ORIGINAL ARTICLE

Abortion and the pregnant teenager

Irene Lipper, m.s.w., Helen Montreal

Cvejic, m.d., Peter Benjamin,

m.d.,

f.r.c.p.[c] and Robert A. Kinch,

m.d.,

f.r.c.s.[c],

A study was carried out at the Adolescent Unit of The Montreal Children's Hospital from September 1970 to December 1972, the focus of which evolved from the pregnant teenager in general to the shortand long-term effects of her abortion. Answers to a questionnaire administered to 65 pregnant girls to determine the psychosocial characteristics of the pregnant teenager indicated that these girls are not socially or emotionally abnormal. A follow-up study of 50 girls who had an abortion determined that the girls do not change their life styles or become emotionally unstable up to one year post-abortion, although most have a mild, normal reaction to the crisis. During the study period the clinic services evolved from mainly prenatal care to mainly abortion counselling, and then to providing the abortion with less counselling, placing emphasis on those cases which require other than medical services.

Summary:

Resume: L'avortement chez les adolescentes enceintes De septembre 1970 a decembre 1972, le service des Adolescents du Montreal Children's Hospital a mene une enquete qui etait centree d'abord sur I'adolescente enceinte en general et plus tard sur les consequences a court et a long terme de son avortement. Un questionnaire a ete remis a 65 filles enceintes en vue d'etablir les caracteristiques psychosociales de I'adolescente enceinte. Les reponses indiquent que ces filles ne sont pas anormales, ni sur le plan social, ni au point de vue emotif. Cinquante des filles qui avaient subi un avortement ont ete suivies regulierement. II appert de cette enquete que ces filles n'ont pas change leur genre de vie et ne sont pas devenues instables sur le plan emotif durant I'annee qui a suivi l'avortement, bien que la majorite d'entre elles aient eu une reaction legere au moment de la crise, ce qui etait du reste considere comme normal. Durant la periode de I'etude, les services cliniques ont evolue; consistant d'abord en soins pre-natals, ils ont porte ensuite principalement sur les conseils en matiere d'avortement et ont fini par fournir le moyen d'avorter tout en reduisant les conseils. Ils ont insiste sur les cas qui avaient besoin d'une aide autre que les services m6dicaux.
852 CMA JOURNAL/NOVEMBER 3, 1973/VOL. 109

damage. The project reported in this paper was designed as a team approach to the pregnant adolescent. The team consisted of a social worker, psychiatrist, psychologist, public health nurse and obstetrician/gynecologist. The aim of the study was to explore the following: 1. The psychosocial characteristics of the pregnant teen ager, noting differences from her non-pregnant peers. 2. The short- and long-term effects of therapeutic abortion on the patient's life style and/or affect immediately after the operation and up to one year post-abortion. 3. The best approach to serving the pregnant teenager in
an

an Obstetrics and Gynecology Clinic was estab lished as part of the Adolescent Unit of The Montreal Children's Hospital. In the next few years, because of the changes in the law with respect to abortion, the obstetrical section of the clinic became increasingly concerned with counselling in regard to abortion and provided a unique opportunity for the study of the effect of therapeutic abor tion on the emotional function and life style of the young female adolescent. This clinic strives to give the adolescent a free choice with respect to the way she deals with her pregnancy. Therapeutic abortion is not stressed as a solu tion to the situation, but individual requests for the opera tion are received sympathetically and rarely refused. The clinic works on the principle that therapeutic abortion is granted to those who apply for it unless study of their problems suggests it would produce emotional or physical

In 1968

individualized

manner.

Review of the literature Since the relaxation of the abortion law in 19681 teenagers in increasing numbers have been asking for abortion. Of the first 500 abortions performed at The Vancouver General Hospital in 1970, 18% were in patients under 19 years of age. Of the 1186 abortions performed at The Montreal General Hospital in 1972, 20.1% were in girls under the age of 19, distributed as follows: 15 years 6.4% and 17 to 18 years 1.8%, 15 to 16 years 11.9%. Studies of abortion have been strongly criticized because of the absence of systematic data gathering, the lack of comparative studies, the "impressionistic" nature of re.

