Around 73 million abortions are performed annually worldwide , and more than 90% occur in the first-trimester . A single first-trimester abortion is physically safe when conducted using WHO-recommended methods by qualified professionals . However, in most cases, an abortion is a stressful life event, that happens in the context of an unwanted/unintended pregnancy and poses challenges to women psychological wellbeing . While some women cope well, others suffer a range of mental health consequences [4, 5].
Negative associations between perceived stress and psychological health have been observed across a wide variety of studies conducted among women having a preterm birth  and those experiencing a miscarriage . Understanding women’s perceptions of coping with abortion, as well as associated factors, can be helpful for health service providers to assess and plan for individual variation in coping. Various models attempt to explain variability in a person’s response to a stressful life event. The Transactional Model derived from stress and coping theories [4, 6], for example, can help to explain factors affecting women’s response to an abortion experience. According to this model, a woman’s psychological experience is shaped by how she appraises the significance of the abortion and her ability to cope . Perceived stress emerges from situations that women appraise as exceeding their ability or resources to cope . Women’s perceptions of stress can influence their choice of specific coping behaviours and subsequent psychological well-being .
Few studies, however, have reported perceptions of stress among women seeking an abortion. Using the 4-item Perceived Stress Scale (PSS-4), Harris et al  revealed minimal stress among 254 women seeking first-trimester abortions in the U.S. (mean of 4.2 on a 0-16 scale). Another study also conducted in the U.S. reported an average PSS-4 score of 7.24 among 784 women at the time of abortion seeking but placed no limitation on gestational age . Variability in findings may be related to heterogeneity in women's gestation and reliability of the PSS-4. A systematic review comparing psychometric properties (e.g. internal consistency reliability, factorial validity, and hypothesis validity) of all three versions of the PSS (4, 10, and 14 items) recommended the PSS-10 to measure perceived stress . Yet, the PSS-10 is rarely used to explore individuals’ perceptions of stress associated with abortion.
Studies on other psychological responses of women to abortion have also reported significantly different outcomes . Prevalence of depression has ranged from 7.9%~53.5% [13, 14]. In addition to heterogeneity in measures and evaluation timeframe, few studies controlled for possible confounders . Possible confounders were identified by the American Psychological Association (APA) Task Force on Mental Health and Abortion (TFMHA)  in a review of 23 studies conducted among U.S. women. Factors such as a prior history of mental health problems, gestational age, low self-esteem, low resilience, low perceived ability to cope with the abortion, ambivalence about the abortion decision, stigma, and low social support were negatively associated women’s abortion psychological experiences.
Another potential factor impacting on women’s psychological outcomes relates to the wider socio-political context within which pregnancy and abortion occur. General statements about the impact of abortion on women psychological wellbeing can be inaccurate, due to the regional differences in legal context, cultural views, as well as associated social stigma of abortion [4, 5]. In 2011, the UK National Collaborating Centre for Mental Health (NCCMH) systematically reviewed a broader international literature on abortion . Among the 27 studies included, only two were conducted in a developing country (South Africa and Russia), with 13 studies conducted in the U.S. and six in Northern Europe . None of the studies had been conducted among the Chinese population.
In China approximately 6-9 million induced abortions are performed every year, corresponding to 15% of the world’s total abortion numbers . China has some of the most liberal abortion laws in the world, which allow first-trimester abortion without restriction as to the reason, with the exception of sex-selective abortions which are prohibited . According to the State of World Population 2018 (UNFPA), many Chinese women report a continued desire for only one child , even though the One-Child Policy ended in 2013. Despite legislation that supports women’s reproductive rights and access to safe abortion services, little is known about how Chinese women perceive having an abortion and their psychosocial responses at the time of abortion-seeking. Furthermore, there is no published evidence regarding factors associated with individual variation in women’s psychological well-being.
This study aimed to 1) determine the prevalence of high perceived stress and depression among women seeking a first-trimester induced abortion in China; and 2) identify factors associated with high perceived stress and depression to help detect high-risk groups.