Refer to: Blumberg- BD, Golbus MS: Psychological sequelae of elective abortion. West J Med 123:188-193, Sep 1975
Psychological Sequelae of Elective Abortion BRUCE D. BLUMBERG, MD, and MITCHELL S. GOLBUS, MD, San Francisco
A mild, short, depressive and guilt ridden period following abortion is quite common, but a severe psychological reaction is rare. The indication for the abortion and the preabortal psychological state of the patient are the two most important factors. Almost all reported instances of postabortion psychoses have occurred in patients who had severe preabortal psychiatric problems. Women undergoing abortion for socioeconomic or psychosocial indications appear to be at minimal risk for long-term negative psychological sequelae. In contrast, women in whom abortion is carried out because of exposure to rubella and the risk of fetal malformation, maternal organic disease or the prenatal diagnosis of a genetically defective fetus are at greater risk and may need
supportive psychotherapy.
THE LITERATURE concerning the psychiatric consequences of abortion is as confusing as it is profuse. In the past 40 years, opinions have been presented from every perspective. Much of the information is devalued by the overt interjection of personal opinions and prejudices concerning the morality of abortion. Even after it was realized that scientific studies were necessary to elucidate the psychological components of abortions, many inquiries were handicapped by the use of inadequate methods for the study of the very complex and subjective phenomena involved. A number of From the Departments of Obstetrics and Gynecology and of Pediatrics, University of California School of Medicine, San Francisco. Submitted February 18, 1975. Reprint requests to: M. S. Golbus, MD, Department of Obstetrics and Gynecology, University of California Medical Center, San Francisco, CA 94143.
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noteworthy reviews are scattered throughout the psychiatric literature, but the subject has received little attention in the obstetric literature.1-5 We will attempt to clarify this confusion by artificially grouping the material according to the basic orientation of the author. The first references will be those classified as impressionistic, a term used to describe material presenting an opinion based upon clinical experience. The label psychoanalytic will be applied to the studies which invoke theoretical psychiatric concepts of pregnancy and its termination. The data analysis studies present data derived from the application of a specific methodology. These categories are intended to simplify the presentation of a heterogeneous mass of information, and many references fit into more than one category. No value judg-
ELECTIVE ABORTION
ment is intended; an impressionistic study based upon years of astute clinical observation may be more noteworthy than a data analysis study in which an ill-conceived methodology is used.
Impressionistic Studies Many of the earliest papers on the subject dealt with the emotional consequences of illegally induced abortions, since legally induced abortions were rare until recent years. Taussig6 warned of the possible outcome of abortion: "not only is the immediate psychic state to be dreaded, but . . . many a mental case, after careful analysis will be shown to date back to the terrifying experience of an induced abortion." He cited several case reports suggesting that sexual anesthesia, dyspareunia, marital quarrels, frigidity, psychoneurosis, depression, irritability or divorce could occur in the wake of abortion, and he concluded that the immediate danger was very serious and the remote harmful sequelae manifold.7 Contrary opinions were reported during the 1950's. Mandy,8 in his "Reflections of a Gynecologist," argued against the exaggerated and frightening warnings of the frequency with which serious depressions may follow induced abortions. His view was supported at the same conference by Lidz,9 who argued that many women have abortions with relief and with little, if any, subsequent disturbance. Lidz observed very few serious psychiatric reactions following an induced abortion and felt they were rarer than the severe emotional reactions to unwanted pregnancy, childbirth and the responsibilities of motherhood. Kraepelin'0 had argued that abortion more often alleviates than precipitates mental disease, and Pearce"1 noted that this concept had evolved to the tacit assumption that abortion per se had a therapeutic effect and few, if any, bad effects. He indicated that this newer concept required substantiating studies. The divergence of opinion regarding the potential deleterious psychological effects of abortion has continued during this past decade. MacDonald12 asserted that following abortion the initial feelings of anxiety and depression fade in time but are replaced by a lasting sense of guilt. Gluckman'3 reported several cases and concluded that abortion may lead to unforeseen psychoses, neuroses and psychosomatic disorders, with special emphasis on, gynecologic symptomatology. He felt such sequelae were more likely to be encountered in an emotionally unstable and psy-
chiatrically predisposed patient. Following the liberalization of the abortion law in Colorado, a preliminary survey of 168 abortion patients showed no untoward emotional reactions in the immediate or delayed postoperative periods.'4 There have been two opinion surveys of psychiatrists published. Kummer'5 found that 75 percent of 32 California psychiatrists had not encountered any moderate or severe psychiatric sequelae of abortion; the others encountered such sequelae only rarely, the highest figure being six cases in 15 years of practice. Kummer also noted that the Mothers Aid Society of Copenhagen reported no psychiatric aftereffects of moderate or severe degree among approximately 30,000 legal abortion patients. The second survey reported a number of psychiatrists who felt that even if there were no immediate psychological traumata from abortions, psychological scars caused by guilt, regret and depression would be seen later in life. The authors, however, questioned why so few of the estimated million abortions per year result in psychiatrically traumatized women coming to the attention of society.'6
Psychoanalytic Studies Deutsch17 observed that accidental pregnancy unleashed the conflict between the instinct of selfpreservation and the urge for motherhood. A possible solution to this dilemma is abortion. This course of action may produce depression in a woman who has a compulsion to conceive, elation in a woman who views pregnancy as an external compulsion, or self-accusation in a woman prone to excessive guilt reactions. Deutsch suggested that even in an unwanted pregnancy, maternal identification with the fetus is characteristic and abortion is likely to arouse feelings of self-destruction. This sense of personal self-sacrifice may irreparably damage the previously stable heterosexual relationship which produced the pregnancy in question. De Beauvoir'8 emphasized the ambivalence engendered by abortion which can lead to self-deprecation. Even when a woman consents to abortion, she feels it is a sacrifice of her femininity and sees her sex as a kind of infirmity and a curse. Dunbar'9 supported this concept of ambivalence, arguing that a woman would experience both relief and deprivation after an abortion but would begin to blame her husband or society for her dilemma and possibly lose conviction in playing the feminine role. THE WESTERN JOURNAL OF MEDICINE
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In a study of 150 abortion patients, Senay2' claimed that more than 90 percent underwent a mourning process which was completed preconsciously or unconsciously, with a rapid resolution of crisis symptoms representing a maturational step. When pregnancy, a potential child or a stay in hospital are focussed upon, awareness of guilt, depression or anxiety could persist for several months after an abortion. Complete resolution or repression usually required a number of months after an abortion. Fleck21 suggested that unfavorable abortion sequelae are magnified in the literature by the presentation of single case reports, and he emphasized that every surgical operation, every inroad on a person's body, leaves psychological scars. He stressed that the psychopathogenic conditions of a hospital stay and disapproving societal attitudes enhance the development of conflict, guilt and shame in a woman in whom abortion has been carried out. Raphael22 added that a woman whose religious beliefs, moral convictions or cultural background conflict with her desire or need for abortion may be at a much higher risk of a postabortal psychological complication, particularly in the form of excessive guilt. She noted that the husband or putative father may also require reassurance and the opportunity to talk over his own feelings of loss, guilt and anger.
