Rapid Repeat Pregnancy Following Induced Abortion Among Adolescent and Low Income Women

A.I.R.V.S.C.
Association for Interdisciplinary Research in Values and Social Change
Vol 16, no. 3, 2001
by Thomas W. Strahan
Reproduced with Permission

Introduction

Rapid repeat pregnancy is defined as a subsequent pregnancy within 12 to 24 months of an earlier pregnancy.(1) This article discusses rapid repeat pregnancy following legally induced abortion particularly with respect to adolescent and low income women in the United States. These two groups of women are of particular interest because of important public policy issues relating to (A) Whether or not induced abortion is in the best interests of an adolescent who is pregnant, and (B) Whether or not the government should use tax dollars to pay for induced abortions for women of low socio-economic status.

Overview of Published Studies

The leading study on rapid repeat pregnancy following induced abortion was done by researchers at the University of Hawaii who evaluated 2,632 women who had abortions in Hawaii during 1970-1974 using record linkage. Women were evaluated at one year intervals following their abortion for subsequent pregnancies over a five-year period. Forty percent of the women were Caucasian while 21% were Japanese. Other subgroups were Filipino, Chinese, Hawaiian or other groups. Two-thirds of the women were under 25, 56% were never married, 9% were divorced, separated or widowed. The women generally were of low parity, and 90% had at least a high school education. Overall, 20.8% of the women had repeat abortions during the study period.

The percentage of women who had rapid repeat pregnancies following their abortion varied widely depending upon specific characteristics. For example, in a two-year period following their abortion women of low socio-economic status had the highest incidence (38.6%), while women of high socio-economic status had a much lower incidence (13.1%). Women under age 18 had a higher incidence (29.2%) compared to married women (18.8%). Overall, 13.1% of the postabortion women became pregnant in the first year following their abortion, and 21.4% became pregnant again within a two year period with 48.4% obtaining another abortion.(2)

The study has certain limitations. For example, the ethnic makeup of women who had abortions in Hawaii is not typical of U.S. women generally. In addition, the repeat abortion rate (20.8%) during the study period was much lower than current repeat abortion rates in the U.S. (45-50%).

Other U.S. studies during the 1970's found an even higher incidence of rapid repeat pregnancy following abortion particularly among low income women or among teenage women. In one study of U.S. women (mean age 22.7 years) who obtained abortions at Yale-New Haven Hospital in 1974-75, it was found that 42% repeated abortion within the next 12 months and 70% had repeated abortion within two years. Many of these women were receiving public welfare assistance and few had skilled employment or professional or managerial positions.(3)

Researchers at Johns Hopkins University in Baltimore inter viewed unmarried teenage women ages 15-19 in 1976 who were living in a metropolitan area and had a rapid repeat pregnancy following a first pregnancy which ended by abortion. It was found that 21.4% had a second pregnancy within 12 months, 36.4% had a second pregnancy within 18 months, and 75.7% had a second pregnancy within two years.(4) A similar subsequent study of unmarried metropolitan are a teenagers ages 15-19 in 1979 found that 27% had a subsequent pregnancy within 12 months following their abortion, 49.8% had a subsequent pregnancy within 18 months, and 73.9% had a subsequent pregnancy within two years.(4)

Later U.S. studies have also found a high incidence of repeat pregnancy following induced abortion. A Maryland study during 1985-86 of 360 unmarried black women age 17 or less with low socio-economic background found that 37% had a repeat pregnancy within two years following their abortion.(5) A Michigan study of 100 pregnant low income women ages 13-21 who were receiving prenatal care at a non-profit health center in 1994-96 reported that 43.6% became pregnant again within 12 months of their prior pregnancy. By 18 months, 63.2% had experienced at least one additional pregnancy. The experience of any form of physical or sexual violence during the study period was associated with rapid repeat pregnancy. Women whose earlier pregnancy had ended in spontaneous abortion were most likely to experience rapid repeat pregnancy. Women whose earlier pregnancy had ended in induced abortion were the next most likely, and women who earlier had delivered at term were the least likely to experience rapid repeat pregnancy.(6)

