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Running Head: An examination

AN EXAMINATION OF INTIMATE PARTNER VIOLENCE AND PSYCHOLOGICAL

STRESSORS IN ADULT ABORTION PATIENTS

Gretchen E. Ely, Ph.D.

Assistant Professor

University of Kentucky

College of Social Work

639 Patterson Office Tower

Lexington, KY 40506

859-257-5740

gretchen.ely@uky.edu

Melanie D. Otis, Ph.D.

Associate Professor

University of Kentucky

College of Social Work

651 Patterson Office Tower

Lexington, KY 40506

859-257-1574

melanie.otis@uky.edu

Citation: Ely, G. E., & Otis, M. D. (2012). An examination of intimate partner violence

and psychological stressors in adult abortion patients. Journal of Interpersonal Violence, 26(16),

3248-3266.

An examination, p. 2 of 27

ABSTRACT

The purpose of this paper is to describe an exploratory study examining the relationship between

intimate partner violence and psychological stressors in a sample of 188 adult abortion patients.

Results indicate the almost 15% of respondents report a history of abuse by the co-conceiving

partner. In addition, women who reported having had one or more past abortions were more

likely to also report that the person involved in the current pregnancy had also emotionally

abused them. Women reporting one type of partner abuse were significantly more likely to also

report other types of abuse. Women reporting abuse were less likely to report informing their co-

conceiving partner of their appointment at the clinic, were less likely to report that their partner

contributed financially to the abortion cost, and more likely to report partner refusal to wear a

condom. Women who reported emotional abuse were more likely to score higher on all but one

of the psychological stressor scales. The implications of these findings are discussed.

KEYWORDS: PARTNER VIOLENCE; ABORTION PATIENTS; MULTIPLE ABORTIONS;

PSYCHOLOGICAL STRESSORS

An examination, p. 3 of 27

AN EXAMINATION OF INTIMATE PARTNER VIOLENCE AND PSYCHOLOGICAL

STRESSORS IN ADULT ABORTION PATIENTS

Intimate partner violence is prevalent in the relationships of men and women of all ages,

races, and socioeconomic groups. A body of research is emerging that focuses on exploring

intimate partner violence during pregnancy. This research suggests that women may often

experience their first incidences of partner violence during pregnancy (Sagrestano, Carroll,

Rodriguez, & Nuwayhid, 2004), and that pregnancy can be a time of increased risk of partner

violence for many women (Jasinski, 2004).

As complex and challenging as an examination of the intersection between partner violence

and pregnancy may be, even greater impediments are encountered when the focus is on the lives

of women who seek to terminate their pregnancies. Social stigma associated with both partner

violence and abortion makes research in either area difficult to undertake, and thus, collectively

contributes to the dearth of efforts to identify and clarify the relationship between partner

violence, pregnancy termination, and the mental well-being of the women involved.

Abortion is one of the most common surgical procedures performed in the United States

(Kaiser Family Foundation, 2002). Estimates suggest that approximately 35% of women in the

United States will have at least one abortion by the time they reach age 45 (Guttmacher Institute,

2003b; National Abortion Federation, 2009b). Rates of abortion in the United States are higher

than rates of other industrialized nations (Guttmacher Institute, 1999; Kaiser Family Foundation,

2002), which has been argued to be attributable to the United States’ lack of commitment to

comprehensive sex education and access to birth control for all citizens (Santelli, et. al., 2006).

An examination, p. 4 of 27

Myths about the associated life problems and psychological effects of abortion abound in our

culture, yet stringent scientific research suggests that having one abortion is not associated with

long term psychological distress or adverse health effects (Lee, 2003; Major, et. al., 2008). While

terms such as ‘post-abortion syndrome’ and ‘post abortion disorder’ permeate the rhetoric related

to abortion, use of these terms is generally noted as the anti-abortion movement’s framing of the

negative consequences of abortion, rather than any medical or social scientific documentation

that suggests the actual existence of such syndromes (Lee, 2003). In reality, severe psychological

reactions to abortions are rare, and the strongest predictor of post-abortion psychological health

is pre-abortion psychological health (Lee, 2003; National Abortion Federation, 2009a; Russo &

Dabul, 1997; Stotland, 1992). This premise is also supported by the American Psychological

Association (APA), which released an issue brief indicating that a single abortion is not typically

a threat to a woman’s mental health (Major, et. al., 2008). This is not to say that abortion patients

do not experience problems, just that the nature of these problems is unlikely to be specifically

related to a decision to have an abortion.

