Riesgos medicos posibles tras la realizacion de un aborto

INFORME SEGÚN ARTÍCULO
24.1.C) DE LA LEY 50/1997, DE 27
DE NOVIEMBRE DEL GOBIERNO
www.vozvictimas.org
7 de agosto de 2008

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La ASOCIACIÓN DE VÍCTIMAS DEL ABORTO (AVA), con número de registro
nacional de asociaciones 172.123 y CIF G-84237155, sita en C/ Montera, 34-4º
10, 28013 Madrid, y en su nombre, Dª Beatriz Mariscal Díaz, Presidenta
A PETICIÓN DE LA SECRETARÍA GENERAL TÉCNICA DEL MINISTERIO
DE SANIDAD Y CONSUMO
EMITE EL SIGUIENTE:
INFORME SEGÚN ARTÍCULO 24.1.C) DE LA LEY 50/1997, DE 27 DE
NOVIEMBRE DEL GOBIERNO
Revisada la documentación enviada mediante oficio con fecha de salida de 21
de julio de 2008, procedemos a realizar las siguientes aportaciones a dicho
material:
1. Con respecto al primer objeto del Real Decreto, sobre la intimidad,
deseamos puntualizar que el cumplimiento de la protección de datos
obligatoria por Ley 15/1999 no se convierta en óbice ni impedimento
para que la interesada o sus familiares debidamente acreditados (en
caso de grave enfermedad o defunción) puedan acceder a una copia del
historial médico completo (salvo anotaciones subjetivas) si es preciso
para aportar en el historial del centro de salud u hospital de la mujer o
para una acción judicial iniciada por la mujer o familiares debidamente
acreditados.

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Actualmente es muy difícil que los centros de realización de IVE accedan a
entregar una copia de la historia clínica a la propia mujer que se ha
sometido a la misma – debidamente acreditada - y sólo lo hacen cuando se
solicita por vía judicial o bien por vía del Defensor del Paciente. Esto no
ocurre así en otras instituciones sanitarias.
2. Con respecto al segundo punto del que es objeto este Real Decreto,
las condiciones para la equidad y calidad en la IVE, creemos necesario
realizar las siguientes sugerencias para su inclusión en el Real Decreto:
2.1. En el Anexo del Real Decreto, apartado I, se incluye el estudio y
valoración por el facultativo especialista que corresponda. A este
respecto, para el supuesto primero de la LO 9/1985 en su acepción de
riesgo para la salud psíquica, es preceptivo que lo realice un psiquiatra.
En la entrevista por el primer supuesto de LO 9/1985, desde AVA se solicita, de
acuerdo con los conocimientos psiquiátricos y psicológicos actuales, la
inclusión en este punto de una síntesis de lo siguiente:
2.1.1. Que la evaluación se realice por un/a psiquiatra y un/a psicólogo/a
independiente desde el punto de vista mercantil del centro de realización
de IVEs, para que no medie interés comercial en la decisión y se
garantice la independencia necesaria en todo peritaje y evaluación
médica.
2.1.2. Que se verifique el cumplimiento del artículo 9 del vigente Real
Decreto 2409/1986, de 21 de noviembre, sobre centros sanitarios
acreditados y dictámenes preceptivos para la práctica legal de la
interrupción voluntaria del embarazo (IVE).

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En dicho artículo 9 del Real Decreto 2409/1986 se expone que “Los
profesionales sanitarios habrán de informar a las solicitantes sobre las
consecuencias médicas, psicológicas y sociales de la prosecución del
embarazo o de la interrupción del mismo”, y “de la existencia de medidas de
asistencia social y de orientación familiar que puedan ayudarle”
Derecho a la información sobre consecuencias:
En cuanto a la información sobre las consecuencias de la IVE, el documento
marco que resume toda esta información es el consentimiento informado, que
para cumplir con las características exigidas en la Ley 41/2002 debería incluir
(según artículos 4 y 10):
a) Las consecuencias relevantes o de importancia que la intervención origina
con seguridad.
b) Los riesgos relacionados con las circunstancias personales o profesionales
del paciente.
c) Los riesgos probables en condiciones normales, conforme a la experiencia y
al estado de la ciencia o directamente relacionados con el tipo de intervención.
d) Las contraindicaciones.
Adjuntamos en el ADJUNTO 1 del presente INFORME la recopilación de la
evidencia científica existente sobre posibles secuelas de aparición tras una
IVE, que deberían constar en los consentimientos informados de todo centro
acreditado para la IVE.
En los centros privados o públicos de realización de IVE no se informa ni
verbalmente ni en el consentimiento informado sobre todas las posibles
secuelas físicas y las secuelas psicológicas de la IVE. Se recomienda en toda
intervención quirúrgica al menos 24 horas de estudio y lectura del
consentimiento informado, y así consta en las recomendaciones de las
Sociedad Española de Cirugía Plástica, entre otras. No procede, por tanto, la

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firma de dicho documento en el mismo día de la intervención y mucho menos
media hora antes tal y como se está realizando. Además, es preciso fomentar
la toma de decisión libre mediante un tiempo de reflexión como se realiza en un
gran número de estados de EEUU, como Texas y Minnessota, siguiendo una
Ley llamada "Derecho de la mujer a la información".
Derecho a la información sobre medidas de asistencia:
Sobre el derecho a la información sobre ayudas y alternativas a la IVE, para
fomentar una decisión libre en la misma por la mujer y que ésta no se
encuentre coaccionada por la violencia machista, la pobreza o la soledad, en la
primera entrevista de evaluación debe entregarse en papel un listado de
recursos con teléfonos y direcciones donde pueda orientársele a la
embarazada en la búsqueda de una vivienda, de ayudas materiales, sociales,
etc. en su maternidad.
Todos los recursos de ayuda a la embarazada en España se encuentran
listados en el Portal Embarazoinesperado.es (www.embarazoinesperado.es) y
se dispone de un teléfono 24 horas gratuito de información de ayudas que
debería proporcionarse en el asesoramiento previo a la IVE. El teléfono 24
horas es el 900 500 505 y su titularidad es de la Fundación Línea de Atención a
la Mujer.
2.1.3. Estudio y evaluación por parte del psiquiatra y psicólogo durante un
mínimo de tres sesiones, separadas en el tiempo por al menos un día
cada una, para realizar evaluación adecuada de:
a. Antecedentes psiquiátricos: si existen antecedentes en la mujer
de depresión, manía, ansiedad o trastornos de personalidad,
existen evidencias científicas de que el aborto puede ocasionar
con mayor probabilidad un trauma y estrés postraumático
posterior.

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b. Presencia de violencia de género machista que pueda estar
induciendo al aborto no deseado.
En numerosos casos, la decisión de la IVE se toma presionada y coaccionada
por el varón machista que lleva a la mujer a abortar en contra de su voluntad.
La relación entre violencia de género y embarazo está referida en el ADJUNTO
2 a este INFORME. Es preciso que en las entrevistas de evaluación previas a
la IVE la mujer reciba ayuda y asesoramiento para que pueda decidir por sí
misma.
Es preceptivo añadir en el ANEXO del Real Decreto que, en aplicación de la
Ley Orgánica 1/2004, de 28 de diciembre, de Medidas de Protección Integral
contra la Violencia de Género, el prestador del servicio deberá comprobar que
la intervención no se solicita como consecuencia de violencia de género sobre
la gestante, en cuyo caso, se comunicará este hecho a la autoridad judicial.
Permitir que se realice una IVE por coacción y violencia machista supone cerrar
el círculo de la violencia de género y silenciarla de forma cómplice desde los
centros acreditados para la IVE.
c. Prestación de conciliación familiar entre miembros de la
familia que puedan estar enfrentados a causa de un embarazo e
influyendo sobre la decisión de la IVE. Tal es el caso de
embarazadas mayores de edad que viven con sus padres u otro
familiar, y que toman la decisión de la IVE fruto de una crisis
familiar que podría solventarse mediante una conciliación
efectiva.
d. En el caso de embarazadas menores de edad, es vital y
preceptiva la realización de cómo mínimo tres visitas para el
estudio y valoración, y de conciliación familiar para la toma de
decisión de acuerdo con las necesidades de la menor y su
adecuado desarrollo psico-social.

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Es ampliamente conocido que numerosos centros de realización de IVEs
incumplen la legislación de la Ley 41/2002 y Ley 14/1986 sobre la mayoría de
edad en la IVE y el consentimiento que debe firmar el padre o madre o tutor de
la embarazada previo a la IVE. Es frecuente que se les solicite para la IVE una
fotocopia del carné de identidad del padre o la madre y con esto se les
practique la intervención, con los riesgos legales y sanitarios que esto puede
conllevar.
El consentimiento informado en los casos de menores deberá ser firmado por
el padre o madre o tutor.
2.2. En el Anexo del Real Decreto, apartado I, se incluye el estudio y
valoración por el facultativo especialista que corresponda. A este
respecto, para el supuesto tercero de la LO 9/1985 en su acepción de
riesgo para la salud psíquica, es preceptivo que lo realicen dos
ginecólogos, distintos de aquél por quien o bajo su dirección se realice la
IVE.
A este respecto, y siguiendo las recomendaciones de las entidades de
discapacitados en su Foro Europeo de Discapacidad en Atenas en el año 2003,
sugerimos la inclusión desde AVA en este Real Decreto de la participación de
los mismos en el asesoramiento preIVE tal y como señalan en sus
conclusiones estos y traemos aquí en el ADJUNTO 3 del presente INFORME.
Además, España ha suscrito el Convenio de la ONU sobre los Derechos de las
personas con discapacidad en diciembre del año 2007 y éste se encuentra ya
vigente.
2.3. En el punto III del ANEXO del Real Decreto, en defensa de la vida y la
salud de la mujer, debería constar la exigencia de que en todos los

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centros exista, además de la sala de recuperación, una unidad de
urgencias y servicio de ambulancia en la puerta preparado para la
derivación a centro hospitalario de tercer nivel en caso de gravedad
manifiesta de la mujer que ha sido intervenida.
2.4. En el punto III del ANEXO del Real Decreto, debería constar que en el
seguimiento post-intervención de posibles incidencias se incluirá no sólo
la revisión ginecológica a los quince días tras la IVE sino también la
revisión psiquiátrica.
2.5. En el punto III del ANEXO del Real Decreto, debería constar que el
informe de alta que se les entregue a las usuarias o tutores sea
completo (obligatorio por Ley 41/2002 y Ley General de Sanidad) y que
incluya una copia del consentimiento informado así como copia de las
ecografías, analíticas, otros documentos firmados por la mujer o tutor y
copia de los dictámenes correspondientes para el primer y tercer
supuesto de la LO 9/1985, así como la factura emitida por el centro con
todos los requisitos legales oportunos.
En el caso de entrega en mano del informe de alta, se debe dejar en la historia
clínica constancia expresa de la entrega con firma por la interesada o tutor.
No es suficiente entregar – como se está haciendo - una hoja resumen en la
que conste el día y lugar de la intervención, sino que la mujer tiene derecho a
llevarse copia de todos los documentos implicados en la intervención.
Así mismo se habrá de facilitar copia del informe y las pruebas realizadas en la
revisión post-intervención a los 15 días.

