Original Study

Psychological Problems Sequalae in Adolescents after Artificial Abortion

Vesna Zul
ci
c-Naki
c MD, PhD 1,3, Izet Pajevi
c MD, PhD 2,3, Mevludin Hasanovi
c MD, PhD 2,3,*,
c PhD , D
Slobodan Pavlovi 2
zenita Ljuca MD, PhD 1, 3

1
Department of Gynecology and Obstetrics, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
2
Department of Psychiatry, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
3
School of Medicine of University of Tuzla, Tuzla, Bosnia and Herzegovina

a b s t r a c t
Study and Objectives: Controversy exists over psychological risks associated with unwanted pregnancy and consecutive abortion. The aim of
this study was to assess the psychological health of female adolescents following artificial abortion up to 12th week of pregnancy.
Design: The control case study.
Setting: The study was carried out in the Department of Gynecology and Obstetrics, University Clinical Center Tuzla, in Bosnia-Herzegovina.
Participants: We assessed 120 female adolescents. The mean (SD) age of the patients was 17.7 (1.5) years experiencing sexual intercourse in
the age of 14e19 years for trauma experiences, presence of posttraumatic stress symptoms, depression and anxiety as state, and anxiety as
trait. Sixty adolescents had intentional artificial abortion and 60 had sexual intercourse but did not become pregnant.
Main Outcome Measures: We used the PTSD Questionnaire, the Beck Depression Inventory, and the Spielberger State Trait Anxiety
Inventory (Form Y) for assessment of anxiety in adolescents. Basic socio-demographic data were also collected.
Results: PTSD presented significantly more often in adolescents who aborted pregnancy (30%), than in adolescents who did not abort
(13.3%) (odds ratio 5 4.91 (95%CI 0.142-0.907) P 5 0.03). Anxiety as state and as trait were significantly higher in the abortion group, as
the mean (SD) anxiety score of patients was 59.8 (8.9), 57.9 (9.7) respectively, than in non-abortion group 49.5 (8.8), 47.3 (9.9) respectively
(t 5 6.392, P ! 0.001; t 5 5.914, P ! 0.001, respectively). Adolescents who aborted pregnancy had significantly higher depression
symptoms severity 29.2 (5.6) than controls 15.2 (3.3) (t 5 8.322, P ! 0.001), and they presented significantly more often depression (75%),
than adolescents who did not abort (10%) (c2 5 53.279, P ! 0.001). Logistic regression showed that only experience of life threatening(s)
and injury of other person(s) reliably predicted PTSD, whereas abortion and experience of life threatening(s) reliably predicted depression.
Conclusion: Adolescents who aborted pregnancy presented significantly greater prevalence of PTSD and depression, and significantly
greater depression severity and anxiety as state and trait than those who did not abort. Abortion predicted depression only, and did not
predict PTSD.
Key Words: Abortion, Adolescents, Depression, Anxiety, PTSD, Bosnia-Herzegovina

