Congressional Record, Volume 146 Issue 125 (Tuesday, October 10, 2000)

[Congressional Record Volume 146, Number 125 (Tuesday, October 10, 2000)]
[House]
[Pages H9524-H9532]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

SENSE OF CONGRESS WITH RESPECT TO POSTPARTUM DEPRESSION

Mr. BILIRAKIS. Mr. Speaker, I move to suspend the rules and agree to
the resolution (H. Res. 163) expressing the sense of the House of
Representatives with respect to postpartum depression.
The Clerk read as follows:

H. Res. 163

Whereas postpartum depression is the name given to a wide
range of emotional, psychological, and physiological
reactions to childbirth including loneliness, sadness,
fatigue, low self-esteem, loss of identity, increased
vulnerability, irritability, confusion, disorientation,
memory impairment, agitation, and anxiety, which challenge
the stamina of the new mother suffering from postpartum
depression and can intensify and impair her ability to
function and nurture her newborn(s);
Whereas as many as 400,000 American women will suffer from
postpartum depression this year and will require treatment.
This constitutes up to 20 percent of women who give birth.
Incidence of mild, ``transitory blues'' ranges from 500 to
800 cases per 1,000 births (50 to 80 percent);
Whereas postpartum depression is the result of a chemical
imbalance triggered by a sudden dramatic drop in hormonal
production after the birth of a baby, especially in women who
have an increased risk. Those women at highest risk are those
with a previous psychiatric difficulty, such as depression,
anxiety, or panic disorder. Levels of risk are greater for
those with a family member suffering from the same, including
alcoholism;
Whereas women are more likely to suffer from mood and
anxiety disorders during pregnancy and following childbirth
than at any other time in their lives. 70 to 80 percent of
all new mothers suffer some degree of postpartum mood
disorder lasting anywhere from a week to as much as a year or
more. Approximately 10 to 20 percent of new mothers
experience a paralyzing, diagnosable clinical depression;
Whereas many new mothers suffering from postpartum
depression require counseling and treatment, yet many do not
realize that they require help. It is imperative that the
health care provider who treats her has a thorough
understanding of this disorder. Those whose illness is severe
may require medication to correct the underlying brain
chemistry that is disturbed. This often debilitating
condition has typically been a silent condition suffered
privately by women because of the feelings of shame or guilt;
Whereas postpartum depression frequently strikes without
warning in women without any past emotional problems, without
any history of depression and without any complications in
pregnancy. Postpartum depression strikes mothers who are in
very satisfying marriages as well as those who are single. It
strikes women who had easy pregnancies and deliveries, as
well as women who suffered prolonged, complicated labors and
caesarean section deliveries. Symptoms may appear at any time
after delivery, often after the woman has returned home from
the hospital. It may strike after the first, third, or even
fourth birth;
Whereas postpartum depression is not a new phenomenon.
Hippocrates observed the connection between childbirth and
mental illness over 2,000 years ago. Louis V. Marce, a French
physician, detailed the identifiable signs and symptoms of
postpartum depression in 1858;
Whereas the most extreme and rare form of this condition,
called postpartum psychosis, hosts a quick and severe onset,
usually within 3 months. 80 percent of all cases of this more
extreme form present within 3 to 14 days after delivery with
intensifying symptoms; once suffered recurrence rate with
subsequent pregnancies is high;
Whereas postpartum mood disorders occur after the mother
has had frequent contact prenatally with health care
professionals who might identify symptoms and those at risk.
In the United States, where medical surveillance of new
mothers often lapses between discharge from the hospital and
the physical checkup 6 weeks later, the recognition of
postpartum illness is left mainly to chance. The focus of the
6-week checkup is on the medical aspects of her reproductive
system and not her mental health;
Whereas having a baby often marks one of the happiest times
in a woman's life. For 9 months, she awaits her child's birth
with a whole range of emotions ranging from nervous
anticipation to complete joy. Society is quite clear about
what her emotions are expected to be once the baby is born.
Joy and other positive feelings are emphasized, while sadness
and other negative emotions are minimized. It is culturally
acceptable to be depressed after a death or divorce but not
by the arrival of an infant. Because of the social stigma
surrounding depression after delivery, women are afraid to
say that something is wrong if they are experiencing
something different than what they are expected to feel.
Mothers are ashamed, fearful, and embarrassed to share their
negative feelings and can also be fearful of losing their
babies;
Whereas treatment can significantly reduce the duration and
severity of postpartum psychiatric illness;
Whereas postpartum depression dramatically distorts the
image of perfect new motherhood and is often dismissed by
those suffering and those around her. It is thought to be a
weakness on the part of the sufferer--self-induced an self-
controllable;
Whereas education can help take away the ``stigma'' of
postpartum depression and can make it easier to detect and
diagnose this disorder in its earliest stages, preventing the
most severe cases;
Whereas at present, the United States lacks any organized
treatment protocol for postpartum depression. Sufferers have
few treatment resources. The United States lags behind most
other developed countries in providing such information,
support, and treatment;
Whereas the United States Government and its agencies
collect very little data on postpartum illness;
Whereas if early recognition and treatment are to occur,
postpartum depression must be discussed in childbirth classes
and obstetrical office visits, as are conditions, such as
hemorrhage and sepsis;
Whereas early detection, diagnosis, and treatment of
postpartum illness will become easier if public education is
enhanced to lift the social stigma, thereby increasing the
chance that women will inform others of her

[[Page H9525]]

symptoms as she would for physical complications;
Whereas research shows that in the first few weeks after
delivery, a woman's chance of requiring a psychiatric
admission is 7 times higher than at any other time in her
life. It is estimated that as many as 90 percent realize
something is wrong, but less than 2 percent report symptoms
to their health care provider. The remaining individuals are
either undiagnosed, misdiagnosed, or seek no medical
assistance;
Whereas it is estimated that as many as 90 percent of women
realize something is wrong; however less than 2 percent
report symptoms to their health care provider. Only about 20
percent of women with the disorder receive treatment. The
remaining individuals are either undiagnosed, misdiagnosed,
or seek no medical assistance;
Whereas in addition to the mother, the effects of
postpartum depression can also impact the child and the
father significantly. Infants of mothers with postpartum
depression are at risk for socioemotional difficulties in
life. Maternal depression can affect the mother's ability to
respond sensitively to her infant's needs. A depressed mother
is less likely to provide her children with appropriate
levels of stimulation and to express positive affect.
Research generally shows that children who receive warm and
responsive caregiving from the moment of birth and are
securely attached to their caregivers cope with difficult
times more easily when they are older. They are more curious,
get along better with other children, and perform better in
school than those who are less securely attached;
Whereas a mother's marriage can also become severely
strained when dealing with a postpartum illness. Husbands/
fathers feel anxious and helpless, not understanding what is
going wrong or what is the source of the depression. They can
express exasperation and even resentment as a result of the
problems created by the illness. They are also more likely to
become depressed themselves, further compromising the
functioning of the family. Lack of support from the partner
can contribute to the development or continuation of
postpartum depression. Husbands, partners, family members,
and friends need access to information on these issues in
order to support their wives, relatives, or friends;
Whereas severe postpartum illness can obstruct the
important pattern of friendship and support that most couples
with newborns tend to form. Family units as a whole can
experience isolation;
Whereas education is helpful to new parents coping with
these emotional and hormonal changes and also helps them to
decide if and when they need to seek outside help; and
Whereas postpartum depression is one of the most treatable
and curable of all forms of mental illness. Learning about
postpartum depression helps prevent it and relieve it: Now,
therefore, be it
Resolved, That the House of Representatives--
(1) recommends that all hospitals and clinics which deliver
babies provide departing new mothers and fathers or family
members with complete information about postpartum
depression, its symptoms, methods of coping with it, and
treatment resources;
(2) encourages all obstetricians to inquire prenatally
about any psychiatric problems the mother may have
experienced, including substance abuse, existence of the
above in any family members, and, ideally screen for ongoing
depression;
(3) encourages all obstetricians to screen new mothers for
postpartum depression symptoms prior to discharge from the
hospital and again when they bring in their babies for early
checkups;
(4) recommends that appropriate health care professionals
be trained specifically in screening women for signs of
postpartum depression in order to improve chances of early
detection;
(5) recognizes that a coordinated system of registry should
be developed to collect data on mental disorders in the new
mother and that the National Institutes of Health should
undertake additional research on postpartum psychiatric
illnesses;
(6) recognizes the impact of a mother's postpartum
depression on fathers and other family members as well and
strongly encourages that they be included in both the
education and treatment processes to help them better
understand the nature and causes of postpartum depression so
they too can overcome the spillover effects of the condition
and improve their ability to be supportive; and
(7) calls on the citizens of the United States,
particularly the medical community, to learn more about
postpartum depression, how to educate women and families
about it, and thus ultimately lower the likelihood that women
around the country will continue to suffer in silence.

