AAPLOG objection to inclusion of "Universal Access to Reproductive Healthcare" as a part of MDG 5-Letter to UN High Commissioner on Human Rights

AAPLOG-AMERICAN ASSOCIATION OF PRO-LIFE OBSTETRICIANS AND GYNECOLOGISTS EXECUTIVE OFFICE: 339 River Ave, Holland, MI 49423 USA

Website: www.aaplog.org November 27, 2009

Office of the United Nations High Commissioner on Human Rights United Nations Office at Geneva CH 1211 Geneva 10 Attn: Cecilia Moeller Dear Commissioner: The American Association of Pro-Life Obstetricians and Gynecologists is honored to offer to the Office of United Nations High Commissioner on Human Rights, information relevant to the preparation of the thematic study on Preventable Maternal Mortality and Morbidity and Human Rights. In brief introduction, AAPLOG is one of the largest special interest groups within the American College of Obstetrics and Gynecology and we speak as obstetricians and gynecologists concerned with the medical care of women not only in the U.S. but also in resource poor nations, where many of our members have served or are actively serving. The moral and legal principle under-girding the obligation to prevent maternal mortality and morbidity is the human right to life, which provides for the right to bodily integrity. The legal right to life has been enshrined in every major UN human rights document since the 1948 the Universal Declaration of Human Rights. This right leads to a right to the highest attainable standard of health, and thus to the need for increased access to health care for all human beings, from fertilization to natural death. Applauding the critically important function of mothers in sustaining the health of the family and community, member nations agreed on Millennium Development Goal 5: Improving Maternal Health, and specifically created a target of reducing the maternal mortality ratio by 75% between 1990 and 2015, after intense discussion. It is absolutely essential to recall that during that same Summit, the proposed goal of “Universal Access to Reproductive Health”was rejected by the member nations. Although this goal included many worthwhile targets, the goal included a target to eliminate “unsafe”abortion, defined as any abortion in a country where abortion was not legal.¹ That the phrase “Universal Access to Reproductive Health”necessarily includes universal access to elective abortion was recently asserted by Secretary of State Hillary Clinton in remarks before the U.S. Congress.² Member states rejected the proposed “Universal Access to Reproductive Health”because of its sponsors’ clear intent to use this proposal as a means to promote legalization of elective abortion worldwide. However, the monitoring mechanisms for achievement of MDG 5 have nevertheless implicitly incorporated the targets related to that rejected goal.³ Incorporating targets of a goal which member states have explicitly rejected into the monitoring mechanism tied to development funding is tantamount to cultural imperialism on the part of resource-rich nations and individuals, and violates the rights of member nations to self-determination. Worse still, the accepted target of reducing maternal mortality has been undermined and subverted to serve a radically absolutist abortion-rights political agenda by resource rich member states, and to impose that agenda on resource poor nations through development funding. This approach seeks to deny morally-rich member nations the right to recognize legal rights of personhood from the moment of conception. To the contrary, abortion rights advocates seek to impose their own morally impoverished, culturally biased views and pro-abortion agenda, often tainted with population-control ideology, through the mechanism of development funding. This sort of cultural imperialism not only violates the right of member nations to national sovereignty, but deprives the member nations of their right and duty to evaluate the medical and policy effects of elective induced abortion within their own religious, cultural, social and regional contexts. It is misleading to suggest that making abortion legal makes it safe and reduces maternal mortality. In resource poor countries, 5% of maternal mortality⁴ is attributed to abortion. The WHO quasi-legal definitions of “unsafe”and “safe”abortion, combined with the target to eliminate “unsafe”abortion, lead to the false conclusion that simply legalizing abortion in a country reduces maternal mortality. However, there are two pitfalls to this logic:

1. As witnessed in many resource rich countries, abortion incidence markedly increases with legalization,⁵ and that increase is accompanied by an absolute increase in mortality and morbidity; and
2. Women experiencing known complications of abortion in resource poor countries do not have access to necessary emergency care, or are too ashamed to seek it. Thus, as in resource rich countries, legalization in resource poor countries effectively amplifies maternal morbidity and mortality.

As obstetricians and gynecologists we are keenly aware of the risks of any surgical procedure include bleeding and infection. These complications may be adequately handled in resource-rich medical systems, but greatly increase fatalities in member nations whose female population does not have ready access to antibiotics, blood transfusions and hospitalization. The recent study of 22,368 “safe”medical abortions in Finland, compared with 20,251 “safe”surgical abortions demonstrated that one out of twenty women who underwent “safe”surgical abortion and 25% of women undergoing “safe”medical abortion had complications including hemorrhage, incomplete abortion and need for repeat surgery. An examination of the first 605 Adverse Event Reports submitted to the FDA in the first three years of “safe”mifepristone (Mifegyne) abortions in the United States, revealed that one third of the women with adverse events (237) experienced severe bleeding requiring emergency surgery, half of these required hospitalization, and forty two women bled over half of their blood volume; these events would be fatal in resource poor nations.⁶ The rate of complications seen with “safe”mifepristone and misoprostol abortions increases with the use of misoprostol alone. In a WHO sponsored study, one out of every five women who had “safe”misoprostol abortions failed to abort⁷ and required surgical intervention, or continued a pregnancy now exposed to a teratogenic drug.