Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Induced abortion and psychological sequelae

Sharon Cameron, Consultant Gynaecologist, Dean *
NHS lothian, Dean Terrace Centre, 18 Dean Terrace, Edinburgh, EH4 1NL, UK
Royal Infirmary of Edinburgh, 51 Little France Crescent, EH16 5SU, UK

Keywords:
The decision to seek an abortion is never easy. Women have
abortion different reasons for choosing an abortion and their social,
mental health economic and religious background may influence how they cope.
psychological health Furthermore, once pregnant, the alternatives of childbirth and
psychiatric illness adoption or keeping the baby may not be psychologically neutral.
Research studies in this area have been hampered by methodo-
logical problems, but most of the better-quality studies have
shown no increased risk of mental health problems in women
having an abortion. A consistent finding has been that of pre-
existing mental illness and subsequent mental health problems
after either abortion or childbirth. Furthermore, studies have
shown that only a minority of women experience any lasting
sadness or regret. Risk factors for this include ambivalence about
the decision, level of social support and whether or not the
pregnancy was originally intended. More robust, definitive
research studies are required on mental health after abortion and
alternative outcomes such as childbirth.
Ó 2010 Elsevier Ltd. All rights reserved.

It has been claimed that the decision to terminate an unwanted pregnancy can lead to mental health
problems for women. However, once a woman is in the situation of having an unwanted pregnancy,
there is no magical state of ‘un-pregnancy’ and the alternative courses of action of childbirth and
raising a child or adoption may also pose a psychological threat. Childbirth can be a physically and
emotionally demanding time for mothers and many studies have demonstrated an increase in
depression and anxiety post-partum. In Scotland in 2002, data collected from a subset of general
practitioner (GP) practices for each face-to-face patient with a GP consultation revealed that 27% of
mothers were diagnosed with depression or anxiety within 12 months of childbirth compared with

* Tel.: þ44 131 343 0912; Fax: þ44 131 332 2941.
E-mail address: Sharon.cameron@ed.ac.uk

1521-6934/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.bpobgyn.2010.02.001
658 S. Cameron / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665

19% in women who had not given birth in the same year.1 Furthermore, there is evidence that if women
are denied an abortion, their children are at an increased risk of mental health problems. A longitudinal
study that followed up children born in 1961–63 in the former Czechoslovakia (now Czech republic), of
women who were denied abortion and forced to continue with the pregnancy, found that compared to
matched controls (children from wanted pregnancies), offspring from unwanted pregnancies were at
increased risk of negative psychosocial development and wellbeing.2 The negative effects on mental
health continued into adulthood and, compared to controls, the children of unwanted pregnancies
were more likely as adults to have a psychiatric illness, less job satisfaction and females were more
likely to be single or divorced at age 26–28 years.2
The question whether abortion has a negative effect on mental health of the woman is a recurring
one. In 1989, the American Psychological Association (APA) reported the results of a systematic review
of the published literature at that time. They reported that most methodologically sound studies
indicated that severe negative reactions after legal non-restrictive first trimester abortion were rare
and could best be understood in the framework of coping with a normal life stress.3
In more recent times, however, there has been renewed interest in the mental health outcomes of
induced abortion, exemplified by a headline for an article in the New York Times in 2007 titled ‘Is there
a Post abortion Syndrome?4 The term ‘post-abortion syndrome’ is not recognised by any medical or
psychological society, but was coined by Vincent Rue.5 It was used to imply post-traumatic stress
disorder following the stress of abortion, where post-traumatic stress disorder is a severe and ongoing
emotional reaction to an extreme psychological trauma.
Given this renewed interest in mental health after abortion and the fact that there had been new
relevant publications since 1989, the APA convened a task force on mental health and abortion in 2007
to review the published literature since 1989.6 A further systematic review of published articles over
a similar time period (1989 and 2008) was conducted by Charles et al. in 2008.7 The conclusions of both
systematic reviews by APA and Charles et al. in 2008 were in agreement with the conclusions of the
earlier report of the APA, and are outlined below.6,7 Both systematic reviews highlighted the numerous
methodological flaws with research in this area.6,7