The SPEAKER pro tempore. Pursuant to the rule, the gentleman from
Florida (Mr. Bilirakis) and the gentleman from Ohio (Mr. Brown) each
will control 20 minutes.
The Chair recognizes the gentleman from Florida (Mr. Bilirakis).

General Leave

Mr. BILIRAKIS. Mr. Speaker, I ask unanimous consent that all Members
may have 5 legislative days within which to revise and extend their
remarks and include extraneous material on H. Res. 163, the legislation
now under consideration.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Florida?
There was no objection.
Mr. BILIRAKIS. Mr. Speaker, I yield myself such time as I may
consume, and I rise today in support of H. Res. 163, a resolution
expressing the sense of the House of Representatives regarding
postpartum depression, legislation introduced by our colleague, the
gentleman from Georgia (Mr. Kingston).
This year, as many as 20 percent of American mothers will suffer from
postpartum depression. The resolution before us recognizes that this
condition is the result of a chemical imbalance triggered by a sudden
dramatic drop in hormonal production after the birth of a baby. H. Res.
163 is designed to increase public awareness and understanding so that
thousands of women will no longer be forced to suffer in silence.
Among its provisions, the resolution encourages all obstetricians to
screen new mothers for postpartum depression symptoms prior to
discharge from the hospital and again when they bring in their babies
for early checkups. It also recommends that appropriate health care
professionals be trained specifically in screening women for signs of
postpartum depression in order to improve chances of early detection.
Mr. Speaker, H. Res. 163 emphasizes our commitment to increased
access to information about postpartum depression, its symptoms and
treatment resources. I ask every Member to join me in supporting
passage of this important resolution by the House today.
Mr. Speaker, I reserve the balance of my time.
Mr. BROWN of Ohio. Mr. Speaker, I yield myself such time as I may
consume.
Mr. Speaker, I rise today in strong support of H. Res. 163, which
focuses on a condition that has not received the attention that it
deserves. I want to commend my colleagues, the gentleman from Georgia
(Mr. Kingston) and especially the gentlewoman from California (Mrs.
Capps), for introducing this resolution.
The gentlewoman from California (Mrs. Capps), a nurse, is one of the
most knowledgeable and active members of the Subcommittee on Health and
Environment of the Committee on Commerce. I feel privileged to work
with her in the subcommittee, and I am proud to join her as a cosponsor
of this resolution.
The gentlewoman from California's district is home to Postpartum
Support International, an advocacy and support group founded by Jane
Honikman. Jane is a pioneer in this field, and I know the gentlewoman
from California would want to acknowledge her important contribution,
as we do here today.
Each year, 400,000 American women, 20 percent of those who give
birth, experience some postpartum depression caused by chemical
imbalance. Hundreds of thousands more experience some of the symptoms,
which can include such impairments as disorientation, memory
impairment, profound anxiety, and heightened fatigue. This is not an
exhaustive list.
It is tragic that so many new mothers are robbed of the joy at such a
miraculous time in their lives, and it is tragic that postpartum
depression is so often ignored or stigmatized when it should be
aggressively treated.
The first months of life are critical for a newborn and profoundly
challenging for new mothers. This resolution recommends several
important steps the Nation can take to help new mothers and to help
their families cope with postpartum depression.
It recommends providing women with information on postpartum
depression before they take their babies home from the hospital so that
women affected by this condition recognize the symptoms and seek help
as soon as possible.
It recommends providing training so health professionals know what
signs to look for in new mothers. Doctors should be encouraged to
screen new mothers for symptoms prior to discharging them from the
hospital and when they bring their babies for early checkups.
And it also recommends we begin to collect data on postpartum
depression in the United States.

[[Page H9526]]

To effectively target public awareness and treatment, it is important
to track the incidence and the prevalence of this condition in
different subpopulations. Again, I applaud the gentleman from Georgia
(Mr. Kingston) and the gentlewoman from California (Mrs. Capps) for
offering this resolution, and I urge its passage.
Mr. DINGELL. Mr. Speaker, I support H. Res. 163, which recognizes the
debilitating effects of post-partum depression on new mothers, their
babies and their families. I want to pay particular tribute to my
friend and colleague, Representative Capps, as well as Representative
Kingston, for their work on this matter.
H. Res. 163 encourages health care providers to become more attuned
to the signs of this common, treatable aftermath of pregnancy in order
to detect the problem in its earliest days and offer appropriate
interventions.
This weeks' announcement that the Nobel prize in medicine is being
awarded to three scientists whose discoveries have unlocked keys to the
central nervous system, including the understanding the biochemical
underpinnings of depression, underscores the importance of the mind-
body connection. Depression is indeed a physiologic response, and there
is no time in a woman's life when her physiology changes as markedly
and as abruptly as it does with the delivery of a baby. Set against the
excitement of a new birth, the emergence of an unexpected mood
disorder, such as post-partum depression, can be frightening and
confusing. Ironically, detecting this problem takes us back to the
heart of the patient-provider relationship by employing our lowest-
tech, most-highly valued tools, talking and listening to the patient.
The American College of Obstetricians and Gynecologists suggests that
thorough medical history-taking as early as the first prenatal visit
can assist providers in identifying those women at highest risk for
post-partum depression. Post-partum depression can be diagnoses by
simply asking a new mother about a number of aspects of here new life.
Her answers and mood are keys to an early and correct diagnosis. This
approach also provides an opening for a woman to discuss feelings she
may finding shameful and frightening. With an accurate diagnosis,
treatment can begin, benefitting mother, baby and family.
As Congress today recognizes the research and treatment needs of
women experiencing post-partum depression, we must also recognize that
many of the women at highest risk for this condition live outside of
the health care safety net, and therefore will not benefit from early
detection and intervention. The Congress must work to solve these
inequities. We must also work to assure that whatever reforms occur in
the healthcare delivery system, providers must never stop talking with
their patients. As the lines between medical and mental health problems
blur, all health care providers need access to the most up-to-date
information, so that opportunities to diagnose and treat problems such
as post-partum depression are not missed. This resolution is one step
in that direction.
Mrs. CAPPS. Mr. Speaker, I rise today in strong support of H. Res.
163, which calls attention to a condition that affects thousands of
women across this country, post partum depression.
This resolution was introduced in May of 1999 by my colleague Jack
Kingston and I. I want to thank him for his hard work and leadership in
this area.
Approximately 400,000 women will experience post partum depression
this year, and many do not even know that they need help. This
condition can put a strain on family relationships, at a time when most
families are often experiencing the joy of the birth of a child.
As a nurse for many years, I have seen firsthand how much women,
their families and partners struggle with this difficult condition.
There is great stigma associated with post partum depression, as many
women feel ashamed of the feelings that they are experiencing.
There are some steps that can be taken to alleviate this suffering.
Our resolution makes some important recommendations.
This legislation recommends that women be provided with information
on post partum depression before they leave the hospitals with their
babies. This way they can know what signs to look for in those early
post-natal days.
It also calls for more training of medical providers, so that they
know what signs to look for in new mothers. Doctors should be
encouraged to screen new mothers for symptoms prior to discharge from
the hospital and when they bring their babies for early check-ups. The
earlier we identify the symptoms, the better.
Finally it recommends that we begin to collect data on post partum
depression in the U.S., so that we can measure its extent. The National
Institute of Mental Health is currently researching the topic, but more
must be done. Federal funding is sorely needed in this area.
My district is home to Post Partum Support International, an advocacy
and support group founded by my constituent Jane Honikman. Jane is a
pioneer in this field, and I applaud the work that she continues to do
on this topic every day.
Mr. Speaker, here in Congress we must work to raise awareness of
post-partum depression, in order to ultimately lower the likelihood
that women around the country will continue to experience it. Women and
families around this country have suffered for too long in silence.
Mr. BLILEY. Mr. Speaker, I rise in support of H. Res. 163, which
expresses the sense of the House of Representatives with respect to
postpartum depression.
The birth of a child is a most joyous occasion for a family.
Unfortunately, postpartum depression after childbirth is a common
condition for some new moms. In fact, up to 80 percent of new moms
experience ``baby blues,'' a mild depression that begins in the first
days after childbirth and lasts 2 weeks or less. Postpartum depression
lasts longer than the ``baby blues'' however and its symptoms are far
more intense and constant.
This condition also affects women who for whatever reason do not
carry their pregnancy to term. The sudden and dramatic drop in hormonal
production after the termination of pregnancy often results in feelings
of guilt, insomnia, and postpartum depression. The same sudden drop in
hormonal production found in women with postpartum depression also
contributes to the feelings of guilt, insomnia, and depression
immediately following an abortion. In fact, a national poll found that
at least 56 percent of women experience a sense of guilt over their
decision to have an abortion, and a 5-year study shows that 25 percent
of women who have had abortions sought out psychiatric care, versus
just 3 percent of women who have not had abortions. Further, numerous
studies reveal that women who have had an abortion experience a high
incidence of depression, stress, low self-esteem, suicidal feelings,
and substance abuse. Some abortion reactions may even fit into the
model of complicated bereavement or pathological grief.
I ask unanimous consent to enter into the Record two studies on the
link between clinical depression and abortion (Angelo, E.J.,
``Psychiatric Sequelae of Abortion: The Many Faces of Post-Abortion
Grief,'' Linacre Quarterly, 59(2): 69-80, 1992; Brown, D., Elkins,
T.E., Lardson, D.B., ``Prolonged Grieving After Abortion,'' J Clinical
Ethics, 4(2): 118-123 (1993)).
In light of these widespread and related afflictions, Congress should
be more attentive to post-abortion depression as a related condition
that calls out for more research from the National Institutes of
Health. I urge Members to join me in supporting passage of H. Res. 163.

