Psychological Sequelae: the debate and the research
By Ellie Lee and Dr
What follows is the text of a paper given at a conference organised
by Pro-Choice Forum called 'Issues in Pregnancy Counselling: What
do Women Need and Want?' The conference was held at Ruskin College,
Oxford in May 1997. It's aim was to give students, academics,
service providers and others interested in ensuring pregnancy
services meet women's needs, the opportunity for a critical discussion
of the provision of counselling as part of these services.
The term 'Post-Abortion Syndrome' (PAS) has become a reference
point in the debate about women's psychological response to abortion.
Literature which deals with abortion psychological sequelae which
has been written over the past few years, is likely to make reference
to PAS as a theory of the way women respond psychologically to
abortion. Although most commentators approach the term with scepticism
because of the association between the theory of PAS and the anti-abortion
movement, little has been written which provides clear criticism
of the approach to abortion psychological sequelae which informs
the PAS theory. I attempt to do so in my comments.
The term PAS was first developed in America. Key proponents of
this theory of abortion psychological sequelae are the American
anti-abortionists, Vincent Rue and Anne Speckhard. In discussing
what the theory of PAS says about the way women respond psychologically
to abortion, I am going to refer mainly to their writings.(1)
Although this theory has its origins in the American debate about
abortion, it has subsequently entered the British discussion.
In particular, organisations opposed to abortion in this country,
such as LIFE and the Society for the Protection of Unborn Children
(SPUC) suggest that PAS explains most accurately how women respond
psychologically to abortion. Both of these organisations run their
own post-abortion counselling services. SPUC has a sister organisation,
British Victims of Abortion (BVA), specifically dedicated to counselling
women who have undergone abortion. LIFE and BVA both use PAS as
the theory of abortion psychological sequelae to underpin the
counselling that they offer to women.
I am going to first explain the argument that the theory of PAS
puts forward about abortion psychological sequelae; second explain
why the theory is wrong; and third explain why I think the theory
needs to be vigorously opposed by anyone who believes it to be
important to uphold an accurate picture of the experience of abortion.
The theory of Post Abortion Syndrome
The main contentions of PAS as a description and theory of abortion
psychological sequelae are as follows. First that there is evidence
of women post-abortion exhibiting an extreme negative psychological
The symptoms are defined as long-lasting and recurring. The symptoms
that are said to characterise this response are:
'..sadness/sorrow, depression, anger or guilt, surprise at the
intensity of their emotional reaction, preoccupation with the
aborted child, a low self-image, repression and discomfort at
being around babies or young children, flashbacks of the abortion
experience, feelings of 'craziness', thoughts of suicide, nightmares
related to the abortion, perceived visitations from the aborted
child, hallucinations related to the abortion. The date upon which
the child would have been born and anniversaries of both the operation
and the 'would-have-been' birthday become focal points for Post
Abortion Trauma Syndrome symptoms.'(2)
The second is that this response to abortion should be categorised
as a form of Post-Traumatic Stress Disorder (PTSD). Society should
perceive PAS as a definable, severe, psychological condition.
It should be borne in mind that what is being suggested here is
that there is evidence of something akin to psychosis, exhibited
by women, which is attributable to termination of pregnancy.
Thirdly that this recognition of the extreme, negative psychological
effects of abortion should lead to a refutation of the argument
that legal abortion is justified on the grounds of benefit to
women's health. In fact, advocates of the theory of PAS argue
that the advent of legal abortion has been a set-back for women.
They suggest that it has created a situation where thousands women
suffer negative psychological consequences as result being able
to terminate pregnancy. In Britain, under the 1967 Abortion Act,
abortion can be provided legally if two doctors agree 'that the
pregnancy has not exceeded its twenty-fourth week, and that the
continuance of the pregnancy would involve risk, greater than
if the pregnancy were terminated, of injury to the physical or
mental health of the pregnant woman or any existing children'.(3)
The proponents of PAS argue that this ground cannot be met, because
abortion damages women psychologically. Hence abortion should
not be legal on these grounds.
