NCCMH Review

Induced Abortion and Mental Health, NCCMH Published December 2011

citation: National Collaborating Centre for Mental Health. Induced abortion and mental health: a systematic review of the mental health outcomes of induced abortion, including their prevalence and associated factors. London (UK): Academy of Medical Royal Colleges; 2011.

The full report can be downloaded from the AoMRC reports and guidance page. A record of all comments received and the developers’ responses can be downloaded here.

The first draft and the comments and responses on the first draft can also be downloaded from Scribd.

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 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.

A commentary upon the revised position statement and the history of this statement is provided in an editorial by David Fergusson, published in The Psychiatrist.

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. 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.

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 pages 39, 43, 91

Studies and Data Excluded in Investigating these Three Questions

The reviewers chose to exclude:

1. 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
2. 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")
3. Any data relative to negative effects associated with aborting a wanted pregnancy for "therapeutic" reasons.

Questions Excluded from Investigation

The report deliberately excluded any investigation of key questions

1. In what cases may abortion contribute to the mental health of women
2. Whether abortion makes pre-existing mental health problems more severe or difficult to treat

Research questions excluded from the review, and the reason for excluding them, are described in the companion document "Comments and Responses, see especially pages 95-103.]"

In their request for public comments, the NCCMH panel was asked to investigate, or at least comment on, the following questions. The panel declined to do so, stating these questions were "beyond the scope and remit of the present review, which was to focus on the three research questions posed." Notably, the panel itself posed the three questions it chose to investigate, and in doing so prevented their review from being a comprehensive examination of abortion and mental health issues. (Indeed, the phrase "beyond the scope" was used 45 times to evade questions raised by commentators.)

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Questions ignored:

• (p35)

This draft makes no attempt to answer the issues raised by the Abortion Act and its amendments. Indeed the authors make assumptions not contained in the Act that women have an unfettered right to choose an abortion. The act is clear that abortion is a medical matter and can only be performed if and when it is necessary to improve or preserve a woman’s health. The real question to be addressed is, what is the evidence of benefit., not what is the data for harm. This was studiously avoided by the authors of this draft. The Fellows of Psychiatry erred in not making their mandate clear and relevant. If a woman has a right to have an abortion when she so elects, then abortion is not a medical matter and should be performed by technicians If a woman has a right to good medical treatment that may include having an abortion on her physician’s recommendation, then this review is valid only if it addresses these questions:

a) Indication Is there a pathological process in pregnant women in general and this patient in particular that warrants having an abortion? (It must be recognized that pregnancy is not a disease.)

b) Benefit What is the evidence that an abortion will benefit women with this condition (pregnancy) and this patient in particular?

c) Harms. What are the adverse effects from an abortion and if there are some, do they outweigh the anticipated benefit?

d) Other options Have all less invasive, more reversible treatments been offered, tried and failed before an abortion is recommended?

e) In good faith Is the physician who is providing this procedure doing so in good faith? Has the abortionist carefully studied to relevant literature in order to practice evidence based medicine, honed his/her skills and performed a careful followed up on his/her ex-abortion patients to know personally that he/she will be providing good treatment?

f) Adoption etc. Has the physician facilitated all options to abortion of a truly unwanted child, i.e., adoption, fostering etc.

g) Informed consent. Has the physician made a clear recommendation to the patient with evidence to support that recommendation, options available, potential benefits and hazards, and shown the ambivalent woman the ultrasound of her fetus? Has he/she been given fully informed consent which requires the patient have full opportunity to ask questions, get a 2nd opinion and make a decision with enough time to do so and without pressure from mate, family, IPPF, physician etc.

It must be remembered that until any treatment is well proven, it must be considered as experimental and constrained as such.

Moreover the burden of proof rests with the performing physician, his/her supporters and those who fund this activity to show abortion is necessary, beneficial etc. not on those who question abortion is a valid treatment to show it is harmful.

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• (p43-44)

The Rawlinson Report and the RCOP response (http://extras.timesonline.co.uk/rowlinsonreport.pdf) highlights important issues that should be much more carefully addressed in this new report.

The Rawlinson report gave a summary of the RCOP's testimony and response to questions asked stating "there are no psychiatric indications for abortion." As per Ney’s elaboration, this concern that there are “no [psychiatric] indications for abortion” refers to the lack of medical indications that the abortion will produce positive mental health effects.

Properly understood, this statement was an attempt to summarize the RCOP’s failure to report to the committee any statistically validated psychiatric criteria which can be used to identifying when an individual woman is likely to either (a) derive psychiatric benefits from an abortion, or (b) be successfully protected from psychological harm that would otherwise occur if the pregnancy continued.

There is still a lack of any such criteria.

It should be carefully noted that the RCOP’s letter of response did not refute the Rawlinson Reports finding that there are no indications for abortion. If they had any indications, they would have stated so in their response. For example, they might have noted that abortion is medically indicated for bi-polar women faced with an unwanted pregnancy, if there was any statistically validated evidence to support that claim, but there was none.

