[Congressional Record (Bound Edition), Volume 146 (2000), Part 15]
[House]
[Page 21894]
[From the U.S. 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 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.
  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.''
       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 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 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 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:
       ``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 
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.

                          ____________________