article information

Shiraz E-Medical Journal: Vol.22, issue 12; e111809
published online: August 17, 2021
article type: Research Article
received: December 27, 2020
revised: February 20, 2021
accepted: May 3, 2021
DOI: https://doi.org/10.5812/semj.111809
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Short-Term Physical and Psychological Health Consequences of Induced and Spontaneous Abortion: A Cross-sectional Study

authors:

avatar Sedigh Alipanahpour ORCID 1 , avatar Naeimeh Tayebi ORCID 2 , avatar Mahnaz Zarshenas 3 , avatar Marzieh Akbarzadeh ORCID 4 , *

Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
Department of Midwifery, School of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran
Department of Midwifery, Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
Department of Midwifery, Maternal-Fetal Medicine Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran

how to cite: Alipanahpour S, Tayebi N , Zarshenas M, Akbarzadeh M. Short-Term Physical and Psychological Health Consequences of Induced and Spontaneous Abortion: A Cross-sectional Study. Shiraz E-Med J. 2021;22(12):e111809. https://doi.org/10.5812/semj.111809.

Abstract

Background:

Abortion is an important pregnancy complication with short-term and long-term adverse physical and psychological effects on women.

Objectives:

The present study aimed to investigate the short-term physical and psychological effects of various types of medical abortion in pregnant women referring to educational and medical centers in Shiraz, Iran.

Methods:

In this cross-sectional study, among 5176 deliveries by the women referring to Shiraz Educational and Forensic Medicine Centers during a 4-month period, 437 pregnancies ended in abortion and thus were included in this study. A questionnaire was completed for each of the abortions, recording demographic characteristics and midwifery information. As well, the Mississippi Post Traumatic Stress Disorder Scale (M‑PTSD) was filled. Data were analyzed by SPSS software using appropriate statistical tests.

Results:

The most common physical complications of induced and spontaneous abortion were fever (10.3%) and the need for transfusion of blood products (4.6%). Among the patients who received abortion therapy, 73.1% had moderate stress due to psychological complications.

Conclusions:

Since the most common complications after abortion are fever, the need for blood transfusion, and bleeding, it is recommended to prepare a protocol to standardize post-abortion care. Most women in both induced and spontaneous abortion groups had moderate levels of stress. Due to the lack of attention to the mental health of the women experiencing abortion, it is necessary for these women to receive adequate supportive counseling, in addition to other medical services, after abortion.

1. Background

It is estimated that 42 million abortions occur every year; 20 million of which are unsafe. The complications of unsafe abortion result in 70,000 maternal deaths and 5 million temporary or permanent maternal disabilities each year. It has also been mentioned that both spontaneous and induced abortion are recorded as spontaneous in medical centers in order to receive post-abortion care (1). Various studies have reported that early vaginal bleeding (a risk factor for miscarriage) has been associated with adverse pregnancy outcomes such as preterm delivery, premature rupture of membranes (PPROM), low birth weight (LBW), intrauterine growth retardation (IUGR), small infants for gestational age (SGA), placental abruption, manual placental abruption, and pregnancy-induced hypertension (PIH) (2-4). Bleeding and infection (endometritis, infectious abortion) are also common following abortion (5). Some studies have reported that miscarriage is a risk factor for breast cancer (6, 7). Job loss, divorce, instability in emotional relationships, and delayed gestational care have also been reported to commonly occur after abortion (8). Vaginal bleeding is a usual problem in pregnancy and is considered an adverse pregnancy outcome and an ominous complication.

Women's reproductive history determines their health outcomes. The women experiencing pregnancy complications and recurrent miscarriages are more prone to bleeding and infection, which are the leading causes of maternal mortality, as well as other adverse outcomes (9). Regarding the psychological effects of abortion, the number and types of distress response symptoms are grouped into four classes: Psychological, emotional, physical, and cognitive/behavioral (10). For some women, abortion can be a traumatic event (10) with long-term psychological effects (11, 12). Pregnancy itself is a period during which women are exposed to high levels of emotional distress, but miscarriage is a traumatic experience. A longitudinal study reported the incidence of a significant proportion of psychological complications shortly after abortion. Most women experience grief, depression, or both after a miscarriage. Some women also experience anxiety, anger, posttraumatic stress disorder (PTSD), and feeling of guilt about having children in future (13). High levels of anxiety, depression, and sadness in some women may persist for a long time after physical recovery. The signs and symptoms of anxiety and depression, which occur after an abortion, may also be extended to subsequent pregnancies (13). Instead of perceiving pregnancy as a happy event, the women bearing a history of abortion often experience the subsequent pregnancy as a time of alertness and excessive and constant caution (14). Hamama et al. showed that spontaneous or selective abortion increased the risk of PTSD in subsequent pregnancies (15).