A recently published prospective study of a group of young women ages 12-18 years of age who were admitted for complications of illegal abortion at a hospital in Northeast Brazil in 1995-97 found that 23% of those who had terminated their pregnancy by abortion became pregnant again within one year. Four out of five of these women were reported to have taken misoprostol to initiate the abortion.(7) A study of Pittsburgh women who had a methotrexate/misoprostol abortion in 1994-95 reported that 24.7% had a subsequent pregnancy within 12 months after their abortion. 91% of these subsequent pregnancies resulted in another induced abortion. The mean age of these Pittsburgh women was 25 years of age. Some 46.2% of the women had had a prior abortion before their methotrexate/misoprostol abortion; 62.4% of the women were Caucasian and 34.4% were African-American. The vast majority were single (68.8%), while 14% were married, 9.7% were divorced, and 7.5% were separated. The author concluded that these women remained at high risk for unintended pregnancy.(8)

Researchers at Lund University also studied the incidence of post abortion conception of all 1,285 women who obtained induced abortions in Malmo, Sweden in 1989. Overall, it was found that 18.9% had a repeat pregnancy within 12 months with 49.6% of these women having another induced abortion. Women who had agreed to participate in the study but dropped out within one week after their abortion had a higher incidence of rapid repeat pregnancy (22.2%) compared to those who did not drop out of the study (17.2%). Those who had dropped out of the study were more likely to be young, unmarried and of low socio-economic status compared to those who remained in the study.(9)

Rapid Repeat Pregnancy as Replacement or Atonement Pregnancies

There are indications that a large percentage of rapid repeat pregnancies may be replacement or atonement pregnancies which follow induced abortion. In 1976 a study was undertaken at a private agency in Chicago which administered social services to pregnant adolescents in order to explore the experiences of young women with two adolescent pregnancies. The clients served by the agency were 95% black and of low socio-economic status. Participants in the study included 20 adolescents who had previously had an ectopic pregnancy, miscarriage, stillbirth, or infant death (miscarriage group), and an additional 20 women who had a previous induced abortion (abortion group). Those who had a previous induced abortion were an average of fourteen years and eight months old at the time their first pregnancy ended by abortion. These women were an average of fifteen years and ten months of age at the time of their next conception. The median time period was nine and one-half months between the Rapid Repeat Pregnancies Following Induced Abortion induced abortion and their next conception (range 1-19 months). The median time period was five months before the miscarriage group became pregnant again.

Some found it difficult to talk or think about the previous loss after termination of the second pregnancy. This was especially true among those with previous induced abortions. In many cases, the second pregnancy closely followed the previous loss and tended to cut off further expression of mourning reactions. For some women, mourning reactions could not be assessed because the young women would not talk about their reactions in any depth. The authors concluded that many of the young women may have had difficulty accepting the previous loss. A majority (25 of 40) said they had purposely become pregnant again as a replacement for the previous loss. Thirteen did not admit planning the subsequent pregnancy but avoided contraception even though they were aware of the consequences for doing so. Women often had little input into the decision to have an abortion and ambivalence was demonstrated by many who had abortions. There were increased negative feelings following abortion compared to pre-abortion reactions. The authors concluded that the women had many difficulties completing adaptive mourning reactions and that becoming pregnant again may have seemed a simple solution.(10)

The desire of postabortion women to have replacement children has been noted in other situations. In a self-reported questionnaire survey of 344 postabortion women receiving services at Akron Pregnancy Services in Akron, Ohio, in 1988-1993, 23% indicated a desire to get pregnant again following their abortion.(11) In a religiously-based post abortion recovery group in Minnesota, 53% of the women reported that they desired to get pregnant again to compensate for their loss.(12) Still another study of women in a post-abortion support group at the Medical College of Ohio where women reported they had poorly assimilated their abortion experience, many of the women expressed an increased desire to have children following their abortion. The authors of the study speculated that, "some women experience an unconscious desire to have an 'atonement' child to replace the aborted fetus and undo their previous abortion."(13)

