Pre-Personality Pregnancy Losses: Miscarriages, Stillbirths, and Abortions

Jack P Carter. Handbook of Death and Dying. Editor: Clifton D Bryant. Volume 1. Thousand Oaks, CA: Sage Reference, 2003.

Researchers examining the psychological effects of miscarriages, stillbirths, and abortions on parents often consider the impacts of miscarriages and stillbirths in the same studies, and many include neonatal deaths as well. Induced abortions are almost always treated independently in research, in recognition of the basic differences between abortion and the other two types of pregnancy loss. The research literature generally assumes some degree of distress or grief following miscarriages and stillbirths because of the involuntary and unexpected nature of these types of embryonic or fetal demise, sometimes severe enough to represent serious psychological pathologies. Induced abortions, on the other hand, are voluntary pregnancy terminations, and thus may result in different sorts of psychological responses. Although researchers have examined guilt, anxiety, stress, and depression as possible consequences of all three forms of pregnancy termination, most of them expect to find greater similarity of psychological responses among parents who have experienced miscarriage and stillbirth compared with those who have experienced abortion.

Noninduced Pregnancy Loss

Length of Gestation

In the research literature on psychological reactions to miscarriage and stillbirth, authors generally agree that a spontaneous pregnancy loss within 20 weeks of gestation is termed a miscarriage, and one after 20 weeks is a stillbirth. Once a live birth has occurred, death within the first 28 days is termed a neonatal death, and death from an unidentifiable cause within the first year is said to result from sudden infant death syndrome (SIDS). Some studies have focused solely on the impacts of miscarriages or stillbirths, some have combined the two, and others have examined various combinations of miscarriages, stillbirths, neonatal deaths, and SIDS deaths. Some scholars have analyzed the reactions of individuals who have experienced different types of pre- and postbirth losses, without attempting to determine the differences in the impacts of the various types. The presence of overlapping foci in this research is justified by the fact that researchers who have examined the independent effects of these various forms of pregnancy loss/infant death have found a high degree of similarity in the effects on the parents involved. In studies of parents’ responses to miscarriage and in studies comparing the impacts of miscarriages and stillbirths, researchers have found that the intensity of response is unrelated to the length of gestation at the time of loss, because significant parental bonding occurs during the early stages of pregnancy (Prettyman, Cordle, and Cook 1993; Jackman, McGee, and Turner 1991; Thomas and Striegel 1994-95; Lasker and Toedter 1991). Peppers and Knapp (1980), for example, found no differences in the patterns and intensity of grief among parents who had experienced miscarriage, stillbirth, and neonatal death. Murray and Callan (1988) found no significant differences in depression and selfesteem between parents who had experienced stillbirths and those who had experienced neonatal deaths, although those who experienced stillbirths were somewhat better off psychologically. In a study of 220 bereaved families, Vance et al. (1995) discovered differences only in the degree of negative response to stillbirth, neonatal death, and SIDS. They found that, compared with the mothers in 226 control families, the bereaved mothers had significantly higher relative risk for anxiety for all three types of losses after 2 months and 8 months, and significantly higher relative risk for depression for all three after 2 months and for neonatal death and SIDS after 8 months. At 8 months, the depressive symptoms for stillbirth were still higher for the bereaved mothers than for controls, but the difference was not statistically significant.

The findings of studies such as those just cited make it seem reasonable for researchers to emphasize the similarities among different types of pregnancy losses and to examine their effects individually or together. However, some scholars assert that the temporal factor actually has a significant effect on parents’ levels of psychological distress. For example, Goldbach et al. (1991) compared parents’ reactions to miscarriages and perinatal deaths and found that grief was more intense following the later losses. These authors posit that researchers who have found length of gestation to have negligible effects have mostly used retrospective designs, interviewing mothers to determine their levels of grief months, or even years, after their losses. Goldbach et al. suggest that their contradictory findings are due to methodological differences between their study and earlier studies, such as their use of the Perinatal Grief Scale, an 84-item Likert-type scale, to measure levels of grief and their practice of interviewing both father and mother soon after the parents’ loss. Although Neugebauer et al. (1992) found equal levels of depression in women who had experienced early and late miscarriages, they further found, because they knew the psychological histories of their respondents, that the women who had late losses exhibited greater increases in symptoms of depression than did those with early losses.

Psychological Impact

Until around 1970, almost no research had examined the psychological impacts of early pregnancy loss because investigators generally assumed that parents experience little serious sense of loss following miscarriage. Since that time, studies of the impacts of miscarriage on parents have typically found miscarriage to be a traumatic event that causes some degree of psychological or emotional distress. It is now well established that postmiscarriage grief can be severe, and that parents’ bereavement reactions are often as intense as those following the death of a loved one of any age (Lasker and Toedter 1991; Peppers and Knapp 1980).

