Effects of Previous Termination Experience on Subsequent Pregnancies and the Role of The Midwife
By Carolina Gnad
As presented at the NZCOM Conference, Hamilton, September 2014
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P.A.T.H.S. Research Project - Literature Review
Impact of Past Abortion on Subsequent Pregnancy, Birth and Post Partum Experiences. Evidence to date.
P.A.T.H.S. undertook a Literature Review in 2010 which we hope will
be of interest and stimulate discussion particularly in the
professional health and welfare sector.
In the course of our work, and that of others around the country,
working in the post abortion area, we have noticed various recurring
issues. For example, we’ve heard about and wonder about: women with a
past abortion who then suffer a miscarriage; concerns and issues around
fertility following an abortion; anxiety in subsequent pregnancy and
around birthing; difficulties and issues with attachment and parenting
with subsequent children; and, the possible correlation between and
incidence of post natal depression (PND) in women with a past abortion.
From this we became curious and are looking to see what evidence there
is to date in the research and literature.
We also want to highlight the difficulties with and limits of
research in the post abortion area and identify where there may be gaps.
This was a new endeavour for us. Jayne Gormley, Colleen Carr, Henrietta Trip and
Carolina Gnad were the team willing to engage in the project and trawl through material.
I was so scared with my next pregnancy that there would be something wrong with the baby, or I would lose it. - Sandy
My past abortion wasn’t an issue until I was married and got pregnant again. - Sue
My main concern after my abortion was if I would be able to have more children. - Rebeccah
At the birth of our second baby, I was really anxious about the pain and memories it would trigger. - Pat
Surgical abortion carries similar risks associated with other surgical procedures(1).
Research is divided on the association between
induced abortion and subsequent preterm delivery(2), low birth
weight(3, 4, 5, 6, 7), spontaneous abortion(1, 8) and /or secondary
infertility(7, 9, 10).
Multiple prior spontaneous or induced abortions are
more likely to be associated with more intense vaginal bleeding during
pregnancy(11). And, associations between abortion & placental
complications in subsequent pregnancy are not clear(12).
Clinically significant mental disorders [associated
with an abortion or TOP] are distinguishable from other reactions or
negative emotions; “...feelings of regret, sadness or dysphoria [in and
of themselves] do not constitute psychopathology.”(14, p 869 )
The research suggests that induced abortion may be
linked to post traumatic stress disorder(15, 16, 14, 17), and anxiety
and depression in subsequent pregnancy(13, 14, 15, 18, 17).
NB. There was a marked absence of spiritual implications of abortion in the literature reviewed.
SOCIAL RELATIONAL EFFECTS:
Post abortion emotional or mental health problems
can impact relationships in various ways e.g. communication, emotional
Pregnancies 5-6 months after a pregnancy loss
can worsen trauma and cause inappropriate grief, and may negatively
affect emotional attachment(18).
Poor bonding following abortion appears to increase the risk of child abuse/neglect(18).
Year ended December 2009
17,550 abortions and the median age was 24 years
Highest abortion rate for women aged 20-24 years (37 abortions per 1,000)
63.3% were first abortions, 25% were second abortions and
11.5% of women had two or more prior abortions
NB This trend was steady over the last five years
Fetal death, repeated spontaneous abortion, preterm deliveries and early neonatal deaths
represent abrupt interruptions of personal and family adaptations to pregnancy.....
These events can generate anxiety during future pregnancies and affect the parents' quality of life. (13,p187)
Some Strategies for Midwives (Health Practitioners) Caring for Pregnant Woman With Past Abortion
Specifically inquire after a prior abortion or TOP during the intake process and assess implications for the current pregnancy.
If a woman discloses a prior abortion or TOP be aware of potential issues e.g. anxiety(13): fear of damage to reproductive system(12) or of a problem pregnancy, higher than normal anxiety around birth, depression(18) during pregnancy or after the birth, difficulties with bonding or attachment during pregnancy or with the newborn(18).
Be comfortable to engage in conversation around the past
abortion - the situation, her feelings or beliefs around the decision,
going through the procedure at the time, changes in her and her life
since then. Women have found reflection on previous abortions promoted
closure(25). Be aware of own limitations and refer for appropriate counselling help if needed
Influencing Midwives’ (Health Practitioners’) Attitudes or Approach to
pregnancy or pregnant women with a past abortion or TOP (22, 23, 24)
Professional ethics and practice guidelines.