^{8, 9} Medical abortion has been linked to deaths from Clostridium sordelii infection, for which the case fatality rate approaches 100%. The encouragement by UNFPA and WHO of the use of mifepristone (RU-486, Mifegyne) and misoprostol (Cytotec) as “safe”abortifacients in medically resource poor nations is unconscionable and a violation of the human right to health of women in resource poor medical systems. Promoting “safe”medical abortions in resource poor nations would predictably increase the risk of hemorrhage, infection and incomplete abortion in medical systems unable to provide adequate medical care for these women. This policy increases, not decreases maternal mortality and morbidity in resource poor nations. The known morbidity and mortality from “safe”surgical or medical abortions¹⁰ would be disastrous to a female population already struggling with malnutrition, anemia, malaria, parasitic infections, etc. Nothing could be more contrary to the purposes underlying the Millennium Summit Declaration’s purpose of protecting pregnant women. The pressure from resource rich donor nations to legalize abortion violates the right to health of women in resource poor nations by exposing them to the mortality and morbidity of induced elective abortion in situations where the available medical care cannot manage the predictable short or long term morbidity and mortality, nor provide adequate monitoring and surveillance. An increase in short term morbidity and mortality, however, are not the only predictable consequences of “safe” abortion. The long term morbidity of “safe” abortion on women is well documented in the medical literature. “Safe”abortion is associated with an increased risk of preterm birth in subsequent pregnancies as attested to by the Epipage,¹¹ Europop,¹² and IOM¹³ studies, and over one hundred other studies,¹⁴ including the most recent review in the British Medical Journal.¹⁵ In resource rich western nations, preterm birth accounts for a significant percentage of the cost of pediatric medical care.¹⁶ In nations without an abundance of medical resources, these preterm births would translate into neonatal deaths. Over 100 studies in the medical literature demonstrate that women undergoing “safe” abortion have a significantly increased risk of subsequent suicide, major depression and substance abuse, as compared with women who bring to birth.¹⁷ Studies which have looked at long term consequences of medical abortion regimens have revealed risks similar to those for surgical abortion.¹⁸ In addition to the direct effects of induced abortion on women, there is the dangerous diversion of financial resources from interventions known to reduce maternal mortality: prenatal care, skilled birth attendants, antibiotics and oxytocics. Abortion, spontaneous and induced, accounts for less than 5% of maternal mortality.¹⁹ It is scientifically, medically and morally unacceptable to divert resources from interventions proven to reduce maternal mortality to the provision of abortion, under the guise of “decreasing unsafe abortion”. The better way to address the human rights dimension of maternal mortality and morbidity is to provide resources targeting the causes of 90% of maternal mortality.²⁰ In summary, we oppose the diversion of resources and attention to the legalization and provision of abortion, which under the guise of improving maternal mortality will result in increased maternal mortality and erosion of the attached human right to health in resource poor countries. We call on the Council to defend the right to maternal health by holding accountable NGOs that divert resources from interventions proven to decrease maternal mortality to the provision of abortion, and deliberately work to subvert national sovereignty and overturn member nations’ religious, moral and social norms and traditions. We implore the Council to refrain from supporting in law and policy, measures influenced by racist and eugenically influenced ideologies that have been empirically proven to hurt rather than help pregnant women. And finally, we call on the Council to defend the right to bodily integrity of all human beings from fertilization to natural death, especially in morally rich sovereign nations who recognize the human rights of fetal human beings. Respectfully submitted, Donna J. Harrison, B.S., B.A., M.D. President, American Association of Pro-Life Obstetricians and Gynecologists Notes 1 Sedgh, G, Henshaw, S and Singh, S. from the Alan Guttmacher Institute, and Ahman, E, and Shaw, from the World Health Organization. Induced abortion: estimated rates and trends worldwide The Lancet 2007; 370: 1338–45 Panel 1: Definitions of safe and unsafe abortion Safe abortions Abortions (a) in countries where abortion law is not restrictive,* and (b) that meet legal requirements in countries where the law is restrictive.† Unsafe abortions Abortions done either by people lacking the necessary skills or in an environment that does not conform to minimum medical standards, or both. These include (a) abortions in countries where the law is restrictive and (b) abortions that do not meet legal requirements in countries where the law is not restrictive. *Defined as countries in which abortion is legally permitted for social or economic reasons or without specification as to reason, and a few countries and territories with more restrictive formal laws in which safe abortion is nevertheless broadly available. †Such abortions are currently too few to be included in these estimates. 2 Reference for Hillary Clinton’s remarks in response to U.S. Congressional Representative Christopher Smith. Available at: http://chrissmith.house.gov/News/DocumentSingle.aspx?DocumentID=123424. (Nov. 20, 2009) 3 World Health Organization, National-level monitoring of the achievement of universal access to reproductive health: conceptual and practical considerations and related indicators – report of a WHO/UNFPA Technical Consultation, 13–15 March 2007, Geneva. ISBN 978 92 4 159683 1 4 World Health Organization “WHO: Causes of Maternal Deaths: A Systematic Review”The Lancet Vol 367 April 1, 2006, the breakdown of maternal mortality causality is as follows: 1. Hemorrhage-31% 2. Hypertensive disorders-10% 3. Anemia -8% 4. Sepsis-11% 5. Obstructed Labor 7% 6. Indirect causes (such as malaria, infectious and parasitic diseases, etc) 14% 7. HIV 3% 8. Other Direct Causes 5% 9. Unclassified 6% 10.