Methodological problems with research on mental health and abortion

The systematic reviews of APA and Charles et al. in 2008 of published studies, which examined mental
health and abortion, observed recurring methodological problems with the studies in this area.6,7

(i) Comparative groups

Few studies have included appropriate comparative groups such as those women denied an abortion,
who give the baby for adoption and women delivering and raising an unwanted child. The general
population of women who deliver a baby are not an appropriate comparison group since women who
plan a pregnancy and deliver a wanted baby may differ in important characteristics from women, such
as level of social support, for whom the pregnancy was clearly unintended.

(ii) Co-occurrence of risk factors

There is good evidence that factors such as poverty, personality or behaviour (e.g., smoking, alcohol and
drugs) can predispose a woman to unplanned pregnancy and abortion as well predispose to mental
health problems.8,9 Few studies assessed or adequately controlled for confounding factors such as the
co-occurrence of unwanted pregnancy with adverse circumstances and adverse circumstances with
mental health problems.

(iii) Sampling
Some studies used volunteer samples that can introduce bias, since women who agree to participate
(e.g., in response to a mailed questionnaire) may report different psychological experiences after
abortion to those who do not agree to participate.10 Some studies have also been small in terms of
sample size or have performed secondary analyses of data sets that were not designed to examine
relative risks of mental health after abortion.11,12 Furthermore, in some studies, there was differential
 S. Cameron / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665 659

exclusion of women who had a child but had a subsequent abortion. This introduces selection bias and
limits the generalisability of the findings to the general population.

(iv) Reproductive history and under-reporting

A major confounder in studies were history of abortion is self-reported is that of under-reporting due to
the stigma associated with termination of pregnancy.
If women who experience most psychological problems following an abortion do not report that they
had an abortion, this leads to an underestimation of any negative effect of abortion on mental health
and, similarly, this leads to overestimation such women are more likely to report that they had an
abortion. Many studies have not specified or clearly reported the gestations that women had abortions,
nor the reason for the abortion or whether the pregnancy was originally intended. This is important
because abortion at later gestations may be associated with more pain and increased risk of compli-
cations with a greater likelihood of being a more distressing experience. A late abortion may also reflect
an underlying ambivalence about terminating the pregnancy or the diagnosis of a foetal anomaly in
what was originally a planned and wanted pregnancy.

(v) Outcome measures and statistical analysis

Some studies used poor or unvalidated measures of mental health. In some studies the timing of the
measurement of mental health relative to the time of the abortion was unspecified or varied. It is
generally accepted that the closer one is to an event, the more accurate ones’ reporting of health or
emotion is likely to reflect health/emotion at the time of the event. Many studies focussed only on
negative mental health outcomes and neglected to consider possible positive outcomes. Some studies
reported outcomes that were based upon results of multiple statistical testing and thus may have
arisen by chance alone. For many studies the loss to follow-up was considerable. This can affect the
validity of results, since if most psychologically disturbed women are lost to follow-up, this will lead to
an underestimation of any effect of abortion on mental health and vice versa.

