Abortion and Mental Health – Why Choice Really Matters.

Having read the Christian Medical Fellowship desperate attempt to put their own spin on the outcome of the NCCMH’s newly published systematic review of the mental health impact of induced abortion I’ve come to the conclusion that the organisation is in dire need of a change of name.

They’re welcome to keep the initials, but their published response to the review, written by Phillipa Taylor (Head of Public Policy) is such a laughable exercise in tendentious nonsense that, henceforth, the ‘C’ in CMF can only be taken to mean ‘Comedy’ rather than ‘Christian’, unless they’d prefer to adopt a much more open and transparent nomenclature and adopt the name ‘Liars for Jesus’.

Yes, there’s a fully caffeinated fisk coming your way – what else would you expect from me? – so get yourself a cup of coffee (or perhaps an urn might be more useful as we’ve a lot of ground to cover), settle back and enjoy the show, while I take a scalpel to their response and carve it into tiny little pieces:

98% of abortions in Britain are technically illegal, and many will lead to mental health problems for women

I’ll deal with both of these claims in detail as I work through the body of the CMF’s response. For now, its enough to state that both statements are not just, they’re not even wrong.

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.

Oh well, at least they correctly indentified the review as one of the most comprehensive to date, however, what the study actually concludes is:

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.

An unplanned pregnancy is not necessarily an unwanted pregnancy. Nevertheless, as the CMF has elected to spin the review’s findings in terms of unplanned pregnancies, its worth look at what the report actually has to say:

Studies that did not control for whether or not the pregnancy was planned or wanted, suggest that there are increased risks of receiving psychiatric treatment, suicide and substance misuse for women who have abortions compared with those who deliver a live birth. Findings for depression, anxiety disorders, suicidal ideation and PTSD did not indicate an increased risk.

In contrast, where studies controlled for whether or not the pregnancy was planned or wanted, there was insufficient evidence to determine whether or not there was an elevated risk of mental health problems, except for a small increase in possible self-harm in those having an abortion compared with the women who delivered an unplanned, but not unwanted pregnancy, and some evidence of lower rates of psychotic illness for women who had an abortion compared with those who delivered the pregnancy at full term.

Adequate control of confounding factors was shown to have an impact on the results, with previously significant findings no longer being significant when a range of confounding factors were accounted for. In essence, where studies controlled for multiple confounding factors (including the wantedness of the pregnancy), the risk of mental health problems following an abortion was comparable to the risk of mental health problems following a delivery.

Pregnancy is a potential stressor and, like any other stressor it can contribute to or serve as a trigger for mental health problems.

Life is, of course, full of stressors and some people are more vulnerable to stress, and to certain types of stress, than others depending on their individual circumstances. However, when take all this account and introduce controls to minimise/eliminated a range of known confounding factors, i.e. things which are already known to be independently associated with both an increased risk of having an unplanned and/or unwanted pregnancy , which may or may not result in abortion, and also known to be associated with an increased risk of developing/experiencing mental health problems, then the evidence for an elevated risk of mental health problems in women who have had an unplanned/unwanted pregnancy ceases to be statistically significant, i.e. down to chance rather than a verifiable effect.

Although the overall quality of the evidence here is poor, hence the report’s conclusion that there is insufficient evidence to determine whether or not there was an elevated risk of mental health problems, the best evidence we have indicates that when a woman has an unwanted pregnancy, rates of mental health problems and, therefore, their overall risk of mental health problems is unaffacted by the eventual outcome of the pregnancy, i.e. whether or not they choose to have an abortion or choose to carry the pregnancy to term.

As for report highlighting which women are most of mental health problems after an abortion, this is only partially true for reasons we’ll explore when we consider the CMF’s next, and perhaps most ridiculous, claim.

Moreover it, in effect, reveals that 98% of the 200,000 abortions carried out in Britain each year are technically illegal.

Quite where the CMF is getting its legal advice is anyone’s guess – possibly from the same place that be advising the Freeman on the Land ‘movement’ but, put simply, this is complete and utter nonsense in addition to being based on an entirely fallacious piece of pseudolegal ‘reasoning’, as follows:

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.’

