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Therapeutic abortion follow-up study
Therapeutic abortion follow-up study ALAN
J.
LESLIE
A.
KARL
H.
SALLY
Francisco,
M.D.
DAVISON,
PH.
HANSON, A.
CYNTHIA San
MARGOLIS,
LOOS, M.
D.
M.D. M.S.W. MIKKELSEN,
M.S.W.
California
A heterogeneous group of preglaant women petitioned for abortion becauseof possible impairment of mentaf and/or physical health; 43 of 50 were followed for 3 to 6 months. Ambivalence and guilt appeared more substantially in young women under 18 years of age. Three to 6 months afterward, 29 patients expressed a positive reaction toward abortion, 10 reported no significant change in their life situations and 4 responded negatively. Of the 41 patients remaining fertile, 4 had purposely become pregnant again; 8 others were apparently without consistent contraception. It was concluded that preabortion counseling should outline the necessary steps for Committee consideration, give reassurance a.s to physical safety, and help fhe patient understand her motives and goals. Postabortion follow-up should emphasize a clear contraceptive program.
Patients
INDUCED ABORTION has become a major method of birth control in many parts of the world. Throughout the United States in the past 3 years, there have been significant modifications of a number of restrictive state abortion laws. Sloane’s1 recent review summarizes the current medical and social dilemma over this problem and concludes that psychiatric labels often mask humanitarian reasons for abortions. After the 1967 abortion law revision in California, there was a rapid evolution in this field. With the ensuing increase in legal abortions, it became possible to study prospectively a heterogeneous group of women who desired abortions for a variety of reasons. This is a preliminary report on the follow-up of such a study group.
and
procedures
From November 1, 1967, to June 30, 1968, 55 women applied to the staff of the Clbstetrical Service of the University of CaliforniaSan Francisco for termination of pregnancy because of its possible significant impairment of their mental or physical health. The screening procedures used in this study included : ( 1) a self-administered questionnaire* at the time of initial appIication for abortion, which provided demographic data and pertinent information; (2) a Minnesota Multiphasic Personality Inventory (MMPI) profile prior to abortion and again 3 to 6 months later (this test was omitted when cultural or linguistic factors obviated its use) ; (3) a psychiatric evaluation of the degree of psychiatric illness and/or possible effects of pregnancy on the patient’s mental health ; (4) a semistructured interview* by a social worker (adapted from Simon and associates’) 3 to 6 months after the abortion to
From the Departments of Obstetrics and Gynecology, Psychiatry, and Social Work, University of California-San Francisco. Presented at the Thirty-seventh Annual Meeting of the Pafific Coast Obstetrical and Gynecological Society, Kauai, Hawaii, November 9-14, 1970.
*Available on request to Dr. Davison. A&It Psychiatric Clinic, University of California-San F~WC~CO, San Francisc~, California 94122.
243
244
Margolis
et al. Amer.
Table I. Therapeutic abortion committee results (Novemeber, 1967, to June, 1968)
Table II. Demographic Age
Total No. of patients considered
55
Abortion refused 3 aborted elsewhere 1 delivered twins at term, had tubal ligation Abortion granted 6 medical indications 44 psychiatric indications 1 refused and went to term
4
51
May 15, 1Y71 J. Obstet. Gynec.
data on 51 patients
[years)
13-14 15-19 20-24 25-29 30-34 35-39 40 and over
3 6 19 8 7 2 6
status Never married Married or common-law relationship Separated, divorced, or widowed
23 21 7
Marital
Follow-up Complete Incomplete
43 7
Race
assess the postabortal responses and psychosocial situation. The abortion techniques included dilatation and curettage in early weeks of pregnancy (in 2 women), aspiration (in 29)) hypertonic injection (in 9)) and hysterotomy (in 1) . At the patients’ own request, tubal ligation was also done in 4 who had aspiration abortion, in one with hypertonic injection, and in one with hysterotomy; 3 also had hysterectomies. Results The Therapeutic Abortion Committee (Table I) accepted 51 of the 55 women who applied, one of whom subsequentIy eIected to carry her pregnancy to term. Three were rejected on the basis of insufficient evidence to substantiate impairment of mental health and obtained abortions elsewhere. A fourth patient, who was rejected because abortion seemed psychiatrically contraindicated, was delivered of twins at term and had a tubal ligation. Information accrued (Table II) from the self-administered questionnaire showed a wide age range-from 13 to 44 years, with 46 per cent of patients falling between 21 and
26 years.
