Her attending physician, the patient's cousin-in-law, realizing the patient was a worrisome, perfectionistic woman, referred her for psychiatric study and care. He thought this care would be beneficial in preparing her for the operation.

A diagnosis of obsessive compulsive neurosis was made. The obstetrician was advised the patient was already so guiltladen that she could not tolerate such a procedure safely. She left the office very

angry.

The abortion was not carried out. A short time ago, and 13 years later, the child was participating in a religious ceremony. The patient went up to her cousin-in-law, the obstetrician, and said, "This is the boy we would have killed if you had not sent me to the psychiatrist." Subsequent to the psychiatric referral, the patient felt much better when she realized the psychiatrist found she was not so ill that she could not have another child.

:

Being told that one is too sick emotionally to tolerate a pregnancy can be extremely upsetting to a patient.

A psychiatrists, Dr. Kolb, who, incidentally, recommends abortion for psychiatric reasons, inadvertently emphasizes the point that psychiatrists have a role in finding psychiatric contraindications for so-called therapeutic abortions. He writes:

I and other psychiatrists recall incidents in which women were allowed to talk themselves out of having an abortion, although we would have been willing to recommend one because we had found some degree of depression present. In discussing the general circumstances, the women, now that they saw it in a different light, decided to have the child. They are among the most grateful patients we have had, and although my contacts with them were limited to two or three interviews, when I see on of them, she reminds me this was a very important factor in her life.

In many States prior to the Supreme Court decision, therapeutic abortions were legal if the life of the mother was in danger. Thus, the principal criteria that psychiatrists used to recommend therapeutic abortions was the possibility of suicide in the mother.

Although some psychiatrists utilized the possibility of suicide as an indication for therapeutic abortion, the data available indicates that suicide in pregnant women is extremely rare. In fact, it is less than in a comparable group of nonpregnant women.

Bolter again states that many psychiatrists admit they do not know of even a single woman who has successfully committed suicide under the conditions of pregnancy. It appears that pregnancy is a deterrent to committing suicide.

Senator BAYH. Doctor, excuse me.

Do those same studies and the statements from those doctors suggest they have had experience knowing women who have committed suicide for any reason?

Dr. BERNSTEIN. Well, the Minnesota statistics, which I know most about, only include women who are followed for 3 months after the pregnancy. Individually, psychiatrists who have treated patients who were not approved for abortions find there is no evidence that they have attempted suicide to any appreciable degree. In fact, all of the evidence is that they attempt suicide less than nonpregnant patients. In the State of Minnesota, there is extremely accurate reporting of all maternal deaths by the Minnesota Mortality Study Group. In a recent 21 year period, 1950 to 1970, there were only 19 suicides in

pregnant women in approximately 1.5 million births. And I believe the study has been given here in detail in the past.

In a British study of 1963 which investigated a 7-year period in Birmingham, not one pregnant woman committeed suicide.

In a California study of three counties-San Mateo, Santa Clara, and San Francisco of 10 million women in 1961, 1962, and 1963, only three instances of suicide by pregnant women were found. This figure was compared with the statistically predicted figure for women of childbearing age in the three counties. The actuarial expectancy of suicide was determined to be 17.6 for the same age group.

The explanation of why so few pregnant women commit suicide may be due to the fact that pregnant women, including unmarried ones, receive considerably more attention from society when pregnant than when not. In reviewing the case histories of the suicides in the Minnesota study mentioned above, it is clear in retrospect that the 19 suicides probably could have been prevented if psychiatric care had been obtained and ultilized. Of these 19 patients, 15 were postpartum—that is, in the first 3 months after the delivery-and 4 were pregnant.

The most tenable psychiatric diagnoses in these cases were either psychotic depressions or schizo-affective types of schizophrenia, for which there are fairly adequate treatment modalities. It should be emphasized that the use of the usual psychiatric therapies is not precluded by pregnancy. Morbidity related to these therapies is not affected by pregnancy.

Statements have been made in the media that certain mental illnesses are made worse by pregnancy. The literature does not bear this out. Noyes and Kolb in their textbook state:

Experience does not show that pregnancy and birth of the child influence adversely the course of schizophrenia, manic depressive illness, or the majority of psychoneuroses.

There is a misprint in the paper that you have, and I will read it correctly now. Zillboorg, who was a great psychoanalyst, stated:

Pregnancies that are marked by psychological tensions, severe moods and anxieties are not really abnormal pregnancies, and common sense to the contrary, the so-called psychologically uneventful, serene pregnancies are apt to be harbingers of severe and even malignant post-partum reactions. This does not mean that all psychologically stormy pregnancies are forerunners of postpartum psychoses but they frequently may, whereas the psychologically stormy pregnancies are seldom such forerunners.

He concludes, therefore, that on purely clinical grounds, it is impossible to predict who might, and who might not, develop a postpartum psychoses. In practice, the typical woman who develops such a psychosis is not one who wanted an abortion, but is rather an obsessive, compulsive patient: for example, a married woman with a strong moral code who had a planned pregnancy and was considered to be a good mother by her peers.