Reprint requests to: Dr. Peter Benjamin, Director, Adolescent Unit, The Montreal Children's Hospital, 2300 Tupper St., Montreal 108,
Que.

and the inadequacies of samples used. Recent accounts of the subject report a lack of serious sequelae and a new impression is emerging: abortion is no longer held to have an adverse effect on personality and functioning. However, the effect of abortion on the young, unmarried girl has not been hitherto described. Concrete data are hard to obtain and most recent statements concerning the effect of abortion on the teenager usually consist of value judgements. In 1969 a study8 was reported from London, Ontario, comparing 149 unmarried mothers with 99 married mothers from similar backgrounds. There were no statistically signi-

ported findings

ficant differences in home background, educational achievement, occupational level of parents, dating history or sexual experience between the groups. Traditionally, abortion has been associated with the words "therapeutic" and "illegal". Much of the literature on abortion consists of case histories of women with an emotional or medical illness. More recent reports con cerning the sequelae of legal abortion indicate that abortion is not psychologically harmful and, in some cases, has had a positive effect. In a study of 250 such patients, Osofosky and Osofosky2 report that the prevalent moods after abor tion were those of "relief and happiness". David3 notes that, although 4000 cases of postpartum psychosis requiring hospitalization are documented each year in the United States, practically no such cases were reported after abor tion. In a post-abortion evaluation of 40 women, Fbrd, Castelnevo-Tedesco and Loy4 found that most had fewer psychiatric symptoms than they did before abortion. Perez-Reyes and Falk5 studied 41 adolescents after abortion and reported that in 50% general health was the same or improved, and in 75% emotional health was the same or improved. They concluded that the patients viewed the crisis and operation as a helpful event in their growingup process.

1968
TIME INTERVAL

1971

FIG. 1.Incidence
40

Hospital Adolescent Clinic (total 329 patients).

(OUARTERLY) of pregnancy at The Montreal

Children's

304
o GO
<

20-^
10

co

1968

1969

1970

1971

1972

English-speaking.

about 16.5 years. Of the 210 pregnant adolescents seen for consideration of abortion between December 1970 and September 1972, 123 (58.6%) were French-speaking and 87 (41.4%) were
mean

Demographic information Figs. 1 to 4 illustrate general characteristics of the clinic population. The figures differ because they are based on different groups at different times over a period of five years, 1968 to 1972. The incidence of pregnancy at the clinic increased steadily over the five-year period (Fig. 1). From 1968 to the middle of 1971 the number of abortions gradually increased, but since the end of 1971 the demand for abortion has stabilized (Fig. 2). Since 1967 the number of babies carried to term has increased gradually, whereas the number of abortions has increased dramatically (Fig. 3). As Fig. 4 shows, most of the patients seen were between ages 15 and 17, with the

(QUARTERLY) FIG. 2.Incidence of therapeutic abortions at the Adolescent Clinic (total, 212 patients).
Incidence B total pregnancies (439) therapeutic abortions (284) H babies carried to term (137) I determination unknown (18)

TIME INTERVAL

Psychosocial characteristics of pregnant teenagers At the onset of the project, in order to form a descriptive
60
50

J
-I

40
o a

30
20 10

-I
-I

J
13 14

1967

FIG. 3.Changing the five-year period.

1969 1971 1970 1972 (projected) annual time intervals pattern of outcome of pregnancy over

1968

15

16

17

18

19

age(6 month intervals) FIG. 4.Age distribution of 332 clinic patients. CMA JOURNAL/NOVEMBER 3, 1973/VOL. 109 853

pital.

picture of the girl and her background, the social worker of the research team administered a questionnaire to 65 girls within three months of either delivery or abortion. The questionnaire was devised by Mrs. Elena Kruger, P.S.W., Social Service Department, The Montreal Children's Hos
The salient findings from the questionnaire
are as

follows:

mainly from the pregnant girl. Because of lack of resources there has been no systematic documentation of the fathers. The findings of the questionnaire were used (a) to familiarize the clinic staff with the characteristics of the patients and (b) to postulate that these girls were not a disturbed group and should not be treated as such by the clinic staff.
Sequelae of the abortion
Material and methods The sample used for the study on short- and long-term effects of abortion included 50 girls who obtained an abortion between September 1970 and September 1971 and were followed up for at least a year after the opera tion by the social worker. Of 89 girls who had an abortion performed during this period 20 did not return to the clinic up to one year post-abortion (10 lived outside the Montreal area). Nineteen other girls were not seen by either the social worker or psychiatrist initially, or by the social worker for follow-up assessments and so were not included in the sample. Twenty-six of the girls were English-speaking and 24 were French-speaking. The age distribution at the time of abortion was as follows: age 13, 2 patients; age 14, 5 patients; age 15, 14 patients; age 16, 14 patients; age 17, 12 patients; and age 18, 3 patients. The findings were based on data collected at nonstructured interviews carried out by the social worker and psychiatrist. All girls were seen by both professionals pre-abortion and by the social worker once up to six weeks post-abortion and at least twice during the first year. The findings are set forth in Table I. The girls were categorized as to their emotional adjustment; from the pre-abortion assessment, positive adjustment was characterized by no history of a previously defined problem or psychiatric contact, or a clearly stated wish for
Table I.-Data obtained at short- and

Background of the girl and her family 1. 56% have many friends, 44% have few friends, and none consider themselves isolated. 2. 44% of the girls are from one-parent families; 56% are from intact families. 3. 19% of the families are receiving welfare; 81% are not. Families are categorized as middle class in 50% and lower class in 50%. 4. 50% have been involved in a recent (within one year) crisis, either the loss of a close family member or a geographic move by the patient or the putative father. 5. Patterns of dominance in the home reveal that there are 63% dominant mothers, 31% dominant fathers and 6% neither. 6. 65% are students, 23% are high-school dropouts and 12% are working. 7. 44% are the eldest child in the family, 25% the middle child, 25% the youngest child and 6% the only child. 8. 62% are from large families (more than four children),
32% are from smaller families and 6% are only children. 9. 75% had knowledge of contraceptives and their use; 25% did not. In only 6% was some form of contracep tion used. 10. 75% have had sexual relations with only one boy, 25% with more than one.

Conclusions from these findings 1. These girls are not isolated but have diverse peer rela
a significant number of girls from one-parent families. 3. These girls are not typically lower class or from deprived income backgrounds. 4. Indications are that in a large number of cases pregnancy is a reaction to a recent crisis. 5. The findings substantiate those of other studies which indicate that there is a predominance of dominant mothers in these families.

2. There is

tionships.

compared with pre-abortion

long-term follow-up

status

ceptive devices, they do not apply this knowledge to themselves. It is interesting to note that in another study6 on teenage pregnancy, a similar conclusion is reached from a popula tion in which 50% of the girls and boys had used contra ceptives on previous occasions. The conclusion was that pregnancy was not due to lack of knowledge about, or even experience with, contraceptives but rather due to a lack of concern for teenage attitudinal patterns consequences and an emphasis on fun. Background of the putative father A large number of putative fathers are unemployed (35%) while 35% are employed and 12% are students; in 18% the status is unknown. The relationship of the girl and the putative father is generally long term, i.e. more than six months in 56%. Information about the putative father has been gathered
.

6. Most pregnant teenagers are continuing their schooling. 7. There is a significant number of eldest children in the group. 8. These girls are most often from larger families. 9. While most of these girls have a knowledge of contra

** ***

*4 girls left home during this period, 1 returned home. 1 girl left home, 2 others returned home. 3 girls returned to school, 2 others left school and took employment. had an IUD inserted immediately post-abortion, 34/36 were taking f2/36 birth control piIls. {4/24 became pregnant again. 3 girls broke with the putative father, 2 others resumed their relationship with him. 4 girls broke with the putative father, 3 others resumed their relationship with him.

