Prevalence and Associated Psychological Effects of Induced Unsafe Abortion

This review intends to provide brief data about the psychological consequences of induced unsafe abortion. The data were collected from different articles, journals, guidelines and related published materials. Emerging data report 30% of women worldwide who practiced abortion experience negative and persistent psychological distress afterward. It is estimated that there are 3.27 million pregnancies in Ethiopia every year, of which approximately 500,000 ends in either spontaneous or unsafely induced abortion. Reasons for seeking abortion are socioeconomic concerns (including poverty, no support from the partner, and disruption of education or employment); family-building preferences (including the need to postpone childbearing or achieve a healthy spacing between births); relationship problems with the husband or partner; risks to maternal or fetal health; and pregnancy resulting from rape or incest; poor access to contraceptives and contraceptive failure. Smoking, drug abuse, eating disorder, depression, anxiety disorders, attempted suicide, guilt, regret, nightmare, decreased self-esteem, and worry about not being able to conceive again were the psychological consequences of abortion.

Keywords:Abortion; Effects; Induced; Psychological; Unsafe

The WHO (2004) defines an unsafe abortion as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both. When abortion is performed by qualified people using correct techniques unsanitary conditions, it is very safe. All those who do not have medical training and even professionals operating under sub-standard conditions are included unsafe abortion [1].

The World Health Organization (WHO) estimates that of 210 million women pregnant each year, 78 million ends in miscarriage, stillbirth, or induced abortion worldwide. Of the estimated 46 million induced abortions each year, nearly 19 million are performed in unsafe conditions and result in the deaths of an estimated 68,000 girls and women (WHO, 2004) [1]. As of 2010–2014, an estimated 55.9 million abortions occur each year-49.3 million in developing regions and 6.6 million in developed regions (Sedgh et al.,2016) [2].

According to Thonneau, et al. 529,000 girls and women die from pregnancy-related causes each year, almost all of them in the developing world. About 68,000 (13 percent) of these deaths are due to unsafe abortion, but the percentage can be much higher at country levels [3]. As of 2010–2014, an estimated 55% of all abortions are safe, 31% are less safe, and 14% are least safe (Ganatra B et al., 2017) [4]. Research conducted by Adetoun et al. 2011 indicated, two in five unsafe abortions occur among women under age 25, and about one in seven women who have unsafe abortions is under 20 [5]. In Africa, about one-quarter of the unsafe abortions are among teenagers (ages 15 to 19), a higher proportion than in any other world region. WHO report showed Ethiopia is the 5th in maternal mortality and unsafe abortion accounts for 32% of the causes of maternal death. It is also one of the top 10 reasons for mothers to seek hospital admission in Ethiopia (shimelis et al., 2015) [6].

For example, the study conducted at the Gondar College of Medical Sciences; complication of abortion is the leading cause of admission to the gynecological ward (Senbeto et al., 2005) [7]. Another study conducted among Wolayta Sodo University students by Gelaye, et al. 2014 indicated that 16 students practiced abortion which was unsafe [8]. On the other hand, a study conducted by Shimelis, et al. 2015 in Wachemo University indicates 27 (5.9%) female students in the study practiced induced abortion [6]. The study was also conducted among Mizan Tepi University students and among the study participants, 5 (1.18%) had practiced abortion. Two (40%) of them practice abortion at the time when the pregnancy was below 3 months, 1 (20%) when the pregnancy was below 6 months of duration and 2 (40%) of them did not remember the exact duration of pregnancy (Mekuriaw et al.,2015) [8].

Despite its prevalence worldwide, several types of research are indicating several psychological complications associated with abortion discussed below. This review provides major psychological complications associated with abortion in general and induced abortion specifically.

The reviewer systematically collected all information from published articles, journals, and manual. The information collected is also paraphrased and cited to acknowledge the authors of journals and articles in text and reference part.

Temporary feelings of relief after abortions are frequently followed by a period psychiatrists identify as emotional "paralysis," or post-abortion "numbness." (Baird et al, 2001) [9]. Baird, et al. further indicated like shell-shocked soldiers, these aborted women are unable to express or even feel their own emotions. Their focus is primarily on having survived the ordeal, and they are at least temporarily out of touch with their feelings.

