Catholic Medical Quarterly Volume 61(4) November 2011, 21-24

Induced Abortion and Mental Health:

A systematic review of the mental health impact of induced abortion

CMA(UK) submission to the Royal college of psychiatrists working group.

Baby In early 2011, the Royal College of Psychiatrists published a document for consultation on the mental health impact of abortion. The CMA worked hard with sister organisations in the UK to prepare a detailed and in depth response.

There is a huge body of evidence that shows that mental health in women who undergo abortions is poor and that mental disorders after abortion are common. In addition, there is considerable evidence that while women appear to recover from miscarriage, mental health following abortion often deteriorates over time. On-going distress years after the event are seen in many women.
The CMA was concerned that the draft report appeared to dismiss some of the evidence and to minimise the impact of abortion. In the end, the draft report attempted to compare women who aborted an unwanted pregnancy with women who kept an unwanted pregnancy. There were many problems with this approach.

Firstly, the study reduced itself to only four published studies. By restricting analysis to these four studies, the power of the review was greatly reduced and we felt that much important information was lost. Secondly, all four papers showed some detriment in the abortion group, but effects were not consistent.

Our submission is too long to publish in paper form and the format that the College asked for was also complex. However, the full report is available online at www.cmq.org.uk/submissions/. A full list of references is available in the draft report.

Here we present what we thought were sensible conclusions, robustly based upon the evidence base. The rationale behind these statements is contained within our full report online.

Recommended evidence based statements and conclusions

The CMA (UK) suggests that, from the published data, evidence based statements and conclusions are as follows.

Question 1: How prevalent are mental health problems in women who have an induced abortion?

When prior mental health is not taken into account, rates of mental health problems post-abortion appear high
Controlling for previous mental health problems has an impact upon the prevalence rates of mental health problems, but they continue to be elevated even after previous mental health problems are accounted for.

Question 2: What factors are associated with poor mental health outcomes following an abortion?

The evidence base reviewed is restricted by a number of limitations including heterogeneity in the factors assessed and the outcomes reported, inconsistent reporting of non-significant factors and variations in follow up times.
When considering prospective studies the only consistent factors associated with poor health problems after abortion are pre abortion mental health problems and negative attitudes towards abortion.
The most reliable predictor of post abortion mental health problems was having a history of mental health problems prior to the abortion. A history of mental health problems was associated with a range of post abortion mental health problems regardless of outcome measure or method of reporting used.
It has not been possible to identify any features (such as positive attitudes towards abortion) that are protective in terms of longer term mental health and it is not therefore possible to identify any groups which are not at risk of poor outcomes following abortion.
However there is particular concern that those who are pressurised into abortion or who are uncertain about their decision may suffer worse outcomes.
The lack of UK based studies may have some implications for the generalizability of data, though few reasons were identified to suggest why this might be the case.
It is likely that a range of factors may be associated with variations in mental health outcomes following an abortion and that those reviewed here do not constitute an exhaustive list.

Question 3: Are mental health problems more common in women who have an induced abortion, when compared with women who delivered a live birth?

There is considerable evidence that there are increased risks of mental health problems requiring psychiatric treatment, hospital admission, suicide and substance misuse for women who undergo abortions compared with those who deliver a live birth.
There is considerable concern about the use of the term “wantedness,” which is a changeable dimension that is hard to measure and which may ensure, when stringently used, that outcomes in women who continue with an unwanted pregnancy may appear particularly poor.
Where studies do control for whether or not the pregnancy was wanted, evidence is conflicting, but studies do indicate some effect in terms of increased risks of anxiety, self harm and psychiatric illness.
Data from all outcomes is still limited by a number of factors including a lack of comparable data across a range of diagnostic categories and also by adequate control of confounding factors.
Most of all, determining causation of effects is complex.
Although there is evidence of increased risks of mental disorder after abortion, even when this is controlled for previous mental health, there is very little evidence of any protective effect of abortion upon subsequent mental health.

Conclusions

Although there are significant limitations with the dataset included in this review, this review is perhaps a little more robust, combining the approaches of both main previous reviews, and confirming many of the findings in previous reviews.
There is a range of mental disorders that are significantly more common after abortion when compared to women who miscarry or continue with a pregnancy. When controlling for previous mental health, risks of abortion to subsequent mental health remain significant. Even when controlling for wantedness, there is some evidence of increased risks to subsequent maternal mental health
Women with mental health problems prior to abortion or birth are associated with increased mental health problems after the abortion or birth. Those with negative attitudes towards abortion are also especially at risk, although there is no evidence of any particular factors that are associated with a favourable outcome after abortion.
For all women who have an unwanted pregnancy, support and monitoring should be offered as the risk of later mental health problems are greater whatever the pregnancy outcome. The offer of support should depend upon the emergence of mental health problems, whether during pregnancy, post-abortion or after birth, and should be underpinned by NICE guidance for the treatment of the specific mental health problems identified.
Women should be told of the possible need for support and monitoring after the abortion and also informed of how to obtain it. This should be included in the consent procedure.
However, women who suffer mental health problems after abortion will require specific targeted psychiatric and psychological interventions as do women who suffer rape, abuse or other trauma. In particular, feelings of guilt, remorse and bereavement for the lost baby indicate a need for careful support. Current provision for this is patchy and often provided by the voluntary sector. There is a need to develop and research the specific therapies that are relevant here.
If women who have an abortion show a negative emotional reaction to the abortion, or are experiencing stressful life events, support and monitoring should be offered as they are more likely than others to develop a mental health problem.
Consent to medical procedures requires a discussion of important risks from that procedure. Risk to mental health from abortion should be discussed as part of pre abortion counselling and informed consent.

References and full report

Abortion Comments Form final.pdf