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A recent meta review (mentioned in some articles in the media, e.g. The Telegraph or CBS News) examining the association between abortion and mental health problems "Abortion and mental health: quantitative synthesis and analysis of research published 1995–2009" by Priscilla K. Coleman in the British Journal of Psychiatry claims

Women who had undergone an abortion experienced an 81% increased risk of mental health problems, and nearly 10% of the incidence of mental health problems was shown to be attributable to abortion.

I've heard previously about a possible correlation between mental health problems and abortion, but I had the impression that no reliable studies could substantiate that. The claim in this meta review, that 10% of mental health problems are attributable to abortion seems to me extraordinary.

Is there any additional evidence that this claim is true? Does this meta review actually support this claim adequately?

  • I'd also like to see the correlation between pregnancies and mental health problems. – Tomas Dec 14 '11 at 3:58
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Is there any additional evidence that this claim is true? Does this meta review actually support this claim adequately?

Apparently the answers are "No" and "No":

http://www.psychologytoday.com/blog/the-skeptical-sleuth/201111/is-having-abortion-likely-damage-womans-mental-health

http://www.psychologytoday.com/blog/the-skeptical-sleuth/201111/more-review-claiming-abortion-hurts-womens-mental-health

Although there is a vast literature concerning mental health effects of abortion, Coleman selects only 22 studies, 11 of them her own. She indicated that she has excluded other studies as being too poorly designed, but she fails to identify which studies were excluded and specifically why.

The Royal College of Psychiatrists... considered all of the Coleman studies that they reviewed to be methodologically poor. A number of her papers were rejected because they had inappropriate control/comparison groups and still other papers were rejected because they used inappropriate measures of mental health after the abortion. In addition to its other limitations, still another Coleman paper was rejected because of a lack of statistical control for mental health prior to the abortion. The Royal College of Psychiatrists report did include one of Coleman's papers, but with serious criticism.

[Coleman] relied heavily on comparisons between women that [sic] received an abortion for unwanted pregnancy and women who had completed a pregnancy that was planned or wanted. Of course, this strategy cannot get at the effects of abortion because presumably the circumstances of having an unwanted or unplanned pregnancy are different from the circumstances of completing a wanted pregnancy. It is not surprising that women having a wanted pregnancy have better mental health than women who did not want to be pregnant. Do you think the Coleman knew what she was doing and proceeded anyway?

Another criticism of Coleman's review is that she often did not control for prior mental health. So, if a woman smoked marijuana or consumed alcohol after an abortion, she was compared to women who dealing with a newborn child, and any differences were attributed to the first group of women having had an abortion, even in situations where ascertainment of drug or alcohol use occurred before the abortion.

[Coleman] states that the population attributable risk (PAR) associated with abortion is 10% of all mental health problems and 34.9% of all suicides in women of reproductive age. PAR is intended to represent the proportion of such problems that can be causally attributed to abortion.

Near the end of her article, Coleman reveals her intention to affect public policy by burdening women interested in terminating an unwanted pregnancy with the necessity of first being warned about the dangers of abortion: "Until sound evidence documenting mental health benefits of abortion is available, clinicians should convey the current state of uncertainty related to benefits of abortion in addition to sharing the most accurate information pertaining to statistically validated risks."

Further evidence that the article was politically motivated (evidence my own):

Anti-choice websites, apparently alerted in advance of the article's publication, created an immediate buzz about it across the US. The article was quickly sent to the Florida state legislature in support of a bill restricting abortion and the article was introduced as evidence in the appeal of a Wisconsin court decision ruling against necessity of warning women seeking abortion of the risk of suicide they face.

See also the published responses to the article itself:

http://bjp.rcpsych.org/content/199/3/180.short#responses

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    To protect us against link rot, it would be good to extract a couple key sentences from each link to give the gist. – Oddthinking Dec 11 '11 at 21:59
  • Enhanced the answer with key points from the review. – Alain Dec 12 '11 at 14:46
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Your question Are 10% of mental health problems caused by abortion might be addressed in a number of ways. First, in considering whether there is any evidence to support the claim, one could simply go to the source studies that were included in the meta-analysis. (You may find the referenced studies for free at http://bjp.rcpsych.org/content/suppl/2011/08/11/199.3.180.DC1/bjp_199_ds180.pdf . The full PDF costs $15.)

Many of the source studies (Cougle 2008 (US), Pergrusson 2008 (Australia), Gilchrist 1995 (UK) and others) report the increase in mental health problems. All of the articles were published in refereed journals, which means that skepticism is built in, as many experts in that field will try to pick apart a submission. By the way, the nature of a meta-study is not to make new claims, but to summarize existing claims.

Canadian authors Mota, Burnett, and Sareen published a study entitled “Associations Between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample” in the Canadian Journal of Psychiatry, Vol 55, No 4, Aprtil 2010. This article was not cited in the Coleman’s meta-analysis, and yet confirms the same results. When compared to women without a history of abortion, those who had an abortion had a 61% increased risk for Mood Disorders. Social Phobia was linked with a 61% increased risk and suicide ideation with a 59% increased risk.

