NCCMH Review - Revision history

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History of NCCMH Review

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	*(p43-44)		*(p43-44)

	The Rawlinson Report and the RCOP response		The [https://abortionrisks.org/docs/Rawlinson(1994)Abortionreport.pdf Rawlinson Report]<ref>House of Lords Commission of Inquiry. [https://abortionrisks.org/docs/Rawlinson(1994)Abortionreport.pdf The physical and psycho-social effects of abortion on women: a report by the Commission of Inquiry into the Operation and Consequences of the Abortion Act] (1994).</ref> and the RCOP response
	(http://extras.timesonline.co.uk/rowlinsonreport.pdf) highlights		(http://extras.timesonline.co.uk/rowlinsonreport.pdf) highlights
	important issues that should be much more carefully addressed		important issues that should be much more carefully addressed

Barb: /* History of NCCMH Review */

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History of NCCMH Review

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	===History of NCCMH Review===		===History of NCCMH Review===

	In 2006, the U.K.'s House of Commons Science and Technology Committee undertook an inquiry into the health effects of abortion on women which included a request (paragraph 139) for the RCP to update their 1994 statement on abortion in light of more recent studies.<ref>House of Commons Science and Technology Committee (2006). ''[https://publications.parliament.uk/pa/cm200607/cmselect/cmsctech/1045/1045i.pdf Scientific Developments Relating to the Abortion Act 1967. Volume 1]''</ref> In 2008, the RCP did update their position statement to recommend that women should be screened for risk factors that may be associated with subsequent development of mental health problems and should be counselled about the possible mental health risks of abortion.<ref>Templeton, Sarah-Kate (2008-03-16). "[https://www.thetimes.com/uk/healthcare/article/royal-college-warns-abortions-can-lead-to-mental-illness-p8glm5s5k8h Royal college warns abortions can lead to mental illness]". ''The Sunday Times''. ISSN 0956-1382.</ref> <ref>Fergusson, David M. (September 2008). "[https://www.~~thetimes~~.~~com~~/uk/~~healthcare/article/royal-college-warns-abortions-can-lead-to-mental-illness-p8glm5s5k8h~~ Abortion and mental health]". ''Psychiatric Bulletin''. '''32''' (9): 321–324. doi:10.1192/pb.bp.108.021022</ref> The revised RCP position statement included a recommendation for a systematic review of abortion and mental health with special consideration of "whether there is evidence for psychiatric indications for abortion." Following the publication of a number of studies between 2002 and 2008 revealing that women who have abortions experience common disorders such as anxiety or depression at a rate about three times higher than other women, Royal College of Psychiatrists issued a [http://www.thesundaytimes.co.uk/sto/style/living/Health/article82769.ece position paper on abortion] ((Royal College of Psychiatrists. Position statement on women’s mental health in relation to induced abortion. 14 March 2008. Royal College of Psychiatrists, 2008) acknowledging that some women may have adverse reactions to abortion and further recommended:		In 2006, the U.K.'s House of Commons Science and Technology Committee undertook an inquiry into the health effects of abortion on women which included a request (paragraph 139) for the RCP to update their 1994 statement on abortion in light of more recent studies.<ref>House of Commons Science and Technology Committee (2006). ''[https://publications.parliament.uk/pa/cm200607/cmselect/cmsctech/1045/1045i.pdf Scientific Developments Relating to the Abortion Act 1967. Volume 1]''</ref> In 2008, the RCP did update their position statement to recommend that women should be screened for risk factors that may be associated with subsequent development of mental health problems and should be counselled about the possible mental health risks of abortion.<ref>Templeton, Sarah-Kate (2008-03-16). "[https://www.thetimes.com/uk/healthcare/article/royal-college-warns-abortions-can-lead-to-mental-illness-p8glm5s5k8h Royal college warns abortions can lead to mental illness]". ''The Sunday Times''. ISSN 0956-1382.</ref> <ref name=":0">Fergusson, David M. (September 2008). "[https://www.researchgate.net/publication/274356401_Abortion_and_mental_health Abortion and mental health". ''Psychiatric Bulletin''.] '''32''' (9): 321–324. doi:10.1192/pb.bp.108.021022. This Appendix to this paper includes the complete 14th March, 2008 RCP revised Position Statement on Women's Mental Health in Relation to Induced Abortion.</ref> The revised RCP position statement included a recommendation for a systematic review of abortion and mental health with special consideration of "whether there is evidence for psychiatric indications for abortion."<ref name=":0" /> Following the publication of a number of studies between 2002 and 2008 revealing that women who have abortions experience common disorders such as anxiety or depression at a rate about three times higher than other women, Royal College of Psychiatrists issued a [http://www.thesundaytimes.co.uk/sto/style/living/Health/article82769.ece position paper on abortion] ((Royal College of Psychiatrists. Position statement on women’s mental health in relation to induced abortion. 14 March 2008. Royal College of Psychiatrists, 2008) acknowledging that some women may have adverse reactions to abortion and further recommended:
	:Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.		:Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.

