From: kauff@neit.cgd.ucar.edu (Brian Kauffman)
Subject: regrets: abortion completed/denied  (long)
Organization: NCAR, Boulder CO
Date: Mon, 14 Sep 1992 17:13:21 GMT

========================================================================
From: psb@eesun1.eece.ksu.edu (Phil Buckland)

SOURCE:
the American Journal of Psychiatry, Volume 148, Issue 5, May 1991.  
copyright by the American Psychiatric Association ((C) 1991) 
copied without permission.

The Psychological Sequelae of Theraputic Abortion - Denied and Completed
by Paul K.B. Dagg, M.D., Department of Psychiatry, Mount Sinai Hospital.

	_________________________________________________________________

	  OBJECTIVE: The purpose of this article is to review the available
	literature on the psychological sequelae of theraputic abortion,
	addressing both the issue of the effects of the abortion on the
	woman involved and the effects on the women and on the child born
	when abortion is denied.  METHOD: Papers reviewed were initially
	selected by using a Medline search.  This procedure resulted in
	225 papers being reviewed, which were further selected by limiting
	the papers to those reporting original research.  Finally, studies
	were assessed as to whether or not they used control groups or
	objective, validated symptom measures.  RESULTS: Adverse sequelae
	occur in a minority of women, and when such symptoms occur, they
	usually seem to be the continuation of symptoms that appeared
	before the abortion and are on the wane immediately after the
	abortion.  Many women denied abortion show ongoing resentment that
	may last for years, while children born when the abortion is
	denied have numerous, broadly based difficulties in social, inter-
	personal, and occupational functions that last at least into early
	adulthood.  CONCLUSIONS: With increasing pressure on access to
	abortion services in North America, nonpsychiatrist physicians
	and mental health professionals need to keep in mind the effects
	of both performing and denying theraputic abortion.  Increased
	research into these areas, focusing in particular on why some
	women are adversely affected by the procedure and clarifying the
	relationship issues involved, continues to be important.
	  (Am J Psychiatry 1991; 148:578-585)
	_________________________________________________________________


	After a period of relative quiescence, theraputic abortion services
	are once again attracting significant political and public attention
	in North America and elsewhere.  Systematic evaluation of any medical
	procedure usually requires examination of both the effects of perform-
	ing that procedure and the effects on that patient when nothing is
	done.  Despite a great deal of concern about the psychological
	effects of theraputic abortions in both the lay and scientific press,
	the research examining either side of this issue, particularly that
	looking at the effects of denying abortion on the parent and child,
	is sparse.

	The last half century has seen a trend toward progressively more
	liberal laws with respect to access to abortion, particularly in
	developed nations.  Currently in the Unites States approximately
	1.5 million theraputic abortions are performed annually, involving
	27.4 of every 1,000 women between the ages of 15 and 44.  Worldwide,
	an estimated 30-40 million legal abortions are performed annually,
	with perhaps another 20 million illegal abortions (1).  Recently,
	in North America, as well as in some European Countries, we have
	seen a trend toward reexamination of this liberalization and reinsti-
	tution of more restrictive laws.  Moreover, in the developing
	countries highly restrictive laws often persist, a situation
	complicated by "right-to-life" groups in Western nations that ally
	themselves with conservative forces in some developing nations to
	try to strengthen restrictive abortion laws there (2).

	This paper has broken down the existing literature in order to
	address the following essential questions.  The first is the
	simplest to address, and hence the one that has generated the most
	research interest.  What are the psychological sequelae of
	theraputic abortion, both the immediate effects and the more subtle,
	long-lasting effects?  When abortion is denied, the issues are more
	varied.  What proportion of women go on to find abortion elsewhere?
	If the fetus is not aborted, how many of the infants are actually
	adopted away, the alternative most often offered?  Most importantly,
	what are the effects on the mother and the child when the abortion
	is denied?  Obviously, these are questions not easily addressed
	scientifically.  There can be no random assignment of pregnant women
	to a group granted abortion and to one denied abortion.  Follow-up,
	particularly for women denied abortion services, is understandably
	difficult.  Cultural, social, and legal variations from place to
	place make comparability of studies difficult.