Data Analysis Studies The desire to make data analysis studies arose from the recognition that impressionistic studies might be biased by recall of particularly outstanding cases in an author's own experience, and by remembering what confirmed a writer's own beliefs. Psychoanalytic studies also may be influenced by the prejudices of an investigator, as shown by Bolter23 who proclaimed "woman's main role here on earth is to conceive, deliver and raise children. Despite all other sublimated types of activity, this is still their primary role. When this function is interfered with, we see all sorts of emotional disorders . . . " It is not difficult to imagine the conclusions of his studies. However, the data analysis protocols have their own problems. Many attempt to follow up abortion patients by mailed questionnaire; the respondents, a self-selected subgroup, may not represent the total population. If personal interview is used, then care must be taken to avoid the interjection of observer bias in collecting the data, and 190
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standardization of a pool of such subjective data into a reportable form may also be difficult. The results of psychometric tests are useful only to the extent that they can be compared with a control group, and it is difficult to define the appropriate control group in this instance. Should it be the general population? Pregnant women? Women who desire but are refused abortion? It is important to keep these problems in mind as we review data analysis studies. Hamilton24 interviewed 537 women within 24 hours of abortion, but only 30 had received elective terminations and the remainder had spontaneous or illegal abortions. More than half of the patients in whom abortion had been electively induced expressed relief or satisfaction while 23 percent felt regret. Further interpretation is impossible because the investigator failed to distinguish between those who had elective and those who had spontaneous abortions. Malmfors25 reported a 37 percent incidence of guilt feelings, and a 12 percent incidence of impaired mental health (anxiety, neurosis, depression or psychosis) in a series of 84 women who had had abortions; all with impaired mental health had exhibited various neurotic complaints before the procedure. Ekblad26 detailed the sequelae of abortion in 479 women, 25 percent of whom admitted self-reproach and approximately half of this subgroup described serious self-reproach or regret. However, their depression was generally mild from a psychiatric viewpoint, with only 1 percent of the entire group reporting a reduction in work capacity-and in all of these there had been severe neurotic symptoms before abortion. When only women with normal personalities were considered, the incidence of serious self-reproach fell to 6 percent, with no resultant psychiatric illness. Ekblad also showed that psychiatric consequences were unrelated to age, intelligence, parity, marital status, subsequent pregnancy, concomitant sterilization or occupation. However, in those women who obtained abortion after coercion by spouse or family, there was a higher incidence of undesirable sequelae (the only factor other than premorbid personality to show such an influence). Mehlan27 reported that 90 percent of 243 German women who had abortions six years earlier still felt that elective abortion had been the proper course of action, while 10 percent regretted the procedure. In a similar Danish study of 135 patients, 83 percent were "glad without reserve," 10 percent "satisfied but doubtful," 4 percent "not happy
ELECTIVE ABORTION
but know the abortion was necessary" and 4 percent "repentant."28 Aren29 studied 100 women who became pregnant and gave birth after an earlier elective abortion; 1.4 stated they had conceived to have a substitute for the aborted "child," and 20 claimed they could not tolerate another abortion even though this pregnancy was unwelcome. Aren concluded that these 34 women provide evidence that their guilt feelings cannot be regarded as trivial, but rather as a serious complication following elective abortion. Gebhard and co-workers30 interviewed a large group of women who had an illegal abortion. They found that less than 10 percent experienced psychological upset following the procedure and concluded that although there appeared to be little psychological trauma in most cases, a considerable amount of unfavorable reaction may show up in a few, and that the ill effects after induced abortion appeared less frequently than previously assumed. Hong3l reported that 90 percent of a large group of Korean women described little or no guilt feelings after resorting to abortion. In contrast to findings in the Scandinavian studies, he found that young wives, wives with fewer pregnancies and wives with higher educational background and greater knowledge of contraceptive methods had greater guilt feelings toward the induced abortion. Osofsky and co-workers,32 who interviewed 250 women shortly after their abortion, reported that 15 percent displayed mild depression. Of the total, 76.2 percent denied guilt feelings while 15.6 percent described some guilt and 8.2 percent described considerable guilt. Some self-reproach was claimed by 7.2 percent, and 1.5 percent were very angry with themselves and negative about their decision to have the abortion. When Opton33 looked at the same question somewhat later after the procedure, only 6 percent of his group had any regrets about having had the abortion. The women generally described a very short period of depression followed by a prompt return to their prepregnant mental state. The Hungarian experience has been that the women most likely to suffer emotional upset after abortion are those who have shown ambivalence in relation to the pregnancy before the abortion.34 Another group of patients who seem to be at more risk for detrimental psychological sequelae of abortion are adolescents. Wallerstein and coworkers35 found that at five to seven months postabortion, only 50 percent of teenagers had
mastered the pregnancy and abortion experience to the point of returning to their previous state of psychosocial functioning. Several studies in the past decade have used psychometric testing to clarify the nature of emotional responses to abortion. In a prospective psychometric study, Brody and associates36 found abnormal psychiatric profiles of abortion applicants, with improvements at six weeks postabortion, and further return to normal at one year after the procedure. Margolis and co-workers37 found that approximately half the women seeking abortion showed psychometric elevation on scales depicting depression, psychopathic deviation or schizophrenia; and more than half of these had normal psychometric profiles after the abortion. In a similar study, Niswander and co-workers3' administered psychometric tests to 58 women undergoing abortion and found the postoperative test scores at six months postabortion were significantly lower than the preoperative scores for maladjustment, depression and anxiety. While there was a significant reduction in stress, the scores still indicated that these patients were more depressed and less well adjusted than a control group of maternity and gynecologic patients.
