Abortion, Informed Consent, and Mental Health
By Nancy Felipe Russo and Lisa Rubin

Unintended pregnancy, whether resolved by an abortion or by giving birth, is a common life event that is typically perceived as stressful, sometimes profoundly so. In general, however, exercising the option of legal abortion is not 'more dangerous' to physical or mental health than giving birth - indeed many reviews of the scientific literature have established that having legal abortion, particularly if it is in the first trimester, poses little particular threat to mental health for most women (see Adler, 1990, 1992; Russo, 1992, 1995; Russo & Denious 2000 for reviews).

The informed consent process has become a pawn in pro-life movement efforts to restrict access to abortion

Scientific evidence not withstanding, under the guise of a 'kinder and gentler' approach in what have been called the 'abortion wars' (Solinger, 1998), the pro-life movement is waging a campaign around the world to portray abortion as a threat to women's mental health. Such efforts contribute to a larger strategy to undermine access to legal abortion that involves subverting the informed consent process.

The campaign began in the United States, where successful construction of a 'postabortion syndrome' could help political forces opposing abortion overturn Roe v. Wade, the Supreme Court decision that legalized abortion, by arguing that the Court failed to balance its concern for the negative effects of unwanted pregnancy with the alleged "fact" that abortion is detrimental to women's mental health.

In response to these allegations, the American Psychological Association established a Task Force on Postabortion Emotional Reponses to examine the issues. The Task Force reviewed the scientific literature and found no scientific basis for such claims.

The Task Force did not view itself has having a vested interest in its conclusions: indeed one could even argue that if abortion had been found to be a widespread and severe risk to mental health, then psychologists could argue for more funding to conduct research and provide psychological services aimed at helping such women. Nonetheless, in order to avoid charges of pro-choice bias in having come to their conclusion that the scientific findings did not support portraying abortion as a severe threat to public health, the initial report of the Task Force was submitted to Science, an independent, highly respected scientific journal that accepted it after an extensive peer review (Adler et al, 1990). Other reviews of the literature, spanning nearly three decades, have come to similar conclusions (e.g., Adler, 1990, 1992; National Academy of Sciences, 1975; Schwartz, 1986; Russo, 1992; Russo & Denious 2000).

Despite a consistent consensus of scientific findings and failure to justify 'postabortion syndrome' as a recognized psychiatric diagnosis, pro-life advocates have turned to prolife legislators who craft bills mandating informed consent scripts that exaggerate abortion's physical and mental health risks while downplaying the risks of giving birth in blatant disregard of research findings. A disturbing illustration of the approach of some politicians involved in these activities is found in the words of Illinois State Representative Dan Reitz, who introduced a mandatory informed consent bill and when criticized for its misleading context was reported in the March 12, 2001 edition of Newsweek as saying: 'I'm not really sure about the science……My intent was strictly about limiting abortion'.

By misrepresenting health risks, pro-life activists use fear to encourage pregnant women to have unwanted births and to deter them from exercising their legal right to an abortion. Such activities also attempt to deter physicians from providing abortions by passing legislation making them civilly and criminally liable for damages from such 'injuries'.

Although the pro-life campaign started in the United States, it is being exported to other countries. For the last several years, a campaign to construct 'postabortion syndrome' has progressed around the world, including such countries as England, Scotland, Australia, New Zealand, and Switzerland.

Recently, the campaign has been taken to a new level in Britain. According to Kaiser Foundation's Daily Reproductive Health Report (http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=11737 ) [accessed June 14, 2002], a British woman has announced her intention to sue the United Kingdom's National Health Service for 'negligence' by failing to warn her of the possible psychological consequences from obtaining an abortion four years previously.

In the report, she describes herself as having experienced feelings of 'guilt and self-hatred' after having an abortion, and coming to 'the brink of a nervous breakdown' after giving birth to a son two-and-a-half years later: 'After I had my son, I realised what I had lost. ... I just looked at him and I just realised what I had done'. The woman, a former employee of the National Health Service, agrees she was counseled about the possible physical risks and side effects of the procedure, but says she was not apprised of the possible psychological effects.