A cohort study on 1,457 women in Sweden showed the development of psychological complications after abortion among 742 women who were followed up for three months and 641 women screened for six months. The prevalence of PTSD before and after abortion was 4.3% and 23.5%, respectively, which was accompanied by high levels of anxiety, depression, and dropout (16). Evidence shows that within one month after abortion, 10% of women may develop ASD diagnostic criteria, and 1% may reveal PTSD symptoms (10). The patterns and trends of access to abortion therapy and perpetrating an abortion in Iran (where abortion is illegal) have changed in recent years. This is important as performing abortion therapy in a hospital is associated with fewer complications for the mother, leading to the application of abortion therapy more safely and effectively in healthcare settings. Since having a successful pregnancy is the dream of every family, the quality of life of each family member will be severely affected if it is not achieved (17, 18). In addition, abortion is a pregnancy complication associated with the occurrence and exacerbation of women’s mental disorders (19). In particular, being pregnant with a malformed fetus is a challenge that makes it difficult for the family, the community, and the physician to make decisions (5). Therefore, the importance of having psychological support for the women experiencing abortion due to abnormal fetuses or mothers with high-risk pregnancies has been emphasized by researchers (20, 21). Due to the presence of a few studies in this field, short-term physical and psychological complications during maternal hospitalization need to be studied.

2. Objectives

The present study aimed to investigate the short-term physical and psychological complications of the women undergoing medical abortion at the educational and medical centers of Shiraz. Our results could help medical staff and health policymakers in improving post-abortion care.

3. Methods

This was a cross-sectional epidemiological study conducted in 2018. The study population included all the women whose pregnancies were aborted in the hospitals affiliated with Shiraz University of Medical Sciences, Shiraz city, Iran. According to the following formula and considering a 95% confidence interval, as well as a sample loss of 10%, 5176 people were enrolled.

N=Z1-α22 ×P 1-Pd2

α = 0.05; P = 0.08; d = 0.1 × P

During four months, all the women who were hospitalized for abortion and those who referred to forensic medicine departments to receive written permission for abortion were included in the study, of whom 437 women accomplished abortion.

Finally, to evaluate physical and psychological complications based on the monthly rate of abortion in each hospital and considering a previous study (22), 104 people were included in this study.

n=Z1-α2+ Z1- βC2+3

r = 0.64; α = 0.01; β = 0.05; Z1 – β = 1.65

3.1. Data Collection Tools

3.1.1. Demographic Information Questionnaire

This tool contained 60 researcher-made items categorized into three sections: (1) personal characteristics, (2) midwifery information, and (3) abortion symptoms and complications.

This questionnaire was used to collect demographic information (including age, education, occupation, per capita income, place of residence, and pre-pregnancy BMI), midwifery information (including information about the current pregnancy such as gestational age, pregnancy complications and problems, pelvic exam results, and vital signs), and finally abortion information (including the cause of abortion, gestational age at the time of abortion, number of abortions, primary or secondary abortion, type of abortion, i.e., spontaneous, obstetric indication, or referral by a forensic doctor in the case of induced abortion). The content validity method was used to determine the scientific validity of the questionnaire. For this purpose, after studying valid scientific books and articles and fully recognizing confounding variables, the questionnaire form was prepared and then approved by several faculty members.

3.1.2. Mississippi Post Traumatic Stress Disorder Scale (M‑PTSD)

This tool included 35 items scored based on a 5-point Likert scale from 1 to 5 (23) to assess women’s mental health after abortion. The total score ranged from 35 to 175, and a score of 107 or higher indicated severe PTSD. The scores of 35 - 70 indicated mild stress; the scores of 70 - 107 indicated moderate stress, and the scores of 107 - 175 indicated severe stress.

