Psychological effects of abortion. An updated narrative review

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East J Med 25(3): 477-483, 2020
DOI: 10.5505/ejm.2020.82246
*Correspon ding A uthor: V ale ntina Luc ia La Ros a, De partment of Educational Sc iences , Univers ity of Cat ania, Via Bibliote ca 4, 95124
Cat ani a, Italy
E-m ail: v ala ros a@u nict.it, Ph one: (+39 ) 3 345390030
ORC ID ID: Korne li a Zareba : 0000-0002-8 262 -4380, V alenti na Luc ia La Rosa: 0000 -00 02-6619-6777, Mic hal Ciebiera: 0000-000 1-5 780-
5983, M arta M akara -Studz ińs ka: 0000-0001-7374-528 X, Elena Commodar i: 0000-0 002-7647- 8743, Jacek Gi eru s: 00 00-0003-2532-3327
Received : 10.03.2020, Accept ed: 07.05.2020
REVIEW ARTICLE
Psychological Effects of Abortion. An Updated
Narrative Review
Kornelia Zareba1, Valentina Lucia La Rosa2*, Michal Ciebiera3, Marta Makara-St udzińs ka4, Elena
Commodari2, Jacek Gierus1
1Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Warsaw, Poland
2Department of Educational Sciences, University of Catania, Catania, Italy
3Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Warsaw, Poland
4Faculty of Clinical Health Psychology Jagiellon ian University Medical College, Krakow, Poland
Introduction
Abortion is perceived as a traumatic experience
affecting an individual in contact with the
healthcare service. According to the most recent
statistics, it has been estimated that during 2010 –
2014, about 56 million induced abortions occurred
each year worldwide. The estimated global
abortion rate in the same period is 35 per 1,000
for married women and 26 per 1,000 for
unmarried women (1).
Apart from medical complications, more and more
attention is being paid to psychological
consequences associated with abortion, which
sometimes occur a long time after the procedure
(2). Termination of pregnancy for medical reasons
is a complex decision, which may lead to long -
term complications, both for the woman and for
the whole family. The results of studies on
psychological consequences experienced by
women after termination are inconclusive. Part of
the studies does not confirm an increased
prevalence of psychological consequences (3, 4). A
review of the study from 2014 assessing fourteen
studies on termination for medical reasons mainly
conducted in the US and the UK indicated that
termination shakes up the woman's fundamental
views, which later need to be reconstructed (5).
For many years, there have been discussions on
the subject of medical, social and psychological
consequences of deciding to undergo an abortion.
There is talk about post-abortion stress syndrome
and medical complications linked to the
procedure. Sometimes loss of fertility for
psychological reasons is also observed (6). Many
women see the experience of termination as
abuse, which leads to a decreased sense of
security. According to studies, 17% of women
who have experienced termination due to fetal
defects report signs of post-traumatic stress
disorder even two to seven years after the
procedure (7). A survey conducted until the third
week, three months after and a year after the
procedure on a small group of nineteen patients
showed that women see termination as a stigma
and loss similar to natural miscarriage (8). Some
ABSTRA CT
The result s of stud ies on the psychological consequences expe rienced by women af ter termination are inconclusive. Some
of the studies do not c onf irm an increased pre valenc e of psycho logical complications. Howeve r, the experience of abortion
can lead to the development of po st -traumatic stress disorder, depression and problems with interpersonal relations. The
main factors whic h influence psycholo gical effects includ e the re ason for abortion, the type of medic al procedur e, the term
of pregnancy as well as personal, social, e con omic, rel igious and cultural fac tors that shape the w oman's attitude towards
abortion. Often women wh ile terminating pregnancy are not aware that they will require psychological support later d ue to
sub sequent psychological effects they experience. U sually, the first symp toms appear within four months up to a year from
the procedure. T her efore, it is important to identify the high-risk wome n susceptible to subseq uent psycho logical
complications.
Key Words: Pregnancy terminatio n, abortion, psychology, mental health, stre ss, post -traumatic stress disorder, post -
abortion syndrome

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women put themselves in the position of a
survivor, saying that “they have survived the worst
thing in their life” (9). Whereas others say that this
experience has made them stronger. They find the
strength to rebuild family relations and inner
empathy (9-11).
In the light of these considerations, this review
aims to propose a general and updated overview
of the literature about the psychological
implications of abortion to underline the
importance of a multidisciplinary approach in the
clinical and psychological management of women
who interrupt their pregnancy.
