Suicide in Pregnancy is much rarer now ‘thanks to legal abortion’

22 Mar 2013

PeadarOGradyfBDr Peadar O’Grady, Doctors for Choice speaking at seminar “Abortion – The Lives and Health of Women”

Article by Dr Peadar O’Grady, Consultant Child and Adolescent Psychiatrist and member of Doctors for Choice

It is important in discussing the relevance of suicide in the current abortion debate that good medical practice does not come second place to legal arrangements for certification. Maternal mental health matters because of the effects on the mother of mental distress, self-harm and the catastrophe of a completed suicide, but also because of the devastating effects any and all of these can have on any children involved. It is often observed that during pregnancy the incidence of mental health problems and suicidal ideas is high but the risk of completed suicide is lower than usual for comparable women. Even so, because the total of maternal deaths in pregnancy is low, suicide is still one of the top 4 causes of maternal deaths in developed countries.

Groups at higher risk of suicide are those with an unwanted pregnancy, particularly teenage mothers and those on low incomes. In its 2009 report on Maternal Mental Health, the UN’s World Health Organisation (WHO) has highlighted the increased risk of mental health problems in, “unintended pregnancy especially among adolescent women”. The WHO emphasises the further risk from factors such as poverty and lack of support, “in contexts in which there are strong, gendered role restrictions on women including lack of reproductive rights”. ‘Reproductive rights’ for women means the right to decide whether or not they want to have children and, if so, how many and when.  To be vindicated this right requires access to abortion services but also access to good quality obstetric, contraceptive and STD services as well as sex education and information. In his 2011 journal article ‘Suicidal Mothers’, Salvatore Gentile agreed that maternal suicide attempts during pregnancy were increased where there was: “teen age, unplanned pregnancy, unmarried status or recent divorce, unemployment, and difficult access to safe abortion service(s).”

It has also been observed that suicide in pregnancy (and the year after delivery, known as the ‘puerperium’) has become much less common with access to legal abortion services. Professor Robert Kendell summarised this conclusion in the title of his 1991 review in the British Medical Journal: ‘Suicide in pregnancy and the puerperium, much rarer now: thanks to contraception, legal abortion and less punitive attitudes’. It is therefore clear from the WHO and peer-reviewed research that restricting access to abortion, that is, denying women ‘the right to choose’, raises the risk of suicide in pregnancy.

Despite this the opposing notion that choosing an abortion increases the risk of mental health problems, and even suicide, persists. This false conclusion is a misreading (often deliberate and repeated) of the fact that there is often a higher incidence of mental health problems found in people who have had abortions than among those giving birth. However ‘correlation is not causation’. When previous mental health and unwanted pregnancy are taken into account there is no higher rate after an abortion. This makes abortion a ‘risk indicator’ rather than a ‘risk mediator’. As we have seen the likely mediators are unwanted pregnancy and previous mental health problems. It is also well known that, following abortion, mental health problems are more common where the woman has had a negative attitude to abortion before and a negative reaction after, especially when she has been under pressure to have an abortion. The ‘right to choose’ must be without pressure to choose a certain way. Good counselling and practical support before and after this decision is the key to supporting women with unwanted pregnancies.

A similar example of prejudice clouding judgement is the observation that LGBT individuals are at higher risk of mental health problems. One conclusion (by many of the same fundamentalist Christians who populate the anti-choice lobby) is that homosexual or transgendered people should be ‘cured’ from this presumed ‘disease’. The modern psychiatric approach, based on evidence, has been to reject the notion of homosexuality or transgender as diseases by identifying the high incidence of bullying and discrimination as causative factors, or ‘risk mediators’, for mental health problems in this group.

When the allegation, that abortion leads to mental health problems or suicide, is systematically investigated, it is found to be false. In the US the American Psychological Association in 2008 found there was no credible evidence that choosing to have an abortion raised the risk of mental health problems. In the UK the National Collaborating Centre for Mental Health’s review in 2011 reached the same conclusion. Where there the choice of legal abortion services is available there is no increase in suicide (or mental health problems) caused by choosing an abortion with informed consent.

