Abortion Among Adolescents: Research Findings and the Current Debate Laurie Schwab Zabin, Valerie Sedivy
ABSTRACT: Utilizing research that focuses on adolescents as well as findings in samples which might have special relevance to young, unmarried women, this report summarizes research on the consequences of abortion among adolescents. It discusses prior literature in the area of parental notifcation and parental consent, subjects on which public opinion is not divided along familiar pro-choice/anti-choice lines. Following a discussion of methodological problems identified in prior research, it reports on a study designed to address these problems in an adolescent population; it discusses implicationsfor the current debate of this and other studies’ findings that there are no identifiable adverse sequelae of the abortion process. (J Sch Health. 1992;62(7):319-324.
W
ith the issue of abortion increasingly divisive in the U.S., it is important that well-designed, credible research be available to inform public policy. Unfortunately, emotion, not credible research often is not the basis for that policy. The development of a solid body of data and objective analysis should be a priority among those who seek to preserve and improve the health of women of childbearing age. The importance of abortion is underscored by two facts: teen-agers obtain one-quarter of all abortions in the U.S. and abortion rates for teen-agers have increased from 43 to 46 per 1,OOO teen-age women between 1981 and 1988.’ Interestingly, the U.S. rates are much higher than those in Canada, England, France, Sweden, and the Netherlands, which ranged from 5 to 26 per 1,OOO teen-age women in 1981.*
THE CONSEQUENCES OF ABORTION Although much is known about the adverse outcomes of early childbearing, there is little evidence of negative consequences to abortion, either overall or specific to teens. Various hypotheses have examined immediate, short-term, and long-term consequences of induced abortion, including relative mortality, morbidity, subsequent fertility, and psychological sequelae among women of all ages. Some studies have included adolescents, and a small number have focused on them. Even if the studies do not focus on teens, characteristics typical of that age group may help to identify findings that might be most relevant to them. These include findings specific to unmarried women, younger adult women, or women who do not want to bear a child. Given that more than 85% of pregnancies among teens are classified by them as unintended, it can be assumed that sequelae of aborting a desired conception would rarely apply to this age group. Physical Consequences
While extremely low rates of abortion-related mortality and morbidity continue to decline among women of all ages, even lower rates are found among teenagers. There is a documented increase in the mortality risk of abortion with increasing gestational age for all age groups,’ but despite the tendency of teen-agers to ~~
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Laurie Schwab Zabin, PhD; and Valerie Sedivy, MHS. Dept. of Population Dynamics, Johns Hopkins School of Hygiene and Public Hearth, 4503 Hygiene, 615 N. Wove St., Baltimore, MD 21205.
delay pregnancy diagnosis, mortality risks appear to be five times greater for teens who continue their pregnancies than they are for teens who terminate them. While Cates‘ also found that younger women were significantly more likely to suffer cervical trauma than older women, rates of cervical trauma for the younger age group declined from 16.8 to 5.5 per 1,OOO procedures between 1971 and 1978, and have declined further since the widespread adoption of less invasive cervical dilation techniques.J Burkman et a16 found adolescents age 17 or younger at higher risk of endometritis as a result of abortion. They suggest the finding could result from the failure to control for higher pre-existing levels of sexually transmitted disease often found among this age group. A major area of interest relative to the sequelae of abortion has been its affects on future pregnancy outcome. Although no evidence exists of significant problems at any age, some methodological issues impede the application of adult findings to teens, such as the possibility of differentail reporting of abortion-related complications, difficulty in determining the gestational age at the time of abortion (especially when cycles are irregular), and the interval between abortion and the subsequent desire for pregnancy, which is likely to be longer for adolescents. In addition, findings from some studies indicate unwanted conception, more commonly experienced by teens, is likely to carry its own physical Nevertherisks, which could introduce a critical less, studies of abortion sequelae among women younger than age 20 indicate that a history of induced abortion is not associated with lower subsequent pregnancy rates or adverse pregnancy ~ u t c o m e s . ~ J ~ Hogue et all1 reviewed 10 studies that assessed the late sequelae of first trimester abortion by vacuum aspiration, the most common method employed for teens. They concluded that assertions of increased risk of low birth weight, prematurity, or subsequent miscarriage among those with a history of induced abortion could not be substantiated from the available evidence, after adjusting for various confounding factors such as smoking, maternal weight, marital status, STD history, socioeconomic status, and delay in seeking care.” Psychological Consequences
Though it has been proposed that psychological consequences of abortion could include serious psychopathology as well as various forms of emotional distress,
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these sequelae have yet to be demonstrated. Incidence of differ from an overall study population with regard to psychopathology among abortion populations would be these characteristics: most adolescent pregnancies are difficult to assess because of the relatively low rate of unplanned, and adolescents may have less well-defined psychopathology in the general population, and because social support systems and different decision-making of the lack of a reporting system for post-abortion psystyles or coping skills. chopathology. However, there appears to be a consenOne study that examined the relationship of pregsus that induced abortion has a negligible effect on the nancy desirability to the psychological outcome of its incidence of psychopathology in women who have undertermination documented that termination of a wanted gone the procedure.” pregnancy is associated with a greater level of depresOne prospective study1 assessed post-abortion sion, indicated by higher scores on the Beck Depression psychosis among all age groups based on psychiatrists’ Inventory three weeks after the abortion.23Women who reports of 1.3 million women. Over a period of 15 derminate an unwanted pregnancy may find that decimonths, only one case was documented, and that was in sion more psychologically beneficial than carrying to a patient with a prior history of mental di~turbance.’~ term .wJ5 Similarly, prior mental disturbance was found in a case As pregnancy desirability appears to affect the report of two teens who attempted suicide after aborwoman’s psychological response to abortion, cohort tion. studies suggest that it also affects her response to her Mueller and Major1’ applied the Beck Depression offspring in the case of a denied abortion. Women in Inventory to first-trimester abortion patients and obSweden and Czechoslovakia who sought and were tained a mean score well below that indicative of clinical denied abortion were followed and compared to women depression. Another study,I6 using the same inventory, with unplanned pregnancies who did not seek abortion; found no differences between teen-agers and adults with both groups gave birth to their unplanned children. regard to post-abortion depression or anxiety. In a More frequent records of social and psychiatric difficulstudy1’ comparing Minnesota Multiphasic Personality ties during the child’s developmental years were docuInventory (MMPI) and Symptom Checklist (SCL) mented among the unplanned children whose mothers scores among women who chose early abortion, late were denied abortion.26 abortion, or term birth, no significant difference was Pregnancy desirability is, in turn, associated with found between groups; each group’s mean score fell greater difficulty in making the decision to terminate, below the cutoff score indicating psychopathology. another factor thought to influence post-abortion emoMost studies that assess the psychological effects of tional response. Though only a few women find the induced abortion seek to measure emotional distress decision difficult, a positive association has been noted similar to that associated with other stressful life events between this difficulty and the subsequent experience of and not necessarily indicative of psychosis. Adler” connegative emotions reflecting loss two to three months tends that guilt, for example, is socially included and after termination. l o Application of this variable to teens would be expected, particularly among women living in is questioned because Bracken,” who found the difsocial environments where abortion is highly unacceptficulty of decision-making was associated with postable. She found unmarried women were more likely to abortion anxiety, noted its effect is stronger for married experience guilt, shame, and fear of disapproval, which women, a group to which few adolescents belong. she notes are “socially-based” emotions, rather than A perception of social support for the decision to those indicative of pathology. Nevertheless, relief is the abort seems associated with a more positive emotional most common emotional reaction reported.