Women's Emotional Care and Psychological Well-Being Post-Termination of Pregnancy: An Integrative Review

Abstract

Background

Emotional support following legal pregnancy termination is a fundamental aspect of comprehensive healthcare. Existing literature points to gaps in psychological care packages offered to women, particularly in low- and middle-income countries. This integrative review extends beyond prior syntheses by incorporating digital interventions, relational dynamics, and community-based support, which are often overlooked, especially in low-resource settings. It highlights critical gaps in service integration, cultural sensitivity, and emotional care for underrepresented populations, such as adolescents and women in stigmatizing environments. To advance the field, future research should explore scalable, culturally grounded interventions that promote long-term psychological well-being following termination of pregnancy. This review evaluates evidence-based psychological support interventions designed to enhance mental health outcomes for women after pregnancy termination.

Methods

An integrative review and thematic synthesis were conducted, adhering to Whittemore and Knafl's (2005) framework. Searches were performed in MEDLINE, CINAHL Complete, and PsycINFO. Eligibility criteria included peer-reviewed publications from 2013 to 2023 focusing on psychological support programs. Methodological quality was assessed using the Joanna Briggs Institute appraisal tool, and thematic synthesis followed a convergent integrated approach.

Results

Empirical studies (n=13) were included. Data screening and extraction, conducted via COVIDENCE, achieved a reliability score of 63% based on Cohen's Kappa measure. Three primary themes emerged: (1) holistic psychosocial support for women after prenatal loss, (2) strengthening community support and reducing stigma around abortion experiences, and (3) enhancing post-abortion recovery through digital, familial, and comprehensive support networks.

Conclusion

Post-termination psychological care plays a critical role in promoting mental well-being. Personalized interventions, encompassing counseling and community-driven support systems, are essential in reducing emotional distress and fostering recovery.

Background

Pregnancy loss encompasses a range of experiences, including spontaneous abortion (miscarriage), termination due to fetal anomaly (therapeutic), and legal abortion (termination of pregnancy, ToP). While miscarriage is an involuntary loss of the pregnancy, pregnancy termination due to fetal anomaly is often a medical decision made when there are severe conditions incompatible with the life of a pregnant person and/or a fetus. Legal abortion, on the other hand, is a voluntary choice made for various personal and socioeconomic reasons. Despite their differences, all forms of pregnancy loss can carry emotional and psychological weight, requiring compassionate support and understanding. [1] There are many risk factors for abortion among pregnant women, as found by many studies, such as legal termination of pregnancy for different causes, including fetal anomaly, and unwanted pregnancies. [2]

Although abortion and pregnancy loss are assumed opposites, there is a surprising amount of similarity between the two. One apparent intersection is that the result is the same as a pregnancy ending in an event other than the birth of a live child. [3] This relationship is also similar to both miscarriage and pregnancy loss due to any reason, depending on the length of the pregnancy when it is terminated. Cultures of stigma and silence surround abortion and miscarriage, causing women to experience a wide range of emotional consequences, promoting stigma and significant psychological sequelae.[4] The relationship between different types of pregnancy loss, legal abortion, spontaneous abortion (miscarriage), pregnancy loss due to fetal anomalies, and other forms of pregnancy loss is deeply intertwined with psychological support. Each of these experiences can carry emotional weight, though the nature of distress varies.[4] For this review, the adopted terminology for all forms of pregnancy loss is termination of pregnancy (ToP) from whatever cause to define the need for emotional care for women during this difficult moment.

Emotional care, from a scientific perspective, refers to the support and interventions aimed at maintaining or improving an individual's emotional well-being.[5] The same authors note that it involves recognizing, understanding, and addressing emotions through psychological, social, and sometimes physiological means. Emotional care is often studied within fields such as psychology, neuroscience, and healthcare, where researchers examine how emotions affect mental health, decision-making, and overall well-being.[6] When it comes to emotional care related to the ToP, scientific research suggests that emotional responses to abortion vary widely among individuals. Studies indicate that abortion itself does not inherently cause emotional distress, but rather, the circumstances surrounding the decision, such as the occurrence of the pregnancy, societal stigma, personal beliefs, and external pressures, can contribute to emotional challenges.[7]

Emotional care in this context involves providing nonjudgmental support, counseling, and resources to help individuals process their emotions during the decisions to end the pregnancy and the time after the pregnancy loss. Studies suggest that abortion stigma can contribute to depressive symptoms, particularly for women who undergo pregnancy termination due to fetal anomalies.[8] Similarly, miscarriage and other pregnancy losses can lead to feelings of guilt, sadness, and even post-traumatic stress, making psychological care essential. [4,7-8] Recognizing the emotional impact of all pregnancy outcomes, whether chosen or involuntary, can help normalize discussions around reproductive health and ensure that women receive the compassionate support they need. For this review, the reviewers were aware of these abortion differences, which in the end necessitate psychological support. Thus, the review considered all forms of pregnancy loss as ToP to locate the designed psychological support interventions to improve women's mental health outcomes.

Legal abortion, also known as ToP, refers to the medically or surgically induced ending of a pregnancy within the framework of laws and regulations that permit the procedure. [9] The legal status of abortion varies across countries, influencing access to safe procedures and psychological support for individuals experiencing this loss. [10] However, because ToP is still taboo to some communities around the world, women note a noticeable judgment after service provision, while literature supports that having individuals who are closer to you and who are willing to truly listen and understand your feelings with compassion without judgment is a great relief.[3]

According to the global commitments on sexual reproductive health and rights (SRHR), is to improve outcomes for all. [7] Better outcomes are associated with women's uniqueness about when to carry the pregnancy or not, as their bodies have different issues. Consequently, most women, while terminating their pregnancies, are not aware of the need for psychological support immediately due to the subsequent psychological effects they experience throughout the process. The American Psychiatric Society distinguishes between two types of disorders concerning post-abortion complications: PAD (post-abortion distress) and PAS (post-abortion syndrome).[11] These two conditions are more prevalent and harm women's mental health post-ToP. Thus, healthcare providers (HCPs) should understand that they should avoid them. Different measures to create a comprehensive and empathetic framework that prioritizes mental health and reduces the emotional burden for those who seek ToP are the cornerstone of women's positive mental health. However, different countries are not conscious of the need for psychological care and support in the ToP service provision. In the Low-and Middle-Income countries (LMICs), including Rwanda, the categories of legal grounds that a woman can access ToP to save lives did not include the mental health part.[1]

