Appendix G- Information Regarding Prior Research

Appendix G: Information Regarding Prior Research

 

Factors to Consider in Post-Abortion Cases

 

Several factors have been identified by Lewis (1997) to be correlated with post-abortion adjustment problems, the first being demographic characteristics of women reporting post-abortion distress. The groups that primarily exhibit feelings of distress following an abortion procedure include adolescents or young adults who are unmarried and who have no children. It must also be recognized that this group of women represent the typical profile for women seeking abortions. Further, women who are Catholic or religious also seem to suffer negative symptoms following abortions (Lewis, 1997). Whether the woman suffers because her actions were against her religious beliefs, or suffers after being exposed to information from her religious organization that informs her of the “consequences” of her choice, or suffers because she recognizes that what she is aborting is an actual human child has not yet been determined. No studies were found that measured the amount of information available to those with religious backgrounds on the nature of abortion versus those with little or no contact with a religious organization.

Lewis (1997) noted that the decision process that leads to the woman accepting or rejecting the option of abortion plays a significant role in her psychological state following the abortion. Greater difficulty with the decision to abort is associated with poorer post-abortion adjustment, including greater feelings of guilt, anxiety, and negative emotions such as regret, depression, and anger. Pressure from a boyfriend, significant other, or parents can pose potential risk factors for negative post-abortion responses (Lewis, 1997).

Meaningfulness of pregnancy has also been shown to be a significant risk factor, especially those women who abort an intended pregnancy compared with those who abort an unplanned pregnancy. Women who indicated that they had some intention of conceiving and giving birth to their child exhibited a significantly higher number of post-abortion symptoms (Lewis, 1997).

The effects of abortion on men and the problems this may cause during the pregnancy have only begun to be assessed. Many of the references used to produce evidence of the effects of abortion on women also dealt with the inability of men to cope with the guilt and their responsibility in the pregnancy (Lewis, 1997; Freed & Salazar, 1993; Doherty, 1995).

The men’s post-abortion problems are prevalent in termination of the pregnancy for genetic or medical reasons. Both men and women who choose abortion in these cases tend to experience lingering post-abortion distress. Part of the distress felt by the couple may be attributed to the likelihood that the pregnancy was intended and wanted in most cases, particularly because genetic fetal anomalies are not usually detected until the second trimester of pregnancy. In the majority of these cases, however, it has also been found that these couples would choose to have the pregnancy terminated again if the same situation presented itself (Lewis, 1997).

Abortion in the second trimester has been associated with a greater risk for post-abortion problems. Some have suggested that abortion during the second trimester may be more traumatic because the pregnancy is advanced enough for the woman to view the fetus as a “future child,” particularly if she has felt movement in the womb. In fact, bodily changes, such as menstrual periods ceasing, hormones beginning to flow through the woman’s system, thickening and enlarging of the waist and breasts make it difficult for the women to deny what is happening. Some of the medical procedures used at this stage in the abortion also have the potential to produce greater psychological distress because of the possibility of the procedure calling for inducing of labor and expulsion of the dead fetus (Lewis, 1997; Selby & Brockmon, 1990). These circumstances may result in the woman being faced with the fact that what she has aborted was not a collection of tissue, but a healthy child. If the woman has not fully faced that idea before the abortion procedure has taken place, this could possibly produce a greater amount of distress. Lewis (1997) also states that only 12% of women undergoing a first trimester abortion indicated that the abortion decision was difficult for them, whereas 51% of women undergoing a second trimester abortion reported similar difficulty. This could indicate that conflicted women delay their decision and have later abortions, which in turn contributes to a poorer post-abortion adjustment (Lewis, 1997).

Women who blame their pregnancy on some aspect of their personal character, or lack thereof, tend to exhibit poorer adjustment following the abortion than those who attribute their abortion decision to some aspect of their behavior. Blaming another person also correlates with poor post-abortion adjustment. Social support appears to be correlated with better post-abortion adjustment, especially when that perceived support comes from the woman’s partner and her parents. Likewise, making the decision to abort alone and problems with the woman’s partner and parents correlate with both pre- and post-abortion distress. It has also been found in relation to a woman’s partner that the women who did not disclose the abortion decision to their partners did equally well post-abortion compared with those who chose to tell their partner of their decision and found him to be supportive (Lewis, 1997).

