Memorandum 30
Submission from Professor Patricia Casey[191]
Main Points: Until recently it was believed
that abortion was only associated with post-abortion psychological
complications in those who had a prior history of such problems
and were therefore vulnerable, A number of well designed recent
studies confirm the view that adverse psychological outcomes occur
after abortion and are not just related to prior psychiatric history.
A range of disorders including depressive illness, substance abuse
and self-harm have been identified. There is evidence for an increase
in psychiatric service utilization (in-patient and out-patient)
also.
Suicide rates are higher in women post-abortion
when compared to pregnant women and non-pregnant women but whether
this is due to the abortion or to some pre-existing common factor
associated with both abortion seeking and suicide (mental illness
or impulsivity) is as yet unanswered. This set of studies (see
no 5 in the submission) confirms the "safe health status"
associated with pregnancy.
Recommendations: Women should be fully informed
of the psychological risks of induced abortion when making abortion
decisions. Those seeking abortion for foetal anomaly should also
be advised of the long duration of the adverse consequences. Written
information dealing with the range of adverse psychological consequences
should be given to women considering abortion so as to allow them
to make a fully informed choice. The failure to do this has potential
medico-legal implications also.
Post-abortion check-ups should include questions
relating to mental illness including suicidal behaviour, depressive
symptoms and psychotic symptoms.
Appropriate interventions, that fully respect
the reality of the adverse consequences of abortion, should be
in place and appropriate training in these interventions given
to those who work with traumatised women.
PSYCHIATRIC CONSEQUENCES
OF ABORTION
The relationship between abortion and mental
health problems has been the subject of considerable debate. Two
theories have been promulgated:
— Abortion causes mental health problems.
— Abortion and mental health problems
are due to some common third factor (confounder) eg previous mental
health problems, childhood trauma etc. that determine abortion
seeking and subsequent mental health problems.
Until this century there were a few studies
linking abortion to subsequent mental health problems and most
studies failed to find any association except in those with prior
mental health problems.
CRITICISMS OF
RESEARCH
Among the criticisms directed at those who argue
that significant psychiatric conditions follow abortion are:
— the failure to control for confounders
such as previous psychiatric history;
— using data obtained from women seeking
psychological treatment post-abortion; and
— comparison groups inappropriate eg
not comparing women having abortions with those giving birth.
— limited outcome measures eg psychiatric
hospitalization, receiving out-patient treatment.
On the other hand those who argue that psychiatric
disorders do occur post-abortion point the a number of flaws in
the contrary studies:
— the absence of long-term data spanning
years/decades;
— high attrition rates in follow-up
studies reducing the potential for identifying psychological problems
(those with psychological problems most likely to default); and
— small sample sizes reducing the statistical
power of the study to identify mental health problems.
However, recent studies have addressed these
methodological flaws.
APPROACHING THE
PRESENT PAPER
Only original research papers, from peer reviewed
learned journals were selected.
Review papers were excluded ...
The term post-abortion syndrome will not be
used since this is not a recognized psychiatric term.
Only papers since 2000 will be presented since
these are the most methodologically and statistically robust.
The conclusions presented at the end of each
summary are those of the authors.
A. OUTCOME MEASURES
1. Psychiatric hospitalisation
Psychiatric admissions of low-income women following
abortion and childbirth.
Reardon et al. Canadian Medical Association
Journal. 2003. 168 (10). 1253-6
Aim:
The aim was to examine psychiatric hospitalisation
following childbirth or abortion.
Method:
A record linkage study:
— California Medicaid records of women
13-49 at time of childbirth/abortion in 1989 followed for 90 days—4
years
— Excluded those with prior psychiatric
admissions.
— Data set—Pregnancy ending in
abortion—15, 299
Results
— Significant differences in admission
rates for women who had abortion compared to those giving birth
— Adjustment reactions (Odds ratio
2.1)
— Depressive episode (Odds ratio 1.9)
— Recurrent depressive disorder (Odds
ratio 2.1)
— Bipolar disorder (Odds ratio 3)
— Post delivery admission rate 634.8/100,000.
— Post-abortion admission rate 1117.1/100,000
(Odds ration 1.7)
Conclusions:
Psychiatric admission rates higher in women
post abortion than post-partum when those with a prior psychiatric
history were excluded.
