One of the most comprehensive and systematic reviews to date into the link between abortion and mental health problems has confirmed that women who have an unplanned pregnancy are at an increased risk of experiencing mental health problems after an abortion. The Review also highlights which women are most at risk of mental health problems after abortion.
Moreover it, in effect, reveals that 98% of the 200,000 abortions carried out in Britain each year are technically illegal.
The new Review by the Academy of Medical Royal Colleges, which was funded by the Department of Health, shows that abortion does not improve mental health outcomes for women with unplanned pregnancies and does not offer any real protection from mental health problems. Yet the vast majority of abortions are being carried out in this country each year on mental health grounds – 185,000 abortions in 2010.
This means that when doctors authorise abortions in order to protect a woman’s mental health they are doing so on the basis of a false belief not supported by the medical evidence. In other words the vast majority of abortions in this country are ‘technically illegal.’
The Review finds that negative attitudes towards abortion, pressure from a partner to have an abortion and negative reactions to the abortion including grief or doubt, may all have a negative impact on mental health after abortion. A history of mental health problems prior to the abortion has an even greater effect.
The controversial conclusion, widely reported in the media, that the increased rates of mental health problems for women with an unwanted pregnancy are the same whether they have an abortion or give birth, is actually based on very weak evidence, which the Review itself acknowledges:
‘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 … These factors limit the interpretation of the results.’ (section 5.5).
Indeed, not just this section, but other key conclusions were similarly preceded by statements such as: ‘The studies included in the review have a number of significant limitations…making it difficult to form confident conclusions or generalisations from these results.’ (section 3.6). And: ‘The lack of UK-based studies further reduces the generalisability of the data.’ (section 4.4). And: ‘The studies included in the review are limited in a number of ways, making it difficult to form confident conclusions from the results.’ (section 6.2.1).
The new report also highlights the difficulties with the whole concept of ‘unwantedness’ as a measurable parameter: ‘However, the measurement of whether the pregnancy was wanted or unwanted is open to many difficulties. For example, a pregnancy that was unwanted may become wanted at a later stage of pregnancy and vice versa. An unplanned pregnancy can be either wanted or unwanted.’
All four main research studies cited in the last, and most widely cited, section of the review (Cougle, Fergusson, Steinberg, Gilchrist) each found some mental health problems were actually MORE common following one or two abortions.
For example, Steinberg found increased risks for multiple abortions, although not for one. Fergusson found higher mental health problems for those exposed to abortion. Gilchrist found increased self-harm and Cougle found anxiety. Hence it is all the more misleading to state there is: ‘NO evidence of an elevated risk…’‘ in the final evidence statement. It would have been more accurate to simply state, at the very least, that there is conflicting evidence about the link between abortion and mental health.
This point has recently been made by Fergusson, the author of the only one of the four papers cited which was judged in the review to be ‘very good’, in a letter to the British Journal of Psychiatry . He contests the claim that abortion has no adverse mental health consequences and promises a new paper making this point soon to be published:
‘ 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… A detailed paper describing these findings is currently under review.’
Moreover, it is notable that the authors re-analysed some important 2008 research by Fergusson, claiming that Fergusson’s data, that they re-analysed, shows women who had an abortion were not statistically significantly more likely to experience anxiety disorders than those who delivered a pregnancy. This completely contradicts the original findings in Fergusson’s paper.
This is an important point of concern as Fergusson’s original 2008 findings have been widely cited to indicate that there is a higher relative risk for those having an abortion. (“…women exposed to induced abortion had risks of mental health problems that were about 30% higher than women not exposed to abortion.” Fergusson, D. et al, 2008 ‘Abortion and Mental Health Disorders: evidence from a 30-year longitudinal study’. British Journal of Psychiatry. 193, pp.444-451.).
Despite the weak evidence base, there are still some useful messages to take home for those offering counselling and support to women with unplanned pregnancies.
First, women with unplanned pregnancies need to know that abortion will not reduce their risks of mental health problems relative to giving birth.
Second, those who have a past history of mental health problems, who believe that abortion is wrong, who are being put under pressure by their partners to have an abortion or who are experiencing other stressful life events, need to know that they are at risk of increased rates of post-abortion mental health problems. If this information is withheld from them they will not be able to make fully informed decisions about their pregnancy outcome.
The first response to an unplanned pregnancy should therefore not be abortion but, as the Review rightly recommends, an offer of proper support and care for women: ‘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.’ (p128).
Government should therefore make the provision of fully independent counselling for all women with an unplanned pregnancy a key priority, in order that they can have access to support and counselling that is not linked to abortion provision.
The Review Conclusions and Recommendations
The Review concludes that:
‘The best current evidence suggests that it makes no difference to a woman’s mental health whether she chooses to have an abortion or to continue with the pregnancy.
- Having an unwanted pregnancy is associated with an increased risk of mental health problems. However, the rates of mental health problems for women with an unwanted pregnancy are the same, whether they have an abortion or give birth.
- The most reliable predictor of post-abortion mental health problems is having a history of mental health problems. In other words, women who have had mental health problems before the abortion are at greater risk of mental health problems after the abortion.
- Some other factors may be associated with increased rates of post-abortion mental health problems, such as a woman having a negative attitude towards abortions in general, being under pressure from her partner to have an abortion, or experiencing other stressful life events.
The Review recommends that:
- 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.
The review was developed for the Academy of Medical Royal Colleges (AOMRC) by the National Collaborating Centre for Mental Health (NCCMH). The review was funded by the Department of Health.
CMF sent a detailed submission to the Review authors, when it was being drafted, which is available on the CMF website, along with a statement and a briefing paper summarising our main points.