Thirty-six
were
in
the
first
trimester at the time of abortion, despite the 10 to 14 day preabortion procedures. The psychiatric evaluations at the time of approval included 15 with a situational reaction, 14 with neurosis, 10 with character disorders, 6 who had a major psychotic illness
Caucasian Negro Filipino Oriental
41 7 2 1
Education
Below high school graduate High school graduate Some college Income
(self
or family)
$10,000 or more 5,000-10,000 3,000 - 5,000 3,000 or less, and welfare Unknown Patient
11 14 26 8 13 12 13 5
status
Private Staff
15 36
pregnancies None Term or premature delivery Spontaneous abortion only Induced abortion
19 25 1 6
Prior
Present
pregnancy
(weeks’
gestation)
6 30 15
6-9
10-13 14-20 Contraception None or irregular Rhythm, douche Withdrawal, Foam Condom, diaphragm Intrauterine device Oral contraceptive Unknown Prior
sociopsychiatric
21 4 7 6 ; 1 assistance
None Individual psychotherapy Hospital or day care Group therapy Social work interviews
i;’ 4 1 1
Volume Number
Therapeutic
110 2
Table III.
Pregnancies following therapeutic
abortion
follow-up
study
245
abortion
- -----_.
Age
Marital status
Prior pregnancies
for
Indications abortion
Months to conception following abortions
Comments
26
Commonlaw relationship
2 Illegal abortions
Mental health
5 months
Conceived intentionally in that prompted therapeutic more secure and continued
26
Married
2 Term deliveries 1 Spontaneous abortion
Recurrent sarcoma
2 months
Regretful that not influence pregnancy.
22
Commonlaw relationship
1 Term delivery 2 Illegal abortions
Mental health
6 months
Therapeutic abortion for pregnancy by undetermined father; currently pregnant by man whom she has married; continued pregnancy.
16
Single
None
Mental health
2 months
concurrent with the pregnancy or in the immediate past, and 6 who had no obvious psychiatric problems. Four to 6 months after abortion, the follow-up interview on 43 patients indicated that 22 had positive psychological changes, demonstrated by growth experience, increased empathy, increased sense of freedom, and greater sense of femininity. Seven reported other positive changes, such as less fear of pregnancy assured by sterilization or knowledge of better birth control methods, and improved marital or family relations. Four had negative reactions, such as guilt or fear of men, and 10 indicated no change in attitude. The patients’ principal fears of abortion were concerned with the possibility of injury as a result of the abortion technique (in 21 women), its effect on mental or physical health (in 6)) retaliation by others or by one’s own conscience (in 5) , feelings about destroying living tissue (in 3)) and Committee rejection (for 2). In the postabortion follow-up, 36 expressed negative reactions centered around the ignorance of the procedural technicalities (in 12)) the time required for processing (in 13)) and some apparently embarrassing personal encounters during the experience (in 11). The 25 positive responses indicated good supportive help
Felt forced and -._--again
abortion extensive
and
same relationship abortion; now felt pregnancy. chemotherapy did sarcoma; continued
to abortion by family; continued pregnancy. --~_
conceived .
. ..-._
from various staff members. The principal suggestion by the patients was a request for more available public information and less complex application requirements. Of the 41 aborted women who were not sterilized, 4 became pregnant again (Table III). In each case the pregnancy was consciously sought for a variety of reasons. In 2, the abortion was a regretful experience, while in the other 2 the abortion seemed to have allowed more stable life situations to become manifest. In addition to the 16 year old, who was pregnant again, a 13 year old and a 14 year old also regretted their preabortion decisions; all three felt very guilty and believed they had injured a living being. The mean preabortion MMPI showed abnormal elevations on the scales depicting depression, psychopathic deviation, and schizophrenia. A study of 36 paired pre- and post-abortion profiles showed that 15 of the 27 initially abnormal tests became essentially normal after abortion. This was a significant change (P < 0.002) by a test for c,orrelated proportions. In response to several questions designed to detect mixtures of feelings, 17 of those responding reported some guilt, and 20 had some ambivalence. Nevertheless, in a direct query as to whether they would repeat the abortion under simiIar circumstances,
246
Margolis
et
al. Amer.
May 15, 1971 J. Obstet. Gym.