Studies indicating a neutral effect of abortion on mental health

One of the studies deemed to be of best quality by both the APA and the systematic review of Charles
et al. in 2008 was a prospective, longitudinal, cohort study conducted in England by the Royal College of
General Practitioners and Royal College of Obstetricians and Gynaecologists.13 The study cohort
comprised 13 261 women recruited between 1976 and 1987, who presented to their GP with an
unplanned pregnancy, of which 6410 proceeded with an abortion, 6151 did not request an abortion,
379 were denied an abortion and 321 who initially requested abortion but then decided to continue
with the pregnancy. At recruitment, socioeconomic data were recorded including history of previous
pregnancies and of pre-existing psychiatric illness. Every 6 months until the end of the study, GPs
provided data on new episodes of illness and any further pregnancies. Morbidity on psychoses,
depression and anxiety was coded using the World Health Organization codes. There was no significant
difference in the rates of total psychiatric disorder or depression or anxiety between women who
underwent pregnancy termination or childbirth.13 An important finding was that women with
a previous history of psychiatric illness were most at risk of psychiatric disorder at the end of the
pregnancy regardless of its outcome. Women without a history of mental illness had an apparently
lower relative risk (RR) of psychosis after abortion than childbirth (RR 0.4, 95% confidence interval (CI):
0.3–0.7). The authors did note that rates of deliberate self-harm were higher in women refused an
abortion (RR 2.9, 95% CI: 1.3–6.3) or having an abortion (RR 1.7, 95% CI: 1.1–2.6) compared to the
childbirth group, but added that this may have been due to possible confounding factors that they were
unable to account for such as co-existing social difficulties associated with the request for termination
and also with self-harm behaviour. This study had the advantages of being large, prospective, with
appropriate comparison groups that account for pregnancy intention and with validated outcome
measures (physician diagnosis). It also had the advantage of comparing across groups at multiple time
points and controlling for pre-existing mental health.
660 S. Cameron / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665

Another study that suggested no overall effect of abortion on mental health was that of Russo and
Zierk, based upon data from the National Longitudinal Survey of Youth (NLSY) from USA.12 This survey
involved annual interviews with a stratified sample of the population aged 14–21 years in 1979, with
oversampling of black, Hispanic and poor white populations. In this study, out of a cohort of 5295
women, interviewed in 1987, those women who reported ever having an abortion (n ¼ 773) had no
different measures of self-esteem than other women who did not report a history of abortion.12 This
study also reported that having repeated unwanted pregnancies (birth or abortion) was significantly
correlated with poverty and low education.
Studies from Norway, which followed up women from 10 days to 5 years after a first trimester
abortion (n ¼ 80) or miscarriage (n ¼ 40), reported no significant differences between the groups in
measures of anxiety, depression or wellbeing.14–16 While this study inferred similar levels of psycho-
logical stress with both miscarriage and abortion; nevertheless, miscarriage is not an appropriate
comparison group for induced abortion as it is not an alternative that can be chosen by women with an
unplanned pregnancy.

Studies indicating a negative effect of abortion on mental health

In 2006 a study from New Zealand reported a negative effect of abortion upon the mental health of
young women who had an induced abortion.17 This was a longitudinal study that followed up a cohort
born in Christchurch in 1977. The cohort included 630 women who reported their reproductive history
between 15 and 25 years of age. The researchers reported higher rates of depression, suicidal ideation
and illicit drug dependence in those undergoing abortion. While the study did measure validated
outcomes and was able to account for confounding factors linked to women’s family and childhood,
a study flaw was that it relied upon self-reported abortion (thus likely under-reporting) and did not
separate single from multiple abortions. A more recent publication from this same study cohort, which
followed 500 women up to age 30 years, reported similar findings of a small increase in mental health
disorders (e.g., depression, anxiety, suicidal ideation and illicit drug dependence) in those undergoing
abortion.18 In the systematic review by Charles et al., the earlier study was deemed to be of ‘fair’ quality
only since it did not account for pregnancy intentions and compared women having an abortion with
women who were not pregnant and women who were delivering a child.7 In addition, the study only
controlled for pre-existing mental health up to 15 years of age, although the majority of pregnancies
occurred more than 3 years later. The more recent study was of recent similar design and could be
criticised for many of the same reasons.
Using the data set from the NLSY, Cougle et al. examined first pregnancy outcome (abortion or
childbirth) among a sub-sample of 1884 women, and reported that those whose first pregnancy ended
in abortion were significantly more likely to exceed the depression score for clinical depression (on
average 8 years later) than those who gave birth.19 This study has been criticised for inappropriate
comparison groups as there was no accounting for intended-ness of pregnancy and women were
excluded from the delivery group if they went on to have subsequent abortions. In the systematic
review by Charles et al., this study was rated as being of poor quality.7 In medical record linkage studies
conducted in Finland, higher rates of death of any cause (including violent death, homicide and suicide)
within 1 year of the pregnancy were reported for women who had an abortion compared to those
delivering a baby.20,21 However, subsequent analyses showed that the abortion group actually had
lower rates of death from causes aggravated or related to pregnancy.22,23 In addition, when abortions
conducted for medical (therapeutic) reasons were excluded, there was no difference in deaths of any
cause in the abortion group compared to the childbirth group. The most recent study from this group23
was rated as ‘very poor’ quality by the systematic review of Charles et al. as there were inappropriate
comparison groups, no control for pre-existing mental health or other confounders and the study
design using record linkage being able to provide contextual information only.7

