-p;-oA few years ago, I started offering abortion in my obstetric and gynaecology practice. As the service gradually became more well-known, I met women in many different circumstances. I have found my perceptions regarding abortion have changed, as these women have told me of their experiences. Perhaps the most salient insight is that there is no single psychological response to abortion. It is not only that an unwanted pregnancy is an emotionally charged situation. As doctors, we are educated on how to communicate with people in difficult circumstances. Concepts such as ‘breaking bad news’ and the five stages of grief are part of our training and serve us well. In obstetrics and gynaecology, we understand that miscarriage or stillbirth is, for most women, an unalloyed sadness, and this guides us in how to respond. Unplanned pregnancy and the decision to terminate is complex. Doubt, guilt, grief and regret can be tempered by relief, empowerment and determination.
Research on psychological effects
Inherent difficulties with researching the psychological effects of abortion include defining appropriate comparison groups and the extremely emotive nature of the research topic. A meta-analysis of 22 studies with more than 800,000 participants concluded that there was an 80 per cent increased risk in mental health problems, with 10 per cent of this risk attributable to the termination.1 The strongest psychological effects were observed when women who had an abortion were compared with women who had carried a pregnancy (not necessarily unwanted) to term, and when the outcomes measured related to substance use and suicidal behaviour. The effects were reported lower in comparison groups who had wanted, but not received an abortion, and in women who had not been pregnant at all. At the time of publication, there was considerable debate regarding the nature of this meta-analysis, study selection and choice of comparison groups, reflecting the controversial nature of this research.
Conversely, it has been suggested that abortion may have some mental health benefits compared to continuing with an unwanted pregnancy. A 2013 meta-analysis of eight studies found there was no evidence that abortion reduced the risk of mental health disorders, but was associated with small to moderate increases in anxiety, substance abuse and suicide.2
Once women realise they are unexpectedly pregnant, appropriate comparison groups for studies of abortion may be women who choose to continue with unplanned pregnancy, or women who are unable to access abortion. The Turnaway Study reported on 956 women approaching clinics in the US for an elective first-trimester abortion, with no known fetal anomalies or fatal demise, and no maternal health indications for termination.3 Women were split into three groups: women up to two weeks before the gestational limit who had an abortion (near limit group); those up to three weeks beyond the gestational limit who did not have an abortion (Turnaway group); and those who received an abortion in the first trimester. Two-thirds of women in the Turnaway group eventually had a live birth, while one-third either miscarried or terminated the pregnancy elsewhere. The study was conducted across 31 clinics with gestational limits from 10 weeks until the end of the second trimester. There was, therefore, some overlap of gestation across the three