We need to dip into the law here. Under the provisions of the Abortion Act 1967 there are seven legal grounds under which woman can obtain an abortion. A to G, of which C is the one we’re interested in. This does account for the vast majority of abortions carried out annually in the UK and reads as follows:

C. 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.

So, straight away we can see that the law does not require doctors to consider whether or not an abortion will improve a woman’s mental health; the only question that has to be considered is whether or not the continuation of a pregnancy would place a woman at a greater risk of injury to her physical or mental health than would be case were she to terminate the pregnancy.

Now, on the face of it, the NCCMH might appear to call decisions to permit a termination to take place under these provision into question. After all, what the research is saying is that, statistically, the overall risk to women of carrying an unwanted preganancy to term is no different to that of having an abortion.

But, and this is major but, that evidence is based on a comparison of rates of mental illness in women who choose to terminate a unwanted pregnancy and the corresponding rates for women who choose to carry an unwanted pregnancy to term. In the latter group, although the pregnancy may not have been wanted at the outset, or at some other point in the pregnancy, that situation will, for most women in this group, have changed by, at the latest, the point at which it would no longer be possible to obtain and abortion. Under current UK law this is 24 weeks gestation although, in practice, the overwhelming majority of women will have made decision their before reaching this point in the pregnancy as relatively few abortions take place after 20 weeks gestation under any grounds.

This is the best comparison that NCCMH could have made, given that UK law does not compel women to carry an unwanted pregnancy to term against their wishes, provided that decision to obtain a termination is made prior to 24 weeks gestation. It is not, however, the ideal comparison – that would compare the mental health outcomes of women who able to legally terminate an unwanted pregnancy with those of women who were afforded no such choice and who were, therefore, compelled to carry an unwanted to term irrespective of whether they wished to do so or not.

This is a critical point of distinction as will become apparent when we look at the factors that have been identified as contributing to women facing a higher risk of mental health problems following an abortion:

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.

That’s according to the CMF. What the review actually had to say was:

2. When considering prospective studies, the only consistent factor to be associated with poor post-abortion mental health was pre-abortion mental health problems.

3. The most reliable predictor of post-abortion mental health problems regardless of study type was having a history of mental health problems prior to the abortion. A history of mental health problems was associated with a range of post-abortion mental health conditions, irrespective of outcome measure or method of reporting used.

4. A range of other factors have more inconsistent results, although there was some limited evidence that life events, negative attitudes towards abortion, pressure from a partner to have an abortion and negative reactions to the abortion including grief or doubt, may have a negative impact on mental health.

5. The lack of UK-based studies further reduces the generalisability of the data.

6. It is likely that a range of factors may be associated with variations in mental health outcomes following an abortion and that those reviewed here did not constitute an exhaustive list.

7. There was an overlap in the risk factors associated with mental health problems following an abortion and those factors associated with mental health problems following a live birth.

The key point here is point 4, which shows that some studies have identified a sub-group of women who do exhibit a higher rate of mental health problems following an abortion than the generally rate associated with having an unwanted pregnancy, after controlling for per-abortion mental health problems. What the women in this sub-group have in common is that:

a) they were uncertain or amibivalent about their decision to have an abortion at the time it took place, and

b) they subsequently came to feel that they had either made the wrong choice or, in some cases, had not been free to make the choice that they really wanted to make, i.e. to continue the pregnancy, due to pressure from a partner, or from family and friends or because other circumstances at the time left them feeling that an abortion was the only choice they could make, even if this was not really what they wanted.

The word ‘choice’ appears three time in that last sentence, which is three more times than it appears in the CMF’s entire response to this review, and the issue of choice is pivotal to understand how the review’s findings actually relate to UK abortion law, as it currently stands.

Women who, after having an abortion, feel strongly that they made the wrong choice or who feel that they were denied a completely free choice as to the outcome of their pregnancy do experience an adverse emotional reaction to the abortion and this does put them at a higher risk of subsequently experiencing mental health problems – and we can legitimately infer from that observation that this would be equally true of women who were denied abortion when this was clearly their choice, even if we don’t have the direct evidence to back that inference up because, since 1967, the law hasn’t forced women to carry pregnancies to term against their express wishes.