Anti-choice proponents have emphasised that ‘Abortion is not a treatment for suicide’ and ignored the fact that there is no such narrowly-defined thing as a ‘treatment’ for suicide. However, abortion, for those who choose it with proper supports, can be as much a ‘treatment’ for the risk of suicide as blood pressure tablets are a ‘treatment’ for the risk of a heart attack. Both can be preventive, lowering the impact of a relevant risk factor; that is, the distress of an unwanted pregnancy and high blood pressure respectively. The ‘treatment’ for unwanted pregnancy is ‘non-directive counselling’ and the ‘treatment’ for suicidal risk in unwanted pregnancy is ‘risk-reduction’, which includes facilitating the choice of accessing abortion services.

In Ireland, abortion, and even access to information on abortion, is heavily restricted with a criminal sanction, confirming the ‘punitive attitude’ Prof Kendell referred to over 20 years ago. Women are forced to travel, usually alone or with a very restricted support network because of the costs of travel. As a result, in this Irish context, the restriction of access to abortion services is mediated by restrictions on travel. The following groups, whose ability to travel is compromised, are therefore at an increased risk of restricted access to abortion and hence at an increased risk of suicide:

  • Women too sick to travel
  • Adolescents and young women
  • Women with young children
  • Migrant women
  • Women with Disabilities
  • Women with no or low incomes
  • Women whose pregnancy, involves a fatal foetal malformation
  • Women pregnant as the result of rape or child sexual abuse.

The obvious solution to these risk factors is to end the unnecessary, dangerous, and, for the most part, ineffective legal restrictions on abortion services. This is the very successful approach taken in Canada for the last 25 years. Abortion there is subject to healthcare guidelines and not criminal law; just like every other medical service. It is an ongoing absurdity that pregnant women are in some way considered to be exceptions to the usual rules of capacity to make a decision.

It seems likely however that, instead of the Canadian model, emergency legislation in Ireland will deal only with the risk to just some of those whose ability to travel is restricted. The ‘need’ to distinguish between, and medically certify, a risk to the life, as opposed to the health, of pregnant women has put an emphasis on suicide that shows little concern for either crisis pregnancy or suicide.

In summary, in terms of mental health concerns, it is important to stress that unwanted pregnancy and previous trauma or mental health problems are the most relevant risk factors for mental health in pregnancy and that women on low incomes and child and adolescent mothers are at particular risk; the focus should be on care and support. Restriction of access to abortion increases suicide risk and supported choice reduces suicide risk. While there is no medical need for aspecial legal framework for abortion, doctors are perfectly capable of certifying the need to support a woman’s choice of abortion services to reduce her risk of mental health problems and suicide.

Doctors for Choice is an organisation of doctors who wish to promote choice in reproductive healthcare. This means advocating for informed consent as the basis for decision making within the doctor-patient relationship. The NWCI and Doctors for Choice recently organised a Seminar on “Abortion – The Lives and Health of Women”, see presentations from the seminar.