This case is a prime example of how women's psychological problems can be put to the service of the prolife political agenda and add a drumbeat to the theme that physicians are deliberately betraying their abortion patients in the informed consent process. Indeed, pro-life advocate Nuala Scarsbrick, a trustee of the antiabortion group Life, is reported as following up the story with the claim that the case demonstrates that women are "deliberately not being told the whole truth" about abortion and are 'not given the chance to make informed decisions', adding that she hopes the case, which is still at a 'very early stage of development', will 'encourage other women to speak out and take action' (BBC News On-line, 12 June, cited in Kaiser's Daily Reproductive Health Report).

Subverting informed consent for political ends undermines women's mental health

Such activities are of concern to all individuals - whether pro choice or pro life - who put a priority on fostering positive mental health in women. In addition to subverting the informed consent process, they compound the stress that a woman experiences when facing an unwanted pregnancy, and damage her confidence in her ability to cope. They distort her appraisals of her experiences and emotionally charge the experience of abortion. As a result, abortion comes to serve as a 'lighting rod' for negative emotions originating in conditions preexisting to and concurrent with pregnancy. Finally, they undermine the therapeutic process by distracting women from dealing with the deeper issues associated with those conditions.

No one can argue with the importance of providing patients with informed consent about any medical procedure, including abortion. However, women who seek abortions are diverse: young and old, rich and poor, highly educated and uneducated, married and divorced, and healthy and unhealthy, among other things. Any particular woman's risks will depend on her personal history and circumstances.

As the American Psychological Association has pointed out in amicus briefs in abortion cases, informed consent for pregnant women is not attained by exposing women to prewritten mandatory counseling 'scripts' written by prolife legislators in the service of their political agenda. Providing appropriate informed consent requires establishing good communication between physician and patient -- communication that is accurate and understandable, and tailored to the patient's individual situation and needs. Mandated abortion scripts subvert this process.

Achieving informed consent for mental health outcomes after abortion requires thoughtful consideration of all options

Informed consent for a pregnant woman is not achieved by providing a 'laundry list' of every possible negative outcome of having an abortion. The positive and negative outcomes for all alternatives - including having an abortion, giving birth and rising the child, and giving birth and having someone else raise the child - must be considered, put in perspective, and weighed in the context of the particular woman's value system.

Relative risks of abortion versus its alternatives will differ depending on the context. For example, the extent to which abortion might lower mental health risk relative to that of birth depends on how much stress women are experiencing from rearing children they already have.

When a woman seeks an abortion to delay a birth, she is engaging in a stress management process and not simply a matter of selfish convenience. In the United States, in 1987 nearly one-half of abortion patients were already mothers, and nearly one in four of those mothers had a child under two years of age (Russo, Horn, & Schwartz, 1992). When children are born less than two years apart, the health of both children is affected. Spacing births more than two years apart reduces the risk of low birth weight and neonatal death - in 1991 by an estimated 5 to 10 percent in the United States (Miller, 1991). Relative risks depend on the cultural and societal context, but one study found the younger child 2 1/2 times more likely to die than a child who is born more than two years after an older sibling. For the older child the increased risk was less, but can still be substantial: 63 per cent (Potts & Thapa, 1991).

The one-sided scripts anti-abortion advocates seek to mandate do not consider the negative consequences of unwanted childbearing and rearing. The remedy is not simply adding the 'other side' to mandatory scripts, however. Mandating the specific content of what a physician must say to all patients is, in fact, the antithesis of providing informed consent. Ultimately, it must be up to the physician and, if needed, an abortion counselor to work with the patient to assess and weigh the risk of various factors in the unique context of the particular patient.