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2.6. En el punto III del ANEXO del Real Decreto, debería constar que en el
tercer supuesto de LO 9/1985 se realizará una autopsia fetal para
confirmar el diagnóstico de riesgo de enfermedad o malformación
realizado previamente a la IVE y deberá incluirse este informe de
autopsia anonimizado en la hoja de notificación de IVE. Estos datos
serán remitidos, a efectos estadísticos, a la administración sanitaria
autonómica.
2.7. En el punto III del ANEXO del Real Decreto, debería constar la creación
y/o mantenimiento obligatorio de una Unidad de Bioética en cada
centro de realización de IVEs, al igual que en los centros hospitalarios,
con la obligación de observación de un código ético y deontológico.

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OTRAS CORRECCIONES PROPUESTAS AL REAL DECRETO
3. En el artículo 2 del Real Decreto, rogamos se incluya y se modifique:
“…de tal manera que se garantice la prestación de la interrupción del
embarazo, en aquellos supuestos y con los requisitos necesarios que prevé
la legislación vigente, respetando en todo caso el derecho a la objeción de
ciencia y de conciencia de los profesionales sanitarios garantizado en el
artículo 16.1 de la Constitución Española”.
La interrupción del embarazo tal y como se contempla en este Real Decreto es
un servicio o prestación de ámbito sanitario y no un derecho en el sentido de la
palabra jurídica. La interrupción del embarazo es un tipo ilícito despenalizado a
fecha de hoy y por ello debe guardarse una coherencia jurídica con las normas
superiores a este Real Decreto tal y como son el código penal vigente (LO
10/1995) y la norma de igual rango del Real Decreto 2409/1986, que, tratando
de este mismo asunto, en ningún momento comete este error jurídico.
4. En el artículo 3 del Real Decreto, punto 3, rogamos añadir “Además, los
datos personales quedarán ocultos bajo un código con numeración
correlativa y única sin saltos numéricos. Este código…”
De esta forma no existirá repetición en el código de la mujer de cada centro o
servicio acreditado para la IVE y la numeración correlativa evitará el fraude
fiscal y estadístico existente actualmente en el número de IVEs realizadas en
los centros.
5. En el artículo 3 del Real Decreto, punto 5 en el último párrafo, rogamos
añadir “…proceda, así como por orden de los Servicios de Inspección de
Sanidad estatales o autonómicos cuando tales datos sean necesarios en el

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ejercicio de la actividad de control e inspección encomendada a tales
servicios.”
Madrid, a 7 de agosto de 2008
Dª Beatriz Mariscal Díaz
Asociación de Víctimas del Aborto (AVA)
G84237155

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ADJUNTO 1
Síntesis de riesgos médicos posibles tras la realización de una IVE para
su inclusión en el consentimiento informado
Revisión actualizada a fecha de julio de 2008 por el Comité Científico de AVA,
desde la Base de Datos de publicaciones médicas PubMed y Medline
EFECTOS SECUNDARIOS FÍSICOS
1. El índice de muerte materna vinculado al aborto es 2.95 veces más
elevado que el de embarazos que llegan al parto en la población de
mujeres de Finlandia entre los 15 y los 49 años de edad. Investigación
realizada en el Centro Nacional de Investigación y Desarrollo para el Bienestar
y la Salud de Finlandia, que concluyó que el embarazo contribuye a la salud de
las mujeres (Autores: Gissler M, Berg C, Bouvier-Colle MH, Buekens P.
Revista: American Journal of Obstetrics and Gynecology 2004, 190:422-427).
2. Las mujeres que se habían practicado abortos tuvieron un índice de
mortalidad casi doble a las controles en los siguientes 2 años, persistiendo
el índice de muerte incrementado elevado durante por lo menos 8 años.
(Autores: Reardon DC, Ney PG, Scheuren F, Cougle J, Coleman PK, Strahan
TW. Deaths associated with pregnancy outcome: a record linkage study of low
income women. Revista: Southern Medical Journal 2002, 95:834-41).
3. Mortalidad de 1.1/100.000 mujeres que abortaron a las 12 semanas de
gestación, investigación realizada por el Departamento de Ginecología y
Obstetricia y Biología de la Reproducción de la Universidad de Paris (Rev Prat.
1995, 45:2361-9).
4. Aparición de muertes sépticas en las usuarias de la RU-486 debido a que
su mecanismo de acción favorece las infecciones por gérmenes especialmente
peligrosos. Recientemente publicado por el Dr. R. Miech de la Brown Medical

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School de Rode Island, EEUU, en julio (Annals of Pharmacotherapy 2005) y por
el equipo del Center for Disease Control and Prevention, Atlanta, EEUU (New
England Journal of Medicine 2005, 353:2352-60).
5. Perforación asociada al aborto provocado hasta un 2% de los casos.
Realizado por el mismo grupo francés del punto 3 (Rev Prat. 1995, 45:2361-9).
6. Trombosis de la vena ovárica con presentación atípica, de Washington
University/Barnes-Jewish Hospital, St. Louis, Missouri, EEUU (Obstet Gynecol.
2000, 96:828-30).
7. El aborto provocado o espontáneo no produce cáncer de mama según los
mejores estudios hasta la fecha, pero está claro que la decisión de retrasar el
embarazo tiene consecuentemente una pérdida de la protección que
aporta éste, con un riesgo neto mayor aumentado, investigación de la
University of North Carolina, EEUU (Lancet 2004, 363: 1007; Obstet Gynecol
Survey 2003, 58:67-79. Review).
8. El aborto provocado por aspiración produce un riesgo aumentado de
pérdida del hijo en el siguiente embarazo, resultados de Shangai Institute of
Planned Parenthood Research, China (International Journal of Epidemiology
2003, 32:449-54).
9. Tras un aborto provocado (curetaje), el riesgo de placenta previa en el
siguiente embarazo y parto prematuro, con posible aborto espontáneo, se
presentó en 3 mujeres con historia de aborto provocado frente a 1 que no había
abortado (OR 2,9, 95% IC 1,0-8,5), resultados del Fred Hutchinson Cancer
Research Center, Division of Public Health Sciences, Seattle, WA, EEUU
(International Journal Gynaecol Obstet. 2003, 81:191-8). Esto se había probado
ya anteriormente en un estudio de la Universidad de Medicina de New Yersey
con un OR de 1,7 (95% IC 1,0-2,9) (American Journal J Obstet Gynecol. 1997,
177:1071-1078).

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10. Las mujeres con antecedente de aborto provocado tuvieron un riesgo
mayor de presentar un recién nacido altamente prematuro. Entre otras
publicaciones, existe una revisión realizada por investigadores de Canadá y
Chicago (B. Rooney y B. Calhoun), que muestra graves incrementos de riesgo
tras un aborto provocado por aspiración frente a controles (OR desde 1.99 y
mayores) (Journal of American Physicians and Surgeons 2003, 2; Bjog. 2005,
112:430-437).
11. En un estudio poblacional de casi 27.000 nacimientos en Finlandia del
Kuopio University Hospital, las madres con antecedentes de abortos
provocados se asociaron con numerosos factores de riesgo para la
maternidad, en concreto, desempleo, estado civil soltera, bajo nivel
educacional, consumo de tabaco y alcohol, sobrepeso y enfermedades
crónicas. Los hijos fueron más frecuentemente prematuros (OR, 1.19; 95% IC
1.01–1.41) en mujeres con un aborto provocado previo (7.3% versus 6.2%) y
fueron de bajo peso (OR, 1.54; 95% IC 1.02–2.32) en mujeres con dos o más
abortos provocados (7.0% versus 4.7%) (Annals of Epidemiology
2006,16(8):587-92).
12. Un aborto previo, provocado o espontáneo, se ha demostrado que no
protege frente a la preeclampsia y la hipertensión gestacional en el
siguiente embarazo; sin embargo, un nacimiento a término previo sí que
protege frente a estas graves situaciones clínicas en el siguiente embarazo a la
mujer (OR 0.41, 95% CI 0.38-0.44). Estudio cohorte del Dr. Xiong y colegas de
la Universidad de Montreal, Québec, Canadá, en colaboración con la
Universidad de Tulane, New Orleans, EEUU (Journal of Reproductive Medicine
2004, 11:899-907).
13. Sánchez Durán en un estudio revisión español publicado en la revista
JANO en el 2000 (número 1349) resume las principales complicaciones de las
que hay que informar a las mujeres en la interrupción voluntaria del embarazo
de primer trimestre. Las complicaciones inmediatas son desgarros
cervicales, perforación uterina, sangrado y persistencia de restos del embrión
dentro del útero. Las complicaciones tardías son las adherencias o sinequias

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uterinas, las cicatrices e incompetencia cervical, que producen parto prematuro
y riego de pérdida aumentada del siguiente hijo.
EFECTOS SECUNDARIOS PSICOLÓGICOS
14. El aborto provocado aumenta los riesgos de alteraciones en el estado
del ánimo (depresión y autolesión), enmarcadas en el síndrome post-aborto,
un estudio de University of North Carolina, EEUU (Obstet Gynecol Survey
2003, 58:67-79).
15. Las mujeres que han sufrido un aborto provocado padecen un síndrome
de estrés generalizado con un 30% más de probabilidad que las que han
llevado adelante su embarazo no deseado. Resultados de Jesse R. Cougle y
colaboradores, publicado en Journal of Anxiety Disorders 2005, 19:137-142.
16. Las mujeres que habían abortado presentaban malestar psicológico
hasta cinco años después de la interrupción, siendo los efectos de evitación,
pesar, angustia y ansiedad mayores en el caso de abortos provocados que
en los espontáneos. Es un estudio reciente de A.N. Broen y col., de la
Universidad de Oslo, en Noruega (BMC Med. 2005, 3:18).
17. El aborto provocado por malformación fetal tiene secuelas igual de graves
que la pérdida de un hijo sano, y la interrupción voluntaria del embarazo en
este supuesto causa aislamiento social y depresión. Son los resultados de
un estudio noruego y otro alemán del Klinik und Poliklinik fur Psychiatrie und
Psychotherapie (Ultrasound Obstet Gynecol. 1997, 9:80-85; Zentralbl Gynakol.
2001, 123:37-41).
18. Se han descrito graves alteraciones en las relaciones sexuales y en el
deseo sexual de numerosas mujeres que abortaron voluntariamente en
estudios de la Universidad de Ginebra, en Polonia y en China (Gynecol Obstet
Invest. 2002, 53:48-53; Pieleg Polozna. 1988, 5:7-9 contd; European Journal of
Obstet Gynecol Reprod Biology 2005). En la reciente investigación de la

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Universidad de China de Hong Kong, se ha detectado que aproximadamente
un tercio de las mujeres del estudio que han abortado provocadamente sufre a
corto plazo una inhibición y un deterioro en su deseo y placer sexual. Además,
un 17% de mujeres se veían mucho menos atractivas tras la interrupción del
embarazo.
19. El equipo de Priscilla K. Coleman del Human Development and Family
Studies, de la Bowling Green State University, EEUU, ha demostrado que las
mujeres con historia de un aborto, espontáneo o provocado, tenían un 99%
más de probabilidad de ejercer abuso físico sobre sus hijos que las que no
habían tenido abortos; si eran varios abortos, el riesgo incrementado era del
189%. Cuando el aborto era provocado, las mujeres tenían un 144% de mayor
riesgo de abuso físico sobre sus hijos (Acta Paediatrica 2005, 94).
20. El equipo de investigación anterior ha demostrado que se presentan en
la gran mayoría de las mujeres tras el aborto graves alteraciones en el
sueño, sobre todo en los 180 días tras el aborto provocado y que éste se
reducía tres años tras el aborto (Sleep, 2005).
21. De nuevo este equipo de P. K. Coleman encontró asociado en las
mujeres que han abortado provocadamente un alto riesgo de consumo de
drogas de abuso de diversos tipos (British Journal of Health Psychology
2005, 10, 255–268). Este hallazgo no se presentaba en las mujeres cuyos
abortos eran espontáneos.

