They found women who had an abortion experienced an 81 percent increased risk for mental problems. Women who had an abortion were 34 percent more likely to develop an anxiety disorder, 37 percent more likely to experience depression, percent more likely to abuse alcohol, percent more likely to commit suicide, and percent more likely to use marijuana.
Previous research hasn't found a definitive link between an abortion and a woman's mental health. In , the American Psychiatric Association charged a task force to review scientific evidence on the link between abortion and mental health.
If you find yourself emotionally or mentally distressed about an abortion either before or after the procedure , learning how to cope is critical to protecting your mental health. Find a friend, family member, coworker, or anyone else who can help you navigate these waters. Sometimes, confiding in a trusted friend is all you need. Although you may feel tempted to withdraw from family and friends, try to stay connected to people who can offer you support.
Isolation may only amplify your feelings in a negative way. Big decisions like this feel overwhelming and stressful. A mental health professional can help guide you through this profound life event. As with many life situations, you may feel pressure from friends, family, or a partner to choose one way or the other. Remember that an abortion is ultimately your choice and yours alone, as you will be the one held responsible for it. In writing this review, I have tried to be as objective and fair as possible.
Yet, as discussed later, since my own informed opinion is also influenced by my own experiences and preconceptions, full disclosure requires that I acknowledge at the outset that I fit most closely under the category of an AMH proponent. The method I used for this review was to carefully examine previous literature reviews regarding mental health effects associated with legal abortion that have been published since In addition, I studied the references cited in these various reviews in order to further my effort to more completely identify a areas of agreement and disagreement, b the underlying reasons for disagreements, and c opportunities to collaborate in light of the current literature.
This undertaking is intended to advance more than just an academic discussion, however. For example, better screening for risk factors should help to identify women who may benefit from additional pre- or post-abortion counseling 24 — 38 and may also help to prevent cases of women being pressured into unwanted abortions.
In addition, more complete insights may help mental health counselors to be more aware and sensitive to providing the counseling services that women want and need.
This review is organized into three sections. The first examines major areas of agreement and offers a synthesis of the findings from major studies. The second section investigates the obstacles to building a consensus between AMH minimalists and AMH proponents, including institutional and ideological biases, research obstacles, poorly defined terms, and similar issues that contribute to the disparity in the conclusions most emphasized by each side. The third section provides recommendations for collaborative research based on the insights gained from the first two sections, addressing such issues as data sharing, mixed research teams, and how to maximize the value of longitudinal prospective studies.
The fact that some women do have maladjustments is most specifically documented in case studies developed by post-abortion counselors successfully treating women with maladjustments, including counselors working from a pro-choice perspective 40 — 44 as well as from those working from a pro-life perspective.
Stotland, who later served as president of the American Psychiatric Association, subsequently began to recommend screening of prospective abortion patients for risk factors in order to guide decision counseling and identify additional counseling needs.
There is a strong research-based consensus that there are numerous risk factors that can be used to identify which women are at greatest risk of negative psychological outcomes following one or more abortions. The incidence rates shown in Table 1 clearly suggest that the majority of women seeking abortion have one or more of the TFMHA identified risk factors. Since exposure to multiple abortions is one of the risk factors, that risk factor alone applies to approximately half of all women having abortions, at least in the United States.
A similar, but longer list is published in the text book on abortion most highly recommended by the National Abortion Federation. The second category contains 25 risk factors related to psychological or developmental limitations , such as pre-existing mental health issues, lack of social support, and prior pregnancy loss.
The ability to identify women who are at greater risk of negative reactions has resulted in numerous recommendations for abortion providers to screen for these risk factors in order to provide additional counseling both before an abortion, including decision-making counseling, and after an abortion.
Notably, while there is no dispute regarding the abundance of research identifying risk factors, there is little if any research identifying which women, if any, acquire any mental health benefits from abortion compared to carrying a pregnancy to term, even if the pregnancy was unintended or unwanted. It is impossible to conduct randomized double-blind studies to investigate abortion-associated outcomes. Such studies would require random selection of women to have abortions.
Notably, the very same fact that would make such a study unethical—forcing a group of women to have abortions—actually occurs in the real world wherein some women feel pressured or even forced into unwanted abortions by their partners, parents, employers, doctors, or other significant persons.
