- Email: [email protected]
Therapeutic abortion: A prospective study. I
Therapeutic abortion: A prospective study. I. HARRY
BRODY,
M.D.,
STEWART
MEIKLE,
RICHARD
GERRITSE,
Calgary,
Alberta,
F.R.C.S.(C) M.A.,
PH.D. B.Sc.
Canada
study made of the emotional reactions of 117 therapeutic abortion showed a marked degree of disturbance of a control group in the same stage of pregnancy. Response
A prosfiective
women applying for compared to those to the abortion was rapid, positive, and lasting. The addition of tubal ligation in 52 of the 94 cases in which abortion was carried out had no deleterious effects on the outcome. Continuing fisychological problems were most obvious in the small group who were rejected and still available for follow-up.
UNTILRECENTLY, theprevailingethica.l atmosphere in North America has been discouraging to those investigators who wished to study the effects of granting or withholding therapeutic abortion from women who faced unwanted pregnancies. The result has been a maximum amount of theorizing on a minimum amount of data, with widely conflicting results being reported. This is particularly true where psychiatric sequelae are concerned. For example, Ekblad4 reporting on 479 women who underwent therapeutic abortion found that 25 per cent experienced some self-reproach but only one per cent suffered a major psychiatric disability. In contrast, Malmfor@ indicated that out of 84 patients undergoing legal abortion 39 were pleased and grateful, 4 did not want to discuss it, 9 were consciously repressing guilt, 22 experienced significant guilt and reFrom the Departments of Obstetrics and Gynecology and the Department of Psychiatry, Foothills Hospital, and the Faculty of Medicine, De;;;;zent of Psychology, University Supported Development Hospital.
morse, and 10 had significant impairment of mental health. The actual techniques by which this type of subjective evaluation is arrived at are seldom made public. A frequent shortcoming in many of the studies reported in the literature lies in their failure to report on the fate of those whose application for abortion was rejected. Exceptions to this are the studies by Baird,l Kolstad,8 and Peck and Marc~s.~~ Based upon these authors’ findings, the frequency of psychiatric complications among patients who are refused therapeutic abortion appears to lie between 6 and 25 per cent, depending upon the population used. Roughly the same frequency of psychiatric sequelae is reported in the refused group reported on by Hook.? The critical review by Simon and Senturia14 summarizes the methodologic shortcomings of many therapeutic abortion studies reported to date. Most of the work has been retrospective and shows little evidence of prestudy planning. The method of selecting patients is unclear. Many studies lack control groups which would enable the effects of pregnancy itself to be assessed. There is usually a lack of clarity concerning the methods by which the patient’s psychological status was evaluated. In addition, wnelusions drawn from one population are frequently discussed as though they could
of
by the Research and Committee, Foothills
Presented at the Twenty-sixth Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada, Jasfier, Alberta, ]une 12 to 14, 1970.
347
348
Brady,
Meikle,
and
Gerritse
be applied without modification to other, quite different, groups. It was with considerations such as these in mind that the present study addressed itself to a number of specific questions. First, compared to a control group in the same stage of do therapeutic abortion applipregnancy, cants show a significant amount of psychological disturbance? Second, assuming that measurable psychological disturbance is found, what effect does therapeutic abortion have on this? In addition, if any change is found in response to abortion, is it short lived, or does it last? Third, does the additional procedure of tubal ligation result in any further unfavorable reactions? Fourth, what are the reported psychological effects of withholding therapeutic abortions from women who apply? In addition to these main questions, it was hoped that the proposed study would supply some descriptive information in regard to psychological reactions from various subcategories of patients, i.e., married versus single applicants and primiparous versus multiparous applicants. Materials
and
methods
The setting for the present study was the Obstetric and Gynecology Department of a general teaching hospital. However, to obtain follow-up information, contact with the patients was continued into the community. The subjects consisted of a group of 117 patients applying for a therapeutic abortion and a control group of 58 patients within the same stage of pregnancy. The control group was recruited from women attending obstetricians’ offices for normal antenatal care. Table I outlines the main details of these two groups. From this it can be seen that there were approximately twice as many applicants as controls and that the former tended- to be a slightly older group. This is because age in the applicants took the form of a bimodal distribution, made up on the one hand of a relatively young single group and on the other of an older married group, some of whom ware reaching the end of their child-
Amer.
February J. Obstet.
1, 1971 Gynec.