Introduction
Adolescence is time of profound physical changes
increasing the adolescent’s awareness of and interest in
sexual behavior.1 The issue of sexuality begins in early
adolescence and creates new challenges to personal and
gender identity during personal maturation. Sexual matu-
ration requires: growth in understanding of oneself as
a sexual being, ability to handle interpersonal relationships
effectively, and the capacity to plan behavior in view of future
outcomes and present problems.2 Family environment in
which adolescents develop, complete families and growing
and shaping of sexual identity.3 The consequences of
unprotected or unsafe sexual practices in adolescents are an
enormous burden for the adolescents, their families, and
society. This is the result of a social milieu in which sex is
frequently portrayed but rarely linked with responsible
behavior or accurate, nonjudgmental information.4 Adoles-
cent pregnancy can have serious physical consequences as
The authors indicate no conflicts of interest.
* Address correspondence to: Mevludin Hasanovi c, Department of Psychiatry,
University Clinical Center Tuzla, Rate Dugonjica bb, 75 000 Tuzla, Bosnia and
Herzegovina
E-mail address: hameaz@bih.net.ba (M. Hasanovi c).
1083-3188/$ - see front matter Ó 2012 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
doi:10.1016/j.jpag.2011.12.072
high maternal and infant mortality rates and there are indi-
cations of low child IQs.1 Pregnancy among adolescents is an
important problem in most developing countries. The
majority of pregnancies in adolescents are unwanted, with
medical, psychological, and mainly social repercussions.5e8
The main immediate consequences of an unwanted preg-
nancy are: induced abortion, lack of prenatal care, personal
and family disruption, adoption, and abandonment.9 Unsafe
sex, unwanted pregnancy, and unsafe abortion are some of
the emerging adolescent reproductive health challenges.10
Controversy exists over psychological risks associated with
abortion.1,11e13 Pope et al14 found that adolescents under age
18 years were less comfortable with their decision, but
showed no other differences compared with those aged
18e21 years. Both groups showed significant improvement
in psychological responses post abortion. Preabortion
emotional state and perception of partner pressure predicted
postabortion response. There was no evidence that abortion
poses a threat to adolescents’ psychological well-being.14 On
the other side, Coleman in her review article found that
women who had undergone an abortion experienced an 81%
increased risk of mental health problems, and nearly 10%
of the incidence of mental health problems was shown to
be attributable to abortion.15 There is no research about
242 V. Zulcic-Nakic et al. / J Pediatr Adolesc Gynecol 25 (2012) 241e247
association of adolescents’ mental health and arteficial
abortion in the post-war period after surviving war trauma-
tization. The young Bosnia-Herzegovina (BH) girls who
survived the 1992e1995 war are a multi-traumatized group.
The adolescents examined revealed a variety os serious
psychological manifestations, including post-traumatic
stress disorder (PTSD), depression, and suicidal thoughts,
somatic and behavioral problems that influenced their
academic achievements.16 Problem of adolescent artificial
abortion in BH was rarely examined.17 Our primary hypoth-
esis was that war trauma of adolescents may cause similar
posttraumatic psychological sequelae among adolescents
regardless of abortion or pregnancy; and secondary, that
artificial abortion may have strong association with psycho-
logical consequences for the adolescent.
Participants and Methods
Participants
The control case study was carried out at Department for
Gynecology and Obstetrics, University Clinical Center,
Tuzla, Bosnia-Herzegovina (BH). We assessed 120 female
adolescents aged 17.7  1.5 years experiencing sexual
intercourse in the age from 14e19 years, for trauma expe-
riences, presence and severity of posttraumatic stress
symptoms, depression and anxiety as state and anxiety as
trait. There were 60 adolescents who had intentional arti-
ficial abortion up to 12 weeks of pregnancy and 60
adolescents who had sexual intercourse but had no preg-
nancy. Participation in the study was anonymous; adoles-
cents were recruited from the regular patients who
attended a woman’s health clinics. Inclusive criteria for the
group of adolescents was abortion at the age of 14e19 years
inclusive, up to the 12th week of pregnancy, and no history
of somatic or psychiatric disease. They were observed one
month following intentional abortion, and asked to
complete questionnaires. The control group consisted of
the same number of subjects matched by age and health
condition and no pregnant. Sequential approach to the
design of matched pairs was used.
All participants voluntarily gave verbal informed consent
together with their parents or legal guardians for whom the
purpose of study and its importance had been explained.
This study was approved by Ethical Committee of
University Clinical Centre Tuzla. There were no conflicts of
interests.
Instruments
The questionnaire with basic personal, familial, gyneco-
logical, and socio-demographic information was designed
specifically for this study, and included questions about age,
parents’ educational background, employment status of
parents, and self-evaluation of the psychosocial family
status and habits. To measure academic achievements,
participants were asked for their average mark with which
they finished the last grade in the compulsory education
(from 1- insufficient to 5 - excellent). To evaluate traumatic
events18 and presence as well as the expressiveness
of posttraumatic stress symptoms, in this study we used
a self-administered questionnaire, the PTSD Checkliste
Civilian Version (PCL-C). The PCL-C is a 17-item self-report
measure of PTSD that takes about five minutes to admin-
ister the items corresponding to the DSM-IV symptoms for
PTSD and yields a total score and three symptoms cluster
subscale scores. Although the PCL-C has not been validated
in the Bosnian-Serbo-Croat language, it is widely used and
has excellent internal consistency, testeretest reliability
and validity in English. The PCL-C scale range from 1 (not at
all) to 5 (extremely), scores higher than 50 are considered
clinically significant.19,20
For assessment of anxiety in adolescents, participants
were invited to complete the Spielberger State Trait Anxiety
Inventory (STAI, Form Y). The STAI21,22 was developed over
25 years ago. It differentiates between the temporary
condition of ‘state anxiety’ and the more general and
long-standing quality of ‘trait anxiety’ using two separate
20-item self-report State and Trait scales, each with 20
4-point items and summarized by a score ranging from 20
to 90; higher scores indicate higher anxiety. The Anxiety
Inventory state-scale, completed first, asks the adolescent
to rate how does she feel right now, at this moment in terms
of intensity (‘not at all’ to ‘very much so’). Characteristic
items include ‘I feel at ease’, ‘I feel upset’. The Trait scale
assesses how does the subject generally feel in terms of
frequency (‘almost never’ to ‘almost always’), e.g. ‘I am
a steady person’ and ‘I lack self-confidence’. The STAI is
considered to be well validated in the general population.23
For assessment of depressiveness in adolescents we used
the Beck Depression Inventory (BDI). The BDI was originally
developed to detect, assess, and monitor changes in
depressive symptoms among people in a mental health care
setting. It is also used to detect depressive symptoms in
a primary care setting. The BDI usually takes between five
and ten minutes to complete as part of a psychological
or medical examination. The long form of the BDI is
composed of 21 questions or items, each with four possible
responses. Each response is assigned a score ranging from
zero to three, indicating the severity of the symptom.
Individual questions of the BDI assess mood, pessimism,
and sense of failure, self-dissatisfaction, guilt, punishment,
self-dislike, self-accusation, suicidal ideas, crying, irrita-
bility, social withdrawal, body image, work difficulties,
insomnia, fatigue, appetite, weight loss, bodily preoccupa-
tion, and loss of libido. Items 1 to 13 assess symptoms that
are psychological in nature, while items 14 to 21 assess
more physical symptoms.24,25
Statistical Analysis
Collected data were statistically analyzed using the
Windows Statistical Package for Social Sciences, version
10.0 (SPSS, Chicago, IL). Statistical tests included multiple
regressions. The results are reported as odds ratios (OR)
with 95% confidence intervals (95%CI), and comparison data
between groups is calculated with t and chi-square test. In
order to assess the influence of various predictive factors
responsible for presence of depression we used logistic
regression.
 V. Zulcic-Nakic et al. / J Pediatr Adolesc Gynecol 25 (2012) 241e247 243

