Unless a pregnant woman's circumstances fulfil one of seven grounds set out by the Abortion Act 1967, induced abortion remains an illegal act in this country. 95% of abortions are performed on Ground C,[1] which exempts a doctor from prosecution for performing an abortion (before the 24th week) if:

'…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… (account may be taken of the pregnant woman's actual or reasonably foreseeable environment…)'[2]

Since the inception of the Abortion Act, doctors have often made the assumption that the clause could be fulfilled for any woman who did not want to keep her pregnancy, because the emotional consequences of giving birth to an unwanted baby or the physical consequences of delivering a baby were greater than that of induced abortion.

Over forty years of the Act and after six million abortions, there is accumulating evidence of the serious and long-lasting consequences of abortion. Could 95% of UK abortions be illegal because of inaccurate assessment of the risks?

Physical Health

Is there evidence that the physical health of a woman is worse following an induced abortion than if she keeps her pregnancy? When considering Ground C one needs to assess the risk of death and other irreversible consequences.

Mortality

The UK maternal mortality rate is estimated to be 13.1 in 100,000.[3] In the 2000-2 confidential enquiry, there were only five abortion-associated deaths from a total of 261 maternal deaths suggesting that abortion is a significantly safer procedure than giving birth.[4] However there are at least two important reasons why these statistics vastly underestimate the mortality associated with abortion. Many deaths go unrecognised because the procedure is often performed in clinics that don't provide on-going care for the woman.The causal association with subsequent illness is not then recognised. But even when it is, it may still not be included on the certificate.The report on maternal deaths acknowledges these shortcomings in ascertainment even for pregnancy.[5]

However an in-depth Finnish study of deaths within a year of delivery, miscarriage or abortion from 1987-94 gives a more complete and disturbing picture. Compared to women who gave birth, women who aborted were 3.5 times more likely to die within the year.[6,7] The risk of death from suicide was seven times higher than the risk of suicide within a year of childbirth.Women who aborted were also four times as likely to experience a fatal accident, 13 times more likely to be murdered and 1.6 times more likely to die of natural causes than women who gave birth.

Morbidity

A recent Scottish study estimated the severe morbidity rate from undisturbed pregnancy to be 3.8 per 1,000 but almost all events, including haemorrhage (incidence 1.9 per 1,000), were treatable with a good long-term outcome.[8]

The serious, but usually treatable, acute complications of surgical abortion are haemorrhage (incidence 0.1%) and uterine perforation (incidence 0.4-2%).The risk of infection [9] (incidence 10%) is greatly increased when Chlamydia or Neisseria are present - up to 23% developing pelvic inflammatory disease (PID) within four weeks.[10] With rapidly rising Chlamydia rates this will be an increasingly common complication of abortion.

Induced abortions may have important effects on future pregnancies. PID can cause infertility and future pregnancies have a greater risk of placenta praevia (increased by 7-15 times), and pre-term labour (twice as likely).[11] The latter is an important cause of chronic lung disease and cerebral palsy in the child.

Finally there is growing evidence (though still disputed by some) that abortion - but interestingly not miscarriage - increases the risk of breast cancer (relative risk of 1.3-2).[12,13] In addition term pregnancy acts as a clear protection against the development of breast cancer.

Mental Health

Is there evidence that the mental health of a woman is worse following an induced abortion than if she keeps her pregnancy?[14]

Countless harrowing testimonies [15] following induced abortions bear witness to the prolonged and profound psychological effects for some woman. But is there any epidemiological evidence to support these individual accounts?

Both sides of the debate have quoted studies to support their views. One reason for this is the demanding methodological criteria for an effective study. It needs to establish whether abortion causes mental illness or mental illness predisposes to abortion, and to adjust for the spurious influence of confounding factors such as income and education. Many women are reluctant to admit their abortion (concealment) leading to an underestimate of any adverse effects from abortion. Finally, to test Ground C the ideal comparison categories of 'abortion performed'verses 'abortion refused'are not available in a society where there is effectively abortion on demand. Sometimes 'unplanned and kept'or 'unplanned and aborted' categories are studied as lesser alternatives.

Bearing these issues in mind what conclusions can we draw from the best published studies? A recent New Zealand study looked at the mental health and pregnancy/abortion history of a cohort of 15-25 year olds by interview. [16] With low concealment rates and adjusting for confounding factors, they found that those keeping their pregnancy had mental illness rates 60% of those who had an abortion. The findings remained significant even when pre-pregnancy mental health was taken into account. This study took no account of the 'plannedness'of the pregnancy but a similar type [17] of study showed a comparable effect when the pregnancy was unintended, though this could not be shown to be statistically significant in unmarried women. In another study the detrimental effect of abortion on mental health was still present eight years later.[18]

Other studies avoid the subjectivity of psychological interviews by using the harder indices of psychiatric admission or suicide rates. Reardon and others looked at psychiatric admissions from the medical records of low income women in Canada (thereby taking into account social background and avoiding problems with concealment).[19] Such admissions were commoner at 90 days (2.6 times) and 4 years (1.5 times) in those women who had abortions than those who delivered their baby.

As already mentioned women who have abortions are much more likely to commit suicide within a year of the event than those who give birth. 4,5 It is noteworthy that the suicide risk following birth was half that of the general population. Though prepregnancy mental state may contribute to some of the difference, the most obvious conclusion is that abortion seriously threatens a woman's mental health whilst undisturbed pregnancy often improves it.

In addition one can reasonably anticipate the adverse mental effects of the physical consequences of abortion on the women including pelvic inflammatory disease, pre-term labour in future pregnancies and breast cancer.

Conclusion

Francis Schaeffer wrote,'Abortion does not end all the problems; it often just exchanges one set for another'.[20] These words from a passionate anti-abortionist without the observations of the last forty years, contain a hint of balance that might suggest that Ground C could sometimes be fulfilled.We now know differently.

Much pain and grief will never be adequately recorded in scientific studies and there are many reasons why studies tend to underestimate the damage of abortion on the woman.[21] Nevertheless, our increasing insight into the true consequences of abortion shows that abortion is never an easy way out. A decision for the life of her foetus generally brings health for the mother, whilst a decision against life often brings a toll of physical destruction and grief that has far-reaching consequences for the woman as well as the foetus.

There are a number of important implications of these findings.

• It may no longer be professionally credible for a practitioner to sign the form that acknowledges legitimate grounds for abortion under Ground C.[22]
• All woman requesting abortions should be warned of these sequelae. How many would change their mind if they were fully informed?
• Without such warning, we can expect women to bring legal action against practitioners and abortion clinics for the damaging consequences.
• We need to warn young people about one of the huge potential costs of pre-marital sex (the majority of abortions are performed on unmarried teenagers).

Finally, as this truth dawns, should we be surprised that pro-abortionists are proposing revision of the 1967 Abortion Act to introduce a clause that more clearly legalizes abortion on demand?