Is abortion associated with mental illness?

Anti-abortion groups, having largely failed to convince the American public that abortion is morally abhorrent, have tried to shift the debate to their concern about women’s health.  The same groups who would forbid abortion after rape or incest, or when the mother’s life is endangered claim to be saving women from “post-abortion syndrome”, a mythical psychological disorder.  There are many reasons good people may oppose abortion, but lying about health risks such as breast cancer (a long-discredited hypothesis) is simply immoral.  But it does seem plausible that abortion might have psychological consequences, although whether these would be good or bad certainly isn’t obvious. A new Danish cohort study published in the New England Journal of Medicine tries to inject some data into this debate.

The study relies on the excellent health records kept by the Danish health care system.  They looked at the approximately 3/4 million women born between 1962-1993. They were able to find out how who sought  psychiatric care (there is no private psychiatric care in Denmark), and who had abortions or gave birth.  Abortions before 12 weeks gestation are legal in Denmark, and nearly all abortions there are done during that period, and nearly all are performed in public clinics or hospitals, so the data are pretty complete.

Combing this data, the authors identified a study population of young women with no history of psychiatric disease and no history of abortion.  They then compared rates of psychiatric care sought in the period from 9 months before abortion or child birth until 12 months after.  They crunched the numbers and the crux of their conclusion was:

The risk of a psychiatric contact did not differ significantly before and after abortion (P=0.19), but the risk after childbirth was significantly greater than the risk before childbirth (P<0.001).

The primary finding was that women who had abortions were just as likely to seek out psychiatric care before their pregnancy as after their abortion.  Having an abortion was not a risk factor for seeking out psychiatric care.

This is an impressive study, made possible by the excellent data collection in Denmark.  Abortion, medical, and psychiatric care are all easily available, significantly lowering confounding economic and social factors that might be found in the US, and in this population, abortion did not appear to lead to psychological illness.  The interesting secondary finding, that having a baby can lead to psychological distress, is a fact often left out by anti-abortion groups.  Post-partum depression and anxiety are common and serious.  Since the question of abortion and mental health is largely asked and answered, it is time to focus our energies on groups truly at risk.

References

Munk-Olsen, T., Laursen, T., Pedersen, C., Lidegaard, �., & Mortensen, P. (2011). Induced First-Trimester Abortion and Risk of Mental Disorder New England Journal of Medicine, 364 (4), 332-339 DOI: 10.1056/NEJMoa0905882

39 Comments

  1. edselpdx

     /  January 26, 2011

    Thanks, PalMD. Right on the nose, and I hadn’t seen this research yet. Being a medical professional who has experienced therapeutic abortion once, spontaneous abortion once, and childbirth to one loved wanted child at the right time–in that order. In all reality, the spontaneous abortion was by far the most traumatic of the three, and I think miscarriage of a wanted child is much worse to mental health than a wanted/needed therapeutic abortion. I was lucky not to experience post-partum depression after my daughter was born, but caring for an infant was clearly more stressful than my own experience after a a therapeutic abortion at age 25, when I was married and in grad school.

    I’ll be sharing this link with friends.

  2. Mara

     /  January 26, 2011

    As someone who nearly committed suicide after childbirth (twice, I might add), I find it rather…frustrating, shall we say, to see “post-abortion syndrome” hyped by these groups, while they ignore post-partum depression and anxiety.

    (Also, thank you for adding anxiety on there. Most people have heard of PPD but when I say I had post-partum panic and anxiety, they look confused.)

    Based on my personal experience and that of my friends, I see several problems that need to be addressed. One, obviously, is the need for affordable mental health care. I was lucky to be able to afford therapy and psychiatric care and drugs, but a friend of mine suffered in silence.

    The other problem is the societal belief that having a baby is happy sunshiny experience and if you dare to point out that you feel miserable, everyone tells you that you just “have a bad attitude.” How dare you imply that a pregnant woman or new mother might be something other than perfectly happy?

    • That’s HUGE. While baby’s are wonderful etc, having massive hormonal changes, massive life/time changes, etc all at once…

      I’m not thrilled with the term “baby blues” either since that seems to minimize the severity.