Emotional Trauma Post-Abortion

 

Studies have indicated that many women who feel a great deal of distress, guilt, or remorse about their abortion have no outlet for the pain that they feel. The social support available for women suffering in the aftermath of an abortion is limited and may even be nonexistent depending on the views of those closest to her on the abortion issue. The woman is left trapped in denial, unable to work through the process, and this can lead to PAS (Selby & Bockmon, 1990).

Since many post-abortion women use repression as a coping technique, there may be long periods of denial before the women seeks psychiatric care or other counseling. Seeking counseling or some other form of help in dealing with post-abortion stress is usually triggered by some crisis situation that causes the woman to face the consequences of her choice to abort. This event could be the anniversary date of the abortion or the projected due date of the aborted child, or several other situations that stir up feelings and memories related to the abortion experience (Reardon, 1990). When post-abortion women seek counseling, it may take time for the abortion story to be exposed because of the woman’s inability to see the abortion as the source of her present problems. In fact, some of the best estimates, according to Reardon, on post-abortion trauma point to an average of a ten-year period of denial during which post-abortion women suppress their feelings (Reardon, 2000).

When a woman feels victimized by the abortion experience, Doherty (1995) recognizes the possibility of her dealing with any of the following issues: (1) the belief that she killed her child, (2) that the death was violent and unjustified, (3) that the post-abortion feelings of loss and grief were unanticipated, and (4) that their coping abilities are overwhelmed. Other women experience post-abortion trauma only when they learn more about fetal development or are in a subsequent wanted pregnancy. At that point, they may become overwhelmed with sadness, loss and guilt over the death of their fetal child (Doherty, 1995).

The range of emotions evoked by the abortion experience may surface unexpectedly. Without having been fully prepared for the depth and intensity of feelings associated with this decision, the woman may resort to denial and other defense mechanisms to protect her from the consequences of this decision. This may lead to re-experiencing the abortion through nightmares, preoccupation about the pregnancy, flashbacks to the abortion, and being aware of anniversary dates. By failing to acknowledge the abortion experience to oneself or others, barriers can be erected, causing other problems such as avoidance of affect/feelings, avoidance of knowledge of the event, behavioral avoidance, and avoidance of communication about the event. These feelings can initially give the woman control over the overwhelming feelings associated with this experience, but over time can lead to avoidance of dealing with the conflict and an inability to function normally in everyday life (Doherty, 1995).

Various types of denial have been described including occluded, periodic, compensatory, segmented, and purposive. Abortion denial has also been listed in stages. The first stage relates to pre-abortion problems including denial of the pregnancy itself, the responsibility of the pregnancy, the baby or humanity of the product of conception (POC) and how she became pregnant. The second stage consists of the abortion itself and her emotional reactions to the procedure, which fall under denial issues during the course of the actual abortion event. Post-abortion denial of certain aspects of the abortion, of all memory of the abortion, and of any relationship between the abortion and self-defeating behaviors can lead to denial in the final stages of the process. These coping mechanisms all impair the process of recovery when it becomes necessary, and allow the woman to further avoid dealing with the abortion’s impact on her life (Doherty, 1995).

A study done by Barnard in 1990 involved women randomly selected for follow-up after their abortion experience. Sixty-percent of the women chosen in the sample had given the wrong phone number, which severely limited the study and was only done on 80 women. Barnard found that 68 percent, at the time of the abortion had little or no religious involvement; three to five years post-abortion eighteen percent of the sample met the full diagnostic criteria for PTSD and 46 percent displayed high stress reactions to their abortion. The psychological testing used to assess these women included the Millon Clinical Multiaxial Inventory (MCMI) and the Impact of Event Scale. She also found one out of four women feeling emotionally detached and one out of three experienced unwanted reactions to the abortion experience, which included hypervigilence, sleep disorders, and startle reactions (Doherty, 1995).

Another study done with 252 aborted women who suffered psychological sequelae reported that 53% felt forced into the abortion by others, and 65% felt forced by their circumstances. Only 33% felt free to make their own decision. Eighty-three percent said they would have kept the pregnancy if they had been encouraged to do so by one or more other persons and 84% said they would have kept the pregnancy under better circumstances. Further, this type of indecisiveness is one of the identifying markers for high-risk abortion patients. Sixty-five to seventy percent of the women seeking abortions have a negative moral view of abortion. This ambivalence is further confounded by evidence from several researchers that show that up to 60 percent of women seeking abortion express some desire to keep the child and 45 percent are hoping for some miracle that will allow them to avoid the abortion. The coercive pressures and unsure feelings at the time of the abortion only multiply the potential for problems post-abortion, making an already traumatic experience significantly worse (Reardon, 1990).

