Julia R. Steinberg

Abortion Stigma: A Reconceptualization of Constituents, Causes, and Consequences

Stigmatization is a deeply contextual, dynamic social process; stigma from abortion is the discrediting of individuals as a result of their association with abortion. Abortion stigma is under-researched and under-theorized, and the few existing studies focus only on women who have had abortions. We build on this work, drawing from the social science literature to describe three groups whom we posit are affected by abortion stigma: Women who have had abortions, individuals who work in facilities that provide abortion, and supporters of women who have had abortions, including partners, family, and friends, as well as abortion researchers and advocates. Although these groups are not homogeneous, some common experiences within the groups--and differences between the groups--help to illuminate how people manage abortion stigma and begin to reveal the roots of this stigma itself. We discuss five reasons why abortion is stigmatized, beginning with the rationale identified by Kumar, Hessini, and Mitchell: The violation of female ideals of sexuality and motherhood. We then suggest additional causes of abortion stigma, including attributing personhood to the fetus, legal restrictions, the idea that abortion is dirty or unhealthy, and the use of stigma as a tool for anti-abortion efforts. Although not exhaustive, these causes of abortion stigma illustrate how it is made manifest for affected groups. Understanding abortion stigma will inform strategies to reduce it, which has direct implications for improving access to care and better health for those whom stigma affects.

Abortion and anxiety: What's the relationship?

Using data from the United States National Survey of Family Growth (NSFG) and the National Comorbidity Survey (NCS), we conducted secondary data analyses to examine the relationship of abortion, including multiple abortions, to anxiety after first pregnancy outcome in two studies. First, when analyzing the NSFG, we found that pre-pregnancy anxiety symptoms, rape history, age at first pregnancy outcome (abortion vs. delivery), race, marital status, income, education, subsequent abortions, and subsequent deliveries accounted for a significant association initially found between first pregnancy outcome and experiencing subsequent anxiety symptoms. We then tested the relationship of abortion to clinically diagnosed generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and social anxiety disorder, using NCS data. Contrary to findings from our analyses of the NSFG, in the NCS analyses we did not find a significant relationship between first pregnancy outcome and subsequent rates of GAD, social anxiety, or PTSD. However, multiple abortions were found to be associated with much higher rates of PTSD and social anxiety; this relationship was largely explained by pre-pregnancy mental health disorders and their association with higher rates of violence. Researchers and clinicians need to learn more about the relations of violence exposure, mental health, and pregnancy outcome to avoid attributing poor mental health solely to pregnancy outcomes.

“It just happens”: a qualitative study exploring low-income women’s perspectives on pregnancy intention and planning☆

OBJECTIVE Unintended pregnancy is common and disproportionately occurs among low-income women. We conducted a qualitative study with low-income women to better typologize pregnancy intention, understand the relationship between pregnancy intention and contraceptive use, and identify the contextual factors that shape pregnancy intention and contraceptive behavior. STUDY DESIGN Semistructured interviews were conducted with low-income, African-American and white women aged 18-45 recruited from reproductive health clinics in Pittsburgh, PA, to explore factors that influence womens pregnancy-related behaviors. Narratives were analyzed using content analysis and the constant comparison method. RESULTS Among the 66 participants (36 African-American and 30 white), we identified several factors that may impede our public health goal of increasing the proportion of pregnancies that are consciously desired and planned. First, women do not always perceive that they have reproductive control and therefore do not necessarily formulate clear pregnancy intentions. Second, the benefits of a planned pregnancy may not be evident. Third, because preconception intention and planning do not necessarily occur, decisions about the acceptability of a pregnancy are often determined after the pregnancy has already occurred. Finally, even when women express a desire to avoid pregnancy, their contraceptive behaviors are not necessarily congruent with their desires. We also identified several clinically relevant and potentially modifiable factors that help to explain this intention-behavior discrepancy, including womens perceptions of low fecundity and their experiences with male partner contraceptive sabotage. CONCLUSION Our findings suggest that the current conceptual framework that views pregnancy-related behaviors from a strict planned behavior perspective may be limited, particularly among low-income populations. IMPLICATIONS This study identified several cognitive and interpersonal pathways to unintended pregnancy among low-income women in Pittsburgh, PA, including perceptions of low reproductive control, perceptions of low fecundity and male partner reproductive coercion.