PSYCHOLOGICAL SEQUELAE OF COMPLETED ABORTION

	The first group to review systematically this particular side of
	the abortion issue was Simon and Senturia (3) in 1966; they commented
	on the wide range of results quoted by various studies, most of whose
	methodology they severely criticized.  In 1981, Doane and Quigley (4)
	published an even more exhaustive review of the literature, also
	commenting on the large proportion of studies that were severely
	hampered by major methodologic flaws.  They criticized in particular
	the lack of any control group and the fact that the majority of
	studies were impressionistic reports of a handful of cases.  Other
	problems included short periods of follow-up, vague and poorly
	defined symptoms without objective measurement, low response rates,
	and unspecified indications for abortion.  The last problem is
	particularly significant in that it has been clearly demonstrated
	that medical or genetic indications for abortion increase the risk
	of adverse psychological sequelae in the mothers (5,6).

	Since those two reviews, research has continued in this area.  The
	ongoing trend to liberalize abortion access laws toward the principle
	of abortion on demand has had an impact on research in this field.
	Early research tended to concentrate on psychiatric or medical
	complications of abortion, emphasizing a disease model, as some
	conception of disease was often required for abortion to be performed
	legally.  The emphasis has now shifted toward a model in which
	research examines the psychological sequelae and antecedents that
	affect a woman who seeks an abortion.  In examining past research
	that covers a variety of legal climates, one must differentiate
	between research on "theraputic" abortion, which requires medical or
	psychiatric consultation in the decision-making process, and
	research on open abortion, in which the woman involved is the sole
	decision maker.  A recent review by Adler et al. (7), which limited
	itself to U.S. studies in order to reduce the confounding variables
	of social, cultural, and legal differences, found that "legal abor-
	tion of an unwanted pregnancy in the first trimester does not pose
	a psychological hazard for women" in the legal context of open
	abortion.  None of the reviews mentioned there, however, address the
	issue of denied abortion.

	Although many studies have examined the short-term consequences of
	theraputic abortions, few have used a comparison group or objective
	measure of symptoms.  A few studies of abortion do meet these criteria.
	Freeman et al. (8), in one of the more objective studies involving over
	400 women, found that SCL-90 scores were elevated on several subscales
	in women before the procedure but decreased significantly toward
	normal quite rapidly after the abortion.  Those scales on which the
	preabortion scores were highest, indicating the highest level of
	disstress, had the greatest decrease after the abortion.  In 1985
	Major et al. (9) surveyed over 200 women before their abortion, 30
	minutes afterward, and at the end of 3 weeks, using the Beck
	Depression Inventory and clinical interviews.  They found the average
	score to be in the nondepressed range immediately after the abortion;
	3 weeks after the abortion the women's mood had continued to improve,
	and there was less depression and less anticipation of negative
	consequences.  Using the SCL-90 before and immediately after the
	procedure, Cohen and Roth (10) demonstrated a dignificant drop after
	the abortion in scores on the depression subscale of the SCL-90 and
	the Impact of Events Scale.  Prospectively following hospital admis-
	sions in a study of theraputic abortion in the United Kingdom,
	Brewer (11) found an admission rate of 0.3/1,000 for postabortion
	psychosis compared to a rate of 1.7/1,000 for postpartum psychosis
	in normal-term deliveries.

	Other studies, using less objective measures and examining theraputic
	abortions that required psychiatric or other medical consultation,
	still seem to point in the same direction when comparison groups are
	available.  Ewing and Rouse (12) found depressive symptoms in 3% of
	women granted abortions for psychological indications and in 12% of
	those women with previous psychiatric contact.  Mackenzie (13) comment-
	ed that women were more likely to be depressed before the abortion than
	after and that 78% expressed predominant feelings of relief, while 33%
	reported some feelings of guilt, with 80% of the guilt rated as mild.
	Niswander and Patterson (14) found that most women report an improve-
	ment in emotional health.  In their study, women who had abortions
	for medical reasons reported more "unfovourable reactions" than those
	who had abortions for psychogenic indications.  In 1965 Jansson (15)
	reported the following rates of admission to psychiatric hospitals
	immediately after abortion or delivery: 0.70% after term delivery,
	1.92% after legal abortion, and 0.27% after illegal abortion and
	spontaneous abortion.  It was felt that the apparent difference in
	reaction to legal and illegal abortion was due to the much higher pro-
	portion of women in the legal abortion group (over 50%) with a previous
	psychiatric history.  Unmarried women were also more likely to be
	hospitalized.  Other short-term studies that lack such comparison
	groups are summarized in table 1 (3, 16-27).