854 CMA

JOURNAL/NOVEMBER 3, 1973/VOL. 109

abortion supported by family and/or putative father. Nega tive adjustment was characterized by a history of psychiatric contact, poor psychological adjustment according to court and school records, or inability of the adolescent and her family to come to a mutual agreement concerning abortion. Post-abortion positive adjustment was defined as no psychopathological symptoms, the expression of mild sadness or regret with regard to the abortion, or expressed satisfaction with the decision to have an abortion. The assumption was made that some emotional reaction to the crises of pregnancy and abortion could be considered a normal and healthy way of dealing with the experience. As David3 points out, "there is no psychologically painless way to cope with an unwanted pregnancy". Negative ad justment was defined as psychosomatic complaints which interfered with overall functioning (sleeping, eating, work or school attendance), severe regret over having had an abortion, continued unstable behaviour, or new symptom formation (drugs, alcohol, truancy). It is apparent from Table I that the distribution of girls with positive or negative adjustment to the crisis changed little during the one year of follow-up. More than 80% of the girls were well adjusted both before and after abortion. In the follow-up period they expressed feelings varying from relief to mild regret. Between 15 and 20% seemed to be poorly adjusted both before and after abortion. They were less able to function productively or to deal with their feelings concerning the pregnancy and abortion. The girls who were unstable before abortion remained so after abortion. In 76% of cases the families supported the girls through the crisis period, but 24% did not. In 16% of the cases, follow-up of one year revealed an improvement in the rela tionship between the girl and her family. This may re present a weakness in some families in coping with a crisis, but once the crisis is over, the family is able to offer support. About 80% of the girls in the sample lived at home before and after abortion. However, 18% had lived away from home before abortion. It is interesting to note that three of them returned home during the year following the abortion. Five other girls left home during this period, all of whom were described as "unstable" after the abortion. Living at home is accepted as an indication of stability in the girl and as evidence of family support. The latter is believed to be important to a girl in crisis. About 80% of the girls continued with their schooling or work despite the pregnancy and subsequent abortion, and 6% returned to school during the first year following abortion. Twenty percent of the girls were neither in school nor working before and after abortion. Fifty-two percent of the girls were employing reliable contraception up to one year post-abortion in contrast to 2% (1) before pregnancy. Approximately 50% of the girls continued their rela tionship with the putative father up to one year after abortion. In the remaining cases the relationship did not have the quality to withstand the crisis of pregnancy. Conclusions The data concerning 50 girls studied by means of unstructured interviews before and up to one year after abortion show that: 1. The majority of the girls were well adjusted and stable. 2. About 20% showed evidence of unstable behaviour and emotional life both before and after abortion. 3. Generally, the girls who were more stable before abor tion remained so and the more disturbed ones continued to be disturbed.

4. The abortion did not

significantly change a girl's life emotional adjustment. 5. The crisis did test a girl's relationships. The relationship with her family seemed to remain stable, whereas that with the putative father did not.
style
or

Evolution of the clinic

ment.

The research effort had a major impact on the role of the professional staff and in the delivery of services to the patient according to her specific need. The Obstetrical Clinic evolved from a prenatal care unit to a pregnancy counselling service, and then to a facility that treated abor tion primarily as a medical problem. Necessarily, staff roles and clinical services changed during each stage of develop

Phase 1 At first the clinic received referrals mainly from com munity agencies and physicians who requested an investiga tion of possible pregnancy. Once the pregnancy was con firmed by the doctor, the social worker took a complete social history and discussed possible alternatives, including abortion, with the girl and her family and the putative father if he was available. Often more than one interview was necessary before a decision was reached. All patients requesting abortion were seen by a psychiatrist during this phase. Her role was to rule out severe psychopathology, to confer with the social worker in making a psychosocial assessment and treatment plan for the girl, and to present her assessment to the medical staff. The psychologist did thorough clinical assessments of a few patients during this phase. Medically, the girl was fol lowed up as needed and visits often coincided with psychosocial appointments. During Phase I the patient tended to be overburdened with professional attention. The girls who continued with the pregnancy were seen in clinic every two weeks until the ninth month and then every week. Each time they attended clinic they interacted with the team. They were offered prenatal care including information about pregnancy, labour and delivery, child care and a tour of the obstetrical floor at The Montreal General Hospital or Catherine Booth Hospital. The services of a dietitian and the VON were available when needed. Phase II The role of the psychiatrist changed in Phase II. The consensus of the research team after one year of operation was that abortions were done for social reasons and not for psychiatric or medical ones. During this phase the psychiatrist assumed a research role in helping the social worker to conceptualize the data collected, and acted as a consultant in certain cases. The psychologist administered the Personality Factor Questionnaire of Raymond Cattell to all pregnant girls on their initial visit to the clinic. The purpose of this test was to establish whether this group had a "distinctive per sonality". Parts of this test were readministered after a post-abortion period of three weeks, and the entire test was readministered after six months, in both cases to discern any follow-up personality change.
Phase III Since the liberalization of the abortion laws and as the clinic became known, more and more requests for abortion were received. The nature of the request changed from diagnosis of pregnancy to obtaining abortion. This was due partly to an increase in community resources which afforded the girl the opportunity to discuss her pregnancy elsewhere. Most often, by the time the girl contacted the CMA JOURNAL/NOVEMBER 3, 1973/VOL. 109 855

