Chapter 2: Review of Literature
The review of literature has been organized into several sections to promote continuity to the wide variety of research that abortion has generated. Rather than beginning with the earliest findings in post-abortion literature and proceeding forward, the information is organized into specific factors associated with post-abortion problems; each section assesses several views on the subject, areas yet to be explored, and research that has received significant support. A more extensive discussion of each contributing factor is found in Appendix G.
Factors in Post-Abortion Cases
Lewis (1997) refers to several factors that should be considered when examining post-abortion women. Some of these factors include demographic characteristics, religion, psychological state, meaningfulness of pregnancy, time of abortion during the pregnancy, and the character of the woman.
In the aftermath of the abortion, women also struggle emotionally. Some of the coping techniques they may use include denial and repression. The woman may also be overwhelmed with sadness, loss, or even guilt. Some of these emotions come to the surface as a result of indecisiveness about the abortion decision and can surface very unexpectedly (Reardon, 1990; Doherty, 1995; Reardon, 2000).
Examining teenagers as women at risk for post-abortion syndrome stems from the statistic that indicates that one third of all abortions are performed on teenagers and half on women 24 years old and younger. Their age, inability to understand the long-term implications, lack of cognitive maturity, and dependence on their parents cause complications that are not necessarily present for older women. They may also receive more pressure from outside sources and develop a negative self-image post-abortion (Speckhard & Rue, 1993; Freed & Salazar, 1993; Mannion, 1994; Franz & Reardon, 1992).
There is still conflict in the literature assessing the presence of post-abortion syndrome in women. Some studies that find no trace of PAS and others find substantial amounts. The political, social, and economic issues surrounding abortion make it difficult to find an unbiased source (Reardon, 2000; Almeling & Tews, 1999; Cozzarelli, 1993; Erikson, 1993; Franz & Reardon, 1992; Major et al, 2000).
Post-abortion women have been found to have a higher risk for many health concerns. According to some studies, they are twice as likely to become heavy smokers and have an increased risk of alcohol abuse and drug abuse. Researchers have also found an increased incidence of violent behavior, divorce, separation, job loss, auto accidents, child abuse, exposure to HIV/AIDS and eating disorders among post-abortion women. Recently, studies have begun to find a higher number of post-abortion women finding breast cancer as well. All of these areas require further research, but lend support to the possibility that abortion affects the woman adversely (Reardon, 2000; Dudley & Tewes, 1999; Coalition on Abortion/Breast Cancer; Reardon, 1999).
Finland Study Assessing Post-Abortion Effects
The STAKES research team in Finland examined the death certificate records for women between the ages of 15 and 49. They focused on women who had died between the years 1987 and 1994, a total of 9,192 women. They proceeded to narrow it down to the 281 women who had died within a year of their last pregnancy and examined these women for certain traits.
They found that women were 76% more likely to die in the year following an abortion than non-pregnant women. They also found a higher suicide, accidental death, and homicide rate among post-abortion women when compared to non-pregnant women and women who carried their baby full term (Reardon, 1994; Morgan, 1997; Zolese & Blacker, 1992; Reardon, 2000).
Limitations of Research on Post-Abortion Effects
The latest news on PAS and/or the evidence of physical or psychological trauma after an abortion has remained controversial. In an article titled “The myth of the abortion trauma syndrome,” Stotland (1992) denies any research conclusively identifying a significant amount of women suffering because of the abortion procedure. For example, he reports that the Surgeon General of the United States, C. Everett Koop, MD, interviewed a wide variety of representatives favoring and opposing abortion and wrote President Ronald Reagan that he did not find, from the available scientific evidence, significant negative or positive mental health effects of abortion. Stotland went on to state that a woman going through with an unwanted pregnancy could be just as traumatic as an abortion on a woman’s mental health. Several articles are cited in which trauma found after abortion was limited and in all circumstances insignificant. He even went further to say that the incidence of diagnosed psychiatric illness is more common after childbirth than following an abortion procedure (Stotland, 1992). Reardon (2000) cites a review of literature that reported rates of adverse post-abortion outcomes ranging from six percent to above fifty percent. With consideration of these findings, it seems rash to claim, as Stotland (1992) did, that no one suffers from post-abortion syndrome (Reardon, 2000).
Butler (1996) noted when examining the long-term psychological effects of abortion, researchers face many challenges. Social class, family support, the pregnancy itself, and cultural values are all confounding variables that can complicate comparisons between control groups and women undergoing termination of their pregnancy. Any pregnancy has some degree of influence on the psychological state of a woman, but being able to do psychological evaluations of women before they become pregnant is a very difficult task. Many of the studies that are often quoted about post-abortion symptoms do not sufficiently follow-up on their clients, and they also fail to compensate for the women who become psychologically ill but show no indication to their physicians for many years. In fact, there have been no studies done, according to Butler (1996) that adequately deal with the difficult issues that long-term suffering from the abortion experience can cause.