While some women are going through negative emotions after ToP, healthcare providers (HCPs) have a role to create and maintain a positive working environment, increasing women's enthusiasm and ensuring their mental health is adequately supported in the long run. HCPs help in transforming worries related to something unknown to feelings of coping with a new and hard experience, as well as responding to strong and conflicting emotions, and reasons for having an abortion.[12] Therefore, it is important to identify the high-risk women susceptible to psychological complications in the gynecology-obstetrics unit during ToP. They also have the responsibility to help women create their way to acknowledge their loss or adopt changes to move forward. Furthermore, literature also mentions protective factors, such as support from the partner and close family. The study about the effect of hope therapy on the psychological well-being of women after an abortion shows that women in the counseling intervention group had significantly higher scores than those in the control group.[13] Psychological support plays a crucial role in helping individuals process these experiences, whether through education and counseling, peer and partner support, social support networks, or medical guidance to relieve the stigma associated with abortion.

Different studies have studied women's perceptions about the service provision [14] and harmonizing national abortion and pregnancy prevention laws and policies for sexual violence survivors with the Maputo Protocol,[15] but there is only a limitation about the available psychological support package included in the ToP service provision to improve women's positive mental health outcomes. The objective of the present review was to assess the existing psychological support packages/interventions. The review was guided by the following question: What are the existing psychological support packages that improve mental health outcomes among women post termination of pregnancy?

Methods

Design

This review employs an integrative approach and thematic synthesis to analyze emotional care and psychological support models without restricting study types to settings, ensuring a broad perspective. Using Whittemore and Knafl's framework [16] it systematically examines psychological support for women before, during, and after termination of pregnancy (ToP) through five key stages: problem identification, literature search, data evaluation, data analysis, and presentation of findings. The review question was “What existing psychological support packages improve mental health outcomes for women post-ToP?” This method offers a comprehensive understanding of healthcare challenges related to ToP.[18] Whittemore and Knafl's framework was combined with a convergent integrated approach (CIA) to capture all rich information from papers. [17]

Literature Search

Whittemore & Knafl[18] suggest that the reviewers identify relevant articles, employing a systematic approach that can include electronic databases, grey literature sources, and hand searching of relevant journals' literature. The same with this review, studies were from relevant databases and journals related subject. Papers were considered if they mentioned any psychological support at any time in the process of ToP, assessed by any described measurement tool, and offered relevant content concerning the emotional care to women for ToP processes. Tracing of papers targeted databases and retrieved papers, including MEDLINE (PubMed), papers were searched, CINAHL Complete (via EBSCOhost, PsychINFO (ProQuest), HMIC (Ovid), PLOS Medicine, Center for Global Mental Health, and World Mental Health Federation. In addition, an internet search was performed on Google Scholar and found papers.

Eligibility criteria

The literature search was conducted using the following search string:

• Used MeSH (Medical Subject Headings) terms for MEDLINE via PubMed

• Applied subject headings for CINAHL (CINAHL Headings) and PsycINFO (APA Thesaurus)

• Structured with Boolean operators (AND and OR)

• Grouped terms with parentheses to maintain logic

• Included synonyms and relevant keywords when a concept lacks an indexed heading

These strings use controlled vocabulary MeSH, MH, and DE (when available), and complement with keywords (tiab or AB) for breadth.

MEDLINE

(“Abortion, Induced” [Mesh] OR “Spontaneous Abortion” [Mesh] OR “Abortion, Legal” [Mesh] OR “Termination of Pregnancy” [tiab] OR “Safe Abortion” [tiab]) AND (“Mental Health” [Mesh] OR “Psychological Phenomena” [Mesh] OR “Psychological Support” [tiab] OR “Emotional Wellbeing” [tiab]) AND (“Women” [Mesh] OR “Female” [Mesh]) AND (“Health Services” [Mesh] OR “Health Education” [Mesh] OR “Social Support” [Mesh] OR “Support Groups” [tiab]).

CINAHL Complete

(AB “abortion” OR AB “termination of pregnancy” OR AB “safe abortion” OR MH “Abortion, Induced” OR MH “Spontaneous Abortion”) AND (AB “mental health” OR AB “psychological support” OR AB “emotional wellbeing” OR MH “Mental Health” OR MH “Psychological Support”) AND (AB “women” OR AB “female clients” OR MH “Women”) AND (AB “support groups” OR AB “health education” OR MH “Social Support” OR MH “Health Services”).

PsycINFO

(DE “Induced Abortion” OR DE “Spontaneous Abortion” OR DE “Pregnancy Termination” OR “abortion” OR “termination of pregnancy”) AND (DE “Mental Health” OR DE “Psychological Intervention” OR “emotional wellbeing” OR “psychological support”) AND (DE “Women” OR “female clients”) AND (DE “Social Support” OR DE “Support Groups” OR “health services” OR “health education”).

Other exclusion criteria included studies with wrong dose (meaning that psychological care was not enough to be used), wrong topic (meaning that the topic is not clear to be considered on the use of psychological care), wrong setting (meaning the setting was note the one preferred at the beginning), wrong outcomes (the outcomes did not show what the research question was looking for), wrong comparator (using an inappropriate or poorly matched control or comparison group in the studies being reviewed), wrong indication (Applying or assessing an intervention for a condition or purpose it wasn't designed or validated for. In this case, the indications of the intervention do not lead to the psychological care outcomes), wrong intervention (Not mentioned the psychological interventions or packages to be used), wrong study design (such as case reports or anecdotal evidence, poorly controlled observational studies, underpowered randomized controlled trials, and inadequate outcome measures…), and wrong patient population (groups not appropriate or relevant to the intervention being assessed).

