Memorandum 23
Submission from Dr Chris Richards and
Dr Mark Houghton
THE SERIOUS
MORBIDITY AND
MORTALITY ASSOCIATED
WITH INDUCED
ABORTIONS
A submission to the Science and Technology Committee
of the House of Commons
EXECUTIVE SUMMARY
Which is safer, to have a baby or an induced
abortion? All abortion decisions hang on this.
1. Accepted practice, promoted by the Royal
College of Obstetricians and Gynaecologists (RCOG), is that induced
abortion is safer for the mother than a delivery. Is this true?
2. We present the flaws in current evidence
for this.
3. Mortality is in fact several times higher
in the year after abortion compared to the year after delivery.
4. Induced abortion and higher mortality
have a causal link.
5. Suicide is much increased after induced
abortion.
6. Morbidity from induced abortion far exceeds
a delivery and has been understated.
7. Conclusions: the RCOG advice is unsound
and harms women.
8. Recommendations: the Act should be re-enforced
to protect women through evidence-based guidelines for doctors
and reliable information to patients.
INTRODUCTION
This paper outlines strong evidence from a range
of studies that termination of pregnancy poses a far greater risk
to the life and health of the mother than continuing the pregnancy.
1. Background
1.1 The Royal College of Obstetrics and
Gynaecology (RCOG) maintain that risks of induced abortion to
a mother are lower than continuing the pregnancy to term at any
gestation.i For this reason many doctors justify the interpretation
of the Ground C under the Abortion Act in a way that allows any
woman requesting an abortion to be offered one because continuation
of pregnancy would pose a "greater risk to her physical and
mental health, than if she had an abortion."
1.2 Such a claim also permits a health professional
to arrange an abortion without parental consent for someone under
16 who can be considered to fulfil "Fraser competency"
in other ways.
1.3 This paper looks in more detail at the
basis on which such claims are made, and the accumulation of scientific
evidence that the risks of induced abortion to the woman far outweigh
the risks to her if she continues her pregnancy.
2. Basis of current claims about the mortality
associated with induced abortion
2.1 The usual source of statistics for the
relative mortality associated with pregnancy and abortion is the
Confidential Enquiry into Maternal Deaths. ii The most recent
report, covering the three years from 2000-2002, records only
five deaths due to abortion. This was out of a total of 261 pregnancy-associated
deaths. These five were early deaths from medical rather than
psychiatric causes. This might suggest that induced abortion contributes
little to pregnancy-related maternal mortality.
2.2 However, there are several reasons for
considering that this data is far from complete:
2.2.1 Underreporting of late deaths. Deaths
caused indirectly, especially from psychiatric causes, often occur
some months after the induced abortion. The Confidential Enquiry
recognises this ascertainment weakness in the comment, "It
is not surprising that these (late) deaths were not reported since,
by the time they died, these women would have lost contact with
their maternity health professional, the person who reports these
cases." iii In order to explore such missed cases a linkage
study quoted in the report found a further 32 out of 50 deaths
caused by suicide, which had not been reported to the Enquiry.
It is not specified how many of these followed induced abortion.
2.2.2 Abortion as an antecedent is often
deliberately hidden. Health professionals may not recognise that
a woman's death is caused by induced abortion because she may
have hidden her abortion from family and friends as well as health
professionals. Induced abortion often occurs at a distant facility
out of the sphere of a woman's usual medical care.
2.2.3 The sensitive nature of abortion.
Health professionals may be reluctant to raise the issue of a
possible association between death and induced abortion in order
to avoid offence to the grieving family.
3. Can the risks of induced abortion be more
accurately assessed?
3.1 We suggest that the inaccuracy of the
Enquiry data has lead to false conclusions. Better information
can be obtained from so-called linkage studies. These identify
women of child-bearing age who have died and then seek out their
medical history from available records. Two such death linkage
studies have been published—one from Finland, and one from
the US.
3.2 A robust Finnish studyiv collected national
data on all women who died between 1987 and 1994 for one year
after their abortion or delivery. The researchers found that compared
to Finnish women who delivered a baby, those who had had an induced
abortion have increased mortality—from both natural and
unnatural causes. This increased risk can be best expressed as
the "age-adjusted odds ratio", which is the number of
times more likely that a woman of a certain age after an induced
abortion dies in a particular way than if she kept her baby. The
odds ratios are 1.63 for deaths from natural causes, 4.24 for
deaths from accidents, 6.46 for deaths from suicide, and 13.97
for deaths from homicide. The suicide rate was independent of
the gestation of abortion ie the raised mortality from suicide
would not be affected by avoiding late abortions.v
3.3 A study of Californian low-income women
confirms the increased mortality associated with induced abortion.
