The relationship between induced abortion and mental health is an area of ongoing political and ethical controversy [1]. Many studies found no direct correlation between elective induced abortion and the development of mental consequences, and that the risk of mentalhealth problems is equal whether an unplanned pregnancy is carried to term or terminated with an elective abortion [1,2]. Since the 1973, US Supreme Court decisions legalizing abortions, more than one million abortions have been performed in the United States every year with the vast majority without a necessary medical reason [3]. The purpose of this article is to review the literature that have described the mental health consequences for the recipients and providers of elective induced abortion.

Several studies have documented no causal relationship between elective abortion and mental-health problems [1-4]. Many of the evidence regarding the psychiatric aspects of voluntary pregnancy termination is of low quality, with inconsistent study designs [5]. Many studies do not use validated mental health measures or control for preabortion mental health, whether the pregnancy is planned, and the presence of variables related to the type of the comparison group [6]. Specifically, many studies compare women with unplanned pregnancies to women planning an ongoing pregnancy. Generalizations across populations are difficult to reach because the psychological responses to pregnancy termination often vary by social, cultural, religious, or legal context [6,7].

Although mental health prior to pregnancy termination is the most important risk factor for psychiatric complications after induced abortions, many abortion recipients develop psychiatric complications without prior pre abortion mental conditions [8]. These women without prior mental conditions also experienced feelings of stress and crisis when offered the option of an induced abortion [9-11].

Other factors that may contribute to mental health problems following induced elective abortion include negative attitudes towards abortion, pressure from a partner to have an abortion, and negative reactions to the abortion including grief or doubt [12]. Some data suggest that the patient population who undergo abortion have a higher baseline rate of mental health disorders [13]. For instance women who were hospitalized for major depression, schizophrenia, substance use disorder, or personality disorder and subsequently became pregnant frequently struggle with the decision to end their pregnancies [13-15].

The US national co-morbidity survey found induced abortion to be related to an increased risk for a variety of mental health problems including ;panic attacks, panic disorder, agoraphobia, PTSD, bipolar disorder, major depression, and substance use disorders after statistical controls were instituted for a wide range of personal, situational, and demographic variables [16,17].

Although studies that have investigated the relation between abortion and suicide have presented mixed findings; [18] induced abortion increased the risks for both a subsequent preterm delivery and mood disorders substantial enough to provoke attempts of self-harm [19]. A nationally representative sample study examined the relation between abortion, mental disorders, and suicidality confirmed a strong association between abortion and several mental disorders including mood disorders, anxiety disorders, substance use disorders, as well as suicidal ideation and suicide attempts with less than one-half of women reported that their mental disorder had begun after the first abortion with attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse) [20]. The widely publicized study that questioned the presence of abortion trauma syndrome (ATS ) [4] is frequently quoted among the elective abortion supporters to disprove the association between that procedure and the development of PTSD, nevertheless review of the available literature suggests that women at particular risk for post abortion stress reactions are those who were pressured/coerced to have the abortion, felt ambivalent about the abortion decision, were raised in a religious home environment, experienced more than one abortion, had abortions for foetal anomalies or other medical problems, were awake during the procedure, became recently pregnant with a “wanted” child; had existing children at the time of the abortion and those who are young and unmarried [21]. The literature regarding ATS and PTSD is frequently confusing and weakened by methodological problems, however despite these difficulties the association between elective abortion and PTSD has been reported [21-23]. Supporters of elective abortion have relied on many political and economic assumptions that elective abortion is a medical procedure with some possible psychological sequelae that are comparable to a caesarean or a normal delivery and that denying an elective abortion could cause dire psychiatric complications [1,24,25]. However no research study has found that induced abortion is associated with a better mental health outcome, and general population studies point out the presence of significant associations with substance use, mood disorders, depression and some anxiety disorders, that has been confirmed nuanced, by longitudinal prospective studies supporting causal relationships [26,27]. Although the short-term emotional reactions to miscarriage appear to be larger and more powerful than those associated with elective induced abortion. In the long term, women who had induced abortion reported significantly more avoidance of thoughts and feelings related to the event than women who had a miscarriage [28].