Indeed, since feeling pressured to abort is a major risk factor, the practice of excluding women aborting intended pregnancies from AMH studies 39 , 69 makes the results from such studies less generalizable to the actual population of all women having abortions. This is just one of many difficulties which makes it truly impossible to conduct any AMH study that does not have significant methodological weaknesses.
While every observational study can be criticized for methodological weaknesses, it is also nonetheless true that is still possible to discover meaningful and actionable results. For example, research demonstrating elevated rates of mental health problems among women who feel pressured to abort contrary to their moral beliefs is generalizable to that specific subset of women.
So while it is important to never generalize to all women who have abortions, insights can be gained from nearly any study when the results are properly narrowed to the limits of the population studied. While there are disagreements on how to best interpret these findings to be discussed later , the findings themselves are not disputed. The results are organized into six sets: all classes of symptoms segregated by inpatient and outpatient treatments when separately reported ; depression and depression-related symptoms such as bipolar disorder; anxiety; substance use disorders segregated by type of substance use when identified ; and other disorders.
Comparison groups include women carrying an unintended pregnancy to term, women delivering a child, women delivering a first pregnancy, women with no known history of abortion, women with any other pregnancy outcome other than abortion, and women not pregnant during the period studied.
What is most notable from Figure 1 is that the trend in results, including those reported by questionnaire and record linkage studies, is consistent. All but three odds ratios are above 1.
This overlap is very important. Since findings only contradict each other when there is no overlap in the CIs, it is clear from Figure 1 that the minority of studies without statistically significant findings do not contradict the findings of studies with statistically significant findings.
Claims to the contrary 69 ignore the relevance of CIs and also the fact that studies with low statistical power are easily prone to Type II errors resulting in false negatives. The risk of such false negatives is increased when there is also any risk of sample bias. In regard to abortion research, the risk of sample bias is especially high since questions about abortion are frequently associated with feelings of shame.
In addition, some researchers choose to exclude groups such as women who abort wanted pregnancies, 69 have later term abortions, or have other risk factors for more negative reactions Table 1 and these methodological choices will also tend to shift results below statistical significance. Despite these problems, the trend in findings, as shown in Figure 1 , is very clear. Women who abort are at higher risk of many mental health problems.
This conclusion is strengthened by the variety of the study designs that have been conducted. Collectively, they reveal the following:. A number of recent studies have also reported the population attributable risk PAR associated with abortion. This statistic estimates the percentage of an outcome that may be attributed to exposure to an abortion experience after statistically removing the effects associated with the available control variables.
He reported that the attributable risk ranged from 1. Of particular interest is a study by Sullins using the National Longitudinal Study of Adolescent to Adult Health that provided three models of analyses, including controls for 25 confounding factors. Collectively, the findings shown in Figure 2 suggest that substance use disorders appear to be most strongly attributable to abortion. Put another way, assessments of substance use perhaps indicating self-medicating behavior may be one of the more sensitive measures of difficulties adjusting to post-abortion.
As shown in Table 1 , a history of mental health problems is a risk factor for higher rates of mental health problems following abortion as compared to women without a history of mental health problems. This association has been known since at least when a case series identified several pre-existing mental health factors that could be used to identify the women who were most likely to experience subsequent psychopathology.
Both AMH proponents and AMH minimalists agree that prior health is a major factor in explaining the negative reactions observed post-abortion. There are differences, however, in how proponents and minimalists distinguish, interpret, and emphasize the interactions between prior mental health, the abortion experience, and subsequent mental health. AMH proponents see poor prior mental health as contributing to the risk that a woman a may become pregnant in problematic circumstances; b may be more vulnerable to pressure or manipulation to have an abortion contrary to personal preference, maternal desires, or moral ideals; and c may have fewer or weakened coping skills with which to process post-abortion stresses.
In addition, from the perspective of abortion as a potential stressor, women exposed to prior traumatic experiences may be more predisposed to experiencing abortion as another traumatic experience. In contrast, AMH minimalists tend to interpret the evidence that a high percentage of women having abortions have prior mental health issues as the primary explanation for higher rates of mental illness observed after abortion. It is also hypothesized that pregnant women with pre-existing mental health problems may be more inclined to choose abortion because they recognize that they are likely to fare worse if they deliver and try to raise an unplanned child.
While a few minimalists suggest that the underlying cause of mental health problems observed after abortion can be entirely explained by prior mental health defects or co-occurring stressors, 30 , 82 I have been unable to find any researchers who have denied that abortion can contribute to mental health problems.