Table I Control Applicants
Data
No. of subjects Mean age Married Single Separated, divorced, Multiparas Primiparas Abortions approved
117 30.0 35 13 82 35
58 26.8 58 0 0 40 18
94
0
69 etc.
subjects
bearing years. It was this latter group which was responsible for altering the mean age of the applicants in an upward direction. Finding a control group of single women proved to be impossible in the present study. However, the available married control subjects allow a number of useful comparisons to be drawn with the married applicants. The multiparous to primiparous ratio for both groups is approximately equal, being 2.34: 1 for the applicants and 2.20: 1 for the control subjects. Of the 117 applicants interviewed, 94 were granted abortions. In addition, 52 of these approved applicants also underwent the additional procedure of sterilization by tubal ligation. By far, the commonest abortion technique was by dilatation and curettage, and 70 patients were dealt with in this way. Individuals applying for a therapeutic abortion at this hospital followed a standard routine. An application form completed by a physician and requesting an abortion was forwarded to the Chairman of the Therapeutic Abortion Committee who then arranged a meeting to consider the case. The patient, husband (if any), and the referring physician were all expected to attend. Having deliberated on the merits of the case, the committee members then individually and independently completed voting forms. The decision was based on a straight majority rule, and all members of the committee, consisting of at least 3 physicians plus a social worker and a psychologist, carried equal voting rights. Prior to being seen by the Committee, each applicant (and husband, if any) had to complete a battery of psychological tests.
Volume Number
109 3
For those patients who successfully petitioned for an abortion, follow-up testing in a reduced form was carried out at intervals of 6 weeks, 6 months, and one year postabortion. For both the rejected group and the control subjects, retesting was limited to 6 weeks after the expected term date. This latter procedure was dictated by the belief that to expect more frequent cooperation from these 2 groups would be unrealistic. The psychological test results were not utilized in determining the committee decisions. Tests were chosen as the main dependent variables in the study because of their relatively standardized administration procedures, their objectivity, and their known reliability and validity. The tests utilized in the study together with brief descriptions of each are shown.
Minnesota multiphasic personality inventory (MMPI) (Hathaway and McKinley6). This test is a 556 item personality inventory resulting in scores on 13 scales, 10 of which represent psychiatric entities. The other 3 scales reflect test-taking attitudes. The 10 clinical scales embraced by the test include hypochondriasis, depression, hysteria, psychopathy, masculinity-femininity, paranoia, psychasthenia, schizophrenia, mania, and social introversion. “Normal” scores are set at 50 for all scaIes, and generally speaking the greater the deviation upward from this the more likely the individual is to reflect the condition associated with the particular scale. The MMPI is certainly the most widely used of the questionnaire type of personality tests and usually felt to be a sensitive indicator of psychiatric disturbance. Pregnancy Research Questionnaire. This test was developed by Schaeffer13 to measure physical and psychological reactions toward pregnancy. This test is divided into two parts. Section I relates to: (1) health problems during the current pregnancy (46 items), (2) health problems before this pregnancy (42 items), and (3) premenstrual problems (17 items). Section II, consisting of 69 items, attempts to sample attitude toward pregnancy in general as well as to the current pregnancy.
Therapeutic
abortion
349
Minnesota-Briggs Social History (Brigg9). This 169 item multiple choice social history aims at obtaining background information in areas such as early family history, school experiences, peer relationships, and both adolescent and adult heterosexual history.
Mooney Problem Check List (Mooney and GordonlO). Consisting of a list of 288 commonly reported psychological problems derived from counseling settings, this test simply requires the patient to check off those problems which apply to her at the present time. Areas covered include heahh, economic security, self-improvement, personality, home and family, courtship, sex, religion, and occupation.
Cornell Medical Index (Brodman, Erdmann, and Wolff3). This is a 195 item general medical and psychological questionnaire. One hundred and thirty-five items refer to physical problems and 57 to psychological difficulties.
Forer Sentence Completion Test ( Forer5). This is a 100 item semiprojective personality test aimed at eliciting attitudes toward important interpersonal relationships in the patient’s life.
Semantic Differential (Osgood, Suci, and Tannenbaumll). This is a method of evaluating the meanings of various verbal concepts to patients. In the present case, 6 concepts had to be rated in terms of goodbad, small-large, fast-slow, etc. The concepts were man, woman, baby, pregnancy, my present self, my ideal self. In the present study, administration of the complete battery of tests was limited to the initial precommittee stage. Thereonly 3 tests were administered: after, Mooney, MMPI, and Semantic Differential. The follow-up tests were delivered to each patient personally by an experienced public health nurse. It was felt that this was likely to increase the number of returns and in addition would enable the investigators to obtain some further impressions as to the current status of the patients. For the study, all test scoring and statistical analysis was conducted by means of an IBM 360 computer.