‘ Perez-Rayes response; Moseley et a12’documented greater emotional et all9 found that resolving the crisis of an unwanted distress among women who held negative feelings for pregnancy was viewed by some study respondents as a their partners, who made the abortion decision alone, “helpful event in development.” and who experienced opposition from parents. Another study found partner support was associated with less Few studies have examined the level of regret or frequent feelings of loneliness.28As would be expected, satisfaction after abortion or childbearing specifically Brackenzofound parental support is more important to among young women. Among those that have, results younger women, and a significantly more favorable redepend on the time frame and the comparison group action to abortion exists when perceived support is used for measurement. One researcher reported that greatest. while still in the clinic, younger, unmarried women were While few studies have examined baseline characterslightly more likely to regret their decision than older istics of women prior to the pregnancy, this single factor women, and that although regret is uncommon among is likely to have the greatest effect on her decisionboth childbearers and aborters, childbearers appear to making ability, her coping skills, and her overall be slightly more satisfied with their decisions.m.21 psychological response to abortion. Cohen and RothZ9 Another study camparing abortions and childbearers found that “avoiders” and “nonapproachers” were found them equally likely to be satisfied with their more likely to experience depression and anxiety when decisions six months after the outcome.2J coping with an abortion. Those who expect to cope well Several factors are thought to influence the emotionshow lower scores on the Beck Depression Inventory, al effect of abortion, including how much the pregnancy both immediately following the procedure and three is desired, the level of support from significant others, weeks later, than those with more negative and the coping and decision-making style of the individexpectations. 21 ual. Most studies failed to control for these factors, Other baseline characteristics may introduce selfwhich are of particular relevance to teens who may
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selection bias. Freeman30 found that volunteer study participants were more likely to be younger, single, and abortion repeaters, and more likely to find the decision difficult. Self-selection also inevitably occurs with regard to pregnancy resolution; those who choose abortion have been found to differ from those who continue the pregnancy. The former group is likely to have higher socio-economic status and educational aspirations, belong to intact families, and enjoy greater financial independence.3 1 Not surprisingly, this group is psychologically healthier at baseline than the group who gave birth. ’’ Other methodological issues complicating the study of the psychological implications of induced abortion in teen-agers include failure to control for the type of procedure and gestational stage at which the procedure is performed. Cates,‘ who refers to an association between these factors and the severity of psychological sequelae, suggests that teens - a group who delay seeking abortion - might therefore be expected to experience greater risk of psychological sequelae. Nevertheless, a large majority of abortion procedures are performed within the first trimester, when the less stressful vacuum aspiration technique can be employed, and are without negative emotional sequelae.
PARENTAL NOTIFICATION AND PARENTAL CONSENT Many recent studies have examined the impact of laws requiring parental notification before a minor obtains an abortion, and thus provide data only about girls who terminate pregnancies. Many of the samples in these studieP6 have shown that more than one-half (55%-70%) the girls notified their parents or at least one parent of their decisions. One study, which found that fewer than one-half notified both parents, did not report the extent to which at least one parent was notified.” Among those reporting parental knowledge, most notified parents voluntarily rather than relying on clinic notification procedure^.)^ Mothers were more likely than fathers to be i n f ~ r m e d . ~ ~ - ’ ~ Factors associated with an increased likelihood of parental notification include younger age,33.34.37 living at a greater distance from the clinic,33good communication with the mother, anticipation of a supportive reaction, and less frequent attendance at religious servi c e ~ . Girls ~ ~ . ~who ~ see themselves as the primary decision makers were more likely to notify neither parent.34One study in Minnesota, with a law requiring notification of both parents before a minor’s abortion, found that girls of lower socioeconomic status were less likely to use the court bypass procedure, and thus more likely to notify both parents.” The effect of living with parents was examined in the Minnesota study. Although researchrs found that girls living with both parents were more likely to notify both parents than to notify one or neither, those who used the court bypass option among this group were more likely to notify neither than to notify at least one. The same girls seem more likely to perceive both poor communication with the mother and greater familial control over their decisions. Interestingly, one-quarter of girls
who used the judicial bypass went to court with one parent, typically the mother. Results from studies examining the effect of clinic notification policies, or state laws mandating clinic notification, seem to depend on whether the study reports notification of one or both parents. One study suggested that girls attending clinics with such policies were more likely to have notified their parents, referring to both parents.’) Another study3s found that while patients in a state requiring parental notification were more likely than patients in a state without such a law to have notified both parents, they were equally likely to have notified at least one parent. Efforts to examine the effects of parental notification laws on subsequent pregnancy rates are impeded by the difficulty of determining the number of abortions sought out-of-state or by illegal means as a result of the law. One study,lgwhich documented lower in-state birth and legal abortion rates among teens, found that a larger proportion of teens obtained abortions in the second trimester. Another study40found that the large group of minors traveling across state lines to obtain abortions accounted for the reduction in in-state abortions. Furthermore, since the drop in births occurred within a very few months after the law went into effect, the allegation of causality is questioned. Torres” reported no effect of gestational age on the likelihood of parental notifiction. There is no reported association with ethnicity, mainly because most studies sampled relatively homogeneous populations. Very little recent research has examined parental involvement in the decision-making process among girls who decide not to abort. One study4’ of 478 pregnant young women, not all teens, found those attending prenatal clinics twice as likely to have discussed their pregnancies with their mothers as those attending abortion clinics, and also more likely to have discussed their pregnancies with their partners and girlfriends. A study4’ examining the effects of parental influence on 43 Puerto Rican teen-agers showed the influence of parents, as well as of siblings, friends, and boyfriends, was much stronger among girls who decided to bear a child than in those who decided to abort. In contrast, a survey of 432 pregnant, unmarried teen-agers in Michigan revealed maternal influence played a role in the girl’s decision in approximately the same percentage (57%) of those who ultimately aborted as it did of those who kept the baby.I6 In the last two studies, it is implied that “influence” and awareness on the part of the influencer are correlated.