The mostly occurred psychological consequences of abortions are discussed in detail as follows:

Suicidal Ideation and Suicide Attempts:Mota (2010) identified a strong statistical association between abortion and suicide in a records-based study [10]. According to Mota, approximately 60 percent of women who experience post-abortion sequel report suicidal ideation, with 28 percent actually attempting suicide, of which half attempted suicide. (Pourreza&Batebi, 2011 study also the same result which indicated the experience of suicidal attempt after abortion.

Substance Abuse:Women who aborted a first pregnancy were five times more likely to report subsequent substance abuse than women who carried to term, and they were four times more likely to report substance abuse compared to those who suffered a natural loss of their first pregnancy (i.e., due to miscarriage, ectopic pregnancy, or stillbirth) (Reardon &Ney, 2000) [11]. This study also indicated Women with a history of abortion or a history of substance abuse were significantly more likely to feel discomfort in responding to the survey.

Eating Disorders:After an abortion, many women report feelings of destructive behaviors such as eating disorders (Pourreza&Batebi, 2011). Disturbance in eating was reported by almost a third of participants, who reported dietary limitations (Obertinca, 2014). These dietary limitations can result in serious malnutrition. Almost all of them reported unwanted weight loss.

Sexual Dysfunction:According to Fok, et al. (2005), vaginal intercourse had the highest reduction rate among all kinds of sexual activities after abortion. Here the reason is attributed to fear or worry of having another unwanted pregnancy .There are changes in various sexual varieties after induced abortions indicated in [12] (Table 1).

Child Neglect or Abuse:according to Benedict, et al. 2010 study, abortion is linked with increased depression, violent behavior, alcohol and drug abuse, replacement pregnancies, and reduced maternal bonding with children born subsequently. These factors are closely associated with child abuse and would appear to confirm individual clinical assessments linking post-abortion trauma with subsequent child abuse [13].

Post-Traumatic Stress Disorder (PTSD or PAS):One large study found significant rates of long term post-traumatic stress disorder in women after abortion (Korenromp et al., 2005) [14]. Of 254 women followed up two to five years after abortion for fetal anomaly before 24 weeks, 17.3 percent had pathological scores of posttraumatic stress disorder (PTSD). Risk factors were poor educational attainment, inadequate partner support, longer gestational age, and finding that the fetal anomaly was compatible with life. In another study, PTSD was found in 14.3 percent of 217 US women ten years after abortion, though in only 0.9 percent of 331 Russian women after six years. The authors concluded that abortion can increase stress and decrease coping abilities in women with histories of adverse childhood events and previous traumas.

Cougle and Reardon's United States National Longitudinal Study of Youth (NLSY) study found that eight years after pregnancy, married women who had an abortion were 65 percent more likely to score in the high-risk range for clinical depression than those who gave birth (Reardon, 2002) [15]. Reardon also studied psychiatric admissions up to four years after abortion and childbirth (Reardon et al., 2003). It found the abortion group had significantly more admissions for depression (both single episode and recurrent), for bipolar and for adjustment disorders. Another study also looked at the NLSY data and claimed the evidence that having an abortion led to a higher risk of depression than giving birth (Schmiege& Russo, 2005) [16].

A Norwegian study found that women who had abortions were more likely to suffer from depression and anxiety (Broen et al., 2006). Researchers compared 80 women who underwent abortion and 40 who miscarried, following them up after 10 days, six months, two and five years. Compared with the general population, the abortion group experienced more anxiety in all four interviews and more depression at ten days and six months, whereas the miscarriage group had higher anxiety at ten days only.

Guilt, regret, nightmare, decreased self-esteem, and worry about not being able to conceive again were the questions asked from the respondents as the psychological consequences of abortion (Pourreza&Batebi, 2011).

Sleeping Problems, according to (Pourreza&Batebi, 2011) insomnia was reported despite the lack of similar problems in the past. Lack of sleep can lead to an inability to concentrate, memory complaints, and deficits in neuropsychological testing. Additionally, sleep disorders can have serious consequences, including fatal accidents related to sleepiness.

Researchers have identified a large number of statistically significant risk factors that identify which women are at greatest risk of experiencing one or more severe reactions to abortion.