A similar conclusion was made by Beverly Raphael, an authority on pregnancy and pregnancy loss. She stated, "In terms of loss and depression as well as self-destruction, a second or third undesired conception may represent a rather pathetic attempt to undo a previous failure -to relive the situation of the last abortion, the previous pregnancy, more satisfactorily. But the woman driven by deep neurotic needs rarely achieves such reparation even if she continues to term, and instead repeats once more her guilt, anxiety and conflict."(14) Psychologists Vincent Rue and Anne Speckhard have made the observation that "Abortion recovery may be unsuccessfully attempted by reenactment through a subsequent pregnancy experience. For some women whose grief about their unborn child is impacted, the compulsion is to attempt mastery of the trauma through resolution of the guilt feelings and replacement of the lost object (the fetal child). For some, the resurfacing of the trauma in a subsequent pregnancy is too threatening and compels another abortion." [also citing other authorities](15)

Impaired Functioning and Development of Women With Rapid Repeat Pregnancy

Various studies have found that young women who have a rapid repeat pregnancy following an induced abortion demonstrate impaired functioning and development or increased psycho-social problems compared to women who do not have a rapid repeat pregnancy. A study of young black women in Baltimore during 198586 found that those with a rapid repeat pregnancy within two years following induced abortion were significantly less likely to remain in school or to graduate (78% vs. 97.4%), more likely to be behind grade for age at 2 years (58.5% vs. 30.7%), and experience a negative educational change (34.1% vs. 8%) compared to those with a prior induced abortion and no rapid repeat pregnancy(5).

Another study was undertaken of 120 black and Puerto Rican adolescent mothers who had a repeat pregnancy within 12 months during 1987-1988. In this study, researchers compared women who had four different rapid repeat pregnancy outcomes: women who had therapeutic abortions, miscarriages, full-term deliveries, and no repeat pregnancy. Overall, 39.6% of the women became pregnant again within 12 months. More delayed grade placement was found among those with therapeutic abortion (-1.6) or full-term births (-1.8) compared to those with no repeat pregnancy (-0.6). School attendance was higher at 12 months postpartum among adolescent mothers with no repeat pregnancy (65%) than among those with therapeutic abortion (35%) or another fullterm birth (24%). Depressive symptoms were higher among those mothers with therapeutic abortion compared to those with another full-term birth or no repeat pregnancy.(16)

It appears that some women with rapid repeat pregnancy following induced abortion are dysfunctional to a degree which requires that they have a guardian appointed by the court. In a French Canadian study of 50 adolescent girls two years following their abortion, nine (18%) became pregnant again within two years. Of those who became pregnant again, four were wards of the court compared to only one of the remaining 41 girls. The researchers concluded that "this suggests a high degree of emotional disturbance in the 'repeaters'".(17)

Rapid repeat pregnancy where both pregnancies resulted in induced abortion also has been found to result in socio-economic deterioration. Researchers at Yale Medical School compared women who repeated abortion within 12-24 months with those with first abortions at Yale-New Haven Hospital in 1974-76. The mean age of the women at the time of their repeat abortion was 24 years of age; the mean age of the women at the time of their first abortion was 22.7 hears. It was found that women who repeated abortion were more likely to receive public welfare (38.2%) compared to women with a first abortion (25.8%). There were substantial differences between white and black women as 12.3% of white women who had a first abortion were receiving public welfare compared to 19.3% of white women who repeated abortion. Among black women, 55.6% with a first abortion were receiving public welfare compared to 65.6% with a repeat abortion. Women who repeated abortion were also more likely to be divorced (11.9% v. 6.1%), and were less likely to be a student (15.7% v. 27.7%) compared to women with a first abortion. The authors concluded that "many women in this population, particularly those on welfare, appear to remain exposed to unprotected coitus and subsequent repeat abortion."(3)

A Finish study also compared socio-economic and psycho-social differences between women with a single abortion and those with a repeat abortion. Women repeating abortion had a poorer economic situation and were more likely to have a history of broken partner relationships. Women repeating abortion more often had prior losses in their family of origin as well as family dysfunction and poorer relationships with their parents. Both groups were similarly educated and had knowledge of contraception. However, women repeating abortion were weaker in impulse control and relied more on their male partner to assume responsibility for contraception while taking less responsibility themselves.(18) A French study also compared psycho-social factors between women with one induced abortion and women repeating abortion. This study concluded that repetitive abortions reveal an ambivalence towards contraception. They believed that a desire for pregnancy does not always coincide with a desire for motherhood and that some women have not overcome a childish rivalry with their mothers and still remain within a symbiotic relationship with them.(19)