Studies indicating a positive effect of abortion on mental health

Several studies have reported that measures of depression and anxiety are lower after either medical
or surgical abortion compared to just prior to the procedure.24,25 This would suggest that it is the state of
 S. Cameron / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665 661

being pregnant with an unwanted pregnancy itself that is stressful and that this is reduced once the
decision to terminate has been agreed and the procedure has been completed. Findings of these studies
are also consistent with others that have reported that the method of termination during the first
trimester does not affect emotional adjustment or psychological experiences after the procedure.24,26
In a study of 360 black teenage women in Baltimore, USA, of similar socioeconomic background who
were attending a family planning service for pregnancy testing, those with a positive test who went on to
have an abortion were more likely to have completed education and were better off economically 2 years
later than those who gave birth.27 Furthermore, teenagers who terminated their pregnancy had no
different levels of stress or anxiety than other teenagers at the time of the pregnancy test and were no
more likely to have psychological problems at the 2-year follow-up.27 Another publication based upon
the Christchurch cohort of women in New Zealand, which examined selected social and educational
outcomes of women who reported an abortion or childbirth prior to age 21 years, reported similar
findings of better subsequent educational achievement and employment in those women who termi-
nated the pregnancy.28 This study was a separate publication based on the same sample from New
Zealand that had reported a negative association between abortion and mental health.

Abortion and psychological response

Women request abortions for different reasons and at different gestations. Furthermore, women
come from different age groups, cultural, religious and socioeconomic backgrounds, all of which may
affect the experience of abortion. Studies that have focussed upon the reactions and feelings of women
who have had an abortion have been used to identify factors that predict individual variation in
psychological response following abortion. Such studies have shown that women at higher risk for
negative emotions several years after an abortion included those with a prior history of mental health
problems, younger age at the time of the abortion, low perceived social support for their decision and
greater personal conflict about abortion.29–32 The degree to which the pregnancy was intended is
important with regard to ambivalence of the decision to terminate. In a study of women attending
a hospital clinic requesting a termination that used a validated questionnaire to determine the
intended-ness of the pregnancy, majority (80%) of pregnancies were deemed to be clearly unintended
with 10% deemed fairly unintended.33,34 This would suggest that the majority of women seeking
a termination may be certain of their decision and may not require the same level of support as the
minority for whom the pregnancy was originally intended and therefore at higher risk of distress or
regret. In recognition of the fact that most women do not experience any lasting psychological distress,
the Royal College of Obstetricians and Gynaecologists in 2004 recommended that post-abortion
counselling should be available for the ‘small minority’ of women who experience long-term post-
abortion distress.35
Personality traits such as low self-esteem and a pessimistic outlook have been reported to be
associated with negative post-abortion experiences.31,36 Many of these same factors also predict how
women cope with unwanted motherhood or adoption.37–39 Studies have also shown that the perceived
stigma of abortion and keeping the abortion a secret from family and friends were associated with
increase in anxiety and depression.40 The presence of anti-abortion protesters outside an abortion
clinic has been shown to increase short-term psychological distress for women seeking an abortion.32
There is some evidence that encouraging women to reappraise an abortion in a more positive or benign
way can lead to improved emotional responses. One study that randomised women to one of three
counselling strategies before the abortion, namely creating positive coping mechanisms, or reducing
the extent to which women attributed the pregnancy to their character, or contraceptive advice only
showed that women counselled on positive coping strategies were significantly less likely to display
negative mood after the abortion.41

