Charles et al

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Abortion and long-term mental health outcomes: a systematic review of the evidence.

Authors: Vignetta E. Charles, Chelsea B. Polis, Srinivas K. Sridhara, Robert W. Blum

Journal: Contraception 78(2008) 436-450

Author's Conclusions

"A clear trend emerges from this systematic review: 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." 

"Lingering post-abortion feelings of sadness, guilt, regret, and depression appear to occur in only a minority of women."

"For example, health professionals involved in pre- and postabortion counseling and treatment may find value in identifying the risk factors to having adverse mental health outcomes after an abortion; including preexisting mental health conditions."

Graded as a Weak and Unreliable Review

An independent research group, the Database for Abstracts of Reviews of Effects, which evaluates systematic reviews concluded that the [ https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0026954/ "reliability of the authors' conclusions is unclear"] due to numerous weaknesses in the authors' methodology.

Presumption -- Neutral is good enough

An underlying presumption of the authors is that abortion is good medical practice as long as it cannot be proven that it causes widespread harm. Therefore, the thrust of their argument is that the "best studies" indicate that there is no effect on mental health . . . or abortion has a "neutral" effect.

In fact, however, it is the obligation of doctors performing abortions, particularly in the UK and many Commonwealth countries, to only perform abortions when the risks associated with abortion are LESS THAN the risks associated with childbirth. Not the SAME AS the risks associated with childbirth, but LESS THAN. In other words, there must be some medical benefit to abortion as opposed to simply letting the pregnancy continue its natural course.

Even with it's selective reporting, obsufication, concealment and stretching of facts and logic, the Contraception review does not even attempt to document any benefit from abortion, because there is no evidence for that position. At best, it seeks to claim that the effects of abortion are likely neutral and that reports of negative reactions are exaggerated.

In the most recent study, now THE best study, which was not reviewed in the Contraception review, Fergusson states in his conclusions:

In general, there is no evidence in the literature on abortion and mental health that suggests that abortion reduces the mental health risks of unwanted or mistimed pregnancy. Although some studies have concluded that abortion has neutral effects on mental health, no study has reported that exposure to abortion reduces mental health risks.

This echoes the a point well articulated by Dr. Philip Ney:

We should remember that in the science of medicine, the onus of proof lies with those who perform or support any medical or surgical procedure to show beyond reasonable doubt that the procedure is both safe and therapeutic. There are no proven psychiatric indications for abortion. The best evidence shows abortion is contraindicated in major psychiatric illness. There is no good evidence that abortion is therapeutic for any medical conditions with possible rare exceptions. In fact, there are no proven medical, psychological, or social benefits. . . . If abortion was a drug or any other surgical procedure about which so many doubts have been raised regarding its safety and therapeutic effectiveness, it would have been taken off the market long ago.

In analzying all of the literature on abortion, these three distinct points should always be kept in mind

1. There are no statistically validated mental health benefits from abortion for women in general nor for any identified group of women, including rape and incest victims)

2. Abortion involves inherent mental health risks, at least for a minority of women, and

3. There are well established, indisputable risk factors that identify which women are at greatest risk of negative psychological reactions and doctors should screen for these.

Some Preliminary Criticisms

At first glance the findings of the recently published “systematic” review by Charles et al. published in Contraception represents a more sophisticated attempt to evaluate the literature than that of the APA’s Task Force on Abortion and Mental Health. However, a careful reading indicates that these Johns Hopkins researchers are guilty of only slightly more crafty deception. Although there are numerous shortcomings of this review including avoidance of quantification of effects, the findings lack credibility entirely for the four key reasons detailed below.

1) The review neglects to cover numerous studies that have linked abortion to substance abuse problems, one of the major mental health concerns of women who have aborted and for women in general. No explanation is provided for this blatant omission.

