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Abortion may not negatively impact women’s mental health

Policies in the United States that warn women about the harms abortion can have on their mental health may be inaccurate, according to research findings published in two psychiatry journals.

One study published in the American Journal of Psychiatry found that women who had abortions and those who were denied abortions had similarly low levels of suicidal thoughts. Findings from the other study, published in JAMA Psychiatry, revealed that having a first abortion was not linked to a higher likelihood of using antidepressants for the first time.

“The notion that women who have an abortion are at higher risk of suicide has been used as a rationale to discourage women from having abortions,” M. Antonia Biggs, PhD, from the department of obstetrics, gynecology and reproductive sciences at University of California, San Francisco, and colleagues wrote in American Journal of Psychiatry. “This view is supported by several studies in the United States and one in Finland finding that abortion increases a woman’s risk for suicidal ideation, suicide attempts and suicide. However, these studies suffer from some serious methodological shortcomings that limit the validity of their results.”

Suicidal ideation, abortion link

Biggs and colleagues interviewed 956 women from 30 abortion facilities in the U.S. via telephone 1 week after their abortion visit, then every 6 months for 5 years to compare whether receiving an abortion or being denied one affected their experiences of suicidal ideation over this period.

Researchers compared women who received abortions — near-limit group — with those who were denied an abortion and carried their pregnancies to term — turnaway-birth group. Women completed suicidal ideation items on the Brief Symptom Interview and the Patient Health Questionnaire, then the researchers used the Sheehan Suicidality Tracking Scale to assess imminent suicidality and used adjusted mixed-effects regression analyses to evaluate whether levels and trajectories of suicidality differed by group.

The results showed no significant difference in suicidal ideation symptoms 1 week after abortion visits among women who received an abortion (1.9%) and women who were denied an abortion (1.3%) as measured by the Brief Symptom Interview. Furthermore, the number of women with any suicidal ideation symptoms dropped in both groups — 0.25% for women in the near-limit group and 0.21% for those in the turnaway-birth group — over the 5-year study period.

Of 7,247 interviews, four (0.06%) women scored as imminently suicidal at one point during the study period. All these women reported abortion was the right choice for them and all had a history of child abuse and/or neglect, according to the authors. In addition, results of mixed-effects regression analyses revealed no significant links between history of depression/anxiety, child abuse/neglect and past-year intimate partner violence with loss to follow-up.

“When we account for the factors that predominantly predispose women to experiencing suicidal ideation, having an abortion does not increase women’s risk of experiencing suicidal thoughts when compared with women who are denied an abortion and carry the unwanted pregnancy to term,” the authors wrote. “Thus, policies requiring that women be warned that they are at increased risk of becoming suicidal if they choose abortion are not evidence-based.”

Antidepressant use and abortion

In the JAMA Psychiatry article, Julia R. Steinberg, PhD, from the department of family science, University of Maryland School of Public Health, and colleagues assessed whether first-trimester first abortion or first childbirth could impact women’s initiation of first-time antidepressant use in Denmark.

“The purported mental health effects of having an abortion are used to justify state policies that limit access to abortion in the United States despite studies and reviews that have failed to show that having an abortion has a causal effect on mental health,” the authors wrote. “One shortcoming of many studies in the field is their reliance on self-report of both abortion and mental health problems, which is subject to both faulty memory and social desirability.”

Using data from Danish population registries, the investigators measured first-time antidepressant prescription redemptions from 396,397 women — 30, 834 of whom had a first-trimester first abortion and 85,592 of whom had a first childbirth. Researchers used the prescription redemptions to indicate episodes of depression or anxiety, then calculated incident rate ratios to compare women who had an abortion with those who did not, as well as women who had a childbirth with those who did not.

In total, 17,294 women had a record of at least one first-trimester abortion and no children, 72,052 had at least one childbirth and no abortions, 13,540 had at least one abortion and one childbirth, 293,511 had neither an abortion nor a childbirth and 59,465 had a record of first antidepressant use. Among all women in the sample, the strongest risk factors connected to antidepressant use were prior psychiatric contact, antianxiety medication and antipsychotic medication.

Although the results of fully adjusted analysis showed women who received a first abortion were at higher risk for first-time antidepressant use compared with those who did not receive an abortion, the incidence rates were not statistically different in the year before (IRR = 1.46; 95% CI, 1.38-1.54) and after the abortion (IRR = 1.54; 95% CI, 1.45-1.62). In addition, the incidence rate ratios dropped as time from the abortion grew (1 to 5 years: IRR = 1.24; 95% CI, 1.19-1.29; 5 years or more: IRR = 1.12; 95% CI, 1.05-1.18). In the fully adjusted models, the incidence rates that compared women who gave birth with women who did not were lower in the year before childbirth than the year after childbirth (P < .001) and rose as time from childbirth went on (1 to 5 years: IRR = 1.52; 5 years or more: IRR = 1.99).

“These findings illustrate that, when pregnancy intention is considered, and the abortion and delivery groups are similar in terms of other life circumstances, having an abortion is not associated with a higher likelihood of mental health problems,” Steinberg and colleagues wrote. “Consequently, policies based on the notion that having an abortion harms women’s mental health may be misinformed.”

Allegations that abortion negatively effects mental health have been used to justify antiabortion legislation, Nada L. Stotland, MD, and Angela D. Shrestha, MD, from the department of psychiatry, University of Illinois at Chicago, wrote in an editorial. Scientific articles published in professional journals claiming these negative outcomes contain many methodological errors, Stotland and Shrestha wrote. No evidence exists that limiting access to abortion improves women’s health, but evidence does report higher morbidity and mortality among women due to unsafe abortions in places where safe abortions are illegal or beyond reach, they wrote.

“As teachers and citizens, we have an obligation to know and promulgate scientific evidence and advocate for laws and policies based on scientific evidence,” they wrote. “As clinicians, we can expect to see many patients who have had abortions and who face decisions about pregnancies. The best outcomes prevail when women have the opportunity to review their own values, beliefs, and circumstances and come to autonomous decisions — and when they can expect nonjudgmental support regardless of the decisions they make.” – by Savannah Demko

References:

Biggs MA, et al. Am J Psychiatry. 2018;doi:10.1176/appi.ajp.2018.18010091.

Steinberg JR, et al. JAMA Psychiatry. 2018;doi:10.1001/jamapsychiatry.2018.0849.

Stotland NL, Shrestha AD. JAMA Psychiatry. 2018;doi:10.1001/jamapsychiatry.2018.0838.

Disclosures: Biggs and colleagues report no relevant financial disclosures. Steinberg reports serving as a scientific expert on the topic of abortion and mental health in three legal challenges to state laws in the United States. She also reports consulting for legal teams at the Center for Reproductive Rights and Planned Parenthood Federation of America. Stotland and Shrestha report no relevant disclosures.