350
Brody,
Meikle,
and
Gerritse
Analysis of the data For reasons of space, the discussion of the results in the present paper will be limited to findings related to only one of the 6 tests administered. The remaining results will be reported in later articles. The main MMPI results are summarized in Figs. 1 to 4. Fig, 1 contrasts the psychological status of the therapeutic abortion applicants prior to their being interviewed by the committee with the control group of patients in the same stage of pregnancy. It can be seen from this that whereas the applicants reported a marked degree of psychological disturbance, as evidenced by the large upward deviation in their profile, the controls ran very close to the “normal” T score of 50. With the exception of the masculinityfemininity scale, all of these differences were highly significant (P < 0.01). Fig. 2 describes the psychological conditions at various points in time of these patients who were granted a therapeutic abortion. When they first appeared before the committee, they were as disturbed as the total applicants’ group. However, by 6 weeks after the abortion, they showed a large decline in psychopathology, and this downward trend continued until by one year post abortion they were close to the “normal” T score of 50 on several of the scales. The differences between the precommittee and post 6 weeks stages were again significant (P < 0.01) across all scales except masculinity-femininity. In the case of the post 6 weeks/post one year comparison, differences on depression, hysteria, and psychasthenia were at less than the 0.01 level of probability and on K and schizophrenia were less than the 0.05 level. Fig. 3 attempts to throw light on the question of whether the additional procedure of tubal ligation resulted in any extra measurable disturbance. The answer appears to be negative. Compared to the applicants in general, the group of patients who had a tubal ligation in addition to a therapeutic abortion show the same downward trend in pathology as those who had
Amer.
February J. Obstet.
1, 1971 Gynec.
abortion alone. Both groups showed a significant drop in disturbance compared to when they first appeared to the committee, but the decrease was equal for both. Fig. 4 compares the precommittee test of the rejected applicants with their profile 6 weeks after the child was born. None of the comparisons on the clinical scales were significantly different. In other words, this group was markedly disturbed on first contact and were still in this state approximately 8 to 9 months later. The small number of patients available on follow-up here, however, makes this conclusion a tentative one. In addition to the above comparisons, a number of other factors was looked at in the study. One of these concerned whether women who were primiparous responded to therapeutic abortion differently from those who were multiparous. No such differential reaction on the MMPI was observed. The differences between these groups’ initially, and at the 6 weeks, 6 months, and one-year stages were generally insignificant. The second additional factor considered was the married/single dichotomy. Here some significant differences were found in the way these groups reacted to abortion. The single group precommittee showed a significantly higher psychopathy score (P < 0.01). In other words, the single girl was probably somewhat more impulsive and less accepting of authority. Six weeks after the abortion, compared to the married women the single women showed significant elevations on psychopathy, schizophrenia, and mania (all P < 0.05 < 0.01). One year after the abortion the relative elevations on schizophrenia and mania still remained for these single girls. Comment These findings suggest a number of interpretations. The results relating to Fig. I appear to indicate that pregnancy itself is not on the whole a highly disturbing event. This is reflected in the control group’s relatively normal profile. One explanation to be considered is that the applicants may have attempted to fake a psychiatric disturbance
Volume
109
Number
3
Therapeutic
-
Fig. 1. MMPI profiles of therapeutic abortion applicants and control subjects. Both groups were within the first 3 months of pregnancy. TA = therapeutic abortion.
. APPROVALS T. A. APPROVALS
(PRE-COMMITTEE)
N-
(POST
N=
T A. 6 weeks)
Fig. 2. MMPI profiles of patients obtaining therapeutic abortion, prior to seeing committee, 6 weeks, and one year post operation.
T.A.APPROVALS
abortion
(Pre-committse)
351
N=94
Fig. 3. MMPI profiles of patients who underwent additional tubal ligation compared to those who did not. The precommittee combined profile for both groups is also included.
---
Fig. files
T.A DENIALS
(Post
4. Precommittee and 6 week of patients denied therapeutic
partum
6 wks)
postpartum abortion.