Despite the large number of women who undergo abortions in the United States each

year, and evidence suggesting that partner violence is associated with pregnancy, much time has

been spent politicizing the issue of abortion. In contrast, less attention has been paid to

researching the potential relationship between partner violence and potential psychological

problems in women who terminate an unwanted pregnancy. Research related to partner violence

and abortion patients is sparse and inconclusive, and little is known about the psychological

factors that may be associated with partner violence in this population (Ely, Nugent & Flaherty,

2009). In the absence of relevant information related to abortion patients, partner violence and

other psychological factors, a best practices approach cannot be developed to meet the needs of

An examination, p. 5 of 27

women seeking abortion. Thus, the current study was designed to address this void by generating

exploratory information in this area, as well as serving as an underpinning for further research

that will contribute to best practices models for this overlooked group of women.

Review of the Literature

Efforts to explore unique aspects of pregnancy-related partner violence suggest that

women may often experience their first incidences of partner violence during pregnancy

(Sagrestano, Carroll, Rodriguez, & Nuwayhid, 2004), and that pregnancy can be a time of

increased risk of abuse for many women (Jasinski, 2004). Extant literature on pregnancy and

partner violence indicates that physical, emotional, and/or sexual abuse may be experienced by

pregnant women of all ages (Jasinski, 2004; Johnson, et. al., 2003; Logan, Cole & Shannon,

2007). Further, intimate partner violence is associated with adverse pregnancy outcomes,

including fetal loss,suicide risk and femicide (Alio, Nana & Salihu, 2009; Garabedian, et. al.,

2008; Garcia-Moreno, 2009; Martin, Macy, Sullivan & Magee, 2007; McFarlane, Campbell,

Sharps & Watson, 2002).

It is not clear whether or not abortion patients experience similar levels of partner

violence and co-occurring psychological stressors that are reported by pregnant women who

carry to term. Clinic concerns regarding confidentiality and patient safety, along with public

attitudes related to abortion, the contentious politics surrounding abortion, patient’s

unwillingness to report abortions, and the sensitive nature of violence studies involving abortion

patients, all may serve to limit scientific inquiry. Results from partner violence studies that

include abortion patients exist but are less common that studies where pregnancies are carried to

term. These findings serve to underscore the need for continued exploration of the relationship

between pregnancy and the prevalence and impact of partner violence and co-occurring factors.

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Estimated rates of partner violence in abortion patients currently range from approximately

14-22 % (Evins & Chescheir, 1996; Lueng, Leung, Chan & Ho, 2002; Weibe & Janssen, 2001;

Woo, Fine & Goetzl, 2005). In a systematic review of the literature, Coker (2007) found that

partner violence was consistently associated with induced abortion. In a population-based sample

of women in New Zealand, those with a history of partner violence were over twice as likely to

report a history of induced abortion, compared to women not reporting a history of partner

violence (Fanslow, Silva, Whitehead & Robinson, 2008). Additionally, partner violence was

found to be the strongest predictor of seeking pregnancy termination in a national cohort study of

Australian women (Taft & Watson, 2007), while various types of partner violence were

associated with pregnancy loss, including induced abortion in a nationally representative sample

of Bangladeshi women (Silverman, et. al., 2007).

In one of the largest U.S. studies of abortion patients (n=818), researchers found that

women who did not disclose a history of abortion to their intimate partner were more likely to

report a tenuous or nonexistent relationship with the father of the pregnancy (Woo, Fine &

Goetzl, 2005). Results from this study further suggested that physical partner violence was twice

as common in those who did not disclose their abortion history to their partner, compared with

those who did disclose their abortion experiences. In a study of gynecology patients, those

seeking abortion reported higher rates of partner violence when compared to patients seeking

general services (Leung, Leung, Chan & Ho, 2002). However, results from a more recent study

of gynecology patients indicate that women who reported a history of abortion did not report

higher rates of partner violence, but instead reported rates similar to those of the general

population (Kazi, Reeves, & Creinin, 2008).