Table 1
Socio-demographic Data, Attitudes towards Education, and Sexual Behavior of 120 Bosnian Female Adolescents, Who Did (n 5 60) and Who Did Not Have Abortion (n 5 60)

Characteristics Abortion* (n 5 60) No Abortion* (n 5 60) OR (95%CI) P

Growing up in town 47 (78.3) 41 (68.3) 1.056 (0.738e3.806) 0.304

Actual living in town 46 (76.7) 42 (70.0) 0.380 (0.624e3.178) 0.537
Both parents together-completed family 49 (81.7) 50 (83.3) 0.0 (0.347e2.287) 1.0
Desire for continuing education 36 (60.0) 47 (78.3) 3.875 (0.186e0.926) 0.030
Very often engaged in sexual relations 56 (93.3) 38 (63.3) 14.072 (2.586e25.400) !0.001
Desire to be pregnant 48 (80.0) 17 (28.3) 29.958 (4.342e23.574) !0.001
Desire to deliver baby 57 (95.0) 48 (80.0) 4.836 (1.266e17.819) 0.028

* Values are n (%).

Results experiences. There were no significant differences in regard

Socio-demographic Data
The average age (SD) of all participants was 17.7  1.7
years, with no difference between the abortion (17.8  1.4)
and no-abortion group (17.7  1.5; t 5 0.624, P 5 0.534).
Forty-six of 60 (76.7%) abortion up to the second month, and
14 (23.3%) it up to the third month of pregnancy; 38 (63.3%)
of them were the age of 14e16, and 21 (36.7%) were the age
of 17e18. Adolescents who received an abortion achieved
significantly lower academic achievement in the school
(mean  SD 3.57  0.95) than their peers who did not have
abortion 4.10  0.86 (t 5 3.236, P 5 0.002). Out of 60
adolescents who had abortion 52 (86.7%) had it only once,
while 8 (13.3%) had it twice. Only one (1.7%) of them had an
abortion during marriage.
Adolescents did not differ with regard to urban or rural
origin and completeness of family. The majority was grew
up in urban settlements and actually lived in urban settle-
ments, too, and had a complete family (Table 1). Out of the
majority of 60 adolescents who had abortion, 38 (63.3%)
had it in the age of 14e16 years, and 22 (36.7%) in the age of
17e18 years.
Adolescents who aborted their pregnancy significantly
less often desired to continue education; in other words
they sacrificed further education significantly more often
than their peers who did not abort pregnancy; also, those
who committed abortion significantly more often expressed
interest to have frequent sexual intercourse, desire to be
pregnant, and desire to deliver baby (Table 1).
In both groups, the majority of adolescents have only one
sibling, with no differences between groups. Adolescents
from abortion groups reported significantly more often bad
and less often excellent family relations compared with no
of surviving: “Someone else was injured”, “My life was in
danger”, “Other person was in life danger”, “I felt helpless-
ness”, “I was horrified” and “Loss of close person(s), but
adolescents who aborted survived significantly more often
“Experience of refugee” and “Body injury” (Table 3).
There was no significant difference ( SD) between
adolescents who had abortion (6.5  2.4) and those who did
not (6.3  2.3) (t 5 0.509, P 5 0.612).
Adolescents who had abortion reported significantly
more severe intensity of posttraumatic stress symptoms
for: “Repeated, disturbing dreams of a stressful experience
from the past?”, “Loss of interest in things that you used to
enjoy?“, “Feeling distant or cut off from other people?”,
“Feeling emotionally numb or being unable to have loving
feelings for those close to you?”, “Having difficulty concen-
trating?”, “Being “super alert” or “watchful on guard?”
(Table 4).
In the whole sample, 26 (22%) of 120 adolescents repor-
ted symptoms that met DSM IV criteria for PTSD; the abor-
tion group had 18 (30.0%) of 60, and the no abortion group
had 8 (13.3%) of 60, OR 5 4.91 (0.142e0.907), P 5 0.03.
Logistic Regression for PTSD
A logistic regression analysis was performed with PTSD
as the dependent variable and abortion, refugee status, loss
of close individual(s), earlier psychological trauma, any
trauma experience(s), body injury(s), injury of other
person(s), experience of life threatening(s), threatening for
Table 2
Socio-demographic Data and Family Relations for 120 Bosnian Adolescents, 60 Who
Did and 60 Who Did Not Have Abortion

abortion adolescents. Adolescents who had abortion Adolescent Abortion* No Abortion* Chi-square df P
reported significantly more often permanent stable relation Characteristics n 5 60 n 5 60 test

