National Partnership for Women & Families

Monthly Women's Health Research Review

Study assesses psychosocial factors and women's psychological health prior to receiving abortion care

Summary of "Psychosocial factors and pre-abortion psychological health: The significance of stigma," Steinberg et al., Social Science & Medicine, Dec. 12, 2015.

"Most research in the area of abortion and mental health has focused on the mental health of women after an abortion," though "research consistently finds that depressive, anxiety, and stress symptoms are higher just before abortion compared to anytime afterwards," according to Julia Steinberg of the University of Maryland College Park and colleagues.

Moreover, they explained that "pre-abortion mental health influences coping with the abortion experience ..., and it is the strongest predictor of post-abortion mental health." As a result, "understanding what influences pre-abortion mental health may help women cope effectively, and such an understanding may help promote mental health before and after an abortion," the researchers wrote.

For the study, the researchers used three conceptual frameworks -- "a common risk-factors approach," "a stress and coping perspective" and a "sociocultural framework" -- "to examine predictors of pre-abortion psychological health."

The common risk factors approach asserts "that the correlation between abortion and subsequent mental health is spurious, and driven by factors that are common -- e.g., pre-existing mental health problems, violence, social disadvantage -- among women having abortions and women having mental health problems," the researchers wrote. They noted, "Studies using this approach find that abortion is not associated with worse subsequent mental health problems when these confounding factors are considered in analyses." The researchers "hypothesized that more frequent [intimate partner violence], reproductive coercion and more childhood adversities would be associated with poorer post-abortion psychological health."

According to the researchers, "The stress and coping perspective ... argues that if an individual perceives a situation as stressful, then coping mechanisms are enacted and these coping mechanisms lead to better or worse psychological health." The researchers hypothesized that a woman's pre-abortion psychological health would be poorer "the sooner [she] desired a future pregnancy (which signals something must be amiss to be having an abortion)" and "the less serious and intimate [she] is with her partner (which may be telling of how supportive her partner is)."

The researchers explained that "the sociocultural framework contends that the sociocultural context such as societal stigma influences post-abortion psychological adjustment by influencing how stressful women perceive an abortion and how they cope with this experience." Citing research showing that women in the United States experience abortion stigma, the researchers "included perceived abortion stigma as a possible contributor to pre-abortion psychological health, hypothesizing that the more a woman expected abortion stigma, the poorer her pre-abortion psychological health."

According to the researchers, the study's primary objective "was to examine which, of a variety of psychological factors -- childhood adversities, adverse experience with an intimate partner, relationship context, pregnancy desires, and perceived abortion stigma -- were independently associated with pre-abortion mental health."

Methods

For the study, the researchers recruited women at three abortion clinics who were seeking abortion care because of an unintended pregnancy between July 2012 and February 2013. Participants had to be at least 18 years old.

Women willing to participate were asked to respond to survey questions at two points during their visit to the clinic: once prior to contraceptive counseling and once after the counseling. Due to differences in clinic flow, women at two of the clinics completed the second part of the survey before their abortion while women at the third clinic completed the survey after their abortion.

The researchers assessed participants' "future pregnancy desires, relationship context, recent adverse experiences with an intimate partner, childhood adversities, perceived abortion stigma, depressive, anxiety, and stress symptoms, sociodemographic factors, type of abortion procedure, and trimester of abortion."

Findings

The researchers included 353 women in their final analysis after excluding several women for a variety of reasons, such as incomplete survey responses. The researchers noted, "For each of the predictors and outcomes in this study, [they] compared the 353 women used in the analysis to those of ... 134 excluded women who were not missing on each measure." Overall, "[s]ample sizes ranged from 63 to 123, with all but two of the measures (perceived abortion stigma and type of abortion procedure) having data on over 100 of the 134 excluded women," the researchers wrote.

In terms of sociodemographic factors, the researchers found that:

  • 60 percent of the 353 participants were ages 20 to 29;
  • 74.4 percent were women of color;
  • 76.8 percent did not have a college degree;
  • 64.3 percent had annual household incomes under $10,000; and
  • 77.1 percent had never been married.

Regarding abortion characteristics, the researchers found that most of the 353 participants had a surgical abortion (68.8 percent) and sought abortion care in the first trimester (93.4 percent).

The researchers also found, in terms of childhood adversities:

  • 55.8 percent of the 353 participants reported low economic status;
  • 50 percent reported psychological abuse;
  • 38.8 percent said they grew up with someone who had a substance use disorder;
  • 34.8 percent grew up with someone who was depressed or anxious;
  • 31.7 percent reported physical abuse;
  • 25.0 percent grew up with a father figure who acted violently toward their mother;
  • 17.8 percent grew up in a house where someone went to prison; and
  • 13 percent reported sexual abuse.

Overall, according to the researchers, 62.3 percent of the 353 participants said they experienced at least two of the eight childhood adversities.

Regarding recent adverse experiences with an intimate partner, the researchers found:

  • 34.6 percent of the 353 participants reported experiencing recent verbal violence;
  • 11.9 percent reported experiencing pregnancy coercion;
  • 7.4 percent reported experiencing recent physical violence;
  • 7.4 percent reported recent contraception sabotage by a partner; and
  • 4.8 percent reported experiencing recent sexual abuse from an intimate partner.

The researchers found that the mean score for participants' depressive symptoms, based on the Center for Epidemiological Study Depression Scale, was 23.4. Relatedly, the researchers found that the mean score for participants' anxiety and stress symptoms -- both based on the Depression, Anxiety and Stress Scale -- were 7.9 and 12.4, respectively. According to the researchers, all three scores "were comparable to previous research assessing psychological health among women just before having an abortion." The researchers noted that younger women "had more depressive ... and anxiety symptoms," while those who had at least some college education "had more stress symptoms than those with a high school education or less." The researchers also found that women who had medication abortion "had more pre-abortion anxiety symptoms than those having a surgical abortion."