      • Mara

         /  January 26, 2011

        Yeah, baby blues makes it sound adorable. “Awww, widdle Mara’s got the baby blues, how cute!” It’s not so adorable when you haven’t slept in five days and can’t think straight.

        When I didn’t want to get pregnant a second time, everyone told me I needed to think positive. Then I would carefully explain that after my daughter was born, I thought quite seriously about killing myself. And then everyone would tell me that if I just had a better attitude about it, it would be fine.

        And everyone (my husband included) told me I was being pessimistic to assume the second time would be as bad. ::coughs:: The second time was worse and I nearly died on the operating table.

        ::headdesk:: I’ve got a bit of a pet peeve on this subject, as you can see 😉

        • Melissa G

           /  January 27, 2011

          You’ve got my utter empathy, Mara. If I had tried to have two instead of the one beloved child I have, I’m sure I would have committed suicide. Post-partum panic sounds very descriptive of my situation as well– I describe my emotional recovery from my son’s first three years as recovery from post-traumatic stress disorder. I still have flashbacks to those times, and my boy is seven. Motherhood is no light romp.

          • Mara

             /  January 28, 2011

            Yes, I also describe it as post-traumatic stress disorder. My life was in danger, I have nightmares about the experience, certain sights and sounds can trigger flashbacks, and the thought of going through it again makes my heart race and my vision blur.

            Add in gunfire and exploding bombs and I’d have a diagnosis of combat trauma!

      • I’m not thrilled with the term “baby blues” either since that seems to minimize the severity.

        Agreed. The term “baby blues” was why I waited so long to seek help after having my son. I’m glad my husband took the initiative to call my doctor.

  3. becca

     /  January 26, 2011

    Yeah, but that study doesn’t count, cause it was done in Denmark! We all know Denmark is not the Shining City on a Hill. Therefore God would not punish those godless heathens with depression for having abortions. I mean, they’ll go to hell for it and everything, but that’s about it. In contrast, in the US, God (acting through such righteous baby-saving angels as Scott Roeder) does His best to make sure the wicked are Punished during there time on Earth.
    /wish I were making it up

    Seriously though, I think there might very well be more adverse mental health effects resulting from abortion for women in the US.
    But yeah. If they really cared about women’s mental health, they would work on providing those services. Heck, if they really cared about reducing abortion and not just shaming those that choose it, they might focus on providing mental health services anyway (the rate of use of psychiatric services in women that had abortions *was* strikingly higher; the inverse casual link is not unreasonable).

    • Nomad

       /  January 26, 2011

      In contrast, in the US, God (acting through such righteous baby-saving angels as Scott Roeder) does His best to make sure the wicked are Punished during there time on Earth

      I’ve seen that sort of logic before. Where was it now… ahh yes, citing mental health problems of homosexuals as evidence of the wrongness of homosexuality while refusing to consider whether said problems might have resulted from a lifetime of persecution and abuse.

      I once brought that up and was chided for attempting to make homosexuals into “victims”. Seriously.. I suspect the other party felt that he was a victim of homosexuals wanting to be gay.

      Sorry, bit of a digression, but it was too similar for me not to make the link.

    • Seriously though, I think there might very well be more adverse mental health effects resulting from abortion for women in the US.

      Anecdotally, I was going to say the same thing. I was debating whether to share the anecdote I have… it is a very sad story, and ultimately I think I am going to keep it to myself. It’s an interesting Rorschach… I think about what happened to my friend, and to me it is a damning indictment of the Catholic church’s teachings on abortion and birth control, as well as the social stigma of abortion in the US. Yet the same story in the hands of an anti-choice activist could be spun as “If you abort as a teenager, you will be wracked with guilt and spiral into mental illness and drugs.”

      In any case, I almost would like to see that there is evidence that abortion in the US has adverse mental health consequences. Because if that were the case, while there was no such correlation in Denmark, that would pretty much show that these religious anti-choice zealots are killing people — as I believe they are.

      • D. C. Sessions

         /  January 27, 2011

        Because if that were the case, while there was no such correlation in Denmark, that would pretty much show that these religious anti-choice zealots are killing people — as I believe they are.