Materials and methods
A review of the articles about the psychological
implications of abortion is presented. Authors
conducted their search i n PubMed of the National
Library of Medicine and Google Scholar.
Databases were extensively searched for all
original and review articles/book chapters using
keywords (one or in combinations): abortion,
pregnancy termination, psychology, post -traumatic
stress disorder published in English until
December 2019. Moreover, additional articles in
the bibliographies of reviewed articles were
searched. Overall, most relevant articles were
reviewed and included as appropriate.
Results
Psychological Consequences of Pregnancy
Termination: All pregnancies, even healthy ones,
may cause an existential and emotional crisis in a
woman, which reinforces pre-existing internal
conflicts (12). Indeed, pregnancy is a unique
experience in a woman's life which is influenced
by several factors, particularly cultural, social,
emotional and psychological ones (13). For most
women, pregnancy is a happy experience
associated with positive expectations. In this
regard, for example, a particular case is that of
women who survive cancer for which the
possibility of becoming a mother has a particular
value. For these women, a child is a symbol of life
that defeats death (14). On the contrary,
pregnancy can be the cause of particular
emotional stress for women with consequent
development, in some cases, of
psychopathological disorders such as maternity
blues and postpartum depression (10, 13, 15).
Mood disorders during and after pregnancy have a
detrimental effect on the mother-child
relationship and family life (16). Finally, pregnancy
may be unwanted or there may be particular
conditions such as fetal abnormalities or
pregnancy complications that make abortion
necessary (5, 17, 18).
Studies about the psychological consequences of
termination provide contradictory results. The
experience of abortion can lead to the
development of post -traumatic stress disorder,
depression and problems with interpersonal
relations (19).
The American Psychiatric Society distinguishes
between two types of disorders concerning post-
abortion complications: PAD (post -abortion
distress) and PAS (post-abortion syndrome).
PAD is defined as a disorder that involves
experiencing strong post -abortion stress. It
appears in the first three months after abortion
and may persist for about a year. Its signs are
experiencing a sense of loss or guilt, a feeling that
life is pointless, sleep disorders and psychological
pain. In terms of sex, it involves the fear of
becoming pregnant again and fear of sexual
intercourse. PAS instead is a chronic disorder that
sometimes develops a long time after abortion or
reappears periodically. It is characterized by the
following symptoms: reliving the trauma
(insomnia, nightmares, retrospection, anniversary
reactions), use of defense mechanisms (repression,
denial, rationalization), avoidance of places and
situations which remind the individual about the
event, excitation, chronic anxiety, a sense of
threat, mood swings and outbursts of anger, sleep
disorders, concentration problems), additional
symptoms (depression, neurosis, obsessive-
compulsive disorder, a sense of harm and
injustice, a sense of shame and guilt, suicidal
thoughts, lowered self-esteem, psychosomatic
disorders, no interest in sex, addictions) (20, 21).
The most common symptoms are nightmares
relating to abortion, repetitive persistent dreams, a
strong sense of guilt and the need to fix it. It
should be added that, according to some experts,
PAS is a social diagnosis that bypassed
professional dissent and diffused into public
policy, especially due to the anti-abortion think
tanks (22).
Whereas the DSM-V classification includes
abortion as one of the risk factors for post-
traumatic stress disorder, according to the
American Psychological Society, a legal abortion
performed in the first trimester does not cause
further psychiatric disorders in women. In 1992,
the Planned Parenthood Federation of America
(PPFA) issued an official statement denying the
existence of the term "post-abortion stress

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syndrome" and informing that the majority of
emotional reactions are positive (23). It should be
noted that the hypothesis was based on an analysis
of studies that mainly concerned the termination
of unwanted pregnancies. Some studies show that
the risk of psychiatric disorders after termination
is lower than after birth (24-26). Whereas other
researchers support the post-abortion stress
syndrome theory despite that the disease has been
officially removed from the classification of
psychiatric disorders (20). Another study from
2011 by Coleman, which analyzed later studies
from 1995-2009 suggests a higher risk of certain
psychiatric disorders after termination (27).
According to Horvath and Schreiber (2017),
depression rate is almost the same between
women obtaining an abortion and those who
denied an abortion and the rates of anxiety
symptoms are higher in women in whom abortion
care has been denied (28). As stated by Reardon,
abortion is consistently associated with elevated
rates of mental problems in comparison with
women who did not have this problem. Reardon
highlights pre-existing mental illness, as one of the
main risk factors of mental health problems after
an abortion and the very important fact that it is
impossible to identify the extent to which mental
problems following an abortion can be rel iably
attributed to it (19).
