judgement of the quality of the relationship. Overall, the women felt that the abortion had not really interfered, or at worst had only slightly interfered, with their everyday activities. Psychological reaction is significantly negatively correlated with physical reaction (r = -0.286t). A stepwise regression analysis was performed using most of the antecedent variables as possible predictors of the post-abortion psychological reaction. Antecedent variables which had little or nor variance, or which had a small number of responses were eliminated from the stepwise regression analysis. The data were split into two samples by clinic. For clinic A, 32 of the variables accounted for 62)/0 of the variance in psychological reaction, with 3 variables accounting for 39)/0 of the variance. The three most important antecedent variables, in order of their ability to predict, were: (1) how angry or happy was the woman's immediate response to the pregnancy, (2) how satisfied was the woman with her decision
Predicting the psychological consequences of abortion to terminate the pregnancy, and (3) how positive was the woman's relationship with her male partner. For clinic B, 31 of the variables accounted for 41~ of the variance in psychological reaction, with 3 variables accounting for 28~o of the variance. The three most important antecedent variables, in order of their ability to predict, were: (1) how satisfied was the woman with her decision to terminate the pregnancy, (2) whether or not the male partner knew of the abortion, and (3) how anxious or worried was the woman's immediate response to the pregnancy. Therefore, the woman's satiafaction with the decision to abort was an important predictor of psychological response in both samples. Also, the angryhappy reaction (Clinic A, variable 1) is highly correlated with the anxiety reaction (Clinic B, variable 3) (r = 0.481t), and whether or not the man knows of the abortion (Clinic B, variable 3) is highly correlated with the quality of the woman's relationship with him (Clinic A, variable 3) (r = 0.3117). Even though the latter variables do not appear in both regression equations, it is not because they are not important in both, but rather because the stepwise regression • analysis eliminates highly correlated variables. Thus, although minor sample variations produced the different equations, in content the predictors are very similar. In order to test the generalizability of the two equations, a cross-validation procedure was employed. The Beta weights from each sample were tested for their ability to predict on the other sample. On the average, each equation accounted for about 21~ of the psychological reaction variance in other sample (RZ= 0.205, R 2 = 0.223). There was considerable agreement between the two equations (R--0.472, R = 0.453). These results indicate that women who do not become very upset when they first think ~hat they are pregnant, who share the abortion experience with their male partner, or who are satisfied prior to the abortion with the decision to terminate the pregnancy are more likely to have favorable emotional reactions, whereas those who do become upset, who do not share the abortion experience with their partner, or who are not satisfied prior to the abortion with the decision to terminate the pregnancy are more likely to have unfavorable emotional reactions. DISCUSSION The main purpose of Part I of the study was to describe the abortion population and the psychological elements of the abortion experience. Almost 75~o of the aborting women were employed o r were attending school. The occupational status of the sample is consistent with other observations I-9] that most abortion patients are not in roles convenient for child care. It is surprising that many of the women belonged to conservative or fundamentalist religious faiths. There are several possible explanations as to why such women terminate their pregnancy even though •their religions are very anti-abortion. First, it may
t Significant to P < 0.01 level.
687
be that although the church organizations and spokespeople espouse anti-abortion views, such views are not shared, or not shared as strongly, by church members. Second, it may be that although most of the church members are against abortion, the women who do abort are an especially liberal group of women within the church. Or, third, it may be that aborting women too are anti-abortion, but when they are faced with an actual pregnancy that they do not want, they end the pregnancy because their desire to get rid of it is greater than their anti-abortion attitude. It could also be that conservative or fundamentalist churches are often opposed to contraception as well as to abortion. Women raised in these faiths may experience psychological obstacles to the use of contraception and, therefore, run a greater risk of becoming unintentionally pregnant than adherents of more liberal churches; because they have more unwanted pregnancies they need abortion more often. One issue for future research would be to determine why women whose attitudes would seem to be very much against induced abortion, make up much of the abortion population. The majority of the abortion patients tended to be involved in positive relationships with their male partner; they tended to confide in him about the pregnancy and the abortion, and they tended to receive much support from him for the decision to abort. Even in recent relationships, women viewed the interaction positively and the male was involved in the abortion decision. These findings dispel the myth that aborting women are promiscuous, casual about sex, and involved in unstable relationships. Two major types of women with very different abortion experiences were found. The first group consisted of young, primagravidae, single women living with their parents, while the second group consisted of older, parous married woman. Younger, primagravida¢, single women were more likely to say that the pregnancy was due to their irresponsibility or the male's irresponsibility about contraception. Part of the reason they were not prepared for intercourse is that they were afraid or embarrassed to see a physician about birth control and that they did not want others (probably their parents) to know that they were engaging in sexual intercourse. Irresponsibility aboutcontraception seems to be one reason for un• wanted pregnancy that could be influenced. What is needed may be more or improved means of public sex education, more easily available birth control, or better doctor-patient interaction. This type of patient decided to abort because they did not feel equipped to handle child-care responsibilities, because they did not want to bear a child while single, and because a child would interfere with their present goals. The second type of abortion patient, the older, parous, married woman was likely to say that the pregnancy was due to birth control failure. The older, parous, married patients decided to abort because they had completed their families and/or they felt that they were too old. to bear a. child. When aborting women first suspected that they were pregnant, their emotional response tended to be realistic and healthy, i.e. they were worried about how they would handle the pregnancy, but they were not hostile nor did they deny the reality of the pregnancy.
