Researching the effects of abortion on women’s mental health outcomes M. Antonia Biggs, PhD June 6, 2017

U.S. Surgeon General Letter to the President, 1989 Dr. C. Everett Koop U.S. Surgeon General Jan 1982 – Oct 1989 Month YEAR

Systematic reviews on the effects of abortion on women’s mental health APA Task Force Conclusions (1989, 2008 & 2009): No evidence that having a single first-trimester abortion causes mental health problems Published studies suffer from serious methodological problems   Several reviews and studies on mental health and abortion reach similar conclusions Reviews: Charles et al 2008; Robinson et al 2009; Major et al 2009; Stotland 2011; Steinberg 2011; National Collaborating Centre for Mental Health at the Royal College of Psychiatrists 2011.

Methodological limitations of existing literature (Major et al., 2009) use of inappropriate comparison groups inadequate control for co-occurring risk factors sampling bias attrition poor measurement of mental health outcomes and reproductive history statistical errors Interpretational errors Month YEAR

Finding the appropriate comparison group Requires comparing women who have an abortion with real alternatives to abortion Common comparisons Childbirth Miscarriage No history of abortion Experiences of women who choose to have an abortion and women who choose to give birth are inherently different Such comparisons may erroneously attribute differences to the abortion Month YEAR

Importance of controlling for risk factors Most significant predictors of having a mental health problem following an abortion: Previous mental health conditions History of trauma, abuse and violence Month YEAR

P.K. Coleman review, 2011 “a moderate to highly increased risk of mental health problems after abortion.” Month YEAR

Nine states with mandated counseling States with mandated counseling on the negative psychological effects of abortion Source: Guttmacher Institute, 2016

Turnaway study (PI: Foster) To assess effects of having an abortion on women’s psychological and well-being outcomes, 5 years after seeking an abortion Improves on the methodological shortcomings of previous studies

Methods

Sample by study group Completed baseline interview Site 28 n=79 Completed baseline interview n=956 First trimester abortion n=254 Near Limit Abortion comparison n=413 Turnaways n=210 Turnaway births n=160 Abortion/ miscarriage n=50

Mental health and well-being measures Depression symptoms and cases: Brief Symptom Inventory (BSI) & Patient Health Quest. (PHQ-9) Includes feeling lonely, blue, worthless, hopeless, loss of interest, and thoughts of ending life Anxiety symptoms and cases: (BSI), 6 items. Includes feeling nervous, tense, scared, terror, restless, and fearful PTSD symptoms, risk and pregnancy-related: (PC-PTSD screen) Self-Esteem: Single-item, 5 point scale Life satisfaction: Single-item, 5 point scale

Bivariate analyses comparing characteristics of study group Multivariate longitudinal analyses for mental health and well-being outcomes linear and logistic mixed effects regression random intercepts for site and for individuals, as necessary Quadratics and cubics as necessary Controlling for baseline differences

Baseline mental health history Biggs et al., 2017, JAMA-Psych

Baseline history of child abuse and neglect Biggs et al., 2017, JAMA-Psych

Results

Depressive symptoms, past week (scale is 0-24) Biggs et al., 2017, JAMA-Psych

Depression cases Biggs et al., 2017, JAMA-Psych

Anxiety symptoms, past week (scale is 0-24) Biggs et al., 2017, JAMA-Psych Month YEAR

Anxiety cases Biggs et al., 2017, JAMA-Psych Month YEAR

PTSD symptom and risk trajectories Biggs et al., 2016, BMJ-open. Controls for age, race, education, employment, marital status, parity, child abuse and neglect, history of sexual assault, IPV, drug and alcohol use, and mental health DX

Events attributed as source of PTSD symptoms Violence, abuse, unlawful activity (30%) Non-violent relationship issues (20%) Index pregnancy-related event (19%) Non-violent death/illness of a loved one (15%) Personal health-related issues including substance use and mental health (6%) Concerns about children (4%) Prior pregnancy/abortion experience (4%) Financial/job/housing insecurity (4%) Accident (4%) Biggs et al., 2016, BMJ-open

Index pregnancy as source of symptoms Biggs et al., 2016,BMJ-open. Controls for age, race, education, employment, marital status, parity, child abuse and neglect, history of sexual assault, IPV, drug and alcohol use, and mental health DX

Felt high self-esteem, past week Biggs et al., 2017, JAMA-Psych Month YEAR

Felt satisfied with your life, past week Biggs et al., 2017, JAMA-Psych

Are mental health outcomes worse for women having later (Near-Limits) vs. earlier abortions? 92% of abortions in US ≤13 weeks gestation (Jatlaoui et al., 2016) No differences in levels or trajectories: Depression cases Anxiety cases Anxiety symptoms PTSD risk Pregnancy-related PTSD Self-esteem Life satisfaction Differences in baseline levels: Depressive symptoms (1st < depressive symptoms) PTSD symptoms (1st Tri > baseline PTSS) Month YEAR

Summary Women denied abortion had more anxiety and lower self-esteem at the time of abortion denial, than those having a wanted abortion Groups converged by 6-12 months Symptoms and cases of depression, PTSD and life satisfaction did not differ by study group For all outcomes and study groups, women improved over the five year study period Month YEAR

Conclusions Denying woman an abortion is more harmful, at least initially, than allowing a woman to get her wanted procedure Overall improvements over time, suggests that other factors-not the abortion-are causing distress at the time of pregnancy discovery or abortion seeking Policies mandating that women be counseled on the negative mental health harms of abortion are not evidence based Month YEAR