It looked at the outcome after first pregnancy for eight years
after a state-funded abortion or delivery between 1989 and 1997.
Over the eight years the age-adjusted odds ratio of dying following
an induced abortion was 1.44 for deaths from natural causes, 1.82
for deaths from accidents, 2.54 for deaths from suicide and 1.59
for deaths from homicide.vi
3.4 These studies would substantiate the
concern of the Enquiry that late pregnancy deaths from suicide
are common and frequently missed. This is especially because the
increased risk from abortion continues so long after the event.
4. Is the increased mortality rate after
induced abortion causally related?
4.1 We can conclude from the above studies
that women who undergo induced abortion are at substantially greater
risk of violent death, especially from suicide than those who
deliver. However, association does not prove causality. Could
it be that the greater incidence of violent death simply reflects
a greater pre-abortion psychiatric disposition? Put another way;
is it that disturbed people are more likely to have an abortion?
And are they more likely to experience a violent death afterwards,
irrespective of having had the abortion?
4.2 The RCOG clearly considers that any
association is incidental and not causal. In their advice leaflet
to women considering abortionvii they ask, "How will I feel
after an abortion?" They reply as follows, "Some studies
suggest that women who have had an abortion may be more likely
to have psychiatric illness or self-harm than other women who
give birth or are of a similar age. However, there is no evidence
that these problems are actually caused by the abortion; they
are often a continuation of problems a woman has experienced before."
But does the evidence from studies support such bold reassurance?
4.3 There are several reasons for recognising
a strong causal association between violent death, especially
from suicide, and induced abortion:
4.4 The association remains after adjustment
for pre-abortion psychiatric state. The Californian study included
an assessment of the psychiatric history one year prior to the
delivery or abortion. Adjusting for this, the likelihood of violent
death and suicide increased after induced abortion as compared
to delivery.
4.5 The same study shows a temporal relationship
between the deaths from suicide and the time from the abortion,
with a steady decrease in suicide rates over the eight year study
period. This contrasted with the women who delivered, in whom
the suicide rate rose slightly over this period. These observations
support a causal link between suicide and induced abortion which
wears off very slowly over an eight year period.
4.6 Another study from Walesviii supports
a causal relationship between abortion and vulnerability to suicide.
The researchers looked at admission rates for suicide attempts
before and after a pregnancy event. Rates almost doubled in women
who had had an induced abortion, compared with a slight diminution
in those who delivered. This also confirms the observation from
other studies that there is a psychiatrically protective effect
when pregnancy ends in birth.
5. Why are women who have had an induced
abortion so much more likely to commit suicide?
5.1 Researchers in the Californian study
suggest that this is caused by "increased psychological stresses
related to unresolved guilt, grief, or depression." Is there
any research evidence that this is the case? There are a number
of recent studies that show raised levels of psychiatric morbidity
such as depression, deliberate self-harm and suicidal ideation
following induced abortion, all of which are recognised predisposing
factors to committing suicide.
5.2 One landmark study from New Zealandix
was able to adjust for pre-pregnancy psychiatric state and found
that those becoming pregnant but not having an abortion had overall
rates of mental disorders, including depression, between 58% and
67% of those who had an induced abortion. Such mood disturbance
would clearly predispose the woman to the risk of suicide. Similar
findings are noted in another study which showed that rates of
depression are increased for eight years after the induced abortion.x
A further study found levels of deliberate self-harm to be almost
three times more frequent in those with unplanned pregnancy and
who had no history of psychiatric illness, but went on to have
an induced abortion, as compared to those who kept their baby.
xi
5.3 Further support for a causal association
between induced abortion and suicide comes from interview-based
studies. These have consistently shown extraordinarily high levels
of suicidal ideation (30-55%) and reports of suicide attempts
(7-30%) among women who have had an abortion. xii In many studies,
the women interviewed have explicitly described the abortion as
the cause of their suicidal impulses.
