Women ’ s demand for late-term abortion – A social or psychiatric issue ?

Introduction/Aim. Induced termination of unwanted pregnancy after 12th gestational week (late-term abortion) is legally restricted in Serbia as well as in many other countries. On the other hand, unwanted pregnancy very often brings women into the state of personal crisis. Psychiatric indications for legally approved late-term abortion on women’s demand include only severe psychiatric disorders. The aim of this paper was to compare sociodemographic, psychological characteristics and claimed reasons for abortion in the two groups of women with late-term demand for abortion – the group of women satisfying legally prescribed mental health indications, and the group of women not satisfying these indications. The aim of the study was also to determine predictive validity of the abovementioned parameters for late-term abortion as the outcome of unwanted pregnancy. Methods. A total of 62 pregnant women with demand for late-term abortion were divided into two groups according to the criteria of satisfying or not satisfying legally proposed psychiatric indications for late-term abortion after psychiatric evaluation. For the assessment of sociodemographic and psychological parameters sociodemographic questionnaire and symptom checklist – 90 revised (SCL-90®) scale were used, respectively. The outcome of unwanted pregnancy was followed 6 months after the initial assessment. Results. The obtained results showed a statistically significant difference between the groups in educational level, satisfaction with financial situation, elevated anxiety and distress reactions. Unfavorable social circumstances were the main reason for an abortion in both groups and were predictive for an abortion. A 6-month follow-up showed that women had abortion despite legal restrictions. Conclusion. Pregnant women with psychiatric indication for late-term abortion belong to lower socioeconomic and educational level group compared to women without this indication who have more frequently elevated anxiety and distress reactions to unwanted pregnancy. It is necessary to have more accurate guidelines for mental health indications for legally approved late-term abortion, respecting social circumstances. Preventive measures are of great importance in order to lower the risk of illegally performed late-term abortions.

Unwanted pregnancy is often personal crisis.Induced abortion in Serbia is a legally restricted service.It is permitted on women's demand up to 12th gestational week.Induced termination of unwanted pregnancy is allowed up to 20th week for law determined reasons considering physical and mental health of women, fetal aberration and pregnancies resulted from rape 1 .After 20th week, it is possible under limited circumstances and has to be approved by Ethical committee of the regional medical center (The abortion law: Official Gazette of the Republic of Serbia no.16/95 and 101/2005.).
Psychiatric assessment of pregnant women who demand abortion after 12th gestational week is required to determine whether their condition satisfies indications due to mental health reasons for abortion, prescribed by the law.
In our clinical practice the problem arises when the woman's demand for an abortion is in contradiction with law -when the reasons are more social rather than medical or psychiatric in nature.
Little is known about the reasons for second trimester (late) abortions in Serbia.In everyday practice, providers have noticed adverse emotional reactions of pregnant women, after they had realized that late abortion is not allowed without medical or psychiatric reasons.
There are no published studies that provide comparative analyses of what happens when access to second trimester abortion is restricted by the law.Psychological neurotic reactions and adverse socioeconomic circumstances are not legally approved indications for abortion in the second trimester.These women could be in a position to continue unwanted pregnancy or terminate it in spite of legal restrictions.It means that woman is forced to continue an unwanted pregnancy with the risk of rejection of the child and the emergence of unfavorable conditions for the psychological development of the offspring.The other option is unsafe, illegal or self-induced abortion, which is a serious risk for her health.
The aim of this paper was to compare sociodemographic, psychological characteristics and claimed reasons for induced abortion in the two groups of women with lateterm demand for abortion -the group of women satisfying legally prescribed mental health indications for abortion, and the group of women not satisfying these indications.The aim of the study was also to determine predictive validity of parameters under study for late-term abortion as the outcome of unwanted pregnancy after a 6-month follow-up.