“Abortion”5% Note that this category includes both spontaneous and induced abortions. 5 Nathanson, Bernard, Co-founder of NARAL Pro-Choice America (formerly National Abortion Rights Action League): “I am personally responsible for 75,000 abortions. This legitimises my credentials to speak to you with some authority on the issue. I was one of the founders of the National Association for the Repeal of the Abortion Laws (NARAL) in the U.S. in 1968. A truthful poll of opinion then would have found that most Americans were against permissive abortion. Yet within five years we had convinced the U.S. Supreme Court to issue the decision which legalised abortion throughout America in 1973 and produced virtual abortion on demand up to birth. How did we do this? It is important to understand the tactics involved because these tactics have been used throughout the western world with one permutation or another, in order to change abortion law. THE FIRST KEY TACTIC WAS TO CAPTURE THE MEDIA We aroused enough sympathy to sell our program of permissive abortion by fabricating the number of illegal abortions done annually in the U.S. The actual figure was approaching 100,000 but the figure we gave to the media repeatedly was 1,000,000. Repeating the big lie often enough convinces the public. The number of women dying from illegal abortions was around 200-250 annually. The figure we constantly fed to the media was 10,000. These false figures took root in the consciousness of Americans convincing many that we needed to crack the abortion law. Another myth we fed to the public through the media was that legalising abortion would only mean that the abortions taking place illegally would then be done legally. In fact, of course, abortion is now being used as a primary method of birth control in the U.S. and the annual number of abortions has increased by 1500% since legalization.”Available at: http://www.aboutabortions.com/Confess.html (Nov. 30, 2009) 6 Gary, M.M., and Harrison, D.J., Analysis of Severe Adverse Events Related to the Use of Mifepristone as an Abortifacient The Annals of Pharmacotherapy 2006 Feb.Vol 40 (Online, 27 Dec 2005, www.theannals.com, DOI 10.1345/aph.1G481). 7 von Hertzen H, Piaggio G, Huong NT, Arustamyan K, Cabezas E, Gomez M, Khomassuridze A, Shah R, Mittal S, Nair R, Erdenetungalag R, Huong TM, Vy ND, Phuong NT, Tuyet HT, Peregoudov A; WHO Research Group on Postovulatory Methods of Fertility Regulation. UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzer- land. vonhertzenh@who.int Efficacy of two intervals and two routes of administration of misoprostol for termination of early pregnancy: a randomized controlled equivalence trial. Lancet. 2007 Jun 9;369(9577):1938-46. 8 British Journal of Obstetrics and Gynecology 107 (April 2000): 519-23. 9 Vargas, FR, et. al. Prenatal Exposure to Misoprostol and Vascular Disruption Defects: A Case Control Study. Am Journal of Medical Genetics 95 (2000) 302-306. 10 Niinimäki, M., M.D., Pouta, A., M.D. PhD, Bloigu, A., Gissler, M., BSc, PhD, Hemminki, E., M.D, PhD, Suhonen, S., M.D., PhD, Heikinheimo, O., M.D. PhD. Immediate Complications After Medical Compared With Surgical Termination of Pregnancy. OBSTETRICS & GYNECOLOGY Vol 114, No 4, October 2009 795-804. 11 Survival of very preterm infants: Epipage, a population based cohort study B Larroque, G Bréart, M Kaminski, M Dehan, M André, A Burguet, H Grandjean, B Ledésert, C Lévêque, F Maillard, J Matis, J C Rozé, P Truffert on behalf of the Epipage study group Arch Dis Child Fetal Neonatal Ed 2004;89:F139–F144. doi: 10.1136/adc.2002.020396. 12 Ancel PY, Lelong N, Papiernik E, Saurel-Cubizolles MJ, Kaminski M. History of induced abortion as a risk factor for preterm birth in European countries: results of EUROPOP survey. Human Repro 2004; 19(3): 734-740. 13 Institute of Medicine: Preterm Birth: Causes, Consequences, and Prevention National Academy of Science Press, July 06 Appendix B Table 5 “Immutable Medical Risk Factors Associated with Preterm Birth”. 14 See Attachment 1. Studies demonstrating an association between Abortion and Preterm Birth in subsequent pregnancies. (Total studies 113). 15 Shah P, Zao J on behalf of Knowledge Synthesis Group of Determinants of preterm/LBW births. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analyses. BJOG 2009;116:1425–1442. 16 Calhoun BC, Shadigian E, Rooney B. Cost Consequences of Induced Abortion as an Attributable Risk for Preterm Birth and Informed Consent. J Reprod Med 2007; 52(10):929-937. 17 SeeAttachment 2. Studies demonstrating an association between Abortion and Adverse Mental Health Outcomes. (Total studies 102). 18 Virk, Jasmeer, MS, MPH, Zhang, Jun MD, PhD, and Olsen, Jar MD, PhD. Medical Abortion and the Risk of Subsequent Adverse Pregnancy Outcomes N Engl J Med 2007;357:648-53. 19 World Health Organization “WHO: Causes of Maternal Deaths: A Systematic Review”The Lancet Vol 367 April 1, 2006. The breakdown of maternal mortality causality is as follows: 1. Hemorrhage-31% 2. Hypertensive disorders-10% 3. Anemia -8% 4. Sepsis-11% 5. Obstructed Labor 7% 6. Indirect causes (such as malaria, infectious and parasitic diseases, etc) 14% 7. HIV 3% 8. Other Direct Causes 5% 9. Unclassified 6% 10.“Abortion”5% Note that this category includes both spontaneous and induced abortions. 20 Ibid. 1-8 above.

Attachment 1. Studies demonstrating an association between Abortion and Preterm Birth in subsequent pregnancies. (Total studies 113)

