Studies - General Research

Abortion & Increased Risk of Child Abuse: Child Maltreatment and Perinatal Loss (AP, 2005)

Acta Pædiatrica, 2005; 94:
Associations between voluntary and involuntary forms of perinatal loss and child maltreatment among low-income mothers

Abstract
Aim:
This study explored maternal history of perinatal loss relative to risk of child physical abuse and neglect.
Methods: The 518 study participants included 118 abusive mothers, 119 neglecting mothers, and 281 mothers with no known history of child maltreatment…

Interviews and observations were conducted in the participants’ homes, and comparisons were made between women without a history of perinatal loss and women with one and multiple losses relative to risk for child maltreatment.

Results: Compared to women with no history of perinatal loss, those with one loss (voluntary or involuntary) had a 99% higher risk for child physical abuse, and women with multiple losses were 189% more likely to physically abuse their children.

Compared to women with no history of induced abortion, those with one prior abortion had a 144% higher risk for child physical abuse.

Finally, maternal history of multiple miscarriages and/or stillbirths compared to no history was associated with a 1237% increased risk of physical abuse and a 605% increased risk of neglect.

Conclusion: Perinatal loss may be a marker for elevated risk of child physical abuse, and this information is potentially useful to child maltreatment prevention and intervention efforts.

 

Background
Pregnancy loss through miscarriage, stillbirth, and induced abortion has been linked with pronounced psychological problems in at least 10–25% of women [1–3].

Among those negatively impacted by voluntary and involuntary forms of perinatal loss, many stress-related responses have been identified including grief reactions [4,5], anxiety [6,7], depression [8,9], sleep disturbances [10,11], post-traumatic stress disorder symptoms [12,13], and, in the case of induced abortion only, increased risk of substance use [14,15] and suicide [16].

Emotional difficulties and unresolved grief responses associated with perinatal loss may hinder effective parenting by reducing parental responsiveness to child needs [1,17], interfering with attachment processes [18], instilling anger, which is a common component of grief [19], or by increasing parental anxiety about child well-being [17].

The existing studies, designed to examine relations between maternal history of perinatal loss and aberrant parenting behavior, have focused nearly exclusively on either involuntary forms of loss (miscarriage and stillbirth) or voluntary forms of loss (induced abortion) with comparison studies currently absent from the published research. One study did reveal an elevated risk of child abuse with both types of perinatal loss; however, due to data constraints, no distinction was made between stillbirth and induced abortion in assessing risk [20].

In a study of parents of stillborn infants, Phillips found that both mothers and fathers frequently showed low levels of pleasure and attachment in conjunction with a subsequent pregnancy [21].

Involuntary perinatal loss has also been found to be associated with heightened risk for child abuse [22]. Paradoxically, other studies of involuntary loss indicate a higher risk for over-protective parenting behavior as well as an inclination to become excessively concerned about the physical health of surviving children [17].

Finally, due to lingering parental grief, children born to mothers with a history of involuntary forms of perinatal loss are apparently more prone than children of mothers without such a history to experiencing emotional and behavioral problems [17,21].

The link between voluntary perinatal loss and parenting behaviors has been less systematically examined, presumably because of the generally held belief that women who freely choose termination are unlikely to be negatively affected [23]. However, recent research on the psychological effects of abortion suggests that this assumption may be ill founded [2,5,6,8,10,13–16] as women who opt for abortion often do so with much ambivalence and under the pressure of others and/or situational constraints [24].

Nevertheless, a few recent studies have identified relations between maternal history of abortion and problematic parenting, including lower emotional support and heightened risk for both child abuse and neglect [18,20,23].

While both voluntary and involuntary forms of loss have been found to be associated with adverse psychological effects as described above, there are several reasons to believe that induced abortion may have a more pronounced negative impact on women’s mental health and parenting behavior.

First, because abortion is a voluntary act, many women may experience a considerable amount of guilt, with moral or religious conflicts likely to precipitate such feelings [24,25]. Abortion-related guilt has been estimated to range from 29.7% to over 75% [24,25].

