Guest blogger Kate summarizes an Iranian study and gives us some thoughts on abortion in a very different context than in the U.S.
An Iranian study1 published last month investigated whether women’s levels of post-traumatic stress after abortion or miscarriage correlated with their “spiritual experiences.” This cross-sectional study, with a sample size of 104, was conducted from 2018 to 2019 at Shiraz University of Medical Sciences. The researchers used the Mississippi Post-Traumatic Stress Disorder (PTSD) Scale to measure the women’s stress levels. They also evaluated the subjects’ religious attitudes. Women completed questionnaires immediately after the loss, then one month later.
The subjects were divided into three groups:
induced abortion with forensic medical letter (ie, an abortion for which the woman had received legal permission based on a physician’s certifying that her pregnancy was a threat to her life or that the fetus was severely abnormal),
miscarriage management (ie, a natural miscarriage completed medically or surgically), and
miscarriage/spontaneous abortion (ie, a miscarriage occurring without intervention).
(In this post, these groups will be referred to as “forensic,” “management,” and “spontaneous,” for brevity.)
The three groups of women were similar in terms of their religious attitudes: 68.7% of the forensic group, 71.8% of the management group, and 72.7% of the spontaneous group were highly religious; the remainder were moderately religious. Their levels of PTSD immediately following their abortions and miscarriages were also similar: 78.1% of the forensic group, 69.2% of the management group, and 72.7% of the spontaneous group had moderate PTSD, while 3.1% (forensic), 12.8% (management), and 6.1% (spontaneous) had severe PTSD. The remainder had mild PTSD.
One month later, PTSD symptoms had decreased in all three groups, but overall levels were still high: 62.5% of the forensic group, 64.1% of the management group, and 66.7% of the spontaneous group had moderate PTSD, while 3.1% (forensic), 5.1% (management), and 0 (spontaneous) had severe PTSD, and the rest had mild PTSD. The decrease in PTSD levels was not significantly associated with the religiosity of the subjects, except in the “management” group. In these women, higher religious attitude scores were correlated with a greater decrease in PTSD scores. In other words, the more religious these women were, the more their PTSD symptoms decreased in the month after their miscarriages.
More than half the pregnancies in this study were unwanted, and most of these parents were “wholeheartedly happy” about their loss. The researchers hypothesize that the mothers’ negative attitudes about their pregnancies may explain why PTSD levels in this study were relatively high and did not markedly decrease with time, as would normally be expected. According to the authors, the fact that these women got pregnant despite not wanting a baby might indicate the presence of other problems (eg, unaddressed mental health issues, marital discord, domestic violence, poverty) known to predispose women to postabortion stress.
The researchers’ recommendations were as follows: improve access to contraceptive services; amend existing abortion laws to prioritize maternal health, including psychological health; and, to the extent health care providers are comfortable, integrate religious practice into postabortion counseling for religious women.
On the surface, this study doesn’t seem to say much: there was little to no relationship between the intensity of the women’s religious faith and the severity of their PTSD symptoms. (The authors recommended centralizing religion in postabortion counseling anyway, because previous studies have provided strong evidence that “religious beliefs [can] reduce the sadness and stress caused by fetal loss and prepare the parents to accept it.”) However, digging a little deeper reveals some nuggets of interest to pro-lifers.
In the introduction, the researchers observe that “abortion can be stressful for family members, doctors, and others in the social support system.” As they note, previous research has established that reactions in postabortive women include sadness, grief, guilt, anger, depression, anxiety, substance abuse, and suicidal thoughts and behaviors. They also mention that abortion can cause problems in the couple’s relationship. Unlike many Western scientists who have published on the subject, the Iranian researchers seem to take for granted that abortion can and often does have negative emotional effects – and not only on the mother, but the father, other family members, and health care workers.
The researchers briefly describe the religious and legal context around abortion in Iran. Namely, most Iranians (between 90% and 95%) are Shiite Muslims. Islam considers that an unborn child has an equal right to life, and therefore, abortion is a sin, punishable under Islamic penal codes. Currently, in Iran, an abortion can be legally performed only with a license and a forensic medical certificate stating that the pregnancy is a threat to the mother’s life or that the fetus has a serious deformity. The women in this study all experienced natural losses, serious pregnancy complications necessitating an early termination, or severe fetal anomalies. This is decidedly not the case for abortion in the US.2
Another factor to consider is that the women who enrolled in the study were not undergoing any type of psychological treatment, either medication or psychotherapy. Women were also excluded from participation if they were currently experiencing life crises, such as financial problems or the death of a loved one. In short, the subjects weren’t especially predisposed to psychological problems. The results of this study may well have been different if women with mental illnesses had been included. It is well established3 that women with preexisting mental health problems4 tend to have more difficulty coping emotionally with an abortion and are more likely to develop new or worsening psychiatric symptoms.5
As noted, most pregnancies in this study were unwanted; half of those women had not used a reliable contraceptive method. For most of the women whose pregnancies were undesired, their religious beliefs and Iranian law prohibited them from seeking an elective abortion. Therefore, they regarded the natural death of their baby as “a kind of divine blessing.” The same is likely true in the US (and elsewhere). Not all miscarriages are of wanted pregnancies. Although public discussions of pregnancy loss almost always focus on maternal feelings of grief and guilt, women who miscarry an unwanted baby may experience a sense of relief when the pregnancy ends without their having to do anything about it.