Indication for Abortion A number of investigators have questioned whether the psychological sequelae of elective abortion might vary with the indication for the procedure. Jansson39 noted that only 0.2 percent of patients undergoing spontaneous or illegal abortion for socioeconomic reasons were admitted to the hospital for psychiatric treatment after the procedure, whereas 1.92 percent of 1,773 Swedish women who had legal abortions because of increased "psychic vulnerability" required admission to hospital for psychiatric reaso,s after the procedure. Peck and Marcus40 compared two groups of 25 women who had had abortions for either psychosocial reasons or because of an exposure to rubella with an increased risk of fetal malformation. The most striking difference between these two groups was their conscious wish for the current pregnancy-96 percent in the psychosocial group did not want the pregnancy, contrasted with 40 percent of the rubella group who did not. A mild and brief depression was reported by only one woman in the psychosocial group but by nine women in the rubella group. All had recovered within three THE WESTERN JOURNAL OF MEDICINE
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ELECTIVE ABORTION
to six months after the abortion, without psychiatric treatment. Of the 50 women, 49 would have chosen to repeat the abortion if the situation recurred, although 6 expressed some regrets about having had the abortion. The groups also differed in that the rubella group more commonly conceived or desired a subsequent pregnancy soon after the abortion. Niswander and Patterson4" reported similar data. Of 90 patients given abortions for psychosocial indications, 23.3 percent noted a negative immediate effect and 12.2 a negative long-term effect. Of 17 patients aborted because of exposure to rubella, 64.7 percent noted negative immediate effects and 47.1 percent negative long-term effects. Of nine patients aborted because of maternal organic disease, 55.6 percent noted a negative immediate effect but only 11.1 percent a negative long-term effect. McCoy42 also found that the incidence of short-term regrets was twice as great in women aborted for medical indications when compared with women aborted for psychosocial indications, but that the long-term regrets occurred with similar frequency in both groups. Pare and Raven43 showed that mild feelings of guilt or loss were not unusual after abortion for psychosocial indications, usually lasting only one to two weeks-and in only 13 percent existing longer than three months. In contrast, 6 of 14 women in whom an organic disease was the primary indication for abortion were very upset and developed severe symptoms of depression. Simon and associates,44 who used psychometric testing to clarify the nature of emotional responses to abortion, found that 67 percent of 16 women given abortions for psychosocial reasons reported positive responses and feelings of relief, 25 percent reported mild depression of one to two weeks duration and 9 percent reported pronounced depression. The corresponding figures for a group of 17 women aborted after exposure to rubella are relief in 38 percent, mild depression in 50 percent and pronounced depression in 12 percent. Of 12 women having abortions for medical indications, 50 percent felt relief, 25 percent felt mild depression and 25 percent felt pronounced depression. Consequently, it seems that a depressive reaction to the abortion experience was more characteristic of those patients having abortions for fetal or medical indications. Guilt feelings were noted much more frequently in those women who were sterilized following the abortion.
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Abortion Carried Out for a Genetic Indication Follow-up studies of women who had an amniocentesis specifically for the prenatal detection of a genetic defect in the fetus have noted that feelings of guilt, doubt and ambivalence were common.45'46 The risk of psychosocial trauma to a family which elects therapeutic abortion upon being told the fetus is genetically defective was recently evaluated by studying 13 families in which the woman had undergone amniocentesis and selective abortion.4 Only 2 of 13 women and 4 of 11 men in that study failed to mention depression in describing their emotional reaction to abortion. Of the 6 nondepressed persons, 1 woman and 2 men had Minnesota Multiphasic Personality Inventory (MMPI) profiles reflecting a tendency to deny emotional problems, so that the actual incidence of depression following selective abortion may have been as high as 12 of 13 (92 percent) among the women and as high as 9 of 11 (82 percent) among the men studied. The role of decision making and the responsibility associated with selective abortion may explain the more serious depression observed in these patients, compared with that following an elective abortion for psychosocial indications. Even when selective abortion is accepted as the preferable alternative to the birth of a defective child, the responsibility for making the decision to abort may prove to be an uncomfortable burden for the parents. There is also the additional problem of the sense of guilt and shame associated with genetic disease. Fletcher45 noted that "added to the guilt associated with being a carrier of genetic disease was the realization that their experiment to get a healthy child had failed." An amniocentesis result indicating a genetically defective fetus may reignite the depression, guilt, or frustration associated with the birth of a previously affected child or close relative. Selective abortion is by technical necessity a second trimester procedure. It has been suggested that late abortion conveys a greater emotional impact than does earlier abortion.48 Bibring and co-workers49 argued that quickening is the physiological event which signals maturation from the narcissism and self-cathexis of early pregnancy to a view of the fetus as an object of increasingly independent existence. After quickening, the fetus comes to be considered a potential future child and there is proliferation of fantasies concerning the child's sex, appearance or talents.50
ELECTIVE ABORTION
Summary The incidence of deleterious psychological sequelae to elective abortion should be assessed in comparison with the incidence of postpartum deleterious emotional reactions. While postpartum psychosis occurs in only 0.1 to 0.2 percent of pregnancies, simpler depressive reactions are far more common. Impressionistic, psychoanalytic and data analysis studies suggest that a severe psychiatric reaction after abortion is rare but that a mild, short, depressive and guilt-ridden period following an abortion is quite common. The indication for the abortion and the preabortal psychological state of the patient are the two most important factors. Almost all postabortal psychoses occur in patients who had severe preabortal psychiatric problems. Women having abortion for socioeconomic or psychosocial indications appear to be at minimal risk for long-term negative psychological sequelae and see the abortion as a solution to an undesired pregnancy and prevention of the birth of a "mistake." Women who have abortions because of exposure to rubella and the risk of fetal malformation, because of maternal organic disease or because of a prenatal diagnosis of a genetically defective fetus are terminating a desired pregnancy-and their action precludes the birth of a wanted child. In the latter group, more