Risk and Protective Factors: The main factors
influencing psychological complications after an
abortion include the reason for undergoing the
abortion, type of medical procedure, the term of
pregnancy as well as personal, social, economic,
religious and cultural factors that shape the
woman's attitude towards abortion (4). In
particular, the factors associated with the most
negative consequences are previous psychiatric
diseases, planned and wanted pregnancy, pressure
from people in the surroundings, no social
support, personality with a higher tendency to
react negatively to stress (low self -esteem,
pessimism, low sense of control). The same
factors may cause mental disorders in women who
decide to continue their pregnancy (20). Risk
factors for short-term complications–occurring
within a few months after termination–are support
from the partner, religiousness, advanced term of
pregnancy and a disease diagnosed in the fetus
(29); in case of long-term complications, the risk
factors include little support from the partner,
advanced term of pregnancy, level of education
and chances for the child's survival (7). Women
who have terminated their first pregnancy were
more at risk of developing anxiety disorders than
women who have given birth to their first child. A
strong predictor of developing anxiety disorders
after abortion is earlier mental health problems.
Exposure to violence and anxiety disorders
experienced before pregnancy also have a
correlation with anxiety disorders after abortion.
In a dynamic study that commenced four months
after termination, it was demonstrated that,
initially, a low psychological response was the
strongest predictor of long-term complications
(29). At this point, we should also mention
stigmatization by professionals as a possible risk
factor (30, 31). The conscientious objection
appears to constitute a barrier to care, especially
for selected groups (32). In this regard, some
professionals who object to abortion stigmatize
women that their decision is wrong and they
should not perform it. Gynecologists frequently
invoke the conscience clause not only when
refusing to terminate a pregnancy but also when
prescribing contraceptives. There are two sides in
this field: professionals who accept to help women
and those who neglect help (33). This might cause
a problem with timely access or access in general
to elective abortion what might have direct
psychical, organizational and ethical implications
(34).
Literature also talks about protective factors, such
as support from the partner and close family, no
past mental illnesses, higher education, no medical
doubts and young age (35, 36). In Lowenstein’s
study comparing the level of stress experienced by
patients who underwent abortion performed with
the use of surgical or pharmaceutical methods, the
patient group who underwent pharmaceutically -
induced miscarriage showed a higher tendency to
develop obsessive-compulsive reactions, had a
stronger sense of guilt and showed more
sensitivity. In that group, more women did not
have children, which is probably why they chose
the safer but more time-consuming method, which
also causes more pain (37). However, the authors
suggest that the respondents who chose
pharmacologically-induced miscarriage probably
felt less comfortable with their decision and chose
a method which bears a smaller psychological load
and is less definitive, leaving the course of events
to fate (37). When comparing acceptance and
selection of the abortion method, Slade indicated
that women who had chosen a surgical method
did not want to be aware of the whole procedure
and did not want to participate in it in any way.
They were very focused on pain and emotional
issues (38).

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The Impact on Couple Relationship and
Sexuality:
A study examining changes in the
quality of life of people deciding to terminate the
pregnancy–which involved 658 mal es and 906
females–showed that the experience of
termination in a previous relationship hurts the
next one. Termination in a current relationship
increases the frequency of arguments about
children by 116% in women and by 196% in men.
Besides, it increases the number of sexual
dysfunctions in women by 122-182% and the
number of conflicts with family members by 80%.
Women who have experienced abortion in their
current relationship also reported an increase in
abuse between the partners. Researchers claim
that people deciding to abort a pregnancy are
more predisposed to have an unstable relationship
for psychological reasons, such as egocentrism
and emotional instability (39). According to
Breslau et al., women who have experienced
abortion, later on, reported numerous sexual
dysfunctions about desire, frequency of
intercourse, ability to reach an orgasm and sexual
satisfaction (40). Whereas couples who have
experienced the death of a child or fetus did not
report sexual dysfunctions, women confirmed a
drop in their interest in sex saying that it reminded
them of how their dead child was conceived (41).
In a study from 2003 conducted among 10,847
women, Sullins showed that twice as many women
who underwent abortion were not married. He
also showed that, if they were married, the
likelihood of divorce was 37% higher (42).
Conklin and Lydon showed that being married
was a protective factor for the individual’s
wellbeing after abortion. In this regard, married
women did not react with negative emotions (43,
44).