Barb: /* History of NCCMH Review */

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History of NCCMH Review

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	===History of NCCMH Review===		===History of NCCMH Review===

	Following the publication of a number of studies between 2002 and 2008 revealing that women who have abortions experience common disorders such as anxiety or depression at a rate about three times higher than other women, Royal College of Psychiatrists issued a [http://www.thesundaytimes.co.uk/sto/style/living/Health/article82769.ece position paper on abortion] ((Royal College of Psychiatrists. Position statement on women’s mental health in relation to induced abortion. 14 March 2008. Royal College of Psychiatrists, 2008) acknowledging that some women may have adverse reactions to abortion and further recommended:		In 2006, the U.K.'s House of Commons Science and Technology Committee undertook an inquiry into the health effects of abortion on women which included a request (paragraph 139) for the RCP to update their 1994 statement on abortion in light of more recent studies.<ref>House of Commons Science and Technology Committee (2006). ''[https://publications.parliament.uk/pa/cm200607/cmselect/cmsctech/1045/1045i.pdf Scientific Developments Relating to the Abortion Act 1967. Volume 1]''</ref> In 2008, the RCP did update their position statement to recommend that women should be screened for risk factors that may be associated with subsequent development of mental health problems and should be counselled about the possible mental health risks of abortion.<ref>Templeton, Sarah-Kate (2008-03-16). "[https://www.thetimes.com/uk/healthcare/article/royal-college-warns-abortions-can-lead-to-mental-illness-p8glm5s5k8h Royal college warns abortions can lead to mental illness]". ''The Sunday Times''. ISSN 0956-1382.</ref> <ref>Fergusson, David M. (September 2008). "[https://www.thetimes.com/uk/healthcare/article/royal-college-warns-abortions-can-lead-to-mental-illness-p8glm5s5k8h Abortion and mental health]". ''Psychiatric Bulletin''. '''32''' (9): 321–324. doi:10.1192/pb.bp.108.021022</ref> The revised RCP position statement included a recommendation for a systematic review of abortion and mental health with special consideration of "whether there is evidence for psychiatric indications for abortion." Following the publication of a number of studies between 2002 and 2008 revealing that women who have abortions experience common disorders such as anxiety or depression at a rate about three times higher than other women, Royal College of Psychiatrists issued a [http://www.thesundaytimes.co.uk/sto/style/living/Health/article82769.ece position paper on abortion] ((Royal College of Psychiatrists. Position statement on women’s mental health in relation to induced abortion. 14 March 2008. Royal College of Psychiatrists, 2008) acknowledging that some women may have adverse reactions to abortion and further recommended:
	:Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.		:Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.

Barb: /* Studies and Data Excluded in Investigating those Questionsn */

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Studies and Data Excluded in Investigating those Questionsn

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	=====Studies and Data Excluded in Investigating ~~those Questionsn~~=====		=====Studies and Data Excluded in Investigating these Three Questions=====

	The reviewers chose to exclude:		The reviewers chose to exclude:

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History of NCCMH Review

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	The reviewers chose to limit their report to three questions: (1) How prevalent are mental health problems in women who have an induced abortion? 2. What factors are associated with poor mental health outcomes following an induced abortion? 3. Are mental health problems more common in women who have an induced abortion when compared with women who deliver an unwanted pregnancy?		The reviewers chose to limit their report to three questions: (1) How prevalent are mental health problems in women who have an induced abortion? 2. What factors are associated with poor mental health outcomes following an induced abortion? 3. Are mental health problems more common in women who have an induced abortion when compared with women who deliver an unwanted pregnancy?