than a casual follow-up should be made, and they should be encouraged to seek psychiatric aid if their depressive or guilt feelings are severe or long-lived. REFERENCES 1. Simon N, Senturia A: Psychiatric sequelae of abortion: Arch Gen Psychiat 15:378-389, 1966 2. White R: Induced abortions-A survey of their psychiatric implications, complications, and indications. Texas Rep Biol Med 24:531-558, 1966 3. Schwartz R: Psychiatry and the abortion laws-An overview. Compr Psychiat 9:99-117, 1968 4. Callahan D: Abortion: Law, Choice and Morality. New York, The MacMillan Company, 1970 5. Simon N: Psychological and emotional indications for therapeutic abortion, In Sloane R (Ed): Abortion: Changing Views and Practice. New York, Grune and Stratton, 1970 (also published in Seminars Psychiat 2(3):283-301, 1970) 6. Taussig F: Abortion, Spontaneous and Induced. St. Louis, CV Mosby Company, 1937, pp 276-278 7. Taussig F: Effects of abortion on the general heath and reproductive functions of the individual, chap 4, In Taylor H (Ed): The Abortion Problem-Proceedings of the conference held under the auspices of the National Committee on Maternal Health, Inc at the New York Academy of Medicine, June 19-20, 1942. Baltimore, Williams-Wilkins Co, 1944, pp 46-47 8. Mandy A: Reflections of a gynecologist, In Rosen H (Ed): Therapeutic Abortion. New York, Julian Press, 1954, pp 284-296 9. Lidz F: Reflections of a psychiatrist, In Rosen H (Ed): Therapeutic Abortion. New York, Julian Press, 1954, pp 276-284 10. Kraepelin E: Psychiatrie. Leipzeig, JA Barth, 1909 11. Pearce J: Discussion: The psychiatric indication for the termination of pregnancy. Proc Roy Soc Med 50:321, 1957 12. MacDonald R: Complications of abortion. Nurs Times 63(1):306-307, 1967 13. Gluckman L: Some unanticipated complications of therapeutic abortion. New Zeal Med J 74(471):71-78, 1971
14. Heller A, Whittington H: The Colorado story: Denver General Hospital experience with the change in the law on therapeutic abortion. Am J Psychiat 125(6):809-816, 1968 15. Kummer J: Post-abortion psychiatric illness-A myth? Am J Psychiat 119(10):980-983, 1963 16. Crowley R, Laidlaw R: Psychiatric opinion regarding abortion-Preliminary report of a survey. Am J Psychiat 124(4) :559562, 1967 17. Deutsch H: Psychology of Women. New York, Grune and Stratton, 1945 18. deBouvoir S: The Second Sex. Edited and translated by H Parshley. New York, Alfred A Knopf, Inc, 1952, pp 490-491 19. Dunbar F: A psychosomatic approach to abortion and the abortion habit, In Rosen H (Ed): Therapeutic Abortion. New York, Julian Press, 1954, pp 22-31 20. Senay E: Therapeutic abortion. Arch Gen Psychiat 23: 408-415, 1970 21. Fleck S: Some psychiatric aspects of abortion. J Nerv Ment Dis 151:42-50, 1970 22. Raphael B: Psyclhosocial aspects of induLced abortion-fts implications for the woman, her family, and her doctor-Part 1. Med J Aust 2:35-40, 1972 23. Bolter S: The psychiatrist's role in therapeutic abortionThe unwitting accomplice. Am J Psychiat 119(4):312-316, 1962 24. Hamilton V: Some sociologic aind psychologic observations on abortion. Am J Obstet Gynec 39:919-928, 1940 25. Malmfors K: Status of women after legal ab.ortion. Svenska Larkartidingen 48:2445, 1951 26. Ekblad M: Induced abortion on psychiatric grounds-A followup study of 479 women. Acta Psychiat Neurol Scand Suppl 99: 1-238, 1955 27. Mehlan KH: Spatfolgen nach Legalem Abort. Deutsche Gesundh 11:876-880, 1956 28. Kolstad P: Therapeutic abortions. Acta Obstet Gynec Scand 36:Suppl 6:7-72, 1957 29. Aren P: Acta Obstet Gynec Scand 37:Suppl 1, 1958, as cited by Year Book of Obstetrics and Gynecology, 1958-1959 Series. Edited by Greenhill. Chicago, Year Book Publishers. 1958, p 65 30. Gebhard P, Pomeroy W, Martin C, et al: Pregnancy, Birth, and Abortion. New York, Harper and Brothers and Paul B Hoebner, Inc, 1958, p 209 31. Hong S: Induced abortion in Seoul, Korea. IPPF: Proceedings of the Regional Conference, Western Pacific Region, 1965. Seoul, Dong-A Publishing Co, 1965, p 53 32. Osofsky J, Osofsky H, Rajan R, et al: Psychologic effects of legal abortion. Mod Treatm 8(1):139-158, 1971 (also published in Clin Obstet Gynec 14(l):215-234, 1971) 33. Opton E: Psychological and Social Outcomes of Abortion. Berkeley, California, The Wright Institute, 1971 34. Kapor-Stanulovic N: Three phases of the abortion process and its influence on women's mental health. Am J Public Health 62(7) :906-908, 1972 35. Wallerstein J, Kurtz P, Bar-Din M: Psychosocial sequelae of therapeutic abortion in young unmarried women. Arch Gen Psychiat 27(6):828-832, 1972 36. Brody H, Meikle S, Gerritse R: Therapeutic abortion-A prospective study. Am J Obstet Gynec 109(3):347-353, 1971 37. Margolis A, Davidson L, Hanson K, et al: Therapeutic abortion follow-up study. Am J Obstet Gynec 110(2):243-249, 1971 38. Niswander K, Singer J, Singer M: Psychologic reaction to therapeutic abortion-Objective response. Am J Obstet Gynec 114(1):29-33, 1972 39. Jansson G: Mental disorders after abortion. Acta Psychiat Scand 41:87-110, 1965 40. Peck A, Marcus H: Psychiatric sequelae of therapeutic interruption of pregnancy. J Nerv Ment Dis 143(5):417-425, 1966 41. Niswander K, Patterson R: Psychologic reaction to therapeutic abortion-Subjective patient response. Obstet Gynec 29(5): 702-706, 1967 42. McCoy D: The emotional reaction of women to therapeutic abortion and sterilization. J Obstet Gynec Brit Cwlth 75:10541057, 1968 43. Pare C, Raven H: Follow-up of patients referred for termination of pregnancy. Lancet 1:635-638, 1970 44. Simon N, Senturia A, Rothman D: Psychiatric illness folowing therapeutic abortion. Am J Psychiat 124(1):59-65, 1967 45. Fletcher J: The brink-The parent-child bond in the genetic revolution. Theol Stud 33:457-470, 1972 46. Golbus M, Conte F, Schneider E, et al: Intrauterine diagnosis of genetic defects: results, problems, and follow-up of one hundred cases in a prenatal genetic detection center. Am J Obstet Gynec 118:897-905, 1974 47. Blumberg B, Golbus M, Hanson K: The psychological sequelae of abortion performed for a genetic indication. Am J Obstet Gynecol, In Press 48. Kaltreider N: Emotional patterns related to delay in the decision to seek legal abortion. Calif Med 118:23-27, May 1973 49. Bibring G: Dwyer T, Huntington D, et al: A study of the psychological processes in pregnancy and of the earliest motherchild relationship. Psychoanal Stud Child 16:9-72, 1961 50. Raphael B: Psychosocial aspects of induced abortion-Its implications for the woman, her family, and her doctor-Part 2. Med J Aust 2;98-101, 1972
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Psychological Sequelae of Elective Abortion BRUCE D. BLUMBERG, MD, and MITCHELL S. GOLBUS, MD, San Francisco
A mild, short, depressive and guilt ridden period following abortion is quite common, but a severe psychological reaction is rare. The indication for the abortion and the preabortal psychological state of the patient are the two most important factors. Almost all reported instances of postabortion psychoses have occurred in patients who had severe preabortal psychiatric problems. Women undergoing abortion for socioeconomic or psychosocial indications appear to be at minimal risk for long-term negative psychological sequelae. In contrast, women in whom abortion is carried out because of exposure to rubella and the risk of fetal malformation, maternal organic disease or the prenatal diagnosis of a genetically defective fetus are at greater risk and may need
supportive psychotherapy.