Table IV. Recent therapeutic abortion follow-up studies within the United States ~_-. --_-Sample sire Source
of
data
Years
of study
Total
group
studied
aborted
Age (mean or range)
Peck and Marcus,s Mt. Sinai Hospital, New York
1963 to 1665
50
85
20-40
Simon and associates,* Jewish Hospital of St. Louis
1955 to 1964
46
65
Not stated
Patt and colleagues,4 Michael Hospital, Chicago
1964 to 1968
35
48
23
Levene and Rigney,s San Francisco
1968
56
70
21
This study
1968
43
50
13-44
Reese
37 said they would, 6 were unsure, and 2 would have refused. In contrast to the generally poor preabortion contraceptive practices, 25 patients were taking oral birth control pills 3 to 6 months after abortion. Two patients were satisfied with IUD’s, and one patient used a diaphragm, and one used a condom. Six patients refused birth control advice, and 6 patients did not return for a postabortal doctor visit. After therapeutic abortion, 3 patients initiated psychotherapy, and 11 continued psychiatric care, while 6 had short-term, problem-directed interviews with a psychiatrist or social worker. Twenty-three women had no sociopsychiatric follow-up observation beyond the tests made to complete this study. Comment
Our data corroborate 4 recent studies of therapeutic abortion patients in the United States (Table IV), which show that terminations of pregnancy do not tend to aggravate mental illness and are often helpful to the life situation adjustment of these patients. The legal, social, and medical sanction for interruption of pregnancy results in minimizing untoward guilt and depressive reactions, leaving the great majority of women
with a sense of rightness of their pregnancy terminations, now culturally approved. Of particular concern to us, however, are the pregnant girls under 18. Although our study group was small, we encountered a great deal of ambivaIence and guilt. As a result, we feel that especially careful evaluation and counseling should be provided for them and their families. The alternative of a teen-ager carrying a pregnancy to term presents great difficulties for the teen-ager and her child, and the delicate balancing of risks often requires the most expert collaborative effort of physician, psychiatrist, and social worker. A large number of patients used oral contraceptives regularly after abortion; however, 8 women were apparently without satisfactory birth control advice 3 to 6 months afterward. Although they were not pregnant, they constitute a significant group of potential repeaters. It is mandatory that a therapeutic abortion unit place a high priority on understanding the patient’s attitude toward birth control and help her to choose a method which she will use regularly. The things that concerned our patients most about abortion were ignorance of what to expect in the preliminary screening process and fear of the physical danger of the
Therapeutic
Vol1rme 110 Number 2
abortion
follow-up
study
247
___ -__-.-..- --Marital
Socioeconomic
status
status
Indication abortion
for General
impression
Mostly married
Caucasian Jewish private patients
25 Psych. 25 Nonpsych.
“The psychiatric status proved or unchanged. “Ninety-eight per cent . sight . . . again elect continuing pregnancy
Not stated
Well-educated Caucasian Protestant or Jewish patients
16 Psych. 30 Nonpsych.
“Little new psychiatric related to abortion.”
23 Unmarried 12 Married
31 Private patients
35 Psych.
‘I. + .
59 Unmarried 11 Married
70 Private patients
70
“Properly
22 Unmarried 21 Married 7 Separated I_~
4 Staff
of 92 per cent . . . in. . .” . . wouId . . . with hindabortion in perference to in question.” illness . . . that could be
with rare exceptions, abortion therapeutic.”
service Psych.
of outcome
self
done induced result
in
significantly
was genuinely
abortion does not in itnoxious emotional
sequelae.” 15 Private patients Staff service
36
44
Psych.
6 Nonpsych.
surgical procedure. Both of these areas should be emphasized in the preabortion counseling, as well as the fact that few requests for therapeutic termination are denied. Concerns over time schedule or anonynity can quickly be dispelled. The conflicting feelings arising from conscience or fear of family repercussions can be pinpointed for more intensive follow-up. As a result of our study, we have tried to shorten the time between patient application, Committee decision, and abortion, as well as to minimize cost and provide efficient, effective care by come-and-go abortion procedures in the first trimester. At present, the time interval from first contact to abortion ranges from 36 hours to 2 weeks. Since California law and others modeled on American Law Institute recommendations do not specify that a psychiatrist must attest to the degree of mental health impair-
29 patients expressed positive reaction after abortion; 10 reported no significant change: 4 responded negatively.
ment of the patient, we have encouraged the patient’s physician to make that assessment. If a psychological problem is unresolved, or if the patient is grossly disturbed, a psychiatric consultation is obviously important. However, an interested and concerned obstetrician can usually make the necessary observations to permit a final judgment by the Committee. Currently, a formal psychiatric consultation is presented to the Committee in 10 per cent of the staff cases and in 20 per cent of the private cases. For many women, therapeutic :lbortion will become an increasingly frequent alternate to a stressful pregnancy. An estimated 60,000 abortions wiI1 have been done in California during 1970. Such a procedure must continue to be carefully scrutinized so that it will be associated with minimal hazards and maximum efficiency and effectiveness.