N=4
pro-
352
Brody,
Meikle,
and
Gerritse
in order to maximize their chances of being accepted. While it is true that no current questionnaire tests are foolproof, the MMPI has built into it 3 scales aimed at detecting such tendencies (Scales L, F, K) . Examination of the individual test results suggests that while there may have been some tendency to exaggerate existing symptoms there was no systematic attempt to fake on the part of the applicants as a whole. The applicant’s profile in Fig. 1 is, of course, a conglomerate and may reflect no individual patient. Rather, it suggests that in this group the following characteristics are frequently found but in a variety of combinations. These include a high degree of depression, considerable concern with bodily preoccupations, difficulties in obeying rules and regulations, trouble in controlling impulses to an extent that leads to serious social difficulties, a tendency to be touchy and critical of others, being an easy prey to anxiety and irrational fears, a marked tendency to withdrawal, and uneasiness in social situations. Fig. 2 suggests some answers to the question of whether therapeutic abortion generates rather than relieves psychiatric problems. The possibility of a guilt reaction has been suggested by a number of previous investigators. Our findings lend no support to this view. On the contrary, within 6 weeks of the procedure our patients showed a marked improvement in their reported psychological status, and this improvement continued up to one year after intervention. This is as far as the follow-up has gone. On the basis of this result, we feel justified in concluding that for the group as a whole abortion has proved to be truly therapeutic. The results summarized in Fig. 3 suggest that the additional effects of tubal ligation over and above an abortion are negligible, and there is no indication here to support the view sometimes expressed that a steriliz&ion procedure is likely to result in a form of involutional-like depression. Our results imply that it is quite reasonable to consider such an additional procedure on its merits
Amer.
February J. Obstet.
1, 1971 Gym.
rather than be swayed by apparently unlikely psychiatric sequelae. Consistent with the findings in other studies, we also have had great difficulty in following-up patients who were refused an abortion. Although the committee chairman carefully explained to all applicants that we would require their assistance in a follow-up study whatever the outcome of the committee’s deliberations, in fact, despite persistent efforts on the part of the follow-up nurse, we were only able to retest 4 out of 23 refused applicants. There are a number of reasons for this. In general, circumstances make this group a relatively nomadic one. Twelve left the city without leaving a forwarding address. Others obtained illegal abortions and were concerned lest further contact with the study might bring legal retribution. Some wanted nothing more to do with the hospital, feeling that since they had been refused help in their time of need they were under no obligation to continue in the project. In addition the 4 remaining women were somewhat atypical insofar as they had carried the child to term, whereas many of the others had managed to terminate the pregnancy by one means or another. With these provisos in mind, the Fig. 4 results suggest that where a woman is forced to carry an unwanted pregnancy to term she is in effect likely to be exposed to a continuing period of emotional disturbance at least up until 6 weeks after the child is born. In our own cases some of this long term disturbance may have been maintained by the added problems associated with surrendering the child for adoption as most of these women chose to do. On the admittedly scanty evidence from this part of the study, we would have to conclude that there seems to be little therapeutic value in forcing a woman to carry an unwanted pregnancy to term. In general, based on the results studied so far, we see little reason to disagree with the conclusion that, provided a reasonable selection procedure is used, abortion of women carrying unwanted pregnancies is gen-
Volume Number
109 3
uinely therapeutic. Our only clear-cut negative results occurred among the admittedly
Therapeutic
abortion
353
small group of women who were denied this form of treatment.
REFERENCES
Baird, D.: Brit. J. Psychiat. 113: 701, 1967. :: Briggs, P. F.: The M-B Social History, University of Minnesota, Mimeo, 1957. 3. Brodman, K., Erdmann, A. J., and Wolff, H. G.: Cornell Medical Index Manual, Cornell University, 1956. 4. Ekblad, M. : Acta Psychiat. Stand. Suppl. p. 99, 1955. 5. Forer, B. R.: The Forer Structured Sentence Completion Test Manual, Los Angeles, 1957, Western Psychological Services. S. R., and McKinley, J. C.: The 6. Hathaway, Minnesota Multiphasic Personality Inventory, New York, 195 1, The Psychological Corporation. 7. Hook, K.: Acta Psychiat., Stand. (Suppl.) 39: 168, 1963. 8. Kolstad, P.: Acta Obstet. Gynec. Stand. 36: Suppl. 6: 1, 1957.
9.
10.
11.
12. 13.
14.
Malmfors, K.: The problem of women seeking abortion, in Calderone M., editor: Abortion in the United States, New York, 1958, Harper & Row, Publishers, p. 133. Mooney, R. L., and Gordon, L. V.: Manual for Mooney Problem Check List, New York, 1950, Psychological Corporation. Osgood, C. E., Suci, G., and Tannenbaum, P.: The Measurement of Meaning, Urbana, 1957, University of Illinois Press. Peck, A., and Marcus, H.: J. Nerv. Ment. Dis. 143: 417, 1966. Schaeffer, E. S.: Pregnancy Research Questionnaire, Bethseda, 1965, National Institutes of Mental Health, Mimeo. Simon, N. M., and Senturia, A. G.: Arch. Gen. Psychiat. 15: 378, 1966.