The Cronbach's alpha coefficient of M-PTSD was reported from 0.86 to 0.94 (24). Sajjad Basharpour reported a Cronbach's alpha coefficient of 0.79 for M-PTSD in Iran (25). M-PTSD has a high validity and a well correlation with other PTSD measurement tools (26). M-PTSD was validated in Iran by Goodarzi (2002) with a Cronbach's alpha coefficient of 0.92 (27).

Inclusion criteria were being in the age range of 10-49 years, experiencing either spontaneous or induced abortion, having no history of taking psychological treatments including medications and psychotherapy, having enough literacy to fill the questionnaires, and having Iranian citizenship. Exclusion criteria were the occurrence of a crisis or stressful event for the patient and the unwillingness to continue cooperation. As mentioned, all types of abortion (unavoidable, complete, missed, incomplete, and induced abortion) were included in this study.

After reviewing the inclusion and exclusion criteria and explaining study objectives to participants, the researcher asked them to complete the questionnaires. The subjects were ensured that their information would remain confidential. Data were analyzed by SPSS 21 statistical software using descriptive statistics.

4. Results

The mean age of the women was 30 ± 5 years (15 - 45), and the mean age of their husbands was 33 ± 6 years (22 - 58). Among the women, 75% (330 people) were housewives, and the rest were either self-employed or state-employed. Among their husbands, 66% (292 people) were self-employed, 2% were unemployed, and the rest were state-employed. Most of the women and their husbands had a high school diploma; 27% of the women and 12.1% of their husbands had lower than high school diploma education, and the rest in both groups had academic degrees.

Regarding short-term physical complications after abortion, 9.33% of mothers with induced abortion and 13.3% of mothers with spontaneous abortion had fever. The need for transfusion of blood products and bleeding were the second most common symptoms in induced (5.42%) and spontaneous (6.7%) abortion groups, respectively. Overall, the most common symptom in all women was fever (10.3%) (Table 1). In 33 patients with spontaneous abortion, 21.2, 72.7, and 6.1% had mild, moderate, and severe stress, respectively. In 71 patients with induced abortion, 18.3, 73.23, and 8.45% had mild, moderate, and severe stress, respectively (Table 2).

Table 1.

Comparison of Post-abortion Complications Between Induced and Spontaneous Abortion Groups

Maternal Physical SymptomsInduced Abortion, No. (%)Spontaneous Abortion, No. (%)Total, No. (%)
Uncomplicated236 (71.8)73 (69.5) 309 (70.7)
Bleeding10 (3.01)7 (6.7)17 (3.9)
Fever31 (9.33)14 (13.3)45 (10.3)
Remaining residues and need to D&C14 (4.21)3 (2.9)17 (3.9)
Hypertension3 (0.9)0 (0)3 (0.7)
Tubectomy1 (0.3)0 (0)1 (0.2)
Bleeding and remaining residues3 (0.9)0 (0)3 (0.7)
Anemia3 (0.9)1 (1)4 (0.9)
Asthma3 (0.9)0 (0)3 (0.7)
Edema1 (0.3)1 (1)2 (0.5)
Transfused with blood and blood products18 (5.42)2 (1.9)20 (4.6)
Placenta Accreta4 (1.2)4 (3.8)8 (1.8)
Hypotension1 (0.3)0 (0)1 (0.2)
Tachycardia, chest pain4 (1.2)0 (0)4 (0.9)
Total332 (100)105 (100)437 (100)
Table 2.

Distribution of Stress in the Induced and Spontaneous Abortion Groups Immediately After Abortion

Posttraumatic Stress ScoreInduced AbortionsSpontaneous AbortionsTotal
Low (35 ‑ 70)13 (18.3)7 (21.2)20 (19.2)
Medium (70 ‑ 107)52 (73.23)24 (72.7)76 (73.1)
High (107 ‑ 175)6 (8.45)2 (6.1)8 (7.7)
Total71 (100)33 (100)104 (100)