Methods
In 2010, 62 pregnant women with demand for late-term abortion were referred by their gynecologist to the Clinic for Mental Health for psychiatric evaluation.This evaluation had to determine the presence of mental disorder as psychiatric indication for late-term abortion in the absence of the other medical indications.Psychiatric evaluation was undertaken by the team of two psychiatrists who did evaluation independently for every woman and after joint discussion made consensus about the indications for termination of pregnancy.When minors have been involved, psychiatrist for children and adolescents was invited to the team.The mental state of women was evaluated in order to determine the presence of disorders which influence sexual behavior and decision making about termination of pregnancy in the first trimester.
The presence of psychotic disorder, major depression, mental retardation, addiction, and the age under 16 were criteria for psychiatric consent for late-term induced abortion.Women with distress reaction and minor depression did not get approval for abortion in the 2nd trimester, according to the abortion law.
For the overall psychiatric evaluation unstructured psychiatric interview was applied just after the admission to the Clinic.Clinical diagnosis was made in accordance with the criteria of the International Classification of Mental Disorders -10 (ICD 10) 3 and using semi-structured Mini International Neuropsychiatric Interview (MINI Version 5.0.0) 4 .The Symptom Check list-90R (SCL-90 R ® ) 5 was used for the evaluation of clinical symptomaology.This is a 90-item self report inventory for the assessment of 9 psychological dimensions: somatization, obsessive-compulsiveness, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism.A score over 63 suggests clinically significant expression of certain dimension.Sociodemographic questionnaire, made for the purpose of this study, contained data about age, gestational age, education level, marital status, employment, subjective satisfaction with Nikoli G, et al.Vojnosanit Pregl 2014; 71 (7): 660-666.financial situation, the number of household members.At the end of the questionnaire, there was an open ended question: "What is the reason for your request for late-term abortion?" After the assessment, the patients were divided into two groups.The women in the group A (n = 32) did not satisfy criteria of psychiatric indication for the 2nd trimester abortion and did not get psychiatric consent for termination of a pregnancy.The women in the group B (n = 30) received psychiatric consent due to the presence of the diagnosis of mental disorder or the age under 16.
The outcome of unwanted pregnancy was followed 6 months after the psychiatric assessment.Women from both groups were phone called by the psychiatrist for a short interview about the outcome of their unwanted pregnancy.
All the participants give their written consent to participate, so the data could be explored.Confidentiality and anonymity were ensured.Ethical approval was obtained from the Ethics Committee of the Clinical Center Niš.
We compared the 2 groups by sociodemographic data, psychological dimensions (score on SCL-90R > 63), presence of the mental disorder, gestational age of pregnancy at the time of demand for abortion, and stated reasons for lateterm demand for abortion.
Statistical Package for Social Sciences (SPSS 15.0) was used for statistical analysis.
The difference between the parameters was calculated using the Student t-test and 2 -square test, p values < 0.05 were considered statistically significant.Univariate logistic regression was used to calculate predictive values of the parameters for late abortion.

