Studies - Depression / Suicide / Mental Health

Induced Abortion and Traumatic Stress: Preliminary Comparison of American, Russian women (MSM,11/04)

Trauma Symptoms After Abortion Are Common

Post-traumatic reactions to induced abortion may be far more common than previously thought, according to a study published in the Medical Science Monitor.

Sixty-five percent of American women studied experienced multiple symptoms of Post-Traumatic Stress Disorder (PTSD), which they attributed to their abortions. Slightly over 14 percent reported all the symptoms necessary for a clinical diagnosis of abortion induced PTSD.

Researchers gathered data from women seeking general health care treatment at clinics and hospitals in both the United States and Russia. Women with a history of pregnancy loss, including miscarriage or abortion, were asked to complete an extensive questionnaire about their experiences.

The sub-sample used in this study included 331 Russian women and 217 American women. American women were significantly more likely to report traumatic reactions they attributed to their abortions, while Russian women were more likely to report disruption of cognitive schema, which is described as the equivalent of one's "psychological road map" for understanding the world and one's place in it.

Both Russian and American women were more likely to experience negative reactions to abortion if they had prior negative opinions of abortion, felt pressured into unwanted abortions, were more religious, or received little or no counseling prior to the abortion.

American women were more likely to report being exposed to one or more of these risk factors. For example, 64 percent of American women felt pressured by others to choose abortion compared to 37 percent of Russian women. In addition, only 25 percent of American women reported receiving adequate counseling prior to their abortions compared to 64 percent of the Russian women.

 

American and Russian women reported fewer postive reactions to abortion than negative ones. The most commonly reported positive reaction was relief, but only 7 percent of Russian women and 14 percent of American women attributed this feeling to their abortions.

American women were more likely to attribute to their abortion subsequent thoughts of suicide (36 percent), increased use of drugs or alcohol (27 percent), sexual problems (24 percent), relationship problems (27 percent), guilt (78 percent), and an inability to forgive themselves (62 percent). Approximately two percent of the American women studied attributed a subsequent psychiatric hospitalization to their abortion.

"This is the first published study to compare reactions to abortion among women in two different countries," said Dr. Vincent Rue, the lead author of the study and a traumatologist who heads the Institute for Pregnancy Loss.

"It is also the first to provide a detailed breakdown of traumatic symptoms which the subjects themselves attribute to their abortions. These results will help mental health workers to be better prepared to recognize and treat the psychological complications of abortion."

While this new study focuses on traumatic reactions to abortion, it follows on the heals of nearly a dozen other peer-reviewed studies published in the last three years linking abortion to increased risk of depression, anxiety, substance abuse, suicidal behavior.

Recent studies have also linked abortion to higher rates of death from heart disease, which investigators believe may be a long term effect of elevated rates of anxiety and depression.

Because of the increasing concern about the mental health effects of abortion on women, legislation has been introduced in Congress to expand funding for treatment programs and research in this area.

Citing: Rue VM, Coleman PK, Rue JJ, Reardon DC. Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Med Sci Monit, 2004 10(10): SR5-16.
Springfield, IL (November 16, 2004)

The article can be downloaded free of charge at

http://www.medscimonit.com/medscimonit/modules.php?name=GetPDF&pg=2&idm=4923
Excerpts below:

Induced abortion and traumatic stress: A preliminary comparison of American and Russian women
Vincent M. Rue1ABCDEFG, Priscilla K. Coleman2CDEF, James J. Rue3AEF,
David C. Reardon4CDEF
1 Institute for Pregnancy Loss, Jacksonville, FL, U.S.A.
2 Human Development and Family Studies, Bowling Green State University, Bowling Green, OH, U.S.A.
3 Sir Thomas More Clinic, Downey, CA, U.S.A.
4 Elliot Institute, Springfi eld, IL, U.S.A.
Source of support: Partial funding for this study was made possible by grants from the Trust Funds Foundation and the Alberto Vollmer Foundation.

Summary
Background: Individual and situational risk factors associated with negative postabortion psychological sequelae have been identified, but the degree of posttraumatic stress reactions and the effects of culture are largely unknown.

Material/Methods: Retrospective data were collected using the Institute for Pregnancy Loss Questionnaire (IPLQ) and the Traumatic Stress Institute’s (TSI) Belief Scale administered at health care facilities to 548 women (331 Russian and 217 American) who had experienced one or more abortions, but no other pregnancy losses.

