Stotland, N.S., Robinson, G. E., Russo, N. F., Lang, J. A., Occhiogrosso, M., . Is there an "Abortion Trauma Syndrome"?: A critical review. Harvard Review of Psychiatry (2009).

Priscilla K. Coleman, Ph.D. - Bowling Green State University - Comments

Critiquing the “Critique”: Efforts to Distort the Post-Abortion Mental Health Literature Become More Obvious with each Successive Attempt

Robinson, Stotland, Russo, Lang, and Occhiogrosso recently published a paper in the Harvard Review of Psychiatry entitled “Is there an “Abortion Trauma Syndrome”? Critiquing the Evidence” This is the latest in a series of attempts to review the world literature on abortion and mental health in an effort to “substantiate” the claim that abortion does not carry risks for psychological harm. Prior efforts included the American Psychological Association’s Task Force Report and a review piece published by Johns Hopkins University researchers in the journal Contraception. In the most recent review, the authors’ primary conclusions that “the most well-controlled studies continue to demonstrate that there is no convincing evidence that induced abortion of an unwanted pregnancy is per se a significant risk factor for psychiatric illness” is entirely unfounded for serious scientifically-based reasons. A few of the problems are highlighted below.

1) The most glaring problem with the article is the arbitrary number of papers selected to review and the manner in which the authors chose particular published reports to analyze. The authors mention having identified 216 peer-reviewed papers on the topic of abortion and mental health and then note selection of a sample of studies that “exemplify common errors in research methodology” as well as “major articles that attempt to correct the flaws.” Their choice of studies in each category was based on the conclusion derived as opposed to the integrity of the design. Numerous methodologically sound studies that have yielded results counter to the authors’ politically driven conclusion are entirely ignored with no rationale offered. In a valid scientific review, criteria for selection (e.g., sample size, representativeness, type of comparison group, how well controlled it is, etc.) are specified at the outset and then the results of each study meeting the criteria are examined to identify general trends. This review lacks a systematic methodology for selection of studies to evaluate rendering the conclusions entirely invalid.

A sampling of important studies with good methodology which were omitted from the review are detailed below. Readers are encourage to visit the Alliance for Post-Abortion Research and Training's website, www.standapart.org, for straightforward, systematic, unbiased synopses of the literature including details pertaining to the studies listed below.

1. Coleman, P. K. (2006). Resolution of unwanted pregnancy during adolescence through abortion versus childbirth: Individual and family predictors and psychological consequences. The Journal of Youth and Adolescence, 35, 903-911.
2. Coleman, P. K. et al. (2009), Induced Abortion and Anxiety, Mood, and Substance Abuse Disorders: Isolating the Effects of Abortion in the National Comorbidity Survey. Journal of Psychiatric Research, 43, 770-776.
3. Coleman, P.K., & Nelson, E.S. (1998). The quality of abortion decisions and college students' reports of post-abortion emotional sequelae and abortion attitudes. Journal of Social and Clinical Psychology, 17, 425-442.
4. Coleman, P. K., Reardon, D. C., & Cougle, J. (2005). Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. British Journal of Health Psychology, 10, 255-268.
5. Dingle, K., et al. (2008). Pregnancy loss and psychiatric disorders in young women: An Australian birth cohort study. The British Journal of Psychiatry, 193, 455-460.
6. Fayote, F.O., Adeyemi, A.B., Oladimeji, B.Y. (2004). Emotional distress and its correlates. Journal of Obstetrics and Gynecology, 5, 504-509.
7. Fergusson, D.M. et al. (2008). Abortion and mental health disorders: Evidence from a 30-year longitudinal study, The British Journal of Psychiatry, 193, 444-451.
8. Hope, T. L., Wilder, E. I., & Watt, T. T. (2003). The relationships among adolescent pregnancy, pregnancy resolution, and juvenile delinquency, The Sociological Quarterly, 44, 555-576.
9. Miller, W. B., Pasta, D. J., & Dean, C. L. (1998). Testing a model of the psychological consequences of abortion. In L. J. Beckman and S. M. Harvey (eds). The new civil war: The psychology, culture, and politics of abortion. Washington, DC: American Psychological Association.
10. Pedersen W. (2008). Abortion and depression: A population-based longitudinal study of young women. Scandinavian Journal of Public Health, 36 (4):424-8.
11. Pedersen, W. (2007). Addiction. Childbirth, abortion and subsequent substance use in young women: a population-based longitudinal study, 102 (12), 1971-78.
12. Pope, L. M. et al. (2001). Post-abortion psychological adjustment: Are minors at increased risk? Journal of Adolescent Health, 29, 2-11.
13. Reardon, D. C., Coleman, P. K., & Cougle, J. (2004) Substance use associated with prior history of abortion and unintended birth: A national cross sectional cohort study. Am. Journal of Drug and Alcohol Abuse, 26, 369-383.
14. Reardon D.C., Ney, P.G. (2002) Abortion and subsequent substance abuse. American Journal of Drug and Alcohol Abuse, 26, 61-75.
15. Rees, D. I. & Sabia, J. J. (2007) The relationship between abortion and depression: New evidence from the Fragile Families and Child Wellbeing Study. Medical Science Monitor, 13(10), 430-36.
16. Sivuha, S. Predictors of Posttraumatic Stress Disorder Following Abortion in a Former Soviet Union Country. Journal of Prenatal & Perinatal Psych & Health,17, 41-61 (2002).
17. Slade, P., Heke, S., Fletcher, J., & Stewart, P. (1998). A comparison of medical and surgical methods of termination of pregnancy: Choice, psychological consequences, and satisfaction with care. British Journal of Obstetrics and Gynecology,105,1288-95.
18. Söderberg et al. (1998). Emotional distress following induced abortion. A study of its incidence and determinants among abortees in Malmö, Sweden. European Journal of Obstetrics and Gynecology and Reproductive Biology 79, 173-8.
19. Suliman et al. (2007) Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia vs. intravenous sedation. BMC Psychiatry, 7 (24), p.1-9.
20. Suri, R, Altshuler, L., Hendrick, V. et al. (2004). The impact of depression and fluoxetine treatment on obstetrical outcome. Archives of Women’s Mental Health, 7, 193-200.

