Abortion and its mental health 'risks'
By Ellie Lee
'Abortion exposes women to higher risk of depression' asserted the headline to an article in the news section of The Times published on October 27. 'Risks of abortion' was the title given to a letter signed by 15 doctors published on the same day that provoked this news story.
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 in Britain should be altered and women seeking abortion should be informed that terminating pregnancy places them at risk of mental ill health. This media coverage of the abortion issue tells us little about what we might learn from attempts made by academics to consider the relationship between reproductive events and women's state of mind. It tells us, rather, about the current state of the abortion debate and those opposed to abortion participating in it.
The study to which the letter refers was published in the Journal of Child Psychology and Psychiatry and is titled 'Abortion in young women and subsequent mental health'. It concludes the following: '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 firstly of young women - it considered the experience of women aged 15-25. 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 also be significant for the relevance of the results for other societies). The most important word in this conclusion is 'may'. Where the signatories to The Times letter make strong assertions and argue for policy changes, the journal article in contrast contains important 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 recognised 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 that the study could not be sensitive to. 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 possible 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 abortion is women with 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) following unwanted pregnancy. 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 perhaps the most prolific researcher and writer on this subject US psychologist Henry David). It shows that denied abortion and unwanted childbirth has stronger association with poor mental health than abortion.
The authors of the Journal of Child Psychology and Psychiatry article are correct to be tentative in their conclusions. They are right 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 a complex task. 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 takes stock, periodically, of the range of published studies on this issue, when drawing up its evidence-based guideline for British abortion providers. In its leaflet for women considering abortion and their families based on its guideline, the RCOG states: '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'. It also notes that, '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 as a balanced approach that takes careful account of available evidence. It tells women and their loved ones what, overall, published, peer-reviewed evidence suggests. This contrasts greatly with the line those associated with The Times letter now want British medical authorities to take. On the basis of one study from New Zealand of women aged under 25 which actually makes only tentative claims and recommends further research, they claim that, for Britain, 'doctors have a duty to advise about the long-term psychological consequences of abortion'.
How could this conclusion be drawn? The emphasis placed in this way 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 through use of the language of risk. We should seek to provoke discussion of its roots in society and 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 author of Abortion, Motherhood and Mental Health: Medicalizing Reproduction in the US and Britain, published by AldineTransaction.
'Doctors' letter sparks debate over abortion and mental health', Abortion Review, 30 October 2006 http://www.abortionreview.org/index.php/site/article/89/
'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.