Friday, December 05, 2008

From A Depressingly Narrow Debate

5 December 2008
Comment: A depressingly narrow debate

The ‘yes it does / no it doesn’t’ reaction to claims that abortion damages mental health distracts from the more useful and difficult questions about women’s experience. By Jennie Bristow.

The publication of some new studies examining the possibility of a link between abortion and mental health has sparked a predictable media debate about whether abortion causes mental illness, and whether women seeking abortion should be ‘informed’ that the procedure might make them depressed.

A study by Professor David Fergusson and colleagues from the University of Otago, published in the British Journal of Psychiatry, claims that women who had abortions had rates of mental health problems that were almost 30% higher than in the other women in the study. A second study in the same journal, by Kaeleen Dingle and colleagues at the University of Queensland, Australia, shows that women who lose a baby by the age of 21 – either through an abortion or a miscarriage – are three times more likely to develop a drug or alcohol problem than others. These studies led to headlines proclaiming ‘Abortions linked to mental illness’ (Daily Telegraph, UK); ‘Abortions may cause drug, alcohol addiction’ (Times of India); ‘NZ research uncovers abortion and mental health link’ (New Zealand Herald); and ‘Call for mental health support after abortion’ (Irish Times).

On the other side, a systematic review of 21 high-quality studies involving more than 150,000 women, conducted by Dr Robert Blum and a team at Johns Hopkins University in Baltimore, USA, and published in the journal Contraception, found no significant differences in long-term mental health between women who choose to abort a pregnancy and other women. ‘The best quality studies indicate no significant differences in long-term mental health between women in the United States who choose to terminate a pregnancy and those who do not,’ they wrote, noting that ‘studies with the most flawed methodology consistently found negative mental health consequences of abortion.’ ‘Abortion not seen linked with depression’, reported Reuters on 4 December.

The ongoing debate about whether abortion is or is not associated with mental health problems has triggered several major reviews: most recently, by the American Psychological Association (APA). New studies attract over-stated, and often contradictory, news headlines, depending on the particular newspaper’s stance on abortion. Attempting to untangle the science of it all could leave even experts rather confused. But for this reason, we need to step back from the claims and counter-claims about this issue, and ask: What is really being said here?

Claims and counter-claims

On the science front, the balance of opinion seems to be a cautious recognition that some women who have abortions may suffer some mental health problems, such as depression, anxiety or self-harm. However, the evidence does not show that the abortion itself causes these problems: rather, these problems are likely to be a continuation of pre-existing mental health problems that the woman has suffered. Furthermore, those women who may experience serious mental health problems are a minority of those who have undergone abortion.

These are the conclusions reached by the APA, and by the British Royal College of Obstetricians and Gynaecologists in its 2004 guidance. It is worth noting that they are also the conclusions broadly reached by Fergusson and his team. Fergusson’s work on abortion and mental health is often used by the anti-abortion lobby in an attempt to strengthen the argument that women need to be protected from abortion. A 2006 study that he published in the Journal of Child Psychology and Psychiatry prompted a group of 15 British obstetricians to write to The Times (London), demanding that the RCOG revisits its guidance and arguing that ‘doctors have a duty to advise about long-term adverse psychological consequences of abortion.’ The APA’s recent review devotes a significant section to examining this 2006 study, and noting where its results should be treated with caution.

However, despite the alarmist headlines that greeted Fergusson’s new study, published this week, the conclusions and findings of his team were measured. They concluded that the overall effects of abortion on mental health were small, and that exposure to abortion accounted for 1.5-5.5 per cent of the overall rate of mental disorder in the group of women studied. Furthermore, they stated:

‘[T]he results do not support strong pro-life positions that claim that abortion has large and devastating effects on the mental health of women. Neither do the results support strong pro-choice positions that imply that abortion is without any mental health effects. In general, the results lead to a middle-of-the-road position that, for some women, abortion is likely to be a stressful and traumatic life event which places those exposed to it at modestly increased risk of a range of common mental health problems.’

Psychiatrists will continue to debate the precise nature of such ‘common mental health problems’, their relationship with abortion, and the number of women who may be affected. As Margaret Oates, consultant perinatal psychiatrist with Nottinghamshire Healthcare Trust, has suggested in a commentary on the 2008 Fergusson study, it is unlikely that even these specialists will ever agree.

Abortion and the Syndrome Society

However, it is undoubtedly the case that abortion can be experienced by some women as a highly stressful and difficult life event, which happens in the context of other problems in their lives. Relationship breakdown, financial and other practical pressures, problems with alcohol or drugs, and ambivalence about whether they want to have a baby or not – we know that these are factors in some women’s decision to have an abortion, all of which can be intensely experienced in a very negative way. This is not the case for all women – for many, the issue is a more practical one of being pregnant when they do not want to be, and the predominant emotion following abortion is relief. But for some, abortion can be experienced as one more bad thing happening in an already bad set of circumstances.

Furthermore, we live in a cultural context where people routinely use the word ‘depressing’ to describe negative feelings or upheavals in their lives, whether that be moving house, having a baby, experiencing trouble at work, or splitting up with a partner. Whether people are actually suffering from depression as a result of these things or whether they simply feel they are is in many ways a moot point: the fact is that they feel they are depressed, that they experience these events as causing mental health difficulties, and they expect that they will receive a particular kind of recognition and support for their problems.

In this way, the category ‘mental health problems’ has expanded to encompass the way that people feel about all manner of difficult life events. It would be highly peculiar if abortion, and all the reasons leading to why women have abortions, were immune to this trend. A woman who has had an abortion may well feel very miserable, even ‘depressed’, and dwell on her decision for some time to come; she may require extra care and support. Abortion providers recognise this, which is why they are very careful to ensure that a woman seeking an abortion is sure about her decision, and why emotional support is offered afterwards as part of the package of care.

It is in many ways unfortunate that discussions about how women experience abortions, and what providers can do to help manage the negative emotions in some of their clients, tend to be clouded by the ‘abortion and mental health’ debate, which has politicised and polarised this issue. As Dr Ellie Lee, author of the important critique Abortion, Motherhood and Mental Health, recently wrote on Abortion Review, the history of the debate about the mental health effects of abortion is a political one. It arises from persistent attempts by the anti-abortion lobby to ‘de-moralise’ claims about the problem of abortion, by using science (or pseudo-science) to argue that abortion has negative effects upon women’s health.

This means that, as Roger Blum’s team argues, ‘[s]cientists are … conducting research to answer politically motivated questions’. The anti-abortion lobby thinks that if a scientific study can prove that abortion causes depression, it will have won an argument; in countering such claims, the pro-choice lobby can sometimes come across as denying the reality of some women’s struggle with abortion. This is not a helpful situation for women seeking abortion, and nor it is a useful framework for the abortion debate. As Margaret Oates argues, ‘abortion is not a psychiatric but a moral, ethical and legal issue’. It is one which should be debated, not in the laboratory, but out in the world.

Jennie Bristow is editor of Abortion Review

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