TABLE 1. Studies of the Immediate Psychological Sequelae of Abortion
___________________________________________________________________________
			Number of		  Results
Study and Year		Subjects	Positive	    Negative
___________________________________________________________________________

Ekblad, 1955 (16)	  479		  ___		2% had severe self-
							reproach

Simon and		  ___*a		  ___		0%-41% felt guilty
  Senturia, 1966 (3)

Patt et al., 1969 (17)	   35		  ___		40% had symptoms,
							all mild; in one-
							half, symptoms were
							present before
							abortion

Bacon, 1969 (18)	    9	    55% felt consid-	33% felt mild guilt
				    erable relief	lasting a few days

Walter, 1970 (19)	  ___*a		  ___		0%-30% felt mild
							guilt

Osofsky and Osofsky,	  250	    65% were happy	14% were sad, 24%
  1972 (20) *b						felt guilty

Lazarus, 1985 (21) *b	  292	    76% felt relief	15% felt guilty and
							were depressed; 10%
							had overall nega-
							tive symptoms

Pare and Raven,		  128	    Most experienced	A few felt mild
  1970 (22)			    marked relief and	guilt for 1-2
				    improved relation-	weeks
				    ships

Marder, 1970 (23)	  147	    Most experienced	      ___
				    marked relief of
				    symptoms and im-
				    proved relation-
				    ships

Bracken et al.,		  489	    Positive reactions	      ___
  1974 (24)			    increased with more
				    support

Adler, 1975 (25) *b	   95	    Most had positive	A few felt guilt
				    feelings		and doubt

Spaulding and Cavenor,	    2*c		  ___		Two subjects devel-
  1978 (26) *b						oped psychosis, one
							organic

McAll and Wilson,	    6*c		  ___		Six subjects devel-
  1987 (27) *b						oped psychiatric
							symptoms
___________________________________________________________________________
*a Review study.
*b Studies examined abortion on request.  All other studies involved
   theraputic abortion requiring some degree of psychiatric or other
   medical consultation.
*c Case reports.


	When studies have examined the effects of abortion months or years
	after the procedure, similar trends continue.  Brody et al. (28) and
	Niswander et al. (29), who used pregnant women with normal deliveries
	for control subjects in examining theraputic abortion, showed that
	MMPI scored, which may be abnormal before the abortion, normalize
	within 6 months to a year after abortion.  The control subjects, who
	had less abnormal scores before delivery, showed no change in their
	scores after delivery.  In the study by Brody et al., a group of
	women who were denied abortion continued to have quite abnormal scores
	after the delivery of the infant.

	Studies of open abortion show similar results.  Athanasiou et al. (30),
	who also used pregnant women with normal deliveries as control subjects
	and matched for socioeconomic status, found no difference in MMPI and
	SCL-90 scores between the two groups after delivery or abortion.  A
	study by Jacobs et al. (31), who used women undergoing minor gyneco-
	logical surgery as control subjects, showed higher preabortion scores
	for the pregnant women on the Psychopathic Deviate, Schizophrenia,
	Hysteria, and Depression scales of the MMPI; these differences
	disappeared after the abortion.  Using a different control group,
	Zabin et al. (32) examined a group of adolescents who presented
	initially for pregnancy testing and subsequently studied three
	groups - those who were pregnant and chose to abort the fetus, those
	who were pregnant and chose to complete the pregnancy, and those
	whose test results were negative.  One and 2 years later they found
	that the abortion group showed no evidence of psychological distress
	compared to either control group and that, indeed, there was a non-
	significant trend toward better psychological health with less anxiety
	on the State-Trait Anxiety Inventory and more internal locus of
	control.  In addition, the women who completed their pregnancy
	showed a significant economic deterioration afterward and were
	significantly more likely to discontinue school than the abortion
	group; this difference actually increased between the first and
	second years after delivery or abortion.  In a study in Denmark (33)
	that tracked psychiatric hospitilization rates for 3 months after
	abortion or delivery, there was no difference between postpartum
	and postabortion rates in married and never married women.  Higher
	postabortion rates of admission were found in seperated, divorced, and
	widowed women, women who were more likely to be isolated and alone.