BRODY,
M.D.,
STEWART
MEIKLE,
RICHARD
GERRITSE,
Calgary,
Alberta,
F.R.C.S.(C) M.A.,
PH.D. B.Sc.
Canada
study made of the emotional reactions of 117 therapeutic abortion showed a marked degree of disturbance of a control group in the same stage of pregnancy. Response
A prosfiective
women applying for compared to those to the abortion was rapid, positive, and lasting. The addition of tubal ligation in 52 of the 94 cases in which abortion was carried out had no deleterious effects on the outcome. Continuing fisychological problems were most obvious in the small group who were rejected and still available for follow-up.
UNTILRECENTLY, theprevailingethica.l atmosphere in North America has been discouraging to those investigators who wished to study the effects of granting or withholding therapeutic abortion from women who faced unwanted pregnancies. The result has been a maximum amount of theorizing on a minimum amount of data, with widely conflicting results being reported. This is particularly true where psychiatric sequelae are concerned. For example, Ekblad4 reporting on 479 women who underwent therapeutic abortion found that 25 per cent experienced some self-reproach but only one per cent suffered a major psychiatric disability. In contrast, Malmfor@ indicated that out of 84 patients undergoing legal abortion 39 were pleased and grateful, 4 did not want to discuss it, 9 were consciously repressing guilt, 22 experienced significant guilt and reFrom the Departments of Obstetrics and Gynecology and the Department of Psychiatry, Foothills Hospital, and the Faculty of Medicine, De;;;;zent of Psychology, University Supported Development Hospital.
morse, and 10 had significant impairment of mental health. The actual techniques by which this type of subjective evaluation is arrived at are seldom made public. A frequent shortcoming in many of the studies reported in the literature lies in their failure to report on the fate of those whose application for abortion was rejected. Exceptions to this are the studies by Baird,l Kolstad,8 and Peck and Marc~s.~~ Based upon these authors’ findings, the frequency of psychiatric complications among patients who are refused therapeutic abortion appears to lie between 6 and 25 per cent, depending upon the population used. Roughly the same frequency of psychiatric sequelae is reported in the refused group reported on by Hook.? The critical review by Simon and Senturia14 summarizes the methodologic shortcomings of many therapeutic abortion studies reported to date. Most of the work has been retrospective and shows little evidence of prestudy planning. The method of selecting patients is unclear. Many studies lack control groups which would enable the effects of pregnancy itself to be assessed. There is usually a lack of clarity concerning the methods by which the patient’s psychological status was evaluated. In addition, wnelusions drawn from one population are frequently discussed as though they could
of
by the Research and Committee, Foothills
Presented at the Twenty-sixth Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada, Jasfier, Alberta, ]une 12 to 14, 1970.
347
348
Brady,
Meikle,
and
Gerritse
be applied without modification to other, quite different, groups. It was with considerations such as these in mind that the present study addressed itself to a number of specific questions. First, compared to a control group in the same stage of do therapeutic abortion applipregnancy, cants show a significant amount of psychological disturbance? Second, assuming that measurable psychological disturbance is found, what effect does therapeutic abortion have on this? In addition, if any change is found in response to abortion, is it short lived, or does it last? Third, does the additional procedure of tubal ligation result in any further unfavorable reactions? Fourth, what are the reported psychological effects of withholding therapeutic abortions from women who apply? In addition to these main questions, it was hoped that the proposed study would supply some descriptive information in regard to psychological reactions from various subcategories of patients, i.e., married versus single applicants and primiparous versus multiparous applicants. Materials
and
methods
The setting for the present study was the Obstetric and Gynecology Department of a general teaching hospital. However, to obtain follow-up information, contact with the patients was continued into the community. The subjects consisted of a group of 117 patients applying for a therapeutic abortion and a control group of 58 patients within the same stage of pregnancy. The control group was recruited from women attending obstetricians’ offices for normal antenatal care. Table I outlines the main details of these two groups. From this it can be seen that there were approximately twice as many applicants as controls and that the former tended- to be a slightly older group. This is because age in the applicants took the form of a bimodal distribution, made up on the one hand of a relatively young single group and on the other of an older married group, some of whom ware reaching the end of their child-
Amer.
February J. Obstet.
1, 1971 Gynec.
