Postabortion psychological adjustment: are minors at increased risk?¹

Article Outline

• Abstract
• Methods
  • Subjects and procedure
  • Preabortion questionnaire
    • Sociodemographic variables
    • Depression
    • Emotion scale
    • Feelings about pregnancy
    • Difficulty of decision
  • Postabortion questionnaire
    • Anxiety
    • Self-esteem
    • Stress
    • Positive states of mind
  • Analytic strategies
• Results
  • Attrition analysis
  • Research questions
    • Are legal minors at greater risk for negative outcomes compared with those over age 18 years?
    • Are adolescents as a whole at risk for negative outcomes?
  • Anxiety
  • Stress
  • Self-esteem
  • Positive states of mind
  • Depression
    • What are the predictors of negative response to abortion among adolescents?
• Discussion
• Acknowledgements
• References
• Copyright

Abstract 

Purpose: To assess whether younger adolescents experience greater adverse psychological outcomes after abortion than those aged 18–21 years, whether abortion places all adolescents at risk for negative sequelae, and what factors predict negative outcomes.

Methods: A total of 96 young women aged 14–21 years seeking counseling for unwanted pregnancies at four clinics completed questionnaires after counseling. These included the Beck Depression Inventory (BDI), an emotion scale, questions regarding sociodemographic and reproductive background, feelings about pregnancy, and decision-making. Sixty-three respondents were reinterviewed 4 weeks postabortion and completed the BDI, emotion scale, Spielberger State Anxiety Inventory, Rosenberg Self-esteem Scale, Impact of Events Scale, and Positive States of Mind Scale. Chi-squares and Student’s t-tests were used to compare: (a) responses of adolescents under 18 years of age with those 18–21 years, (b) preabortion and postabortion responses, and (c) the current sample with other samples of adolescents.

Results: Adolescents under age 18 years were less comfortable with their decision, but showed no other differences compared with those aged 18–21 years. Both groups showed significant improvement in psychological responses postabortion. Postabortion scores did not differ significantly from those of other adolescent samples reported in the literature. Preabortion emotional state and perception of partner pressure predicted postabortion response.

Conclusions: Despite its legal significance, age 18 years was not a meaningful cutoff point for psychological response to abortion in this sample. There was no evidence that abortion poses a threat to adolescents’ psychological well-being.

Keywords:  Abortion, Adolescents, Psychological response

Many states have passed, or are considering, legislation mandating parental consent or notification before an adolescent may terminate her pregnancy. An assumption underlying such legislation, often made explicit, is that legal minors, adolescents under age 18 years, are at substantially greater risk for negative postabortion outcomes.

This assumption has not been systematically examined. The psychological sequelae of abortion have been well-studied in adult women. The overwhelming evidence is that when women freely choose to terminate a pregnancy they are unlikely to experience severe negative psychological responses [1]. Whereas some studies have found that younger age is associated with increased risk of negative responses after abortion, these studies include women across the whole childbearing age range and do not isolate adolescents 2, 3. They also do not assess the magnitude of the difference associated with younger age. As a result, they reveal little about whether age 18 years is a meaningful cutoff for increased risk of negative responses. The question of whether adolescents are at substantially greater risk for negative outcomes has implications not just for legislation, but also for health care policy in terms of whether younger women have a greater need for supportive services than do older women.

In establishing whether legal minors are at risk after abortion, it is important to choose appropriate comparison samples. Adolescents who have undergone an abortion can be compared with other adolescents, preferably those who are pregnant or sexually active. Alternatively, to examine the impact of abortion itself (rather than the entire experience of unwanted pregnancy terminated by abortion), adolescents’ postabortion scores on psychological measures can be compared with their own baseline scores taken before the abortion. In addition, rather than using the whole range of older women, adolescents who are legal minors could be compared with slightly older women who have obtained abortions.

No studies to date have explicitly examined responses of patients under age 18 years with those over age 18 years. Two early studies made somewhat different comparisons. In 1974, Bracken et al. compared postabortion responses of patients aged 14–22 years with those aged 22–44 years on a composite (and nonvalidated) measure of anxiety, depression, happiness, guilt, and relief [3]. Younger subjects responded less favorably on the measure than did older subjects. In 1983, Eisen and Zellman examined satisfaction with their decision among adolescents aged 13–19 years [4]. Postabortion, older adolescents were more likely to be satisfied with their decision than younger ones. However, this association disappeared when other factors, such as mother’s level of education and subject’s favorable opinion of abortion, were controlled for.