The myth of Post Abortion Syndrome
I want to dispute the argument that evidence exists to sustain
the notion that women experience this 'condition' in response
to termination of pregnancy. The psychological effects of abortion
have been extensively surveyed since the advent of legal abortion
in the USA, Britain and Europe. Literally hundreds of studies
have been carried out, to assess the extent of the risk of psychological
complications of termination of pregnancy. The very fact that
so much research has been commissioned and carried out indicates
that those involved with abortion are very sensitive to the claim
that abortion can be psychologically damaging, and feel the need
to investigate whether this is the case. Yet regardless of which
country the research has been conducted in, where abortion is
legal, and carried out safely, there is no evidence that abortion
leads to psychological damage.
In fact the results generated by survey after survey are remarkably
uniform and each survey simply acts to reaffirm what has been
already found out. The overall result is that the number of women
exhibiting severe, negative psychological sequelae is small, and
that where a negative response is indicated, it results from the
particular circumstances of the woman, rather than the abortion
There are numerous studies that can be referred to to confirm
this observation. Characteristic are the studies carried out by
Greer et al (1976) and Frank et al (1985). The first study followed
up 326 aborted women and found that 6.5 per cent were undergoing
psychiatric treatment post-abortion. The second assessed 6105
women post-abortion, using the criteria of psychiatric morbidity
to measure psychological state. It found that 2.5 per cent of
women could be classified as exhibiting this response. Both these
studies, like others, indicate that a small minority of women
indicate severe psychological problems after termination. However
crucially, where this is the case, it does not follow that this
psychological state is attributable to the abortion itself. Most
commonly, women with psychiatric complications post-abortion exhibited
those conditions prior to the operation, so their difficulties
cannot be linked to termination. Other groups of women that are
found in the minority exhibiting negative reactions are very young
women; women with a wanted pregnancy who aborted for foetal abnormality;
women with strong religious convictions. It is the particular
situation of these women that creates their unusual response to
abortion. The survey which Anne Gilchrist was involved with, which
she will talk about shortly, confirms the salient points of these
Where a severe, negative psychological response is indicated,
this does not mean we can draw any conclusions from it about abortion.
Even where a woman does find, because of her circumstances, termination
of pregnancy to be psychologically problematic, this still does
not mean that the other alternative, giving birth, would have
been less so.
The evidence given by those who argue that there is such a condition-which
they then label PAS-if anything confirms the findings of other
research. Analysed properly, it suggests that small numbers of
women, because of particular circumstances, experience severe
psychological complications post-abortion. One such piece of research,
which was never actually published, but was used by Speckhard
and Rue to justify the term PAS, was a doctoral thesis written
by Speckhard. The research for this thesis was 45-90 minute interviews
with 30 women. This is a small sample size to begin with, but
the women were also self-selected. They were chosen because they
themselves defined abortion as 'highly stressful'.
The sample included women who had undergone both legal and illegal
abortions. Undoubtedly illegal abortion can be psychologically
problematic because of the need of secrecy and the stigma associated
with being involved with something society deems illegal. Additionally
46 per cent of trimester abortions.(4) The nature of the medical
procedure involved in these instances could explain why these
women found abortion psychologically difficult. Speckhard's research
provides no grounds to sustain the PAS theory. Rather it indicates
that these particular women experienced psychological difficulties
post-abortion, for particular reasons.
Beyond this research, the evidence I have seen to sustain the
case for PAS comes from accounts in letters or interviews with
women who describe their abortion as a traumatic experience. Undoubtedly
these women found abortion difficult to cope with. Many women
who write these accounts regretted having terminated pregnancy.
This does not, however, constitute evidence to suggest that abortion
leads to a specific psychological or psychiatric condition.
Further, these women are not typical. Their cases cannot be used
to make general comments on reactions to abortion, or to predict
which reactions are most likely to follow from the procedure.
In contrast there is a large body of evidence that provides a
more objective account. It indicates that the majority of women
experience no major negative sequelae and that severe psychological
reactions are rare.
Abortion psychological sequelae
Author Sample size Criteria Negative outcome (%)
Niswander & Paterson (1967) 161 Emotional Health 6.9
Clark et al (1968) 111 Worse 0.9
Pare & Raven (1970) 169 Guilt, depression 17.2
Meyerowitz et al (1971) 77 Adaptation 9.1
Ewing & Rouse (1973) 126 Emotional reaction 6.3
Ashton (1980) 64 Guilt 7.8
Lazarus (1985) 292 Depression 15
PSYCHOLOGICAL EFFECTS OF THERAPEUTIC ABORTION
These surveys assess not psychiatric disorder, but what is commonly
called 'post-abortion feelings'. The most obvious point to make
it that even negative feelings, never mind psychiatric disturbance
post-abortion, are exhibited by only a minority of women.