Psychiatric Sequelae of Abortion: The Many Faces of Post-Abortion Grief

(By E. Joanne Angelo, M.D.)

This paper was presented at the N.F.C.P.G. annual meeting
in October of 1991.
Induced abortion is the surgical or medical intervention in
a pregnancy for the purpose of causing the death of the
embryo or fetus. (If the procedure results in a live birth,
the outcome is a preterm delivery, not an abortion.) Every
abortion, then, is an iatrogenic death. Every post-abortion
woman has undergone a real death experience--the death of her
child.
Grief is a natural consequence of death. Current
obstetrical and psychiatric literature abounds with articles
about grief following perinatal death--death due to
spontaneous abortion, premature birth, stillbirth, and Sudden
Infant Death Syndrome. However, it is only in recent years
that the medical profession has begun to understand that
perinatal losses can be followed by a grief reaction similar
to the loss of an older child or an adult as illustrated by
the following statement in Clinics of OB/GYN in 1986. ``I can
state most assuredly that couples with recurrent, unexplained
or explained early pregnancy losses grieve as intensely as
those with later losses or losses of live-born children.
Their grief is not visible, however, since society, family,
friends, press, or clergy do not support or are not trained
to support them. The grief is very real and if unattended can
eventually be felt by them to be aberrant, unnatural, or even
unhealthy.''
Hospital obstetrical units have developed teams of
physicians, nurses, and social workers to help parents deal
with perinatal death and the issues of grief, anger, and
guilt which it raises. The September 1990 issue of the
British Journal of Obstetrics and Gynecology states: ``Ways
of helping parents cope with their losses have been
recommended and have reduced the frequency of prolonged
emotional disturbance and of abnormal grief reactions. . . .
Ways of facilitating the grieving process have been
identified. These include seeing and holding the dead baby,
giving it a name and taking photographs; all help make the
situation a reality and to create memories. It is difficult
to grieve when no memory of the individual exists.''

[[Page H9527]]

In addition to the 20 to 30 percent of pregnancies thought
to end in spontaneous abortion in this country, there is now
one elective abortion for every three live births. Evidence
is mounting that the reaction to the loss of a child from
induced abortion is part of the same continuum of grief.
In an editorial in the Lancet (March 2, 1991) entitled,
``When is a fetus a dead baby?,'' the author acknowledges
that grief follows early pregnancy loss regardless of its
cause, ``There is no doubt that the profession, led by
society, more readily accepts that miscarriage,
termination, stillbirth, and neonatal death lie in a
spectrum of the same grief. . . . Why should the death of
a baby be a unique zone of grief? Perhaps it is because to
the parents, and to the mother in particular, an unknown
potential has been lost.'' With half of all pregnancies
resulting in fetal death, our society is facing a
potential epidemic of invisible mourning and pathological
grief.
Grief after induced abortion is often more profound and
delayed than grief after other perinatal losses. Grief after
elective abortion is uniquely poignant because it is largely
hidden. The post-abortion woman's grief is not acknowledged
by society because the reality of her child's death is not
acknowledged. In order to gain her consent for the abortion
she has been told that the procedure will remove a ``blob of
tissue'' a ``product of conception'', or a ``pre-embryo.''
She has been assured that her ``problem will be solved'' and
that she will be able to ``get on with her life'' as though
nothing significant had happened.
Yet the pregnant woman knows by the changes in her body
that something very significant is happening to her: her
menses have stopped, her breasts are enlarging, she is sick
in the morning (or all day long), and she knows that the
process which has begun in her will most likely result in the
birth of a baby in nine months time if allowed to run its
course. She is aware of the expected date of delivery and she
has often thought of a name for her baby as she has begun to
picture the child as he or she would be at birth (Bonding
begins very early in pregnancy.). All of these feelings and
fantasies about her pregnancy must be denied in order to
undergo an elective abortion. The pregnant woman is asked to
deny the fact that she is carrying a child at all!
Society offers her no support in grieving. Her decision to
undergo an abortion is made very quickly without time for
calm reflection or seeking advice. The whole process is
usually kept secret from her family and friends and
professional colleagues, and often even from the father of
her child. Abortion clinics offer no ``Perinatal Loss Team''
to help her deal with her confusing and perhaps overwhelming
feelings. She is typically alone, without her partner during
the procedure. There is no dead child to hold, no
photographs, no funeral, burial, or grave to visit, no
consolation from friends, relatives or clergy. Her only
memories are of a rushed, painful procedure and of her own
efforts to convince herself that what her ``abortion
counselor'' had told her was true. The psychological defense
mechanisms of denial and repression are massively in effect
by the time she leaves the clinic. It is not surprising then,
that ``exit poll'' research and studies of the immediate
post-abortion days, weeks and months find that women feel
relieved and claim to have no adverse psychological
aftereffects of elective abortion. When pain and bleeding
remind her of the physical assault on her body and when
the sudden and unnatural endocrine changes cause her to
become emotionally labile, society continues to expect her
to act as if nothing had happened. Her attempts to comply
with those expectations are at great personal expense. She
may begin to dose herself with alcohol or sleeping pills
to deal with the nightmares and her feelings of grief and
guilt; she may throw herself into intense activity--work
or study or attempts to repair her intimate relationships
or to develop new ones. When waves of sadness, anger,
emptiness, and loneliness overwhelm her she berates
herself for not ``feeling fine'' as is expected of her.
Women who have chosen abortion are often haunted by the
obsessive thought, ``I killed my baby!'' They find themselves
alone to cope not only with the loss of the child they will
never know, but also with their personal responsibility in
the child's death. their guilt is not merely subjective or
neurotic; it is objective and real. Reminders are all around
them--the expected date of delivery, children the same age
that their children would have been, a visit to the
gynecologist, the sound of the suction machine in the
dentist's office, a baby in a television ad, a new birth,
another death experience. Each of these may trigger a
breakthrough of guilt, grief, anger, and even despair. This
cycle typically continues for many months or years before
appropriate help is found because until recently mental
health professionals have failed to recognize the many faces
of post-abortion grief.