THE LITERATURE concerning the psychiatric consequences of abortion is as confusing as it is profuse. In the past 40 years, opinions have been presented from every perspective. Much of the information is devalued by the overt interjection of personal opinions and prejudices concerning the morality of abortion. Even after it was realized that scientific studies were necessary to elucidate the psychological components of abortions, many inquiries were handicapped by the use of inadequate methods for the study of the very complex and subjective phenomena involved. A number of From the Departments of Obstetrics and Gynecology and of Pediatrics, University of California School of Medicine, San Francisco. Submitted February 18, 1975. Reprint requests to: M. S. Golbus, MD, Department of Obstetrics and Gynecology, University of California Medical Center, San Francisco, CA 94143.
188
SEPTEMBER 1975
*
123 * 3
noteworthy reviews are scattered throughout the psychiatric literature, but the subject has received little attention in the obstetric literature.1-5 We will attempt to clarify this confusion by artificially grouping the material according to the basic orientation of the author. The first references will be those classified as impressionistic, a term used to describe material presenting an opinion based upon clinical experience. The label psychoanalytic will be applied to the studies which invoke theoretical psychiatric concepts of pregnancy and its termination. The data analysis studies present data derived from the application of a specific methodology. These categories are intended to simplify the presentation of a heterogeneous mass of information, and many references fit into more than one category. No value judg-
ELECTIVE ABORTION
ment is intended; an impressionistic study based upon years of astute clinical observation may be more noteworthy than a data analysis study in which an ill-conceived methodology is used.
Impressionistic Studies Many of the earliest papers on the subject dealt with the emotional consequences of illegally induced abortions, since legally induced abortions were rare until recent years. Taussig6 warned of the possible outcome of abortion: "not only is the immediate psychic state to be dreaded, but . . . many a mental case, after careful analysis will be shown to date back to the terrifying experience of an induced abortion." He cited several case reports suggesting that sexual anesthesia, dyspareunia, marital quarrels, frigidity, psychoneurosis, depression, irritability or divorce could occur in the wake of abortion, and he concluded that the immediate danger was very serious and the remote harmful sequelae manifold.7 Contrary opinions were reported during the 1950's. Mandy,8 in his "Reflections of a Gynecologist," argued against the exaggerated and frightening warnings of the frequency with which serious depressions may follow induced abortions. His view was supported at the same conference by Lidz,9 who argued that many women have abortions with relief and with little, if any, subsequent disturbance. Lidz observed very few serious psychiatric reactions following an induced abortion and felt they were rarer than the severe emotional reactions to unwanted pregnancy, childbirth and the responsibilities of motherhood. Kraepelin'0 had argued that abortion more often alleviates than precipitates mental disease, and Pearce"1 noted that this concept had evolved to the tacit assumption that abortion per se had a therapeutic effect and few, if any, bad effects. He indicated that this newer concept required substantiating studies. The divergence of opinion regarding the potential deleterious psychological effects of abortion has continued during this past decade. MacDonald12 asserted that following abortion the initial feelings of anxiety and depression fade in time but are replaced by a lasting sense of guilt. Gluckman'3 reported several cases and concluded that abortion may lead to unforeseen psychoses, neuroses and psychosomatic disorders, with special emphasis on, gynecologic symptomatology. He felt such sequelae were more likely to be encountered in an emotionally unstable and psy-
chiatrically predisposed patient. Following the liberalization of the abortion law in Colorado, a preliminary survey of 168 abortion patients showed no untoward emotional reactions in the immediate or delayed postoperative periods.'4 There have been two opinion surveys of psychiatrists published. Kummer'5 found that 75 percent of 32 California psychiatrists had not encountered any moderate or severe psychiatric sequelae of abortion; the others encountered such sequelae only rarely, the highest figure being six cases in 15 years of practice. Kummer also noted that the Mothers Aid Society of Copenhagen reported no psychiatric aftereffects of moderate or severe degree among approximately 30,000 legal abortion patients. The second survey reported a number of psychiatrists who felt that even if there were no immediate psychological traumata from abortions, psychological scars caused by guilt, regret and depression would be seen later in life. The authors, however, questioned why so few of the estimated million abortions per year result in psychiatrically traumatized women coming to the attention of society.'6
Psychoanalytic Studies Deutsch17 observed that accidental pregnancy unleashed the conflict between the instinct of selfpreservation and the urge for motherhood. A possible solution to this dilemma is abortion. This course of action may produce depression in a woman who has a compulsion to conceive, elation in a woman who views pregnancy as an external compulsion, or self-accusation in a woman prone to excessive guilt reactions. Deutsch suggested that even in an unwanted pregnancy, maternal identification with the fetus is characteristic and abortion is likely to arouse feelings of self-destruction. This sense of personal self-sacrifice may irreparably damage the previously stable heterosexual relationship which produced the pregnancy in question. De Beauvoir'8 emphasized the ambivalence engendered by abortion which can lead to self-deprecation. Even when a woman consents to abortion, she feels it is a sacrifice of her femininity and sees her sex as a kind of infirmity and a curse. Dunbar'9 supported this concept of ambivalence, arguing that a woman would experience both relief and deprivation after an abortion but would begin to blame her husband or society for her dilemma and possibly lose conviction in playing the feminine role. THE WESTERN JOURNAL OF MEDICINE
189
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In a study of 150 abortion patients, Senay2' claimed that more than 90 percent underwent a mourning process which was completed preconsciously or unconsciously, with a rapid resolution of crisis symptoms representing a maturational step. When pregnancy, a potential child or a stay in hospital are focussed upon, awareness of guilt, depression or anxiety could persist for several months after an abortion. Complete resolution or repression usually required a number of months after an abortion. Fleck21 suggested that unfavorable abortion sequelae are magnified in the literature by the presentation of single case reports, and he emphasized that every surgical operation, every inroad on a person's body, leaves psychological scars. He stressed that the psychopathogenic conditions of a hospital stay and disapproving societal attitudes enhance the development of conflict, guilt and shame in a woman in whom abortion has been carried out. Raphael22 added that a woman whose religious beliefs, moral convictions or cultural background conflict with her desire or need for abortion may be at a much higher risk of a postabortal psychological complication, particularly in the form of excessive guilt. She noted that the husband or putative father may also require reassurance and the opportunity to talk over his own feelings of loss, guilt and anger.