This inference is more than sufficient to satisfy the legal requirements of ground C, i.e. that 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. The risk would be greater were women to be denied an abortion when this was clearly their choice. By highlighting the existence of risk factors that are both linked to, and a product of, the choices that women make when faced with an unwanted pregnancy, the review actually demonstrates that abortions carried out under ground C are, in fact, perfectly legal within the terms specified in the Abortion Act and not ‘technically illegal’ as the CMF claims, even within the limitations of review.

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.’

The NCCMH review is commendably clear and transparent in regards to its limitations, which stem, of course, from the limitations of the studies included in the review and, more generally, of the extant research in this field – and this transparency affords the CMF with numerous opportunities to quote mine the review paper, which runs to 252 pages in total, for comments that can be readily presented out of context in an effort to downplay the significance of its findings.

So let’s add some rather important context.

Since the late 1990’s, a small but close interconnected group of anti-abortion researchers have been busily engaged in a deliberate effort to construct a body of published research literature linking abortion to adverse mental health outcomes in order to generate evidence that can be used by the anti-abortion lobby to try to justify placing stringent legal restrictions on women’s access to legal abortion services. THe key figures in this group include Priscilla K Coleman, of Bowling Green State University, David C Reardon of the Eliott Institute, Vincent M Rue and Jesse R Cougle. Collectively, this rather incestuous group of anti-abortion researchers has succeeded in placing 26 papers with peer reviewed journals since 1997, the most recent of which, Priscilla Coleman’s “Abortion and mental health: quantitative synthesis and analysis of research published 1995–2009” appeared in the British Journal of Psychiatry in September of this year. Coleman and Reardon are, by some distance, the most prolific members of this group, with each appearing as either lead or co-author on 17 of the 26 papers, although Reardon’s output has dried up since 2005, when he was outed by Chris Mooney as having obtained his PhD in bioethics from what was, at the time, an unaccredited ‘university’.

So, for the last 14 years, this little clique of researchers has been chruning out papers at a rate of just two a year in a concerted effort to generate evidence linking abortion to higher rates of mental health problems in women to suit an explicitly political agenda which is nicely illustrated by this Powerpoint presentation, given by Coleman at the annual conference of the American Association of Pro-Life Obstetricians and Gynaecologists, which has been unearthed by Ben Goldacre:

We need to develop organized research communities to continue the research, apply for grants, recruit young academics, critique data produced by pro-choice researchers, challenge politically biased professional organizations, train experts to testify, and disseminate cohesive summaries of evidence.

And even more explicitly:

The rapidly accumulating literature on the negative effects of abortion is rarely made available to practitioners and to women considering abortion as professional organizations, including the APA and the AMA, along with the liberal press expend incredible amounts of energy to hide the now scientifically verified truths.

Yep, its those damn librulz in the press, along with the Amercian Psychological Association and the American Medical Association who’re the villians of the piece, but just in case you’re still unsure as to where Coleman coming from, other than the road to Cranksville, there’s also this slide:

Treatment Efficacy Studies

There are excellent faith-based therapies for women seeking help after abortion; however, the lack of empirically validated treatment protocols in the mainstream indirectly affirms the position of the APA and other professional organizations suggesting no harm and leaves many women without hope for relief.

An essential future goal is therefore to develop treatment protocols, test them, and publish the results.

Yep, there’s nothing that can’t be fixed, in some people’s eyes, by a good old-fashioned dose of god and Coleman is just such a person.

This bring us t0 Coleman’s personal magnum opus, to date, the study published in the BJP only three months ago, which she touts, in the paper as:

an unbiased, quantitative analysis of the best available evidence addressing abortion as one risk factor among many others that may increase the likelihood of mental health problems.

And as:

the largest quantitative estimate of mental health risks associated with abortion available in the world literature.

I gave Coleman’s paper the once over when it was published in September and, amongst other things, came with this striking finding:

61% of the data used by Coleman to generate her claim that women who had undergone an abortion exhibited an 81% increase in their risk of developing a mental health problem and that close on 10% of the overall incidence of mental health problems is directly attributable to abortion was not found to be of sufficient quality or reliability to merit its inclusion in RCPsych’s own analysis.