5. Discussion

According to our results, the most common symptom in all women experiencing abortion was fever (10.3%), and the second most common complication was the need for being transfused with blood and blood products. In Nepal, a study was performed on 300,000 abortions, demonstrating that 8 out of every 1000 women had abortion complications (28). A study in Ivory Coast showed that the most common complications of abortion were infections (81.8%) and bleeding (68.2%) (29). Shekarchi reported spotting (65.4%) and severe bleeding (54.7%) as the most common symptoms (30), while bleeding was the most common symptom in studies by Saharkhiz (37%) (31) and Fouad (38.4%) (32). It is noteworthy that Saharkhiz studied the women using infertility therapeutic methods, and Fouad studied infection-induced abortion. Fever can be due to both infections and consuming misoprostol for abortion. The high percentage of infections and bleeding in the above-mentioned studies could be due to unsanitary abortions outside the hospital. In the present study, however, all abortions were performed in a hospital. Usually, a pregnant woman knows that she should report vaginal bleeding immediately to receive prompt treatment. Although vaginal bleeding is a common complication of pregnancy (33) and occurs in about 20 - 25% of women early in pregnancy, other causes of bleeding should also be considered, including intrauterine fetal implantation, abortion, ectopic pregnancy, hydatidiform mole, cervical changes, infections, local lesions such as polyps, and bleeding due to embryonic factors and fibroids (34-37). The results of a study on infection-induced abortion showed that uterine perforation with or without intestinal damage (13%), septicemia (61%), peritonitis (15%), and disseminated intravascular coagulation (DIC) (2%) occurred in these women (38). A study on unsafe abortion in Pakistan showed that the most common complication was uterine perforation and gastrointestinal damage (54%), followed by bleeding (26%) and death (12%) (39). A study in Ardabil, Iran, showed that vaginal bleeding (5.70%) and infections (4.7%) were common events following induced abortion (40). This indicates that bleeding and infections are among the most common complications in studies on deliberate abortions and the manipulated abortions performed in unsafe environments. In another study, the most common complications of abortion were fever and lower abdomen pain (41). Also, fever was the most common complication in the present study as well, which may be explained by consuming misoprostol, the most common drug used for abortion, by a considerable proportion of women in these two studies. Fever, as a side effect of misoprostol caused by the effect of the drug on prostaglandins, can be easily managed by taking painkillers and antipyretics (42).

The present study showed a 73.1% prevalence of PTSD in both induced and spontaneous abortion groups. Since there were no studies on the frequency of psychological stress caused by abortion in Iran and other countries, the results of the present study were compared with studies related to the prevalence of psychological stress in high-risk pregnancies. In a review study by Abdollahpour (2019), the overall prevalence of traumatic delivery was 51.3% (out of 800 cases), while the overall prevalence of PTSD was 29.1% out of 2687 samples (43). In a systematic review and meta-analysis by Yildiz (2017), 59 studies were reviewed, and the prevalence of PTSD was reported 4% in the total population and 18.5% in high-risk pregnancies. Most of the reviewed articles had examined patients 6 - 8 weeks postpartum. The prevalence of PTSD in the general population of Iran was reported to be 77.5% (44). Abdollahpour (45) and Modarres (46) reported the total prevalence of traumatic labor in Iran as 48.3 and 54.4%, respectively. Similar to the present study, both of the above studies had used DSM-IV-A to determine traumatic deliveries, which is an appropriate diagnostic tool for primary trauma (47). The present study did not investigate the prevalence of stress; however, some mothers had mild stress while the majority had moderate stress. This is important as chronic stress during pregnancy can lead to anxiety and PTSD.

The results of a review study by Reardon showed that abortion was always associated with an increase in the incidence of mental disorders, as compared with women without any record of abortion. Indeed, abortion has been directly related to mental health problems. One of the identified risk factors is a previous history of mental illnesses, exaggerating the risk of such problems in the women experiencing abortion. Nevertheless, it is difficult to determine that to what extent such mental illnesses are caused by abortion or if they can be reliably attributed to abortion (19). About one-fourth of all pregnancies end in one type of pregnancy loss during the prenatal period (14). Generally, abortion can be highly stressful for mothers, fathers, families, doctors, and others working in the social protection system (10). Hence, the need for familial support in the pregnancies leading to abortion should be considered by health care officials. There is a need for more studies in this field and on women at different ages, and the results should be made available to the medical community (in particular midwifery experts), as well as the women and mothers who intend to become pregnant. It is of particular importance for medical teams to become acquainted with psychiatry concepts and jurisprudential and religious laws of abortion and identify risk factors for psychological stress so that they can consult women to adapt after abortion and psychologically help them in subsequent pregnancies (48, 49). In addition, screening women before pregnancy and after delivery is recommended to identify those who have experienced a traumatic delivery. It is also recommended to use structured clinical interviews in future studies to evaluate the effectiveness of midwife-assisted brief counseling interventions on post-abortion women's mental health. Therefore, according to the results of this study, due to the high number of abortions in the society and its subsequent psychological damage, it is necessary for the women undergoing abortion to seek psychological counseling and support.