2) Another major problem with the review is the use of very dated sources to make sweeping claims. For example, on the first page, the risk of death from abortion in the U.S. is reported as 1:160,000 with reference to a single 1992 citation. A brief sampling of problems with this statistic is offered below.

a. The International Classification of Diseases (ICD-9) defines maternal death as one that occurs during pregnancy or within 42 days of the termination of pregnancy. Pregnancy-associated deaths occurring outside this window are not captured in the data.

b. Coding rule 12 of the ICD-9 requires deaths due to medical and surgical treatments to be reported under the complication of the procedure (e.g., infection) rather than the treatment (e.g., elective abortion).

c. Most women leave abortion clinics within hours of the procedure and go to hospital emergency rooms if there are complications. The data reported by abortion clinics to state health departments and ultimately to the CDC therefore under-represents abortion morbidity and mortality.

d. Abortion reporting is not required by federal law and only 27 states report abortion complications.

e. The abortion-related mortality rates typically fail to factor in abortions beyond the first trimester, which constitute 12-13% of al abortions [1-2]. Using national U.S. data spanning the years from 1988 to 1997, Bartlett and colleagues reported the relative risk of mortality was 14.7 per 100,000 at 13–15 weeks of gestation, 29.5 at 16-20 weeks, and 76.6 at or after 21 weeks [3].

1. Jones, R.K., Zolna, M.R., Henshaw, S. K. & Finer L.B. (2008). Abortion in the United States: Incidence and Access to Services, 2005. Perspectives on Sexual and Reproductive Health 40, 6-16.
2. Gamble, S.B., Strauss, L.T. Parker, W. Y., Cook, D. A. Zane, S. B., & Hamdan, S. (2008). Abortion Surveillance – United States, 2005. MMWR Surveillance Summaries 57 (SS-13). Atlanta, Ga: Centers for Disease Control and Prevention, Department of Health and Human Services.
3. Bartlett, L. A. et al. (2004). Risk Factors for Legal Induced Abortion-Related Mortality in the United States. Obstetrics & Gynecology, 103 (4), 729–37.

f. At least 50% of women who have aborted deny the experience and therefore the medical records of many women who have aborted are not likely to contain an accurate history.

g. Suicide deaths are rarely, if ever, linked back to abortion in state reporting of death rates. Further, suicides are often not recorded on death certificates.

3) Studies pertaining to increased risk for substance abuse are omitted just as they were in the Contraception report. Substance abuse disorders are widely accepted mental health problems and they have been implicated in anxiety and mood disorders.

