Introduction: Scientific evidence from the United States and European countries shows that women who have had an induced abortion are not more likely to become depressed and several factors may confound this outcome. In contrast, in the case of Latin America, there are practically no studies in this regard due to restrictive legislation prevailing in the region. This paper aims to determine the prevalence of a probable major depressive episode (PMDE) in women who have legally terminated a pregnancy by way of public service in Mexico City and whether there are any psychosocial factors reported by the international literature associated with this outcome. Method: In a cross-sectional study, 274 women aged 15 years or older were interviewed two weeks after undergoing a medical abortion between November 2018 and November 2019. The Center for Epidemiological Studies Depression Scale 35-item version (CES-D-R35) was used to measure the PMDE in a structured interview. Results: The prevalence of a PMDE was 15.8%. Multivariate logistic regression was used for adjusted analysis. Perceived abortion stigma (OR = 6.74, 95% CI = 3.29-13.82), child sexual abuse (OR = 2.23, 95% CI = 1.01-4.93), and previous childless pregnancies (OR = 6.07, 95% CI = 1.52-24.21) were associated with PMDE. Conclusions: The prevalence of PMDE is similar to or lower than that reported in studies with women who continued a pregnancy; post-abortion counseling and clinical considerations should include the impact that stigma and gender-based violence have on women’s mental health.

Keywords:
Induced legal abortion, depression, psychosocial factors, contextual factors, abortion stigma, Latin America

08_RLP_55_22108_Depression

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). [DSM-IV]. American Psychiatric Publishing, Inc.

American Psychological Association (2008). Report of the task force on mental health and abortion. American Psychological Association. https://www.apa.org/pi/women/programs/abortion/mental-health.pdf

Amuchástegui, A., Flores, Edith., & Aldaz, E. (2015). Disputa social y disputa subjetiva. Religión, género y discursos sociales en la legalización del aborto en México. Revista de Estudios de Género La Ventana, 5(41), 153-195. https://doi.org/10.32870/lv.v5i41.4315

Assis, M. P., & Erdman, J. N. (2021). Abortion rights beyond the medico-legal paradigm. Global Public Health, 17(10), 2235-2250. https://doi.org/10.1080/17441692.2021.1971278

Biggs, M. A., Brown, K., & Foster, D. G. (2020). Perceived abortion stigma and psychological well-being over five years after receiving or being denied an abortion. Plos One, 15(1), e0226417. https://doi.org/10.1371/journal.pone.0226417

Biggs, M. A., Gould, H., Barar, R. E., & Foster, D. G. (2018). Five-Year Suicidal Ideation Trajectories Among Women Receiving or Being Denied an Abortion. The American Journal of Psychiatric, 175(9), 845-852. https://doi.org/10.1176/appi.ajp.2018.18010091

Biggs, M. A., Upadhyay, U. D., McCulloch, C. E., & Foster, D. G. (2017). ’Women’s mental health and well-being 5 years after receiving or being denied an abortion: A prospective, longitudinal cohort study. JAMA Psychiatry, 74(2), 169-178. https://doi.org/10.1001/jamapsychiatry.2016.3478

Boersma, A. A., Van Den Berg, D., Van Lunsen, R. H., & Laan, E. T. (2014). Induced abortion is not associated with a higher likelihood of depression in Curaçao women. The European Journal of Contraception & Reproductive Health Care, 19(5), 359-367. https://doi.org/10.3109/13625187.2014.927422

Cedeño, L., & Tena Guerrero, O. (2022). Estigma y empoderamiento posterior al aborto en mujeres mexicanas. Iberoforum. Revista de Ciencias Sociales, 2(1), 1-46. https://doi.org/10.48102/if.2022.v2.n1.212

Charles, V. E., Polis, C. B., Sridhara, S. K., & Blum, R. W. (2008). Abortion and long-term mental health outcomes: A systematic review of the evidence. Contraception, 78(6), 436-450. https://doi.org/10.1016/j.contraception.2008.07.005

Cockrill, K., Upadhyay, U. D., Turan, J., & Greene-Foster, D. (2013). The stigma of having an abortion: Development of a scale and characteristics of women experiencing abortion stigma. Perspectives on Sexual and Reproductive Health, 45(2), 79-88. https://doi.org/10.1363/4507913