The largest quantitative estimate of mental health risks associated with abortion available in the world literature consistent with the tenets of evidence-based medicine confirmed the serious mental consequences of abortion and called upon abortion providers to question the conclusions that were reached from traditional reviews [29]

A comprehensive review of the psychiatric and psychological consequences of abortion [30] that evaluated women who had had an abortion, compared with those who had either given child birth to those who had had a miscarriage analyzed a total of 36 studies which led to the exclusion of 6 studies due to methodological bias and found that depression, anxiety disorders, PTSD, and substance use disorders were the most studied outcome. In 13 studies a clear risk for at least one of the reported mental problems occurred in the abortion group versus childbirth, five papers showed no difference, in particular if women do not consider their experience of abortion to be difficult, or if after an abortion the desired fetus survives. Only one paper reported a worse mental outcome for childbearing. In the abortion versus unplanned pregnancies ending with childbirth: Four studies found a higher risk in the abortion groups and three, no difference. In comparing abortion versus miscarriage: three studies showed a greater risk of mental disorders due to abortion, four found no difference and two found that short-term anxiety and depression were higher in the miscarriage group, while long-term anxiety and depression were present only in the abortion group

In summary; the mental health of elective abortion recipients may reflect preexisting and co-occurring conditions and the coping strategies that need to be used to reverse or minimize the mental health consequences of that procedure. The sociocultural contexts in which elective abortion occur could also affect the mental health of abortion recipients. Future research are to further understand and alleviate the conditions that lead to unwanted pregnancy and abortion and to understand the conditions that present elective abortion as the only solution for an unwanted pregnancy shape how women respond to these life events, with the ultimate goal of improving mental well-being and preventing mental consequences [1].

The celebrated Greek physician Hippocrates, a contemporary of the historian Herodotus was born in the island of Cos between 470 and 460 B.C., and belonged to the family that claimed descent from the mythical Æsculapius, son of Apollo [31]. Before his day, there was already a long medical tradition in Greece which was chiefly inherited through 2,500 B.C from Egypt and Imhotep [32,33]. Hippocrates enlarged his education by extensive travel and may have taken part in the efforts to check the great plague which devastated Athens at the beginning of the Peloponnesian war [34] which strengthened his core beliefs in the value of human life. The Hippocratic Oath which was traditionally sworn by each new medical school graduating class is a sincere vow to protect all life, to hold in highest regard one’s teachers, to recognize one’s limitations, and to renounce self-interest in the treatment of patients. Although the values that are inherent in the Hippocratic Oath continue to be echoed in the modern views of physicians’ professionalism, ethics and values, unfortunately the Hippocratic oath has been either eliminated or modified in modern day medical school graduating ceremonies [35]. Despite the many attempts to discredit the Hippocratic oath as being irrelevant to modern day practice of medicine; studies has confirmed its importance for 21st century medical practice [36]. The Oath of Hippocrates unequivocally states that a physician will not to give a woman a pessary to produce abortion [37,38].

By definition elective induced abortion is the termination of pregnancy by any means to prevent the viability of a fetus at the request of a pregnant woman, but not for reasons of impaired maternal health or foetal disease [39]. Although the description of a foetus as an ‘unborn child’ continues to be a matter of ongoing debate and controversy [40]; The definition of viability (the ability to live outside the uterus) is becoming more and more obsolete since the modern advances in obstetrics and gynaecology have made it possible to save the lives of babies born after only thirty weeks of pregnancy and some infants born at twenty-six to twenty-seven weeks or even younger have survived through sophisticated medical intervention and support. At the same time, abortions are now sometimes performed at up to twenty-five to twenty-six weeks of pregnancy. As a result it has been medically accepted that nearly all pregnancies are viable after the 27th week, and no pregnancies are viable before the 21st week while everything in between is a “grey area” [41-43]. These medical facts make it extremely difficult for abortion providers to reconcile the seemingly contradictory elements of legalizing elective induced abortion based on the assumption that a fetes or an unborn child is not a person until delivery while a person who accidently or intentionally lead to a death of a pregnant women could be legally charged with double homicide regardless of the fetus gestational age [44,45]. Therefore, the old definition of viability is not helpful in determining whether an induced abortion is a voluntary act of ending the life of an unborn child [45-47].