Second, professionals who work with women who have experienced a miscarriage or stillbirth are inclined to encourage healing focusing on the loss of the fetus [12], but this is rarely a part of routine post-abortion care.

Third, feelings of shame and secrecy that may surround an abortion experience might preclude reaching out to others for needed support, and studies clearly suggest that the presence of a continuously available, informed, and sympathetic social support system is a vital component to recovery for the bereaved [26].

Fourth, although very few studies have examined the long-term effects of abortion, miscarriage, and stillbirth, there is some preliminary evidence indicating that negative abortion-related emotions are more difficult to resolve than those associated with involuntary forms of loss. For example, a Norwegian team of researchers led by Broen [27] recently reported that women who had an abortion 2 y earlier were more likely than those who had miscarried to be suppressing thoughts and feelings about the event. Specifically, nearly 17% of 80 women who had an abortion scored highly on a scale measuring avoidance symptoms, compared with about 3% of those who miscarried.

The purpose of this study was to explore the extent to which perinatal loss operates as a risk factor for child physical abuse and neglect.

Based on the previously reviewed literature, the following hypotheses were tested: (1) women with a history of one perinatal loss, when compared to women without a prior perinatal loss, were expected to be at a higher risk for engaging in child physical abuse and neglect; (2) when examined separately, both maternal history of one induced abortion and maternal history of one miscarriage/stillbirth were hypothesized to be associated with a higher risk for both child physical abuse and neglect than not having experienced either form of loss; and (3) induced abortion was expected to be associated with a greater risk for both forms of maltreatment when compared to miscarriage and stillbirth.

Various environmental, personal, and social factors enhance the risk for child maltreatment [28]; therefore, many variables (described below) were explored as potential covariates to be included in the primary analyses. Finally, exploratory analyses were conducted to examine the extent to which risk for child maltreatment is elevated when women experience more than one perinatal loss compared to no prior losses.

Very little previous research attention has focused on multiple losses, precluding specific hypotheses pertaining to possible associations between multiple perinatal losses and elevated risk for child maltreatment.

Material and methodsPartic
ipants
The respondents in this study consisted of 518 women who were residents of Baltimore, Maryland, in the mid-1980s and were receiving Aid to Families with Dependent Children (AFDC). Each participant had at least one living child age 12 or under. Exactly 100 women (19.3%) had experienced one abortion, and 59 women (11.4%) experienced two or more abortions; whereas 99 women (19.1%) had experienced one miscarriage or stillbirth, and 34 women (6.6%) had experienced multiple miscarriages or stillbirths. The majority of the participants were single (78.8%), with the remainder separated from spouses (18.9%) or married (2.3%). The 518 study participants included 118 abusive mothers, 119 neglecting mothers, and 281 mothers who had no history of substantiated child maltreatment offenses. At the time of testing, the participants ranged in age from 18 to 50 y (mean 27.31, SD 5.65). The average number of children was 2.64 (SD 1.71), with a range extending from 1 to 11.

The sample was predominantly Black (79.9%), with 19.7% White, and 0.4% Asian or Native American…For the 100 women who had experienced one prior abortion, a mean of 6.50 (SD 4.11) y had elapsed since the procedure; whereas for the 99 women who had experienced a miscarriage or stillbirth, a mean of 7.16 (SD 5.37) y had elapsed since the loss.