Data Analysis Studies The desire to make data analysis studies arose from the recognition that impressionistic studies might be biased by recall of particularly outstanding cases in an author's own experience, and by remembering what confirmed a writer's own beliefs. Psychoanalytic studies also may be influenced by the prejudices of an investigator, as shown by Bolter23 who proclaimed "woman's main role here on earth is to conceive, deliver and raise children. Despite all other sublimated types of activity, this is still their primary role. When this function is interfered with, we see all sorts of emotional disorders . . . " It is not difficult to imagine the conclusions of his studies. However, the data analysis protocols have their own problems. Many attempt to follow up abortion patients by mailed questionnaire; the respondents, a self-selected subgroup, may not represent the total population. If personal interview is used, then care must be taken to avoid the interjection of observer bias in collecting the data, and 190
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standardization of a pool of such subjective data into a reportable form may also be difficult. The results of psychometric tests are useful only to the extent that they can be compared with a control group, and it is difficult to define the appropriate control group in this instance. Should it be the general population? Pregnant women? Women who desire but are refused abortion? It is important to keep these problems in mind as we review data analysis studies. Hamilton24 interviewed 537 women within 24 hours of abortion, but only 30 had received elective terminations and the remainder had spontaneous or illegal abortions. More than half of the patients in whom abortion had been electively induced expressed relief or satisfaction while 23 percent felt regret. Further interpretation is impossible because the investigator failed to distinguish between those who had elective and those who had spontaneous abortions. Malmfors25 reported a 37 percent incidence of guilt feelings, and a 12 percent incidence of impaired mental health (anxiety, neurosis, depression or psychosis) in a series of 84 women who had had abortions; all with impaired mental health had exhibited various neurotic complaints before the procedure. Ekblad26 detailed the sequelae of abortion in 479 women, 25 percent of whom admitted self-reproach and approximately half of this subgroup described serious self-reproach or regret. However, their depression was generally mild from a psychiatric viewpoint, with only 1 percent of the entire group reporting a reduction in work capacity-and in all of these there had been severe neurotic symptoms before abortion. When only women with normal personalities were considered, the incidence of serious self-reproach fell to 6 percent, with no resultant psychiatric illness. Ekblad also showed that psychiatric consequences were unrelated to age, intelligence, parity, marital status, subsequent pregnancy, concomitant sterilization or occupation. However, in those women who obtained abortion after coercion by spouse or family, there was a higher incidence of undesirable sequelae (the only factor other than premorbid personality to show such an influence). Mehlan27 reported that 90 percent of 243 German women who had abortions six years earlier still felt that elective abortion had been the proper course of action, while 10 percent regretted the procedure. In a similar Danish study of 135 patients, 83 percent were "glad without reserve," 10 percent "satisfied but doubtful," 4 percent "not happy
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but know the abortion was necessary" and 4 percent "repentant."28 Aren29 studied 100 women who became pregnant and gave birth after an earlier elective abortion; 1.4 stated they had conceived to have a substitute for the aborted "child," and 20 claimed they could not tolerate another abortion even though this pregnancy was unwelcome. Aren concluded that these 34 women provide evidence that their guilt feelings cannot be regarded as trivial, but rather as a serious complication following elective abortion. Gebhard and co-workers30 interviewed a large group of women who had an illegal abortion. They found that less than 10 percent experienced psychological upset following the procedure and concluded that although there appeared to be little psychological trauma in most cases, a considerable amount of unfavorable reaction may show up in a few, and that the ill effects after induced abortion appeared less frequently than previously assumed. Hong3l reported that 90 percent of a large group of Korean women described little or no guilt feelings after resorting to abortion. In contrast to findings in the Scandinavian studies, he found that young wives, wives with fewer pregnancies and wives with higher educational background and greater knowledge of contraceptive methods had greater guilt feelings toward the induced abortion. Osofsky and co-workers,32 who interviewed 250 women shortly after their abortion, reported that 15 percent displayed mild depression. Of the total, 76.2 percent denied guilt feelings while 15.6 percent described some guilt and 8.2 percent described considerable guilt. Some self-reproach was claimed by 7.2 percent, and 1.5 percent were very angry with themselves and negative about their decision to have the abortion. When Opton33 looked at the same question somewhat later after the procedure, only 6 percent of his group had any regrets about having had the abortion. The women generally described a very short period of depression followed by a prompt return to their prepregnant mental state. The Hungarian experience has been that the women most likely to suffer emotional upset after abortion are those who have shown ambivalence in relation to the pregnancy before the abortion.34 Another group of patients who seem to be at more risk for detrimental psychological sequelae of abortion are adolescents. Wallerstein and coworkers35 found that at five to seven months postabortion, only 50 percent of teenagers had
mastered the pregnancy and abortion experience to the point of returning to their previous state of psychosocial functioning. Several studies in the past decade have used psychometric testing to clarify the nature of emotional responses to abortion. In a prospective psychometric study, Brody and associates36 found abnormal psychiatric profiles of abortion applicants, with improvements at six weeks postabortion, and further return to normal at one year after the procedure. Margolis and co-workers37 found that approximately half the women seeking abortion showed psychometric elevation on scales depicting depression, psychopathic deviation or schizophrenia; and more than half of these had normal psychometric profiles after the abortion. In a similar study, Niswander and co-workers3' administered psychometric tests to 58 women undergoing abortion and found the postoperative test scores at six months postabortion were significantly lower than the preoperative scores for maladjustment, depression and anxiety. While there was a significant reduction in stress, the scores still indicated that these patients were more depressed and less well adjusted than a control group of maternity and gynecologic patients.