uncomplicated bereavement (normal grief)

Grief is the subjective experience which follows the death
of a loved one. Psychiatrists agree that the period of
mourning after a significant loss normally continues for at
least a year after the death, and that if ``grief work'' is
not accomplished appropriately, unresolved grief can produce
a variety of psychological and psychosomatic symptoms over
time.
Horowitz divides normal grief into four stages:
1. OUTCRY which occurs immediately after the death when
there may be an intense expression of emotion and an
immediate turning to others for help and consolation.
2. DENIAL PHASE during which the bereaved person may avoid
reminders of the deceased and focus attention on other things
and during which an emotional numbness of blunting may occur.
3. INTRUSION PHASE during which negative recollections of
the deceased become frequent, including bad dreams and
daytime preoccupations which may interfere with concentration
on other tasks.
4. WORKING THROUGH during which the bereaved person begins
to experience both positive and negative memories of the
deceased, but without the intrusive, disturbing quality which
they had had previously and when emotional numbness lessens.
The process of working through has reached completion when
the bereaved person once again has the emotional energy to
invest in new relationships, to work, to create, and to
experience positive states of mind.

Pathological Grief

Pathological grief occurs when the normal stages of grief
are intensified, prolonged or delayed and when the bereaved
person is not able to resume normal functioning due to the
development of other psychiatric of psychophysiologic
symptoms. Horowitz gives the following examples of
pathological grief.
Immediately following the death the OUTCRY may be
intensified into a panic state where behavior is erratic, and
self-coherence is lost in a flood of uncontrolled fear and
grief. Alternatively, the bereaved person's withdrawal may be
exaggerated into a dissociative state or a reactive psychotic
state.
When the DENIAL PHASE is pathological the following may
occur; ``overuse of alcohol or drugs to anesthetize the
person to pain. Some persons may seek to jam all channels of
consciousness with stimuli, avoiding thinking and feeling
about the death. To escape feeling dead and unreal, one may
engage in frenzied sexual, athletic, work, thrill-seeking, or
risktaking activities.''
Risk factors for the development of pathological grief are
listed in Michels' 1990 textbook Psychiatry:
``Some circumstances are likely to increase the severity or
duration of grief reactions. These include pre-existing high
dependency on the deceased, pre-existing frustration or
anxiety in relating to the deceased, unexpected or tortuous
deaths, a sense of alienation from or antagonism to others, a
history of multiple, unintegrated earlier losses or
simultaneous losses, and real or fantasied responsibility for
the suffering or death itself. When several of these factors
are present, a complicated bereavement reaction may result
that warrants diagnosis as one of the anxiety or depressive
disorders (including Post-traumatic Stress Disorder), an
adjustment disorder, reactive psychosis, or a flare up of a
pre-existing personality disorder.''

Depression

Pathological or unresolved grief has long been recognized
as a precursor to serious depressive illness. Shakespeare's
Macbeth says, ``Give sorrow words; the grief that does not
speak knits up the o'erwrought heart and bids it break . .
.'' The current Diagnostic and Statistical Manual of Mental
Disorders states, ``morbid preoccupation with worthlessness,
suicidal ideation, marked functional impairment, or
psychomotor retardation, or prolonged duration suggests that
bereavement is complicated by a Major Depressive Episode.''
In a review article, ``Mental Health and Abortion'' in the
Psychiatric Journal of the University of Ottowa (1989),
Phillip Nay concludes that although depression was once a
frequent indicator for induced abortion, ``depression is
likely to be worsened by abortion because if increases guilt
and causes another loss.''
Depressive disorders are the most common reason for
psychiatric referral of post-abortion women in my experience.
Suicidal ideation, impairment of the ability to carry out
daily functions at work, school, or home, somatic symptoms
such as weight loss and insomnia make psychiatric care
imperative. Psychiatric intervention often includes anti-
depressant medication and/or hospitalization, as well as
intensive psychotherapy. Although the diagnosis of Major
Depressive Episode is made and appropriate initial treatment
instituted, the significance of the early pregnancy loss
through abortion as a causative factor is often overlooked.
This may occur for a number of reasons.
1. The patient may not volunteer her abortion history, and
may be reluctant to answer routine questions about her
reproductive history because of intense shame and guilt and
because of a lack of a trusting relationship with her
therapist, which takes time to develop.
2. A long time may have passed since her abortion, and the
psychiatrist may not be aware of the very common delay of
eight to ten years from the induced abortion until the woman
seeks help for her depression, which has become so severe
that she can no longer function and her life is in danger. An
eight to ten year delay in seeking help has been a common
finding in outreach programs to post-abortion women across
the United States.
3. So many other negative factors in the history could
account for the woman's depression: alcohol and drug abuse,
failed marriages, job stress, intrusive obsessive

[[Page H9528]]

thoughts which may appear to be psychotic in nature. An
example of the latter is the case of a 75 year old woman in a
nursing home who was heard muttering over and over again ``I
killed my baby!'', and who, in fact, had an abortion sixty
years before.
4. Society's ``blind spot'' regarding the significance of
perinatal loss and the grief following induced abortion is
shared by many psychiatrists and other mental health
professionals. If her tentative attempts to share her
profound grief and guilt with her therapist are not heard or
are belittled, the post-abortion women's sense of
worthlessness and despair may increase and she may be
confirmed in her conviction that no one will ever understand
or be able to help. She may discontinue her medication,
cancel appointments, and sink even more deeply into
depression.
Peterson, who is studying post-abortion women in Germany,
believes that when deep feelings of guilt which have been
suppressed for a long time are followed by ``a breakthrough
of destructive deep awareness, with chaos and panic,
revulsion and hate'' these feelings must be acknowledged and
the woman helped to come to ``acceptance of existing reality,
responsibility and feeling of guilt toward the dead child.''
It is my experience that only when the therapist can endure
the flood of primitive emotions which the patient needs to
pour out over a number of sessions without rejecting her
or asking her to diminish their intensity, can he or she
begin to help the post-abortion woman in her work of
mourning.
Although there are no visual memories of her child, no
pictures, no shared experiences to help her work through the
grief process, she has frequently formed a mental image of
her child. It is in fact that mental image which has been
haunting her, intruding itself into her thoughts day and
night. Often the image is of an infant being torn to pieces
sucked down into a tube, crying out in pain, or reaching out
to her for help. She has often named her child and may have
regularly occurring conversations with him or her in her
mind. The work of therapy involves allowing her to share
these images and to accept her guilt while at the same time
the therapist is kind and supportive to her. Gradually she
will learn to accept the reality of what has happened and her
own responsibility in the death of her child. In time she can
begin to develop a mental image of her child no longer
suffering and crying out to her but at peace and at rest.
The treatment of depression in a post-abortion woman
involves more than providing for her safety and physical
well-being (emergency psychiatric care) or offering her
appropriate anti-depressant medication if indicated. One must
also allow her to share the overwhelming guilt, sorrow, anger
and self-hate which she has harbored perhaps for years and
which she has attempted to deal with by dosing herself with
alcohol, drugs, and frenzied activity. Her fantasies about
her dead child must also be acknowledged for these are her
only memories of her baby. Gradually these fantasies can be
shaped in a more positive and consoling manner so that she
can finally put them to rest. Clergy can be helpful in this
process both in helping the woman seek forgiveness and in
offering prayers and/or a memorial service for her baby.