INFORME SOBRE ABORTO POR MALFORMACIÓN Y RIESGO PSICOLÓGICO – AVA - 4-07-2008
1
INFORME SOBRE LA EVIDENCIA CIENTÍFICA DEL RIESGO
PSICOLÓGICO DEL ABORTO PROVOCADO POR DIAGNÓSTICO DE
MALFORMACIONES
Beatriz Mariscal Díaz
Psicóloga Presidenta de la Asociación de Víctimas del Aborto (AVA)
www.vozvictimas.org
equipomedico@vozvictimas.org
Dadas las nuevas evidencias y estudios recientes sobre el trauma tras el
aborto, se ha realizado este Informe sobre la evidencia científica actualizada
del riesgo psicológico que pueden sufrir las madres y padres que abortan a un
hijo por habérsele diagnosticado durante el embarazo un riesgo más o menos
elevado de malformación. Sólo se han empleado artículos científicos
publicados en revistas de alto índice de impacto con revisión doble e indexadas
en la U.S. Nacional Library of Medicine (Pubmed.gov)1
.
En estudios realizados hace ya 8 o más años se demostraba que el aborto
provocado por malformación fetal tiene riesgos psicológicos que es preciso
conocer y a los que había que dar respuesta.
De hecho, cuatro estudios, dos de 1993, y otros de 1997 y 2001 demostraron
que las mujeres que abortaban a un hijo por un diagnóstico prenatal positivo
presentaban secuelas igual de graves que la pérdida de un hijo sano
durante el embarazo o parto, y que la interrupción voluntaria del embarazo en
este supuesto causa aislamiento social y depresión (Iles and Gath 1993;
Zeanah, Dailey et al. 1993; Salvesen, Oyen et al. 1997; Schutt, Kersting et al.
2001).
En dichos estudios se comparaba el estado psicológico posterior de dos grupos
de mujeres: el primer grupo que abortó por malformación y el segundo que
perdió un hijo por aborto espontáneo, ambas pérdidas en el segundo trimestre
de gestación. Los investigadores de estos cuatro trabajos internacionales
alertan de que el aborto supuso en casi todos los casos un trauma. Los
resultados mostraron que la sintomatología no difería entre ambos grupos y
que entre las mujeres cuyo aborto era provocado por malformación – no
espontáneo - un 17% fueron diagnosticadas de depresión mayor y un 23%
precisaron tratamiento psiquiátrico (Zeanah, Dailey et al. 1993).
1
Accesible online en: http://www.ncbi.nlm.nih.gov/sites/entrez/

2
Además, hubo en la década de los 90 otros estudios indicaron el estrés grave
que podía llevar el aborto por malformación y sus graves efectos en la madre y
padre (Di Giusto, Lazzari et al. 1991; White-van Mourik, Connor et al. 1992;
White-Van Mourik, Connor et al. 1992; Kolker and Burke 1993; Lilford, Stratton
et al. 1994).
En los dos estudios de los investigadores de Glasgow se demostró que
después de 2 años tras el aborto por malformación, todavía un 20% de madres
del estudio de 68 matrimonios tenían brotes de llanto, tristeza e
irritabilidad tras el aborto (White-Van Mourik, Connor et al. 1992). Los
maridos también relataron en un porcentaje elevado falta de concentración e
irritabilidad durante el primer año. Además, un 12% de los matrimonios
sufrieron crisis temporales durante este primer año e incluso algún
matrimonio llegó a romperse durante este breve periodo.
Por su parte, otro estudio de Leeds en Reino Unido examinó a 57 parejas que
habían abortado de forma espontánea o provocada por malformación,
ofreciéndoles asesoramiento psicológico de forma aleatoria tras abortar y no
presentar problemas psicológicos graves tras éste (Lilford, Stratton et al. 1994).
Querían evaluar si resultaría clínicamente útil ofrecer el asesoramiento
psicológico a todas las parejas, incluso aquellas que parecían no tener
problemas psicológicos tras el aborto por anomalía fetal. Entre los resultados
cabe destacar que, aunque no pudo demostrarse de forma rotunda que la
intervención del psicólogo que se empleó fuera eficaz, sí resultó de interés
contar con esta asistencia ya que las parejas del grupo con psicoterapia
que la recibieron adecuadamente integraron mejor la pérdida que las que
faltaron a la misma. Además, se encontró sintomatología ligeramente más
grave en las parejas cuyo aborto fue provocado y no espontáneo.
En 1995, el Servicio de Genética del Centro Médico de Investigación Pediátrica
de la Universidad de Montreal, en Québec, Canadá, realizó un estudio
comparativo de las reacciones psicológicas de dos grupos de padres que
abortaron tras el diagnóstico prenatal (Dallaire, Lortie et al. 1995). El primer
grupo de 76 pacientes tenían riesgo familiar de tener un hijo con malformación
y el segundo grupo, de 124, no lo tenían. El sentimiento de culpabilidad tras
el aborto estuvo presente en ambos grupos (29 y 79%, primer y segundo grupo
respectivamente), así como la necesidad de recibir asistencia psiquiátrica
(19 y 7%, respectivamente). La Universidad concluye la necesidad del apoyo
psicológico durante el diagnóstico prenatal dado la gravedad del duelo que
puede presentarse tras el aborto por malformación.

3
¿Cuál es la evidencia científica más relevante y novedosa sobre el tema?
Los siguientes estudios poseen una metodología más adecuada para el estudio
del trauma postaborto por malformación. Por ello se explicarán brevemente con
sus principales resultados.
Un estudio del Centro Universitario Médico de Utrecht en Holanda publicado en
el 2005 examinó a los 2-7 años de la intervención a 151 parejas – madres y
padres - que había abortado por malformación (Korenromp, Page-Christiaens
et al. 2005). Usaron cuestionarios estandarizados de duelo, estrés
postraumático, ansiedad y depresión. Entre los resultados citaban que había
todavía parejas que presentaban puntuaciones patológicas en estas
escalas. Alertaron de que los hombres también presentan estrés postraumático
tras el aborto. Los factores que se asociaron a una mayor sintomatología
fueron el bajo nivel educacional, tiempo de embarazo o edad gestacional mayor
y que la malformación fuera compatible con la vida, entre otros.
En el mismo centro y ese mismo año, dicho equipo publicó otro trabajo, esta
vez examinando a 254 mujeres entre 2 y 7 años del aborto por malformación
(Korenromp, Christiaens et al. 2005). En este caso, un 17,3% de mujeres
presentaron puntuaciones patológicas de estrés postraumático, con lo
cual los investigadores concluyeron alertando que el aborto provocado por
malformación se asocia fuertemente a secuelas de larga duración para un
número elevado de mujeres. De nuevo se asociaron las mismas características
enumeradas arriba para presentar mayor sintomatología.
El estudio más reciente de este equipo experto del Centro Universitario Médico
de Utrecht ha sido publicado en el 2007, y ha examinado 217 mujeres y 169
varones a los 4 meses del aborto de sus hijos con malformación (Korenromp,
Page-Christiaens et al. 2007). Se han demostrado altos niveles de síntomas
de estrés postraumático (44 y 22% para mujeres y hombres,
respectivamente) y de depresión (28 y 16%, respectivamente)(Korenromp,
Page-Christiaens et al. 2007). Se señaló en el estudio que eran factores de
riesgo para presentar mayores problemas psicológicos, entre otros, haber
dudado en su toma de decisión, la edad gestacional elevada y la baja
autoconfianza. Además, tan sólo a los 4 meses del aborto por
malformación, ya un 2% de las madres estaban arrepentidas de haber
abortado.

4
En España cada año se encuentran en riesgo de sufrir este trauma más de
6.000 personas sumando madres y padres.
Con todos estos datos de estudios internacionales, AVA indica que resulta
relevante e imprescindible la inclusión de estas secuelas demostradas en los
consentimientos informados que firman las madres y padres previamente a la
intervención en los centros acreditados para el aborto provocado. Estos
documentos son obligatorios por la Ley 14/1986 y la Ley 41/2002 y entregar
con la suficiente antelación para comprender las consecuencias posibles, con
lo que debería proporcionarse al menos con 24 horas de antelación a la
intervención (tal y como se recomienda en otras intervenciones quirúrgicas).
Además es un deber sanitario facilitar la asistencia psicológica y psiquiátrica a
todos los padres tras un aborto por malformación durante la elaboración del
duelo.
Vistos los porcentajes de sintomatología de estrés postraumático y depresión
demostrados (al menos en un 44 y 28%, respectivamente, en mujeres a los 4
meses del aborto; y al menos en un 17,3% para el estrés postraumático de los
2 a 7 años tras el aborto), resulta gravemente contrario al beneficio de la
salud de los padres no alertar previamente de estos riesgos y ocultar la
posibilidad de que se precise elaborar el duelo por la pérdida fetal.

