In Norway, induced abortion within the first 12 weeks of pregnancy became an unconditional legal right in 1978. Norway has approximately 4.6 million inhabitants; about 15,000 induced abortions and 8,000–10,000 miscarriages are treated in general hospitals per annum.
This study was approved by the Norwegian Regional Ethics Committee. Our study comprised 120 women between the ages of 18 and 45 years (80 of whom had had an induced abortion and 40 of whom had experienced a miscarriage), who were treated in the gynecology department of Buskerud Hospital between April 1998 and February 1999. Buskerud Hospital is the main hospital in Buskerud County and is situated in Drammen, a city of 55,000 citizens located 40 km west of Oslo, Norway. All women who had an induced abortion were less than 13 weeks pregnant, and no terminations were due to fetal anomalies. Of the women who experienced miscarriage, one was 21 weeks pregnant whereas the rest were less than 17 weeks pregnant. In our study, all surgery performed was completed under anesthesia, and the women left hospital a few hours after the procedure. The staff contacted the women shortly after the abortion while they were still in hospital. Those who agreed to participate in the study were then contacted by a female psychiatrist (ANB) employed in the psychiatry department of the hospital.
Two hundred and sixty-eight women were approached. Of these, 13 were excluded on the basis of defined exclusion criteria: (1) not Norwegian-speaking (n = 9); (2) mentally disabled or suffering from serious psychiatric illness (n = 3); and (3) pregnancy following rape (n = 1). Of the 255 women who were asked to participate, 120 (47%) agreed and were included (46% of the women who had had an induced abortion and 50% of those who had experienced a miscarriage). For women who had had an induced abortion, the response rate varied between 52% and 30%, depending on staff motivation and the person who asked the women to participate. When nurse G. asked the women, 52% agreed to participate in the study. For several years, this nurse had cared for women during the first hours after an induced abortion. She was genuinely interested in the project and had a positive attitude towards taking part in it. When other staff members asked the women, only 30% agreed to participate. The project leader (who was also the interviewer) was not well known to the staff, and some of the staff were skeptical about the study being carried out in their department. At the beginning of December 1998, when all but three of the women who had had an induced abortion were included, only half the women who had had a miscarriage were included. The project leader then had the opportunity to address the staff at a meeting that lasted for two hours. After this meeting, several staff members said that they were much more positive about the project than previously, and that they felt more comfortable about asking women to participate in the study. Before this meeting, the inclusion rate of women who had experienced a miscarriage was 36.5%; after the meeting it increased to 75%.
The mean ages of the women who had had an induced abortion and did or did not participate were 27.7 and 27.5 years, respectively (not statistically significant [n.s.]). The corresponding values for women who had had a miscarriage were 30.1 and 30.5 years (n.s.). We had no demographic information other than age for the women who did not participate in the study.
The women were interviewed 10 days (T1), six months (T2), two years (T3), and five years (T4) after the end of pregnancy. The interviews were semi-structured and included self-administered questionnaires. Of the 80 women who had had an induced abortion, 74 completed the interviews at T2, 72 at T3, and 70 at T4. Of the 40 women who had experienced a miscarriage, 40 completed the interviews at T2, 39 at T3, and 39 at T4. Thus, of the 120 women taking part in the project, 91% (43% of eligible women) completed the study.
At T1, all the women were asked if they felt that the time after the pregnancy termination had been difficult. Twelve women did not feel that it had been difficult (one of whom had had a miscarriage, 11 an induced abortion). All these women completed the study. Eleven women did not complete the study, one of whom experienced a miscarriage and 10 of whom had had an induced abortion. Of these, the woman who miscarried and seven of the women who had had induced abortions said that they wanted to discontinue their participation in the study because it was too difficult for them to answer questions about the pregnancy termination.
All interviews were conducted face-to-face by a female psychiatrist, except two at T3 (one by telephone, one by mail) and nine at T4 (eight by telephone, one by mail). The women's mental health before the pregnancy termination was measured by self-report and by diagnostic evaluation by the interviewer.
Self-reported six-point scale assessment of the previous need for psychiatric help
-
1.
No help ever required from health services.
-
2.
No contact with or help from health services, but the woman felt that she had needed professional help on previous occasions.
-
3.
The woman had consulted a general practitioner about psychological problems.
-
4.
Previous contact with a private practitioner (psychiatrist or psychologist).
-
5.
Previous treatment at a psychiatric outpatient clinic.
-
6.
Previous inpatient treatment at a psychiatric clinic or at a clinic for substance abuse.
Diagnostic evaluation
After the first interview, the women were assigned one or more ICD-10 (International Statistical Classification of Diseases, 10th Revision) lifetime psychiatric diagnoses, if applicable. We devised a three-point scale, the Former Psychiatric Health Scale, based on a combination of the self-reporting assessment and the diagnostic evaluation:
-
1.
Good. The woman rated herself as 1 or 2 and received no diagnosis from the psychiatrist.
-
2.
Medium. The woman rated herself as 1 or 2, but was given a diagnosis by the psychiatrist.
-
3.
Previous psychiatric problems. The woman rated herself as 3–6 and was given a diagnosis by the psychiatrist.
Questionnaires
The following questionnaires were completed at all interviews.