Also, at least from the clinical perspective of AMH proponents treating women with a history of both abortion and abuse, a history of abuse may increase the vulnerability of women consenting to unwanted abortions. The differences between AMH minimalists and proponents on these issues will be more thoroughly discussed later. At this point, it is sufficient to note that both sides agree that poor prior mental health is a major predictor of higher rates of mental health problems after an abortion.
At the very least, a history of abortion is a useful marker for identifying women at greater risk of mental health problems and a corresponding elevated risk of a variety of related chronic illnesses and reduced longevity. Table 2 summarizes specific factual propositions to which the vast majority of both AMH minimalists and AMH proponents would agree. As indicated in the table, each side may typically emphasize some points over others and might underemphasize, reluctantly admit, or even evade discussion of some of these propositions.
Still, while some may quibble over the exact formulation of any particular proposition in Table 2 , the underlying consensus relative to each proposition is easily discernible in the body of references by both sides cited in this review.
In summary, the consensus of expert opinion, including that of both AMH proponents and minimalists, is that a a history of abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; b the abortion experience can directly contribute to mental health problems in some women; c there are risk factors, including pre-existing vulnerability to mental illness, which can be used to identify the women who are at greatest risk of mental health problems following an abortion; and d it is impossible to conduct research in this field in a manner that can definitively identify the extent of any mental illnesses following abortion, much less than the proportion of disorders that can be reliably attributed solely to abortion itself.
Facts are facts. But there is plenty of room for disagreement regarding which facts are generalizable, much less on how to best synthesize and interpret sets of facts, especially when there are flaws in the research and gaps in what one would want to know.
Indeed, the greater the ideological differences between people regarding any question, the easier it is to disagree about what the available evidence really means.
As shown in Table 2 , even areas around which there is a fundamental agreement by experts under sworn testimony may appear muddied by shifts of emphasis and the insertion of nuances that may be technically true but misleading to non-experts who imagine there are simple, global answers.
For example, the same APA task force which produced the list of risk factors shown in Table 1 did not highlight these findings in their press releases with a recommendation for screening. This statement was widely reported as the APA officially concluding that abortion has no mental health risks. But as shown in Table 1 , this reassuring conclusion was actually couched in nuances which make it applicable to only a minority of women undergoing abortions on any given day.
The above example demonstrates that the same set of facts, presented and interpreted by AMH minimalists in a way that suggests that few women face any risk of negative reactions to abortion, could also have been worded by AMH proponents in a way that would have underscored a conclusion that most women having abortions are at greater risk compared to the minority who have no risk factors.
Therefore, one of the purposes of the following discussion is to invite direct engagement and thoughtful responses to the specific obstacles identified below. These shortcuts or biases help us to a be more efficient in drawing conclusions and making decisions and also b be more consistent in how we perceive ourselves and reality, or conversely, to avoid the stress of cognitive dissonance which occurs when some fact or experience clashes with our core beliefs and values.
Our biases are not just personal. They also have a communal element. We tend to adopt the biases of our peers for several practical reasons. First, by adopting the opinion of our peers as our own, we are embracing a collective wisdom that frees us from the need to deeply research and consider every idea on our own.
Second, the more completely our beliefs are aligned within our community of peers, the less we will face conflict and suspicion. Obviously, there is never perfect alignment or cessation of independent thinking. The impact of biases among academics on the interpretation of data and suppression of contrary opinions has been well documented.
In the fields of psychology and psychiatry, such confirmatory bias may contribute to the promotion or suppression of research findings that favor liberal causes. While much of the confirmatory bias observed in peer reviewers may be unconscious, at least one survey of research psychologists found high rates of admissions that they or their colleagues would openly and knowingly discriminate against conservative views when providing peer review In regard to the abortion, mental health controversy, studies by AMH minimalists tend to be written in a way that minimizes any disruption of the core pro-choice aspiration that abortion is a civil right that advances the welfare of women.
Politics have also stood in the way of good research being conducted to examine psychological responses in a nationally representative sample to all pregnancy outcomes: live birth, miscarriage, induced abortion, and stillbirth and perhaps even including adoption. I offered in to our National Center for Health Statistics a simple mechanism for collecting such data via a short interview to be attached to an already existing survey—but fear of the answers—on both sides of the issue staunchly squelched the idea.