Results
The youngest woman in our sample was 15, and the oldest one 43 years old.Gestational age was from 15 to 25 gestational weeks.The average age in the group A was 28.7 years and in the group B 28.4 years.The average gestational age in the group A was 19.1 gestational weeks, and in the group B 18.6.gestational weeks.There was no statistically significant difference between the two groups in the mean age, or in the gestational age of pregnancy (Table 1).
The analysis of sociodemographic characteristics of women in our sample showed a statistically significant difference between the two groups in relation to the level of education and subjective satisfaction with financial situation.
Nineteen women in the group A had 12 years of education, significantly more than women in the group B.More than 12 years of education had only 4 women in the group A, and none in the group B. In the group B most of the women had only 8 years of education.
Subjective feeling of satisfaction with financial situation was present in 13 women in the group A, whereas most of the women in the group B were dissatisfied with their financials.
There was no statistically significant difference between the two groups comparing the other sociodemographic parameters (Table 2).Answers to the question about the reason for late request for abortion were divided into 5 groups according to the answer that was marked as the main.All the reasons were present in both groups.The most frequent reasons in both groups were: interrupted partner relationship during pregnancy and poor financial situation.The other listed reasons were marital conflict, unknown partner and conflict with parents.There was no statistically significant difference in frequencies of these variables between the groups (Table 3).
More than a half of women in the group A had no mental disorder and the rest had distress reaction -15 women, significantly more than in the group B. Frequencies of mental disorders in the group B, in decreasing order were: major depressive episode, recurrent depression, mental retardation, opioid addiction, schizophrenia and emotional immaturity -age 15 years.On the SCL-90 R questionnaire, elevated anxiety dimension was statistically significantly more frequent in the group A. There were 13 women with clinically significant elevation of anxiety score in the group A and only 3 women in the group B. There was no statistically significant difference between the groups on the other dimensions of this questionnaire (Table 4).
The outcome of unwanted pregnancy was almost the same in both groups.In a phone conversation, 6 months after psychiatric evaluation, we received the information that only two women from the group A decided to keep their pregnancy.The rest of the women from the group A had late abortion despite legal restriction.
We used the model of logistic regression including all of the variables.Predictive value of each single parameter for motherhood and abortion was obtained, but with no statistically significant difference between the group.The model based on parameter B, with all variables under the study included, was a significant predictor of unwanted pregnancy outcome.
Abortion in the 2nd trimester, without medical and mental health reasons was predicted with: older age, lower education, unmarried status, life in incomplete parent family, dissatisfaction with financials, hostility, obsessiveness, broken partner relationship or unknown partner, conflictual relationship with parents (Table 5).

Table 5 Results of univariant logistic regression with predictive values of the parameters for the outcome of unwanted pregnancy
Step