Results: Overall, the fi ndings here indicated that American women were more negatively infl uenced by their abortion experiences than Russian women. While 65% of American women and 13.1% of Russian women experienced multiple symptoms of increased arousal, re-experiencing and avoidance associated with posttraumatic stress disorder (PTSD), 14.3% of American and 0.9% of Russian women met the full diagnostic criteria for PTSD. Russian women had signifi cantly higher scores on the TSI Belief Scale than American women, indicating more disruption of cognitive schemas. In this sample, American women were considerably more likely to have experienced childhood and adult traumatic experiences than Russian women. Predictors of positive and negative outcomes associated with abortion differed across the two cultures.

Conclusions: Posttraumatic stress reactions were fo

und to be associated with abortion. Consistent with previous research, the data here suggest abortion can increase stress and decrease coping abilities, particularly for those women who have a history of adverse childhood events and prior traumata. Study limitations preclude drawing defi nitive conclusions, but the fi ndings do suggest additional crosscultural research is warranted.

Full-text PDF: http://www.MedSciMonit.com/pub/vol_10/no_10/4923.pdf
Word count: 4645
Tables: 7
Figures: 1
References: 50

BACKGROUND
Beyond politics, increasing public health concern is focusing on the adverse emotional outcomes women can experience following abortion [1–15]. Researchers on both side of
the abortion debate agree that some women’s mental health is negatively impacted by abortion and that more investigation is warranted to better assist those women and to prevent
future harm to others. Extensive research has documented how traumatic stress can significantly alter individuals’ lives [16]. Traumatic stressors are strong predictors of PTSD. While the lifetime prevalence of PTSD has been estimated to be up to 12% of U.S. women [17], limited research has examined the role of induced abortion as a traumatic stressor.

Anxiety and depression have long been associated with induced abortion [18]. In a major review of the literature, anxiety symptoms were identifi ed as the most common adverse
postabortion response [19]. As an anxiety disorder, posttraumatic stress disorder (PTSD) can be identified with an overwhelming and life-threatening event and with an inability to process the trauma. Earlier research reported a connection between experiencing a traumatic abortion and the onset of posttraumatic stress related symptoms [20–24].

These studies were limited due to their reliance upon either case studies or small samples, with the exception of one larger
study that reported a 1% incidence of PTSD following abortion [25]. The present study focused on the degree to which induced abortion was associated with posttraumatic stress and whether or not posttraumatic responses following abortion were evident in another culture.

Women’s psychological responses to abortion are likely influenced by complex socio-cultural factors. In some nations the social environment surrounding abortion is defined by strong moral sanctions against it; whereas in other parts of the world abortion is a passively accepted medical practice.

The present study represents an exploratory comparison of abortion reactions of American and Russian women. The comparison of these two groups is especially interesting because abortion continues to be a highly charged political issue in the United States since its legalization in 1973, while there has been very little political controversy about abortion in Russia following its legalization in 1955. For many years, Russian women have used abortion as one of their principle means of birth control due to the relative scarcity of other birth control options; although more restrictive policies are emerging [26–28].

Some research has suggested that PTSD is not just limited to Euro-Americans [29]. However, assessment of PTSD symptoms may vary widely due to ethnocultural infl uences [30–32]. While there is some evidence of PTSD following abortion in the U.S. [20–24], no equivalent research has been conducted with Russian women.

Hence, the primary purpose of this research was to examine whether or not abortion was perceived as traumatic, and if so, whether or not its manifestations were equivalent to PTSD symptoms in both American and Russian women.

The secondary purposes of this research included identifying demographic and pregnancy circumstances most predictive of possible negative outcomes, as well as evaluating the extent to which negative responses could be due to cultural factors, rather than individual
characteristics in American and Russian women.

MATERIAL AND METHODS
Women who had experienced a pregnancy loss (spontaneous abortion, induced abortion, stillbirth, or adoption) were asked to participate in a study of women’s reactions to a pregnancy loss. Data were collected in 1994 at U.S. and Russian healthcare facilities (public and private hospitals, and health care clinics).

All women between the ages of 18 and 40 were surveyed on a continuous basis until 992 women with at least one pregnancy loss had been identifi ed. The sample used in the current study includes only those women who had one or more induced abortion and no miscarriages, stillbirths, or adoptions (n=548 or 55.2% of the larger sample). If multiple abortions were reported, the respondent was asked to identify and only report on the “most stressful” one. As to nationality, the sample used in the current study included 331 Russian and 217 American women.

At the time of their reported abortion experience, the mean age of the Russian women was 22.11 (SD=5.80) and for the American women, the mean age was 23.07 (SD=5.71).
The mean age at the time the women completed the questionnaire was 28.24 (SD=9.67) for the Russians and 33.86 (SD=8.85) for the American. Among Russian women, the mean number of weeks pregnant at the time of the abortion was 6.75 (SD=3.19); whereas among the American women, the mean number of weeks pregnant was 10.07 (SD=4.55).

