Courtesy of the UK’s National Collaborating Centre for Mental Health (NCCMH), arrives this report from December 2011, which comprehensively contradicts what those in the pro-life camp would like us to believe.
Namely that the mental health outcome for a woman (with an unplannned pregnancy) who has an abortion is worse than for the woman who chooses to have a baby.
The outcomes, according to the study, are the same.
In fact, It lists stigma, the need for secrecy and lack of social support among the contributing factors in a “negative post-abortion outcome”.
The report’s recommendations state:
“it is important to consider the need for support and care for all women who have an unwanted pregnancy, because the risk of mental health problems increases whatever the pregnancy outcome”.
Hat tip: Susan Mitchell
Download here (2MB, PDF)
Brief report overview
6.1 Overview
The review questions
When a woman is carrying an unwanted pregnancy in most Western societies, she has
the option to continue with the pregnancy to a full-term birth or to elect to terminate
the pregnancy, subject to the relevant legal framework (for example, rules on timing and
the presence of risk to either the mother or child). It is important in this context for a
woman to understand the possible physical and mental health risks associated with
each course of action. It is also important that healthcare professionals can identify
factors that may be associated with a poor outcome following abortion or birth of an
unwanted pregnancy. It is reasonably well accepted that there is a broad range of physical and mental health risks known to be associated with birth. However, it is less certain whether the mental health risks associated with birth are altered if the pregnancy is unwanted. Similarly, for abortion, it is well accepted that there are some physical risks directly related to the timing and techniques used to undertake an abortion. There is less certainty about the mental health impact of abortion for an unwanted pregnancy.
6.2 Findings
6.2.1 How prevalent are mental health problems in women who have an induced
abortion?
What does the evidence say?
The evidence statements from this part of the review are shown in full in Section 3.6.
The key points are as follows:
1. The studies included in the review are limited in a number of ways, making it difficult
to form confident conclusions from the results.
2. The most important confounding variable appears to be mental health problems prior to the abortion.
3. Where studies included women with previous mental health problems, the rates of mental health problems after an abortion were higher than in studies which excluded women with a history of mental health problems.
The single largest confounding variable within this section of the review was the
prevalence of mental health problems prior to the abortion. Where studies controlled for previous mental health problems, the prevalence rates reported after abortion were substantially lower than in studies where previous mental health problems were not accounted for.
6.2.2 What factors are associated with poor mental health outcomes following an
induced abortion?
What does the evidence say?
The evidence statements from this part of the present review are shown in full in Section
4.4. The key points are as follows:
1. The evidence reviewed is restricted by a number of limitations and the lack of
UK-based studies reduces the generalisability of the data.
2. The most reliable predictor of post-abortion mental health problems is having
a history of mental health problems prior to the abortion.
3. A range of other factors produced more mixed results, although there is some
suggestion that life events, pressure from a partner to have an abortion, and negative attitudes towards abortions in general and towards a woman’s personal experience of the abortion, may have a negative impact on mental health.
4. Women who show a negative emotional reaction immediately following an abortion are likely to have a poorer mental health outcome
5. There was an overlap in the risk factors associated with mental health problems
following an abortion and those factors associated with mental health problems
following a live birth, and factors associated with mental health problems for women in general.
The most reliable predictor of post-abortion mental health problems was having a history of mental health problems prior to the abortion, a finding that emerged regardless of the specific outcome measure or method of reporting used.
In other reviews, stigma, the perceived need for secrecy and lack of social support have also been reported to be important factors associated with poorer post-abortion outcomes. Importantly, the findings suggesting that women who show a negative emotional reaction immediately following the abortion are likely to have a poorer outcome, may act as a useful means of identifying those at risk of developing mental health problems.
When considering the risk of post-abortion mental health problems, it is also instructive
to consider factors associated with poorer mental health outcomes following a live birth. In 2007, NICE published a clinical guideline on antenatal and postnatal mental health
(NCCMH, 2007). The guideline conducted a systematic review of the best available
evidence (large-scale prospective studies and existing systematic reviews) that assessed
the mental health outcomes for women following a birth. Similar to the findings from the
present review, the most important risk factor for poor mental health following a live birth was a history of mental health problems both before and during the pregnancy. Other important risk factors included low levels of perceived social support, exposure to recent life events, low self-esteem, childcare difficulties, relationship status, ‘neuroticism’, birth complications, marital discord, obstetric factors, socioeconomic status, age at time of pregnancy and a family history of depression. These risk factors can increase a new mother’s chances of developing a range of mental health problems, including depression, puerperal psychosis, anxiety disorders and eating disorders.
In summary, there is some overlap in the factors associated with poor mental health
outcomes for post-abortion, postpartum women and for women in general, although
large scale comparative data were lacking. The overlap in risk factors suggests,
nevertheless, that in particular, for women with a history of mental health problems,
monitoring and support may be required regardless of the pregnancy resolution.
6.2.3 Are mental health problems more common in women who have an induced
abortion, when compared with women who deliver an unwanted pregnancy?
What does the evidence say?
The evidence statements from this part of the review are shown in full in Section 5.5.