Other Scandinavian studies have also found that women repeating abortion are more likely to live alone without a partner, or have an unstable partner relationship. They also have been found to be more likely to be unemployed and to have had contact with a social service system compared to women with a single abortion.(20)

Case Study: Meredith

Meredith, a Caucasian, is 21 years of age at the time of this interview. She has had three pregnancies and three induced abortions between ages 17 and 19. Her parents divorced when she was young and she moved in with her grandparents. Her mother ran off never to be seen again and her grandfather molested her. She dropped out of high school, slipping into alcoholism and heavy drug use at age 19 when she had her third abortion. She cries several times during her interview, suddenly looking young, frightened, and very much in need of love. Then she resumes a tough exterior, snapping when she finds a question insulting, intent on maintaining her dignity.

She says, "I was in a lot of trouble when I was 17. I was sent to an Outward Bound course. And I was pregnant. On some level I knew I was pregnant, although I avoided taking a test. I basically denied it for the longest time. But it really started to be a problem when I got dizzy a lot." Being pregnant didn't go with a survival training course. When Meredith was three months into her pregnancy, she fell, and the group leaders, thinking she may have had a concussion, took her to a hospital. Meredith said, "The nurse just looked at me and said, 'You need a pregnancy test.'" Suddenly her private pregnancy became very public. The Outward Bound leaders called Meredith's dad and stepmother, who cut short their trip in Europe. Meredith had to tell them about the pregnancy. Meredith's father and stepmother assumed full authority over her pregnancy. "My parents didn't even ask me. They told me I was getting an abortion."

She had an abortion but her denial helped her feel little emotion. She felt no connection with the life within her. "It was like this alien thing. I just tried to deny it, what was happening to my body, what I was thinking." Meredith says the abortions "had certain pain for me, and emotions come up from time to time. Last abortion I felt very mechanical. I plunged myself back into whatever my life was at the time. I just kept going." Meredith thinks it unwise to dwell on thoughts about the aborted child. "If you really want to screw yourself up, you could play with a bunch of ideas about boy or girl, or what it would look like. I learned the first time that was not how one survives one of these things. You just put it behind you. At that time I put it behind me by drinking."(21)

Comments:

Meredith's home life included abandonment by the mother and being molested by her grandfather. A study by researchers at the Medical College of Ohio of adolescents who said they had poorly assimilated their abortion experiences reported that adolescents recalled their homes as being chaotic and their parents' marriage unhappy. The researchers stated, "This lends support to the theory that adolescents may use sexuality as a means of acting out their anger toward parents, or as an emotional or physical escape from an unpleasant environment."(13)

Meredith is a specific example of rapid repeat pregnancy leading to induced abortion and dropping out of high school. Her behavior is consistent with the findings of researchers at Johns Hopkins which found that repeat pregnancy following abortion by urban black teenagers more frequently resulted in negative educational change, being behind grade for age or not being in school.(5)

Meredith is still struggling with the effects of her abortions, although it has been about two years since her last abortion and about four years since her first abortion. She appears to be unable to mourn her losses. This is consistent with the Chicago study by Nancy Horowitz which found that adolescents experiencing two adolescent pregnancies found it difficult to talk or think about their previous losses and that this was particularly true among those with previous induced abortion.(10)

Use of alcohol and/or drugs as a coping mechanism is relatively common. A study of 344 postabortion women at Akron Pregnancy Services during 1988-1993 found that 17% reported alcohol/drug abuse as a psychological complaint following their abortion. In this study, the average age of the women at the time of their first abortion was about 18 years of age, most of the women were Caucasian, and an average of about six years had elapsed from the time of their first abortion to the time of the survey."

