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

2. U.S. Surgeon General Letter to the President, 1989
Dr. C. Everett Koop
U.S. Surgeon General Jan 1982 – Oct 1989
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3. 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.

4. 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
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5. 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
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6. 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
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7. P.K. Coleman review, 2011
“a moderate to highly increased risk of mental health problems after abortion.”
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8. Nine states with mandated counseling
States with mandated counseling on the negative psychological effects of abortion
Source: Guttmacher Institute, 2016

9. 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

10. Methods

11. 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

12. 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

13. 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

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

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

16. Results

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

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

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

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

21. 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

22. 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

23. 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

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

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

26. 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)
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27. 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
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28. 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
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