The best-designed study of abortion among adolescents was conducted by Zabin et al. [5]. They interviewed 360 adolescents aged 11–21 years seeking pregnancy tests and observed them for 2 years, comparing those with negative pregnancy tests, those with positive tests who terminated the pregnancy, and those with positive tests who carried to term. Adolescents who chose abortion scored significantly better on several of the psychological measures 2 years later than either those who carried to term or those with negative pregnancy tests. In addition, adolescents who obtained abortions showed no decrements in functioning from preabortion to postabortion. Thus, this study revealed no evidence of negative psychological sequelae resulting from abortion. Two other studies of adolescents had small sample sizes, but similarly found no negative effects of abortion up to 2 years later 6, 7.

In addition to examining the relative risk of adolescents for negative postabortion responses, it is also important to identify which individuals may be at increased risk. Factors associated with adverse postabortion response among general samples of abortion patients include age, religion/religiosity, length of gestation, type of medical procedure, difficulties in deciding on abortion, wanting to be pregnant, perceived social support, relationship with partner, level of preabortion psychological functioning, attributions for pregnancy, and coping expectancies 1, 8. Because these findings emerged from studies of adult women, their significance in adolescence remains unclear.

The current study examined three aspects of adolescent postabortion response. We first asked whether adolescents under age 18 years are at greater risk for negative sequelae than those over age 18 years. We did this by comparing postabortion responses on key psychological measures for women aged 14–17 years with those aged 18–21 years from the same population. Second, we examined whether the experience of abortion places adolescents at heightened risk of negative psychological states. We did this in two ways: by comparing postabortion scores on psychological measures with those from other samples of adolescents (e.g., high school students, pregnant adolescents) and by comparing preabortion and postabortion scores to examine the extent to which the abortion itself contributed to negative response. Third, we examined predictors of negative responses to abortion within this sample.

Of note, this study was conducted in California, which has no parental consent requirement. In 1992, the abortion rate for women aged 15–19 years in California was estimated to be 64/1000; for legal minors, those aged 15–17 years, it was 42/1000. Nationwide that year, the rates were 35/1000 and 23/1000, respectively [9].

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Methods 

Subjects and procedure 

This study was conducted at four clinics in San Francisco, California: two hospital clinics, a family planning clinic, and an independent abortion clinic. Young women aged 14–21 years were invited to participate in the research at the time they received counseling for pregnancy termination. Subjects were eligible for participation if they had a positive pregnancy test, had decided to terminate their pregnancies, were 6–12 weeks’ gestational age, and spoke English. The use of human subjects was approved by the Committee on Human Research of the University of California, San Francisco. Informed consent was obtained from all subjects before enrollment in the study. Data were not collected on individuals who refused participation.

Subjects participated in two face-to-face interviews, one a day or two before the abortion and another 4 weeks after. The counseling and procedures did not vary by age. Subjects received $15 for the initial interview and $25 for the follow-up. Initially 96 subjects were interviewed; 63 were reinterviewed following their abortion. The subjects were of varied ethnic backgrounds: 32% African-American, 22% Latina, 21% white, 11% Asian American, and 14% mixed or other. A third of the sample was Catholic, a quarter was Protestant, 15% was Jewish or “other,” and a quarter reported no religion. Twenty-two of the subjects (37%) had undergone a previous abortion.

Preabortion questionnaire 

Before their abortion, all participants completed a questionnaire assessing variables that might be associated with adjustment:

These included age, ethnicity, religion, frequency of attendance at religious services, marital status, living situation, and level of education.

Subjects completed the Beck Depression Inventory (BDI) [10]. Although the BDI was developed for use in adult populations, numerous studies have shown it to be appropriate for adolescents 11, 12, 13, 14. As a screening test for depression, recommended cutoff points are: 0–9, nondepressed; 10–15, mild depression; 16–23, moderate depression; ≥24, severe depression. Reported Cronbach alpha reliability for adolescent samples is .88 [11]. Alpha for this sample was .83.