Report of APA task force on mental health and abortion

The APA conducted a systematic review of English-language, peer-reviewed articles published since
1989 relating to mental health and abortion. They examined quantitative data relating to women
undergoing induced abortion with one or more post-abortion measures of mental health.6 The
662 S. Cameron / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665

systematic review included 50 studies. These studies incorporated a comparison group for the abortion
group. Twenty-five studies were secondary analyses of public data sets or records, 19 studies were
primary research studies and six studies were of women having an abortion for foetal anomaly. The
reviewers defined a ‘mental health problem’ as clinically significant disorders such as depression,
anxiety disorder and psychosis. The reviewers defined ‘negative psychological experiences’ as regret,
sadness and substance misuse. The APA task force set out a series of questions to address regarding
abortion and mental health. They stated that the question of whether or not abortion ‘causes’ harm to
mental health could not be answered since this would require a randomised controlled trial of abortion
compared to delivery, which was neither ethical nor desirable. They wished to determine how prev-
alent mental health problems are after abortion, the relative risk of mental health problems post
abortion compared to alternative courses of action and what factors predicted individual variation in
psychological experiences.
The main findings of their report were published in April 2008.6 The authors concluded that, based
upon the best evidence, the relative risk of mental health problems in women undergoing a single
elective first trimester abortion was no greater than women delivering a child. The risk for mental
health problems with multiple abortions was judged equivocal with the same risks that predispose
women to multiple unintended pregnancies possibly also predisposing to mental health problems.
With regard to data pertaining to late abortion for foetal abnormality, six studies with sample sizes
ranging between 23 and 83 were included.42–47 All of these studies had considerable loss to follow-up.
The reviewers concluded that women having an abortion for fetal anomaly are more likely to expe-
rience depression and anxiety than those delivering a healthy child, but with a risk similar to women
having a late miscarriage. The authors impressed that abortion for foetal anomaly is different from
abortion for an unplanned pregnancy since it often occurs later and in the context of what was orig-
inally a planned and wanted pregnancy. One UK study examined depression and anxiety in women
who proceeded with abortion for a severe foetal cardiac abnormality, women who gave birth to healthy
children and women delivering a child with undiagnosed fetal cardiac abnormalities.46 While anxiety
in women post termination was more common than in those who delivered a healthy child, the risk of
depression and anxiety was greatest in those giving birth to a child with an undiagnosed life-
threatening abnormality.

Systematic review by Charles et al

This systematic review covered 21 studies (seven prospective cohort, 11 retrospective cohort and
three cross-sectional studies) that fulfilled the researchers’ inclusion criteria (over 100 subjects, follow-
up of over 90 days post abortion) and focussed exclusively on long-term mental health effects of
abortion.7 Studies of women having abortion due to foetal abnormality or studies of women having
multiple abortions were excluded. This review differed from that of APA in that it rated the study
quality based on methodological factors. Studies were rated as excellent (no studies), very good (four
studies), fair (eight studies), poor (eight studies) or very poor (one study). None of the 21 studies
included was judged as being of excellent quality. The four studies judged to be the most methodo-
logically sound were rated as ‘very good’, indicating that they provided good evidence and were at low

Table 1
Quality of studies (n ¼ 21) included in systematic review by Charles et al 2008, and reported association of abortion and mental
health.

Number of studies No association Mixed findings Negative association abortion

(N ¼ 21) Abortion and and mental health
mental health
Excellent (n ¼ 0)
Very Good (n ¼ 4) 4
Fair (n ¼ 8) 3 3 2
Poor (n ¼ 8) 1 4 3
Very Poor (n ¼ 1) 1
 S. Cameron / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665 663

Table 2
Summary of studies rated as ‘very good’ quality by systematic review of Charles et al 2008.7