suicide

``Women in the first year after childbirth and during
pregnancy have a low risk of suicide'' is the conclusion
reached by Appleby after studying all women aged 15 to 44 who
committed suicide in England and Wales from 1973 to 1984.''
The actual number of suicides in this group was only one-
sixth of that expected relative to other women of the same
age leading him to conclude, ``Motherhood seems to protect
against suicide. Concern for dependents may be an important
focus for suicide prevention in clinical practice.''
The same study found, however, that the suicide rate after
stillbirth was six times that for all mothers after
childbirth. While the birth of a living child seems to
``protect against suicide'', it would appear that the birth
of a dead child greatly increases the risk of suicide. What
then of the risk of suicide after elective abortion when the
mother is not only dealing with the death of her child but
with her responsibility in causing that death? In my search
of the literature I have not found any such demographic
studies.
It is well known that youthful suicides are increasing at
an alarming rate, and that the majority of these occur
between the ages of 15 and 24 years which is the same age
group where most induced abortions occur. Most adolescent
suicides occur in the middle and upper socioeconomic class as
do most abortions. ``Suicidal behavior in `normal'
adolescents'' is the topic of a 1989 study published in the
American Journal of Orthopsychiatry, Sexuality and loss were
two of four risk factors which causes a nearly five fold
increase in the risk of suicidality in a sample of 300 public
high school students in grade 9-12 in a small Northeastern
community. Although the report of the study does not include
data about abortions, the correlation between teen sexual
activity, pregnancy and loss through abortion is apparent in
this population.
The newsletter of the American Suicide Foundation observes
that, ``Specific crises and environmental stressors may
precipitate suicidal behavior, although it can be hard to
appreciate the stressfulness of a seemingly minor event that
falls on the shoulders of an adolescent who is already
burdened with depression.''
Some case vignettes from my own practice may illustrate why
elective abortion is anything but a minor event in the lives
of young women and their partners.
``Lorna'', a 22 year-old woman in the military was referred
to me because of an eating disorder. In our first visit she
told me that for the past year since her elective abortion
she had wanted to die. In fact she had made a suicide attempt
two days before he scheduled abortion when she felt that she
could neither go through with it nor face the rest of her
tour of duty in the military as a single parent. When she was
unsuccessful in causing a fatal automobile accident after she
had overdosed on drugs and alcohol, she had been admitted to
a psychiatric inpatient unit.
Her psychiatrist advised her to go through with the
abortion which has been scheduled for her the next day. Since
that time her cocaine and alcohol use had escalated and her
weight had continually dropped. She was haunted by a strong
desire to be united with her baby, and by the urge to kill
herself. In the year in which I worked intensely with her she
made several suicide attempts and was re-hospitalized once.
Before she moved out of the area she thanked me for having
helped her, saying: ``I'm not going to kill myself now, but
when I die I know that's how it will happen.'' A year later
it did happen.
A 23 year old single woman whom I have called ``Joyce'' was
referred to me after a suicide attempt which also involved a
planned drunk driving accident. Her obsessive through was,
``I want my babies!'' She had had two abortions, one at the
age of 17, and once at the age of 18 while in high school.
She was the youngest in a large family and still living at
home. Her fear was that if she told her parents (who were
older and in precarious health) that she has become pregnant
and had the abortions they would ``drop deaf of heart
attacks.'' She suffered alone for six years with her guilt
and her longing for her lost children. When an uncle who was
a priest returned from overseas she planned to tell him her
tragic story. Before she could talk with him he suddenly died
of a heart attack. Mourning his death and now convinced that
she would never be able to share her guilt and grief without
risking further losses, she planned her own death both to end
her pain and to achieve a reunion with her children and her
uncle.
An 18 year old gas station attendant, ``Peter'', shot
himself and died three months after his father's unexpected
death. Only his closest friend knew that at the time of his
suicide he was despondent over his girlfriend's abortion.
Their child had been conceived on the day of his father's
death. In Peter's mind a mental image of the child had
formed: he had told his friend that he would have a son and
that he planned to name the boy after his father. The loss of
that child and all that he represented to Peter was more than
he could bear.

Post-Traumatic Stress Disorder

Post-traumatic Stress Disorder is one of the Anxiety
Disorders listed in the Diagnostic and Statistical Manual of
Mental Disorders. ``The characteristic symptoms involve re-
experiencing the traumatic event, avoidance of stimuli
associated with the event or numbing of general
responsiveness, and increased arousal . . . The most common
traumata involve either a serious threat to one's life or to
physical integrity; a serious threat or harm to one's
children, spouse, or other close relatives and friends. . . .
The disorder is apparently more severe and longer lasting
when the stressor is of human design.'' A list of life events
which may cause sufficient stress to produce Post-Traumatic
Stress Disorder includes abortion. The most familiar type of
Post Traumatic stress disorder or P.T.S.D., is ``Post Vietnam
Syndrome.'' Following induced abortion, many women experience
similar symptoms. In fact the similarities are so striking
that some clinicians have coined the term ``Post Abortion
Syndrome.''
Characteristic symptoms of Post Traumatic Stress Disorder
include: recurrent and intrusive distressing recollections
and/or dreams of the event, sudden acting or feeling as if
the traumatic event were recurring (flashbacks), and intense
psychological distress at exposure to events that symbolize
or resemble an aspect of the traumatic event, including
anniversaries of the trauma; persistent avoidance of stimuli
associated with the trauma, emotional numbness and an
inability to feel emotions of any type, especially those
associated with intimacy, tenderness and sexuality; and
increased symptoms of arousal i.e. startle responses;
recurrent nightmares and sleep disturbances. A case vignette
follows:
``Alice'', an attractive professional woman in her early
thirties, was referred because of marital problems,
sleeplessness, anxiety and a sense of being hyperalert and
over-reactive to loud noises. These latter symptoms
interfered with her work which placed her constantly in the
public eye. She had had a traumatic abortion a year before
arranged for her by her husband in a clandestine manner. She
had been experiencing frightening dreams, daytime flashbacks,
intense anger and loathing for her husband and suicidal
preoccupations for the past year. ``I killed my baby! I don't
deserve to live!'' were the intrusive thoughts which haunted
her waking hours. She had been seriously contemplating
suicide.

Anniversary Reactions

Suicide attempts on the expected date of delivery of the
aborted child or subsequent

[[Page H9529]]

anniversaries of that date or the date of the abortion
are common. Tishler describes two adolescent girls who
attempted suicide on the approximate date the fetus would
have been born had it come to term although one of them
was not consciously aware of the significance of the date
prior to her medication overdose.
Thirty out of 83 women surveyed regarding post-abortion
coping reported anniversary reactions associated with the
abortion or the due date in a 1989 study from the Department
of Psychiatry of the Medical College of Ohio. In addition to
intense and persistent emotional pain after abortion, these
anniversary reactions were characterized by physical symptoms
most commonly involving the reproductive system--abdominal
pain and dyspareunia, also headaches, chest pain, eating
irregularities and increased drug and alcohol abuse. The
authors state, ``The time-specific relationship of the
symptoms to the original experience is often not recognized
by the subject and appears to be an attempt to master through
reliving rather than remembering. Unresolved grief and pre-
existing dysphoria have been suggested as increasing the
likelihood of anniversary reactions.''
If the conflicted issues could be sequestered on a
subconscious level throughout most of the year and arise only
under camouflage to some extent, then a protective role is
certainly possible. The woman might be able to receive
concern and attention from others without necessarily having
the conflict identified. The authors advise physicians and
therapists to ask about particular events which may have
occurred around the time of year when the patient presents
poorly explained physical or psychiatric symptoms. It is easy
to see how excessive medical work-ups could lead to
unnecessary tests and procedures and even unnecessary
surgery.
The authors also report that women in the non-anniversary
group in their study mentioned self-punishment as their
reason for having a hysterectomy or tubal ligation or for
suicidal behavior.
The following case illustrates an unusual anniversary
reaction:
``Akiko'', a Japanese college student, was referred for
presumed Premenstrual Syndrome (PMS) which was in fact an
acute anniversary reaction to her abortion which recurred
monthly. One or two days each month her dormitory staff
reported that she would not come out of her room for meals or
for classes and spent the time crying inconsolably--a most
unusual occurrence among Asian students in their experience.
Akiko had had an abortion the day before she left Japan to
come to the U.S. to study early childhood education. Her
first college classes focused on pre-natal development.
During a film showing intra-uterine life she suddenly became
aware of the actual developmental stage of the fetus she had
aborted a few weeks before. From then on, each month on the
anniversary of her abortion she had become overwhelmed and
inconsolable by sadness and guilt which she could not share
with anyone.
In the context of helping her to work through her grief, I
asked Akiko about how women in Japan deal with post-abortion
grief. I learned that it is common for mothers in Japan to
request memorial services for their children whom they
believe they have ``sent from dark to dark.'' At Buddhist
temples parents rent stone statues of children for a year
during which time prayers are offered for the babies to the
god Jizu. More recently, the goddess Mizuko Kanon is
believed to be better able to care for these water babies
who arrive with smashed heads and shredded bodies because
she has large hands with webbed fingers. Parents regularly
visit these statues and leave toys, flowers and written
messages for their babies.