Researchers in this area make the distinction between normal and pathological grief that has been accepted for decades in the literature on mourning in general. Normal grief, which is also referred to as acute or typical grief, is a syndrome that is characterized by a particular set of psychological and physiological symptoms. These symptoms begin at the time of the loss and remain in effect for some period of time. The bereaved passes through a series of stages, the last of which involves resolution and recovery. There is some disagreement among scholars in this area regarding the time frame for completion of acute grief, with estimates ranging from 2 months or less to a year or more, but all agree that it does end. Early symptoms of the typical grief reaction include somatic distress, such as reduced strength, digestive problems, shortness of breath, trouble sleeping, difficulty swallowing, feelings of emptiness, and a tendency to sigh frequently. The ensuing stages are characterized by psychological reactions that include guilt, anger, helplessness, anxiety and stress, and depressive symptoms (Lindeman 1944).

Pathological grief, also known as morbid grief reaction, is a distortion or postponement of acute grief. One form of pathological grief—chronic or prolonged grief—is bereavement of unlimited duration that often involves the same phases as acute grieving, but at intensified levels, and highly exaggerated psychological symptoms. Excessive and ongoing forms of these symptoms militate against the achievement of acceptance and resolution. Another type of pathological grief is delayed grief, which is exhibited by people who do not appear to feel grief following a loss. Delayed grief is characterized as pathological because, in most cases, after a relatively short period of time, it is followed by chronic grief. In addition, symptoms of “distorted grief”—such as hyperactivity, alienation, hostility, or severe depression in the absence of a sense of loss—that occur during the nonreactive period are viewed as pathological (Lindeman 1944).

Some researchers who have studied parents’ severe grief following miscarriages have focused on pathological grief as a whole, whereas others have examined chronic and delayed grief independently. Researchers have found that morbid grief reactions following early pregnancy loss can cause indefinite and negative changes in relationships with close family members and friends, unwillingness or inability to resume normal activities, increased abuse of alcohol and drugs, and other negative psychosocial consequences (Corney and Horton 1974; Raphael 1977). Lasker and Toedter (1991) conducted a 5-year longitudinal study (one of the few such studies undertaken to date) to examine both chronic and delayed grief following pregnancy loss or infant death. They found higher rates of both types of pathological grief among parents who had suffered miscarriages compared with parents who had experienced stillbirths or neonatal deaths, although rates for both were still significant after perinatal loses. Lasker and Toedter attribute this finding to the relative lack of support accorded parents who suffer early pregnancy losses.

Some studies have examined different dimensions of miscarriage-related grief independently or in various combinations. Several researchers have found guilt to be a part of the typical grieving experience of parents following a miscarriage. Parents in mourning after miscarriage often blame themselves for the loss, believing that they failed to care for and protect the fetus adequately, that their ambivalence about the pregnancy perhaps subconsciously contributed to spontaneous termination, or that the loss is some sort of retribution for their lifestyle, habits, or ambitions. Most scholars agree that unresolved guilt can predominate and complicate the normal process of grieving (Dunn et al. 1991; Leppert and Pahlka 1984; Stack 1984).

It is common for early pregnancy loss to produce anger in parents. Women often direct such anger at themselves, feeling that they are responsible because their bodies’ perceived betrayal has resulted in tragedy. The anger following miscarriage may be more intense than that following stillbirth or neonatal death (Stirtzinger and Robinson 1989; Toedter, Lasker, and Alhadeff 1988). Normal grieving after a miscarriage can also include anger directed at physicians and other medical personnel for a number of reasons. Many women who have miscarried feel that health care professionals were insensitive, treating them in an uncompassionate and routine fashion, refusing to acknowledge the symbolic importance attached to the removal of nonviable tissue, and “abandoning” them by releasing them from the hospital soon after treatment. Indeed, researchers have found that physicians tend to avoid women who have suffered miscarriages and to overprescribe mood elevators for them (Stirtzinger and Robinson 1989; Peppers and Knapp 1980; Wall-hass 1985).

Studies that have focused on postmiscarriage anxiety and stress have consistently revealed elevated levels of these dimensions of grief in parents (Day and Hooks 1987; Prettyman et al. 1993; Johnson and Puddifoot 1996). The criteria for acute stress disorder (ASD) are intense negative emotions that include dissociative symptoms and reliving the trauma for up to 4 weeks. Posttraumatic stress disorder (PTSD) is characterized by the continuation of these symptoms after a month. Citing what they see as similarities between grief-related behaviors in response to miscarriage and ASD and PTSD, Bowles et al. (2000) suggest that more research should examine the relationship between miscarriage and these serious syndromes, which can impair sufferers’ psychological and general functioning. Based on their analysis of anecdotal evidence, Bowles et al. assert that up to 10% of women may experience ASD within 4 weeks of having a miscarriage, and up to 1% exhibit the symptoms of PTSD a month afterward.

