Prior Abortions Predict Worsening Depression, Sleep and Stress Trajectories Through Pregnancy and Postpartum

Women who have had two or more previous abortions are markedly more likely to follow adverse psychological trajectories throughout pregnancy and the first six months after delivery, according to a prospective longitudinal cohort study conducted at a tertiary hospital in China. The research, published in Frontiers in Psychiatry, tracked 254 pregnant women with eight repeated assessments from 13 weeks of gestation to 24 weeks postpartum and found that the number of prior abortions, but not the number of previous deliveries, predicted which women fell into worsening or persistently elevated symptom groups across depression, perceived stress, sleep quality, psychological flexibility and anxiety.

The study recruited women consecutively at their first prenatal visit between March and May 2022. Eligible participants were at least 20 years old, had early pregnancy confirmed by ultrasound, could read and understand Chinese, and were willing to complete follow-up. Women were excluded if they had a diagnosed severe psychiatric disorder such as schizophrenia or bipolar disorder, were currently taking psychotropic medication, carried a fetus with severe abnormalities requiring termination, or had cognitive impairment that would prevent questionnaire completion. Of 298 women enrolled, 44 who completed fewer than three follow-up assessments were excluded, leaving 254 in the trajectory analysis; baseline characteristics did not differ significantly between included and excluded participants.

At baseline, trained research nurses collected demographic and obstetric information, including age, education, residence, occupation, household income, family history of depression, and the numbers of previous deliveries and previous abortions, which included both spontaneous and induced losses. In this sample, 128 women (50.39 percent) reported no abortion history, 86 (33.86 percent) reported one, and 40 (15.75 percent) reported two or more. By delivery history, 127 women were in their first pregnancy, 99 had one previous delivery, and 28 had two or more. Women with an abortion history were significantly less likely to hold a bachelor’s degree or above, and satisfaction with parental, marital and mother-in-law relationships declined as the number of previous abortions and deliveries increased.

Participants completed face-to-face psychological assessments at eight time points: 13, 20, 26, 32 and 37 weeks of gestation, and 1, 6 and 24 weeks postpartum. Depressive symptoms were measured with the Edinburgh Postnatal Depression Scale, perceived stress with the 14-item Chinese Perceived Stress Scale, sleep quality with the Pittsburgh Sleep Quality Index, psychological flexibility with the 15-item short form of the Comprehensive Assessment of Acceptance and Commitment Therapy Processes, and anxiety with the seven-item Generalized Anxiety Disorder scale. All scales showed good internal consistency across time points, with Cronbach’s alpha coefficients ranging from 0.717 to 0.931.

The researchers applied group-based trajectory modeling, a semi-parametric finite mixture approach, to identify latent subgroups following distinct developmental courses for each outcome. Models with one to six classes were estimated, and the optimal number was chosen based on lower information criteria, entropy approaching 1.0, average posterior probability of assignment of at least 0.70 for each class, and each class comprising at least 5 percent of the sample. Associations between obstetric history and trajectory membership were then examined with logistic regression, in both unadjusted models and models adjusted for age, education, income, residence, occupation and family history of depression.

The modeling revealed substantial heterogeneity. For depressive symptoms, three trajectories emerged: low-stable (38.98 percent), mild-stable (47.24 percent) and moderate-increasing (13.78 percent), with the high-risk class already showing moderate symptoms, an EPDS score of roughly 14, at 13 weeks of gestation before symptoms worsened and then improved from late pregnancy onward. Perceived stress also split into three groups: low-stable (31.89 percent), moderate-increasing (16.54 percent) and high-stable (51.57 percent). Sleep quality produced a good-stable group (50.00 percent), a mild-worsening group (38.58 percent) whose difficulties gradually deepened during pregnancy and persisted postpartum, and a persistent poor group (11.42 percent). Psychological flexibility followed two paths, continuously declining (57.87 percent) versus high-stable (42.13 percent), and anxiety split into a large low-stable group (93.70 percent) and a small moderate group (6.30 percent) whose symptoms peaked in the third trimester and declined after delivery.

