A 38-year-old woman with a legal and voluntary interruption of pregnancy due to mental health risk. An unexpected outcome

Abstract

Objective

To describe a case of legal and voluntary interruption of pregnancy due to a mental health risk in the mother. However, the foetus survived and the mother decided to care for the child.

Methods

Description of the case and a non-systematic review of the relevant literature.

Results

A multiparous woman of 38 years with unknown gestational age who requests legal and voluntary interruption of pregnancy. After abortion a male child born of 1050 g was born, intubated and admitted to intensive care. Subsequently, the mother, without the mental problems that led to abortion, gradually assumed the care of the child.

Discussion

To address this complex case, several aspects are analysed: first, the change of mind of a woman in her desire to be a mother. Second, the disappearance of mental symptoms in the immediate postpartum. Third, the need to review the clinical, ethical and legal foundations of the legal ruling that allows therapeutic abortion in Colombia.

Resumen

Objetivo

Describir un caso clínico de interrupción legal y voluntaria del embarazo por riesgo para la salud mental de la madre con sobrevida del feto y posterior deseo de la madre de cuidar del niño.

Métodos

Descripción del caso clínico y revisión no sistemática de la literatura relevante.

Resultados

Mujer de 38 años multigestante, con edad gestacional desconocida, solicitó interrupción legal y voluntaria del embarazo por riesgo para la salud mental por embarazo no deseado. Luego de la interrupción del embarazo, nació un varón de 1.050 g de peso, al que se intubó y trasladó a cuidados intensivos. Tras el parto, los síntomas mentales que llevaron a esta mujer al aborto terapéutico desaparecieron, y decidió asumir el cuidado del niño.

Discusión

Frente a este complejo caso, se analizan varios aspectos: primero, el cambio de opinión de una mujer sobre su deseo de ser madre; segundo, la desaparición de los síntomas mentales en el posparto inmediato, y tercero, la necesidad de revisar los fundamentos clínicos, éticos y legales de la norma legal que permite el aborto terapéutico en Colombia.

Introduction

Human reproduction has been termed a complex phenomenon from the psychological point of view.¹ Pregnancy is always a novel event that implies stress and adaptation, and both the desire to be a mother, to experience pregnancy and childbirth, and the desire to resort to abortion are processes that put women's mental health to the test.²

The feelings a woman experiences on finding out that she is pregnant can be different and contrasting: happiness, disbelief, worry, fear, frustration, anger or an ambivalent mixture. The subjective response of the individual is dependent on multiple factors, including age, physical condition, the relationship with the child's father, financial and employment circumstances, family and social support, and the cultural context.³

In Colombia, in accordance with sentence C-355 of 2006, abortion is legal in the following three circumstances: a) when the mother's physical, mental and/or emotional health is in danger as a direct result of the pregnancy; b) when the pregnancy is a result of rape or a fertility treatment that was not consented to by the mother; and c) when the foetus presents serious deformities that render life outside the womb impossible.⁴

The objective of this case report is to present the complex clinical case of a mother who requested a legal and voluntary interruption of pregnancy (LVIP) due to mental health risk. The informed consent of the woman described herein was obtained, which states that her information would be used for academic and scientific publication purposes. To protect the identity of the mother and child and the right to confidentiality of the information provided by the patient, no specific information that could identify her or the child was included.

Case report

A 38-year-old woman was admitted as an outpatient of a public hospital in the city of Medellín to undergo a LVIP procedure. A few days previously, she was seen as an outpatient at the healthcare facility for a medical assessment as she thought she might be pregnant. The pregnancy was confirmed and the woman was informed of her right to a LVIP, as she felt “sad and unenthusiastic” which, for the healthcare professionals treating her, constituted a “risk to maternal mental health”. The woman was referred to a tertiary-level hospital with a judge's order to undergo the LVIP procedure.

