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Wantedness & Coercion: Key Factors in Understanding Women's Mental Health After Abortion


A.I.R.V.S.C.
Association for Interdisciplinary Research in Values and Social Change
by Martha Shuping, M.D.
Wantedness & Coercion: Key Factors in Understanding
Women's Mental Health After Abortion
Volume 23, Number 2 -- Spring 2011
Reproduced with Permission
Research Bulletin

In 1973, as a 19-year-old undergraduate student, I worked as a volunteer at a clinic that helped women to access abortion services. I received one evening of training in which I was taught that abortion was a safe, simple procedure, and there were no side effects.

I was incorrectly taught that the developing baby was nothing more than a clump of cells. After that, I was considered to be a qualified pregnancy counselor, and I helped some women to obtain abortions.

Thirty-eight years later, many abortion counselors are still giving women that same misinformation. But today I know that many women have adverse psychological reactions following abortion.

I have known more than one thousand post-abortive women who have been unhappy about their abortions. Much of my professional life has been spent in helping women to deal with the emotional impact of abortion.

The published literature is clear that abortion puts women at increased risk for mental health problems. For one example, a 2008 study using data from the National Comorbidity Survey (a large nationally representative data set) showed that abortion was a risk factor for eight different psychiatric conditions, "above and beyond the effects of the 22 control variables."[1,2] A bibliography prepared in 2008 by Dr. Priscilla Coleman, identified more than 50 strong studies in peer reviewed journals that "provide clear evidence of causation,"[3] while a newer bibliography lists more than 100 such studies published from 1981-2010.[4]

In September of 2011, a meta-anlysis was published, the "largest quantitative estimate of mental health risks associated with abortion available in the world literature." This showed that "women who had undergone an abortion experienced an 81% increased risk of mental health problems, and nearly 10% of the incidence of mental health problems was shown to be attributable to abortion."[5]

Rather than addressing the question of whether or not some women have mental health problems after abortion, which is already clearly established, we will examine here some of the reasons that women are having mental health problems after abortion.

The stories of real women (not their real names) may help to make clear why some women are having problems, contrary to what everyone expected many years ago.*

Melody's Story

Melody[6,7] was happily married with two children, and a husband with a good career. They were financially secure enough that Melody chose to stay home with her children, and she enjoyed being a mother. She was happy when she became pregnant with her third child. But she was shocked to find out that her husband believed he was too busy for another baby. He wanted her to have an abortion.

When she hesitated to terminate the life of a baby she already loved, her husband asked her to talk with their minister, who strongly encouraged Melody to respect her husband's wishes. Melody agreed to the abortion, but it was not what she desired. She wanted her baby.

After the abortion, she found herself disabled by grief and depression. She could not make herself get out of bed to take care of her living children as she grieved for the baby she had lost.

Melody clearly identified the abortion as the cause of her problems. She did not have mental health problems before the abortion. Her symptoms started immediately after the abortion. Her depression was so severe, with thoughts of suicide, that she was admitted to a hospital for psychiatric treatment.

Donna's Story:

Donna was 17 years old and a senior in high school, engaged to be married. While her fiancée was away at training required by his job, Donna discovered she was pregnant. She was happy about the pregnancy. She wanted her baby, and concealed the pregnancy from her mother for as long as possible.

When her mother found out about the pregnancy, she told Donna that she could not live at home and remain pregnant. That would be an embarrassment to the family. Donna did not have a job and could not find another place to live. Her mother made an appointment at an abortion clinic.

Donna sought help at a pregnancy resource center, but the center could not find housing for her in time. Donna was taken to the clinic by her mother when the day arrived.

Donna told the nurse and the doctor clearly: "I do not give consent for this abortion. I want my baby." But she was not of legal age, and her mother had signed for and paid for an abortion, so Donna was sedated with medication. Then she was pushed down forcibly on the table, and the abortion was done without her consent.

After the abortion, Donna experienced more than a decade of severe emotional distress that later resolved when she participated in a faith-based abortion recovery program.