2) The ranking system employed ignores two of the most central methodological considerations when conducting reviews of prospective research designs: 1) the percent consenting to participate at baseline (information was not even provided by the authors of one study, Gilchrist et al., that this team ranked as “Very Good”); and 2) retention of subjects over time. Obviously when women are more harmed by an abortion they are less inclined to want to continue to participate. Further, women who are suffering from an abortion are likely to have less stable lives and are therefore more likely to be unavailable to be assessed. If the sample suffers from high attrition rates (in excess of 20-30%), then the results can not be applied to the general population.

3) Five quality indicators were employed to derive the ratings of each study from “Excellent” to “Very Poor”. These indicators were each deemed met or not met by the raters of the studies. However, no explanation is given for the extent to which evidence of the indicator had to be present in order to be marked as “met”. This leaves the evaluation method open to considerable bias. There is no way that several of the studies listed as “Very Good” would have met 4 out of 5 of the quality indicators necessary for the rating if rated by an objective evaluator who was not invested in deriving a conclusion that is consonant with pro-choice ideology. Similarly, studies rated as “Fair” such as the one by Fergusson and colleagues published in 2006 would have been rated higher by an objective evaluator.

4) The review “missed” numerous high quality studies that meet their inclusion criteria. The result is an extremely biased selection. A sampling of the ignored studies is provided below.

  • Coleman, P. K. (2006). Resolution of Unwanted Pregnancy During Adolescence Through Abortion versus Childbirth: Individual and Family Predictors and Consequences. Journal of Youth and Adolescence, 35, 903-911.
  • Henshaw, R., Naji, S., Russell, I., & Templeton, A. (1994). Psychological responses following medical abortion (using mifepristone and gemeprost) and surgical vacuum aspiration: A patient-centered, partially randomized prospective study. Acta Obstetrica et Gynecologica Scandinavica, 73, 812-818.
  • Lauzon, P., Roger-Achim, D., Achim, A., & Boyer, R. (2000). Emotional distress among couples. involved in first trimester abortions. Canadian Family Physician, 46, 2033-2040.
  • Lyndon, J., Dunkel-Schetter, C., Cohan, C. L., & Pierce, T. (1996). Pregnancy decision making as a significant life event: A commitment approach. Journal of Personality and Social Psychology, 71, 141-151.
  • Major, B., Cozzarelli, C., Cooper, M.L., Zubek, J., Richards C., Wilhite, M., & Gramzow, R.H. (2000). Psychological responses of women after first trimester abortion. Archives of General Psychiatry, 57, 777-84.
  • Major, B. Cozzarelli, C., Sciacchitano, A. M., Cooper, M. L., Testa, M., & Mueller, P. M. (1990). Perceived social support, self-efficacy, and adjustment to abortion. Journal of Personality and Social Psychology, 59, 186-197.
  • Miller, W. B. (1992). An empirical study of the psychological antecedents and consequences of induced abortion. Journal of Social Issues, 48, 67-93.
  • Miller, W. B., Pasta, D. J., & Dean, C. L. (1998). Testing a model of the psychological consequences of abortion. In L. J. Beckman and S. M. Harvey (eds.), The new civil war: The psychology, culture, and politics of abortion. Washington, DC: American Psychological Association.
  • Reardon, D.C., & Coleman, P. K. (2006). Relative Treatment Rates for Sleep Disorders Following Abortion and Childbirth: A Prospective Record-Based Study. Sleep, 29, 105-106.
  • Slade, P., Heke, S., Fletcher, J., & Stewart, P. (1998). A comparison of medical and surgical methods of termination of pregnancy: Choice, psychological consequences, and satisfaction with care. British Journal of Obstetrics and Gynecology, 105, 1288-1295.

Bias of the journal Contraception

Contraception has numerous abortion providers as editors, including David Grimes and Philip Darney. It’s the equivalent of the Guttmacher Institute’s Perspective on Sexual & Reproductive Health for the family planning crowd.