Ben Goldacre and William Lee, on the other hand, sent his own assessment of the paper direct to the BJP:

Professor Coleman’s systematic review and meta-analysis of the literature on termination of pregnancy and mental health1 featured several significant omissions: an undislosed conflict of interest; no assessment of publication bias; and no assessment of the quality of studies included. The search strategy was also inadequately reported, and the meta-analytic technique was faulty…

…unusually for a systematic review and meta-analysis, there was no attempt to account for the role of publication bias in the findings. We have replicated the meta-analysis by importing Coleman’s data into Stata 11. After verifying that the summary odds ratios and confidence intervals produced were identical, we went on to create a funnel plot (Figure 1) using metafunnel. This found evidence strongly suggestive of publication bias in the literature presented. We further used Egger’s test using the metabias command in Stata 11, and again found very strong evidence suggesting publication bias (p<0.0001).

Publication bias, in this case, carries some rather interesting connations, which I noted in my own article but which were also picked up and highlighted by Professor James C Coyne of the University of Pennsylvania School of Medicine:

Many of the studies included in the Coleman meta-analysis, including most of the studies conducted by her group, are strongly criticized by other researchers and excluded from consideration in other systematic reviews, including a forthcoming report by the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists (RCPsych). One can only speculate on the timing of the BJP’s publishing of Coleman’s review relative to the impending release of the RCPsych report. Results of some of the original Coleman studies are not replicated in subsequent re-analyses of the same data sets by others. Coleman integrates results from studies without controlling for measures of mental health outcomes obtained prior to an abortion and in a number of instances, the mental health outcomes entered into her meta analysis were obtained before the abortion. In other instances, the effects reflect differences between women who obtained an abortion for an unwanted pregnancy versus women who delivered a wanted baby, a grossly inappropriate comparison if the intention is to obtain a valid estimate of the effects of abortion on mental health.

It is a matter of technical details, but important to evaluating Coleman’s meta analysis that she used the wrong formula to calculate population-attributable risk and violated basic assumptions for such a calculation.

Julie Littell, in conjunction with Professor Coyne, also notes that:

Coleman is the first author on 6 studies and coauthor on 5 additional studies in her review; thus, she authored or coauthored fully half of the 22 studies included. According to the Cochrane Handbook, this is another potential conflict of interest, since it may “unduly influence judgements made in a review (concerning, for example, the inclusion or exclusion of studies, assessments of the risk of bias in included studies or the interpretation of results)…. This should be disclosed in the review and, where possible, there should be an independent assessment of eligibility and risk of bias by a second author with no conflict of interest.” Coleman did not obtain an independent assessment of the studies she authored or co-authored, nor did she acknowledge these conflicts in the review.

To which Coleman’s own response is particularly illuminating:

“Using the criteria outlined above, a significant proportion of the included studies (11/22) were articles that I authored or co- authored. However, having published 33 peer-reviewed articles, I believe I am more widely published on this topic than any other researcher in the world. It makes sense, therefore, that I am a co-author on a significant proportion of the included studies. Moreover, no studies satisfying the inclusion criteria were left out of the analyses.”

Of course it makes sense – Coleman did, after all, design her own inclusion criteria and just prior to this statement she tries to explain away the criticism of her failure to adequately grade the studies she did include in the following manner:

I purposely avoided selecting from among the many more peripheral methodological criteria that could be argued as a necessary basis for including or excluding studies, when there is not universal agreement regarding strengths necessary to consider a study’s results sufficiently reliable and valid, nor is there consensus on the particular deficiencies necessary for the wholesale dismissal of a study.

The problem with this statement is that the ‘more peripheral’ criteria that Coleman refers to simply aren’t as peripheral as she would have people believe:

Thirdly, we are concerned to note that there was no attempt to account for quality of evidence, since a previous systematic review and meta-analysis found strong evidence for a relationship between methodological rigour and study results: “The highest quality studies had findings that were mostly neutral, suggesting few, if any, differences between women who had abortions and their respective comparison groups in terms of mental health sequelae. Conversely, studies with the most flawed methodology found negative mental health sequelae of abortion.” – Ben Goldacre & William Lee.