In fact research has consistently indicated that the most stressful
and emotionally difficult time for women is immediately before
the abortion, when they are making the decision to terminate.
This is not surprising, given the stigma involved with abortion.
Women are often concerned at how others will react to their decision,
increasing stress; there may be worry about 'getting it over with',
where women are concerned about whether the procedure will hurt
and how long it will last; also the fact that unplanned pregnancy
will for large numbers of women create a confused response needs
to be taken into account here. Many women are unsure about what
they want to do. They want a child at some point in their lives,
but are concerned about whether this point, given their financial
situation, career plans, relationship with their partner and a
range of other issues, is the right one. Making the decision therefore
inevitably involves ambivalence and emotion.
In contrast post-abortion, the most common response exhibited
by women is relief. The decision has been made, the procedure
is over, and the woman can re-establish her pre-pregnant state.
She experiences relief (and in some cases euphoria) because she
is back in control of her circumstances. She is more able to predict
what will happen to her, in contrast to her experience of unplanned,
Negative post-abortion emotions, where they are indicated, are
short-lived and understandable. Guilt for example is to be expected
given that society has stigmatised abortion. Those women who feel
guilty do so because discourse on abortion consistently suggests
that opting for abortion is at best a very serious decision, at
worst the taking of a life.
Feelings of depression are best understood as a continuation of
pre-abortion ambivalence. The woman may want a child, and wish
she had been able to carry the pregnancy through, but knew that
circumstances did not allow for it. This should not, however,
be taken as grounds to assume that she feels she made the wrong
decision. A woman can certainly know what she did was right, but
at the same time feel depressed, wishing the situation of her
pregnancy had been different.
This account of post-abortion feelings emphasises further the
importance of understanding psychological response contextually.
Both the broad context of abortion as a stigmatised procedure
and the narrow context of the woman's individual circumstance
shape her response. These factors, not abortion itself, explain
Undoubtedly there are some women who terminate pregnancy and deeply
regret having done so. However, this should be viewed in the same
way in which we view other decisions we might make in life that
we can deeply regret and feel bad about afterwards. Getting divorced
or never having children can generate similar psychological responses.
These events, like a regretted abortion are simply a part of life.
The fact that we make wrong decisions on occasion does not mean
that the ability to make that decision should be taken away from
The surveys referred to above are criticised by advocates of the
theory of PAS on the grounds that their sample size is too small,
the drop-out rate of respondents in follow-up is sometimes high
and that they use different criteria to assess psychological state.
All research can be criticised for not conforming to the ideal.(5)
However, there is an indisputable, consistent body of evidence
that indicates that PAS does not exist.
This fact is something that PAS advocates are aware of. In response
they employ the psychological category of 'repression' to explain
the lack of evidence for their theory. This category describes
the phenomenon where negative psychological responses to events
are repressed in the subconscious, but may emerge at a later date.
The person subject to repression can then be described as exhibiting
'denial'.6 They deny their true psycho-logical response, by refusing
to make it conscious. This thesis is useful for those who want
to sustain the idea of PAS, but lack the evidence to do so. Women
who indicate no negative symptoms post-abortion can be classified
as exhibiting 'repression' and 'denial'.
As a preferable alternative to this approach, we can chose to
simply believe women who say that abortion was the right decision
for them to make, that they feel content with the decision, and
are experiencing no emotional difficulties.
PAS and Post-Traumatic Stress Disorder (PTSD)
Those who support the theory of PAS utilise the same psychological
concepts to argue that PAS should be defined as a form of PTSD.
The term PTSD was first employed to define the psychological condition
apparent in veterans of the Vietnam War. These veterans exhibited
severe psychological disorders, which appeared to have no immediate
explanation. The PTSD thesis contends that such severe reactions
resulted from the experience of Vietnam, but the meaning of that
experience was repressed in the minds of the veterans, generating
no conscious connection between their behaviour and psychological
state, and the Vietnam War. The psychological disturbance could
emerge at varying times after the return from the war. Subsequently,
PTSD has been applied to describe the delayed psychological response
to a number of other experiences, including child abuse, rape
and the Hillsborough football stadium disaster.