Numerous studies have found that depressive symptoms increase significantly following miscarriages, and many researchers have concluded that this psychological impact poses the most serious public health concern relative to other manifestations of grief after early pregnancy loses. In some North American studies, women have been found to exhibit significantly elevated depression levels shortly after miscarriage and significantly reduced but still pathological levels after 6 months (Neugebauer et al. 1992, 1997; Robinson et al. 1994). Neugebauer et al. (1992, 1997) have conducted studies utilizing research designs that employed women who had not experienced recent reproductive losses as comparison groups, in order to establish the “relative risk” of depression. They found that the depression scores of miscarrying mothers in their sample were three and one-half to four times those of mothers in the control groups after 2 weeks and two and one-half to three times higher after intervals of 6 weeks and 6 months.

Some British studies, however, have questioned the significance of depressive responses relative to anxiety (Prettyman et al. 1993; Thaper and Thaper 1992). In a longitudinal study using standardized measures, Prettyman et al. (1993) found pathological anxiety in 41% of respondents 1 week after miscarriage and in 32% at 12 weeks. By contrast, they found rates of clinical depression to be 22% at week 1, dropping to levels comparable to those in the general population by week 6.

Research addressing the intensity and nature of grief following stillbirth has drawn the same distinctions noted above between normal (acute or typical) and pathological grief, which includes chronic and delayed grief. These studies have typically included respondents who have experienced stillbirths and others who have suffered other types of pregnancy loss, such as miscarriage, neonatal death, and, in some cases, SIDS. Whereas the above-cited research on the psychological impacts of miscarriage included only samples of parents who had suffered early pregnancy losses, in this section I also examine studies in which the respondents had experienced these various types of losses, as long as a significant number of study participants had experienced stillbirths. Ample empirical evidence, as cited above, indicates that parents’ psychological reactions to stillbirths and losses involving neonates and infants are similar.

Research conducted in several countries has produced relatively consistent results regarding chronic grief as a reaction to stillbirth. Studies conducted in the United States, Great Britain, Australia, and Canada have found that 20-50% of parents exhibit symptoms of grief within a year of a perinatal loss, with the proportion falling to between 10% and 30% after a year (Lasker and Toedter 1991; Forrest, Standish, and Baum 1982; LaRoche et al. 1984; Nicol et al. 1986). In a Swedish study that specifically examined grief following stillbirth, Laurell-Borulf (1982) found chronic grief in 31% of respondents 12 to 14 years following the loss. Far fewer studies have focused on delayed grief following stillbirth, but Lasker and Toedter (1991) did find a rate of delayed grief of more than 13% among parents who had experienced perinatal death.

Following up on Lasker and Toedter’s (1991) study, Lin and Lasker (1996) conducted research to examine the proposition that the conventional categories of grief (acute, chronic, and delayed) are inadequate to capture the complexity of the grieving process following perinatal loss. After examining their respondents at the time of the loss as well as 1 year and 2 years afterward, they questioned whether the “normal grieving pattern”—of temporarily high levels of grief following the loss that eventually give way to low levels—is typical at all. They found several bereavement patterns among their respondents that were not consistent with the conventional concept of pathological grief. For example, some respondents who exhibited “chronic grief” at 1 year appeared to recover by the second year, some showed little or no initial grief and never developed chronic grief, and some exhibited levels of grief that worsened significantly between the first and second years. The validity of Lin and Lasker’s conclusions is supported by the fact that they are based on an analysis of the data from Lasker and Toedter’s (1991) earlier study, which were collected from 138 women and 56 of their partners over a 5-year period. Furthermore, Janssen, Cuisinier, and Hoogduin (1996) assert that there is practically no consistency across studies in the operationalization of the various types of grief. Similarly, DeFrain (1991) asserts that it is best for family therapists not to try to differentiate between acute and pathological grief in their patients after perinatal death because the distinction is usually blurred, because acute grief sufferers often have irrational thoughts (sometimes including thoughts of suicide), and because all forms of grief stemming from pregnancy loss constitute serious crises that must be addressed.

Parents often experience guilt following perinatal loss. DeFrain (1991) cautions family therapists to be aware of and sensitive to this common and irrational guilt while counseling the bereaved. Forrest et al. (1982) found that many mothers who have had stillbirths and perinatal losses blame themselves for their inability to keep the fetus alive.

Research has also revealed that parents experience elevated levels of anxiety and stress as a result of stillbirth and perinatal loss. Vance et al. (1995) tracked changes in the independent effects of stillbirth, neonatal death, and SIDS on levels of anxiety and depression in parents at intervals of 2 and 8 months after the loss. They found significant differences between mothers who had stillbirths and mothers in comparison groups, with mothers who had experienced losses being five times more likely to exhibit severe anxiety at 2 months and three times more likely at 8 months. They also found significantly higher levels of anxiety for fathers at 2 and 8 months after stillbirth. Similarly, in an Australian study, Boyle et al. (1996) found that 33% of mothers who had perinatal losses were anxious after 2 months, 15% were anxious after 15 months, and 14% were anxious after 30 months—a proportion that was still twice that found in control groups. Studies focusing on stress as a bereavement response have consistently found dramatic elevation of stress following perinatal loss (Leon 1986; Stack 1982). Dyregrov and Matthiesen (1987) equate the psychological impact of perinatal death to the symptoms of PTSD, described above.

