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detect fetal abnormalities has become routine. The amount

of genetic information that has become available through

such testing has expanded enormously within the past few

years. There are a number of ways of carrying out these

tests, yet for each of them there is a danger of inaccurate

results, and for some of them there is the additional hazard

of injury to the fetus. Pregnant women and their partners

are often unprepared for the news that they are carrying a

“defective” fetus. An abortion agreed to in haste and under

coercive pressure, can have devastating consequences, not

only for the parents, but for other children. Is enough being

done to inform women about the implications of prenatal

testing, and to provide them with alternative choices to

abortion when tests prove positive?

* We are indebted to Dr Bridget Campion for her invaluable help in

preparing this chapter.

Chapter 12

12

Abortion after Prenatal Testing *

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Abortion after Prenatal Testing

Selective or genetic abortions are undertaken not because

the pregnancy itself is unwanted but because some fetal

attribute discovered through prenatal diagnosis has made the

particular fetus unwanted. According to one study, “as many

as four out of every 1000 recognized pregnancies are termi-

nated in the second trimester for fetal abnormality”

as dis-

covered during prenatal diagnostic testing.

Prenatal diagnosis is increasingly seen as a routine part of

prenatal care, although it seems rarely to be linked explicitly

to abortion, at least in the minds of pregnant women and

their partners. Yet an abortion following the detection of a

fetal anomaly can be devastating for all concerned.

Additionally, even the diagnostic tests carry risks to fetal

well-being quite apart from abortion.

Testing for Fetal Abnormality

Over the past two decades, little emphasis has been placed

on the psychological outcome for women who abort a child

owing to genetic disorders following prenatal diagnosis. But

one significant change in the past decade has been the

growing amount of available genetic information about indi-

vidual fetuses. This information increases the likelihood that

a woman will opt for abortion, perhaps at a late stage in her

pregnancy.

Since the early 1980s,

amniocentesis

has been used to diag-

nose chromosomal anomalies such as Down Syndrome or

Tay-Sach’s disease after the sixteenth week of pregnancy.

The introduction of ultrasonography has also allowed physi-

cians to identify the presence of neural tube defects (spina

bifida).

In the mid 1990s, the application of the technique of

chorionic villi sampling

has led to further advances in early

detection.

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Through prenatal diagnosis it is now possible to detect med-

ical conditions such as cystic fibrosis and late or adult-onset

diseases such as Huntington's Chorea or multiple sclerosis.

Further, it is now possible to test for what is known as

“genetic susceptibility” or predisposition for conditions such

as breast cancer or Alzheimer’s disease.

Methods of Prenatal Diagnosis

There are four types of prenatal diagnosis commonly offered

to women.

1. Ultrasonography (“ultrasound”):

Through the use of sound waves, ultrasound provides a

visual picture of the developing fetus. It is a test used to

detect anomalies that are physically distinctive – defects of

limbs and internal defects of the abdomen, chest, and heart.

Neural tube defects, such as anencephaly, can also be diag-

nosed quite reliably by the fourteenth to sixteenth week of

pregnancy. Ultrasound may also be used to confirm the

presence of more that one fetus in the womb or measure the

progress of fetal growth.

2. Maternal Serum Alpha Fetoprotein Screening (MSAFP):

Raised alpha fetoprotein levels in the pregnant woman’s

blood may mean that the fetus has a neural tube defect. The

test is usually done in the fifteenth to seventeenth week of

gestation with results available up to two weeks later.

Because MSAFP has a high ratio of false-positives,

the test is

usually followed by an ultrasound or amniocentesis to con-

firm the presence of an anomaly in the fetus.

3. Amniocentesis

Amniocentesis normally involves inserting a needle into the

uterus through the abdomen and withdrawing fluid. This

may be a therapeutic intervention, as when a pregnant

woman suffers from polyhydramnios – that is, an excess of

amniotic fluid. For diagnostic purposes, however, amniotic

fluid is withdrawn in order to test for the presence of

chromosomal abnormalities or neural tube defects in the

fetus. Amniocentesis is usually performed at sixteen to

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20 weeks’ gestation, with the results being available three

to four weeks later. The risk of miscarriage with amniocen-

tesis, while small (one per cent), is nevertheless real.

well, there is the possibility that the fetus may be hit by

the needle.