The crisis situation and the attachment that the woman has unknowingly formed to the fetal child are addressed by Speckhard & Rue (1993) as having the potential to complicate grief experienced by some post-abortion. This has been shown to occur even when the woman desires to rid herself of the POC/baby. The grief felt by women post-abortion when this attachment has been formed is not easy to resolve; this process is complicated by the confusion felt by the woman about her relationship to the fetus coupled with attempts to deny the incident ever took place.

Many women, especially those suffering from PAS, bury their feelings about the fetal child after the abortion occurs. Unconsciously they agonize over the decision (a stage called preoccupation), but maintain an image of regret mixed with relief that the abortion has taken place. This stage of regret is followed by several others including bargaining, reenactment, and delayed reactions which all impact the life of the woman and those around her. Dealing with the grief, denial, and deep-rooted emotions that occurs post-abortion requires that the woman recognize her pain and begins the process of dealing with the consequences of her abortion decision (Speckhard & Rue, 1993).

Teenagers and Post-Abortion Problems

Freed & Salazar (1993) found that teenagers are often prevented by their age and circumstances from fully understanding and exploring the effects that an abortion can have on their future, which places them under a greater risk for post-abortion problems. Women who already have children and choose to abort struggle with the maternal instinct that calls them to protect, love, and nurture the child growing within them. Women who delay their abortion until the second or third trimester have increased risk of medical complications and are much more likely to come in contact with the aborted child if he/she survives and even if he/she does not. Those who struggle with a value conflict related to abortion many times are faced with family and friends who will not approve of their decision. Even religious beliefs may be in direct opposition to their decision, which leads to an even greater struggle when attempting to resolve feelings of loss, especially when guilt becomes an issue (Freed& Salazar, 1993).

In fact, “In the United States, one-third of all abortions are to teenagers and one-half are to women 24 years of age and under” (Mannion, 1994). The concern about the lack of cognitive maturity and the dependence that adolescents and young adults still have on their parents seems to be reinforced by these statistics. Many researchers have studied the differences between adolescents and adults having abortions, and they have found considerable evidence that adolescents suffer significantly more from this decision. According to recent studies, adolescents are significantly more likely to develop parental and/or marital difficulties, to attempt suicide following abortion, and to have severe nightmares following abortion (Mannion, 1994).

The worsening self-image issue related to abortion in teenagers has also been recognized by several sources. The self-image damage that abortion causes can delay the development of a stable identity in female teenagers who may have been unsatisfied with the abortion decision, or with how the abortion procedure was carried out, and/or were feeling pressure to have the abortion. According to Mannion (1994), the younger the woman when she had her abortion, the longer amount of time passes before she seeks help for her post-abortion problems. Another significant correlation found that the younger the woman was at the time of the abortion, the less satisfied she was with her decision post-abortion. Thus, one could pursue, based on these findings, the possibility that women who have abortions at a younger age are apt to be in denial longer and to be more negatively affected by the abortion than older women are (Mannion, 1994).

Franz & Reardon’s study (1992) also recognized the effects on self-image sparked by the abortion experience. Adolescents more frequently felt their self-image was damaged by many characteristics of the abortion experience including services rendered at the time of the abortion, feeling the greatest pressure to have the abortion, having the least amount of information about the abortion and making a poorly thought-out decision regarding the procedure. These problems could impair the development of a healthy self-image (Franz & Reardon, 1992).

The effect of the abortion decision on the adolescent also seems to inhibit their ability to grow, develop, and mature in a normal way. Some characteristics seen in teenagers who have aborted include an inclination toward being self-involved and egocentric. Their inability to conceptualize the long-range implications of their decision only aids them in denial afterwards, allowing them to place the blame elsewhere and deny responsibility for the pain they are feeling. For many adolescent girls, the consequences of their abortion decision were not faced until they had developed self-control and responsibility for their actions, which actually has the potential to cause the characteristics of PAS to surface for the first time. At this point, counseling and resolving those feelings that have been buried during their years of transition from adolescent to adulthood becomes critical. Therefore, the decision to abort may delay natural maturation processes in the young adolescent female, encouraging the use of defense mechanisms instead of facing the reality of their decision. The possible limitations of pre-abortion counseling are revealed through this research. Few counselors have the training to overcome adolescent egocentric thinking, and to do so would be counterproductive of their economic interests (Mannion, 1994).