All citations meeting inclusion criteria, studies from any country, published in English between 2013 and 2023, addressing psychological support after abortion or pregnancy loss, were classified into empirical research. This included experimental and quasi-experimental designs, observational studies, and qualitative research.

Data Extraction and Evaluation

Whittemore & Knafl[18] emphasize the need for a critical evaluation of studies to assess rigor, validity, and relevance before inclusion. Similarly, this review conducted a thorough assessment before analysis, ensuring only relevant studies were considered. Data evaluation followed these steps:

Assessing certainty in the included papers

The reviewers conducted all steps, ensuring selected studies highlighted psychological support packages for mental health or emotional care at any stage of the ToP service provision are maintained. Methodological quality was assessed using the Joanna Briggs Institute (JBI)'s critical appraisal tools.[18] Papers were entered into Covidence, which removed duplicates before title and abstract screening, followed by full-text review. Data extraction was performed using a predefined template, and the resulting Excel sheet, which was downloaded from Covidence, was cleaned before analysis.

Synthesis methods and charting the data

Data synthesis involved extracting and organizing evidence from individual sources.[19] Of the 34 papers retrieved from Covidence, 17 were retained after cleaning, focusing on study identification, methods, population, intervention details, and outcomes. Four review papers were excluded, and the final selection consisted of 13 empirical scientific papers for data analysis. Table 1 below (in the results section) summarizes key aspects, including author, aim, sample, variables, analysis methods, main results, and psychological interventions identified.

Table 1.

Variables used in the data synthesis and charting stage in the data evaluation step

Author	Aim and sample	Variables and analysis	Main Results	Psychological interventions identified
Shereda et al., 2018	Effect of psychological intervention on post-traumatic stress symptoms and pregnancy outcomes among pregnant women with previous recurrent abortion on a sample of (n=40) women.	Post-traumatic stress disorder and the Statistical Manual of the American Psychiatric Association IV diagnostic criteria (PTSD-IV)	Psychological interventions were associated with positive pregnancy outcomes. Psychological intervention decreased post-traumatic stress symptoms as well.	Suggesting to have a customized management plan that includes education, resources, and the opportunity to discuss women's loss post-ToP.
Wang et al., 2023	Develop an intervention to promote the psychological well-being of Chinese women undergoing an abortion with a sample of (n=14) women	Real-life stressors and support needs were considered using A five-step iterative approach informed by intervention mapping, together with the Transactional Model of Stress and Coping	Eight stressors and women's support needs varied with the time trajectory of abortion. The integrated strategies were instructional support, informational support, and timely communication	Women's needs for consideration throughout the ToP services were: Face-to-face consultation, easy-access online, information platform, communication inside the hospital, timely communication after discharge, confidentiality, interactive and remote services, take away information booklets (soft-copy or hard-copy), avoid all judgments and criticism, encourage support person's involvement, discharge education, build a reliable social/emotional support network and reassure women of the legal position of abortion.
Reider et al., 2014	Explore the factors that contribute to emotional distress post abortion and interventions used to mitigate such distress and clinicians (n=12) who provided the service were interviewed.	Clinicians described their personal experiences with abortion and their process of healing from associated emotional distress, as well as the experiences of their patients and interventions that mitigated distress for their patients.	Abortion experience was associated with emotional distress. Individual counseling and connection to other women who have experienced abortion (as a support group, talk-line), supportive relationships, non-judgmental space, psycho-education about the emotional component of abortion, and referrals to counseling were mitigating interventions.	The results inform its use in other context to inform emotional distress among women experiencing ToP.
IwanowiczPalus et. Al., 2021	Assess the impact of social support on the psycho-physical condition. health, and satisfaction with quality of life among women after miscarriage and ectopic pregnancy among (n=610) women.	Psycho-physical condition, satisfaction with health and quality of life, sources of support, using a diagnostic survey of Berlin Social Support Scales (BSSS)	Psycho-physical condition, health, and QoL were determined by their education, financial standing, and obstetric history.	The results from this study suggested including these components (partner support, an obstetrician-gynecologist's support, Midwife's support, Psychologist, Family, Friends, and a member of the clergy's support) in the service provision
Quinley et al., 2014	Determine whether a patient's pre-procedural report of her psychological well-being would predict how she would cope psychologically in the immediate wake of the procedure among (n=62) women	Self-reported responses regarding psychological well-being before and after abortion, plus anticipated post-procedural psychological coping, were used	Average predicted psychological scores were 9.7% better than pre-procedural psychological states, and women who scored poorly on pre-procedural psychological assessments were more likely to have post-procedural psycho-social concerns	Family planning clinicians and staff may use pre-procedural psychological scores as a clinical tool to focus their resources on helping women heal and cope psychologically following ToP services.
Lafarge et al., 2013	Find out what coping strategies women (n=27) have with ToP for fetal anomaly	During and after the procedure, the account was on experience where women completed an online survey. Data were analyzed using interpretative phenomenological	Coping comprised four structures: support, acceptance, avoidance, and meaning attribution.	The study's findings indicate the need to provide sensitive, acknowledging the unique nature of ToP. Enabling women to reciprocate for emotional support, promoting adaptive coping strategies, the value of spending time with the baby, and providing long-term support, including subsequent pregnancies.
Kong et al., 2014	To assess the effectiveness of supportive counselling after miscarriage among (n=208) women	Supportive counselling from a nurse or routine care for the control group, and psychological well-being was measured with the General Health Questionnaire (GHQ-12) and Beck Depression Inventory (BDI). t-test and the Mann–Whitney U-test were used, and the trend of psychological well-being over time was assessed using repeated-measures analysis of variance (rANOVA). Complete case analysis and intention-to-treat were the main measures	Among the results, the proportion of women continuing to score high in BDI was significantly lower in the counselling group	Supportive counselling program for selected women with high levels of psychological distress is commended and merits further investigation
Ramdaney et al., 2015	To study the awareness and utilization of support resources in women (n=51) at the time of the procedure, at 6 weeks, and at 3 months following the event.	Pregnancy and support resources she was aware of and anticipated using. Women were given a space to write additional information they felt would help other women in similar situations. Using STATA (v.13, College Station, TX), categorical and continuous variables were run. Free text comments were evaluated qualitatively using thematic analysis, mostly on the theme of the termination procedure pursued.	Responses from the 6-week and 3-month assessments were consistent with previous literature, as many women indicated not coping as expected and were unprepared for the psychological consequences following the procedure.	They further suggest that guidelines for routine follow-up care should include a flexible timeframe for support uptake. Anonymity and easy access need to be developed for this population.
Sudhinaraset et al.,2022	To evaluate a person-centered abortion care mobile-based intervention on perceived social stigma, social support, mental health and post-abortion care experiences among (n=371) women.	Women were randomized three arms; 1) standard of care (by service provider call center); 2) post-abortion phone follow-up by a peer counselor (a woman who has had an abortion herself and is trained in person-centered abortion care); or 3) post-abortion phone follow-up by a nurse (a nurse who is trained in person-centered abortion care). The evaluation focused on effects on mental health, social support, and abortion related stigma scores. A Kruskal-Wallis one-way ANOVA test was used to assess the effect of each intervention compared to the control group.	The nurse arm improved mental health scores from baseline to week two. No difference was noted from other arms	The person-centered mobile phone-based intervention may improve mental health and decrease perceived stigma among women who received abortion services in private clinics.
Kamranpour et al., 2019	To determine the supportive needs of women (n=27) who have experienced pregnancy termination due to fetal abnormalities	Data were collected through in-depth personal interviews and were analyzed simultaneously using conventional content analysis.	Support from the husband (mental support and necessary accompaniments), support from the family and friends, support from peers (communicating with the peers and receiving information from them) and “creating a sense of confidence and hopefulness	Findings suggest inclusiveness of husbands, family members and the peers along with other professional care.
Alqassim et al., 2022	To investigate the social support needs and the role of online spaces in social support provision among (n=44) women with miscarriage experience	16 activities (discussions, creative tasks, and surveys) in two closed, secret Facebook groups over eight weeks. Descriptive statistics were used to analyze quantitative data, and content analysis for qualitative data.	Miscarriage Circle of Care Model (MCCM), with peer advisors improve communication channels, social support provision promoted acceptance, the use of emotional support, self-distraction, active coping and online support as well	Findings suggested an initial communication model between formal and informal care networks and use online support sources.
Bellhouse, 2018	To explore (n=15) women's experiences of social support following miscarriage	Major reproductive events including miscarriage and experience. Thematic analysis was used	Partner support, acknowledging the loss, and little support from social are the main findings	Raising awareness and knowledge of the frequency and impact of miscarriage in the community is essential to improving social support for women experiencing miscarriage and dispelling the secret and hidden nature of the experience. friends and family in providing appropriate support for their loved ones
Raphi et al., 2021	To evaluate the effect of counseling with hope therapy on psychological well-being and quality of life of women (n=52) with an experience of abortion.	An RCT with 8 sessions of 45 minutes twice a week for 4 weeks in the intervention group. t-Test and repeated measures ANOVA were used to compare the outcomes in the two groups	Psychological well-being (PWB) in the counseling group was significantly higher than that in the control group. The total mean score of QOL in the counseling group was significantly higher than in the control group. All sub-domains of PWB and QoL in the counseling group were significantly higher than those in the control group	Using hope therapy can improve the psychological well-being and quality of life of women after abortion