4. Chorionic Villi Sampling (CVS):

In this relatively new procedure, the villi are used to provide

chromosomal information about the fetus. The test can be

done in the first trimester, with the results available within

one or two days. However, because placental rather than

fetal material is used, CVS is not as accurate as amniocen-

tesis. Because it is performed so early, it cannot be used to

detect anomalies that develop later in the pregnancy

(e.g. neural tube defects). CVS carries with it a 3.2 per cent

risk of miscarriage

and the danger of “limb reduction” in the

fetus. In one study of 394 fetuses, four genetically “normal”

babies nevertheless had damage to their limbs; in another

study of 289 pregnancies, five fetuses were similarly affected.

These deformities were attributed to CVS.

However, propo-

nents of CVS believe that its advantage lies in the early

detection of fetal anomalies which allows for the early termi-

nation of those pregnancies.

Parents Unprepared for Diagnosis

There appears to be dissonance between the practitioner’s

understanding of the purpose of prenatal diagnosis and the

pregnant woman’s perception of the procedure. While the

practitioner may offer or even insist on the diagnostic tests

as a way of preventing the birth of a “defective” child, preg-

nant women seek them out for reassurance that their babies

are well and healthy.

For many expectant couples, the link

between testing and abortion, at least initially, does not

exist.

This may be in part because genetic counselors do not

make this link explicit to their clients. In her study of the

effects of prenatal diagnosis on the dynamics of pregnancy,

Barbara Katz Rothman found that, while genetic counselors

might presume that selective abortion would follow the

detection of an anomaly, rarely did they offer any informa-

tion about actual abortion procedures. Indeed, some did not

even include a discussion of abortion in the first counseling

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session.

Even when birth defects and abortions are explicitly

discussed, couples seem to “deny this possibility, and when

faced with the reality, react as though they were hearing for

the first time that birth defects can occur.”

The pregnant

woman and her partner simply do not link this outcome to

prenatal diagnosis.

Quick Decision

Despite the shock and grief they may experience upon hear-

ing the news of a fetal anomaly, the pregnant woman and

her partner are usually urged to make the decision to termi-

nate quickly.

Behind this urgency is the physician’s desire

to avoid complications of “late” terminations of pregnancy.

Because of the delays involved in amniocentesis, abortions

may occur in the second and even third trimesters of preg-

nancy. In health care settings, the issue of such late abor-

tions has raised ethical and legal questions.

In one early

study, most of the terminations occurred within 72 hours of

the woman receiving the news of the abnormality.

This

hardly allows enough time for the couple to become

informed about parenting children born with that anomaly

and thus consider carrying through with the pregnancy.

Methods of Termination

The method of termination chosen will depend on the stage

of pregnancy. CVS, with its results available in the first

trimester, may be followed by dilation and curettage, the

type of abortion normally done at an early stage of pregnan-

cy.

Later terminations following amniocentesis may be

carried out by dilation and evacuation or by the instillation

of urea or saline into the uterus, to kill the fetus and initiate

labor.

14

While D&E may be relatively fast and physically

painless for the pregnant woman, the destruction of the fetus

makes post-mortem examination almost impossible. Similarly,

instillation procedures that kill the fetus make fetal tissue

unsuitable for later examination.

This type of abortion may

take up to 40 hours.

More commonly, women undergoing

late termination of pregnancy have labor induced through

the use of prostaglandins.

It is a procedure that has the

advantage of delivering the fetus intact, therefore making the

baby suitable for post-mortem examination.

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Unless urea is injected into the womb prior to delivery, the

procedure carries the possibility of delivering the baby alive,

normally not a desired outcome.

The labor itself can be

lengthy and intense

but because of a desire not to interfere

with the labour, analgesics are usually not administered.

According to one study, “virtually all of the women experi-

enced the termination procedure as one where they felt sick,

painful, or frightened.”

21

Sequelae of Genetic Termination of Pregnancy

While couples may not be completely aware of the physical

aspects of genetic abortions, they usually know even less

about the accompanying and subsequent psychological and

emotional distress of the procedure.

In interviews conduct-

ed by White-Van Mourik and colleagues and by Zeanah and

colleagues

all of the study subjects

found the pregnancy termi-

nation to be a traumatic experience.

Rayburn and Laferla

support the finding, observing that, “Terminating a pregnan-

cy because of a major fetal malformation is often a shattering

experience, and time for adjustment may be prolonged.”

