Elsevier

Contraception

Volume 78, Issue 6, December 2008, Pages 436-450
Contraception

Review article
Abortion and long-term mental health outcomes: a systematic review of the evidence

https://doi.org/10.1016/j.contraception.2008.07.005Get rights and content

Abstract

Claims that women who have elective abortions will experience psychological distress have fueled much of the recent debate on abortion. It has been argued that the emotional sequelae of abortion may not occur until months or years after the event. Despite unclear evidence on such a phenomenon, adverse mental health outcomes of abortion have been used as a rationale for policy-making. We systematically searched for articles focused on the potential association between abortion and long-term mental health outcomes published between January 1, 1989 and August 1, 2008 and reviewed 21 studies that met the inclusion criteria. We rated the study quality based on methodological factors necessary to appropriately explore the research question. Studies were rated as Excellent (no studies), Very Good (4 studies), Fair (8 studies), Poor (8 studies), or Very Poor (1 study). A clear trend emerges from this systematic review: the highest quality studies had findings that were mostly neutral, suggesting few, if any, differences between women who had abortions and their respective comparison groups in terms of mental health sequelae. Conversely, studies with the most flawed methodology found negative mental health sequelae of abortion.

Introduction

While there have been notable improvements in the research on abortion and mental health in the past 2 decades, methodological limitations persist, and studies continue to be biased by political motivations. Claims that women who have elective abortions will experience psychological distress, or a “postabortion syndrome” akin to posttraumatic stress disorder, have fueled much of the recent debate on abortion. It has been argued that the emotional sequelae of abortion often may not occur until months or years after the event [1], [2]. Recently, the US Supreme Court referenced adverse mental health outcomes for women as part of the rationale for limiting late term abortions1. Despite claims of emotional harm, the existence of such an abortion-related syndrome has yet to be established empirically [3], [4]. This article will systematically review recent research that has explored the associations between elective abortion and long-term mental health outcomes.

In 1989, C. Everett Koop, then the U.S. Surgeon General well-known for his opposition to abortion, reviewed the research examining the psychological sequelae of elective abortion and concluded in a letter to President Reagan that the politics of abortion skewed our scientific understanding of its impact and that the empirical evidence was inconclusive [5]. Other reviews have also found the literature either to be inconclusive [6], [7], [8] or reflective of normal stress and coping rather than psychopathology [9], [10], [11], [12], [13], [14], [15], [16]. This perspective was once again reinforced recently by the American Psychological Association [17].

The present study differs from previous systematic reviews of the topic in that it focuses solely on long-term mental health effects, delineates clear criteria for research quality, and presents a framework against which all published research was judged.

Section snippets

Search strategy and selection criteria

We identified studies published between January 1, 1989, and August 1, 2007, using PubMed via Medline, EMBASE, Scopus and PsycINFO. Combinations of the following keywords were used in the search: abortion, mental health, mental disorders, mental health services, adjustment disorders, depression, anxiety, and suicide. Reference lists of relevant review articles were also reviewed (details of the search strategy available upon request).

In order to be included, articles had to: (1) be published

Results

Fig. 1 summarizes the results of the search process. Our search strategy identified over 700 articles. After excluding articles determined to be inappropriate on the basis of title and/or abstract review, full texts of all remaining articles (n=61) were reviewed for potential inclusion. Of these, 36 did not meet inclusion criteria. In total, 25 articles were retained and abstracted, including 212

Discussion

A clear trend emerges from this systematic review: the highest quality studies had findings that were mostly neutral, suggesting few, if any, differences between aborters and their respective comparison groups in terms of mental health sequelae. Conversely, studies with the most flawed methodology consistently found negative mental health sequelae of abortion. A similar trend was present in our examination of descriptive studies, but we do not focus on those studies in this review.

Elective

Acknowledgments

The authors wish to thank Duff Gillespie, Ph.D., and Freya Sonenstein, Ph.D., for their input, suggestions and review of initial manuscript drafts. This study was supported in part through the Frary Family Fund.

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