Discussion
The women of both groups of our sample had very similar sociodemographic and psychoogical profiles, contrary to our expectancies.Women were in the 3rd decade of life and the average gestational age of pregnancy in both groups was 19 weeks.Unwanted pregnancies occured in both younger and older reproductive ages, in married and single women who never used contraception.In general, they had low or middle level of education, they were not satisfied with their financial situation and less careful in sexual behavior.This might be not only psychological issue, it could be a part of their lifestyle or a consequence of insufficient sexual education.These findings are similar to the results reported by Upson et al. 6 .They showed that almost half of pregnancies in 2006 in USA were unintended the highest rates occured in women younger than 24 years, and in the older women, who did not want any more children.Unwanted pregnancies were associated with no using contraceptives, having no partner and being unmarried.Other findings showed that highly educated women in America have 4-5 times less unwanted pregnancies than poor and uneducated women who deliver unwanted children.According to the National Survey of Family Grow in USA unwanted pregnancy is associated with young age, single status, black race, less education and having one or more children 7 .
A statistically significant difference between the two groups in our sample was found in sociodemographic variables: educational level and subjective satisfaction with finances.Women with psychiatric disorder were less educated and more dissatisfied with their financial situation.These could be explained by the fact that psychiatric patients, in general, belong to lower socioeconomic levels, usually their education becomes interrupted because of their disorder, and they have less chances for employment.
We noticed that the two groups of women with unwanted pregnancy did not differ much in psychological dimensions.Elevated anxiety dimension was significantly more frequent in the group A. This finding is understandable having in mind that distress reaction to unwanted pregnancy was much more represented in this group.Evidenced distress reaction in the group A was also characterized with emotional reactions as despair and helplessness.Women were afraid of future life they could not even imagine.Some had nightmares and sleepless nights.Expressed anxiety and other elevated dimensions in the group A were symptoms of their distress reaction, on the other hand, in the group B, they were expressed as the part of the underlying disease.We did not take into account absolute numerical values of every dimension, but only the frequencies of clinically significant elevation.On the other hand, psychological dimensions were not clinically significantly elevated in the group B in comparison with the group A despite the presence of serious mental disorder, because none of the women in this group was actually in exacerbation of her psychiatric disease at the time of psychiatric evaluation.
None of the women knew that psychosocial issues are not sufficient enough for terminating unwanted pregnancy.Psychiatric approval for women in the group B was based upon the diagnosis of mental illness which was present before unwanted pregnancy, and women in the group A were unpleasantly surprised and even more distressed when they found out about the absence of appropriate psychiatric indications for late-term abortion in their cases.Our clients were not aware of legal restrictions and they believed that the stated reasons were sufficient enough for permission for abortion in the 2nd trimester.Distress reaction evidenced in the group A was additionally due to legal obstacles and complicated administrative procedures in the process of obtaining permission for abortion.
Active legislation in Serbia does not recognize emotional distress reactions due to adverse social circumstances, as indication for termination of unwanted pregnancies older than 12 gestational weeks.If mental disorder (psychosis, major depressive disorder) is not present, late-term abortion is not allowed.Our experience and results of this study, quite a contrary, point to the fact that unwanted pregnancy is unique life situation influenced by many personal and social factors which should not be neglected.Mujovic-Zornic 8 in his article also indicates the inadequacy of regulations that force woman to give birth to a child, she does not want.
Our results point to the fact that a change in social circumstances preceded claim for abortion at almost all pregnant women in our sample.Most of the women, even 82.26%,quoted this change as the main reason for demanding termination of their pregnancy, regardless the presence or the absence of psychiatric disorder "appropriate" for late-term abortion.
This begs the question of the importance of psychosocial factors for legal late-term abortion, even in the absence of severe mental illness.Medoff 9  sive studies with a large number of women in reproductive age, based on self-reported data, could define some important issues in sexual behavior.Possible psychosocial issues could influence decision making and delay of abortion.Providers should predict latter capability for motherhood in unfavorable life circumstances [10][11][12][13] .
A study in Japan showed that continuation of unwanted pregnancy to the term was associated with health risk for mother and child.The psychological risk is depression, risk health behavior during pregnancy, lack of parental care, low birth weight 14 .Not less important is the fact that abortion in late gestational age is associated with the risk of surgical intervention as well as moral and ethical issues that consider "killing" of a baby, that has right to live.
Notably, little research attention has been paid to explaining why women seek for an abortion in the second trimester instead of the first.A study from England indicates multiple reasons for late abortion: lack of recognizing the signs of pregnancy, denied pregnancy, or rejection of pregnancy after changes in life circumstances 15 .Contributing factors are also difficulties in accessing gynecological services and emotional ambivalence towards parenting 16 .
These findings are similar to ours.All the stated reasons for late termination of pregnancy in both groups were equally represented.Our patients based their late request for abortion mainly on changed circumstances in their lives.Late recognizing of pregnancy was always mentioned as additional reason at most of the women, but this was not the main issue for lateness.This occurred in the first two months of pregnancy, but after that period other reasons were the main ones.We expected difference between the groups regarding stated reasons for late request for abortion, but conflict relations and dissatisfaction with financials were equally present regardless psychiatric diagnose in pregnant women.Coleman et al. 17 had very similar results.They concluded that psychiatric disorder was not associated with unwanted pregnancy in all ages.