Indication for Abortion A number of investigators have questioned whether the psychological sequelae of elective abortion might vary with the indication for the procedure. Jansson39 noted that only 0.2 percent of patients undergoing spontaneous or illegal abortion for socioeconomic reasons were admitted to the hospital for psychiatric treatment after the procedure, whereas 1.92 percent of 1,773 Swedish women who had legal abortions because of increased "psychic vulnerability" required admission to hospital for psychiatric reaso,s after the procedure. Peck and Marcus40 compared two groups of 25 women who had had abortions for either psychosocial reasons or because of an exposure to rubella with an increased risk of fetal malformation. The most striking difference between these two groups was their conscious wish for the current pregnancy-96 percent in the psychosocial group did not want the pregnancy, contrasted with 40 percent of the rubella group who did not. A mild and brief depression was reported by only one woman in the psychosocial group but by nine women in the rubella group. All had recovered within three THE WESTERN JOURNAL OF MEDICINE
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to six months after the abortion, without psychiatric treatment. Of the 50 women, 49 would have chosen to repeat the abortion if the situation recurred, although 6 expressed some regrets about having had the abortion. The groups also differed in that the rubella group more commonly conceived or desired a subsequent pregnancy soon after the abortion. Niswander and Patterson4" reported similar data. Of 90 patients given abortions for psychosocial indications, 23.3 percent noted a negative immediate effect and 12.2 a negative long-term effect. Of 17 patients aborted because of exposure to rubella, 64.7 percent noted negative immediate effects and 47.1 percent negative long-term effects. Of nine patients aborted because of maternal organic disease, 55.6 percent noted a negative immediate effect but only 11.1 percent a negative long-term effect. McCoy42 also found that the incidence of short-term regrets was twice as great in women aborted for medical indications when compared with women aborted for psychosocial indications, but that the long-term regrets occurred with similar frequency in both groups. Pare and Raven43 showed that mild feelings of guilt or loss were not unusual after abortion for psychosocial indications, usually lasting only one to two weeks-and in only 13 percent existing longer than three months. In contrast, 6 of 14 women in whom an organic disease was the primary indication for abortion were very upset and developed severe symptoms of depression. Simon and associates,44 who used psychometric testing to clarify the nature of emotional responses to abortion, found that 67 percent of 16 women given abortions for psychosocial reasons reported positive responses and feelings of relief, 25 percent reported mild depression of one to two weeks duration and 9 percent reported pronounced depression. The corresponding figures for a group of 17 women aborted after exposure to rubella are relief in 38 percent, mild depression in 50 percent and pronounced depression in 12 percent. Of 12 women having abortions for medical indications, 50 percent felt relief, 25 percent felt mild depression and 25 percent felt pronounced depression. Consequently, it seems that a depressive reaction to the abortion experience was more characteristic of those patients having abortions for fetal or medical indications. Guilt feelings were noted much more frequently in those women who were sterilized following the abortion.
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Abortion Carried Out for a Genetic Indication Follow-up studies of women who had an amniocentesis specifically for the prenatal detection of a genetic defect in the fetus have noted that feelings of guilt, doubt and ambivalence were common.45'46 The risk of psychosocial trauma to a family which elects therapeutic abortion upon being told the fetus is genetically defective was recently evaluated by studying 13 families in which the woman had undergone amniocentesis and selective abortion.4 Only 2 of 13 women and 4 of 11 men in that study failed to mention depression in describing their emotional reaction to abortion. Of the 6 nondepressed persons, 1 woman and 2 men had Minnesota Multiphasic Personality Inventory (MMPI) profiles reflecting a tendency to deny emotional problems, so that the actual incidence of depression following selective abortion may have been as high as 12 of 13 (92 percent) among the women and as high as 9 of 11 (82 percent) among the men studied. The role of decision making and the responsibility associated with selective abortion may explain the more serious depression observed in these patients, compared with that following an elective abortion for psychosocial indications. Even when selective abortion is accepted as the preferable alternative to the birth of a defective child, the responsibility for making the decision to abort may prove to be an uncomfortable burden for the parents. There is also the additional problem of the sense of guilt and shame associated with genetic disease. Fletcher45 noted that "added to the guilt associated with being a carrier of genetic disease was the realization that their experiment to get a healthy child had failed." An amniocentesis result indicating a genetically defective fetus may reignite the depression, guilt, or frustration associated with the birth of a previously affected child or close relative. Selective abortion is by technical necessity a second trimester procedure. It has been suggested that late abortion conveys a greater emotional impact than does earlier abortion.48 Bibring and co-workers49 argued that quickening is the physiological event which signals maturation from the narcissism and self-cathexis of early pregnancy to a view of the fetus as an object of increasingly independent existence. After quickening, the fetus comes to be considered a potential future child and there is proliferation of fantasies concerning the child's sex, appearance or talents.50
