ORIGINAL ARTICLE

Abortion and the pregnant teenagerIrene Lipper, m.s.w., Helen Cvejic, m.d., Peter Benjamin, m.d., f.r.c.p.[c] and Robert A. Kinch, m.d., f.r.c.s.[c],Montreal

Summary: A study was carried out at the AdolescentUnit of The Montreal Children's Hospital from September1970 to December 1972, the focus of which evolvedfrom the pregnant teenager in general to the short-and long-term effects of her abortion. Answers toa questionnaire administered to 65 pregnant girls todetermine the psychosocial characteristics of the pregnantteenager 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 stylesor become emotionally unstable up to one yearpost-abortion, although most have a mild, normalreaction to the crisis.

During the study period the clinic services evolvedfrom mainly prenatal care to mainly abortion counselling,and then to providing the abortion with less counselling,placing emphasis on those cases which require otherthan medical services.

Resume: L'avortement chez les adolescentes enceintes

De septembre 1970 a decembre 1972, le service desAdolescents du Montreal Children's Hospital a meneune enquete qui etait centree d'abord sur I'adolescenteenceinte en general et plus tard sur les consequencesa court et a long terme de son avortement. Unquestionnaire a ete remis a 65 filles enceintes en vued'etablir les caracteristiques psychosociales de I'adolescenteenceinte. Les reponses indiquent que ces filles ne sontpas anormales, ni sur le plan social, ni au point devue emotif.

Cinquante des filles qui avaient subi un avortementont ete suivies regulierement. II appert de cette enqueteque ces filles n'ont pas change leur genre de vie et nesont pas devenues instables sur le plan emotif durantI'annee qui a suivi l'avortement, bien que la majorited'entre elles aient eu une reaction legere au momentde la crise, ce qui etait du reste considere commenormal.

Durant la periode de I'etude, les services cliniquesont evolue; consistant d'abord en soins pre-natals,ils ont porte ensuite principalement sur les conseils enmatiere d'avortement et ont fini par fournir le moyend'avorter tout en reduisant les conseils. Ils ont insistesur les cas qui avaient besoin d'une aide autre que lesservices m6dicaux.

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

In 1968 an Obstetrics and Gynecology Clinic was estab¬lished as part of the Adolescent Unit of The MontrealChildren's Hospital. In the next few years, because of thechanges in the law with respect to abortion, the obstetricalsection of the clinic became increasingly concerned withcounselling in regard to abortion and provided a uniqueopportunity for the study of the effect of therapeutic abor¬tion on the emotional function and life style of the youngfemale adolescent. This clinic strives to give the adolescenta free choice with respect to the way she deals with herpregnancy. 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. Theclinic works on the principle that therapeutic abortion isgranted to those who apply for it unless study of theirproblems suggests it would produce emotional or physicaldamage.The project reported in this paper was designed as a

team approach to the pregnant adolescent. The teamconsisted of a social worker, psychiatrist, psychologist,public health nurse and obstetrician/gynecologist. The aimof 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 immediatelyafter the operation and up to one year post-abortion.

3. The best approach to serving the pregnant teenager inan individualized manner.

Review of the literatureSince the relaxation of the abortion law in 19681 teen-

agers in increasing numbers have been asking for abortion.Of the first 500 abortions performed at The VancouverGeneral Hospital in 1970, 18% were in patients under19 years of age. Of the 1186 abortions performed at TheMontreal General Hospital in 1972, 20.1% were in girlsunder the age of 19, distributed as follows: 15 years .1.8%, 15 to 16 years 6.4% and 17 to 18 years .11.9%.

Studies of abortion have been strongly criticized becauseof the absence of systematic data gathering, the lack ofcomparative 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.

ported findings and the inadequacies of samples used.Recent accounts of the subject report a lack of serioussequelae and a new impression is emerging: abortion isno longer held to have an adverse effect on personalityand functioning. However, the effect of abortion on theyoung, unmarried girl has not been hitherto described.Concrete data are hard to obtain and most recent state-ments concerning the effect of abortion on the teenagerusually consist of value judgements.

