In her Perspective on navigating the loss of abortion services, Harris¹ mentions that “the perinatal mental health needs of pregnant patients who are continuing undesired pregnancies, including those resulting from sexual assault, will undoubtedly intensify as well, further stressing an overtaxed mental health care system.” However, it is important to note that these are not the only mental health consequences of undesired pregnancies, as there may also be consequences for the mental health of unwanted or undesired children. These children are not easy to study, as designing studies of this type of children may not be possible for ethical reasons. However, at times, nature or society creates conditions for natural experiments— observational studies that allow researchers to observe individuals under conditions that are not under the control of investigators. Several studies have reported on the mental health consequences for unwanted or unplanned children^2-11 in a natural experiment setting. Unwanted children are those born to mothers who were refused or denied abortion for various reasons; unplanned children are those whose mothers did not plan or intend to have them.

Studies of the negative impact of abortion on the mental health of unwanted children

The first studies of the mental health consequences of abortion or its denial were conducted in the Nordic countries, namely Sweden, where in 1946 the grounds for therapeutic abortion were expanded to include serious consequences for the mother’s mental or physical health. A host of studies focused on various consequences for mothers and fathers. Then, in 1966, Forssman and Thuwe² published the results of a study of 120 children whose mothers were refused legal abortion and compared them to closely matched controls. The investigators obtained data from multiple sources and followed the participants until age 21. The unwanted children “had not had the advantage of a secure family life during childhood” compared to controls and received less education. Furthermore, compared to the control participants, they received more psychiatric care; were more often registered for antisocial and criminal behavior and slightly more often for drunken misconduct; and more often received public assistance. The authors extended their follow-up period to 35 years.³ Though the unwanted children still had more frequent records of social and psychiatric difficulties than the control group, there were no statistical differences demonstrated for any single variable. The authors concluded that the differences leveled out and were most apparent early in life.

A similar study was conducted in Czechoslovakia several years later. In the late 1950s, Czechoslovakia liberalized its abortion rules and allowed termination of pregnancy on medical and other grounds during the first trimester of pregnancy. Pregnancy termination was granted or denied by the District Abortion Commission, and appeals were handled by another commission. As a result of abortion disapprovals by these commissions, a number of unwanted children were born. A group of researchers^4-7 followed 220 unwanted children born between 1961 and 1963 and 220 matched controls for 35 years. This study was more methodologically robust than the one by Forssman and Thuwe.^2,3 Sources of data included “delivery, pediatric clinic and school health records; the child’s case history, drawn from interviews with the mother by an experienced social worker and by a psychiatrist; a highly detailed physical examination of the child at the time of the study conducted by an experienced pediatrician; and a psychological examination of the child by a clinical psychologist.”⁴ Thus, the data included more than 400 different measures. The researchers used controls born to accepted pregnancies and also siblings of unwanted and accepted pregnancies. The evaluations were performed at ages 9,4 14 to 16, 21 to 23, 30, and 35. In the initial 9-year follow-up evaluation,⁴ the unwanted children had a higher incidence of illness and psychiatric hospitalization, slightly poorer school marks and performance despite the same level of intelligence, and somewhat worse integration into their peer group compared to controls. The authors noted that the situation of unwanted children is a complex one and that the unwanted child is born to a potentially handicapped situation.⁴ They also noted that the unwanted children in their study were ultimately kept by their mothers and not given up for adoption, and that their study deals with the group mean data.

The follow-up at age 305 revealed less favorable psychosocial development in unwanted children compared to controls, though the difference had narrowed, similar to the results of the Swedish study.³ Interestingly, unwanted female children were frequently emotionally disturbed compared to female controls, while there was no difference between male participants and controls. Although criminality, alcohol-related disorders, and heavy smoking were not associated with unwanted pregnancy, the unwanted children “became psychiatric patients (especially psychiatric inpatients) more frequently than their siblings and the accepted controls.”⁶ The final report from this study⁷ that included a 35-year follow-up concluded that the results support the hypothesis that “being born from an unwanted pregnancy entails an increased risk for negative psychosocial development and mental well-being.”

Several other studies have also reported negative impacts of unwanted pregnancies on child development. Hummer et al⁸ noted that data from the National Maternal and Infant Health Survey–Longitudinal Follow-up indicate that pregnancies retrospectively classified as unwanted or mistimed are associated with worse child well-being. Hayatbakhsh et al⁹ reported that in a study conducted in Brisbane, Australia, unwanted pregnancies “as reported by mothers at the first antenatal visit predicted elevated levels of problem behaviours and increased substance use in children at 14 years.” They suggested that though some of their findings may be explained by other variables (eg, mother’s sociodemographic status, mental health, substance use during pregnancy), unplanned pregnancy may be associated with child aggressive and externalizing behaviors and early drinking.