Parents often exhibit depressive symptoms following stillbirth or perinatal loss. Vance et al. (1995) found that, following a stillbirth, mothers in their sample were almost seven times more likely to be depressed after 2 months compared with mothers in a control group, and about two and one-half times more likely after 8 months. They also found lower but significant levels in the fathers in their sample at 2 and 8 months after the loss. Other researchers who have examined depression following perinatal death have noted similar patterns, such as Murray and Callan (1988) and Boyle et al. (1996), who found significant reductions in depression over time, but still at a level three times higher than that found in comparison groups after 30 months.

Other Pregnancy/Fertility-Related Factors

Researchers have examined variables related to couples’ pregnancy and reproductive histories other than the length of gestation to determine if any of these may be related to level of distress following miscarriage. Some have focused on whether the pregnancy was planned or unplanned as an indicator of attitude toward the pregnancy (i.e., whether it was wanted or unwanted) and have found that early loss of an unplanned pregnancy generated higher levels of distress. In their discussions of their findings, these researchers have cast doubt on the assumption that all unplanned pregnancies are unwanted and have speculated that ambivalence toward a pregnancy may result in guilt-driven distress when a loss occurs (Prettyman et al. 1993; Thaper and Thaper 1992). In contrast, Neugebauer et al. (1992, 1997) found this factor to have no significant effect on the severity of parents’ reaction to a loss. However, in these later studies, unlike those cited above, the investigators had data on respondents’ attitudes toward their pregnancies as well as their psychological histories, and they also utilized comparison groups. Thus, although they did find that women who had lost pregnancies were equally distressed whether the pregnancies were wanted or unwanted, their more detailed findings revealed that symptom levels after the loss of an unwanted pregnancy did not increase compared with those of a control group, because these women were already highly distressed before the loss. Therefore, the apparent inconsistency in these findings may be due to the difference in their independent variables. Indeed, Prettyman et al. (1993) note that they would like to have known how many of the unplanned pregnancies in their sample were unwanted as well as the nature of their respondents’ preloss psychological states.

Neugebauer et al. (1992, 1997) and Jackman et al. (1991) are among the majority of researchers who have found no apparent effect of previous miscarriage on distress, although some have found that elevated symptom levels resulted (Friedman and Gath 1989; Thaper and Thaper 1992). Among the small number of investigators who have examined this variable, some have claimed that previous infecundity has a significant impact on postmiscarriage psychological impact (e.g., Slade 1994), whereas others have found no effect (e.g., Friedman and Gath 1989).

Very few researchers have investigated the impacts of attitude toward the pregnancy and previous infecundity on psychological responses to stillbirths and neonatal deaths. Regarding the former, Kennell, Slyler, and Klaus (1970) and Benfield, Leib, and Vollman (1978) found that positive feelings toward the pregnancy caused more intense grief for one or both parents. Murray and Callan (1988) found previous infecundity to be associated with more intense reactions. Some researchers who have studied the effects of previous stillbirths or losses of neonates have found significant effects on levels of responses (Lasker and Toedter 1991; Peppers and Knapp 1980; Lin and Lasker 1996), whereas others have reported finding no impacts (Benfield et al. 1978; Nicol et al. 1986).

Demographic Variables

In the postmiscarriage grief research, the gender of parents has received relatively little attention, because researchers have generally assumed that male partners are much less affected than women. Indeed, some researchers, such as Leppert and Pahlka (1984) and Stirtzinger and Robinson (1989), have concluded that men’s grief after miscarriage is less intense than that of their partners. However, Johnson and Puddifoot (1996; Puddifoot and Johnson 1997) suggest that fathers’ levels of grief and stress are similar to those of mothers. They convincingly support their assertion that qualitative research incorporating personal semistructured interviews can reveal men’s true feelings about miscarriage. They conclude that men often fail to acknowledge these psychological responses because of normative assumptions that the father is less emotionally attached to the fetus than is the mother as well as social expectations that define the man’s appropriate primary role as being supportive of his distraught partner.

