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Therapeutic Abortion—Quo Vadimus
Therapeutic Abortion-Quo Vadimus FRA:-';CIS J. KA:-';E, JR.,
M.D.
AND JOHK
A.
EWING,
M.D.
missed as impressionistic and impassioned or having major deficiencies in design. Most of the literature commented upon here is from European sources. Suicide. The principal psychiatric indication for therapeutic abortion under the older laws was the prospect of suicide of the mother as a response to pre b1J1ancy. Several studies have documented the rarity of suicide during pregnancy. Barno' reviewed the experience in Minnesota for the years 1950-1965, and found only 14 suicides in obstetrical patients. Not one was illegitimately pregnant and not one had requested a therapeutic abortion. All were Caucasian. Suicide in females was only one-fifth that of the male population, and pregnant women a small fraction of female suicides. It is of interest that only four committed suicide with the fetus in utero, while 10 committed suicide in the postpartum period. Lindbergc• reports a similar absence of suicide attempts in a study of 304 women whose application for abortion was refused. Other studies have reported similar findings. G•• Impairment of Mental Health. On the question of grave impairment of mental health, the Swedish literature provides the best data from which we can draw some guidelines. There is a similarity in Swedish legislation, in that therapeutic abortion is permitted for what is termed "social medical indication." This permits abortions, "when in view of the woman's condition of life and her circumstances in other respects, it may be presumed that her physical or mental strength would be seriously impaired by the advent and care of the child."- This addition to their law was accompanied by the greatest increase in legal abortion in Sweden. 9 Ekblad'" studied 479 women in the early post abortion period and 2 to 312 years later by interview and questionnaire. Only 42 percent were judged to be normal personalities.
• In the states of l\orth Carolina, Colorado, and California, there now exist statutes liberalizing considerably the indications for a therapeutic abortion, and similar legislation is pending in many other states. This will provide a measure of relief for a small number of mothers who are pregnant as a result of rape and for those wherc illness or drug ingestion during pregnancy seem to preclude a favorable outcome. Abortion for eugenic reasons is also permitted in the statutes. The American Psychiatric Association and the American Medic..{l Association have issued position statements supporting these legislative changes. The response from the medical profession as a whole has been mixed, as it has been in the past, but psychiatrists in general seem favorably disposed to this liberalization of the abortion laws. Several recent studies have pointed out that, while other indications for abortion have remained stable, those done for psychiatric reasons now exceed all other categories combined.'-" It thus seems as though the present statutory changes merely legitimize an already widespread practice. 'Vhen one searches the scientific literature, it is hard to find much support for this position, however laudable it may seem on humanitarian and ethical grounds. We shall review the available literature bearing on the subject of therapeutic abortion in psychiatric patients, bec.'1use we believe it shows that psychiatric patients, in the present state of the art, constitute the poorest group for therapeutic abortion. Simon, et a1.," have pointed out that much of the American literature on therapeutic abortion in psychiatric patients must be disDr. Kane is Associate Professor of Psychiatry, l'nivcrsity of :'\lorth Carolina, School of Medicine, Chapel Hill, N. C. Dr. Ewinj.! is Professor and Chairman, Department of PsychiatrY. Univprsity of North Carolina, School of ~1edidm'. Chapel Hill, :'\. C.
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Thirty-six percent of the entire group had some self-reproach or reaction to operation, but only 1 percent had work impairment. This 1 percent had severe neurotic manifestations even before the abortion. Undesirable sequelae were not seen often, but he concluded, "the greater the psychiatric indications for legal abortion, the greater is the risk for unfavorable sequelae." In a study of 100 women three vears after a legal abortion, Mehlan" found'14 had become pregnant because the\' wanted a substitute for the aborted child. Another 20 said they would not go through a legal abortion again even if it meant having an unwanted child. Twenty-three percent had "severe guilt" and 25 percent "mild guilt," and those with severe guilt included a significant number of clinically recognized psychoneurotic depressive reactions. There was no investigation of prior psychiatric illness in this study. Arens~ studied 142 women who had been approved for legal abortion, but had not carried it out. For 89 percent of the women, the follow-up showed that abstention from the operation was justified. In only 11 percent of the cases were consequences for the woman such that one mi!J;ht ask whether performance of the granted abortion might not have been better. Serious deterioration of health and energy occurred only in a few cases and the unfavorable course was, in part, caused by irrelevant factors. Five women had to be admitted for treatmC'nt to a mental hospital during tIl(' obsC'rvation pC'riod, two of them after the subsequent performance of le~al abortion. He compared his material with that of Ekblad on socioeconomic variables and found them to be similar in most respects. Arens felt that the results of his investigation seemed to support his assumption that one gets fewer somatic and psychic complications connC'cted with the completion of pregnancy than are seen with termination by legal abortion. Hook'" studied the reactions of women whose applications for abortion had been refused. He found that 73 percent of the women were satisfied with the way the situation had developC'd, whilC' 27 percent would have preferred a legal abortion. Certification for unfitness for ,,;ork on account of mental troubles occurred in 7 percent of the cases within 18 months aftC'r the rejection of the application and at a later date in 13 percent. During the