The associations with abortion history were striking. Compared with women without an abortion history, those with two or more prior abortions had significantly higher adjusted odds of membership in the mild-stable depression class (OR = 5.14, 95% CI: 1.79–14.78) and, most dramatically, the moderate-increasing depression class (OR = 19.12, 95% CI: 5.26–69.44). The same group also faced elevated odds of mild-worsening sleep (OR = 3.06, 95% CI: 1.32–7.09), persistent poor sleep (OR = 5.51, 95% CI: 1.73–17.59) and continuously declining psychological flexibility (OR = 2.61, 95% CI: 1.20–5.99). One previous abortion was associated with mild-stable depression (OR = 1.99), mild-worsening sleep (OR = 2.03), declining flexibility (OR = 2.44), the moderate-increasing stress trajectory (OR = 2.54), the high-stable stress trajectory (OR = 2.16) and moderate anxiety (OR = 4.18, 95% CI: 1.23–20.95). The gradient across abortion counts supported a dose-dependent pattern for depression, sleep and flexibility.

Not every association was monotonic. For women with two or more abortions, no statistically significant link emerged with any stress trajectory, which the authors attribute either to the very small size of that subgroup, which limited statistical power, or to the possibility that women with multiple losses develop adaptive habits or proactive coping mechanisms. Similarly, the association between two or more abortions and moderate anxiety was not statistically significant (OR = 2.14, 95% CI: 0.36–12.60), with the estimate imprecise because the moderate anxiety class contained only 6.30 percent of the sample. Across all five psychological domains, the number of previous deliveries showed no statistically significant association with any trajectory, a null result the authors note is compatible with a mixed parity literature in which primiparity and multiparity have each been linked to different symptom patterns in prior studies.

The authors argue that the findings carry direct clinical implications. Because the number of previous abortions is inexpensive, routinely collected information, it could be used at the first prenatal visit to flag women at elevated risk of worsening depression, deteriorating sleep, declining flexibility and persistent stress, with particular attention to those who have had two or more. Since the high-risk depression class already showed moderate symptoms at 13 weeks, they suggest screening should begin in the first trimester and be repeated across pregnancy and the postpartum period rather than relying on a single assessment. They also point to psychological flexibility as a modifiable target, noting that Acceptance and Commitment Therapy, which directly targets flexibility, has shown feasibility and preliminary efficacy in perinatal populations and may suit women with repeated pregnancy loss. Persistent poor sleep and elevated stress well beyond delivery further suggest that support should extend past birth and include sleep-focused and stress-management components.

The study has important limitations. Its single-center design and sample size limited precision for small trajectory classes, and substantial attrition by the end of postpartum follow-up contributed to wide confidence intervals. Outcomes relied on self-report questionnaires rather than clinical diagnostic interviews. The study did not distinguish spontaneous from induced abortions, which may carry different psychological consequences, and residual confounding by unmeasured factors cannot be ruled out despite covariate adjustment. Follow-up ended at 24 weeks postpartum, so trajectories may evolve further during the first postpartum year. Finally, although average posterior probabilities exceeded the recommended 0.70 threshold, entropy values of 0.70 to 0.75 for some models indicate some uncertainty in class assignment. The authors call for larger, multicenter studies with longer follow-up to confirm the associations and validate the trajectories in independent samples.

Subject of Research: Longitudinal trajectories of perinatal depression, anxiety, stress, sleep quality and psychological flexibility and their association with the number of previous abortions and deliveries

Article Title: Trajectories of perinatal depression, anxiety, perceived stress, sleep quality, and psychological flexibility from pregnancy to six months postpartum and their relationship with the number of abortions and deliveries

Article References: Gao, Y., Sun, J., Yang, L., Zhang, Y., Nan, Y., & Li, X. (2026). Trajectories of perinatal depression, anxiety, perceived stress, sleep quality, and psychological flexibility from pregnancy to six months postpartum and their relationship with the number of abortions and deliveries. Frontiers in Psychiatry, 17, 1973469. https://doi.org/10.3389/fpsyt.2026.1973469

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.1973469

Keywords: perinatal mental health, depression, anxiety, perceived stress, sleep quality, psychological flexibility, abortion history, pregnancy, postpartum, group-based trajectory modeling, cohort study, China