Abortion, Reproductive History
and Substance Abuse
Editor's Note: The following five studies examine the
association between substance use/abuse and reproductive history,
including elective abortion. Their findings sometimes have been
misinterpreted as suggesting that substance abuse is an effect
of abortion. With the exception of Reardon & Ney, none of these
researchers reached this conclusion. The evaluation of each study
indicates why the assumption that abortion causes substance abuse
is unwarranted. In sum, data were primarily retrospective, potential
confounding variables were not considered or, when considered,
the relationship between abortion and substance use disappeared.
It should be noted that the Amaro, Zuckerman & Cabral (1989) and
Frank et al. (1988) articles analyze different samples from the
same data set, and the Klassen & Wilsnack (1986) and the Wilsnack,
Wilsnack & Klassen (1984) articles are also from the same general
Reardon, R. C. [Elliot Institute, P.O. Box 7348, Springfield,
IL 62791-7348], & Ney, P.G. (2000). Abortion and subsequent
substance abuse. American Journal of Drug and Alcohol Abuse,
Introduction: Past studies
suggest a possible association between abortion and substance
abuse but the reasons for this relationship are not clear. This
study attempted to clarify the relative risk of post-abortion
Method: An exploratory
survey was sent to a national sample of 4929 women aged 24-44
was randomly selected from a mailing house list. The questionnaire
centered on reproductive history and asked about age at each pregnancy
and pregnancy outcome. Also included were items measuring whether
drugs or alcohol had ever been abused (yes-no), ages of onset
and termination of substance abuse, demographic characteristics
and emotional reaction to the survey. Fourteen percent of the
surveys (700) were returned; non-white women were substantially
underrepresented in the sample. Groups (substance abusers and
non-substance abusers, women who had abortions and women with
other pregnancy outcomes) were compared using chi-square.
Results: Fifteen percent
of all pregnancies in the sample were reported to terminate in
abortion, which suggests that some respondents concealed their
abortions and/or women who had abortions were under-represented
among survey completers. The analysis, which focused on outcome
of first pregnancy, was restricted to 491 white women who either
never had an abortion or terminated their first pregnancy by abortion.
Results indicated that women who abused alcohol or drugs were
younger at first intercourse and first pregnancy and more likely
to have had an abortion. Thirty-five percent of participants with
a history of substance abuse reported onset of substance abuse
"subsequent" to first pregnancy, defined as occurring
in the same year or later (27 women). When only those with
"subsequent" substance abuse were included, women who
had an elective abortion were found to be 4-5 times more likely
to report post-pregnancy onset of substance abuse than women with
births or pregnancy loss (16.5% versus 3.7%). Women who had an
abortion or reported substance abuse also indicated they experienced
more emotional difficulty in answering the survey.
Evaluation: This study's
limited measurement of onset, type and degree of abuse, along
with its retrospective design, undermine its ability to adequately
examine the temporal ordering of abortion and substance abuse.
Other significant limitations include its failure to consider
demographic and reproductive history differences between the comparison
groups, small sample of substance abusers, very low response rate
and analysis limited to white women. This research certainly does
not support the contention that having an abortion causes alcohol
or drug abuse. Moreover, it provides no data to support the authors'
assumption that abortion is a psychological stressor that can
be relieved through substance use. Better-designed research is
necessary to understand the circumstances under which an association
exists between history of abortion and substance abuse and the
reasons for such an association. Practical applications recommended
by the authors include evaluation of women seeking prescription
drugs and women entering substance abuse treatment programs for
issues related to unresolved post-abortion grief, and informing
women seeking abortion about the increased risk of post-abortion
substance abuse. As there is no reputable research evidence showing
that abortion causes substance abuse, these recommendations are
unwarranted. Rather it is desirable to screen all women seeking
reproductive services (including pregnancy termination and prenatal
services) for alcohol and drug abuse and promptly provide treatment
for those in need.
Citation: Wilsnack, R.W.
[Dept. of Sociology, University of North Dakota, Grand Forks,
ND, 58202], Wilsnack, S.C., & Klassen, A.D. (1984). Women's
drinking and drinking problems: Patterns from a 1981 national
survey. American Journal of Public Health, 74, 1231-1238.
Introduction: At the time
of this data collection (1981), increased attention had been focused
on women's drinking without clear indication that drinking among
women had actually increased. This study addresses some limitations
of previous research by using a large national representative
sample of women to examine drinking levels, drinking behavior,
and related health behaviors and symptoms of alcohol dependence.
were administered to 917 women and 396 men (as a control group),
and included items about alcohol consumption, drinking contexts,
problems resulting from drinking, and symptoms of alcohol dependence.