And there are other serious problems to take into account as noted by Gregory Kinney of the Colorado School of Publich Health:

Coleman however does not address a specific analytical observation made by authors that have commented (Coyne, Polis, Littel and Thygesen among others). Coleman included multiple analyses performed within multiple studies that represent the same study populations (Table 1, citation 10, 20, 21, 22, 24, 27, 29, 30, 32, 39 where each of these citations represents a study population being counted more than once in the meta-analysis). Doing so inappropriately increases the sample size and reduces the variance in the pooled measure. This causes the pooled estimate to be biased as the analytical technique was not applied in an appropriate manner and represents an inflated N.

Kinney believes that this, and other flaws in the paper, are sufficiently serious to warrant a withdrawal/retraction.

Finally, we’ll return to Professor James Coyne who, as ‘The Skeptical Sleuth’, published a series of three articles covering Coleman’s paper at Psychology Today and, more recently, some pretty strong criticism of the BJP’s decision to publish this paper, which includes this rather useful summary of its manifest flaws:

Coleman provided no public a priori design for her meta-analysis indicating how her meta analysis would be conducted. She gives no indication that she specified ahead of time which outcomes she would examine and from which studies.

She did not describe her search strategy in sufficient detail to allow someone else to replicate it. We certainly could not take her description of her strategy and redo the search ourselves.

A list of excluded studies was not provided. We do not know what studies she left out and why.

She did not provide sufficient descriptive information on the studies she selected, such as demographic characteristics of participants. We cannot tell if women of particular backgrounds were overrepresented or left out.

The scientific quality of studies that were included was not documented. We are not given ratings or told anything about limitations or sources of bias in the studies that Coleman retrieved.

The quality of included studies was not considered in formulating conclusions. Her conclusions is simply stated, without any indication of whether they depend on strong or weak studies.

Appropriate methods were not used in combining the findings of studies, with clear violation of basic standards. This is admittedly a technical issue, but obvious to someone familiar with meta-analysis. As an example, she combined multiple mental health outcomes from the same study over and over again, which violates assumptions that the effect sizes will be independent.

The likelihood of publication bias was not assessed. Coleman does not tell us if the distribution of study findings have some gaps that would indicate studies are missing due to publication bias.

Conflicts of interest and sources of support were not acknowledged. The serious conflict of interest is that Coleman and one of her co-authors have gone on record strongly opposing women’s right to choose to have an abortion and to try to instill fear in women by raising concerns about mental health effects. Readers should have been made aware of these statements.

On the last point, Coyne provides what is perhaps the most illuminating exposition of Coleman’s real agenda in his e-letter to the BJP in the form of a direct quotation from a 2002 ‘ethics paper’ by Coleman’s sometime co-author, David C Reardon:

“For the purpose of passing restrictive laws to protect women from unwanted and/or dangerous abortions, it does not matter if people have a pro-life view…In some cases, it is not even necessary to convince people of abortion’s dangers. It is sufficient to simply raise enough doubts about abortion that they will refuse to actively oppose the proposed anti- abortion initiative. In other words, if we can convince many of those who do not see abortion to be a “serious moral evil” that they should support anti-abortion policies that protect women and reduce abortion rates, that is a sufficiently good end to justify NRS efforts. Converting these people to a pro-life view, where they respect life rather than simply fear abortion, is a second step. The latter is another good goal, but it is not necessary to the accomplishment of other good goals, such as the passage of laws that protect women from dangerous abortions and thereby dramatically reduce abortion rates.”

Although, as I’ve noted on a previous occasion. Reardon also does a nice line in spectacularly offensive Nazi analogies as well:

The similarity between Nazi manipulations of the Jews and the abortionists’ manipulation of women faced with crisis pregnancies is striking. Just as the victim-Jews were forced to choose between losing everything, or just a little, so abortion counselors encourage the victim-woman to view “this pregnancy” as a threat to everything she has, her relationships, her family, her career, her entire future. She is assured that by sacrificing this one thing (a tiny unborn child), she can save the rest. During this process, the victim-woman is urged to view the abortion decision not as a moral choice, but as a rational choice of “saving what you can.”

Step away from the copy of ‘Sophie’s Choice’ David, you’ll only make it obvious that you’re a frothing loon.