As an aside it is worth noting that the thesis that attempts to
link psychosis directly to a past event is currently disputed.
Some literature suggests that psychological response cannot be
linked in a linear way to a particular event. Rather the prevailing
discourse in society that constructs that event in a particular
way links psychological disturbance to an event.(7) This argument
means that the argument about PTSD in general is far from straightforward.
However, accepting the definition and diagnosis of PTSD as given
for the sake of argument, it is worth noting the definition of
abortion, as an event capable of inducing PTSD, that including
PAS as an example of PTSD would entail. The type of stressor severe
enough to generate the kind of psychological response characteristic
of PTSD would have to be, as American Psychiatric Association
..an event that is outside the range of usual human experience...e.g.
serious threat to one's life or physical integrity; serious threat
or harm to one's children..or seeing another person who has been
or is being seriously injured or killed as the result of physical
Suggested stressors include military combat, violent personal
assault and being held hostage. In this definition, induced abortion
would have to be defined as a violent, threatening act, which
is hardly sensible given that women opt for the procedure voluntarily,
and no violence is involved. Abortion is certainly not 'outside
the range of usual human experience'. It is the most commonly
carried out operation in the UK, with one in four women undergoing
it at some point in their lives. Abortion is a common fact of
life for sexually active women, not an unusual event that cannot
be easily integrated into a woman's life. Unsurprisingly, the
APA has rejected the suggestion that induced abortion be defined
as a PTSD stressor.
Conclusion-PAS and the politics of the anti-abortion movement
There is no evidence that women experience abortion in the way
that the theory of PAS suggests. Therefore I can confidently argue
that there is no such thing as PAS. In fact it is no more than
a term that has been invented by opponents of abortion to discredit
PAS bears no relation to the extent or nature of abortion psychological
sequelae. Rather it is best understood in political terms. The
reason why PAS has emerged as a theory is as an attempt by those
opposed to abortion to generate an argument that can give them
a hearing in the contemporary context. This is a context where
the traditional arguments against abortion, based on the idea
that abortion is 'sinful' carry less weight than in the past.
As a result anti-abortion argument is expressed, through the PAS
theory, in the terms of more popular discourse-the language of
feminism (concern for women's best interests) expressed through
apparent concern for their psychological well-being.(9)
The idea that the theory of PAS represents an exposition of concern
for women should be strongly disputed. The opposite is the case.
It presents women as 'victims' of abortion, who are incapable
of making and living with the decision to end an unwanted pregnancy.
Its consequence is to suggest that legal abortion is bad for women,
where to the contrary, the advent of legal abortion has given
women the freedom to decide when and by whom they become pregnant.
Dr Anne Gilchrist
Questions about the psychological sequelae of abortion arise both
in clinical practice and in public debate. Psychological difficulties
or disorders are in fact rarely attributable to any one single
factor, and in relation to abortion, as in any other life circumstances,
multiple adverse and protective factors interact for any individual.
Two (disguised) case examples illustrate this clinical complexity,
as well as the variety of beliefs which are held about psychological
effects of abortion.
A 16 year old admitted to hospital for an abortion is referred
for counselling. She feels an abortion is the best option for
her, expects she will feel some guilt and upset, but balances
that against what she expects to feel if she continues the pregnancy.
Her mother, however, is extremely worried about psychological
'damage' after an abortion. In the second case, a 14 year old
is referred by her GP for 'post abortion counselling'. Her mother
feels the abortion caused all the problems, but the girl herself
feels the main problem is that she was persuaded to have an abortion
and now has no-one to whom she can talk about her mixed feelings.
In contrast to the complexity of clinical situations, public debates
sometimes appear to incorporate polarised and oversimplified views
about any psychological aspects of abortion. For example, from
a psychiatric perspective, the term 'post abortion syndrome',
implies there is one unique and specific pattern of difficulties
after abortion, a view inconsistent with clinical experience.
Individual accounts of abortion, whether of psychological upset
or of psychological benefit, can be powerful, but do not allow
any predictions about other women, each in their own unique circumstances.
Research findings, based on studies of groups of women, are therefore
essential to inform patients, families and professionals. Follow
up studies of women who have had an abortion consistently find
that 10-20 per cent experience psychological problems, most commonly
short lived guilt and depression. Those ambivalent about the abortion
are at risk, as are those with previous psychological problems(10).