Hospital admission

The woman, whose gestational age was unknown and who had been living in a consensual union for 3 months, had been educated up to the fourth year of primary school and who was a housewife, was admitted into the gynaecology and obstetrics department where she stated that this was her fourth pregnancy. The physical examination describes a woman seemingly in good general health: hydrated, conscious, alert, with a blood pressure reading of 120/80 mmHg, a heart rate of 80 bpm, 16 breaths per minute and afebrile; with no cardiac or pulmonary auscultation findings; pregnant abdomen, fundal height of 22 cm. On the patient's medical history, “no foetal heart rate taken” is specified. Normal external genitals; during the vaginal examination, the neck of the anterior cervix measured 3 cm in length, with an external orifice admitting one finger; a little foul-smelling vaginal discharge was also observed. Normal extremities with no oedemas. No neurological deficits were observed. On the analysis and admission report, the following was noted “38-year-old patient, approximately 20–22 weeks pregnant according to fundal height, unplanned and unwanted pregnancy, admitted for a LVIP due to mental health. Procedure and risks explained to the patient, who accepts”.

The LVIP procedure was initiated with 400 μg sublingual misoprostol every 3 h, in 5 doses. “Emotional lability” is reported in the gynaecology/obstetrics observations, so a psychological assessment was requested. Psychology assessed the patient and wrote in her medical history: “She wishes to terminate this pregnancy due to relationship problems and her mental health. On an emotional level, she feels distressed by what she is going through”. Following this evaluation, Psychology discharged her with no follow-up plan.

The birth

36 hours after admission, the following was recorded in the patient's medical history: “Patient delivers live foetus, in a poor physical condition; weight, 1050 g; transferred to perinatology”. The mother was discharged the following day, in good health.

Referral to liaison psychiatry

Five months after the aforementioned birth, liaison psychiatry received a clinical referral request to assess a 5-month-old baby whose mother, as described by the paediatricians in the medical history, “objected to any necessary medical procedures and processes”. They also noted the following in the paediatrics record: “Aggressive, intolerant mother who does not accept the explanations offered by the medical personnel and does not comply with the strict isolation measures”.

Liaison psychiatry reviewed the infant's medical history and summoned the mother for assessment, with no information on the circumstances of the birth or the reason behind the infant's prematurity. The mother attended the psychiatric consultation at the specified time. Her socio-demographic information was confirmed; the woman was living in a town in Antioquia, had received a primary education and was unemployed. She had three older daughters and had separated from the child's father 3 months prior due to physical and verbal abuse following a 9-month relationship.

The mother said she had no pre-existing medical conditions. She did not use psychoactive substances. She had not attempted suicide. She had no personal or family history of mental illness. She had not been seen by psychology or psychiatry beforehand. She described her family as “very close”, where they all look out for one another; she claimed she had the support of her sisters, mother and daughters. She had no contact with her ex-partner, who is unaware about what happened with his son.

What the patient said at the psychiatric consultation

“I got with him because I had no money...” (explaining why she began the relationship with her ex-partner).

“I was scared my daughters would completely reject me for having his child... the guy was the worst” (explaining why she initially rejected the pregnancy).

“I was in hospital for two days; when I got out, my family were really worried because they didn’t know where I was; I told my sister what happened, she was very confused, but told me to reconsider and that she urged me to keep going with my son... to not give him up” (explaining how her family found out that she was pregnant and that she had been to hospital for a LVIP).

“When I saw him, I felt awful, I really regretted what I had done, it was all my fault” (explaining the first time she went to visit her son, who was hospitalised in the intensive care unit).

“Now I’m in the hospital looking after him” (explaining how she started going to the paediatrics department where her son was and how she gradually took on caring for him).

“...the idea is to go back to the village to my parents’ house... They gave my sister custody of the child, but I intend to sort everything out with Family Welfare so he can stay with me” (explaining what she is thinking of doing when they discharge her son).

“All I want is to fight for my baby and to move forward to make up for lost time and give him all my love and affection, because he's not to blame for what happened” (expanding on the previous idea).

Mental status examination based on the psychiatric assessment

The woman's personal appearance was appropriate and she was pleasant and cooperative during the consultation. Oriented to person, place and time. Normal attention. Seemingly calm. Makes visual contact. No motor disorders. Modulated, resonant, euthymic affect. Normal speech. Coherent, logical thought, with ideas of guilt regarding her son's condition. No suicidal or delusional thoughts expressed. Preserved memory. Appropriate judgement and reasoning. Intelligence seems normal. Positive prospection, adequate introspection.