A number of studies have consistently found that age, socioeconomic status, and marital status have negligible impacts on levels of distress following miscarriage (Prettyman et al. 1993; Neugebauer et al. 1992, 1997; Toedter et al. 1988; Thaper and Thaper 1992). Some studies have produced contradictory findings regarding the effect of number of living children on intensity of response to miscarriage: Prettyman et al. (1993) found no effect of childlessness, whereas Toedter et al. (1988) and Neugebauer et al. (1992, 1997) report that parity is a significant factor (the latter finding, however, was produced by studies with relatively robust designs). Prettyman et al. (1993) studied responses to miscarriage after 1, 6, and 12 weeks, with no comparison group, and their sample size had shrunk from an initial 65 to 50 by the time the final questionnaire was administered. In their 1992 and 1997 studies, Neugebauer et al. interviewed 232 and 229 women, respectively, who had miscarried, and somewhat larger numbers in comparison groups of women who had not experienced recent pregnancy losses. The researchers were thus able to study the effects of parity on postmiscarriage distress after 2 weeks and 6 months, and to report authoritatively not only the finding that a strong negative relationship existed, but also more detailed findings, such as that the percentage of childless miscarrying women with severe symptoms was 11 times that of women in the childless comparison group and that miscarrying women with several children exhibited distress levels similar to those of comparison group women with children.

Researchers who have investigated reactions to stillbirth and perinatal loss agree that both mothers and fathers grieve. Most have found that women’s grief is more intense or lasts longer because of the physical attachment to the fetus, and that men grieve less or differently due to their being socialized to avoid open expression of intense emotion and to play a supportive role in the grieving process (Murray and Callan 1988; Benfield et al. 1978; LaRoche et al. 1984; Vance et al. 1995). DeFrain (1991) asserts, however, that fathers and grandfathers suffer as much as their female counterparts; they simply express their grief less openly. It seems reasonable that DeFrain’s qualitative study, conducted from a family therapy perspective, might well have uncovered repressed male grief. Furthermore, Vance et al. (1995) caution that their findings might reflect men’s greater tendency to internalize grief and to express it differently than women do; this does not necessarily mean that men’s grief is any less intense than women’s.

Researchers have consistently concluded that neither parents’ age nor their socioeconomic status has any significant effect on the level of grief following stillbirth (LaRoche et al. 1984; Lasker and Toedter 1991; Nicol et al. 1986; Benfield et al. 1978). Lasker and Toedter (1991) found that distress after late pregnancy loss was lessened by the presence of living children, whereas other researchers have reported no significant effect of this variable or the opposite impact (e.g., LaRoche et al. 1984; Laurell-Borulf 1982).

Previous Emotional/Mental Distress

Apparently, a history of emotional or mental problems significantly increases the probability of a morbid grief reaction following miscarriage. Friedman and Gath (1989) found that women who required psychiatric treatment after early pregnancy losses had high scores on measures of emotional “neuroticism.” They also found that a documented history of previous depression or other personality disorder was strongly associated with pathological bereavement. Both of these findings have been corroborated by other studies (Prettyman et al. 1993; Neugebauer et al. 1997; Hall, Beresford, and Quinones 1987).

Similar findings have been reported regarding grief after perinatal loss and depression before the pregnancy. Lasker and Toedter (1991) found prior depression to be one of the strongest predictors of chronic grief, with respondents who exhibited depressive symptoms before their pregnancies experiencing the most intense grief after 2 years.

Level of Support

There is general agreement among researchers that levels of social support of all kinds are relatively low for miscarriage sufferers compared with those who mourn other types of losses. Day and Hooks (1987) and Forrest et al. (1982) have demonstrated the need for such support. Stirtzinger and Robinson (1989) assert that support in the form of rituals, a normatively prescribed period of mourning, and any other recognition of the loss represented by miscarriage is virtually nonexistent. There is no body, and thus no funeral or mementos for the parents, and prevailing social standards may constrain them from telling even family and friends about the loss of a pregnancy of which only they may have been aware (Leppert and Pahlka 1984; Hall et al. 1987; Robinson et al. 1994). Furthermore, respondents in many studies have reported that when they sought support after miscarriage from family, friends, and health care professionals, they consistently received responses that were insensitive, evasive, or unhelpful, even though a lack of support is clearly a risk factor for psychological morbidity (Day and Hooks 1987; Stack 1984; Stirtzinger and Robinson 1989).

There is some evidence to indicate that in recent years our collective consciousness has been raised regarding the importance of support of all kinds for lessening the intensity and duration of parents’ grief following stillbirth or neonatal death. For some time, researchers have documented the emergence of a new cultural ethos that emphasizes the invalidity of the old belief that treating a late pregnancy loss as an inconsequential and unimportant event will lessen the mother’s distress. Some hospital neonatal units have developed programs that include perinatal loss counselors and policies that research indicates should provide positive forms of support for the bereaved. These policies include the recommendation that physicians interact compassionately and at length with parents in such cases. In addition, the policies recommend that staff encourage the parents of a deceased infant to hold their baby, to keep photos and other mementos, to arrange for a funeral or other disposition of the remains, and to join support groups (Pauw 1991; Murray and Callan 1988; Nicol et al. 1986). Research evidence has led family therapists to recognize the importance of strong spousal and family support, and support groups, for the recovery of parents following a pregnancy loss (Thomas and Striegel, 1994-95; Nicol et al. 1986; Rowe et al. 1978; Day and Hooks 1987; DeFrain 1991). The Australian government has initiated similar policies, including the creation of a “rural pregnancy loss team” that flies to remote parts of the country to assist grieving parents after perinatal loss in all of the ways noted above, including setting up local support groups (Knowles 1994).