5.1. Conclusions

The most common post-abortion complications were fever, transfusion of blood and blood products, and bleeding. Overall, it is recommended to develop a protocol to standardize post-abortion care. Most of the participants in both induced and spontaneous abortion groups had moderate levels of stress. Considering the lack of Persian language articles on the psychological trauma caused by abortion and the lack of attention to the mental health of the women who experience abortion, it is necessary for these individuals to benefit from counseling support, along with other medical services, after abortion. Providing basic educational content in mental health to all those who work in the field of women's health is of special importance and should be considered.

References

  • 1.

    Melese T, Habte D, Tsima BM, Mogobe KD, Nassali MN. Management of post abortion complications in Botswana -The need for a standardized approach. PLoS One. 2018;13(2). e0192438. [PubMed ID: 29451883]. [PubMed Central ID: PMC5815579]. https://doi.org/10.1371/journal.pone.0192438.

  • 2.

    Saraswat L, Bhattacharya S, Maheshwari A, Bhattacharya S. Maternal and perinatal outcome in women with threatened miscarriage in the first trimester: A systematic review. BJOG. 2010;117(3):245-57. [PubMed ID: 19943827]. https://doi.org/10.1111/j.1471-0528.2009.02427.x.

  • 3.

    Amro B, Almahdi S. Outcome of pregnancy among women with threatened miscarriage in Latifa Hospital-Dubai. Hamdan Med J. 2019;12(2):72. https://doi.org/10.4103/hmj.hmj_77_18.

  • 4.

    Aris IM, Logan S, Lim C, Choolani M, Biswas A, Bhattacharya S. Preterm prelabour rupture of membranes: A retrospective cohort study of association with adverse outcome in subsequent pregnancy. BJOG. 2017;124(11):1698-707. [PubMed ID: 28029224]. https://doi.org/10.1111/1471-0528.14462.

  • 5.

    Giakoumelou S, Wheelhouse N, Cuschieri K, Entrican G, Howie SE, Horne AW. The role of infection in miscarriage. Hum Reprod Update. 2016;22(1):116-33. [PubMed ID: 26386469]. [PubMed Central ID: PMC4664130]. https://doi.org/10.1093/humupd/dmv041.

  • 6.

    Balekouzou A, Yin P, Pamatika CM, Bekolo CE, Nambei SW, Djeintote M, et al. Reproductive risk factors associated with breast cancer in women in Bangui: A case-control study. BMC Womens Health. 2017;17(1):14. [PubMed ID: 28264686]. [PubMed Central ID: PMC5340027]. https://doi.org/10.1186/s12905-017-0368-0.

  • 7.

    Yeganeh Z, Sheikhan Z, Kariman N, Hajian P, Nasiri M, Mirzadeh N. [Relationship between pregnancy-associated variables and breast cancer risk: A systematic review]. Iran J Obstet Gynecol Infertil. 2018;21(2):85-97. Persian. https://doi.org/10.22038/ijogi.2018.10716.

  • 8.

    Monea E, Thomas A. Unintended pregnancy and taxpayer spending. Perspect Sex Reprod Health. 2011;43(2):88-93. [PubMed ID: 21651707]. https://doi.org/10.1363/4308811.

  • 9.

    Studnicki J, Fisher JW, Reardon DC, Craver C, Longbons T, Harrison DJ. Pregnancy outcome patterns of medicaid-eligible women, 1999-2014: A national prospective longitudinal study. Health Serv Res Manag Epidemiol. 2020;7:2333392820941350. [PubMed ID: 32844103]. [PubMed Central ID: PMC7416150]. https://doi.org/10.1177/2333392820941348.