Data description and procedure
Physical abuse segment. The 118 mothers comprising the final physical abuse segment were self-selected from a sample of 152 abusive mothers (78% interview completion rate) who were identified from a cohort of 1744 families receiving Child Protection Services (CPS) from the Baltimore City Department of Social Services (BCDSS) during January 1984. All women who were known or suspected abusers were included in the original sample of 152 mothers in addition to a
random sample of remaining cases where someone else was known or suspected of being the abuser. The operational definition of physical abuse used in this study was as follows: “Respondent had as of January 1984 at least one natural child who was the victim of excessive inappropriate physical force by the respondent herself and/or another caretaker and, as a result of the force, sustained injuries at a minimum severity level of 4 on the 6-point Magura-Moses Physical Discipline Scale” [29, p. E5-2]. Severity-level 4 injuries include bruises, welts, cuts, abrasions, or first-degree burns that are restricted to one or two bodily areas. The principle investigator reported that information derived from CPS case records of 105 of the abusive respondents revealed that, in 59% of the situations, the mother was the one who inflicted the injuries and, for 60% of the situations, child neglect was also a problem.
Finally, 39% of the injuries were mild, involving injuries not requiring medical intervention such as bruises, welts, and abrasions; 45.7% of the situations involved moderate injuries such as second-degree burns, mild concussions, breaks of small bones, etc.; and 15.2% of the situations were classified as severe, involving third-degree burns, internal injuries, severe concussions, breaks of long bones, etc. [29].
Neglect segment. The 119 mothers included in the final neglect segment were self-selected from a sample of 164 neglectful mothers (73% interview completion rate) who were identified from the same cohort of families receiving CPS from the BCDSS during January 1984 that was used to identify the abusive mothers.

The original sample of 164 neglecting mothers was constructed by including all identified Caucasian women and a random sample of non-Caucasian families. The operational definition of neglect used in the study was as follows: “Respondents neglected one or more children in at least one of the following eight areas: physical health care, mental health care, nutrition/diet, personal hygiene, household sanitation, physical safety in the home, supervision of activities, and arrangements for substitute childcare. In addition, as of January 1984, the respondent had no children who met the study definition for physical abuse.”

Information derived from CPS case records of 102 neglecting respondents reported by the principle
investigator indicated that the two most common forms of neglect were inadequate physical health care (48%) and inadequate supervision (44%) [29]. In addition, 75% of the cases involved at least two types of neglect and, in 36% of the situations, the child had experienced adverse consequences due to the neglect [29]…

Results
In order to examine the strength of relations between
maternal history of perinatal loss (voluntary and
involuntary) and child physical abuse and neglect,
several logistic regression analyses were conducted. In
the analyses focusing on miscarriage/stillbirth, history
of induced abortion was statistically controlled and,
in the analyses focusing on induced abortion, history
of miscarriage/stillbirth was statistically controlled.

Further, the following demographic, personal history,
and social variables, which were found to be positively
correlated with physical abuse, were entered as
covariates into the analyses using this variable as the
outcome measure: more residences in the last 5 y
( p=0.001), more children ( p50.0001), frequent
worries regarding income ( p=0.003), more schooling
( p=0.003), older age ( p=0.009), history of depression
lasting 2 wk or more ( p=0.019), history of
one or more alcohol binges ( p=0.003), White race
( p=0.005), lower than average interviewer-estimated
intelligence ( p50.0001), sad appearance/dejected
posture during the interview ( p=0.001), and difficulty
understanding the interview questions ( p=0.004).

Finally, the following demographic, personal history,
and social variables, which were found to be positively
correlated with neglect, were employed as covariates in
the analyses using neglect as the dependent variable
:
more residences in last 5 y ( p50.0001), more people
living in the household ( p=0.001), more children
( p50.0001), currently unemployed ( p=0.001),
history of marriage ( p=0.002), older age ( p50.0001),
tendency to spend time alone rather than with others
( p=0.001), history of depression lasting 2 wk or
more ( p50.0001), history of one or more alcohol
binges ( p50.0001), having no one to share personal
problems ( p50.0001), White race ( p50.0001), lower
than average interviewer-estimated intelligence
( p50.0001), a sad appearance/dejected posture
during the interview ( p50.0001), and difficulty
understanding the interview questions ( p50.0001).

The first hypothesis predicted that a maternal
history of perinatal loss would be associated with
elevated risk of child physical abuse and neglect. The
results of the regression analyses conducted to test this
hypothesis are presented in Table I. Support was
partially obtained for this hypothesis as there was a 99% higher risk for physical abuse when the participants had experienced a voluntary or an involuntary perinatal loss; however, a significant effect was not detected for child neglect.