        You will, I hope, forgive me for pointing out that the Tiller family isn’t in doubt on that point?

        For that matter, here in tolerant Arizona, we have managed to put enough roadblocks in the way of even emergency, they’re-bot-gonna-die-before-dawn abortions that people just drive to New Mexico, Colorado, or California rather than schedule the several consecutive appointments that are required here?

        So, yeah, they’re killing people. Before, during, and after.

        • Yeah, heh, what I said seemed a bit of an understatement in light of the Tiller and other shootings, eh?

          I meant that even without the violence, even without the obstructive laws, even without the protesters… I believe that just the stigma and the guilt is indirectly killing people, in the same way that anti-gay rhetoric is responsible for the scandalously high suicide rate among LGBT teens.

  4. Nomad

     /  January 26, 2011

    Since the question of abortion and mental health is largely asked and answered, it is time to focus our energies on groups truly at risk.

    tsk tsk tsk… this simply isn’t how this sort of thing is done.

    But I suppose you know that.

  5. William Wallace

     /  January 27, 2011

    I imagine this might be a cultural thing. That is, Tahitian women in the 1700s probably didn’t think much at all about the moral implications of their own promiscuity, at least until the Christian missionaries started spreading their views that gratuitous fortification was sinful. And the collision of an automobile, driven by a city liberal, with a deer, 2 weeks after watching Bambi with his child, is probably much more likely to have a psychological effect than when a hunter who has been killing, gutting, and butchering deer since she was 11 gets another one for her freezer.

    A much more interesting question is: Why have pro-life groups largely failed to convince the American public that abortion is morally abhorrent?

    • Dianne

       /  January 27, 2011

      Why have pro-life groups largely failed to convince the American public that abortion is morally abhorrent?

      Probably because they don’t believe it themselves. If the so-called prolife movement was really about saving zygotes, embryos, and fetuses, it would be more concerned with the up to 80% of products of conception that die naturally, not the relatively few that die in abortion. Yet there are no lobbying groups to support research into the causes of spontaneous abortion (especially early spontaneous abortion), no call for a war on miscarriage, no private foundations…in short, no effort to save “babies” dying in early spontaneous abortion at all. Why is that? Probably because, really, the average “prolife” person recognizes that an 8 week zygote that doesn’t even have neurons yet is nothing like a baby and won’t be for a very, very long time.

      • D. C. Sessions

         /  January 27, 2011

        If the so-called prolife movement was really about saving zygotes, embryos, and fetuses, it would be more concerned with the

        ones who die or suffer birth defects resulting from malnutrition, lack of prenatal care, lack of affordable obstetrical services, etc.

        Let’s not even get into neonatal heath or early childhood nutrition.

        • Dianne

           /  January 27, 2011

          Let’s not even get into neonatal heath or early childhood nutrition.

          I’d be willing to if they were, but it’s a rare pro-lifer who is interested in the fate of babies and children. Much less adults.

      • Nomad

         /  January 27, 2011

        If the so-called prolife movement was really about saving zygotes, embryos, and fetuses, it would be more concerned with the up to 80% of products of conception that die naturally, not the relatively few that die in abortion

        I’m late to the party reacting to this, but YES, exactly.

        It’s this sort of thing that has convinced me that the anti abortionists are really anti choice, not pro life. A fetus that is lost against the desires of the mother doesn’t appear to show up on their radar, there is no concern for protecting that life. This should be an overwhelming concern if their concern were simply “life” as they constantly proclaim.

        • William Wallace

           /  January 31, 2011

          Pro-life people like Representative Michele Bachmann, who, with her husband, have taken in 23 foster children? Anyway, it’s a non-sequitur to argue that you can’t be pro-life if you don’t dedicate your life to stopping natural spontaneous abortions. It’s like arguing that you can’t be against murder if you don’t work to find a cure for cancer.

          • Vicki

             /  January 31, 2011

            It’s more like arguing that you aren’t really against murder if you get upset when a white man is killed, and make dismissive remarks about how “it’s probably his own fault” if the victim is black, or shrug it off as “normal” if a man murders his ex-wife. Or as “they knew the risks” when a police officer is shot in cold blood.