5
BIBLIOGRAFÍA EMPLEADA CON LOS RESÚMENES DE LAS PUBLICACIONES
Dallaire, L., G. Lortie, et al. (1995). "Parental reaction and adaptability to the prenatal diagnosis
of fetal defect or genetic disease leading to pregnancy interruption." Prenat Diagn 15(3): 249-
59.
The objective of the study was to evaluate the psychological reaction of two groups of
parents to a pregnancy termination after they had undergone a prenatal diagnostic
procedure. The analysis involved interviews with a study group of 76 patients who were
at risk of giving birth to a child with a genetic disease or defect and a comparison group
of 124 who had a pregnancy termination after a major anomaly had been detected by
routine ultrasound and who were not at known risk for a genetic disease. Only patients
in the study group had received counselling before the prenatal diagnosis and were
aware that the fetus could be affected. The overall reaction of the comparison group
was one of shock, denial of fetal abnormality, and guilt over 'abandoning the fetus'. A
feeling of guilt was expressed by patients in the comparison group (73 per cent versus
29 per cent) in the period immediately following the interruption. One-third of patients in
both groups felt obliged to undergo a therapeutic abortion. More patients in the study
group than in the comparison group expressed the need to see a psychiatrist at the time
of the study (19 per cent versus 7 per cent) and viewed future pregnancies as a
replacement for the lost pregnancy (63 per cent versus 19 per cent). The
recommendations of the study focus on information sessions to personnel, nursing
support, analgesia during the expulsion period, an atmosphere of respect that should be
present at the time that the fetus is viewed, the anticipation of mourning, and the long-
term follow-up of the couple to ensure that counselling for future pregnancies and
psychological support are provided when needed.
Di Giusto, M., R. Lazzari, et al. (1991). "Psychological aspects of therapeutic abortion after early
prenatal diagnosis." Clin Exp Obstet Gynecol 18(3): 169-73.
The early discovery of a fetal pathology creates a "crisis" situation fraught with psychic
problems for the couple who must live through it. The Authors observed a group of
patients in the second trimester of pregnancy. They had all requested therapeutic
abortion since serious malformation of the fetus had been confirmed. By means of a
questionnaire constructed for the purpose, certain characteristics of fetal malformation
and of pregnancy were evidenced, as well as the way these were experienced by the
patients. The immediate and delayed reactions to the diagnosis of malformation were
also studied, as was the experience lived when faced with the choice of abortion.
Iles, S. and D. Gath (1993). "Psychiatric outcome of termination of pregnancy for foetal
abnormality." Psychol Med 23(2): 407-13.
Termination of pregnancy for foetal abnormality has become frequent with the
increasing sophistication of techniques of antenatal diagnosis. The aim of this study
was to obtain quantitative and qualitative information about psychiatric morbidity in
women after termination of pregnancy for foetal abnormality. Two samples of women
were compared. The first consisted of 71 women who had had a termination of
pregnancy for foetal abnormality (FA group). The second consisted of 26 women who
had experienced so-called missed abortion (MA group). Both groups had lost a
pregnancy in the mid-trimester of pregnancy, but the MA group had no element of
choice. Standardized psychiatric and social measures were used to assess both groups
on three occasions after the termination. In both groups, 4 weeks after the termination
psychiatric morbidity was high (four to five times higher than in the general population of
women), and social adjustment was impaired. Six months and 12 months after the
abortion, levels of psychiatric morbidity were near normal. Semi-structured interviewing
was used to obtain information about the experience of grief after mid-trimester
termination. For many women, symptoms of grief persisted throughout the year. These
symptoms included typical features of grief as well as grief symptoms specific to
pregnancy loss. The findings have implications for the counselling of women after
termination for foetal abnormality or after missed abortion.

6
Kolker, A. and B. M. Burke (1993). "Grieving the wanted child: ramifications of abortion after
prenatal diagnosis of abnormality." Health Care Women Int 14(6): 513-26.
Prenatal diagnosis is increasingly common. Whereas amniocentesis is typically
performed in the second trimester, chorionic villus sampling (CVS) is a first-trimester
procedure, which makes an earlier, safer abortion possible. However, CVS carries a
slightly higher risk of miscarriage and other complications. In choosing a procedure,
couples (with the aid of genetic counseling) must weigh the risks of miscarriage against
the odds and implications of an abnormal diagnosis. Interviews with women who
decided on abortions after amniocentesis or CVS and meetings with genetic counselors
indicate that both types of abortion are more traumatic than is commonly realized. Both
dash dreams and hopes. Termination after amniocentesis also forces the mother to
take an active part in the life and death of a nearly viable fetus. Yet, because abortions
for fetal abnormality are statistically rare, there is little societal understanding and
minimal support for those who experience them. This is true of health care workers as
well as for the couple's primary support group.
Korenromp, M. J., G. C. Christiaens, et al. (2005). "Long-term psychological consequences of
pregnancy termination for fetal abnormality: a cross-sectional study." Prenat Diagn 25(3): 253-
60.
OBJECTIVE: We examined women's long-term psychological well-being after
termination of pregnancy (TOP) for fetal anomaly in order to identify risk factors for
psychological morbidity. METHODS: A cross-sectional study was performed in 254
women, 2 to 7 years after TOP for fetal anomaly before 24 weeks of gestation. We used
standardised questionnaires to investigate grief, posttraumatic symptoms, and
psychological and somatic complaints. RESULTS: Women generally adapted well to
grief. However, a substantial number of the participants (17.3%) showed pathological
scores for posttraumatic stress. Low-educated women and women who had
experienced little support from their partners had the most unfavourable psychological
outcome. Advanced gestational age at TOP was associated with higher levels of grief,
and posttraumatic stress symptoms and long-term psychological morbidity was rare in
TOP before 14 completed weeks of gestation. Higher levels of grief and doubt were
found if the fetal anomaly was presumably compatible with life. CONCLUSION:
Termination of pregnancy for fetal anomaly is associated with long-lasting
consequences for a substantial number of women. Clinically relevant determinants are
gestational age, perceived partner support, and educational level.
Korenromp, M. J., G. C. Page-Christiaens, et al. (2005). "Psychological consequences of
termination of pregnancy for fetal anomaly: similarities and differences between partners."
Prenat Diagn 25(13): 1226-33.
OBJECTIVE: We examined the psychological responses to termination of pregnancy
(TOP) for fetal anomaly from both men and women. The aim was to find risk factors for
poor psychological outcome both for the individuals and for the couple. METHODS: A
cross-sectional study was performed in 151 couples 2-7 years after TOP. We used
standardized and validated questionnaires to investigate grief, symptoms of
posttraumatic stress, somatic complaints, anxiety, and depression. RESULTS: Most
couples adapted well to their loss, although several patients had pathological scores on
posttraumatic stress symptoms and depression. Differences between men and women
were slight. Higher education, good partner support, earlier gestational age, and life-
incompatibility of the disorder positively influenced the outcomes, more for women than
for men. Men and women with pathological scores rarely had such scores
simultaneously. CONCLUSION: We emphasize the importance of equally involving both
parents in the counselling because the outcomes of grief and posttraumatic stress
symptoms between men and women only moderately differ and post-TOP
psychopathology occurs in men as well. Good adjustment to TOP in women seems
dependent on the level of support that they perceive from their partners. The intracouple
results of the study suggest a mutual influence in the process of grieving between the
partners.

7
Korenromp, M. J., G. C. Page-Christiaens, et al. (2007). "A prospective study on parental
coping 4 months after termination of pregnancy for fetal anomalies." Prenat Diagn 27(8): 709-
16.
OBJECTIVE: To identify short-term factors influencing psychological outcome of
termination of pregnancy for fetal anomaly, in order to define those patients most
vulnerable to psychopathology. STUDY DESIGN: A prospective cohort of 217 women
and 169 men completed standardized questionnaires 4 months after termination.
Psychological adjustment was measured by the Inventory of Complicated Grief (ICG),
the Impact of Event Scale (IES), the Edinburgh Postnatal Depression Scale (EPDS),
and the Symptom Checklist-90 (SCL-90). RESULTS: Women and men showed high
levels of posttraumatic stress (PTS) symptoms (44 and 22%, respectively) and
symptoms of depression (28 and 16%, respectively). Determinants of adverse
psychological outcome were the following: high level of doubt in the decision period,
inadequate partner support, low self-efficacy, lower parental age, being religious, and
advanced gestational age. Whether the condition was Down syndrome or another
disability was irrelevant to the outcome. Termination did not have an important effect on
future reproductive intentions. Only 2% of women and less than 1% of men regretted
the decision to terminate. CONCLUSION: Termination of pregnancy (TOP) for fetal
anomaly affects parents deeply. Four months after termination a considerable part still
suffers from posttraumatic stress symptoms and depressive feelings. Patients who are
at high risk could benefit from intensified support.
Lilford, R. J., P. Stratton, et al. (1994). "A randomised trial of routine versus selective
counselling in perinatal bereavement from congenital disease." Br J Obstet Gynaecol 101(4):
291-6.
OBJECTIVE: To find out whether routine counselling improves psychological wellbeing
after bereavement for fetal abnormality. DESIGN: A randomised trial among bereaved
couples who did not demonstrate any unexpected strain or psychopathology after
bereavement. SETTING: St. James's University Hospital, Leeds. SUBJECTS: Fifty-
seven couples. INTERVENTIONS: Independent counselling by an experienced
psychotherapist. MAIN OUTCOME MEASURES: Self-administered questionnaires
measuring grief, anxiety and depression and a structured psychological interview 16 to
20 months after the loss. Anniversaries of a death or expected birth date were avoided.
RESULTS: There were no differences in outcome between women randomised to the
study group or randomised to the control group with respect to grief, anxiety, depression
or the results of the structured overview. Among those in the randomised study group,
women who attended for counselling had a much better outcome than women who
defaulted from counselling. Overall, women who underwent termination of pregnancy
did slightly worse than those who had experienced stillbirth or neonatal death. On an
informal basis, the clinician concerned believes that he was better able to help
bereaved couples as a result of feedback and criticism from the independent counsellor.
CONCLUSIONS: (1) The hypothesis that all couples should have independent
counselling after prenatal loss for congenital abnormality is unproven, but it is likely that
clinicians can benefit from feedback from a counsellor; (2) it is possible that termination
of pregnancy is more psychopathogenic than other forms of fetal loss; (3) people who
attend for their counselling sessions are probably inherently better able to adjust to
bereavement; (4) trials of psychological intervention are feasible, but follow up is either
difficult to achieve or expensive.
Salvesen, K. A., L. Oyen, et al. (1997). "Comparison of long-term psychological responses of
women after pregnancy termination due to fetal anomalies and after perinatal loss." Ultrasound
Obstet Gynecol 9(2): 80-5.
The objective of the study was to compare psychological responses of women following
a pregnancy termination due to ultrasound-detected fetal anomalies (ultrasound group)
with the psychological responses of women following a late spontaneous abortion or a
perinatal death (perinatal loss group). The assessments, which were performed on four
occasions in the year after the life event, included Montgomery and Asberg Depression
Rating Scale, Goldberg General Health Questionnaire, Impact of Event Scale, State-
Trait Anxiety Inventory and Schedule for Recent Life Events. In the acute phase, a few
days after the life event, the women in the ultrasound group reported statistically