Response to Reardon paper in Canadian Medical
Association Journal:
Following a number of exchanges in the letters
pages, the journal editorialised in a piece entitled "Unwanted
Results: The Ethics of Controversial Research".
It defended publication of this paper saying
"The attack in our letters column is largely an ad hominum
objection to the authors" ideological biases and credential.
There are two questions here: first does ideological bias necessarily
taint research? Second are those who publish research responsible
for its ultimate use?"
"In light of the passion surrounding the
subject of abortion we subjected this paper to especially cautious
review and revision ... the hypothesis that abortion (or childbirth)
might have a psychological impact is not unreasonable and to desist
from posing a question because one may obtain an unwanted answer
is hardly scientific. If we disqualified these researchers from
presenting their data, we would never hear from pro-choice views,
either".
"But if it is true that more explicit research
into women's health issues will point the way to better care,
better outcomes and more equity in access, we cannot toss out
data any time we don't like their implications".
2. Psychiatric out-patient attendance
State funded abortions versus deliveries: a
comparison of out-patient mental health claims over 4 years.
Coleman et al. American Journal Orthopsychiatry.
2002. 72,1. 141-152
Aim:
The objective was to ascertain if:
— First time psychiatric out-patient
contact in 4 years post-abortion.
— 14,297 abortion group, 40,122 birth
group
— Controlling for pre-existing psychological
problems, age, number of pregnancies and months of eligibility
Results:
90 days post-abortion —63% more claims.
180 days post-abortion—42% more claims.
1 year post-abortion —30% more claims.
2 years post-abortion— 16% more claims.
Conclusion:
At all time points out-patient mental health
funding claim were higher in pos-abortion group when prior psychological
problems controlled.
3. Any psychiatric disorder
The course of mental health after miscarriage
and induced abortion: a longitudinal, five-year follow-up study.
Broen et al. BMC 2005 December 12:3, 18.
Aim:
To determine whether there are differences in
the patterns of normalization of mental health scores after two
pregnancy termination events ie induced abortion and miscarriage.
Methods:
40 women who experienced miscarriages and 80
women who underwent abortions were interviewed at 10 days (T1),
six months (T2), two years (T3), and five years (T4) after the
pregnancy termination using valid interview schedules. Prior psychiatric
history controlled for.
Results
— Women who had had a miscarriage exhibited
significantly quicker improvement in scores throughout the observation
period.
— Women who experienced induced abortion
had significantly higher scores than the miscarriage group at
two and five years after the pregnancy termination and at 5 years
20% were still "cases".
Conclusion:
Women experiencing an induced abortion have
higher and more persistent mental health problems than those experiencing
a miscarriage.
A history of induced abortion in relation to substance
abuse during subsequent pregnancies carried to term.
Coleman et al. American Journal Obstetrics and
Gynaecology. 2002. 187,6. 1673-1678.
Aim:
To compare substance abuse in those subsequently
giving birth after abortion or a delivery.
Methods:
607 women derived from the National Pregnancy
and Health Survey in the United States.
3 groups of women who had recently delivered
a baby but with one previous pregnancy with a resolution in:
— induced abortion (gravida 2, para
1).
— delivery (gravida 2, para 2).
— A further analysis was carried out
on those giving birth for the first time (gravida 1, para 1).
Information on substance abuse (licit and illicit
drugs including cigarettes, benzodiazepines and alcohol) during
the recent pregnancy was gathered by questionnaire administered
shortly after giving birth.
Results:
Women who had aborted were significantly more
likely to:
— abuse marijuana (Odds ratio OR 10.29).
— abuse other illicit drugs (OR 5.6).
— abuse alcohol (OR 2.2).
during a subsequent pregnancy when compared to those
who had no history of induced abortion.
This pattern was replicated, apart the findings
relating to cigarette consumption, when the abortion group was
compared to first time mothers.
Within the post-abortion group substance abuse
was higher in those for whom the time since abortion was longest.
Conclusion:
"A history of abortion appears to be a
marker for increased risk of substance abuse in subsequent pregnancies".
Note:
Fergusson et al (2006) also found an increased
risk of substance abuse in the post-abortion group (see 4 below).