Elective abortion is the most common surgical procedure in the United States. Vincent Rue identifies that the contradictory results concerning abortion affects are primarily due to the methodological process used in most of these studies. In a recent study done by researchers from the American Psychological Association on the after-effects of abortion, they reported to have found that first trimester abortions do not pose a psychological hazard for most women. However, they acknowledged the following limitations of their study and others: (1) each has methodological shortcomings and limitations, (2) no definitive conclusions can be drawn about longer-term effects, and (3) women who are more likely to find the abortion experience stressful may be under-represented in volunteer samples (Doherty, 1995).
Reardon (1997) found similar shortcomings in his studies. He found that the variety of negative reactions reported by women is so broad that it is impossible to encompass every claimed dysfunction in a single study, the cooperation of the study population is often inconsistent and unreliable, and the use of questionnaires and other standardized survey instruments can be inadequate when attempting to uncover deep-seated emotional problems.
The literature presents additional limitations concerning post-abortion adjustment including the following issues: actual prevalence of post-abortion symptoms has not been established, the follow-up after abortion is typically no longer than several weeks and most studies that describe post-abortion implications were done in the 1970s. Researchers have also failed to follow-up on all the women who have experienced abortions ten or more years in their past and are just now beginning to recognize the significant impact the abortion had on their life (Lewis, 1997).
Some other methodological problems recognized by Congleton & Calhoun (1993) included high attrition rates; the absence of control or comparison groups; poor statistical analyses; differences in results from pre/posttest and comparison group designs; non-standardized measures; and a lack of assessment for delayed effects (Congleton & Calhoun, 1993). Franz & Reardon (1992) discussed the high rate of loss of subjects as a major methodological problem when assessing long-term follow-up of women who have had abortions. In fact, it is possible that those who drop out of these studies are those women suffering the greatest psychological distress and may be the most likely to develop PAS (Franz & Reardon, 1992).
Major et al (2000) also notes the methodological shortcomings of the present literature on post-abortion responses. The claim that post-abortion problems are common is sometimes based on clinical case studies of women who have sought professional help for psychological problems and therefore the results cannot be generalized. The claims that post-abortion problems are rare seems to be based primarily on studies done with women who arrive at clinics, physicians’ offices, or hospitals to have an abortion. Therefore, they include only short-term assessments of the woman’s post-abortion adjustment underestimating long-term post-abortion problems (Major et al, 2000).
In fact, findings compiled by Reardon (2000) from researchers who favored legalized abortion indicated post-abortion problems in significant amounts. Reardon feels that these findings should lead to abortion clinics improving the quality of information they give to women prior to an abortion procedure. Some of the information should include pre-consent information about the types of psychological reactions, which have been linked to a negative abortion experience, and the risk factors associated with these adverse reactions.
In addition they should provide adequate pre-abortion screening using criteria to identify women who are at a greater risk of negative post-abortion reactions. They should also provide individualized counseling to high risk patients, which would more fully explain why the patient is at a higher risk level along with more detailed information concerning possible post-abortion reactions. Finally, they should assist women who have pre-identifying high risk factors in evaluating and choosing lower risk solutions to their social, economic, and health needs (Reardon, 2000).
In summary, the nature of the syndrome makes it difficult to obtain reliable data. Boyland (1992) recognized that the resulting consequences could be a significant underestimation of the number of women suffering from PAS. The process of gathering reliable data has been criticized by a number of sources for faulty methodologies and questionnaires that are not giving an accurate estimation of the widespread effects of abortion on women. Another problem found in this process deals with the fact that suppression and denial do not allow most women to deal with the effects of their abortion until several years after it has taken place. By the time these symptoms become prevalent, she may not even associate them with her past pregnancy; doctors and counselors also tend to overlook this possibility (Boyland, 1992). Handy (1982) also recognized methodological shortcomings when assessing the psychological attributes of women seeking abortion in an attempt to discover character traits women possessed that made some more likely to conceive unwanted pregnancies.
The limitations of post-abortion studies are widespread within the research examined. The researchers must deal with the confounding variables of social class, family support, the pregnancy itself, cultural values, and the psychological state of the woman before the abortion takes place (Butler, 1996). Many researchers stated that women who found the abortion experience stressful might be underrepresented in the present literature (Doherty, 1995; Franz & Reardon, 1992; Boyland, 1992). The lack of follow-up with the women long-term has been repeatedly stated as a weakness in most research (Lewis, 1997; Congleton & Calhoun, 1993; Major et al, 2000). Some other weaknesses include the absence of control or comparison groups, poor statistical analyses, and non-standardized measures (Congleton & Calhoun, 1993).
In hopes of clarifying the effects of abortion on women, the research proposal outlined below describes a post-hoc descriptive comparison of psychological factors experienced by women who have recently experienced an abortion and women who experienced an abortion 10-15 years previously. There will be three groups of women assessed: those that have had an abortion in the past year (GP1), those that have had an abortion in the past ten to fifteen years (GP2), and a control group of women (GP3) seeking other medical care at the cooperating facility. One of the primary purposes will be to assess whether PAS or other negative effects increase as time passes after the initial abortion experience. This study seeks to provide both qualitative and quantitative data that can be contributed to the information about post-abortion symptoms and provide data concerning under-researched areas.