Elective abortion in addition to its violation of the Hippocratic oath could also precipitate mental health consequences in its providers who took the oath as well as those who did not take the oath and scarce studies have been done on the doctors, nurses, counsellors and other staff that are involved in abortion procedures and despite its legalization abortion is one of the most difficult, controversial, and painful subjects in modern American society and some of its performers chose silence, fearing judgment and violence, while others chose disclosure to maintain psychological consistency and be a source of support to others. Either approach could lead to painful interpersonal disconnections [48]. Elective abortion providers may become targets of stigma, harassment and violence. As a result, many providers remain silence about their work in everyday encounters, their silence could perpetuate a stereotype that abortion work is unusual or deviant, or that legitimate, mainstream medical professionals do not perform abortions. This contributes to marginalization of abortion providers within medicine and the ongoing targeting of providers for harassment and violence. This reinforces reluctance to disclose abortion work, and the cycle continues leading to social isolation [49].

The psychological consequences of performing abortion may include obsession about it, depression, fatigue, anger, lowered selfesteem, and identity conflicts. Although no recent studies have been published about the effects of abortion on providers who are ambivalent about participating in the procedure; uncharacteristic feelings and behaviour have been reported, including withdrawal from colleagues, resistance to going to work, lack of energy, impatience with patients, and an overall sense of uneasiness in addition nightmares, images that could not be shaken, and preoccupation were commonly reported [50,51]. Other stress factors “thinking that the aborted fetus deserved to live” and “difficulty in controlling emotions during abortion care” were associated with compassion fatigue. These findings indicate that providing abortion services is a highly distressing experience for nurses and midwives [52,53]. Despite the severity and the disabling nature of these symptoms, the case for widespread clinical or sub-clinical PTSD among abortion practitioners, cannot yet be strongly made without further research [54].

The author of the book “The Hand of God”, [55] who was a physician that performed so many to count elective abortion in New York ;described the procedure as a tedious, assembly-line, marginally respectable occupation, that demands little from the providers, technically or ethically. Most meet their patient on the operating table when her legs are lifted into the stirrups. There is little or no contact afterwards. Then he asks rhetorically if this is what the conscientious, dedicated obstetrician and gynaecologist, who has spent many years in training wants to do. “The deliberate destruction of a living, demonstrably human being, is a practice anathema to all but the most morally insouciant (unconcerned) physicians, and can justifiably be described as bearing low prestige in the medical community”. Abortion is surgically unchallenging work that hardly fits within the classic bounds and aspirations of young physicians in training. The advances in the field of embryology and the increased sophistication in ultrasound technology has given medical students new insights and greater appreciation of the unborn. In addition, there are new opportunities and challenges in the speciality, that draw students away from abortion. As a result the number of abortion providers has been declining [56]. At issue, ultimately, is whether elective abortion is an appropriate medical intervention compatible with the medical commitment to preserving life and health, and whether depending on the determination of viability there is only one or two persons involved in each pregnancy the mother and the unborn child [47,57].

Many medical providers with religious convictions and others who abide by the Hippocratic oath which very clearly states “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone”, [35,37] chose to opt out of performing elective abortion and rely on the “best practice” standard advocated by the American Medical Association(AMA) is that conscientious objector doctors both advertise their unpreparedness to provide abortion services as well as dispense information locating alternative practitioners well in advance of any consultation [58]. Elective non-medically necessary abortion seems to oppose all the tenants of medical practice because it disposes a fetes who is not ill and who is not spreading illness to anybody else and many doctors feel they cannot reconcile this act with the life-preserving demands of their profession

In contrast to other countries with legalized elective abortion, in the United States it is an “industry” in its own right [59]. Most abortion clinics are run as a franchise business and have to be competitive in terms of pricing and costs. Their profitability is based on processing as many procedures as possible, so may be the practice of elective abortion should be assigned to non-medical professionals, certain well trained skilled technicians who would choose that narrow field of practice and will acquire a newly devised label of “abortionists”

Recipients and performers of elective induced abortion could develop mental health consequences and future research is needed to identify mediating mechanisms linking abortion to various disorders and to understand individual difference factors associated with vulnerability to developing a particular mental health condition after an induced abortion. In order to prevent the psychological complications of elective abortion future research should identify and understand the conditions that lead to unwanted pregnancy and abortion and by preventing and or addressing these conditions, and then other alternative will be available to prevent unplanned pregnancy instead of elective abortion, with the ultimate goal of improving mental health and preventing negative mental consequences.

To my wife and children and to my colleagues in Fresno, California, Lebanon and Hanover New Hampshire for their support and encouragement.