Since therapeutic abortions are being carried out, consideration must be given to what happens after the procedure. There are controversial reports in the literature as to whether there are psychiatric complications after abortion or whether there are not. The reports range from zero to 100 percent, and none are long-term studies.

One that just came out last week, which is in the Clinical Psychiatric News of June 1974, page 16, which I would like to read you, is a report from two doctors in Boston who report their experience with women undergoing abortions at Boston Hospital for Women. They confirm that psychiatric illness is very rare after abortionthat is what they say-although mild, transient negative feelings of guilt, sadness, or regret are part of the normal response. They add, the greatest likelihood of post-abortion psychiatric illness probably exists in the woman or girl who probably does not view the decision for an abortion as her own. Other situations most likely to lead to post-abortion psychiatric illness are abortion under coercion for medical indications or for the woman who has severe ambivalence or already has a severe psychiatric illness.

What I tried to bring out here is that the reports of what happens after abortion are so vague and inconsistent, I do not think anybody could make much sense from them at the present time.

In my own experience, I have struggled to help many patients over their guilt about having had an abortion, and incidentally, none of the patients that have been referred to me for a recommendation for abortion and did not obtain it ever committed suicide. To date, these mothers are not known to have disturbed children.

This brings up another point for discussion. At the present time, any woman who does not want a particular pregnancy can have an abortion in order to prevent so-called battered babies. If this kind of permissiveness was present when most of us were in utero we could have all been aborted, since my research corroborated Menninger's that all women reject their pregnancies to some degree, especially early in the pregnancy.

So it is conceivable that some of our mothers many years ago, when times were not as permissive as they are now, could have gone to the doctor and said, I do not want this baby. They could have gotten an abortion and that would have been it. Some of us would not be here today.

Menninger wrote:

Even with complete willingness for the role there are so many changes in the physiological and social life of the woman that no prospective mother escapes from the emotional stresses that result from these changes. There are pronounced hormonal changes, which even without a tumor of the abdomen, might theoretically account for some emotional changes from the normal.

The pronounced readjustments required by this growing tumor-the disturbance of her activities and social relationships, the changes in her relationship with her husband, her wounded pride because of her "deformity" all are realistic causes for her emotional distress. The social status is an important determinant in the intensity of these maladjustments. For the social butterfly the "figure" is all important. For the peasant laborer it is of no importance. In our culture, even in the ideal situation of an intelligently desired pregnancy, the woman may be expected to display some transient evidences of rejection or denial of the pregnancy.

In every woman, then, we may expect positive and negative emotional attitudes to express themselves, sometimes fleeting, sometimes prolonged in duration-and these attitudes will be manifested in definite disturbances in her reactions and feelings. The specific reactions and disturbances may be understood only in terms of the life situation of that individual.

What might have occurred can be demonstrated by the following, which incidentally was printed in Holiday magazine a few years

ago.

I am so busy living my life that I cannot seem to find time to write about it. If I ever do an autobiography I shall call it A Fairy Tale, because that is what it has always been. It is a fairy tale right now. Even before I was born, something remarkable happened to me. Let me tell you about it.

I was my mother's seventh child. My mother did not want a seventh child, so she decided to get rid of me before I was born. Then a marvelous thing happened. My aunt dissuaded her, and so I was permitted to be born. Think of it, my dear fellow. It was a miracle.

And as if to show my gratitude for my debut in the world, right away I began to show an aptitude for music. You see, I wasted no time. When I was a year old, believe it or not, I could carry a tune, and at four I played the overture to Poet and Peasant four hands with my sister.

This was from an article in Holiday magazine, and the musician was Artur Rubenstein. The point is, just because a woman does not want a pregnancy at a particular time, does not mean she will continue to not want it and produce a battered child.

This point can also be demonstrated by a patient I saw a few days ago. She was 49 and was referred here because of a sexual problem. In her history she mentioned she had seven children, all doing well, but with whom she had seven uncomfortable pregnancies. She added she was happy that the opportunity was not offered in her childbearing period to have an abortion, because she would have aborted all of them. Now, of course, she was pleased they were all living.

Her sexual problem, which sounded pretty bad, incidentally, was able to be helped in a matter of four interviews.

There are many statistical reports in the Scandinavian literature concerning what happened post-therapeutic abortion. In a 1965 Swedish study of 57 cases of abortion, which included legal, illegal, and postaneous, Jansson reported that psychiatric difficulties were much higher afte rlegal abortions than after illegal and spantaneous abortions. In this study, as in other studes, it appears that those who supposedly need the abortion most for psychiatric reasons develop the most psychiatric reasons develop the most psychiatric complications after the abortion. It therefore could be deduced that these patients who can tolerate a therapeutic do not need it in the first place. Linberg's study emphasizes that pregnant patients who demand na abortion and threaten suicide rarely carry it out. In his series, 304 patients whose request for therapeutic abortion had been refused, not one committee suicide, although 62 indicated they would if their requests were refused.

