Do women experience psychological reactions after abortion? If so, what are they? Can we predict them? What do we make of the case of a woman who is applying for legal aid to sue the NHS for the psychological trauma she claims to have experienced after an abortion?[1] What are the links, if any, between depression and induced abortion? Firstly, we must recognise that research design problems are considerable in this field of research. Obviously, prospective baseline assessments and control groups before becoming pregnant are impossible. Moreover, women who have abortions often may not be amenable to questions on how they feel and they may be less likely to return for follow-up.

Reactions after abortion

So do psychological reactions occur after abortion? A study[2] of all pregnant women in the entire population of Denmark comparing women within three months post abortion with pregnant women who declined abortion, showed that psychiatric hospitalisation was higher amongst postabortion women (1.84/1000) than in those who declined abortion and delivered (1.2/1000).

The Rawlinson Report on the Operation of the Abortion Act in 1994[3] reported this study as superior to - because of its comprehensiveness - an English study[4] on a sample of women which found a lower incidence of serious mental disturbance causing hospitalisation in those who had an abortion (0.3/1000) than in those who delivered (1.7/1000).

An American study[5] linked 173,000 women who had abortions or gave birth in 1989 to death certificates. Women who had abortions were 2.6 times more likely to die from suicide compared to those who delivered their babies. This is backed up by a recent study[6] in Finland looking at the death certificates of all fertile-aged women (1987-1994). Those who had had an abortion in their last year of life were seven abortions were also almost twice as likely to harm themselves after the abortion than before.

Another study[7] from Wales showed that in women with unplanned pregnancies and no history of psychiatric illness, deliberate self-harm was commoner in those who had abortions than in those who did not request an abortion. A further study[8] on unplanned pregnancies showed that those women who aborted the pregnancy had more depression than those who gave birth and who had the social support of a marriage.

Emotional consequences

So who is at risk? Psychological problems following induced abortion undoubtedly occur, but who suffers from them? A meta-analysis[9] of 24 studies with different assessment methods and follow-up periods found about a 10% incidence of negative psychological outcome. A meta-analysis of ten articles from 1998[10] showed that the levels of depression and anxiety decreased once abortion had taken place, but that 'induced abortion may yield both negative and positive effects. Women who experience decision making difficulties and may lack social support may experience negative emotional consequences to induced abortion'.

In a German study[11] of 263 women screened before the abortion and at one year, 79% had adjusted without problems; 14% were still 'in a state of emotional imbalance'; 7% were impaired emotionally and in their everyday functioning. 21% of the women with adjustment problems had a history of depression. Significantly correlated with later emotional difficulties were low social class, financial problems, 'lack of intrapsychic differentiation between sex and reproduction', no partner or poor support from partner.

An American study[12] showed that those who have had depression in the past are significantly more at risk of depression, lower self-esteem and a negative view of the abortion after two years.

Women with high levels of mood disturbance prior to abortion, are smokers or who have medical complications following abortion, were at highest risk of a mood disorder, according to a Scottish study.[13] An Italian study[14] found that women tested as neurotic on the Eysenck Personality Inventory tended to have high degrees of psychological distress before the abortion and got worse afterwards.

Risk factors

The following risk factors for psychological disturbance after abortion have been proposed in a review article: [15] previous psychiatric history and/or degree of psychological disturbance at presentation; poor support from close relationships; negative religious or cultural attitudes to abortion; those having abortion because of foetal abnormalities or serious medical complications.

Another phenomenon occurring in women (30/83) reporting continuing depression up to ten years following abortion is the 'anniversary reaction' at the date the aborted baby would have been due. It was more often associated with ambivalence whether to abort or not.[16]

Advance warning

So are women warned about possible adverse psychological effects of abortion? The Royal College of Obstetricians and Gynaecologists[17] states:

'Psychological sequelae: only a small minority of women experience any long term, adverse psychological sequelae after abortion. Early distress, although common, is usually a continuation of symptoms present before the abortion. Conversely, long-lasting, negative effects on both mothers and their children are reported where abortion has been denied.'

This last sentence seems to be economical with the evidence and appears to misrepresent, for instance, findings from a huge meta-analysis of 225 studies. [18] 'Abortion for medical or genetic indications, a history of psychiatric contact before the abortion, and mid-trimester abortions often result in more distress afterwards. When women experience significant ambivalence about the decision or when the decision is not freely made, the results are more likely to be negative.' (pp.583-84) Therefore, in an atmosphere where abortion is made easy and there appears to be little information given to women about the psychological sequelae of abortion, it is of concern that in one study, women themselves only instigated 30% of abortions.[16]

The Commission of Inquiry into the Operation and Consequences of the Abortion Act[3] heard from witnesses representing the Royal College of Psychiatrists who stated that 'although the majority of abortions are carried out on the grounds of danger to the mother's mental health, there is no psychiatric justification for abortion. Thus the Commission believes that to perform abortions on this ground is not only questionable in terms of compliance with the law, but also puts women at risk of suffering a psychiatric disturbance after abortion without alleviating any psychiatric problems that already exist' (p15).

The Commission stated that 'far from being a choice of several alternatives, the decision to have an abortion often appeared to be the only 'choice' available to them. Such a decision does not represent a free choice' (pp 15-16). Since that time, there may be more 'choice' because of the work of Christian organisations such as LIFE and CARE who offer counselling and practical help.

Conclusions

Many studies show that adverse psychological reactions occur after induced abortion. Repeated studies consistently show that certain risk factors have been identified, especially a history of depression. It is likely that patients are not being warned of this. As Christians and doctors who are concerned with evidence-based medicine, we should insist that they are appropriately counselled and forewarned.