METHODOLOGICAL PROBLEMS In 1987, the U.S. Surgeon General was asked to report on the psychological consequences of abortion, a report which was produced in 1989. At that time, Surgeon General Koop concluded the evidence was not available to document negative sequelae and proposed that the only way to do so would involve a longitudinal study that would be expensive and require a long period of ob~ervation.~~ His protocol, by enrolling its population before conception (or even before first intercourse), would have to follow a very large group of women until they conceived and either aborted or carried to term. A
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review by the American Psychological Association (APA)44also addressed methodological issues in this research. Among others, APA identified the following problems: 1) A failure to include appropriate control populations or, in many cases, to identify any controls at all; 2) Follow-up at a single point in time - because, for example, attitudes manifested in the hours immediately following an abortion or childbirth may be very different from those a few days or months later; 3) A failure to use validated instruments for the measurement of psychological sequelae - causing many of the studies to rely on the subjective impressions of the interviewer; 4) A lack of baseline data - making it impossible to control for prior psychological status, or when a comparison group is used, to control for differences in baseline characteristics; 5 ) The use of populations whose circumstances are extremely different - such as failing to distinguish between a married women forced to terminate a wanted conception because of health and a woman voluntarily terminating an unwanted conception, or failing to distinguish between women having legal vs. illegal abortions.
in question was tapped in the abbreviated telephone interview; 5 ) Validated measures of psychological status were used; 6) A measure of anxiety status that separated the transient state from the underlying trait made it possible to minimize the effects of the respondent's stress at baseline so changes over time in this variable could be included; and 7) Enough questions about sexual and contraceptive behavior were asked so that internal checks on the validity of the data were possible, and variables covering a large range of background and demographic data, as well as socioeconomic and educational status, made it possible to control for and to define the characteristics of the sample. Thus, rather than seeing the relative homogeneity of the group as a disadvantage - because it makes it impossible to generalize the findings over the population at large - that homogeneity makes it possible to minimize differences between subgroups that might have confounded the study. Furthermore, because it deals with a population at uniformly high risk of conception, information specific to these young women has considerable importance. Findings
A STUDY OF ABORTION SEQUELAE Responding to a request for proposals from the National Institutes of Health in 1984 to study the consequences of pregnancy loss among adolescents, staff at Johns Hopkins designed a protocol to focus on young women during the two years following their presentation for a pregnancy test at one of two inner-city clinics in Baltimore. Young, Black women age 17 and younger were admitted while awaiting the results of their tests. A lengthy interview at that time was followed by telephone contacts at six and 18 months and face-to-face interviews at one and two years. Girls who tested positive and who terminated their pregnancies were compared with two control populations: those who carried the index pregnancy to term and those whose tests were negative. The research design was conceived to avoid as many problems as possible later identified by APA. The design sought to do so with a homogeneous sample over a realistic period of time - long enough to report longitudinal results and short enough so outcomes would not be unduly affected by the proliferation of intervening events. Design aspects which addressed specific problems identified above included: 1) Two appropriate control populations were identified that were similar in age, socioeconomic condition, and the sexual experience that brought them into the study; 2) The design was essentially prospective but utilized retrospective data collected at baseline to permit comparisons within and between groups; 3) By controlling for baseline differences, the study could focus on change in levels of the relevant variables over time, rather than on their absolute values; 4) Follow-up measurements were made at two or four points in time, depending on whether the variable
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When the three groups are examined at baseline, the major differences between them are in education: young women who choose abortion are considerably more ambitious in their aspirations and significantly are more likely to be at the appropriate grade level for age and In the less likely to have repeated a grade in scho01.4~~~~ course of the two year follow-up, educational trajectories diverge dramatically as the childbearing group falls far behind. A measure of negative educational change, defined as leaving school before graduation or, if still in school, failing to progress at the expected rate, shows more than twice the negative change among the childbearers as among the abortion group. In addition to calculating a change variable during the two-year period, multiple regression analyses showed the differences between the groups at follow-up remain significant when controlling for baseline characteristics in each of the areas reported. Economic dependency was explored using two household measures: a job dependeny ratio representing the proportion of adults who were working and a measure of welfare dependency. Negative change in the two-year period was related highly to the respondent's work status at the end of the f~llow-up.~' Whereas dependency status in the abortion group's households improved over each interval of the follow-up period, childbearers experienced a setback and then a slight recovery. Therefore, although differences between them were not significant at baseline, they were at the two-year mark. Psychological sequelae were a major area of interest and were explored with three measures. To control for the stresses on these young women while awaiting the results of their tests, the Spielberger State-Trait Anxiety Index4*was used to separate the passing state from the more stable trait. It appeared to discriminate successfully and revealed that, although underlying anxiety traits were not significantly elevated at baseline, state mea-