In 1969 a study8 was reported from London, Ontario,comparing 149 unmarried mothers with 99 married mothersfrom similar backgrounds. There were no statistically signi-

1968 1971

TIME INTERVAL (OUARTERLY)FIG. 1.Incidence of pregnancy at The Montreal Children'sHospital Adolescent Clinic (total 329 patients).

40

304

oGO< 20-^co

Z 10

1968 1969 1970 1971 1972

TIME INTERVAL (QUARTERLY)FIG. 2.Incidence of therapeutic abortions at the AdolescentClinic (total, 212 patients).

IncidenceB total pregnancies (439)

therapeutic abortions (284)H babies carried to term (137)I determination unknown (18)

1967 1968 1969 1970 1971

annual time intervals

1972(projected)

FIG. 3.Changing pattern of outcome of pregnancy overthe five-year period.

ficant differences in home background, educational achieve-ment, occupational level of parents, dating history or sexualexperience between the groups.

Traditionally, abortion has been associated with thewords "therapeutic" and "illegal". Much of the literatureon abortion consists of case histories of women with anemotional or medical illness. More recent reports con¬

cerning the sequelae of legal abortion indicate that abortionis not psychologically harmful and, in some cases, has hada positive effect. In a study of 250 such patients, Osofoskyand Osofosky2 report that the prevalent moods after abor¬tion were those of "relief and happiness". David3 notesthat, although 4000 cases of postpartum psychosis requiringhospitalization are documented each year in the UnitedStates, 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 fewerpsychiatric symptoms than they did before abortion.

Perez-Reyes and Falk5 studied 41 adolescents afterabortion and reported that in 50% general health was thesame or improved, and in 75% emotional health was thesame or improved. They concluded that the patients viewedthe crisis and operation as a helpful event in their growing-up process.

Demographic information

Figs. 1 to 4 illustrate general characteristics of the clinicpopulation. The figures differ because they are based ondifferent groups at different times over a period of fiveyears, 1968 to 1972.The incidence of pregnancy at the clinic increased steadily

over the five-year period (Fig. 1). From 1968 to the middleof 1971 the number of abortions gradually increased, butsince the end of 1971 the demand for abortion has stabilized(Fig. 2). Since 1967 the number of babies carried to termhas increased gradually, whereas the number of abortionshas increased dramatically (Fig. 3). As Fig. 4 shows, mostof the patients seen were between ages 15 and 17, with themean 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%) wereEnglish-speaking.

Psychosocial characteristics of pregnant teenagersAt the onset of the project, in order to form a descriptive

60

50 J

oa

40 -I

30 -I

20 -I

10 J

13 14 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

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

Background of the girl and her family1. 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 fathersand 6% neither.

6. 65% are students, 23% are high-school dropouts and12% are working.

7. 44% are the eldest child in the family, 25% the middlechild, 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 onlychildren.

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 findings1. These girls are not isolated but have diverse peer rela¬

tionships.2. There is 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 dominantmothers in these families.

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¬

ceptive devices, they do not apply this knowledge tothemselves.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 thatpregnancy was not due to lack of knowledge about, oreven experience with, contraceptives but rather due toteenage attitudinal patterns . a lack of concern forconsequences and an emphasis on fun.

Background of the putative fatherA 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 thegirl and the putative father is generally long term, i.e. morethan six months in 56%.

Information about the putative father has been gathered

mainly from the pregnant girl. Because of lack of resourcesthere 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 thepatients and (b) to postulate that these girls were not adisturbed group and should not be treated as such by theclinic staff.

Sequelae of the abortion

Material and methodsThe sample used for the study on short- and long-term

effects of abortion included 50 girls who obtained anabortion between September 1970 and September 1971and were followed up for at least a year after the opera¬tion by the social worker. Of 89 girls who had an abortionperformed during this period 20 did not return to theclinic up to one year post-abortion (10 lived outside theMontreal area). Nineteen other girls were not seen byeither the social worker or psychiatrist initially, or by thesocial worker for follow-up assessments and so were notincluded in the sample.