Studies published from 2000 to 2009. (30 studies) 1. Foix-L’Helias L, Ancel PY, Blondel B. Changes in risk factors of preterm delivery in France between 1981 and 1995. Paediatric and Perinatal Epidemiology. Oct 2000;14(4): 314-323. 2. Foix-L’Helias L, Ancel, Blondel B. Risk factors for prematurity in France and comparisons betweeen spontaneous prematurity and induced labor; results from the National Perinatal Survey 1995. J Gy necol Obstet Bio Reprod (Paris) Feb 2000;29(1);55-65 3. Gardosi J, Francis A. Early Pregnancy predictors of preterm birth: the role of a prolonged menstruation-conception interval. BJOG 2000;107(2):228-237 4. 87 Bettiol H, Rona RJ, Chin S, Goldani M, Barberi M. Risk Factors Associated with preterm births in Southeast Brazil: a comparison of two birth cohorts born 15 years apart. Paediatric Perinatal Epidemiol 2000;14(1):30-38 5. Letamo G, Majelantle RG. Factors Influencing Low Birth Weight and Prematurity in Botswana. J Biosoc Sci 2001;33(3):391-403 6. Henriet L, Kaminski M. Impact of induced abortions on subsequent pregnancy outcome: the 1995 French national perinatal survey. BJOG 2001;108(10):1036-1042 7. Grimmer I, Buhrer C, Dudenhausen JW. Preconceptional factors associated with very low birth weight delivery: a case control study. BMC Public Health 2002; 2:10 [fusion_builder_container hundred_percent=”yes” overflow=”visible”][fusion_builder_row][fusion_builder_column type=”1_1″ background_position=”left top” background_color=”” border_size=”” border_color=”” border_style=”solid” spacing=”yes” background_image=”” background_repeat=”no-repeat” padding=”” margin_top=”0px” margin_bottom=”0px” class=”” id=”” animation_type=”” animation_speed=”0.3″ animation_direction=”left” hide_on_mobile=”no” center_content=”no” min_height=”none”][Germany]. 8. Balaka B, Boeta S, Aghere AD, Boko K, Kessie K, Assimadi K. Risk factors associated with prematurity at the University of Lme, Togo. Bull Soc Pathol Exot Nov 2002;95(4):280-283 9. Han WH, Chen LM, Li CY. Incidences of and Predictors for Preterm Births and Low Birth Weight Infants in Taiwan. Chinese Electronic Periodical Services 2003:131-141 10. El-Bastawissi AY, Sorensen TK, Akafomo CK, Frederick IO, Xiao R, Williams MA. History of Fetal Loss and Other Adverse Pregnancy Outcomes in Relation to Subsequent Risk of Preterm Delivery. Maternal Child Health J 2003;7(1):53-58 11. Reime B, Schuecking BA, Wenzlaff P. Perinatal outcomes of teenage pregnancies according to gravidity and obstetric history. Annals of Epidemiology 2004;14(8):619-619 [German subjects] http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T44-4D8V8F5-2R&_user=10&_coverDate=09%2F01%2F2004&_alid=1115807546&_rdoc=1&_fmt=high&_orig=search&_cdi=4964&_sort=r&_docanchor=&view=c&_ct=2&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=192ab2c282d8ef5a9bd4788834eb90f7 12. Ancel PY, Lelong N, Papiernik E, Saurel-Cubizolles MJ, Kaminski M. History of induced abortion as a risk factor for preterm birth in European countries: results of EUROPOP survey. Human Repro 2004; 19(3): 734-740. 13. Umeora OUJ, Ande ABA, Onuh SO, Okubor PO, Mbazor JO. Incidence and risk factors for preterm delivery in a tertiary health institution in Nigeria. J Obstetrics Gynaecology Nov. 2004; 24(8):895-896 14. Moreau C, Kaminski M, Ancel PY, Bouyer J, et al. Previous induced abortions and the risk of very preterm delivery: results of the EPIPAGE study. British J Obstetrics Gynaecology 2005;112(4):430-437 [France] [abstract online: http://www.blackwell-synergy.com/links/doi/10.1111/j.1471-0528.2004.00478.x/abs/] 15. Conde-Agudelo A, Belizan JM, Breman R, Brockman SC, Rosas-Bermudez. Effect of the interpregnancy interval after an abortion on maternal and perinatal health in Latin America. Int J Gynaecol & Obstet 2005;89 (Supp. 1):S34-S40. 16. Stang P, Hammond AO, Bauman P. Induced Abortion Increases the Risk of Very Preterm Delivery; Results from a Large Perinatal Database. Fertility Sterility Sept 2005;S159 17. Etuk SJ, Etuk IS, Oyo-Ita AE. Factors Influencing the Incidence of Pre-term Birth in Calabar, Nigeria. Nigerian J Physiological Sciences 2005;20(1-2):63-68 18. Poikkens P. Unkila-Kallio L,Vilska S, Repokari L. et al. Impact of Infertility Characteristics and treatment modalities on singleton pregnancies after assisted reproduction. Reproductive Tiomed July 2006;13(1):135-144 19. Samin A, Al-Dabbagh, Wafa Y Al-Taee. Pregnancy and Childbirth. BMC 2006;6:13 20. Smith GCS, Shah I, White IR, Pell JP, Crossley JA, Dobbie R. Maternal and biochemical predictors of spontaneous preterm birth among nulliparous women: a systematic analysis in relation to degree of prematurity. Intl J Epidem 2006;35(5):1169-1177 21. Briunsma F, Lemley J, Tan J, Quinn M. Precancerous changes in the cervix and risk of subsequent preterm birth. BJOG Jan. 2007;114(1):70-80 22. Jackson JE, Grobman WA, Haney E, Casele H. Mid-trimester dilation and evacuation with laminaria does not increase the risk for severe subsequent pregnancy complications. Intl J Gynecol Obstet 2007;96:12-15 23. Chung-Chin Lo, Jenn-Jeih Hsu, Ching-Chang Hsieh, T’sang-T-sang Hsieh, Tai-Ho Hung. Risk Factors For Spontaneous Preterm Delivery Before 34 Weeks of Gestation Among Taiwanese Women. Taiwan J Obstet Gynecol 2007;46(4):389-394 24. Curry AE,Vogel I, Drews C, Schendel D, Skogstrand K, et al. Mid-pregnancy maternal plasma levels of interleukin 2, 6, and 12, tumor necrosis factor-alpha, interferon-gamma, and granulocyte-macrophage colony-stimulating factor and spontaneous preterm delivery. Acta Obstectica et Gynecologica 2007:86:1103-1110 25. Brown TS, Adera T, Masho SW. Previous abortion and the risk of low birth weight and preterm births. J Epidemiol Commun Health 2008;62:16-22 26. Reime B, Schuecking BA, Wenzlaff P. Reproductive Outcomes in Adolescents Who Had a Previous Birth or an Induced Abortion Compared to Adolescents’ First Pregnancies. BMC Pregnancy and Childbirth 2008;8:4 27. Voigt M, Olbertz D, Fusch C, Krafczyk D. Briese V, Schneider KT.The infuluence of previous pregnancy terminations, miscarriages, and still-birth on the incidence of babies with low birth weight and premature births as well as somatic classication of newborns. Z Geburtshilfe Neonatol 2008;212:5-12 28. Freak-Poli R, Chan A, Gaeme J, Street J. Previous abortion and risk of preterm birth: a population study. J Maternal-Fetal Med Jan. 2009;22(1):1-7 29. Vpoit M, Henrich W, Zygmunt M, Friese K, Straube S, Briese V. Is induced abortion a risk factor in subsequent pregnancy? Journal Perinatal Medicine 2009;37:144-149. 30. Shah P, Zao J on behalf of Knowledge Synthesis Group of Determinants of preterm/LBW births. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analyses. BJOG 2009;116:1425–1442. Studies prior to 2000: (83 studies) 1 Barsy G, Sarkany J. Impact of induced abortion on the birth rate and infant mortality. Demografia 1963;6:427-467. 2 Miltenyi K. On the effects of induced abortion. Demografia 1964;7:73-87. 3 Furusawa Y, Koya Y. The Influence of artificial abortion on delivery. In: Koya Y, ed. Harmful effects of induced abortion. Tokyo: Family Planning Federation of Japan,1966:74-83. 