  • 10.

    Bowles SV, James LC, Solursh DS, Yancey MK, Epperly TD, Folen RA, et al. Acute and post-traumatic stress disorder after spontaneous abortion. Am Fam Physician. 2000;61(6):1689-96. [PubMed ID: 10750876].

  • 11.

    Iversen GA, Lokeland M, Fjereide AK, Bjorge L, Iversen OE. [Is it possible to obtain reliable information about the long-term effects of induced abortion?]. Tidsskr Nor Laegeforen. 2012;132(12-13):1450-2. Norwegian. [PubMed ID: 22766816]. https://doi.org/10.4045/tidsskr.11.0376.

  • 12.

    Alipanahpour S, Zarshenas M, Ghodrati F, Akbarzadeh M. The severity of post-abortion stress in spontaneous, induced and forensic medical center permitted abortion in Shiraz, Iran, in 2018. Iran J Nurs Midwifery Res. 2020;25(1):84-90. [PubMed ID: 31956603]. [PubMed Central ID: PMC6952917]. https://doi.org/10.4103/ijnmr.IJNMR_36_19.

  • 13.

    Haghparast E, Faramarzi M, Hassanzadeh R. Psychiatric symptoms and pregnancy distress in subsequent pregnancy after spontaneous abortion history. Pak J Med Sci. 2016;32(5):1097-101. [PubMed ID: 27882001]. [PubMed Central ID: PMC5103113]. https://doi.org/10.12669/pjms.325.10909.

  • 14.

    Hutti MH, Armstrong DS, Myers JA, Hall LA. Grief intensity, psychological well-being, and the intimate partner relationship in the subsequent pregnancy after a perinatal loss. J Obstet Gynecol Neonatal Nurs. 2015;44(1):42-50. [PubMed ID: 25782190]. https://doi.org/10.1111/1552-6909.12539.

  • 15.

    Hamama L, Rauch SA, Sperlich M, Defever E, Seng JS. Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy. Depress Anxiety. 2010;27(8):699-707. [PubMed ID: 20577979]. [PubMed Central ID: PMC2939862]. https://doi.org/10.1002/da.20714.

  • 16.

    Wallin Lundell I, Sundstrom Poromaa I, Ekselius L, Georgsson S, Frans O, Helstrom L, et al. Neuroticism-related personality traits are associated with posttraumatic stress after abortion: findings from a Swedish multi-center cohort study. BMC Womens Health. 2017;17(1):96. [PubMed ID: 28969621]. [PubMed Central ID: PMC5625823]. https://doi.org/10.1186/s12905-017-0417-8.

  • 17.

    Jamilian H, Jamilian M, Soltany S. The comparison of quality of life and social support among fertile and infertile women. Patient Saf Qual Improv. 2017;5(2):521-5.

  • 18.

    Ghodrati F. Jurisprudence study of the importance of the role of a woman’s right to have a child: A review. Curr Women's Health Rev. 2020;16(3):188-93. https://doi.org/10.2174/1573404816666200218141849.

  • 19.

    Reardon DC. The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities. SAGE Open Med. 2018;6:2050312118807620. [PubMed ID: 30397472]. [PubMed Central ID: PMC6207970]. https://doi.org/10.1177/2050312118807624.

  • 20.

    Gholamzadeh S, Godrati F, Saadatmand N, Akbarzadeh M. The obstetrics and gynecology and genetic counseling of mother with legal abortion had been referred to in Fars province center since 2007 - 2013. Shiraz E-Med J. 2016;17(2). e35271. https://doi.org/10.17795/semj35271.

  • 21.

    Godrati F, Saadatmand N, Dinpazhoh M, Akbarzadeh M. Epidemiological Study of Legal Abortion due to Fetal Defects in the Files Referred to Fars Province Forensic Medicine Centers from 2007 to 2013. Shiraz E-Med J. 2016;17(11). e40023. https://doi.org/10.17795/semj40023.

  • 22.

    Cowchock FS, Lasker JN, Toedter LJ, Skumanich SA, Koenig HG. Religious beliefs affect grieving after pregnancy loss. J Relig Health. 2010;49(4):485-97. [PubMed ID: 19690963]. https://doi.org/10.1007/s10943-009-9277-3.