This could mean that a changed life situation, unfavorable family circumstances, lack of social support, risk sexual behavior, influence on decision making process may contribute to the request for late-term abortion 18 .In some cases, previously wanted pregnancy turned into unwanted.The conflicts within the household or with marriage partner were also present.Some married women had an affair and had difficulty to decide between abortion or deceiving their husbands.Most of them thought this a good reason to terminate pregnancy without any obstacles.They were distressed to find out this not legally possible.
Mental disorder was the main reason for psychiatric approval of late abortion in the group B. Findings in the literature indicate that women with any psychiatric disorder are not more likely to have undesired pregnancy, compared with healthy ones 19,20 .They experience more often poverty, divorce, partner abuse and negative life events.Psychiatric disorder can affect woman's ability to care for child and her judgment about conception, recognizing pregnancy and ability for motherhood [21][22][23] .Psychiatric medication and toxic substances used in the first 3 gestational months, can damage the baby.
Our patients with mental disorder did not pay much attention to their amenorrhea, or gave no reason for delaying.Two of them were hospitalized for a long time and had chronic incomplete remission of schizophrenia and no control of their sexual activity.Drug addicts were taking heroin, anti-anxiety medications and analgesics during the whole time of pregnancy and had passive attitude till late in pregnancy.Married psychiatric patients, who had children, did not feel capable to have more children.All of the subjects in the group B were chronically ill, taking antidepressants and neuroleptics for a few previous years and also during their pregnancy.Two minors in our sample, 15 years old, suspected pregnancy but did nothing about it because they were hiding it until it was obvious, or denied it for fearing the reaction of their parents.The same reason was noted in the article of the Coleman 13 , explaining that denial of pregnancy in teens might be correlated with their parent's negative response to their pregnancy and cultural attitudes towards unmarried mothers.
After psychiatric evaluation and denied or approved second trimester abortion, all the women were offered counseling.Gynecological counseling for birth control was also recommended.During the follow-up period of 6 months, none of them returned for further psychological help, and we have no data about further use of contraceptives.
The most disturbing result of our study certainly is that, despite being rejected for late-term abortion, almost all (30 out of 32) women from the group A obtained abortion within private gynecology practice or in suspicious circumstances.In the phone interview after six months, the subjects felt uncomfortable to talk about what had happened with their pregnancy.We got only brief answers: women did not want to explain much on how and where they carried out abortion.This observation raises questions about safety and potential health consequences of their late-term abortion.
The other very important question is: which factors have the strongest influence on performing abortion even despite law restrictions, within assumed risky circumstances?In our study logistic regression was used for calculating predictive values of parameters under the study for the outcome of unwanted pregnancy.The statistical model showed that adverse social circumstances and hostility were crucial for late termination of pregnancy.
The limitation of our study is a small sample size, which represents only those women who had some psychological reaction to restriction of abortion.We do not have data about women who accepted their previously unwanted pregnancy, without psychiatric consultation and also those who terminated pregnancy in the second trimester, without coming for psychiatric approval.We also have not got data about psychological and health consequences after late abortion.The question is being raised: could unwanted pregnancy and delivery harm mental health and could it be associated with postpartum psychiatric disorders?Is late termination of unwanted pregnancy less harmful for women's mental health than unwanted parenting?What are the risks for mental health and development of unwanted children?
restrictions.More information about accessibility of abortion service, upper time limits for termination of pregnancy and legal restrictions involved, should be available to women in reproductive age.Educative health prevention programs including education about contraceptive use might reduce this unwanted reproductive event.Valid data on 2nd trimester abortion in Serbia and conditions for its performance would show various aspects of this phenomenon.Medical providers should consider many different issues during the decision making process: consequences for physical and psychological health, contextual social circumstances and law restrictions.

Conclusion
Pregnant women with psychiatric indication for lateterm abortion belong to lower socioeconomic and educa-tional level compared to women without this indication.Pregnant women without psychiatric indication for lateterm abortion are more often anxious and have distress reaction than women with psychiatric disorder.Social circumstances unfavorable for pregnancy, especially conflict family and partner relationship, as well as poor financial situation are associated with demand for late-term abortion in both groups of women.These factors are predictive for abortion as the outcome of unwanted pregnancy.The second trimester unwanted pregnancy outcomes in abortion despite legal restrictions.It would be important to have more accurate guidelines for mental health indications for legally approved late-term abortion, respecting social circumstances.It would be of great importance to include preventive measures to lower the risk of illegally performed late-term abortions.

Table 3 The reasons for requesting late abortion
² -

Table 4 Distribution of frequencies of elevated psychological dimensions and psychiatric diagnoses with group comparison
Group A -pregnant women not satisfying legal criteria of psychiatric indication for second trimester abortion; Group B -pregnant women satisfying legal criteria of psychiatric indication for second trimester abortion; MINI -mini-international neuropsychiatric interview.Nikoli G, et al.Vojnosanit Pregl 2014; 71(7): 660-666.