Affective and Substance Abuse Disorders Following Abortion by Pregnancy Intention in the United States: A Longitudinal Cohort Study

Abstract

Background and Objectives: Psychological outcomes following termination of wanted pregnancies have not previously been studied. Does excluding such abortions affect estimates of psychological distress following abortion? To address this question this study examines long-term psychological outcomes by pregnancy intention (wanted or unwanted) following induced abortion relative to childbirth in the United States. Materials and Methods: Panel data on a nationally-representative cohort of 3935 ever-pregnant women assessed at mean age of 15, 22, and 28 years were examined from the National Longitudinal Survey of Adolescent to Adult Health (Add Health). Relative risk (RR) and incident rate ratios (IRR) for time-dynamic mental health outcomes, conditioned by pregnancy intention and abortion exposure, were estimated from population-averaged longitudinal logistic and Poisson regression models, with extensive adjustment for sociodemographic differences, pregnancy and mental health history, and other confounding factors. Outcomes were assessed using the Diagnostic and Statistical Manual, Version 4, American Psychiatric Association (DSM-IV) diagnostic criteria or another validated index for suicidal ideation, depression, and anxiety (affective problems); drug abuse, opioid abuse, alcohol abuse, and cannabis abuse (substance abuse problems); and summary total disorders. Results: Women who terminated one or more wanted pregnancies experienced a 43% higher risk of affective problems (RR 1.69, 95% CI 1.3–2.2) relative to childbirth, compared to women terminating only unwanted pregnancies (RR 1.18, 95% CI 1.0–1.4). Risks of depression (RR 2.22, 95% CI 1.3–3.8) and suicidality (RR 3.44 95% CI 1.5–7.7) were especially elevated with wanted pregnancy abortion. Relative risk of substance abuse disorders with any abortion was high, at about 2.0, but unaffected by pregnancy intention. Excluding wanted pregnancies artifactually reduced estimates of affective disorders by 72% from unity, substance abuse disorders by 11% from unity, and total disorders by 21% from unity. Conclusions: Excluding wanted pregnancies moderately understates overall risk and strongly understates affective risk of mental health difficulties for women following abortion. Compared to corresponding births, abortions of wanted pregnancies are associated with a greater risk of negative psychological affect, particularly depression and suicide ideation, but not greater risk of substance abuse, than are abortions of unwanted pregnancies. Clinical, research, and policy implications are discussed briefly.

The Effects of Abortion Decision Rightness and Decision Type on Women’s Satisfaction and Mental Health

“…Ideally, more prospective longitudinal studies should be undertaken which include data on prior mental health, pregnancy intention, and other confounding factors years prior to the participants’ first pregnancies. Unfortunately, while a few high quality prospective studies have been done, the underlying data gathered for these studies was general in nature: The questionnaires were not designed to focus on research questions specific to the abortion experience [ 8 , 20 , 37 ]. Therefore, we recommend that new and existing national prospective survey designs should include input from experts on both sides of the abortion and mental health controversy to ensure better that the most useful questions are included.…”

A Reanalysis of Mental Disorders Risk Following First-Trimester Abortions in Denmark

“…The Danish researchers' conclusions have also been called into question by both prior studies which employed better methodologies, [3,4] and subsequent studies. [11][12][13][14] For example, an analysis of the National Longitudinal Study of Adolescent to Adult Health (Add Health) which controlled 25 confounding factors, including prior mental health and exposure to violence, found that each exposure to abortion increased the risk of subsequent mental health disorders, a finding that could not be explained by prior mental health. [11] In addition, the subset of women who reported aborting a wanted child experienced a 122% higher rate of depression and a 244% higher rate of suicidality.…”

A Cohort Study of Mental Health Services Utilization Following a First Pregnancy Abortion or Birth

“…The range of possible examples of mental health problems or issues and the means by which they can be operationalized or measured are extensive. Just a few examples to illustrate the diversity: depression scores from a questionnaire; 16 bipolar disorder and unplanned or interrupted pregnancies; 17 past adverse pregnancy outcome (stillbirth, abortion, or a child’s death) associated with depression; 18 insomnia, anorexia and severe depression requiring hospitalization following therapeutic abortion; 19 clinical psychologist assessment of depression within one week of chemical or surgical abortion; 20 alcohol, tranquilizer and other substance abuse related to abortion; 21 substance abuse and suicide rates following termination of unwanted versus wanted pregnancies; 22 National Comorbidity Survey, history of abortion and substance abuse disorder; 23 detoxification center patients and prior abortions; 24 history of abortion and smoking and drinking during pregnancy; 25 and drug overdose both before and after abortion. 26 This very small sample of studies suggests the need for some more comprehensive measure of overall mental health service utilization which can be applied to population denominators.…”