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In one study that examined abusive tactics of violent partners, Coggins and Bullock (2003)

found that women identified forced abortions as one method of control used by their abusers.

Further, the pressure to seek an abortion appeared to be a continuation of ongoing intimate

partner violence and control, as women in the study reported feeling they were allowed very

little control over their reproductive health throughout the relationship. Although the

relationship between partner violence and the decision to terminate a pregnancy was not

specifically examined, in an exploratory study of 294 women accessing services that included

abortion at a family planning clinic in the UK, researchers found that 35% of respondents

reported having experienced partner abuse at some time in their lives (Keeling & Birch, 2004).

Furthermore, it has been suggested that violence against a pregnant partner may be more likely to

occur when men perceive a pregnancy as unplanned (Jasinski, 2001).

While public debate may forward a number of potential explanations for a woman’s

decision to have more than one abortion, in reality, little is known about the motivations of the

women seeking multiple abortions. . Recent study results suggest that abortion patients have high

rates of intimate partner violence, and that violence increases with frequency of abortion (Saftlas

et. al., 2010). Research involving 1221 women who underwent repeat abortions in Canada

suggests that that such women were more likely to report having experienced partner violence

from a male partner compared to those seeking a first abortion (Fisher, et. al., 2005). Other

studies have supported this potential link between intimate partner violence and multiple

abortion decisions, as well (Evins & Chescheir, 1996; Glander, Moore, Michielutte, & Parsons,

1998; Keeling, Birch, & Green, 2004). However, the specific nature of the relationship between

intimate partner violence and multiple abortions remains unclear.

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Clearly, the need for seeking abortion services arises in light of unwanted pregnancy.

This is an important factor when considering issues of partner violence in abortion patients, as

partner violence is associated with unintended pregnancy in extant literature. In particular, rape

and sexual assault within a violent relationship is reportedly common (Campbell, 2002), and rape

was found to result in a pregnancy in 20% of respondents (Logan, Cole & Shannon, 2007;

McFarlane, et. al., 2005). Others have found that 41% of the rape-related pregnancies identified

in their study occurred after repetitive assaults (Holmes, Resnick, Kilpatrick, & Best, 1996).

While Holmes and colleagues (1996) did not examine the relationship between multiple assaults

and rape-related pregnancy, approximately 47% of the perpetrators were identified as either

spouses or boyfriends, suggesting the ongoing presence of partner violence in a portion of the

cases included in the study.

Psychological stressors have also been found to co-occur with partner violence in both

abortion patients and pregnant women who carry to term. In one longitudinal study, results

suggest that young women who reported a previous abortion also reported elevated rates of

mental health problems, including suicidal behaviors, depression and anxiety (Fergusson,

Horwood & Ritter, 2005). Results from another analysis of this longitudinal data indicate that

women who had prior abortions had a 30% greater chance of having a current mental health

disorder (Fergusson, Horwood & Boden, 2008). In one of the few studies that examined

psychological stressors both pre- and post-abortion, Faure and Loxton (2003) indicate that high

levels of anxiety and moderate levels of depression were reported pre-abortion in their sample,

yet generally decreased within a 3 week period post-abortion, however, partner violence was not

specifically examined. Results from a another descriptive study of young abortion patients

indicate that 30% or more of respondents reported levels of depression, self-esteem problems,

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stress and problems with family that surpassed the clinical instrument cutoff score indicating

levels of clinical concern, while over 50% reported problems with school at levels of clinical

concern (Ely & Dulmus, 2008). At the same time, fewer than 20% of respondents reported

problems with other psychosocial stressors such as problems with mother, problems with

friendship and suicide risk. Further, partner violence was associated with depression, problems

with self-esteem, personal stress, guilt, confused thinking and disturbing thoughts, and it was

found that as levels of partner violence increased, so did the severity of the associated

psychological stressors in a sample of adolescent abortion patients (Ely, Nugent & Flaherty,

2009).