Wanted Babies:

This frequent reality of abortion being chosen by others and imposed on the woman is a factor that needs to be considered in interpreting current research and in planning for future research. The fact of an abortion taking place suggests that someone didn't want the baby, but as we have seen with Melody and Donna, the mother herself may have wanted the baby very much. The fact that an abortion took place can not be assumed to mean that the baby was "unwanted," or that the mother did not want the baby.

It would seem to be intuitively obvious and not surprising that women who abort wanted babies would have adverse mental health outcomes, and there is some published literature that addresses this question.

Researchers who favor abortion and those who are considered pro- life have been able to agree that "terminating a pregnancy that is wanted or meaningful" is "associated with more negative psychological reactions."[8] In fact, one recent report said that the extent to which the woman felt committed to the pregnancy was "predictive of more negative psychological reactions."8 In plain English, women who want their babies but abort anyway are more likely to have mental health problems, a fact that has been recognized in the literature for decades.[9]

However, there seems to be some confusion in the literature on several points regarding the concept of "wantedness." The phrase "unplanned and unwanted pregnancy" is sometimes used at times when it is not clear that the pregnancy was actually unwanted. The assumption seems to be that if the pregnancy was unplanned, then it is also unwanted, but as we saw with both Melody and Donna, although their pregnancies were not planned, they nevertheless wanted their babies.

The 2008 Report of the American Psychological Association Task Force on Mental Health and Abortion (APA Report)[8] says that only a very small percentage of abortions involve "planned and wanted pregnancies," referring to women who had intended pregnancies but aborted due to "fetal anomalies or risks to their own health"). A 2006 report by Guttmacher Institute also stated that there are few abortions of wanted pregnancies.[10]

Women like Melody and Donna, with unplanned pregnancies but wanted babies, are seemingly not considered in these reports, yet I see them in such large numbers myself, that my own experience gives me reason to think that their numbers are not trivial.

In a 2004 study in Medical Science Monitor, 17.7% of post-abortive women in a general gynecology population in the U.S. stated that the pregnancy was "desired" even though abortion was chosen.[11] That would indicate that more than 200,000 wanted babies are aborted annually in the U.S.

However, in many studies, women are not asked if the baby was wanted,[12] and there are difficulties in obtaining a true number of women aborting wanted babies, given the tendency to equate "wantedness" with "intendedness" and the fact that the degree of wantedness can change over the course of the pregnancy.[13] There is also concern that the recollection of pregnancy intentions may change over time when reported at a later date.[13,14] Additionally, questions relating to pregnancy intentions have been answered differently when women responded to two different sets of questions.[15] Further, it is "generally assumed" that pregnancies ending in abortion were "unintended."[15]

Forced and Coerced Abortions:

Research on forced or coerced abortions may give us insight into how many abortions of wanted babies may be taking place, since logically one would expect that only if a woman truly wanted her baby would a situation exist in which she might be coerced or forced by a parent or a partner. If the baby were unwanted, presumably coercion would not be needed by those who desired the woman to abort. Thus, data on coerced or forced abortions may provide an indirect measurement regarding the number of women aborting wanted babies.

Some people find the concept of forced abortion in America so shocking as to be almost unbelievable. But news reports from Philadelphia about Dr. Kermit Gosnell's clinic have given some clear evidence that this really does take place.

Robyn Reid, age 15, was taken to Dr. Gosnell's clinic by her grandmother. Robyn did not want the abortion; when she refused, she was physically struck, then sedated and restrained, and the abortion was done without her consent.[16]

Davida Johnson was an adult woman who came to Dr. Gosnell's clinic for an abortion, but then changed her mind, stating, "I don't want to do this." She described an experience similar to Reid's, being struck, restrained and drugged by staff members, then subjected to a forced abortion.[16]

There is a continuum of pressure with intensity that can range from the more subtle to the extreme of forced abortion. It may be the boyfriend saying, "I will never love that baby," or a parent saying, "You can't live at home," or, "We'll cut off your college funds," all the way to the extreme of being sedated, restrained, and forcibly aborted.