This is true for both “early” as well and “late” genetic abor-

tions.

Indeed, there may be instances in which an early

abortion may present more difficulties than a later abortion.

One study subject reported this to be so because “there was

no fetus to see and hold” after an early termination.

Boss

speculates that “it is possible that the ‘privacy’ of first

trimester prenatal diagnosis and selective [genetic] abortion

may actually increase the unresolved ‘disenfranchised’ grief

since so few people know about the person’s loss.”

Researchers offer various explanations for this phenomenon.

In almost all cases, pregnancies terminated for genetic anom-

alies were pregnancies in which maternal attachment had

begun,

28

even as women may have hoped to avoid such

attachment.

Many of the women choosing or urged to

undergo prenatal diagnosis were older and, as some authors

speculate, the pregnancy may have been seen to be one of a

declining number of opportunities to have a child.

As well,

unlike a miscarriage, a genetic termination occurs because

the woman chooses or consents to it. According to Kolker

and Burke, “genetic abortions are especially poignant

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because the parents take an active part in the baby’s

death.”

Blumberg and colleagues speculate that “Perhaps

the role of decision making and the responsibility associated

with selective abortion explains [sic] the more serious

depression following [the abortion].”

Whatever the reason,

as Boss observes, “Prospective parents are rarely

prepared...for the extent of the psychological trauma experi-

enced after a selective [genetic] abortion.”

According to

Brown, after having a genetic abortion, “It took several

weeks to recover physically; emotional scars are raw two

years later.”

34

Grief, Guilt, Depression

The extent and intensity of grief can be a surprise to many

couples.

Iles and Gath found that nearly one half of the

women in their study had symptoms of grief six months after

the abortion and almost one third continued to grieve

thirteen months after the termination.

Seller and colleagues

discovered that “the loss of a fetus can cause intense grief

reactions, often commensurate with those experienced over

the loss of a spouse, parent, or a child.”

Zeanah and

colleagues found that neither the method of termination nor

the type of anomaly seems to have affected the intensity of

grief, and Kolker and Burke found that women grieved

abortions following both CVS and amniocentesis.

White-Van

Mourik and colleagues observed that, with abortions follow-

ing ultrasound and maternal serum alpha fetoprotein testing,

there was “more confusion, numbness and subsequently

more prolonged grief reactions....” They suggest that, with

these “relatively non-invasive procedures...less thought is

usually given by the women to preparation for an abnormal

finding.”

Following genetic termination of pregnancy, women endure

the normal but difficult symptoms of grief, such as psychoso-

matic disturbances, guilt and anger, as well as the symptoms

characteristic of an abruptly ended pregnancy in which the

fetus dies – distress upon seeing pregnant women or new-

born babies, continuing to feel pregnant, and experiencing

more pronounced stress around the due date and anniver-

saries.

Recovery can take a very long time

and, because of

the nature of genetic abortions, the grief may be accompa-

nied or complicated by other factors.

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Guilt and shame are often experienced after a genetic abor-

tion. In one study, this was the case for one-third of sub-

jects.

42

In another, researchers found that, more than a year

after the abortion, 31 per cent of the women who had termi-

nated their pregnancies for fetal indications continued to feel

guilt and anger.

Following a genetic abortion, the guilt and shame may be

two-pronged. On the one hand there is a sense of failure

elicited by the fact of the fetal anomaly. Parents may feel

that they are to blame for their child’s imperfection.

Sixty-

one per cent of woman and thirty-two percent of men felt

this way in one study.

In another study, 43 per cent of the

women suffered from this sense of guilt.

On the other hand, there is the guilt generated by having

made the decision to terminate the pregnancy.

In one

study, “forty per cent of the women and nine per cent of the

men” felt this way.

One researcher found that many women

are reluctant to admit that they have had a genetic abortion

and will tell relatives and friends that they had suffered a

miscarriage instead.

A very common form of psychological disturbance following

a genetic abortion is depression.

Taking into account some

study subjects’ strong denial of feelings, Blumberg and

colleagues speculate that “the actual incidence of depression

following selective abortion may be as high as 92 per cent

among women and as high as 82 per cent among the men

studied.”

In another study, researchers found that, six

months after the abortion, almost half of the study subjects

suffered from depression and anxiety and that ten of 48

women were receiving psychiatric treatment.