4. General population studies
Abortion in Young Women and Subsequent Mental
Health
Fergusson et al. Journal of Child Psychology
and Psychiatry. 2006. 47 (1), 16-24.
Aim:
To test the hypothesis that those who developed
mental health problems post-abortion did so because of prior vulnerability.
Methods
— 25 year longitudinal birth cohort
study of 1,265 New Zealand children from Christchurch.
— History of pregnancy/abortion/no
pregnancy over 15-25 year interval.
— Measures of DSM-IV mental disorders
and suicidal behaviour using structured interviews.
— Data on childhood and family adversity
as well as psychiatric history (confounders) controlled for in
the analysis.
— Face to face interviews with subjects
at ages 15, 16, 18, 21 and 25.
— Present analysis based on 506-520
females comparing:
— Those pregnant and ending in
abortion.
— Those pregnant and ending in
delivery.
Results:
Among those who had abortions compared with
those who had not been pregnant or who had delivered significantly
higher risk of.
— Major depression 78.7-41.9% (depending
on age group).
— Anxiety disorder 64.3-39.2%.
— Suicidal ideation 50-27%.
— Illicit drug dependence 0-12.2%.
— Overall number of mental health problems
1.93-1.27 depending on age.
When confounders controlled, all the above except
anxiety disorders still significantly higher risk ratios in those
who had an abortion
Predictive analysis:
— To ascertain if these associations
are cause or effect.
— Pregnancy/abortion history prior
to age 21 used to predict subsequent mental health history while
confounders controlled.
— Rate ratio—No pregnancy 0.6
— Pregnant no abortion 0.67
Conclusions
Abortion caused mental health problems in some
women and this was not due to prior vulnerability.
The author wrote "The present research
raises the possibility that for some young women, exposure to
abortion is a traumatic life event which increases longer-term
susceptibility to common mental disorders. These findings are
inconsistent with the current consensus on the psychological effects
of abortion. In particular, in its 2005 statement on abortion,
the American Psychological Association concluded that "well
designed studies of psychological responses following abortion
have consistently shown that the risk of psychological harm is
low ... the percentage of women who experience clinically relevant
distress is small and appears to be not greater than in general
samples of women of reproductive age" ...
"This relatively strong conclusion about
the absence of harm from abortion was based on a relatively small
number of studies which had one or more of the following limitations
... the statement appears to disregard the findings of a number
of studies that had claimed to show negative effects for abortion
... While it is possible to dismiss these findings as reflecting
shortcomings in the assessment of exposure to abortion or control
for confounders it is difficult to disregard the real possibility
that abortion amongst young women is associated with increased
risks of mental health problems".
Comment:
This is the largest and best designed study
of the psychological consequences of abortion to date as it has
a large sample, with an almost 100% follow-up rate, using face
to face interviews, with recognized diagnostic instruments and
a long follow-up.
The American Psychological Association has now
removed references to the safety or otherwise of abortion from
its website and established a committee to investigate the issue
further (see conclusions) above. Of note, the author is by his
admission pro-choice and he set out to demonstrate that those
who developed psychological problems post-abortion were those
who had prior problems.
Depression and unintended pregnancy in the National
Longitudinal Survey of Youth: a cohort study
Reardon et al. British Medical Journal 2002.
324. 151-152.
Aim:
To test the hypothesis that psychological maladjustments
after abortion are related to prior history of depression.
Methods:
Using data from the National Longitudinal Study
of Youth the authors identified those with depression using a
diagnostic instrument.
Results:
Among those who were married the odds ratio
for developing depression post-abortion still remained significant
after prior psychiatric state was controlled when compared to
those bringing an unintended pregnancy to term.
Conclusion:
Prior psychiatric history does not predict post-abortion
depression.
AND
Depression and unwanted first pregnancy: longitudinal
cohort study
Schmiege et al. British Medical Journal. 2005.
331. 1303-
This study failed to find any independent link
between abortion and subsequent depression using the same dataset
as that used in the above study.
The authors wrote that this difference may reflect
differences in the coding of pregnancies eg those who had an abortion
after the index pregnancy were included as controls (rather than
being excluded). Reardon et al also expressed the view that it
was wrong to exclude from the analysis those who any point were
ambivalent about the abortion.
5. Suicide
Injury deaths, suicides and homicides associated
with pregnancy, Finland 1987-2000
Gissler et al . European Journal of Public Health.