4) The review seems to have been put together rather hastily as two of the studies, #23 which is Fergusson and colleagues’ 2006 paper and #39 which is one published in the Canadian Medical Association Journal by Reardon et al. in 2003, had conclusions contradicting their conclusion yet these studies are cited among others as supporting their claim.

5) A final point to consider, the Impact Factor (IF) for the journal that published this review is considerably lower than that of most of the journals where the omitted studies were published. The IF indicates the number of citations to articles published in science and social science journals and it is a widely accepted indicator of the relative importance of a journal to the developing knowledge of a field. If this review truly had merit, surely it would have been submitted to one of the leading journals.

Is the Demand for Causal Proof Flawed?

The most common argument being advanced by Stotland, [Brenda Major] and [Nancy Russo] is that while there are studies showing a statistical association between abortion and mental health problems, this fails to prove causality. In essence, they argue, it is the obligation of abortion critics to prove that abortion "in and of itself" is the cause of mental health problems. In the absence of such convincing proof of a causal relationship, women should not be exposed to "false" claims that abortion is linked to mental health problems. The following section includes responses to Stotland's paper in particular, but also to this broader question regarding causality.

More Comments By Others

1. Abortion is at least a marker for higher risk of mental health problems, and therefore it is a useful marker for screening mental health patients. What is at dispute is only whether abortion itself is the cause of mental health problems or whether it is merely something that women at risk of mental health problems for other reasons are more likely to experience. In their haste to dismiss abortion as a mental health risk, the authors fail to underscore that it is a marker which should be utilized in screening new patients.

This omission is curious since Stotland has recently suggested that psychiatrists should take a sexual history and include questions about previous abortions.

"If a woman has had an abortion, ask about the circumstances surrounding her decision-whether she thought it through beforehand and talked about her experience with friends and/or relatives," Stotland advised.

The patient should also be asked whether she is comfortable with her decision and experience. "If not, ask whether she wants to work on unresolved issues. This can be accomplished by various means including a religious consultation and psychotherapy," she advised.[1]

1. All studies have methodological flaws.
2. Different studies have different flaws. When examined as a group, the strengths of one study may fill in for the flaws of another.
3. All agree, and Surgeon General Koop recommended, that the best way to study the mental health effects is by means of a longitudinal cohort study. Perhaps the most methodologically sound longitudinal cohort study has been done by Fergusson. Robinson et al, however, only discuss Fergusson's 2006 study. They appear to do so because that 2006 study can be criticized for lacking a control variable regarding wantedness of the pregnancies. That weakness was corrected in the 2008 study, which showed that abortion was associated with elevated mental health problems after controlling for prior mental health and wantedness. That the 2008 study was omitted from the review can only be explained by the fact that it is clearly the best study done to date and does not have the flaws the authors wanted to criticize.
4. The authors give great praise to the Gilchrist study but they fail to note any of it's major flaws. See Here Curiously, one of the points the criticize about the Fergusson study is that in New Zealand two doctors have to agree that the abortion is necessary. But the exact same condition applies to Great Britain, where Gilchrist's study was conducted. If Fergusson's study is not generalizable for this reason, why would Gilchrist's be? Moreover, they suggest that physician screening may create "an inclusion bias toward vulnerable, high-risk women in the abortion group." But if physicians are in fact doing their job and screening out abortion candidates for whom abortion is more likely to cause harm than good, the "bias" should be exactly in the opposite direction, in other words physician screening should lead to a bias toward providing abortion for those women who are most likely to benefit from it and who are least likely to experience negative reactions.
5. The authors ignore a whole host of strong studies showing a consistent association between abortion and substance use.
6. They assert there is “there is no convincing evidence that induced abortion of an unwanted pregnancy is per se a significant risk factor for psychiatric illness." In other words, after deliberately excluding the problem of women who abort 'wanted pregnancies' due to coercion (an area where even they cannot deny subsequent psychological injury), they effectively dismiss the objective standard of judging evidence based on statistical tests of significance and simply assert that statistically significant findings can be dismissed if it is no “convincing” enough for them.
7. The authors ignore the fact that there are no studies showing statistically validated mental health benefits associated with abortion. At best they can point to a number of studies indicating that abortion is "benign" for the majority of women studied. Even if they could bring forth such studies, if the same standards for proving causality were to apply, it is unlikely that they could ever provide enough proof of benefits that abortion, if it were a drug, could be approved by the FDA using the same standards for proving benefits which apply to drugs.
8. Reports of "relief" are inconsistent and vague as relief can mean anything. Relief to have survived. Relief that one's boyfriend is no longer badgering her to have an abortion. Relief that it is simply over.
9. Their argument regarding causality is severely flawed for the following reasons:

1. Causality is nearly impossible to prove in regard to any effects associated with any freely chosen human activity. It is impossible to do a double blind study of a representative random sample of women to be impregnated with a random sample selected for abortion.
2. In many, perhaps most cases, abortion will be a contributing cause to mental health issues. It will be a stressor that will trigger or aggravate problems in a direction for which the individual is most prone to have problems. Their is no obligation on the part of aboriton critics to prove that the abortion procedure itself--totally exclusive other factors going into the abortion experience such as pressure to abort, pre-existing problems, lack of adequate followup--is the sole cause of negative mental health effects. Such an argument reveals the great weakness in their position because literally all of their own studies consistently show at least small subgroups of women who are at elevated risk for having negative reactions to abortion. Traditionally, they have dismissed these subsets of women with "blame the victims" type comments such as "they would likely have fared worse if they had carried to term." In fact, they have yet to provide any evidence in a well designed study that women with risk factors for negative reactions to abortion fair better after an abortion than do similar women who carry to term.
3. Regarding causality, deniers ignore that women self-attribute their symptoms to abortion.  Self-awareness is an important piece of evidence regarding causality.  For example, deniers fail to mention suicide notes by women attributing their suicides to grief over their abortions. This dismissal of literally thousands of women's testimonies is an insult to the witness of women themselves.
4. They ignore that trained therapists have affirmed the association between abortion and subsequent problems and their reports that treating unresolved abortion issues alleviates the associated mental illnesses. Stotland herself previously wrote about her surprise when treating a woman whose past abortion emerged as a major psychological issue years later when she experienced a subsequent miscarriage. She states that "the loss of a potential life" caused by abortion "leaves the person vulnerable to reminders and reenactments, to difficulties that may surface in life and in subsequent psychotherapy." (In 'Abortion: Social Context, Psychodynamic Implications" Am J Psychiatry, 155(7):964-967, 1998')
5. Critics of abortion do not claim that large scale studies have, by themselves, "proven" a causal connection between abortion and mental health problems. Instead, critics argue that at least in isolated cases a causal connection has been clearly proven through individual self-attribution and confirmed by treating therapists. The question raised by these isolated cases, however, is if these kinds of reactions are occurring often enough to show up in large scale studies. Studies designed to examine this question indicate that yes, negative reactions reported by women to their therapists are associated with abortion at statistically significant rates in the general population.
6. They presume that it is the obligation of abortion critics to prove a causal connection between abortion and subsequent mental health problems but ignore that an equal burden is on them to prove a casual connection between abortion and positive outcomes.

On Causality

The argument that it is the obligation of abortion critics to prove that abortion is the sole cause of mental illness is an inappropriate shift of concerns, driven by political considerations, not medical one. Even if abortion is only a common risk factor, it is still a useful marker to identify women at risk of substance abuse, depression, anxiety, sleep disorders, suicidal behavior, etc.

Furthermore, their apparent definition of and arguments regarding causality are too simplistic. The medical definition of causality, is broader:

causality: The relating of causes to the effects they produce. Causes are termed necessary when they must always precede an effect and sufficient when they initiate or produce an effect. Any of several factors may be associated with the potential disease causation or outcome, including predisposing factors, enabling factors, precipitating factors, reinforcing factors, and risk factors.

The same definition is applied to "multiple causation" -- which is important since many, if not most mental health problems, probably involve multiple factors of causation, including genetic, physical environment, physical health, experiences, relationships, etc.

So, while all would agree that abortion is certainly not a necessary cause of depression, since there surely other reasons people experience depression, there is plenty of evidence that abortion can be a predisposing factor, enabling factor, precipitating factor, or reinforcing factor, all of which are risk factors that should be considered by the recommending physician and the woman and her trusted advisers.

Normally, as described evidence based medical practice and implicit in the medical principle "first do no harm," the lack of strong evidence that a proposed treatment is the likely and direct cause of benefits which will outweigh the risks of the treatment is sufficient reason to avoid such a dubious treatment option, or at the very least to treat it as highly experimental treatment with no proven benefits and many suspected risks.