A survey by Desrochers conducted among seven
males who had experienced a termination in the
previous four months showed that the termination
had no negative impact on the relationship. Four
out of the seven respondents even claimed that
their relationship got stronger after this
experience (45).
The Role of Counseling Before and After
Pregnancy Termination: According to available
data, most of the women are seeking an
uncomplicated referral process. The main opinion
is that this process should be easy and quick as
possible and the counseling should be available
for those who need it (46). As stated by Brown et
al., most women make their decision before
counseling visit and they discuss their decision
with someone close to them. Many women
undergoing pregnancy termination think that
counseling prolongs the whole process and causes
additional stress (46). In the study by Baron et al.,
only 9% of patients reported pre-termination
counseling. The authors concluded that counseling
is not necessary in every case and should be
targeted at women with risk factors for
psychological complications (47). According to
another recent study, women do not exp ect
systemic support, as they believe it is marginal
(48). A different voice about counseling comes
from an interesting study by Vandamme et al.,
according to which most women were distressed
before the counseling session, but after it, they felt
very satisfied and experienced less distress and
greater decisiveness (49). Additional data about
the real needs and new methods of counseling and
decision-making process in the topic of pregnancy
termination is still needed to make it less stressful
or harmful and more patient-tailored.
While terminating pregnancy, women are often
not aware that they will require psychological
support later due to a delayed sense of sadness
that they experience. Usually, the first symptoms
appear within four months up to a year from the
procedure (29). According to a study by Fisher
conducted by an organization that helps 500
people a year (who have experienced termination),
parents usually seek support and contact with
others two or three months after the procedure.
This correlates in time with the anniversary of the
child’s death and with the family’s and friends’
wish to go back to normal (50). There is a lot of
new studies trying to help women who require
psychological support, however data are still
limited and it is necessary to better investigate the
characteristics of these women (51).
Most of the studies presented herein are limited to
small groups of patients and show significant
differences in results–depending on the country
where the study is conducted. The first issue is the
lack of control groups. People are unable to
predict how they would act in an extreme
situation. Control groups in such studies usually
consist of women who have never been pregnant,
have given birth to planned children or have
miscarried planned pregnancies. Results also vary
due to the place where the study is conducted.
From private clinics in America only accessible to
the more affluent part of society to countries with
different socio-political circumstances (law,
religion, family model). Women from countries
with restrictive laws and religion are less willing to
talk about abortion, which leads to a low response
ratio sometime after the procedure (52). They are
also unwilling to talk about mental health and

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emotional problems, which are a stigmatized
subject in many countries.
Results are also influenced by the nature of
pregnancy and the grounds for performing the
procedure. Most studies examine abortions
without medical grounds, mainly performed due
to the pregnancy being unwanted, financial
problems and young age (26, 53) Different results
are obtained for women who have terminated a
wanted pregnancy due to fetal defects and for
young women deciding to abort an unwanted
pregnancy. Such terminations are performed at a
later time, which leads to a more painful and
aggravating procedure and more attachment of the
mother to the fetus. The procedure is comparable
to miscarrying a wanted pregnancy, stillbirth,
death of a newborn or giving birth to a child with
severe physical defects.
Women in a worse mental state withdraw from
further stages of studies more often than women
without such disorders. Similarly, studies on
subsequent psychiatric disorders were often
conducted on support groups and similar
organizations for people seeking assistance rather
than on women undergoing abortions as a whole.
Moreover, it is difficult to choose the right time
for subsequent interviews, as there are no clear
indications of when such an interview should be
carried out.
Previous research indicates that the main factors
influencing the physical consequences of
miscarriage are the term of the pregnancy at the
time of termination, the woman's age and health
as well as the experience of the person performing
the procedure. Whereas easy access to the
procedure minimizes medical complications.
Complications mainly involve trauma which may
occur after the surgery. Emotional complications
depend mainly on the own resources of patients,
e.g. support from loved ones and society, reasons
for terminating the pregnancy and the degree of
reconciliation with the decision. Often women
while terminating pregnancy are not aware that
they will require psychological support later due to
subsequent psychological effects they experience.
Therefore, it is important to identify the high-risk
group susceptible to subsequent psychological
complications.
Despite numerous limitations, such studies
provide a lot of useful information and the issue
undoubtedly requires further research.
Acknowledgment: This material was not
presented elsewhere.
This study was funded by the Center of
Postgraduate Medical Education.
Grant number 501-1-21-27-17, 501-1-21-27-18
and 501-1-21-27-19.
Disclosure Statement: All authors declare no
conflict of interest.
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