The key points are as follows:
1. The evidence for this section of the review was generally rated as poor or very poor,
with many studies failing to control for confounding variables and using weak controls
for previous mental health problems, such as 1-year previous treatment claims. There
was also a lack of comparable data across the diagnostic categories, which restricted
the use of meta-analysis. These factors limit the interpretation of the results.
2. There was some evidence from studies that did not control for whether or not the
pregnancy was planned or wanted suggesting that, compared with women who
delivered a pregnancy:
• there are increased risks of psychiatric treatment, suicide and substance misuse
for women who undergo abortions
• there was insufficient evidence to determine if there was an increased risk
of depression, anxiety disorders, suicidal ideation or PTSD.
3. Where studies controlled for whether or not the pregnancy was planned or wanted, compared with women who delivered a pregnancy:
• there was insufficient evidence of elevated risk of mental health problems such
as depression, anxiety and non-psychotic illness following abortion
• there was some limited evidence to suggest increased rates of self-harm
following an abortion, but only in the unplanned group
• there was some evidence of lower rates of psychotic illness for women following
abortion.
4. Inadequate control for confounding factors was shown to have an impact on the
results. Differences between groups did not remain significant when factors such
as previous experience of abuse and violence were controlled for.
5. For women with no prior recorded history of psychiatric contact up to 9 months
before a pregnancy event:
• those who have an abortion have significantly higher rates of psychiatric contact
before the abortion than do women in the same 9 month period prior to birth
• those who have an abortion have rates of psychiatric contact after an abortion
no greater than before the abortion
• those who go onto birth have rates of psychiatric contact after birth significantly
higher than before birth.
6. This suggests that women who have an abortion are already at higher risk of mental health problems, which does not increase following abortion.
• An unwanted pregnancy may lead to an increase risk of mental health problems,
or other factors may lead to both an increased risk of unwanted pregnancy and
an increased risk of mental health problems.
• When a woman has an unwanted pregnancy, rates of mental health problems
will be largely unaffected whether she has an abortion or goes on to give birth.
In contrast, where studies controlled for whether or not the pregnancy was planned or wanted, there was insufficient evidence to determine whether or not there was an elevated risk of mental health problems, except for a small increase in possible self-harm in those having an abortion compared with the women who delivered an unplanned, but not unwanted pregnancy, and some evidence of lower rates of psychotic illness for women who had an abortion compared with those who delivered the pregnancy at full term.
Crucially, since the APA and Charles reviews, one national prospective study (MUNKOLSEN2011) indicated that rates of psychiatric treatment were higher in the abortion group in the 9 months prior to the abortion when compared with the rates in the 9 months prior to delivery, despite controlling for mental health problems prior to this period. Furthermore, rates of psychiatric contact did not increase following an abortion A SYSTEMATIC REVIEW 125 when compared with the 9 months before the abortion. This suggests that women who have an abortion develop mental health problems before the abortion and that this may be a reaction to an unwanted pregnancy. However, it is also possible that people who develop mental health problems are more likely to have an unplanned and/ or unwanted pregnancy. Importantly, the rates of psychiatric contact in women who delivered was significantly higher after delivery than for the same women in the 9 months before delivery.
Finally, a number of studies have suggested that women who have an abortion are more
likely to experience a range of risk factors associated with mental health problems, such
as exposure to intimate partner violence, childhood physical and sexual abuse. Each of
these explanations is consistent with the data in this review, previous reviews and the
MUNK-OLSEN2011 study.
6.3 Conclusion
Evidence from the narrative review and meta-analysis indicated that for the majority
of mental health outcomes, there was no statistically significant association between
pregnancy resolution and mental health problems. Where we found a statistically
significant association between abortion and a mental health outcome, for example
increased rates of self-harm and lower rates of psychosis, the effects were small
(psychosis) and prone to bias (for instance, there were common factors underlying
seeking an abortion and later self-harm). In this review, we have surmised that the
association between abortion and mental health outcomes are unlikely to be meaningful. Overall, we have therefore largely confirmed the findings of the APA and Charles reviews, both through our narrative review and meta-analysis. When a woman has an unwanted pregnancy, rates of mental health problems will be largely unaffected whether she has an abortion or goes on to give birth.
Further interpretation of the relationship between abortion and mental health outcomes has been made possible through the finding that unwanted pregnancies are associated with higher rates of mental health problems before an abortion, compared with women who give birth. That is, women who have an abortion, presumably for an unwanted pregnancy in the majority of cases, are more likely to experience a mental health problem in the 9 months before the abortion, compared with women who give birth, even when previous mental health problems before this 9-month period are controlled for. Furthermore, the rate of mental health problems did not increase following the abortion.
What does seem to be more certain is that for women with an unwanted pregnancy, abortion does not appear to harm their mental health.
Recommendations
• In the light of these findings, it is important to consider the need for support and care for all women who have an unwanted pregnancy, because the risk of mental health problems increases whatever the pregnancy outcome.
• If a woman has a negative attitude towards abortion, shows a negative emotional
reaction to the abortion or is experiencing stressful life events, health and social care professionals should consider offering support, and where necessary treatment, because they are more likely than other women who have an abortion to develop mental health problems.
• There is a need for good quality prospective longitudinal research to explore the
relationship between previous mental health problems and unwanted pregnancy,
especially in a UK context, to gain a better understanding of which women may be at
risk of mental health problems and to identify those in need of support.