Regarding factors relevant to evaluation of causality, see Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965;58:295–300. and Ward AC. The role of causal criteria in causal inferences: Bradford Hill's "aspects of association". Epidemiol Perspect Innov. 2009 Jun 17;6:2. See [Hills Criteria of Causation http://www.drabruzzi.com/hills_criteria_of_causation.htm]

• temporal relationship,
• biological plausibility,
• strength of association,
• dose–response effect (increased risk with increasing number of abortions),
• consistency (reported by several studies)
• coherence (matching with current theory of knowledge).
• alternate explanations (are alternate reasons for the outcome addressed?)
• specificity (is abortion the only cause for an associated outcome)
• alteration of outcome (can an opposite experiment demonstrate an opposite outcome)

EXAMPLE of applying these criteria Shah and Zao. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analyses

"A step further, we would like to mention that this strong association meets several of the criteria suggested by Professor Hill78 regarding causation such as temporal relationship, biological plausibility, strength of association, dose–response effect (increased risk with increasing number of abortion), consistency (reported by several studies) and coherence (matching with current theory of knowledge). The criteria of an alternate explanation (accounting for other confounders/reasons for the outcome) could be considered satisfied. Two criteria for causation are not satisfied: Specificity (I-TOP is the only cause of LBW/PT births) and alteration of outcome with an opposite experiment are not satisfied. We must caution readers that we have restricted ourselves to explore the association of I-TOP and pregnancy outcomes. Several biomedical, social, environmental, lifestyle-related, genetic and other factors contribute to a preterm and/or LBW births and this needs to be kept in mind in interpreting our results. We caution interpretation being causal as confounding effects of socio-economic factors, which are important, were considered in very few studies only. Discussion regarding downsides of I-TOP are incomplete without discussing downside of unwanted pregnancies as they are also at risk of adverse outcomes. From pragmatic viewpoint, future studies should assess benefits and risks in both situations."

A Risk is Still a Risk Even When There is Uncertainty

A "risk" by it's very nature is uncertain. Otherwise we would call it a certainty.

So any uncertainty regarding causation is no different than the uncertainty that any particular individual might be the unlucky one who has a complication. The two conflate into an overall general risk that (a) the link may be causal and (b) you may be the unlucky one. Patients face a risk that both (a) and (b) are true and should not be denied information about that risk just because the doctor doubts (a) or (b) will in the end be untrue.

Mathematically, the two risks might be combined in this way. A 50% risk that an observed risk is truly causal and a 10% risk of complications, yields a 5% risk that both the risk is true and a particular individual will experience the complication. If abortion is a contributing risk factor, but not 100% causal, then the mathematical risk attributed to abortion might be reduced even more. For example, if further research showed that only 20% of the observed 50% increased risk was due to abortion and the remainder was due to other co-existing contributing factors, the risk would be reduced to a 2% risk that any particular individual would have the complication. But even in this case, the risk is not reduced to zero. It is only reduced to zero if it is conclusively proven that abortion has zero effect on the complication rates. Moreover, if it is a contributing factor, then once that is identified along with the other contributing factors, the importance of screening is heightened even more. For a 10% risk of complications among all women who have abortion includes many, even most women, who do not have the other contributing factors. If for example, the two key contributing factors leading to suicide are a history of depression and abortion, the risk rate for this subset of women will be much higher than the base rate of 10%.

Federal Circuit Court on Disclosing Associated Risks

In an en banc ruling the 8th U.S. Circuit Court of Appeals (Planned Parenthood v. Rounds, 2012) rejected Planned Parenthood's argument that risks need not be disclosed unless causality has been proven, observing that "[i]t is a typical medical practice to inform patients of statistically significant risks that have been associated with a procedure through medical research, even if causation has not been proved definitively."

The court noted that federal rules for labeling of prescription drugs require a warning to be included "as soon as there is reasonable evidence of an association of a serious hazard with a drug; a causal relationship need not have been proved." (emphasis added, 21 C.F.R. § 201.80(e))

The "standard practice" in medicine, the court wrote, is to "recognize a strongly correlated adverse outcome as a 'risk,' even while further studies are being conducted to investigate which factors play causal roles." The court went on to sharply criticize Planned Parenthood's "contravention of that standard practice," concluding that "there is no constitutional requirement to invert the traditional understanding of 'risk' by requiring, where abortion is involved, that conclusive understanding of causation be obtained first."