	Among the older studies of theraputic abortions with less rigorous
	methodology, Peck and Marcus (34) and Smith (35) found more symptoms
	of depression and negative feelings, up to 2 years afterward, in
	women for whom the abortion was performed for medical/genetic
	indications.  Significant distress occurred in less than 10% of
	women who had abortion for psychosocial indications.  Ewing and Rouse
	(12) found that approximately 95% of their study subjects reported
	improved emotional health as a result of the abortion at 2-year
	follow-up.

	Table 2 presents data on other long-term studies (16, 17, 22, 36-47)
	that lacked comparison or control groups (thereby making interpretation
	difficult).  All studies in this group involved theraputic abortion
	in which psychiatric or other medical consultation was required before
	the abortion.  Noteworthy, again, is the relative lack of significant
	negative responses in the women.  The two studies that found relatively
	higher rates of negative responses are those of Wallerstein et al. (42)
	and Ashton (46).  The low response rate (less than 20%) to a mailed
	questionaire in the first study and the minor nature of symptoms
	measured in the second may account for the difference.

	Table 3 presents data on studies (12, 14, 17, 22, 36, 37, 39, 44, 45,
	48) that queried subjects concerning the presence of regrets after
	the procedure (a measure of ambivalence about the abortion decision).
	This question is frequently posed, and yet despite the subjective
	nature of the question, the results are surprisingly uniform.  They
	reveal that for the large majority of women, the decision about
	abortion, although undoubtedly difficult, is not one for which a
	great deal of conscious ambivalence exists.


TABLE 2. Studies of the Long-Term Psychological Effects of Abortion *a
____________________________________________________________________________
			Length of  Number of		Results
Study and Year		Follow-up  Subjects	Positive	Negative
____________________________________________________________________________

Ekblad, 1955 (16)	2 years	     479	  ___	     11% had self-
							     reproach

Kretzchmar and Norris,	1-5 years     24	  ___		  ___
  1967 (36)

Patt et al., 1969 (17)	2-6 months    35	  74%		  14%

Pare and Raven,		3 months     321	  ___	     13% felt guilty
  1970 (22)

Whittington, 1970 (37)	2-12 months   31	  87%		   6%

Ford et al., 1971 (38)	6 months      22	  ___		  14% *b

Margolis et al., 1971	3-6 months    43	  67%		  9%
  (39)

Meyerowitz et al.,	1-84 months  114	  78%		  9%
  1971 (40)

Todd, 1972 (41)		1-3 years     83    91% had no ad-	 ___
					    verse symptoms

Wallerstein et al.,	5-7 months    22	  ___		 32%
  1972 (42)

Perez-Reyes and Falk,	3 months      41	75%-90%		 ___
  1973 (43)

Lask, 1975 (44)		3 months      50	68%-89%		  8%

Greer et al., 1976 (45)	18 months    217	  ___	     7% felt guilty,
							     19% had other
							     symptoms

Ashton, 1980 (46)	6 weeks       64	  ___	     24% felt guilty,
							     31% felt worried

Schmidt, 1981 (47)	3-6 years     10    Normalization	 ___
					    of scale
					    scores *c

____________________________________________________________________________
*a All studies involved theraputic abortion requiring some degree of
   psychiatric or other medical consultation.
*b According to the MMPI.
*c On the Hostility and Direction of Hostility Questionnaire and the
   Symptom-Sign Inventory



Table 3. Studies of the Prevalence of Regrets After Abortion *a
_______________________________________________________________

			    Total
Study and Year		  Subjects	Subjects With Regrets
_______________________________________________________________

Greer et al., 1976 (45)	    217		3% at 3 months, 3.7% at
						18 months

Niswander and		    116			3%
  Patterson, 1967 (14)

McCoy, 1968 (48)	     62		32% had regrets of some
					degree at some time

Ewing and Rouse,	    126			3%
  1973 (12)

Margolis et al.,	     43			4.4%
  1971 (39)

Patt et al., 1969 (17)	     35			5.7%

Whittington, 1970 (37)	     31			6.5%

Kretschmar and Norris,	     24		12.5% had occasional
  1967 (36)					regrets

Lask, 1975 (44)		     50		16% had some regrets

Pare and Raven,		    321			1.6%
  1970 (22)

_______________________________________________________________

*a All studies involved theraputic abortion requiring some
   degree of psychiatric or medical consultation.