The

researchers concluded that it was not the case that women

were simply relieved not to be giving birth to or raising a

child with an anomaly.

According to Donnai and col-

leagues, “women undergoing termination of a planned or

wanted pregnancy after prenatal diagnosis constitute a high

risk group, vulnerable to depression and social disruption.”

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Grief, Whether Pregnancy Had Been Planned or Unplanned

The assumption of many researchers is that genetic abortions

are the terminations of planned or “wanted” pregnancies.

this respect, researchers contend that genetic abortions differ

from elective terminations of pregnancy.

Further, the

assumption of many researchers is that the grief and depres-

sion that often follow genetic abortions occur precisely

because the pregnancy was planned and “wanted”.

In many

cases, maternal attachment may even have begun.

Thus

researchers have compared genetic abortions to miscarriages

and stillbirths insofar as they evoke grief and depression

arising from the loss of an anticipated and hoped-for baby.

The sequelae following genetic terminations of pregnancy

may not be so easily explained, however. Research indicates,

first, that not every pregnancy terminated because of fetal

indications is a “wanted” or planned pregnancy. In the study

by Iles and Gath, 23 per cent of pregnancies aborted for

genetic reasons were unplanned as were 27 per cent of the

pregnancies in the White-Van Mourik study. As well, two per

cent of women remained “ambiguous” about their pregnan-

cies in the latter study.

Second, and more importantly, research indicates that grief

and depression are not confined to the termination of

planned and “wanted” pregnancies.

The “ambiguous” sub-

jects of the White-Van Mourik study “felt very guilty about

the intervention two years after the event.”

Reardon’s study

shows a clear link between depression and the abortion of

“unintended” pregnancies.

Similarly, work by Brown links

grieving and elective abortions, not normally considered to

be terminations of “wanted” pregnancies.

While grief and depression often follow genetic terminations

of pregnancy, it is a mistake to attribute this reaction solely

and simply to the “wantedness” of the pregnancy.

Living Children

The decision to abort for genetic reasons can have a nega-

tive impact on living children. Although it is not often con-

sidered a factor in the initial decision-making process, the

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abortion of a sibling can have emotional consequences for

children in a family. Children are affected by the anxiety of

parents over the abortion and react to the absence of the

baby (whose presence they will have been aware of from

the third or fourth month of pregnancy).

Furlong and Black studied the impact of genetic abortion on

families and found that even very young children react to

their parents’ distress and may have difficulty understanding

and coping with the outcome. They show that young child-

ren are unable to deal with the complexity of the decision.

In the presence of prenatal life, young children do not sepa-

rate the concept of “fetus” from the concept of “baby”. The

conceptual difference between the two is a medical and

social construct of adults and is not easily understood by

children whose approach to the world is concrete.

The couples who participated in the Furlong and Black

research adopted one of three approaches in explaining the

abortion to their children. The first was a partial explanation

that avoided discussing the role of their own choice. The

children who received such an explanation expressed sad-

ness, disappointment, and guilt and one child wrote an essay

on the event as the worst thing that had ever happened to

him. Parents of very young children chose to give no expla-

nation and yet observed behavioral changes such as motor

regression in their children. Those parents who chose the

third option – to give a complete explanation – did not find

that it solved the problem. Rather, they reported marked and

disturbing reactions. Garton reports that “Abortion can pro-

duce a deep, subtle (and often permanent) fracture of the

trusting relationship that once existed between a child and

parent.”

Looking at this problem from a psychodynamic

perspective, Ney and Peeters have identified a number of

“post-abortion survivor syndromes”. They conclude that:

“There are terrible conflicts that arise from these situations,

and these have an impact on the individual and society.”

67

Public Opinion versus Medical Opinion

At present, in the general population, there appears to be a

gap between acceptance of testing for disorders and accep-

tance of abortion of the affected fetus. When a similar group

of Canadian adolescents was presented with already com-

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pleted prenatal test results, the researchers Curtis and

Standing found that “females are consistently more opposed

to abortion than are males and both sexes show a consider-

able opposition to abortion in absolute terms”.

But Drake,

Reid and Marteau note that “Health professionals hold more

positive attitudes towards termination of pregnancy for a

fetal abnormality than do lay groups.”

Under the present

circumstances, this could lead to “stimulating a demand for

services” rather than responding to a perceived need.