Data Analysis and Synthesis

In the Whittemore & Knafl [18] data analysis is conducted systematically, extracting key themes, concepts, and findings from the selected articles. For this review, data were analyzed systematically, developing key themes from categories, subcategories, and codes in consideration of the findings from the included papers.

Sequence and data transformation

The convergent integrated approach (CIA) combines quantitative and qualitative data, including components from mixed methods studies, through data transformation.[17] This process involves either converting qualitative data into quantitative data (quantitizing) or converting quantitative data into qualitative data (qualitizing).[20]

In this review, quantitized qualitative papers were integrated with existing qualitative studies to support textual descriptions and narrative synthesis, ultimately shaping the final themes on psychological support and emotional care post-ToP (Figure 1 below about Convergent synthesis design informed the process of synthesis).

Figure 1.

Convergent synthesis design informed by CIA

Results

Description of included reviews in Covidence The findings were synthesized through coding, categorization, and thematic analysis, following Whittemore & Knafl's (2005) guidance on clear and coherent presentation. The bibliographic database search identified 1215 records, with the highest contributions from CINAHL Complete (n=354), MEDLINE (n=312), and PsychINFO (n=224), alongside other sources. After 755 duplicates were removed, 422 studies were excluded due to factors such as wrong dose (n=2), wrong topic (n=109), wrong setting (n=8), wrong outcomes (n=137), wrong comparator (n=18), wrong indication (n=10), wrong intervention (n=75), wrong study design (n=56), and wrong patient population (n=7). The final number of studies included for extraction was 34. The extraction followed a structured review process, ensuring consistency among all reviewers.

Typology of possible synthesis design in mixed studies review

Of the 34 studies included, data cleaning resulted in 17 papers for final analysis: quantitative (n=8), qualitative (n=4), mixed methods (n=1), and reviews (n=4). Among these, 76.4% (n=13) were based on empirical evidence, presented psychological support packages, and were used for data representation. The 4 reviews, while relevant, were excluded from the final analysis but incorporated into the discussion part.

The extraction followed a structured review process, ensuring consistency among all reviewers. Kohen's Kappa analysis from Covidence showed a moderate agreement level (60-79), with 63% reliability. Covidence facilitated exclusion decisions, clarifying misaligned studies based on predefined criteria related to psychological support intervention, setting, outcomes, and target population.

The emerging themes

During data analysis, 28 codes were organized into six subcategories, resulting in seven categories. These were further grouped based on meaning, resulting in three final themes: “Holistic psychosocial support for women after prenatal loss”, “strengthening community support and reducing stigma around abortion experiences”, and “enhancing post-abortion recovery through digital, familial, and comprehensive support networks”. Table 2 below outlines the progression from coding to thematic synthesis.