	In women undergoing induced abortion, several factors have been
	identified that correlate with higher rates of psychological distress
	after abortion.  As previously mentioned, it has been clearly demon-	
	strated that a medical or genetic indication for abortion increases
	the risk of a negative reaction (5, 6, 34, 35).  Previous psychiatric
	contact has also been clearly shown to increase the likelihood of
	the woman having a negative emotional response to the abortion (12,
	34, 38).  The presence of support seems to be a more complex issue,
	with possibly contradictory results.  Several studies have shown that
	a woman's perceived degree of support at the time of the abortion was
	positively correlated with a good psychological response afterward
	(20, 24, 33, 49, 50), but Major et al. (9) found that women whose
	partners accompanied them to the clinic for the procedure were more
	likely to feel depressed afterward and experienced more physical
	complaints.  Similaryl, Robbins (51) found that single women who
	maintained a strong relationship with their partners after the
	abortion were more likely to experience regrets at 1 year and had more
	negative scores on the MMPI at 6 months.

	The decision on whether to abort the fetus or to carry it to term is
	a complex one that has several effects on the psychological state of
	the woman.  Not surprisingly, women undergoing mid-trimester abortions
	experienced more difficulty with the decision than those having first-
	trimester abortions (25), and they experienced greater ambivalence
	about the pregnancy (52).  They also appearedmore likely to experience
	negative reactions after the abortion (25, 30, 53), particularly if
	the late abortion required induction of labor and delivery (54).
	Adolescents who felt that they themselves made the decision to abort,
	regardless of the length of the pregnancy, without pressure from
	parents or others, were less likely to experience negative emotions
	after the abortion (24, 43).

	Several studies have examined the effect of the woman's preabortion
	psychological status on her postabortion course.  Spreckhard (55),
	inlooking at women who reported significant postabortion distress,
	found that they used a great deal of denial and repression, as well
	as projectino on their partner or the medical staff, in dealing
	with the stress of their pregnancy and subsequent abortion.  These
	women also described high degrees of boundary ambiguity with respect
	to the aborted fetus and maintained an ongoing, high level of
	attachment to the fetus, despite its loss.  Athanasiou et al. (30)
	found that women who experienced the most distress after an abortion
	were more likely to have lower self-esteem, a higher sense of
	alienation, and less knowledge of contraceptives before the abortion.
	Bracken et al. (56) found that women with a relatively internal locus
	of control and high level of ego resiliency responded most favorably
	to the abortion.

PSYCHOLOGICAL SEQUELAE OF DENIED ABORTION

	Even more difficult to determine, and hence even less often examined,
	is the issue of the effects of denying abortion on the mother and
	child. The studies that have been done are often older, since the
	access to abortion has improved in many countries.

	Before an examination of the direct effects of the denied abortion,
	two issues need to be clarified.  How many pregnancies will go on
	to completion if abortion is not performed as requested, and of those,
	how many women will eventually put their infants up for adoption?
	Table 4 presents data on studies (22, 34, 40, 57-67) that addressed
	the first question.  Particularly in the more recent studies, a
	large proportion of women (over 40% in one large study [64]) will
	continue to seek abortion elsewhere and will succeed.  Particularly
	alarming are the reported rates of "spontaneous" abortion in this
	population.  Because women who request abortion are often past the
	first trimester (the stage at high risk for spontaneous abortion),
	truly spontaneous miscarriage should be rare.  However, when these
	pregnancies are carried to term, studies (22, 60, 61, 65, 66, 68, 69)
	show that the proportion of children put up for adoption is quite
	small, ranging from 6.7% to 19.0% (table 5).  From these studies it
	would seem that when an abortion request is denied, the result is
	often either an abortion obtained elsewhere or a mother raising an
	infant from an unwanted pregnancy in the situation that led her to
	request the abortion in the first place.


TABLE 4. Studies of the Outcome of Pregnancy After Abortion Was Denied
______________________________________________________________________________

			  Number	  Full-Term	     Abortion (%)
Study and Year		of Subjects	Pregnancy (%)	Induced    Spontaneous
______________________________________________________________________________

Lindberg, 1948 (57)	    344		    ___		  14.5	       ___

Delcomyn, 1952 (58)	    136		    ___		  39	       ___

Hultgren, 1959 (59)	  4,214		   85.6		  10	       4.4

Hook, 1963 (60)		    249		   69		  ___	       ___

Peck and Marcus,	      9		    ___		  56	       ___
  1966 (34)

