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Depression associated with abortion and childbirth: A long-term analysis of the NLSY cohort

Authors:
  • Elliot Institute

Abstract

Existing research pertaining to emotional reactions to abortion is limited by (a) short follow up periods, (b) the absence of information on prior psychological state, and (c) lack of nationally representative samples. Therefore the purpose of this study was to compare women with a history of abortion vs. delivery relative to depression using a nationally representative longitudinal design, which enabled inclusion of a control for prior psychological state. The current study employed data for all women from the National Longitudinal Survey of Youth (NLSY) who experienced their first pregnancy event (abortion or childbirth) between 1980 and 1992 (n=1,884). Depression scores in 1992, an average of 8 years after the subjects' first pregnancy events, were compared after controlling for age, race, marital status, divorce history, education, income, and external locus of control scores. The latter was used to control for pre-pregnancy psychological state. Results were also examined separately for groups based on race, marital status, and divorce history. After controlling for several socio-demographic factors, women whose first pregnancies ended in abortion were 65% more likely to score in the 'high-risk' range for clinical depression than women whose first pregnancies resulted in a birth. Differences were greatest among the demographic groups most likely to report an abortion. Abortion may be a risk factor for subsequent depression in the period of 8 years after the pregnancy event. The higher rates of depression identified may be due to delayed reactions, persistence of depression, or some other common risk factor.
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Depression associated with abortion and childbirth:
a long-term analysis of the NLSY cohort
Jesse R. Cougle
1
ACDEF, David C. Reardon
2
ADEFG, Priscilla K. Coleman
3
AcDE
1
Department of Psychology, University of Texas, Austin, TX, U.S.A.
2
Elliot Institute for Social Sciences Research, Springfield, IL, U.S.A.
3
Human Development and Family Studies, Bowling Green State University, Bowling Green, OH, U.S.A
Source of support: A grant from The Elliot Institute.
Summary
Background: Existing research pertaining to emotional reactions to abortion is limited by (a) short follow
up periods, (b) the absence of information on prior psychological state, and (c) lack of nation-
ally representative samples. Therefore the purpose of this study was to compare women with
a history of abortion vs. delivery relative to depression using a nationally representative longi-
tudinal design, which enabled inclusion of a control for prior psychological state.
Material/Methods: The current study employed data for all women from the National Longitudinal Survey of
Youth (NLSY) who experienced their first pregnancy event (abortion or childbirth) between
1980 and 1992 (n=1,884). Depression scores in 1992, an average of 8 years after the subjects’
first pregnancy events, were compared after controlling for age, race, marital status, divorce
history, education, income, and external locus of control scores. The latter was used to control
for pre-pregnancy psychological state. Results were also examined separately for groups based
on race, marital status, and divorce history.
Results: After controlling for several socio-demographic factors, women whose first pregnancies ended
in abortion were 65% more likely to score in the ‘high-risk’ range for clinical depression than
women whose first pregnancies resulted in a birth. Differences were greatest among the
demographic groups most likely to report an abortion.
Conclusion: Abortion may be a risk factor for subsequent depression in the period of 8 years after the
pregnancy event. The higher rates of depression identified may be due to delayed reactions,
persistence of depression, or some other common risk factor.
key words: induced abortion • childbirth • depression
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Word count:
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Tables:
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Figures:
References:
44
Received: 2002.09.05
Accepted: 2003.03.27
Published: 2003.04.23
Author’s address:
David C. Reardon, Elliot Institute, PO Box 7348, Springfield, IL 62791-7348, USA, email: dcr@mine4ever.net
Authors’ Contribution:
A
Study Design
B
Data Collection
C
Statistical Analysis
D
Data Interpretation
E
Manuscript Preparation
F
Literature Search
G
Funds Collection
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Med Sci Monit, 2003; 9(4): CR157-164Clinical Research
BACKGROUND
Research on emotional adjustments following induced
abortion suggests that although women generally per-
ceive abortion as a stressful event, the majority of
women do not suffer from severe negative reactions
soon after the procedure [1–2]. Unfortunately, most of
these studies have employed only short-term follow-up
interviews of women who had abortions at a small num-
ber of abortion clinics. Data on post-abortion reactions
has typically been collected within hours or weeks of the
event. Assessments extending beyond six months are
uncommon.
Recent research, however, indicates that women under-
going an abortion may experience delayed reactions
long after the period of time usually studied. Miller,
Pasta and Dean conducted a longitudinal investigation
with women involved in clinical trials of the abortifa-
cient, RU-486 [3]. Women in this study were inter-
viewed prior to the abortion, 2 weeks later, and then
6–8 months after the abortion. They found that regret
increased from 2 weeks to 6–8 months post-abortion. In
regard to delayed reactions, Miller and his colleagues
concluded that ‘there is very likely a time course associ-
ated with the coping process that follows abortion and
this time course almost certainly does not show a
straight line of improvement. In other words, the low
point following the abortion may not occur for days,
weeks, or even months’ (p. 262). Miller had found simi-
lar results indicating the presence of delayed reactions
in a prior study covering three years [4].