Table 2.

Results of data analysis

Sub-categories	Categories	Themes
Fostering an environment for women to feel supported, understood, and empowered to take care of their mental health	Psycho-education about the emotional component of abortion	Holistic Psychosocial Support for Women After Prenatal Loss
Provision of psychological support and care	Psychological counseling
	Emotional and Social Support	Strengthening Community Support and Reducing Stigma around Abortion Experiences
Community-Based Mental Health Support	Community and Mental Health Awareness
Digital and Remote Support Services	Digital Support Systems	Enhancing Post-Abortion Recovery Through Digital, Familial, and Comprehensive Support Networks
Holistic Support and Reintegration	Comprehensive Support Network
Therapeutic Interventions and Quality of Life Enhancement	Enhancing Well-being and Quality of Life

Description of the emerged themes with their sub-themes

Theme 1. Holistic Psychosocial Support for Women After Prenatal Loss

Theme 1 captures the multi-dimensional nature of support that women seek and value after experiencing prenatal loss, encompassing emotional, psychological, social, cultural, and occasionally spiritual domains. It encompasses the need for understanding the emotional aspects of ToP while highlighting the importance of both education and counseling to support individuals through this experience.[21]

They further emphasized the importance of safe spaces where they could express grief, sadness, guilt, and anger without judgment. Compassionate listening, validation of emotions, and continuity of care were seen as critical to recovery. Support needs often extend beyond the immediate aftermath, especially during anniversaries, subsequent pregnancies, or interactions with children. Several women described needing space to revisit their experiences months or years later, which conventional short-term models failed to provide.

Emotional support in this context is crucial for helping individuals navigate the complex emotions and challenges that can arise before, during and after the procedure and the years to come. Lack of empathetic response from providers often exacerbates trauma and leads to withdrawal from formal care systems. Thirteen articles included in this review reveal the emotional needs triggered after ToP, identifying aspects of education and counseling that have an impact on the psychological well-being of women and thus, suggesting a customized management plan that includes education, resources, and the opportunity to discuss their loss.[22] The approach of psychological education and counseling in the antenatal care to identify women at risk for psychological problems can enhance emotional care throughout the ToP service provision when it occurs.

Sub-theme 1: Psycho-education about the emotional component of abortion

Numerous factors were seen to contribute to the increased risk of negative emotional health in perinatal loss in our review. The fact by which the pregnancy was obtained, the lack of memories of the baby's existence, and the self-blame for the pregnancy loss.[22-23] were among these. Shereda and colleagues.[22] emphasized that psychological support plans, which include women's and HCPs' education about abortion and its consequences, decreased post-traumatic stress symptoms among women with recurrent abortion. Lafarge and colleagues.[24] conducted a cross-sectional retrospective study on women's experiences of coping with pregnancy termination and suggested a need to provide sensitive education and non-directive care rooted in the acknowledgment of the unique nature of ToP. Educating and supporting women to reciprocate for emotions, promoting adaptive coping strategies, highlighting the potential value of spending time with the baby, and providing long-term support (including during subsequent pregnancies) were considered a pillar to positive mental health post ToP. Educational resource provision, especially providing information about what to expect emotionally and physically before, during, and after an abortion, can help individuals feel more prepared and less anxious.[25] Knowledge empowers and reassures.

Sub-theme 2: Psychological counseling

Psychological counseling plays a critical role for individuals facing the emotional and psychological challenges associated with ToP. Kong and colleagues.[26] stipulated that the impact of supportive counselling on women's psychological well-being after ToP and other supportive counselling programs for selected women with high levels of psychological distress may be more promising and be implemented as routine care before, during, and after an abortion. Emphasizing that the provision of emotional support, which focuses on the availability of a safe space for women to express feelings and concerns related to the abortion decision, helps individuals explore their feelings about the abortion and the factors influencing their decisions should be maintained. As counseling involves different considerations, including (1) individual therapy: a one-on-one session focusing on personal feelings, fears, and experiences, (2) group therapy, and couple counseling [21], it is essential to consider these steps to enhance emotional well-being and facilitate healing during and after the abortion experience.

Theme 2: Strengthening Community Support and Reducing Stigma Around Abortion Experiences

This theme explores how community perceptions, social networks, and shared narratives can either facilitate healing or perpetuate harm in the aftermath of abortion, especially when silence and stigma dominate public and private discourse. It emphasizes the importance of lived experience, mental health awareness, and culturally sensitive dialogue in creating safe spaces where women can heal, be heard, and access resources without fear or shame in their communities. Many women described abortion as a hidden trauma, often unacknowledged even within families or health systems, and the absence of public discourse, coupled with fear of judgment, led to self-censorship and isolation. Women desired shifts in cultural framing, from blame or moral failure to one of compassion and contextual understanding. Women advocated for policy reforms, inclusive reproductive health education, and community sensitization to challenge harmful norms.

Sub-theme 1: Emotional and social support

Community mental health and emotional support awareness related to ToP services is crucial for ensuring that individuals receive comprehensive care during and after the ToP process. Most of the time, community engagement in this situation was seen to be limited, and members of the family and friends are not supportive due to numerous factors, including lack of knowledge about the service provision and the law regulating it, abortion stigma, religious beliefs, and cultural values and beliefs.[27] Lack of support from the community, especially close family members, can increase the risk of depression and anxiety.[14,28] Having a strong support system, including friends, family, and intimate partners, can significantly impact mental health outcomes for individuals provided with ToP services. [29] Having a supportive network of friends, family, or support groups can provide individuals with the reassurance that they are not alone. These networks offer a safe space to share feelings and experiences. [21] Access to HCPs who are specialized in reproductive health can help individuals process their emotions and manage any feelings of guilt, sadness, or anxiety.[29] Non-judgmental listening, being there for someone, offering a shoulder to lean on, and validating their feelings are incredibly comforting.[30] In addition, the authors stipulated that joining support groups, either in-person or online, can connect individuals with others who have had similar experiences.[31] Sharing stories and coping strategies can foster a sense of community and reduce feelings of isolation.