Studies Country Design Sample Size Groups Outcome Relative Effect

measure of abortion
Gilchrist et al UK Prospective 13 261 Abortion, Psychosis Neutral
1995(ref 13) cohort Refused abortion, Depression
Delivered Anxiety
Self Harm
Russo and Zerk USA Retrospective 5295 Abortion, Self esteem Neutral
1992 (ref 12) cohort Delivered
Schmiege and USA Longitudinal 1247 Abortion, Depression Neutral
Russo 2005 survey Delivered
(ref 48)
Steinberg and Russo USA Longitudinal 3482 Abortion, Delivered Anxiety Neutral
(ref 49) survey

risk of bias. One of these very good studies was that of Gilchrist et al. from UK.13 All four very good
studies reported no association between abortion and subsequent mental health (Tables 1 and 2).
In one ‘very good’ study by Schmiege and Russo, which was a re-analysis of data from the NSLY data
from USA, the authors concluded that women who had an abortion were no more likely to be
depressed than women having a baby.48 Another study rated as ‘very good’ that controlled for pre-
pregnancy anxiety concluded that there was no difference in anxiety between women who had an
abortion and those who had a baby.49 The review reported a clear trend for the higher-quality studies
to report findings that were mostly neutral, suggesting few, if any, differences between women who
had abortions and their respective comparison groups in terms of mental health sequelae. By contrast,
those studies judged to have the most flawed methodology found negative mental health sequelae of
abortion (Table 1). The systematic review highlighted the importance of appropriate comparison
groups as those women who have an unintended pregnancy may be very different from women who
may be predisposed to mental health problems regardless of the abortion experience.7
In summary, induced abortion is a common event with almost one in three women in the UK and
other European countries undergoing this procedure.50 If abortion did have an adverse effect upon
mental health then one might expect long-term post-abortion mental disorders to be prevalent. The
best-quality research from the English-language published literature in countries where abortion is
legal indicates that abortion is not associated with any greater risk of adverse mental health problems.
Women with risk factors for poor mental health following an abortion include those with pre-existing
mental health problems. Long-lasting feelings of sadness, regret and guilt only occur in a minority of
women, more often in those with ambivalence about the termination, poor social support, for whom
the pregnancy was originally intended or women who have moral objections to abortion. Identification
of these risk factors in women by health professionals involved in pre-abortion assessment may be of
value in directing these women for further post-abortion counselling and support.

Practice points

Women having a single first trimester abortion are not at any higher relative risk of mental health
problems than if they deliver that pregnancy.
A previous history of psychiatric illness has been identified as one of the strongest predictors of
mental health problems after abortion or childbirth.
Women who are ambivalent about the decision to have the abortion, or for whom the pregnancy
was originally intended, or who lack a supportive partner, or belong to a cultural group that
considers abortion to be wrong are at higher risk of negative psychological responses such as
sadness and anxiety.
These same risk factors are also predictive of negative psychological responses following
childbirth.
664 S. Cameron / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665

Research agenda

Most studies examining mental health outcomes following abortion have suffered from meth-
odological problems or failed to account for possible confounding factors.
Future studies should contain appropriate comparison groups and should be sufficiently large to
include critical variables including intended-ness of the pregnancy.