  • 23.

    Papazoglou K, Blumberg DM, Chiongbian VB, Tuttle BM, Kamkar K, Chopko B, et al. The role of moral injury in PTSD among law enforcement officers: A brief report. Front Psychol. 2020;11:310. [PubMed ID: 32194477]. [PubMed Central ID: PMC7064734]. https://doi.org/10.3389/fpsyg.2020.00310.

  • 24.

    Raghibi M, Shirabadi A, Moallemi S, Narimani M. [Demographic characteristics and post-traumatic stress disorder in prison inmates of Zahedan, Iran]. Mil Caring Sci. 2016;3(1):10-7. Persian. https://doi.org/10.18869/acadpub.mcs.3.1.10.

  • 25.

    Basharpoor S. [The effectiveness of cognitive processing therapy on the improvement of posttraumatic symptoms, quality of life, self esteem and marital satisfaction in the women exposed to infidelity]. Family Counseling and Psychotherapy. 2012;2(2):193-208. Persian.

  • 26.

    Keane TM, Caddell JM, Taylor KL. Mississippi scale for combat-related posttraumatic stress disorder: Three studies in reliability and validity. J Consult Clin Psychol. 1988;56(1):85-90. [PubMed ID: 3346454]. https://doi.org/10.1037//0022-006x.56.1.85.

  • 27.

    Goodarzi MA. [Evaluating validity and reliability of mississippi post traumatic stress disorder scale]. Journal of Psychology. 2003;7:153-78. Persian.

  • 28.

    Puri M, Singh S, Sundaram A, Hussain R, Tamang A, Crowell M. Abortion incidence and unintended pregnancy in Nepal. Int Perspect Sex Reprod Health. 2016;42(4):197-209. [PubMed ID: 28825899]. [PubMed Central ID: PMC5568822]. https://doi.org/10.1363/42e2116.

  • 29.

    Ake-Tano SOP, Kpebo DO, Konan YE, Tetchi EO, Sable SP, Ekou FK, et al. [Abortion practices in high school students in Yamoussoukro, Cote d'Ivoire]. Sante Publique. 2017;29(5):711-7. French. [PubMed ID: 29384305]. https://doi.org/10.3917/spub.175.0711.

  • 30.

    Shekarchi B, Birang S, Saneei TM. [Sonographic Evaluation of the abortion-Induced Curettages in Imam Hossien Medical Center during 1380-1383]. Annals of Military and Health Sciences Research. 2008;6(1 (21)):15-7. Persian.

  • 31.

    Saharkhiz N, Ghalambar Dezfooli F, Nikbakht R. Rate of bleeding, abortion and ectopic pregnancy and their relationship with the patient’s age in three different methods of infertility treatment induction ovulation, Iui and Ivf. SSU_Journals. 2007;14(4):44-8.

  • 32.

    Fawad A, Naz H, Khan K, Aziz un N. Septic induced abortions. J Ayub Med Coll Abbottabad. 2008;20(4):145-8. [PubMed ID: 19999229].

  • 33.

    Yang J, Savitz DA. The effect of vaginal bleeding during pregnancy on preterm and small-for-gestational-age births: US National Maternal and Infant Health Survey, 1988. Paediatr Perinat Epidemiol. 2001;15(1):34-9. [PubMed ID: 11237112]. https://doi.org/10.1046/j.1365-3016.2001.00318.x.

  • 34.

    Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, Hartmann KE. Patterns and predictors of vaginal bleeding in the first trimester of pregnancy. Ann Epidemiol. 2010;20(7):524-31. [PubMed ID: 20538195]. [PubMed Central ID: PMC2884141]. https://doi.org/10.1016/j.annepidem.2010.02.006.

  • 35.

    Al-Memar M, Vaulet T, Fourie H, Nikolic G, Bobdiwala S, Saso S, et al. Early-pregnancy events and subsequent antenatal, delivery and neonatal outcomes: prospective cohort study. Ultrasound Obstet Gynecol. 2019;54(4):530-7. [PubMed ID: 30887596]. https://doi.org/10.1002/uog.20262.

  • 36.