observation period a further 16 percent had shown such symptoms of illness in connection with a fresh pregnancy that the outcome was a legal abortion or sterilization. He also found poor adjustment to refusal of abortion in 42 percent of deviated personalities, as compared with 12 percent of women seen as normal. Hook regarded these figures as indicating a worse state of health in these women than in the women who were granted legal abortions. Jansson'~ reported a study of women who entered mental hospitals after any kind of abortion (legal, illegal, or spontaneous). He found that hospitalization for mental illness was more common after legal abortion than after other kinds of abortion or after delivery. His material was, from a numerical standpoint, slightly less than 2 percent of the population having abortions. He thought that it seemed easier for an unmarried woman to be hospitalized for mental illness after an abortion and reflected that this was true of the data described by Hook. Among the important factors that differentiated legal abortion cases from others were: 1) frequency of complaint about unsatisfactory conditions in adolescence; 2) a marked predominance of legal cases with previous psychiatric care; not less than 50 percent of the legal cases had previously been under care in a psychiatric hospital in comparison to only 13 percent of the other abortion cases; 3) the women who had psychiatric hospitalization after an illegal abortion had strikingly less psychiatric history, suggesting that the illegal abortion had a relatively great importance as an exogenous factor; 4) a previous legal abortion sC'emed to have substantially increased the risk of mental illness after a second legal abortion. Jansson found that more patients who suffered mental illness leading to hospitalization had significantly more inpatient care in a psychiatric hospital, pointing, he felt, to greater seriousness or more vulnerability among the abortion mental illness cases than among those following delivery. He concludes: "'Ve have thus the paradOXical situation that it is in the cases in which a legal abortion can be best justified from a psychiatric standpoint that the risk of a mental illness during the postabortion course is greatest." This same group of women, however, as shown by Hook, has also an increased proneness to psychiatric reactions when their application for abortion is
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rejec:ted. Jansson concluded that legal abortions stand out as a fairly ineffective phychiatric therapeutic maneuver. In the U. S., Peck and Marcus" report on a study of therapeutic abortion in 50 women, 25 of whom had abortions for rubella and 25 for psychiatric reasons. Most of the women were Jewish, married private patients ranging from 20 to 40 years in age. Sixteen were pregnant for the first time and the others had from 1 to 6 children. Twenty-four were college graduates. Of the psychiatric group, 72 percent were judged to have schizophrenic disorders, 24 percent were depressed, and one had a severe character disorder. Eleven had been previously hospitalized for psychiatric treatment. In the non-psychiatric group, 13 women were judged to be psychiatrically ill but none were judged to be schizophrenic. Three were mildly deprt'ssed, three had mild anxiety rt'actions and seven showed mild neurotic character disorders. Only two of the non-psychiatric group had previous psychiatric treatment given on an outpatient basis. The patients were studied immediately before tht' abortion and six months later. Thirty-six percent of the non-psychiatric group had had mild grief reactions from which all had recovered before the follow-up interview. Twenty-eight percent of the psychiatric group had similar depressions. They found only one woman who had a new psychiatric group post-abortion and they felt this resulted from her being pressured into ahortion by her husband; this brought her into conflict with her religious beliefs. The psychiatric group had "somewhat stronger" guilt reactions to the tennination of pregnancy. Of those terminated for psychiatric indications, 68 percent were reported clearly improved at follow-up examination. There are a few criticisms one might make of this study, the most important being the short duration of the follow-up. The authors make it clear that there was no basic change in the psychiatric status of these women. Schizophrenic and neurotic reactions remained, yet the anxieties and depressions which were direct consequences of the pregnancy were relieved. In a recently completed study of 90 private patients at this hospital, wetS have demonstrated that more than 50 percent of a non-psychiatric population had symptoms of anxiety and depression during pregnancy. A considerahle diminution in such
complaints was seen in the early post-partum period. It may well be asked whether the clinical data reported by Peck and Marcus is any different than might be ordinarily seen in such a pregnant group. In other words, would a group of schizophrenic and neurotic women who wanted to go through with a pregnancy appear healthier? The absence of objective psychological test data further undermines the acceptance of the study at face value. One may also question whether these findings can be applied to other ethnic groups in the general population. Another recent study on a similar population by Simon, et al.,tG involved 46 women at the Jewish Hospital in St. Louis. Of the 46 patients aborted, 16 were for psychiatric reasons, 18 for rubella and 12 for medical reasons. Thirty-two of the 46 revealed diagnosable psychiatric illness at the follow-up, with 30 of these having shown psychiatric symptoms prior to abortion. Thirteen women reported suffering mild self limited depressions. Nine patients showed significant emotional disturbance related to the abortion. Four were hospitalized, and three had significant depressions post-abortion which lasted eight months to six years. One chronically depressed woman had relief of her symptoms after becoming pregnant. Two other patients suffered onset of duodenal ulcer in the post abortion period. The authors' conclusion was that serious psychiatric illness following abortion was related to the pre-existing psychiatric illness and only rarely related to or precipitated by the abortion. Their data however, seem to indicate considerable morbidity. Nine women of 46 suffered significant illness related in some degree to the abortion, if one allows that the patients with ulcers may also be giving evidence of considerable psychological conOict. They state that the abortion was not connected with psychiatric hospitalization one month post-abortion, or with depression related to later pregnancy and childbearing in some of the rubella patients. In a retrospective study such as this, access to all the primary data is often difficult, and we must wonder if these really are coincidence, and unrelated phenomena are presented. We need to know if this level of morbidity is significantly better or worse than in the group denied abortion. Volmne IX