Contraception was founded by Alan Guttmacher in 1963 as the official journal of the Association of Reproductive Health Professionals (ARHP), which was formed as the educational arm of Planned Parenthood Federation of America. The following is taken directly from the official Position Statements of ARHP:

Abortion care is a critical component of comprehensive reproductive health care. ARHP supports a woman’s right to choose to have an abortion, just as we support her right to choose to become a parent or to carry an unintended pregnancy to term and choose adoption. The topic areas below represent ARHP’s positions on the range of ways in which a woman’s access to abortion care can be affected.
Medical Misinformation about Abortion
ARHP is foremost governed by evidence-based information and practices. We are troubled by the anti-choice movement’s continued dissemination of medical misinformation about abortion. In addition to spreading misinformation through organizational materials and public websites, the anti-choice movement has been successful in inserting medical misinformation into required patient materials under mandatory counseling laws. The spread of medical misinformation about risks associated with abortion and specific abortion procedures is a dishonest attempt to bolster legal and legislative efforts to restrict access to abortion. The anti-choice movement often advertises abortion myths under the guise of “protecting women from abortion” but, in reality, perpetuating misinformation about abortion only puts women at risk.
Because medical misinformation about abortion is so widespread, and sometimes even distributed by state and federal government agencies, ARHP applauds efforts by the media to dispel myths about abortion. We encourage members of the press to commit to evidence-based reporting about abortion given the vigorous and deliberate efforts by the anti-choice movement to confuse and distort medical information about abortion in the public’s eye.
To learn more about recurring myths about abortion put forward by the anti-choice movement, click here .
Legal Access to Abortion and Abortion Policy
ARHP supports the legal right of a woman to obtain an abortion. ARHP supports the United States Supreme Court decision, Roe v. Wade, and opposes any legislation, regulation, or Constitutional amendment that weakens this decision and/or intervenes in medical decision-making regarding abortion. Roe v. Wade made it legal, and therefore safe, for a woman to choose abortion. Prior to Roe v. Wade, women successfully obtained abortions on a regular basis, but often at the expense of her own health and life. Today, in countries where abortion is illegal, women continue to obtain abortions at high rates and often under unsafe circumstances. Abortion has always taken place regardless of its legal status; legalization simply allows a woman to obtain her abortion in a medical setting under safe circumstances.
The anti-choice movement continues its campaign of restricting access to abortion and ultimately eliminating the laws that protect a woman’s right to choose.”
ARHP’s Position Statement on abortion was modified and approved by Policy Committee, May 2008

Thus, with such obvious bias and advocacy orientation, the Charles et al. piece could hardly be considered objectively “peer-reviewed” and its “conclusions” should be considered suspect.

Bias of Authors

As many acquainted with this Johns Hopkins research team can attest, there is much more to "Abortion and long-term mental health outcomes: a systematic review of the evidence" than meets the eye. The university department of Population, Family, and Reproductive Health, where three of the four study authors hail from, is funded by Planned Parenthood of Maryland. Raising more suspicions about the validity of the study is the presence of co-author Robert Blum, who heads up one of the most heavily funded population control programs in the world -- worth roughly $1 billion. Blum has been a long-time supporter of unrestricted abortion, including his service on the Guttmacher Institute's Board of Directors from 1989 to present and as Chair from 1999-2002. He has testified in several statutory challenges against any parental involvement in a minor child's abortion decision.

Not surprisingly, the Hopkins study is severely tainted by the team's pro-abortion bias. As our experts have been quick to point out, Blum's review of 21 surveys conveniently omitted the stacks of research published in peer-reviewed journals that showed an association between abortion and negative mental health effects. He and the other authors claim that any studies showing a link between abortion and depression are politically motivated, but considering the Department's ties to Planned Parenthood, theirs is living proof!

As more evidence pours in contradicting Blum and company, this is just poor science. Just this week, two new articles add to the body of research demonstrating that abortion is associated with increased risk of adverse mental health effects. The two peer-reviewed papers were published in the British Journal of Psychiatry and the Journal of Psychiatric Research. Both had strong methodology and controls for confounding or alternate variables.

See also Nada L. Stotland