REFERENCES
1. Sloane, R. B.: New Eng. J. Med. 280: 1206, 1969. 2. Simon, N. M., Senturia, A. G., and Rothman, 3.
D.: Amer. J. Psychiat. Peck, A., and Marcus, 143: 417, 1966.
124: 59, 1967. H.: J. Nerv. Ment.
Dis.
4. 5.
Patt, S. L., Rappaport, P.: Arch. Gen. Psychiat. Levene, H., and Rigney, Dis. 151: 51, 1970.
R. G., and Barglow, 20: 408, 1969. F.: J, Nrrv. Merit.
248
Margolis
et al. Amer.
Discussion DR. JOHN C. MCDERMO~, San Mateo, California. Dr. Margolis, along with many others, recognizes that abortion is not a simple matter and that problems other than morbidity and deaths are involved. He has attempted a prospective study for which he should be commended but to believe that observations over the 6 month postabortal period are of much importance is to give them more weight than they deserve. While anecdotal discussion is derogated by our scientific colleagues, my thoughts go back to the time I started private practice in 1936. During the great depression, abortions were as popular as they are today. At that time, most abortions were done by experts, since staying out of San Quentin was a strong incentive. They were also done early, a factor favoring a good outcome. As the depression receded, the number of infertility patients was high. Careful study disclosed a history of induced abortion in many. Among these persons, the feeling of guilt was great, and they were difficult to handle. Fortunately in most cases the blocked tubes opened up 6 to 8 years post abortion, and pregnancies ensued to the point where the problem was one of the opposite sort. As chairman of the abortion committee from the time the California abortion law was changed to the present time, I bave been forced to learn about a whole group of persons whose values differ from mine in almost all respects. These values do not stem from tradition but seem to represent those in the nonthinkers who dominate the news media. Samples of this thinking are: “If you feel like doing something, do it. Don’t take a chance on injuring your psyche by any sexual repression. If anyone warns you of dangers in your course of action, ignore him because he represents the “straight” generation. Don’t use birth control pills, they’re dangerous. Do have an abortion, it’s simple, quick, and safe.” I could go on with samples of cliches promoted by news media-unfortunately supported by enthusiasts in our profession who think any means should be used to promote their goals. Persons with these attitudes by and large form the group requesting abortions at our hospital. Now, the question arises, should we go along with these misconceptions so that the patient will regard the abortion as an exciting episode in her young life and become an authoritative dispenser of misinformation to her friends. The complete lack of correct information appears to me to be the biggest problem to be
May 15, 1971 J, Obstet. Gynec.
solved relative to abortions. This we attempt to correct among our abortion applicants. Each case is considered individually. Trained social workers spend much time trying to work out problems bearing on the patient’s decision. All community resources are brought to her attention. Pressure from the husband, boy friend, or parent is determined and discussed, and, in some instances with extensive discussion, other solutions than abortion are selected. The true facts with regard to abortion dangers and sequeIae are presented, so that a truly knowledgeable decision can be made. After abortion, we have “rap” sessions where an effort is made to present to the patient the effect of life style on health, both mental and physical. Without scientific knowledge to tell us the real end result of abortions, we reason the extensive individual effort will help to diminish the adverse results. The current efforts to streamline the process and make only formal compliance with legal requirements brings me to the observation made by my social worker, that ultimate efficiency will have as its result the barren goal of nothingness. DR. EUGENE C. SANDBERG, Palo Alto, California. It is interesting to note the similarity in figures emanating from different areas. The recurrence rate of undesired pregnancies in Dr. Margolis’ series was ten per cent. Two years ago, Dr. Von der Ahel mentioned in a report to this Society that the recurrence rate for illegitimate (and presumably undesired) pregnancies was nine per cent among the patients at 4 Los Angeles facilities for unwed pregnant women. At Stanford University Hospital during the past three years, we have also noticed that five to ten per cent of patients requesting therapeutic abortions have had prior undesired pregnancies. Similarity in figures is also noticeable regarding subsequent utilization of contraception. Two years ago Tyler and associates2 studied a group of women who had been admitted to Grady Memorial Hospital in Atlanta with or for an induced abortion. Upon dismissal, only seventyfive per cent accepted contraception. In Dr. Margolis’ group, the figure was essentially the same. This seems to be a very low rate of acceptance of contraception for a group of women who have just procured an abortion. Last, I think it would be foolhardy for anyone to believe that pregnancy will be prevented on a long-term basis, even in the group accepting contraception. It is well known that the two-year dropout rate is approximately fifty per cent for
J.