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This study is better than that of Peck and Marcus, since the follow-up period is longer. There is also some attempt to characterize psychologically the women who became involved in therapeutic abortion procedures and how the abortion fitted into their overall psychological economy. PSYCHOLOGICAL CHARAcrERISTICS OF WOMEN HAVING THERAPEUTIC ABORTIONS
One of the few studies in the U. S. literature deserving of imitation is that of Simon, et al.,16 who provided some data about the underlying psychological characteristics in women who seek therapeutic abortion for psychiatric reasons. The author felt that these patients had important psychological conflicts in the area of expression of anger; they also had a strong need for punishment. Many of these women stated they did not want to become pregnant by men who used and abused them, others that their pregnancy was a great burden or life threatening. Therapeutic abortion seemed to offer an optimal circumstance for acting out of aggressive and self-punitive fantasies and impulses both in terms of the interaction between the patient and the physician, and also hy the actual physical circumstances of the abortion. Pregnancy in many cases fulfilled the role of gratifying a woman's unconscious need for punishment while the abortion gratified her aggressive impulses, particularly directed against the fetus, as well as her wishes for punishment in the form of assault on her body. OTHER SEQUELAE
Recurrent PregnanctJ-Ekblad 10 reports 117 women of the sample had become "unintentionally" pregnant while 39 had become pregnant intentionally during the follow-up period. This finding of large numbers of women becoming pregnant shortly after legal abortion is by no means exceptional, since Arens 9 reported 40 percent of women legally aborted had conceived again within three years, and Mehlan" reported almost two-thirds of a German population became pregnant in a five-year, post-abortion period. Other studies from Japan and Rumania report recurrent abortion as a frequent occurrence, but give no data as to psychiatric status pre- and postabortion. In Rumania, therapeutic abortion
may be had on demand, yet follow-up studies cannot be done because false names are given so often,17 Medica! Risk of Abortion-Another factor. seldom noted in psychiatric literature, concerns the inherent risks of the evacuation of the uterus by any means whatever. Surgical evacuation of the uterus remains the procedure of choice through the twelfth week, while other techniques such as saline injection or hysterotumy are used thereafter. Vacuum aspiration is widely used in Europe at this time. One recent report 2 of experience with 262 abortions, 90 of which were done for psychiatric reasons, reported major complications in 23 patients (9 percent). These included uterine perforation (4), serious hemorrhage (8 ), septicemia ( 2 ), and one case of pulmonary embolism. Two patients required laparotomy after curettage. There was one death from cerebral hemmorhage in a patient with hypertension. Other reports show a lower incidence of complications. Cernoch 18 reports one death per 40,000 abortions, traumatic lesions in 0.06 percent and infection in 3 to 4 percent. Mehlan 11 reports 0.06 percent to 5 per_ cent complications, but admits only 30 percent of his sample were followed up. Cee '9 reports seven perforations in 6,600 abortions and a 3.9 percent incidence of parametritis. A Japanese study 20 reported eight serious complications in 821 abortions with one death. In this series, 43 percent were followed by questionnaire for two months; it also indicated that habitual abortion and premature birth occurred more often after induced abortion than after normal delivery. Such consequences, which vary with the skill of the surgeon involved, must be carefully considered. One defect of these studies is the absence of any information relative to the emotional state. Another Japanese report2 ' on saline infusion techniques reports complications, many major ones, in nearly 50 percent of 6,600 procedures. 12 deaths in 1950 alone, resulted in suspension of the use of the procedure for a time. DISCUSSION
There seems to be little in the literature indicating that benefit to psychiatric patients from a therapeutic abortion will occur on any but a chance basis. The two most recent 205
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studies in the U. S. seem a bit more hopeful, but these studies have major deficiencies in design, especially with regard to follow-up of women who are denied abortion. Another limitation, perhaps more apparent than real, is that they are confined to a single racial and cultural group. Suicide is very rare during pregnancy, and does not seem to constitute a realistic problem. Since the major rise in incidence of therapeutic abortion occurred prior to the new laws, it indicates that the previous law was liberally interpreted. As with many other problems of great social importance, it would seem to provide a fertile area for projection of the therapists beliefs in the form of overidentification with the patient, or with the prevailing mores of the society. Unconscious, punitive attitudes may be directed toward the patient, on the basis of unresolved attitudes toward sexuality in the therapist. \Vhat is certain is that more abortions will be done; and it is our hope that this provides an opportunity to imitate the thoroughness of the Swedish studies, to try to follow-up those who arc granted abortions, yet do not have them, and those who apply but are refused. In addition, we have the opportunity of improving on previous studies by making more sophisticated psychodynamic evaluations accompanied by extensive formal psychological testing. There also seems an urgent need for the use of quantitative measuring devices. The use of control groups seems especially important and critical since it would make the data obtained from any quantitative rating devices more meaningful. It is not only psychiatric patients who suffer serious disturbances following abortion. The more recent American studies included abortions for rubella, some of these suffered postabortal effects and post-partum reactions probably connected with the abortions. The list of such indications, and frequency of related therapeutic abortion, will doubtless increase in the future as our knowledge of genetically induced defects and teratogenic agents grows. If the studies outlined above are performed they should enable us to predict better who will need pre-and post-abortion psychiatric care. Another serious problem is the phenomenon of recurring pregnancy, even if it only involves a limited number in a given sample.