4 Arvay A, Gorgey M, Kapu L. La relation entre les avortements (interruptions de la grossesse) et les accouchements prematures. Rev Fr Gynecol Obstet 1967;62:81-86 5 Drac P, Nekvasilova Z. Premature termination of pregnancy after previous interruption of pregnancy. Cesk Gynekol 1970;35: 332-333. 6 Dolezal A, Andrasova V, Tittlbachova S, et al. Interruption of pregnancy and their relation to premature labous and hyptrophic foetuses. Cesk Gynekol 1970:36:331 7 Pantelakis SN, Papadimitriou GC, Doxiadis SA.Influence of induced and spontaneous abortions on the outcome of subsequent pregnancies. Amer J Obstet Gynecol. 1973;116: 799-805. 8 Van Der Slikke JW, Treffers PE. Influence of induced abortion on gestational duration in subsequent pregnancies. BMJ 1978;1: 270-272 [>95% confident of preterm risk for gestation less than 32.0 weeks]. 9 Richardson JA, Dixon G. Effect of legal termination on subsequent pregnancy. British Med J 1976;1:1303-1304. 10 Papaevangelou G,Vrettos AS, Papadatos D, Alexiou C. The Effect of Spontaneous and Induced Abortion on Prematurity and Birthweight. The J Obstetrics and Gynaecology of the British Commonwealth. May 1973;80:418-422. 11 Bognar Z, Czeizel A. Mortality and Morbidity Associated with Legal Abortions in Hungary, 1960-1973. AJPH 1976;66:568-575. 12 Grindel B, Lubinski H,Voigt M. Induced abortion in primigravidae and subsequent pregnancy, with particular attention of underweight. Zentralbl Gynaekol 1979;101:1009-1114. 13 Obel E, et al. Pregnancy Complications Following Legally Induced Abortion With Special Reference to Abortion Technique. Acta Obstet Gynecol Scand 1979;58:147-152. 14 World Health Organization Task Force on the Sequelae of Abortion. Gestation, birthweight and spontaneous abortion. Lancet 1979;1:142-145. 15 Ratten G et al. Effect of Abortion on Maturity of Subsequent Pregnancy. Med J Australia June 1979: 479-480. 16 Roht LH, Aoyama H, Leinen GE, et al. The association of multiple induced abortions with subsequent prematurity and spontaneous abortion. Acta Obstet Gynaecol Jpn 1976;23: 140-145. 17 Harlap S, Davies AM. Late sequelae of induced abortion: Complications and Outcome of Pregnancy and Labor. Amer J Epidemiology 1975;102:219-224. 18 Koller O, Eikhom SN. Late Sequelae of Induced Abortion in Primigravidae. Acta Obstet Gynecol Scand 1977;56:311-317. 19 Lean TH, Hogue CJR, Wood J. Low birth weight after induced abortion in Singapore, Presented at the 105th Annual Meeting of the Americal Public Health Association, Washington DC, Oct. 31, 1977. 20 World Health Organization. Special Programme of Research, Development and Research Training in Human Reproduction: Seventh Annual Report, Geneva, Nov. 1978. 21 Hungarian Central Statistical Office. Perinatalishalazons. Budapest: Hungarian Central Statistical Office, 1972. 22 Czeizel A, Bognar Z, Tusnady G, et al. Changes in mean birth weight and proportion of low-weight births in Hungary. Br J Prev Soc Med 1970;24:146-153. 23 Dziewulska W. Abortion in the past versus the fate of the subsequent pregnancy. State of the newborn. Ginekol Pol 1973;44:1143-1148 [Poland]. 24 Kaminski M, Goujard J, Rumeau-Roquette. Prediction of low birthweight and prematurity by a multiple regression analysis with maternal characterisitics known since the beginning of the pregnancy. Intl J Epidem 1973;2:195-204 25 Chabada J, Pontuch A, Sutta I, Pohlova G. Interruptions of gravidity as a cause of premature labour Cesk Gynekol 1974;49(5):329-330 26 Fredrick J. Antenatal identification of women at high risk of spontaneous preterm birth. BJOG 1976;83:351-354 27 Pohanka O, Balogh B, Rutkovszky M. The impact of abortion on the birth weight of newborns. Orb Hetil 1975;116:1983-1989 28 Mikolas M. The effect of the legalization of abortion on public health and some of its social concomitants in Hungary. Demografia 1973;16:70-113 29 Link M, Wichmann A. Pregnancy in adolescents. Zentrabl Gynekol 1976;98(11):682-689 30 Knarre P. Influence of abortions and interruptions of pregnancy in subsequent deliveries. II Cause of labor. Zentrabl Gynekol 1976;98(10):591-594 31 Kreiblich H, Ehring E. Zentralfl Gynokol 1978;100(19):1254-1260 32 Macku F, Rokytova V, Titmann O. Artificial Interruption of Pregnancy in Primigravidae as a risk factor in future pregnancies. Cesk Gynekol 1978;43(5):340-343 33 Zwahr C, Coigt M, Kunz L, Thielemann F, Lubinski H. Multidimensional investigations to elucidate relationships between case histories of interrupted pregnancies and premature deliveries and low birth weight. Zentrabl Gynekol 1979;101(23):1502-1509 34 Zwahr C,Voigt M, Kunz L, et al. Relationships between interruption abortion, and premature birth and low birth weight. Zentrabl Gynaekol 1980;102:738-747. 35 Kreibich H, Ludwig A. Early and late complications of abortion in juvenile primigravidae (including recommended measures). Z Aerztl Fortbild (Jena) 1980;74:311-316. 36 Levin A, Schoenbaum S, Monson R, Stubblefield P, Ryan K. Association of Abortion With Subsequent Pregnancy Loss. JAMA 1980;243(24):2495-2499 37 Legrillo V. Quickenton P, Therriault GD, et al. Effect of induced abortion on subsequent reproductive function. Final report to NICHD. Albany, NY: New York State Health Department, 1980. 38 Slater PE, Davies AM, Harlap S. The Effect of Abortion Method on the Outcome of Subsequent Pregnancy. J Reprod Med 1981;28:123-128. 39 Lerner RC,Varma AO. Prospective study of the outcome of pregnancy subsequent to previous induced abortion. Final report, Contract no. (N01-HD-62803). New York: Downstate Medical Center, SUNY, January 1981. 40 Berkowitz GS. An Epidemiologic Study of Preterm Delivery. American J Epidemiology 1981;113:81-92. 41 Lampe LG, Ratar I, Bernard PP, et al. Effects of smoking and of induced abortion on pregnancy outcome. IPPF Med Bull 1981;15:3 42 Schoenbaum LS, Monson RR. No association between coffee consumption and adverse outcomes of pregnancy. N Engl J Med 1982;306:141-145 43 Pompe-Tansek NM, Andolsek L, Tekovcic B. Jugosl Ginekol Opstet Sept.-Dec. 1982;22(5-6):118-120 44 Puyenbroek J, Stolte L. The relationship between spontaneous and induced abortions and the occurrence of second-trimester abortion in subsequent pregnancies. Eur J Obstet Gynecol Reprod Biol 1983;14:299-309 45 Zwahr C,Voigt M. The effect of various parameters on the incidence of premature births. Zentralbl Gynakol 1983;105:1307-1312 46 Schuler D, Klinger A. Causes of low birth weight in Hungary. Acta Paediatrica Hungarica 1984;24:173-185 47 Pickering RM, Forbes J. Risk of preterm delivery and small-for-gestational age infants following abortion: a population study. British J Obstetrics and Gynecology 1985;92:1106-1112. 