This concern is heightened by the refusal of AMH minimalists to allow examination of their data by AMH proponents, as will be discussed in more detail later. This leads us to an important and perhaps closely related observation.
It is not only political, philosophical, or ideological beliefs that contribute to the AMH controversy. Conflicts in the perceiving AMH controversy are also colored by direct and indirect personal experiences. The fact that pro-choice feminists are more focused on feelings of relief and other liberating aspects of having a right to abortion 3 may be accurately representing their own positive personal experiences.
Conversely, anti-abortion conservatives, who presume that AMH problems are common, may be accurately representing their own relative rate of exposure to negative experiences. A similar disparity relative to personality types was observed by Major et al.
Conversely, AMH proponents, especially those who directly meet and counsel women having problems dealing with past abortion 45 may have little or no experience with women who have had positive abortion experiences. The concentrated experience of meeting with scores or hundreds of women struggling with past abortions would understandably incline AMH proponents to believe that negative experiences with abortion are more common than positive ones.
A victim of verbal, emotional, and physical abuse, including three incidents of sexual molestation, she has low self-esteem with bouts of anxiety, depression, and suicidal ideation. While her parents are not regular churchgoers, she attended a Catholic grade school, believes in God, and believes abortion is the killing of a baby.
She is not a good student and has no concrete career goals. She has always wanted to be a mother, loves babies, and fantasizes about how she will find fulfillment in giving the love to her children that she never received from her own mother. When she learns she is pregnant, her initial reaction is excitement. While not planned, the pregnancy is welcomed.
She believes she can now start building a family with her lover. She feels she has no choice. In addition, her parents would be furious and insist on an abortion, too. Indeed, given her need to please others, she gives in with barely a complaint. She begins to have obsessive thoughts. Her baby is no longer in her body, but it is constantly in her thoughts.
She has no history of mental illness and has a good family life. Her parents were both well-educated secularists. They preach education, hard work, and honest success as the only ethical standards Betsy needs to guide her. Betsy is popular, has many friends, and has always had high career aspirations, toward which, with grit, she has proudly made good progress.
Even as a child, Betsy had little or no interest in being a mother. Married to her career, she now has even less interest in maternity. Having successfully used birth control since she was 15, when her mother got her an IUD, Betsy is shocked when she realizes she is pregnant. But contraceptive failures happen. Her decision to abort is immediate and made without any emotional conflict.
When she flips through the state mandated informed consent booklet given to her at the abortion clinic, the pictures of developing fetuses have no effect. Betsy has seen similar photos many times in the past. Betsy is not surprised when her abortion is completed without drama or even a tinge of angst.
She thinks of it rarely. The only negative feelings ever associated with it come when she hears the right of women to choose abortion attacked by self-righteous busybodies who should know better. One is focused on her loss and the other on how her abortion helped her to avoid any loss. Given these differences, it would be unfair to them try to interpret their abortion experiences from within a single ideological framework.
Similarly, the women who reside at different places along the wide spectrum between the extreme poles of Allie and Betsy are also very different and unique. We will employ Allie and Betsy in our discussion later in this review.
Despite the convenience of standard diagnostic criteria, mental illnesses do not necessarily fit into neat, single classifications with distinct and exclusive symptoms arising from a single cause for each illness. A psychiatric complication is a disturbance that occurs as an outcome that is precipitated or at least favored by a previous event …. Every psychiatric outcome is of a multi-factorial origin.
Predisposing factors including polygenic influence and precipitating factors such as stressful events are involved in this outcome; in addition, there are modulating, both risk and protective, factors. The impact of the events depends on how they are perceived, on psychological defense mechanisms put into action unconscious to a great extent and on the coping style.
An abortion does not occur in isolation from interrelated personal, familial, and social conditions that influence the experience of becoming pregnant, the reaction to discovery of the pregnancy, and the abortion decision. These are all parts of the abortion experience. Therefore, the mental health effects of abortion cannot be properly limited to the day on which the surgical or medical abortion takes place. The entirety of the abortion experience, including the weeks before and after it, must be considered.
Moreover, there is no reason to believe that there is a single model for understanding, much less predicting, all of the psychological reactions to the abortion experience.
Miller alone identified and tested six models for interpreting psychological responses to abortion and concluded that. To some extent what appears to happen following abortion involves not so much a unitary as a broad, multidimensional affective response.