This group need special study to assess the reasons for recurring pregnancy, especially in an advanced society, where contraceptive advice is easily available. Do these women represent a group who become pregnant in guilty restitution for the previous abortion, or are they pregnant in response to changed life circumstances? Is this sado-masochistic acting out? There are presently no data, but the entire responsibility cannot be left by default to our colleagues in Obstetrics. These problem patients may need the type of approach described by Dr. C. Lee Buxton in a recent symposium where he outlined the multi-disciplinary efforts necessary for the resolution of the problem of recurrent teenage pregnancy.~2 A variety of social, cultural, and psychodynamic factors are probably involved, and obstetricians cannot be asked to bear the brunt of these problems alone. Sterilization appears to be fairly undesirable as a method for control since psychiatric morbidity is considerable in response to such procedures. It is fairly likely that before long there will be a further liberalization of legislation permitting termination of pregnancy. This may ultimately become termination on demand of the patient. While this may be of considerable help in dealing with the problem of illegal abortion, it is quite likely to provide more, rather than fewer, problems for psychiatrists. REFERENCES
I. Rovinsky, J. J. and Gusberg, S. B.: Amer. ]. OIJ~tet. Gyncco/., 98: 11-17, 1967. 2. Spivack, M.: Amer. ]. OIJstet. Gynecol., 97:316322, 1967. . 3. Simon, A. and Sentmia. A.: Arch. GCII. Psuchiat., 15:378-389, 1936. 4. Barno, A: Amer. J. O/Jstet. Gym·col., 98:356-367, 1967. .5. Lindber~, B. J.: St;clIska Lak-Tidll, 45:1381, 1948. 6. Sim, ~I.: Brit. Med. J., 2: 145, 1963. 7. Rosenberg, A. J. and Silus E.: California Med., 102:407, 1965. 8. Swedish Aborton Act, as amcndl'<1 in 1946. 9. Arens, Per and Amark, Curt.: Acta Psychiatricli NCllroulgica Scand. 36:203-278, 1961. W. Ekblad, ~f.: Acta Psyc1tiatrica NCllr%gica SClI/ll/., Suppl. 99, 1955. II. ~1l'hlan. K. H.: In YearlJOok of OIJstl'tr;cs and Gynecology. Chicago: Yearbook ~fedical Publishers, Inc., pp. 57-58. 1956. 12. Hook, K.: Ada Psychiatrica Scand., Suppl. 168, 1963. Volume IX
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19. Cee, K.: In Yearbook at Obstetrics and Gynecology, p. 62, 1965-1966. 20. "Harmful Effects of Induced Abortion." Report of Family Planning Fed!'ration of Japan, 1956. 21. Yamamoto, \1.: In Progress in Obstetrics and Gynecology, P. 59, 1966-1967. 22. Buxton, C. Lee: "Teenage Pregnancy" presented at the University of i"orth Carolina School of Public Health. "Symposium in Th!'rapeutic Abortion", 15 St'ptcmhcr, 1967.