with boyfriend(s) related to their peers with no abortion. Family relations

Bad 24 (40.0) 5 (8.3) 20.568 2 !0.001
Majority of adolescents were of Bosnyak ethnicity with
Good 25 (41.7) 26 (43.3)
Islamic religious background; there were no significant Excellent 11 (18.3) 29 (48.3)
differences between groups in ethnicity (Table 2). Boyfriend relations
No 1 (1.7) 4 (6.7) 11.243 3 0.010
Permanent stable relation 37 (61.3) 22 (36.7)
Exposure to Traumatic Events, severity of the Posttraumatic Stress From time to time 20 (33.3) 34 (56.7)
Symptoms and Presence of PTSD Often partner exchange 2 (3.3) 0 (0)
Ethnicity
Bosnyak (Muslim) 36 (60.0) 37 (61.7) 0.660 3 0.996
Adolescents in this sample were equalized in regard to Croat (Catholic) 10 (16.7) 9 (15.0)
average number of trauma experiences. All adolescents in Serb (Orthodox) 6 (10.0) 6 (10.0)
the sample had one to eleven trauma exposures; there were Parents mixed marriage 8 (13.3) 8 (13.3)

no significant differences of average number of trauma * Values are n (%).

244 V. Zulcic-Nakic et al. / J Pediatr Adolesc Gynecol 25 (2012) 241e247

Table 3
War Related Trauma Experiences and PTSD Prevalence of 120 Bosnian Female Adolescents, Who Did (n 5 60) and Who Did Not Have Abortion (n 5 60)

Adolescent characteristics Number of adolescents n (%) OR (95% CI) P

War related trauma experience Abortion n 5 60 No abortion n 5 60

Experience of refugee 55 (91.7) 41 (68.3) 8.729 (1.757e14.786) 0.003

Body injury 12 (20.0) 3 (5.0) 4.836 (1.266e17.819) 0.028
Someone else was injuried 8 (13.3) 8 (13.3) 0 (0.349e2.865) 1.0
My life was in danger 19 (31.7) 10 (16.7) 2.886 (0.971e5.530) 0.089
Other person was in life danger 12 (20.0) 9 (15.0) 0.229 (0.548e3.663) 0.632
I felt helplessness 24 (40) 15 (25) 2.411 (0.917e4.362) 0.120
I was horrified 24 (40.0) 18 (30.0) 0.908 (0.73e3.313) 0.341
Loss of close person(s) 52 (86.7) 48 (80.0) 0.536 (0.612e4.316) 0.464

life to other person(s), experience(s) of helplessness, and
experience(s) of fear and horror as the predictor variables. A
total of 120 cases were analyzed and the full model was
significantly reliable (c2 5 88.133, P ! 0.001) and explained
between 52.0% and 80.2% variance of PTSD presence.
Overall 92.5% of predictions were accurate. Table 4 gives
coefficients and the Wald statistic and associated degrees of
freedom and probability values for each of the predicted
variables. This shows that only experience of life threaten-
ing(s) and injury of other person(s) reliably predicted PTSD.
The values of the coefficients reveal that in the case of
experience of life threatening(s), the chances for appear-
ance of depression increased 17 times, while in the case of
experience of injury of other person(s) the chances of
appearance of PTSD increased 43 times (Table 5).
Severity of Anxiety and Depression and Prevalence of Depression
Adolescents who had pregnancy abortion had signifi-
cantly higher anxiety as trait (59.8  8.9) and as state
(57.9  9.7), than those who did not (49.5  8.8, t 5 6.392,
P ! 0.001; 47.3  9.9, t 5 5.914, P ! 0.001, respectively).
Also they had significantly higher depression symptoms
severity (29.2  5.6) than controls (15.2  3.3, t 5 8.322,
P ! 0.001). The prevalence of moderate, serious, and
extreme levels of depression was significantly higher
among adolescents who had abortion than those without
pregnancy (Table 6).
Logistic Regression for Depression
A logistic regression analysis was performed with
depression as the dependent variable and abortion, refugee
status, loss of close individual(s), earlier psychological
trauma, any trauma experience(s), body injury(s), injury of
other person(s), experience of life threatening(s), threat-
ening for life to other person(s), experience(s) of helpless-
ness, and experience(s) of fear and horrifying as the
predictor variables. A total of 120 cases were analyzed and
the full model was significantly reliable (c2 5 68.834, P !
0.001) and explained between 43.7% and 58.8% variance of
depression presence. Overall prediction accuracy was 85.8%.
Table 6 gives coefficients and the Wald statistic and asso-
ciated degrees of freedom and probability values for each of
the predicted variables. This shows that only artificial
abortion and experience of life threatening(s) reliably pre-
dicted depression. The values of the coefficients reveal that
in the case of experience of intentional abortion, the
chances for appearance of depression increased 17 times,
while in the case of experience of life threatenig experi-
ence(s) the chances for appearance of depression increased
66 times (Table 7).
Discussion
All adolescents in the sample had one to eleven trauma
exposures; there were no significant differences of average