clinic, she knew that she was pregnant, was aware of the alternatives, had discussed them and had made a decision. These changes had an impact on the clinic's service role. By September 1972 it was no longer necessary for the social worker to interview all the pregnant girls and their families. During Phase III the physician evaluated tlre medical and psychological aspects of all cases and referred any girls with severe social or emotional problems to the social workers. The indications for referral to social service or psychiatry were: 1. Indecision about the abortion on the part of the girl and/or the family. 2. Conflict between the girl and her family about the abortion. 3. No support for the girl from parents or putative father through the crisis. 4. Request by the patient for help with a problem other than the abortion, i.e. employment, placement, financial assistance. The social worker continued to follow up girls through their pregnancy during Phases II and III and continued to follow up the 50 girls who were selected for the study of the after effects of abortion. The psychologist administered questionnaires in order to discern personality changes after abortion. The results from his studies are in press.7 The new abortion cases were seen in a group each week by the nurse. The parents of the girls were seen in a separate group by the social worker. The purpose of these groups was to (a) discuss any feelings and questions pertaining to the abortion, and (b) evaluate whether there were problems other than the abortion if so, a referral was made to Social Service. In general, the clinic has undergone an evolutionary process since 1970. Staff roles and services have changed as the nature of the patients' requests have changed from mainly prenatal care to mainly abortion counselling, and then to providing the service requested with less emphasis on counselling. The research findings have also been used to shift the focus of professional care in abortion cases from seeing all patients to seeing only those who have been identified as needing other than medical services. Services to the girl who carries her pregnancy to term have remained constant as the demand for this service has been constant during the three phases.

Conclusion The two general objectives of the research were to describe the pregnant teenager - her background and functioning - and to determine whether abortion is harmful to her social and/or emotional life. Our findings from a questionnaire administered to 65 pregnant girls indicated that they were neither emotionally disturbed nor socially deprived. They were generally functioning well. From nonstructured interviews over a period of one year post-abortion we conclude that, for the most part, the girls have a normal reaction to the abortion crisis, handle it adequately, and seem to carry on afterwards as they did before. Generally, the mere disturbed a *.'s peinality -nd lif&!yle w pre-abortion, the more likely it was that she would react adversely to or not cope adequately with the crisis. The increasing number of requests for abortion has shifted the focus of study from the characteristics of pregnant teenagers to abortion sequelae. The findings from the research project have in turn altered professional roles and clinic services from a widespread use of psychosocial personnel for assessment and treatment planning to a medically focused handling of abortion requests. At present patients are offered professional attention according to their individual needs rather than because they are pregnant. The clinic is continuing to operate on the basis of Phase III, and the sample of 50 girls is being followed for the second year post-abortion. We gratefully acknowledge the assistance of Dr. Robert H. Aikman, Obstetrician/Gynecologist; Mr. William Lawrence,
Psychologist; Miss Elizabeth Pilley, R.N.; and Miss Gayle McLachlan, M.S.W.
1. Abortion Law in Canada (excerpt from Criminal Law Amendment Act 1968-69), 17-18 Eliz II, chap 38, s 14, p 33 2. OSOFOSKY JD, OSOFOSKY HJ: The psychological reaction of patients to legalized abortion. Am J Orthopsychiatry 42: 59, 1972 3. DAVID HP: Abortion in psychological perspective. Ibid, p 62 4. FORD CV, CASTELNEVO-TEDESCO P, LoY KD: Abortion, is it a therapeutic procedure in psychiatry? JAMA 218: 1173, 1971 5. PEREz-REYES MG, FALK R: Follow-up after therapeutic abortion in early adolescence. Arch Gen Psychiatry 28: 120, 123; 1973 6. PANNOR R, et al: The Unmarried Father. New York, Springer, 1971, pp 71-73 7. LAWRENCE W: Anxiety-adjustment and other personality factors in teenage patients before and after abortion. Proc 81st Ann Conv Am Psychol Assoc, 1973. In press 8. KINCH RA, WEARING MP, LovE EJ, et al: Some aspects of pediatric illegitimacy. Am J Obstet Gynecol 105: 20, 1969

References

856 CMA JOURNAL/NOVEMBER 3, 1973/VOL. 109