Table I Control Applicants
Data
No. of subjects Mean age Married Single Separated, divorced, Multiparas Primiparas Abortions approved
117 30.0 35 13 82 35
58 26.8 58 0 0 40 18
94
0
69 etc.
subjects
bearing years. It was this latter group which was responsible for altering the mean age of the applicants in an upward direction. Finding a control group of single women proved to be impossible in the present study. However, the available married control subjects allow a number of useful comparisons to be drawn with the married applicants. The multiparous to primiparous ratio for both groups is approximately equal, being 2.34: 1 for the applicants and 2.20: 1 for the control subjects. Of the 117 applicants interviewed, 94 were granted abortions. In addition, 52 of these approved applicants also underwent the additional procedure of sterilization by tubal ligation. By far, the commonest abortion technique was by dilatation and curettage, and 70 patients were dealt with in this way. Individuals applying for a therapeutic abortion at this hospital followed a standard routine. An application form completed by a physician and requesting an abortion was forwarded to the Chairman of the Therapeutic Abortion Committee who then arranged a meeting to consider the case. The patient, husband (if any), and the referring physician were all expected to attend. Having deliberated on the merits of the case, the committee members then individually and independently completed voting forms. The decision was based on a straight majority rule, and all members of the committee, consisting of at least 3 physicians plus a social worker and a psychologist, carried equal voting rights. Prior to being seen by the Committee, each applicant (and husband, if any) had to complete a battery of psychological tests.
Volume Number
109 3
For those patients who successfully petitioned for an abortion, follow-up testing in a reduced form was carried out at intervals of 6 weeks, 6 months, and one year postabortion. For both the rejected group and the control subjects, retesting was limited to 6 weeks after the expected term date. This latter procedure was dictated by the belief that to expect more frequent cooperation from these 2 groups would be unrealistic. The psychological test results were not utilized in determining the committee decisions. Tests were chosen as the main dependent variables in the study because of their relatively standardized administration procedures, their objectivity, and their known reliability and validity. The tests utilized in the study together with brief descriptions of each are shown.
Minnesota multiphasic personality inventory (MMPI) (Hathaway and McKinley6). This test is a 556 item personality inventory resulting in scores on 13 scales, 10 of which represent psychiatric entities. The other 3 scales reflect test-taking attitudes. The 10 clinical scales embraced by the test include hypochondriasis, depression, hysteria, psychopathy, masculinity-femininity, paranoia, psychasthenia, schizophrenia, mania, and social introversion. “Normal” scores are set at 50 for all scaIes, and generally speaking the greater the deviation upward from this the more likely the individual is to reflect the condition associated with the particular scale. The MMPI is certainly the most widely used of the questionnaire type of personality tests and usually felt to be a sensitive indicator of psychiatric disturbance. Pregnancy Research Questionnaire. This test was developed by Schaeffer13 to measure physical and psychological reactions toward pregnancy. This test is divided into two parts. Section I relates to: (1) health problems during the current pregnancy (46 items), (2) health problems before this pregnancy (42 items), and (3) premenstrual problems (17 items). Section II, consisting of 69 items, attempts to sample attitude toward pregnancy in general as well as to the current pregnancy.
Therapeutic
abortion
349
Minnesota-Briggs Social History (Brigg9). This 169 item multiple choice social history aims at obtaining background information in areas such as early family history, school experiences, peer relationships, and both adolescent and adult heterosexual history.
Mooney Problem Check List (Mooney and GordonlO). Consisting of a list of 288 commonly reported psychological problems derived from counseling settings, this test simply requires the patient to check off those problems which apply to her at the present time. Areas covered include heahh, economic security, self-improvement, personality, home and family, courtship, sex, religion, and occupation.
Cornell Medical Index (Brodman, Erdmann, and Wolff3). This is a 195 item general medical and psychological questionnaire. One hundred and thirty-five items refer to physical problems and 57 to psychological difficulties.
Forer Sentence Completion Test ( Forer5). This is a 100 item semiprojective personality test aimed at eliciting attitudes toward important interpersonal relationships in the patient’s life.
Semantic Differential (Osgood, Suci, and Tannenbaumll). This is a method of evaluating the meanings of various verbal concepts to patients. In the present case, 6 concepts had to be rated in terms of goodbad, small-large, fast-slow, etc. The concepts were man, woman, baby, pregnancy, my present self, my ideal self. In the present study, administration of the complete battery of tests was limited to the initial precommittee stage. Thereonly 3 tests were administered: after, Mooney, MMPI, and Semantic Differential. The follow-up tests were delivered to each patient personally by an experienced public health nurse. It was felt that this was likely to increase the number of returns and in addition would enable the investigators to obtain some further impressions as to the current status of the patients. For the study, all test scoring and statistical analysis was conducted by means of an IBM 360 computer.