2005. 15, 5. 459-463.
Aim:
To examine mortality from external causes by
pregnancy outcome and examine possibility of a healthy pregnancy
effect.
Methods:
Information on deaths from external causes among
women aged 15-49 years in Finland in 1987-2000 (n = 5,299) was
linked to three national health registers to identify pregnancy-associated
deaths (n = 212).
Results:
Table 1
PREGNANCY-ASSOCIATED
MORTALITY PER
100,000 PREGNANCIES AND
MORTALITY AMONG
NON-PREGNANT
WOMEN PER
100,000 PERSON-YEARS
FROM EXTERNAL
CAUSES BY
CAUSE OF
DEATH AND
BY PREGNANCY
OUTCOME
| Pregnancy associated mortality
| Age adjusted and crude mortality rates in non-pregnant women
|
| Pregnancy or birth |
Miscarriage / ectopic | Induced abortion
| Total | |
|
| | |
| | | |
| All external causes | 9.6*** |
34.6* | 60.0*** | 19.1***
| 24.2 | 29.9 |
| Unintentional injuries | 3.9***
| 14.3 NS | 20.4*** | 7.3***
| 10.8 | 14.7 |
| Suicide | 5.0*** | 16.0 NS
| 31.9*** | 9.8 NS | 11.8
| 13.3 |
| Homicide | 0.7** | 4.2 NS
| 7.7*** | 2.0 NS | 2.1
| 2.3 |
Test of relative proportions compared with the age-adjusted mortality
among non-pregnant women: NS: not significant; NA: not applicable.
*** P <0.001; ** P <0.01; * P <0.05.
Conclusion:
The authors wrote "In the year after undergoing an abortion,
a woman's mortality rate for unintentional injuries, suicide and
homicide was substantially higher than among non-pregnant women
in all age groups combined. It is unlikely that induced abortion
itself causes death due to injury; instead, it is more likely
that induced abortions and deaths due to injury share common risk
factors ... and more detailed background information for example
on mental health, social well-being, substance abuse and socio-economic
circumstances among the deceased would be necessary for further
analysis".
"The new recommendation for post-induced abortion care,
however, includes the statement that a check-up visit is necessary
in order to detect signs of depression and to identify the rare
cases of psychosis after an induced abortion".
"The low rate of deaths from external causes suggests
the protective effect of childbirth, but the elevated risk after
a terminated pregnancy needs to be recognized in the provision
of health care and social services".
Comments:
This was part of a series of record linkage studies by Gissler,
one of which related to suicide and was published in the British
Medical Journal in 1996. The suicide rate among all women in Finland
was 11.3/100,000, associated with birth 5.9/100,000 and associated
with abortion 34.7/100,000. He concluded that either abortion
caused suicide or that there were attributes associated with both
suicide and abortion such as impulsivity or mental illness.
B. ABORTION FOR
FOETAL ANOMALY
Complicated grief after traumatic loss: a 14 month follow-up
study
Kersting et al. European Archives Psychiatry and Clinical
Neuroscience. 2007. July (epub ahead of print).
Aim:
To obtain information on the course of grief following termination
of pregnancy for foetal anomaly.
Methods:
62 women had abortion for foetal abnormality between 15th
and 32nd gestational week compared with 65 who had given birth
on measures of grief, post -traumatic stress disorder, depression
and anxiety using structured diagnostic interview schedules.
Results:
Women following abortion were significantly more stressed on all
measures:
— At 14 days 25% met DSM-IV criteria for psychiatric
disorder.
— At 6 months 25% met DSM-IV criteria for psychiatric
disorder.
— At 14 months 16.7% met DSM-IV criteria for psychiatric
disorder.
Conclusions:
The authors wrote "All in all, 25% of these women were
critically affected by the traumatic loss.
Long-term psychological consequences of pregnancy termination
for fetal abnormality: a cross-sectional study
Korenromp et al. Prenatal Diagnosis. 2005. 25,3. 253-260.
Aim:
To examine the long term psychological well being of women
after pregnancy termination for foetal anomaly.
Method:
254 women 2-7 years post termination of pregnancy for foetal
anomaly before 24 weeks gestation. Standardised questionnaires
administered.
Results:
17.3% pathological scores for PTSD.