Liaison psychiatry intervention

An unstructured psychiatric interview was performed in which no anxious, depressive or psychotic symptoms were observed that constitute any major psychiatric disorder according to the DSM-5 criteria.⁵ Suicidal risk was ruled out. It was established that the woman had adequate family support, including three older daughters. It was determined that the woman had separated from her son's father and felt at ease with this decision. The mother was encouraged to cooperate with the instructions of the nursing and medical staff for the favourable development of the child. The woman was responsive and promised to cooperate.

Discussion

This complex clinical case can be analysed from multiple perspectives, including: a) the rights of the premature baby; b) the reproductive rights of the woman; c) LVIP in Colombia and the legal vacuum regarding the maximum age at which the procedure can be performed; d) the physicians performing the LVIP on a woman of advanced gestational age; e) what constitutes a “risk to mental health” in the context of an unwanted pregnancy; f) the rights of the child's father; and g) society, which may not understand the outcome of a LVIP procedure.

For practical reasons, the following two perspectives are analysed: the legal vacuum regarding maximum age at which the LVIP procedure can be performed, which led to the survival of a foetus subjected to a medical procedure designed to end the gestation, and what constitutes a risk to the mental health of the mother in the context of an unwanted pregnancy.

The Sentence issued by the Colombian Court, which made therapeutic abortion constitutional, did not establish the maximum gestational age at which abortion could be performed.³ This legal vacuum enabled the case presented herein to go from being a therapeutic abortion to a preterm birth with a critically ill premature baby. Terminations of pregnancy in the second trimester represent between 10% and 15% of all induced abortions worldwide and cause two-thirds of all abortion-related complications.⁶ In Colombia, according to the Technical Standard for interrupting pregnancy,⁷ after 12 full weeks following the last menstrual period, a regimen of mifepristone and misoprostol must be administered, with 97% efficacy.⁸ The difficulty lies in the fact that it did not consider that, after a certain gestational age, the procedure could give rise to a premature birth instead of a therapeutic abortion, and the Technical Standard bans physicians from requesting meetings or asking for a second opinion because these are considered to be strategies that exclusively aim to deny or delay the LVIP procedure.

In terms of the second perspective, although the concept of health is broad, there is no doubt that “health” is more than the absence of disease. The World Health Organisation defines mental health as “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”.⁹ Millions of unwanted pregnancies occur every year. A lack of correspondence between the expectations of women and their partners regarding the number of children they want and the many situations women face in which they have to control their fertility make unwanted pregnancies likely.¹⁰

Therapeutic abortion for the purpose of preserving the woman's mental health is explicitly recognised in the laws of 23 countries around the world, including Colombia.¹¹ However, no study has found therapeutic abortions due to mental health risk to be associated with improved mental health outcomes,³ nor is it evident despite the debate that therapeutic abortion exacerbates mental health. The outcomes concerning this controversial topic are dotted with social and political disputes, which is difficult to avoid and can lead us to overlook the importance of supporting arguments based on valid, statistically sound study results that control confounding factors and consider pre-pregnancy mental illness,¹² without it being necessary to assimilate a woman's wish to abort as pathological or a synonym of “risk to mental health” when she faces an unwanted pregnancy.

In recent decades, there has been increasing interest in establishing whether abortion constitutes a risk factor for mental illness; the outcomes studied are, among others, depression,^13,14 anxiety,^15,16 substance use^17,18 and suicidal behaviour.^19,20 Moreover, although recent studies have tried to control these confounding factors, further evidence is needed to appropriately resolve the existing disputes.

Conclusions

This case reveals the need to revise the maximum age at which the conduct of a LVIP procedure is allowed in Colombia and the measures that must be taken to ensure the woman undergoes therapeutic abortion and not a preterm birth.

It is also a priority to establish the meaning of the “risk to maternal mental health” concept in Colombia, so that a woman facing an unwanted pregnancy does not need to undergo a psychiatric assessment.check

Ethical disclosures

Protection of human and animal subjects

The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.

Conflicts of interest

The authors have no conflicts of interest to declare.