Twenty-six of the girls were English-speaking and 24were French-speaking. The age distribution at the timeof abortion was as follows: age 13, 2 patients; age 14, 5patients; 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 andby the social worker once up to six weeks post-abortionand at least twice during the first year. The findings areset forth in Table I.The girls were categorized as to their emotional adjust-

ment; from the pre-abortion assessment, positive adjustmentwas characterized by no history of a previously definedproblem or psychiatric contact, or a clearly stated wish for

Table I.-Data obtained at short- and long-term follow-upcompared with pre-abortion status

*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.f2/36 had an IUD inserted immediately post-abortion, 34/36 were takingbirth control piIls.

{4/24 became pregnant again.§3 girls broke with the putative father, 2 others resumed their relationshipwith him.

§§4 girls broke with the putative father, 3 others resumed their relationshipwith 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 psychiatriccontact, poor psychological adjustment according to courtand school records, or inability of the adolescent andher family to come to a mutual agreement concerningabortion.

Post-abortion positive adjustment was defined as no

psychopathological symptoms, the expression of mild sad-ness or regret with regard to the abortion, or expressedsatisfaction with the decision to have an abortion. The as-

sumption was made that some emotional reaction to thecrises of pregnancy and abortion could be considered anormal and healthy way of dealing with the experience.As David3 points out, "there is no psychologically painlessway to cope with an unwanted pregnancy". Negative ad¬justment was defined as psychosomatic complaints whichinterfered with overall functioning (sleeping, eating, workor school attendance), severe regret over having had an

abortion, continued unstable behaviour, or new symptomformation (drugs, alcohol, truancy).

It is apparent from Table I that the distribution of girlswith positive or negative adjustment to the crisis changedlittle during the one year of follow-up. More than 80%of the girls were well adjusted both before and afterabortion. In the follow-up period they expressed feelingsvarying 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 dealwith their feelings concerning the pregnancy and abortion.The girls who were unstable before abortion remained soafter abortion.

In 76% of cases the families supported the girls throughthe 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 homebefore and after abortion. However, 18% had lived awayfrom home before abortion. It is interesting to note thatthree of them returned home during the year followingthe abortion. Five other girls left home during this period,all of whom were described as "unstable" after theabortion. Living at home is accepted as an indication ofstability in the girl and as evidence of family support. Thelatter 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 followingabortion. Twenty percent of the girls were neither inschool nor working before and after abortion.

Fifty-two percent of the girls were employing reliablecontraception up to one year post-abortion in contrast to2% (1) before pregnancy.

Approximately 50% of the girls continued their rela¬tionship with the putative father up to one year afterabortion. In the remaining cases the relationship did nothave the quality to withstand the crisis of pregnancy.

Conclusions

The data concerning 50 girls studied by means of un-structured interviews before and up to one year afterabortion 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 continuedto be disturbed.

4. The abortion did not significantly change a girl's lifestyle or emotional adjustment.

5. The crisis did test a girl's relationships. The relationshipwith her family seemed to remain stable, whereas thatwith the putative father did not.

Evolution of the clinic

The research effort had a major impact on the role of theprofessional staff and in the delivery of services to thepatient according to her specific need. The ObstetricalClinic evolved from a prenatal care unit to a pregnancycounselling service, and then to a facility that treated abor¬tion primarily as a medical problem. Necessarily, staff rolesand clinical services changed during each stage of develop¬ment.

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 completesocial history and discussed possible alternatives, includingabortion, with the girl and her family and the putativefather if he was available. Often more than one interviewwas necessary before a decision was reached.

All patients requesting abortion were seen by a psychiatristduring this phase. Her role was to rule out severe psycho-pathology, 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 withpsychosocial appointments. During Phase I the patienttended 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 thenevery week. Each time they attended clinic they interactedwith the team. They were offered prenatal care includinginformation about pregnancy, labour and delivery, childcare and a tour of the obstetrical floor at The MontrealGeneral Hospital or Catherine Booth Hospital. The servicesof a dietitian and the VON were available when needed.