Clinical management issues.
Individual or professional socio-cultural factors,
may include bias, values, conflicts - moral,
Institutional policies, protocols and procedures.
Effect on midwives regarding their role in abortion services, TOPs, and fetal or neonatal death.
Supervision, support and ongoing professional development, or lack of.
Personal and professional coping strategies.
Own pregnancy and pregnancy-baby loss experiences.
Opportunities for further research
• Experience of subsequent pregnancy around
decision making, relationships, emotions, expectations, recurrence of
memories or trauma.
• Anxiety during subsequent pregnancy and impact on birth experience.
• Attachment during subsequent pregnancy and bonding after birth.
• Incidence of postnatal depression (PND) in pregnancy and association with a past abortion.
• Concerns or issues for midwives (or other
health practitioners) caring for pregnant women with a past abortion
and their families.
References for Literary Review Poster Material:
Zhou, W., Olsen, J., Nielsen, G. L. & Sabroe, S. (2000). Risk of
Spontaneous Abortion following induced abortion is only increased with
short interpregnancy interval. Journal of Obstetrics and Gynaecology,
20 (1), 49-54
Che, Y., Zhou, W., Gao, E., & Olsen, J. (2001). Induced abortion
and prematurity in a subsequent pregnancy: a study from Shanghai.
Journal of Obstetrics and Gynaecology, 21 (3), 269-273
Mirmilsten, V., Rowlands, S., & King, J. F. (2009). Outcomes for
subsequent pregnancy in women who have undergone misoprostol
mid-trimester termination of pregnancy. Australian and New Zealand
Journal of Obstetrics and Gynaecology, 49, 195-197
Moreau, C., Kaminski, M., Ancel, P. Y., Bouyer, J, E., Escande, B.,
Thiriez, G., Boulot, P., Fresson, J., Arnaud, C., Subtil, D., Marpeau,
L., Roze, J. C., Maillard, F., & Larroque, B. (2005). Previous
induced abortions and the risk of very preterm delivery: Results of the
EPIPAGE study. BJOG: An International Journal o Obstetrics and
Gynaecology, 112, 430-437
Parazzni, F., Cipirani, S., Chiaffarino, F., & Sandretti, F.,
Bortolus, R., & Chiantera, V. (2007). Induced abortion and risk of
small-for-gestational age birth. BJOG: An International Journal o
Obstetrics and Gynaecology, 114 (11), 1414-1418
Tan, T-C., Chang, A. M. Z., & Rogers, M. S. (1990). Birth weight
to Chinese women subsequent to a previous abortion. Australian and New
Zealand Jounnal of Obstetrics and
Gynaecology, 30 (3), 217
C., Zou, Y., Wu, S., Li, Y., & Liu, Q. (2008). The influence
of medical abortion compared with surgical abortion on subsequent
pregnancy outcome. International Journalof Gynaecology and Obstetrics,
101, 231-238; Trichopoulos, D., Handanos, N., Danezis, J., Kalandidi,
Kalapothaki, V. (2005). Induced abortion and seconday infertility.
BJOG: An International Journal o Obstetrics and Gynaecology, 83 (8),
Frank, P., McNamee, R., Hannaford, P. C., & Kay, C. F. (2005).
The effects of induced abortion on sebsequent fertility. BJOG: An
International Journal o Obstetrics and Gynaecology, 100 (6), 575-580
Yang, J., Savitz, D. A., Dole, N., Hartmann, K. E., Herring, A. H.,
Olshan, A. F., & Thorp, J. M. Jr. (2005). Predictors of vaginal
bleeding during the first two trimesters of pregnancy. Pediatric and
Perinatal Epidemiology, 19 (4), 276-283
Zhou, W., Neilsen, G. L., Larsen, H., & Olsen, J. (2002).