RESULTS
Various demographic and psychosocial background variables were assessed. In this sample, as to ethnicity, most of the women from the former Soviet Union identified themselves as Russian (78.2%); in the American sample, 59.4% were white, 24.9% Hispanic, and 10.1% black.

Most Russian women worked full-time (63.4%) compared to 34.3% of the women in the American sample. In both cultures, the majority of women worked in the professional/ business sector (62% Russian v. 57.9% American). More Russian women were married (59.1%) compared to American women (49.1%), and Russian women had slightly more years of education than American women (48.9% had 16 years of education v. 42.9%). As to number of children, 52% of Russian women had none compared to 30.4% of American women.

Regarding the psychosocial variables, these data generally suggest that women in the Russian sample perceived their childhoods (8.5% Russian v. 51.6% American) and adolescence (74.2% Russian v. 36.6% American) to be happier than American women. American women were considerably more likely to report being physically or sexually abused before age 18 (42.3% American v. 11.4% Russian).

When asked about religious convictions, 63.1% of the Russian sample and 89.4% of the American sample indicated having religious beliefs. The mean rating of the importance of these beliefs was 2.49 (SD=0.73) for the Russian sample and 1.49 (SD=

0.71) for the American sample on a scale of 1 to 4, with scores closer to 1 suggesting more importance.
Table 1 contains the descriptive statistics for all the outcome measures for both the Russian and American samples.

On a 1 to 4 scale, women in both countries generally reported their abortion experiences as stressful. Overall, when compared to Russian women, American women who chose to abort were more than twice as likely to experience negative psychological effects and report PTSD symptoms of arousal, re-experience, and avoidance, particularly the latter. Russian women only scored higher than American women on the TSI scale.

DISCUSSION
Women from Russia and the U.S. were compared with respect to negative and positive outcomes after an induced abortion. Compared to Russian women, American women exhibited more negative effects, more symptoms of PTSD, and reported higher levels of stress associated with experiencing an abortion. However, the Russian women reported significantly higher rates of disruption in cognitive schemata.

No nationality differences were observed relative to positive effects. In the present study, American women were exposed to considerably more preabortion traumatic events than their Russian counterparts. The percentage of American women reporting preabortion trauma is high but roughly equivalent to an earlier study that found 40% of females reported unwanted sexual experiences prior to age 18 [40] and another which found 38% reported childhood emotional abuse [41].

Approximately half of women who experience early childhood trauma also experience PTSD at some point [42]. Other research has confirmed that childhood traumata are more likely to result in subsequent high risk-taking behaviors, including a significantly higher number of abortions [43–45].

The findings here suggest that abortion may well exacerbate prior posttraumatic stress symptoms, even if in remission. Hence, an individual’s trauma history should be fully explored in counseling prior to obtaining an abortion.

In this study, for Russian women, the least endorsed PTSD subscale was that of avoidance. This finding corroborates prior research that the PTSD subscale of avoidance is more difficult to assess in non Euro-American cultures, and that failure to diagnose PTSD is often due to lack of cultural comprehension of avoidance symptoms [29].

The TSI Belief Scale was used in this study to examine disruption
of cognitive schemata relative to basic needs impacted by trauma: self/other-safety, self/other-trust, self/other esteem,
self/other-intimacy, and self/other-control.

The higher the total score, the greater the degree of disrupted
cognitive schemata. Numerous factors may explain why Russian women scored higher on this scale than American women, e.g., repeated exposure to abortion as birth control, or a combination of that with repeated and cumulative re-experiencing of other traumata in Russian life, i.e., severe economic shortages, exposure to criminal/gang violence, enduring regimes which were totalitarian and dehumanizing,
and disintegration of family life. Comparing the overall TSI score with other known populations of impacted individuals in the U.S. may help

CONCLUSIONS
In conclusion, this study provides increased insight into the
manifold reactions of women to induced abortion while also identifying convergent predictors of adverse psychological adjustment following abortion in two diverse cultures. This study furthers our understanding of traumatic responses across cultures, and in particular, suggests that for some women, abortion is a traumatic stressor capable of causing PTSD symptoms. Finally, the results also significantly expand our knowledge of risk factors associated with negative postabortion outcomes, and therefore may help to improve preabortion screening and counseling.