Context matters and in this case the relevant context is that of a group of ideologically driven and biased researchers trying, and failing, to generate credible evidence of a direct causal link between abortion and mental health problems, and I say failing because the NCCMH review, one of the most comprehensive and systematic reviews to date by the CMF’s own admission, fails to provide any support for the claims of Coleman et al despite the inclusion of the ‘best’ of their evidence in the review.

So, if you’re an anti-abortion organisation that’s desperate to put a positive spin on what, from your perspective, are some rather embarrassing findings in an authoritative and comprehensive evidence review, what do you do?

Easy – you start quote-mining the report and cherry-picking scraps of evidence from individual papers included in the review which you can present out of context in an effort to manufacture doubt and undermine the review’s overall findings…

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.

So let’s look at what three of these four studies actually found:

Steinberg (2011) Study 2 – rated ‘Good’

Multiple abortions were only significantly associated with increased rates of anxiety disorders and not mood disorders or Substance-use disorders when no risk factors were controlled for (mood disorders OR = 1.4; 95% CI, 0.5-3.9, p >0.05; anxiety disorders OR = 2.1; 95% CI,1.2 to 3.6, p <0.05 and Substance-use disorders OR = 2.5; 95% CI, 1.0- 6.26, p <0.1).

When prior risk factors such as previous mental health and violence were accounted for, the difference in anxiety disorders was no longer significant, although there was now a significant difference in Substance-use disorders (mood disorders OR = 0.9; 95% CI, 0.3 to 2.7, p >0.05; anxiety disorders OR = 1.4; 95% CI, 0.7 to 2.7, p >0.05 and Substance-use disorders OR = 2.8; 95% CI, 1.0 to 7.8, p <0.05).

When all risk factors were taken into account, none of the differences in mental health rates in women who had one abortion or multiple abortions remained significant (mood disorders OR = 0.8; 95% CI, 0.3 to 2.7, p >0.05; anxiety disorders OR = 1.5; 95% CI, 0.8 to 2.9, p >0.05 and Substance-use disorders OR = 3.0; 95% CI, 0.9 to 9.7, p >0.05).

Fergusson (2008) – rated ‘Very Good’

Depression: there was not a statistically significant difference in rate of depression between women who had an abortion and those whodelivered an unwanted pregnancy (OR = 0.70; 95% CI, 0.32 to 1.96, p >0.05).

Anxiety: women who had an abortion were not statistically significantly more likely to experience anxiety disorders than those who delivered a pregnancy (OR = 1.82; 95% CI, 0.67 to 4.94, p >0.05).

Alcohol and illicit drug dependence: there was insufficient evidence to suggest that having an abortion was statistically significantly associated with an increased risk when compared with delivering an unwanted pregnancy due to the large confidence intervals (alcohol dependence: OR = 7.1; 95% CI, 0.51 to 97.94, p >0.05; illicit drug dependence: OR = 13.20; 95% CI, 0.82 to 212.14, p >0.05).

Mental health problem: women who had an abortion were no more likely to experience mental health problems compared with those who delivered either an unwanted pregnancy (OR = 1.12; 95% CI, 0.9 to 1.4, p >0.05) or an unplanned pregnancy (OR = 1.10; 95% CI, 0.95 to 1.27, p >0.05).

NB. Fergusson’s original 2008 paper did report statistically higher rates of mental health problems in women following an abortion but did not control for whether pregancies were wanted or unwanted, despite Fergusson having access to this data. The result given here are from NCCMH’s own reassessment of Fergusson’s original findings, taking into account ‘wantedness’ based on data obtained from Fergusson.

Cougle (2005) – rated ‘Fair’

Comparison results  – OR 1.34 (1.05 to1.70) p <0.018. (a slight, statistically significant, increase in prevalance)

However, the factor results for this paper state:

Age: Women who had an abortion under the age of 20 years had slightly higher rates of anxiety symptoms (14.1%) than women over the age of 20 (12.8%). Converting this raw data into odds ratios indicated that there was no significant difference between age groups (OR = 1.15; 95% CI, 0.79 to 1.65, p >0.05).

Ethnicity: Fewer black women developed post-pregnancy anxiety (6.0%) compared with white women (16.3%), Hispanic women (14.9%) and women of other ethnic backgrounds (24.2%). When converting the raw percentages into odds ratios, black women had significantly lower rates of anxiety when compared with white women (OR = 0.33; 95% CI, 0.19 to 0.57, p <0.001) and all other ethnic groups (OR = 0.31; 95% CI, 0.16 to 0.61, p <0.001).