48 Lumley J.Very low birth-weight (less than 1500g) and previous induced abortion: Victoria 1982-1983. Aust NZ J Obstet Gynecol 1986;26:268-272. 49 Shiono PH, Lebanoff MA. Ethnic Differences and Very Preterm Delivery. Am J Public Health 1986;76:1317-1321. 50 Peterlin A Ardolsek L. The effect of induced abortion in adolescence on the manifestations of spontaneous abortion, premature abortion, and birth weight. Jugosl Ginekol Perinatol May-Aug 1986;26(3-4):49-52 51 Ross MG, Hobel CJ, Bragenier JR, Bear MB, Bemis RL. A simplified risk-scoring system for prematurity. Amer J Perinatology 1986;3:339-344 52 Lieberman E, Ryan KJ, Monson RR, Schoenbaum SC. Risk Factors Accounting For Racial Differences in the rate of premature birth. NEJM 1987;317:743-748. 53 Seidman DS, Ever-Hadani P, Slater PE, Harlap S, et al. Child-bearing after induced abortion: reassessment of risk. J Epidemiology Community Health 1988;42:294-298. 54 Zwahr, C, Neubert D,, Triebel U,Voight M, Kruppel KH. Correlation between some environmental, anamnestic and social markers of pregnant patients and the delivery of autotrophic premature and hypotrophic newborn infants. Zentralbl Gynakol 1988;110:479-487 55 Mueller-Heubach E, Guzick DS. Evaluation of risk scoring in a preterm birth prevention study of indigent patients. Am J Obstetrics & Gyn 1989;160:829-837. 56 Vasso L-K, Chryssa T-B, Golding J. Previous obstetric history and subsequent preterm delivery in Greece. European J Obstetrics & Gynecology Reproductive Biology 1990;37: 99-109. 57 Li YJ, Zhou YS. study of factors associated with preterm delivery. Zhongjua Liu Xing Bing Xue Za Chi. Aug 1990;11(4):229-234 58 Haper JH, Hsing AW, Tuomala RE, Gibbs RS, et al. Risk factors for preterm premature rupture of fetal membranes: A multicenter case-control study. Am J Obstet Gynec 1990;163:130-137 59 McGregor JA, French J, Richter R. Antenatal microbiologic and maternal risk factors ssociated with prematurity. Amer J Obstet Gynecol 1990;163:1465-1473 60 Pickering RM, Deeks JJ. Risks of Delivery during 20th to the 36th Week of Gestation. Intl. J Epidemiology 1991;20:456-466. 61 *Zhang J, Savitz DA. Preterm Birth Subtypes among Blacks and Whites. Epidemiology 1992;3:428-433. 62 *Michielutte R, Ernest JM, Moore ML, Meis PJ, Sharp PC, Wells HB, Buescher PA. A Comparison of Risk Assessment Models for Term and Preterm Low Birthweight. Preventive Medicine 1992;21:98-109. 63 Gong JH. Preterm delivery and its risk factors. Zhounghua Fu Chan Ke Za Chi Jan. 1992;27(1):22-24 64 Mandelson MT, Maden CP, Daling JR. Low Birth Weight in Relation to Multiple Induced Abortions. Am J Public Health 1992;82;391-394 65 Lumley J. The epidemiology of preterm birth. Bailliere’s Clin Obstet Gynecology. 1993;7(3):477-498 66 Algert C, Roberts C, Adelson P, Frammer M. Low birth weight in New South Wales, 1987: a Population-Based Study. Aust New Zealand J Obstet Gynaecol 1993;33:243-248 67 Ekwo EE, Grusslink CA, Moawad A. Previous pregnancy outcomes and subsequent risk of premature rupture of amniotic sac membranes. Brit J Obstet Gynecol 1993;100(6):536-541 68 Lekea-Karanika V, Tzoumaka-Bangoula C. Past obstetric history of the mother and its association with low birth weight of a subseaquent child: a population-based study. Paediatr Perinat Epidemiol 1994;8:173-187 69 Guinn D, Goldenberg RL, Hauth JC, Andrews WA et al. Risk factors for the development of preterm premature rupture of membranes after arrest of preterm labor. AJOG 1995;173 (4):1310-1315. 70 *Hillier SL, Nugent RP, Eschenbach DA, Krohn MA,et al. Association Between Bacterial Vaginosis And Preterm Delivery Of A Low-Birth-Weight Infant. NEJM 1995;333: 1737-1742. 71 Khalil AK, El-Amrawy SM, Ibrahim AG, et al. Pattern of growth and development of premature children at the age of two and three years in Alexandria, Egypt. Eastern Mediterranean Health Journal 1995;1(2):186-193. 72 Meis PJ, Michielutte R, Peters TJ, Wells HB. Factors associated with preterm birth in Cardiff, Wales. Amer J Obstet Gynecol 1995; 173:590-596 73 Lang JM, Lieberman E, Cohen A. A Comparison of Risk Factors for Preterm Labor and Term Small-for-Gestational-Age Birth. Epidemiology 1996;7:369-376. 74 Hagan R, Benninger H, Chiffings D. Evans S, French H.Very preterm birth – a regional study. Part 1: Maternal and obstetric factors. BJOG 1996;103:230-238 75 Chie-Pein Chen, Kuo-Gon Wang,Yuh-Cheng Yang, Lai-Chu See. Risk factors for preterm birth in an upper middle class Chinese population. Eur J Obstet Gynecol Reprod Bio 1996;70(1):53-59 76 Jacobsen G, Schei B, Bakketeig LS. Prepregnant reproductive risk and subsequent birth outcome among Scandinavian parous women. Norsk Epidemiol 1997;7(1):33-39 77 Lumley J. The association between prior spontaneous abortion, prior induced abortion and preterm birth in first singleton births. Prenat Neonat Med 1998;3:21-24. 78 Martius JA, Steck T, Oehler MK, Wulf K-H. Risk factors associated with preterm (<37+0 weeks) and early preterm (<32+0 weeks): univariate and multi-variate analysis of 106 345 singleton births from 1994 statewide perinatal survey of Bavaria. European J Obstetrics & Gynecology Reproductive Biology 1998;80:183-189. 79 Small Babies in Scotland A Ten Year Overview 1987-1996. Information and Statistics Division. The National Health Service in Scotland. Scottish Program for Clinical Effectiveness. Edinburgh 1998 ISBN 1-902076-07-9. 80 Lee KS, Lee WC, Meng KH, Lee Ch, Kim SP. Maternal Factors Associated with the Premature Rupture of Membrane in the Low BIrth Weight Infant Deliveries. Korean J Prev Med 1998;21(2): 207-216 81 Ancel PY, Saurel-Cubizolles M-J, Renzo GCD, Papiernik E, Breart G.Very and moderate preterm births: are the risk factors different? British J Obstetrics and Gynaecology 1999;106:1162-1170. 82 Zhou W, Sorenson HT, Olsen J. Induced Abortion and Subsequent Pregnancy Duration. Obstetrics & Gynecology 1999;94:948-953. 83 Ancel PY, Saurel-Cubizolles, Di Renzo GC, Papiernik E, Breart G. Social Differences of very preterm birth in Europe: interaction with obstetric history. American J Epi 1999;149(10):908-915.