Psychosomatic Symptoms

In addition to the psychophysiological anniversary
reactions described above, the chronic stress of unresolved
post-abortion grief can also provide classical
psychophysiologic reactions as the following case
illustrates.
``Jerry'' was doubled over in pain before a scheduled media
presentation. He had not had time for breakfast and forgotten
the antacid medication he regularly took to control the
peptic ulcer which he had recently developed. Jerry's wife
had aborted their first child without his knowledge, and had
aborted their second child without his consent. After the
birth of their third child, Jerry had become over-protective
of the boy, spending every waking moment with him, even
changing his work schedule so as to be alone with him while
his wife worked. A divorce ensued and sole custody of the
child was awarded to his ex-wife. Jerry's grief became
profound and his psychosomatic symptoms increased.

Family Issues

As has been described above, post-abortion grief may be
responsible for marital conflicts, problems with sexual
intimacy, and parent-child relationship difficulties. Two
additional case vignettes will further illustrate these
issues.
``John'' was a 28 year old office worker who entered
psychotherapy because of a depressed mood, difficulty
sleeping, lack of concentration at work, and conflicts with
his wife and children. After several apparently unproductive
sessions with his therapist, he reported a dream during which
a former girlfriend brought him into a room and introduced
him to a ten year old boy, stating, ``This is your son!''
Only then did he recall her pregnancy with their child and
his active participation in her abortion. Subsequent work
with him revealed that it was his unresolved grief and guilt
over that child's loss which was responsible for his current
symptoms.
``Jeannie'' was a six year old girl who was referred for
evaluation of school phobic symptoms. Her separation anxiety
began at kindergarten and had not abated in first grade. She
often stayed home complaining of stomach aches and headaches.
She would only go to school accompanied by her mother, and
terrible scenes occurred each time her mother was encouraged
to leave with crying, screaming and kicking. Jeannie's mother
was afraid to leave her at school in that state even though
the teachers assured her that within a few minutes after her
mother's departure Jeannie was able to enter the classroom
and participate with the other children.
Jeannie's mother had aborted her previous pregnancy--a
decision which she deeply regretted. This next child was
burdened with her mother's pathologically intense attachment
to her which did not allow for age-appropriate separation and
growth for her child.

conclusion

In 1973, an article in the Journal of the National Medical
Association stated, ``Early information would tend to alert
the physician to the need for systematic follow-up of all
abortion patients . . . The epidemologic consequences of
abortion may (therefore) become statistically relevant in the
not-too-distant future with far-reaching public health
significance.''
With 26 million abortions in this country in the 18 years
since Roe v. Wade, and the continuing rate of 1.6 million
abortions per year, we can no longer deny the public health
significance of their psychological and psychophysiological
sequelae. Epidemological studies are urgently needed which
are statistically sound and which follow women and men for at
least ten years post-abortion.
In the meantime, case reports remain valid psychiatric
documentation of the many faces of post-abortion grief. The
traditional teaching of our profession has not been by means
of controlled studies with a sample of several hundred and
statistically significant standard deviations. Sigmund Freud,
Eric Erikson, Viktor Frankl, Jean Piaget, and Robert Coles
have told us about individuals who they have studied in
depth. Their detailed case studies have led to lasting
insights into human development and the origins and treatment
of psychopathology.
The best treatment for any illness, of course, is primary
prevention. Primary prevention of the negative psychiatric
sequellae of abortion involves the prevention of abortion
itself by means of offering compassionate alternatives such
as support in child bearing, child rearing and adoption, but
more importantly the prevention of untimely pregnancy by
teaching the true meaning of an reverence for human
sexuality.
____

[From the Journal of Clinical Ethics, Summer 1993]

Prolonged Grieving After Abortion: A Descriptive Study

(By Douglas Brown, Thomas E. Elkins, and David B. Larson)

introduction

``Legal abortion of an unwanted pregnancy in the first
trimester does not post a psychological hazard for women.''
As exceptions to this widely held generalization, most
gynecologists have an anecdotal story or two about a
patient's prolonged grieving after undergoing an abortion.
Clinicians searching for perspective on a patient's
prolonged grieving may be surprised by the number of
publications about potentially negative psychological sequel
following induced abortion. Reviews of this vast literature
have located at least 30 attempts to design either randomized
longitudinal studies or retrospective studies of prolonged
grieving after abortion. Based on questionnaires,
psychological tests, and interviews, these studies have
reported prevalences of negative psychological sequel ranging
from 2 percent to 41 percent. Most of the studies did not
follow participants past one year after their abortions. The
six studies that attempted to identify and interpret
prolonged negative experiences after induced abortion all
reported the phenomenon, but they questioned whether the
abortion itself or circumstances precipitating the choice of
abortion brought on the symptoms.
Together, these studies have tended to encourage the
generalization that abortion, when a conflict-free decision,
brings relief to the patient. A corollary to this
generalization is that abortion can have a disturbing or
stabilizing impact, depending upon the past mental health
history, emotional dynamics, and life circumstances peculiar
to each woman who aborts. Most of the researchers who
conducted these studies have been careful to admit that their
conclusions are somewhat tenuous, given the possibly inherent
incompatibility between the objectivity sought in a
randomized study and the deeply personal subject matter.
Recent literature reviews have drawn specific attention to
such methodological limitations.
A clinician's search for perspective may be further
complicated when the literature-review articles are
themselves compared. For instance, American Family Physician
and Psychiatric Journal of the University of Ottawa published
review articles that had less

[[Page H9530]]

than one-third of their research citations in common. Of
those few citations in common, one-third were presented with
nearly opposite interpretations by the two reviews.
Both the research and the reviews of research that favor
the generalization that in most instances abortion does not
precipitate debilitating psychological sequelae appear to be
significantly limited. Nonetheless, we do not in this article
take issue with this generalization about abortion. We do
contend that attention to each patient's well-being and to
the containment of healthcare costs keeps the issue of
potentially negative and prolonged psychological sequelae
clinically relevant. For instance, given the annual average
of 1.5 million abortions in this country alone, a 1 percent
prevalence of a single psychiatric disorder--major
depression--tranlates into 15,000 patients.
In response to a presidential assignment, Surgeon General
Koop reported in 1989 that the research to date was so
ambiguous or flawed that no conclusion about psychological
consequences from abortion could be drawn. He believed the
subject was important enough to recommend a definitive,
multimillion dollar, randomized, longitudial study. However,
when the initiation of such a study remains doubtful and when
retrospective studies have proven inconclusive, some
perspective on this concern can still be sought through a
presentation of cases.
Accordingly, this article examines the experience of
negative emotional sequelae after abortion expressed by one
previously undescribed group of patients, with particular
focus on the prolonged nature of their experience. What is
lacking in objectivity from these unstructured responses is
partially offset by the open-ended admission of feeling and
still-active painful memories. Current attention in medical
ethics literature to patients' life stories, which a case-
series design complements, provides a conceptual framework
within which to hear these women share a portion of their
stories.