Ineffectiveness of Abortion in Preventing Future Pregnancy

Based upon the studies which were reviewed in this article, and considering that most involved adolescents or low income women, induced abortion followed by contraceptive counseling does not result in reducing the incidence of rapid repeat pregnancy. This was a somewhat unexpected finding because abortion is most often represented as the "termination of an unwanted pregnancy." With the high incidence of rapid repeat pregnancy, it appears that other factors are involved.(22)

Some recent studies have found that a rapid repeat pregnancy is more likely following illegal induced abortion than following childbirth. In a study of adolescents ages 12-18 in Northeast Brazil during 1995-97, 23% of adolescents whose last pregnancy was an induced abortion had a subsequent pregnancy within 12 months compared to 20% among adolescents whose last pregnancy resulted in an intended childbirth and 14% whose last pregnancy was an unintended childbirth. A Michigan study of 100 young low income women ages 13-21 who were receiving services at a non-profit health center reported that 43.6% became pregnant again within 12 months of the outcome of their previous pregnancy. By 18 months, 63.2% had experienced at least one additional pregnancy. Women whose earlier pregnancy had ended in a spontaneous abortion were the most likely to experience rapid repeat pregnancy. Those whose earlier pregnancy had ended in induced abortion were the next most likely, and women whose earlier pregnancy had ended in childbirth were the least likely to experience rapid repeat pregnancy.(6)

Another study of economically disadvantaged teen mothers during 1980-83 found that 16.7% had a repeat pregnancy within 12 months following their earlier pregnancy, and 44% had a repeat pregnancy within 24 months following an earlier pregnancy. There was no significant difference in rapid repeat pregnancy among women who had a previous abortion compared to women without a previous abortion.(23)

Three studies have found that postabortion women have a somewhat less likelihood of rapid repeat pregnancy compared to child-bearing women. A 1985-86 study of black women aged 17 or younger in the Baltimore area found that 37% of postabortion women and 47% of childbearing women had a repeat pregnancy within two years of their previous pregnancy outcome.(5) A 1976 study of metropolitan area teenagers ages 15-19 found that 75.7% of postabortion women had a repeat pregnancy within two years compared to 99.7% of childbearing women. A similar 1979 study of metropolitan area teenagers ages 15-19 found that 74.9% of postabortion women had another pregnancy within two years compared to 84.1% of childbearing women.(4)

Two additional studies of women with a mean age in their early 20's found that postabortion women were at high risk for subsequent pregnancy. One study involved women who had undergone abortion by methotroxate/misoprostol.(8) The other involved women of low socio-economic status by researchers at Yale Medical School.(3)

Conclusions

Adolescent women and women of low socio-economic status are at high risk of rapid repeat pregnancy following induced abortion. Many of these rapid repeat pregnancies result in another induced abortion. The incidence of rapid repeat pregnancy ranged from 17% to 42% after one year, and 29% to 75% after two years.

In many instances, rapid repeat pregnancies following induced abortion appear to be replacement or atonement pregnancies. Pregnancy may represent an immature attempt to cope with the loss due to an impairment of the process of mourning.

Impaired functioning or development of adolescent women who have a rapid repeat pregnancy following induced abortion has been observed. This includes being behind grade for age, not remaining in school or failing to graduate, depressive effects, or requiring appointment of a guardian. Impaired functioning or development among young women of low socio-economic status who have a rapid repeat pregnancy following induced abortion includes being more likely to be on welfare, more broken marriage relationships, and being less likely to be in school.

Rapid repeat pregnancy following induced abortion is evidence that induced abortion and postabortion contraceptive counseling is ineffective in preventing subsequent pregnancies. Some of the reasons are: (1.) Adolescents and low income women have been identified as being at risk for irregular or non-use of contraceptives. (2.) The available studies indicate that the incidence of rapid repeat pregnancy among these women is similar to that of rapid repeat pregnancy among childbearing women. (3.) Contraception is likely to be ineffective when a woman seeks to replace or atone for an earlier pregnancy loss. (4.) Women of low socio-economic status may rely on the male partner to a greater degree to use contraception and take less responsibility themselves, may be more impulsive or ambivalent or have other personal or social characteristics which reduce the likelihood of contraceptive use.