Induced Abortion

Psychological Impact

Although debates arise concerning the public policy implications of many different kinds of research findings, few areas of inquiry are as openly controversial and politicized as that of the psychological impact of the intentional termination of pregnancy. Even within the body of research reported in established scientific journals, distinctly political references to sociopolitical movements that seek to restrict or expand women’s access to legal, medically safe abortions are common, as is the questioning of other researchers’ methodology (which some view as the healthy functioning of the organized skepticism that allows us to have confidence in scientifically generated knowledge). The literature reveals widely divergent findings regarding the severity and frequency of serious psychological distress after induced abortion.

Most recent research into the psychological impact of abortion employing large samples, pre- and posttests, standardized measures, longitudinal designs, and comparison groups has found that a majority of women who have had abortions do not regret having done so or experience severe psychological problems. For example, Major et al. (2000) assessed levels of distress preabortion and postabortion, at 1 hour, 1 month, and 2 years, in a sample of 882 women, 442 of whom remained in the sample for the full 2 years. They found that rates of depression among these women were comparable to those in the general population, and most respondents reported that they were satisfied with their decisions to abort and had few regrets. Russo and Zierk (1992) followed 5,295 women for 8 years after they had abortions and concluded that opting for an abortion increased the respondents’ selfesteem and improved their well-being. Russo and Zierk’s study is also one of a number that have found that women who terminated pregnancies were no more negatively affected psychologically than women who bore and raised their babies (Zabin, Hirsch, and Emerson 1989; Lydon et al. 1996). After reviewing 225 articles, Dagg (1991) concluded that a minority of women who abort are adversely affected, whereas most women who seek but are denied abortions have lengthy psychological difficulties, and their children often have serious problems until, and sometimes well into, adulthood. Dagg notes that most studies have found that a large majority of women experience positive responses following abortions; for example, Lazarus (1985) found that 17% of respondents in one study experienced guilt, whereas 76% felt relief and happiness.

Some authors, however, claim that severe, long-term mental pathological disorders often result from the decision to abort. Speckhard and Rue (1992) assert that experiencing an elective abortion can cause PTSD, and that, in this context, it should be called “postabortion syndrome” (PAS). They cite several publications to support their position (e.g., Barnard 1990; Vaughn 1991; Rue 1985; Speckhard 1987) and attack studies that have found minimal negative effects as being ideologically driven and methodologically flawed. A forceful response to Speckhard and Rue’s 1992 article was forthcoming and understandable, given the fairly strong consensus that has developed regarding this area of inquiry. In an article published in the Journal of the American Medical Association that same year, Stotland (1992) reviewed the relevant literature and asserted that PAS is a “myth” based on anecdotal evidence and a small number of studies reported in religious and nonspecialty publications. In another 1992 literature review, Wilmoth, de Alteriis, and Bussell, although at least somewhat critical of all the research in this area, characterized the “pro-choice” studies as more methodologically robust, by far, than those of PAS advocates, who typically have studied only women who have complained of serious problems long after their abortions. In a study that followed 5,300 women for 8 years, Russo and Dabul (1997) found that abortion did not cause longlasting severe trauma. Major et al. (2000) similarly found that the rate of PTSD 2 years after an abortion was 1%, compared with 48.5% and 46% for rape and child abuse victims, respectively, and 10.5% for the general population.

Pregnancy/Fertility-Related Variables

Contradictory findings and professional disagreements aside, there is almost total agreement among researchers that some women do experience pathological psychological sequelae following abortion, and that it is important to identify the potential risk factors for such an outcome. Not surprisingly, the woman’s attitude toward the pregnancy—that is, whether she felt any commitment to it or was ambivalent about the decision to abort—has been found to be related to negative reactions (Lydon et al. 1996; Miller 1992). Other studies have shown that women who assign blame for their pregnancies, either to themselves or to their partners, are at greater risk of postabortion distress (Mueller and Major 1989; Major and Cozzarelli 1992). Most abortions are performed during the first trimester, but some are performed later, and several studies have found that second-trimester abortions, including those done because of fetal anomalies, cause relatively high rates of severe psychological reaction (Stotland 1992). Researchers who conducted a study in the Netherlands similarly found that advanced gestational age produced extreme grief as opposed to the generally positive responses to most abortions (Hunfeld, Wladimiroff, and Passchier 1994).