RCOG letter of response shifted attention away the actual claim of fact regarding lack of known indications for abortion to a distinctly separate issue, namely that "the risks to psychological health from the termination of pregnancy in the first trimester are much less than the risks associated with proceeding with a pregnancy which is clearly harming the mother's mental health." (emphasis added.)

Notably, this statement has a huge qualifying clause which is exceptionally vague. The letter fails to give any means of determining when and how often a pregnancy is “clearly harming a mother's mental health.”

It actually implies that In cases where the pregnancy is not clearly harming a mother’s mental health, abortion may involve equal or greater risks. So the standard of identifying when a pregnancy is clearly harming mental health should be examined to identify the indicators for abortion which were requested by the Rawlinson committee.

Moreover, there is no research that has examined the assertion made by this qualifier. Specifically, there are no studies comparing psychiatric outcomes for women whose pregnancies were clearly harming their mental health who had abortions versus those who did not . In this light, it seems clear that the statement on page 61 of the report, contested by the RCOG’s letter of response, merely conflates the finding that there are no psychiatric indications for abortion into the statement that there is no psychiatric justification for abortion.

While there is plenty of room to debate whether “justification” can rightly be substituted for “indications,” two key question remain unanswered: (1) What evidence demonstrates when, if ever, abortion is likely to improve a woman’s mental health? And (2) what does the best evidence show regarding when, if ever, abortion protects future mental health, i.e., by reducing psychological stresses without creating new psychological stresses?

These are questions which should be clearly articulated in this report, even if the only answer that can be given is that the research done to date has failed to address these important questions.

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• p46

First, good medical care involves at least four components:

(a) accurate diagnosis of the problem,

(b) identification of treatments most likely to be efficacious,

(c) evaluation of treatment risks, and

(d) a risk / benefit analysis regarding treatment alternatives.

Unfortunately, in the context of the abortion controversy, these distinct steps are often confused or conflated. An unspoken, but medically inappropriate paradigm appears to exist with regard to abortion, namely:

(a) if the woman requests the abortion, and

(b) there is no clear risk that she will die on the operating table, and

(c) critics abortion have not proven, beyond all reasonable doubt, that abortion is and of itself the sole cause of all the risks statistically associated with abortion, then

(d) physicians should feel free to recommend or perform abortions on request.

This medical decision paradigm is simply not justified by the principles of evidence based medicine and medical ethics which apply to any other procedure.

Therefore, to shed light on the core issues regarding abortion decision making, especially in the context of UK law, this literature review should identify and grade the medical evidence relative to two very specific questions:

First: “What medical conditions and/or psychosocial indicators predict when the risks of continuing a pregnancy are greater than if the pregnancy were terminated?” These are the indications for induced abortion.

Secondly, what are the statistically validated risk factors which can help to identify the subsets of women who appear to be at greater risk of negative effects associated with a history of one or more abortions? These risk factors are the medical contraindications for induced abortion.

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• (p63)

The glaring gap in this draft is the lack any consideration of the effect of abortion on men and children. It makes this report invalid, if for no other reason than because what effects spouse and children will have a pronounced effect on the woman’s mental health.

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• (p65)

1/2 Since many post-aborted women use repression as a coping mechanism, there may be a long period of denial before a woman seeks psychiatric care. These repressed feelings may cause psychosomatic illnesses and psychiatric or behavioural disorders in other areas of her life.

As a result, some counsellors report that unacknowledged post-abortion distress is the causative factor in many of their female patients, even though their patients have come to them seeking therapy for seemingly unrelated problems. Kent, et al., “Bereavement in Post-Abortive Women: A Clinical Report”, World Journal of Psychosynthesis (Autumn-Winter 1981), volume 13, no’s 3-4

Note the area of Sexual Dysfunction – Thirty to fifty per cent of aborted women report experiencing sexual difficulties, of both short and long duration, beginning immediately after their abortions. These problems may include one or more of the following: loss of pleasure derived from sexual intercourse, increased pain, an aversion to sexual activity, and/or males in general, or the development of a promiscuous lifestyle. Speckhard, Psych-social Stress Following Abortion, Sheed & Ward, Kansas City, MO 1987; and Belsey et al., “Predictive Factors in Emotional Response to Abortion: King’s Termination Study – IV,” Soc. Sci. & Med., 11:71-82 (1977)

Response of reviewers: Although these are important points, they are beyond the scope of the present review.

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• (p95)

1. "Question 3 should be reworded to properly reflect UK law, as follows: 3. Are mental health problems less common in women who have an induced abortion, when compared with women who deliver an unplanned or unwanted pregnancy? [This was recommended since UK law allows induced abortion only when the health risks of abortion are less than those of allowing the pregnancy to continue.]"

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• (p95) 1. How prevalent are mental health problems in women who do not terminate an unplanned or unwanted pregnancy compared to the general population and to women who deliver a wanted pregnancy?

2. What factors are associated with improved mental health following abortion compared to similar women who carry an unplanned or unwanted pregnancy to term?

3. What factors are associated with a lower decline in mental health following abortion when compared to women who do not terminate an unplanned or unwanted pregnancy?