Partial support for the second hypothesis, which
predicted significant associations between maternal
history of one induced abortion and one miscarriage or
stillbirth and both child physical abuse and neglect,
was obtained based on a significant association
between maternal history of induced abortion and
child physical abuse (see Table I). Women with a history of induced abortion were 144% more likely to physically abuse their children than women without a history of induced abortion.

The experience of one induced abortion was not associated with elevated risk for neglect, and there were not any significant effects
detected between history of one miscarriage and either form of child maltreatment.

Finally, the
third hypothesis entailed a prediction
that history of one induced abortion would function as
a more serious risk factor for child maltreatment than
history of one miscarriage or stillbirth. This hypothesis
was partially supported based on the fact that a greater
risk was observed between maternal history of induced
abortion and child physical abuse compared to
maternal history of miscarriage/stillbirth and child
physical abuse.

Exploratory analyses were conducted to examine
the relative risk of child maltreatment based on
multiple perinatal losses versus no history of losses (see
Table II).

The results revealed that history of multiple losses (at least one abortion and one miscarriage/stillbirth) was related to a 139% greater risk for child physical abuse; however, multiple losses encompassing
both voluntary and involuntary losses were not associated
with elevated risk of neglect.

Multiple induced abortions were not related to significant increased risk
for physical abuse or neglect; however, strong associations
were observed between maternal history of multiple miscarriages/stillbirths and both child physical abuse (1237% higher risk) and neglect (605% higher risk).

Discussion
This study was designed to examine the risk for
child maltreatment based on maternal history of
voluntary and involuntary forms of perinatal loss.

After controlling for several demographic, personal, and social factors associated with the particular form of maltreatment (abuse or neglect), a maternal history of one miscarriage or stillbirth was not related to an
elevated risk for either form of maltreatment.

These findings contradict previously described research [21]; however, the earlier research did not include many controls. Miscarriage or stillbirth may not be directly related to negative outcomes, but may instead influence parenting behavior through other variables, such as partner relationship quality, depression, substance use, etc., and when these variables are controlled, the effect is lost.

Support for this interpretation is provided by the unadjusted results of the present study wherein maternal history of one miscarriage or stillbirth was significantly associated with neglect.

Another possible reason for the lack of associations between one involuntary loss and the two forms of child maltreatment is that negative effects of miscarriage and stillbirth tend to resolve within 2 y of the loss [27], and an average of over 7 y had elapsed since the women in this study had experienced their single loss. This explanation also helps interpret the exploratory findings of this study wherein multiple miscarriages or stillbirths were found to be strongly associated with elevated risk for both child physical abuse and neglect which stand in contrast to the results observed with one involuntary loss, because women who had more than one miscarriage or stillbirth tended
to experience more recent losses.

Moreover, suffering from multiple involuntary losses is logically more
psychologically challenging than experiencing only one, and the cumulative stress of the losses may explain the findings.

A final interpretation of the discrepant results relative to one versus multiple involuntary losses is that there may be a variety of unmeasured third variables operative in the associations between multiple voluntary losses and child maltreatment including stress, relationship difficulties, physical health problems, and drug use. The findings regarding repeated involuntary loss should be viewed cautiously as only 34 women fell into this category in the current
study.

Consistent with expectations, after controlling for a number of demographic, personal, and social factors associated with physical abuse, a maternal history of induced abortion was found to be associated with a 144% greater likelihood of child physical abuse.

However, counter to expectations, maternal history of induced abortion was not linked with enhanced risk for neglect after the effects of a number of variables associated with neglect were controlled. The lack of significance relative to associations between both voluntary and involuntary forms of perinatal loss and neglect might be partly a function of the forms of neglect most commonly observed in the sample.

Specifically, inadequate health care and inadequate supervision may be more of a function of poverty as opposed to being indicative of the mother’s attitude toward the child.

The correlational nature of the design obviously
precludes cause-and-effect conclusions, and there are a
number of possible explanations for enhanced risk of
physical abuse based on maternal history of one
induced abortion.