References

1. NHS quality improvement Scotland 2004 health indicators report, http://www.indicators.scot.nhs.uk/Reports/2004-

Health-Indicators. Report.pdf (accessed 3.01.2009).
*2. David HP. Born unwanted, 35 years later. The Prague Study. Reproductive Health Matters 2006; 14(27): 181–190.
3. Adler NE, David HP, Major BN et al. Psychological responses after abortion. Science 1990; 248: 41–44.
4. Is there a post abortion syndrome?, www.nytimes.com/2007/01/21/magazine/21abortion.t.html (accessed 10.10.2008).
5. Speckhard A & Rue V. Post abortion syndrome: an emerging public health concern. J Soc Issues 1992; 48: 95–120.
*6. Report of the APA task force on mental health and abortion 8/13/2008, www.apa.org/releases/abortion-report.pdf
(accessed 19.10.2008).
*7. Charles VE, Polis CB, Sridhara S et al. Abortion and long term mental health outcomes: a systematic review of the evidence.
Contraception 2008; 78: 436–450.
8. Willoughby T, Chalmers H & Busseri MA. Where is the syndrome? Examining co-occurrence among multiple problem
behaviors in adolescence. Journal of Consulting and Clinical Psychology 2004; 72: 1022–1037.
9. Jones RK & Kost K. Underreporting of induced and spontaneous abortion in the United States: an analysis of the 2002
National Survey of Family Growth. Studies in Family Planning 2007; 38(3): 187–197.
10. Reardon DC & Ney PG. Abortion and subsequent substance abuse. American Journal of Drug and Alcohol Abuse 2000; 26:
61–75.
11. Reardon DC & Cougle JR. Depression and unintended pregnancy in the National Longitudinal Survey of Youth: a cohort
study. BMJ 2002; 324: 151–152.
12. Russo NF & Zierk KL. Abortion, childbearing, and women’s well-being. Professional Psychology: Research and Practice 1992;
23: 269–280.
*13. Gilchrist AC, Hannaford PC, Frank P et al. Termination of pregnancy and psychiatric morbidity. Br J Psychiatry 1995; 167:
243–248.
14. Broen AN, Moum T, Bodtker AS et al. The course of mental health after miscarriage and induced abortion: a longitudinal,
five-year follow-up study. BMC Med 2005; 3: 51.
15. Broen AN, Moum T, Bodtker AS et al. Psychological impact on women of miscarriage versus induced abortion: a 2-year
follow-up study. Psychosom Med 2004; 66: 265–271.
16. Broen AN, Moum T, Bodtker AS et al. Predictors of anxiety and depression following pregnancy termination: a longitudinal
five-year follow-up study. Acta Obstet Gynecol Scand 2006; 85: 317–323.
*17. Fergusson DM, Horwood LJ & Ridder EM. Abortion in young women and subsequent mental health. J Child Psychol Psychiatr
Allied Discipl 2006; 47: 16–24.
*18. Fergusson DM, Horwood LJ & Boden JM. Abortion and mental health disorders: evidence from a 30-year longitudinal
study. Br J Psych 2008; 193: 444–451.
19. Cougle JR, Reardon DC & Coleman PK. Depression associated with abortion and childbirth: a long-term analysis of the
NLSY cohort. Med Sci Monitor 2003; 9: CR105–CR112.
20. Gissler M, Hemminki E & Lonnqvist J. Suicides, 1987–94: register linkage study. B Med J 1996; 313: 1431–1434.
21. Gissler M, Kauppila R, Merilainen J et al. Pregnancy associated deaths in Finland 1987–1994. Definition problems and
benefits of record linkage. Acta Obste Gynecol Scan 1997; 76. pp. 651–657.
22. Gissler M, Berg C, Bouvier-Colle MH et al. Pregnancy associated mortality after birth, spontaneous abortion or induced
abortion in Finland 1980–2000. Am J Obstet Gynecol 2004; 190: 422–427.
23. Gissler M, Berg C, Bouvier-Colle MH et al. Injury deaths, suicides and homicides associated with pregnancy, Finland
1987–2000. E J Pub Health 2005; 15: 459–463.
24. Ashok PW, Hamoda H, Flett GM et al. Psychological sequelae of medical and surgical abortion at 10-13 weeks gestation.
Acta Obstetrica et Gynecologica Scandinavica 2005; 84(8): 761–766.
25. Sit D, Rothschild AJ, Creinin MD et al. Psychiatric outcomes following medical and surgical abortion. Hum Rep 2007; 22:
878–884.
26. Howie FL, Henshaw RC, Naji SA et al. Medical abortion or vacuum aspiration? two-year follow up of a patient preference
trial. BJOG 1997; 104: 829–833.
27. Zabin LS, Hirsch MB & Emerson MR. When urban adolescents choose abortion: effects on education, psychological status
and subsequent pregnancy. Fam Plan Perspect 1989; 21(6): 248–255.
*28. Fergusson DM, Boden JM & Horwood LJ. Abortion among young women and subsequent life outcomes. Perspectives on
Sexual and Reproductive Health 2007; 39(1): 6–12.
29. Cozzarelli C, Sumer N & Major B. Mental models of attachment and coping with abortion. Journal of Personality and Social
Psychology 1998; 74(2): 453–467.
30. Major B, Zubek JM, Cooper M et al. Mixed messages: implications of social conflict and social support within close
relationships for adjustment to a stressful life event. Journal of Personality and Social Psychology 1997; 72: 1349–1363.
 S. Cameron / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665 665