This 12-item scale was developed in earlier research to measure the degree to which women experience a variety of emotions surrounding abortion [2]. Prior factor analysis had revealed three factors: socially based negative emotions (shame, guilt, and fear of disapproval) which reflect reactions to norm violations; internally based negative emotions (regret, anxiety, depression, doubt, and anger) which may represent reactions to the loss of the pregnancy; and positive emotions (happiness and relief). Alpha reliabilities for the three subscales for this sample were .88, .76, and .60.

Subjects responded to seven questions regarding how they felt about being pregnant, how much they wanted to get pregnant, how much they planned to get pregnant, and whether they initially planned to have an abortion or to carry to term. These items were subjected to principal components analysis. Before rotation, all items loaded highly (>.51) on the first factor. The items were standardized and summed (α = .77).

Subjects were asked five questions about their decision-making process, including questions about the degree of difficulty they had in deciding on abortion and how sure they were of their decision. When these items were subjected to principal components analysis, three items loaded highly (>.60) on the first factor. Items were standardized and summed (α = .77).

Data were also collected on subjects’ number of prior pregnancies and prior abortions, and subjects’ current relationship with their partners and their view of the future of the relationship; the latter two items were highly correlated and were summed (α = .75). Perceived pressure from partner and from parents were each measured on five-point scales.

Postabortion questionnaire 

At follow-up, subjects rated whether they felt the decision to have an abortion was the right one, on a six-point scale, and how comfortable they were with the decision on a five-point scale. The BDI and Emotion Scale were repeated, in addition to four additional measures of psychological functioning:

The Spielberger State-Trait Anxiety Inventory (STAI) A-state scale measures current feelings of anxiety [15]. Owing to clerical error, the final five items were omitted from the scale; thus, total scores were adjusted to allow comparison with other studies. Reported alpha reliability in adolescent samples is .86 [16]. Alpha for this sample on the 15-item scale was .87.

The Rosenberg Self-esteem Scale is a measure of self-esteem widely used in adolescent populations [17]. Published alpha reliability for adolescent samples is .84 [18]. Alpha for this sample was .87.

The Impact of Events Scale (IES) measures response to stressful life events [19]. The IES has two subscales, one assessing intrusive thoughts about an event and the other assessing avoidance. Because the latter may reflect coping style as well as stress response, only the intrusion score was used. Alpha for intrusion for this sample was .82; reported reliability is .86 [20].

The Positive States of Mind Scale (PSOM) assesses the ease with which subjects are able to achieve six positive states of mind which, in clinical experience, become more difficult to attain in periods of stress 21, 22. Alpha was .75; reported reliability is .77 [21].

Scores for the six measures of postabortion psychological response (BDI, Emotion Scale, STAI, Rosenberg, IES, and PSOM) were highly correlated. Principal components analysis revealed that all variables except the third factor of the Emotion Scale, positive emotions, loaded highly (.67–.85) on the first unrotated factor. To generate a single measure of general postabortion response, all scale scores except positive emotions were standardized and summed (α = .87).

Analytic strategies 

To examine whether legal minors are at greater risk for negative sequelae than older adolescents, we compared subjects younger than age 18 years with those age 18 years and older, using Chi-squares for categorical variables such as ethnicity and religion, and Student’s t-tests for continuous variables such as psychological outcomes. To examine whether the experience of abortion places adolescents at heightened risk of negative psychological states, we first compared preabortion and postabortion scores on psychological measures, using paired Student’s t-tests. Subsequently, we compared the psychological functioning of our sample with the functioning of other groups of adolescents reported in the literature, by calculating Student’s t-tests in cases where other investigators had provided standard deviations for their samples. Finally, to determine the predictors of negative responses to abortion, we calculated Pearson correlation coefficients for continuous predictors (e.g., difficulty of abortion decision) and Student’s t-tests for categorical predictors (e.g., pressure from partner).

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Results 

Attrition analysis 

Sixty-three of the initial 96 subjects (66%) participated in the follow-up interview. This compares favorably with other studies, in which follow-up rates are often under 50% [23]. Factors associated with attrition could be correlated with negative postabortion response [24]. We compared the 63 subjects retained in the research with the 33 who were not on age, religion, marital status, number of prior abortions, difficulty in deciding on abortion, and preabortion emotional state. Each of these variables was assessed in the initial interview and has been associated with more negative response in other studies 2, 25.