            Nobody is saying “you must dedicate your life to this cause.” It is reasonable to say “if you really care about embryos and fetuses, you should care about the ones that are wanted.” If you’re not putting energy into helping women who want to have a child but are having medical or social difficulties because you have no energy to spare, or all your charity is going to a soup kitchen or a youth orchestra, fine. But don’t scream at the woman who wants an abortion, and then shut down the woman who miscarried a wanted pregnancy with “that’s okay, you can try again” or even “it’s not like you lost a real baby.”

            If I know that the only way someone would care about my hypothetical embryo is if they knew I didn’t want it, it’s hard to believe that’s about the embryo. The moment a woman decides she wants a child, a lot of anti-abortion people are back to “it’s your decision, and your responsibility.”

          • Dianne

             /  January 31, 2011

            Yes, if 80% of the population was dying of cancer-in the first days or weeks of life no less-and you were totally unconcerned about it because people sometimes-much less frequently-were murdered, I’d wonder a bit about your priorities. And morals. Do you think we should defund the NIH because the murder rate is not zero?

  6. I see PPD as a physiological “feature”. A time of very low NO following birth, just in case the new mother develops puerperal fever and goes into sepsis. The very high NO from iNOS during sepsis (necessary to prevent bacterial biofilms from growing in the vasculature) is somewhat counteracted by the low NO of the post partum period. Evolution has minimized the sum of non-survival from all events, trading off deaths from suicide from PPD with survival from puerperal fever. Blood loss does the same thing. Hemoglobin is the sink for NO, so some blood loss at birth would slightly protect against the high NO of sepsis.

    WW, why? I can’t speak for anyone but myself, but those who call themselves pro-life are demonstrable liars (as their propaganda on the connection between abortion and cancer and now mental health issues demonstrates). They are hypocrites in holding everyone else to different standards than they hold themselves (Bob Barr drove his wife to the abortion clinic and paid for her abortion). They hypervalue a fetus, but neglect people after they are born. When there is such a disconnect between what people say, what they do, and reality, I find no basis for accepting their judgment on matters that are more complex and nuanced, such as morality. If they can’t get their facts right, what exactly are their opinions based on?

    As far as I can tell, it is strident speech, unsupported feelings and threats. Conveniently it provides them with a rationalization as to why they hate people who are not like them. As far as I can tell, the hate came first and the rationalizations came second, hating a whole group because a few members may have certain characteristics.

  7. Cashmoney

     /  January 27, 2011

    For the same reason animal right’s groups have failed to convince that shooting Bambi is morally abhorrent, WW.

  8. Dianne

     /  January 27, 2011

    This outcome is completely unexpected and very consistent with past high quality studies. There’s really no evidence of reasonable quality that abortion leads to mental illness.

    Something I’d like to see some studies on is maternal outcomes after relinquishing a child for adoption. That’s always presented as the “good” choice by the “prolife” movement, yet the available evidence suggests that it is extremely high risk for severe and long lasting mental disturbance in the relinquishing mother. I would like to see high quality studies on this issue and, if the results from the few available studies are confirmed, laws requiring pregnant women considering giving birth and relinquishing the infant be counseled before she makes this potentially life threatening decision.

    • Mara

       /  January 27, 2011

      That’s a really good point. I’d love to see some research on the results of giving up a baby for adoption. Because I’m quite sure that giving up a baby that I’d carried for all that time and gave birth to would be a hell of a lot worse. PPD without the baby? Yikes.

    • Mara, not having the metabolic stress of lactation probably makes PPD easier. The psychological loss and the lack of a sufficient social and other support system (presumed because if a woman did have those things she wouldn’t give up her baby) probably make it worse. Being vilified by those who think of her as a bad mother because she did what was best for her infant probably makes it worse too (my guess it that being vilified dominates).

      I suspect that the long lasting mental health problems from putting up a child for adoption are mostly due to societal pressures. Over evolutionary time, women lost most infants that were born to childhood diseases. I presume that losing a child to death is worse than losing one to adoption. It would be for me, but I am not a woman who carried a child for a pregnancy so my opinion is not very informed. I did once date a woman who was a social worker who worked with pregnant teens and she said that the women who gave up their child were usually healthier mentally, had better reality testing, and were more concerned with the welfare of the child they were giving up than the women who didn’t.