4. Among women who do experience negative reactions which they attribute to their abortions, what reactions are reported and what treatments are effective?

5. Is presenting for an abortion, or a history of abortion, a meaningful diagnostic marker for higher rates of mental illness and related problems?

6. Does abortion ever cause or exacerbate mental health problems in women, even in rare cases? (p95)

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Some Conclusions

• The most reliable predictor of post-abortion mental health problems is having a history of mental health problems prior to the abortion.
• A range of other factors produced more mixed results, although there is some suggestion that life events, pressure from a partner to have an abortion, and negative attitudes towards abortions in general and towards a woman’s personal experience of the abortion, may have a negative impact on mental health.
• Women who show a negative emotional reaction immediately following an abortion are likely to have a poorer mental health outcome.
• This section of the review aimed to assess factors associated with mental health problems following an abortion. Identifying these factors would enable healthcare professionals to monitor and provide greater support for women identified as potentially ‘at risk’.

From News Releases

While acknowledging that women with a history of abortion have higher rates of mental illness than the general population, the director of NCCMH of Tim Kendall, said, “It could be that these women have a mental health problem before the pregnancy. On the other hand, it could be the unwanted pregnancy that's causing the problem. Or both explanations could be true. We can't be absolutely sure from the studies whether that's the case - but common sense would say it's quite likely to be both. The evidence shows though that whether these women have abortions - or go on to give birth - their risk of having mental health problems will not increase. They carry roughly equal risks. We believe this is the most comprehensive and detailed review of the mental health outcomes of abortion to date worldwide.”

Sophie Corlett, director of external relations at the mental health charity Mind, said of the report, “It is important that medical professionals are given the correct information to provide support for all women, but particularly those with a pre-existing history of mental health problems. This study makes it absolutely clear that this group is at the greatest risk of developing post-pregnancy mental health problems and should be given extra support in light of this.”

Dr Peter Saunders, chief executive of the Christian Medical Fellowship, said, “This new review shows that abortion does not improve mental health outcomes for women with unplanned pregnancies, despite 98% of the 200,000 abortions being carried out in this country each year on mental health grounds. This means that when doctors authorize 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.”

Critique by Priscilla Coleman

The Royal College of Psychiatrist’s recently conducted review of scientific literature published from 1990 to the present on abortion and mental health is hauntingly similar to the American Psychological Association Task Force Report released in 2008. The report by the RCP is, however, far more complex and on the surface it may appear to be more rigorous than the APA report. An enormous amount of time, energy, and expense has been funneled into a work product that was not undertaken in a scientifically responsible manner. In this critique, I provide evidence that should incite scientists and clinicians to reject the conclusions of the report and work together to provide an accurate and truly exhaustive review of the peer-reviewed research.

Unjustified Dismissal of Studies

The RCP review incorporates four types of studies: 1) reviews of the literature; 2) empirical studies addressing the prevalence of post-abortion mental health problems; 3) empirical studies identifying risk factors for post-abortion mental health problems; and 4) empirical studies comparing mental health outcomes between women who choose abortion and delivery. In each category, there are studies that are ignored and large numbers of studies that are entirely dismissed for vague and/or inappropriate reasons. With regard to the first type of study, only 3 reports are considered (APA Task Force Report, 2008; Charles et al., 2008; Coleman, 2011). The authors of the RCP report “missed” 19 reviews of the literature (listed at the end of this document), published between 1990 and 2011. Moreover, no criteria were identified for selection of particular reviews to discuss and to provide context for the current report. In relation to the third type of study, only 27 studies are included in the RCP report. At the end of this document, citations to 20 relevant and unmentioned articles published in highly respected peer-reviewed journals are provided. They are not listed in Appendix 7 of the RCP report, which contains all included and excluded studies.

Among the scores of studies identified and excluded across study types 2 through 4 above, the most common reasons are the nebulously defined “no usable data” and “less than 90 days follow-up.” The latter resulted in elimination of 35 peer-reviewed studies in each of the prevalence, risk factor, and comparison study types. The RCP authors state that “Because the review aimed to assess mental health problems and substance use and not transient reactions to a stressful event, negative reactions and assessments of mental state confined to less than 90 days following the abortion were excluded from the review.” This is highly problematic for various reasons. First, elimination of studies that only measured women’s mental health up to 90 days, does not effectively remove cases of transient reactions. Just because the authors of these dozens of studies did not follow the women long-term, it does not mean that the women were not still suffering quite significantly beyond the early assessment. Moreover, when investigating the mental health implications of an event, it is logical to measure outcomes soon after the event has occurred as opposed to waiting months or years to gather data. As more time elapses between the stressor and the outcome(s), healing may naturally occur, there may be events that moderate the effects, and more confounding variables may be introduced. Finally, focusing only on mental health events that occur later in time effectively misses the serious and more acute episodes that are effectively treated soon after exposure.

Ironically, many of the studies removed from the analyses due to the abbreviated length of follow-up, had incorporated controls for prior psychological history and other study strengths. As a result, the samples of studies included in each section of the RCP review were not representative of the best available evidence and many of the eliminated effects coincidentally revealed adverse post-abortion consequences. In the category wherein the authors sought to derive prevalence estimates, only 34 studies were retained, including 27 without controls for previous mental health. In contrast, in the Coleman review, 14 out of the 22 studies had controls for psychological history.