There are some studies of the immediate after-affects of abortion cited by Franz & Reardon (1992) that indicate no negative effects on teenagers as a group and that the procedure may even be beneficial. However, each of these studies contains subgroups of teens that have problems. Adolescents sometimes suffer guilt, emotional stress and even show signs of psychological problems such as attempting suicide following the abortion procedure (Franz & Reardon, 1992). A study done in 1986 by researchers at the University of Minnesota found that a teenage girl is ten times more likely to attempt suicide if she had an abortion in the last six months than a comparable teenage girl who has not had an abortion (Reardon, 1993).

Furthermore, in a study of teenage abortion patients, half suffered a worsening of psychosocial functioning within seven months after the abortion. The immediate impact appeared to be greatest on the patients who were under seventeen years of age and for those with previous psychosocial problems. Symptoms included self- reproach, depression, social regression, withdrawal, obsession with need to become pregnant again, and hasty marriages (Reardon, 1990).

A study cited by Reardon (2000) followed researchers from the University of Albany in New York. They found that teens that have children were as well or better adjusted than teens that did not have children. Compared to their peers, they had fewer mental disorders, reported less stress, were less likely than their peers to engage in denial as a coping strategy, and were less dependent on social support. These two studies directly contradict the popular notion that abortion benefits women in general and teens in particular (Reardon, 2000).

Recent Studies of Post-Abortion Attitudes

Findings cited by the National Abortion Federation discount the existence of PAS. They use the results of the 1989 meeting of the American Psychological Association (APA), which reported that the studies with the most scientifically rigorous designs found no trace of post-abortion syndrome and that such a syndrome has yet to be medically recognized (Almeling & Tews, 1999).

Cozzarelli (1993) studied the effects of self-efficacy and personality as coping mechanisms post-abortion and found that women who imagine themselves as handling their abortions well can translate these expectancies into effective coping strategies. The relationship of personality to motivational factors and coping behaviors was revealed related to women in abortion situations. When put in a stressful life situation (i.e. abortion), increasing feelings of self-efficacy motivated individuals to increase or exert appropriate coping behaviors (Cozzarelli, 1993).

Major et al (1998) confirmed the findings of Cozarelli (1993) in his study of personal resilience, cognitive appraisals, and coping and adaptation. He found that the more resilient personality resources the woman had available to her, the less likely she was to feel stressed by the abortion beforehand; and self-efficacy for coping with the abortion afterwards was higher as well. Their conclusion stated that women who appraise the abortion experience as harmless are more likely to cope through acceptance and less likely to engage in denial and disengagement behaviors (Major et al, 1998).

Major et al also found in his earlier study in 1990 that social well-being enhances the coping of those going through the abortion experience. Self-efficacy beliefs were also related strongly to better psychological adjustment following the abortion (Major et al, 1990).

Major et al (2000) studied the psychological responses of women after first-trimester abortions and found that two years post-abortion 72% were satisfied with their decision, 69% said they would have the abortion again, 72% reported more benefit than harm from their abortion, and 80% were not depressed. One percent reported post-traumatic stress disorder. Depression decreased and self-esteem increased from pre-abortion to post-abortion, but negative emotions increased and decision satisfaction decreased over time. The younger the woman was at the time of the abortion and having more children before the abortion predicted negative abortion reflection. Their conclusion was that most women do not suffer ill effects from abortion, and those who suffer have a history of depressive symptoms before the abortion occurs (Major et al, 2000).

Erikson (1993) highlights some of the studies proving the effects of post-abortion problems and shows concern over the resistance within the medical and professional communities to acknowledge the fact that abortion can be a traumatic experience. This resistance is exemplified in Stotland’s (1992) article claiming there is no evidence for post-abortion syndrome.