Induced abortion and complications in the subseqent pregnancy. Acta
Obstetricia et Gynecologica Scandinavica, 80 (12), 1115-1120
Couto, E. R., Couto, E., Vian, B., Gregorio, Z., Nomura, M.,
Zaccaria, R., & Junio, R. P. (2009). Quality of life, depression
and anxiety among pregnant women with previous adverse pregnancy
outcomes. Sao Paulo Medical Journal, 12 (4), 185-189
Major, B., Applebaum, M., Beckman, L., Dutton, M. A., Russo, N. F.,
& West, C. (2009). Abortion and Mental Health: Evaulating the
Evidence. American Psychologist, 64 (9), 863-890
Coleman, P. K., Rue, V., M., & Spence, M. (2007). Intrapersonal
processes and post-abortion relationshipchallenges: A review and
consolidation of relevant literature. International Journal of Mental
Health, 4 (2)
Kersting, A., Kroker, K., Steinhard, J., Hoering-Franz, I.,
Wesselmann, U., Luedorff, K., Ohrmann, P., Arolt, V., & Suslow, T.
(2009). Psychological impact on women after second and third trimester
termination of pregnancy due to fetal anomalies versus women after
preterm birth: A 14 month follow up study. Achives of Women’s Mental
Health,12 (4), 193-20117
Steinberg, J. R., & Russo, N. F. (2008). Abortion and Anxiety?
What’s the Relationship. Social Science and Medicine, 67 (2), 238-252
Ney, P. G., Fung, T., Wickett, A. R., & Beaman-Dodd, C. (1994).
The effects of pregnancy loss on women’s health. Social Science and
Medicine, 38 (9), 1193-1200
Alex, L., & Hammarstrom, A. (2004). Women’s experiences in
connection with induced abortion - a feminists perspective.
Scandinavian Journal of Caring Science, 18, 160-168
Coleman, P. K., Coyle, C. T., Shuping, M., & Rue, V. M. (2009).
Induced abortion and anxiety, mood, and substance abuse disorders:
Isolating the effects of abortion in the national comorbidity survey.
Journal of Psychiatric Research, 43 (8), 770-776
- Robinson, G. E. (2008). Is there an “Abortion Trauma Syndrome”?
Critiquing the evidence. Harvard Review of Psychiatry, 17 (4), 268-290
Garel, M., Etienne, E., Blondel, B., & Dommergues, M. (2007).
French midwices’ practice of termination of pregnancy for fetal
abnormality. At what psychological and ethical cost? Prenatal
Diagnosis, 27 (7), 622-628
- Jones, R. K., & Kost, K. (2007). Underreporting of induced and
spontaneous abortion in United States: An analysis of the 2002 National
Survey of family growth. Studies in Family Planning, 38 (3), 187-197
Kane, R. (2009). Conscientious objection to termination of
pregnancy: The competing rights of patients and nurses. Journal of
Nursing Management, 17, 907-912
Trybulski, J. (2005). Women and abortion: The past reaches into the
present. Issues and Innovations in Nursing Practice, 54 (6), 683-690
Copyright @ P.A.T.H.S. 2010
ABORTION and ANXIETY: What's the relationship?
Source: Department of Psychology, Arizona
85287-1104, United States.
Abstract: Using data from the United States National Survey of Family
Growth (NSFG) and the National Comorbidity Survey (NCS), we conducted secondary
data analyses to examine the relationship of abortion, including multiple
abortions, to anxiety after first pregnancy outcome in two studies. First, when
analyzing the NSFG, we found that pre-pregnancy anxiety symptoms, rape history,
age at first pregnancy outcome (abortion vs. delivery), race, marital status,
income, education, subsequent abortions, and subsequent deliveries accounted
for a significant association initially found between first pregnancy outcome
and experiencing subsequent anxiety symptoms. We then tested the relationship
of abortion to clinically diagnosed generalized anxiety disorder (GAD),
post-traumatic stress disorder (PTSD), and social anxiety disorder, using NCS
data. Contrary to findings from our analyses of the NSFG, in the NCS analyses
we did not find a significant relationship between first pregnancy outcome and
subsequent rates of GAD, social anxiety, or PTSD. However, multiple abortions
were found to be associated with much higher rates of PTSD and social anxiety;
this relationship was largely explained by pre-pregnancy mental health
disorders and their association with higher rates of violence. Researchers and
clinicians need to learn more about the relations of violence exposure, mental
health, and pregnancy outcome to avoid attributing poor mental health solely to
SYNOPSIS OF RECENT POST-ABORTION RESEARCH
(by Vincent M. Rue, Ph.D. Institute for Pregnancy Loss, Stratham, New Hampshire)
Extensive research has documented how traumatic stress
can significantly alter individuals’ lives. Traumatic stressors
are strong predictors of post-traumatic stress disorder or PTSD
(Foy, Osato, Houskempt & Neuman 1992).