Cullen, P., & Korolczuk, E. (2019). Challenging abortion stigma: Framing abortion in Ireland and Poland. Sexual and Reproductive Health Matters, 27(3), 6-19. https://doi.org/10.1080/26410397.2019.1686197

Dadi, A. F., Miller, E. R., Bisetegn, T. A., & Mwanri, L. (2020). Global burden of antenatal depression and its association with adverse birth outcomes: An umbrella review. BMC Public Health, 20(1), 1-16. https://doi.org/10.1186/s12889-020-8293-9

Eaton, W.W., Smith, C., Ybarra, M., Muntaner, C., & Tien, A. (2004). Center for Epidemiologic Studies Depression Scale: Review and Revision (CESD and CESD-R). In Maruish M. E. (Ed.), The use of psychological testing for treatment planning and outcomes assessment: Instruments for adults (pp. 363-377). Routledge, NY.  https://doi.org/10.4324/9781410610614

Faure, S., & Loxton, H. (2003). Anxiety, depression and self-efficacy levels of women undergoing first trimester abortion. South African Journal of Psychology, 33(1), 28-38. https://doi.org/10.1177/008124630303300104

Fisher, W. A., Singh, S. S., Shuper, P.A., Carey, M., Otchet, F., MacLean-Brine, D., Dal Bello, D., & Gunter, J. (2005). Characteristics of women undergoing repeat induced abortion. Canadian Medical AssociationJournal, 172(5), 637-641. https://doi.org/10.1503/cmaj.1040341

Foster, D. G., Steinberg, J. R., Roberts, S.C., Neuhaus, J., & Biggs, M. A. (2015). A comparison of depression and anxiety symptom trajectories between women who had an abortion and women denied one. Psychological Medicine, 45(10), 2073-2082. https://doi.org/10.1017/S0033291714003213

Galli, B. (2020). Challenges and opportunities for access to legal and safe abortion in Latin America based on the scenarios in Brazil, Argentina, and Uruguay. Cadernos De Saúde Pública, 36(1), e00168419. https://doi.org/10.1590/0102-311X00168419

González-Forteza, C., Jiménez-Tapia, J. A., Ramos-Lira, L., & Wagner, F. A. (2008). Aplicación de la Escala de Depresión del Center of Epidemiological Studies en adolescentes de la ciudad de México. Salud Pública de México, 50(4), 292-299. https://doi.org/10.1590/S0036-36342008000400007

Grose, R. G., Chen, J. S., Roof, K. A., Rachel, S., & Yount, K. M. (2021). Sexual and reproductive health outcomes of violence against women and girls in lower-income countries: A review of reviews. The Journal of Sex Research, 58(1), 1-20. https://doi.org/10.1080/00224499.2019.1707466

Hailes, H. P, Yu, R., Danese, A., & Fazel, S. (2019). Long-term outcomes of childhood sexual abuse: An umbrella review. Lancet Psychiatry, 6(10), 830-839. https://doi.org/10.1016/S2215-0366(19)30286-X

Hanschmidt, F., Linde, K., Hilbert, A., Riedel-Heller, S. G., & Kersting, A. (2016). Abortion stigma: A systematic review. Perspectives on Sexual and Reproductive Health, 48(4), 169-177. https://doi.org/10.1363/48e8516

Hernández-Rosete, D., & Estrada-Hipólito, R. (2019). Dificultades de acceso al aborto en contextos de interrupción legal del embarazo: narrativa de estudiantes de bachillerato en una comunidad campesina de México. Cadernos De Saúde Pública, 35(3), 1-11. https://doi.org/10.1590/0102-311X00046218

Kumar, A., Hessini, L., & Mitchell, E. M. (2009). Conceptualising abortion stigma. Culture, Health & Sexuality, 11(6), 625-639. https://doi.org/10.1080/13691050902842741

Lewis, E. G., & Dave, U. (2021). Long-term mental health & financial outcomes associated with abortion access and denial: A systematic review. Journal of Clinical Obstetrics & Gynecology,
31(3), 97-99. https://doi.org/10.5336/jcog.2021-85039

Li, D., Chu, C. M., & Lai, V. (2020). A developmental perspective on the relationship between child sexual abuse and depression: A systematic and meta-analytic review. Child Abuse Review, 29(1), 27-47. https://doi.org/10.1002/car.2592