Prenatal diagnosis, already accepted as part of obstetrical

care, is expanding to include many conditions, disorders,

and personality traits. With these new opportunities for

aborting affected pregnancies come issues about informed

consent and possible social coercion to abort.

As noted, health professionals are more in favor of abortion

for genetic reasons than the general public. If women

choose to abort as a result of medical pressure then the

decision will be conflicted and a violation of their personal

autonomy. Indeed, Feitshans raises issues of autonomy and

informed consent and also asks: “Does genetic testing of a

foetus empower women or pose an unanticipated threat to

autonomy? To address these issues there is a need to articu-

late a feminist perspective on genetic testing and possibly to

legislate protection for women’s rights during prenatal

care.”

Furthermore there is a negative presumption in the

medical milieu regarding children with these conditions.

There is an imbalance of information, with little provided

that is favorable to children with special needs.

Informed Consent

Generally speaking, practitioners must have the patient’s

consent before undertaking any treatment. To make an

informed choice, the patient must have the pertinent infor-

mation, including the benefits and risks of the treatment,

explained in a way that can be understood by her; she must

be deemed competent to make this particular decision; and

the choice must be voluntary. Given current practices, there

is some question as to whether the criteria for informed

choice are met when women choose genetic abortions.

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a) Information:

As Kolker and Burke note, “To make a truly informed deci-

sion, clients need to be aware not only of the risk of miscar-

riage entailed in the two procedures [CVS and amniocentesis]

but also of the consequences of the abortion experience. Yet

counselors rarely discuss this prior to the test and the diag-

nosis.”

71

While genetic counselors may simply assume that

clients come to the initial sessions with ready knowledge,

Kolker and Burke point out that ignorance may in fact

underlie clients’ tendency to ask few questions about genetic

terminations of pregnancy. Because clients do not make a

ready link between prenatal diagnosis and abortion, because

they have little or no knowledge of the procedures or of the

aftermath, they do not know what they should be asking.

This ignorance is an obstacle to informed choice.

As Brown

points out, learning that there is a fetal anomaly is not the

only information that is needed. “We had only one isolated

piece of information, not a whole crystal ball. How were we

to know what would be best?”

Additionally, there appears

to be little or no positive information given about the choice

of parenting a child with a given condition.

b) Competence:

A further obstacle to informed choice is the state in which

parents find themselves upon learning of the fetal anomaly.

Most are in shock initially and, as Brown writes, “a person

reeling from shock, numbed by a sudden catastrophe,

cannot think.”

Nevertheless, patients are urged to make

the decision quickly, often before they have completely

recovered from the shock. In a study undertaken by White-

Van Mourik, 21 per cent of the study participants agreed to

an abortion even as they had uncertainty about the decision

because they were experiencing numbness and shock. In

their cases, “the decision was made about an event which

felt unreal.”

75

c) Voluntariness:

Genetic abortions involve two separate but related choices:

prenatal testing and abortion. A study presented at the

American Society of Human Genetics in 1997 found that

36

per cent of obstetricians did not mention to their patients that

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prenatal testing is voluntary

. The National Institutes for

Health (NIH) note: “Care should be taken to ensure that the

decision to have testing is completely voluntary.”

Despite current emphasis on the principle of respect for

patient autonomy and the practice of informed consent,

studies suggest that, for many women, there was not always

a sense of having had a choice in the matter. Jones and

colleagues found that, for 93 per cent of the women studied,

the genetic termination of pregnancy was something that

simply had to be done.

The pressure to abort can be

subtle. Even as genetic counselors consciously attempt to be

non-directive in their sessions, many nevertheless believe in

the efficacy of genetic terminations of pregnancy.

overtly, some physicians will insist that their patients agree

not to continue the pregnancy in which a fetal defect has

been found before undertaking the amniocentesis.

Coercion is not only an obstacle to informed choice but is a

contributing factor in post-abortion distress. (See also

Chapters 11 and 15.)

Conclusion

Prenatal testing is expanding rapidly, as ever more genetic

markers are discovered and women are urged to undergo

these tests. It seems that there can be enormous pressures

applied to mothers to go through with terminations if an

anomaly is found.

Couples are not prepared for the

depression and guilt that frequently ensue. Nor are they

usually informed about the help that is available for raising

children with special needs. For an informed choice to be

truly available pregnant women and their partners need to

be told about the possible impact of abortion on them and

their other children, and they also need to have information

about the care of children with special needs.