So yes, there is evidence to support the claim.

Let us examine the detractors of the article. One of the strongest, most cogent critiques of Coleman’s meta-analysis may be found at http://bjp.rcpsych.org/content/199/3/180/reply#bjrcpsych_el_33923 .

Here is an outline of objections from Louise M Howard, Hind Khalifeh, Melissa Rowe, Kylee Trevillion, and Trine Munk-Olsen.

  1. Did not follow robust methodologies for systematic reviews 1a. No details on search terms 1b. Only two databases included 1c. Lacks citation tracking 1d. Non-standardized measure of mental disorders 1e. Lack of adjustment for pre-existing mental illness 1f. No adjustment for key confounders.
  2. Munk-Olsen, the last author of the critique, published in the NEJM that “reported no difference between the incidence of first psychiatric contact before and after abortion.” (7. Munk-Olsen, T., et al., Induced first-trimester abortion and risk of mental disorder. N Engl J Med, 2011. 364(4): p. 332-9)
  3. Eleven of the twenty-two papers were authored by Coleman.
  4. Synthesis of the data and summary statistics are flawed.
  5. Erroneous conclusions drawn regarding the Population Attributable Risk (PAR).

I would respond to the Howard, et. al. critique:

  1. The lack of citations doesn’t invalidate the meta-study. Lack of key confounders means the critique suggests that Coleman did not account for problems such as social deprivation or rape. On the other hand, it also means that Coleman did not “cherry pick” patients just to prove her point.
  2. Munk-Olsen has a single study that contradicts a much larger meta-study. Unfortunately, their study did cherry pick the more healthy ones, for example, excluding women with previous psychiatric history. (See http://www.aaplog.org/get-involved/letters-to-members/danish-nejm-study/).
  3. While Coleman had written half of the papers in the meta-study, there are many other studies in many different countries that corroborate the meta-study. (Data table for original meta-analysis article, http://bjp.rcpsych.org/content/suppl/2011/08/11/199.3.180.DC1/bjp_199_ds180.pdf)
  4. The fact that there multiple effects reported in 13 of the 22 studies does not diminish the importance that there are 9 with single factors. (same site, http://bjp.rcpsych.org/content/suppl/2011/08/11/199.3.180.DC1/bjp_199_ds180.pdf)
  5. I think the critique is implying that Coleman uses circular reasoning: assuming that the risk factor (abortion) causes the disease (mental health problems) while trying to prove the same. I am not familiar with this particular branch of statistics and cannot confirm or dismiss the critique on this point.

To the second part of your question, Does this meta review actually support this claim adequately?, I would say “yes,” mostly because the critique does not make a compelling case. While the Howard, et. al. critique implies that Coleman is in self-interest, there may be an element of self-interest in Munk-Olsen detracting from Coleman while promoting the NEJM article (which is in the minority).

Taking a parallel line of reasoning, it is interesting to note that abortion is correlated with not only mental but physical outcomes, such as breast cancer. (See “Induced abortion as an independent risk factor for breast cancer: a comprehensive review and meta-analysis” at http://jech.bmj.com/content/50/5/481.short, for example.) The window for reproductive problems arising from abortion is limited to the time when the woman can reproduce, say twenty years. In contrast, mental problems can have a much longer delay in onset from the provocative event. For example, PTSD may occur more than twenty years after the provocative event. So the 10% estimate may be underestimating the effect. And if there are physical repercussions to abortion, it is not unreasonable to assume that there may be some mental repercussions as well.

On a different line of reasoning: there was a point when there were scientific studies that contradicted the notion that using tobacco products were correlated with lung cancer. (Of course, the tobacco companies vigorously held on to this notion.) With enough studies (and meta-studies), it became better understood that there was a strong correlation.

So in conclusion, yes and yes to your questions. The science supports the meta-study’s conclusions.

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    Hi. Your five rebuttals of the critique sounds a bit like OR, since they are unsourced. If they aren't just your opinions, could you provide references? Furthermore, I fail to see how the comparison to the tobacco industry is relevant to this question. – Zano Dec 11 '11 at 23:35
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    @Zano, rebuttal 2 had a reference in my original post. Rebuttal 1 should be evident on its face: lacking details that the critiquers desire may weaken the argument, but does invalidate the conclusion. I have added a reference from the original meta-analysis for points 3 and 4. I have claimed ignorance on point 5 and not rebutting the critique. I used a comparison to tobacco because the 1) state of science is in transition, with evidence accumulating in favor of patients having abortions requiring more mental health, and 2) a published single article does not refute a wider body of evidence. – rajah9 Dec 12 '11 at 0:31
  • Your rebuttals #2 and #3 are very much on-point. That being said, the leap between physical and mental effects, while perhaps logical, is almost entirely opinionated, so might be best left out, and I also agree with Zano that you'd be better off without the tobacco analogy. Otherwise, this is the correct answer. – TVann May 16 '17 at 16:31

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