methodology

This study documents the selfreported suffering experienced
by 45 women after undergoing induced abortions. In 1987, the
surgeon general invited several religious leaders from across
the United States to Washington, D.C., to relate and comment
upon the possible adverse consequences of abortion in the
experience of women in their congregations. Among the
invitees was the pastor of a large Protestant congregation in
Florida. The congregation was predominantly of white, urban,
and middle-to-upper-class.
After informing a Sunday morning gathering--which included
from 1,600 to 2,000 women on any given Sunday--of the
upcoming meeting, this pastor asked for descriptive letters
from women who had negative experiences that they perceived
to be linked with a past abortion. One week later, 61
replies, most anonymously forwarded through the mail, had
arrived. No follow-up requests were made. Of the original 61
replies, five came from significant others (two husbands, two
sisters, and one parent) who recounted the negative impact of
an abortion on a family member. Another 11 letters were too
brief to be useful. This report is an attempt to describe and
analyze the remaining 45 letters.
We categorized the content of the letters for descriptive
and comparative purposes. The categories we used were those
found in the literature on negative psychological responses
and on the comparison between the expressions of grief
following abortion to expressions of grief associated with
perinatal death, spontaneous abortion, and birth of a
severely handicapped newborn. The symptomatic categories we
included were masking, anger, loss, depression, regret,
shame, fantasizing, suicidal ideation, and guilt. One of
these classifications needs clarification. We used
``masking'' to categorize the disclosure that a patient hid
inner feelings beneath an apparently stable and peaceful
outward manner.

results

The letters revealed what these 45 women perceived to be
the most acute consequences from their abortions. Since the
women were not asked to provide specific clinical information
or to comment on their perceived rationale for specific
symptoms, we have avoided speculation about what the women
did not mention. Categorization of reported experiences was
based on explicit comments in the letters.
The ages of these women ranged from 25 to over 60 years; 87
percent of those who mentioned their age were less than 40
years old. Their ages at the time of abortion (a few had
experienced multiple abortions) ranged from 16 to early 40s;
80 percent of those who mentioned age were under 30 years
old. Of these women, 81 percent indicated they had undergone
first-trimester abortions. Of those who indicated the reasons
they sought abortions, 19 percent attributed their having
abortions to overt family pressure; a few spoke of medical (4
percent) or financial (9 percent) reasons. Of the
respondents, 64 percent spoke of more than incidental and
transient grief immediately after the procedure. Half of the
respondents mentioned having children subsequent to their
abortions. Of the women who mentioned marital status, 75
percent were single at the time of the procedure, and 71
percent placed the time of their abortions after Roe v. Wade.
Table 1 gives a summary of the negative sequelae
experienced by these women following their abortions.
Analysis of the letters is reported both for the total group
and for various subgroups.

TABLE 1.--NEGATIVE FEELINGS FOLLOWING ABORTION
--------------------------------------------------------------------------------------------------------------------------------------------------------
Feelings (percentage of respondents)
------------------------------------------------------------------------------------------------------------
Masking Anger Loss Depression Regret Shame Fantasizing Suicidal Guilt
--------------------------------------------------------------------------------------------------------------------------------------------------------
All respondents (N=45)..................... 35.5 20.0 31.1 44.4 44.4 26.7 57.8 15.5 73.3
Age at time of abortion:
Pre-21 (N=19).......................... 47.4 21.0 36.8 47.4 42.1 31.6 52.6 10.5 73.7
21-30 (N=17)........................... 17.6 29.4 17.6 47.0 47.0 35.3 58.8 17.6 82.3
Age at time of contact (1987):
21-30 (N=18)........................... 16.7 27.8 27.8 50.0 50.0 22.2 44.4 11.1 72.2
31-40 (N=14)........................... 42.8 28.6 35.7 35.7 42.8 42.8 71.4 7.1 78.6
Reason for abortion:
Elective (N=33)........................ 32.2 17.6 29.4 44.1 47.0 26.5 52.9 17.6 73.5
Pressured (N=12)....................... 41.7 33.3 50.0 66.7 41.7 33.3 75.0 16.7 100.0
Subsequent children (N=26)................. 38.5 11.5 46.1 50.0 50.0 19.2 73.1 19.2 73.1
Marital status at time of abortion:
Single (N=30).......................... 36.7 26.7 23.3 53.3 36.7 30.0 56.7 16.7 76.7
Married (N=10)......................... 30.0 10.0 40.0 40.0 70.0 30.0 70.0 10.0 90.0
Practicing Christian at time of abortion:
No (N=19).............................. 42.1 15.8 10.5 47.4 42.1 31.6 52.6 15.8 73.7
Yes (N=11)............................. 18.1 27.2 18.1 54.5 36.4 36.4 54.5 27.2 72.7
Time of abortion:
Before Roe (N=10)...................... 60.0 10.0 10.0 50.0 20.0 30.0 50.0 30.0 60.0
After Roe (N=32)....................... 31.3 25.0 34.4 40.6 46.9 31.3 56.3 12.5 84.1
--------------------------------------------------------------------------------------------------------------------------------------------------------

The responses of the women who described their abortions as
uncoerced were not noticeably different from the total
responses. However, the presence of coercion in the decision-
making process did distinguish these womens' responses from
the total responses more than any other variable. The mention
of negative sequelae was consistently more frequent for women
who felt coerced. The responses of women who had borne
children subsequent to an abortion varied little from the
total responses, except in the mention of loss and of
fantasizing about the infant they might have had.
The most frequently mentioned long-term experience was the
continued feeling of guilt. Every woman who recalled being
coerced to have an abortion spoke of guilt. Those who had
terminated pregnancies after Roe v. Wade spoke more
frequently of guilt than those who had aborted before Roe v.
Wade. Fantasizing about the aborted fetus was the second most
frequently mentioned experience, with more attention given to
this experience by the older respondents and by those who
felt coerced to have an abortion.
Many of the respondents noted, with varying wording, that
they were writing ``the most difficult letter'' they had ever
written. Half of the participants referred to their abortions
as murder. Others used such phrases as ``a horrid mistake,''
my worst experience,'' ``a living hell.'' Several mentioned
that hearing the word ``abortion'' would awake painful
emotions. A number of the women spoke of suicidal ideation
(15.5 percent), recurrent nightmares (13.3 percent), marital
discord (15.5 percent), phobic responses to infants (13.3
percent), fear of men (8.9 percent), and disinterest in sex
(6.7 percent).
Half of the women who admitted fantasizing about the infant
they might have had referred to that aborted fetus as ``my
baby.'' One woman, subsequent to the abortion, had named
``her baby'' Jeremy. Several commemorated the anniversaries
of the abortion and of the aborted child's projected
birthday. These women described drifting into thoughts about
the aborted child's sex, talents, appearance, and interests.
Some found relief in vividly anticipating a reunion with
their aborted infants in an afterlife. Unavoidable
reminders--such as celebrating Mother's Day, receiving the
news of a friend's pregnancy, being invited to a baby shower,
seeing children on a playground, and even planning a birthday
party for their own children--kept many of these women moving
from one painful emotional fantasy to the next. One woman
explained:

[[Page H9531]]

``One cannot escape children--their birth, the joy of a
baby whether it be next door or around every corner you turn.
After all, who would want to? Unless the reminder is
unbearable. It takes years and you always remember. Your own
children remind you. As I face the rest of my life I will be
reminded daily, sometimes hourly. One day I will be a
grandmother--I hope--and then the pain will once again become
unbearable. I will always be there. An abortion is forever.''
Another woman commented: ``It (an abortion) may seem the
fastest way and easiest way to put a bad experience behind
them, but it does not stay there. It will surface when they
fall in love, when they consider marriage, at the birth of
their child(ren), each time they have a physical, each time
the word ``abortion'' is mentioned, when your child shows an
interest in the opposite sex, when you look into the face of
a baby, etc., etc. You see, it never goes away. Never.''
Of these women, 20 percent related negative responses to
the abortion procedure itself. Some recalled crying
continuously, while others remembered trying to stop the
procedure once it had started. Every woman who mentioned the
procedure expressed dissatisfaction with the lack of or
superficial counseling they received and with the physicians
involved in the procedure.
In some cases, the onset of negative sequelae was
immediate; Table 2 illustrates the length of time these
symptoms had been experienced. Of the respondents, 64 percent
described their suffering as beginning immediately after (or
during) the procedure, and 42 percent reported negative
emotional sequelae endured over 10 years. One woman
experienced such symptoms for 60 years. After years of
turmoil, few at the time of writing expressed confidence that
their symptoms might be eradicated.

