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ss triple helix - Christmas 2011,  Abortion and mental health - the evidence builds

Abortion and mental health - the evidence builds

key points

The link between induced abortion and mental health problems has often been dismissed on the basis of lack of any compelling academic evidence however the author suggests this dominant view may be challenged by new research.

Coleman's review asserts that as many as 10 per cent of all mental health problems are directly attributable to abortion. Despite some questions regarding the methodology of the review the clear conclusion is that women should be better informed about all the potential risks involved.

Acknowledging that there are mental health risks for post-abortive women will be a major hurdle when the pretext for most abortions in the UK is the reduction of mental health problems for the woman.

The standard rhetoric that well designed studies have failed to show any adverse effects of abortion on women is being increasingly undermined by solid new evidence showing that there are indeed increased rates of mental health problems for women post-abortion, even where the pregnancy is unwanted and/or unplanned.

The question of whether abortion is linked to mental health problems has long been a topic of debate. The majority (98 per cent) of abortions carried out in the UK under the Abortion Act 1967 in 2010 were carried out on the premise that it is better for a woman's mental health to have an abortion than to continue with an unwanted pregnancy. (1) Any challenge to this premise would effectively suggest that most abortions are not justified under the Act.

Not surprisingly therefore, despite consistent anecdotal evidence to the contrary from counselling centres and testimonies of women (2) and research findings, (3) many academics and health professionals (not least the Royal College of Obstetricians and Gynaecologists) have refused seriously to countenance any challenges to the long-held belief that no well-designed studies show adverse effects of abortion on mental health. At most it is ceded that perhaps a few women might experience problems, but only if they manifest mental health problems before the abortion.

The recent, and important, draft review of this topic by the Royal College of Psychiatrists (RCPsych) did include a few studies that showed some negative effects however, in our view, their conclusions failed fairly to represent these studies and undermined their findings. CMF sent in detailed comments on this draft, which are available on our website. (4) The draft conclusion of the RCPsych is that there are negligible adverse effects on women post-abortion compared to postpregnancy, except when women have prior mental health problems. Their final report, funded by the NHS, will be highly influential and is expected to be published in the autumn. (5)

However one academic, Priscilla Coleman, who has published extensively in academic journals on this topic for many years, and who was referenced in the RCPsych draft, has for many years produced findings suggesting a clear link between abortion and adverse mental health effects. Her latest paper, a systematic review of 22 studies (6) has, in part through our efforts at CMF, received considerable attention in sections of the media.

Coleman's latest findings are striking. She claims that nearly 10 per cent of all mental health problems are directly attributable to abortion. Her findings show that women with an abortion history experience nearly double the risk of mental health problems when compared with women who had not had an abortion. Even compared to women delivering an unintended pregnancy, post-abortion women still have a 55 per cent increased risk of mental health problems.

The study reports increased risks that abortion has for specific outcomes. For example, Coleman found that there is a 220 per cent increased risk of marijuana use post-abortion, 155 per cent risk of suicide behaviours, 110 per cent risk of alcohol abuse, 37 per cent risk of depression and 34 per cent increased risk of anxiety disorders.

Coleman's work has a number of strengths. It has been published in the prestigious British Journal of Psychiatry, hence has passed extensive scrutiny by three peer reviewers prior to publication. It undertakes a meta-analysis of 22 published studies, it analyses 36 effects and brings together data on nearly 900,000 participants, 164,000 of whom experienced an abortion. It uses clear selection criteria and a good range of controls, including prior history of mental health problems.

Coleman's research also has a number of methodological weaknesses that have been criticised by researchers who have come to different conclusions. (7) Coleman herself acknowledges that research on abortion is unable to demonstrate causality because: 'when the independent variable cannot be ethically manipulated, as is the case with abortion history, definitive causal conclusions are precluded'. She does however add that: 'as more prospective studies with numerous controls are being published, indirect evidence for a causal connection is beginning to emerge.'