Marital status: No association between marital status at time of first pregnancy and post-abortion anxiety, with 17.2% of married women and 13.5% of unmarried women meeting criteria (OR = 1.33; 95% CI, 0.66 to 2.69, p >0.05).

This brings us to Gilchrist (1995) and a perfect illustration of the CMF’s use of cherry-picking.

Gilchrist did indeed find statistically significant evidence of a higher rated of self-harm for women who had an abortion following an unplanned preganancy – OR* = 1.7 (1.1 to 2.6) p <0.05.

However, Gilchrist’s finds for women who had an abortion following an unwanted pregnancy were not statistically significant – OR* 0.59 (0.17 to 2.08) p >0.05.

What we again have is evidence that choice is a central issue here and that an elevated risk of mental problems is associated with either feeling that one has made the wrong choice or a denial of choice – and again, this is the one key point that the CMF studiously ignore throughout.

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.’

What the CMF are quote-mining here is actually an e-letter by Fergusson which relates to the Coleman paper which recently appeared in the BJP and what Fergusson takes issue with is the assertion that there is currently no evidence of adverse mental health effects linked to abortion:

The letter by Louise Howard and colleagues (above) follows 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. In this strategy:

a) Methodological criteria are constructed to classify studies

b) No numerical analysis combining study findings is provided

c) Strong conclusions are drawn on the basis of a small number of “high quality” studies.

The use of this strategy led the APA review to claim that there was no evidence of adverse effects of single first trimester abortion on the basis of a single study, the conclusions drawn by Charles et al  were based on four studies. Howard et al use a similar strategy in which they question the methodological quality of studies reviewed in the Coleman analysis and draw conclusions about the absence of association between abortion and mental health on the basis of a small number of studies. If the evidence is indeed as weak and as limited as these reviewers have claimed the appropriate conclusion to be drawn is that no firm conclusions can be made about the mental health consequences of abortion until further and better research is completed.

Although the draft version of this review did suggest that there was ‘no evidence’ this assertion is not part of the final review which, after public consulation and peer review, concludes that:

Evidence from the narrative review and meta-analysis indicated that for the majority of mental health outcomes, there was no statistically significant association between pregnancy resolution and mental health problems. Where we found a statistically
significant association between abortion and a mental health outcome, for example increased rates of self-harm and lower rates of psychosis, the effects were small (psychosis) and prone to bias (for instance, there were common factors underlying
seeking an abortion and later self-harm). In this review, we have surmised that the association between abortion and mental health outcomes are unlikely to be meaningful. Overall, we have therefore largely confirmed the findings of the APA and Charles reviews, both through our narrative review and meta-analysis. When a woman has an unwanted pregnancy, rates of mental health problems will be largely unaffected whether she has an abortion or goes on to give birth.

Further interpretation of the relationship between abortion and mental health outcomes has been made possible through the finding that unwanted pregnancies are associated with higher rates of mental health problems before an abortion, compared with women who give birth. That is, women who have an abortion, presumably for an unwanted pregnancy in the majority of cases, are more likely to experience a mental health problem in the 9 months before the abortion, compared with women who give birth, even when previous mental health problems before this 9-month period are controlled for. Furthermore, the rate of mental health problems did not increase following the abortion. However, we cannot be sure whether the unwanted pregnancy is the result of mental health problems; or that an unwanted pregnancy leads to mental health problems;
or, indeed, that some other factors, such as intimate partner violence, may lead to both mental health problems and an unwanted pregnancy. What does seem to be more certain is that for women with an unwanted pregnancy, abortion does not appear to harm their mental health.

The review then adds the following recommendations:

 – 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.

This, rather more cautious view of current evidence is entirely consistent with the views expressed by Fergusson, particularly in his 2009 follow-up study in which he reanalysed the results of his 2008 paper in light of academic criticism of the lack of controls for wantedness in that first paper, in which Fergusson concluded:

The finding that the extent of distress associated with abortion modifies the risks of subsequent mental health problems is consistent with the view that it is the woman’s reaction to abortion that increases risks of mental health rather than the experience of unwanted pregnancy. Our results suggest that women who have unwanted pregnancy terminated by abortion who do not experience distress do not show increased risks of mental health problems. This finding is consistent with the results of our previous study that showed that unwanted pregnancies that came to term were not associated with a detectable increase in risks of mental health problems.