Attachment 2. Studies demonstrating an association between Abortion and Adverse Mental Health Outcomes. (Total studies 102)

1. Allanson, S., & Astbury, J. (2001). Attachment style and broken attachments: Violence, pregnancy, and abortion. Australian Journal of Psychology, 53, 146-151. 2. Amaro H., Zuckerman B, & Cabral H. (1989). Drug use among adolescent mothers: profile of risk. Pediatrics, 84, 144-151. 3. Barnett, W., Freudenberg, N., & Wille, R. (1992). Partnership after induced abortion: A prospective controlled study. Archives of Sexual Behavior, 21(5), 443-455. 4. Bianchi-Demicheli, F et al (2002). Termination of pregnancy and women’s sexuality. Gynecol Obstet Invest, 53, 48-53. 5. Boesen, H.C., Rorbye C., Norgaard, M., Nilas, L. (2004). Sexual behavior during the first eight weeks after legal termination of pregnancy. Acta Obstetricia et Gynecologica Scandinavica, 83, 1189-1192. 6. Bradley, C.F. (1984) Abortion and subsequent pregnancy. Canadian Journal of Psychiatry, 29, 494. 7. Bradshaw, Z., & Slade, P. (2003). The effects of induced abortion on emotional experiences and relationships: A critical review of the literature. Clinical Psychology Review, 23, 929-958. 8. Bradshaw, Z., & Slade, P. (2005). The relationship between induced abortion, attitudes toward sexuality, and sexual problems. Sexual and Relationship Therapy, 20, 390-406. Brockington, I. F. (2005). Post-abortion psychosis, Arch Womens Ment Health 8: 53–54. 9. Broen, A. N., Moum, T., Bodtker, A. S., & Ekeberg, O. (2004). Psychological impact on women of miscarriage versus induced abortion: A 2-year follow-up study. Psychosomatic Medicine, 66(2), 265-271. 10. Broen, A. N., Moum, T., Bodtker, A. S., & Ekeberg, O. (2005a). The course of mental health after miscarriage and induced abortion: A longitudinal, five-year follow-up study. BMC Medicine, 3, 18. 11. Broen, A. N., Moum, T., Bodtker, A. S., & Ekeberg, O. (2005b). Reasons for induced abortion and their relation to women’s emotional distress: A prospective, two-year follow-up study. General Hospital Psychiatry, 27(1), 36-43. 12. Broen, A. N., Moum, T., Bodtker, A. S., & Ekeberg, O. (2006). Predictors of anxiety and depression following pregnancy termination: A longitudinal five-year follow-up study. Acta Obstetricia et Gynecologica Scandinavica, 85(3), 317-323. 13. Burnell, G. M., & Norfleet, M. A. (1987). Women’s self-reported responses to abortion. The Journal of Psychology, 121, 71–76. 14. Butlet, C. (1996). Late psychological sequelae of abortion: Questions from a primary care physician. Journal of Family Practice, 43, p. 396-401. 15. Campbell, N., Franco, K. & Jurs, S. (1988). Abortion in Adolescence. Adolescence 23, 813-823. 16. Cohan, C. L., Dunkel-Schetter, C., & Lydon, J. (1993). Pregnancy decision making: Predictors of early stress and adjustment. Psychology of Women Quarterly, 17, 223-239. 17. Coleman, P. K. (2006a). Resolution of unwanted pregnancy during adolescence through abortion versus childbirth: Individual and family predictors and psychological consequences. Journal of Youth and Adolescence, 35, 903-911. 18. Coleman, P. K., Maxey, C. D., Rue,V. M., & Coyle, C. T. (2005). Associations between voluntary and involuntary forms of perinatal loss and child maltreatment among low-income mothers. Acta Paediatrica, 94(10), 1476-1483. 19. Coleman, P. K., & Nelson, E. S. (1998). The quality of abortion decisions and college students’ reports of post-abortion emotional sequelae and abortion attitudes. Journal of Social & Clinical Psychology, 17, 425-442. 20. Coleman, P. K., Reardon, D. C., & Cougle, J. (2002). The quality of the caregiving environment and child developmental outcomes associated with maternal history of abortion using the NLSY data. Journal of Child Psychology and Psychiatry, 43, 743-757. 21. Coleman, P. K., Reardon, D. C., & Cougle, J. R. (2005). Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. British Journal of Health Psychology, 10(2), 255-268. 22. Coleman, P. K., Reardon, D. C., Rue,V. M., & Cougle, J. (2002a). A history of induced abortion in relation to substance use during subsequent pregnancies carried to term. American Journal of Obstetrics and Gynecology, 187, 1673-1678. 23. Coleman, P. K., Reardon, D. C, Rue,V. M., & Cougle, J. (2002b). State-funded abortions versus deliveries: A comparison of outpatient mental health claims over 4 years. American Journal of Orthopsychiatry, 72, 141-152. 24. Coleman, P. K., Reardon, D. C., Strahan, T., & Cougle, J. R. (2005). The psychology of abortion: A review and suggestions for future research. Psychology and Health, 20, 237-271. 25. Congleton, G. K., & Calhoun, L. G. (1993). Post-abortion perceptions: A comparison of self-identified distressed and non-distressed populations. International Journal of Social Psychiatry, 39, 255-265. 26. Congleton, G. & Calhoun, L. (1993). Post-abortion perceptions: A comparison of self-identified distressed and non-distressed populations. International Journal of Social Psychiatry, 39, 255-265. 27. Conklin, M. P., & O’Connor, B. P. (1995). Beliefs about the fetus as a moderator of post-abortion psychological well-being. Journal of Social & Clinical Psychology, 14, 76-95. 28. Cote-Arsenault, D., Dombeck, M. T. B. (2001). Maternal assignment of fetal personhood to a previous pregnancy loss: Relationship to anxiety in the current pregnancy. Health Care for Women International 22, 649-665. 29. Cougle, J. R., Reardon, D. C., & Coleman, P. K. (2003). Depression associated with abortion and childbirth: A long-term analysis of the NLSY cohort. Medical Science Monitor, 9(4), CR105-112.79. 30. Cougle, J. R., Reardon, D. C., & Coleman, P. K. (2005). Generalized anxiety following unintended pregnancies resolved through childbirth and abortion: A cohort study of the 1995 National Survey of Family Growth. Journal of Anxiety Disorders, 19, 137-142. 31. Cozzarelli, C. (1993). Personality and self-efficacy as predictors of coping with abortion. Journal of Personality and Social Psychology, 65, 1224-1236. 32. David, H., Rasmussen, N. & Holst, E. (1981). Postpartum and postabortion psychotic reactions. Family Planning Perspectives, 13, 88-91. 33. Fayote, F.O., Adeyemi, A.B., Oladimeji, B.Y. (2004). Emotional distress and its correlates. Journal of Obstetrics and Gynecology, 5, 504-509. 34. Fergusson, D. M., Horwood, L. J., & Ridder, E. M. (2006). Abortion in young women and subsequent mental health. Journal of Child Psychology and Psychiatry, 47, 16-24. 35. Fergusson, D.M. Horwood, L.J., & Boden, J.M. (2009) Reactions to abortion and subsequent mental health The British Journal of Psychiatry (2009) 195, 420–426. doi: 10.1192/bjp.bp.109.066068 36. Fielding, S. L., & Schaff, E. A. (2004). Social Context and the Experience of a Sample of U.S. Women Taking RU-486 (Mifepristone) for Early Abortion. Qualitative HealthResearch, 14, 612-627. 37. Franz, W., & Reardon, D. (1992). Differential impact of abortion on adolescents and adults. Adolescence, 27(105), 161-172. 38. Gissler, M., Hemminki, E., & Lonnqvist, J. (1996). Suicides after pregnancy in Finland, 1987-94: Register linkage study. British Medical Journal, 313, 1431-1434. 