      The large dichotomy between women who had an abortion and then became anti-choice and women who had an abortion and remained pro-choice supports that too. The pregnant woman who was the plaintiff in Roe v Wade had a change of heart many years later and worked to overturn RvW. Her daughter (born because the case didn’t move fast enough for her to be aborted) was tracked down by a tabloid and is pro-choice.

      • Dianne

         /  January 27, 2011

        Actually, evolutionarily, I would guess that being forced to abandon a living, healthy child might well be worse than losing a child to death. Mammals that want to avoid extinction don’t abandon their living, healthy young. And I’m not sure that the subconscious can distinguish between placing a child with a loving family and leaving it out for the wolves to eat.

        Then, too, there’s the problem of lack of closure. A dead child can be mourned. A child lost to adoption, one would always wonder about…Are they safe? Healthy? Happy? Is that story in the paper about a child abused by their adoptive or foster parents mine? Will he or she want to find out who I am as an adult? Will s/he forgive me? And so on.

        I must admit, though, that I don’t have hard data for any of the above. It’s just speculation. The available evidence concerning relinquishing mothers is not encouraging for their mental health, though. See, for example:
        http://www.ncbi.nlm.nih.gov/pubmed/10438084
        http://www.ncbi.nlm.nih.gov/pubmed/3945198

        • mb

           /  February 8, 2011

          I know I’m terribly late to the party here, but in case anyone is looking, I want to point out that one of your abstracts refers to a a meta-analysis where no data is newer than 1978, and the other is from the 80s. So many more adoptions are ‘open’ now, which I have to think is a tremendously different situation than the old days od shaming young women into placing their babies for adoption. Birth-mothers now can arrange a situation where they have ongoing contact and will have met (and possibly selected) the adoptive parents before the birth. And everything I’ve read indicates that the women who make an adoption plan for their babies do better in the long run. So, the rhetoric of ‘abandoning’, ‘losing’, and wondering if the child will search for his/her birth parents as an adult seems about 30 years out of date.

          • Dianne

             /  February 8, 2011

            Unfortunately, it’s not at all clear that women who place a child in open adoption do any better than those who use “closed” adoption. For example, this review which was published in 1999 and includes several papers from the 1990s (just 2 decades out of date;) found that the data on open adoption were conflicting and that grieving was still a major issue in open adoptions. If you have information suggesting otherwise, I’d love to see it.

          • mb

             /  February 9, 2011

            Your link doesn’t work for me.
            I found a few references for open adoption being less traumatic in the long term for birth mothers, but sadly, no free source for the full text except for one that only went out to 9 or so months post-placement. Some others are summarized here. I fully acknowledge that an adoption website could be accused of cherry picking data out of these studies to promote their cause.
            http://www.adoptionhelp.org/open_adoption/research.html
            I find it pretty plausible that birth mothers who choose open adoption have a better time psychologically over the long term than do birth mothers who choose closed adoptions.
            I’m biased myself, from a personal angle. My husband and I chose to pursue open domestic adoption. The risks for us are high as we have learned through bitter experience*, but our study of open adoption indicated that it was probably going to be a lot better for the child than a closed adoption, and we wouldn’t have to wonder if an impoverished pregnant woman in a faraway country was being coerced or forced into placing her children.
            I take issue with your statement about how much worse it would be from an evolutionary perspective to ‘be forced to abandon’ a baby than to leave it to be killed. The baby left for the wolves does not get your genes into the next generation. The baby that you cannot raise for whatever reason (historically: famine, maternal death, it’s an icky girl, or some other more modern reason) who is brought up by someone else, whether it is a relative or a stranger, propagates your genes. More of a direct evolutionary win there than in being the one who would choose to love and raise a non-biological child.

            I’m also not keen on the ‘forced to abandon’ terminology. At least in the US, no one is forcing women to abandon their babies. The only situation I can imagine where children are forcibly removed is when Child Protective Services removes children from their parents care. Oh yeah, and in the state where I live (see * above) a birth parent of either gender has 30 days to change their mind, at which point the child will be removed from the prospective adoptive home and returned to the birth parent. And the adoptive parent in this case can’t even console themselves with the thought that the child will have a chance at a better life.