8
significantly less depressive symptoms and less intrusion and avoidance symptoms
than the perinatal loss group. No differences in psychological responses in the two
groups were found at the examinations at approximately 7 weeks, 5 months or 1 year. A
statistically significantly higher proportion of women in the ultrasound group reported
that they had tried to become pregnant in the following year. A few subjects in each
group reported persisting high psychological distress throughout the year, but only one
woman fulfilled the criteria of a post-traumatic stress disorder. It is concluded that the
long-term psychological stress response in women to pregnancy termination following
ultrasonographic detection of fetal anomalies does not differ from the stress responses
seen in women experiencing a perinatal loss.
Schutt, K., A. Kersting, et al. (2001). "[Termination of pregnancy for fetal abnormality--a
traumatic experience?]." Zentralbl Gynakol 123(1): 37-41.
The diagnosis of a lethal anomaly of the fetus can affect a pregnant woman in a
traumatic way. Almost immediately she has to decide whether she wishes the
pregnancy to be terminated or not. Literature shows that such a loss is very difficult to
cope with, and can lead to social isolation and depression. Contrary to popular belief
the loss felt by the woman is at least the same to that following a stillbirth. Problems
arise when the woman has difficulties in expressing her feelings, has a lack of self-
esteem or receives very little social support. The prenatal diagnosis evokes an acute
grief reaction. Only few studies are available regarding length, course and severity of
grief in this case. Although an abortion through a fetal anomaly is a traumatic
experience, research is vague on the trauma caused. Present day research of the
psychological sequelae after the termination will be summarized. In respect to the
current trauma-research lies the question of which psychiatric conditions arise from
such a traumatic experience.
White-van Mourik, M. C., J. M. Connor, et al. (1992). "The psychosocial sequelae of a second-
trimester termination of pregnancy for fetal abnormality." Prenat Diagn 12(3): 189-204.
A retrospective study to investigate the psychosocial sequelae of a second-trimester
termination of pregnancy (TOP) for fetal abnormality (FA) is described. After appropriate
consent was obtained, 84 women and 68 spouses were visited 2 years after the event
and asked to complete an extensive questionnaire. Most couples reported a state of
emotional turmoil after the TOP. There were differences in the way couples coped with
this confusion of feelings. After 2 years about 20 per cent of the women still complained
of regular bouts of crying, sadness, and irritability. Husbands reported increased
listlessness, loss of concentration, and irritability for up to 12 months after the TOP. In
the same period, there was increased marital disharmony in which 12 per cent of the
couples separated for a while and one couple obtained a divorce. These problems
could be attributed to a lack of synchrony in the grieving process. Confusing and
conflicting feelings led to social isolation and lack of communication. Difficulties in
coming to terms with the fetal loss were not found to be linked to the type of fetal
abnormality or religious beliefs but were related to parental immaturity, inability to
communicate needs, a deep-rooted lack of self-esteem before the pregnancy, lack of
supporting relationships, and secondary infertility. Suggestions for improved
management are given.
White-Van Mourik, M. C., J. M. Connor, et al. (1992). "The psychosocial sequelae of a second
trimester termination of pregnancy for fetal abnormality over a two year period." Birth Defects
Orig Artic Ser 28(1): 61-74.
Zeanah, C. H., J. V. Dailey, et al. (1993). "Do women grieve after terminating pregnancies
because of fetal anomalies? A controlled investigation." Obstet Gynecol 82(2): 270-5.
OBJECTIVE: To test the hypothesis that grief responses do not differ between women
who terminate their pregnancies for fetal anomalies and women who experience
spontaneous perinatal losses. METHODS: A case-control study was conducted.
Twenty-three women who underwent terminations through the genetics service of a
tertiary referral obstetric hospital from January 1991 to April 1992 were assessed
psychiatrically 2 months after the termination. The grief responses of these women on
the Perinatal Grief Scale and the Beck Depression Inventory were compared to a

9
demographically similar group of women assessed 2 months after they experienced
spontaneous perinatal loss. Differences between the groups were assessed through
one-way analysis of covariance. RESULTS: After matching women in the two groups, it
became clear that women who terminated for fetal anomalies were significantly older
than women in the comparison group, and age was inversely correlated with intensity of
grief. Therefore, age was covaried in comparing the grief responses of women in the
two groups. Neither statistically significant nor clinically meaningful differences were
found in symptomatology between the groups. By the time of assessment, four of 23
women (17%) who terminated their pregnancies were diagnosed with a major
depression, and five of 23 (22%) had sought psychiatric treatment. CONCLUSIONS:
Women who terminate pregnancies for fetal anomalies experience grief as intense as
those who experience spontaneous perinatal loss, and they may require similar clinical
management. Diagnosis of a fetal anomaly and subsequent termination may be
associated with psychological morbidity.

16
ADJUNTO 2
Síntesis sobre la relación entre violencia de género y embarazo
SÍNTESIS DE LA EVIDENCIA CIENTÍFICA DISPONIBLE A FECHA DE
JULIO DE 2008
FUENTE: DOCUMENTOS OFICIALES DEL MINISTERIO DE SANIDAD Y
CONSUMO
El Ministerio de Sanidad y Consumo en su protocolo para la detección de la
violencia desde la atención primaria, en su edición de 20031
y en la reciente de
abril de 2007, señala como factor de sospecha de sufrir violencia la existencia
de abortos involuntarios y provocados en el historial clínico. Además, el
embarazo se considera, junto con otras situaciones, factor de riesgo para sufrir
dicha violencia2
.
En el Documento del Ministerio de Sanidad y Consumo del año 2003, se señala
que el primer episodio de violencia doméstica ocurre en el primer año de
matrimonio en casi la mitad de los casos y en muchos de ellos en el primer
embarazo. Se señala en este documento médico que hay hombres que viven el
embarazo como una amenaza para su dominio.
Además, se señaló como vital para prevenir la violencia de género desde la
Atención Primaria, el hecho de identificar situaciones de riesgo o mayor
vulnerabilidad, citando como resumen las siguientes: abuso de alcohol,
1
Violencia Doméstica. Grupo de Salud Mental del Programa de Actividades de Prevención y
Promoción de la Salud (PAPPS) de la Sociedad Española de Medicina de Familia y
Comunitaria (semFYC) Ministerio de Sanidad y Consumo. 2003.
http://www.msc.es/ciudadanos/violencia/docs/VIOLENCIA_DOMESTICA.pdf
2
Protocolo común para la actuación sanitaria ante la violencia de género. Comisión Contra la
Violencia de Género del Consejo Interterritorial del Sistema Nacional de Salud. Ministerio de
Sanidad y Consumo. 2007.
http://www.msc.es/organizacion/sns/planCalidadSNS/pdf/equidad/protocoloComun.pdf

17
pérdida de empleo, consumo de drogas, embarazo, conflictos, pérdidas o
fracasos, separación, disfunción familiar.
La trabajadora social y directora de la ONG Mujeres, Solidaridad y
Cooperación, Belarmina Martínez, ha señalado recientemente que el 35% de
las mujeres recibe su primera paliza en situación de embarazo.
Además, según el último informe estadístico de interrupciones del embarazo
publicado por el Ministerio de Sanidad, un 30% de las mujeres que abortan son
casadas y un 70% son solteras. En 50.402 casos (50%), las mujeres
embarazadas no convivían en pareja. Lo más grave es que en 12.890 de los
casos “no existe” pareja o sustentador principal al preguntársele por este hecho
y en 14.434 casos no consta la situación laboral del padre. Así, se puede
concluir que en el 26,9% de los casos, las mujeres que abortaron en el 2006 no
tenían ningún apoyo económico de su pareja.
FUENTE: ESTUDIOS INTERNACIONALES
Las últimas encuestas internacionales revelan que de un 3% a un 17% de las
embarazadas sufren violencia de género durante su embarazo3
.
El homicidio se considera la primera causa de muerte materna4
. El grupo que
tiene mayor riesgo de sufrir violencia de género son las adolescentes
embarazadas y las mujeres con embarazos no planificados. De hecho un
estudio del año 2000 reveló que las mujeres con embarazos no planificados
3
Jeanjot I, Barlow P, Rozenberg S. Domestic violence during pregnancy: survey of patients and
healthcare providers. J Womens Health (Larchmt). 2008 May;17(4):557-67.
4
Chambliss LR. Intimate partner violence and its implication for pregnancy. Clin Obstet
Gynecol. 2008 Jun;51(2):385-97.

18
tenían un riesgo 2,5 veces mayor de sufrir abuso físico frente a las
embarazadas con embarazos “planificados”5
.
Un estudio de Fisher y colaboradores (2005)6
de la Universidad de Ontario, ha
detectado como factor de riesgo para que se realicen más de dos abortos
provocados el sufrir abuso psicológico y físico de la pareja. Adjuntamos dicho
artículo por su especial relevancia.
Algunos estudios han encontrado una asociación entre la violencia y problemas
a lo largo del embarazo entre los que se encuentran retraso en la asistencia,
mayor número de abortos, partos prematuros y riesgo de recién nacidos con
bajo peso7
. De hecho, estudios recientes han confirmado que las mujeres que
sufren violencia física y psicológica durante el embarazo tienen mayor riesgo
de aborto espontáneo8
.
La violencia doméstica durante el embarazo es una agresión que pone en
peligro no sólo una sino dos vidas. Se detalla en un estudio que si bien en la
mayor parte de la violencia doméstica los golpes van dirigidos a la cabeza de la
víctima, durante el embarazo estos también van dirigidos a los senos, el
abdomen o los genitales9
.
5
Goodwin, J.A. Gazmararian, C.H. Johnson, B.C. Gilbert, L.E. Saltzman and The PRAMS
Working Group. Pregnancy intendedness and physical abuse around the time of pregnancy:
findings from the pregnancy risk assessment monitoring system, 1996–1997, Maternal and
Child Health Journal 4 (2) (2000), pp. 85–92.
6
Fisher WA, Singh SS, Shuper PA, Carey M, Otchet F, MacLean-Brine D, Dal Bello D, Gunter
J. Characteristics of women undergoing repeat induced abortion. CMAJ. 2005 Mar
1;172(5):637-41.
7
Gin NE, Rucker L, Frayne S et al. Prevalence of domestic violence among patiens in three
ambulatory care internal medicine clinics. J.Gen Int Med 1991;6:317-322.
8
Morland LA, Leskin GA, Block CR, Campbell JC, Friedman MJ. Intimate partner violence and
miscarriage: examination of the role of physical and psychological abuse and posttraumatic
stress disorder. J Interpers Violence. 2008 May;23(5):652-69.
9
Bewley, C. Coping with Domestic Violence During Pregnancy. Nursing Standard, 8:1994

19
Una encuesta norteamericana realizada por el Centro de Control y Prevención
de Enfermedades de los Estados Unidos en el año 2002 demuestra que el
embarazo incrementa el riesgo de violencia doméstica en un 60,6%.
En Canadá se estima que 1 de cada 7 mujeres sufre maltrato y en el 40% de
las víctimas se inicia durante el primer embarazo.
RECOMENDACIÓN DE EFECTUAR DETECCIÓN DE VIOLENCIA DE
GÉNERO EN EL PROCESO DEL ABORTO PROVOCADO
La violencia está especialmente patente entre los adolescentes que abortan, en
comparación con los que continúan su embarazo, tal y como demuestra un
reciente estudio de Québec que encontró el triple de riesgo de ser víctima de
violencia en las adolescentes que abortaron frente a las que tuvieron a sus
hijos10
.
Se ha propuesto por ello en el estudio anterior y en decenas de recientes
publicaciones, entre ellas una del Departmento de Ciencias de la Salud Pública
del Karolinska Institute de Estocolmo (Suecia)11
y otra del Departamento de
Ginecología de la Universidad Kaiser de Carolina del Norte (EE.UU.) del
200712
, que los centros de ginecología y de realización de abortos descarten
siempre la violencia de género en toda gestante.
10
Bourassa D, Bérubé, J. The prevalence of intimate partner violence among women and
teeegers seeking abortion compared with those continuing pregnancy. J Obstet Gynaecol Can.
2007 May;29(5):415-23.
11
Emenike E, Lawoko S, Dalal K. Intimate partner violence and reproductive health of women in
Kenya. Int Nurs Rev. 2008 Mar;55(1):97-102. ADJUNTO.
12
Gunter J. Intimate partner violence. Obstet Gynecol Clin North Am. 2007 Sep;34(3):367-88,
ix-x. Review.