Impact of Event Scale (IES)
The Impact of Event Scale [17] has been widely used as a measure of stress reactions after traumatic events. It has a two-factor structure: one measures intrusion (flashbacks, bad dreams, and strong feelings related to the traumatic event) and the other measures avoidance of thoughts and feelings related to the event. An evaluation of the scale after 20 years of use [18] reported that IES has been valuable for measuring stress reactions in a number of different populations. The type of event was shown to be a strong predictor of intrusive and avoidant symptoms after the traumatic event.
The IES version that we used contained 15 questions. Seven questions dealt with intrusion and eight dealt with avoidance. The women were asked to rate, on a scale from 0 to 5, their perceived level of specified symptoms during the previous week. The scale thus ranged from 0 to 35 for intrusion and from 0 to 40 for avoidance. Examples of questions on the intrusion scale are: "I have had bad dreams about the pregnancy termination" and "Things I have seen or heard suddenly reminded me of the pregnancy termination." Examples of questions on the avoidance scale are: "I know that I have many pent-up feelings about the pregnancy termination, but I have pushed them away", "I have tried not to talk about the pregnancy termination", and "I have not allowed myself to have thoughts about the pregnancy termination".
A recent review [19] showed that the IES is a reliable index of the degree of subjective distress associated with a particular trauma. A high score on the IES, especially on the intrusion scale, seems to be closely related to the presence of Acute Stress Disorder (ASD) or PTSD, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). In our study, we did not use specific criteria for assigning these diagnoses but used the term "case", defined as a score of > 19 points on either of the two subscales, IES intrusion or IES avoidance, as is common practice [20, 21].
Quality of life
The Quality of Life questionnaire that we used consisted of 12 items. The women were asked to choose between "never", "seldom", "sometimes", "often" or "all the time" to indicate the extent to which each of 12 statements applied to their lives during the previous two weeks. Examples of statements are: "I felt fit and strong", "I felt that life is worth living", and "I felt close to another person". The twelfth and last item was "When you think about how you are doing nowadays, are you mostly content with your life, or mostly discontent?" To this last item, the women were allowed to select from six different alternative answers. Thus, the total scores ranged from 12 to 61 points; the higher the score, the better the quality of life. Cronbach's alpha at the four interviews varied between 0.92 and 0.94. The questionnaire is a more comprehensive version of "Subjective Well-Being", which has been used in other studies in Norway [22–24]. The correlation between items in the version used in our study and "Subjective Well-Being" is 0.93. Normative values for this test are not available. However, an indication of normative values may be found in another study that used the same material to investigate hypertension screening [22]; the mean score for 60 women aged 25–45 years was 47.90 (SD = 7.60).
Hospital Anxiety and Depression Scale (HADS)
Zigmond and Snaith [25] introduced the HADS questionnaire in 1983. The questionnaire was shown to be valuable in detecting symptoms of anxiety and depression in a wide variety of patients [26]. It contains 14 questions, each rated from 0 to 3. Seven questions deal with anxiety during the previous week, and seven questions deal with depression during the previous week. The scores for anxiety and depression thus range from 0 to 21 points. For normative values, we used data from the "HUNT" (Helse Undersøkelse Nord Trøndelag) study, a large population study conducted in Norway from 1995 to 1997. This study was performed in the county of Northern Trøndelag (situated in the central part of Norway and containing about 3% of the population of Norway) [27]. Of all people aged between 20 and 89 years, 62,344 (67.7% of the total population) completed valid ratings of HADS. The data were kindly provided by Dr. Eystein Stordal. Women aged 30–35 years (n = 2,879) had the following mean scores: HADS anxiety = 4.6 ± 3.4, HADS depression = 2.6 ± 2.7. We used this age category for comparison because the women in our study had mean ages of 30.1 years (miscarriage) and 27.7 years (induced abortion) at T1, and 35.1 and 32.7 at T4, respectively.
Feelings associated with the abortion
Feelings after an induced abortion have been rated by other studies [9, 12, 28], which used Likert-type scales ranging from 1 (not at all) to 5 (extremely). We used a similar scale and measured the intensity of various feelings that the women experienced at the time of the interview when asked to think about the abortion. The participants were asked to rate their feelings of relief, grief, loss, guilt, shame and anger. For each feeling, they rated the intensity as either 1 (not at all), 2 (a little), 3 (a great deal), 4 (much) or 5 (very much).
Statistics
The study was designed to detect "medium" effects when comparing the two abortion groups (defined as 0.5 by Cohen [29] and requiring sample sizes of approximately 70 individuals for each group when the alpha [type I] error level is set at 5% and the beta [type II] error level is set at 10%). After attrition, our study groups contained 70 (induced abortion) and 39 (miscarriage) participants at T4, yielding statistical power slightly above 70% for medium-sized effects and above 98% for "large (> 0.80) effects. This was considered satisfactory for our purposes.
Statistical associations between both pregnancy termination groups and other categorical independent variables were tested using the χ2 test. Mean differences between pregnancy termination groups for continuous variables were tested by point biserial r/ANOVA (t-tests). The significance of changes in mean scores over time within each pregnancy termination group was tested with paired-sample t-tests. The significance of differential changes between groups was assessed by analysis of covariance (ANCOVA), using follow-up scores as the dependent variable, pregnancy termination group and categorical confounders as factors, and baseline scores for the outcomes as linear covariates (using the GLM procedure of SPSS). Effect sizes for changes are expressed as Cohen's d [29]. Partial product-moment correlations were computed between continuous outcome variables with linear controls for previous psychiatric health.