Destruction of the fetal child through abortion disrupts the stability of that woman’s internal structure, and can bring about the onset of PTSD symptoms. The intuitive sense of the gender, a name for the child, the habit of calling that which is growing inside a baby rather than a fetus; all of these factors represent this well-developed internal structure adapted to the new life within the woman. These perceptions of the humanity of the victim are sources of the most extreme distress felt by the mother. Dehumanization of the “fetus” growing inside the woman, according to Erikson, would be indications of the woman’s aggressor identity that has been set into motion by the abortion procedure (Erikson, 1993).

Two recent studies have also uncovered a significant difference in mental health among women who have had abortions versus women having gone through childbirth. One study done in California looked at women who had received state funded medical care and had aborted or given birth in 1989. They examined their medical records up to six years afterward and found that women who had abortions had significantly higher health claims than women who had given birth. This study provided a more thorough analysis of the women post-abortion because of its long-term assessment (Reardon, 2000).

Franz & Reardon (1992) also discovered in their research that counseling prior to abortion should be sensitive to the woman being fully informed, having time to make an adequate decision, and to not be pressured into the abortion if they do not feel that it is necessary. Psychological distress post-abortion occurs in association with desire to give birth to a child and a very negative view of abortion before the pregnancy. Women who have been coerced into the abortion decision may suffer negative consequences because abortion was not their first choice (Franz & Reardon, 1992; Reardon, 2000).

An article written by David Reardon in 2000 called “The cover-up” follows an investigative reporter’s search through death certificates for women of reproductive age in Los Angeles County. He pulled autopsy reports and found twenty-nine abortion-related deaths in this county alone between 1970 and 1987. Four of those deaths occurred during a year when the Centers for Disease Control (CDC) reported zero abortion-related deaths for the entire state of California, and only twelve deaths for the whole country. After he was done searching for this type of research, the investigative reporter had found 30 to 40 percent more abortion-related deaths than were initially reported by the CDC. Several other parts of the United States including Chicago have done similar investigations with more abortion-related deaths being discovered than were initially recorded (Reardon, 2000).

Another recent and disturbing finding revealed that sixty percent of women who experience post-abortion sequelae report suicidal ideation, with twenty-eight percent actually attempting suicide, of which half attempted suicide two or more times. Another study (Reardon, 2000) done in Finland found the suicide rate to be three times higher for women who had an abortion within the last year compared to all women, seven times higher than for women carrying their baby to term, and nearly twice as high as women who suffered a miscarriage. These suicide attempts proved to be especially evident among post-abortion teenagers (Reardon, 2000).

Post-Abortion Women and Other Health Risks

There have been many other links discovered recently with post-abortion stress by Reardon (2000). Women who abort are twice as likely to become heavy smokers and suffer the corresponding health risks. They are also likely to continue smoking during subsequent wanted pregnancies. Abortion is significantly linked with increased risk of alcohol abuse. Abortion followed by alcohol abuse is linked to violent behavior, divorce or separation, auto accidents, and job loss. There have also been links with abortion and subsequent drug abuse, which is then linked to increased exposure to HIV/AIDS infections, congenital malformations, and assaultive behavior. Some women even suffer from eating disorders post-abortion such as binge eating, bulimia, and anorexia nervosa.

Abortion has also recently been linked with increased depression, violent behavior, alcohol and drug abuse, replacement pregnancies, and reduced maternal bonding with children born subsequently. These factors are closely linked with child abuse but the correlation requires further study. These women also experience greater difficulty forming lasting bonds with a male partner. Women who have more than one abortion, which represents about 45% of all abortions, are more likely to require public assistance in part because they are more likely to become single parents (Reardon, 2000).

In addition to the previously named connections, new findings are now connecting abortion and breast cancer. A study done by Janet Daling in 1994 funded by the National Cancer Institute found an overall 50 percent increased breast cancer risk among women who had reported having an abortion compared with a control group who had not (Coalition on Abortion/Breast Cancer). There have been over two dozen studies published since 1957 that found possible links between abortion and breast cancer, yet women are still unable to make the abortion decision with this information available to them (Coalition on Abortion/Breast Cancer). Dudley and Tews (1999) also cited Daling’s study but elaborated on the statistics report. The higher percentage of risk only raises the chance of developing breast cancer for a woman in her thirties to 1.5 in 2,525.