Additionally, in a comprehensive review of the literature, Charles and colleagues (2008)

found that studies with the most flawed methodologies were more likely to suggest an

association between abortion and mental health sequelae, while the most methodologically

rigorous studies were more likely to suggest neutral results, finding few if any associations

between abortion and mental health issues. Those authors indicate that, despite unclear outcomes

on the issue, the adverse mental health effects of abortion tend to be promoted to influence

public policy. Thus, additional research in this area is needed.

A body of evidence is beginning to suggest that the collective findings related to intimate

partner violence and co-occurring psychological stressors in relation to unintended pregnancy

need further exploration. Many areas have not been explored in depth and results are sometimes

inconsistent, and can be controversial. Against this backdrop, the current study contributes to the

understanding of adult abortion patients in various ways. First, the study identifies the prevalence

of intimate partner violence among a convenience sample of adult abortion patients.

Subsequently, this study expands on past research by considering incidences of partner violence

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associated specifically with the father of the pregnancy being terminated. This relationship is

explored further by examining the association between reports of abuse and abortion-related and

birth control-related decision-making, an area that has not been thoroughly addressed in the

literature. Further, this study examines the relationship between specific psychological stressors

and experiences of intimate partner violence in this sample of adult abortion patients. Finally,

the study addresses the research question of whether women who indicate having had multiple

abortions are more likely to also indicate that they have experienced intimate partner violence.

Methods

Data Collection and Sample

This study was funded by a grant from the University of Kentucky Center for the

Research on Violence Against Women. Approval for the project was given by the institutional

review board (IRB) at the researchers’ home institution. Study data was collected through self-

report surveys administered to women seeking abortion services at a clinic in an urban

Southeastern city. Between January 2006 and April 2006 clinic personnel offered each patient 18

and over an opportunity to participate in the study. Participants consisted of a convenience

sample of 188 women (18 – 46 years of age) who sought termination services from the clinic. To

protect the anonymity of the participants, written consent was not obtained. Thus, the return of a

completed questionnaire was interpreted as consent to participation. Approximately 84% of

eligible patients participated in the study. In a cover letter accompanying the instrument, women

were provided with informed consent information which explained that their participation was

strictly voluntary and in no way tied to their clinic services, their identity would be unknown to

the researchers, and their responses would be unknown to the clinic staff. Women had the option

of declining the research packet, accepting the packet and choosing not to complete the survey,

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or accepting the packet and completing some or all of the survey. Regardless of their decision

about whether or not to complete the survey, women were asked to seal the survey in an

envelope provided in their research packet and place it in a locked box located in a discrete area

of the clinic. Each woman who accepted a packet for examination also received a $5 gift card for

a local retailer. The gift card was hers to keep regardless of her participation in the study. One

hundred eighty-eight patients participated in the study

Measures

The Brief Adult Assessment Scale (BAAS) was used to measure 13 domains of personal

and social functioning, conceptualized as psychological stressors. The instrument was selected

based on its previously-established high levels of reliability and validity, ease of administration

and time required for administration (Hudson, Mathiesen & Lewis, 2000; Hudson & McMurtry,

1997). In their examination of the psychometrics of the BAAS and its individual subscales,

Hudson and colleagues (2000) reported strong Cronbach’s alphas ranging from a low of .87

(aggression and self-esteem subscales) to a high of .97 (personal stress). The self-administered

instrument utilizes a Likert-scale response format to assess psychosocial problems related to

depression, self-esteem, personal stress, aggressive behavior, problems with friends, problems

with family, thoughts of suicide, alcohol abuse, drug abuse, partner relationship problems, sexual

discord, non-physical and physical abuse. For each item the respondent indicates how often in

the last 30 days they have had the identified feeling or experience. Response options range from

None of the time (1) to All of the time (7). Additionally, respondents may indicate that the item

does not apply to them. Each respondent’s subscale score is computed by summing responses to

the appropriate items and subtracting the number of items for that subscale. Clinical cutting score

for most scales is 30, with higher scores suggesting the presence of a more serious problem. Five

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subscales have lower clinical cutting scores due to the potential for more serious and potentially

life-threatening problems associated with these areas.