In the U.S. there are cases where this escalates to physical violence and even murder of women who refuse to abort; homicide is now the leading cause of death of pregnant women.[17-24]

The APA Report cites one study that indicates only a very few women report experiencing coercion.[8] However, in a 2004 study of a general gynecology population, 64% of the post-abortive women reported feeling "pressured" to abort.[11]

In a survey of women who were dissatisfied with their abortions, 39% reported they were "very much" pressured by others and a total of 73% reported some degree of pressure from others.[25]

In this same survey, women were asked if they would have made a different choice if they had been encouraged differently by others (boyfriends, parents, etc.), with 76% of the women responding "very much," indicating they wanted their babies but were influenced by others.[25]

There may be differences in how "pressure" or "coercion" is defined or measured. Tabitha reported to me that she told clinic staff, "I am being coerced." A staff person asked her to explain in what way she was being coerced. Tabitha says that after she explained her situation to the staff person, she was informed, "No, that is not coercion," and the abortion was performed.

Researchers and experts on both sides agree that pressure, coercion or even "perceived coercion" puts women at risk for increased mental health problems after abortion.[8], [11], [26-29]

It is important to note that "perceived pressure" or "perceived coercion," would indicate that pressure is in the eye of the beholder, and if a woman believes she is being pressured or coerced, her perception of the situation is definitive, not the opinion of clinic staff or researchers.

In addition to those women, who are pressured or coerced by other people into aborting wanted babies, there are women who are pressured by circumstances to abort a wanted baby.

Rose's Story: Pressured by Circumstances

Rose[6, 7] was 17 years old, and her pregnancy had advanced far enough that she had felt the baby move. She said, "I really wanted this child, but I didn't know what to do." She worked to earn money for the abortion, and also pawned some cherished possessions to have enough money. She said, "I wanted this child," but "I went ahead with [the abortion]"

Her emotional reaction was severely negative. She said, "I hated myself after the abortion and tried to commit suicide. I got a gun and went to a parking lot at night. I put the gun to my head, pulled the trigger, but it didn't fire. I hit the butt of the gun to the asphalt and it fired, grazing the side of my head. Then I put it back to my head and it wouldn't fire. Finally I took a huge amount of pills but I only slept for two days."

The doctor had told Rose that her child was a boy, and for years, she continued to think about the aborted child, naming him Joseph: "I thought about him every day...how old he would be, what color were his eyes, what color was his hair...I read about pregnancy and infant care, to learn about baby boys." In Rose's case, no one knew about the pregnancy or the abortion, so there was no pressure from other people. However, Rose was still in high school, and as she said, "I didn't know what to do." Although there was no pressure from other people, it might be considered that Rose was pressured by her perception of her circumstances, in that no counseling was offered at the clinic, and she received no information on support services or assistance that would be available to a single mother.

This is a frequent experience. I have repeatedly heard from women, "I wanted my baby, but..." or, "I wanted my baby, but I didn't have a choice." Part of the reason for lack of choice is that women are not being given information about support services and assistance that would give them options. In one study, only 17.5% of women received information on alternatives, less than one in five.[11] In a study of women who had emotional problems after abortion, when asked to what degree they felt "forced" by circumstances to abort, 54% responded "very much," and 84% reported some degree of feeling "forced" by circumstances.[25]

This does not necessarily mean that women were in fact forced, but that they felt that they were forced. One woman I know aborted a baby she wanted, later stating she would not have had her abortion had she known at the time she would have been eligible for Medicaid. Lack of information, not actual lack of resources, is often what creates the pressure.

Maternal - Fetal Attachment:

There is a large body of research on maternal - fetal attachment which may shed light on Rose's experience.

The fact of prenatal bonding is widely accepted in the medical literature. A PubMed search on this topic shows hundreds of published studies. These studies discuss questions such as which factors in prenatal attachment correlate with which factors in postnatal attachment, but the studies do not question whether prenatal bonding exists.