The complexity of considering so many models, or pathways, combined with the multiplicity of symptoms women attribute to their abortions, 45 contributes to discord in the literature produced by AMH proponents and AMH minimalists.
When there is no agreement on what outcomes are relevant or what theoretical pathways should be investigated, there are countless reasons to disagree about both a the adequacy of any specific studies and b how any specific set of findings should be best interpreted.
The act of undergoing an abortion can be both a stress reliever and a stress inducer. Positive and negative feelings can co-exist and frequently do. Almost one-half also had parallel feelings of guilt, as they regarded the abortion as a violation of their ethical values. Applying this insight to our polar extremes, Annie All-Risks would be more likely to experience strong negative feelings more profoundly than her feelings of relief, whereas Betsy Best-Case would be more likely to focus on her relief than any doubts or reservations.
Moreover, because Annie has low expectations for coping well itself a TFMHA risk factor , she may be less likely to agree to participate in a follow-up study. The faster she can get out of the abortion clinic without talking to anyone, the better. Conversely, Betsy is confident that her decision is right and will improve her life and is therefore much more likely to participate.
Obviously, it is impossible to know what the most common reaction of women is based on surveys of only a minority of self-selected women. This insight also underscores the difficulty of making any generalizations regarding prevalence rates from any study involving volunteer participation or questionnaires.
Broadly speaking, there are three groups of women: a those with no regrets or negative feelings, b those with deep regrets and profound negative feelings, and c those with a mix of feelings, including contradictory feelings. As discussed above, the best evidence indicates that women with the most negative feelings are least likely to agree to participate in studies initiated at abortion clinics.
But it also follows that women with no regrets are unlikely to be represented in studies of women seeking post-abortion counseling. Not all negative emotions constitute a diagnosable mental illness.
Therefore, the fact that only a minority of women have diagnosable mental illnesses following abortion does not preclude the possibility that a majority experience negative emotional reactions. Structured interviews of women who received abortions at participating clinics reveal that the majority report at least one negative emotion that they attribute to their abortions.
The opinion that negative reactions are experienced by the majority of abortion patients is also shared by a number of abortion providers, such as Poppemna and Henderson: The sorrow is revealed by the fact that most women cry at some point during the experience …. The grieving process may last from several days to several years. Similarly, Julius Fogel, who as both a psychiatrist and OB-GYN and as a pioneer of abortion rights performed tens of thousands of abortion, testified that while abortion may be necessary and generally beneficial, it always exacts a psychological price:.
Every woman—whatever her age, background or sexuality—has a trauma at destroying a pregnancy. A level of humanness is touched.
This is a part of her own life. When she destroys a pregnancy, she is destroying herself. There is no way it can be innocuous. One is dealing with the life force. It is totally beside the point whether or not you think a life is there. You cannot deny that something is being created and that this creation is physically happening …. But it is not as harmless and casual an event as many in the pro-abortion crowd insist. A psychological price is paid. It may be alienation; it may be a pushing away from human warmth, perhaps a hardening of the maternal instinct.
I know that as a psychiatrist. This distinction between negative reactions and diagnosable mental illness is another important reason why AMH proponents and minimalists appear to disagree more than they really do. In short, if pressed, both sides would agree that the best evidence indicates that most women do experience at least some negative feelings related to their abortion experiences. Yet at the same time, the majority do not experience mental illnesses as defined by standard diagnostic criteria that can be solely attributed to their abortions.
Majorities matter in elections. But in regard to medical ethics and public policy, negative reactions are important among even a minority of patients … especially when it is possible to screen for risk factors that identify the patients at greatest risk of adverse reactions.
Most studies can only capture evidence spanning very limited timeframes. In the s and s, most studies of emotional reactions after abortion were based on volunteer samples limited to a few hours, days, or weeks after the abortion.
Early reactions, however, are not necessarily predictive of longer range reactions. In addition, the self-selection bias of this volunteer sample was further magnified by the study protocol that also excluded women aborting an intended pregnancy or a second trimester pregnancy, two of the risk categories for elevated risk of negative reactions. The fact that negative reactions may unfold over a long period of time is also evident from retrospective surveys.