350
Brody,
Meikle,
and
Gerritse
Analysis of the data For reasons of space, the discussion of the results in the present paper will be limited to findings related to only one of the 6 tests administered. The remaining results will be reported in later articles. The main MMPI results are summarized in Figs. 1 to 4. Fig, 1 contrasts the psychological status of the therapeutic abortion applicants prior to their being interviewed by the committee with the control group of patients in the same stage of pregnancy. It can be seen from this that whereas the applicants reported a marked degree of psychological disturbance, as evidenced by the large upward deviation in their profile, the controls ran very close to the “normal” T score of 50. With the exception of the masculinityfemininity scale, all of these differences were highly significant (P < 0.01). Fig. 2 describes the psychological conditions at various points in time of these patients who were granted a therapeutic abortion. When they first appeared before the committee, they were as disturbed as the total applicants’ group. However, by 6 weeks after the abortion, they showed a large decline in psychopathology, and this downward trend continued until by one year post abortion they were close to the “normal” T score of 50 on several of the scales. The differences between the precommittee and post 6 weeks stages were again significant (P < 0.01) across all scales except masculinity-femininity. In the case of the post 6 weeks/post one year comparison, differences on depression, hysteria, and psychasthenia were at less than the 0.01 level of probability and on K and schizophrenia were less than the 0.05 level. Fig. 3 attempts to throw light on the question of whether the additional procedure of tubal ligation resulted in any extra measurable disturbance. The answer appears to be negative. Compared to the applicants in general, the group of patients who had a tubal ligation in addition to a therapeutic abortion show the same downward trend in pathology as those who had
Amer.
February J. Obstet.
1, 1971 Gynec.
abortion alone. Both groups showed a significant drop in disturbance compared to when they first appeared to the committee, but the decrease was equal for both. Fig. 4 compares the precommittee test of the rejected applicants with their profile 6 weeks after the child was born. None of the comparisons on the clinical scales were significantly different. In other words, this group was markedly disturbed on first contact and were still in this state approximately 8 to 9 months later. The small number of patients available on follow-up here, however, makes this conclusion a tentative one. In addition to the above comparisons, a number of other factors was looked at in the study. One of these concerned whether women who were primiparous responded to therapeutic abortion differently from those who were multiparous. No such differential reaction on the MMPI was observed. The differences between these groups’ initially, and at the 6 weeks, 6 months, and one-year stages were generally insignificant. The second additional factor considered was the married/single dichotomy. Here some significant differences were found in the way these groups reacted to abortion. The single group precommittee showed a significantly higher psychopathy score (P < 0.01). In other words, the single girl was probably somewhat more impulsive and less accepting of authority. Six weeks after the abortion, compared to the married women the single women showed significant elevations on psychopathy, schizophrenia, and mania (all P < 0.05 < 0.01). One year after the abortion the relative elevations on schizophrenia and mania still remained for these single girls. Comment These findings suggest a number of interpretations. The results relating to Fig. I appear to indicate that pregnancy itself is not on the whole a highly disturbing event. This is reflected in the control group’s relatively normal profile. One explanation to be considered is that the applicants may have attempted to fake a psychiatric disturbance
Volume
109
Number
3
Therapeutic
-
Fig. 1. MMPI profiles of therapeutic abortion applicants and control subjects. Both groups were within the first 3 months of pregnancy. TA = therapeutic abortion.
. APPROVALS T. A. APPROVALS
(PRE-COMMITTEE)
N-
(POST
N=
T A. 6 weeks)
Fig. 2. MMPI profiles of patients obtaining therapeutic abortion, prior to seeing committee, 6 weeks, and one year post operation.
T.A.APPROVALS
abortion
(Pre-committse)
351
N=94
Fig. 3. MMPI profiles of patients who underwent additional tubal ligation compared to those who did not. The precommittee combined profile for both groups is also included.
---
Fig. files
T.A DENIALS
(Post
4. Precommittee and 6 week of patients denied therapeutic
partum
6 wks)
postpartum abortion.