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Women’s Health after Abortion: The Medical and Psychological Evidence

168

Key Points Chapter 12

• Prenatal diagnosis is increasingly seen as a routine part

of prenatal care, yet in the minds of pregnant women and

their partners it is rarely linked explicitly to abortion.

• The growing amount of available genetic information

about individual fetuses over the past decade has increased

the likelihood that a woman will opt for abortion, perhaps at

a late stage in her pregnancy.

• When testing reveals a fetal anomaly the pregnant

woman and her partner are usually urged to make the

decision to terminate quickly.

• Terminating a pregnancy because of a major fetal

malformation is often a shattering experience for women.

The grief, guilt, and depression experienced after a genetic

abortion can come as a complete surprise to many couples.

• These negative experiences occur whether the pregnancy

has been planned or unplanned.

• The decision to abort for genetic reasons can also have a

negative impact on living children.

• Positive information needs to be given about the choice

of parenting a child with special needs resulting from physi-

cal or mental handicaps.

Chapter 12 07/02/02 19:48 Page 14

Notes

1 Elder SH, Laurence KM. The impact of supportive intervention after

second trimester termination of pregnancy for fetal abnormality. Prenatal

Diagnosis 1991;11:47-54, p. 47.

2 Rayburn WF, Barr M Jr. The malformed fetus: Diagnosis and pregnancy

management. Obstetrics and Gynecology Annual 1985;14:112-126, p. 116.

3 Boss JA. First trimester prenatal diagnosis: Earlier is not necessarily bet-

ter. Journal of Medical Ethics 1994;20:146-151, p. 146.

4 Boss 1994. See n. 3, p. 146.

5 Boss 1994. See n. 3, p. 147.

6 Green JM. Obstetricians’ views on prenatal diagnosis and termination

of pregnancy: 1980 compared with 1993. British Journal of Obstetrics and

Gynaecology 1995 March;102(3):228-232, p. 231.

Mander R. Loss and Bereavement in Childbearing. Oxford: Blackwell

Scientific Publications, 1994, p. 44.

7 Mander 1994. See n. 6, pp. 44-45.

8 Rothman Barbara Katz.

The Tentative Pregnancy: How Amniocentesis

Changes the Experience of Motherhood

. Revised. New York: W.W. Norton

and Company, 1993, pp. 36-47.

Kolker A, Burke BM. Grieving the wanted child: Ramifications of abortion

after prenatal diagnosis of abnormality. Health Care for Women

International 1993 November-December;14(6):513-26, p. 515.

9 Jones OW, Penn NE, Shuchter S, Stafford CA, Richards T, Kernahan C,

Gutierrez J, Cherkin P. Parental response to mid-trimester therapeutic abor-

tion following amniocentesis. Prenatal Diagnosis 1984;4:249-256, p. 250.

10 Rayburn WF, Laferla JJ. Mid-gestational abortion for medical or genetic

indications. Clinics in Obstetrics and Gynaecology 1986;13:71-82, p. 72.

Rothman 1994. See n. 8, pp. 192-3.

Blumberg BD, Golbus MS, Hanson KH. The psychological sequelae of

abortion performed for a genetic indication. American Journal of

Obstetrics and Gynecology 1975;122:799-808, p. 806.

169

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Chapter 12 07/02/02 19:48 Page 15

11 Green 1995. See n. 6, p. 232

Hunfeld JAM, Wladimiroff JW, Passchier J, Venema-Van Uden MU, Frets,

PG, Verhage F. Emotional reactions in women in late pregnancy (24 weeks

or longer) following the ultrasound diagnosis of a severe or lethal fetal

malformation. Prenatal Diagnosis 1993;13:603-612, p. 603.

12 Donnai P, Charles N, Harris R. Attitudes of patients after “genetic” ter-

mination of pregnancy. British Medical Journal 1981;282:621-622, p. 622.

13 Rayburn and Laferla 1986. See n. 10, p. 71.

Kolker and Burke 1993. See n. 8, p. 515.

14 Rayburn and Laferla 1986. See n. 10, p. 73.

Rothman 1993. See n. 8, p. 195.

15 Rayburn and Laferla 1986. See n. 10, p. 78.

16 Lorenzen J, Holzgreve W. Helping parents to grieve after second

trimester termination of pregnancy for fetopathic reasons. Fetal Diagnosis

and Therapy 1995 May-June;10(3):147-56, p. 149.