Although having a legal abortion does not directly increase risk for anxiety and depression, it can indirectly lower such risk by enabling access to coping resources (e.g., an education and higher income), and permitting women to avoid stressful circumstances (e.g., early, excessive, or unwanted childbearing; becoming tied to violent men). Women's concerns about the potential impact of a child on their lives and their ability to meet childbearing responsibilities are backed by a host of data documenting the negative effects of having too many babies, too early, and too closely spaced together. (For a discussion of research on effects of unwanted childbearing, see the essay on the effects of unwanted pregnancy and childbearing by Russo and David http://www.prochoiceforum.org.uk/psy_ocr2.php).

Identifying and weighing mental health risks is a complex enterprise

Providing informed consent for mental health outcomes of a pregnant woman's options is complex, particularly when a major determinant of how a woman responds to an abortion is how she appraises the meaning of abortion and its alternatives. Abortion can be viewed as a profound threat, a coping tool, or both.

As Brenda Major and her colleagues (Major, et al., 1998) concluded from their longitudinal research on the effectiveness of women's coping responses after experiencing an abortion:

it is each woman's personal appraisals of the abortion that matter--how stressful or anxiety provoking she regards it, and how well she expects to be able to cope with it. These appraisals are shaped, in part, by the personal resources that the woman has to draw upon, including personality attributes such as high self-esteem and perceived control, as well as the support of significant others… (Major et al., 1998, p. 750).

These findings have profound implications for the informed consent process as well as effective prevention and intervention. They point to the importance of providing informed consent in ways that will help women to understand the role their appraisal process plays in shaping their psychological responses to however they choose to resolve their pregnancy.

Informed consent is also complicated by the fact that mental health outcomes can be difficult to define and may not be easily separated from the effects of preexisting conditions. Pregnant women may have a history of mental problems, lack coping skills, and live in unsupportive social environments. As a result, they may be anxious and depressed and at risk for unwanted pregnancy. If such women have histories of physical and sexual abuse or have violent partners, they may even suffer from posttraumatic stress (McGrath, et al., 1990).

Given that women who have unwanted pregnancies are much more likely to have experienced childhood physical and sexual abuse and intimate violence, the pro-life targeting of the appraisal process is particularly disturbing. The myths and misinformation of pro-life propaganda reinforce the historical silencing of women around violence issues, and may distract women from dealing with the effects of preexisting conditions. In particular, women suffering from posttraumatic stress due to experiencing violence can recognize their symptoms and 'see themselves' in postabortion syndrome propaganda.

Women need to understand the importance of their appraisals of abortion and its alternatives in determining their mental health outcomes and be alerted to the fact that they may encounter pro-life propaganda designed to make abortion traumatic by manipulating those appraisals.

We do not argue that all symptoms are necessarily due to pre-existing conditions - abortion can be made to be a traumatic experience, particularly if it is illegal or stigmatized, or if the decision-making process involves juggling deeply held but conflicting values. Pro-life activists, however, create and enhance abortion trauma by attacking the most important immediate determinant of a woman's postabortion emotional responses - her appraisal, or interpretation, of the meaning of the event.

Women's responses to unwanted pregnancy terminated by a voluntarily chosen legal abortion can range from feelings of satisfaction and empowerment derived from successfully dealing with the challenge of unwanted pregnancy - to guilt and shame for not having the psychological, social, and/or economic resources to commit to the future child. Abortion can be experienced as a relatively benign experience or a threat to a women's self-construal and her relationships with significant others, depending on how a woman appraises it.

Resolving an unwanted pregnancy involves a profound and personal decision, arguably the most important decision a woman will make in her entire life. The easy path would be to just let 'nature take its course' and 'let come what may'. The responsible path, however, forces a woman to examine her values, responsibilities, and realities, and involves a process that can involve painful self-judgments. Making a thoughtful decision, whatever alternative is chosen, requires the courage to strip illusions from one's self, relationships, and circumstances, the strength to take responsibility for one's irrevocable actions, and for women who are or want to become mothers, the caring to put the well-being of one's current and future children first and foremost in what is a complicated decision-making equation.

