The Lancet recently published "Ending Preventable Stillbirth," a series geared toward elucidating the global stillbirth problem (2 to 6 million deaths per year) and calling for more acknowledgment of the tragedy as well as concerted efforts to reduce the numbers. The five paper series is a collaborative effort involving over 200 authors, investigators, and advisers, representing more than 40 countries and 100 organizations.
This level of focused attention by one of the world's oldest and best known general medical journals is powerful, yet quite overdue and will leave many readers wondering about the needs of women suffering other forms of infant loss.
Charlotte Bronte, the British novelist, addressed perinatal loss, a common occurrence 175 years ago with chilling intensity:
"There is, I am convinced, no picture that conveys in all its dreadfulness, a vision of sorrow, despairing, remediless, supreme. If I could paint such a picture, the canvas would show only a woman looking down at her empty arms."
Since Bronte's time and indeed well before, the experiences of mothers who have suffered the loss a child during the prenatal, neonatal, and postnatal periods, have been conveyed in diverse literature forms, fiction and non-fiction alike as well as poetry. More recently scientists in medicine and the behavioral sciences have published numerous empirical investigations of women who have undergone an infant loss.
In the Lancet executive summary to the series, one of the headline messages described is the heavy psychosocial and economic cost on families and nations. The series editor writes:
"The burden of stillbirth affects women, families, caregivers, communities, and societies. Parents experience various psychological symptoms that often persist long after the death of their baby.."
Several authors of the articles in the series point out that most of the causes of stillbirth are ultimately avoidable (infections, non-communicable diseases, and obstetrical complications); therefore we understand that with the right priorities and resources directed to preventive efforts, the future holds great promise for bringing an end to the systemic suffering associated with millions of stillbirths.
Concerned professionals from around the globe joining together to issue a passionate call to end this plight has left me encouraged to see a horrifically painful experience recognized, mothers' wellbeing prioritized, and new life so highly valued. However, as someone who has studied and actively published on the adverse psychological consequences of another form of loss, induced abortion, I am left wondering if induced abortion, which affects at least 40 million women per year or 1.2 billion in the world over the last 30 years will ever be pitched by a high profile journal as deserving of such attention and resources.
The idea of induced abortion being promulgated by the medical community as a preventable loss seems like quite a stretch when it is seldom acknowledged by the major professional organizations as even carrying the potential to bring harm in the first place.
Despite professional denial, there are actually sound reasons why induced abortion may lead to even more severe and insidious psychological distress than stillbirth. First, unlike stillbirth, abortion is typically voluntary and as a result, many women experience intense guilt, self-criticism, or even self-loathing [1-4].
Second, as indicated by this series in Lancet, sadness and grief are becoming culturally recognized with involuntary forms of loss; whereas grief after induced abortion is rarely validated. Women may suppress abortion-related emotions, as Kluger-Bell comments:
"When other people are reluctant to listen to us, when there are no ceremonies to publicly acknowledge the impact of our experiences, we receive the covert message that others would rather not hear what we have to say, and this makes it difficult to even identify our reactions to our losses." [5]
Finally, the grief process after abortion may be more complicated than with stillbirth, because grief resolution requires acknowledgment of death. Women who abort may find themselves in a state of denial or avoidance of the death; and in order to escape the reality, they might engage in unhealthy coping behaviors, including excesses related to alcohol, drugs, food, work, and or sex, which can in turn initiate or increase symptoms of anxiety and depression.
Studies with large nationally representative samples, and a variety of controls for personal and situational factors that may differ between women choosing to abort or carry to term, indicate that abortion increases risk for depression, anxiety, substance abuse, and suicidal behavior [6-18]. In fact, abortion is associated with a higher probability of negative psychological outcomes when compared to other forms of perinatal loss and with unintended pregnancy carried to term [10-13,16,17,18].
A conservative estimate is 20 to 30% of women who abort suffer from serious, prolonged negative psychological consequences [19-20]. The available peer reviewed scientific research further indicates that adverse mental health effects of induced abortion typically persist longer than the negative effects of involuntary loss [16-18, 21].
The human cost of induced abortion is more devastating when we widen our lens and examine how this choice adversely affects relationships. Many couples choose abortion believing that the decision will preserve their relationship if one or both partners feel unprepared to have a child; yet the available data provides evidence to the contrary, with abortion introducing significant challenges and stress into the partnership [22-26]. For example, an increased risk for separation or divorce following an abortion has been reported in several studies.
Among the over one million abortions performed in the U.S. each year, 3% are attributable to fetal anomaly, 3% are the result of a maternal health problem, and only 1% are a choice made based on rape or incest [27]. The primary non-physical reasons women choose abortion are concerns with single parenthood, partner relationship difficulties, future education, career, or personal plans, age, parenting readiness, insufficient financial resources, desire to postpone childbirth, and perceptions of lack of time and energy for another child [28].
Clearly the vast majority of reasons women elect to terminate their pregnancies could be eliminated with more focused efforts to provide them with meaningful psychological, relational, social, and material supports.
In addressing the long history of stillbirth being ignored and marginalized in diverse cultures, Richard Horton writes in the Lancet,
"Perhaps the greatest obstacle to addressing stillbirths is stigma. The utter despair and hopelessness felt by families who suffer a stillbirth is often turned inwards to fuel feelings of shame and failure."
This same phenomenon has been and remains highly relevant to women's experiences and sentiments surrounding induced abortion. Moreover, we are not seeing major professional organizations rallying together and advocating to help women make the choice to carry to term to preserve their mental health and save the lives of millions.
Instead we see massive cultural denial of abortion as a potentially traumatic event in the face of strong empirical evidence; and if there has ever been a burden that millions of women carry alone, suffering in silence side by side it is with the pain inflicted by abortion.