Most recently, Major and colleagues analyzed the psy-
chological state of women one hour pre-abortion, and
one hour, one month, and two years post-abortion [5].
They found an increase in negative emotions and a
decrease in relief and positive emotions between the
assessments at one hour post-abortion and two years
post-abortion. The results also revealed an increase in
depression and a decrease in satisfaction with the abor-
tion decision over time. The proportion of women
reporting satisfaction with their abortion decision after
one month dropped by 6.7% when asked about decision
satisfaction after two years. The difficulty in obtaining a
gauge of the exact prevalence of delayed reactions was
complicated by the fact that 50% of their original sample
were lost to attrition by the time that the two year fol-
low-up had taken place. Even though Major and her
colleagues did not detect significant demographic differ-
ences between the final sample and the attrition sample,
previous research has found that those lost to sample
attrition are generally more vulnerable to negative post-
abortion reactions [6–7].
One longitudinal study that has been employed to study
the aftereffects of abortion is the National Longitudinal
Survey of Youth (NLSY). This interview-based cohort
study began in 1979 and has continued to the present.
Men and women aged 14–21 at the time of the 1979
interview have annually answered questions relating to
employment, education, marital status, and reproduc-
tive history. The primary purpose of the NLSY is the
study of labor practices, but variables associated with
different social science fields have also been included at
various years.
As a tool for studying abortion, the NLSY data set, like
all surveys that inquire about abortion history, is
plagued with a high rate of underreporting. Analysis of
the abortion rate reported by the NLSY cohort com-
pared to the national statistics compiled by the Alan
Guttmacher Institute has shown that women in the
NLSY report approximately 40% of the abortions that
would be expected [8]. Discrepant concealment rates
have been noted based on demographic variables. Jones
and Forrest reported that married women were over
twice as likely to report an abortion as unmarried
women (74% vs. 30%) [8]. In addition, White (non-Black
and non-Hispanic) women (45%) were much more like-
ly to report an abortion than Blacks (27%) or Hispanics
(19%). Post-abortion research has revealed that women
who conceal their abortion experience from others are
more likely to suppress thoughts of the abortion, expe-
rience more intrusive abortion-related thoughts, and
feel greater psychological distress [9]. This suggests that
the women who admitted having a past abortion in the
NLSY study may have been less likely to experience
psychological distress than those who concealed their
abortions.
Two previous post-abortion psychological studies car-
ried out using the NLSY data set were conducted by
Russo and Zierk and Russo and Dabul [10–11]. These
researchers analyzed the ten-item Rosenberg Self-
Esteem Scale [12], which was included in the 1980 and
1987 NLSY interviews, and found comparable self-
esteem scores between aborting and non-aborting
women. From this finding the authors drew the broad
conclusion that abortion has no independent effect on
women’s general well-being. This conclusion is not sup-
ported, however, by the results of the study by Miller et
al, which revealed that the Rosenberg Self-Esteem scale
may not be a sensitive measure of post-abortion adjust-
ment [3]. Their study suggested that self-esteem scores
remained virtually unchanged at three different time
points while other emotional states varied significantly.
Major and colleagues found that post-abortive women’s
self-esteem scores increased over time although negative
reactions also increased [5]. These results suggest that
self-esteem may be a trait among aborting women that is
less sensitive to environmental stressors, with question-
naires assessing depression or anxiety representing bet-
ter indicators of post-abortion adjustment.
Fortunately, self-esteem is not the only measure avail-
able to researchers for the assessment of psychological
well-being in the NLSY data set. In 1979, respondents
were presented with an abbreviated version of the
Rotter Internal-External Locus of Control Scale.
Suitability of the Rotter scale as a marker for depression
is confirmed by previous investigations demonstrating
an association between external locus of control and
greater depression [13–17]. Moreover, theoretical work
pertaining to the etiology of depression has postulated
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a causal link between feelings of lack of control and the
development of depression [18]. In addition, a short,
preliminary analysis of CES depression scores revealed
that women who aborted a first pregnancy were at sig-
nificantly higher risk of depression compared to similar
women who carried an unintended first pregnancy to
term [19,20]. Two additional items relating to psycho-
logical disturbance were included in the survey in 1998:
a question regarding any past diagnoses of mental prob-
lems and a self-assessment of current ‘depression, exces-
sive worry, or nervous trouble of any kind.
