ABORTION

ABORTION. The medical or surgical termination of a pregnancy, abortion is one of the oldest, most commonly

practiced, and most controversial medical procedures currently performed in the United States. It has been a legal procedure in all states since Roe v. Wade (1973). when the Supreme Court ruled that the abortion decision was protected by a woman’s right to privacy. The Court also noted that the state has legitimate interests in protecting both the pregnant woman’s health and potential human life, interests that grow and reach a compelling point at later states of gestation. Subsequent Supreme Court decisions have eroded the broad abortion rights articulated in Roe, while at the same time upholding the general principle of that decision. For example, in Webster v. Reproductive Health Services (1989), and Planned Parenthood of Southeastern Pennsylvania v. Casey (1992), the Court significantly expanded the states’ ability to place restrictions on access to abortion, so long as these restrictions do not impose an “undue burden” on women seeking abortions.

Approximately I .5 million legal abortions have been performed each year in the United States since Roe v.Wade. resulting in the annual termination of about 25%” of known pregnancies. Most abortions (more than 90%) are performed in the first trimester of pregnancy; less than L% are performed at more than 20 weeks.

The abortion rate in the United States has been gradually declining since the early 1980s. This decline may be due to a variety of factors. They include the decreased availability of abortion services: increased harassment by antiabortion activists: the increased cost of obtaining an abortion: reluctance of providers to perform abortions at more than 13 weeks gestation: changing attitudes toward abortion and unwed motherhood: exclusion of abortion from Medicaid coverage; and legislative barriers such as the implementation of waiting periods and parental consent rules.

Role of Psychologists

The American Psychological Association (APA) and individual psychologists have had a long history of involvement in matters related to psychological factors associated with abortion and in disseminating results of research on abortion-related issues. In 1969, the APA Council of Representatives adopted a resolution that identified termination of unwanted pregnancies as a mental health and child welfare issue, resolving that termination of pregnancy be considered a civil right of the pregnant woman. In 1980, APA passed a resolution supporting the right to conduct scientific research on abortion. In 1989, APA passed a resolution to initiate

a public awareness effort to correct the record on the scientific findings of abortion research, and appointed a panel of experts to review the best scientific studies of abortion outcomes. The report of this panel was published in I990 in Science.

Individual psychologists conduct crisis pregnancy counseling, help women and girls decide how to resolve an unwanted pregnancy, and counsel women who have had an abortion and who report associated distress.

Psychological researchers conduct and disseminate research on attitudes toward abortion, psychological responses to abortion. and predictors of those responses. Psychologists also serve as expert witnesses in court cases dealing with abortion-related issues.

Characteristics of Abortion Patients

Demographic characteristics of women obtaining abortions are derived from national surveys of abortion providers. According to the Alan Guttmacher Institute, the majority of women obtaining abortions are young (55% are younger than 25) and never married (66%). The majority have had one or more children (55%), but no prior abortions (53%). Based on total numbers, more White women (61%) than African American or His- panic women obtain abortions. However, the abortion rate for White women is lower than it is for minority women. Black women are approximately three times as likely to have an abortion as White women and Hispanic women are roughly two times as likely to do so.

Abortion rates are also disproportionately higher among women who are disadvantaged economically because of poverty or lack of education. Many of these demographic factors are intercorrelated, making it difficult to attribute differences in abortion rates to any single variable.

The most common reasons women report for obtaining an abortion are concern that having a baby at that point would interfere with work, school, or other responsibilities; the inability to afford a baby financially: and partner-related reasons. Motivations to have an abortion differ substantially among different subgroups of women. Adult mothers, for example, are more likely than nonmothers to cite as reasons for obtaining an abortion, completion of childbearing along with responsibilities to others, including other children.

Controversy over Psychological

Consequences of Abortion

Contemporary debates over abortion often focus on psychological issues. One controversy centers on whether abortion is psychologically damaging to women. This controversy became a public policy debate in 1987, when President Ronald Reagan directed Surgeon- General C. Everett Koop to prepare a report on the psychological and physical health effects of abortion. After reviewing the evidence, Koop declined to issue such a report. Rather, in a letter to President Reagan, the surgeon-general concluded that “the scientific studies d6 not provide conclusive data on the health effects of abortion on women.” Individuals on both sides of the abortion debate disagree with Koop’s conclusion. Prolife advocates argue that over time, many or most women who have an abortion suffer psychological damage as a result. Advocates of this view have lobbied the American Psychiatric Association to recognize postabortion syndrome as a psychiatric diagnostic category. Support for this position is based on clinical case studies that derive from two separate sources: (I) women who have sought

professional help for psychological problems following their abortions: ( 2 ) women who were specifically solicited as participants because they identified themselves in advance as having suffered psychological trauma following abortion. In addition to relying on samples of women who identified themselves as experiencing postabortion adjustment problems, many of these studies fail to distinguish between whether the abortion was performed legally or illegally and whether it was performed in the first or second trimester of pregnancy. Because of these methodological issues, this group of studies is likely to be biased in the direction of overestimating the prevalence of postabortion problems among women who obtain legal, first trimester abortions. Psychological experts, including the panel convened by the APA, argue in contrast that the very best scientific studies show that freely chosen abortion, particularly in the first trimester of pregnancy, does not pose a significant mental health risk for most women. This conclusion is derived from studies based on random samples of women who have arrived at a doctor’s office, clinic. or hospital for an abortion. They are asked to participate in a study and are then interviewed on the day of their abortion andlor some time afterward.

These studies generally find that most women do not report psychological distress after an abortion and that the highest rates of distress are generally reported prior to the abortion. The conclusion that abortion does not pose a mental health risk for most women is also derived from epidemiological studies of large populations of women whose prior abortion history is known. These studies generally find no higher incidence of psychological problems among women who have had an abortion than among women who have not. Although these studies also have methodological limitations, they are generally much sounder scientifically than those used to support the argument that severe negative reactions to abortion are common.

Part of the difficulty in drawing firm conclusions about the psychological effects of abortion results from the fact it is impossible to separate the effects of abortion from the effects of experiencing an unwanted pregnancy.

Both of these are potentially stressful events. U1- timately, the mental health risks of abortion must be compared to the mental health risks of its alternativesmotherhood or adoption. However, no well-controlled studies are available that compare all three groups, perhaps because relatively few women choose the adoption alternative. In contrast, a number of well-designed studies have compared the psychological well-being of women who have had abortions to the well-being of women who have carried an unintended pregnancy to term and kept the child. The measures of well-being that were used in these studies include self-esteem, anxiety, incidence of psychiatric disorder, progress in school, and economic status. All of these studies have reached the same conclusion-that the well-being of women who have abortions is generally either better than, or not significantly different from, that of women who carry an unplanned pregnancy to term and keep the baby.

Although most women do not experience significant psychological distress following an abortion, some do. The reactions of these women should not be dismissed as inconsequential and deserve attention from psychologists. It is important to remember, however, that disABORTION tress that occurs after an abortion is not necessarily caused by the abortion, even though it may be attributed to this event. Furthermore, it is important to distinguish between feelings such as sadness and regret that can be experienced after any difficult life choice, and significant mental health outcomes, such as depression or psychosis. Women who feel a sense of sadness, loss, or regret over an abortion may not necessarily experience a psychological disorder following an

abortion.