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sures were very high. At follow-up, the anxiety state came down; both measures were at levels comparable to the national norm for high school females, the abortion group somewhat closer to the norm than the childbearing group. Neither group experienced significant change over time in psychological status; in fact, most change was in a positive direction. This was true not only in anxiety but also in self-esteem measured by the Rosenberg scale,49and locus of control measured by items from the Rotter scale.5o Because small differences, even if statistically significant, may have little substantive importance, a measure of negative psychological change was created that included those respondents whose scores in each of the three dimensions showed a deterioration, however small. Such a pattern seemed of interest because most girls in the childbearing and the abortion groups had improved in self-esteem, become more internal in their locus of control, and showed less anxiety. Only 5% and 4.5070, respectively, demonstrated “negative change.” These findings also were explored in the negative test group with interesting results. Their negative psychological change was more than double that of the abortion group and almost double the childbearing group. In most other areas, they were similar to the childbearing group. Their high-risk status was confirmed when 58% of them became pregnant within 18 months of the original test, which explained their initial resemblance to the childbearers. Subsequent pregnancy was apparently responsible for what little educational change occurred in the abortion group; those who became pregnant again in the follow-up period absorbed almost all the observed negative change, which was trivial among those who managed to avoid a conception. The fact that fewer members of the abortion group became pregnant (37%) than of the negative test or the childbearing group (47Oi’o) contributed to their positive advantage at the two-year interview. Thus, both in absolute and relative terms, the abortion group appear to be doing well. These data give no evidence of negative psychological sequelae to pregnancy termination, and also suggest considerable advantage in educational and economic areas. Since no such sequelae have emerged in a two-year period, either in the short-term or long-term, it seems clear that longer follow-up could add little useful information: intervening events would make it impossible to attribute new characteristics to the abortion or childbearing experience which have not developed at all during the four follow-up interviews. A STUDY OF PARENTAL NOTIFICATION The same data permitted an exploration of the issue - “With whom do adolescents communicate when deciding on the outcomes of their pregnancies?” The study” examined communication in two time periods, one ending at the time of the pregnancy test visit and one ending with the outcome decision. The study confirmed what other studies have suggested: more than 91Yo consulted voluntarily with their mothers or parent surrogates, more than 86% specifically with the mother.
The designation of a parent surrogate group is of some importance because many young women report they were “responsible to” some female other than the mother, such as a grandmother, aunt, etc., or that the surrogate had “raised” them. It was logical that they selected that individual to confide in, especially when the mother was not in the home. A surprising 66% who did not live with their mothers had consulted with them nonetheless, usually in addition to the surrogate with whom they lived. A very small number, less than 9%, attempted to make the decision without some level of parental guidance and a minimum of almost half of this group turned to another adult. In this study, the partner was not defined as an “adult” confidant whatever his age. Also excluded were the few individuals whose age was not determined but who may have been an adult, such as an older sister. Therefore, this estimate of those who did not have adult support is conservative. Is consultation with a parent related to the psychological sequelae - of abortion or childbearing - that a young woman experiences, or with her level of satisfaction with her outcome decision? Most respondents were “satisfied” and, as reported, showed no negative psychological change. The few girls who chose not to communicate were as happy with their decisions as those who did consult and received support for their decisions. The only ones who were more likely to express dissatisfaction were those who did communicate with a parent and did not receive that support. Thus, it would appear that the small number who did not communicate made a responsible determination. CONCLUSION The Johns Hopkins study supports other studies that suggest almost unanimously that there are no significant negative sequelae to abortion among teen-age women. The medical consequences of childbearing are more adverse than those of abortion at all stages of gestation. In addition, the evidence seems increasingly clear that no negative psychological sequelae exist. The fact that, in their educational and economic condition, adolescents in the abortion group are doing well - both in absolute terms and relative to the other groups - and that they are experiencing fewer unintended conceptions, suggests that their status relative to the others has little reason to change. Under these circumstances, it is difficult to support policies that put barriers in the way of a young woman’s selection of the safer outcome, abortion, because of concerns about physical or psychological consequences. Mandated parental involvement proposed by the current administration in Washington represents such a barrier. One-half the states in the U.S. already permit a minor to obtain the means to prevent conception clearly the more desirable option - without compulsory parental involvement. Given that she has conceived, however, she is permitted without consultation to choose the more dangerous outcome, childbearing, the one that will most profoundly affect her life and that of her family. In the absence of evidence of adverse sequelae, it would seem unwise not to permit her the rn same discretion when she elects the safer option.