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LISA ROSEMANSHUSTERMAN
By the time of the abortion, almost all of the women were very satisfied with their decision. The results showed that women who were certain about the abortion from the first suspicion of pregnancy tended to get more male, friend, and parent support for the abortion, whereas those who were not so certain got less support. In the two weeks following the abortion, few women suffered negative physical or psychological after-effects. Such a finding supports wevious research on the sequelae of legal ~ abortion [8, 15, 18, 21-26]. Women felt relieved and satisfied after the procedure, and said that they would abort again given the same circumstances. It is interesting that psychological sequelae and physical sequelae are significantly negatively correlated. It may be that women who had a negative physical response attributed all negative feelings to the adverse bodily reactions, whereas those who had a positive or neutral physical reaction could only attribute negative feelings to psychological response. The major purpose of Part II of the study was to determine an "at risk" population for negative emotional reaction to abortion. The findings indicated three variables which help predict psychological sequelae. The first variable was the woman's overall preabortion satisfaction with her decision to terminate the pregnancy. If a woman is not satisfied with the decision before the abortion, she will be more likely to feel unhappy, guilty, resentful, etc. afterwards than those who are satisfied with their decision. Satisfied women will have received more preabortion support from their significant others. It is also more likely that the decision to abort will have been theirs, and not forced on them by someone else. The second variable was the degree of intimacy between the woman and her male partner, and whether or not he participated in the abortion experience. Women involved in more intimate, permanent relationships were more likely to have recieved male partner support for the abortion. Thus, if the woman can share her feelings about the abortion with the other person most directly involved in the pregnancy, and can be supported by him in the pregnancy termination, then she is not likely to experience adverse psychological consequences. The third variable that contributed to the prediction of psychological reaction was the woman's emotional response to the suspicion of her pregnancy. If the woman was especially anxious or angry then she will be more likely to have an unfavorable reaction. The findings show that such women were more likely to be involved in less intimate, less permanent and less positive relationships with the male partner and to abort because they do not want to bear that male's child. It may be that such women become upset because they are not involved in a positive, supportive, heterosexual relationship. Or, it may be that for some other reason, not tapped by the present research, such women are the type who tend to react with strong negative emotions to important life situations--pregnancy and abortion. Why such women react negatively should be investigated. The three variables--satisfaction with the abortion decision, whether or not the male shares in the abortion experience, and immediate response to preg-
nancy--account for about one-third of the variance in psychological reaction. The remainder of the variance is unaccounted for. Future studies might investigate whether variables not included in the present study, such as atmosphere of the clinic, the amount of pain experienced during the procedure, the type of pre-abortion counselling, the psychological wellbeing of the women or other variables relate to emotional response to abortion. The findings of Part II of the study have immediately applicable, practical values. The three issues which proved to be the best predictors of emotional response should be explored by abortion counsellors. Although counsellors usually try to ascertain how satisfied the woman is with the decision to abort, they do not necessarily do so systematically. In addition, they rarely question how the male is involved in the abortion or how the woman responded to the pregnancy. Such questions could be used routinely by abortion counsellors to assist them in spotting those who would react unfavorably to the abortion. Several qualifications should be added to the above discussion. First, the study is concerned only with the short-term effects of abortion. From the results, it cannot be determined whether the negative sequelae decrease over time, whether they affect responses to future crises or decision points, or how they compare with sequelae of Other procedures. In addition, the results are not necessarily generalizable to women obtaining abortions in hospital or private settings, at later periods of gestation, or by other methods of abortion. Lastly, the study was conducted shortly after the U.S. Supreme Court decision to legalize abortion. It is possible that changes in the public attitudes toward abortion could affect emotional responses. Further research is needed to answer the remaining questions about the abortion experience. REFERENCES
