Back in 2002 I reviewed the evidence regarding psychological ill effects after abortion and concluded that these reactions did occur; risk factors included a previous psychiatric history and the lack of a supportive relationship.[1] The Royal College of Obstetricians and Gynaecologists was not adequately warning about this risk, despite representatives from the Royal College of Psychiatrists stating that there was no psychiatric justification for abortion.[2]

Important new evidence The most significant new evidence is that psychological ill effects have been shown to occur after abortion, even in women with no previous psychological problems.[3] This very important prospective longitudinal study followed up 500 New Zealand girls and young women from the time of their birth to 25 years of age. Each woman's mental health was measured at 16, 18, 21 and 25. Ninety reported having had an abortion, and these women experienced nearly twice the level of mental health problems as those who had either given birth or never been pregnant. They also had three times the risk of major depressive illness compared to the other groups. These results were statistically significant even after controlling for previous mental health.

The epidemiologist author Fergusson, himself pro-choice and not religious, was told by the New Zealand Abortion Supervisory Committee that it would be '…undesirable to publish the results in their “unclarified state”'.[4] Fergusson replied that it would be scientifically irresponsible not to publish these results: '…the findings did surprise me, but the results appear to be very robust because they persist across a series of (mental) disorders and a series of ages'.[5]

Current controversies

The robustness of abortion studies has been a key issue over the last four years. The methodology is hotly debated. How should we interpret the data? Fergusson's study controlled for social background, education, ethnicity, previous mental health and exposure to sexual abuse. He recognised that potential limitations remained: that further confounding factors may exist; that probably only 81 percent of abortions had been found; and that contextual factors such as an unwanted pregnancy's effects need to be addressed. Nevertheless, this study's findings cannot be ignored.

Fergusson quoted and was critical of a statement by the American Psychological Association – 'Well-designed studies of psychological responses following abortion have consistently shown that risk of psychological harm is low… the percentage of women who experience clinically relevant distress is small and appears to be no greater than in general samples of women of reproductive age' – because it did not appear to take note of studies that reported different findings.[6] Instead, it had reported on only a small number of studies with severe limitations: limited controls; lack of comparison groups; and lack of comprehensive mental disorder assessment. Following this criticism, the APA withdrew their statement.[7]

One of these omitted studies was Cougle and Reardon's United States National Longitudinal Study of Youth (NLSY): this study found that, eight years after pregnancy, married women who had an abortion were 65 percent more likely to score in the high risk range for clinical depression than those who gave birth.[8] They controlled for age, race, socioeconomic status, education and history of divorce but not for previous mental health. And again, they calculated 60 percent of abortion non-reporting.

Another study also looked at the NLSY data and claimed the evidence that having an abortion led to a higher risk of depression than giving birth is 'inconclusive'.[9] Reardon, a biomedical ethicist, replied that any woman who thought of continuing the pregnancy was excluded, a group whose ambivalence might place them at risk of emotional problems.[10]

Reardon also studied psychiatric admissions up to four years after abortion and childbirth.[11] It found the abortion group had significantly more admissions for depression (both single episode and recurrent), for bipolar and for adjustment disorders. California-based psychologist Major criticised this study: '…it is more appropriate to compare women who abort an unwanted pregnancy with women who are denied or unable to obtain an abortion, and hence are forced to carry to term a pregnancy that is unwanted. Another appropriate comparison group would be women who deliver a child and give it up for adoption. [This] partly is controlling for the “wantedness”of pregnancy'.[12] She concluded: 'A truly definitive study of the psychological effects of abortion is impossible, as such a study would involve randomly assigning women with unwanted pregnancies to continue or abort their pregnancies, a prospect that is clearly unethical'.

Review articles

There have been three review articles, though they have not looked at the most recent literature. Firstly, Thorp et al reviewed a number of studies up to 2002 which contained more than 100 women per study, all followed up for more than 60 days.[13] Their summary: '… induced abortion increased the risks for pre-term delivery and mood disorders substantial enough to provoke attempts of self harm. Thus, we conclude that informed consent before induced abortion should include information about the subsequent risk of pre-term delivery and depression'.

Secondly, forming the opposite opinion, Bradshaw reviewed six studies dating from 1990 to 2000, and concluded that there were no long term differences between those who had abortions and those who gave birth.[14]

Lastly, Reardon reported on 35 studies that identified those statistically validated risk factors which most reliably predict women likely to report negative reactions.[15]

Post-traumatic stress disorder

One large study found significant rates of long term post-traumatic stress disorder in women after abortion.[16] Of 254 women followed up two to five years after abortion for fetal anomaly before 24 weeks, 17.3 percent had pathological scores of posttraumatic stress disorder (PTSD). Risk factors were poor educational attainment, inadequate partner support, longer gestational age, and finding that the fetal anomaly was compatible with life.

In another study, PTSD was found in 14.3 percent of 217 US women ten years after abortion, though in only 0.9 percent of 331 Russian women after six years.[17] The authors concluded that abortion can increase stress and decrease coping abilities in women with histories of adverse childhood events and previous traumas.

Comparing abortion with miscarriage

A Norwegian study found that women who had abortions were more likely to suffer from depression and anxiety.[18] Researchers compared 80 women who underwent abortion and 40 who miscarried, following them up after 10 days, six months, two and five years. Compared with the general population, the abortion group experienced more anxiety at all four interviews and more depression at ten days and six months, whereas the miscarriage group had higher anxiety at ten days only. Predictors at six months and five years for anxiety and depression were previous psychiatric history and life events. Depression at six months was associated with doubt about the decision to abort. Anxiety at six months and five years was associated with a negative attitude to abortion.

Conclusion

There is strengthening evidence that there are psychological ill effects after abortion. Although methodological issues remain problematic in many studies, a large longitudinal, methodologically robust study from New Zealand has set a new landmark. A woman having an abortion can no longer be said to have a low risk of suffering from psychiatric conditions like depression. It is our duty to warn every woman considering an abortion that there may be long-term adverse psychological effects.