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27. Moseley DT, Follingstad DR, Harley H, Heckle RV. Psychological factors that predict reaction to abortion. J Clin Psychol. 1981;37:276-279. 28. Robbins JM. DeLameter JD. Support from significant others and loneliness following induced abortion. SOC Psychiatr. 1985;20(2): 92-99. 29. Cohen L, Roth S. Coping with abortion. J Human Stress. 1984;10(3):140-145. 30. Freeman EW. Influence of personality attributes on abortion experiences. Am J Orthopsychiatr. 1977;47(3):503-513. 31. Phipps-Yonas S.Teen pregnancy and motherhood: A review of the literature. Am J Orthopsychiatr. 1980;50(3):408-430, 32. Olson L. Social and psychological correlates of pregnancy resolution among adolescent women. Am J Orthopsychiatr. 1980;50 (3):432-435. 33. Torres A, Forrest JD, Eisman S. Telling parents: Clinic policies and adolescents’ use of family planning and abortion services. Fam Plann Perspect. 1980;12(6):284-292. 34. Blum RW, Resnick MD, Stark T. Factors associated with the use of court bypass by minors to obtain abortions. Fam Plann Perspect. 1990;22(4):158-160. 35. Blum RW, Resnick MD, Stark TA. The impact of a parental notification law on adolescent abortion decision-making. Am J Public Health. 1987;77(5):619-620. 36. Rosen RH. Adolescent pregnancy decision making: Are parents important? Adolescence. 1980;15(57):43-54. 37. Clary F. Minor women obtaining abortions: A study of parental notification in a metropolitan area. Am J Public Health. 1982;72(3):283-285. 38. Zabin LS, Hirsch MB. Emerson MR, Raymond E. To whom do girls talk about their pregnancies? Adolescents’ communication with parents and parent surrogates. Fam Plann Perspect. 1992;24(4): 148-154. 39. Rogers JL, Boruch RF, Stoms GB. DeMoya D. Impact of the Minnesota parental notification law on abortion and birth. Am J Public Health. 1991;81(3):294-298. 40. Cartoff VG, Klerman LV. Parental consent for abortion: Impact of the Massachusetts law. Am J Public Health. 1986;76(4): 397-400. 41. Bracken MB, Klerman LV, Bracken M. Abortion, adoption, or motherhood: An empirical study of decision-making during pregnancy. Am J Obstet & Gynecol. 1978;130(3):251-262. 42. Ortiz CG, Nutall EV. Adolescent pregnancy: Effects of family support, education, and religion on the decision to carry or terminate among Puerto Rican teenagers. Adolescence. 1987;22(88):897-917. 43. Koop CE. Letter to the President. Washington, DC: Dept of Health and Human Services; January 9, 1989. 44. Psychological Sequelae of Abortion. Washington DC: American Psychological Association; 1987. 45. Zabin LS, Hirsch MB, Emerson MR. When urban adolescents choose abortion: Effects on education, psychological status and subsequent pregnancy. Fam Plann Perspect. 1989;21(6):248-255. 46. Hardy JB, Zabin LS. Adolescent Pregnancy in an Urban Environment: Issues, Programs, and Evaluation. Washington, DC: The Urban Institute; 1991. 47. Zabin LS, Wong R, Weinick RM, Emerson MR: Dependency in urban Yack families following the birth of an adolescent’s child. J Marriage,Fam. 1992;54(August):496-507. 48. Spielberger CD. State-Trait Anxiety Inventory. Palo Alto, Calif: Consulting Psychology Press; 1983. 49. Rosenberg M. Society and the Adolescent Selfimage. Princeton, NJ: Princeton University Press; 1965. 50. Rotter JB. The Rotter internal-external locus of control. Psychol Monogr. 1966;80609.
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ABSTRACT: Utilizing research that focuses on adolescents as well as findings in samples which might have special relevance to young, unmarried women, this report summarizes research on the consequences of abortion among adolescents. It discusses prior literature in the area of parental notifcation and parental consent, subjects on which public opinion is not divided along familiar pro-choice/anti-choice lines. Following a discussion of methodological problems identified in prior research, it reports on a study designed to address these problems in an adolescent population; it discusses implicationsfor the current debate of this and other studies’ findings that there are no identifiable adverse sequelae of the abortion process. (J Sch Health. 1992;62(7):319-324.
W
ith the issue of abortion increasingly divisive in the U.S., it is important that well-designed, credible research be available to inform public policy. Unfortunately, emotion, not credible research often is not the basis for that policy. The development of a solid body of data and objective analysis should be a priority among those who seek to preserve and improve the health of women of childbearing age. The importance of abortion is underscored by two facts: teen-agers obtain one-quarter of all abortions in the U.S. and abortion rates for teen-agers have increased from 43 to 46 per 1,OOO teen-age women between 1981 and 1988.’ Interestingly, the U.S. rates are much higher than those in Canada, England, France, Sweden, and the Netherlands, which ranged from 5 to 26 per 1,OOO teen-age women in 1981.*
THE CONSEQUENCES OF ABORTION Although much is known about the adverse outcomes of early childbearing, there is little evidence of negative consequences to abortion, either overall or specific to teens. Various hypotheses have examined immediate, short-term, and long-term consequences of induced abortion, including relative mortality, morbidity, subsequent fertility, and psychological sequelae among women of all ages. Some studies have included adolescents, and a small number have focused on them. Even if the studies do not focus on teens, characteristics typical of that age group may help to identify findings that might be most relevant to them. These include findings specific to unmarried women, younger adult women, or women who do not want to bear a child. Given that more than 85% of pregnancies among teens are classified by them as unintended, it can be assumed that sequelae of aborting a desired conception would rarely apply to this age group. Physical Consequences
While extremely low rates of abortion-related mortality and morbidity continue to decline among women of all ages, even lower rates are found among teenagers. There is a documented increase in the mortality risk of abortion with increasing gestational age for all age groups,’ but despite the tendency of teen-agers to ~~
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Laurie Schwab Zabin, PhD; and Valerie Sedivy, MHS. Dept. of Population Dynamics, Johns Hopkins School of Hygiene and Public Hearth, 4503 Hygiene, 615 N. Wove St., Baltimore, MD 21205.
