Tuesday, July 17, 2007

The Mental Health 'Risks' of Abortion

31 October 2006 Abortion Review www.abortionreview.org

The mental health ‘risks’ of abortion

Ellie Lee examines the basis for claims in the Times (London) that ‘abortion exposes women to higher risk of depression’.

‘Abortion exposes women to higher risk of depression’, asserted a headline in the Times (London) on 27 October 2006. The story was provoked by a Letter to the Editor, signed by 15 doctors, which ran under the heading ‘Risks of abortion’.

The Times letter asserts that recently published research provides definitive evidence that abortion and the development of psychiatric conditions are causally linked. Those who signed the letter claim, on this basis, that the practice of abortion providers should be altered.
The media coverage of the abortion issue resulting from this letter tells us little about what we might learn from academics’ attempts to consider the relationship between reproductive events and women’s state of mind, and how this might inform abortion practice. It tells us much, however, about the current state of the abortion debate and those opposed to abortion who participate in it.

The research to which the letter refers was published in the Journal of Child Psychology and Psychiatry in January 2006 and is titled ‘Abortion in young women and subsequent mental health’. It concludes that: ‘The findings suggest that abortion in young women may be associated with increased risks of mental health problems’. For those who take research seriously, this single line suggests very different conclusions to those presented in the Times.

The study was of young women – it considered the experience of women aged 15-25 who experienced a pregnancy. The researchers make no claims about women in general; indeed, their interest appears to be in the experience of adolescents and young adults. (It should also be noted that these young women grew up in a particular area of New Zealand, which may be significant for the relevance of the results for other societies).

The most important word in the study’s conclusion, however, is may. Where the signatories to the Times letter make strong assertions and argue for policy changes, the journal article is full of riders.
These are:
Confounding factors that this study may not have accounted for. The authors note that their findings may not have taken into account factors other than abortion that might account for the observed association between abortion and particular states of mind.

Under-reporting of abortion in the sample. This is a well-known problem with research about abortion. For this study, the authors note there was a statistically significant difference between the rate of abortion in the sample and that in the general population.

Contextual factors associated with abortion-seeking to which the study could not be sensitive.

The authors note: ‘It is clear the decision to seek (or not seek) an abortion following pregnancy is likely to involve a complex process’ and that as a result, ‘it could be proposed that our results reflect the effects of unwanted pregnancy on mental health rather than the effects of abortion per se on mental health’.

This last point, about the effects of unwanted pregnancy, is especially important. The comparator groups to participants in this study who had an abortion were those who stated they had not experienced a pregnancy, and those who continued a pregnancy to term. It was against this background that an association between abortion and poorer mental health emerged.

Yet this study was conducted in a context where abortion is legal, and relatively freely available. It should therefore be taken into account that it may be that the only group of women among these three groups compared who experienced a pregnancy that was truly and consistently unwanted were those who went on to terminate the pregnancy.

This point can be developed further. Since this study was conducted in a context where abortion is legal, and relatively freely available, it is likely that the pregnancies of those who continued to term and gave birth were in the majority self-defined as wanted. The importance of this point is that it raises questions about what experiences are being compared.

The most valid comparator group to women who have an abortion is women with an unwanted pregnancy who are denied abortion and then give birth. Where these groups are compared it can at least be assumed that the context of pregnancy in similar, and what is being compared is the effects of the resolution of the pregnancy (birth or abortion). Yet this study – for obvious reasons given the abortion law in New Zealand - did not include such a group of women.

Other research, however, has - most notably, that by Henry David, perhaps the most prolific researcher and writer on this subject. It shows that denied abortion and unwanted childbirth has stronger association with poor mental health than abortion.

On this basis, the authors of the Journal of Child Psychology and Psychiatry article are correct to be tentative in their conclusions. They are correct to make their strongest conclusion that ‘the issue of whether or not abortion has harmful effects on mental health remains to be fully resolved’, and call for more research into the area.

In taking this approach, they also reflect what seems to be something of a consensus about this area of abortion research. Academic research about the psychological effects of abortion is widely recognised to be a complicated enterprise. As Henry David has noted, designing research that can make definitive statements about the psychological effects of abortion (and other reproductive events) is complex.

It is harder to make definitive statements than it is for physical health (where clear statements regarding the relative safety of abortion can be made).

It is for this reason that, very wisely, the British Royal College of Obstetricians and Gynaecologists (RCOG) takes stock, periodically, of the range of published studies on this issue, when drawing up its Evidence-based Guideline for abortion providers.

In its leaflet for women considering abortion and their families, the RCOG states, on the basis of this evidence: ‘How you react will depend on the circumstances of your abortion, the reasons for having it and on how comfortable you feel about your decision. You may feel relieved or sad, or a mixture of both’.

The RCOG also notes: ‘Some studies suggest that women who have had an abortion may be more likely to have psychiatric illness or to 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’.

This reads like a balanced approach that takes careful account of available evidence. It tells women and their loved ones what published, peer-reviewed evidence suggests overall. This contrasts greatly with the line those associated with the Times letter now want medical authorities to take.

On the basis of one study from New Zealand of women aged under 25 which actually makes only tentative claims, the letter’s signatories claim: ‘doctors have a duty to advise about the long-term psychological consequences of abortion’.

How could this conclusion be drawn? The emphasis on the ‘risks of abortion’ and their alleged implications for abortion practice clearly arises not from balanced consideration and debate about well-designed academic research. Rather its roots lie in the sociology of abortion. In the current context it is hard for those who are hostile to abortion to find support for arguments framed in moral terms. We live in an age where, for a range of reasons, few agree that abortion is simply ‘wrong’, so few agree with those who moralise against abortion. In turn, the language of risk more and more provides a medicalised vocabulary in which anti-abortion argument is made.

Those of us with training in social science can work to draw to public attention this ‘medicalisation’ of anti-abortion argument, and seek to provoke discussion of its consequences. It is to be hoped that those with scientific and medical expertise will respond by upholding the highest possible standards in relation to evidence-based abortion care.

Dr Ellie Lee is a lecturer in social policy at Kent University, and co-ordinator of Pro-Choice Forum. She is also author of Abortion, Motherhood and Mental Health: Medicalizing Reproduction in the US and Britain, published by AldineTransaction. Buy this book from Amazon.
Doctors’ letter sparks debate over abortion and mental health, Abortion Review, 30 October 2006
The Care of Women Requesting Induced Abortion, Evidence-based Clinical Guideline Number 7, RCOG September 2004
Abortion in young women and subsequent mental health. Fergusson DM, Horwood LJ, Ridder EM. Journal of Child Psychology and Psychiatry. 2006 Jan;47(1):16-24.

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