Results of the attrition analysis showed significant differences on three variables. First, those who returned for follow-up were more likely to be Catholic and less likely to be Protestant than those who did not [24% of the returners were Protestant vs. 56% of the nonreturners, whereas 36% of the returners were Catholic vs. 19% of the nonreturners (χ² = 10.25, df = 4, p < .05)]. Second, fewer of those who returned for follow-up had expected, before being pregnant, that they would choose an abortion in the event of an unplanned pregnancy [51% of the returners vs. 74% of the nonreturners (χ² = 3.82, df = 1, p < .05)]. Third, the returners had higher mean depression scores at baseline compared with those lost to follow-up (returners = 15.54 and nonreturners = 12.18, t = 2.01, p < .05). Because previous studies have identified being Catholic, being less certain of the abortion decision, and being more depressed preabortion as risk factors for negative outcomes, this sample would not be biased toward low-risk subjects. If anything, the follow-up sample overrepresents those at risk for negative postabortion response.

Research questions 

Before assessing outcomes, we examined whether the two age groups differed on demographic variables. No differences were found on ethnicity, religion, or religiosity. Older subjects were more likely than younger ones to have had a prior abortion and were less likely to be living with a parent. When outcome measures for younger and older subjects were compared, the only significant finding was that the younger group was less comfortable with the decision to have an abortion (Table 1). Despite this difference, subjects under age 18 years were still fairly comfortable with their decision: on a scale of 1 (“not at all comfortable”) to 5 (“very comfortable”), the older subjects had a mean score of 3.80, whereas the younger subjects had a mean score of 3.09. Only one subject scored 1. Although younger adolescents were also somewhat less sure the decision was the right one, this difference did not reach significance. Again, those under age 18 years were still sure they made the right choice. Scores could range from 1 (“wrong decision”) to 6 (“right decision”); the younger adolescents had a mean score of 5.09 and the older adolescents 5.53. On the more standardized measures of functioning, younger subjects appeared no worse off psychologically than did older subjects. A power analysis based on our sample size of 23 and 40 subjects indicated that we had a power of .80 to detect an effect size of d = .65, which is midway between moderate and large [26]. When the older and younger groups were compared on each of the psychological measures, no significant differences were found.

Table 1. Measures of Psychological Response: Subjects Under Age 18 Years Compared With Those 18 Years or Older

Because the two age groups did not differ on any of the psychological measures, younger and older subjects were combined and the scores for the entire follow-up sample were examined for evidence of postabortion psychological distress. A power analysis based on our sample size of 63 subjects showed that we had a power of .80 to detect a moderate effect size of d = .45. We first compared subjects’ preabortion and postabortion scores on psychological measures to test the impact of abortion itself using paired Student’s t-tests on two measures that were administered both preabortion and postabortion: the BDI and the Emotion Scale (Table 2). The group showed significant decreases in depression: mean scores dropped from 15.54 to 9.84. Subjects also showed a significant decrease in internally-based negative emotions (regret, doubt, and anger) and significant increases in positive emotions (happiness and relief). Socially based negative emotions (shame, guilt, and fear of disapproval) dropped postabortion but the difference was not significant.

Table 2. Measures of Psychological Response: Comparing Pre- and Postabortion Scores for Follow-up Sample

We also compared scores from this sample with those of other groups of adolescents reported in the literature. There is no perfect comparison sample. As much as possible, we used groups similar to ours in age, sex, and ethnicity, and included samples of pregnant adolescents. Table 3, Table 4, Table 5, Table 6, Table 7, Table 8 present scores on anxiety, intrusion, self-esteem, positive states of mind, and depression from the current sample and from comparison samples.