Sub-theme 2: Community and Mental Health Awareness

Community mental health awareness is an essential component. It fosters a supportive and inclusive environment for all individuals.[14,28] Different approaches were highlighted from the review, such as hosting workshops, seminars, and campaigns to educate community members about mental health, its importance, and how to recognize signs of mental health issues in women who underwent abortions, including ToP is of paramount importance to improve quality of life.[27,14] Knowledge can break down stigma and encourage open conversations. Public awareness campaigns and open dialogue on the ToP services and mental health associated with this can provide information and offer resources for those in need while informing the community.[31]

Theme 3: Enhancing Post-Abortion Recovery Through Digital, Familial, and Comprehensive Support Networks

This theme emphasizes the interconnected support systems that women lean on, or wish they could, after an abortion. The literature highlights the emerging role of digital technologies, the nuanced role of family relationships, and the importance of having a well-coordinated care system to promote long-term wellbeing.[27] Women increasingly turned to anonymous digital platforms, forums, social media, and chat-based counseling apps as primary avenues for emotional processing and peer validation. Creating comprehensive digital support networks can greatly enhance well-being by providing accessible, flexible, and diverse resources for mental health and emotional support, especially to women who have undergone an abortion. Digital counseling and tele-health in providing abortion care can also be used to foster a positive follow-up with women who might not be able to come in person when needed.[32] Support from close family, especially mothers, sisters, or partners, was sometimes central to healing, offering security, shared rituals, and emotional validation. But in other cases, family responses were dismissive, coercive, or moralizing, contributing to shame and internalized distress. For example, women felt they needed to “curate” their stories depending on the listener, selectively revealing emotional depth based on anticipated judgment or support. Effective recovery often relied on multi-pronged support, where digital, familial, peer, and professional components complemented each other. Women advocated for continuity across services, where initial clinical encounters would seamlessly refer them to counselors, peer groups, or digital options rather than leaving them to navigate recovery alone.

Sub-theme 1: Digital Support Systems

This sub-theme emphasizes how virtual consultations with healthcare professionals can provide safe and confidential access to mental health talks related to ToP service provision, especially in areas where in-person follow-up services are limited. [27] It includes the provision of emotional and psychological support through online counseling sessions, helping individuals navigate their feelings and decisions regarding post-abortion quality of life. The online (digital) platforms also offer comprehensive and evidence-based information to educate individuals about their options and what to expect during and after the abortion process, including psychological support or emotional care options for positive mental health. It is noted that digital platforms are secure and confidential, which in turn protects individuals' privacy throughout their abortion care journey.[32] The personalized online services, including virtual counseling, 24/7 chat services, and mental health apps, are designed to offer assistance at the individual level, where a woman who has undergone ToP and needs psychological care support can interact with a psychologist or any other trained healthcare provider on psychological counseling for ToP (32). Additionally, it can be integrated to in-person care to ensure a seamless and supportive experience, from initial consultation to post-abortion care. [27]

Sub-theme 2: Comprehensive Support Network

This sub-theme highlights the importance of a multi-layered care system that connects women to emotional, familial, and professional resources following abortion experiences. It emphasizes the role of coordinated support from HCPs to peer networks and loved ones in fostering psychological recovery, promoting resilience, and improving overall quality of life. Through community engagement, the network aims to ensure no woman navigates post-abortion healing alone. Creating a comprehensive support network for individuals during and after the ToP is essential for women's emotional, physical, and mental well-being.[33] The authors stipulated different activities that can improve mental health and well-being, such as emotional preparation, informed decision-making, medical support, and follow-up care, creating a support group for each, crisis intervention, and other resources.[34] Community awareness emphasis helps to reduce stigma and promote understanding of the emotional and mental health needs related to abortion.

Sub-theme 3: Enhancing Well-being and Quality of Life

Situated within the broader framework of Enhancing Post-Abortion Recovery Through Digital, Familial, and Comprehensive Support Networks, this sub-theme focuses on the lived outcomes of holistic care, emotional resilience, restored daily functioning, and a renewed sense of purpose.[33] It reflects how multi-modal support systems, ranging from mobile-based interventions and online communities to family involvement and therapeutic guidance, can actively foster psychological healing, instill hope, and uplift women's overall life satisfaction following abortion. [13] This binds together mechanisms of care with impacts on well-being, showing how diverse support channels converge toward recovery and empowerment.

Discussion

This review aimed to explore the existing psychological interventions for women post-ToP. It also emphasized the psychosocial support mechanisms for women following an abortion, with particular emphasis on culturally resonant, community-engaged, and digitally facilitated interventions. The synthesis revealed three overarching themes: (1) holistic psychosocial care, (2) stigma and community narratives, and (3) support networks that span digital, familial, and health system domains. The review included 13 empirical studies on psychological support, emotional care from before, during, and post ToP.

Different elements that have an impact on the psycho-social well-being of women in this situation were enumerated through different themes, sub-themes, categories, and codes. Most of the evidence extracted for this review indicates that psychological care as part of the healthcare provision related to ToP could have a positive effect on women's mental health. In this review, each theme specifies what women need in ToP service provision, identifying aspects such as education and counseling needs, which have an impact on the psychological well-being of women. The findings further underscore the need to reconceptualize post-abortion and prenatal loss care beyond clinical confines. Suggesting that holistic emotional support, tailored to women's cultural identities, personal histories, and community contexts, emerges as a foundational element of meaningful care. Digital tools offer scalable solutions but must be carefully designed to ensure emotional safety, personalization, and cultural compatibility. Meanwhile, community narratives and informal support networks hold untapped potential for stigma reduction and relational healing.

Holistic Psychosocial Support for Women after Prenatal Loss

Psycho-education involves providing information and support to help individuals understand their emotional responses and mental health needs related to abortion.