LESLIE
A.
KARL
H.
SALLY
Francisco,
M.D.
DAVISON,
PH.
HANSON, A.
CYNTHIA San
MARGOLIS,
LOOS, M.
D.
M.D. M.S.W. MIKKELSEN,
M.S.W.
California
A heterogeneous group of preglaant women petitioned for abortion becauseof possible impairment of mentaf and/or physical health; 43 of 50 were followed for 3 to 6 months. Ambivalence and guilt appeared more substantially in young women under 18 years of age. Three to 6 months afterward, 29 patients expressed a positive reaction toward abortion, 10 reported no significant change in their life situations and 4 responded negatively. Of the 41 patients remaining fertile, 4 had purposely become pregnant again; 8 others were apparently without consistent contraception. It was concluded that preabortion counseling should outline the necessary steps for Committee consideration, give reassurance a.s to physical safety, and help fhe patient understand her motives and goals. Postabortion follow-up should emphasize a clear contraceptive program.
Patients
INDUCED ABORTION has become a major method of birth control in many parts of the world. Throughout the United States in the past 3 years, there have been significant modifications of a number of restrictive state abortion laws. Sloane’s1 recent review summarizes the current medical and social dilemma over this problem and concludes that psychiatric labels often mask humanitarian reasons for abortions. After the 1967 abortion law revision in California, there was a rapid evolution in this field. With the ensuing increase in legal abortions, it became possible to study prospectively a heterogeneous group of women who desired abortions for a variety of reasons. This is a preliminary report on the follow-up of such a study group.
and
procedures
From November 1, 1967, to June 30, 1968, 55 women applied to the staff of the Clbstetrical Service of the University of CaliforniaSan Francisco for termination of pregnancy because of its possible significant impairment of their mental or physical health. The screening procedures used in this study included : ( 1) a self-administered questionnaire* at the time of initial appIication for abortion, which provided demographic data and pertinent information; (2) a Minnesota Multiphasic Personality Inventory (MMPI) profile prior to abortion and again 3 to 6 months later (this test was omitted when cultural or linguistic factors obviated its use) ; (3) a psychiatric evaluation of the degree of psychiatric illness and/or possible effects of pregnancy on the patient’s mental health ; (4) a semistructured interview* by a social worker (adapted from Simon and associates’) 3 to 6 months after the abortion to
From the Departments of Obstetrics and Gynecology, Psychiatry, and Social Work, University of California-San Francisco. Presented at the Thirty-seventh Annual Meeting of the Pafific Coast Obstetrical and Gynecological Society, Kauai, Hawaii, November 9-14, 1970.
*Available on request to Dr. Davison. A&It Psychiatric Clinic, University of California-San F~WC~CO, San Francisc~, California 94122.
243
244
Margolis
et al. Amer.
Table I. Therapeutic abortion committee results (Novemeber, 1967, to June, 1968)
Table II. Demographic Age
Total No. of patients considered
55
Abortion refused 3 aborted elsewhere 1 delivered twins at term, had tubal ligation Abortion granted 6 medical indications 44 psychiatric indications 1 refused and went to term
4
51
May 15, 1Y71 J. Obstet. Gynec.
data on 51 patients
[years)
13-14 15-19 20-24 25-29 30-34 35-39 40 and over
3 6 19 8 7 2 6
status Never married Married or common-law relationship Separated, divorced, or widowed
23 21 7
Marital
Follow-up Complete Incomplete
43 7
Race
assess the postabortal responses and psychosocial situation. The abortion techniques included dilatation and curettage in early weeks of pregnancy (in 2 women), aspiration (in 29)) hypertonic injection (in 9)) and hysterotomy (in 1) . At the patients’ own request, tubal ligation was also done in 4 who had aspiration abortion, in one with hypertonic injection, and in one with hysterotomy; 3 also had hysterectomies. Results The Therapeutic Abortion Committee (Table I) accepted 51 of the 55 women who applied, one of whom subsequentIy eIected to carry her pregnancy to term. Three were rejected on the basis of insufficient evidence to substantiate impairment of mental health and obtained abortions elsewhere. A fourth patient, who was rejected because abortion seemed psychiatrically contraindicated, was delivered of twins at term and had a tubal ligation. Information accrued (Table II) from the self-administered questionnaire showed a wide age range-from 13 to 44 years, with 46 per cent of patients falling between 21 and
26 years.