Since the previous and widely cited analyses of NLSY
data were limited only to an examination of self-esteem
scores [10-11], the objective of this study was to more
completely examine this study population with an
analysis of the depression scores and responses to the
two psychological disturbance items, that are also avail-
able in the data set, in regard to a history of delivery
versus abortion controls instituted for age, race, marital
status, divorce history, education, family income, and
external locus of control scores. Based on Jones and
Forrest’s [8] work indicating that the rate of conceal-
ment of past abortions was highest among non-White
women and unmarried women, another goal was to
examine differences relative to race, marital status, and
divorce history
MATERIAL AND METHODS
Subjects
This analysis is based on data collected through 1992
from the National Longitudinal Survey of Youth
(NLSY), a survey conducted by the Center for Human
Resource Research at Ohio State University and funded
by the United States Department of Labor. Although its
primary purpose is the study of U.S. labor practices, a
considerable amount of data of potential interest to
other fields of inquiry were also collected. The survey
began in 1979 and involved the follow-up of 12,686
youths aged 14–21 at the time of the first interview. The
nationwide sample used for this study had an over-sam-
pling of Blacks (25.0%), Hispanics (15.8%), and poor
Whites (20.7%). A routine set of questions are asked in
each annual survey, and items pertaining to specific
subject interests, which vary from year to year, are also
included.
Since the 1979 Rotter scale assessment was used as
a marker of emotional state prior to the first pregnancy
outcome, the sample of women used in these analyses
includes only women who met two criteria: 1) first abor-
tion or first delivery was between 1980 and 1992, and 2)
both the 1979 Rotter scale and the 1992 CES-D scale
(n=1,884) were completed.
The average age of post-abortive women in 1992 was
29.82 (SD=2.1; n=293); among non-abortive mothers,
the average age was 30.30 (SD=2.2; n=1, 591). Among
all women with a history of abortion, 23.2% were
Hispanic, 24.2% were Black, and 52.6% were non-Black
and non-Hispanic. Among all women with a history of
childbirth, 20.7% were Hispanic, 24.1% were Black, and
55.1% were non-Black and non-Hispanic. The average
number of children among the childbirth group in 1992
was 1.90 (SD=0.9); whereas the average number of chil-
dren among the abortion group in 1992 was 1.32
(SD=1.2). With regard to income, the average for the
women with a history of childbirth was $33,969
(SD=$21,645) and the average for the women with a
history of abortion was $33,554 (SD=$22,405). Finally,
the average number of years of formal education among
the women with a history of childbirth was 12.96
(SD=2.13); whereas the women with a history of abor-
tion reported an average of 13.37 (SD=2.28) years of
formal education. Since women reported the year of
their abortions or deliveries, rather than age, we calcu-
lated the average year of their first pregnancy events.
Among women who had abortions, the average year of
their first abortion was 1985 (SD=3.5). Among women
who did not report any abortions, the average year of
their first childbirth was 1985 (SD=3.4).
Variables used for analysis
Women were queried regarding their childbirth history
every year beginning in 1979. Starting in 1984, women
were asked about their abortion history every two years
by way of a confidential abortion card. This self-report
card was used to more accurately obtain this sensitive
information. The first childbirths recorded for the sam-
ple occurred in 1970; the first abortion occurred in
1971. All variables regarding abortion and childbirth
outcomes were used to construct a reproductive history
profile for each woman. The two groups include women
whose first reproductive event was either an abortion or
a birth (with no subsequent abortions).
The Rotter Internal-External Locus of Control Scale
was included in the NLSY 1979 interview in the form of
a four-item abbreviated version of the more widely
known scale [21]. This scale is intended to measure the
extent to which one feels in control of one’s own destiny
versus the extent to which one believes one’s fate is
decided by environmental or chance circumstances. On
this abbreviated scale, higher internal control is associat-
ed with higher self-esteem, social class, and education
[22]. As noted earlier, studies using extended versions
of the Rotter scale have revealed correlations between
external scores and higher depression scores [13–17].
The four items included on the scale used for the pre-
sent analysis are the following: 1) ‘What happens to me
is my own doing’ vs. ‘Sometimes I feel that I don’t have
enough control over the direction my life is taking’, 2)
‘When I make plans, I am almost certain that I can
make them work’ vs. ‘It is not always wise to plan too far
ahead, because many things turn out to be a matter of
good or bad fortune anyhow’, 3) ‘In my case, getting
what I want has little or nothing to do with luck’ vs
‘Many times we might just as well decide what to do by
flipping a coin’, and 4) ‘Many times I feel that I have lit-
tle influence over the things that happen to me’ vs ‘It is
impossible for me to believe that chance or luck plays an
important role in my life.’ For each question, respon-
dents are asked to report how close the statement is to
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their own opinion. Internal statements are scored ‘1’ for
‘much closer’ and ‘2’ for ‘slightly closer.’ External state-
ments are scored ‘3’ for ‘slightly closer’ and ‘4’ for
‘much closer’. Overall scores range from 4 to 16. Higher
scores indicate a more ‘externally controlled’ individual,
and lower scores indicate a more ‘internally controlled’
individual.