A comparison of depression and anxiety symptom trajectories between women who had an abortion and women denied one

BACKGROUND This study prospectively assesses the mental health outcomes among women seeking abortions, by comparing women having later abortions with women denied abortions, up to 2 years post-abortion seeking. METHOD We present the first 2 years of a 5-year telephone interview study that is following 956 women who sought an abortion from 30 facilities throughout the USA. We use adjusted linear mixed-effects regression analyses to assess whether symptoms of depression and anxiety, as measured by the Brief Symptom Inventory-short form and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, differ over time among women denied an abortion due to advanced gestational age, compared with women who received abortions. RESULTS Baseline predicted mean depressive symptom scores for women denied abortion (3.07) were similar to women receiving an abortion just below the gestational limit (2.86). Depressive symptoms declined over time, with no difference between groups. Initial predicted mean anxiety symptoms were higher among women denied care (2.59) than among women who had an abortion just below the gestational limit (1.91). Anxiety levels in the two groups declined and converged after 1 year. CONCLUSIONS Women who received an abortion had similar or lower levels of depression and anxiety than women denied an abortion. Our findings do not support the notion that abortion is a cause of mental health problems.

Abortion and mental health: findings from The National Comorbidity Survey-Replication.

OBJECTIVE: To examine whether a first abortion increases risk of mental health disorders compared with a first childbirth with and without considering prepregnancy mental health and adverse exposures, childhood economic status, miscarriage history, age at first abortion or childbirth, and race or ethnicity. METHODS: A cohort study compared rates of mental disorders (anxiety, mood, impulse-control, substance use, eating disorders, and suicidal ideation) among 259 women postabortion and 677 women postchildbirth aged 18–42 years at the time of interview from The National Comorbidity Survey-Replication. RESULTS: The percentage of women with no, one, two, and three or more mental health disorders before their first abortion was 37.8%, 19.7%, 15.2%, and 27.3% and before their first childbirth was 57.9%, 19.6%, 9.2%, and 13.3%, respectively, indicating that women in the abortion group had more prior mental health disorders than women in the childbirth group (P<.001). Although in unadjusted Cox proportional hazard models, abortion compared with childbirth was associated with statistically significant higher hazards of postpregnancy mental health disorders, associations were reduced and became nonstatistically significant for five disorders after adjusting for the aforementioned factors. Hazard ratios and associated 95% confidence intervals dropped from 1.52 (1.08–2.15) to 1.12 (0.87–1.46) for anxiety disorders; from 1.56 (1.23–1.98) to 1.18 (0.88–1.56) for mood disorders; from 1.62 (1.02–2.57) to 1.10 (0.75–1.62) for impulse-control disorders; from 2.53 (1.09–5.86) to 1.82 (0.63–5.25) for eating disorders; and from 1.62 (1.09–2.40) to 1.25 (0.88–1.78) for suicidal ideation. Only the relationship between abortion and substance use disorders remained statistically significant, although the hazard ratio dropped from 3.05 (1.94–4.79) to 2.30 (1.35–3.92). CONCLUSIONS: After accounting for confounding factors, abortion was not a statistically significant predictor of subsequent anxiety, mood, impulse-control, and eating disorders or suicidal ideation. LEVEL OF EVEDIENCE: II

Does the outcome of a first pregnancy predict depression, suicidal ideation, or lower self-esteem? Data from the national comorbidity survey

This study examines the risk of depression, suicidal ideation, and lower self-esteem following an abortion versus a delivery, with and without adjusting for important correlates. Using the National Comorbidity Survey, we tested how first pregnancy outcome (abortion vs. delivery) related to subsequent major depression, suicidal ideation, and self-esteem. Models controlling for risk factors, such as background and economic factors, prepregnancy violence experience, and prepregnancy mental health, as well as a model with all risk factors, were examined. When no risk factors were entered in the model, women who had abortions were more likely to have subsequent depression, OR=1.53, 95% CI [1.05-2.22], and suicidal ideation, OR=2.02, 95% CI [1.40-2.92], but they were not more likely to have lower self-esteem, B=-.02. When all risk factors were entered, pregnancy outcome was not significantly related to later depression, OR=0.87, 95% CI [0.54-1.37], and suicidal ideation, OR=1.19, 95% CI [0.70-2.02]. Predictors of mental health following abortion and delivery included prepregnancy depression, suicidal ideation, and sexual violence. Policies and practices implemented in response to the claim that abortion hurts women are not supported by our findings. Efforts to support womens mental health should focus on known risk factors, such as gender-based violence and prior mental health problems, rather than abortion history.