Generalized negative post-abortion emotions, such as depression or anxiety and/or adverse emotions tied specifically to the abortion (e.g., feelings of guilt or shame that could prompt feelings of not deserving a child or of not being a good mother), may compromise women’s ability to effectively parent.

Alternatively, it is possible that women who choose abortion are less oriented to children and/or are less interested in parenting, and it is these characteristics, as opposed to the abortion itself, which are linked with a greater chance of engaging in subsequent child physical abuse.

The latter explanation seems less likely based on the finding that induced abortion is not a risk factor for neglect. If the underlying cause is disinterest in children and/or parenting, then the relation between induced abortion and neglect would seem to have a
high probability of being statistically significant.

On the other hand, if the underlying cause is a negative
emotional reaction to the abortion experience, then
an association with physical abuse might be more
understandable than an association with neglect.

Women who are emotionally scarred from an abortion experience might be able to go through the motions and provide basic care for their children because it does not require a great deal of psychological energy or investment. Emotional management, particularly
refraining from angry outbursts leading to abuse as well
as coping with parent–child conflict, however, may
prove more challenging for women who have suffered
psychologically from an abortion…

However, there is reason to examine the effects of
distinct combinations of involuntary and voluntary
perinatal losses, because there is reason to believe
that a history of induced abortion might exacerbate
negative emotions associated with miscarriage [30].
Specifically, Klock and colleagues found that
those with a history of induced abortion had higher
levels of anxiety, lower marital adjustment, and
different attributions regarding their involuntary
pregnancy losses than women without a history of
induced abortion
.

The strengths of this study are many: the use of
a carefully conducted sampling methodology, which
included confirmed cases of child maltreatment,
an extended time frame, and a racially diverse sample.
Nevertheless, the data were gathered in only
one geographical locale and the study adopted
a retrospective methodology that relied primarily on
self-report assessments, which could compromise
the integrity of the data gathered as well as the generalizability
of the findings.

A final limitation pertains to how the abuse and neglect cases were selected. The majority of the mothers in the abuse group
were perpetrators of physical abuse; however, women
who allowed their children to be abused were also
included, and there was no way to distinguish between
the two segments. These two segments may differ
in ways that are critically relevant to mo
thers’ feelings
about parenting.

For example, women who allow others to abuse their child may feel power
less to do anything about the abuse, possibly due to a sense
of learned helplessness originating from a personal history of having been abused, but their unwillingness to engage in abusive behavior themselves suggests more self-restraint.

In addition, some of the cases in the
abuse group also included a neglect history; whereas
the neglect group did not include any cases with
evidence of abuse. Finally, some of the women who
were in the unidentified group may have been guilty
of child maltreatment, but they simply had not
been reported to child protection services. With
“cleaner” maltreatment groups, the effects observed
may have been stronger and more in line with the
hypotheses.

Future work using a prospective methodology,
more distinct maltreatment groups, and a nationally
representative sample, which incorporates a multimethod
data collection effort, seem warranted. In the
event that such a large-scale effort yields robust
findings consistent with those described herein, more
effort should be directed toward helping women
restore their emotional health following an abortion.

Investment in such programs is likely to improve
the quality of their lives and increase the likelihood
that their future families will be violence free.

 

References
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Authors: PRISCILLA K. COLEMAN1, CHARLES D. MAXEY2, VINCENT M. RUE3 &
CATHERINE T. COYLE4
1Human Development and Family Studies, Bowling Green State University, Bowling Green, OH, USA, 2Department of
Psychology, Bowling Green State University, Bowling Green, OH, USA, 3Institute for Pregnancy Loss, Jacksonville, FL, USA,
and 4Edgewood College, Madison, WI, USA

Priscilla K. Coleman, Human Development and Family Studies, 16D Family and Consumer Sciences Building, Bowling Green State
University, Bowling Green, OH 43403, USA. Tel: +1 419 372 6492. Fax: +1 419 372 7854. E-mail: [email protected]
(Received 16 May 2005; accepted 2 June 2005)
Acta Pædiatrica, 2005; 94:
ISSN 0803-5253 print/ISSN 1651-2227 online # 2005 Taylor & Francis Group Ltd
DOI: 10.1080/08035250510042960

*********************************************

Authors Say Emotional Healing After Abortion will Increase the Likelihood of “Violence Free” Families

Springfield, IL (October 24, 2005) — A new study published in the medical journal Acta Paediatrica has found that women who have had an abortion ar
e 2.4 times more likely to physically abuse their children
.