Demographic Variables

Within the extensive research literature on abortion, there is a noticeable dearth of studies investigating the impacts on the men involved (Major and Cozzarelli 1992). U.S. researchers who have examined gender issues related to abortion have typically pointed out that women are the final authority in the abortion decision and that men sometimes suffer psychological distress but tend not to express or acknowledge that distress; in addition, researchers usually study only men who complain of distress (Rue 1985; Coyle and Enright 1997). In a Swedish study, Kero et al. (1999) found that their 75 male respondents had wanted their partners to abort, but a majority experienced contradictory feelings after the abortion, such as relief, release, anxiety, grief, guilt, and anguish. Johansson et al. (1998) report that in Vietnam, men are recognized as being the family decision makers, and, although some consider abortion to be immoral, they prioritize their responsibility to control family size.

Because most of the subjects in studies on abortion are relatively young women, researchers often do not consider age as a variable, but Major et al. (2000) did find that younger women in their sample had the most negative feelings about abortion. Various dimensions of socioeconomic status, such as employment status, educational attainment, and income, have been shown to be positively related to well-being and self-esteem following an abortion, and the number of children a woman has is positively associated with the probability of postabortion distress (Russo and Dabul 1997; Russo and Zierk 1992; Major et al. 2000).

Researchers who have examined the effects of religion on adjustment after an abortion have found that high religiosity and affiliation with a conservative or fundamentalist religion are clearly risk factors for psychological problems and regret (Miller 1992; Congleton and Calhoun 1993). Russo and Dabul (1997) found somewhat higher levels of distress in practicing Catholic women, but they attribute this finding to lower preabortion self-esteem in these particular women, rather than to religion.

Personal History and Characteristics

One of the issues researchers have addressed is the question of whether the severe psychological symptoms exhibited by some women after abortion are the result of the abortion per se, the result of preexisting psychological conditions, or products of the life satisfaction or general coping capabilities the women exhibited before pregnancy. Those who conduct such studies assert that pre- and posttest designs are essential for determining the possible risk factors for negative postabortion reactions. Major et al. (2000) found that women who were depressed or who expressed regret 2 years after their abortions typically had histories of depression before they became pregnant. Russo and Dabul (1997), who, as noted above, followed 5,300 women for 8 years after their abortions, found that the most powerful indicators of postabortion emotional/mental health were psychological history and level of self-esteem before the pregnancy. Mueller and Major (1989) note that a history of depression was common for postabortion depressive women in their sample. They also found that a woman’s level of coping self-efficacy—that is, her degree of selfconfidence in her ability to cope with adjusting to new experiences—was a significant determinant of her psychological well-being. In their review of a large number of studies addressing these issues, Major and Cozzarelli (1992) found widespread empirical support for the claim that much of the distress some women experience after abortion is not a direct consequence of the procedure. Russo and Denious (2001) note that in addition to prepregnancy mental health and personal coping capabilities, researchers should pay attention to the impacts of women’s life histories on their responses to abortion. In their sample, a significant number of postabortion depressive respondents had life histories that included rape, sexual abuse, battery, and other circumstances that led to preexisting depression and low life satisfaction. Russo and Denious also point to the possible counterproductive effects on counseling practices and public policy of misattributing such women’s psychological problems to their having had abortions.

Level of Support

The importance of social, professional, and societal support for women deciding to abort is noted in most of the relevant research literature. Miller (1992) found that independent women who did not feel the need to have the approval of family members, partners, or friends but had mutually supportive relationships with stable partners were least likely to experience postabortion distress. Major and Cozzarelli (1992) report that the studies they reviewed showed the woman’s partner to be the source of social support that most significantly affected her adjustment; support from parents and friends was less important.

Professional counseling and therapy have been found to be effective in averting long-term problems for women who experience distress after abortion. Congleton and Calhoun (1993) found that counseling that included recognition of the abortion as a loss for which grieving was appropriate and encouraged the establishment of support groups to facilitate communication among similarly distressed women reduced the intensity and duration of symptoms. These authors also point out that some well-intentioned counseling approaches that prescribe selfforgiveness to relieve guilt or remorse may engender those responses rather then dispel them. They base this assertion on research findings that have shown that retrospectively altering a woman’s view of her abortion in this manner can result in her perceiving it as an act for which she should feel guilty. Similarly, Russo and Denious (2001) assert that therapy based on enabling women with postabortion problems to reappraise the event is often beneficial; however, counseling that uses the same approach but encourages women to reconceptualize their abortion experiences in ways that portray them as victims (e.g., as having been duped or misinformed by abortion providers) can cause psychological harm. Counselors who take such an approach may be harming their clients unintentionally, or they may be interested in creating martyrs and spokespersons for the anti-choice movement.