Psychological distress and post-abortion contraceptive method effectiveness level chosen at an urban clinic

OBJECTIVE We investigated whether more psychological distress before an abortion is associated with the effectiveness of contraception selected (low, moderate, or high effectiveness) at an abortion clinic visit. METHOD Using data from 253 women attending an urban abortion clinic that primarily serves low-income women, we tested the association between pre-abortion psychological distress and the effectiveness level of post-abortion contraceptive choice. Based on typical use failure rates, we classified effectiveness of contraceptive choice into three levels-low, moderate, and high effectiveness. We measured psychological distress with four validated measures of depressive, anxious, and stress symptoms, and negative affect, as well as with a global measure comprising these four measures. We used multivariable ordinal logistic regression to measure the association of each psychological distress measure with post-abortion contraceptive method effectiveness level, adjusting for sociodemographic factors, pregnancy history, trimester of abortion, and importance of avoiding pregnancy in the next year. RESULTS We found that compared to women experiencing less stress symptoms, negative affect and global psychological distress, women experiencing more stress symptoms [AOR=1.028, 95% CI: 1.001-1.050], negative affect [AOR=1.05, 95% CI: 1.01-1.09] and global psychological distress [AOR=1.46, 95% CI: 1.09-1.95] were more likely to choose more effective versus less effective methods, p<.05, in adjusted models. Using dichotomous psychological measures we found similar results. CONCLUSIONS Women experiencing more psychological distress before an abortion selected more effective contraceptive methods after their abortion. Future research should examine whether this distress is associated with subsequent contraceptive use or continuation. IMPLICATIONS The current study suggests that contraceptive providers should not assume that women experiencing more psychological distress prefer to use less effective contraceptive methods.

Coleman, Coyle, Shuping, and Rue make false statements and draw erroneous conclusions in analyses of abortion and mental health using the National Comorbidity Survey.

We are writing regarding “Induced abortion and anxiety, mood, and substance use disorders: Isolating the effects of abortion in the national comorbidity survey” (Coleman et al., 2009) and its associated corrigendum, which was published in July 2011 (Coleman, Coyle, Shuping, and Rue, 2011). In a separate publication (Steinberg and Finer, 2011), we reported that we were unable to replicate the findings reported by Coleman et al. in their original paper. We followed with an inquiry to the editors of the Journal of Psychiatric Research. In response to our inquiry, Coleman and colleagues prepared a corrigendum, indicating that they had used incorrect weights in their original analyses and reporting the results of their analyses re-run with correct weights. We are now able to replicate the numbers in the corrigendum and, equally importantly, we are also able to deduce the specific analyses performed. We conclude that the corrigendum is an insufficient response. Once the problem of incorrect weighting is resolved, a more serious problem becomes evident, involving untrue statements about the nature of the dependent variables and associated false claims about the implications of the findings. In the National Comorbidity Survey (NCS) data, which are publicly available, mental health diagnoses are coded as present or absent by NCS staff over various time periods, including the 30 days preceding the interview, the 12 months preceding the interview, and anytime during the respondent’s lifetime. Determining the “effects of abortion” — i.e., relating the likelihood of mental health diagnoses to the experience of abortion — is not possible unless it can be established that the diagnoses occurred after the abortion. Diagnoses in the past 30 days are more likely to occur after reported abortions than are diagnoses made in the past 12 months, and certainly more likely than diagnoses over one’s lifetime. Lifetime measures provide no assurance that the abortion preceded the mental health diagnoses. In fact, for many women, the first onset of psychiatric illness occurred before the abortion (see Steinberg and Finer, 2011; and Steinberg et al., 2011). Coleman et al. (2009) explicitly acknowledge the importance of temporal order in establishing causal effects. Despite this, they not only use inappropriate measures of psychiatric diagnoses, but repeatedly claim that they are using something else. In Section 2.3 of their 2009 paper, they state (p. 772), “The psychiatric illnesses were assessed as “present” or “absent” at the time of data collection, providing assurance that in most cases, the abortion preceded the diagnosis.” While they do not explicitly state that they used the 30-day diagnoses, the only time period that can be considered an assessment as “present” or “absent” at the time of the interview is the 30-day (also called current) diagnosis. In later statements, Coleman et al. change their claim and declare that they were using 12-month measures. They explicitly state this in a December 2010 blog post on the Washington Post-web site (http://voices.washingtonpost.com/checkup/2010/12/study_disputes_abortion_mental.html) and in a March 2011 presentation for the American Association of Pro-Life Obstetricians and Gynecologists (found online at: http://www.aaplog.org/media_files/Coleman_2011.ppt). Finally, in their July 2011 corrigendum, they never explicitly state the time period under consideration, but claim their only mistake was that they used incorrect weights. Table 1 below presents Coleman et al.’s corrected findings in the corrigendum and compares them with the 30-day, one-year, and lifetime diagnoses. This replication of the corrigendum analyses, which used correct weights, shows that the authors did not use the 30-day or 12-month diagnoses, but rather lifetime diagnoses in both cases. (We were also able to determine that the original Coleman et al. [2009] paper used lifetime diagnoses.) Table 1 Percent of women with mental health diagnoses during different time frames (30-day, 12-month, and lifetime) by abortion history. The use of lifetime diagnoses, which readers are led to believe are 30-day diagnoses, renders the findings meaningless and provides no support for a number of statements that remain in the paper. For example, Table 6, which presents measures of population attributable risk, does not make sense given that there is no way of ensuring that the abortion occurred before the mental health problems. In their original discussion (which is not modified in the corrigendum), Coleman et al. comment on their findings as though the abortions preceded the mental health diagnoses. For example, they refer to “post-abortion mental health problems” (p. 775), state that their study “is essential to the process of clarifying the mental health risks unique to abortion” (p. 776), and note that future research should examine mediating mechanisms linking abortion to these various disorders. Moreover, the language in the very title, “Isolating the effects of abortion in the national comorbidity survey,” is simply wrong. All of these are erroneous statements or analyses given that the mental health diagnoses used were lifetime diagnoses. In sum, the corrigendum that these authors have offered unfortunately fails to disclose key information and maintains the false impression that temporal order has been addressed. The paper and corrigendum contain misleading and erroneous information that serves to confuse the relationship of abortion and mental health even more, and reveals the invalidity of the original analyses. These deficiencies are fundamental analytical errors that were incorrectly presented in the original paper and perpetuated in the corrigendum, not a scholarly difference of opinion.