Results

Statistical Analysis

All analyses were completed using the Statistical Package for the Social Sciences (SPSS)

software program, version 16.1. Due to the overlap between reports of emotional abuse and

either physical or sexual abuse by the male responsible for this pregnancy, we combined the

three types of abuse into a single measure of intimate partner violence. An analysis of the

characteristics of the BAAS subscales was completed, including an examination of bivariate

correlations among the subscales. Descriptive statistics were completed for all study variables. A

series of chi-square analyses examined the relationship between experiences of emotional abuse

by partner and other forms of abuse, past abortion experience, and a number of factors associated

with their decision to seek an abortion. T-tests were conducted to examine the relationship

between emotional abuse by the father of the pregnancy and the outcome variable and each of

the domains of personal and social functioning captured in the Brief Adult Assessment Scale.

Finally, a series of one-way analysis of variance (ANOVA) were conducted to examine the

association between multiple abortions and measures included in the BAAS.

Characteristics of BAAS Subscales

Table 1 provides Cronbach’s alphas, descriptive statistics and clinical cutting score

information for the subscales for the current study. In the last column of Table 1, the percentage

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of study participants with BAAS subscale scores above the clinically significant cut score is

provided. The largest percentage reported is for personal stress with a little over 70% of the

sample exceeding the clinical cut score of 30, and 9 respondents exceeding the serious clinical

cut point of 70 points. Additionally, over one-third of all respondents exceeded the cut score for

depression (40.2%), self-esteem (33.8%), partner relationship problems (41.9%), and sexual

discord (32.5%).

Zero-order Correlations

To further verify the functioning of the measures captured in the BAAS, bivariate

correlations among all of the BAAS scales were examined. All relationships were in the

expected direction and the majority of the Pearson’s correlations were significant at the .001

level. Of particular interest for the current study were the correlations between relationship-

specific scales (partner problems and sexual discord) and the other psychological and behavioral

factors captured by the BAAS. As Table 2 notes, these relations were in the weak to moderately

strong range, with the strongest relationships being between depression and self-esteem (r = .763,

p < .001). Only the bivariate correlation between partner problems and drug use problems proved

to be non-significant (r = .103, p = .309). Characteristics of Sample

The sample consisted of 188 women who received services at the clinic. The average

participant was approximately 25 years of age (SD = 6 years). The majority of participants

(86.9%) have less than a college education (some college courses, but have not completed a

degree), with almost 42% indicating a high school degree or less. Three out of four participants

identified as White (76.5%), 41 (20%) identified as African-American, 2 (1.1%) identified as

Table 1

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Reliability Coefficients and Descriptive Statistics for the 13 Brief Adult Assessment Scale

(BAAS) Subscales for Study Participants

Subscale # of

Items

Mean Standard

Dev.

Min –

Max

Score

Cronbach’s

alpha

% Above

Clinical

Cutting Score

Depression 12 28.34 19.20 0 - 86 .900 40.2

Self-Esteem 12 27.42 12.98 6.7 - 71 .872 33.8

Personal Stress 12 22.66 23.57 0 - 100 .969 70.2

Friend Problems 13 15.2 15.83 0 - 65 .897 17.3

Aggression 10 16.49 15.69 0 - 83 .871 15.6

Family Relations 13 21.76 21.18 0 - 96 .940 28.6

Suicidal Thoughts 11 5.50 15.31 0 - 89 .980 12.5a

Alcohol Abuse 15 14.26 16.16 0 - 80 .939 27.3a

Drug Abuse 10 6.59 15.14 0 - 72 .939 15.0a

Partner Relations 13 30.09 24.91 0 - 98 .939 41.9

Sexual Discord 12 23.45 21.73 0 - 96 .919 32.5

Non-Physical

Abuse

13 10.09 20.04 0 - 100 .960 22.0a

Physical Abuse 12 3.89 14.15 0 - 100 .983 10.9b

a Clinical cutting score = 15 b Clinical cutting score = 5

Hispanic, and 4 indentified as Asian (2.1%). Approximately one-quarter of the participants

indicated that they were either married (n = 23) or living with a partner (n = 23), while 65%

indicated that they were single (n = 132). Although a little over 40% of the women indicated that

they did not have children, nearly 56% indicated that they had one to three children (range = 1 –