Thirty-six
were
in
the
first
trimester at the time of abortion, despite the 10 to 14 day preabortion procedures. The psychiatric evaluations at the time of approval included 15 with a situational reaction, 14 with neurosis, 10 with character disorders, 6 who had a major psychotic illness
Caucasian Negro Filipino Oriental
41 7 2 1
Education
Below high school graduate High school graduate Some college Income
(self
or family)
$10,000 or more 5,000-10,000 3,000 - 5,000 3,000 or less, and welfare Unknown Patient
11 14 26 8 13 12 13 5
status
Private Staff
15 36
pregnancies None Term or premature delivery Spontaneous abortion only Induced abortion
19 25 1 6
Prior
Present
pregnancy
(weeks’
gestation)
6 30 15
6-9
10-13 14-20 Contraception None or irregular Rhythm, douche Withdrawal, Foam Condom, diaphragm Intrauterine device Oral contraceptive Unknown Prior
sociopsychiatric
21 4 7 6 ; 1 assistance
None Individual psychotherapy Hospital or day care Group therapy Social work interviews
i;’ 4 1 1
Volume Number
Therapeutic
110 2
Table III.
Pregnancies following therapeutic
abortion
follow-up
study
245
abortion
- -----_.
Age
Marital status
Prior pregnancies
for
Indications abortion
Months to conception following abortions
Comments
26
Commonlaw relationship
2 Illegal abortions
Mental health
5 months
Conceived intentionally in that prompted therapeutic more secure and continued
26
Married
2 Term deliveries 1 Spontaneous abortion
Recurrent sarcoma
2 months
Regretful that not influence pregnancy.
22
Commonlaw relationship
1 Term delivery 2 Illegal abortions
Mental health
6 months
Therapeutic abortion for pregnancy by undetermined father; currently pregnant by man whom she has married; continued pregnancy.
16
Single
None
Mental health
2 months
concurrent with the pregnancy or in the immediate past, and 6 who had no obvious psychiatric problems. Four to 6 months after abortion, the follow-up interview on 43 patients indicated that 22 had positive psychological changes, demonstrated by growth experience, increased empathy, increased sense of freedom, and greater sense of femininity. Seven reported other positive changes, such as less fear of pregnancy assured by sterilization or knowledge of better birth control methods, and improved marital or family relations. Four had negative reactions, such as guilt or fear of men, and 10 indicated no change in attitude. The patients’ principal fears of abortion were concerned with the possibility of injury as a result of the abortion technique (in 21 women), its effect on mental or physical health (in 6)) retaliation by others or by one’s own conscience (in 5) , feelings about destroying living tissue (in 3)) and Committee rejection (for 2). In the postabortion follow-up, 36 expressed negative reactions centered around the ignorance of the procedural technicalities (in 12)) the time required for processing (in 13)) and some apparently embarrassing personal encounters during the experience (in 11). The 25 positive responses indicated good supportive help
Felt forced and -._--again
abortion extensive
and
same relationship abortion; now felt pregnancy. chemotherapy did sarcoma; continued
to abortion by family; continued pregnancy. --~_
conceived .
. ..-._
from various staff members. The principal suggestion by the patients was a request for more available public information and less complex application requirements. Of the 41 aborted women who were not sterilized, 4 became pregnant again (Table III). In each case the pregnancy was consciously sought for a variety of reasons. In 2, the abortion was a regretful experience, while in the other 2 the abortion seemed to have allowed more stable life situations to become manifest. In addition to the 16 year old, who was pregnant again, a 13 year old and a 14 year old also regretted their preabortion decisions; all three felt very guilty and believed they had injured a living being. The mean preabortion MMPI showed abnormal elevations on the scales depicting depression, psychopathic deviation, and schizophrenia. A study of 36 paired pre- and post-abortion profiles showed that 15 of the 27 initially abnormal tests became essentially normal after abortion. This was a significant change (P < 0.002) by a test for c,orrelated proportions. In response to several questions designed to detect mixtures of feelings, 17 of those responding reported some guilt, and 20 had some ambivalence. Nevertheless, in a direct query as to whether they would repeat the abortion under simiIar circumstances,
246
Margolis
et
al. Amer.
May 15, 1971 J. Obstet. Gym.