          • Dianne

             /  February 10, 2011

            I’m also not keen on the ‘forced to abandon’ terminology. At least in the US, no one is forcing women to abandon their babies.

            Forcing, possibly not. Though even there I’m not sure what’s happening with girls younger than 18 and parental notification laws. But “pregnancy crisis centers” and other “pro-life” organizations present adoption as a pain and problem free way of dealing with an unwanted pregnancy. That is simply untrue. Adoption, even open adoption, leaves the birth mother feeling like crap, sometimes permanently, but inevitably initially. The birth hormones simply aren’t going to let you get away with anything else.

            The link you provided did have a couple of articles on the effects of adoption on the birth mother, and they do seem to indicate that open adoption is easier on the mother. But easier is not easy. The mother will still be left grieving and in some distress, despite everyone’s best intentions. If you’re working with a reputable agency, they should provide counseling and help for the birth mother.

            I don’t mean to criticize adoptive parents. It certainly sounds like you’re taking every step you can to ensure that the adoption is fair to the relinquishing mother and to the child. But it’s not going to be easy for the birth mother and I don’t like having people out there lying to vulnerable women with the claim that it is.

          • Interestingly enough, birth mothers who are minors rarely need to obtain their parent’s permission to place their child for adoption. Adoption laws do vary widely by state, but it appears in my quick little search that most states do not require grandparental permission, and anecdotes I’ve heard about young women concealing pregnancies from their families and making adoption plans confirm that this is the case.

            I absolutely do not want to indicate that I think that relinquishing a child for adoption is pain-free. I’m sure it is gut wrenching and that there is significant grieving. Sadly, gut wrenching grief is something that comes with the territory of being human, and hopefully, any woman placing her child for adoption will do so through an ethical organization that provides counseling and support. What hurts the most/least among abortion, miscarriage, ill-timed or unwanted parenting, or placing a child for adoption? I think it all depends on the circumstances. I know which of these hurt me, but that doesn’t mean that I know which of them would hurt any other woman.

            One article I found indicated that women who made a plan for an open adoption had a worse time at first, but were better able to resolve that grief and continue with their lives than were women who voluntarily relinquished their babies for a closed placement or had hidden their pregnancies.

      • Mara

         /  January 27, 2011

        I’ve carried two children to term and lost one to miscarriage and (although anecdotes are not evidence, etc and so on) I can say that I would have found it much harder to give a baby up for adoption, even given that I didn’t entirely want to be pregnant the second time.

        I agree with Dianne below that I could mourn the miscarriage and move on, but I would worry about a living child.

        (Interesting psychological note: I would not be concerned about giving up my four remaining IVF embryos for adoption. I think my subconscious believes that people who go to the trouble of IVF are going to be better parents.)

  9. becca

     /  January 27, 2011

    “Why have pro-life groups largely failed to convince the American public that abortion is morally abhorrent?”
    Oh, I think they have. It’s just that we live in a culture seeped in death and they have to convince people:
    1) that it is morally abhorrent to kill
    AND
    2) abortion is worse than other deaths.
    As an aside, they also have to convince people:
    3) forcing a woman to have her bodily integrity violated is *not* as morally abhorrent as killing people.
    Personally, I can agree with 1), and 2) at least has the virtue of appealing to the emotion (innocent babies! ahh!). But 3) is where they loose me.

    • Dianne

       /  January 27, 2011

      I’d argue that even 1) is questionable: It’s morally abhorrent to kill…what? Few people would find it morally abhorrent to kill a bunch of relatively undifferentiated, rapidly dividing cells that might kill them if it were a cancer. Why should it be different for a zygote or embryo? When you start to talk about later fetuses, yeah, there’s an argument to be made, but I see little difference between preventing conception and stopping the pregnancy before the brain develops.

  10. JJM

     /  January 29, 2011

    @WW “A much more interesting question is: Why have pro-life groups largely failed to convince the American public that abortion is morally abhorrent?”

    Maybe because we already know it; but we recognize that forcing a woman to carry an unwanted child to term is more abhorrent.

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