Barber and East¹⁰ studied the impact of unintended births on the sibling(s) and their development. They found that unintended births had negative spillover effects—the birth of an unintended sibling was associated with a larger decline in the quality of the child’s home environment compared to the birth of intended siblings, and boys had more behavioral problems. Interestingly, mistimed births had larger negative effects than unwanted births. Finally, de La Rochebrochard and Joshi¹¹ studied the impact of unplanned pregnancy on cognitive development at age 3. They found that unplanned pregnancies were associated with a child’s cognitive delay. However, this association vanished for mothers with a low or middle level of education when socioeconomic circumstances were controlled; among mothers with a high level of education, this association remained significantly high and unexplained even after controlling for socioeconomic characteristics and parental behavior.

Conclusion

The studies of unwanted and/or unplanned children provide interesting findings on the possible unintended long-term consequences of the lack of abortion services. While some may argue that the number of participants has been low, the results are still convincing and remarkable for a long-term follow-up of 35 years. Growing up unwanted can clearly “leave scars that last into adulthood.”¹² Barber and East¹⁰ suggested that we do not pay attention to key questions—why unintended pregnancies are so prevalent and what can we do to better understand and prevent their occurrence. These are valid questions, but not necessarily key ones for the situation we will be facing. Unintended pregnancies are here to stay and presumably we will see more unwanted children being born. While the debate about what to do for children born as a consequence of the lack of abortion services has started and includes issues such as schooling and social services, the possible mental health consequences of “compulsory childbearing”⁴ for unwanted children have not been included in these deliberations. Do we have the means to screen for mental health consequences of these children and resources to provide them and their parents with psychiatric/psychological help? 

CORRESPONDENCE

Richard Balon, MD
Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University
Tolan Park Building, 3rd floor
3901 Chrysler Service Dr
Detroit, MI 48201 USA

EMAIL
[email protected]

REFERENCES

1. Harris LH. Navigating loss of abortion services—a large academic medical center prepares for the overturn of Roe v. Wade. N Engl J Med. 2022;386(22):2061-2064.
2. Forssman H, Thuwe I. One hundred and twenty children born after application for therapeutic abortion refused. Their mental health, social adjustment and educational level up to the age of 21. Acta Psychiatr Scand. 1966;42(1):71-88.
3. Forssman H, Thuwe I. Continued follow-up of 120 persons born after refusal of application for therapeutic abortion. Acta Psychiatr Scand. 1981;64(2):142-149.
4. Dytrych Z, Mate˘jc˘ek Z, Schüller V, et al. Children born to women denied abortion. Fam Plann Perspect. 1975;7(4):165-171.
5. Kubic˘ka L, Mate˘jc˘ek Z, David HP, et al. Children from unwanted pregnancies in Prague, Czech Republic revisited at age thirty. Acta Psychiatr Scand. 1995;91(6):361-369.
6. Kubic˘ka L, Roth Z, Dytrych Z, et al. The mental health of adults born of unwanted pregnancies, their siblings, and matched controls: a 35-year follow-up study from Prague, Czech Republic. J Nerv Ment Dis. 2002;190(10):653-662.
7. David HP, Dytrych Z, Mate˘jc˘ek Z. Born unwanted. Observations from the Prague study. Am Psychol. 2003; 58(3);224-229.
8. Hummer RA, Hack KA, Raley RK. Retrospective reports of pregnancy wantedness and child well-being in the United States. J Fam Issues. 2004;25(3):404-428.
9. Hayatbakhsh MR, Najman JM, Khatun M, et al. A longitudinal study of child mental health and problem behaviours at 14 years of age following unplanned pregnancy. Psychiatry Res. 2011;185(1-2): 200-204.
10. Barber JS, East PL. Children’s experience after the unintended birth of a sibling. Demography. 2011; 48(1):101-125.
11. de La Rochebrochard E, Joshi H. Children born after unplanned pregnancies and cognitive development at 3 years: social differentials in the United Kingdom Millennium Cohort. Am J Epidemiol. 2013;178(6):910-920.
12. Komisar E. The human cost of restricting abortion. Wall Street Journal. July 28, 2022. Accessed November 3, 2022. https://www.wsj.com/articles/the-human-cost-of-restricting-abortion-mental-health-depression-anxiety-neglect-dobbs-substance-abuse-unwanted-pregnancy-11659018533