REFERENCES:
1. Thorp JM, Hartman KE, Shadigian EM: Long-term physical and
psychological health consequences of induced abortion: Review of the
evidence. Ob Gyn Survey, 2002; 58: 67–69
2. Burke T, Reardon DC: Forbidden grief: the unspoken pain of
abortion
. Springfi eld (IL): Acorn Books, 2002
3. Coleman PK, Reardon DC, Rue VM, Cougle JR: State-funded
abortions vs. deliveries: A comparison of outpatient mental health claims over four years. Amer J Ortho, 2002; 72: 141–52
4. Coleman PK, Reardon DC, Rue VM, Cougle JR: A history of induced
abortion in relation to substance abuse during pregnancies carried
to term. Amer J Ob Gyn, 2002; 187: 1673–78
5. Reardon D, Ney P: Abortion and subsequent substance abuse.
Amer J Drug Alcohol Abuse, 2000; 26: 61–75
6. Reardon DC, Cougle JR: Depression and unintended pregnancy
in the National Longitudinal Survey of Youth: A cohort study. BMJ,
2002; 324: 151–52
7. Reardon DC, Cougle JR, Rue VM et al: Psychiatric admissions of
low income women following abortion and childbirth. Can Med Assoc
J,
2003; 168: 1252–56
8. Ostbye T, Wenghofer E, Woodward C et al: Health services utilization after induced abortions in Ontario: A comparison between community clinics and hospitals. Amer J Med Quality, 2001; 16: 99–106
9. Rue V, Speckhard A: Post abortion trauma: Incidence and diagnostic
considerations. Med & Mind, 1992; 6: 57–74
10. Russo N, Denious J. Violence in the lives of women having abortions. Prof Psych, 2001; 32: 142–50
11. Stotland N: Abortion: Social context, psychodynamic implications. Am J Psychiatry, 1998; 155: 964–67
Med Sci Monit, 2004; 10(10): SR5-16 Rue VM et al – Induced abortion and traumatic stress SR15 SR
12. Cougle JR, Reardon DC, Coleman PK: Depression associated with abortion and childbirth: A long term analysis of the NLSY cohort. Med Sci Monit, 2003; 9(4): CR157–CR164
13. DePuy C, Dovitch D: The healing choice. New York, Fireside, 1997
14. Ring-Cassidy E, Gentles I: Women’s health after abortion: The medical and psychological evidence. Toronto: De Veber Institute, 2002
15. Soderberg H, Janzon L, Sjoberg N: Emotional distress following induced abortion: A study of its incidence and determinants among adoptees in Malmo, Sweden. Eur J Obstetr Gyn Reprod Biol, 1998; 79: 173–78
16. Litz B, Roemer L: Post-traumatic stress disorder: An overview, Clin Psych & Psychotherapy, 1996; 3: 153–68
17. Resnick H, Kilpatrick D, Dansky B et al: Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol, 1993; 61: 984–91
18. Illsley R, Hall MH: Psychological aspects of abortion: A review of issues and needed research. Bull World Health Organ, 1976; 53: 83–106
19. Bradshaw Z, Slade P: The effects of induced abortion on emotional
experiences and relationships: A critical review of the literature. Clin
Psych Rev
, 2003; 23: 929–58
20. Bagarozzi D: Post traumatic stress disorders in women following abortion: Some considera