Also included were items on role performances, life stressors,
symptoms of anxiety and depression, and physical health. No demographic
characteristics were reported for the sample, although some of
these variables were considered in the analysis.
Results: No clear increase
in drinking was found, although more women over age 50 were abstinent
and women between 35 and 64 drank more than previously. Drinkers
or heavy drinkers were more likely to be of higher education or
income, Caucasian, and of no indicated religious preference. Marital
status appeared relatively salient, with divorced, separated,
never married, or cohabitating women being more likely to drink
heavily. It was also noted that women often shared the drinking
habits of their husband or partner and close friends. Patterns
also indicated that many women may experience problems or symptoms
related to heavy drinking and abstain temporarily in response
to these problems. Current drinking was not related to serious
injury or illness, although drinking in the year preceding pregnancy
was related to more premature deliveries, miscarriages, stillbirths,
birth defects, and failure to become pregnant. No mention was
made of prevalence of elective abortion. Chronic heavy drinking
was also related to depressive symptoms.
Evaluation: As these data
are relatively dated, especially with regard to the research question,
no suggestions about current drinking trends among women can be
made. Whatever the current trends and relationships, however,
the authors make a solid point that conclusions about direction
of effect with regard to any correlates of heavy drinking are
impossible with this type of data. This is especially true of
what the authors term "obstetrical and gynecological problems",
which in this study includes premature delivery, miscarriage,
and stillbirth, but not abortion. Recency of the data aside, this
study is a good methodological template for future research, and
sheds light on characteristics of women and their partners/companions
that may be salient when assessing for alcohol abuse.
Citation: Amaro, H. [School
of Public Health, Boston University School of Medicine, 85 E.
Newton St., M-840, Boston, MA 02118], Zuckerman, B., & Cabral,
H. (1989). Drug use among adolescent mothers: Profile of risk.
Pediatrics, 84, 144-151.
drug use and pregnancy are known to be related in the adolescent
population, few studies have systematically and prospectively
examined this relationship. This study was conducted to identify
drug use patterns in currently pregnant adolescents and to compare
characteristics between drug users and non-drug users.
Methods: Data was collected
on 253 pregnant females between the ages of 13 and 19. The sample
was mostly African-American and Latina, unmarried, and low-income.
The majority were not living with the father of the baby. A combination
of self-report and urine assay was used to determine lifetime
drug use, use within the past year, and use during pregnancy.
Data was also collected regarding demographics, current depression,
life stress, social support, history of violence, and drug use
by the father of the baby. Data for users and non-users was comparison
analyzed using chi-square, t-tests, and regression analysis.
Results: The majority of
this sample has used alcohol and marijuana both before and during
pregnancy, with cocaine use occurring to a lesser extent. Drug
users here were more likely to be older, married, or living with
the father of the baby. They were also more likely to have had
an elective abortion in the past, to have had a sexually-transmitted
disease, and to report negative life events that led to negative
effects for them. Further analysis using regression to control
for age, ethnicity, and other psychosocial variables showed no
significant relationship between drug use and history of elective
abortion. Amount of social support between the two groups did
not differ, but drug users were more likely to receive their social
support from their male partners (who are more likely to be drug
users). Drug users were also more likely to be threatened, abused,
or involved in fights during pregnancy. No differences in current
depression were found.
Evaluation: This study
represents a strong contribution to the literature given its combination
of self-reported drug use and urine assay to address previous
underidentification of drug use. Elective abortion was examined
as a variable here due to previous findings of drug use among
teens who become pregnant compared to teens who are not sexually-active.
One weakness of the paper is that elective abortion is mentioned
as something that provides added risk for poor outcomes for future
pregnancies, but not supported in the text by any literature references.
Practical applications provided by the authors are strong, and
consist of including an adolescent's male partner (likely also
a drug user) in her drug treatment, recognizing drug use as a
potential risk factor in any adolescent pregnancy, and training
staff to adequately assess for adolescent drug use.
Citation: Frank, D.A. [Division
of Developmental and Behavioral Pediatrics, FGH Bldg 3, Boston
City Hospital, 818 Harrison Ave., Boston, MA 02118], Zuckerman,
B.S., Amaro, H., Aboagye, K., Bauchner, H., Cabral, H., Fried,
L., Hingson, R., Kayne, H., Levenson, S.M., Parker, S., Reece,
H., and Vinci, R. (1988). Cocaine use during pregnancy: Prevalence
and correlates. Pediatrics, 82, 888-895.
Introduction: Much research
has targeted the potential negative effects of cocaine during
pregnancy, although methodological problems have prevented strong
recommendations from being made. This study uses a non-clinical
(i.e., not seeking drug treatment) sample of women seeking routine
prenatal care and also targets potentially confounding variables
that have not been addressed previously. The study was designed
to assess prevalence and patterns of cocaine use, identify other
correlates of cocaine use, and to compare women's self-report
of cocaine use to urine assay identification.