While the prevalence of PTSD has been estimated to
affect up to 12% of the U.S. population (Breslau, Davis, Andreski &
Peterson 1991), limited research has examined the role of elective
abortion as a traumatic stressor causing symptoms of PTSD. Most trauma
victims encounter feelings of horror or terror at the time of the
traumatic episode. Bagarozzi has reported that women who came for
mental health treatment were in complete denial that they had
experienced an abortion and that indeed it was a traumatic and horrific
experience for them. ”This denial was seen as a major
contributing factor to the development of post traumatic stress in
these women” (1993:67).
Clinical research findings highlighting the power of denial
before, during and after an abortion have also been reported by
Torre-Bueno (1996). As a pro-choice advocate and long-time
Planned Parenthood abortion counselor, her assertion is all the more
compelling: “I believe passionately that I can be supportive of every
woman’s right to make her own pregnancy decisions, and still recognize
the fact that her decision may cause her tremendous suffering.
While many women do not have emotional or spiritual difficulty after an
abortion, I know from twenty years of experience working with women
before, during, and after abortions, that many women have more
emotional and spiritual pain after abortion than the current research
In another clinical study, pro-choice psychotherapists De Puy
and Dovitch (1997:13-14) reported that 10% of women experience “severe
emotional trauma” following abortion. According to these
clinicians/researchers: “Many women acknowledge a feeling of relief
after their abortion, yet are understandably upset by facets of the
experience that they had never anticipated. Many are distressed
and unaware of the ways in which their choice has changed their lives
and, sometimes, the lives of those around them.” In a study
of 80 women in the U.S., Barnard (1990) used standardized posttraumatic
stress disorder (PTSD) instruments and found: 3-5 years following the
abortion, l8% of the sample met the full diagnostic criteria for
posttraumatic stress disorder (PTSD) and 46% displayed high stress
reactions to their abortion. Her findings were not
explained by religiosity as 68% reported that at the time of the
abortion they had little to no religious involvement. Subsequently,
similar findings were also reported by Hanley et al. (1992) in a
comparison study of women distressed postabortion which also used
standardized PTSD instruments and interviews. They found: “Women
who were distressed following an abortion scored significantly higher
than the non-distressed group on PTSD symptoms of intrusion and
The investigators evaluated whether some women in outpatient
mental health treatment with a presenting problem of postabortion
distress met Diagnostic & Statistical Manual of Mental Disorders
III Revised (DSM-III-R) criteria for the posttraumatic stress disorder
(PTSD) categories of intrusion, avoidance, and hyperarousal. One
hundred and five women were administered the SCID-PTSD module, the
Impact of Event Scale, as well as the Social Support Questionnaire and
the Interview for Recent Life Events, in addition to completing a
The researchers concluded: “the data from this study are
suggestive that women can report abortion-related distress similar to
classic PTSD symptoms of intrusion, avoidance and hyperarousal and that
these symptoms can be present many years after the abortion.”
Posttraumatic reexperiencing has also been documented in
anniversary reactions. In a small study conducted by Franco et
al. (1989:154), 30 out of 83 women reported experiencing anniversary
reactions that included intense emotional psychosomatic pain.
They noted: “Unresolved grief and preexisting dysphoria have been
suggested as increasing the likelihood of anniversary reactions.”
Another recent study compared two groups of 25 women who elected
abortion: those who identified themselves as distressed (D) and those
who reported more neutral or non-distressing responses (ND). PTSD
symptomatology was found in the distressed group: changes in
male-female relationships, suppression of feelings/thoughts about the
abortion, reactions to catalytic events that aroused thoughts/feelings
about the abortion, trying to get pregnant again, becoming promiscuous,
and avoiding reminders of babies. More than two out of three
women in Group D were distinguished by reports of “suppression” or
“denial” of parts of the abortion experience or negative emotional
reactions to it. Additionally, women in the distressed group were more
than twice as likely to report abortion trauma related symptoms on the
Impact of Event Scale than those in the non-distressed group (Congleton
and Calhoun 1993). In this same study, women who identified themselves
as distressed postabortion indicated feeling: a sense of
loss/emptiness (48%); shock/detachment (28%); anger toward
partner/others (24%); depression (20%); loneliness, betrayal, loss of
self-worth, and relief (16%); guilt and sorrow (12%); confusion (8%);
fear of dying and suicidal thoughts (4%). Interestingly, in the
group of women who elected abortion and did not believe they were
distressed, 20% had symptoms of depression, an equivalent percentage
experienced by the distressed group.