    Bever AM, Pugh SJ, Kim S, Newman RB, Grobman WA, Chien EK, et al. Fetal growth patterns in pregnancies with first-trimester bleeding. Obstet Gynecol. 2018;131(6):1021-30. [PubMed ID: 29742672]. [PubMed Central ID: PMC6223322]. https://doi.org/10.1097/AOG.0000000000002616.

  • 37.

    Madan I, Romero R, Kusanovic JP, Mittal P, Chaiworapongsa T, Dong Z, et al. The frequency and clinical significance of intra-amniotic infection and/or inflammation in women with placenta previa and vaginal bleeding: An unexpected observation. J Perinat Med. 2010;38(3):275-9. [PubMed ID: 20146660]. [PubMed Central ID: PMC3419578]. https://doi.org/10.1515/jpm.2010.001.

  • 38.

    Jabeen A, Dawood NS, Riaz S, Tanveer S. Methods and complications of septic induced abortion in patients managed at a tertiary care hospital. J Ayub Med Coll Abbottabad. 2013;25(1-2):12-5. [PubMed ID: 25098042].

  • 39.

    Zhang HK, Luo FW, Geng Q, Li J, Liu QZ, Chen WB, et al. [Analysis of fetal chromosomal karyotype and etiology in 252 cases of early spontaneous abortion]. Zhonghua Yi Xue Yi Chuan Xue Za Zhi. 2011;28(5):575-8. Chinese. [PubMed ID: 21983739]. https://doi.org/10.3760/cma.j.issn.1003-9406.2011.05.024.

  • 40.

    Motavalli R, Alizadeh L, Namadi vosoughi M, Shahbazzadegan S. [Evaluation of the prevalence, reasons and consequences of induced abortion in women of Ardabil in 2011]. J Ardabil Univ Med Sci. 2012;12(4):384-91. Persian.

  • 41.

    Jahangir M, Behrashi M, Fazel M, Arbabi M. [Efficacy of vaginal Misoprostol for terminating missed abortion]. Feyz. 2005;9(2 (34)):1-5. Persian.

  • 42.

    Whitehouse K, Brant A, Fonhus MS, Lavelanet A, Ganatra B. Medical regimens for abortion at 12weeks and above: A systematic review and meta-analysis. Contracept X. 2020;2:100037. [PubMed ID: 32954250]. [PubMed Central ID: PMC7484538]. https://doi.org/10.1016/j.conx.2020.100037.

  • 43.

    Abdollahpour S, Khadivzadeh T. Prevalence of traumatic childbirth and post-traumatic stress after delivery in Iran: A systematic review and meta-analysis. J Obstet Gynecol Cancer Res. 2019;4(3):86-92. https://doi.org/10.30699/jogcr.4.3.86.

  • 44.

    Yildiz PD, Ayers S, Phillips L. The prevalence of posttraumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis. J Affect Disord. 2017;208:634-45. [PubMed ID: 27865585]. https://doi.org/10.1016/j.jad.2016.10.009.

  • 45.

    Abdollahpour S, Mousavi SA, Motaghi Z, Keramat A, Khosravi A. Prevalence and risk factors for developing traumatic childbirth in Iran. J Public Health. 2016;25(3):275-80. https://doi.org/10.1007/s10389-016-0783-y.

  • 46.

    Modarres M, Mirmolaie ST, Rahimikian F, Afrasiabie S. An epidemiologic assessment of post traumatic stress disorder following childbearing. Hayat. 2010;16(3/4):108.

  • 47.

    Gamble J, Creedy D, Moyle W, Webster J, McAllister M, Dickson P. Effectiveness of a counseling intervention after a traumatic childbirth: A randomized controlled trial. Birth. 2005;32(1):11-9. [PubMed ID: 15725200]. https://doi.org/10.1111/j.0730-7659.2005.00340.x.

  • 48.

    Ghodrati F. Controversial issues of abortion license according to religious and jurisprudential laws in Iran: A systematic review. Curr Women's Health Rev. 2020;16(2):87-94. https://doi.org/10.2174/1573404816666200206112854.

  • 49.

    Ghodrati F. Importance and necessity of training the medical team regarding religious-moral doctrines related to abortion, a narrative review. Curr Women's Health Rev. 2020;16(4):277-84. https://doi.org/10.2174/1573404816666200210122049.