TABLE 2.--DURATION OF NEGATIVE FEELINGS FOLLOWING ABORTION
------------------------------------------------------------------------
Duration (percent of respondents)
-------------------------------------
Characteristics of respondents Immediate 0 to 5 6 to 10 10+
onset years years years
------------------------------------------------------------------------
All respondents (N=45)............ 64.4 6.7 40.0 42.2
Age at time of abortion:
Pre-21 (N=19)................. 68.4 5.3 36.8 57.9
21-30 (N=17).................. 70.6 11.8 28.6 42.8
Age at time of contact (1987)
21-30 (N=18).................. 61.1 16.7 55.5 16.7
31-40 (N=14).................. 57.1 ....... 7.1 64.3
Reason for abortion
Elective (N=33)............... 51.5 3.0 33.3 42.4
Pressured (N=12).............. 100.0 ....... 37.5 25.0
Subsequent children (N=26) 65.4 3.8 34.6 53.8
Marital status at time of abortion
Single (N=30)................. 73.3 10.0 46.7 36.7
Married (N=10)................ 70.0 ....... 30.0 60.0
Practicing Christian at time of
abortion
No (N=19)..................... 68.4 5.7 47.4 31.6
Yes (N=11).................... 63.6 18.1 27.2 36.3
Time of abortion
Before Roe (N=10)............. 50.0 ....... ....... 90.0
After Roe (N=32).............. 68.7 9.4 46.9 34.4
------------------------------------------------------------------------
Note.--Because 11 respondents did not specify length of time,
percentages do not add up to 100 percent.

discussion

Due to the manner in which the data became available, this
study's design falls far short of the gold standard--a
randomized, double-blind longitudinal study. The data are
retrospective and self-reported. The person responsible for
gathering the data made no provision to control for
population variables. No uniform instrument was used. The
participants came from a self-selected population group (the
Protestant congregation) with a known bias against induced
abortion. The possibility of embellishment by the sample
population, given the stated purpose for the requested
letters, existed. Only negative responses to the experience
of abortion were solicited. No psychological testing could be
done, nor was the frequency or perceived effectiveness of
mental health treatment noted. Incomplete demographic
information permitted limited aggregate evaluation and
conclusions.
Still, we believe that the testimony of these women permits
four observations that suggest some perspective on prolonged
negative sequelae possibly associated with abortion. First,
this series of cases reinforces a clinician's anecdotal
awareness that such sequelae occur. If ethics has to do with
what ought to be done all things considered, then clinicians
should be careful not to be inattentive to indications that
an abortion may create for the woman terminating her
pregnancy a period of crisis, requiring effective counseling
and reliable support.
Such attention has not been encouraged by the social and
political turmoil that has surrounded abortion since Roe v.
Wade. Opinion about whether abortion inevitably causes
psychological harm for women terminating their pregnancies
had begun to shift when the U.S. Supreme Court decided Roe v.
Wade. The American Psychiatric Association membership, for
instance, did an about-face between 1967 and 1969 on the
issue of legalizing abortion on request--with those in favor
increasing from 24 to 72 percent. In the aftermath of Roe v.
Wade, elective abortion came widely to be seen, in most
instances, as a conflict-free decision. Consistent with this
perception, interpreters of data that suggested the
occurrence of negative psychologic sequelae tended to
minimize the incidence. For instance, Smith reported that
``only'' 6 percent of the 80 women studied had necessitated
psychiatric treatment within two years of their abortions.
Lazarus found that ``only'' 15 percent of the 292 women
followed for two weeks after abortion acknowledged feelings
of guilt and depression. American medical literature turned
to other facets of potential perinatal grief responses. The
cultural climate permitted preabortion counseling to become
optional, rather than a prerequisite to the procedure.
Second, it has been estimated that nearly half of all women
who received abortions deny having had abortions. The letters
in this article suggest that such denial is a refusal to
publicize an experience, but not a refusal privately to face
painful consequences. Of these women, 35 percent spoke of
masking their experience with the appearance of well-being.
Women who received abortions before they were 21 mentioned
masking their psychological pain far more frequently than the
women who had abortions when they were older. Women who had
abortions before Roe v. Wade mentioned this hidden pain twice
as often as women who had abortions after Roe. This
difference may illustrate that since Roe, the social stigma
associated with having an abortion has lessened.
Third, a clinician has reason to be concerned when a women
perceives the termination of her pregnancy as a coerced
decision. The responses of the women who described their
decisions to abort as freely chosen did not differ
significantly from the total responses, suggesting doubt
about the perception that only coerced decisions put a woman
at risk. However, the responses of the women who spoke of
being coerced (by peers, family, medical complications,
economic fears) to have an abortion showed a higher incidence
of negative sequelae in all but one emotional category (Table
1). They unanimously admitted guilt feelings. Their problems
were, without exception, manifest immediately after the
procedure, whereas only half of the women who did not feel
coerced but later experienced problems mentioned such
immediate sequelae. This difference draws attention to the
need for professionals as well as significant others to probe
signals of ambiguity from women considering abortion in a
manner that is sensitive yet accurate.
Fourth, these letters raise questions about the hypothesis
that religious fervor causes and/or magnifies psychological
complications after abortion. Two out of three respondents
mentioned that they were not practicing Christians or active
members of this particular church when they had their
abortions. Although there is the possibility that religious
beliefs encouraged the prolonged grieving, the responses of
those women who were not practicing Christians when they had
their abortions did not differ significantly from the
responses of all the respondents. Those who were practicing
Christians when they had their abortions did indicate a
slightly higher incidence of depression and shame. The
letters suggest that religious convictions and religious
involvement appear to have deepened the psychological pain
for some of the women, while for others the same convictions
and involvement served as an important resource to reduce the
feelings of guilt and despair that had already developed.

conclusion

These letters have provided a window into the ramifications
that can surround abortion. We are not taking issue with the
generalization, ``legal abortion of an unwanted pregnancy in
the first trimester does not pose a psychological hazard for
women.'' However, generalizations are, by definition, subject
to exception. The more frequent the exceptions, the more
tenuous becomes the generalization. Here, 81 percent of the
women who experienced painful and prolonged emotional
sequelae indicated that their abortions were first-trimester
abortions.
Our interpretation of these letters does not reinforce
either of the categorical positions--for or against
abortion--that are presently polarized in public debate. This
study does reinforce the need, if possible, for clinically
valid studies of the syndrome of delayed grief among what
appears to be a small but significant number of women who
have abortions. The causal relationship (or lack thereof)
between such women's abortions and their enduring,
psychologic pain needs research documentation. The frequency
needs to be determined. Factors that predict such problems
need to be identified so that psychologic intervention can be
made more readily available and even encouraged in some
settings.
Clinical implications, not political ramifications, have
prompted their descriptive study. The quality of medical care
and the assurance of truly informed consent in the
termination of pregnancy depend ultimately upon prospective
research of negative psychological sequelae. Until such
research is achieved, case services of such experiences
should not be discounted on methodological grounds or
exploited in public debate. Instead, they should be
documented as reminders that abortion is, for some women, a
moment of crisis of immediate and/or enduring proportion.
What is at stake is not the validity of either side in the
ongoing public debate over abortion, but the issue of patient
care.
Mr. BROWN of Ohio. Mr. Speaker, I have no further requests for time,
and I yield back the balance of my time.
Mr. BILIRAKIS. Mr. Speaker, I have no further requests for time, and
I yield back the balance of my time.
The SPEAKER pro tempore. The question is on the motion offered by the
gentleman from Florida (Mr. Bilirakis) that the House suspend the rules

[[Page H9532]]

and agree to the resolution, House Resolution 163.
The question was taken; and (two-thirds having voted in favor
thereof) the rules were suspended and the resolution was agreed to.
A motion to reconsider was laid on the table.

____________________