N=4
pro-
352
Brody,
Meikle,
and
Gerritse
in order to maximize their chances of being accepted. While it is true that no current questionnaire tests are foolproof, the MMPI has built into it 3 scales aimed at detecting such tendencies (Scales L, F, K) . Examination of the individual test results suggests that while there may have been some tendency to exaggerate existing symptoms there was no systematic attempt to fake on the part of the applicants as a whole. The applicant’s profile in Fig. 1 is, of course, a conglomerate and may reflect no individual patient. Rather, it suggests that in this group the following characteristics are frequently found but in a variety of combinations. These include a high degree of depression, considerable concern with bodily preoccupations, difficulties in obeying rules and regulations, trouble in controlling impulses to an extent that leads to serious social difficulties, a tendency to be touchy and critical of others, being an easy prey to anxiety and irrational fears, a marked tendency to withdrawal, and uneasiness in social situations. Fig. 2 suggests some answers to the question of whether therapeutic abortion generates rather than relieves psychiatric problems. The possibility of a guilt reaction has been suggested by a number of previous investigators. Our findings lend no support to this view. On the contrary, within 6 weeks of the procedure our patients showed a marked improvement in their reported psychological status, and this improvement continued up to one year after intervention. This is as far as the follow-up has gone. On the basis of this result, we feel justified in concluding that for the group as a whole abortion has proved to be truly therapeutic. The results summarized in Fig. 3 suggest that the additional effects of tubal ligation over and above an abortion are negligible, and there is no indication here to support the view sometimes expressed that a steriliz&ion procedure is likely to result in a form of involutional-like depression. Our results imply that it is quite reasonable to consider such an additional procedure on its merits
Amer.
February J. Obstet.
1, 1971 Gym.
rather than be swayed by apparently unlikely psychiatric sequelae. Consistent with the findings in other studies, we also have had great difficulty in following-up patients who were refused an abortion. Although the committee chairman carefully explained to all applicants that we would require their assistance in a follow-up study whatever the outcome of the committee’s deliberations, in fact, despite persistent efforts on the part of the follow-up nurse, we were only able to retest 4 out of 23 refused applicants. There are a number of reasons for this. In general, circumstances make this group a relatively nomadic one. Twelve left the city without leaving a forwarding address. Others obtained illegal abortions and were concerned lest further contact with the study might bring legal retribution. Some wanted nothing more to do with the hospital, feeling that since they had been refused help in their time of need they were under no obligation to continue in the project. In addition the 4 remaining women were somewhat atypical insofar as they had carried the child to term, whereas many of the others had managed to terminate the pregnancy by one means or another. With these provisos in mind, the Fig. 4 results suggest that where a woman is forced to carry an unwanted pregnancy to term she is in effect likely to be exposed to a continuing period of emotional disturbance at least up until 6 weeks after the child is born. In our own cases some of this long term disturbance may have been maintained by the added problems associated with surrendering the child for adoption as most of these women chose to do. On the admittedly scanty evidence from this part of the study, we would have to conclude that there seems to be little therapeutic value in forcing a woman to carry an unwanted pregnancy to term. In general, based on the results studied so far, we see little reason to disagree with the conclusion that, provided a reasonable selection procedure is used, abortion of women carrying unwanted pregnancies is gen-
Volume Number
109 3
uinely therapeutic. Our only clear-cut negative results occurred among the admittedly
Therapeutic
abortion
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small group of women who were denied this form of treatment.
REFERENCES
Baird, D.: Brit. J. Psychiat. 113: 701, 1967. :: Briggs, P. F.: The M-B Social History, University of Minnesota, Mimeo, 1957. 3. Brodman, K., Erdmann, A. J., and Wolff, H. G.: Cornell Medical Index Manual, Cornell University, 1956. 4. Ekblad, M. : Acta Psychiat. Stand. Suppl. p. 99, 1955. 5. Forer, B. R.: The Forer Structured Sentence Completion Test Manual, Los Angeles, 1957, Western Psychological Services. S. R., and McKinley, J. C.: The 6. Hathaway, Minnesota Multiphasic Personality Inventory, New York, 195 1, The Psychological Corporation. 7. Hook, K.: Acta Psychiat., Stand. (Suppl.) 39: 168, 1963. 8. Kolstad, P.: Acta Obstet. Gynec. Stand. 36: Suppl. 6: 1, 1957.
9.
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Malmfors, K.: The problem of women seeking abortion, in Calderone M., editor: Abortion in the United States, New York, 1958, Harper & Row, Publishers, p. 133. Mooney, R. L., and Gordon, L. V.: Manual for Mooney Problem Check List, New York, 1950, Psychological Corporation. Osgood, C. E., Suci, G., and Tannenbaum, P.: The Measurement of Meaning, Urbana, 1957, University of Illinois Press. Peck, A., and Marcus, H.: J. Nerv. Ment. Dis. 143: 417, 1966. Schaeffer, E. S.: Pregnancy Research Questionnaire, Bethseda, 1965, National Institutes of Mental Health, Mimeo. Simon, N. M., and Senturia, A. G.: Arch. Gen. Psychiat. 15: 378, 1966.