Factual Errors

Perhaps even more disturbing than the elimination of large segments of the literature, are the factual inaccuracies that are present in the RCP report. As the author of the Coleman (2011) review cited in the report, I was alarmed to see the content in “Section 1.4.4: Summary of Key Findings from the APA, Charles, and Coleman Reviews.” The first 6 points are not reflective of the conclusions derived from the meta-analysis and the 7th and final point in this section wrongly states, with reference to the meta-analysis that “previous mental health problems were not controlled for within the review.” In fact, as noted above, the meta-analysis incorporated more studies into the final analyses with controls for prior psychological problems than the current review. Moreover, the conclusions derived from the meta-analysis were based on more studies with controls for prior psychological history than the Charles and the APA reviews as well.

I do not have the time or interest in identifying all errors present, but a few others jumped out at me. First, several studies are eliminated from the RCP report, because the outcome(s) assessed are lifetime estimates of mental health problems, deemed inappropriate by the RCP team. Nevertheless, the Coleman et al. (2009) and the Mota et al. (2010) articles, which relied upon lifetime estimates, are included in the prevalence section of the report. Inclusion reflects an inaccurate read of the two studies. I also noticed my affiliation is stated as the Department of Psychiatry at Bowling Green State University. I wish we had a medical school, it would make retrieval of articles much less expensive, but unfortunately we do not.

Problematic “Quality Assessments”

This review is being pitched as methodologically superior to all previously conducted reviews, largely because of the criteria employed to critique individual studies and to rate the overall quality of evidence. However, the quality scales employed to rate each individual study are not well-validated and require a significant level of subjective interpretation, opening the results to considerable bias. The main problems with the quality scale employed to rate the individual studies are as follows: 1) the categories used are missing key methodological features including initial consent to participate rates and retention of participants across the study period; 2) the relative importance assigned to the included criteria is arbitrary, as opposed to being based on consensus in the scientific community; 3) the specific requirements for assigning a “+” or “-” within the various categories are not provided; 4) the authors fail to explain (as their predecessors, Charles et al. 2008 did) how combinations of pluses and minuses in the distinct categories add up to an overall rating ranging from “Very Poor” to “Very Good.” Incredulously, the Gilchrist et al. (1995) study received a rating of “Good”, when very few controls for confounding 3rd variables were employed, meaning the comparison groups may very well have differed systematically with regard to income, relationship quality including exposure to domestic violence, social support, and other potentially critical factors. Further Gilchrist et al. reported retaining only 34.4% of the termination group and only 43.4% of the group that did not request a termination at the end of the study. No standardized measures for mental health diagnoses were employed and evaluation of the psychological state of patients was reported by general practitioners, not psychiatrists. The GPs were volunteers and no attempt was made to control for selection bias. Despite these facts, the study received a mark of “+ thorough” for confounder control, a “+” for representativeness, and a “+” for validated tools. I can provide a similar rebuttal to many more of the individual study ratings provided by the RCP; and the reader should not trust these “quality” assessments.

Similarly, when it came to evaluating the quality of evidence associated with specific outcomes, such as anxiety, depression, suicide ideation, drug or alcohol abuse, psychiatric treatment, etc. with regard to the comparative studies, “Grade Working Group grades of evidence” were employed by the RCP. The anchors on this scale are vague and oftentimes only one reason is identified as the basis for a “Very Low” rating. For example, in the category of “Any Psychiatric Treatment,” which actually only included the Munk-Olsen et al. study (p.104), the basis for the “Very Low” (very uncertain about the estimate) rating was not controlling for pregnancy intention. As if this isn’t problematic enough, when the study is again evaluated (see pages 198 and 199), it is rated as “Good” in the comparison category. There are loose, poorly conceived rationales and inconsistencies like this throughout the report and the problem lies in the application of an inadequate quality assessment protocol for individual studies and for the body of evidence.

Faulty Conclusions

Each section in the RCP report includes conclusions that are based on a very small number of studies that are not properly rated for quality. The results should, therefore, not be trusted as a basis for professional training protocols or health care policy initiatives. To illustrate how incomplete and misleading the conclusions provided by the RCP are, I will use one example. I recently identified 119 studies published between 1972 and 2011 using the MEDLINE, PubMed, and PsycINFO data bases specifically related to risk-factors associated with post-abortion psychological health. Below is a list of the most common risk factors derived from the 119 peer-reviewed journal articles identified.