5.4 Interpretation of these statistical
studies is aided by numerous publications describing individual
cases of completed suicide following abortion. xiii In many cases,
the attempted or completed suicides have been intentionally or
subconsciously timed to coincide with the anniversary date of
the abortion or the expected due date of the aborted child. xiv
5.5 Each of these studies absolutely contradicts
the RCOG conclusion that any psychiatric illness after abortion
is simply a continuation of that present prior to the abortion.
Instead it is clear that psychiatric illness after induced abortion
is often caused by the procedure. The above findings also contradict
the RCOG when they quote the assessment of Dagg that such complications
are "on the wane immediately after the abortion".xv
Rather they are commonly pervasive and often continue for a number
of years after the procedure.
5.6 These recent studies are not saying
anything new. The Royal College of Psychiatrists gave witness
to the private commission of enquiry headed by Lord Rawlinson
in 1994xvi which looked into the operation and consequences of
the Abortion Act. The report observed "that although the
majority of abortions are carried out on the grounds of danger
to the mother's mental health, there is no psychiatric justification
for abortion." The commission concluded "that to perform
abortions on this ground is not only questionable in terms of
compliance with the law but also puts women at risk of suffering
a psychiatric disturbance after abortion without alleviating any
psychiatric condition that already exist."
6. Non-psychiatric morbidity of induced abortion
compared to delivery
6.1 So far this paper has addressed the
increased mortality caused by induced abortion. But how does the
health of women after abortion compare with those who give birth?
It is widely assumed that induced abortion has low rates of complications
especially when performed in the first trimester.
6.2 However, there is strong evidence that
both surgical and medical abortions cause significant short and
long term morbidity which is greater than undisturbed pregnancy.
6.3 Short term complications of surgical
abortion.
6.3.1 The RCOGxvii quote complication rates
per 1,000 surgical abortions of one for haemorrhage, 10 for cervical
trauma, four for perforation of the uterus and one for retained
products of conception. The most common complication is secondary
infection at a rate of 100 per 1,000. Untreated infection can
lead to pelvic inflammatory disease, which has a known association
with infertility. Abortion clinics would say that they test beforehand,
but considering the short time between consultation and abortion
in some places it is doubtful if this can always be done.
6.3.2 These rates place surgical abortion
at higher risk of short-term complications than giving birth.
A recent Scottish study estimated the severe morbidity rate from
undisturbed pregnancy to be 3.8 per 1,000 and almost all events,
including haemorrhage (incidence 1.9 per 1,000), were treatable
with a good long-term outcome. xviii
6.4 Short term complications of medical
abortion.
6.4.1 It has been widely assumed that the
introduction of mifepristone for early medical abortion would
be safer than surgical abortion; and this despite the fact that
its safety has never been assessed in those under 18 years. The
RCOG described this method of abortion as "safe and effective"
and recommend its use for women up to nine weeks gestation.
6.4.2 Relatively minor complications such
as abdominal pain and nausea occur in the majority of women after
taking mifepristone. Vaginal bleeding usually continues for between
9-16 days, but sometimes much longer. 5-8% of women require surgical
intervention following medical termination. Therefore, medical
abortions are five to 10 times more likely to "fail"
than surgical ones; and will subsequently require surgical intervention
in more advanced pregnancy. xix
6.4.3 However, more serious still is the
finding that medical abortions have ten times the mortality of
surgical abortion. There have been at least five deaths in North
America following medical abortion using mifepristone (RU-486).
The women died from a rapidly progressing infection with Clostridium
sordellii. xx
6.5 Long term complications of surgical
and medical abortions.
6.5.1 Prolonged psychiatric disturbance
has already been discussed. However, psychiatric disease is not
limited to depression, suicidal ideation and deliberate self-harm.
Many women also suffer from features of post-traumatic stress
syndrome after induced abortion. xxi
6.5.2 In addition, induced abortions may
have important effects on future pregnancies. Pelvic inflammatory
disease is a recognised complication of both medical and surgical
abortions and can cause infertility. xxii Future pregnancies have
a greater risk of placenta praevia (increased by 7-15 times),
and pre-term labour (twice as likely). xxiii The latter is an
important cause of chronic lung disease and cerebral palsy in
the child.
6.5.3 There are also reported cases of post
abortion morbidity such as infertility after a foetal bone was
left inside, vii and congenital paraplegia after pregnancy "reduction."
viii
6.5.4 Finally there is growing evidence
(though still disputed by some) that abortion increases the risk
of breast cancer (relative risk of 1.3-2). In addition, term pregnancy
acts as a clear protection against the development of breast cancer.
xxiv
7. Conclusion
7.1 The following conclusions can be made
about induced abortion:
7.1.1 Mortality following abortion, especially
due to psychiatric disease, is much higher than is currently recognised
by the RCOG and many clinicians.