Most socialized adults desire society’s approval or support for their actions, at least implicitly. The abortion decision represents a dilemma for Americans, because U.S. society is conflicted regarding this issue. Abortion is legal, and thus “normative.” Since 1973, there have been an average of 1.5 million abortions a year in the United States (Dagg 1991). Approximately 20% of American women of reproductive age have had abortions (Russo and Denious 2001; Major and Cozzarelli 1992), yet, still, relatively widely held moral sanctions persist against abortion, even among some who support its legal status. One result of these conflicts is the lack of recognition that a loss has occurred; another is the common practice of not discussing it. In fact, one of the reasons partner support is especially important for women’s postabortion well-being is that usually the partner is told about the abortion; in comparison, women tell much smaller proportions of their friends or parents, and practically nobody else. One reason women typically keep their decisions to abort secret is their knowledge that they may encounter active opposition or criticism from normal sources of support, or even from strangers. Some studies have shown that these nonsupportive reactions create a higher risk of postabortion distress than no support at all (Major and Cozzarelli 1992). Women who are confronted and harassed by protesters when they arrive at and leave abortion clinics report feeling intense nonsupportive social condemnation, and they are more likely than other women to experience severe psychological problems (Russo and Denious 2001).

Although the principal sources of support in America for women who have had abortions appear to be the women’s spouses/partners, there is some societal support from the judicial/criminal justice system and an ongoing high-profile public debate that serves to remind American women that a majority of their fellow citizens support their right to legal abortions. International comparisons show that the United States falls in the middle of a continuum regarding societal support for those who chose to abort. For example, in Ireland, abortion is illegal and socially unacceptable, whereas in Japan abortion has long been legal and accepted, and rituals exist to help resolve parents’ postabortion distress. Fletcher (1995) describes the frustration of Irish pro-choice activists who cannot persuade women who have had abortions to speak out publicly because of their society’s strong social/normative prohibitions, which make them reluctant to confide in anyone regarding their decision. The activists assert that as long as women remain silent, anti-choice factions are free to claim that there is no demand for abortion and therefore no need to amend the constitution to allow them. In Japan, abortion is a common form of birth control, and because of the tradition of remaining in contact with dead ancestors in this Buddhist-based culture, parents ritually maintain bonds with their aborted fetuses. The ritual, mizuko kuyo, which involves small statues representing the spirits of aborted fetuses, ensures that the “dead children” will be cared for in the afterlife and thus helps to resolve parents’ grief (Klass and Heath 1996-97).

Discussion

Due largely to differences in methodology and research design, the literature reveals differential findings regarding the effects of specific variables on levels of distress following both miscarriages and stillbirths and differing conclusions with respect to the generally accepted ways of categorizing these psychological responses. There is, however, almost total agreement that parents typically experience some degree of grief following these types of pregnancy losses and that, in some cases, the distress is long-term and pathological. There are striking differences between these findings and those from research on the psychological impact of induced abortion. Most of the latter studies have found that a majority of women who elect to terminate pregnancies do not experience negative psychological impacts; that stress caused by an unwanted pregnancy is often alleviated by an abortion; that many who have experienced abortion report positive impacts, such as relief, happiness, and heightened self-esteem and well-being; and that in the minority of cases in which extreme, long-term postabortion distress occurs, the distress is often not attributable to the abortion per se.

Some research indicates that certain variables have similar effects on the psychological impacts of all three types of losses, the most striking being the significant effect of a history of psychological problems on postloss adjustment and the importance of support for helping individuals to avoid severe distress and for assisting those who experience extreme grief reactions. There is widespread agreement that at least some parents exhibit the symptoms of serious negative psychological reactions to all three types of loss, whatever the facilitating factors; for those people, the availability of all forms of support is essential for the resolution of their distress. Much of the literature emphasizes the similarity between miscarriages and stillbirths in regard to almost universal negative initial parental psychological responses and significant rates of morbid grief reactions in contrast to the responses of those who chose to abort. However, when the focus is on those individuals who respond to pregnancy loss with severe long-term grief, miscarriage and abortion bear some important similarities. For example, those who are distressed following a miscarriage or abortion often find less support than do parents who experienced a stillbirth. In both cases, the absence of fetal remains and the common perception that early pregnancy losses should be relatively easy to cope with too often mean that support is not forthcoming from the usual sources, and parents who have suffered such losses are often reluctant to seek professional assistance. Those who suffer serious postabortion emotional problems, although relatively small in number, may face the greatest challenge in resolving their grief (Ney et al. 1994). The low level of support following miscarriages usually takes the form of insensitivity to, or a lack of appreciation of, the parents’ sense of loss and attendant grief. Although this is also true regarding abortion, those who abort must also face the possibility of active opposition and even confrontation and condemnation. The process of psychological resolution for these individuals can be further complicated because they may think that others see compassionate support for an elected loss as unnecessary or inappropriate, or they may worry that mourning the loss implies that their decision to abort was wrong, creating additional guilt.

Research investigating the psychological impacts of all three types of pre-personality losses has indeed revealed some important differences in the frequency, intensity, and nature of responses. As DeFrain (1991) notes, however, they all have one thing in common: Parents can come to accept the event and recover from the emotional distress that results from any pregnancy loss, but they will still have somewhat painful memories, as they would following the loss of any loved one.