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Abstract

The aim of the present review was to explore the role of the psychiatrist in late terminations of pregnancy. A literature review was conducted using MEDLINE and psycINFO databases, focussing on articles that explored (i) existing decision-making processes in late terminations; (ii) psychological sequelae of both early and late termination of pregnancy; (iii) the role of psychiatry in both early and late termination of pregnancy; and (iv) the involvement of psychiatry in complex medical decisions. The decision to perform a late termination of pregnancy is complex. Contributing to its complexity is an array of political, legal, societal, and ethical factors. The literature regarding psychological sequelae is frequently confusing and weakened by methodological problems. Methods of assisting in this decision-making process include the involvement of committees and psychiatrists. There are precedents for the involvement of psychiatrists in such a setting. Historically, psychiatrists played a role in screening women who requested an early termination. Psychiatrists are often involved in ethically challenging and complex clinical decisions in the general hospital setting. The involvement of psychiatry in this complex decision-making process has potential advantages and disadvantages. It is timely for psychiatrists to consider their position on their discipline's involvement.

Keywords

clinical ethics decision making emotional adjustment induced abortion post-traumatic stress disorder

Before discussing the role of the psychiatrist in late-term termination of pregnancy, the legal and ethical issues pertaining to terminations will be outlined. These issues are particularly pertinent currently given the recent discourse regarding terminations in both the political arena and the media.

Legal setting

Australian States originally based their abortion legislation on British abortion law, which was incorporated into their respective Crimes Acts [1]. In Britain, termination was illegal under the British Offences Against the Person Act of 1861. In 1967 the United Kingdom Abortion Act was passed. This allowed termination on the basis of two doctors deciding that there is either risk to the life of the woman or of injury to her physical or mental health greater than if the pregnancy were terminated, or that there is substantial risk of serious handicap to the child [1]. Since 1967 most Australian States also liberalized their laws. However, this was not done uniformly and legislation regarding both early and late terminations varies between states [1]. The Australian Capital Territory is the only State or Territory that does not refer to termination in its criminal code. South Australia, Western Australia, Tasmania, and the Northern Territory have legislation explaining when termination is not unlawful. Elsewhere, common law interpretation of the relevant Crimes Act has made termination lawful in certain circumstances [2]. The focus of this article is on New South Wales (NSW).

In NSW, termination is governed by the NSW Crimes Act 1900. This has been liberalized by case law interpretation such that abortion is legal if performed with the consent of the woman by a legally qualified medical practitioner; if the medical practitioner procuring the termination believes that it is necessary to protect the woman from serious danger to life, or physical, or mental health, based on medical, economic, or social grounds; and if termination is not out of proportion to the danger intended to be avoided [1]. The definition of late-term termination (hereafter referred to as late termination) varies but in NSW indicates termination after 20 weeks of gestation. There is no specific law regarding late terminations in NSW.

In 2000 the NSW Department of Health issued a circular that suggested a framework for termination of pregnancy in NSW public hospitals [3]. It summarized the legal framework in relation to termination of pregnancy as aforedescribed and advised that all women seeking termination of pregnancy are to be offered counselling by an appropriately qualified health-care professional. It directed that in the case of termination after 20 weeks of gestation, the treating medical practitioner should seek advice from a multidisciplinary team including experts in fetal medicine, neonatology, psychiatry or specialist mental health, and any other relevant specialties [3]. The reason for the involvement of mental health professionals was not explained. In 2005 this circular was superseded by a policy directive that clarified the assessment of need and consent, and encouraged the development and review of local protocols [4]. This slightly clarified the mandated mental health involvement by explaining that the purpose of the multidisciplinary team is to assist the treating medical practitioner in undertaking an assessment of need.

Ethical setting

The ethical dilemmas surrounding late termination have been thoroughly explored and are pertinent to a consideration of the psychiatrist's role [5–7]. There are two main areas of tension. First there is the issue of legal versus moral fetal personhood and rights [7]. In Australia the fetus is not recognized as a person in the eyes of the law. Morally, however, respect for fetal life increases after viability (the definition of which varies) and this is often thought of as the beginning of personhood. Second, once the fetus reaches viability, there is a sense of conflict between the rights of the mother and those of the fetus [6, 7].