	Note, the first question dealing with prevalence is easily answered by record linkage studies from which the mental health treatment rates of women having abortions can be tabulated. The question does not ask how much of the observed mental health problems are attributable to abortion, but rather how common are mental health problems among women with a history of abortion.		Note, the first question, dealing with prevalence, is easily answered by record linkage studies from which the mental health treatment rates of women having abortions can be tabulated. The question does not ask how much of the observed mental health problems are attributable to abortion, but rather how common are mental health problems among women with a history of abortion. The results unequivocally show that rates of mental health problems among women with a history of abortion are higher than rates for other groups of women, including the general population of women and women giving birth who do not have a history of abortion. Yet this is not fully discussed in the conclusions, which instead shift the discussion to evidence that women who have mental health problems after an abortion may also have higher rates of mental health problems before having abortions. Which actually raises a new issue which the reviewers refused to address, namely, is there evidence that women with pre-existing mental health problems get better or worse following an abortion.

			Regarding the second question, the reviewers actually failed to systematically investigate all risk factors that predict poor mental health outcomes.

	====Studies and Data Excluded ~~from Investigation~~====		Regarding the third question, the reviewers acknowledged that the definition of what constitutes "an unwanted pregnancy" is imprecise and also that they were declining to investigate the alternative of whether there are any mental health benefits of abortion, which is actually the pertinent issue under UK law. (see [http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf pages 39, 43, 91 ]




			=====Studies and Data Excluded in Investigating those Questionsn=====

	The reviewers chose to exclude:		The reviewers chose to exclude:

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Studies and Data Excluded from Investigation

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	The reviewers chose to exclude:		The reviewers chose to exclude:
	# Any studies related to mood disorders, including reactions such as guilt, shame and regret. Although the - although these were considered important - and also assessments of mental state within 90 days of an abortion. This was because the research was not about “transient reactions to a stressful event”.occurring within the first 90 days of an abortion		# Any studies related to mood disorders, including reactions such as guilt, shame and regret. Although the - although these were considered important - and also assessments of mental state within 90 days of an abortion. This was because the research was not about “transient reactions to a stressful event”.occurring within the first 90 days of an abortion
	# Any studies of qualitative data (qualitative interviews, case studies, self-reports etc) (p135		# Any studies of qualitative data (qualitative interviews, case studies, self-reports etc) (p135 We agree that qualitative evidence is important in this area.Unfortunately it was beyond the scope and resources of the review to consider qualitative evidence")
	We agree that qualitative evidence is important in this area.Unfortunately it was beyond the scope and resources of the review to consider qualitative evidence")		# Any data relative to negative effects associated with aborting a wanted pregnancy for "therapeutic" reasons.
	# Any data relative to negative effects associated with aborting a wanted pregnancy for "therapeutic" reasons.


	====Questions Excluded from Investigation====		====Questions Excluded from Investigation====

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Questions Excluded from Investigation

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	Note, the first question dealing with prevalence is easily answered by record linkage studies from which the mental health treatment rates of women having abortions can be tabulated. The question does not ask how much of the observed mental health problems are attributable to abortion, but rather how common are mental health problems among women with a history of abortion.		Note, the first question dealing with prevalence is easily answered by record linkage studies from which the mental health treatment rates of women having abortions can be tabulated. The question does not ask how much of the observed mental health problems are attributable to abortion, but rather how common are mental health problems among women with a history of abortion.


			====Studies and Data Excluded from Investigation====

			The reviewers chose to exclude:
			# Any studies related to mood disorders, including reactions such as guilt, shame and regret. Although the - although these were considered important - and also assessments of mental state within 90 days of an abortion. This was because the research was not about “transient reactions to a stressful event”.occurring within the first 90 days of an abortion
			# Any studies of qualitative data (qualitative interviews, case studies, self-reports etc) (p135
			We agree that qualitative evidence is important in this area.Unfortunately it was beyond the scope and resources of the review to consider qualitative evidence")
			# Any data relative to negative effects associated with aborting a wanted pregnancy for "therapeutic" reasons.