Almost as devastating as the after-affects of abortion on women are the deceptive practices that appear to be used by abortion doctors and “counselors” at abortion clinics daily to convince a woman to perform a significant medical procedure immediately. They has been evidence found that they use professional advertising campaigns and PR budgets to promote their cause as well as hiring “trained salespersons” rather than actual licensed counselors that will begin to orient the customer toward abortion. In fact, a woman who once directed an abortion clinic in Texas admitted to training her counselors to identify a women’s problems and concerns that were uppermost in her mind and to use those to orient her toward the abortion decision whenever her confidence began to wane. This can lead to abortion being viewed as a consumer product or an easy solution. The heavy consequences of this procedure can be lost in what seems to be a business venture (Reardon, 1999).

Finland Study Assessing Post-Abortion Effects

The statistical analysis unit of Finland’s National Research and Development Center for Welfare and Health, called STAKES, did a record-based study, which pulled the death certificate records for all the women of reproductive age (15-49) who died between 1987 and 1994 (Reardon, 2000). The sample size was 9,192 women; since Finland has socialized medical care, these records are very accurate and complete. They searched through the national health care database to identify pregnancy-related deaths for each of these women in the twelve months prior to their deaths. There were 281 women who had died within a year of their last pregnancy. The unadjusted mortality rate per 100,000 cases was 48 for women who had miscarriages or ectopic pregnancies, 27 for women who had given birth, and 101 for women who had abortions. When the researchers calculated the age-adjusted odds ratio of death, women who have abortions were found to be 76 percent more likely to die in the year following abortion compared to non-pregnant women. Compared to women who carry their pregnancy to term, women who abort are 3.5 times more likely to die within a year (Reardon, 2000).

Their findings related to suicide were even more astonishing. In a previous study, they found that the risk of death from suicide within the year of an abortion was more than seven times higher than the risk of suicide within a year of childbirth. Among the 281 women used for the present study, 27 percent (77) had committed suicide. The risk of suicide was cut in half for women following a birth, while the suicide rate of women who had abortions was almost four times the rate of women who went through with their pregnancy (Reardon, 2000).

This statistical finding has been backed by two other studies, which also found a dramatic increase in suicide risk post-abortion. An interview-based study found that suicidal ideation was between 30 and 55 percent and reports of suicide attempts were 7 to 30 percent among women who have had an abortion (Reardon, 1994). The other study was done at the South Glamorgan Health Authority in Great Britain who examined their data for suicide attempts before and after pregnancy events. They found that, after their pregnancies, there were 8.1 suicide attempts per thousand women among those who had abortions, compared to only 1.9 suicide attempts among those who gave birth. The researchers also concluded that their data did not support the view that the suicide rate after abortion was based on the poor mental health of the individual before the abortion procedure took place; the increased risk for suicide may be a consequence of the procedure itself (Morgan, 1997).

The STAKES researchers also reported that the risk of death from accidents was over four times higher for women who had aborted in the year prior to their deaths than for women who had carried to term. That was twenty percent of the 281 women (57 women). STAKES also found that 14 of the 281 women died by homicide, and most of these deaths were women who had abortions. Their rate was four times greater than the risk of homicide for the general population, and when combined with the statistics for suicides and accidents it seems to suggest that women who have had abortions engage in more risk-taking behaviors (Reardon, 2000).

Some of the short-comings of the research done by STAKES includes births or abortions occurring outside of Finland that would not have been identified in the records, but they believe that these results would not significantly shift the findings of their study. Unfortunately, it is also unclear what constitutes a solid causal connection between a death and a previous pregnancy, miscarriage, or abortion; the researchers here have no way of proving that one event led to the other. Their examination of only one-year of reproductive history for these women also contributes as a limitation because of the association of suicides and the anniversary dates of the abortion procedure, so it may be possible that more suicides or accidents were missed. It also does not deal with how long this elevated ratio of death lasts for women who have had an abortion, or whether the women were engaging in suicide or risk-taking behavior before their abortions. Although some abortion activists would argue that abortion did not cause any of these deaths, the fact still needs to be addressed that it was also found that birth provided a protective effect and significantly lower levels of all risk-taking behaviors (Reardon, 2000).

Zolese & Blacker (1992) examined a study on children born of unwanted pregnancies and found significant delays in psychosocial development and underachievement academically. This information lends a larger context to the outcomes of the STAKES research by considering the child as well as the mother’s health after birth.

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