‘Abortion does not cause mental illness’. Discuss.

A new factsheet produced for schools by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Faculty of Sexual and Reproductive Healthcare (FSRH) states as one of the ‘myth buster‘ headlines that ‘abortion does not cause mental illness’.

Underneath the headline they explain: Successive studies and research reviews have demonstrated that the experience of abortion makes little or no difference to women’s mental health.

This ‘myth buster’ headline needs some myth busting.

The question of whether abortion is linked to mental health problems in women is very important and has long been a debating point. Journalist Caitlin Moran made the following astonishing claim about the effects of abortion her regular Saturday Times column on 23February  2019:

‘Since legalisation, 8.7 million safe, legal terminations have been carried out – and there is not a single survey or statistic  that shows any negative impact from this. If you want to point at the downside of legal abortion, you cannot do it using any evidence.’ (her emphasis)

I would hope that even the RCOG might have some objection to Moran’s false claim. The RCOG cite a well-known, NHS funded, review of abortion and mental health in their fact sheet, a review that quite clearly states there are some negative mental health consequences from some abortions.

So is the RCOG correct to say ‘Abortion does not cause mental illness?’ What does peer reviewed evidence show?

Assessing the effect of abortion on mental health is complex and controversial and findings are frequently conflicting. Even though studies may show an association or link between abortion and a subsequent health effect, the way that studies are designed mean that we cannot always be certain that the abortion definitely causes the health effect. It is simply not possible to conduct a randomised controlled trial assigning some women to an abortion group and others to a birth group.

One problem with even some of the best known and most widely cited research studies is choosing what groups to compare with women who have an abortion (Women who have had a miscarriage? Given birth? Women who have never been pregnant? With an intended pregnancy or not?) because there is no direct equivalence. Then there is selection bias (many studies have high drop-out rates and low recruitment rates) because those who are least likely to participate will be those most affected negatively by the abortion. And many studies simply fail to follow up women long enough after the initial study – often women cope well initially, but years later reappraise the abortion negatively.

So, reviews of the psychological effects of abortion have arrived at disparate conclusions.

However as noted above, there was a comprehensive, NHS funded, review into the mental health outcomes of abortion, carried out in the UK in 2011, which the RCOG reference, and this found that having an unwanted pregnancy is associated with an increased risk of mental health problems. However, it found that the rates of mental health problems for women with an unwanted pregnancy were the same, whether they had an abortion or gave birth. In other words, abortion made no difference to the outcome.

It appears then, that the RCOG fact sheet sub-heading may be correct, according to this review.

But it is not quite so simple.

The review also found that women who have mental health problems before an abortion are at greater risk of mental health problems afterwards. And it found that several other factors such as stressful life events, pressure from a partner to have an abortion, a negative attitude towards abortion in general and a negative emotional reaction immediately following an abortion (which are all common feelings), also have a negative impact on mental health.

So, for these women, it suggests abortion is a risk for causing mental illness.

Prof David Fergusson, veteran research in the field who said he was not ‘pro-life’ and is cited in the review, published a number of his own peer reviewed papers on abortion. He found small to moderate increases in risks of some mental health problems post-abortion.  See here for more of his research, in the British Journal of Psychiatry, 2018.

A brief but important aside here, Fergusson also noted that no study has reported that abortion reduces mental health risks.

There is a growing body of evidence that suggests that women are at an increased risk of mental health disorders, notably major depression, following abortion, even with no previous history of problems. Researchers not associated with vested interest groups have published this growing scientific evidence. As well as Fergusson, Pedersen and Broen have found similar links in Norway, along with Mota in the USA.

Then there are researchers who are known to be more ‘pro-life’ who have also published extensively in academic journals on this topic for many years. See for example Sullins, Reardon, Rue and Coleman (summarised here). Coleman’s findings suggest a clear link between abortion and adverse mental health effects. She found that nearly 10% of all mental health problems are directly attributable to abortion, and women with an abortion history experience nearly double the risk of mental health problems when compared with women who have not had an abortion.

Coleman’s work has strengths and weaknesses. It was published in the British Journal of Psychiatry, passing extensive scrutiny, and is a meta-analysis of 22 published studies, with nearly 900,000 participants. However, it has several methodological weaknesses that have been criticised by researchers who have come to different conclusions.

Yet Fergusson, who described himself as a pro-choice atheist, defended Coleman and concurs with her overall finding: ‘There is a clear statistical footprint suggesting elevated risks of mental health problems amongst women having abortions.‘

Women – and now school girls – are being told that abortion is an emotion-free, quick and safe process requiring a simple operation or a couple of pills. They are entitled to be told that it is more significant than this and that there is evidence (despite the claims of Caitlin Moran) for associated mental health risks. Moreover, many women who present for abortion are ambivalent which is a known risk factor for later adverse effects.

For those still not persuaded by the research evidence on the link, perhaps a visit to a local crisis pregnancy centre, or a read of some of these stories of women who have undergone an abortion might help bust the myths.