A society's position regarding these ethical issues influences its law and policy. In the USA the third trimester has been deemed the statutory age of viability. At this time the fetus gains legal personhood and rights, making termination largely illegal [7]. Israel exemplifies a country where the fetus has no legal and little moral personhood. The interests of the mother are primary. Late-termination policy is liberal but committees attempt to restrict third trimester abortions to medical reasons [7]. In many countries the fetus is not granted legal personhood and therefore has no legal rights. However, viability is recognized as endowing the fetus with moral personhood and consequent rights including life and medical care. This is the case in the UK, Denmark, the Netherlands, and Canada, which have partially restricted late-termination laws [7]. Australian policy could be seen as falling within this category. In these countries, late termination is generally acceptable when there is a threat to the mother's health or a serious fetal anomaly (although this latter indication has not yet been legally tested in NSW).

Existing processes for decision-making in late terminations

Little literature exists on the processes involved in decision-making in late-term termination other than that which simply describes the legal frameworks. Many countries do not have explicit law or policy and seek the help of committees [7].

In Israel, multidisciplinary High Committees for the Elective Termination of Pregnancy comprising obstetric, neonatal, genetic counselling, and social work directors are involved in making the decision [8]. Psychiatry involvement is not described. Gagin et al. (2001) described the large degree of responsibility of the committee, the difficulty of uncertain diagnoses, and the uncertain extent to which maternal emotional stability should influence the decision [8]. They advocate the creation of a systematic protocol such as a points system that weights medical and social factors.

An Australian article described the creation of “termination review committees” at two major teaching hospitals in Victoria in 2003 [9]. These committees considered terminations after 20 weeks of gestation. One consisted of hospital staff not clinically involved with the case, including administrators. The other was composed mainly of clinicians involved in the patient's care. The committees could consult “non-voting members”, but there is no specific reference to psychiatry involvement [9]. The author describes these committees as having a decision-making role and argues that this is inappropriate because it undermines the woman's autonomy and the doctor–patient relationship.

Psychological effects of termination of pregnancy

The decision to offer a termination must ensure that the harm caused by the termination does not exceed the harm that may ensue should the termination not proceed. The question of whether termination of pregnancy causes psychological harm continues to be debated today. Research in this area is difficult for many reasons: low participation rates and large drop-out rates; difficulty selecting an appropriate control group; large number of confounders; large variety of potential outcome factors; and the potential influence of the political and social environment on results [10, 11].

Early terminations

The psychological sequelae of early terminations will be addressed first. There is a large amount of literature and a number of reviews [11–16]. Before the 1940s terminations were often done for medical reasons whereas by the 1950s psychiatric reasons were common. Studies had mixed results and are difficult to interpret due to methodological weaknesses as outlined by Shusterman [17]. Reviews of early research from the 1930s to 1960s suggest that distress (e.g. depression, anxiety, and guilt) was common before termination but diminished after the procedure [15, 18, 19]. Positive reactions and relief were often reported and prolonged negative reactions were rare [19, 20].

The 1970s was the first decade of legalized terminations in many countries. The literature from this period was well reviewed in 1989 by Romans-Clarkson who described ongoing methodological problems [12]. A number of prospective studies from this period included pre-abortion psychological evaluations and control groups [21–35]. The predominant finding was of improvement or no change in symptoms and there were no marked psychological differences between the study and control groups.

Several methodologically flawed studies from this era attempted to compare the outcome for women who were either granted or denied a termination. They reported that there were more psychological problems for the women who were denied a termination and more psychosocial problems for their children [23, 36–39].

Although the volume of research decreased over the next decade, the quality improved with greater use of control groups, pre- and post-abortion measures and longer follow-up periods [40–46]. Again, women tended to be distressed prior to the procedure but this reduced at follow-up when many women felt relieved.

Bradshaw and Slade (2003) reviewed the literature from 1990 to 2000, excluding studies in which termination was performed for fetal abnormality [47]. They reported a great variation in distress prior to termination, with “caseness” (on measures of depression, anxiety, and overall psychological distress) ranging from 15% to 69%. Controlled studies showed more anxiety and distress (but not more depression) in women planning a termination than in those planning to continue pregnancy or with threatened miscarriage. Psychological morbidity decreased in the month after termination but it is unclear if it returned to general population levels. Longer term studies followed subjects for up to 10 years [48–51]. These suggested that women who had a termination did not have more psychological morbidity than the general population. Those that used controls reported that rates of psychiatric disorder in women with unplanned pregnancies were no higher in women who had terminations compared with those who continued to term [51, 52].