Table IV. Recent therapeutic abortion follow-up studies within the United States ~_-. --_-Sample sire Source
of
data
Years
of study
Total
group
studied
aborted
Age (mean or range)
Peck and Marcus,s Mt. Sinai Hospital, New York
1963 to 1665
50
85
20-40
Simon and associates,* Jewish Hospital of St. Louis
1955 to 1964
46
65
Not stated
Patt and colleagues,4 Michael Hospital, Chicago
1964 to 1968
35
48
23
Levene and Rigney,s San Francisco
1968
56
70
21
This study
1968
43
50
13-44
Reese
37 said they would, 6 were unsure, and 2 would have refused. In contrast to the generally poor preabortion contraceptive practices, 25 patients were taking oral birth control pills 3 to 6 months after abortion. Two patients were satisfied with IUD’s, and one patient used a diaphragm, and one used a condom. Six patients refused birth control advice, and 6 patients did not return for a postabortal doctor visit. After therapeutic abortion, 3 patients initiated psychotherapy, and 11 continued psychiatric care, while 6 had short-term, problem-directed interviews with a psychiatrist or social worker. Twenty-three women had no sociopsychiatric follow-up observation beyond the tests made to complete this study. Comment
Our data corroborate 4 recent studies of therapeutic abortion patients in the United States (Table IV), which show that terminations of pregnancy do not tend to aggravate mental illness and are often helpful to the life situation adjustment of these patients. The legal, social, and medical sanction for interruption of pregnancy results in minimizing untoward guilt and depressive reactions, leaving the great majority of women
with a sense of rightness of their pregnancy terminations, now culturally approved. Of particular concern to us, however, are the pregnant girls under 18. Although our study group was small, we encountered a great deal of ambivaIence and guilt. As a result, we feel that especially careful evaluation and counseling should be provided for them and their families. The alternative of a teen-ager carrying a pregnancy to term presents great difficulties for the teen-ager and her child, and the delicate balancing of risks often requires the most expert collaborative effort of physician, psychiatrist, and social worker. A large number of patients used oral contraceptives regularly after abortion; however, 8 women were apparently without satisfactory birth control advice 3 to 6 months afterward. Although they were not pregnant, they constitute a significant group of potential repeaters. It is mandatory that a therapeutic abortion unit place a high priority on understanding the patient’s attitude toward birth control and help her to choose a method which she will use regularly. The things that concerned our patients most about abortion were ignorance of what to expect in the preliminary screening process and fear of the physical danger of the
Therapeutic
Vol1rme 110 Number 2
abortion
follow-up
study
247
___ -__-.-..- --Marital
Socioeconomic
status
status
Indication abortion
for General
impression
Mostly married
Caucasian Jewish private patients
25 Psych. 25 Nonpsych.
“The psychiatric status proved or unchanged. “Ninety-eight per cent . sight . . . again elect continuing pregnancy
Not stated
Well-educated Caucasian Protestant or Jewish patients
16 Psych. 30 Nonpsych.
“Little new psychiatric related to abortion.”
23 Unmarried 12 Married
31 Private patients
35 Psych.
‘I. + .
59 Unmarried 11 Married
70 Private patients
70
“Properly
22 Unmarried 21 Married 7 Separated I_~
4 Staff
of 92 per cent . . . in. . .” . . wouId . . . with hindabortion in perference to in question.” illness . . . that could be
with rare exceptions, abortion therapeutic.”
service Psych.
of outcome
self
done induced result
in
significantly
was genuinely
abortion does not in itnoxious emotional
sequelae.” 15 Private patients Staff service
36
44
Psych.
6 Nonpsych.
surgical procedure. Both of these areas should be emphasized in the preabortion counseling, as well as the fact that few requests for therapeutic termination are denied. Concerns over time schedule or anonynity can quickly be dispelled. The conflicting feelings arising from conscience or fear of family repercussions can be pinpointed for more intensive follow-up. As a result of our study, we have tried to shorten the time between patient application, Committee decision, and abortion, as well as to minimize cost and provide efficient, effective care by come-and-go abortion procedures in the first trimester. At present, the time interval from first contact to abortion ranges from 36 hours to 2 weeks. Since California law and others modeled on American Law Institute recommendations do not specify that a psychiatrist must attest to the degree of mental health impair-
29 patients expressed positive reaction after abortion; 10 reported no significant change: 4 responded negatively.
ment of the patient, we have encouraged the patient’s physician to make that assessment. If a psychological problem is unresolved, or if the patient is grossly disturbed, a psychiatric consultation is obviously important. However, an interested and concerned obstetrician can usually make the necessary observations to permit a final judgment by the Committee. Currently, a formal psychiatric consultation is presented to the Committee in 10 per cent of the staff cases and in 20 per cent of the private cases. For many women, therapeutic :lbortion will become an increasingly frequent alternate to a stressful pregnancy. An estimated 60,000 abortions wiI1 have been done in California during 1970. Such a procedure must continue to be carefully scrutinized so that it will be associated with minimal hazards and maximum efficiency and effectiveness.