Phase II

The role of the psychiatrist changed in Phase II. Theconsensus of the research team after one year of operationwas that abortions were done for social reasons and notfor psychiatric or medical ones. During this phase thepsychiatrist assumed a research role in helping the socialworker to conceptualize the data collected, and acted asa consultant in certain cases.The psychologist administered the Personality Factor

Questionnaire of Raymond Cattell to all pregnant girls ontheir initial visit to the clinic. The purpose of this test wasto 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 testwas readministered after six months, in both cases todiscern any follow-up personality change.Phase III

Since the liberalization of the abortion laws and as theclinic became known, more and more requests for abortionwere received. The nature of the request changed fromdiagnosis of pregnancy to obtaining abortion. This wasdue partly to an increase in community resources whichafforded the girl the opportunity to discuss her pregnancyelsewhere. 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 thealternatives, 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 thesocial worker to interview all the pregnant girls and theirfamilies. During Phase III the physician evaluated tlremedical and psychological aspects of all cases and referredany girls with severe social or emotional problems to thesocial workers. The indications for referral to social serviceor 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, financialassistance.The social worker continued to follow up girls through

their pregnancy during Phases II and III and continued tofollow up the 50 girls who were selected for the studyof the after effects of abortion.The psychologist administered questionnaires in order to

discern personality changes after abortion. The results fromhis studies are in press.7 The new abortion cases wereseen in a group each week by the nurse. The parents of thegirls were seen in a separate group by the social worker.The purpose of these groups was to (a) discuss any feelingsand questions pertaining to the abortion, and (b) evaluatewhether there were problems other than the abortionif so, a referral was made to Social Service.

In general, the clinic has undergone an evolutionaryprocess since 1970. Staff roles and services have changedas the nature of the patients' requests have changed frommainly prenatal care to mainly abortion counselling, andthen to providing the service requested with less emphasison counselling. The research findings have also been used toshift the focus of professional care in abortion cases fromseeing all patients to seeing only those who have beenidentified as needing other than medical services. Servicesto the girl who carries her pregnancy to term have re-mained constant as the demand for this service has beenconstant during the three phases.

Conclusion

The two general objectives of the research were todescribe the pregnant teenager - her background andfunctioning - and to determine whether abortion is harm-ful to her social and/or emotional life. Our findings froma questionnaire administered to 65 pregnant girls indicatedthat they were neither emotionally disturbed nor sociallydeprived. They were generally functioning well. From non-structured interviews over a period of one year post-abortionwe conclude that, for the most part, the girls have a normalreaction to the abortion crisis, handle it adequately, andseem to carry on afterwards as they did before. Generally,the mere disturbed a *.'s peinality-nd lif&!yle wpre-abortion, the more likely it was that she would reactadversely 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 pregnantteenagers to abortion sequelae. The findings from the re-search project have in turn altered professional roles andclinic services from a widespread use of psychosocial per-sonnel for assessment and treatment planning to a medicallyfocused handling of abortion requests. At present patientsare offered professional attention according to their in-dividual needs rather than because they are pregnant.The clinic is continuing to operate on the basis of PhaseIII, and the sample of 50 girls is being followed for thesecond 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 GayleMcLachlan, M.S.W.

References1. Abortion Law in Canada (excerpt from Criminal Law Amendment Act1968-69), 17-18 Eliz II, chap 38, s 14, p 332. OSOFOSKY JD, OSOFOSKY HJ: The psychological reaction of patientsto legalized abortion. Am J Orthopsychiatry 42: 59, 19723. DAVID HP: Abortion in psychological perspective. Ibid, p 624. FORD CV, CASTELNEVO-TEDESCO P, LoY KD: Abortion, is it a thera-peutic procedure in psychiatry? JAMA 218: 1173, 19715. PEREz-REYES MG, FALK R: Follow-up after therapeutic abortion inearly adolescence. Arch Gen Psychiatry 28: 120, 123; 19736. PANNOR R, et al: The Unmarried Father. New York, Springer, 1971,pp 71-737. LAWRENCE W: Anxiety-adjustment and other personality factors in

teenage patients before and after abortion. Proc 81st Ann Conv AmPsychol Assoc, 1973. In press8. KINCH RA, WEARING MP, LovE EJ, et al: Some aspects of pediatric

illegitimacy. Am J Obstet Gynecol 105: 20, 1969

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