Table 4
Severity of Posttraumatic Stress Disorder Symptoms of 120 Bosnian Female Adolescents, Who Did (n 5 60) and Who Did Not Have Abortion (n 5 60)

PTSD Checklist e Civilian Version (PCL-C) Abortion No abortion t P

Repeated, disturbing memories, thoughts, or images of a stressful experience from the past? 1.98 (1.35) 1.72 (1.24) 1.130 0.261
Repeated, disturbing dreams of a stressful experience from the past? 2.05 (1.47) 1.48 (0.97) 2.500 0.014
Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)? 2.00 (1.37) 1.62 (1.09) 1.699 0.092
Feeling very upset when something reminded you of a stressful experience from the past? 2.12 (1.46) 1.90 (1.43) .819 0.414
Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something 1.98 (1.42) 1.65 (1.22) 1.380 0.170
reminded you of a stressful experience from the past?
Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it? 2.08 (1.41) 1.70 (1.31) 1.548 0.124
Avoid activities or situations because they remind you of a stressful experience from the past? 1.95 (1.38) 1.60 (1.17) 1.498 0.137
Trouble remembering important parts of a stressful experience from the past? 1.95 (1.43) 1.57 (1.18) 1.598 0.113
Loss of interest in things that you used to enjoy? 1.87 (1.33) 1.35 (0.82) 2.557 0.012
Feeling distant or cut off from other people? 2.08 (1.45) 1.37 (0.94) 3.209 0.002
Feeling emotionally numb or being unable to have loving feelings for those close to you? 2.05 (1.45) 1.55 (1.14) 2.095 0.038
Feeling as if your future will somehow be cut short? 2.03 (1.50) 1.70 (1.32) 1.295 0.198
Trouble falling or staying asleep? 2.03 (1.45) 1.62 (1.21) 1.710 0.090
Feeling irritable or having angry outbursts? 1.98 (1.40) 1.55 (1.13) 1.871 0.064
Having difficulty concentrating? 2.13 (1.53) 1.57 (1.16) 2.285 0.024
Being “super alert” or watchful on guard? 1.97 (1.43) 1.43 (0.95) 2.415 0.017
Feeling jumpy or easily startled? 2.03 (1.50) 1.70 (1.21) 1.342 0.182

Values are mean (SD) of PTSD symptom(s) severity.

 V. Zulcic-Nakic et al. / J Pediatr Adolesc Gynecol 25 (2012) 241e247 245

Table 5
Logistic Regression of Abortion, Refugee Status, Loss of Close Individual(s), Earlier Psychological Trauma, any Trauma Experience(s), Body Injury(s), Injury of Other Person(s),
Experience of Life Threatening(s), Threatening for Life to Other Person(s), Experience of Helplessness, and Experience of Fear and Horrified as Predictor Variables Related to
Ptsd of 120 Female Adolescents From Bosnia and Herzegovina

Predictor variables B S.E Wald df P* Exp (B)

Abortion 1.499 0.971 2.382 1 0.123 4.476

Refugee status 3.395 2.127 2.545 1 0.110 0.034
Loss of close person(s) 0.586 1.400 0.175 1 0.676 1.797
Earlier psychological trauma(s) 0.633 0.960 0.435 1 0.510 1.883
Trauma experience(s) 18.605 4366.688 !0.001 1 0.997 1.202
Bodily injury 0.049 1.134 0.002 1 0.966 1.050
Injuries of other person(s) 3.776 1.683 5.033 1 0.025 43.636
Experience of life threatening(s) 2.845 1.159 6.023 1 0.014 17.194
Experience of threatening(s) for others’ lives 0.392 1.289 0.093 1 0.761 0.675
Experience of helplessness 1.066 1.447 0.543 1 0.461 2.905
Experience of fear and horrified 0772 1.742 0.196 1 0.658 0.462
Constant 21.917 4366.688 0.000 1 0.996 0.000

Chi-square for model 88.133

df for model 11
Significancy for model P ! 0.001
Cox & Snell R2 0.520
Nagelkerke R2 0.802

* Logistic regression.