7 children). Finally, although the majority of the respondents had not had an abortion previously

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(n = 121, 66.1%), 37 women (20.2%) had one previous abortion, 16 women (8.7%) had two

previous abortions, and 9 women (4.9%) had three or more previous abortions.

Prevalence of Intimate Partner Violence among Clinic Sample

Of the total sample, 29 women (14.2%) indicated having experienced emotional abuse,

13 women (6.4%) indicated having experienced physical abuse, and 8 women (3.9%) indicated

having experienced sexual abuse. Further investigation indicated that many of the women who

said “Yes” to one type of abuse also said “Yes” to another, thus, these figures represent 30

(14.7%) unique respondents. For example, 12 (92%) of women who indicated having

experienced physical abuse also indicated that they had experienced emotional abuse.

Emotional Abuse and Reproductive and Abortion-Related Decisions

As shown in Table 2, a bivariate analysis examining history of previous abortions and

history of abuse by the father of the pregnancy indicated that women who reported having had

one or more past abortions were more likely to also report that the person who got them pregnant

had abused them (χ, p < .05, Cramer’s V = .171). Examination of the impregnating

partners’ knowledge and support of the abortion decision indicated that women who reported

that they were abused were less likely to have told the person that they were at the clinic (χ2 =

4.84, p < .05, Cramer’s V =162) and less likely to have their clinic services paid by the male who

impregnated them (χ p < .001, Cramer’s V = .251). These women were also more likely

to report that they used some type of birth control (χ p < .001, Cramer’s V = .31) and

that their partner refused to wear a condom (χ, p < .001, Cramer’s V = .341).Table 2

Chi-Square Results of Comparisons for Women With and Without a History of Partner

Abuse Involving Father of Pregnancy

Variable Abuse Chi-Square Cramer’s V

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No (n/%) Yes (n/%)

Previous Abortion

No 107 (69.5) 11 (45.8) 5.20* .171

Yes 47 (30.5) 13 (54.2)

Male Knows of Abortion

No 35 (22.2) 11 (42.3) 4.84* .162

Yes 123 (77.8) 15 (57.7)

Male Supports Decision

No 33 (22.1) 8 (34.8) 1.75 .101

Yes 116 (77.9) 15 (65.2)

Male Paid for Abortion

No 59 (37.6) 19 (73.1) 11.49** .251

Yes 98 (62.4) 7 (26.9)

Male Refused Condom Use

No 136 (98.6) 12 (48.0) 21.18** .341

Yes 2 (1.4) 13 (52.0)

Birth Control Use

No 146 (94.2) 17 (68.0) 17.27** .310

Yes 9 (5.8) 8 (32.0)

** p < .05; ** p < .001

Intimate Partner Violence and Psychosocial Well-Being

Women who indicated that the person who got them pregnant was emotionally abusive

scored significantly higher on all but one of the BAAS scales. As can be seen in Table 3, only

the group means comparison for problems with friends failed to reach significance at the .10

level. The strongest relationships centered around partner relationship problems (t = - 8.21, p <

.001) and sexual discord (t = -5.84, p < .001). Additionally, the last column of Table 3 provides

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effect sizes computed using a pooled standard deviation formula as described by Ray and

Shandish (1996). With the exception of the effect for friend problems, all other effects were in

the medium to medium large range.

Women who indicated that the person who got them pregnant was physically abusive to

them reported significantly higher levels of non-physical abuse (t = -5.19, p < .001), personal

stress (t = -3.05, p < .01), partner relationship problems (t = -6.62, p < .001), and sexual discord

(t = -5.66, p < .001).