20
Adjuntamos íntegro el artículo del Karolinska Institute por su especial
relevancia. El estudio vincula estadísticamente en una amplia muestra de
Kenya la violencia de género con los abortos provocados.
Por otra parte, en el artículo de la Universidad Kaiser, los prestigiosos autores
indican que es preceptivo descartar la violencia de género en toda mujer con
pareja, especialmente durante el embarazo13
.
13
En el resumen de la publicación, destacan los autores: “Intimate partner violence (IPV) has a lifetime
prevalence of approximately 60% and is a leading cause of morbidity and mortality for women of all
reproductive ages, especially among younger women and during pregnancy. Providers should recognize
that every woman who has ever been partnered is at risk for IPV and should screen appropriately.”

CMAJ • MAR. 1, 2005; 172 (5) 637
© 2005 CMA Media Inc. or its licensors
Research
Recherche
R
epeat pregnancy termination procedures are com-
mon in Canada (where 35.5% of all induced abor-
tions are repeat procedures)1,2
and the United
States (where 48% of induced abortions are repeat proce-
dures).3–7
Rates of repeat induced abortion increased in
both countries for an initial period after abortion was le-
galized, as a result of an increase in the number of women
who had access to a first, and consequently to repeat, legal
induced abortion.1,6,8,9
At present, rates of initial and repeat
abortion in Canada and the United States appear to be
stabilizing.2,7
Research concerning characteristics of women who un-
dergo repeat induced abortions has been limited in scope.
In a literature search we identified fewer than 20 studies in
this area published over the past 3 decades. However, avail-
able research has shown several consistent findings. Wo-
men undergoing repeat abortions are more likely than
those undergoing a first abortion to report using a method
of contraception at the time of conception.7,8,10,11
In addi-
tion, women seeking repeat abortions report more chal-
lenging family situations than women seeking initial abor-
tions: they are more likely to be separated, divorced,
widowed or living in a common-law marriage, and to re-
port difficulties with their male partner.1,5,8,11,12
They also are
older,7,13
have more children1,5,13
and are more often non-
white7,11,13
than women seeking initial abortions.
There is little evidence to suggest that women seeking
repeat abortion are using pregnancy termination as a meth-
od of birth control.1,5,6,8,11
Evidence also does not indicate
that women seeking repeat abortion are psychologically
maladjusted.8,13
Our literature review showed that many studies of re-
peat abortion are 20 to 30 years old and are based on data
collected when abortion was a newly legalized procedure.5,11
Furthermore, in studies of correlates of repeat abortion the
investigators did not examine a range of personality charac-
teristics that are known to influence women’s reproductive
health outcomes,14,15
including attitudes about sexuality,14
health locus of control,16,17
degree of social integration,16
at-
titudes about contraception18,19
and history of sexual or
physical abuse.20–22
The objective of the current study was to
identify characteristics of women who undergo repeat in-
duced abortion.
Characteristics of women undergoing repeat
induced abortion
William A. Fisher, Sukhbir S. Singh, Paul A. Shuper, Mark Carey, Felicia Otchet,
Deborah MacLean-Brine, Diane Dal Bello, Jennifer Gunter
Abstract
Background: Although repeat induced abortion is common, data
concerning characteristics of women undergoing this proce-
dure are lacking. We conducted this study to identify the char-
acteristics, including history of physical abuse by a male part-
ner and history of sexual abuse, of women who present for
repeat induced abortion.
Methods: We surveyed a consecutive series of women presenting
for initial or repeat pregnancy termination to a regional
provider of abortion services for a wide geographic area in
southwestern Ontario between August 1998 and May 1999.
Self-reported demographic characteristics, attitudes and prac-
tices regarding contraception, history of relationship violence,
history of sexual abuse or coercion, and related variables were
assessed as potential correlates of repeat induced abortion.
We used χ2
tests for linear trend to examine characteristics of
women undergoing a first, second, or third or subsequent
abortion. We analyzed significant correlates of repeat abortion
using stepwise multivariate multinomial logistic regression to
identify factors uniquely associated with repeat abortion.
Results: Of the 1221 women approached, 1145 (93.8%) consented
to participate. Data regarding first versus repeat abortion were
available for 1127 women. A total of 68.2%, 23.1% and 8.7% of
the women were seeking a first, second, or third or subsequent
abortion respectively. Adjusted odds ratios for undergoing repeat
versus a first abortion increased significantly with increased age
(second abortion: 1.08, 95% confidence interval [CI] 1.04–1.09;
third or subsequent abortion: 1.11, 95% CI 1.07–1.15), oral con-
traceptive use at the time of conception (second abortion: 2.17,
95% CI 1.52–3.09; third or subsequent abortion: 2.60, 95% CI
1.51–4.46), history of physical abuse by a male partner (second
abortion: 2.04, 95% CI 1.39–3.01; third or subsequent abortion:
2.78, 95% CI 1.62–4.79), history of sexual abuse or violence
(second abortion: 1.58, 95% CI 1.11–2.25; third or subsequent
abortion: 2.53, 95% CI 1.50–4.28), history of sexually transmit-
ted disease (second abortion: 1.50, 95% CI 0.98–2.29; third or
subsequent abortion: 2.26, 95% CI 1.28–4.02) and being born
outside Canada (second abortion: 1.83, 95% CI 1.19–2.79; third
or subsequent abortion: 1.75, 95% CI 0.90–3.41).
Interpretation: Among other factors, a history of physical or sex-
ual abuse was associated with repeat induced abortion. Pres-
entation for repeat abortion may be an important indication to
screen for a current or past history of relationship violence and
sexual abuse.
DOI:10.1503/cmaj.1040341
CMAJ 2005;172(5):637-41
ß See related article page 653

Methods
We surveyed a consecutive series of women presenting for in-
duced abortion at the London Health Sciences Centre, London,
Ont., the regional provider of abortion services for a wide geo-
graphic area, between August 1998 and May 1999. Women were
given a description of the study at the beginning of their initial
appointment at the clinic and were asked to consider participat-
ing. They were assured that their identity and responses would re-
main confidential and that their decision concerning participation
would not affect their care in any way. Participants completed a
confidential self-report questionnaire in a private setting at the
clinic before receiving any counselling or other intervention.
These procedures were approved by the University of Western
Ontario’s Office of Research Ethics.
The participants completed a 65-item self-report question-
naire. We developed this instrument on the basis of the research
literature1,7,8,15–18
as a means of collecting data concerning correlates
of repeat induced abortion with a brief assessment that could be
administered readily in a clinical setting. Most questionnaire items
represented face-valid single-item self-reports of demographic or
personal characteristics that were developed and pilot tested spe-
cifically for this investigation and in accordance with standard
procedures for research in this area.18,23,24
The questionnaire included initial items assessing the woman’s
demographic characteristics, relationship status, and reports of re-
lationship conflict, a history of sexual abuse or coercion, or physi-
cal abuse by a male partner at any time in the past. Subsequent
items assessed attitudes and practices regarding contraception, in-
cluding method of contraception (if any) used at the time of con-
ception, whether the woman had missed taking any birth control
pills during the month that conception occurred, whether she had
taken formal sex education classes in high school, and history of
STD and HIV testing. Self-report items also sought information
regarding past pregnancy and abortion.
We used one-way analysis of variance to compare the mean
age of women presenting for first, second, or third or subsequent
abortions and χ2
tests for linear trend to examine other character-
istics. Conceptually and clinically significant correlates of repeat
induced abortion were then entered into a stepwise multivariate
multinomial logistic regression to identify factors that were sig-
nificantly and uniquely associated with number of induced abor-
tions.25
This analysis allows for a reference category (women pre-
senting for a first abortion) to be compared with 2 or more other
reference categories (women presenting for a second abortion
and women presenting for a third or subsequent abortion). Char-
acteristics are entered into the regression analysis beginning with
the characteristic most strongly associated with the reference cat-
egory, and additional characteristics are added in order of de-
creasing strength of association until a characteristic is entered
that is not significantly associated with the reference categories
under study.25
Results
Of the 1221 women approached, 1145 (93.8%) provided
informed consent to participate in the study. Data for 18
women were excluded from the statistical analyses owing to
missing responses that precluded stratification into initial
versus repeat abortion categories, resulting in a final sample
of 1127. Of the 1127 women, 769 (68.2%) were undergo-
ing a first induced abortion, 260 (23.1%) a second abortion,
and 98 (8.7%) a third or subsequent abortion. The partici-
pants were young (mean age 23.65 years [standard devia-
tion (SD) 6.36 years]), primarily white (971 [86.2%]) and
primarily Canadian born (962 [85.4%]).
More than a quarter of the participants (288 [26.4%])
reported significant conflict in their relationship with the
man involved in their pregnancy, and 1 in 5 (218 [19.5%])
reported having been physically abused at least once by a
male partner. More than a quarter (301 [27.0%]) reported
that they had experienced sexual abuse or sexual violence at
least once in the past.
Most of the participants (1013 [90.1%]) had used con-
traception at some point in the past. Although most (947
[87.8%]) felt that oral contraception is a good form of birth
control, more than half (565 [52.6%]) felt that the best
form of birth control would be one that they did not have
to remember to take. Nearly 1 in 5 women (196 [18.3%])
indicated that they sometimes could not afford to buy their
method of birth control. More than half (616 [55.3%]) re-
ported that they or their partner had been using a method
of birth control at the time of conception, with use of con-
doms (371 [60.2%]) and orally administered contraceptives
(244 [39.6%]) predominating.
Women seeking a second abortion (mean age 25.3 [SD
6.2] years) or a third or subsequent abortion (mean age 26.7
[SD 5.7] years) were significantly older than those seeking a
first abortion (mean age 22.7 [SD 6.3] years) (p < 0.05,
Tukey’s honestly significant difference test).26
Women un-
dergoing repeat abortion were also more likely than those
undergoing a first abortion to be born outside Canada and
to be black or of Middle Eastern ethnicity (p < 0.025)
(Table 1).
Women undergoing repeat abortion were more likely
than those seeking a first abortion to report having been
physically abused by a male partner, having experienced
sexual abuse or sexual violence (p < 0.001) and having expe-
rienced substantial conflict with the man involved in their
current pregnancy (p < 0.01). They were less likely to re-
port that they had “lots of friends” (p < 0.001), were a “tra-
ditional woman” (p < 0.025) and had “lots of plans for the
future” (p < 0.001).
Women presenting for repeat abortion were less likely
than those seeking an initial abortion to report that they
had had formal sex education (p < 0.001). They were more
likely to have had an STD, to have undergone HIV testing
and to have given birth (p < 0.001).
Finally, women presenting for repeat abortion were
more likely than those presenting for a first abortion to re-
port that they had used birth control at some point (p <
0.001), that they or their partner were using birth control
at the time of conception (p < 0.05) and that they were us-
ing the birth control pill when conception occurred (p <
0.001). (Note, however, that reports of having missed pills
during the month in which conception occurred did not
Fisher et al
638 JAMC • 1er MARS 2005; 172 (5)