31. Major B, Cozzarelli C, Cooper ML et al. Psychological responses of women after first-trimester abortion. Archives of General
Psychiatry 2000; 57: 777–784.
32. Cozzarelli C, Major B, Karrasch A et al. Women’s experiences of and reactions to antiabortion picketing. Basic and Applied
Social Psychology 2000; 22(4): 265–275.
33. Schunmann C & Glasier A. Measuring pregnancy intention and its relationship with contraceptive use among women
undergoing therapeutic abortion. Contraception 2006; 73: 520–524.
*34. Lakha F & Glasier A. Unintended pregnancy and use of emergency contraception among a large cohort of women
attending for antenatal care or abortion in Scotland. Lancet 2006 Nov 18; 368(9549): 1782–1787.
35. Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. Evidence based
guideline number 7, ; September 2004 (accessed 8.10.2008).
36. Adler NE, David HP, Major BN et al. Psychological factors in abortion. A review. Am Psychol 1992; 47: 1194–1204.
37. Beck CT. Predictors of postpartum depression: an update. Nursing Research 2001; 50(5): 275–285. 3194.
38. Grote NK & Bledsoe S. Predicting postpartum depressive symptoms in new mothers: the role of optimism and stress
frequency during pregnancy. Health and Social Work 2007; 32(1): 107–118.
39. Logsdon MC & Usui W. Psychosocial predictors of postpartum depression in diverse groups of women. Western Journal of
Nursing Research 2001; 23(6): 563–574.
40. Major B & Gramzow RH. Abortion as stigma: cognitive and emotional implications of concealment. Journal of Personality
and Social Psychology 1999; 77: 735–745.
41. Mueller P & Major B. Self-blame, self efficacy and adjustment to abortion. Journal of personality and social psychology 1989;
57: 1059–1068.
42. Zeanah C, Dailey JV, Rosenblatt MJ et al. Do women grieve after terminating pregnancies because of fetal anomalies? A
controlled investigation. Obstet Gynecol 1993; 82(2): 270–275.
43. Iles S & Gath D. Psychiatric outcome of termination of pregnancy for fetal abnormality. Psychological Medicine 1993; 23(2):
407–413.
44. Lorenzen J & Holzgreve W. Helping parents to grieve after second- trimester termination of pregnancy for fetopathic
reasons. Fetal Diagnosis & Therapy 1995; 10(3): 147–156.
45. Salvesen KA, Oyen L, Schmidt N et al. Comparison of long-term psychological responses of women after pregnancy
termination due to fetal anomalies and after perinatal loss. Ultrasound Obstet Gynecol 1997; 9: 80–85.
*46. Rona RJ, Smeeton NC, Beech R et al. Anxiety and depression in mothers related to heart of the child and foetus. Acta
Paediatr 1998; 87: 201–205.
47. Kersting A, Dorsch M, Kreulich C et al. Trauma and grief 2-7 years after termination of pregnancy because of fetal
anomaliesdA pilot study. Journal of Psychosomatic Obstetrics & Gynecology 2005; 26(1): 9–14.
48. Schmiege S & Russo NF. Depression and unwanted first pregnancy: longitudinal cohort study. B Med J 2005; 331(7528):
1303.
49. Steinberg JR & Russo NF. Abortion and anxiety: what’s the relationship? Soc Sci Med 2008; 67: 238–252.
*50. Sedgh G, Henshaw SK, Singh S et al. Legal abortion worldwide: incidence and recent trends. International Family Planning
Perspectives 2007; 33(3): 106–116.