The authors concluded:
(1) for some women, abortion is a “critical event” which produces high levels of psychological distress;
(2) informed consent should ensure accurate information is
conveyed about physical pain and possible negative and positive
emotional reactions; and
(3) when dealing with depression among women, exploring
reproductive history for unresolved emotional reactions to pregnancy
termination may prove beneficial.
In a large scale prospective cohort study (N=13,261, of whom
6410 experienced a pregnancy termination) conducted in the United
Kingdom, Gilchrist et al. (1995) found evidence of the traumagenic
nature of abortion when examining relative risks of suicidal behavior
in women who had previously terminated their pregnancy, and who had no
prior history of psychiatric illness. A recent study in Finland
of all deaths of women of childbearing age concluded: “Our data clearly
show, however, that women who have experienced an abortion have an
increased risk of suicide which should be taken into account in the
prevention of such deaths” (Gissler, Hemminki and Lönnqvist 1996:8).
A recent Swedish study examined emotional distress (ranging
from 1 month to 12 months follow-up) after abortion at a university
hospital. Risk factors identified were: living alone, poor emotional
support from family and friends, adverse postabortion change in
relations with partner, underlying ambivalence or adverse attitude to
abortion, and being actively religious. The researchers
concluded: “Thus, 50-60% of women undergoing induced abortion
experienced some measure of emotional distress, classified as severe in
30% of cases.” (Soderberg, Janzon & Sjoberg, 1998:173)
In a study just published, Reardon & Ney (2000) examined
the mental health risks of abortion relating to subsequent substance
abuse. They found that women who aborted a first pregnancy were five
times more likely to report subsequent substance abuse than women who
carried to term, and they were four times more likely to report
substance abuse compared to those who suffered a natural loss of their
first pregnancy due to miscarriage, ectopic pregnancy or stillbirth.
Rue (2001) applied a trauma sensitive perspective to the
understanding of how women coped with pregnancy losses, particularly
induced abortion. He conducted a transnational retrospective
descriptive study of 765 women in the United States and Russia.
In this study, the average number of years since the abortion was 11
years for American women and 6 years for Russian women. Similar
to preceding studies, the most common positive emotional outcome for
women in both countries was relief with 11% of U.S. women attributing
this positive feeling to their abortion compared to 8% in Russia. In
the U.S. sample, 58% of women who aborted experienced 6-10
posttraumatic stress disorder symptoms following the abortion, compared
to 12% in the Russian sample. Overall, the findings indicated that
women in the U.S. sample were more likely to experience posttraumatic
stress related symptoms following their abortion than Russian
women. Using Pearlman’s traumatic stress scale (TSI), Russian
women who obtained an abortion had higher mean total TSI scores than
U.S. women (276 vs. 260), indicating considerable disruption of
Cougle, Reardon & Coleman (2001) employed the National
Longitudinal Survey of Youth (NLSY) a general purpose study which has
interviewed 6283 women since 1979. They found using standardized
assessments: “Compared to post-childbirth women, aborting women (n=735)
were found to have significantly higher depression scores as measured
an average of 10 years after their pregnancy outcome. Controlling
for age, total family income, and locus of control scores prior to the
first pregnancy event, post-abortive women were found to be 41% more
likely than non-aborting women to score in the ‘high risk’ range for
clinical depression. In response to a self-assessment question,
aborting women were 73% more likely to complain of ‘depression,
excessive worry, or nervous trouble of any kind’ an average of 17 years
And finally, in the first record linkage study conducted in
the U.S. on 173,279 low income women who had aborted, Reardon et
al. (2001) found the following: “Compared to women who delivered, those
who aborted had a significantly higher age adjusted risk of dying
during the subsequent eight years from suicide (2.54), accidents
(1.82), and all causes (1.62). Higher suicide rates were most
pronounced in the first four years. Notably, the average annual suicide
rates per 100,000 in our sample, 3.0 for delivering women and 7.8
for aborting women, bracketed the national average suicide rate of 5.2
for women ages 15-44.” In addition to the above, there are a number of
reviews of the literature on postabortion sequelae that are instructive
(Speckhard & Rue, 1992; Rue, 1995; Speckard, 1997; Ney &
Wickett, 1989; and Angelo, 1992).