delay pregnancy diagnosis, mortality risks appear to be five times greater for teens who continue their pregnancies than they are for teens who terminate them. While Cates‘ also found that younger women were significantly more likely to suffer cervical trauma than older women, rates of cervical trauma for the younger age group declined from 16.8 to 5.5 per 1,OOO procedures between 1971 and 1978, and have declined further since the widespread adoption of less invasive cervical dilation techniques.J Burkman et a16 found adolescents age 17 or younger at higher risk of endometritis as a result of abortion. They suggest the finding could result from the failure to control for higher pre-existing levels of sexually transmitted disease often found among this age group. A major area of interest relative to the sequelae of abortion has been its affects on future pregnancy outcome. Although no evidence exists of significant problems at any age, some methodological issues impede the application of adult findings to teens, such as the possibility of differentail reporting of abortion-related complications, difficulty in determining the gestational age at the time of abortion (especially when cycles are irregular), and the interval between abortion and the subsequent desire for pregnancy, which is likely to be longer for adolescents. In addition, findings from some studies indicate unwanted conception, more commonly experienced by teens, is likely to carry its own physical Nevertherisks, which could introduce a critical less, studies of abortion sequelae among women younger than age 20 indicate that a history of induced abortion is not associated with lower subsequent pregnancy rates or adverse pregnancy ~ u t c o m e s . ~ J ~ Hogue et all1 reviewed 10 studies that assessed the late sequelae of first trimester abortion by vacuum aspiration, the most common method employed for teens. They concluded that assertions of increased risk of low birth weight, prematurity, or subsequent miscarriage among those with a history of induced abortion could not be substantiated from the available evidence, after adjusting for various confounding factors such as smoking, maternal weight, marital status, STD history, socioeconomic status, and delay in seeking care.” Psychological Consequences
Though it has been proposed that psychological consequences of abortion could include serious psychopathology as well as various forms of emotional distress,
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these sequelae have yet to be demonstrated. Incidence of differ from an overall study population with regard to psychopathology among abortion populations would be these characteristics: most adolescent pregnancies are difficult to assess because of the relatively low rate of unplanned, and adolescents may have less well-defined psychopathology in the general population, and because social support systems and different decision-making of the lack of a reporting system for post-abortion psystyles or coping skills. chopathology. However, there appears to be a consenOne study that examined the relationship of pregsus that induced abortion has a negligible effect on the nancy desirability to the psychological outcome of its incidence of psychopathology in women who have undertermination documented that termination of a wanted gone the procedure.” pregnancy is associated with a greater level of depresOne prospective study1 assessed post-abortion sion, indicated by higher scores on the Beck Depression psychosis among all age groups based on psychiatrists’ Inventory three weeks after the abortion.23Women who reports of 1.3 million women. Over a period of 15 derminate an unwanted pregnancy may find that decimonths, only one case was documented, and that was in sion more psychologically beneficial than carrying to a patient with a prior history of mental di~turbance.’~ term .wJ5 Similarly, prior mental disturbance was found in a case As pregnancy desirability appears to affect the report of two teens who attempted suicide after aborwoman’s psychological response to abortion, cohort tion. studies suggest that it also affects her response to her Mueller and Major1’ applied the Beck Depression offspring in the case of a denied abortion. Women in Inventory to first-trimester abortion patients and obSweden and Czechoslovakia who sought and were tained a mean score well below that indicative of clinical denied abortion were followed and compared to women depression. Another study,I6 using the same inventory, with unplanned pregnancies who did not seek abortion; found no differences between teen-agers and adults with both groups gave birth to their unplanned children. regard to post-abortion depression or anxiety. In a More frequent records of social and psychiatric difficulstudy1’ comparing Minnesota Multiphasic Personality ties during the child’s developmental years were docuInventory (MMPI) and Symptom Checklist (SCL) mented among the unplanned children whose mothers scores among women who chose early abortion, late were denied abortion.26 abortion, or term birth, no significant difference was Pregnancy desirability is, in turn, associated with found between groups; each group’s mean score fell greater difficulty in making the decision to terminate, below the cutoff score indicating psychopathology. another factor thought to influence post-abortion emoMost studies that assess the psychological effects of tional response. Though only a few women find the induced abortion seek to measure emotional distress decision difficult, a positive association has been noted similar to that associated with other stressful life events between this difficulty and the subsequent experience of and not necessarily indicative of psychosis. Adler” connegative emotions reflecting loss two to three months tends that guilt, for example, is socially included and after termination. l o Application of this variable to teens would be expected, particularly among women living in is questioned because Bracken,” who found the difsocial environments where abortion is highly unacceptficulty of decision-making was associated with postable. She found unmarried women were more likely to abortion anxiety, noted its effect is stronger for married experience guilt, shame, and fear of disapproval, which women, a group to which few adolescents belong. she notes are “socially-based” emotions, rather than A perception of social support for the decision to those indicative of pathology. Nevertheless, relief is the abort seems associated with a more positive emotional most common emotional reaction reported.‘ Perez-Rayes response; Moseley et a12’documented greater emotional et all9 found that resolving the crisis of an unwanted distress among women who held negative feelings for pregnancy was viewed by some study respondents as a their partners, who made the abortion decision alone, “helpful event in development.” and who experienced opposition from parents. Another study found partner support was associated with less Few studies have examined the level of regret or frequent feelings of loneliness.28As would be expected, satisfaction after abortion or childbearing specifically Brackenzofound parental support is more important to among young women. Among those that have, results younger women, and a significantly more favorable redepend on the time frame and the comparison group action to abortion exists when perceived support is used for measurement. One researcher reported that greatest. while still in the clinic, younger, unmarried women were While few studies have examined baseline characterslightly more likely to regret their decision than older istics of women prior to the pregnancy, this single factor women, and that although regret is uncommon among is likely to have the greatest effect on her decisionboth childbearers and aborters, childbearers appear to making ability, her coping skills, and her overall be slightly more satisfied with their decisions.m.21 psychological response to abortion. Cohen and RothZ9 Another study camparing abortions and childbearers found that “avoiders” and “nonapproachers” were found them equally likely to be satisfied with their more likely to experience depression and anxiety when decisions six months after the outcome.2J coping with an abortion. Those who expect to cope well Several factors are thought to influence the emotionshow lower scores on the Beck Depression Inventory, al effect of abortion, including how much the pregnancy both immediately following the procedure and three is desired, the level of support from significant others, weeks later, than those with more negative and the coping and decision-making style of the individexpectations. 21 ual. Most studies failed to control for these factors, Other baseline characteristics may introduce selfwhich are of particular relevance to teens who may
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selection bias. Freeman30 found that volunteer study participants were more likely to be younger, single, and abortion repeaters, and more likely to find the decision difficult. Self-selection also inevitably occurs with regard to pregnancy resolution; those who choose abortion have been found to differ from those who continue the pregnancy. The former group is likely to have higher socio-economic status and educational aspirations, belong to intact families, and enjoy greater financial independence.3 1 Not surprisingly, this group is psychologically healthier at baseline than the group who gave birth. ’’ Other methodological issues complicating the study of the psychological implications of induced abortion in teen-agers include failure to control for the type of procedure and gestational stage at which the procedure is performed. Cates,‘ who refers to an association between these factors and the severity of psychological sequelae, suggests that teens - a group who delay seeking abortion - might therefore be expected to experience greater risk of psychological sequelae. Nevertheless, a large majority of abortion procedures are performed within the first trimester, when the less stressful vacuum aspiration technique can be employed, and are without negative emotional sequelae.