It is likely that there are patterns relative to which women are at greater risk of experiencing early negative reactions and those who are likely to experience later reactions. After all, she felt coerced into aborting an unplanned but welcomed pregnancy against her maternal preferences and moral beliefs. In addition, given her history of abuse and psychological problems, her coping skills were already stretched to the limit prior to her abortion.
Similarly, it is also easy to imagine that Betsy Best-Case would cope well in the immediate hours, days, months, and even years after her abortion. She freely chose to abort a pregnancy that was both unintended and unwanted for rational reasons. Clinical experience indicates, however, that there is no certainty that Betsy will always remain symptom free. Subsequent reproductive events such as miscarriage, infertility, or even a wanted birth may unexpectedly trigger existential crises deeply intertwined with a nearly forgotten abortion experience.
I had an abortion when I was 22 years old. Now it is haunting me. I think about it every day of my life. I have so much regret. I wish I could turn the clock and undo my mistakes. I am not coping. The guilt is too much. At that time the decision was perfect. But now it kills me day by day. Please help me.
Whatever the trigger, whatever the contributing factors, the internal turmoil over a past abortion is centered on, or at least intertwines with, the abortion and will not be resolved by pretending the abortion is not part of the problem. The great variability in the time frame for negative reactions greatly complicates the interpretation of studies examining limited time frames, and even those covering long time frames but at infrequent intervals.
Moreover, the single year in which depression was evaluated in the NLSY could only provide a bit of cross-sectional information about the women surveyed. Cross-sectional data regarding current symptoms will simply miss symptoms that have ceased, either due to medication, counseling, or by the healing effects of time or a replacement pregnancy.
It will also miss symptoms that may be delayed beyond the date of the assessment. The weakness of such general purpose prospective studies also explains why AMH proponents and AMH minimalists can look at the same data and come to different conclusions. Notably, their analysis also excluded results segregated by marital status, the finding most significant in the earlier study. Based on these weaknesses, it was simply misleading for Schmiege and Russo 69 to interpret their reanalysis as conclusive evidence that abortion does not contribute to the risk of depression in some women.
In summary, the efforts to estimate the prevalence rate of negative reactions to abortion are complicated by a the wide variety of reactions, b the existence of both early and delayed reactions, c a wide variety of triggers for delayed reactions, and d the prospect that in any assessment years after the abortion, a number of women who previously had significant reactions may have experienced full or partial recovery by the time of that assessment.
Each of these factors would tend to skew the results of any prevalence estimates based on questionnaires toward underestimating the total lifetime risks. Data collected to investigate reactions to abortion may also be distorted by any number of defense mechanisms.
Avoidance, denial, repression, suppression, intellectualization, rationalization, projection, splitting, and reaction formation may all contribute to the conscious or unconscious underreporting of symptoms attributable to unresolved abortion issues. Active defense mechanisms are also the most likely explanation for selection bias and the high rate of concealing abortion history found in national longitudinal studies. Avoidance, and other defense mechanisms, clearly works.
Research has shown that the subset of women who anticipate the most difficulty dealing well with their abortions are right; they do have higher rates of negative reactions. Clearly, women who feel more stress at one wave may be more likely to decline to participate again in subsequent waves.
These findings are consistent with studies showing that women refusing to participate in follow-up studies are likely at greater risk of negative reactions to their abortions.
Notably, the act of avoiding a post-abortion evaluation may itself be evidence of a post-traumatic stress response. A study of employees exposed to an industrial explosion revealed that those employees who were most resistant to a psychological checkup following the explosion had the highest rates and most severe cases of PTSD. Our understanding of defense mechanisms also suggests there may be cases where the denial of a link between abortion and abortion-specific symptoms is evidence of both avoidant behavior and an elevated risk of mental illness.
It seems likely that defense mechanisms may contribute to a significant underreporting of negative reactions, especially in survey responses. Conversely, questionnaire-based reports may also lead to the exaggerated rating of some positive reactions due to splitting or reaction formation. The statistical impact of defense mechanisms is also double edged. First, self-censure, dropouts, and concealment of past abortions are all likely to suppress measurements of the prevalence rate of mental illnesses among those volunteers admitting to a past abortion.
Second, comparison groups that include women who conceal their history of abortion who are most likely to have AMH effects are likely to have inflated prevalence rates for mental illness due to the misclassification of women with a history of abortion into the comparison group of women who, according to the study design, have not been exposed to abortion. It is also worth noting that defense mechanisms may also impede the ability of women to receive good follow-up care.