In another series, Dr. Hooks investigated 249 cases who were refused legal abortion and not one committed suicide, even though seven of the series had previously made attempts, unassociated with pregnancy. This author felt that two-thirds of the 213 women who bore the children had become well adjusted.

In summary, then, there are no psychiatric indications for therapeutic abortion because: (1) therapeutic abortion is not effective treatment for the patient or for the situation, and just kills babies; (2) the abortion will not solve the battered child syndome problem; (3) suicide is less of a risk in pregnant women than in nonpregnant women; (4) it is impossible to predict who will develop a postpartum psychosis; (5) therapeutic abortion has its own psychiatric morbidity; (6) adequate treatment methods are available to handle psychiatric difficulties occuring during pregnancy. Thank you very much, Senator.

[The full text of Dr. Bernstein's testimony and additional material follow:]

PSYCHIATRIC ASPECTS OF ABORTION BY IRVING C. BERNSTEIN, M.D., CLINICAL PROFESSOR OF PSYCHIATRY, OBSTETRICS AND GYNECOLOGY, UNIVERSITY OF MINNESOTA MEDICAL SCHOOL, MINNEAPOLIS, MINN.

Mr. Chairman: My name is Irving C. Bernstein, M.D. I have been a physician since 1942 and a practicing psychiatrist in Minneapolis since 1951. I am a clinical professor of psychiatry and obstetrics and gynecology at the University of Minnesota Medical School where I teach part time.

I am chairman of the Mental Health Committee of the Minnesota State Medical Association, psychiatric consultant to the Hennepin County Welfare Department, chairman of the Clinical Faculty Committee of the Department of Obstetrics and Gynecology of the University of Minnesota Medical School, and Chief of the Psychiatric Department of Mt. Sinai Hospital.

From the psychiatric point of view there are no indications for recommending therapeutic abortions. Yet, prior to the Supreme Court Decision regarding abortion, it was estimated that 80% of all abortions done in hospitals were done for so-called psychiatric indications. More appropriately, the function of a psychiatrist in this field should be to help manage the occasional patient who requires an abortion for medical reasons, since termination of pregnancy is not without psychiatric risk. Sims (1) states, "Abortion, even if therapeutic, may in itself produce a psychosis." Noyes and Kolb (2) state, "As high as onefifth of the women allowed therapeutic abortions later expressed regret for accepting the procedure".

As already stated, prior to the Supreme Court Decision most abortions done in hospitals were done for psychiatric indications. In my opinion the psychiatrists involved in recommending this procedure were recommending them not on the basis of medical facts, but for the convenience of some adult, and not necessarily for the pregnant patient. The patient was usually referred to the psychiatrist after she had missed one or two menstrual periods and the referring physician wanted an opinion quickly because he wished to operate within the first trimester of pregnancy if at all possible. Because the phychiatrist was under pressure of the shortage of time and the pressure of the referring physician, who had already decided that the patient should have a therapeutic abortion, but who had been unable to find an acceptable medical reason for it, the examination was usually neither complete nor objective. At that particular time threats of suicide and the fear of the future were at their height, and thus some psychiatrists, probably in good conscience, believed the possibility of suicide was imminent and recommended an abortion.

Abortion is an area in psychiatry in which some psychiatrists were intent on dealing with the neurotic symptom as a primary maneuver. It is customary for the psychiatrist to deal with what is behind the presenting symptoms, and not to take statements of patients at face value. Actually, it is better to treat a pregnant woman for her psychiatric illness, rather than abort her and not treat her psychiatrically.

In the area of abortion, psychiatrists do have a role to play. Psychiatric consultation is beneficial in helping patients tolerate the occasional abortion which is indicated for other than psychiatric reasons. Termination of pregnancy is not without psychiatric risks. Psychiatrists are valuable to referring physicians in determining psychiatric contraindications for therapeute abortons. For example, a patient was referred because of her adamant demands to have an abortion because it was inconvenient for her to have a baby at that particular moment. She was threatening suicide. Her attending physician, the patient's cousin-in-law, realizing the patient was a worrisome, perfectionistic woman, referred her for psychiatric study. He thought psychiatric care would be beneficial in preparing her for the operation. A diagnosis of Obsessive Compulsive Neurosis was made. The obstetrician was advised the patient was already so guilt laden that she could not tolerate such a procedure safely. She left the office very angry. The abortion was not carried out. A short time ago, and thirteen years later, the child was participating in a religious ceremony. The patient went up to her cousin-in-law, the obstetrician, and said, "This is the boy we would have killed if you had not sent me to the psychiatrist". Subsequent to the psychiatric referral, the patient felt much better when she realized the psychiatrist found she was not so ill that she could not have another