a. Timing during adolescence or younger age (18 studies confirm: 2 studies do not)

b. Religious, frequent church attendance, personal values conflict with abortion (18 studies confirm; 1 study does not)

c. Decision ambivalence or difficulty, doubt once decision was made, or high degree of decisional distress (29 studies confirm; 3 studies do not)

d. Desire for the pregnancy, psychological investment in the pregnancy, belief in the humanity of the fetus and/or attachment to fetus (21 studies confirm; 1 does not)

e. Negative feelings and attitudes related to the abortion (16 confirm; 1 does not)

f. Pressure or coercion to abort (10 studies confirm; 1 does not)

g. Conflicted, unsupportive relationship with father of child (24 confirm; 6 do not)

h. Conflicted, unsupportive relationships with others (28 confirm; 7 do not)

i. Character traits indicative of emotional immaturity, emotional instability, or difficulties coping including low self-esteem, low self-efficacy, problems describing feelings, being withdrawn, avoidant coping, blaming oneself for difficulties etc. (42 studies confirm; 1 study does not)

j. Pre-abortion mental health/psychiatric problems (35 studies confirm; 3 studies do not)

k. Indicators of poor quality abortion care (feeling misinformed/inadequate counseling, negative perceptions of staff, etc.) (10 studies confirm)

The RCP conclusions relative to studies addressing risk factors for post-abortion mental health problems make no mention of most of the variables described above. They simply state (based on 27 studies) that “The most reliable predictor of post-abortion mental health problems is having a history of mental health problems prior to abortion” and “A range of other factors produced more mixed results, although there is some suggestion that life events, pressure from a partner to have an abortion, and negative attitudes towards abortion in general and towards a woman’s personal experience of the abortion, may have a negative impact on mental health.”

I am one academic, without a lab full of graduate students and with a heavy teaching load (not a Department of Psychiatry), yet I was able to find all these studies. Why wasn’t this high powered research team able to do a better job? Simply glancing at titles and abstracts to determine which studies merit further attention will not yield the information needed and resulted in a short-sighted view of the available evidence.

Before I leave this section on poorly developed conclusions, I should note how curious it was to read one of the conclusions under the risk factor section: “Women who show a negative emotional reaction immediately following an abortion are likely to have a poorer mental health outcome.” How can this “conclusion” be derived if studies that only examined women in the first 3 months following abortion were eliminated? Moreover, if this is true, why would these studies have been eliminated in the first place? Shouldn’t the researchers be most concerned with those most likely to be adversely impacted?

Appropriateness of Meta-Analysis

Counter to the claims of the authors of this report, a quantitative review or meta-analysis can be performed when there is heterogeneity present in the effects one wishes to summarize. The random effects model is specifically designed to address heterogeneity. In addition, separate meta-analyses, based on distinct comparison groups and outcomes can be performed. There is no excuse not to perform extensive meta-analyses from the vast literature that has accumulated. Such an approach is much more reliable and the results derived yield more valid conclusions than a narrative review; data that can be translated more readily into practice.

A Call for Change

The bottom-line conclusion of the RCP review, based on only 4 studies, is that abortion is no riskier to women’s mental health than unintended pregnancy delivered. When this report was released a few days ago, several of my colleagues emailed “Here we go again…” Many of us are left wondering, how many of these purposefully driven “systematic reviews” have to be published with results splashed all over the world, before women’s psychological health will finally take precedence over political, economic, and ideological agendas? This report constitutes no less than a crafty abuse of science and if the merits of this report are not seriously challenged, we will shamefully grow more distant from our ability to meet the needs of countless women. Until there is acknowledgement than scores of women suffer from their decision to undergo an abortion, we will remain in the dark ages relative to the development of treatment protocols, training of professionals, and our ability to compassionately assist women to achieve the understanding and closure they need to resume healthy lives.

Narrative Reviews Not Addressed

1) Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Science 1990 6; 248(4951):41-4. Psychological responses after abortion.

2) Adler NE, David HP, Major BN, Roth SH, Russo NF, Wyatt GE. Psychological factors in abortion. A review. Am Psychol. 1992;47(10):1194-204.

3) Adler NE, Ozer EJ, Tschann J. Abortion among adolescents. Am Psychol. 2003; 58(3):211-7.

4) Allanson S, Astbury JJ. Psychosom Obstet Gynaecol. 1995;16(3):123-36.The abortion decision: reasons and ambivalence.

5) Bhatia MS, Bohra N. The other side of abortion. Nurs J India. 1990; 81(2):66, 70.

6) Cameron S. Induced abortion and psychological sequelae. Best Practice & Research. Clinical Obstetrics & Gynaecology 2010; Vol. 24 (5), pp. 657-65.

7) Coleman PK, Reardon DC, Strahan T, Cougle R. The psychology of abortion: A review and suggestions for future research. Psychology & Health 2005; 20(2), p237-271.

8) Dagg PK. The psychological sequelae of therapeutic abortion--denied and completed. Am J Psychiatry. 1991;148(5):578-85.

9) Harris AA. Supportive counseling before and after elective pregnancy termination. Midwifery Women’s Health. 2004; 49(2):105-12.

10) Lie ML, Robson SC, May CR. Experiences of abortion: a narrative review of qualitative studies. BMC Health Serv Res. 2008; 8:150.

11) Lipp A. Termination of pregnancy: a review of psychological effects on women. Nursing Times 2009; 105 (1), pp. 26-9.

12) Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C. Abortion and mental health: Evaluating the evidence. Am Psychol. 2009; 64(9):863-90.