The Center for Epidemiological Studies Depression
scale [23] contains 20 items relating to depressive symp-
toms and was given to women in 1992. This scale is
widely-used and has correlated well with other mea-
sures of depression [23,24]. Studies have demonstrated
good test-retest reliability of the CES-D among diverse
population subgroups [25–28]. In addition, the CES-D
has been found to discriminate fairly well between indi-
viduals who are participating in clinical treatment for
depression and those who are not [23,24]. However,
researchers have cautioned the use of the CES-D in
obtaining a firm clinical diagnosis of depression [29].
Breslau found the CES-D to predict generalized anxiety
just as well as it predicts major depression [30].
Therefore, it’s proper use may be as a general indicator
for psychological distress. The CES-D may be self- or
interviewer-administered; the National Longitudinal
Survey used professional interviewers to score the CSE-
D scale. Respondents were asked to rate on a 4-point
scale how often they had been experiencing a certain
sensation during the past week, 0 being ‘Rarely or None
of the Time/1 Day’ and 3 being ‘3=Most or All of the
Time/5–7 Days.’ Possible scores range from 0 to 60, with
higher scores indicating greater depression. The aver-
age score for a normal population is 9.25, and the stan-
dard cut-off score of 16 has usually been used to distin-
guish clinically depressed individuals from those classi-
fied as non-depressed [31].
In 1998 two items relating to mental health were pre-
sented to a subset of the NLSY cohort. The first of these
items asked the interviewees ‘Has a doctor ever told you
that you had emotional, nervous, or psychiatric prob-
lems?’ The second asked if the respondent were cur-
rently experiencing ‘depression or excessive worry or
nervous trouble of any kind.’ Analyses of these variables
were included in the present paper to provide addition-
al indicators of psychological well-being. However, only
202 women in the sample groups completed these
items, reducing the power of the statistical tests incorpo-
rating them.
In order to control for the effects that socio-marital sup-
port may have on depression, variables were extracted
from 1992 pertaining to marital history: what years they
began/ended their first marriage, what years they
began/ended their second marriage, and what year they
began their third marriage. The data set does not show
information beyond the third marriage. Women for this
study were categorized according to whether they were
a) in their first or second marriage, or if they were b)
never-married or had not remarried after their first or
second divorce. Women who had been married three
times were excluded from marital analyses since it was
not possible to determine if they were still married.
Divorce history (1st marriage did or did not end in
divorce) data were also extracted from 1992.
Finally, a variable pertaining to total family income was
extracted for 1992. Race and age data for women at the
time of the first interview in 1979 were also extracted
and used for these analyses. Only three races are identi-
fied in NLSY: Black, Hispanic, and non-Black and non-
Hispanic. For convenience, the latter is generally identi-
fied as White in most NLSY-based studies, and this ter-
minology will be used in this paper. In actuality, White
in this and other NLSY studies includes Native
Americans, Asians, Pacific Islanders, and other non-
Black and non-Hispanic racial minorities.
RESULTS
Prior to running logistic regressions designed to com-
pare depression rates among women whose first preg-
nancy ended in either an abortion or a birth, zero-order
correlational tests were conducted between depression
scores and various socio-demographic variables as well
as locus of control scores using data derived from the
full sample. The results of these tests are provided in
Table 1 and the data pertaining to significant associa-
tions were used to select covariates (age, race, educa-
tion, income, marital status, locus of control scores, and
history of divorce).
In order to determine whether or not a history of abor-
tion was related to a higher probability of experiencing
scores considered at high risk for clinically significant
levels of depression (scores of 16 or higher on the CES-
D) (Table 2), a logistic regression analysis was conducted
with controls instituted for age, race, education, income,
marital status, history of divorce, and locus of control
scores. The result of the analysis was significant with an
odds ratio of 1.65 (p=0.011; CI: 1.12–2.43) indicating
that a prior history of abortion was associated with
greater risk of depression. The percentage of women
with CES-D scores above 16 in the abortion and delivery
groups were 27.3% and 21.4% respectively.
Age
Income
Years of formal education
Number of children
Marital status
Divorce history
Race
Locus of control
–0.05*
–0.27***
0.18***
0.04
–0.20***
0.21***
0.14***
0.16***
Characteristic CES-D scores
Table 1. Full sample zero-order correlational analyses between
participant characteristics and total depression (CES-D)
scores.