number of trauma experiences. There were no significant voluntarily exposed to an artificial bodily injury which can
differences in regard of surviving: “Someone else was be life threatening for them. After surviving previous
injured”, “My life was in danger”, “Other person was in life trauma experiences, this new trauma can provoke different
danger”, “I felt helplessness”, “I was horrified” and “Loss of posttraumatic symptoms as result of re-experience of
close person(s)”. previous exposure to life-endangering experiences caused
Adolescents who had abortion reported significantly by the 1992e1995 war in Bosnia-Herzegovina.26e28 PTSD
more severe intensity of post-traumatic (PT) symptoms of among adolescents who aborted was significantly more
disturbing dreams, loss of interest, feeling distant from often frequent. After conducting logistic regression, we
others, emotionally numb or inability to have loving feelings found that experience of life threats and experience of
for close person(s), difficulty concentrating, and being super injury of other person(s) had significant influence on
alert. The present study indicated that those adolescents appearance of PTSD and that abortion did not predict PTSD
who aborted pregnancies were older and from time to time presence. In other words, intentional abortion was a risk for
had instable boyfriend relation(s). Also, this study indicated developing of certain PT symptoms among investigated
that adolescents who aborted pregnancy significantly more adolescents in postwar BH were, but at the same time it was
often sacrificed further education. Further, severity of PT not arisk for the presence of PTSD. It may be explained by
symptoms: “Repeated, disturbing dreams of a stressful the fact that the period of one month between abortion and
experience from the past”, “Loss of interest in things that one the interview was not long enough to allow appearance of
used to enjoy”, “Feeling distant or cut off from other people”, PTSD related to abortion. We found in our study that
“Feeling emotionally numb or being unable to have loving adolescents in abortion group reported significantly higher
feelings for those close to one”, “Having difficulty concen- level of anxiety as both trait and as state, and that they were
trating”, “Being “super alert” or watchful on guard” were significantly more depressed than those who did not have
significantly more severe among adolescents who aborted abortion.29 We found that appearance of depression was
pregnancy than among their peers who did not. This could predicted by abortion and experience of life threats. It can
be explained by the fact that induced abortion is the be explained by the understanding of depression as clinical
surgical or medical intervention in a pregnancy with the response characterized primarily by a loss of self-esteem.
purpose of causing the death of the embryo or fetus. These This loss can be stimulated by inadequate fulfillment of
young adolescents with abortion, for whatever reason, were needs for affection as well as by frustration of significant
hopes and desires. All depressive reactions have one aspect
in commonda sense of loss.30 Franz and Reardon found
Table 6
Frequency of Depression Measured by Beck’s Depression Inventory of 120 Bosnian that adolescents may be developmentally limited by
Female Adolescents, who did (n 5 60) and Who Did not Commit Abortion (n 5 60) immature decision making abilities, idealism, egocentrism,
Beck’s Depression Abortion* No abortion* Chi-square df P and believe in a personal fable which places them at greater
Inventory n 5 60 n 5 60 test risk for postabortion stress. Inadequate counseling appears
Normal (0-10) 9 (15.0) 41 (68.3) 59.486 5 !0.001 to also contribute to this stress.31 Controversy exists over
Mild depression (11-16) 4 (6.7) 8 (13.3) psychological risks associated with abortion.1,11e15
Borderline (17-20) 2 (3.3) 5 (8.3)
Moderate (21-30) 24 (40.0 2 (3.3)
The average age of all participants in this study was below
Serious (31-40) 10 (16.7) 2 (3.3) the age of majority, the threshold of adulthood. Among these
Extremely (41 and more) 11 (18.3) 2 (3.3) adolescents more than half were aged 14e16 years. Adoles-
* Values are number (%). cents who aborted reported significantly lower academic
246 V. Zulcic-Nakic et al. / J Pediatr Adolesc Gynecol 25 (2012) 241e247

Table 7
Logistic Regression of Abortion, Refugee Status, Loss of Close Individual(s), Earlier Psychological Trauma, any Trauma Experience(s), Body Injury(s), Injury of Other Person(s),
Experience of Life Threatening(s), Threatening for Life to other Person(s), Experience of Helplessness, and Experience of Fear and Horrified as Predictor Variables Related to
Depression of 120 Female Adolescents From Bosnia and Herzegovina

Predictor variables B S.E Wald df P* Exp (B)

Abortion 2.879 0.604 22.692 1 !0.001 17.794

Refugee status 0.070 0.762 0.008 1 0.927 1.072
Loss of close person(s) 1.291 0.848 2.315 1 0.128 0.275
Earlier psychological trauma(s) 1.058 0.927 1.302 1 0.254 2.880
Trauma experience(s) 0.927 1.320 0.491 1 0.483 2.522
Bodily injury 18.697 9003.723 0.000 1 0.998 1.295
Injuries of other person(s) 1.414 2.084 0.461 1 0.497 4.112
Experience of life threatening(s) 4.191 1.397 9.001 1 0.003 66.093
Experience of threatening(s) for others’ lives 2.296 2.243 1.048 1 0.306 0.101
Experience of helplessness 0.715 2.244 1.101 1 0.750 0.489
Experience of fear and horrified 1.272 2.162 0.346 1 0.556 0.280
Constant 1.287 0.474 7.365 1 0.007 0.276

Chi-square for model 68.834

df for model 11
Significancy for model P!0.001
Cox&Snell R2 0.437
Nagelkerke R2 0.588

* Logistic regression.