This study helps illustrate that abortion can look different in other cultures. The Iranian women were all married. They were older (with an average age of 30) and more religious than the average American abortion patient.6 And most fundamentally, none of these abortions were elective. All were cases of natural demise or rare medical emergencies (notwithstanding the pro-life point that killing a dying or disabled fetus is not actually a question of medical necessity).
In the same vein, the researchers’ recommendation that clinicians who provide postabortion counseling encourage religious patients to make their faith part of their recovery process is sound but probably more practical in Iran than in the US. Presumably, Iranian health care providers and their patients tend to practice the same religion (Shiite Islam). Many Iranian medical practitioners are likely devout Muslims themselves, which would make it easier to discuss faith and prayer with their Muslim patients. The religious diversity of the US makes such conversations between provider and patient more difficult.
Still, this study is interesting because it provides a cross-cultural perspective on postabortion mental health. Historically, most research on this topic was conducted in the US or other Western, predominantly Christian nations, whereas this study concerns a Muslim country in the Middle East. There were many differences between the Iranian women and the average American woman who obtains an abortion. In addition, the authors’ attitudes towards religion and abortion are noticeably different from those of most of their Western peers: more positive regarding religion and more negative regarding abortion. However, their results are broadly consistent7 with existing research8 indicating that abortions often result in varying degrees of emotional distress9 (although not necessarily full-blown PTSD) and that religious faith10 can be helpful in the healing process.11
Alipanahpour S, Zarshenas M, Taheri M, Akbarzadeh M. A cross-sectional study of psychosocial problems following therapeutic abortion with the mother’s spiritual experiences. Int J Women’s Health Reprod Sci. 2021;x(x):xx. doi: 10.15296/ijwhr.2021.xx
Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Reasons U.S. women have abortions: quantitative and qualitative perspectives. Perspect Sex Reprod Health. 2005;37(3):110-118. doi: 10.1363/psrh.37.110.05
APA Task Force on Mental Health and Abortion. Report of the Task Force on Mental Health and Abortion. American Psychological Association; 2008. Accessed 11 July 2021. https://www.apa.org/pi/women/programs/abortion/mental-health.pdf
Academy of Medical Royal Colleges; National Collaborating Centre for Mental Health. Induced Abortion and Mental Health: A Systematic Review of the Mental Health Outcomes of Induced Abortion, Including Their Prevalence and Associated Factors. Academy of Medical Royal Colleges; 2011. Accessed 11 July 2021. http://www.aomrc.org.uk/wp-content/uploads/2016/05/Induced_Abortion_Mental_Health_1211.pdf
van Ditzhuijzen J, ten Have M, de Graaf R, Lugtig P, van Nijnatten CHCJ, Vollebergh WAM. Incidence and recurrence of common mental disorders after abortion: results from a prospective cohort study. J Psychiatr Res. 2017;84:200-206. doi: 10.1016/j.jpsychires.2016.10.006
Jerman J, Jones RK, Onda T. Characteristics of U.S. Abortion Patients in 2014 and Changes Since 2008. Guttmacher Institute; 2016. Accessed 11 July 2021. https://www.guttmacher.org/sites/default/files/report_pdf/characteristics-us-abortion-patients-2014.pdf
Major B, Cozzarelli C, Cooper L, et al. Psychological responses of women after first-trimester abortion. Arch Gen Psychiatry. 2000;57(8):777-784. doi: 10.1001/archpsyc.57.8.777
Fergusson DM, Horwood LJ, Boden JM. Abortion and mental health disorders: evidence from a 30-year longitudinal study. Br J Psychiatry. 2008;193(6):444-451. doi: 10.1192/bjp.bp.108.056499
Bellieni CV, Buonocore G. Abortion and subsequent mental health: review of the literature. Psychiatry Clin Neurosci. 2013;67(5):301-310. doi: 10.1111/pcn.12067
Cowchock FS, Lasker JN, Toedter LJ, Skumanich SA, Koenig HG. Religious beliefs affect grieving after pregnancy loss. J Relig Health. 2010;49(4):485-497. doi: 10.1007/s10943-009-9277-3
Layer SD, Roberts C, Wild K, Walters J. Postabortion grief: evaluating the possible efficacy of a spiritual group intervention. Res Soc Work Pract. 2004;14(5):344-350. doi: 10.1177/1049731504265829