Regarding psychosocial factors and psychological health, the researchers found that the "more childhood adversities" a woman experienced, "the more pre-abortion depressive ..., anxiety ..., and stress symptoms" she reported. Similarly, "the more often women experienced intimate partner violence or reproductive coercion the more pre-abortion depressive, anxiety, and stress symptoms women reported," the researchers wrote. According to the researchers, the less a woman spoke to her intimate partner about "things that really mattered," the more she experienced "pre-abortion depressive and stress symptoms." A woman also reported more depressive and stress symptoms the "less amount of time in which [she] desired a future pregnancy," the researchers found. They also found that "[p]erceiving more abortion stigma was strongly associated with more pre-abortion depressive, anxiety, and stress symptoms."

When assessing the information via a hierarchical linear regression model, the researchers found that the "total amount of variance explained by all the predictors" -- including "sociodemographics, abortion characteristics, number of childhood adversities, adverse experiences with an intimate partner, relationship context factors, future pregnancy desires, and perceived abortion stigma" -- on depressive, anxiety and stress symptoms "was 32.0% of depressive symptoms, 30.1% of anxiety symptoms, and 27.7% of stress symptoms." They noted, "Perceived abortion stigma, which was entered last, explained the most total additional variance for both depressive and stress symptoms," adding 13.2 percent to the total variance of depressive symptoms and 10.7 percent to the total variance of stress symptoms. It also "explained the second most additional total variance in anxiety symptoms, an additional 9.6%," the researchers wrote.

They noted, "In order to further examine whether perceived abortion stigma seemed to explain the most additional variance when entered last in the regression analysis, we also ran models in which we entered each of the other four types of psychosocial factors -- childhood adversities, adverse experiences with intimate partner, relationship context, and pregnancy desires -- last." When the researchers added in childhood adversity last, they found that it "seemed to account for the next highest amount of total variance," accounting for 4.5 percent of the variance in depressive symptoms, 5.7 percent of the variance in anxiety symptoms and 3.6 percent of the variance in stress symptoms.

According to the researchers, "The other factor that explained a large proportion of total variance was number of childhood adversities, which explained 10.4%, 10.8%, and 8.3% of the total variance in depressive, anxiety, and stress symptoms, respectively."

The researchers wrote that in the study's final model, "significant predictors of depressive symptoms were: age, education (high school or less versus at least some college), total number of childhood adversities, intimate partner violence, and perceived abortion stigma." Specifically, they found that women tended to have more pre-abortion depressive symptoms if they were younger, had some college education, had a higher number of childhood adversities, more frequently experienced intimate partner violence and perceived more abortion stigma. According to the researchers, "Pre-abortion anxiety and stress symptoms had the same predictors in the same direction with the exception of the predictor of intimate partner violence, which was not associated with either of these in final models." Rather, women reported more pre-abortion anxiety and stress symptoms "the more often [they experienced] reproductive coercion in the past six months."

Discussion

"While various factors independently predicted pre-abortion psychological health, perceived abortion stigma appeared to explain the most amount of additional variance in depressive, anxiety, and stress symptoms after all other predictors were entered," the researchers wrote. According the researchers, the findings that showed that "[t]he association between abortion stigma and pre-abortion depressive, anxiety and stress symptoms was strong and highly significant" indicate "that helping women feel less stigmatized about having an abortion may be important for lowering pre-abortion depressive, anxiety and stress symptoms." Moreover, the finding that "pre-abortion psychological health was the strongest predictor of post-abortion psychological health ... also suggest[s] that abortion stigma is a large contributor to post-abortion psychological health," the researchers wrote, noting that, as a result, "reducing abortion stigma may also promote post-abortion mental health."

The researchers explained that other factors contributing "to pre-abortion psychological health were number of childhood adversities, age and education, with more adversities, younger age and higher education predicting more pre-abortion depressive, anxiety, and stress symptoms." Further, "experiencing more frequent reproductive coercion predicted more pre-abortion anxiety and stress symptoms, while experiencing more frequent intimate partner violence predicted more pre-abortion depressive symptoms," they wrote, noting that that the study was the first "to show reproductive coercion relates to mental health."

According to the researchers, the levels of depressive, anxiety and stress symptoms found among pre-abortion women in the study "are similar to other samples of women just about to receive an abortion," but they are "elevated relative to other samples." For example, they noted that "women of similar demographics not just about to have an abortion" had a lower mean score on the depressive measure, while a sample of U.S. adults and a sample of post-partum women had lower scores on the anxiety and stress scales. The researchers wrote, "The elevated levels of depressive, anxiety, and stress symptoms pre-abortion compared to other (similar) samples suggests that understanding what contributes to pre-abortion psychological health is warranted."

Noting that "pre-abortion psychological health has consistently been shown to be a strong predictor of post-abortion psychological health," the authors contended that "helping women reduce pre-abortion psychological distress is important and to do that, we need to understand what predicts pre-abortion psychological health." They recommended that further research examine "other potential predictors such as attitudes and feelings towards abortion, partner support more directly, and the abortion decision-making process among women."

The researchers added that the study's findings on the role of perceived abortion stigma on variance in pre-abortion psychological health "suggest more research adopting the sociocultural perspective, which considers the sociopolitical climate of the abortion, to examine the relationship between abortion and subsequent mental health would be fruitful." They concluded that "reducing abortion stigma may promote mental health before an abortion."