achievement in the schools than their peers who did not
abort. The problem is not that teens are sexually active but
rather that they have little preparation and guidance in
developing responsible sexual behavior. Developmentally,
adolescents reach physical maturity before they are cogni-
tively able to appreciate the consequences of their behavior.4
Societal effects include replacing of old sex roles and norms
with new ones such as freedom, self actualization, and
parental emancipation combined with economic adulthood
postponed by the skills demands of the industrial society.1
In our study adolescents did not differ in terms of urban or
rural origin and in terms of completeness of family. The
majority had grown up in urban settlements and actually
lived in urban settlements too, and had a complete family. A
majority of sixty adolescents had abortion at the age of
14e16 years, and only one had it after the age of 18 years.
Factors associated with the abortion decision varied strongly
according to age.32 Abortion is less popular in younger teens,
indicating a falling rate.1 A teenager’s primary source of
information regarding sexuality is his or her peer group, all of
whom are experiencing and reinforcing the same behaviors.3
It is worth to notice the importance of the source of infor-
mation related to the intimate issues during period of
education and the resolution of everyday life problems such
as separate room the for adolescent in the dwelling, actual
income per family member, etc.33
Adolescents who had an abortion significantly more often
did not desire to continue education, in other words they
sacrificed further education. Also, they significantly more
often expressed interest for frequent sexual intercourse,
desire to be pregnant, and desire to give birth to a baby. This
is in line with findings of Black and DeBlassie1 who found
that adolescent single mothers are likely to be poor and to
sacrifice education. Isolation, unstable marriages, stress, and
guilt are among many social/psychological problems.1
In this study, family relations of adolescents from abor-
tion groups were significantly worse and the families were
poorer compared with adolescents who didn’t have abor-
tion. As in other study, complete families and stable family
relationships are very important, and create a safe place in
growing and shaping of sexual identity.3 In the case of
pregnant adolescents from dysfunctional, non-supportive
families, abortion has to be treated with particular care-
fulness.34 The family, the major socializer of other behav-
iors, is not as powerful as force in shaping responsible
sexual behavior because of parental discomfort with sex
education and sexual discussions.3 The paramount role in
the prevention of artificial pregnancy interruption among
adolescents is the healthy life style of family, the content of
family relationship, the confidential relationship between
children and their parents (including issues related to
sexual life).33
This study has a few limitations. It has the same weak-
nesses as existing research pertaining to emotional reac-
tions to abortion: it is limited by short follow-up period, the
absence of information on prior psychological state, and the
lack of a representative sample. We didn’t have access to
data about current education level, socioeconomic status,
and current marital status of the adolescents in both groups,
which could correlate with outcomes in this study. Also, the
study looked at PT symptoms severity among female
adolescents more than seven years after the war conflict in
BH had ended. PT symptoms have a tendency to both
increase and decrease over the years due to different
reasons. Since no baseline data had been collected for these
participants, we cannot know whether reported PT symp-
toms were changed during the recent period. Also, we
cannot know if the existing PT symptoms were the results of
trauma experiences during war or in the post-war transi-
tion period.24e26 Given that our participants were equalized
in regard of average number of survived trauma experi-
ences in preabortion period, we can consider abortion as an
additional trauma which may produce cumulative effects
on existing traumatization. Even so, it may be a trigger for
development of PT symptoms as participants reported in
this study. Since this was a case control study, our results
present the situation in the period of one month after
adolescents intentionally aborted, it might be interesting to
 V. Zulcic-Nakic et al. / J Pediatr Adolesc Gynecol 25 (2012) 241e247
evaluate what will happen after one or two years after these
abortions.
In conclusion, our findings suggest that of adolescents
who aborted pregnancy, significantly more were raised in
families with weak and unregulated relationships. Between
adolescents who did and who did not abort pregnancy
there was no significant difference in regard of surviving
experience of average number of previous trauma. Adoles-
cents who aborted pregnancy presented significantly more
severe PT symptoms: “Repeated, disturbing dreams of
a stressful experience from the past”, “Loss of interest in
things that one used to enjoy”, “Feeling distant or cut off from
other people”, “Feeling emotionally numb or being unable to
have loving feelings for those close to one“, “Having diffi-
culty concentrating,”, “Being “super alert” “or watchful on
guard.” They presented more often moderate, serious and
extremely level of depression, as well as higher severity of
depression symptoms; also they presented significantly
higher anxiety as state and trait than those who did not
abort.
Our study may be helpful in better understanding of
female adolescents’ psychosocial postwar problems in