Psychological disturbance after abortion is evidently not universal,
and there are some clues as to who is vulnerable.
However, this kind of study clearly cannot show whether women
feel better or worse after the procedure, compared with before
it. Where pre and post abortion assessments have been included
in the research design, up to 20 per cent of women show problems
before an abortion, and later improvement in psychological state.
Thus research on women who have an abortion shows both that some
women experience psychological disturbance, and that many do not.
It can give no information on whether abortion itself is linked
with an increased risk of psychological disorder, since women
who did not have an abortion are not included.
To investigate that question, it is essential to start from the
idea that abortion becomes potentially relevant when a women experiences
a particular life crisis-a pregnancy which is unwanted or associated
with problems. This kind of experience in itself is psychologically
difficult. So to find out whether there is a psychological effect
of abortion it is crucial to compare women who choose that option
with women who continue their pregnancy. The largest and most
recent study of this type in the UK is the collaborative study
of induced abortion by the Royal College of General Practitioners
and the Royal College of Obstetricians and Gynaecologists.(11)
The study aimed to answer two main questions about psychological
disorders and abortion. First, is the risk of psychological disorder
after abortion increased? Second, is the risk of psychological
disorder greater in women with a past history of psychological
or psychiatric problems?
The study was based on data collected from general practitioners
and obstetricians. Between 1976 and 1979 volunteer general practitioners
in England and Wales recruited to the study women who requested
an abortion and a similar sized group of women who had not planned
their pregnancy, but intended to continue it. Of the women who
requested abortion, some were refused and some changed their minds
before the procedure so that there were ultimately four 'comparison
groups' of women : 6151 who had an abortion, 6410 who did not
request an abortion, 379 who were refused an abortion and 321
who changed their mind. A study of this size was important since
it was unlikely that any rare complications of abortion, or a
small increase in risk would be detected unless the number of
women included was of this order. Women who agreed to participate
in the study were not identified; all details were sent anonymously
to the study centre. Data were collected by the GP when women
were recruited (age, marital status, age at completing full time
education, past medical, obstetric and psychiatric history etc.),
information about women who had an abortion was supplied by gynaecologists,
and follow up data for all women was provided by GPs from their
records, up to 1987 where possible.
There are obvious disadvantages in this type of follow up in that
the clinical information is not detailed, and the diagnoses made
are relatively imprecise. However, while the data are relatively
crude, the key point is that they are equally crude for all women.
The study did not rely on interviews, questionnaires or any other
form of self reports, partly to allow for the large number of
women involved, but more importantly to reduce the risk of biased
responding. If attempts are made to directly assess women after
the end of their pregnancy, particularly if they have an abortion,
there is a risk that women who take part will be different in
some way from those who are not willing or able to participate.
In this case, over 50 per cent of women in a pilot sample indicated
they would refuse to be interviewed and the likelihood is that
they would have differed in important respects from the group
It was expected that there would be some imprecision in the diagnoses
recorded by GP's, so psychological or psychiatric disorders were
grouped into three categories- major mental illness (diagnoses
including puerperal psychosis, schizophrenia and manic depressive
psychoses), minor mental illness (diagnoses of depression, anxiety
or other emotional disorders) and deliberate self harm (drug overdoses,
self cutting etc.).
In order to isolate the effect of abortion as far as possible,
each comparison group (continued pregnancy, abortion, refused
abortion, changed mind) was divided into four subgroups according
to their history of psychological or psychiatric disorder before
the study pregnancy. This meant that women with equivalent previous
histories of psychological or psychiatric problems but different
outcomes to their pregnancies could be compared. In addition,
the results were statistically adjusted, to allow for differences
between the groups at recruitment, for example in age and marital
status, which might explain any findings. It is, however, important
to recognise that observational research of this type is always
subject to difficulty in fully adjusting for alternative explanations.
Women who choose to seek an abortion may well be different from
those who do not, and these differences may influence the risk
of subsequent psychological disorder. For example, women may request
an abortion because of their lack of social support or difficulties
in the relationship with their partner, reasons which themselves
can make women vulnerable to psychological problems. These issues
need to be borne in mind when the findings are interpreted.