Before adding the following observations from his own research:

Combining the findings of our two studies leads to the following generalisations about the links between unwanted pregnancy, abortion and mental health in this birth cohort.

a. First, unwanted pregnancy terminated by abortion was associated with modestly increased risks of common mental health problems for women who reported significant distress about the abortion (RR = 1.4–1.8).

b. Second, unwanted pregnancy terminated by abortion was not associated with significantly increased risks of mental health problems for women who did not report significant distress about the abortion (RR = 1.14–1.24).

c. Third, unwanted pregnancy that came to term was not associated with significant increases in mental health problems (RR = 1.05–1.11).

d. Finally, any associations between unwanted pregnancy, abortion and mental health problems were small to moderate, with adjusted relative risks in the region of 1.1–1.8. Estimates of the population attributable risk suggested that exposure to unwanted pregnancy terminated by abortion accounted for fewer than 5% of the mental health problems experienced by women in this cohort.

Needless to say, when citing Fergusson’s research, anti-abortion groups tend to studiously avoid referencing hsi 2009 paper and focus instead on pimping his 2008 study which appeared to produce results more suited to their own agenda, as here:

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.).

The reason that Fergusson’s 2008 results were re-analysed by NCCMH, with what appears to have been Fergusson’s own full cooperation, was fully explained in the draft review paper and, equally, in the final review paper, and its also an issue that I picked up on and explained back in July, when I fisked the CMF’s own submission to the review consultation and found it to be a pile of crap. That the organisation is still banging on about the same thing, six months later and after its been fully explained and accounted for on several occasions only serves as further confirmation of the organisation’s inability to look beyond its own prejudices and biases and evaluate evidence in this field in an objective manner.

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.

It’s not entirely clear that anyone has ever made the latter claim but, in any case, the CMF’s take on this complete disregards the fact that he evidence does suggest that choice is a pivotal consideration here to the extent that women who are denied a free choice in relation to the outcome of an unwanted pregnancy are more likely to experience an adverse psychiatric reaction to the pregnancy.

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.

And women should also be clearly informed that the decision as to whether to have an abortion or not is their choice and that any attempt to restrict that choice or pressure/influence them towards making a particular choice, against their wishes, is likely to place them at a higher risk of subsequent mental health problems.

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).

The first response to an unplanned pregnancy is already a pre-abortion counselling and assessment session at which a woman’s support needs are assessed and at which additional support can be offered if this is what the woman wants. However, as Fergusson notes in his 2009 paper:

…unwanted pregnancy terminated by abortion was not associated with significantly increased risks of mental health problems for women who did not report significant distress about the abortion.

Women who are clear in their own mind that an abortion is the right choice for them do not face an elevated risk of subsequent mental health problems, unless they already have a prior history of such problems.

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.

This idea of ‘independent counselling’ cuts both ways here. At the present time, the main alternative to a referral to BPAS or Marie Stopes International, is a referral into a chain of so-called ‘crisis pregnancy centres’ operated by anti-abortion groups and while there is no independent evidence of either BPAS or MSI operating under an unethical conflict of interest there is clear evidence that some of these CPC’s have been operating unethically by feeding false information to clients and actively seeking to influence their decision against choosing to have an abortion.

When it comes to the provision of pre-abortion counselling, independence is secondary consideration and a distraction from the most important issues, which are whether or not women are offered a free choice of whether or not take up an offer of counselling and whether the counselling that is offer conforms to the highest possible ethical standards, and on both counts the anti-abortion lobby has consistently been found to be seriously wanted.

To conclude, I fully welcome the NCCMH’s recommendation that there is a clear need for good quality prospective longitudinal research is this area but would add that, if and when such research is undertaken, study designs must take into account the evidence which already suggests that the freedom to make their own informed choice as to the otucome of an unplanned pregnancy is likely to exert an significant influence over the mental health outcomes of women who do unexpectedly fall pregnant, particularly where that pregnancy is unwanted.