Unir;ersity of North Carolirul Chapel Hill, North Carolina 27514
THIRD ANNUAL PSYCHIATRIC CONFERENCE Th!' Third Annual Conference in Psychiatry for the General Practitioner will he held at the \Iarriott \Iotor Hotel in Philadelphia, Pennsylvania on November 2 and 3, 1968. This Conference is heing s-ponsored by the Department of Psychiatry, Temple University, Philadelphia. Participants include educators in psychiatry from the Philadelphia area and elsewhere. Intt'rviewing techniques, the problems of psychiatric consultation and other related prohlems will be considered in depth. Dr. Herhert Freed, Co-chairman of the Conference, has assured the Editor that the meeting will adjourn at 3 P.\f., November 3 so that doctors and their families can return home at an early hour. \VD
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missed as impressionistic and impassioned or having major deficiencies in design. Most of the literature commented upon here is from European sources. Suicide. The principal psychiatric indication for therapeutic abortion under the older laws was the prospect of suicide of the mother as a response to pre b1J1ancy. Several studies have documented the rarity of suicide during pregnancy. Barno' reviewed the experience in Minnesota for the years 1950-1965, and found only 14 suicides in obstetrical patients. Not one was illegitimately pregnant and not one had requested a therapeutic abortion. All were Caucasian. Suicide in females was only one-fifth that of the male population, and pregnant women a small fraction of female suicides. It is of interest that only four committed suicide with the fetus in utero, while 10 committed suicide in the postpartum period. Lindbergc• reports a similar absence of suicide attempts in a study of 304 women whose application for abortion was refused. Other studies have reported similar findings. G•• Impairment of Mental Health. On the question of grave impairment of mental health, the Swedish literature provides the best data from which we can draw some guidelines. There is a similarity in Swedish legislation, in that therapeutic abortion is permitted for what is termed "social medical indication." This permits abortions, "when in view of the woman's condition of life and her circumstances in other respects, it may be presumed that her physical or mental strength would be seriously impaired by the advent and care of the child."- This addition to their law was accompanied by the greatest increase in legal abortion in Sweden. 9 Ekblad'" studied 479 women in the early post abortion period and 2 to 312 years later by interview and questionnaire. Only 42 percent were judged to be normal personalities.
• In the states of l\orth Carolina, Colorado, and California, there now exist statutes liberalizing considerably the indications for a therapeutic abortion, and similar legislation is pending in many other states. This will provide a measure of relief for a small number of mothers who are pregnant as a result of rape and for those wherc illness or drug ingestion during pregnancy seem to preclude a favorable outcome. Abortion for eugenic reasons is also permitted in the statutes. The American Psychiatric Association and the American Medic..{l Association have issued position statements supporting these legislative changes. The response from the medical profession as a whole has been mixed, as it has been in the past, but psychiatrists in general seem favorably disposed to this liberalization of the abortion laws. Several recent studies have pointed out that, while other indications for abortion have remained stable, those done for psychiatric reasons now exceed all other categories combined.'-" It thus seems as though the present statutory changes merely legitimize an already widespread practice. 'Vhen one searches the scientific literature, it is hard to find much support for this position, however laudable it may seem on humanitarian and ethical grounds. We shall review the available literature bearing on the subject of therapeutic abortion in psychiatric patients, bec.'1use we believe it shows that psychiatric patients, in the present state of the art, constitute the poorest group for therapeutic abortion. Simon, et a1.," have pointed out that much of the American literature on therapeutic abortion in psychiatric patients must be disDr. Kane is Associate Professor of Psychiatry, l'nivcrsity of :'\lorth Carolina, School of Medicine, Chapel Hill, N. C. Dr. Ewinj.! is Professor and Chairman, Department of PsychiatrY. Univprsity of North Carolina, School of ~1edidm'. Chapel Hill, :'\. C.
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Thirty-six percent of the entire group had some self-reproach or reaction to operation, but only 1 percent had work impairment. This 1 percent had severe neurotic manifestations even before the abortion. Undesirable sequelae were not seen often, but he concluded, "the greater the psychiatric indications for legal abortion, the greater is the risk for unfavorable sequelae." In a study of 100 women three vears after a legal abortion, Mehlan" found'14 had become pregnant because the\' wanted a substitute for the aborted child. Another 20 said they would not go through a legal abortion again even if it meant having an unwanted child. Twenty-three percent had "severe guilt" and 25 percent "mild guilt," and those with severe guilt included a significant number of clinically recognized psychoneurotic depressive reactions. There was no investigation of prior psychiatric illness in this study. Arens~ studied 142 women who had been approved for legal abortion, but had not carried it out. For 89 percent of the women, the follow-up showed that abstention from the operation was justified. In only 11 percent of the cases were consequences for the woman such that one mi!J;ht ask whether performance of the granted abortion might not have been better. Serious deterioration of health and energy occurred only in a few cases and the unfavorable course was, in part, caused by irrelevant factors. Five women had to be admitted for treatmC'nt to a mental hospital during tIl(' obsC'rvation pC'riod, two of them after the subsequent performance of le~al abortion. He compared his material with that of Ekblad on socioeconomic variables and found them to be similar in most respects. Arens felt that the results of his investigation seemed to support his assumption that one gets fewer somatic and psychic complications connC'cted with the completion of pregnancy than are seen with termination by legal abortion. Hook'" studied the reactions of women whose applications for abortion had been refused. He found that 73 percent of the women were satisfied with the way the situation had developC'd, whilC' 27 percent would have preferred a legal abortion. Certification for unfitness for ,,;ork on account of mental troubles occurred in 7 percent of the cases within 18 months aftC'r the rejection of the application and at a later date in 13 percent. During the