Table 3. Spielberger State Anxiety Inventory: Comparing Postabortion Score With Other Sampleslegend

Table 4. Impact of Events Scale—Intrusion Subscale: Comparing Postabortion Score With Other Samples

Table 5. Rosenberg Self-esteem Scale: Comparing Postabortion Score With Other Sampleslegend

Table 6. Positive States of Mind Scale: Comparing Postabortion Score With Other Samples

Table 7. Beck Depression Inventory: Comparing Postabortion Score With Other Sampleslegend

Table 8. Beck Depression Inventory: Comparing Percentage of Subjects Scoring in the Depressed Range

Anxiety 

The state anxiety score for our sample was not significantly different from that of 10th-grade female high school students [15] or of a group of pregnant adolescents with similar demographic characteristics [27] (Table 3). Because Zabin et al. did not report standard deviations on anxiety scores from their three groups of pregnancy test subjects, Student’s t-tests could not be performed [5]. However, our results are consistent with Zabin’s: The postabortion score for our sample was comparable to that shown at follow-up by Zabin’s abortion group and lower than that of the childbearing and sexually active but nonpregnant groups. Postabortion, the patients in our sample scored similarly to nonpregnant, nonparenting subjects studied by Barth et al., but scored significantly higher than the pregnant and parenting groups in that study [28].

Stress 

There is little information available on the use of the IES in adolescent populations; however, there is some evidence that scale scores may not vary greatly with age [29]. Our sample showed a similar intrusion score to that of a group of adults coping well with the loss of a parent, and scored significantly lower than a group of adult psychiatric outpatients from the same study [20] (Table 4). Postabortion, our sample scored similarly to a group of abortion patients across the childbearing age range [30]. In comparison with a group of adolescents who had experienced a traumatic event, our sample had a significantly lower score [29].

Self-esteem 

The mean Rosenberg score for our sample is similar to that of subjects in the study by Zabin et al. [5] (Table 5). Again, because standard deviations were not reported, we could not perform Student’s t-tests. Our sample scored significantly higher than did three samples of female high school students 31, 32, 33.

Positive states of mind 

Our sample had a significantly higher PSOM score than a sample of college-aged women, and scored similarly to a group of pregnant adult women 21, 22 (Table 6).

Depression 

The postabortion BDI score of the abortion sample was not significantly different from that of a large sample of female high school students [14] or of a group of parenting, pregnant, and nonpregnant young women demographically similar to our sample [28] (Table 7). The mean BDI score of our sample was significantly lower than that of a group of clinically depressed adolescents, but was not significantly different from the normative high school students or nondepressed patients in that same study [12]. The abortion sample did score higher than a group of predominantly white high school students; standard deviation was not reported for the female sample, so Student’s t-tests could not be performed [11].

Overall, the mean BDI score of the current sample does not indicate poor adjustment postabortion. However, using sample means to evaluate psychological functioning does not provide information about the portion of the sample that may be experiencing severe negative responses. To do this, we examined what percentage had scores >16, the standardized cutoff for moderate to severe depression. At the preabortion interview, 35% of the total sample (n = 34 of 96) had BDI scores of ≥16; of the subset who went on to complete the study, 41% (n = 26 of 63) exceeded this cutoff at baseline. Postabortion, only 19% (n = 12 of 63) had scores of ≥16. This rate of moderate depression is significantly lower than the preabortion rate and is similar to that reported in other samples of randomly selected male and female adolescents (Table 8).

As noted earlier, the psychological measures loaded on a single factor and were combined to form a single adjustment measure. None of the demographic variables (age, ethnicity, religion, frequency of attendance at religious services, marital status, living situation, and level of education) were significantly correlated with this measure of adjustment; as a result, there was no need to control for these in subsequent analysis. We then examined correlations between the adjustment index and variables hypothesized to be associated with postabortion response. Postabortion adjustment was significantly correlated with baseline emotional state: Subjects who scored lower on the adjustment index at baseline fared worse postabortion (correlation coefficient .507, p < .01). Relationship with partner, feelings about pregnancy, difficulty of abortion decision, prior pregnancy, and prior abortion were not related to postabortion adjustment (correlations ranged from .01 to .19, not significant). The only other variable that was significantly related to postabortion adjustment was the degree to which the subject felt pressured by her partner (t = 2.07, df = 55, p < .05). Young women who felt pressure from their partner (n = 32) showed more negative responses than those who did not (n = 24). Among those who reported pressure from their partner, those who felt pressured to have the abortion (n = 16) showed somewhat poorer adjustment than those who felt pressured to continue the pregnancy (n = 16), although this did not reach statistical significance.