This issue continues to be researched in the current decade with similar results. Several studies from this period are weakened by their retrospective design, lack of control group or poorly selected control group and lack of controlling for confounders [53–57]. Well-designed studies with long follow-up periods or controls will be briefly discussed.

Broen et al. (2004, 2006) examined trauma reactions, anxiety and depression in a longitudinal study of 40 women after miscarriage and 80 women after termination [58, 59]. This was weakened by a low response rate of 47%. Initially, more miscarriage subjects were traumatized, but at 2 years 18.1% of termination subjects compared with 2.6% of miscarriage subjects were “cases”. It is unclear how this compares with general population levels of traumatic stress. There were no significant differences in depression and anxiety scores between the two groups once confounders were controlled. Nonetheless, women who had terminations had higher levels of anxiety for 5 years and depression for 6 months compared to general population levels.

Reardon and Cougle's 2002 analysis of the United States National Longitudinal Survey of Youth cohort found that women with an unplanned first pregnancy who had a termination were at higher risk of depression than those who carried the pregnancy to term [60]. Schmiege and Russo (2005) described errors in coding in that analysis, leading to misidentification of unwanted first pregnancies and exclusion of women in the delivery group with subsequent terminations [61]. Their reanalysis of the data showed no differences in depression between the two groups.

Another longitudinal study by Fergusson et al. was based on a population cohort using data from the Christchurch Health and Development Study [62]. Three groups were examined: women who were pregnant by age 25 and either had a termination or continued to term and women who were not pregnant by 25. Rates of depression, suicidal ideation and illicit drug dependence were highest in the termination group and lowest in the not-pregnant group. Confounders adjusted for included social background, mental health history and personality factors. It is possible that mental health problems increased the likelihood of termination, but the association persisted in the analysis of later mental health outcomes in subjects pregnant before age 21. The authors concede that the incidence of termination might have been underestimated and that other confounders might have been overlooked (such as other traumas).

Many studies have attempted to identify predictors of psychological sequelae. Early studies reported that past psychiatric history, lack of social support, ambivalence about the decision, negative religious attitudes and critical family or staff were related to negative reactions [23, 29, 30, 63, 64]. Later studies also included personal conflict about the decision, blaming the pregnancy on one's character, the pregnancy being meaningful or intentional, difficult relationship with partner, low pre-abortion coping expectancy, subjective perception of the event and coercion from partner [46, 65–67].

Late terminations

A small body of literature has examined the psychological effects of terminations performed for reasons of fetal abnormality, usually in the second trimester.

Several retrospective descriptive studies report that distress is common after second trimester termination for fetal abnormality but tends to reduce with time and that most couples do not regret their decision [68–72]. Nonetheless, approximately 40% of women were still experiencing grief at 24 months. In keeping with these results, a prospective descriptive study by Geerinck-Vercammen and Kanhai (2003) reported minimal psychosocial consequences after second or third trimester termination for fetal abnormalities [73]. These studies are compromised by their poorly controlled or uncontrolled design, small subject numbers, and unvalidated instruments [69–71, 73].

In a large cross-sectional study, Kersting et al. compared women 14 days after second trimester termination for fetal abnormality, women 2–7 years after second trimester termination for fetal abnormality, and women after normal delivery [74]. That study was well designed but had only a 49% response rate. There were minimal differences between the termination groups in terms of traumatic experience or grief, but both termination groups experienced significantly more trauma than the normal delivery group. The persistence of high levels of distress for 2–7 years after termination is striking and in contrast to other studies that show that the high levels of initial distress subsequently decrease. Interestingly most women reported that they would repeat their actions. The ongoing grief is consistent with findings of other studies [72, 75].