Journal disavows study touted by U.S. abortion foes

By Sharon Begley<>


NEW YORK (Reuters) – A leading psychiatry journal has distanced itself from a controversial study that it published in 2009 which suggested a link between abortion and mental illness, including such severe forms as post-traumatic stress disorder, panic attacks, and drug addiction.
In an unusual commentary, one of the Journal of Psychiatric Research’s editors-in-chief and a co-author warned that the 2009 paper, which has been widely cited by legislators and advocates to argue that abortion raises a woman’s risk of mental illness and to push for laws requiring providers to tell women that, in fact “does not support assertions that abortions led to psychopathology.”
Led by Priscilla Coleman, a professor of Human Development and Family Studies at Bowling Green State University in Ohio, the study used data from the Harvard-based National Comorbidity Survey, which assesses the prevalence of mental illness in the United States. She and her co-authors concluded that there is a link between past abortions and mental illness.
In 2010 Julia Steinberg of the University of California, San Francisco, and Lawrence Finer of the nonprofit Guttmacher Institute published their own analysis of the same data from the comorbidity survey. They identified a number of errors in the Coleman paper, including statistical ones.
The Guttmacher Institute is a non-profit research and education group that advocates for reproductive rights, including access to abortion.
The U.S. Supreme Court legalized abortion in 1973 but opponents have sought, particularly at the state level, to impose restrictions on the procedure.
Steinberg said that the biggest problem in the original Coleman study was that “many of the incidents of mental illness she included came before the abortion.” That cast doubt on whether abortion triggered mental illness. Instead, women with mental illness might have been more likely to have an unwanted pregnancy and terminate it.
“Determining the ‘effects of abortion’ is not possible unless it can be established that the diagnoses occurred after the abortion,” said Steinberg. “For many women, psychiatric illnesses occurred before the abortion.”
Last July Coleman acknowledged the statistical errors, but that was far from the end of the battle. A letter from Steinberg and Finer in the March issue of the Journal of Psychiatric Research reiterates the criticism about including episodes of mental illness over a woman’s entire lifetime.
In a published response, Coleman conceded that she had used lifetime estimates of mental illness, rather than only episodes after an abortion. It “is certainly true” that this makes it difficult to figure out whether the abortion or the mental illness came first, she wrote.
In an email Tuesday from London, where she had addressed members of Parliament “about the abortion and mental health association,” Coleman said that “the pattern of results” -greater incidence of mental illness among women who have had an abortion – “did not change much” when she made the statistical corrections. Moreover, she wrote, “we never made assertions of causality.”
The title of her paper included the phrase “the effects of abortion.”
Coleman’s arguments did not sway the journal. In an unusual step, a commentary co-authored by Alan Schatzberg, an editor-in-chief and professor of psychiatry at Stanford University School of Medicine, concludes that the criticism of the Coleman study “has considerable merit.”
Her analysis “does not support assertions that abortions led to psychopathology,” it continued, and using lifetime diagnoses of mental illness is “flawed.” Studies of abortion and mental illness “should consider only mental disorders subsequent to the pregnancy.”
Despite these problems the paper has not been retracted. “The ultimate decision to retract is made by the publisher using preset procedures including an independent committee,” Schatzberg said in an email to Reuters.
Journal publisher Elsevier “has specific policies and procedures for evaluating and instituting any possible retraction decisions. Authors are also free to request a retraction.” Editors can also initiate the process leading to a retraction.
Critics say the paper is flawed enough to be excised from the scientific literature. “This is not a scholarly difference of opinion; their facts were flatly wrong. This was an abuse of the scientific process to reach conclusions that are not supported by the data,” said Steinberg. “The shifting explanations and misleading statements that they offered over the past two years served to mask their serious methodological errors.”
Another concern has been whether Coleman fully disclosed any possible conflicts of interest. In a presentation she gave in 2011 to the American Association of Pro-Life Obstetricians and Gynecologists, she said, “I have a plan to develop a new non-profit organization devoted to understanding and publicizing the real risks of abortion. I would like to bring together many credentialed scientists with a research program pertaining to the physical, psychological, and/or relational effects of abortion on women and their families.”
Advocates on both sides of the abortion debate disagree on whether the strongly worded commentary, plus a letter to the editor pointing out serious mistakes in the 2009 study, will affect policy.
Thirty-five states require pre-abortion counseling, according to the Guttmacher Institute.
Of those, nine include only negative psychological consequences, such as depression, anxiety, post-traumatic stress disorder, suicidal thoughts or other forms of mental illness. Courts have thrown out some of these requirements, including South Dakota’s that abortion providers tell women that the procedure “increased risk of suicide ideation and suicide.”
There is no shortage of studies on abortion and mental illness. But expert analyses have found that many are as poorly done as the 2009 paper. Two reviews of the science, one by the American Psychological Association, found that higher quality studies were much less likely to find adverse psychological effects from abortion than lower-quality studies were.
Opponents of legalized abortion believe there are enough studies linking the procedure to mental illness to support state laws mandating that women be told of that risk. Kansas requires a doctor to say that “after having an abortion, some women suffer from a variety of psychological effects ranging from malaise, irritability, difficulty sleeping, to depression and even posttraumatic stress disorder.”
Texas tells women that some “have reported serious psychological effects after their abortion,” including depression, anxiety, suicidal thoughts and behavior, flashbacks, and substance abuse. West Virginia says that many women “suffer from Post-Traumatic Stress Disorder Syndrome following abortion,” and can experience suicidal thoughts or acts, depression, fear and anxiety, and alcohol and drug abuse.
The 2009 study was “not alone in driving legislation” requiring pre-abortion counseling that includes a mental health warning, said Jeanne Monahan, director of the Center for Human Dignity at the Family Research Council, a non-profit group that opposes abortion rights. “A number of other authors have reached the same conclusion, so my read is that it’s very solid.”
Many of those studies compare mental health after abortion to mental health after childbirth. But the crucial comparison, argued Schatzberg, is between women with unwanted pregnancies who aborted or gave birth. To compare women with wanted pregnancies who gave birth to women with unwanted pregnancies who aborted can be misleading.
For the journal that published the controversial 2009 paper to essentially disown it can “help put a spotlight on the issue and encourage states to revisit their existing materials to ensure that they are accurate,” said Elizabeth Nash, a policy expert at Guttmacher. “States give the misinformation the same weight as the empirical evidence. The problem is that when states include inaccurate information, a woman reading the materials does not have the information she needs to make an informed decision.”


