A new study in the Harvard Review of Psychiatry called “Is there an ‘Abortion Trauma Syndrome?’ Critiquing the Evidence” looks at all of the studies related to abortion and mental health to conclusively determine what impact, if any, abortion has on a woman’s mental health. “Abortion trauma syndrome” has also been called “post-abortion syndrome.” In a review of 216 peer-reviewed articles on the subject of abortion and mental health, the authors of this study found that “the most well controlled studies continue to demonstrate that there is no convincing evidence that induced abortion of an unwanted pregnancy is a per se significant risk factor for psychiatric illness.” (p. 276)

For starters, let’s contextualize abortion. According to the 2005 World Health Report

• 211 million pregnancies occur worldwide each year; 46 million end in induced abortions.
• 40% of these abortions occur in unsafe conditions, resulting in 68,000 maternal deaths.
• In the US, 1.3 million of the 6 million pregnancies each year end in induced abortion.
• 20% of American women have had an abortion.
• The risk of death in the US from abortion is 1:160,000, which is lower than the risk of death from childbirth, appendectomy, or tonsillectomy.

Given the relatively low risk of death, the debate about abortion has shifted to focus on the perceived mental health impacts of abortion in order for abortion opponents to claim that they are concerned about the health and welfare of women.  However, “Abortion Trauma Syndrome” and “Post-Abortion Syndrome” are not recognized by the American Psychiatric Association as mental illnesses, and they are not listed in the Diagnostic and Statistical Manual of Mental Disorders.

In their review of 216 peer-reviewed articles on the topic of mental health and abortion, the authors found numerous methodological flaws with the studies that purport to find a link between abortion and mental health.

1. Sampling Errors

According to the authors, “in some of the studies of abortion outcome, researchers recruited women who had already self-identified as suffering negative psychological effects from abortion, and then used the self-reports of these women as evidence for high rates of ill effects in all women who have had abortions.” (p. 270)

Some of the surveys asked respondents to report on the effects of their abortion years after the event actually occurred.

The use of retrospective reports from women who had an abortion years earlier is problematic. Recall bias can affect any individual’s perspective on a historical event. Mood-related memory effects also may bias recall of both the abortion experience and the timing of previous psychiatric episodes–especially if many years have passed. Later feelings about abortion may be influenced by subsequent reproductive experiences, failure to recall the circumstances leading to the decision to abort, current depression related to stressful life events, or the effects of public campaigns attributing psychological problems to abortion. (p. 270)

Additionally, studies must be limited to women who have had abortions within the first trimester if they are to be representative of all abortions, because most abortions (88.7%) occur within the first twelve weeks of pregnancy. (Source: Guttmacher Institute)

Delay in seeking abortions may be related to inadequate coping mechanisms, more ambivalence, less social support, barriers to access, poor maternal health, and detection of fetal abnormalities (which may involve terminating a wanted pregnancy).

All of these factors can independently effect a patient’s mental health. Therefore, it is inappropriate to generalize these experiences to that of all women who seek abortions.

2. Selection of Comparison Groups

According to the authors:

Some studies of abortion fail to use a comparison group, or use as a comparison group women in general or women who have never been pregnant, who have never delivered (with the wantedness of the pregnancy unspecified) but have never had an abortion, who are currently pregnant who had a spontaneous abortion, or who have delivered following wanted pregnancies . . . [These circumstances] are not comparable to those associated with a voluntary, elective abortion . . . At a minimum, the appropriate comparison group for assessing the relative risks of negative mental health outcomes of such abortions is women who carry unwanted pregnancies to term. An unwanted pregnancy is different from an unplanned pregnancy. Women with unwanted pregnancies are more likely to suffer from a number of co-occurring life stressors, including childhood adversity, relationship problems, exposure to violence, financial problems, and poor coping capacity, all of which contribute to emotional distress. These factors increase the risk of poor mental health, whether or not a woman has an abortion.  (p. 270, emphasis mine)

3. Independent and Dependent Variables

If you’ve taken a basic stats class, you know that independent and dependent variables can effect the outcome of a study. One of the flaws in many of these studies was that depression is not defined by the researcher, and many of the studies had respondents self-report feelings of depression, rather than including a clinical diagnosis of depression from a physician. “Depressive feelings should be distinguished from clinical depression,” and “feeling regret is not a psychiatric condition . . . Moreover, few studies ask about positive outcomes that may offset any existing negative feelings or put them in perspective; for example, women may feel slightly sad and guilty about having an abortion, but extremely relieved and satisfied with their decision.” (p. 271)

Many of these studies also failed to take into account the context in which women receive services.

• Did the women have to travel far distances to obtain an abortion?
• Was there a waiting period involved that delayed the abortion?
• Did the patient have to walk through a crowd of protesters in order to enter the clinic?
• Did the physician read a state-mandated script about abortion that described (with varying levels of scientific accuracy) the risks of abortion, fetal development up to the term, and unsubstantiated allegations of fetal pain at early periods of gestation?

All of these questions may impact the woman’s feelings about her abortion.  Ironically, any negative mental health outcomes of abortion can be directly attributed to the anti-choice movement itself, which is purportedly seeking to protect women from negative mental health impacts. On the other hand:

[Entering] abortion clinics through a group of anti-abortion demonstrators [is] a stressor that has been shown to be associated with psychological distress . . . [And] increasing a women’s belief in her ability to deal with having an abortion decreased her likelihood of experiencing depressive symptoms following abortion. Such findings suggest that insofar as inaccurate “informed consent scripts” undermine a woman’s belief in her ability to cope after an abortion, they may contribute to her risk for depression. (p. 270, emphasis mine)

After analyzing all of the possible variables that could effect the outcome of these studies, the authors concluded that “even if a study were to include all know covariates, however, it is essential to remember that correlation does not prove causality.” (p. 272)

It is true that some women have feelings of sadness or regret, and that some women can be made to feel stigmatized and guilty, about choosing to terminate an unwanted pregnancy. For women who have more significant problems, the causal contribution of the abortion is not clear; a wide range of factors, both internal and external, affect women’s responses–and interact in complex ways. These women should receive appropriate support and counseling. It should also be remembered that the best predictor of mental disorder after an abortion is a pre-exsiting mental disorder, which is strongly associated with exposure to sexual abuse and intimate violence; to ignore these factors would be potentially to ignore the actual causes of women’s distress following an abortion.

Conclusion

Aside from the obvious questions this study raises about the intentions of the researchers who claim a link between abortion and mental health, I think it’s important to contextualize the idea of a “post-abortion syndrome,” or “abortion trauma syndrome” within the larger move to pathologize women’s bodies. Women have historically been deemed as mentally unfit by the psychiatric industry. The term “hysteria” comes from the same root as the word “hysterectomy,” and hysterectomies were actually used as a treatment for mental illness at the turn of the Twentieth Century.

Pro-choice advocates need to be savvy and educate themselves about the so-called “science” behind the claims that the other side is using to eliminate access to women’s health. Hopefully my summary of the HRP study was easy enough to understand – the article itself was a lot to chew on. If you have any confusion, please leave a comment and I’ll do my best to answer it or recruit someone who can.