Several cohort studies compared women who underwent second trimester termination for fetal abnormality with women who experienced late spontaneous miscarriages or perinatal death [75–78]. These studies tended to have small subject numbers [76, 77]. Shortly after the event both groups had similarly high levels of psychiatric morbidity, particularly depression. Lorenzen and Holzgreve (1995) reported that 2 months later, the spontaneous loss group expressed more grief than the terminations group [78]. Salvesen et al (1997) reported that the termination group had less depressive, intrusion and avoidance symptoms than the spontaneous loss group [77]. Psychiatric symptoms subsequently decreased to general population levels in most subjects. However, grief persisted in a number of women for up to 13 months after termination [75].

Overall, it seems that termination due to fetal abnormality elicits significant psychological distress, including depression, grief and symptoms of trauma. These symptoms generally decrease with time but can sometimes persist. It is possible that the actual diagnosis of fetal abnormality contributes to this psychological reaction.

What is the role of the psychiatrist in early terminations?

Historical role

Prior to liberalization of abortion laws, some jurisdictions in both Australia and overseas permitted abortions if the mother's life was at risk from psychiatric or medical conditions (e.g. cardiac disease, renal disease and diabetes) [11]. As medical treatment improved, psychiatric reasons played a more prominent role. Assessing whether a patient fulfilled criteria regarding potential psychiatric or psychological harm was difficult. It assumed that a psychiatrist could predict when carrying a pregnancy to term would be more harmful than termination [79]. The limited evidence in the area of denied terminations suggests no basis for individualized predictions of harm should termination not occur [80]. Many psychiatrists believed that abortion should be based on a decision between the woman and her doctor and argued against psychiatry having such a role [81]. Some writers suggested that obligatory psychiatric referral could do harm rather than good unless a psychiatric disorder exists [82]. Psychiatry was even described as “society's face-saving answer to providing freely available abortion without outcry” [83]. Others believed that psychiatrists should play an advocacy role by assessing a woman favourably if termination was in the patient's best long-term psychosocial interest [84]. Some even suggested a boycott in order to force reform towards less restrictive laws [80]. The Royal Australian and New Zealand College of Psychiatrists issued a position statement on abortion in 1970 [85]. This suggested that termination should be a decision made between the woman and her doctor. Once abortion laws were liberalized, the involvement of psychiatrists waned.

According to NSW Health, “counselling” should be offered to all women requesting a termination of pregnancy [3]. Peterson suggested that the concept of “abortion counselling” arose from both the historical practice of psychiatric involvement and also the Lane Report 1974, which reviewed the operation of the United Kingdom Abortion Act [86]. This counselling is usually provided by staff of the abortion service and does not require a psychiatrist.

Current roles

Psychiatrists now rarely have a place in the area of early termination of pregnancy. Limited roles might exist in assessing or counselling an existing patient with an unwanted pregnancy [83], providing information about mental illness and pregnancy [87] and providing counselling for patients after diagnosis of fetal abnormality [23, 88].

What is the role of the psychiatrist in late terminations?

As early terminations became legally and socially accepted, the need for psychiatry involvement disappeared. Psychiatry now seems to have acquired a role in late terminations. Terminations of pregnancy at later gestations have a long history. They were originally performed predominantly for maternal medical indications [89]. This became less common as maternal medical treatment improved. Advances in technology (including ultrasound, amniocentesis, chorionic villus sampling, fetal blood sampling and fetal magnetic resonance imaging) have allowed abnormalities to be diagnosed in utero [89]. Often, however, there are few or no treatments available and couples have to decide whether or not to continue with the pregnancy [90]. Many anomalies are not identified until the second trimester, which is therefore when terminations might occur [75]. Terminations for fetal abnormality sometimes occur in the third trimester because of difficulty diagnosing the abnormality earlier (e.g. structural abnormalities revealed by intrauterine growth retardation), prognostic uncertainty (e.g. cerebral ventriculomegaly) and false-negative screening tests (e.g. myelomeningocele and trisomy 18) [91].

Later terminations have also been associated with social factors including teenage pregnancies, long distance to termination service, single status, lower educational level and psychological factors including denial, ambivalence and fear [92–94].