Characteristics of women having repeat abortion
CMAJ • MAR. 1, 2005; 172 (5) 639
Table 1: Correlates of repeat pregnancy termination: χχχχ2
tests for linear trend
No. (%) of women
Correlate
First abortion
n = 769
Second abortion
n = 260
Third or subsequent
abortion
n = 98 p value
Born outside Canada 99 (12.9) 49 (18.8) 18 (18.4) < 0.025
Ethnicity
Black 23 (3.0) 16 (6.2) 9 (9.3) < 0.001
Middle Eastern 4 (0.5) 3 (1.2) 3 (3.1) < 0.025
Education
Completed community college, nursing
school or technical school 129 (16.8) 66 (25.4) 27 (27.6) < 0.001
Currently attending high school 142 (18.5) 22 (8.5) 3 (3.1) < 0.001
Completed some high school 73 (9.5) 34 (13.1) 14 (14.3) < 0.05
No formal education 2 (0.3) 2 (0.8) 3 (3.1) < 0.01
Living arrangements
Lives with children 193 (25.2) 105 (40.5) 45 (45.9) < 0.001
Lives with parent(s) 284 (37.0) 54 (20.8) 15 (15.3) < 0.001
Lives with other friends or relatives 96 (12.5) 28 (10.8) 5 (5.1) < 0.05
Lives with common-law partner 86 (11.2) 34 (13.1) 19 (19.4) < 0.05
Relationship status
Partner or boyfriend 367 (47.9) 112 (43.4) 36 (36.7) < 0.025
Divorced 18 (2.3) 12 (4.7) 6 (6.1) < 0.025
Relationship conflict and history of abuse
Substantial conflict and fights with man
involved in current pregnancy 181 (24.0) 73 (29.6) 34 (35.4) < 0.01
Good relationship with man involved in
current pregnancy 608 (81.0) 189 (75.3) 65 (68.4) < 0.01
History of physical abuse by a male partner 105 (13.7) 73 (28.9) 40 (41.2) < 0.001
History of sexual abuse or sexual violence 168 (22.0) 90 (35.2) 43 (45.3) < 0.001
Social variables
Has “lots of friends”* 674 (89.4) 208 (81.6) 69 (71.1) < 0.001
Is a “traditional woman”† 386 (57.1) 119 (51.5) 37 (45.7) < 0.025
Has “lots of plans for the future”‡ 702 (92.7) 231 (90.6) 81 (85.3) < 0.001
Sex education, STDs and practices regarding
contraception
Took sex education classes in school 692 (91.1) 216 (84.4) 78 (82.1) < 0.001
History of STD 86 (11.3) 50 (19.5) 27 (28.1) < 0.001
Has been tested for HIV 323 (42.7) 136 (52.3) 57 (60.6) < 0.001
Has given birth to 1 or more children 276 (35.9) 147 (56.5) 66 (67.3) < 0.001
History of use of birth control 673 (87.7) 247 (95.7) 93 (95.9) < 0.001
Self or partner or both were using birth
control when current pregnancy occurred 397 (53.1) 160 (62.3) 55 (58.5) < 0.05
Was using birth control pill when current
pregnancy occurred 137 (17.8) 78 (30.0) 28 (28.8) < 0.001
Agreed with following statements
The best birth control for me would be one
that I don’t have to remember to take 353 (48.1) 151 (59.9) 61 (64.9) < 0.001
The birth control pill is a good form of
birth control 681 (92.5) 204 (82.3) 62 (67.4) < 0.001
Sometimes I can’t afford to buy birth control 122 (16.3) 50 (20.1) 24 (25.8) < 0.025
Birth control pills are too expensive for me 57 (7.6) 26 (10.4) 14 (15.2) < 0.025
Note: Proportions reported are based on the number of participants who made a specific response divided by the number of participants who responded to the item
in question.
*Single-item assessment of participants’ degree of social integration.
†Single-item assessment of participants’ sex-role traditionality.
‡Single-item assessment of participants’ future orientation.

differ between the 2 groups.) Women presenting for re-
peat abortion were more likely to agree that “the best birth
control for me would be one that I don’t have to remem-
ber to take” (p < 0.001) and that “birth control pills are too
expensive for me” (p < 0.025).
Characteristics examined in stepwise multivariate
multinomial logistic regression analysis included age,
country of origin, living with children, conflict with the
man involved in the current pregnancy, history of physi-
cal abuse by a male partner, history of sexual abuse or sex-
ual violence, having many friends, having plans for the fu-
ture, having had formal sex education, having had an
STD, use of birth control at the time of conception and
oral contraceptive use at the time of conception. The
analysis indicated that increased age, oral contraceptive
use at the time of conception, history of physical abuse by
a male partner, history of sexual abuse or sexual violence,
having had an STD and being born outside Canada were
uniquely associated, in descending order of strength of as-
sociation, with undergoing repeat compared with initial
abortion (Table 2).
Interpretation
We found unique associations between repeat induced
abortion and increased age, oral contraceptive use, physi-
cal abuse by a male partner and history of sexual abuse or
sexual violence. Our observations confirm earlier studies
indicating an association between repeat abortion and
age,7,13
relationship conflict1,5,8,11,12
and relatively greater
contraceptive use,7,8,10,11
and go well beyond existing liter-
ature1,5,8,11,12
in identifying unique associations of a history
of relationship violence or of sexual abuse or coercion
with repeat abortion. Women presenting for a third or
subsequent abortion were more than 2.5 times as likely as
those seeking a first abortion to report a history of physi-
cal abuse by a male partner or a history of sexual abuse or
violence.
Our findings of a relation between repeat abortion and
physical abuse by a male partner and sexual abuse or vio-
lence suggest continued effects of these factors20–22
on
women’s health outcomes. It is possible that a history of
physical abuse by a partner or of sexual abuse or violence
results in lasting psychologic changes that lead the woman
to decide that carrying a pregnancy to term is not desirable.
It is also possible that physical or sexual abuse is an indica-
tor of the existence of social environment factors that were
initially conducive to abuse and that are currently con-
ducive to the decision to terminate a pregnancy in the
event that one occurs. Women undergoing repeat induced
abortion do not, however, appear to be inconsistent users
of contraception compared with women undergoing a first
abortion. In fact, we found that the former were somewhat
more likely than the latter to report using birth control at
the time of conception.
Limitations of our study include reliance on self-reports
of sensitive issues (e.g., use of contraceptives at the time of
conception), which could result in social desirability re-
sponse bias, and use of single items to measure most con-
structs in order to create brief assessments usable in clinical
settings. Although considerable validity research attests to
the accuracy of self-reports in the area of sexual and repro-
ductive health behaviour,23,27,28
our study is based entirely on
self-reports that are potentially subject to response bias and
not subject to independent verification.
In summary, a key finding of our study is that women
undergoing repeat induced abortion were considerably
more likely than those undergoing a first abortion to have
experienced physical abuse by a male partner or sexual
abuse or coercion. These results emphasize the need for
screening for a current or past history of physical or sexual
abuse at the time of presentation for abortion.29,30
Such
screening could result in offers of referral and counselling
that might prove helpful to the woman in dealing with a
history of physical or sexual abuse, and could potentially
help avert a future abortion.
Fisher et al
640 JAMC • 1er MARS 2005; 172 (5)
Table 2: Correlates of repeat abortion: multivariate multinomial logistic regression*
Second abortion Third or subsequent abortion
Predictor
Unadjusted
OR (95% CI)
Adjusted
OR (95% CI)
Unadjusted
OR (95% CI)
Adjusted
OR (95% CI)
Age 1.07 (1.04–1.09) 1.08 (1.04–1.09) 1.10 (1.06–1.13) 1.11 (1.07–1.15)
Self or partner or both were using
birth control when pregnancy
occurred 1.98 (1.43–2.73) 2.17 (1.52–3.09) 1.85 (1.15–2.97) 2.60 (1.51–4.46)
History of physical abuse by a male
partner 1.92 (1.41–2.61) 2.04 (1.39–3.01) 2.93 (1.89–4.54) 2.78 (1.62–4.79)
History of sexual abuse or sexual
violence 2.55 (1.81–3.59) 1.58 (1.11–2.25) 4.41 (2.80–6.94) 2.53 (1.50–4.28)
History of STD 1.90 (1.30–2.78) 1.50 (0.98–2.29) 3.08 (1.87–5.06) 2.26 (1.28–4.02)
Born outside Canada 1.57 1.83 (1.19–2.79) 1.52 (0.87–2.64) 1.75 (0.90–3.41)
Note: OR = odds ratio, CI = confidence interval.
*Reference group is “initial abortion.” For all factors entered, p < 0.05.

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29. Wiebe ER, Janssen P. Universal screening for domestic violence in abortion.
Womens Health Issues 2001;11:436-41.
30. Glander SS, Moore ML, Michielutte R, Parsons LH. The prevalence of do-
mestic violence among women seeking abortion. Obstet Gynecol 1998;91:
1002-6.
Characteristics of women having repeat abortion
CMAJ • MAR. 1, 2005; 172 (5) 641
Correspondence to: Dr. William A. Fisher, Departments of
Psychology and of Obstetrics and Gynaecology, Social Sciences
Centre, University of Western Ontario, London ON N6A 5C2;
fisher@uwo.ca
This article has been peer reviewed.
Competing interests: William Fisher is the recipient of a Research Scientist in Re-
productive Health Behavior award funded by Janssen-Ortho (Canada).
Contributors: William Fisher contributed to study conception and design and data
analysis and to writing of the draft. Sukhbir Singh and Paul Shuper contributed to
data analysis and interpretation and to drafting and revising the article. Mark
Carey and Felicia Otchet contributed to study conception and design and data ac-
quisition, and reviewed and revised the manuscript. Deborah MacLean-Brine and
Diane Dal Bello contributed to study design and data acquisition, and read and
contributed revisions to the manuscript. Jennifer Gunter contributed to study de-
sign and data acquisition, and read and revised the manuscript. All of the authors
gave their final approval of the version submitted to be published.
Acknowledgements: We acknowledge the assistance of Larry Stitt with the statisti-
cal analyses.
This research was supported by a Janssen-Ortho (Canada) Research Scientist in
Reproductive Health Behavior award and an Academic Enrichment Fund award,
from the Department of Obstetrics and Gynaecology, University of Western On-
tario, to William Fisher and Mark Carey respectively, and by a Gynecologic Oncol-
ogy Research Fund award from the London Health Sciences Centre to Mark Carey.
From the Departments of Psychology (Fisher, Shuper, Otchet) and Obstetrics and
Gynaecology (Fisher, Singh, Carey, Otchet, Gunter), University of Western On-
tario, and the London Health Sciences Centre (Singh, Carey, Otchet, MacLean-
Brine, Dal Bello), London, Ont. Jennifer Gunter is currently with the Department
of Obstetrics and Gynecology, University of Colorado, Denver, Colo.