39. Gissler, M., et al. (2005). Injury deaths, suicides and homicides associated with pregnancy, Finland 1987-2000. European Journal of Public Health, 15, 459-463. 40. Guilbert, E., & Rotter, D. (1997). Assessment of satisfaction with induced abortion procedure. The Journal of Psychology, 131, 157-166. 41. Harlow, B. L., Cohen, L. S., Otto, M. W., Spiegelman, D., & Cramer, D. W. (2004). Early life menstrual characteristics and pregnancy experiences among women with and without major depression: the Harvard Study of Mood and Cycles. Journal of Affective Disorders, 79, 167176. 42. Hemmerling, F., Siedentoff, F., & Kentenich, H. (2005). Emotional impact and acceptability of medical abortion with mifepristone: A German experience. Journal of Psychosomatic Obstetrics & Gynecology, 26, 23-31. 43. Henshaw, R., Naji, S., Russell, I., & Templeton, A. (1994). Psychological responses following medical abortion (using mifepristone and gemeprost) and surgical vacuum aspiration: A patient-centered, partially randomized prospective study. Acta Obstetrica et Gynecologica Scandinavica, 73, 812-818. 44. Hittner, A. (1987). Feelings of well-being before and after abortion. American Mental Health Counselors Association Journal, 9, 98-104. 45. Hope, T. L., Wilder, E. I., & Terling Watt, T. (2003). The relationships among adolescent pregnancy, pregnancy resolution, and juvenile delinquency. Sociological Quarterly, 44, 555-576. 46. Husfeldt, C., Hansen, S. K., Lyngberg, A., Noddebo, M., & Pettersson, B. (1995). Ambivalence among women applying for abortion. Acta Obstetricia et Gynecologia Scandinavica, 74, 813-17. 47. Kero, A., Hoegberg, U., Jacobsson, L., & Lalos, A. (2001). Legal abortion: A painful necessity. Social Science and Medicine, 53, 1481-1490. 48. Kero, A., Hoegberg, U., & Lalos, A. (2004). Wellbeing and mental growth – long-term effects of legal abortion. Social Science and Medicine, 58, 2559-2569. 49. Kero A, Lalos A. (2000). Ambivalence – a logical response to legal abortion: a prospective study among women and men. Journal of Psychosomatic Obstetrics and Gynecology; 21, 81-91. 50. Kitamura, T., Toda, M. A., Shima, S., & Sugawara, M. (1998). Single and repeated elective abortions in Japan: A psychosocial study. Psychosomatic Obstetrics and Gynecology, 19, 126-134. 51. Lauzon, P., Roger-Achim, D., Achim, A., & Boyer, R. (2000). Emotional distress among couples involved in first-trimester induced abortions. Canadian Family Physician, 46, 2033-2040. 52. Lazarus, A. & Stern, R. (1986). Psychiatric Aspects of Pregnancy Termination” Clinics in Obstetrics & Gynaecology 13, 125-134. 53. Lazarus, A. (1985). Psychiatric Sequelae of Legalized Elective First Trimester Abortion. Journal of Psychosomatic Ob&Gyn, 4, 141-150. 54. Lemkau, J. P. (1988). Emotional sequelae of abortion: Implications for clinical practice. Psychology of Women Quarterly, 12, 461–472. 55. Lewis, W. J. (1997). Factors associated with post-abortion adjustment problems: Implications for triage. The Canadian Journal of Human Sexuality, 6, 9-17. 56. Llewellyn, S. P., & Pytches, R. (1988). An investigation of anxiety following termination of pregnancy.Journal of Advanced Nursing, 13, 468–471. 57. Lodl, K. McGettigan, A. & Bucy, J. (1985). Women’s Responses to Abortion. Journal of Social Work & Human Sexuality, 3, 119-132. 58. Lydon, J., Dunkel-Schetter, C., Cohan, C. L., & Pierce, T. (1996). Pregnancy decision-making as a significant life event: A commitment approach. Journal of Personality and Social Psychology, 71, 141-151. 59. Major, B. (1989). Self-blame, Self-efficacy and Adjustment to Abortion. Journal of Personality and Social Psychology, 5, 1059-1068. 60. Major, B.,Cozzarelli, C., Cooper, M.L., Zubek, J., Richards C., Wilhite, M., & Gramzow, R.H. (2000).Psychological responses of women after first trimester abortion. Archives of General Psychiatry, 57, 777-84. 61. Major, B. Cozzarelli, C., Sciacchitano, A. M., Cooper, M. L., Testa, M., & Mueller, P. M. (1990). Perceived social support, self-efficacy, and adjustment to abortion. Journal of Personality and Social Psychology, 59, 186-197. 62. Major, B.,& Gramzow, R. H. (1999).Abortion as stigma: Cognitive and emotional implications of concealment. Journal of Personality and Social Psychology ,77, 735-745. 63. Miller, W. B. (1992). An empirical study of the psychological antecedents and consequences of induced abortion. Journal of Social Issues, 48, 67-93. 64. Miller, W. B., Pasta, D. J., & Dean, C. L. (1998). Testing a model of the psychological consequences of abortion. In L. J. Beckman and S. M. Harvey (eds.), The new civil war: The psychology, culture, and politics of abortion. Washington, DC: American Psychological Association. 65. Morgan, C., Evans, M., Peter, J. R., & Currie, C. (1997). Mental health may deteriorate as a direct result of induced abortion. British Medical Journal, 314, 902. 66. Moseley, D. T., Follongstad, D. R., Harley, H., & Heckel, R.V. (1981). Psychological factors that predict reaction to abortion. Journal of Clinical Psychology, 37, 276-279. Mueller, P. & 67. Mufel, N., Speckhard, A. & Sivuha, S. Predictors of Posttraumatic Stress Disorder Following Abortion in a Former Soviet Union Country. Journal of Prenatal & Perinatal Psych & Health,17, 41-61 (2002). 68. Ney, P. G., Fung, T., & Wickett, A.R. (1993). Relations between induced abortion and child abuse and neglect: Four studies. Pre and Perinatal Psychology Journal, 8, 43-63. 69. Ney, P. G., Fung, T., Wickett, A. R., & Beaman-Dodd, C. (1994). The effects of pregnancy loss on women’s health. Social Science & Medicine, 38, 1193-1200. 70. Ostbye, T., Wenghofer, E. F., Woodward, C. A., Gold, G., & Craighead, J. (2001). Health services utilization after induced abortions in Ontario: A comparison between community clinics and hospitals. American Journal of Medical Quality, 16, 99-106. 71. Patterson, M. J., Hill, R. P., & Maloy, K. (1995). Abortion in America: A consumer-based perspective. Journal of Consumer Research, 21, 677-694. 72. Pedersen, W. (2008). Abortion and depression: A population-based longitudinal study of young women. Scandinavian Journal of Public Health,Vol. 36, No. 4, 424-428. 73. Pedersen, W. (2007). Addiction. Childbirth, abortion and subsequent substance use in young women: a population-based longitudinal study, 102 (12), 1971-78. 74. Pope, L. M., Adler, N. E., & Tschann, J. M. (2001). Post-abortion psychological adjustment: Are minors at increased risk? Journal of Adolescent Health, 29, 2-11. 75. Posavac, E., & Miller, T. (1990). Some problems caused by not having a conceptual foundation for health research: An illustration from studies of the psychological effects of abortion. Psychology and Health, 5, 13-23. 76. Prommanart, N., et al. (2004). Maternal grief after abortion and related factors. Journal of the Medical Association of Thailand, 87, 1275-1280. 77. Reardon, D. C., & Coleman, P. K. (2006). Relative treatment for sleep disorders following abortion and child delivery: A prospective record-based study. Sleep, 29(1), 105-106. 78. Reardon, D. C., Coleman, P. K., & Cougle, J. R. (2004). 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