A 15-year old girl is raped by a family acquaintance and becomes pregnant. She is distraught and wants to get an abortion.
A married couple has grown children who are estranged from them. The wife becomes pregnant in her 40s and wants to keep the baby, but her husband doesn't and recommends an abortion.
A married woman has a planned pregnancy but finds out that the fetus has genetic or other abnormalities and is considering abortion.
These cases reflect the wide range of reproductive scenarios that may lead women to seek psychiatric help. "Our job as psychiatrists is to remain neutral and conduct a thorough assessment to help the patient think through her options, whether it's motherhood, giving up the baby for adoption, allowing a relative to raise the baby, or abortion. She has to make her own decision and live with it," said Nada Stotland, M.D., M.P.H., at APA's 2003 annual meeting in May. She chaired the session "Abortion and Psychiatry: Caring for Women and Families."
Psychiatrists and mental health professionals should be aware of their position on and feelings about abortion and not pass them on to the patient, Stotland said. "However, if they can't restrain themselves from presenting their positions or making moral judgments, they should refer the patient to someone they know who would be familiar with the issues."
Stotland recommended that when doing an initial evaluation of a woman patient, psychiatrists should take a sexual history and include a question about previous pregnancies and outcomes.
"If a woman has had an abortion, ask about the circumstances surrounding her decision-whether she thought it through beforehand and talked about her experience with friends and/or relatives," Stotland advised.
The patient should also be asked whether she is comfortable with her decision and experience. "If not, ask whether she wants to work on unresolved issues. This can be accomplished by various means including a religious consultation and psychotherapy," she advised.
When a patient becomes pregnant and she or her partner is considering an abortion, Stotland recommended asking the woman these questions:
"Patients may have magical expectations for abortion or motherhood," said Stotland. "To help her realize the implications of each scenario, ask the patient to imagine herself the next day, week, month, year, and five years from the procedure."
She also recommended that patients obtain as much information as possible to guide their decision making. "I suggest they visit the labor and delivery room at a local hospital to talk with staff about childbirth procedures. Or I suggest they visit a local abortion clinic to discuss procedures with staff," said Stotland.
If religion is a factor in the patient's decision making, she may benefit from being referred for a consultation with a clergy member.
Having a mental illness is not a contraindication for parenthood, but it does pose challenges that should be acknowledged and addressed, said Stotland. "Psychiatric patients may be vulnerable to unwanted pregnancies, for example, when a woman is promiscuous during a manic phase of bipolar disorder. Other considerations are whether the patient is severely cognitively impaired and what impact that has on her ability to make decisions and care for a child and the implications of continuing or discontinuing her psychotropic medications during pregnancy," said Stotland. Once a woman is faced with an unplanned or unwanted pregnancy, it is hard for her to go through any of her options- to have and keep the baby, put the baby up for adoption or have a relative raise the child, have an abortion, and so on- without support. However, social taboos and politics may make it hard for some women to talk about their decision openly, said Stotland.
"A psychiatrist can help a patient find support by helping her decide who will be helpful and for what purpose," she said. "Past experience of support from an individual is the best predictor of future support."
Adolescents may need help in deciding whether to tell their parents about their pregnancy. In some states, minors are required to have parental consent to obtain an abortion. If an adolescent decides to tell her parents, the psychiatrist may need to help her decide how and what to tell them.
"Most teens tell and involve their parents; with a few exceptions they usually don't get the worst-case-scenario reactions they expect," said Stotland.
Of course, taking steps to prevent an unwanted pregnancy is the best course for women to follow. While some women practice abstinence, the vast majority of women are sexually active, said Stotland.
While obtaining a sexual history, a psychiatrist can ask whether the woman wants to have children and can discuss contraception.
She suggested that psychiatrists establish a relationship with a local obstetrician/ gynecologist to refer patients who may want more information about contraception, pregnancy, or other reproduction-related topics.
Stotland emphasized that such a relationship is mutually beneficial. "I give regular talks to obstetricians and gynecologists who are hungry for psychiatric information and receive frequent referrals from them," said Stotland.
"There are many psychiatric aspects to dealing with sexual and reproductive issues. For example, a hormonal contraceptive may cause mood changes. I work with the ob/gyn to try to find another hormonal regimen that is equally effective but has less of an impact on mood," said Stotland.
Some sexually active women with psychiatric disorders may be at increased risk of pregnancy because they are less likely to obtain contraception or negotiate having sexual intercourse with their partners, said Stotland. "They may also feel why bother, because they feel worthless and/or that they have no future."
She continued, "In addition to psychiatric treatment and working on negotiation skills, a patient who is sexually active may benefit from a referral to an ob/gyn colleague to discuss contraceptive options for her and/or her partner."▪