Forssman and Thuwe,	    196		   65.3		  34.7	       ___
  1966 (61)

Pare and Raven,		    120		    ___		  36	       ___
  1970 (22)

Meyerowitz et al.,	      4		    ___		  75	       ___
  1971 (40)

Hultin and Ottosson,	  1,008		   81.2		  ___	       ___
  1971 (62)

Dytrych et al.,		    439		   72		  10	       18
   1975 (63)b

Hunton, 1977 (64)	    253		   34.5		  46.6		5

Drower and Nash,	     69		   55		  ___	       ___
  1978 (65, 66)

Binkin et al.,		    258		   72		  20	       ___
  1983 (67)

______________________________________________________________________________



TABLE 5. Studies of the Adoption of Children
Born After Abortion Was Denied
____________________________________________________________

			  Number of	    Children Adopted
Study and Year		Children Born		Away (%)
____________________________________________________________

Malmfors, 1951 (68)	     85			   8

Aren and Amark,		    162			   7.4
  1957 (69)

Forssman and Thuwe,	    120			   6.7
  1966 (61)

Hook, 1963 (60)		    204			   7.4

Pare and Raven,		     73			  19
  1970 (22)

Drower and Nash,	     38			  16
  1978 (65, 66)

____________________________________________________________


	The few studies that have examined the effect of the denied abortion
	on the parents have focused on the effects on the mother.  While the
	effects on the father have been reported occasionally in an anecdotal
	fashion, systematic studies are lacking.  The earliest study (60)
	evaluated 249 women 7 years after the denied abortion.  It found that
	27% of the women had been able to cope fully with the pregnancy and
	the child, 22% still showed signs of mental illness and poor adjust-
	ment, and 51% had shown symptoms of mental disturbance and great
	emotional strain for a period of considerable length since the birth
	but seemed to have overcome these problems.  Unfortunately, the study
	did not distinguish between women who aborted the fetus elsewhere,
	gave the child up for adoption, or raised the child themselves.
	Drower and Nash (65, 66) reported that those women denied abortion
	expressed greater guilt and anxiety than for women for whom an
	abortion had been performed.  In the most compelling of these
	studies, Pare and Raven (22) looked at 73 women 1-3 years after their
	request for abortion was denied and found that 59% reported that
	they accepted the child and were glad that they had not aborted the
	fetus, while 34% reported that the child was a burden that they
	frequently resented.  Addmittedly quite subjective, these studies
	nonetheless show that although an unwanted pregnancy does not
	always result in an unwanted child, there is reason to be concerned
	that significant numbers of these women will continue to harbor quite
	negative feelings toward their children, feelings that are easily
	elicited by interviewers.

	The final and most difficult question concerns the effects on the
	children themselves of being born after an abortion request is
	denied.  In a study of the world literature on infanticide, Resnick
	(70) found that 83% of the newborns killed and 11% of the children
	killed by their mothers had been born of unwanted pregnancies.
	Studies by Blomberg (71) and Hultin and Ottosson (62) found no
	difference in the rate of pregnancy-related or perinatal complications
	in children born of unplanned pregnancies, while Nielsen (72) found
	a slightly above normal rate of physical abnormalities in newborns
	born in this situation.

	In a classic study that continues to have relevanve today, Forssman
	and Thuwe (61) compared, up to age 21 years, 120 children born of
	unwanted pregnancies with control subjects matched by date of birth.
	They found that the study group had a more insecure childhood, more
	psychiatric care, more childhood delinquency, and more early marriages
	and were more often young mothers; all these findings were statistic-
	ally significant.  Even after socioeconomic class was controlled,
	fewer of the study subjects had more than secondary education and
	fewer were without defects of any kind, when all these problems were
	grouped together.  A recent update (73) on the study group, then 35
	years old, found that the differences were diminishing; however, the
	study subject were still significantly more likely to appear on some
	kind of registry, indicating contact for psychiatric care, because of
	crime or delinquency, or for public assistance.  Hook (cited in
	reference 74) studied 88 children born after abortion was denied,
	comparing them with a control group made up of the same-sex class-
	mate of nearest age to each study individual.  At age 18, the boys
	in the study group had a higher rate of conduct disorder, criminality,
	and unstable homes, with lower emotional maturity.  At 23, more of the
	men in the study group were likely to require economic assistance,
	and the women in the study group began to show evidence of lower
	self-esteem and more depression.  A study (75) with a more rigorous
	control group, which was matched for age, sex, number of siblings,
	and socioeconomic class at the time of the child's birth, evaluated
	the children until their 15th birthday.  The study group had poorer
	school performance throughout this time, as well as more neurotic
	and psychocomatic symptoms recorded in the school health registry,
	and more likelihood of being registered with social welfare authori-
	ties.