Finally, women who indicated that the person who got them pregnant was sexually

abusive to them reported significantly higher levels of non-physical abuse (t = -2.79, p < .05),

self-esteem problems (t = -2.55, p < .05), and personal stress (t = -3.84, p < .001).

Abortion Experiences and Psychological Well-Being

To examine the relationship between past abortion experiences and psychological well-

being, the measure of previous abortions was recoded into three categories: no previous abortion

(0); one previous abortion (1); and 2 or more previous abortions (2). Once recoded a series of

one-way analyses examined group differences for depression, self-esteem, perceived stress,

problems with family relations, problems with friends, suicidal ideation, alcohol use problems,

drug abuse problems, sexual discord with partner, and partner problems. Only group differences

on levels of depression (F = 4.11, p < .05) and perceived stress (F = 3.50, p < .05) were found to

Table 3

Independent Samples t Tests Comparing BAAS Scale Mean Differences for Women Reporting

Abuse by Partner and Women Not Reporting Emotional Abuse by Partner

Abuse

Yes No t-value (df) p-value Cohen’s d

Mean (sd) Mean (sd)

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Depression 40.23 (25.53) 26.46 (17.31) -2.044 (24.25)a .022 .47

Perceived Stress 37.50 (29.88) 20.13 (21.07) -2.733 (27.06)a .011 .60

Aggression 21.69 (16.08) 14.30 (14.07) -2.321 (162) .022 .51

Suicide 13.91 (25.38) 3.30 (11.29) -.1.971 (23.55)a .061 .45

Self-Esteem 34.10 (14.28) 26.13 (11.92) -2.944 (166) .004 .65

Friend problems 19.01 (16.56) 13.82 (14.41) -.1.566 (160) .119 .35

Family problems 29.34 (21.56) 20.04 (19.77) -2.101 (163) .037 .46

Alcohol Abuse 24.06 (21.17) 12.08 (14.33) -2.486 (23.62)a .020 .59

Drug use 15.25 (24.47) 4.25 (11.15) -1.889 (20.96)a .073 .49

Partner prob 65.85 (16.95) 25.30 (21.53) -8.210 (145) .000 1.94

Sexual Discord 46.46 (24.53) 19.92 (18.81) -5.839 (150) .000 1.35

a = equality of variance not assumed

be statistically significant. For depression, women who have experienced two or more abortions

had higher levels of depression (mean = 37.8) compared to women who had not had a previous

abortion (mean = 26.4). No differences were found between both groups’ depression level and

the depression level of those women who indicated that they had experienced one previous

abortion (mean = 24.23). For perceived stress, women who had experienced two or more

abortions indicated a significantly higher level of perceived stress (mean = 32.2) than women

who had one previous abortion (mean = 16.9). While the differences were not statistically

significant, women who had never had an abortion previously had a mean stress score that fell

between the scores of the two other groups (mean = 21.37).

In summary, this analysis indicated that compared to women who had not experienced

abuse, women indicating that they had experienced abuse from the male responsible for the

current pregnancy were more likely to indicate that the man did not know they were seeking an

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abortion (42.3% compared to 22.2%), had refused to wear a condom (52% compared to 1.45%),

and that there was some type of birth control use prior to the pregnancy (32% compared to

5.8%). The analyses also indicated that women who experienced multiple abortions were more

likely to indicate that the person responsible for the current pregnancy was abusive. Additionally,

women who had experienced a previous abortion reported higher levels of depression and

perceived stress and were more likely to indicate that they had experienced some type of abuse

(emotional, physical, and/or sexual).