Most people intuitively have some concept of mother - child bonding, even before birth. Popular magazines and best-selling baby books have alerted moms-to-be that bonding begins in the womb, and that moms can enhance bonding by talking and reading stories to their pre-born baby. Many women recall that moment when they first felt their baby move and identified it as "my baby." The existence of businesses that offer 3-D and 4-D imaging for baby's first photo would be another commonplace indication of prenatal attachment.

Prenatal bonding, like postnatal bonding, is not all-or-none. Mothers demonstrate greater or lesser degrees of bonding; studies examine what factors can lead to better, more secure attachment. One definition of maternal-fetal attachment is: "the extent to which women engage in behaviors that represent affiliation and interaction with the unborn child."[30] This definition reflects the fact that there may be varying degrees of attachment. However, that prenatal bonding does occur, is a fact.[31]

Published studies spanning more than sixty years have consistently concluded that attachment between parent and child begins in pregnancy, not at birth.[31-42]

Abortion causes a disruption of this bonding which may be experienced as a trauma. In fact, the degree of bonding that is established during pregnancy is actually predicative of the degree of trauma symptoms that are experienced after abortion.[11], [28], [31], [41-43]

For Melody, Donna, and Rose, the serious emotional distress they experienced after their abortions appears to be related to prenatal bonding that had already taken place prior to the abortion, bonding which was painfully disrupted by the abortion.

Even when pregnancy is unplanned, and occurs in challenging circumstances, significant maternal bonding can still take place, and this bond can persist even beyond fetal death.31 Even when bonding may be weak or ambivalent at the time of the abortion, the attachment can persist and grow stronger over time.

In Rose's case, she continued to engage in further attachment behaviors as she read about parenting of boys and tried to form mental images of her baby.

Informed Consent

The Beijing Declaration and Platform for Action[44] were adopted by consensus of all the United Nations member nations, including the United States, and these documents have been reaffirmed annually by consensus. The Platform for Action mandates that women receive full information about all their reproductive options and that they be informed concerning potential side effects. Additionally, while not specifically referring to abortion, these documents state clearly that consent for all women's health services must be both "voluntary and informed." The Platform for Action also specifically condemns "forced abortion" as an act of violence against women.

There is good reason to believe that many women are not receiving the informed consent prior to abortion that is mandated by this U.N. document. For example, in a study of post-abortive women in a general gynecology population, two thirds of the women reported they had received no counseling at all, and only 10.8% said they had received adequate counseling.[11]

One important aspect of abortion about which women are rarely informed has to do with maternal - fetal attachment. Women are not being informed that they may already be bonding to their babies in utero, although that is actually a very frequent occurrence, experienced by a substantial number of women.

Abortion clinic personnel are trained to tell women, "It's just a clump of cells." When women are led to expect that they are having a clump of cells removed, there is no basis for making an informed decision in regard to possible bonding to the baby, and the emotional reaction that may emerge after this loss.

In one survey, 90% of the women said they had received no information concerning fetal development.[25] In this study, no questions were even asked regarding what information they received regarding maternal - fetal bonding, but it seems very likely that if they were not given information about fetal development, they were not informed about possible bonding to their baby, either.

Melody, Donna, and Rose knew they wanted their babies, and experienced extreme distress after the abortion. Some women want their babies later, when it's too late. It may be when they hold their firstborn in their arms and realize, heartbreakingly, there was another baby.

Darla's abortion was not coerced, and she did not experience any emotional problems at the time. But she reported that nearly 20 years later, while employed at a children's hospital where she worked with premature babies, "then it hit." She experienced severe emotional distress associated with thoughts about her past abortion, severe enough distress that she sought mental health treatment, later participating in an abortion recovery program with benefit.

Mary's experience was similar. As a student nurse, helping a woman in the midst of a miscarriage, Mary ended up with a fetus in her hand, about the same size and age as her own baby would have been. Mary experienced distressing recollections of her abortion which led her to seek treatment.