In the literature, emotional support is very important during the provision of ToP, as some women may present different behaviors, including anxiety, depressive behaviors, or grief post-ToP.[35] This is consistent with the study[22] on women experiencing prenatal loss, confirming that there should be a customized management plan that may include education (to both HCPs and women), resources, and the opportunity to discuss their loss, integrating the psychological assessment in the antenatal care to identify women at risk for psychological problems. [22] Furthermore, literature notes the usefulness of education about what to expect from the beginning to post ToP and some days to come improves women's confidence and autonomy in decision-making.[12] When HCPs inform women the process and the possible outcomes resulted from ToP, they can also find together the following support needed such as individual counseling and connection to other women who have experienced abortion (as a support group, talk-line), supportive relationships, non-judgmental space, psycho-education about the emotional component of abortion and referrals to counseling as mitigating interventions.[30] Consequently, the same authors stipulate that training and building capacity for HCPs to improve their interpersonal and communication skills and to improve their attitude towards women seeking ToP services in legally liberal settings is commended, in addition to expanding the scope of abortion providers, they should have refresher training on any newer methodological advances in ToP services. Additionally, continued training in interpersonal and communication skills of providers is important to address negative and judgmental attitudes towards women seeking ToP services.[12]

Additionally, psychological counseling is a component of women's mental health and well-being. The impact of supportive counselling on women's psychological well-being after an abortion can help women process emotions, deal with practical issues, and plan for self-care.[36]

The authors note that a supportive counselling program for selected women with high levels of complicated grief may be helpful and can be implemented as routine care before, during, and after an abortion. Providing emotional support that focuses on the availability of a safe space to express feelings and concerns related to the abortion decision helps individuals explore their feelings about the abortion and the factors influencing their decision. Furthermore, counseling involves different considerations including (1) individual therapy: a one-on-one session focusing on personal feelings, fears, and experiences, (2) group therapy: Facilitates sharing experiences with others who have undergone similar situations, fostering a sense of community and (3) couples counseling which involves partners in discussions about feelings and decisions, enhancing communication and support. [21] The effort to enhance emotional well-being and facilitate healing during and after the abortion experience is emphasized in all review papers. Despite strong evidence supporting psychosocial education and counselling after abortion or prenatal loss, these interventions are frequently underutilized due to (1) stigma and silence (Reproductive experiences like abortion are still taboo in many communities, making open dialogue and psychoeducation difficult to initiate), (2) lack of training (HCPs may lack the skills or confidence to deliver sensitive counselling, especially in resource-constrained settings, (3) systemic neglect (Mental health support is often deprioritized in reproductive care, with limited integration in primary services especially, in abortion services), (4) resource limitations (Time constraints, staffing shortages, and lack of infrastructure hinder consistent implementation) and (5) unclear protocols (In some settings, no formal guidelines exist for when, how, or by whom education and counselling should be offered).[37–39]

Strengthening Community Support and Reducing Stigma around Abortion Experiences

Literature noted gaps in the community awareness about ToP and suggested a mass assessment of community awareness, perception, and attitude towards ToP service delivery to strengthen the service. [37] The review papers provided different activities that need to be implemented while informing the community about this service. A previous cross-sectional study shown that social support which includes male partners, relatives, friends may contribute to the optimization of obstetric care and minimization of negative effects on the mental health of patients after pregnancy loss and positively affect their psycho-physical condition, health, and quality of life;[21] especially male partners play important roles in improving mental health, helping in quick recovery and their rapid return to normal life. Sharing stories and coping strategies can foster a sense of community and reduce feelings of isolation during ToP service processes. In the study conducted in Iran.[28]

Highlighted the supportive needs of women who have experienced pregnancy termination due to fetal abnormalities from different aspects. It appears that, by determining and emphasizing these needs and presenting them to the health system authorities, effective strategies for improving constant participation of the husband, family members, friends, and peers, along with other professional care for these people, could be provided, and conditions for their rapid return to normal life would be provided. Community outreach programs that focus on reproductive health education, mental health awareness, and the availability of support services post-ToP are also important to challenge the status quo.[29] Run campaigns to reduce stigma and promote understanding of the emotional and mental health needs related to abortion in the community, as noted in different literature, as in this review.[10]

Wellness activities such as cognitive therapy, mindfulness, sand play therapy, psychological counseling, family support, peer support, empathy nursing, bereavement care, solution-focused psychological nursing, staged psychological nursing and art therapy workshops can help individuals manage stress and improve their mental health in addition to the compassionate care, empathy and understanding of HCPs who provide ToP services.[32] These programs are not well implemented due to factors including cultural and religious taboos surrounding abortion, which discourage open discussion and community engagement,[41] limited funding and policy prioritization,[42] especially in low-resource settings where reproductive health is narrowly framed around maternal survival, lack of trained personnel to deliver sensitive mental health and reproductive education in community about the topic,[42] fear of backlash or legal ambiguity, particularly in regions with restrictive abortion laws or unclear guidelines and fragmented service delivery, where mental health and reproductive care are siloed, making integrated outreach difficult.[43] If these programs are implemented, they can help in reducing stigma and promoting a supportive environment.

Enhancing Post-Abortion Recovery Through Digital, Familial, and Comprehensive Support Networks

Digital support systems offer comprehensive care and support to individuals during and after the abortion process, promoting their emotional and mental well-being. Different authors testified to this when they applied digital technology in ToP processes. Women seeking ToP services valued various supportive activities, including accessible online platforms for communication with healthcare providers, informational resources on post-service outcomes, and available remote support services.[27] This is consistent with other literature about the use of digital platforms for the ToP services. [38] Literature suggests what to include when designing platforms, especially a consideration of anonymity and privacy, as it encourages more women to seek support without fear of judgment or stigma. Easy access without moving from one area to another, except when needed, was also highlighted as important. Our review highlighted the importance of availing an online counseling service to be able to access a certified mental health professional through secure video or chat platforms, receive professional guidance and support at any time.[27] Another component of digital support that our review found important was the online support network.[23]

The authors from our review noted that facilitating online communities where individuals can share their experiences and offer mutual support opens discussions and encourages women to speak out. This was also noted in the other literature about digital technology and abortion service provision. [39] It is also to notify that implementing 24/7 crisis hotline, text lines, and chat services staffed by trained counselors who can provide immediate assistance in urgent situations, developing apps that include features like guided meditation, relaxation exercises, mood tracking, and cognitive behavioral therapy techniques specifically tailored for post-abortion care, hosting regular virtual support group meetings where individuals can connect in a safe and confidential environment to discuss their feelings and experiences, ensuring easy access to tele-health appointments for follow-up care, medical advice, and prescriptions, inclusive designs (ensuring that digital platforms are accessible to all individuals, including those with disabilities and non-English speakers, to provide equitable support for all users), were seen as important in ToP services provision in enhancing positive mental health and psychological care support.[23-24,29,39-40] These platforms can host moderated forums, chat rooms, and discussion boards. Also, a recurring finding was the importance of giving women control over how, when, and with whom they engaged in support.