A woman may feel sad or guilty after an abortion - such feelings are normal given she has just had an unwanted pregnancy that required her to examine her self and her circumstances without protection of stress-buffering positive illusions. That doesn't mean that she is mentally ill. Most women who report mild feelings of sadness also say they are happy and satisfied with their decision, and get on with their lives.

But abortion can become traumatic when women believe the myths they are told, interpret what otherwise might be temporary feelings of sadness and distress as signaling serious difficulties, lose confidence in their ability to cope with an abortion, and come to fear death and disability after having one. In addition to fostering concerns about mental health, one of the crueler campaigns has involved putting the claim that 'abortion causes breast cancer' on signs in buses and subways (see the website of the National Cancer Institute Cancer Facts: Abortion and Breast Cancer at http://cis.nci.nih.gov/fact/3_53.htm or read Melbye, et al. (1997) for reputable scientific information on this issue).

An abortion decision can also be made traumatic even for a mentally healthy woman if the decision is coerced or stigmatized by others (e.g., by a partner, parent, or important authority). Portrayals of fetal pain can also be disturbing to women who are uninformed about fetal development and don't know that the neocortical physiology involved in pain perception doesn't even begin developing until about the 20th week of pregnancy.

Even the relatively benign experience of early legal abortion can be a source of fear and terror (a critical factor in the development of posttraumatic stress) in a context in which abortion providers are murdered and abortion clinics are bombed and vandalized. The screaming at, stalking, and photographing of women at clinics takes on an added dimension of threat in such a context.

If women feel troubled after abortion they should seek help from a licensed mental health provider. Their feelings should not be trivialized or dismissed, but need to be examined beyond focusing on the abortion per se or the 'baby that might have been'. A host of issues need to be explored, including negative self-discrepancies in women's visions of themselves as good and worthy persons, intimate partners, mothers, and daughters, among other things (for examples of the complexities underlying negative feelings in response to abortion see Torre-Bueno (1996) or visit http://www.peaceafterabortion.com).

Informed consent requires that a women and her abortion provider (physician and/or pregnancy counselor working with the physician) discuss a woman's situation calmly and thoughtfully until she is ready to make what must be her own decision - a decision that she must come to terms with and put to rest. The bottom line is that there are no absolute risks for legal abortion that apply to all women. For any individual woman, both the absolute and relative risks of the negative physical and mental heath outcomes of abortion and its alternatives will be unique to her personal history and situation. Given the intense campaign to manipulate the appraisal process, her risk will depend on her future exposure to pro-life propaganda as well.

References

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Adler, N. E., David, H., Major, B., Roth, S., Russo, N., & Wyatt, G. (1992). Psychological factors in abortion: a review, American Psychologist, 47, 1194-1204.

Kaiser Foundation's Daily Reproductive Health Report (http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=11737) [accessed June 14, 2002]

Major, B., Cozzarelli,C., Sciacchitano, A. M., Cooper, M. L., Testa, M. & Mueller, P. M. (1990). Perceived social support, self-efficacy, and adjustment to abortion. Journal of Personality and Social Psychology, 59, 452-463.

Major, B., Richards, C., Cooper, M. L., Cozzarelli, C. & Zubek, J. (1998). Personal resilience, cognitive appraisals, and coping: An integrative model of adjustment to abortion. Journal of Personality and Social Psychology, 74, 735-752.

McGrath, E., Keita, G. P., Strickland, B. R., & Russo, N. F. (1990). Women and depression: Risk factors and treatment issues. Final report of the National Task Force on Women and Depression. Washington, DC: American Psychological Association

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Russo, N. F. & Denious, J. (2000). The Socio-Political Context of Abortion and its Relationship to Women's Mental Health. In J. Ussher (Ed.). Women's Health: Contemporary International Perspectives (pp. 431-439). London: British Psychological Society.

Russo, N. F., Horn, J. & Schwartz, R. (1992). Abortion in context: Characteristics and motivations of women who seek abortion, Journal of Social Issues, 48, 182-201.

Torre-Bueno, A. (1996). Peace after abortion. San Diego, CA: Pimpernel Press.