* p<0.05;
** p<0.01;
***p<0.001
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Principle components factor analysis with varimax rota-
tion was conducted using the 20 items composing the
CES-D scale and the results of the analysis revealed the
presence of 3 factors with eigenvalues over 1.00 and
explaining 25%, 13.7%, and 8.7% of the variance
respectively. Examination of the content of the 15 items,
which loaded on Factor 1 with positive correlations
above 0.35 suggested that this factor could be conceptu-
alized as a Sadness factor. The items that loaded highly
(all in a positive direction) on this factor dealt with vari-
ous subjective negative personal experiences associated
with depression. Factor 2 was interpreted to represent
an Enjoyment factor as it contained 4 items that were
negatively correlated above 0.68 with content pertaining
to happiness, feeling good, and hope. Finally, the third
factor only contained 2 items; however the positive cor-
relations were in excess of 0.74. The content of the
items loading on Factor 3 dealt with Negative Rela-
tionships (feeling disliked by others and feeling as if oth-
ers were unfriendly). Items loading on the 3 factors
were combined to form three subscales to enable com-
parisons between the abortion and delivery groups,
which might reveal the more specified aspects of
depressive symptomatology likely to be associated with
an abortion experience. The potential range of scores
on the three subscales was from 0 to 42, 0 to 12, and 0
to 6 respectively. A multivariate analysis of covariance
was conducted to compare the abortion and delivery
groups relative to the Sadness, Enjoyment and Negative
Relationships factors using age, race, education, income,
marital status, history of divorce, and locus of control
scores as covariates. The overall analysis using
Hotelling’s Trace statistic as the omnibus F test was sig-
nificant, F (3,1367) = 4.29, p<0.005. Further, signifi-
cant differences were detected based on reproductive
history relative to the Sadness (F (1,1369)=5.59,
p=0.018) and the Negative Relationships (F (1,1369)=10.90,
p<0.001) subscales. On the Sadness subscale, women
with a history of abortion had higher scores (M=8.04,
SE=0.51) than women with a history of delivery
(M=6.75, SE=0.19). Women in the abortion group
were also more likely to report negative relationships
(M=0.66, SD=0.07) when compared to the delivery
group (M=0.41, SE=0.03). No significant difference
was detected based on reproductive history relative to
the Enjoyment subscale (F (1,1369)=1.03, p>0.05).
Because one of the items on the CES-D scale was con-
ceptually similar to self-esteem in that the respondents
were asked to indicate the extent to which they felt ‘as
good as other people’, an analysis of covariance was
conducted to examine the extent to which abortion
experience was linked to this brief indicator of self-
esteem after controlling for age, race, education,
income, marital status, history of divorce, and locus of
control scores. The result was not significant (F
(1,1369)=1.86, p=0.173).
Analysis of the two variables related to mental health
collected in 1998 was complicated by the fact that these
two questions were presented to only a small sample of
the entire cohort. Among women who had their first
childbirth or abortion between 1980 and 1998, only 177
of the childbirth group and 25 of the abortion group
completed the two items relating to psychiatric distur-
bance. To examine the data, two separate logistic
regression analyses were conducted after controlling for
age, race, education, income, marital status, history of
divorce, and locus of control scores. In regard to the
first question, ‘Has a doctor ever told you that you had
emotional, nervous, or psychiatric problems?’ 6.2% of
the childbirth group answered in the affirmative to this
question compared to 8.0% of the abortion group.
However the group difference was not significant
(OR=1.52, 95% CI: 0.14 to 15.9, p>0.05). For the sec-
ond question, pertaining to whether the women were
currently experiencing ‘depression or excessive worry
or nervous trouble of any kind’ 13.6% of the childbirth
group answered in the affirmative to this item com-
pared to 28.0% of the women in the post-abortion
group. This difference was stronger, but did not reach
significance (OR=2.51, 95% CI: 0.53 to 12.01, p>0.05).
Race
White
Black and Hispanic
Marital status
Married
Not married
History of divorce
1
st
marriage ended in divorce
1
st
marriage did not end in divorce
37/154 or 24.0%
43/164 or 26.2%
35/131 or 26.7%
152/877 or 17.3%
204/1197 or 17.0%
162/1026 or 15.8%
OR=1.79 (1.04 to 3.07), p=0.034*
OR=1.49 (0.85 to 2.62), p=0.168*
OR=2.16 (1.40 to 3.36), p=0.001**
OR=0.88 (0.56 to 1.39), p=0.581**
OR=0.63 (.28 to 1.38), p=0.246***
OR=2.19 (1.41 to 3.41), p=0.0001***
* Covariates included marital status, history of divorce, age, 1992 income, number of years of formal education, and 1979 Rotter Locus of Control scores;
** Covariates included race, history of divorce, age, 1992 income, number of years of formal education, and 1979 Rotter Locus of Control scores;
***Covariates included for race, marital status, age, 1992 income, number of years of formal education, and 1979 Rotter Locus of Control scores
Frequency and %
of abortion group with
scores at or above 16
on the CES-D
Frequency and %
of birth group with
scores at or above 16
on the CES-D
Adjusted Odds-Ratios (95% CI)
using the birth group as the reference group
Table 2. Results of logistic regression analyses conducted separately based on demographic characteristics with reproductive history
as the predictor and ‘high risk’ scores on the CES-D as the criterion in each analysis.