observation period a further 16 percent had shown such symptoms of illness in connection with a fresh pregnancy that the outcome was a legal abortion or sterilization. He also found poor adjustment to refusal of abortion in 42 percent of deviated personalities, as compared with 12 percent of women seen as normal. Hook regarded these figures as indicating a worse state of health in these women than in the women who were granted legal abortions. Jansson'~ reported a study of women who entered mental hospitals after any kind of abortion (legal, illegal, or spontaneous). He found that hospitalization for mental illness was more common after legal abortion than after other kinds of abortion or after delivery. His material was, from a numerical standpoint, slightly less than 2 percent of the population having abortions. He thought that it seemed easier for an unmarried woman to be hospitalized for mental illness after an abortion and reflected that this was true of the data described by Hook. Among the important factors that differentiated legal abortion cases from others were: 1) frequency of complaint about unsatisfactory conditions in adolescence; 2) a marked predominance of legal cases with previous psychiatric care; not less than 50 percent of the legal cases had previously been under care in a psychiatric hospital in comparison to only 13 percent of the other abortion cases; 3) the women who had psychiatric hospitalization after an illegal abortion had strikingly less psychiatric history, suggesting that the illegal abortion had a relatively great importance as an exogenous factor; 4) a previous legal abortion sC'emed to have substantially increased the risk of mental illness after a second legal abortion. Jansson found that more patients who suffered mental illness leading to hospitalization had significantly more inpatient care in a psychiatric hospital, pointing, he felt, to greater seriousness or more vulnerability among the abortion mental illness cases than among those following delivery. He concludes: "'Ve have thus the paradOXical situation that it is in the cases in which a legal abortion can be best justified from a psychiatric standpoint that the risk of a mental illness during the postabortion course is greatest." This same group of women, however, as shown by Hook, has also an increased proneness to psychiatric reactions when their application for abortion is
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rejec:ted. Jansson concluded that legal abortions stand out as a fairly ineffective phychiatric therapeutic maneuver. In the U. S., Peck and Marcus" report on a study of therapeutic abortion in 50 women, 25 of whom had abortions for rubella and 25 for psychiatric reasons. Most of the women were Jewish, married private patients ranging from 20 to 40 years in age. Sixteen were pregnant for the first time and the others had from 1 to 6 children. Twenty-four were college graduates. Of the psychiatric group, 72 percent were judged to have schizophrenic disorders, 24 percent were depressed, and one had a severe character disorder. Eleven had been previously hospitalized for psychiatric treatment. In the non-psychiatric group, 13 women were judged to be psychiatrically ill but none were judged to be schizophrenic. Three were mildly deprt'ssed, three had mild anxiety rt'actions and seven showed mild neurotic character disorders. Only two of the non-psychiatric group had previous psychiatric treatment given on an outpatient basis. The patients were studied immediately before tht' abortion and six months later. Thirty-six percent of the non-psychiatric group had had mild grief reactions from which all had recovered before the follow-up interview. Twenty-eight percent of the psychiatric group had similar depressions. They found only one woman who had a new psychiatric group post-abortion and they felt this resulted from her being pressured into ahortion by her husband; this brought her into conflict with her religious beliefs. The psychiatric group had "somewhat stronger" guilt reactions to the tennination of pregnancy. Of those terminated for psychiatric indications, 68 percent were reported clearly improved at follow-up examination. There are a few criticisms one might make of this study, the most important being the short duration of the follow-up. The authors make it clear that there was no basic change in the psychiatric status of these women. Schizophrenic and neurotic reactions remained, yet the anxieties and depressions which were direct consequences of the pregnancy were relieved. In a recently completed study of 90 private patients at this hospital, wetS have demonstrated that more than 50 percent of a non-psychiatric population had symptoms of anxiety and depression during pregnancy. A considerahle diminution in such
complaints was seen in the early post-partum period. It may well be asked whether the clinical data reported by Peck and Marcus is any different than might be ordinarily seen in such a pregnant group. In other words, would a group of schizophrenic and neurotic women who wanted to go through with a pregnancy appear healthier? The absence of objective psychological test data further undermines the acceptance of the study at face value. One may also question whether these findings can be applied to other ethnic groups in the general population. Another recent study on a similar population by Simon, et al.,tG involved 46 women at the Jewish Hospital in St. Louis. Of the 46 patients aborted, 16 were for psychiatric reasons, 18 for rubella and 12 for medical reasons. Thirty-two of the 46 revealed diagnosable psychiatric illness at the follow-up, with 30 of these having shown psychiatric symptoms prior to abortion. Thirteen women reported suffering mild self limited depressions. Nine patients showed significant emotional disturbance related to the abortion. Four were hospitalized, and three had significant depressions post-abortion which lasted eight months to six years. One chronically depressed woman had relief of her symptoms after becoming pregnant. Two other patients suffered onset of duodenal ulcer in the post abortion period. The authors' conclusion was that serious psychiatric illness following abortion was related to the pre-existing psychiatric illness and only rarely related to or precipitated by the abortion. Their data however, seem to indicate considerable morbidity. Nine women of 46 suffered significant illness related in some degree to the abortion, if one allows that the patients with ulcers may also be giving evidence of considerable psychological conOict. They state that the abortion was not connected with psychiatric hospitalization one month post-abortion, or with depression related to later pregnancy and childbearing in some of the rubella patients. In a retrospective study such as this, access to all the primary data is often difficult, and we must wonder if these really are coincidence, and unrelated phenomena are presented. We need to know if this level of morbidity is significantly better or worse than in the group denied abortion. Volmne IX