13) Major B, Cozzarelli C. Psychosocial Predictors of Adjustment to Abortion. Journal of Social Issues 1992; 48 (3), p121-142.

14) Robinson GE, Stotland NL, Russo NF, Lang JA, Occhiogrosso M. Is there an "abortion trauma syndrome"? Critiquing the evidence. Harvard Review of Psychiatry 2009; 17 (4), pp. 268-90.

15) Rosenfeld JA. Emotional responses to therapeutic abortion. Am Fam Physician. 1992; 45(1):137-40.

16) Speckland A., Rue V. Complicated Mourning: Dynamics of Impacted Pre and Post-Abortion Grief," Pre and Perinatal Psychology Journal 1993; 8 (1):5-32.

17) Stotland NL. Psychosocial aspects of induced abortion. Clin Obstet Gynecol. 1997 Sep;40(3):673-86.

18) Turell SC, Armsworth MW, Gaa JP. Emotional response to abortion: a critical review of the literature. Women Ther. 1990;9(4):49-68.

19) Zolese G, Blacker CV. The psychological complications of therapeutic abortion. Br J Psychiatry. 1992; 160:742-9.

Studies of Statistically Validated Risk Factors Not Addressed

1) Allanson S. Abortion decision and ambivalence: Insights via an abortion decision balance sheet. Clinical Psychologist 2007; 11 (2), p50-60.

2) Brown D, Elkins TE, Larson DB. Prolonged grieving after abortion: a descriptive study. J Clin Ethics 1993; 4(2):118-23.

3) Fielding SL, Schaff EA. Social context and the experience of a sample of U.S. women taking RU-486 (mifepristone) for early abortion. Qualitative Health Research 2004; 14 (5), pp. 612-27.

4) Hill RP, Patterson MJ, Maloy K. Women and abortion: a phenomenological analysis. Adv Consum Res. 1994; 21:13-4.

5) Kero A, Lalos A. Ambivalence--a logical response to legal abortion: a prospective study among women and men. J Psychosom Obstet Gynaecol. 2000; 21(2):81-91.

6) Linares LO, Leadbeater BJ, Jaffe L, Kato PM, Diaz A. Predictors of repeat pregnancy outcome among black and Puerto Rican adolescent mothers. J Dev Behav Pediatr. 1992;13(2):89-94.

7) Mufel N, Speckhard AC, Sivuha S. Predictors of posttraumatic stress disorder following abortion in a former Soviet Union country. Journal of Prenatal & Perinatal Psychology & Health 2002; 17(1), pp. 41-61.

8) Osler M, David HP, Morgall JM. Multiple induced abortions: Danish experience. Patient Educ Couns. 1997; 31(1):83-9.

9) Østbye T, Wenghofer EF, Woodward CA, Gold G, Craighead J. Health services utilization after induced abortions in Ontario: a comparison between community clinics and hospitals. American Journal of Medical Quality 2001; 16 (3), pp. 99-106.

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Comments of Anne Speckhard, Ph.D.

In regard to NCCMH review, I would suggest that it completely fails to address the reality that each woman's unique and individual view of her abortion experience is the most important defining issue for what constitutes a trauma.

That means that if she perceives her pregnancy as involving a human life (i.e. in our research we keyed this as recognition of human life) and then furthermore attaches to that life (i.e. feels any type of attachment, refers to the embryo/fetus as "my baby", or herself as a mother, etc.) she has perceived/defined the abortion event in a manner that will make it likely to experience it as a criterion A stressor event capable of causing posttraumatic stress disorder.

We found these two variables - the woman's own recognition of life and attachment to be the highest predictors in our research of PTSD responses after an abortion.

On the other hand if she sees the abortion as nothing much for her, i.e. it is not experienced as a traumatic and she will not experience PTSD symptoms unless she is traumatized by other things which can also be additive in the first case (coercion to get the abortion, a very painful invasive experience, an abusive doctor or clinic protocol, even protestors outside the clinic, etc.)

From an outsiders perspective the first case (recognizing fetal life and attaching to it) can be seen as sick (the normal pro-choice view - that she is sick to define her pregnancy abortion experience so personally and relationally because after all it is not a human child) and the second case can also be seen as sick - morally detached, insensitive, or unhealthy because for her the abortion doesn't carry enough weight to be likely to cause her trauma (the view being expounded here from a pro-life perspective). Both are outsiders perspectives and can be argued strongly depending on the view of pregnancy that person holds. But what is operational for the woman and whether or not she suffers PTSD is not the view of the outsider but the woman's own view. She will experience trauma based on her own perceptions.

Likewise her own unique view can change overtime. She may be callous to her abortion at the time she has it but years later encounter a sonogram that deconstructs her first view that it's not a life worth worrying about and become deeply traumatized that what she aborted was (again in her view) deeply human and something she may at this late stage wish to make a relationship to (i.e. creating psychological presence of an aborted fetal child that she now grieves over). Again this is from her perspective and that is the only thing that matters as far as getting PTSD - in this case a delayed reaction.