7.1.2 A substantial part of the mortality
is causally related to the abortion and occurs regardless of the
gestation at which the abortion occurs.
7.1.3 Morbidity is substantial, both in
the short and long term and caused by both medical and surgical
abortions.
7.1.4 Doctors have failed to follow the
Abortion Act in the light of known medical evidence. The RCOG
advice is unfit for the purpose. It is likely that a large number
of healthy women have suffered, and some have died, because of
this.
8. Recommendations
8.1 In the light of these findings we recommend
to the committee:
8.1.1 There is no easing of legal restrictions
on induced abortion.
8.1.2 The RCOG advice to women considering
abortion should be updated with evidence from recent studies about
the mortality and morbidity of abortion. Women considering abortion
have a right to know the potential serious long term consequences.
8.1.3 Ground C of the Abortion Act can no
longer be legally applied to a woman in anticipating an improved
psychiatric state following abortion compared to her keeping the
pregnancy.
REFERENCES
i The care of women requesting induced abortion.
RCOG September 2004:29.
ii Why mothers die 2000-02. The Sixth
Report of the Confidential Enquiries into Maternal Deaths in the
UK. Chapter 1.
iii ibid.
iv Gissler M et al Pregnancy associated
deaths in Finland 1987- 1994. Acta Obstetricia et Gynecologica
Scandinavica 1997; 76:651--657.
v Gissler M Personal communication. Data available
from author.
vi Reardon D C et al. Deaths associated
with pregnancy outcome: a record linkage study of low income women.
Southern Medical Journal 2002; 95: 834-841.
vii About abortion care: what you need to know
RCOG September 2004: 7.
viii BMJ 1997; 314: 902 (22 March).
ix Fergusson et al. Abortion in young
women and subsequent mental health J Child Psychol Psych 2006;
47: 16-24.
x Cougle JR et al. Depression associated
with abortion and childbirth: a long-term analysis of the NLSY
cohort. Med Sci Monit 2003; 9(4): 157-164.
xi Gilchrist A et al. Termination of pregnancy
and psychiatric morbidity. Brit J Psych 1995; 167: 243-248.
xii David Reardon. "Psychological Reactions
Reported After Abortion," The Post-Abortion Review, 2(3):
4-8, Fall 1994; Anne C Speckhard, The Psychological Aspects of
Stress Following Abortion (Kansas City: Sheed & Ward, 1987).
xiii E Joanne Angelo. Psychiatric Sequelae of
Abortion: The Many Faces of Post-Abortion Grief," Linacre
Quarterly 59: 69-80, May 1992; David Grimes, "Second-Trimester
Abortions in the United States, Family Planning Perspectives"
16(6): 260.
xiv Carl Tischler. "Adolescent Suicide Attempts
Following Elective Abortion," Pediatrics 68(5): 670, 1981.
xv The care of women requesting induced abortion.
RCOG September 2004: 35.
xvi Rawlinson Report 1994 page 15, paragraph
89.
xvii About abortion care: what you need to know
RCOG September 2004: 8.
xviii Brace V et al. Quantifying severe maternal
morbidity: a Scottish population study. BJOG 2004; 111: 481-4.
xix FDA-approved Data sheet on Mifepristone [Mifeprex,
Danco Laboratories], July 2005; www.fda.gov/cder/foi/label/2004/020687lbl—Revised.pdf
xx Fischer M et al. Fatal toxic shock
syndrome associated with Clostridium sordellii after medical abortion.
N Engl J Med 2005; 353: 2352-60.
xxi Korenromp MJ et al. Psychological
consequences of termination of pregnancy for fatal anomaly: similarities
and differences between partners. Prenat Diagnosis 2005; 25: 253-260.
xxii Mr R Balfour, consultant gynaecologist,
personal communication to MH, 29 August 2007.
xxiii The care of women requesting induced abortion.
RCOG September 2004 : 34.
xxiii Naftalin NJ, BJOG (1999) 106, 1098-9.
xxiii Paradisis M et al BJOG (2002) 109,
582-4.
xxiv Brind J The abortion-breast connection.
National Catholic Bioethics Quarterly 2005; Summer: 303-328.
September 2007
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