Higher levels of grief if anomaly compatible with life.
Poorer prognosis associated with gestational age, perceived
partner support and educational level.
Conclusion: The authors wrote "Termination of pregnancy
for foetal anomaly is associated with long-lasting consequences
for a substantial number of women.
Psychological outcome for women undergoing termination of pregnancy
for ultra-sound detected fetal abnormality: a pilot study.
Davies et al. Ultrasound Obstet Gynaecol. 2005. 25,4. 389-392.
Aim:
Examine psychological morbidity for women having 1st and
2nd trimester abortions for foetal abnormality.
Methods:
14 women having first trimester and 16 having 2nd. trimester
abortions.
20-40 years.
Follow-up 6weeks, 6 months and 12 months.
Measures included GHQ, BDI, IES and Perinatal.
Grief Scale.
Results
High levels of distress for both groups.
Present at all time points.
Depression: 36%, 39%, 32% > cut-off score.
Post-traumatic stress: 67%, 50%, 41% > cut-off score.
Conclusion:
The authors wrote "Psychological morbidity following
termination for foetal anomaly is prevalent and persistent".
C. QUALITATIVE STUDIES
These studies are designed to evaluate feelings and emotions
in greater depth. They do not measure prevalence. Their value
lies in the depth of the interviews which last many hours, are
taped recorded and subsequently analysed so as to identify common
themes that emerge. Due to their labour intensity sample sizes
are small.
Women's reflections upon their past abortions
Goodwin and Ogden. Psychology and Health 2007.22,2. 231-248.
10 women interviewed 1 to 10 years post abortion to ascertain
their reflections in the longer term:
— Some described a linear pattern of change with
decreasing symptoms over time.
— Many described other patterns including.
2. later onset distress with no distress in the immediate
aftermath.
3. No distress at any time.
The reactions were related to view of foetus as human, poor
social supports, a belief that society is either over judgmental
or alternatively negates impact of abortion on women.
Women's responses do not always follow the suggested reactions
of grief.
REFUSED ABORTION
I have been unable to identify any papers on this topic published
since 2000 and most appear to be pre-1990.
CONCLUSIONS AND
IMPLICATIONS
A number of well designed recent studies confirm the view
that adverse psychological outcomes occur after abortion and are
not just related to prior psychiatric history. A range of disorders
including depressive illness, substance abuse and self-harm have
been identified. There is evidence for an increase in psychiatric
service utilization (in-patient and out-patient) also.
Suicide rates are higher in women post-abortion when compared
to pregnant women and non-pregnant women but whether this is due
to the abortion or to some pre-existing common factor associated
with both abortion seeking and suicide (mental illness or impulsivity)
is as yet unanswered. This set of studies (5 above) confirms the
safe health status associated with pregnancy.
Written information on the psychological consequences of
abortion should be provided to women considering abortion so that
their decisions are fully informed. Those seeking abortion for
foetal anomaly should also be advised of the long duration of
the adverse consequences.
Post-abortion check-ups should include questions relating
to mental illness including suicidal behaviour, depressive symptoms
and psychotic symptoms.
Appropriate interventions that fully respect the reality
of the emotional consequences of abortion should be in place.
September 2007
191
Brief Biography: I am Professor of Psychiatry at University College,
Dublin and Consultant Psychiatrist at the Mater Misericordiae
University Hospital, Dublin since 1992. I have published a large
number of papers in international peer reviewed journals and I
am lead member of a research consortium that has conducted research
on depressive disorders in five European countries, having achieved
some 40 publications in peer reviewed journals (The Outcome of
Depression International Network-ODIN). My competencies as an
epidemiological and clinical researcher, as well as my role in
reviewing manuscripts for leading international journals such
as the Lancet and the British Journal of Psychiatry, I believe,
render me competent to evaluate the quality of research addressing
the psychological consequences of abortion. I am the author of
five academic books on psychiatry and have recently published
a book on mental health for the general public also. I have contributed
to over 21 academic textbooks. I am editor of the Quarterly Journal
of Mental Health and have recently been appointed editor of Psychiatric
Bulletin, published by the Royal College of Psychiatrists, London
(confidential-as this is not yet in the public domain). I have
significant experience of treating women with psychological complications
following induced abortion. Back
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