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DISCUSSION
The present study revealed that women with a prior
history of abortion were 65% more likely to score in the
‘high-risk’ range for depression after controlling age,
race, education, income, marital status, and history of
divorce. In addition, an abbreviated version of the
Rotter Internal-External Locus of Control scale [12] was
used in order to control for psychological state prior to
abortion or childbirth. In this study, as in others, there
was a significant correlation between external locus of
control and depression scores in general. The higher
rates of depression identified years after the pregnancy
may be due to persistence of depression associated with
abortion, a delayed reaction which may be precipitated
by subsequent events, such as a later pregnancy, or by
some other unknown common risk factor.
Since depression is a risk factor for suicide, our primary
finding of higher depression rates among post-abortive
women in the NLSY cohort is consistent with studies link-
ing abortion to an increased risk of suicide [32–36]. In
the largest record based study of suicide subsequent to
pregnancy outcome, the age-adjusted odds ratio of dying
from suicide in the year following an induced abortion
was 6.46 compared to women who delivered and 3.68
compared to women who had not been pregnant in the
prior year [36]. These findings suggest that childbirth
may have a protective effect against suicide while abor-
tion may have a deleterious effect. If aborting women
experience a different type of depression than childbear-
ing women, it may be possible that this type of depression
is more closely correlated to suicidal ideation. Further
exploration of the relationships among depression, sui-
cide, abortion, and childbirth would be beneficial.
One of the weaknesses of this study is the high rate of
concealment of past abortions among NLSY women.
Jones and Forrest’s analysis of the NLSY data found
that the overall concealment rate was approximately
60%, with unmarried women and minorities more likely
to conceal past abortions [8]. To examine the impact of
concealment on our findings, we conducted additional
separate analyses based on marital status and race. The
odds ratios for ‘at risk’ depression scores were highest
within those groups who were most likely to report an
abortion (married and White). Conversely, among the
groups with the highest concealment rate (all unmar-
ried and all Blacks and Hispanics) significant differences
were lost. One possible explanation for these findings is
that, among groups which have the highest concealment
rate, women who admit to an abortion are less likely to
experience depression than their counterparts who con-
ceal their abortions. This explanation is supported by
the finding of Major and Gramzow that women who
conceal their abortion are more likely to suppress
thoughts of the abortion and feel greater psychological
distress [9]. Another possibility is simply that conceal-
ment introduces the misclassification of aborting women
as non-aborting women with high depression scores.
In the comparison of the one individual CES-D item
with conceptual congruence with self-esteem, feeling
‘just as good as other people’ no difference was detected
between the women with a history of abortion vs. birth.
The absence of any significant difference between
groups on this item is consistent with prior research of
post-abortion reactions showing little effect of abortion
on self-esteem [3,5,10,11].
The finding of greater depression without a loss of self-
esteem may be evidence of the complex nature of post-
abortion emotional responses. A certain quality of
depression that is independent of self-esteem is found in
grief reactions [37]. Also, accumulating research sug-
gests that positive and negative well-being are two dis-
tinct concepts [38–41]. Assessments of positive well-
being such as the Rosenberg self-esteem scale have
items which appear to relate more to personality than
emotional state. Measures of negative affect, such as the
CES Depression scale, include questions relating to spe-
cific emotional states and behaviors that may vary a
great deal at different points in time. Researchers con-
ducting studies designed to examine the effects of abor-
tion should carefully attend to the selection of measures
to ensure that instruments used to capture reactive
emotional experiences are sufficiently sensitive. If the
goal is to tap into positive emotions after an abortion,
then researchers should use assessments that tie reactive
emotions directly to the abortion event. For example,
one might ask the respondent if she has experienced
increased levels of happiness or contentment since the
time of the abortion.
A primary strength of the present study is that we were
able to examine psychological state many years after the
target pregnancy events. Since the average year women
obtained their first abortion was 1984, this study pro-
vides insight into the association between abortion and
depression approximately eight years after the abortion.
The present study was limited in that the full psychiatric
history of aborting and child-bearing women is
unknown. The NLSY did not include the same assess-
ments every year of the study. If a questionnaire mea-
suring depression had been given to women during
each year of the survey, more support for a cause and
effect relationship between pregnancy outcome and
mental health might have been obtained. Nevertheless,
this data set enabled control for factors other than abor-
tion or childbirth that could contribute to poor mental
health, such as marital status, divorce history, socio-eco-
nomic status, and locus of control scores prior to the
abortion and childbirth events.