Prof David Fergusson, of the University of Otago, New Zealand, who has published some of the most robust research on abortion and whose work is cited in the RCPsych report (and who does not consider himself to be at all 'pro-life') counterbalances some of the criticisms against Coleman. He suggests, interestingly, that her critics '…follow a well-trodden strategy which has been used in a number of reviews to dismiss any evidence suggesting that abortion may have adverse effects on mental health' namely, by undermining the methodology used and playing down the strength of findings. Fergusson says Coleman has done the field a service in her research and concurs with her overall finding: 'There is a clear statistical footprint suggesting elevated risks of mental health problems amongst women having abortions.' Fergusson even re-analysed the data because of the criticisms against Coleman, concluding that: 'It is our view that the scientifically appropriate and cautious assessment is that: there is currently suggestive evidence indicating that abortion is associated with modest increases in risks of common mental disorders.' (8)

While it appears that there may be some methodological questions over Coleman's findings, it also serves to demonstrate that at present there is no evidence to suggest the counter argument, that abortion has no mental health consequences. Policies and strategies need to be put in place to ensure women are better informed about the potential risks of abortion. Coleman's modest recommendation is simply that clinicians should: '... convey the current state of uncertainty related to benefits of abortion in addition to sharing the most accurate information pertaining to statistically validated risks.'

Women have been told that abortion is an emotion-free, quick and simple lunch-time op. They have the right to be told that it is much more significant than this. They need to be informed that research shows that some will experience painful emotions, that some will develop alcohol and drug problems and that some will encounter relationship problems as a direct consequence. At the very least they should be told that there is a real lack of academic studies showing any benefits from abortion – despite the fact that so many are carried out on the presumption that abortion reduces mental health risks!

At the very least, the uncertainty in the evidence, and the possibility that abortion may carry significant potential adverse effects to women's mental health, needs to be conveyed to the public, otherwise women are being inadequately informed. While these statistically validated findings are not disseminated to the public, or are undermined for ideological reasons, then women are not in a position to give fully informed consent or make an informed choice about what pathway to take with an unexpected pregnancy. It is not simply a matter of different ideologies at stake here but the lives and emotional health of many women.

Coleman's research raises separate questions around counselling and its content, as well as the legitimacy of most abortions in the UK. Some of these questions have been the centre of heated Parliamentary debates recently which has served to raise the public profile and nature of counselling before abortion. (9)

A further interesting development is the campaign by The Times newspaper on adoption, which has recently gained the public backing of the Prime Minister. The Times recommends a number of measures to overhaul adoption, including the following: 'Adoption should be presented as an option by local authorities, pregnancy advisory services and charities to women who choose to continue with unwanted pregnancies, alongside the option of keeping the child with the support of social services'. (10)

Presenting adoption as a positive option and a genuine alternative pathway for woman presenting with an unplanned pregnancy, or properly supporting a woman in keeping her child, would give a woman in a crisis pregnancy genuine choices about the pathway to take, rather than feeling that her only real option is to climb onto the conveyor belt towards abortion. This is surely what being 'pro-choice' should be about.

While there is no doubt that abortion continues to be a major political, cultural and spiritual battleground, these small but significant developments which are helping to expose the real truth about the effects of abortion for some women, while offering genuine alternatives, should encourage us that change is possible. It is often the small acts and changes (in this case, through research, counselling, caring and prayer) that, when multiplied, will transform our world.

  1. 'Ground C: the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman' (section 1(1)(a)) Abortion Act 1967.
  2. For example, see the stories online at www.careconfidential. com/PeoplesStories.aspx
  3. Fergusson, A. Consequences of Abortion CMF File 35 2007.
  4. Submission to the RCPsych Review on Induced Abortion and Mental Health, 29 June 2011.
  5. Induced Abortion and Mental Health: A systematic review of the mental health impact of induced abortion.
  6. Coleman PK. Abortion and mental health: quantitative synthesis and analysis of research published 1995–2009. Br J of Psych 2011;199:180-186.
  7. Howard L et al. Flawed conclusions on abortion and mental health, Br J of Psych published response, 14 September 2011.
  8. Fergusson D. A Further Meta- Analysis, Br J of Psych published response , 5 October 2011.
  9. Taylor P. Abortion counselling vote: a defeat but not a loss. CMF Blog.
  10. Adoption: the way forward. Times, 6 October 2011.
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