Empowerment was tied not just to recovery outcomes, but to the process of reclaiming decision-making and voice after an abortion.

Review strengths

The review's strength lies in its ability to provide a comprehensive understanding of a sensitive and often underexplored topic about psychological support and ToP. Additionally, this review is integrative, which provides a holistic perspective in synthesizing findings from various studies, offering a well-rounded view of women's emotional care and psychological well-being post-ToP. The review provided evidence-based insights by analyzing existing research, highlighted the existing emotional care strategies, and identified gaps in current practices. The findings from this review can inform healthcare policies and practices, ensuring that emotional and psychological support is prioritized for women undergoing such experiences. The review also provided the tailored approaches that can be used for women's emotional care and psychological distress related to pregnancy loss from any type. The present review can raise awareness about the psychological impact of pregnancy termination and advocate for better mental health resources and support systems. By shedding light on women's experiences, this review can empower individuals and communities to address emotional care more effectively.

Review limitation

Women's emotional and psychological responses post-ToP are highly individualized. Capturing the full spectrum of these experiences may be difficult, as all pregnancy losses do not have the same cause and intensity, leading to potential oversimplification. The findings of the present review might be influenced by cultural or regional factors, limiting their applicability in diverse settings. Further, an integrative review relies on existing research; if the quality or methodology of the included studies is inconsistent, it could affect the reliability of the conclusions.

The sensitive nature of the topic may lead to underreporting or biased data, as participants might hesitate to share their true experiences, and this review reported what others did. Emotional and psychological responses may evolve. The present review might not capture long-term effects, especially for the included studies, which have short follow-up periods. The integration of perspectives from psychology, sociology, and healthcare can be complex and might lead to gaps in understanding of highlighted perspectives from the review, or make it difficult to draw cohesive conclusions.

Conclusion

The emotional care and psychological well-being of women post-termination of pregnancy remain a critical yet often overlooked aspect of reproductive health. This synthesis reveals that empathic care following termination of pregnancy (ToP) is not merely a clinical obligation; it is a moral imperative rooted in dignity, autonomy, and healing. As abortion and prenatal loss remain silenced topics in many communities, women's narratives call for urgent reforms in health systems, social discourse, and support infrastructures. The integration of culturally sensitive, emotionally attuned, and accessible care approaches is essential to transforming ToP recovery into a pathway of resilience rather than retraumatization. By fostering holistic support systems and reducing stigma, healthcare providers and policymakers can play a pivotal role in ensuring that women receive the care and understanding they deserve, ultimately promoting emotional resilience and overall well-being.

Recommendations

This review provides a broad perspective on existing emotional and psychological care interventions, highlighting the gaps that hinder their effective implementation.

Healthcare Providers

Healthcare professionals play a crucial role in improving emotional support for women following pregnancy termination. They should advocate for the integration of counseling services designed to address emotional and psychological needs. These services could include grief counseling, stress management, and coping strategies to help women navigate their experiences. Additionally, providers should recommend training programs that enhance their sensitivity and understanding of the emotional challenges women face. Ensuring compassionate care is essential in supporting their psychological well-being. A multidisciplinary approach combining medical, psychological, and social support is also necessary to comprehensively address women's post-termination needs.

Community-Based Support

Women are integral members of society, and their well-being impacts the broader community. There is a need for community-driven interventions that foster emotional resilience. One such approach is the establishment of support groups where women can share their experiences, receive peer encouragement, and reduce feelings of isolation and stigma. In addition, public awareness campaigns should be developed to promote understanding of the emotional challenges associated with pregnancy termination and reduce societal stigma. These initiatives can help create a more supportive environment that acknowledges women's emotional experiences.

Policy Makers & Advocacy

Policies should be designed and reinforced to ensure access to mental health services for women post-pregnancy termination. Policymakers should prioritize initiatives that integrate emotional well-being into the broader continuum of reproductive healthcare. Establishing policies that guarantee mental health support will help address the emotional and psychological impact of pregnancy termination while ensuring women receive the care they need.

Research & Academic Exploration

Notable gaps persist in understanding how interventions function across life stages, identities, and cultural contexts, especially in Sub-Saharan Africa and other underrepresented regions. More participatory research is needed to explore how digital, familial, and community supports interact synergistically. Longitudinal designs could illuminate how support needs evolve over time and during subsequent reproductive experiences. Further research is required to deepen the understanding of emotional and psychological effects following pregnancy termination. Studies should investigate the long-term psychological impact, as well as evaluate the effectiveness of various intervention strategies. Research findings can guide healthcare improvements, policy formulation, and community support systems to enhance care for women post-termination.

Figure 2.

Data Search and Screening Process

Declaration

The study protocol is registered with PROSPERO number: CRD42023431372 (16/06/2023)

Conflicts of interest

The authors declared no conflicts of interest related to this review in the screening, analysis, and presentation of the results.

Authors contributions

The first reviewer (SM) conducted the first stage of screening titles and abstracts before full screening of the studies by 3 experienced reviewers (TU, AG, and DM), in addition to SM, and assessed relevance against the inclusion/exclusion criteria. Further reviewers assessed the inclusion of related psychological support (MAK and SR) in addition to SM. The last reviewer (OB) resolved the possible conflict from the paper agreement before extraction in Covidence. For the use of Covidence, all reviewers were invited to register, and MAK played a crucial role in allowing all reviewers to use Covidence.