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Summary The incidence of deleterious psychological sequelae to elective abortion should be assessed in comparison with the incidence of postpartum deleterious emotional reactions. While postpartum psychosis occurs in only 0.1 to 0.2 percent of pregnancies, simpler depressive reactions are far more common. Impressionistic, psychoanalytic and data analysis studies suggest that a severe psychiatric reaction after abortion is rare but that a mild, short, depressive and guilt-ridden period following an abortion is quite common. The indication for the abortion and the preabortal psychological state of the patient are the two most important factors. Almost all postabortal psychoses occur in patients who had severe preabortal psychiatric problems. Women having abortion for socioeconomic or psychosocial indications appear to be at minimal risk for long-term negative psychological sequelae and see the abortion as a solution to an undesired pregnancy and prevention of the birth of a "mistake." Women who have abortions because of exposure to rubella and the risk of fetal malformation, because of maternal organic disease or because of a prenatal diagnosis of a genetically defective fetus are terminating a desired pregnancy-and their action precludes the birth of a wanted child. In the latter group, more than a casual follow-up should be made, and they should be encouraged to seek psychiatric aid if their depressive or guilt feelings are severe or long-lived. REFERENCES 1. Simon N, Senturia A: Psychiatric sequelae of abortion: Arch Gen Psychiat 15:378-389, 1966 2. White R: Induced abortions-A survey of their psychiatric implications, complications, and indications. Texas Rep Biol Med 24:531-558, 1966 3. Schwartz R: Psychiatry and the abortion laws-An overview. Compr Psychiat 9:99-117, 1968 4. Callahan D: Abortion: Law, Choice and Morality. New York, The MacMillan Company, 1970 5. Simon N: Psychological and emotional indications for therapeutic abortion, In Sloane R (Ed): Abortion: Changing Views and Practice. New York, Grune and Stratton, 1970 (also published in Seminars Psychiat 2(3):283-301, 1970) 6. Taussig F: Abortion, Spontaneous and Induced. St. Louis, CV Mosby Company, 1937, pp 276-278 7. Taussig F: Effects of abortion on the general heath and reproductive functions of the individual, chap 4, In Taylor H (Ed): The Abortion Problem-Proceedings of the conference held under the auspices of the National Committee on Maternal Health, Inc at the New York Academy of Medicine, June 19-20, 1942. Baltimore, Williams-Wilkins Co, 1944, pp 46-47 8. Mandy A: Reflections of a gynecologist, In Rosen H (Ed): Therapeutic Abortion. New York, Julian Press, 1954, pp 284-296 9. Lidz F: Reflections of a psychiatrist, In Rosen H (Ed): Therapeutic Abortion. New York, Julian Press, 1954, pp 276-284 10. Kraepelin E: Psychiatrie. Leipzeig, JA Barth, 1909 11. Pearce J: Discussion: The psychiatric indication for the termination of pregnancy. Proc Roy Soc Med 50:321, 1957 12. MacDonald R: Complications of abortion. Nurs Times 63(1):306-307, 1967 13. Gluckman L: Some unanticipated complications of therapeutic abortion. New Zeal Med J 74(471):71-78, 1971
14. Heller A, Whittington H: The Colorado story: Denver General Hospital experience with the change in the law on therapeutic abortion. Am J Psychiat 125(6):809-816, 1968 15. Kummer J: Post-abortion psychiatric illness-A myth? Am J Psychiat 119(10):980-983, 1963 16. Crowley R, Laidlaw R: Psychiatric opinion regarding abortion-Preliminary report of a survey. Am J Psychiat 124(4) :559562, 1967 17. Deutsch H: Psychology of Women. New York, Grune and Stratton, 1945 18. deBouvoir S: The Second Sex. Edited and translated by H Parshley. New York, Alfred A Knopf, Inc, 1952, pp 490-491 19. Dunbar F: A psychosomatic approach to abortion and the abortion habit, In Rosen H (Ed): Therapeutic Abortion. New York, Julian Press, 1954, pp 22-31 20. Senay E: Therapeutic abortion. Arch Gen Psychiat 23: 408-415, 1970 21. Fleck S: Some psychiatric aspects of abortion. J Nerv Ment Dis 151:42-50, 1970 22. Raphael B: Psyclhosocial aspects of induLced abortion-fts implications for the woman, her family, and her doctor-Part 1. Med J Aust 2:35-40, 1972 23. Bolter S: The psychiatrist's role in therapeutic abortionThe unwitting accomplice. Am J Psychiat 119(4):312-316, 1962 24. Hamilton V: Some sociologic aind psychologic observations on abortion. Am J Obstet Gynec 39:919-928, 1940 25. Malmfors K: Status of women after legal ab.ortion. Svenska Larkartidingen 48:2445, 1951 26. Ekblad M: Induced abortion on psychiatric grounds-A followup study of 479 women. Acta Psychiat Neurol Scand Suppl 99: 1-238, 1955 27. Mehlan KH: Spatfolgen nach Legalem Abort. Deutsche Gesundh 11:876-880, 1956 28. Kolstad P: Therapeutic abortions. Acta Obstet Gynec Scand 36:Suppl 6:7-72, 1957 29. Aren P: Acta Obstet Gynec Scand 37:Suppl 1, 1958, as cited by Year Book of Obstetrics and Gynecology, 1958-1959 Series. Edited by Greenhill. Chicago, Year Book Publishers. 1958, p 65 30. Gebhard P, Pomeroy W, Martin C, et al: Pregnancy, Birth, and Abortion. New York, Harper and Brothers and Paul B Hoebner, Inc, 1958, p 209 31. Hong S: Induced abortion in Seoul, Korea. IPPF: Proceedings of the Regional Conference, Western Pacific Region, 1965. Seoul, Dong-A Publishing Co, 1965, p 53 32. Osofsky J, Osofsky H, Rajan R, et al: Psychologic effects of legal abortion. Mod Treatm 8(1):139-158, 1971 (also published in Clin Obstet Gynec 14(l):215-234, 1971) 33. Opton E: Psychological and Social Outcomes of Abortion. Berkeley, California, The Wright Institute, 1971 34. Kapor-Stanulovic N: Three phases of the abortion process and its influence on women's mental health. Am J Public Health 62(7) :906-908, 1972 35. Wallerstein J, Kurtz P, Bar-Din M: Psychosocial sequelae of therapeutic abortion in young unmarried women. Arch Gen Psychiat 27(6):828-832, 1972 36. Brody H, Meikle S, Gerritse R: Therapeutic abortion-A prospective study. Am J Obstet Gynec 109(3):347-353, 1971 37. Margolis A, Davidson L, Hanson K, et al: Therapeutic abortion follow-up study. Am J Obstet Gynec 110(2):243-249, 1971 38. Niswander K, Singer J, Singer M: Psychologic reaction to therapeutic abortion-Objective response. Am J Obstet Gynec 114(1):29-33, 1972 39. Jansson G: Mental disorders after abortion. Acta Psychiat Scand 41:87-110, 1965 40. Peck A, Marcus H: Psychiatric sequelae of therapeutic interruption of pregnancy. J Nerv Ment Dis 143(5):417-425, 1966 41. Niswander K, Patterson R: Psychologic reaction to therapeutic abortion-Subjective patient response. Obstet Gynec 29(5): 702-706, 1967 42. McCoy D: The emotional reaction of women to therapeutic abortion and sterilization. J Obstet Gynec Brit Cwlth 75:10541057, 1968 43. Pare C, Raven H: Follow-up of patients referred for termination of pregnancy. Lancet 1:635-638, 1970 44. Simon N, Senturia A, Rothman D: Psychiatric illness folowing therapeutic abortion. Am J Psychiat 124(1):59-65, 1967 45. Fletcher J: The brink-The parent-child bond in the genetic revolution. Theol Stud 33:457-470, 1972 46. Golbus M, Conte F, Schneider E, et al: Intrauterine diagnosis of genetic defects: results, problems, and follow-up of one hundred cases in a prenatal genetic detection center. Am J Obstet Gynec 118:897-905, 1974 47. Blumberg B, Golbus M, Hanson K: The psychological sequelae of abortion performed for a genetic indication. Am J Obstet Gynecol, In Press 48. Kaltreider N: Emotional patterns related to delay in the decision to seek legal abortion. Calif Med 118:23-27, May 1973 49. Bibring G: Dwyer T, Huntington D, et al: A study of the psychological processes in pregnancy and of the earliest motherchild relationship. Psychoanal Stud Child 16:9-72, 1961 50. Raphael B: Psychosocial aspects of induced abortion-Its implications for the woman, her family, and her doctor-Part 2. Med J Aust 2;98-101, 1972
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