Methods: Interviews were
conducted with 679 women prenatally and in the immediate postpartum
period. Participants were primarily low-income, African-American
or Latina, and unmarried. A minority of women in this sample (comprised
of drug users and non-drug users) also had histories of what the
authors termed "risk factors", including sexually-transmitted
diseases (STDs--19%), low birth weight infants (9%), stillborn
infants (9%), and previous spontaneous (22%) or induced abortion
(36%). Interview questions centered around use of cocaine, marijuana,
alcohol, and tobacco during pregnancy, as well as the substance
use of the father of the baby. Participants were also asked for
a urine sample at each interview, which was tested for marijuana
and cocaine metabolites. Cocaine users and non-users were compared
using Chi-square and t-tests.
Results: Data from self-report
and urine assay combined showed the following prevalence rates:
cocaine 17%, marijuana 28%, tobacco 44%, alcohol 59%, opiates
4%, and other illicit drugs 3%. Of the cocaine users, 24% denied
use in self-report, but were detected by urine assay. Compared
cocaine nonusers, cocaine users were more likely to be unmarried,
Caucasian, and less well nourished. Users also reported significantly
more STDs, prior low birth weight infants, spontaneous abortions
(one or more), elective abortions (two or more), and greater use
in frequency and amount of alcohol, tobacco, marijuana, opiates,
and other illicit drugs during pregnancy.
Evaluation: This study's
particular strength is that it surveyed women who were merely
seeking routine obstetrical care and not drug treatment. It also
solidifies the importance of using urine testing to identify cocaine
users, at least with regard to conducting further research in
this area. The authors' conclusion that cocaine use is common
enough to include in routine screening for prenatal patients is
certainly justified. Given the co-occurrence of other substances
with cocaine in prenatal patients, this study provides important
information on patients who might be at risk for cocaine use as
well as important confounding variables to consider for future
research in this area. With regard to rates of elective abortion,
it is important to note that this study found that users and non-users
were not statistically different in their likelihood of having
had one elective abortion. The increased likelihood was only found
for cocaine users with regard to two or more abortions. This might
indicate that cocaine users are simply more likely to experience
repeated unintended pregnancies. As this study did not report
data on number of previous pregnancies, pregnancy rates for users
versus nonusers are unknown.
Citation: Klassen, A.D.
[Department of Sociology, University of North Dakota, Grand Forks,
N.D., 58202], and Wilsnack, S.C. (1986). Sexual experience and
drinking among women in a U.S. national survey. Archives of
Sexual Behavior, 15, 363-392.
examining the relationship between alcohol and sexual behavior
has consisted of the almost exclusive study of male subjects,
and has also been limited by small non-representative samples.
This study used a large representative sample of women to address
sexual feelings, behaviors, and dysfunctions according to differing
levels of alcohol consumption.
were administered to 917 women and 396 men (as a control group),
and included items on current and lifetime alcohol consumption,
demographics, sexual experience, and other psychosocial variables.
Several measures for drinking levels were used to categorize women
as moderate-to-heavy, light-drinking, abstaining, or temporarily-abstaining
women. Sexual experience was measured by using various techniques
based on general principles of Kinsey's sex research work. No
demographic information was provided for the sample, and was apparently
not considered in the analysis.
Results: A majority of
women reported that drinking reduces sexual inhibitions and makes
sexual activity more pleasurable. A minority of women reported
that drinking increases sexual assertiveness and less particular
choice of sexual partners, while more than half of all women here
reported that someone who had been drinking became more sexually
aggressive with them. Moderate-to-heavy drinkers were more likely
to report premarital intercourse, masturbation to orgasm, possible
interest in homosexuality, and abortion. Relationships between
drinking and sexual dysfunction were relatively weak, although
this was a non-clinical (i.e., non-alcoholic) sample.
Evaluation: The representative
nature of the study is certainly a strength. While this was a
retrospective study, and thus cannot imply direction of effect,
the results here are important to consider in any women's health
care setting. Acknowledging that alcohol use can be an antecedent,
concomitant, or consequence of sex-related or reproductive issues
can be useful. In terms of alcohol treatment programs, it is also
important to recognize the role of alcohol in sexual experience
and behavior. What is found here, though, is an overall theme
of more "sexually liberated" behavior among the moderate-to-heavy
drinkers that encompasses a wide range of behaviors. The authors
propose either a disinhibiting effect of alcohol, a different
moral value system among these women, or both as an explanation.
The study certainly does not provide any reason to assume that
having an abortion causes women to consume more alcohol. Obviously
a major limitation of the study is its recency, as the data was
collected in 1981.