Compiled by Thomas W. Strahan
J.D., Editor

Footnotes

1. Risk Factors for Rapid Repeat Pregnancy Among Adolescent Mothers: A Review of the Literature, D C Rigsby et al, J. Pediatr Adolesc Gynecol 11: 115-126, 1998
2. Women Who Obtain Repeat Abortions: A Study Based on Record Linkage, P G Steinhoff et al, Family Planning Perspectives 11 (1): 30-38, Jan/Feb 1979
3. Contraceptive Practice and Repeat Induced Abortion: An Epidemiological Investigation, M J Shepard and M B Bracken, J Biosocial Science 11 289-302, 1979
4. Repeat Pregnancies Among Metropolitan-Area Teenagers: 1971-1979, M A Koenig and M Zelnik, Family Planning Perspectives 14(6): 341-344, Nov/Dec 1982
5. When Adolescents Choose Abortion: Effects on Education, Psychological Status and Subsequent Pregnancy, L S Zabin et al, Family Planning Perspectives 21(6): 248-255, Dec 1989
6. Rapid Repeat Pregnancy and Experience of Interpersonal Violence Among Low Income Adolescents, Mark Jacoby et al, Arn J Prev. Med. 16(4): 318-321, 1999
7. Adolescent Pregnancy 1 Year Later: The Effects of Abortion vs. Motherhood in Northeast Brazil, P E Bailey et al, Journal of Adolescent Health 29:223-232, 2001
8. Conception rates after abortion with methotrexate and misoprostol, M D Crenin, Int'l Journal Gynecology & Obstetrics 65: 183-188, 1999
9. Selection bias in a study on how women experienced induced abortion, H Soderberg et al, European Journal Obstetrics & Gynecology 77:67-70, 1998
10. Adolescent mourning reactions to infant and fetal loss, Nancy Horowitz, Social Casework 551-559, November, 1978
11. Physical and Psychological Injury in Women Following Abortion: Akron Pregnancy Services Survey, Lee E H Gsellman, Association for Interdisciplinary Research in Values and Social Change Newsletter 5(4): 1 8, Sept/Oct 1993
12. Post Abortion Trauma. 9 Steps to Recovery. Jeanette Vought 1991, 103
13. Abortion in Adolescence, NB Campbell et al, Adolescence XXIII No. 92: 813-823, Winter 1988
14. Psychosocial Aspects of Induced Abortion - Its Implications for the Woman, Her Family and Her Doctor: Part 1, Beverley Raphael, The Medical Journal of Australia 2:35-40, 1972
15. Postabortion Syndrome: An Emerging Public Health Concern, Anne Speckhard and VM Rue, Journal of Social Issues 48(3): 95-119, 1992
16. Predictors of Repeat Pregnancy Outcome among Black and Puerto Rican Adolescent Mothers, L O Linares et al, Developmental and Behavioral Pediatrics 13(2): 89-94, 1992
17. Follow-up of 50 adolescent girls 2 years after abortion, H Cvejic et al, CMA Journal 116:44-46, Jan 1977
18. The First Abortion and the Last? A Study of the Personality Factors Underlying Failure of Contraception, P Niemela et al, Int'l Journal Gynaecol Obstet 19:193-200, 1981
19. L'interruption volontaire de grossesse a' repetition, I Tamian-Kungel, Gyuecol Obstet Fertil 28:137-140, 2000
20. Repeat Abortion in Denmark, M Oster et al, Danish Medical Bulletin 39(1): 89, 1992; Repeat Abortion: A Comparative Study, M Tornbom et al, J. Psychosomatic Obstet Gynecoll 7:208, 1996; The influence of social class conparity and psychological reactions in women coming in for induced abortion, B Hamark et al, Acta Obstet Gynecol Scand 74(4) 302, 1995
21. Experiencing Abortion. A Weaving of Women's Words. Eve Kushner, 1997, 111-113
22. Psychiatric aspects of contraceptive utilization, P Barglow and D Klass, Am J Obstet Gynecol 114(1): 93-96, 1972; Psychology of the misuse and rejection of contraception,E C Sandberg and R I Jacobs, Am J Obstet Gynecol 110(2): 227242, 1971; Contraceptive Use and Repeat Pregnancies Among Welfare Dependent Teenage Mothers, R Maynard and A Rangarjar, Family Planning Perspectives 26(5): 198-205, 1994; Psychiatric aspects of adolescent pregnancy, C Peterson et al, Psychosomatics 23(7): 723-733, 1982
23. Early Subsequent Pregnancy among Economically Disadvantaged Teenage Mothers, D F Polit and J R Kahn, Am J Public Health 76:167-171, 1986

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