Lira, L. R., & Méndez, M. T. S. (2008). ¿Violencia episódica o terrorismo íntimo? Una propuesta exploratoria para clasificar la violencia contra la mujer en las relaciones de pareja. Salud Mental, 31, 469-478. http://www.revistasaludmental.mx/index.php/salud_mental/article/view/1257

López, M. M., Celis, K. F., González-Forteza, C., Saltijeral, M. T., Schiavon, R., Collado, M. E., Ortiz, O., & Lira, L. R. (2019).  Relationship between perceived stigma and depressive symptomatology in women who legally interrupt pregnancy in Mexico City. Salud Mental, 42, 25-32. https://doi.org/10.17711/SM.0185-3325.2019.004

Major, B., Appelbaum, M., Beckman, L., Dutton, M. A., Russo, N. F., & West, C. (2009). Abortion and mental health: Evaluating the evidence. American Psychologist, 64(9), 863-890. https://doi.org/10.1037/a0017497

Maroto-Vargas, A. (2010). Al amparo de la noche: abortos clandestinos y salud mental. Revista Costarricense de Psicología, 29(4), 65-75. http://www.rcps-cr.org/openjournal/index.php/RCPs/article/view/56

National Collaborating Centre for Mental Health (2011). Induced abortion and mental health: A systematic review of the mental health outcomes of induced abortion, including their prevalence and associated factors. Academy of Medical Royal Colleges. https://www.aomrc.org.uk/wp-content/uploads/2016/05/Induced_Abortion_Mental_Health_1211.pdf

O’Donnell, A. T., O’Carroll, T., & Toole, N. (2018). Internalized stigma and stigma-related isolation predict women’s psychological distress and physical health symptoms post-abortion. Psychology of Women Quarterly, 42(2), 220-234. https://doi.org/10.1177/0361684317748937

Oram, S., Khalifeh, H., & Howard, L. M. (2017). Violence against women and mental health. Lancet Psychiatry, 4(2), 159-170. https://doi.org/10.1016/S2215-0366(16)30261-9

Orihuela-Cortés, F., Álvarez del Río, A., Lagunes-Córdoba, R., & Marván, M. L. (2022). Stigma toward women who have had an induced abortion and associated variables. Women’s Reproductive Health, 1-12. https://doi.org/10.1080/23293691.2022.2094738

Pedersen, W. (2008). Abortion and depression: A population-based longitudinal study of young women. Scandinavian Journal of Public Health, 36(4), 424-428. https://doi.org/10.1177/1403494807088449

Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385-401. https://doi.org/10.1177/014662167700100306

Ramos-Lira L., Celis, K. F., López M. M., Saltijeral M. T., González-Forteza, C., Schiavon R., Collado M. E., & Ortiz, O. (2021). Salud mental e interrupción legal del embarazo: resultados de un estudio exploratorio en la ciudad de México. In Pérez Armendariz E. M., Durante Montiel I., & Figueroa Pérez, M. I. (Eds.), Ciencia, salud y género (pp. 156-172). Universidad Nacional Autónoma de México, Facultad de Medicina. http://libros.facmed.unam.mx/wp-content/uploads/2021/09/Ciencia-salud-y-genero.pdf

Ramos-Lira, L., Saltijeral-Méndez, M. T., Romero-Mendoza, M., Caballero-Gutiérrez, M. A., & Martínez-Vélez, N. A. (2001). Violencia sexual y problemas asociados en una muestra de usuarias de un centro de salud. Salud Publica de México, 43, 182-91. https://saludpublica.mx/index.php/spm/article/view/6305

Rees, D. I., & Sabia, J. J. (2007). The relationship between abortion and depression: new evidence from the fragile families and child well-being study. Medical Science Monitor, 13(10), CR430-436. https://doi.org/10.12659/msm.502357

Roberts, S. C., Biggs, M. A., Chibber, K. S., Gould, H., Rocca, C. H., & Foster, D. G. (2014). Risk of violence from the man involved in the pregnancy after receiving or being denied an abortion. BMC Medicine, 12(144). https://doi.org/10.1186/s12916-014-0144-z

Rostagnol, S. (2014). ¿Tolerancia?: debates sobre la legalización del aborto. In Gioscia L. (Ed.), Más allá de la tolerancia. Ciudadanía y diversidad en el Uruguay contemporáneo (pp. 170-187). Ediciones Trilce.