CONCLUSIONS
At an average of eight years after their first pregnancy,
women who aborted their first pregnancy have signifi-
cantly higher likelihood of being at risk for clinical
depression than childbearing women who do not report
a history of abortion. This finding may be explained by
preexisting differences related to personality or mental
health between women most likely to choose abortion
and those who are not inclined to opt for the proce-
dure. The alternative explanation that there is a causal
CR163
Med Sci Monit, 2003; 9(4): CR157-164 Cougle JR et al – Depression associated with abortion and childbirth
CR
relationship between abortion and subsequent depres-
sion is strengthened, however, by our ability to control
the results using a pre-pregnancy assessment of locus of
control.
In his recommendation for a longitudinal study to
investigate psychological reactions to abortion, Surgeon
General C. Everett Koop raised the concern that 50% or
more of women who have had an abortion will conceal
it from interviewers [42]. Despite the same problem in
this study, in which only 40% of the expected number of
abortions were revealed, significant differences still
emerged. This suggests that concealment, while a prob-
lem, may not pose an insurmountable obstacle if the
effects measured are strong enough to overcome the
diluting effects of concealment. In addition, our analysis
of the reporting patterns in the NLSY data suggest that
women who deny abortions at one point in time may
admit to them during some prior or subsequent inter-
view. In a longitudinal study, where women are asked
to recount their complete reproductive history every
year, it may be possible to fill in significant gaps.
Another way to help mitigate this problem might be to
periodically request the study participants’ permission
to obtain and review their medical records. A third
approach might entail the employment of trained coun-
selors who would undertake periodic psychological eval-
uations of a small sample of the study cohort. After
establishing an appropriate level of trust, a review of the
woman’s history of pregnancy losses may correct omis-
sions from prior surveys. This approach would also pro-
vide a means for a more in depth look at women’s men-
tal health relative to reproductive health. Research sug-
gests that, compared to studies utilizing questionnaires,
interview-based studies are much better indicators of
the extent and severity of post-abortion grief [43].
We recommend a major longitudinal cohort study to
examine the interactions between obstetric history and
emotional well-being. This would enable researchers to
gauge the interactions among mental health and child-
birth, parenting, adoption, abortion and miscarriage. In
addition, the effects of marriage, divorce, single parent-
ing, multiple partners, domestic violence, PMS and
menstrual irregularities, contraceptive practices, and
other confounding factors related to reproductive and
mental health could also be investigated. This type of
research would go beyond the scope of the study pro-
posed by Koop [42] but would serve to better illuminate
a wide variety of psychological, medical, and social
issues that are uniquely related to women.
Prior studies of post-abortion sequelae that claim to
have controlled for pre-existing psychological problems
have used relatively weak methodology. For example,
Major et al. asked women one hour before their abor-
tion whether they had felt certain symptoms of depres-
sion during the past month, and their responses to
these questions were taken to be an indicator of a prior
history of depression. [5] However, emotional distur-
bance in the month prior to the abortion may suggest
ambivalence and distress regarding the decision to
abort. In addition, research has found that depressed
mood makes one less likely to recall positive experiences
and more likely to recall negative experiences [44]. This
phenomenon is of particular importance given the dis-
tress that many women feel at the time of the abortion.
In light of these confounding factors, history of depres-
sion and psychological dysfunction among aborting
women should be assessed prior to the conception date.
The findings of the present study suggest that future
research efforts should be directed toward the examina-
tion of long-term post-abortion reactions. As previously
noted, other researchers have likewise expressed a need
for more extensive, long-term investigations [3]. Such
research efforts would be beneficial in attempts to
understand why abortion, or the circumstances surroun-
ding abortion, may be problematic for some women. A
greater knowledge of various abortion-related stressors
would be helpful in pre- and post-abortion counseling.
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... In some studies, induced abortion has also been associated with negative consequences such as anxiety, depression, and even suicidal behaviour (Cougle et al., 2003Fergusson et al., 2006;Reardon & Cougle, 2002). These findings, however, are subject to a number of serious methodological and interpretative flaws (Steinberg & Rubin, 2014; see, e.g., Steinberg & Russo, 2008). ...