Of course how others define things can also cause mental health problems. A woman who is traumatized but is told by her society to buck up as it was nothing has to go underground with her feelings and a woman who is condemned for feeling nothing can also find that difficult to deal with.

In either case though I want to emphasize for this discussion we really have to take into account the woman's own perspective.

I realize that says nothing about the critique of the study under question but I did want to comment that how we define "sick" is also often defined by our own views of the experience. Whereas actually becoming "sick" from an abortion experience may have much more to do with the individualistically defined view of the woman herself.

Anne Speckhard, Ph.D.

Adjunct Associate Professor of Psychiatry

Georgetown University Medical School annespeckhard.com

Comments of Philip Ney, M.D.

This report confirms what has been known for at least 3 decades, abortion not only does not prevent mental illness, it aggravates every known mental illness. Abortion is contraindicated as treatment for mental ills. It must be made very clear to politicians etc, that this study only confirms the fact that abortion is not good treatment.

Without defining "wantedness" these authors write a conclusion that unwantedness is the real problem. Isn't it convenient? Now they can make wantedness mean anything that suits their purpose. My own research team has studied wantedness and found, (no surprise) that wantedness fluctuates hourly, depending on hormones, mood, partner, finances etc but following the first trimester when nausea and vomiting, partners hesitance dominate, wantedness grows throughout the pregnancy. Moreover wanting a child has very little relationship to wanting to not be pregnant. "Intendedness" is no better. So basing the results of such high blown research on such an ephemeral criteria is about as bad research as there can be.

No country in the world recognizes abortion as a woman's unfettered right. There is in no country I know where a woman can at any time in her pregnancy, for any reason, walk up to a physician and state "It's my right. I demand you abort my pregnancy right now." Why? Because it is illegal to practice bad medicine. And since the evidence from all studies and surveys shows there is no benefit, only various degrees of harm, abortion is bad medicine. This is what we must emphasize. On the other hand, abortion is legal everywhere if it is necessary to treat a disease like eclampsia, sometimes.

Statistics can blind as easily as illluminate. We must not forget that statistics are to find canaries (rare events) as they used to say in medical school or to determine if some small measure is significant ( important enough to be bothered with). If when you give some new medication to your patients and 1/2 die, statistics aren't needed. We are dealing with events that make huge differences in people. It is to our embarrassment we have such difficulty quantifying these changes. I believe in that regard, smaller samples using the subject as there own control and using Visual Analogue scales which can represent fine slices of the continuum which are almost always there, is the way forward. Besides its less expensive.

NOTE: A more complete review of the NCCMH review by Dr. Ney is "A Common Sense Scientific Critique of the NCCMH and Royal College of Psychiatry Review" WebMedCentral. REPRODUCTION 2013;4(10):WMC004429

Comments of Martha Shuping, M.D.

It has been shown in a number of studies that prior mental health, before the abortion, is a risk factor for more problems after the abortion. I don’t think anyone on either side of the issue disputes that. It is well established.

Therefore, it certainly accurate for the NCCMH report to note this fact. The problem is they treat it as being practically the only relevant finding and draw unsupported and misleading conclusions from it.

If you have a preconceived bias to defend abortion as a basic human right, it would be convenient to also believe that if people were having problems after abortion, it was purely and simply due to the fact that they were troubled individuals to start with.

Interestingly, in some countries, abortion has been legal specifically in cases in which the woman is believed to be suicidal. I know women in England who tell me they were coached by counselors to tell the doctor, “I will commit suicide if I have to have this baby,” and they were not really suicidal but they said it to get the abortion. So abortion is permitted or advocated in some cases because a woman has mental health problems though the data indicate that these are the women who are more vulnerable to problems after abortion. It would make sense to spend some time doing more counseling at the front end to explore whether this woman truly wants the abortion, whether she understands her risks and so on, rather than actually advocating for the abortion, since this is a vulnerable population, and their mental health actually may be worsened by the abortion rather than improved by the abortion. So it is paradoxical in a way that these are the very women who in countries are given access to abortion when others are not or where it is viewed in some way as a solution, when of course abortion has never been demonstrated as evidence based treatment for suicidal ideation or for any psychiatric illness.

From my own experience with large numbers of women in abortion recovery programs, I believe that many women are having mental health problems after abortion who did not have problems before, and also that those who did have problems before now have problems that are qualitatively and quantitatively more severe after the abortion.

The women themselves can often pinpoint the start of their problems to the time of the abortion, and their symptoms often specifically relate to the abortion such as nightmares about dead babies or dreams about crying babies, having panic attacks when they are around things or places that remind them of the abortion, and so on. But you do not get at this type of information in the larger studies with huge databases; you only get the general before and after perhaps from insurance claims or health records as far as past diagnoses and dates of treatment.

When one is doing record based studies, there is important information to be gained, but in doing qualitative studies, or doing studies that could be designed to interview women very specifically about their experience, one might discover there are specific aspects about the symptoms that tend to indicate the post-abortion symptoms are related to the abortion, and not related to prior mental health issues. Someone could have had transient depression during high school or college, but then develop PTSD after the abortion. If they are having nightmares about dead babies after the abortion but not before, and then finding they need to consume alcohol to sleep at night, these would seem to be new problems.