Russo, N. (1976). The motherhood mandate. Journal of Social Issues, 32(3), 143-153. https://doi.org/10.1111/j.1540-4560.1976.tb02603.x

Shellenberg, K. M., Moore, A. M., Bankole, A., Juarez, F., Omideyi, A. K., Palomino, N., Sathar, Z., Singh, S., & Tsui, A. O. (2011). Social stigma and disclosure about induced abortion: results from an exploratory study. Global Public Health, 6(1), S111-S125. https://doi.org/10.1080/17441692.2011.594072

Singh, S., Remez, L., Sedgh, G., Kwok, L., & Onda, T. (2018). Abortion worldwide 2017: Uneven progress and unequal access. Guttmacher. https://www.guttmacher.org/report/abortion-worldwide-2017

Sorhaindo, A. M., Juárez-Ramírez, C., Díaz Olavarrieta, C., Aldaz, E., Mejía Piñeros, M. C., & Garcia, S. (2014). Qualitative evidence on abortion stigma from Mexico City and five states in Mexico. Women & Health, 54(7), 622-640. https://doi.org/10.1080/03630242.2014.919983

Steinberg, J. R., & Rubin, L. R. (2014). psychological aspects of contraception, unintended pregnancy, and abortion. Policy Insights from the Behavioral and Brain Sciences, 1(1), 239-247. https://doi.org/10.1177/2372732214549328

Steinberg, J. R., McCulloch, C. E., & Adler, N. E. (2014). Abortion and mental health: Findings from The National Comorbidity Survey-Replication. Obstetrics & Gynecoly, 123(2), 263-270. https://doi.org/10.1097/AOG.0000000000000092

Steinberg, J. R., Tschann, J. M., Furgerson, D., & Harper, C. C. (2016). Psychosocial factors and pre-abortion psychological health: The significance of stigma. Social Science & Medicine, 150, 67-75. https://doi.org/10.1016/j.socscimed.2015.12.007

Stotland, N. L. (2019). Update on reproductive rights and women’s mental health. Medical Clinics of North America, 103(4), 751-766. https://doi.org/10.1016/j.mcna.2019.02.006

Sumner, S. A., Mercy, A. A., Saul, J., Motsa-Nzuza, N., Kwesigabo, G., Buluma, R., Marcelin, L. H., Lina, H., Shawa, M., Moloney-Kitts, M., Kilbane, T., Sommarin, C., Ligiero, D. P., Brookmeyer, K., Chiang, L., Lea, V., Lee, J., Kress, H., Hillis, S. D., & Centers for Disease Control and Prevention (CDC; 2015). Prevalence of sexual violence against children and use of social services – seven countries, 2007-2013. Morbidity and Mortality Weekly Report, 64(21), 565-569. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4584766/

Turan, J. M., & Budhwani, H. (2021). Restrictive abortion laws exacerbate stigma, resulting in harm to patients and providers. American Journal of Public Health, 111(1), 37-39. https://doi.org/10.2105/AJPH.2020.305998

van Ditzhuijzen, J. (2019). Common risk factors for abortion and suicide attempts. Lancet Psychiatry, 6(12), 972-973. https://doi.org/10.1016/S2215-0366(19)30443-2

van Ditzhuijzen, J., ten Have, M., de Graaf, R., Lugtig, P., van Nijnatten, C., & Vollebergh, W. (2017), Incidence and recurrence of common mental disorders after abortion: Results from a prospective cohort study. Journal of Psychiatric Research, 84, 200-206. https://doi.org/10.1016/j.jpsychires.2016.10.006

Yin, X., Sun, N., Jiang, N., Xu, X., Gan, Y., Zhang, J., Qiu, L., Yang. C., Shi, X., Chang, J., & Gong, Y. (2021). Prevalence and associated factors of antenatal depression: Systematic reviews and meta-analyses. Clinical Psychology Review, 83, 101932. https://doi.org/10.1016/j.cpr.2020.101932

Zia, Y., Mugo, N., Ngure, K., Odoyo, J., Casmir, E., Ayiera, E., Bukusi, E., & Heffron, R. (2021). Psychosocial experiences of adolescent girls and young women subsequent to an abortion in sub-Saharan Africa and globally: A systematic review. Frontiers Reproductive Health, 3(638013), 1-13. https://doi.org/10.3389/frph.2021.638013