PARENTAL NOTIFICATION AND PARENTAL CONSENT Many recent studies have examined the impact of laws requiring parental notification before a minor obtains an abortion, and thus provide data only about girls who terminate pregnancies. Many of the samples in these studieP6 have shown that more than one-half (55%-70%) the girls notified their parents or at least one parent of their decisions. One study, which found that fewer than one-half notified both parents, did not report the extent to which at least one parent was notified.” Among those reporting parental knowledge, most notified parents voluntarily rather than relying on clinic notification procedure^.)^ Mothers were more likely than fathers to be i n f ~ r m e d . ~ ~ - ’ ~ Factors associated with an increased likelihood of parental notification include younger age,33.34.37 living at a greater distance from the clinic,33good communication with the mother, anticipation of a supportive reaction, and less frequent attendance at religious servi c e ~ . Girls ~ ~ . ~who ~ see themselves as the primary decision makers were more likely to notify neither parent.34One study in Minnesota, with a law requiring notification of both parents before a minor’s abortion, found that girls of lower socioeconomic status were less likely to use the court bypass procedure, and thus more likely to notify both parents.” The effect of living with parents was examined in the Minnesota study. Although researchrs found that girls living with both parents were more likely to notify both parents than to notify one or neither, those who used the court bypass option among this group were more likely to notify neither than to notify at least one. The same girls seem more likely to perceive both poor communication with the mother and greater familial control over their decisions. Interestingly, one-quarter of girls
who used the judicial bypass went to court with one parent, typically the mother. Results from studies examining the effect of clinic notification policies, or state laws mandating clinic notification, seem to depend on whether the study reports notification of one or both parents. One study suggested that girls attending clinics with such policies were more likely to have notified their parents, referring to both parents.’) Another study3s found that while patients in a state requiring parental notification were more likely than patients in a state without such a law to have notified both parents, they were equally likely to have notified at least one parent. Efforts to examine the effects of parental notification laws on subsequent pregnancy rates are impeded by the difficulty of determining the number of abortions sought out-of-state or by illegal means as a result of the law. One study,lgwhich documented lower in-state birth and legal abortion rates among teens, found that a larger proportion of teens obtained abortions in the second trimester. Another study40found that the large group of minors traveling across state lines to obtain abortions accounted for the reduction in in-state abortions. Furthermore, since the drop in births occurred within a very few months after the law went into effect, the allegation of causality is questioned. Torres” reported no effect of gestational age on the likelihood of parental notifiction. There is no reported association with ethnicity, mainly because most studies sampled relatively homogeneous populations. Very little recent research has examined parental involvement in the decision-making process among girls who decide not to abort. One study4’ of 478 pregnant young women, not all teens, found those attending prenatal clinics twice as likely to have discussed their pregnancies with their mothers as those attending abortion clinics, and also more likely to have discussed their pregnancies with their partners and girlfriends. A study4’ examining the effects of parental influence on 43 Puerto Rican teen-agers showed the influence of parents, as well as of siblings, friends, and boyfriends, was much stronger among girls who decided to bear a child than in those who decided to abort. In contrast, a survey of 432 pregnant, unmarried teen-agers in Michigan revealed maternal influence played a role in the girl’s decision in approximately the same percentage (57%) of those who ultimately aborted as it did of those who kept the baby.I6 In the last two studies, it is implied that “influence” and awareness on the part of the influencer are correlated.
METHODOLOGICAL PROBLEMS In 1987, the U.S. Surgeon General was asked to report on the psychological consequences of abortion, a report which was produced in 1989. At that time, Surgeon General Koop concluded the evidence was not available to document negative sequelae and proposed that the only way to do so would involve a longitudinal study that would be expensive and require a long period of ob~ervation.~~ His protocol, by enrolling its population before conception (or even before first intercourse), would have to follow a very large group of women until they conceived and either aborted or carried to term. A
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review by the American Psychological Association (APA)44also addressed methodological issues in this research. Among others, APA identified the following problems: 1) A failure to include appropriate control populations or, in many cases, to identify any controls at all; 2) Follow-up at a single point in time - because, for example, attitudes manifested in the hours immediately following an abortion or childbirth may be very different from those a few days or months later; 3) A failure to use validated instruments for the measurement of psychological sequelae - causing many of the studies to rely on the subjective impressions of the interviewer; 4) A lack of baseline data - making it impossible to control for prior psychological status, or when a comparison group is used, to control for differences in baseline characteristics; 5 ) The use of populations whose circumstances are extremely different - such as failing to distinguish between a married women forced to terminate a wanted conception because of health and a woman voluntarily terminating an unwanted conception, or failing to distinguish between women having legal vs. illegal abortions.