The data compared rates of child abuse and neglect among women who had experienced either an involuntary (miscarriage or stillbirth) or voluntary (induce
d abortion) pregnancy loss.

The study, led by Priscilla Coleman of Bowling Green State University, looked at data taken from a survey of 518 low-income women in Baltimore who were receiving Aid to Families with Dependent Children and who had at least one child aged 12 years or younger.

The results showed that women with a history of one induced abortion were 2.4 times more likely to physically abuse their children than women who had not had an abortion.

In addition, the increase in risk among women who had experienced an abortion was more significant than the increase among women who had experienced a miscarriage or stillbirth.

The authors suggested that “emotional difficulties and unresolved grief responses” from pregnancy loss, whether voluntary or involuntary, could have a negative impact on women’s mental health and lead to unhealthy parenting responses.

Past studies have linked pregnancy loss to an increase in grief reactions, anxiety, depression, sleep disturbances, and symptoms of post-traumatic stress disorder, all of which can have a negative impact on parent/child relationships.

In addition, induced abortion has been linked to an increased risk of substance abuse and suicidal thoughts, and a 2002 study published in the Journal of Child Psychiatry and Psychology found that children whose mothers had a history of abortion tended to have less supportive home environments and more behavioral difficulties.

The current study showed that although a single involuntary pregnancy loss did not significantly increase the risk of child abuse or neglect, physical abuse was more common among women who had experienced multiple involuntary pregnancy losses. However, women who had repeat abortions were not more likely to abuse their children than women who had one abortion, although abortion increased the risk of physical abuse overall.

In addition, neither form of pregnancy loss was linked to child neglect, leading the authors to speculate that mothers with unresolved losses may be able to “go through the motions” of meeting their children’s basic needs but have difficulty coping with issues such as anger or parent/child conflict.

“Regardless of the specific mechanisms at play, maternal history of one induced abortion does appear to be a marker for increased risk of physical abuse,” the authors wrote.

They also noted that while emotional difficulties related to miscarriage or stillbirth are usually resolved within a few years, women who have abortions are often not given an opportunity to resolve feelings of grief or other related emotions.

According to Elliot Institute director Dr. David Reardon, who has worked on more than a dozen published studies documenting abortion’s negative impact on women, many women either feel a need to keep the abortion a secret or are told to simply “move on” when they try to discuss their pain.

Reardon said that greater attention needs to be focused on the long-term effects of abortion on women and their families.

“The common perception seems to be that abortion solves the immediate problem of a crisis pregnancy and that therefore it must be a positive thing for women,” he said. “However, more and more studies such as this one show that abortion can have a severe and lasting impact on women’s lives, shaping their futures and the futures of their families for years to come.”

The current study is one of the first to compare rates of child abuse among women who had experienced an involuntary pregnancy loss as opposed to those who experienced a voluntary loss. However, the authors noted that the findings were limited by the size of the study and called for more research to be done using larger groups of women.

“In the event that such a large scale effort yields robust findings consistent with those described … more efforts should be directed toward helping women restore their emotional health following abortion,” the authors wrote. “Investment in such programs is likely to improve the quality of their lives and increase the likelihood that their future families will be violence free.”

Study Citation:

Priscilla K. Coleman, Charles D. Maxey, Vincent M. Rue, and Catherine T. Coyle, “Associations between voluntary and involuntary forms of perintal loss and child maltreatment among low-income mothers,” Acta Paediatrica 94, 2005.

[Elliot Institute, 10/05]