Later abortions and mental health: psychological experiences of women having later abortions--a critical review of research.

BACKGROUND Some abortion policies in the U.S. are based on the notion that abortion harms womens mental health. The American Psychological Association (APA) Task Force on Abortion and Mental Health concluded that first-trimester abortions do not harm womens mental health. However, the APA task force does not make conclusions regarding later abortions (second trimester or beyond) and mental health. This paper critically evaluates studies on later abortion and mental health in order to inform both policy and practice. METHOD Using guidelines outlined by Steinberg and Russo (2009), post 1989 quantitative studies on later abortion and mental health were evaluated on the following qualities: 1) composition of comparison groups, 2) how prior mental health was assessed, and 3) whether common risk factors were controlled for in analyses if a significant relationship between abortion and mental health was found. Studies were evaluated with respect to the claim that later abortions harm womens mental health. RESULTS Eleven quantitative studies that compared the mental health of women having later abortions (for reasons of fetal anomaly) with other groups were evaluated. Findings differed depending on the comparison group. No studies considered the role of prepregnancy mental health, and one study considered whether factors common among women having later abortions and mental health problems drove the association between later abortion and mental health. CONCLUSION Policies based on the notion that later abortions (because of fetal anomaly) harm womens mental health are unwarranted. Because research suggests that most women who have later abortions do so for reasons other than fetal anomaly, future investigations should examine womens psychological experiences around later abortions.

Race and reproductive coercion: a qualitative assessment.

BACKGROUND Unintended pregnancy is common and disproportionately occurs among low-income and African-American (AA) women. Male partners may influence womens risk of unintended pregnancy through reproductive coercion, although studies have not assessed whether racial differences in reproductive coercion impact AA womens disparate risk for unintended pregnancy. We sought to describe womens experiences with pregnancy-promoting behaviors by male partners and explore differences in such experiences by race. METHODS Semistructured interviews were conducted with low-income, AA and White women aged 18 to 45 years recruited from reproductive health clinics in Western Pennsylvania to explore contextual factors that shape womens contraceptive behaviors. Narratives were analyzed using content analysis and the constant comparison method. FINDINGS Among the 66 participants (36 AA and 30 White), 25 (38%) described experiences with male partner reproductive coercion. Narratives provided accounts of contraceptive sabotage, verbal pressure to promote pregnancy and specific pregnancy outcomes, and potential motives behind these behaviors. AA women in the sample reported experiences of reproductive coercion more often than White women (53% and 20%, respectively). AA women were also more likely than White women to attribute a current or prior pregnancy to reproductive coercion. AA women identified relationship transiency and impending incarceration as potential motivations for men to secure a connection with a female partner via pregnancy. CONCLUSIONS Our findings suggest that reproductive coercion may be a factor contributing to disparities in unintended pregnancy. More research, including population-level studies, is needed to determine the impact of reproductive coercion on unintended pregnancy and to understand the social and structural factors associated with pregnancy-promoting behaviors.