These examples show that even women who choose an abortion without coercion, who do not have a strong attachment to the fetus, may at a later time, through additional experience or information, come to recognize the presence of persistent attachment which is surprisingly strong. Darla's experience with premature babies, and Mary's with the miscarried baby, may have "put a face" to the children they lost and increased the strength of the attachment and their experience of trauma from the abortion.

This is very pertinent to current questions regarding medication abortion, such as abortion by use of RU-486, since this method of abortion intrinsically offers more opportunities for the baby to be seen by the woman as she terminates the pregnancy at home.

Understanding the APA Report:

The 2008 APA Report8 was widely regarded as concluding that most women do not have mental health problems associated with abortion. But that is not what the report or its conclusion actually says. In fact, the conclusion excludes most of the real women having abortions in the U.S., and the conclusions clearly apply to only a small minority of U.S. women. The carefully worded conclusion states that it is intended to apply only to adult women having a single first trimester abortion of an unplanned pregnancy.[8]

The stated conclusion specifically indicated it was intended to apply only to adult women, not those under 21, discussing in the body of the report that "younger age has been linked in some studies to more negative psychological outcomes."[8] The APA's conclusion excludes Rose, Donna, and Robyn Reid who were all in their teens. During 2006, 206,880 teens under age 20 had abortions in the U.S. and the conclusion does not apply to these women.[45]

Addtionally, the conclusion as stated only applies to women having a "single" abortion, with the report presenting evidence that those who have multiple abortions have more negative outcomes.[8] However, Guttmacher Institute reports that 48% to 52% of all U.S. abortions are repeat abortions; the APA's conclusion of no increased risk does not apply to these women.[46]

As we have already seen, the APA Report recognizes that women aborting wanted pregnancies, and those women experiencing coercion have more negative outcomes. So the APA conclusion indicating no increased risk of mental health problems from abortion was not intended to include Dr. Gosnell's patients Robyn Reid and Davida Johnson, nor women like Melody, Donna and Rose. As we have seen, one study indicated that 64% of abortions were pressured.[11]

Additionally, the APA report discusses findings that indicate women who have pre-existing mental health problems are more vulnerable to increased mental health problems after abortion,[8] and thus the conclusion of no increased risk was not intended to apply to these women.

Thus, it is readily seen that the stated conclusion of no increased risk applies only to a minority of women, with a large majority having been excluded from the conclusion.

In addition to excluding a majority of the women, it was also necessary to exclude much of the world literature on abortion in order to reach this conclusion. For one example, a 2007 study from an abortion clinic in South Africa, not included in the 2008 APA Report, revealed that 18% of their patients were diagnosed as having posttraumatic stress disorder three months after abortion.[47] The authors conclude, "High rates of PTSD characterize women who have undergone surgical abortions (almost one fifth of the sample meet criteria for PTSD)." (This is similar to other published reports).[48]

By way of comparison, 15.2% of male Vietnam veterans received a diagnosis of posttraumatic stress disorder in a U.S. government study in the 1980's.[49]

Conclusion:

Many women experience unwanted abortions under conditions of varying degrees of pressure, coercion or force. Many women experience uninformed abortions, with very inadequate counseling if any. These women have no awareness about possible harmful effects of abortion, no information about the full range of options available to them regarding babies they want, and no information about their own risk factors for possible adverse reactions.

It is essential that harmful mental health effects be acknowledged and that truly informed and voluntary consent is given, as mandated by the Beijing Declaration and Platform for Action,[44] to which all United Nations member nations have agreed, including the United States.

Prior to abortion, women must be evaluated to determine whether or not they are being pressured, coerced or forced.

As part of the informed consent process, it is essential for women to be counseled on maternal-fetal child attachment which is a fundamental interest of the pregnant woman; for many women, the disruption of this attachment is the source of the loss and distress they may experience following the abortion.

Additionally, women also deserve to have a comprehensive evaluation as to whether or not they have risk factors which may increase the likelihood for adverse psychological outcomes after abortion. This is part of the information they need in order to make a fully informed decision. Why would women deserve anything less?

References

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