	Perhaps the most ambitious study to date is that of Matejcek et al.
	(63, 76-80), who compared a control group of 220 children born in
	Prague in 1961-1963, after abortion was denied.  The two groups were
	matched for socioeconomic class, sex, age, birth order, number of
	siblings, and parental marital status.  Early findings in 1970
	found that the study subjects were less likely to be breast fed,
	had more acute medical illness, were more likely to be reported as
	difficult when they were preschoolers, were more likely to be
	rejected by friends and teachers, and were less adaptive to frustra-
	tion;  boys were more likely to be affected.  At ages 14-16 (79), 216
	of the original 220 were still being studied.  School performance in
	this group continued to deteriorate, and various indicator scales
	showed that this group had more negative relationaships with their
	mothers.  Current studies (80) of the children in their early 20s
	show an ongoing propensity for social problems that remains markedly
	prevalent in this group.  The study subjects had more job dissatis-
	faction and fewer friends and reported dissatisfaction with life (all
	significant findings) and less education, more criminality, and more
	registration by the authorities for drug and alcohol problems
	(trends).

DISCUSSION

	In spite of numerous difficulties facing researchers who attempt
	to address the issue of theraputic abortion, the findings do appear
	to be remarkably uniform.  Precise answers, unaffected by bias, are
	probably not possible, but the research examined here does highlight
	several things.

	Immediately after abortion, symptoms of distress and dysphoria do
	occur in many women.  However, these symptoms seem to be continuations
	of symptoms present before the abortion and more a result of the
	circumstances leading to the abortion than a result of the procedure
	itself.  Indeed, many studies report significant positive feelings
	after the abortion.  When the women are studied over the course of
	the episode, the dysphoria is found to wane after the abortion.
	Longer-term studies, over months and years, show similar trends;
	the majority of women express positive reactions to the abortion,
	and only a small minority express any degree of regrets.  Similarly,
	negative feelings present before abortion disappear, with normalization
	of various scores.

	Although it is difficult to generalize about factors that are more
	likely to be involved in women who experience a negative psychological
	response to abortion, and potentially misleading when dealing with an
	individual, several trends are evident.  Abortion for medical or
	genetic indications, a history of psychiatric contact before the
	abortion, and mid-trimester abortions often result in more stress
	afterward.  When women experience significant ambivalence about the
	decision or when the decision is not freely made, the results are
	also more likely to be negative.  The issue of support is a more
	complex one and is not easily measured; many studies indicate that
	support by the parent or partner can be positive, although apparently
	contradictory studies exist.  Prior psychological coping styles and
	resiliency also appear to play an important role in the psychological
	sequalea of an abortion, in that certain defensive styles such as
	projection, repression, and denial may hinder a woman's working
	through and resolving the loss of a fetus, particularly when it is
	one that is ambivalently regarded.

	When abortion is denied, a different picture seems to arise.  Many
	women, up to 40% in some studies, have the abortions elsewhere,
	depending on availability.  Relatively few of the children are put
	up for adoption, and the majority born of unwanted pregnancies are
	raised by their biological mother.  A significant minority - about
	30% - of the women examined in the few long-term studies continue
	to report negative feelings toward their child and difficulty in
	adjusting.

	Finally, the most disturbing part of the whole issue is the evidence
	of significant negative effect on the child.  With the caveat that
	the unwanted pregnancy does not necessarily result in an unwanted
	child, the carefully designed and executed prospective studies of
	Matejcek et al., Hook, Blomberg, and Forssman and Thuwe reveal long-
	lasting, broadly based, negative effects of the denial of abortion on
	the children subsequently raised in the situation that the parents
	had tried so desperately to avoid.

	While this paper has not addressed any of the ethical issues raised
	by theraputic abortion, it has attempted to give a psychiatric
	perspective that has hitherto been unavailable in this debate.
	Further research on some of the questions examined is important,
	particularly if society moves toward more restrictive legislation
	on the issue, since the question of the effects on the mother and
	child in particular has only begun to be explored.

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