tions and implications for marital/couple therapy. Int J Family Marriage, 1993; 1: 51–68
21. Congleton GK, Calhoun LG: Postabortion perceptions: A comparison
of self-identifi ed distressed and non-distressed populations. Int J Soc
Psychiatry
, 1993; 39: 255–65
22. Barnard C: The long-term psychosocial effects of abortion.
Jacksonville(Florida): Institute for Pregnancy Loss, 1990
23. Hanley D, Piersma H, King D et al: Women outpatients reporting continuing post-abortion distress: A preliminary inquiry. Paper presented at the annual meeting of the International Society for Post-Traumatic Stress Studies, Los Angeles, 1992
24. Pope L, Adler N, Tschann J: Postabortion psychological adjustment: Are minors at increased risk? Unpublished paper, Exhibit 2, Affidavit of Nancy E. Adler, Ph.D. in North Florida Women’s Health and Counseling Services, Inc, et al. v. State of Florida, et al. In the Circuit Court of the Second Judicial Circuit in and for Leon County, Tallahassee, Florida, 1999
25. Major B, Cozzarelli C, Cooper ML et al: Psychological responses of women after fi rst-trimester abortion. Arch Gen Psych, 2000; 57(8): 777–84
26. Vishnevsky AG: Family, fertility and demographic dynamics in Russia: Analysis and forecast. In: DaVanzo J, editor. Russia’s demographic “crisis.” Santa Monica, CA: Rand Conference Proceedings, 1996; 1–35
27. Vikhlayeva EM, Nikolaeva E: Epidemiology of abortions in Russia. Entre Nous Cph Den, 1996; 34–35: 18
28. Parfitt T: Russia moves to curb abortion rates. Lancet, 2003; 362: 968
29. Marsella AJ, Friedman MJ, Gerrity ET, Scurfi eld RM: Ethnocultural aspects of ptsd: Some closing thoughts. In: Marsella AJ, Friedman MJ,
Gerrity ET, Scurfi eld RM, editors. Ethnocultural aspects of posttraumatic stress disorder: Issues, research and clinical applications. Washington, DC: American Psychological Association, 1996; 529–38
30. Frey C: Post traumatic stress disorder and culture. In: Yilmaz AT, Weiss MG, Riecher-Rossler A, editors. Cultural psychiatry: Euro-international perspectives. Basil, Switzerland: Karger, 2001; 103–16
31. Kleber RJ, Figley CR, Gersons BP, editors: Beyond trauma: Cultural and social dynamics. New York, Plenum, 1995
32. Resick PA: Stress and trauma. London: Psychology Press, 2001
33. Pearlman L, MacIann P: The TSI Belief Scale: Normative Data from
Four Criterion Groups. Unpublished manuscript. South Windsor, CT:
Traumatic Stress Institute, 1992
34. Pearlman LA: Psychometric review of TSI Belief Scale Revision L. In: Stamm BH, editor. Measurement of stress, trauma and adaptation.
Lutherville, Md.: Sidran Press, 1996
35. The TSI Belief Scale was recently renamed the Trauma, Attachment & Belief Scale as described at http://www.tsicaap.com/research.htm and is being made available through Western Psychological Services
36. Pearlman LA: Traumatic Stress Institute Belief Scale. Revision L.
Unpublished. Copyright Western Psychological Services, Los Angeles,
2000
37. American Psychiatric Association: Diagnostic criteria for posttraumatic stress disorder. In: Diagnostic & statistical manual of mental disorders IV. Washington, D.C.: American Psychiatric Press, 1994; 427–28
38. Janoff-Bulman R: Shattered assumptions: Towards a new psychology of trauma. New York: Free Press, 1992
39. McCann I, Pearlman L: Psychological trauma and the adult survivor:
Theory, therapy and transformation. New York: Brunner/Mazel, 1990
40. Kellogg ND, Huston RL: Unwanted sexual experiences in adolescents. Clin Ped, 1995; June: 306–12
41. Walker EA, Koss MP, Katon WJ: Medical sequelae of sexual and physical victimization of women. NASPOG Annual Meeting Abst, 1995; 5: 77–78
42. Kessler RC, Sonnega A, Bromat E et al: Post-traumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry, 1995; 52: 1048–60
43. Walker EA et al: Costs of health care utilization by women HMO members with a history of childhood abuse and neglect. Arch Gen Psychiatry, 1999; 56: 549–55
44. Walker EA, Katon WJ: Research the health effects of victimization: The next generation. Psychosom Med, 1996; 58: 16–17
45. Green BL, Schnurr PP: Trauma and physical health. Clin Qrtly Nat
Center for Post-Traumatic Stress Disorder, 2000; 9: 3–5
46. Dutton M et al: Battered women’s cognitive schemata. J Traumatic Stress, 1994; 7: 237–55
47. Jones EF, Forrest JD: Under reporting of abortion in surveys of U.S.
women: 1976 to 1988. Demography, 1992; 29: 113–26
48. Major B, Gramzow RH: Abortion as a stigma: cognitive and emotional implications of concealment. J Person Soc Psychol, 1999; 77(4): 735–45
49. Miller WB: An empirical study of the psychological antecedents and
consequences of induced abortion. J Soc Iss, 1992; 48: 67–93
50. Miller WB, Pasta DJ, Dean CL: Testing a model of the psychological consequences of abortion. In: Beckman LJ, Harvey SM, editors. The new civil war: The psychology, culture, and politics of abortion. Washington: American Psychological Association, 1998

Special Report Med Sci Monit, 2004; 10(10): SR5-16;  PMID: 15448616

Acknowledgements
The authors gratefully acknowledge the generous assistance
of Suzi Tellefsen, Susan Stanford-Rue, Ph.D, Frida Rotlewicz,
Ph.D, Anne Speckhard, Ph.D, B. Hudnall Stamm, Ph.D, Cui
Xinja, M.D, Teri Reisser, M.A, Paul Reisser, M.D, Svetlana
Sysoeva, M.D, Nina Kirbasowa, M.D, Michael Mannion, S.T.D,
Kerry Cielinski, Ph.D, Eugenia Riordan Mule, Alexander
Rodriguez, Nancy Austin & Elizabeth Blake.