Parental pressure was not significantly related to postabortion adjustment, but this may have been owing to small numbers. Whereas 87% (n = 55) of the follow-up sample told their partners about the abortion, only 38% (n = 24) told their mothers and only 10% (n = 6) told their fathers. Among subjects under age 18 years, 41% told their mothers compared with 31% of those 18 years or older; 10% of each age group told their fathers. There was no significant difference in adjustment between those subjects who told their parents and those who did not.

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Discussion 

Although not tested until now, the assumption that adolescents under age 18 years are at heightened risk for negative outcomes postabortion has strongly influenced abortion legislation. Results of this study suggest that, despite its legal import, age 18 years is not a meaningful cutoff point for psychological responses to abortion. We found no support for the notion that legal minors experience more adverse postabortion outcomes than young women aged 18 years or older. Instead, younger adolescents in our sample fared as well as their older peers. The only difference between younger and older patients was that whereas both groups reported considerable comfort with the decision to have an abortion, younger adolescents were relatively less comfortable with this decision.

We also found that adolescents across the age range of 14–21 years are not at high risk for psychological distress after abortion. When comparing postabortion functioning of our sample with other samples of nonpregnant adolescents and pregnant adolescents carrying to term, only a few differences emerged. Our sample reported levels of depression similar to most other samples. They did score higher than the group of high school students studied by Roberts et al.; however, that sample was predominantly white, whereas our abortion sample is more ethnically diverse [11]. Research on ethnicity and BDI scores has found that European Americans tend to score significantly lower than other ethnic groups 34, 35. The percentage of patients scoring in the depressed range was significantly lower postabortion than beforehand and was no higher than in samples of mixed male and female adolescents 11, 12, 13. Because males score lower on the BDI than females, these mixed gender samples provide stringent comparison groups. Our sample reported higher levels of anxiety than one sample of female high school students [28] but were no higher than several other samples 15, 16, 27.

Our sample reported higher self-esteem postabortion than female high school students in three studies 31, 32, 33. The higher self-esteem score for our sample may be due in part to the fact that African-American adolescents tend to score higher on measures of self-esteem 34, 35. Subjects in the studies by Allgood-Merton et al. [31] and by Moran and Eckenrode [32] were primarily European American, whereas one-third of our subjects were African-American. However, this finding is also consistent with findings from other research which has shown that having had one abortion is positively correlated with self-esteem 5, 25, 38. Our sample also demonstrated more positive states of mind than a sample of college-age women for whom reproductive status was not reported [21].

We also compared psychological functioning immediately before abortion and 4 weeks after abortion. Young women showed decreased depression, decreased internally based negative emotions, and increased positive emotions after abortion compared with preabortion levels. This is consistent with the findings of other studies comparing preabortion and postabortion measures of psychological functioning in adult women [30].

The generalizibility of this study is limited by its small sample size, the strictly urban setting, and a brief follow-up time frame. However, the sample is ethnically diverse and draws from a variety of clinic sites. It provides important information about a population about which little is currently known. We included only subjects in their first trimester of pregnancy (≤12 weeks’ gestational age). However, the vast majority of abortions in the United States are in the first trimester: Of all abortions in 1992, 88.8% were performed at ≤12 weeks, 10.1% at 13–20 weeks, and 1.1% at ≥20 weeks [39].

Although postabortion scores for this sample were well within normal ranges, the question of what factors are associated with negative responses remains clinically important. Of variables which other studies have shown to be associated with postabortion response, only two were significantly related to adjustment in this sample of adolescents: subjects’ preabortion emotional state, and the degree to which they felt pressured by their partners. This suggests that a preabortion assessment of baseline psychological functioning (focusing on depression) and the degree to which a young woman’s decision to have an abortion is her own rather than a response to outside pressure may help to identify adolescents at greater relative risk for adjustment difficulties postabortion. Our findings suggest that partners, rather than parents, may represent the most important source of outside pressure for young women.

Once an adolescent, or any woman, has become pregnant, the only alternative to abortion is childbirth. When the pregnancy is unwanted, and especially when it occurs during adolescence, childbirth can have negative consequences for mother and child 40, 41. In this light, our findings have important implications, for they provide evidence that abortion, when freely chosen, does not pose a threat to adolescents’ psychological well-being.[36] [37]

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Acknowledgements 

This research was supported by Grant ROI HD 23880 from the National Institutes of Child Health and Human Development, to Nancy Adler, Primary Investigator.

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