17 Rayburn and Laferla 1986. See n. 10, p. 81.

Rayburn and Barr 1985. See n. 2, p. 119.

Rothman 1993. See n. 8, p. 195.

18 Rayburn and Barr 1985. See n. 2, p. 119.

19 Jones et al. 1984. See n. 9, p. 253.

Rothman 1993. See n. 8, pp. 194-200.

Kolker and Burke 1993. See n. 8, pp. 516-7.

20 Kolker and Burke 1993. See n. 8, pp. 516-7.

21 Jones et al. 1984. See n. 9, p. 253.

22 Boss 1994. See n. 3, p. 147.

Kolker and Burke 1993. See n. 8, p. 516.

23 White-Van Mourik MCA, Connor JM, Ferguson-Smith MA. The psycho-

logical sequelae of a second trimester termination of pregnancy for fetal

abnormality over a two year period. Birth Defects: Original Articles Series

1992;28:61-74, p. 71.

Zeanah CH., Dailey JV, Rosenblatt MJ, Saller, DN Jr. Do women grieve

after terminating pregnancies because of fetal abnormalities? A controlled

investigation. Obstetrics & Gynecology 1993;82:270-275, p. 275.

Women’s Health after Abortion: The Medical and Psychological Evidence

170

Chapter 12 07/02/02 19:48 Page 16

24 Rayburn and Laferla 1986. See n. 10, p.80.

Blumberg et. al. 1975. See descriptions, n. 10, pp. 803-805.

25 Kolker and Burke 1993. See n. 9, p. 519, p. 520, p. 524.

Rothman 1993. See n. 8, p. 261.

Black RB. A 1 and 6 month follow-up of prenatal diagnosis patients who

lost pregnancies. Prenatal Diagnosis 1989;9:795-804, p. 801.

26 Seller M, Barnes C, Ross S, Barby T, Cowmeadow P. Grief and mid-

trimester fetal loss. Prenatal Diagnosis 1993;13:341-348, p. 344.

27 Boss 1994. See n. 3, p. 147.

28 Lorenzen and Holzgreve 1995. See n. 16, p. 154.

Kolker and Burke 1993. See n. 8, p. 519.

Seller et al. 1993. See n. 26, p. 347.

29 Lorenzen and Holzgreve 1995. See n. 16, p. 154.

30 Kolker and Burke 1993. See n. 8, p. 524.

Iles S, Gath D. Psychiatric outcome of termination of pregnancy for foetal

abnormality. Psychological Medicine 1993 May;232:407-13, p. 407.

31 Kolker and Burke 1993. See n. 8, p. 524.

32 Blumberg et al. 1975. See n. 10, p. 805.

33 Boss 1994. See n. 3, p. 147.

34 “Brown, Judy.” (pseudonym) The choice. Journal of the American

Medical Association 1989;262:2735.

35 Kolker and Burke 1993. See n. 8, p. 522.

36 Iles and Gath 1993. See n. 30, p. 411.

37 Seller et al. 1993. See n. 26, p. 346.

Mander 1994. See n. 6, p. 47.

38 Zeanah 1993. See n. 23, pp. 273-4;

Kolker and Burke 1993. See 8, p. 523.

39 White-Van Mourik 1992. See n. 23, p. 72.

40 Iles and Gath 1993. See n. 30, see Table 3, p. 410.

Seller et al. 1993. See n. 26, p. 343.

Abortion after Prenatal Testing

171

Chapter 12 07/02/02 19:48 Page 17

41 Kolker and Burke 1993. See n. 8, p. 522.

White-Van Mourik 1992. See n. 23, p. 72.

42 Jones et al. 1984. See n. 9, p. 254.

43 Iles and Gath 1993. See n. 30, p. 411.

44 Blumberg et al. 1975. See n. 10, p. 806.

Kolker and Burke 1993. See n. 8, p. 520.

45 White-Van Mourik 1992. See n. 23, pp. 69-70.

46 Jones et al. 1984. See n. 9, p. 254.

47 Mander 1994. See n. 6, p. 46.

Seller et al. 1993. See n. 26, p. 343.

48 White-Van Mourik 1992. See n. 23, p. 70.

49 Seller et al. 1993. See n. 26, p. 343.

50 Donnai et al. 1981. See n. 12, p. 622.

Blumberg et al. 1975. See n. 10, p. 805.