1. Smith R., Diamond M. and Steinhoff P. Abortion in Hawaii: 1970-1971. Hawaii reed. J. inter-Isl. Nurs. Bull. 32, 213-220, 1973. 2. Duffy E. The Effect of Changes in the State Abortion Laws. Washington, United States Government Printing Office, 1971. 3. Pakter J. and Nelson F. Abortion in New York City: the first nine months. Family Plan. Perspect. 3, 5-12, 1971. 4. Rovinsky J. Abortion in New York City, preliminary experience with a permissive abortion statute. Obstet. Gynec. N.Y. 38, 333-342, 1971. 5. Tietze C. and Lewit S. Joint program for the study of abortion (JSPA): early medical complications of legal abortions. Stud. jam. Plann. 3, 97-122, 1972. 6. Steinhoff P., Diamond D., Palmore J. and Smith R. Who are the new abortion patients. Presented at Abortion Research Workshop, New Orleans, April, I970. 7. Miller W. Psychological antecedents to conception in pregnancies terminated by therapeutic abortion. Unpublished manuscript, Stanford University, 1973. 8. Smith E. A follow up study of women who request abortion. Am. J. Orthopsychiat, 43, 574-585, 1973. 9. Steinhoff P., Smith R. and Diamond M. The Hawaii Pregnancy, Birth Control and Abortion Study: social psychological aspects. Conference Proceedings: Psychological Measurement in the Study of Population Problems. Institute of Personality Assessment and Research, University of California, Berkeley, 33-40, 1972.
Predicting the psychological consequences of abortion 10. Peck A. and Marcus H. Psychiatric sequelae of therapeutic interruption of pregnancy. J. nerv. ment. Dis. 143, 417M25, 1966. 11. Moore-Cavar E. International Inventory of Information on Induced Abortion. Division of Social and Administrative Sciences. Internal Institute for th e Study of Human Reproduction. Columbia University, 1974. 12. Tietze C. Two year's experience with a liberal abortion law: its impact on fertility trends in New York City. Family Plann. Perspect. 5, 36-41, 1973. 13. Dagenais F. and Marascuilo L. The effect of factor scores, Guttman scores, and simple sum scores on the size of F ratios in an analysis of variance design. Multivar. behav. Res. 8, 491-502, 1973. 14. Diamond M., Steinhoff P., Palmore J. Y. and Smith R. Sexuality, birth control and abortion: a decisionmaking sequence. J. Biosoc. Sc. 5, 347-361, 1972. 15. Monsour K. and Stewart B. Abortion and sexual behavior in college women. Am. J. Orthopsych. 43, 804-813, 1973. 16. Kane F., Lachenbruch P. and Lipton M. Motivational factors in abortion patients. Am. J. Psychiat. 130, 290-293, 1973. 17. Ford C, Castelnuova-Tedesco P. and Long K. Women who seek abortion: a comparison with women who complete their pregnancies. Am. J. Psychiat. 129, 546-552, 1972. 18. Osofsky J. and Osofsky H. The psychological reaction of patients to legalized abortion. Am. J. Orthopsychiat. 42, 48-60, 1972.
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I9. Steinhoff P. Background characteristics of abortion patients. In Abortion Experience in the United States (Edited by Osofsky J. and Osofsky H.), pp. 206-236. Harper & Row, New York, 1973. 20. Steinhoff P. Ethnic and social class differences in the use of abortion. Presented at Population Studies Seminar, East-West Center, University of Hawaii, November 1971. 21. Osofsky J., Osofsky H. and Rajah R. Psychological effects of legal abortion. Clin. Obstet. Gynec. 14, 215-234, 1971. 22. Shusterman L. The psychosocial factors of the abortion experience: a review. Psychot Women Q. 1, 79-106, 1976. 23. Athanasious R., Michelson L. and Oppel W. A longitudinal study of sequelae to term birth and therapeutic abortions. Presented at 21st Annual Clinical Meeting of the American College of Obstetricians and Gynecologists, Bal Harbour, May 23, 1973. 24. Adler N. Dimensions underlying emotional responses of women following therapeutic abortion. Presented at American Psychological Association meeting, Montreal, August 30, 1973. 25. Addelson F. Induced abortion: source of guilt or growth? Am. J. Orthopsychiat. 43, 815-823, 1973. 26. Walter G. Psychologic and emotional consequences of elective abortion. Obstet Gynec. 36, 482-487, 1970.