	====Questions Excluded from Investigation====		====Questions Excluded from Investigation====

	The report deliberately excluded any investigation of key questions~~, including (1) when, if ever,~~ abortion ~~contributes~~ to mental health of women~~, or (2) whether~~ abortion makes pre-existing mental health problems more severe or difficult to treat~~, (3) negative effects within the first 90 days after an abortion, (4) negative effects associated with aborting a wanted pregnancy for "therapeutic" reasons.~~		The report deliberately excluded any investigation of key questions
			# In what cases may abortion contribute to the mental health of women
			# Whether abortion makes pre-existing mental health problems more severe or difficult to treat

	The scope of the review excluded reactions such as guilt, shame and regret - although these were considered important - and also assessments of mental state within 90 days of an abortion. This was because the research was not about “transient reactions to a stressful event”.

	Research questions excluded from the review, and the reason for excluding them, are described in the companion document "[http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf Comments and Responses], see especially pages 95-103.]"		Research questions excluded from the review, and the reason for excluding them, are described in the companion document "[http://afterabortion.org/pdf/AbortionReviewConsultationTable1.pdf Comments and Responses], see especially pages 95-103.]"

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Questions Excluded from Investigation

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 more abortions? These risk factors are the medical
 contraindications for induced abortion.
 ----

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Incorrectly classified studies

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	*Three prospective cohort studies using record linkage (Coleman2003A, Reardon2002A, Reardon2003A) were improperly listed as "retrospective." Oddly, Munk-Olsen2011 which used the same methodology was correctly listed. In the discussion section (p59) the authors also wrongly describe these three studies as based on a sample of women whose first pregnancies ended in abortion. In fact, the sample included all women who had any pregnancy outcome within a specific period, and as a cross sectional snapshot, it did not have information on whether these were first, second, third or higher order pregnancies.		*Three prospective cohort studies using record linkage (Coleman2003A, Reardon2002A, Reardon2003A) were improperly listed as "retrospective." Oddly, Munk-Olsen2011 which used the same methodology was correctly listed. In the discussion section (p59) the authors also wrongly describe these three studies as based on a sample of women whose first pregnancies ended in abortion. In fact, the sample included all women who had any pregnancy outcome within a specific period, and as a cross sectional snapshot, it did not have information on whether these were first, second, third or higher order pregnancies.

	*Findings from the above studies were not completely reported in Table 9, including for example, the rates reported for bipolar disorder in Reardon2002A (OR 3.0, 95% CI 1.5-6.0). They were also rated as "poor" while Munk-Olsen2011 was rated good, even though there was no significant difference in study design. Indeed, Munk-Olsen2011 is arguably much poorer given mixing of women into both groups and other ~~problems~~.		*Findings from the above studies were not completely reported in Table 9, including for example, the rates reported for bipolar disorder in Reardon2002A (OR 3.0, 95% CI 1.5-6.0). They were also rated as "poor" while Munk-Olsen2011 was rated good, even though there was no significant difference in study design. Indeed, Munk-Olsen2011 is arguably much poorer given mixing of women into both groups, shorter followup (only one year rather than four years), the failure to control for mental health treatment rates prior to pregnancy for delivering women, and other roblems.

	*A number of studies are described as prospective (the Broen, Major, Rizzardo and Suliman) when they would be better described as case series studies, since they have no data prior to the abortion and simply follow the cases for a period of time.		*A number of studies are described as prospective (the Broen, Major, Rizzardo and Suliman) when they would be better described as case series studies, since they have no data prior to the abortion and simply follow the cases for a period of time.

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History of NCCMH Review

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	This statement also called for a systematic review of the evidence, which led to the commissioning of Britain's National Collaborating Centre for Mental Health (NCCMH)to undertake such a review. The NCCMH subsequently undertook a review which was limited to addressing just three questions related to abortion and mental health.		This statement also called for a systematic review of the evidence, which led to the commissioning of Britain's National Collaborating Centre for Mental Health (NCCMH)to undertake such a review. The NCCMH subsequently undertook a review which was limited to addressing just three questions related to abortion and mental health.

			====Questions Addressed in the Review====
			The reviewers chose to limit their report to three questions: (1) How prevalent are mental health problems in women who have an induced abortion? 2. What factors are associated with poor mental health outcomes following an induced abortion? 3. Are mental health problems more common in women who have an induced abortion when compared with women who deliver an unwanted pregnancy?

			Note, the first question dealing with prevalence is easily answered by record linkage studies from which the mental health treatment rates of women having abortions can be tabulated. The question does not ask how much of the observed mental health problems are attributable to abortion, but rather how common are mental health problems among women with a history of abortion.


	====Questions Excluded from Investigation====		====Questions Excluded from Investigation====