Dear AAPLOG Colleague: Regarding the “original article” found in the Jan 27, 2011 New England Journal of Medicine (pages 332-339) entitled Induced First-Trimester Abortion and Risk of Mental Disorder, by Trine Munk-Olsen, Ph.D., et. al.: This study concludes that the evidence does not support the hypothesis that there is an increased risk of mental disorders after a first-trimester induced abortion. It is interesting that the New England Journal of Medicine, given it’s prestigious reputation, would choose to publish a study with so definitive a conclusion, based (as it is) on less than 39% (see below) of women having an abortion. And from that number, the authors “cherry pick” the more healthy ones (ie, they excluded many women with a previous psych history, and women with previous psych history are known to have a higher incidence of post abortion mental health problems.) We try hard to adhere to “evidence based medicine.” This article is a fine example of “conclusion-based medicine,” i.e., one establishes a conclusion, and then makes the “evidence” fit that conclusion. Certainly, an isolated study does not establish scientific fact. This Danish study must be balanced by a comparison to the large number of studies that conclude that there is indeed, for many women, a serious and long lasting untoward result on their mental health wholeness. For a synopsis of several recent studies, we suggest the reader go to https://www.aaplog.org/complications-of-induced-abortion/induced-abortion-and-mental-health/ Here one will find abundant evidence, by researchers at least as qualified as the Danish group, of the opposite conclusion for many women who have experienced an induced abortion (50% of abortions are repeat abortions, and the Danish study does not even comment on this half of the affected population. Additionally, 11% of abortions happen after the first trimester, and these women are likewise not included in this analysis.) This is such a crucial discussion for the 1/3 of the women of reproductive age in this country (the number who have experienced induced abortion), that it surely merits a balanced look at the bulk of the studies done. These women deserve no less from those responsible for their healthcare. For a more extended critique of the NEJM study, we offer the following analysis by Dr. Priscilla Coleman : Comments regarding the study by Danish researchers Munk-Olsen, Laursen, Pedersen, and colleagues in the 1-27 11 NEJM addressing the risk of mental health disorders in women who have a first trimester abortion and those who experience a first childbirth. The researchers focus on the fact that there is not a statistically significant difference in first-time inpatient admissions and outpatient psychiatric visits before and after an abortion, concluding that it is unlikely that the abortion procedure causes mental health problems. However there are some major problems with this conclusion. First, the measure of pre-abortion mental health is likely high (more than 3 times greater than prior to birth, 14.6% vs. 3.9%), because many of the women were probably in the midst of abortion decision-making when they experienced their first psychiatric visit. This high rate of pre-abortion mental health problems is construed to indicate that women who choose abortion will often experience mental health problems based on factors other than the procedure. In fact, the women in the sample are quite unlikely to fall into this “vulnerable” category since none of the women included in the study had any history of psychological diagnoses prior to 9 months before the abortion. These researchers used a window of 0-9 months to measure pre-abortion mental health; however, the assessment should instead have been before the pregnancies were detected. The data do indicate that rates of mental health problems are significantly higher after abortion compared to after childbirth (15.2% vs. 6.7%) and compared to not having been pregnant (8.2%). The bottom line is the fact that they found comparable rates before and after abortion does not negate a possible causal link between abortion and mental health. This is true because many women were likely disturbed to the point of seeking help, because they were pregnant and contemplating an abortion or had already chosen one and were awaiting the procedure. There are numerous published studies indicating high levels of stress among women facing an unplanned pregnancy and considering an abortion. Second, the authors note in the beginning of their article that previous studies lack controls for third variables, but the only third variables they consider are age and parity. There are no controls for pregnancy wantedness, coercion by others to abort, marital status, income, education, exposure to violence and other traumas, etc. Many studies have been deemed inadequate based on only one of these variables not being accounted for (see APA Task Force Report, 2008), yet the study design was considered adequate to merit publication in the NEJM. Third, all women who had psychiatric histories more than 9 months prior to the abortion were not included in the study and there are many studies showing that these women are at heightened risk for post-abortion mental health problems. In this study, the researchers have narrowed the participant pool to only the healthiest of women and there are high rates before and after abortion…imagine if all women had been included! Women who experience repeat abortions are likewise not considered at all and they are more likely to be at risk for mental health problems post-dating the procedure. Fourth, the results follow women for only one year post- abortion or childbirth and there is plenty of evidence suggesting that the negative effects of abortion may not surface for several years. There is also data indicating that women are most likely to experience postpartum psychological problems soon after birth with the benefits of motherhood often manifesting later than the first year wherein many life-style adjustments are necessary. A more appropriate analytic strategy would have been to include all women experiencing an abortion, a birth, or no pregnancy and then compare pre and post-pregnancy mental health visits with statistical controls for all psychiatric visits pre-dating conception and all other relevant third variables described above. I am confident that the data would then be quite consistent with the dozens of studies published in recent years in high impact journals indicating that abortion increases risk for a variety of mental health problems. Even without appropriate improvements to the design, the data reported does indicate increased rates of particular diagnoses at specific points in the first year. Relative risk for psychiatrics visits involving neurotic, stress-related, or somatoform disorders was 47% and 37% higher post-abortion compared to pre-abortion at 2 and 3 months respectively. In addition, psychiatric contact for personality or behavioral disorders was 56%, 45%, 31%, and 55% higher at 3, 4-6, 7-9, and 10-12 months respectively. Priscilla K. Coleman, Ph.D. Professor of Human Development and Family Studies 16D FCS Building Bowling Green State University Bowling Green, OH 43403
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