• The lack of information on family planning and the lack of access to contraceptive methods contribute to the increase of these pregnancies and consequently to the increase of abortions in unsafe conditions (Silva & Vieira, 2009; Kaba 2000; Kebede et al. 2000) [17,18].
• The study by Kebede, et al. at Jimma hospital revealed that the reason for induced abortion was due to the economic problem which is 20% and 95% of the women had used either rubber tubes or roots of plants to induce abortion [18].
• Not to disrupt education or employment and too young to bear a child; could not afford to cater for a baby; Partner refused to accept pregnancy to delay, postpone, or stop childbearing were identified as the major factors contributing for abortion(Mote, et al. 2010) [11].
• The study conducted by Desalegn. et al. 2015 indicated that not wanting more children, pre-marital pregnancy, bad timing, the desire to remain in school, the high cost of having more children, and the feeling that the pregnancy was not socially acceptable are some of the most common reasons to abortion [19].
• Personality or behavioral factors may also predispose a woman to unplanned pregnancy and abortion, as well as to mental health problems. There is substantial evidence that problem behaviors tend to co-occur among the same individuals (Willoughby et al, 2004) [20]. Personality factors that diminish the ability to regulate negative emotion also put people at risk for engaging in problem behaviors. For example, high impulsivity and an avoidance style of coping with negative emotions are risk factors for risky sexual behavior, substance use, delinquent behavior, and educational underachievement (Cooper et al., 2003) [21].
• According to Obertinca, 2016, decision of the couple until, anomalies of central nervous system, genetic syndromes, multiplex fetal anomaly, abnormality of the urinary tract, anomaly of the gastrointestinal system, feto-maternal pathology, maternal chronic disease, cardiovascular system anomalies, musculoskeletal system anomalies, pathology of placental are the basic causes of the occurrence of abortion [22-31] (Table 2).
• Other 31 factors are listed in Table 3.

It is estimated that worldwide Very large numbers of abortions are performed each year by unskilled providers and/or in unsanitary conditions. These results indicate the magnitude of abortion in general and unsafe abortion specifically is increasing.

Studies show that hospitals in some developing countries spend almost half of their budgets to treat complications of unsafe abortion. Very high numbers of deaths are due to unsafe abortion, and the percentage can be much higher at country levels.

Abortion could be associated with uncountable psychological problems like Regret, anger, guilt, shame, sense of loneliness or isolation, loss of self-confidence, insomnia or nightmares, relationship issues, suicidal thoughts, and feelings, eating disorders, depression, anxiety is identified by several researchers.

Lack of information on family planning and the lack of access to contraceptive methods, economic problems, not to disrupt education or employment and too young to bear a child; could not afford to cater for a baby; Partner refused to accept pregnancy; to delay, postpone, or stop childbearing were identified as the major factors contributing for abortion

Not all unintended pregnancies are unwanted, and it may be that refining the measurement of pregnancy unwantedness is necessary to understand the combined and independent effects of common risk factors and pregnancy unwantedness on mental health outcomes. Identifying pregnant women who may be at risk for mental health problems and in need of support is an important first step in the process of developing culturally-appropriate and effective programs for the prevention of unintended pregnancy as well as negative mental health outcomes.

There are three known ways to reduce the prevalence of unsafe abortion and its harmful consequences.

A. Expanding access to effective modern methods of contraception and improving the quality of contraceptive information and services may be the strategy that is the most achievable in the near term, and that is most responsive to women’s long-term health needs.

B. Making abortion legal and ensuring that safe abortion services are accessible to all women in need is urgent health, economic and moral imperatives. Unsafe abortion damages the health of millions of women—the poor, predominantly. The consequences of unsafe abortion are costly to already struggling health systems (and more costly than services to prevent unintended pregnancy or provide safe abortion). And restrictive abortion laws are an unacceptable infringement of women's human rights and medical ethics.

C. Improving the quality and coverage of post-abortion care through the increased use of the safest and most cost-effective methods for such care—MVA and medication abortion—at primary-level facilities would allow a higher proportion of cases to be safely treated, and would reduce both maternal mortality and morbidity and the cost of post-abortion services.

Reducing levels of unintended pregnancy would lessen women’s recourse to unsafe abortion. It would also make significant contributions to the survival and health of women and children, the status of women, and the financial stability of households. Eliminating unsafe abortion and providing access to safe abortion would reduce ill health, death and lost years of productivity among women, and avert the financial burden of treating related health complications. Achieving these goals would lead to enormous individual and societal benefits—for women, their families and countries as a whole.

I would like to thank MaddaWalabu University Research, Community Engagement and Technology Transfer Directorate for its initiation to develop this review