Discussion

The results of the current study add to growing information suggesting that a best practice

approach for patients seeking abortion could include brief mental health and partner violence

assessments. These findings support recent recommendations that screening and counseling in

reproductive health settings could be beneficial for those in coercive relationships (Jordan,

Levensen & Silverman, 2010). Although the use of a non-probability sampling approach

underscores the need for a caution in interpreting these preliminary findings, the current study

suggests that such assessments may be particularly beneficial for women who seek multiple

abortion procedures. This recommendation is also consistent with recommendations for

adolescent abortion patients (Ely, Nugent & Flaherty, 2009) as well as recommendations

suggesting that the receipt of a brief behavioral intervention could discernibly reduce the risk of

further assault in pregnant women who carry to term (Kiely, et. al., 2010). Further, when

assessment is offered as part of the abortion counseling process, providers have the opportunity

to suggest referrals and safety planning with patients experiencing abuse (Glander, Moore,

Micheleutte & Parsons, 1998; Jasinski, 2004; McFarlane, et. al., 2005). In addition, past research

suggests that there are certain characteristics of pregnant women who present in health settings

An examination, p. 20 of 27

that are suggestive of involvement in intimate partner violence (Reichenheim, Patricio, &

Moraes, 2008). If such characteristics can be better identified in abortion patients as well, the

chances for assisting such patients to exit abusive situations can be increased. Introducing rapid

assessment instruments for mental health problems and partner violence into the pre-abortion

counseling protocol, and combining those with comprehensive referrals, as has been

recommended by Reichenheim, Patricio and Moraes (2008), could increase the effectiveness of

the pre-abortion counseling session for women experiencing these problems who may not appear

in another medical setting where help can be accessed. Others have also recommended universal

screening for partner violence by abortion providers (Woo, Fine & Goetzl, 2005). In settings

where referrals, follow-up and support cannot be provided, such as in the developing world, a

best practices approach could include integrating comprehensive services into the family

planning clinic itself.

In addition, consistent with past research, the current study indicates that women who

experience partner violence are less likely to inform their partner of their decision to seek

abortion services (Glander, Moore, Michelutte & Parsons, 1998). Although the current

exploration precludes making any specific assertions concerning a woman’s motivation for

choosing not to share this information with the abusive partner, for service providers the absence

of an involved partner may signal a need for further exploration.

Limitations of Study

While this study does provide some new insights into the relationship between partner

violence and psychological distress among women seeking abortion services, it is not without

limitations. One limitation of the current study is the small sample size. In particular, sample

size constraints precluded any detailed examination of relationships among multiple predictors

An examination, p. 21 of 27

and outcomes of interest. Future research in this area needs to employ larger samples. Another

limitation is the limited generalizability of these results. First, these results are based upon a

non-probability sample obtained in a single city in the southeastern United States. Thus, the

generalizability of the results from this sample to young women in other regions of the U.S.

needs to be demonstrated in future research. Given the sensitive nature of both focal areas of

interest – IPV and pregnancy termination – the utilization of probability sampling strategies is

challenging at best. While probability sampling strategies are a worthy pursuit, more immediate

next steps may include replication of the current study in other clinics around the country, as

well as efforts to conduct longitudinal studies of non-probability samples. Further, since the

study mostly involved Caucasian women seeking to terminate an unwanted pregnancy, the

results cannot be generalized to diverse groups of women. Future research related to partner

violence in abortion patients among young women seeking to terminate an unwanted pregnancy

should include women from diverse groups.

Conclusion

While still small, a body of literature is beginning to develop suggesting the presence of

partner violence and co-occurring mental health issues in abortion patients that could be

detrimental to their future health. While this research does not imply that choosing an abortion is

related to mental health problems, the life circumstances surrounding unwanted pregnancy may

warrant additional service approaches that would better address the psychological needs of

women seeking abortion services without stigmatizing the decision itself. Although more

research with larger sample sizes and more diverse samples is needed, as more evidence is

gathered, a compelling case can already be made that a best practice approach to counseling

women who seek abortion services could beneficially include an assessment for partner violence

An examination, p. 22 of 27

and associated mental health problems, as well as the provision of referrals for services outside

the family planning clinic setting. Many women in the U. S. seek abortion services and this

population of women is overlooked by researchers. The politicization of the abortion debate may

contribute to the lack of research in this area, as researchers may wish to avoid the topic in order

to avoid stigmatization. In the meantime, the women who seek abortion services are

experiencing partner violence and other issues that are not being adequately addressed.

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