in question was tapped in the abbreviated telephone interview; 5 ) Validated measures of psychological status were used; 6) A measure of anxiety status that separated the transient state from the underlying trait made it possible to minimize the effects of the respondent's stress at baseline so changes over time in this variable could be included; and 7) Enough questions about sexual and contraceptive behavior were asked so that internal checks on the validity of the data were possible, and variables covering a large range of background and demographic data, as well as socioeconomic and educational status, made it possible to control for and to define the characteristics of the sample. Thus, rather than seeing the relative homogeneity of the group as a disadvantage - because it makes it impossible to generalize the findings over the population at large - that homogeneity makes it possible to minimize differences between subgroups that might have confounded the study. Furthermore, because it deals with a population at uniformly high risk of conception, information specific to these young women has considerable importance. Findings
A STUDY OF ABORTION SEQUELAE Responding to a request for proposals from the National Institutes of Health in 1984 to study the consequences of pregnancy loss among adolescents, staff at Johns Hopkins designed a protocol to focus on young women during the two years following their presentation for a pregnancy test at one of two inner-city clinics in Baltimore. Young, Black women age 17 and younger were admitted while awaiting the results of their tests. A lengthy interview at that time was followed by telephone contacts at six and 18 months and face-to-face interviews at one and two years. Girls who tested positive and who terminated their pregnancies were compared with two control populations: those who carried the index pregnancy to term and those whose tests were negative. The research design was conceived to avoid as many problems as possible later identified by APA. The design sought to do so with a homogeneous sample over a realistic period of time - long enough to report longitudinal results and short enough so outcomes would not be unduly affected by the proliferation of intervening events. Design aspects which addressed specific problems identified above included: 1) Two appropriate control populations were identified that were similar in age, socioeconomic condition, and the sexual experience that brought them into the study; 2) The design was essentially prospective but utilized retrospective data collected at baseline to permit comparisons within and between groups; 3) By controlling for baseline differences, the study could focus on change in levels of the relevant variables over time, rather than on their absolute values; 4) Follow-up measurements were made at two or four points in time, depending on whether the variable
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When the three groups are examined at baseline, the major differences between them are in education: young women who choose abortion are considerably more ambitious in their aspirations and significantly are more likely to be at the appropriate grade level for age and In the less likely to have repeated a grade in scho01.4~~~~ course of the two year follow-up, educational trajectories diverge dramatically as the childbearing group falls far behind. A measure of negative educational change, defined as leaving school before graduation or, if still in school, failing to progress at the expected rate, shows more than twice the negative change among the childbearers as among the abortion group. In addition to calculating a change variable during the two-year period, multiple regression analyses showed the differences between the groups at follow-up remain significant when controlling for baseline characteristics in each of the areas reported. Economic dependency was explored using two household measures: a job dependeny ratio representing the proportion of adults who were working and a measure of welfare dependency. Negative change in the two-year period was related highly to the respondent's work status at the end of the f~llow-up.~' Whereas dependency status in the abortion group's households improved over each interval of the follow-up period, childbearers experienced a setback and then a slight recovery. Therefore, although differences between them were not significant at baseline, they were at the two-year mark. Psychological sequelae were a major area of interest and were explored with three measures. To control for the stresses on these young women while awaiting the results of their tests, the Spielberger State-Trait Anxiety Index4*was used to separate the passing state from the more stable trait. It appeared to discriminate successfully and revealed that, although underlying anxiety traits were not significantly elevated at baseline, state mea-
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sures were very high. At follow-up, the anxiety state came down; both measures were at levels comparable to the national norm for high school females, the abortion group somewhat closer to the norm than the childbearing group. Neither group experienced significant change over time in psychological status; in fact, most change was in a positive direction. This was true not only in anxiety but also in self-esteem measured by the Rosenberg scale,49and locus of control measured by items from the Rotter scale.5o Because small differences, even if statistically significant, may have little substantive importance, a measure of negative psychological change was created that included those respondents whose scores in each of the three dimensions showed a deterioration, however small. Such a pattern seemed of interest because most girls in the childbearing and the abortion groups had improved in self-esteem, become more internal in their locus of control, and showed less anxiety. Only 5% and 4.5070, respectively, demonstrated “negative change.” These findings also were explored in the negative test group with interesting results. Their negative psychological change was more than double that of the abortion group and almost double the childbearing group. In most other areas, they were similar to the childbearing group. Their high-risk status was confirmed when 58% of them became pregnant within 18 months of the original test, which explained their initial resemblance to the childbearers. Subsequent pregnancy was apparently responsible for what little educational change occurred in the abortion group; those who became pregnant again in the follow-up period absorbed almost all the observed negative change, which was trivial among those who managed to avoid a conception. The fact that fewer members of the abortion group became pregnant (37%) than of the negative test or the childbearing group (47Oi’o) contributed to their positive advantage at the two-year interview. Thus, both in absolute and relative terms, the abortion group appear to be doing well. These data give no evidence of negative psychological sequelae to pregnancy termination, and also suggest considerable advantage in educational and economic areas. Since no such sequelae have emerged in a two-year period, either in the short-term or long-term, it seems clear that longer follow-up could add little useful information: intervening events would make it impossible to attribute new characteristics to the abortion or childbearing experience which have not developed at all during the four follow-up interviews. A STUDY OF PARENTAL NOTIFICATION The same data permitted an exploration of the issue - “With whom do adolescents communicate when deciding on the outcomes of their pregnancies?” The study” examined communication in two time periods, one ending at the time of the pregnancy test visit and one ending with the outcome decision. The study confirmed what other studies have suggested: more than 91Yo consulted voluntarily with their mothers or parent surrogates, more than 86% specifically with the mother.
The designation of a parent surrogate group is of some importance because many young women report they were “responsible to” some female other than the mother, such as a grandmother, aunt, etc., or that the surrogate had “raised” them. It was logical that they selected that individual to confide in, especially when the mother was not in the home. A surprising 66% who did not live with their mothers had consulted with them nonetheless, usually in addition to the surrogate with whom they lived. A very small number, less than 9%, attempted to make the decision without some level of parental guidance and a minimum of almost half of this group turned to another adult. In this study, the partner was not defined as an “adult” confidant whatever his age. Also excluded were the few individuals whose age was not determined but who may have been an adult, such as an older sister. Therefore, this estimate of those who did not have adult support is conservative. Is consultation with a parent related to the psychological sequelae - of abortion or childbearing - that a young woman experiences, or with her level of satisfaction with her outcome decision? Most respondents were “satisfied” and, as reported, showed no negative psychological change. The few girls who chose not to communicate were as happy with their decisions as those who did consult and received support for their decisions. The only ones who were more likely to express dissatisfaction were those who did communicate with a parent and did not receive that support. Thus, it would appear that the small number who did not communicate made a responsible determination. CONCLUSION The Johns Hopkins study supports other studies that suggest almost unanimously that there are no significant negative sequelae to abortion among teen-age women. The medical consequences of childbearing are more adverse than those of abortion at all stages of gestation. In addition, the evidence seems increasingly clear that no negative psychological sequelae exist. The fact that, in their educational and economic condition, adolescents in the abortion group are doing well - both in absolute terms and relative to the other groups - and that they are experiencing fewer unintended conceptions, suggests that their status relative to the others has little reason to change. Under these circumstances, it is difficult to support policies that put barriers in the way of a young woman’s selection of the safer outcome, abortion, because of concerns about physical or psychological consequences. Mandated parental involvement proposed by the current administration in Washington represents such a barrier. One-half the states in the U.S. already permit a minor to obtain the means to prevent conception clearly the more desirable option - without compulsory parental involvement. Given that she has conceived, however, she is permitted without consultation to choose the more dangerous outcome, childbearing, the one that will most profoundly affect her life and that of her family. In the absence of evidence of adverse sequelae, it would seem unwise not to permit her the rn same discretion when she elects the safer option.
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