51 Blumberg et al. 1975. See n. 10, p. 805.

52 Lloyd J, Laurence KM. Sequelae and support after termination of

pregnancy for fetal malformation. British Medical Journal 1985;290:907-909,

p. 908.

53 Iles and Gath 1993. See n. 30, p. 412.

Mander 1994. See n. 6, p. 44.

54 Donnai et al.1981. See n. 12, p. 622.

55 Elder and Laurence 1991. See n. 1, p. 47.

White-Van Mourik 1992. See n. 23, p. 69.

Donnai et al. 1981. See n. 12, p. 622.

56 Rayburn and Laferla 1986. See n. 10, p. 72.

Kolker and Burke 1993. See n. 8, p. 524.

57 Rayburn and Laferla 1986. See n. 10, p. 72.

Blumberg 1975. See n. 10, p. 805.

Kolker and Burke 1993. See n. 8, p. 520.

58 Lorenzen and Holzgreve 1995. See n. 16, p. 154.

Kolker and Burke 1993. See n. 8, p. 519.

Seller et al. 1993. See n. 26, p. 347.

Women’s Health after Abortion: The Medical and Psychological Evidence

172

Chapter 12 07/02/02 19:48 Page 18

59 Zeanah 1993. See n. 23, p. 274.

Kolker and Burke 1993. See n. 8, p. 524.

Iles and Gath 1993. See n. 30, p. 412.

60 Iles and Gath 1993. See n. 30, p. 409.

White-Van Mourik 1992. See n. 23, p. 63.

61 Neugebauer R, Kline J, Shrout P, et al. Major depressive disorder in

the 6 months after miscarriage. Journal of the American Medical

Association 1997 February; 277(5):383-8, p. 387.

62 White-Van Mourik 1992. See n. 23, p. 63.

63 Reardon DC, Cougle JR. Depression and unintended pregnancy in the

National Longitudinal Survey of Youth: a cohort study. British Medical

Journal 2002 January 19; 324:151-152.

64 Brown D, Elkins TE, Larson DB. Prolonged grieving after abortion: A

descriptive study. The Journal of Clinical Ethics 1993 (4):118-123.

65 Furlong RM, Black RB. Pregnancy termination for genetic indications:

the impact on families. Social Work in Health Care 1984, Fall;10(1):17-34.

66 Garton J. The cultural impact of abortion and its implications for a

future society. In: Mannion M, editor.

Post-Abortion Aftermath

. Kansas City:

Sheed and Ward, 1994: 88-99; p. 91.

67 Ney P, Peeters A.

Hope Alive: Post Abortion and Abuse Treatment. A

Training Manual for Therapists.

Victoria, B.C.: Pioneer Publishing, 1993;

pp. 29-33.

68 Curtis M, Standing L. The decision to abort: No sex-role bias, and little

enthusiasm. Social Behavior & Personality. 1992;20(4):237-242, p. 239.

69 Drake H, Reid M, Marteau T. Attitudes towards termination for fetal

abnormality: comparisons in three European countries. Clinical Genetics

1996 March;49(3):134-40, p. 139.

70 Feitshans IL. Legislating to preserve women's autonomy during preg-

nancy. Medical Law (South Africa) 1995;14(5-6):397-412, p. 397.

71 Kolker and Burke 1993. See n. 8, p. 515.

72 Kolker and Burke 1993. See n. 8, p. 516.

Blumberg et al.1975. See n.10, p. 808.

73 “Brown” 1989. See n. 24, p. 2735.

Abortion after Prenatal Testing

173

Chapter 12 07/02/02 19:48 Page 19

174

74 “Brown” 1989. See n. 24, p. 2735.

75 White-Van Mourik, 1992. See n. 23, p 64.

76 Genetic testing for cystic fibrosis. National Institutes of Health

Consensus Development Conference Statement on Genetic Testing for

Cystic Fibrosis. Archives of Internal Medicine 1999 July 26;159(14):1529-39,

p. 1534.

77 Jones et al. 1984. See n. 9, p. 253.

78 Rothman 1994. See n. 8, pp. 46-7.

79 Green 1995. See n. 6, p. 228.

Mander 1994. See n. 6, p. 44.

80 Mander 1994. See n. 6, p. 45.

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