Examining the association of abortion history and current mental health: A reanalysis of the National Comorbidity Survey using a common-risk-factors model  

Julia R. Steinberg, Lawrence B. Finer
SocSciMed   Jan 2011, vol 72(1) Pages 72-82


Using the US National Comorbidity Survey (NCS), Coleman, Coyle, Shuping, and Rue (2009) published an analysis indicating that compared to women who had never had an abortion, women who had reported an abortion were at an increased risk of several anxiety, mood, and substance use disorders. Here, we show that those results are not replicable. That is, using the same data, sample, and codes as indicated by those authors, it is not possible to replicate the simple bivariate statistics testing the relationship of ever having had an abortion to each mental health disorder when no factors were controlled for in analyses (Table 2 in Coleman et al., 2009). Furthermore, among women with prior pregnancies in the NCS, we investigated whether having zero, one, or multiple abortions (abortion history) was associated with having a mood, anxiety, or substance use disorder at the time of the interview. In doing this, we tested two competing frameworks: the abortion-as-trauma versus the common-risk-factors approach. Our results support the latter framework. In the bivariate context when no other factors were included in models, abortion history was not related to having a mood disorder, but it was related to having an anxiety or substance use disorder. When prior mental health and violence experience were controlled in our models, no significant relation was found between abortion history and anxiety disorders. When these same risk factors and other background factors were controlled, women who had multiple abortions remained at an increased risk of having a substance use disorder compared to women who had no abortions, likely because we were unable to control for other risk factors associated with having an abortion and substance use. Policy, practice, and research should focus on assisting women at greatest risk of having unintended pregnancies and having poor mental health—those with violence in their lives and prior mental health problems.

Teens who have abortions are no more likely to become depressed or have low self-esteem than their peers whose pregnancies do not end in abortion, according to “Do Depression and Low Self-Esteem Follow Abortion Among Adolescents? Evidence from a National Study,” by Jocelyn T. Warren of Oregon State University et al., which is available online and will appear in the December issue of Perspectives on Sexual and Reproductive Health. The study found that the factors most closely linked with depression and low self-esteem after abortion are having experienced those problems in the past.

A 2008 study by the American Psychological Association (APA) found no evidence that induced abortion causes mental health problems in adult women, but because of a scarcity of evidence on teens, no conclusions were drawn at that time about the impact on adolescents. The new study is the first to look at depression and low self-esteem as potential outcomes of abortion among a nationally representative group of teens, and the results are consistent with the findings of the earlier APA report—induced abortion does not cause mental health problems in adolescent women.

While 34 states currently require that women receive counseling before an abortion is performed, seven of these states specifically require that women be warned of possible negative psychological consequences resulting from the procedure. “Paradoxically,” the authors of the new study suggest, “laws mandating that women considering abortion be advised of its psychological risks may jeopardize women’s health by adding unnecessary anxiety and undermining women’s right to informed consent.”

The study is based on data from the 289 respondents to the National Longitudinal Study of Adolescent Health who reported at least one pregnancy between the survey’s first two waves, 69 of whom reported an induced abortion.

The article is currently available online and will appear in the December 2010 issue ofPerspectives on Sexual and Reproductive Health.