Sarah K. Rivelli, MD. System Director, Consult Liaison, Department of Psychiatry and Behavioral Medicine, Carilion Clinic. Dr. Rivelli has no financial relationships with companies related to this material.
Your patient became pregnant during a recent manic episode and seeks guidance on her options. She is worried that her mental health will worsen if she keeps the baby, while her family is concerned that termination puts her at risk for becoming less stable.
Abortion is becoming more difficult to obtain in the United States, and the arguments against legalization of abortion include the claim that it is harmful to a woman’s mental health. This is particularly relevant for psychiatric patients, who often suffer from behavioral problems that place them at risk for unwanted pregnancies and abortion. In this article, we’ll explore that claim and look at the psychiatric impact of abortion.
In 2011, a controversial review in the British Journal of Psychiatry concluded that elective abortions increase a woman’s risk of mental health problems by 81%, and that abortion is responsible for one in 10 mental health disorders among women (Coleman PK, Br J Psychiatry 2011;199(3):180–186). A vigorous round of letters followed, robustly critiquing the review’s methodology, results, and conclusions, and even calling for retraction. The Academy of Medical Royal Colleges conducted an independent review on the topic. They found methodologic flaws with the 2011 review and argued that the study could not qualify as a systematic review. Women with unwanted pregnancies, they concluded, have the same risk of psychiatric problems whether they seek an abortion or carry the pregnancy to term.
Some scientists noted that the review’s author was a known antiabortion activist, but in fairness, the critics may have had political biases of their own. Lacking randomized controlled trials, studies can only compare groups of women who chose to have an abortion with those who did not, and those populations differ in many ways beyond the abortion itself.
Abortion is a common procedure. About one in three women in the US will have had an abortion by the time they are 45 years old. Women seek to terminate a pregnancy for various reasons, many of which overlap with risk factors for mental illness. Poverty, lack of social support, being too young, needing to complete education, employment considerations, and intimate partner violence are among the most common.
Early studies suggested that psychiatric problems are more common after an elective abortion, but that difference disappeared when investigators controlled for preexisting mental illness. For example, the National Comorbidity Study assessed 936 women with a structured DSM-IV psychiatric interview, 28% of whom had had an elective abortion. Compared to women who carried their pregnancy to term, those who chose abortion had higher rates of mood and anxiety disorders, substance use disorders, or suicidal ideation (Steinberg JR et al, Obstet Gynecol 2014;123(2 Pt 1):263–270). That difference disappeared, however, in a later analysis that controlled for preexisting psychiatric problems.
Controlling for confounding variables is an imprecise science, so a cleaner approach would be to compare groups of women who are similar in most respects except for the elective abortion. The Turnaway study came close to that ideal (Horvath S and Schreiber CA, Curr Psychiatry Rep 2017;19(11):77). All of the 956 women from 21 states in this study had unwanted pregnancies and sought an abortion. However, 543 were denied abortion because their gestational age was slightly past their state’s legal limit for elective abortion, which ranged from 10 weeks to the end of the second trimester. Twenty-one percent of those turned away went on to have an abortion elsewhere during the study period, and the authors were able to examine those women separately as well.
At first, mental health appeared worse among those denied an abortion, with higher rates of anxiety, low self-esteem, and poor life satisfaction in this “turned-away” group (Horvath and Schreiber, 2017; Biggs MA et al, JAMA Psychiatry 2017;74(2):169–178). However, those differences settled over the next six to 12 months, suggesting only transient symptoms rather than actual disorders. On follow-up five years later, 95% of the women who’d had an abortion felt it was the right decision.
The Turnaway study also looked at posttraumatic stress symptoms using the Primary Care PTSD Screen. Though nearly half (39%) of the women had PTSD symptoms, the rates were similar for those who had abortions and those who gave birth (Biggs MA et al, BMJ Open 2016;6(2):e009698). Most of these PTSD symptoms were due to sexual, emotional, or physical abuse rather than abortion or pregnancy. Other prospective studies have also found no evidence of posttraumatic symptoms after an elective abortion (Biggs et al, 2016).
The Turnaway study suggests that being denied an abortion may be detrimental to mental health, as does another study of women who became pregnant prior to the 1973 Supreme Court decision that legalized abortion in the US. This study compared women with unwanted pregnancies who could not abort to women with planned pregnancies. When the women were followed up 35 years after childbirth, the rates of both depressive symptoms and full clinical episodes were higher among those who carried unwanted pregnancies to term, even after controlling for confounders like socioeconomic status (Herd P et al, Am J Pub Health 2016;106(3):421–429). Studies of more recent cohorts support that trend. Postpartum depression is more common when women give birth after an unintended pregnancy, and it is also more common in states that prohibit Medicaid funding of abortions (Steinberg et al, 2014; Medoff MH, Soc Work Public Health 2014;29(5):481–490).
Putting it into practice
Elective abortions are unlikely to harm or help a woman’s mental health, and we can tell our patients that fears of psychological consequences need not guide their decision. This may conflict with the official messages they receive. In some states, abortion providers are required to warn patients that the procedure can impair their ability to bond with future children or cause mental health problems such as depression, substance use disorders, or suicide (particularly Kansas, Louisiana, Michigan, Nebraska, North Carolina, South Dakota, Texas, and West Virginia, according to the Guttmacher Institute).
There is no evidence to support those claims. Rather, it is the circumstances surrounding abortion that can impact mental health, such as feelings of stigma, perceived need for secrecy, exposure to antiabortion picketing, and low social support for the abortion decision (American Psychological Association. Report of the APA Task Force on Mental Health and Abortion; 2009). We can help our patients by listening without judgment, encouraging open dialogue, and helping them connect with social and community supports.
Carlat Verdict: Whether or not to terminate a pregnancy is a personal and individual decision. Unwanted pregnancies and the stressors that accompany them may worsen mental health, but we can let our patients know that abortion itself does not.
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