Later terminations present a more emotive and ethically challenging situation for both the patient and staff for a number of reasons: (i) the pregnancy is often wanted [75]; (ii) the fetus becomes more like a baby at later gestations [75]; (iii) attachment to the fetus may be strong, particularly if movements have been felt or the fetus has been seen on ultrasound [95]; (iv) although a fetus might not have legal rights (as in Australia), respect for the fetus increases with gestation [96]; also, with treatment options becoming available for third trimester fetuses, it is starting to be seen as a patient [5]; and (v) later terminations might require an induction of labour as opposed to dilatation and evacuation [97].

The consultation–liaison psychiatrist's clinical role has often included involvement in complex medical decisions including assessment of potential organ transplant recipients [98], organ donors [99] and patients requesting genetic testing [100]. Late termination of pregnancy could be conceptualized as one such complex medical decision. In some settings and with some procedures, other health professionals such as social workers, psychologists or specialist nurses perform the psychosocial assessment. The choice of professional can be influenced by the philosophy of the particular institution and by the novelty of the procedure in question [98].

There is little literature regarding the role of the psychiatrist in late terminations. However, the literature already described highlights the challenges of the procedure, the likely psychosocial vulnerabilities of the patient and the uncertainty about psychological sequelae. The role could therefore conceivably include an assessment of coping ability and follow-up in case of adverse psychological outcomes.

Assessment of decision-making ability could also be an important part of the role. It is not uncommon for psychiatrists to be asked to assess a patient's ability to provide informed consent [101, 102]. There are arguments for and against such a role [102, 103]. Depression and distress caused by illness and hospitalization can hamper the conditions needed for informed consent [103]. Depression has been shown to colour decisions about pregnancy outcome and obstetric interventions [104]. However, the point at which depression impairs competence is unclear. The ambiguities for the psychiatrist in assessing competence are highlighted by the contentious issue of legalized euthanasia [105, 106]. Furthermore, the brief experience of legalized euthanasia in the Northern Territory demonstrated that patients withheld key information in order to obtain their desired outcome [107].

The psychiatrist's role might also involve supporting staff. Performing terminations is particularly stressful for nursing staff because they are usually present when the fetus is aborted and are often excluded from the decision-making process [108, 109].

Discussion

There is little doubt that the clinical decision to perform a late termination of pregnancy is a difficult and complex one. The environment in which such a decision is made is influenced by a multitude of political, legal, societal and ethical factors. Even at a clinical level the question of psychological sequelae is unclear. In terms of early terminations it seems that short-term distress is common but decreases with time. There is inadequate evidence to suggest that termination is more likely to lead to psychiatric sequelae than continuation of pregnancy and the balance of evidence suggests that there is no difference between these groups. One might expect more psychological sequelae from late terminations and the literature does suggest that distress and grief can persist for more than 12 months. Further research in this area is required and consideration given to appropriate control groups, for example parents who raise disabled children.

One method, which has been used to assist in the decision-making process, has been the involvement of a committee. This might range from a formal committee removed from the clinical case to a multidisciplinary team the members of which are clinically involved. There are a number of ways in which a psychiatrist might assist in the decision-making process. These include assessment of competence, coercion, coping skills, and psychiatric vulnerability; psychoeducation; provision of psychiatric treatment in the case of psychiatric complications; and staff support. However, the involvement of psychiatry in this process may also have disadvantages. Some might argue that as with early terminations, psychiatry is at risk of being used as a gate-keeper for a procedure that society is not at ease with. Mandated psychiatric assessment can hinder the development of a therapeutic alliance and potentially compromise the quality of assessment. Perhaps assessment by alternate health professionals could provide a more appropriate and cost-effective method of ensuring psychosocial care and informed decision-making.

Possibly the involvement of psychiatrists and other mental health professionals will wane if this procedure becomes more acceptable to society and clinicians. However, it is conceivable that demand for psychiatry involvement might increase according to the prevailing political, legal and social climate. The recent revival of debate about termination of pregnancy could also lead to increased scrutiny of medical and psychiatric involvement. Perhaps it is timely for psychiatrists to consider their position on their discipline's involvement in this process.

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Is there a Role for Psychiatry in Late Termination of Pregnancy?

Abstract

Keywords

Legal setting

Ethical setting

Existing processes for decision-making in late terminations

Psychological effects of termination of pregnancy

Early terminations

Late terminations

What is the role of the psychiatrist in early terminations?

Historical role

Current roles

What is the role of the psychiatrist in late terminations?

Discussion

References