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This study is better than that of Peck and Marcus, since the follow-up period is longer. There is also some attempt to characterize psychologically the women who became involved in therapeutic abortion procedures and how the abortion fitted into their overall psychological economy. PSYCHOLOGICAL CHARAcrERISTICS OF WOMEN HAVING THERAPEUTIC ABORTIONS
One of the few studies in the U. S. literature deserving of imitation is that of Simon, et al.,16 who provided some data about the underlying psychological characteristics in women who seek therapeutic abortion for psychiatric reasons. The author felt that these patients had important psychological conflicts in the area of expression of anger; they also had a strong need for punishment. Many of these women stated they did not want to become pregnant by men who used and abused them, others that their pregnancy was a great burden or life threatening. Therapeutic abortion seemed to offer an optimal circumstance for acting out of aggressive and self-punitive fantasies and impulses both in terms of the interaction between the patient and the physician, and also hy the actual physical circumstances of the abortion. Pregnancy in many cases fulfilled the role of gratifying a woman's unconscious need for punishment while the abortion gratified her aggressive impulses, particularly directed against the fetus, as well as her wishes for punishment in the form of assault on her body. OTHER SEQUELAE
Recurrent PregnanctJ-Ekblad 10 reports 117 women of the sample had become "unintentionally" pregnant while 39 had become pregnant intentionally during the follow-up period. This finding of large numbers of women becoming pregnant shortly after legal abortion is by no means exceptional, since Arens 9 reported 40 percent of women legally aborted had conceived again within three years, and Mehlan" reported almost two-thirds of a German population became pregnant in a five-year, post-abortion period. Other studies from Japan and Rumania report recurrent abortion as a frequent occurrence, but give no data as to psychiatric status pre- and postabortion. In Rumania, therapeutic abortion
may be had on demand, yet follow-up studies cannot be done because false names are given so often,17 Medica! Risk of Abortion-Another factor. seldom noted in psychiatric literature, concerns the inherent risks of the evacuation of the uterus by any means whatever. Surgical evacuation of the uterus remains the procedure of choice through the twelfth week, while other techniques such as saline injection or hysterotumy are used thereafter. Vacuum aspiration is widely used in Europe at this time. One recent report 2 of experience with 262 abortions, 90 of which were done for psychiatric reasons, reported major complications in 23 patients (9 percent). These included uterine perforation (4), serious hemorrhage (8 ), septicemia ( 2 ), and one case of pulmonary embolism. Two patients required laparotomy after curettage. There was one death from cerebral hemmorhage in a patient with hypertension. Other reports show a lower incidence of complications. Cernoch 18 reports one death per 40,000 abortions, traumatic lesions in 0.06 percent and infection in 3 to 4 percent. Mehlan 11 reports 0.06 percent to 5 per_ cent complications, but admits only 30 percent of his sample were followed up. Cee '9 reports seven perforations in 6,600 abortions and a 3.9 percent incidence of parametritis. A Japanese study 20 reported eight serious complications in 821 abortions with one death. In this series, 43 percent were followed by questionnaire for two months; it also indicated that habitual abortion and premature birth occurred more often after induced abortion than after normal delivery. Such consequences, which vary with the skill of the surgeon involved, must be carefully considered. One defect of these studies is the absence of any information relative to the emotional state. Another Japanese report2 ' on saline infusion techniques reports complications, many major ones, in nearly 50 percent of 6,600 procedures. 12 deaths in 1950 alone, resulted in suspension of the use of the procedure for a time. DISCUSSION
There seems to be little in the literature indicating that benefit to psychiatric patients from a therapeutic abortion will occur on any but a chance basis. The two most recent 205
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studies in the U. S. seem a bit more hopeful, but these studies have major deficiencies in design, especially with regard to follow-up of women who are denied abortion. Another limitation, perhaps more apparent than real, is that they are confined to a single racial and cultural group. Suicide is very rare during pregnancy, and does not seem to constitute a realistic problem. Since the major rise in incidence of therapeutic abortion occurred prior to the new laws, it indicates that the previous law was liberally interpreted. As with many other problems of great social importance, it would seem to provide a fertile area for projection of the therapists beliefs in the form of overidentification with the patient, or with the prevailing mores of the society. Unconscious, punitive attitudes may be directed toward the patient, on the basis of unresolved attitudes toward sexuality in the therapist. \Vhat is certain is that more abortions will be done; and it is our hope that this provides an opportunity to imitate the thoroughness of the Swedish studies, to try to follow-up those who arc granted abortions, yet do not have them, and those who apply but are refused. In addition, we have the opportunity of improving on previous studies by making more sophisticated psychodynamic evaluations accompanied by extensive formal psychological testing. There also seems an urgent need for the use of quantitative measuring devices. The use of control groups seems especially important and critical since it would make the data obtained from any quantitative rating devices more meaningful. It is not only psychiatric patients who suffer serious disturbances following abortion. The more recent American studies included abortions for rubella, some of these suffered postabortal effects and post-partum reactions probably connected with the abortions. The list of such indications, and frequency of related therapeutic abortion, will doubtless increase in the future as our knowledge of genetically induced defects and teratogenic agents grows. If the studies outlined above are performed they should enable us to predict better who will need pre-and post-abortion psychiatric care. Another serious problem is the phenomenon of recurring pregnancy, even if it only involves a limited number in a given sample.