... Tatsächlich finden sich in internationalen Fachzeitschriften zahlreiche Veröffentlichungen zu den psychischen Konsequenzen von Schwangerschaftsabbrüchen, welche sich meist auf verschiedene Indikatoren mentaler Gesundheit fokussieren. Während ein Großteil der Untersuchungen keine Hinweise darauf findet, dass induzierte Abtreibungen die Wahrscheinlichkeit nachhaltiger psychischer Störungen erhöhen (Schmiege & Russo, 2005;Steinberg & Russo, 2008;Taft & Watson, 2008), assoziieren einige Studien Schwangerschaftsabbrüche mit einer erhöhten Depressionsneigung, Angststörungen sowie Suizidgedanken (Cougle et al., 2003Fergusson et al., 2006;Reardon & Cougle, 2002). Verschiedene Autoren fassen diese Befunde unter dem Terminus "Post-Abtreibungs-Syndrom" (PAS) zusammen, wodurch den Folgen eines Schwangerschaftsabbruchs ein eigenes Krankheitsbild zugeschrieben wird (Dadlez & Andrews, 2010;Speckhard & Rue, 1992;Trumpy, 2014). ...
... Zur Überprüfung der Güte einer Angleichung von Subgruppen durch ein PSM werden typischerweise standardisierte Mittelwertunterschiede in den Kovariaten (auch standardisierter Bias genannt) verwendet (Gangl, 2010;Kainz et al., 2017). In der Literatur wird häufig ein Schwellenwert von 0,1 empfohlen, bei dessen Überschreitung die Kovariaten als unbalanciert gelten (Kainz et al., 2017 (Cougle et al., 2003;Fergusson et al., 2006;Reardon & Cougle, 2002;Taft & Watson, 2008). Die fehlende Berücksichtigung existierender Selektionseffekte führte mit einer hohen Wahrscheinlichkeit zur Schätzung von verzerrten Abtreibungseffekten (Robinson et al., 2009 (Major et al., 2009). ...
... One thing that has been done in some studies is to make the groups as similar as possible, instead of comparing women who have abortions with women who do not, they compare women who have abortions with women who wanted an abortion but were denied an abortion / women who carried an unwanted pregnancy to term, in both groups the women had an unwanted pregnancy, only in one group it was aborted and in the other it was not, so the groups are very similar and thus the risk of uncontrolled confounding factors influencing the results is reduced (although this does not mean that there may not be uncontrolled confounding factors). In 4 of the 17 studies Coleman was author or co-author (Cougle et al ,2003;Coleman et al ,2002;Coleman et al , 2005, Coleman, 2006. ...
... Consequently, the results would not have been generalizable to all early pregnancies, even if they had been based on correctly coded data. It should be noted that Schmiege and Russo (2005) Cougle et al (2003;pp 159-160 (Robinson et al , 2009;Major et al , 2009), moreover, this is also stated by Coleman herself in the paper, stating: ...
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... The potential for abortion-related consequences on mental health has been extensively debated in the scientific literature for more than 20 years, with little clear resolution (Tsoi et al., 1976;Gibbons, 1984;Adler et al., 1992;Thorp et al., 2005;Major et al., 2009;Coleman, 2011;Reardon, 2018). These consequences include an increased risk of mood disorders (including depression), anxiety (Cougle et al., 2003;Fergusson et al., 2006;Pedersen, 2008), substance abuse (Reardon et al., 2004a;Fergusson et al., 2006Fergusson et al., , 2008Dingle et al., 2008) and suicide (Reardon et al., 2004b;Thorp et al., 2005;Fergusson et al., 2006;Luo et al., 2018). Given that approximately 20% of pregnancies in the United States end in abortion (Jones and Kooistra, 2011;Finer and Zolna, 2016), the seriousness of the potential mental health consequences, and the clinical difficulties associated with their treatment and/or prevention (Crosby et al., 2011;Lau and Rapee, 2011;Kupfer et al., 2012), it becomes necessary to objectively investigate any potential links between abortion and specific negative consequences that may arise from the procedure. ...
... A number of recent studies have sought to investigate the comorbid relationship between abortion and psychopathological behaviors (e.g., depression, anxiety etc.) with reports of positive (Reardon and Cougle, 2002;Cougle et al., 2003;Reardon et al., 2004a;Thorp et al., 2005;Dingle et al., 2008;Fergusson et al., 2008;Pedersen, 2008;Mota et al., 2010;Coleman, 2011;Huang et al., 2012;Luo et al., 2018), negative Biggs et al., 2016b) or no relationship (Rees and Sabia, 2007;American Psychological Association, 2008;Robinson et al., 2009;Warren et al., 2010;Munk-Olsen et al., 2011;Biggs et al., 2015Biggs et al., , 2016aFoster et al., 2015;van Ditzhuijzen et al., 2018). These conflicting findings are likely to arise due to the retrospective nature of most studies, differences in the follow-up period of the subjects involved in the study after the abortion procedure took place (Coleman, 2011;Coleman et al., 2012;Reardon, 2014;Biggs et al., 2016a) or the perspective of interpretation of those utilizing the data (Reardon, 2018). ...
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