Intimate partner violence and reproductive
health of women in Kenya
E. Emenike1
MSc, S. Lawoko2,3
MSc, PhD & K. Dalal4
MSc
1 Master’s Student, 2 Lecturer, 4 Course Coordinator and Doctoral Student, Department of Public Health Sciences,
Karolinska Institute, Stockholm, 3 Senior Researcher, Stockholm Centre for Public Health, Stockholm, Sweden
EMENIKE E., LAWOKO S. & DALAL K. (2008) Intimate partner violence and reproductive health of women
in Kenya. International Nursing Review 55, 97–102
Background: Reproductive age represents an augmented risk of intimate partner violence (IPV) despite its
occurrence in women of all ages. IPV has been associated with various reproductive health outcomes (e.g.
terminated pregnancies and infant mortality), although multi-country studies indicate that the findings may
not be consistent across all cultures.
Study aim and method: The current work describes the association between IPV and reproductive health of
women in Kenya using the Demographic and Health Survey of 2003.
Results: A significant association between physical/emotional/sexual abuse of women and negative
reproductive health outcomes such as terminated pregnancies and infant mortality was identified. In addition,
IPV exposure was associated with use of family planning methods and high fertility.
Conclusion and recommendations: Practitioners in the healthcare sector should inquire about abuse.
Provision of counselling services and information regarding IPV effects on reproductive outcomes as well as
referring abused women to relevant institutions is recommended in secondary prevention of IPV and to
improve the reproductive health status of abused women.
Keywords: Intimate Partner, Kenya, Reproductive Health, Violence
Introduction
There has been an increased awareness of the implications of key
demographic, social and behavioural factors for women’s health
status. One such area that has received global recognition is the
impact of domestic violence on women’s health and quality of
life in general. Recent estimates from African countries indicate a
lifetime prevalence of between 25% and 48% (i.e. 48% in
Zambia, 47% in Kenya, 34% in Egypt, 30% in Uganda and 25%
in South Africa) and an annual prevalence ranging between 10%
and 26% (Jewkes et al. 2002; Kishor & Johnson 2004; Koenig
et al. 2003; Mwenesi et al. 2003). These figures are comparable
with data from other developing countries such as Cambodia,
India, Haiti and Nicaragua where the lifetime prevalence of
domestic violence ranges between 17% and 52%, and the annual
prevalence between 13% and 21% (Ellsberg et al. 2000; Gage
2005; Kishor & Johnson 2004).
Intimate partner violence (IPV) has profound effects on
women’s physical and psychosocial health outcomes. Findings
from Africa suggest that physically assaulted women are likely to
sustain injuries ranging in severity from bruises to fractured
bones (Koenig et al. 2003; Mwenesi et al. 2003). Further, abused
women are likely to report various forms of psychological mor-
bidity such as depression and anxiety (Aidoo & Hapham 2001;
Campbell 2002; Mayeya et al. 2004). Reports on the health con-
sequences of IPV seem to follow a similar pattern in non-African
countries (Campbell et al. 2002; Golding 1999; Heise & Garcia-
Moreno 2002; Koss 1990; Petersen et al. 2001; Plichta et al. 2004;
Correspondence address: Stephen Lawoko, Stockholm Centre for Public
Health, Vastgotagatan 2, PO Box 17533, SE-118 91 Stockholm, Sweden.
Tel: 46-8-7373609; Fax: 46-8-7373880; E-mail: stephen.lawoko@sll.se.
Original Article
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses 97

Tjaden & Thoennes 2000; Tolman & Rosen 2001). Moreover,
data from non-African countries suggest that female victims of
IPV face social isolation in the form of restricted access to com-
munity services, constrained relationship with healthcare pro-
viders and employers (Heise & Garcia-Moreno 2002; Plichta
et al. 2004), and are more likely to adopt behaviours that present
health risks such as substance abuse, alcoholism and suicide
attempts (Heise & Garcia-Moreno 2002; Plichta et al. 2004;
Roberts et al. 2005; Silverman et al. 2001).
Although IPV occurs to women of all ages, reproductive age
represents an augmented risk. IPV has therefore been linked to
reproductive health outcomes such as terminated or undesired
pregnancies, child loss during infancy, use of family planning
methods and high fertility in Africa (Kishor & Johnson 2004) and
elsewhere (Garcia-Morena et al. 2005; Jejeebhoy 1998; Kishor &
Johnson 2004; Rose et al. 2000). Multi-country studies suggest,
however, that the findings are not consistent across all cultures.
For instance,undesired pregnancies were not associated with IPV
in Haiti,and use of contraceptives was not related to IPV in India,
while these variables were associated with IPV in Zambia,Colom-
bia, Cambodia, Peru and Egypt (Kishor & Johnson 2004). These
findings warrant an assessment of IPV and its association with
reproductive health outcomes in each unique culture.
Little has been published in Africa regarding the relationship
between IPV and reproductive health, not least in Kenya.Yet such
information may contribute to the growing literature in the field
in Africa and may inform policy interventions to manage vio-
lence, and to improve the reproductive health of women in
Kenya.
Therefore, the aim of this study was to assess the association
between IPV and reproductive health outcomes of women in
Kenya. Specifically, the association between IPV and use of family
planning methods, fertility, terminated pregnancy and infant
mortality was scrutinized.
Methods
Sampling design
This study is based on the Kenyan Demographic and Health
Survey of 2003 (KDHS 2003). Financed by the United States
Agency for International Development and implemented by the
Kenyan Central Bureau of Statistics (KCBS) in collaboration
with the ministry of health and the Kenyan medical research
institute, the KDHS 2003 covered the entire nation. The survey
utilized a two-stage sampling design. Based on the list of the
enumeration areas covered in the 1999 census, 400 clusters of
areas (129 urban areas and 271 rural areas) were selected in the
first phase. The second phase involved systematic sampling of
households from a national database at the KCBS. Women
residents or visitors at the sampled households during the survey
were eligible for recruitment for the KDHS. A more detailed
description of the sampling procedure is reported in the KDHS
2003 final report (Otieno & Opiyo 2003).
Subjects
All women 15–49 years of age residents or visitors at the sampled
household at the time of the survey were eligible for participa-
tion (a total of 8195 women). The domestic violence module,
however, was only administered to one woman in the household,
randomly chosen, in compliance with the World Health
Organization’s (WHO) ethical and safety recommendations for
research on domestic violence (WHO 2001). Thus, data on
domestic violence were obtained from 5878 women, constituting
98% of those eligible for participation in the study. For the
purpose of this study, only women ever (currently or formerly)
married/having a partner and who responded to the domestic
violence module (n = 4312) were included to study the associa-
tion between IPV and reproductive health outcomes.
Measure
A comprehensive questionnaire covering demographic and
health issues was administered to the eligible women. The ques-
tionnaire covered women’s background, reproductive health,
access to reproductive facilities, fertility preferences, child care
and nutrition, child mortality, adult mortality, awareness of and
precaution against sexually transmitted diseases, marriage and
sexual behaviour, and domestic violence.
For the current paper, the questions on domestic violence and
reproductive health were of primary interest.
Reproductive health (the dependent outcome variable in this
study) was measured using the following indicators:
1 family planning preference (participants were asked if they
had ever used any of the following methods – folkloric, tradi-
tional, or modern),
2 terminated pregnancy (i.e. if the respondent has ever experi-
enced a terminated pregnancy),
3 infant mortality (defined as death of an infant before first
birthday), and
4 fertility (number of live births).
Intimate partner violence (the independent variable in the
study) was assessed using a modified and previously validated
version of the Conflict Tactic Scale (Strauss 1990), where IPV is
defined as exposure to one or several of the following experiences
perpetrated by a husband/partner ever:
1 pushing, shaking or throwing something at her,
2 slapping her or twisting her arm,
3 punching or hitting her with something harmful,
4 kicking or dragging her,
98 E. Emenike et al.
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses

5 strangling or burning her,
6 threatening her with a weapon (e.g. gun or knife),
7 attacking her with a weapon,
8 humiliating her in public,
9 threatening her or someone close to her,
10 forced sexual intercourse, and
11 other sexual act when undesired.
Thus, the questions covered physical (1–7), emotional (8,9) and
sexual (10,11) abuse.
Ethical considerations
The WHO recommendations for research on domestic violence
aim to ensure women’s safety while maximizing disclosure of
actual violence, promoted, among other means, by offering
adequate training and support to field workers together with
informed consent and guarantee of privacy to respondents
(WHO 2001). The survey procedure (e.g. organization and sam-
pling methods) and instruments used in the KDHS 2003 received
ethical approval from the Institutional Review Board of Opinion
Research Corporation (ORC) Macro International Incorporated,
a demographic, health, and market research and consulting
company based in New Jersey, USA.
Statistical analysis
Cross-tabulation was used to study the association between the
dependent and independent variables, and significant levels were
tested using chi-squared test. Because age may be associated with
both reproductive health and IPV, age-adjusted associations
between IPV and reproductive health indicators were calculated
using logistic regressionanalyses. The spss version 13.0 statistics
program was used for all analyses. Statistical significance was
assumed at P < 0.05.
To account for differences in probability because of clustering
in the sampling design of DHS surveys in general, sample weights
are usually recommended if the aim is to estimate national preva-
lence. However, it has been argued by DHS experts that if a study
aims primarily at investigating associations between variables (as
is the case in the current study), weighted data are inappropriate
(Rutstein & Rojas 2003). Thus, results presented here will be
based on the unweighted actual observations.
Results
Table 1 shows the proportion of women exposed to IPV (total),
and by reproductive health indicators. Of all participants
(n = 4312), a significant proportion had experienced physical
(38%), emotional (24%) and sexual (14%) abuse by an intimate
partner. Exposure to physical abuse was more common among
women using folkloric and modern family planning methods
than among peers using traditional methods and those not using
any method at all (P < 0.001). In addition, exposure to emotional
or sexual violence was more frequent among women using
family planning methods than among peers not using any
method (P < 0.001). Women exposed to physical, emotional or
sexual violence were also more likely to have experienced a ter-
minated pregnancy (P < 0.001). Further, women who had previ-
ously lost one or more children were more likely to have
experienced physical, emotional or sexual abuse (P < 0.001).
Finally, a higher proportion of women with three or more live
births had ever been exposed to physical, emotional or sexual
violence than peers with fewer than three births ever (P < 0.001).
Table 2 shows the age-adjusted associations between IPV and
reproductive health indicators expressed as odds ratios. As
shown by the odds ratios and their confidence intervals, using
any family planning method, having an experience of terminated
pregnancy, having an experience of infant mortality and having
three or more births ever were associated with an increased vul-
nerability to physical and emotional violence after adjusting for
age effects in a logistic regression. In addition, using a family
planning method and having an experience of infant mortality
were associated with increased exposure to sexual violence after
adjusting for age effects.
Discussion
The findings of the current study suggest a relationship between
IPV and reproductive health of abused women in Kenya.
Table 1 Proportion of women exposed to intimate partner violence (IPV)
by reproduction health indicators
Variable (N) Physical IPV Emotional IPV Sexual IPV
n % n % n %
Family planning method
None (1632) 568 34.8 320 19.6 166 10.0
Folkloric (20) 11 55.0 6 30.0 3 15.0
Traditional (329) 104 31.6 74 22.5 37 11.2
Modern (2331) 979 42.0 638 27.4 400 17.2
Terminated pregnancy
Yes (619) 275 44.4 186 30.0 98 15.8
No (3692) 1386 37.5 851 23.0 507 13.7
Infant mortality
Yes (1122) 552 49.2 354 31.6 188 16.8
No (2929) 1059 36.2 654 22.3 391 13.4
Number of births ever
Less than three (1757) 542 30.8 341 19.4 211 12.0
Three or more (2555) 1120 43.8 697 27.3 395 15.5
All participants (4312) 1662 38.0 1038 24.0 606 14.0
N is the total number within category, n is the number within category
exposed to IPV, % is the proportion within category exposed to IPV.
Intimate partner violence and reproductive health 99
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses

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