This group need special study to assess the reasons for recurring pregnancy, especially in an advanced society, where contraceptive advice is easily available. Do these women represent a group who become pregnant in guilty restitution for the previous abortion, or are they pregnant in response to changed life circumstances? Is this sado-masochistic acting out? There are presently no data, but the entire responsibility cannot be left by default to our colleagues in Obstetrics. These problem patients may need the type of approach described by Dr. C. Lee Buxton in a recent symposium where he outlined the multi-disciplinary efforts necessary for the resolution of the problem of recurrent teenage pregnancy.~2 A variety of social, cultural, and psychodynamic factors are probably involved, and obstetricians cannot be asked to bear the brunt of these problems alone. Sterilization appears to be fairly undesirable as a method for control since psychiatric morbidity is considerable in response to such procedures. It is fairly likely that before long there will be a further liberalization of legislation permitting termination of pregnancy. This may ultimately become termination on demand of the patient. While this may be of considerable help in dealing with the problem of illegal abortion, it is quite likely to provide more, rather than fewer, problems for psychiatrists. REFERENCES
I. Rovinsky, J. J. and Gusberg, S. B.: Amer. ]. OIJ~tet. Gyncco/., 98: 11-17, 1967. 2. Spivack, M.: Amer. ]. OIJstet. Gynecol., 97:316322, 1967. . 3. Simon, A. and Sentmia. A.: Arch. GCII. Psuchiat., 15:378-389, 1936. 4. Barno, A: Amer. J. O/Jstet. Gym·col., 98:356-367, 1967. .5. Lindber~, B. J.: St;clIska Lak-Tidll, 45:1381, 1948. 6. Sim, ~I.: Brit. Med. J., 2: 145, 1963. 7. Rosenberg, A. J. and Silus E.: California Med., 102:407, 1965. 8. Swedish Aborton Act, as amcndl'<1 in 1946. 9. Arens, Per and Amark, Curt.: Acta Psychiatricli NCllroulgica Scand. 36:203-278, 1961. W. Ekblad, ~f.: Acta Psyc1tiatrica NCllr%gica SClI/ll/., Suppl. 99, 1955. II. ~1l'hlan. K. H.: In YearlJOok of OIJstl'tr;cs and Gynecology. Chicago: Yearbook ~fedical Publishers, Inc., pp. 57-58. 1956. 12. Hook, K.: Ada Psychiatrica Scand., Suppl. 168, 1963. Volume IX
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THERAPEUTIC ABORTION-KANE AND EWING 13. Janson, B.: Ada P~lIchiatrica Scand., 41:87-110, 1965. 14. Peck, A. and \larctlS II.: }. Nerr;. Mellt. Dis., 143:417-425, 1966. 15. Jarrahi-Zadeh, A., Kane, F., Van de Castle, R. and Ewing, J.: "Emotional and Cognitive Disturhancl' Assodated with the Child Bearing Pt'riod," presented 1967 Annual \Ieeting American Psychiatric Association, May, 1967. 16. Simon, A., Senturia, A. and Rothman, D.: }. Amer. P~chi(ft. Assn., 124:59-66, 1967. 17. \Il'hlan, K.: }. Sex Res., 1:31-38, 1965. 18. Ccrnoch, A: In Progress ill Obstetrics and Gynecology, p. 65, 1966-1967.
19. Cee, K.: In Yearbook at Obstetrics and Gynecology, p. 62, 1965-1966. 20. "Harmful Effects of Induced Abortion." Report of Family Planning Fed!'ration of Japan, 1956. 21. Yamamoto, \1.: In Progress in Obstetrics and Gynecology, P. 59, 1966-1967. 22. Buxton, C. Lee: "Teenage Pregnancy" presented at the University of i"orth Carolina School of Public Health. "Symposium in Th!'rapeutic Abortion", 15 St'ptcmhcr, 1967.
Unir;ersity of North Carolirul Chapel Hill, North Carolina 27514
THIRD ANNUAL PSYCHIATRIC CONFERENCE Th!' Third Annual Conference in Psychiatry for the General Practitioner will he held at the \Iarriott \Iotor Hotel in Philadelphia, Pennsylvania on November 2 and 3, 1968. This Conference is heing s-ponsored by the Department of Psychiatry, Temple University, Philadelphia. Participants include educators in psychiatry from the Philadelphia area and elsewhere. Intt'rviewing techniques, the problems of psychiatric consultation and other related prohlems will be considered in depth. Dr. Herhert Freed, Co-chairman of the Conference, has assured the Editor that the meeting will adjourn at 3 P.\f., November 3 so that doctors and their families can return home at an early hour. \VD
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