perspective of unwanted pregnancies and intentional
interruption of the same and for the prospective planning of
preventive intervention strategies in improving women’s
mental health in postwar conditions.
Acknowledgments
This study was supported by Ministry of Education,
Science, Culture, and Sport of the Tuzla Canton, Department
of Gynecology and Obstetrics University Clinical Center
Tuzla, and Federal Ministry of Health of Bosnia and Herze-
govina. We thank all of them for support and thank
adolescents and their parents who accepted to participate
in this study. We would like to extend our particular thanks
to Professor Matko Marusi c for his generosity and the
meaningful critical review of the manuscript.
References
1. Black C, DeBlassie RR: Adolescent pregnancy: contributing factors, consequences,
treatment, and plausible solutions. Adolescence 1985; 20:281
2. Chilman CS: Teenage pregnancy: a research review. Soc Work 1979; 24:492
3. Keddie AM: Psychosocial factors associated with teenage pregnancy in Jamaica.
Adolescence 1992; 27:873
4. Grant LM, Demetriou E: Adolescent sexuality. Pediatr Clin North Am 1988; 35:
1271
5. Barbosa SM, Costa PN, Vieira NF: Stages of change in parents’ discussions with
their children about HIV/Aids prevention. Rev Lat Am Enfermagem 2008; 16:1019
247
6. Ratlabala ME, Makofane MD, Jali MN: Perceptions of adolescents in low
resourced areas towards pregnancy and the Choice on Termination of
Pregnancy (CTOP). Curationis 2007; 30:26
7. Taffa N, Omollo D, Matthews Z: Teenage pregnancy experiences in rural Kenya.
Int J Adolesc Med Health 2003; 15:331
8. Roemer R: Legislation on contraception and abortion for adolescents. Stud Fam
Plann 1985; 16:241
9. Pinto e Silva JL: Pregnancy during adolescence: wanted vs. unwanted. Int J
Gynaecol Obstet 1998; 63(Suppl 1):S151
10. Lema VM, Mpanga V, Makanani BS: Socio-demographic characteristics of
adolescent post-abortion patients in Blantyre, Malawi. East Afr Med J 2002;
79:306
11. Warren JT, Harvey SM, Henderson JT: Do depression and low self-esteem follow
abortion among adolescents? Evidence from a national study. Perspect Sex
Reprod Health 2010; 42:230
12. Major B, Cozzarelli C, Cooper ML, et al: Psychological responses of women after
first-trimester abortion. Arch Gen Psychiatry 2000; 57:777
13. Robinson GE, Stotland NL, Russo NF, et al: Is there an “abortion trauma
syndrome”? Critiquing the evidence. Harv Rev Psychiatry 2009; 17:268
14. Pope LM, Adler NE, Tschann JM: Postabortion psychologica adjustment: are
minors at increased risk. J Adolesc Health 2001; 29:2
15. Coleman PK: Abortion and mental health: quantitative synthesis and analysis of
research published 1995-2009. Br J Psychiatry 2011; 199:180
16. Hasanovi c M: Psychological consequences of war-traumatized children and
adolescents in Bosnia and Herzegovina. Acta Med Acad 2011; 40:45
17. Bali
c A, Bali
c B, Lazarevi  et al: Namjerni prekid trudno
c C, ce kod adolescentica u
Tuzli u periodu 1991-1993 god. Acta Med Saliniana 1995; 24:13
18. Pavlovic S: Upitnik traume. Indentifikacija traumatskog do zivljaja i simptoma
posttraumatskog stresnog poreme caja (UT-PTSP). PrintCom d.o.o., grafi cki
in
zenjering Tuzla: Tuzla. 2009
19. Weathers FW, Litz BT, Herman DS, et al: The PTSD checklist: reliability, validity,
and diagnostic utility. Presented at the Annual Meeting of the International
Society for Traumatic Stress Studies. San Antonio, TX; October 1993
20. Blanchard EB, Jones-Alexander J, Buckley TC, et al: Psychometric properties of
the PTSD Checklist (PCL). Behav Res Ther 1996; 34:669
21. Spielberger CD, Gorsuch RL, Lushene RE: STAI: Manual for the State-Trait
Anxiety Inventory (STAI). Palo Alto, CA, Consulting Psychologists Press, 1970
22. Spielberger CD: Manual for the State-Trait Anxiety Inventory: STAI (Form Y).
Palo Alto, CA, Consulting Psychologists Press, 1983
23. Barnes LBL, Harp D, Jung WS: Reliability generalization of scores on the
Spielberger State-Trait Anxiety Inventory. Educ Psychol Meas 2002; 62:603
24. Beck AT, Rush AJ, Shaw BF, et al: Cognitive therapy of depression. New York,
Guilford Press, 1979
25. Beck AT, Steer RA: Internal consistencies of the original and revised Beck
Depression Inventory. J Clin Psychol 1984; 40:1365
26. Hasanovi c M, Sinanovi c O, Pavlovi c S: Acculturation and psychological
problems of adolescents from Bosnia and Herzegovina during exile and
repatriation. Croat Med J 2005; 46:105
27. Hasanovi c M, Sinanovi c O, Selimbasic Z, et al: Psychological disturbances of
war-traumatized children from different foster and family settings in Bosnia
and Herzegovina. Croat Med J 2006; 47:85
28. Hasanovi c M, Srabovi c S, Rasidovic M, et al: Psychosocial assistance project
decreased posttraumatic stress disorder and depression amongst primary and
secondary schools students in post-war Bosnia and Herzegovina. Acta
Medica Academica 2011; 40:122. http://www.anubih.ba/ama/vol-40-no-2-y11/
Mevludin%20Hasanovic.pdf.
29. Cougle J, Reardon DC, Coleman PK: Depression associated with abortion and
childbirth: a long-term analysis of the NLSY cohort. Med Sci Monit 2003; 9:CR105
30. Bibring E: The mechanism of depression. In: Greenacre P, editor. Affective
disorders. New York, International Universities Press, 1953
31. Franz W, Reardon D: Differential impact of abortion on adolescents and adults.
Adolescence 1992; 27:161
32. Sihvo S, Bajos N, Ducot B, et al: Women’s life cycle and abortion decision in
unitended pregnancies. J Epidemiol Community Health 2003; 57:601
33. Zakorkina NA, Banushevich IA: [The causes of abortions among adolescents
residing in the rural area]. Probl Sotsialnoi Gig Zdravookhranenniiai Istor
Med 2009; 4:20
34. Johannsen L: Adolescent abortion and mandated parental involvement. Pediatr
Nurs 1995; 21:82