- Angelo, J. (1992) Psychiatric sequelae of abortion: The many faces of Post-Abortion Grief. Linacre Quarterly, 59:2, 69-80.
- Bagarozzi, D. (1993) Post traumatic stress disorders in
women following abortion: Some considerations and implications for
marital/couple therapy. International Journal of Family and Marriage
- Barnard, C. (1990) The Long Term Psychosocial Effects of Abortion. Institute for Pregnancy Loss. Stratham, New Hampshire.
- Breslau, N., Davis, G., Andreski, P. & Peterson, E.
(1991) Traumatic events & posttraumatic stress disorder in an urban
population of young adults. Archives of General Psychiatry 48: 216-222.
- Congleton, G. and Calhoun, L. (1993) Post-abortion
perceptions: A comparison of self-identified distressed and
non-distressed populations. International Journal of Social Psychiatry
- Conklin, M. and O’Connor, B. (1995) Beliefs about the fetus
as a moderator of postabortion psychological well-being. Journal
of Social Psychiatry 39: 76-81.
- Cougle, J., Reardon, D. & P. Coleman (2001) Depression
associated with abortion and childbirth: A long-term analysis of the
National Longitudinal Survey of Youth. Presented at the 1st World
Congress on Women’s Mental Health, Berlin, Germany and published in
Archives of Women’s Mental Health, Vol. 3/4, Supplementum 2.
- Foy, D., Osato, S., Houskamp, B. & Neuman, D. (1992)
Etiology of posttraumatic stress disorder. In P. Saigh (ed.),
Posttraumatic Stress Disorder (pp. 28-49). Boston: Allyn &
- Franco, K. et al. (1989) Anniversary reactions and
due date responses following abortion. Psychotherapy and
- Gilchrist, A., Hannaford, P., Frank, P., and Kay, C.
(1995) Termination of pregnancy and psychiatric morbidity. Bri.
Journ. of Psychiatry 167:243-248.
- Gissler, M., Hemminki, E., and Lönnqvist, J. (1996)
Suicides after pregnancy in Finland, 1987-94: Register linkage. Brit.
Med. Journal 313:1-11.
- Ney, P. & Wickett, A. (1989) Mental health and
abortion: Review and analysis. Psychiatric Journal of the
University of Ottawa, 14:4, 506-516.
- Reardon, D. & Ney, P. (2000) Abortion and subsequent
substance abuse. American Journal of Drug and Alcohol Abuse. 26:1,
- Reardon, et al. (2001) Suicide deaths associated with
pregnancy outcome: A record linkage study of 173,279 low income
American women. Presented at 1st World Congress on Women’s
Mental Health, Berlin Germany, published in Archives of Women’s
Mental Health, Vol. 3/4, Supplementum 2.
- Rue, V. (1995) Post-Abortion Syndrome: A Variant of
post-traumatic stress disorder. In P. Doherty (ed.) Post-Abortion
Syndrome: Its Wide Ramifications. Dublin: Four Courts Press,
- Rue V. (2001) Posttraumatic stress symptoms following
induced abortion: A comparison of U.S. & Russian Women.
Presented at the 1st World Congress on Women’s Mental Health, Berlin,
Germany and published in Archives of Women’s Mental Health, Vol. 3/4,
- Soderberg, H., Janzon, L. & Sjoberg, N. (1998)
Emotional distress following induced abortion. A study of its
incidence and determinants among abortees in Malmo, Sweden.
European Journal of Obstetrics & Gynecology, 79, 173-178
- Speckhard, A. (1997) Traumatic death in pregnancy:
The significance of meaning and attachment. In Figley, C., Bride,
B. & Mazza, N. (Eds.) Death & Trauma: The Traumatology of
Grieving. Washington, D.C.: Taylor & Francis, 67-100.
- Speckhard, A. & Rue, V. (1992) Postabortion syndrome:
An emerging public health concern. Journal of Social Issues, 48
- Torre-Bueno, A. (1996) Peace after abortion. San Diego: Pimpernel Press.