Was the risk of psychological disorder after abortion increased
compared with the risk if the unplanned pregnancy continued? Overall,
women who had an abortion did not have an increased risk of psychological
disorder compared with women who continued their pregnancy. Were
women with a previous history of psychological or psychiatric
disorder more at risk? This proved to be the case irrespective
of the outcome of the pregnancy. Thus, in women who had an abortion,
those who had previously had psychological problems were more
at risk of subsequent psychological problems than women without
such a previous history. Similarly, in women who continued their
unplanned pregnancy those who had previously had psychological
problems were more at risk after the end of the pregnancy.
Two further aspects of the results illustrate the caution required
when interpreting the research findings. First, the rates of major
mental illness reported after childbirth in this study were much
higher than previously reported rates (usually about one per 1000
women). Review of the study follow up forms indicated that general
practitioners were using the term 'puerperal psychosis' for a
wide range of psychological disturbances after childbirth, resulting
in an artificially high rate. We therefore repeated the analysis,
including only women who were admitted to hospital as a result
of their 'puerperal psychosis', a group likely to be severely
ill. In this analysis, too, there was no difference in risk of
major mental illness in the group who had an abortion and those
who continued their pregnancy. We can therefore be confident that
the rate of major mental illness after abortion is not increased.
Second, in women who had no previous history of psychological
disorder, deliberate self harm was more common after abortion,
or after an abortion was refused, than after childbirth. The number
of events was very small, so any interpretation should be particularly
circumspect, but a likely explanation is that these women are
experiencing some common social stress or lack of support. This
finding emphasises the need to be aware that women who request
an abortion are likely to be different from those who do not and
may already be at risk of later distress.
The findings from this study indicate that, as a group, women
who have an abortion are not at increased risk of psychological
disorder. Women who have had previous psychological problems are
a vulnerable subgroup, whether they seek an abortion or continue
an unplanned pregnancy. These research findings may offer one
helpful perspective in clinical situations, both in identifying
women at risk, and in indicating that there is no inevitability
about any psychological disorder after an abortion. There is a
clear need for further information on how psychological difficulties
which do occur after an abortion are related to risk and protective
factors for individual women. In clinical situations this individual
perspective is essential, and it is helpful to recognise that
polarised expectations about the psychological effects of abortion
are neither warranted nor helpful. Women may have a variety of
feelings or difficulties after abortion, and are most likely to
feel supported when others acknowledge and accept their individual
(1) See 'Postabortion Syndrome: An Emerging Public Health Concern',
Journal of Social Issues, Vol. 48, No. 3, 1992, 95-119.
(2) Peter Garrett, Post Abortion Trauma Syndrome, Life pamphlet,
(3) Abortion Act 1967, as amended.
(4) Henry P. David, 'Postabortion Psychological Responses', briefing
published by the Transnational Family Research Institute, 1996.
(5) See 'Postabortion Syndrome: An Emerging Public Health Concern',
Journal of Social Issues, Vol. 48, No. 3, 1992, 95-119 and Peter
Garrett, Post Abortion Trauma Syndrome, Life pamphlet, 1993.
(7) See Allan Young, The Harmony of Illusions: Inventing Post-Traumatic
Stress Disorder, Princeton University Press, New Jersey, 1995
and Elaine Showalter, Hysteries: Hysterical Epidemics and Modern
Culture, Picador, London, 1997 for interesting accounts of the
social construction of trauma.
(8) American Psychiatric Association, Diagnostic and Statistical
Manual for mental disorders (DSM III-R), Washington DC, 1987.
(9) See Nick Hopkins, Steve Richer and Jannat Saleem, 'Constructing
women's psychological health in anti-abortion rhetoric', The Sociological
Review, Vol. 44, No. 3, August 1996, 539-64.
(10) G. Zolese, C. V. R. Blacker (1992), 'The Psychological Complications
of Therapeutic Abortion', British Journal of Psychiatry 160, 742-749;
P. K. B. Dagg (1991), 'The Psychological Sequelae of Therapeutic
Abortion-Denied and Completed', American Journal of Psychiatry
148, 578-585; B. K. Doane, B. G. Quigley (1981), 'Psychiatric
aspects of therapeutic abortion', Canadian Medical Association
Journal 125, 427-432.
(11) A. C. Gilchrist, P.C. Hannaford, P. Frank, C. R. Kay (1995),
'Termination of Pregnancy and Psychiatric Morbidity', British
Journal of Psychiatry 167, 243-248.