From my experience, my opinion is that there are many women with new onset of mental health problems after abortion, and many with different and more severe problems after the abortion. I think this has not been fully captured or demonstrated by current studies. But certainly there are some excellent studies that do control for prior mental health and show that past abortion is in itself a risk factor for mental health problems. These studies support what I have seen in clinical experience. It is not “only” the past mental health that is the complete and total cause of all abortion related problems, because some studies controlled for prior mental health and still show abortion as a risk factor for mental health problems after abortion.

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A major weakness of this review is the oversimplified way in which they collapse mental health problems into being all the same. If there are “problems” after birth and “problems” after abortion, the reviewers treat these as equal without looking at the nature of the problems and how long these problems last.

This occurs, for example, in a study looking at Medicaid claims to see if there was any mental health treatment in the year prior to the abortion, and then perhaps look at claims after. In these exploratory studies, they are just looking for the “yes” that there was past mental health treatment, and not necessarily the number of times treatment was received or the seriousness of the disorder or how long it lasted. Typically researchers would only be considering whether or not there was a diagnosis or treatment. And it would tend to serve the viewpoint of those who favor abortion if it was all treated equally.

Similarly, the reviewers appear to asserting that while, yes, there can be problems after abortion, there can also be problems after childbirth, and so it is all equal.

But they are not equal. Consider, for example, a woman I know who was in her 80’s who was still having grief and guilt concerning a past abortion from about fifty years earlier, who contacted me for help with an abortion related issue. Also, on abortion recovery weekends, I have taken women in their 60’s who are now grandmothers who still have grief and guilt concerning past abortions.

So, yes, it is true that women can have post-partum depression after having a baby, but my experience with post-partum depression is that it resolves on medication within a few weeks. I have never seen women in their 60’s or their 80’s with post-partum depression. In contrast, I have experience with women in their 60’s and even 80’s who are still having symptoms they specifically attribute to their abortion, which seem to be abortion related.

So, no, the severity or the duration of the post-abortion problems are not being considered.

Keep in mind that many women do meet criteria for posttraumatic stress disorder after abortion, for example, about 18% in a 2007 study by Suliman in South Africa. The authors considered this “high.” They were concerned that almost one in five women in their study had PTSD after their abortion.

There are studies showing that PTSD is a very long lasting disorder that can be very disabling, so it is a more serious psychiatric illness.

Studies that only look at mental health after abortion vs. mental health after childbirth are perhaps unintentionally misleading if they consider only whether the person was diagnosed or whether the person had treatment in a particular time frame in a “yes or no” fashion. It is important to know the nature, severity and duration of the disorders in question and that would be more difficult information to obtain. You can find out from medical records or insurance claims whether or not a person had treatment in a particular period of time after the end of the pregnancy, yes or no. But to follow women to see who is still experiencing symptoms in their 60’s or 80’s would be a very long study indeed, and it is difficult to study women for decades.

Similarly, if we are considering mental health before the abortion vs. mental health after the abortion, it would also be good to consider not simply whether or not treatment occurred, but what was the severity and duration of the illness, and again this can be difficult to determine. For some women, their symptoms may emerge later, and may be severe and long-lasting, sometimes persisting for decades.

These questions are not being carefully considered, but they would be difficult studies to do.

But, there are clearly are studies that use control groups, that do control fro prior mental health, and that show abortion itself is a risk factor for mental health problems in women after abortion. It by no means only women with prior mental health problems who are having the problems after abortion. But when they do make the comparison and treat the problems before and after as equivalent, they have not truly demonstrated whether the two conditions are in fact equivalent.

Other Notes

Rating Scale Misleading

The rating scale for studies was strongly criticized by a number of reviewers during the first draft for it's failure to rank studies for women refusing to participate or dropping out of the study before completion. The review team acknowledged this problem but provided only a fake fix.

The "fix" was adding a new category, "Representativeness" to table 3, p28. As described on page 29, the criteria for this scale were so watered down that all the studies with high drop out rates were still allowed to score high. Indeed, a study could have over a 50% refusal or drop out rate and still be rated as "+" as long as the authors provided even a mediocre statistical comparison of the participants and non-participants....even if the comparison showed significant differences!

The rating scale appears to have also been designed, or at least interpreted, to specifically justify rating the Finland record based studies on suicide as "very poor" -- even though they revealed a 650% increased risk of suicide. They also ignored the Morgan study, published in BMJ with data.

Incorrectly classified studies

• 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, 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.

• Reardon2006 was excluded for the specious reason "sleep disorders beyond scope of the review"--but that was an arbitrary decision, since clearly sleep disorders can be due to mental health problems, indeed, they are strongly linked to PTSD.

Misc

• They incorrectly excluded Soderberg (p171) stating that the sample included distressed women. In fact, the sample included all women who had abortions.

Official Comments and Responses

The most complete listing of shortcomings of this review, including explanations for why key issues were not covered in the report, are found in the NCCMH's companion document to the report "Comments and Responses, see especially pages 95-103.]"