Long-term Psychological Consequences of Pregnancy Termination for Fetal Abnormality: A Cross-sectional Study

Abstract

Most couples that conceive a child having a severe congenital anomaly decide to terminate the pregnancy. In The Netherlands, approximately 500 of 200,000 annual pregnancies end in termination of pregnancy (TOP) because of fetal anomaly. Such terminations are complex life events; many women-and their partners-find the decision to be an almost inhuman act. The voluntary nature of the act may conflict with normal grief responses. Studies have shown that gestational age, severity of the anomaly, and its compatibility with extrauterine life all play a major role in the decision-making process. This cross-sectional study enrolled 254 woman 2 to 7 years after TOP for fetal anomaly. In all cases, TOP took place before 24 weeks gestation. The mean age at termination was 34 years and the mean gestational age was 18 weeks. Standard questionnaires served to estimate grief, posttraumatic symptoms and psychologic and somatic sequelae. Final results were available for 196 women who completed all the questionnaires. Scores on tests of grief, posttraumatic stress, and psychosomatic symptoms correlated closely with one another. These measures, however, correlated only moderately, at best, with feelings of doubt and regret. Eight of the women reported feelings of regret, and 10% reported being in doubt. Both educational level and perceived support from the partner correlated closely and consistently with outcome measures. Less educated women and those perceiving limited support from their partners had the lowest scores on psychologic outcomes. None of the predictors correlated significantly with feelings of regret. Outcomes did not relate significantly to religion, having living children, method of TOP, or recent life events. On multiple regression analysis, grief was independently predicted by educational level, gestational age, and lethality. Educational level significantly predicted posttraumatic stress. Less educated women more often had somatic complaints. Both anxiety and depression appeared to increase over time. Advanced gestational age at TOP predicted doubt about the decision to terminate, as did presumed fetal viability and having living children. Perceived partner support independently influenced grief, most aspects of posttraumatic stress, anxiety, and depression. Five women (2.6% of those studied) had pathologic scores for grief and 33 (17%) for posttraumatic stress. In the latter group, elevated scores did not relate to the time since TOP. Women having TOP before 14 completed weeks of gestation had relatively low scores for grief and posttraumatic stress. The major modifiable factor predicting subsequent psychologic status in this study was perceived support by the partner, suggesting that more attention to counseling of partners would be appropriate. Less educated women are in particular need of support. Outcomes are likely to be best when prenatal screening and diagnostic tests are carried out early in the course of pregnancy.