This phenomenon may be at least partially due to defense mechanisms employed by healthcare professional professionals themselves. Since it is impossible to randomly assign women to different groups to be exposed to abortion or not, there are no true control groups in relation to abortion among humans.
Given this limitation, comparisons to other groups of women who have not been exposed to abortion are the only option. While no comparison group is perfect, — nearly every comparison can be useful for teasing out patterns that may help to inform patients and caregivers regarding the many varieties of abortion experiences.
Comparisons have been made to each of the following: the general population of women, 77 , women who have never been pregnant, 94 women with no reported history of abortion, 74 , 84 , 85 , 91 , 92 , 94 , 95 , , women giving birth, 30 , 69 , 71 — 73 , 75 — 77 , 81 , 83 , 86 — 90 , 94 , 97 — 99 , women giving birth to a first pregnancy, 69 , 86 , women having miscarriages or other involuntary losses, 81 , 88 , 91 , 94 , — women experiencing both births and pregnancy loss abortions or miscarriages , 69 , 82 , women giving birth to unintended pregnancies, 69 , 72 , 75 , 76 , 86 , 90 , 92 , 98 and women denied abortions.
Notably, most of these comparisons are based on general-purpose longitudinal cohort studies. As discussed previously, due to the temporal limits, cross-sectional data, self-selection bias, concealment, and the misclassification of women with an abortion history into the comparison groups, the results of these studies most certainly skew toward underestimating the true relative risks between the groups compared.
Still, while every choice for a comparison group is imperfect, , below we will argue that there are valid insights that can be gained by every comparison. Acting on that premise, many researchers have chosen to simultaneously compare women who abort to multiple other groups whenever the data allow it. By contrast, Charles et al. Second, as Romans has convincingly argued, the differences in women who choose to carry an unintended pregnancy to term and those who abort are simply immeasurable.
No conceivable comparison between the two groups can control for all the possible variations between them.
These findings are meaningful and actionable since they should be used to guide pre-abortion screening and counseling and post-abortion care 25 and for informed consent procedures. Third, the argument for discounting studies that lack information on pregnancy intention appears to have been advanced primarily as an excuse to denigrate the majority of studies on AMH.
The highly biased and subjective application of Charles et al. Moreover, Charles et al. Thus, by ignoring issues related to selection bias, the Charles et al. The fact that Charles et al. In response to Charles et al. I argue that, while no comparison is perfect, every option for a comparison group can be a useful tool in developing a multidimensional perspective on the complexity of AMH issues. First, comparisons to women with a history of abortion and the general population of women provide a useful baseline, especially when combined with comparisons to women who miscarry or carry to term.
For example, a record linkage in Finland revealed that the age-adjusted risk of death within a year of pregnancy outcome was 5. Suicide attempt rates per , women before and after designated pregnancy outcome.
Source: Morgan et al. Comparisons to women who have never been pregnant nulligravida are especially important when the aborting women have no live born children. Another important comparison is between women who have induced abortions and women who miscarry. Both have experienced the effects of pregnancy, which may produce long-lasting changes to the brain, , , and maternal attachment. Moreover, this comparison may allow insights into the psychological differences between intentionally choosing the end of a pregnancy versus an unintended loss, both of which may be experienced as a form of disenfranchised grief.
Comparisons to women giving birth are also meaningful. Comparisons between women aborting a first pregnancy and women carrying a first pregnancy to its natural conclusion birth, miscarriage, or neo-natal loss are extremely valuable. By excluding the confounding effects of multiple pregnancy outcomes, these studies offer at least a small window on the effects associated with exposure to a single pregnancy outcome.
Moreover, they are the proper starting point for investigating the interactions between multiple pregnancy outcomes. This is important since significantly different outcome patterns have been observed relative to multiple pregnancy outcomes and their sequences, including both multiple losses and losses followed or preceded by live births.
As will be discussed further, we recommend that the best practice for all studies examining the interactions between mental and reproductive health is to include stratification of results by the order and number of exposures to births, abortions, miscarriages, and other pregnancy losses.
In addition, we would note that the argument of Charles et al. For all the reasons given above, the best evidence indicates that reasonable patients may consider any and all of the comparisons discussed above to be of value in their efforts to evaluate the potential risks and benefits of an abortion in their own personal circumstance 23 ,
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