REFERENCES
1. Sloane, R. B.: New Eng. J. Med. 280: 1206, 1969. 2. Simon, N. M., Senturia, A. G., and Rothman, 3.
D.: Amer. J. Psychiat. Peck, A., and Marcus, 143: 417, 1966.
124: 59, 1967. H.: J. Nerv. Ment.
Dis.
4. 5.
Patt, S. L., Rappaport, P.: Arch. Gen. Psychiat. Levene, H., and Rigney, Dis. 151: 51, 1970.
R. G., and Barglow, 20: 408, 1969. F.: J, Nrrv. Merit.
248
Margolis
et al. Amer.
Discussion DR. JOHN C. MCDERMO~, San Mateo, California. Dr. Margolis, along with many others, recognizes that abortion is not a simple matter and that problems other than morbidity and deaths are involved. He has attempted a prospective study for which he should be commended but to believe that observations over the 6 month postabortal period are of much importance is to give them more weight than they deserve. While anecdotal discussion is derogated by our scientific colleagues, my thoughts go back to the time I started private practice in 1936. During the great depression, abortions were as popular as they are today. At that time, most abortions were done by experts, since staying out of San Quentin was a strong incentive. They were also done early, a factor favoring a good outcome. As the depression receded, the number of infertility patients was high. Careful study disclosed a history of induced abortion in many. Among these persons, the feeling of guilt was great, and they were difficult to handle. Fortunately in most cases the blocked tubes opened up 6 to 8 years post abortion, and pregnancies ensued to the point where the problem was one of the opposite sort. As chairman of the abortion committee from the time the California abortion law was changed to the present time, I bave been forced to learn about a whole group of persons whose values differ from mine in almost all respects. These values do not stem from tradition but seem to represent those in the nonthinkers who dominate the news media. Samples of this thinking are: “If you feel like doing something, do it. Don’t take a chance on injuring your psyche by any sexual repression. If anyone warns you of dangers in your course of action, ignore him because he represents the “straight” generation. Don’t use birth control pills, they’re dangerous. Do have an abortion, it’s simple, quick, and safe.” I could go on with samples of cliches promoted by news media-unfortunately supported by enthusiasts in our profession who think any means should be used to promote their goals. Persons with these attitudes by and large form the group requesting abortions at our hospital. Now, the question arises, should we go along with these misconceptions so that the patient will regard the abortion as an exciting episode in her young life and become an authoritative dispenser of misinformation to her friends. The complete lack of correct information appears to me to be the biggest problem to be
May 15, 1971 J, Obstet. Gynec.
solved relative to abortions. This we attempt to correct among our abortion applicants. Each case is considered individually. Trained social workers spend much time trying to work out problems bearing on the patient’s decision. All community resources are brought to her attention. Pressure from the husband, boy friend, or parent is determined and discussed, and, in some instances with extensive discussion, other solutions than abortion are selected. The true facts with regard to abortion dangers and sequeIae are presented, so that a truly knowledgeable decision can be made. After abortion, we have “rap” sessions where an effort is made to present to the patient the effect of life style on health, both mental and physical. Without scientific knowledge to tell us the real end result of abortions, we reason the extensive individual effort will help to diminish the adverse results. The current efforts to streamline the process and make only formal compliance with legal requirements brings me to the observation made by my social worker, that ultimate efficiency will have as its result the barren goal of nothingness. DR. EUGENE C. SANDBERG, Palo Alto, California. It is interesting to note the similarity in figures emanating from different areas. The recurrence rate of undesired pregnancies in Dr. Margolis’ series was ten per cent. Two years ago, Dr. Von der Ahel mentioned in a report to this Society that the recurrence rate for illegitimate (and presumably undesired) pregnancies was nine per cent among the patients at 4 Los Angeles facilities for unwed pregnant women. At Stanford University Hospital during the past three years, we have also noticed that five to ten per cent of patients requesting therapeutic abortions have had prior undesired pregnancies. Similarity in figures is also noticeable regarding subsequent utilization of contraception. Two years ago Tyler and associates2 studied a group of women who had been admitted to Grady Memorial Hospital in Atlanta with or for an induced abortion. Upon dismissal, only seventyfive per cent accepted contraception. In Dr. Margolis’ group, the figure was essentially the same. This seems to be a very low rate of acceptance of contraception for a group of women who have just procured an abortion. Last, I think it would be foolhardy for anyone to believe that pregnancy will be prevented on a long-term basis, even in the group accepting contraception. It is well known that the two-year dropout rate is approximately fifty per cent for