Statistical Association is Sufficient Reason for Warnings

The following is another good example of why risks statistically associated with abortion should be disclosed, taken from Abortion’s Impact on Prematurity: Closing the Knowledge Gap by Martin McCaffrey, M.D.:

If statistics exclude chance as an explanation for the association, then there is a real association, and investigators turn to analyzing whether the associated factor is possible cause for the outcome. The relationship between smoking during pregnancy and preterm birth illustrates the concept of “association.” While an association has been reported to exist between smoking and preterm birth, preterm birth does occur in mothers who do not smoke. Similarly, all mothers who smoke do not experience preterm birth. Smoking during pregnancy, according to some studies, is associated with an increased likelihood of preterm birth; but not all studies have reached this conclusion. The IOM report concluded:

Many studies have examined the association between smoking and preterm birth, and they generally find modest associations. Recent studies continue to show such a pattern. However, some reports suggest a stronger association and others suggest no association at all.5

Despite just a “modest association,” and lack of proof of probable causality, public health experts have identified smoking as a modifiable risk factor that might reduce a mother’s risk for delivering a preterm baby. As a result, the U.S. Surgeon General in 1985 determined it was his duty to warn mothers who smoked of the association with an increased risk for a preterm birth. The concern regarding this association remains significant enough that the Surgeon General’s warnings on cigarette packages issued in 1985 continue to this day: “Smoking By Pregnant Women May Result in Fetal Injury, Premature Birth, And Low Birth Weight.”6

Citing

5. Institute of Medicine. Preterm Birth: Causes, Consequences, and Prevention Committee on Understanding Premature Birth and Assuring Healthy Outcomes; Behrman RE, Butler AS, editors. Washington (DC): National Academies Press (US); 2007:p

6. Reducing the Health Consequences of Smoking: 25 YEARS OF PROGRESS A Report of the Surgeon General 1989

Notably,if an association is due to some common risk factor rather than direct causation, there is still good reason to tell people who have this "marker" for a health risk that they are at higher risk. In the example of smoking and premature birth, it's possible that the risk is directly causal due to impacts of smoking on the woman's body and fetal development, but it is also possible that the association is due to general unhealthy behaviors, for which smoking is just an indicator of poorer nutrition (for example).

Dose Effect Evidence

mental health dose effect

Previous pregnancy loss has an adverse impact on distress and behaviour in subsequent pregnancy. McCarthy F, Moss-Morris R, Khashan A, et al.BJOG An Int J Obstet Gynaecol. 2015;122(13):1757-1764. doi:10.1111/1471-0528.13233.

Women with one previous termination displayed elevated perceived stress (adjusted mean difference 0.65; 95% CI 0.08–1.23) and depression (aOR 1.25; 95% 1.08–1.45) at 15 weeks of gestation. Women with two previous terminations displayed increased perceived stress (adjusted mean difference 1.43; 95% CI 0.00–2.87) and depression (aOR 1.67; 95% 1.28–2.18).

Depression Following Induced Abortion. Koyun, A., Kır Şahin, F., Çevrioğlu, S., Demirel, R., & Geçici, Ö. (2016). Gynecology Obstetrics & Reproductive Medicine, 13(2). doi:http://dx.doi.org/10.21613/GORM.2007.521

Note. The researchers also observed a dose effect, with multiple abortions increasing depression risk.

Increased risk for postpartum psychiatric disorders among women with past pregnancy loss. Giannandrea SAM, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt) [Internet]. 2013;22(9):760–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24007380 PMID: 24007380

Multiple losses, either from miscarriage or induced abortion, predict elevated rates of postpartum anxiety.(2)

physical health dose effect

Birth outcomes after induced abortion: a nationwide register-based study of first births in Finland. Klemetti R, Gissler M, Niinimäki M, Hemminki E. Hum Reprod. 2012 Nov;27(11):3315-20. doi: 10.1093/humrep/des294. Epub 2012 Aug 29.

After adjustment, perinatal deaths and very preterm birth (<28 gestational week) suggested worse outcomes after IA. Increased odds for very preterm birth were seen in all the subgroups and exhibited a dose-response relationship: 1.19 [95% confidence interval (CI) 0.98-1.44] after one IA, 1.69 (1.14-2.51) after two and 2.78 (1.48-5.24) after three IAs. Increased odds for preterm birth (<37 weeks) and low birthweight (<2500 g and <1500 g) were seen only among mothers with three or more IAs: 1.35 (1.07-1.71), 1.43 (1.12-1.84) and 2.25 (1.43-3.52), respectively.

life expectancy / elevated mortality rate dose effect

Reproductive history patterns and long-term mortality rates: a Danish, population-based record linkage study. Coleman PK, Reardon DC, Calhoun BC. Eur J Public Health. 2012 Sep 5.

Risk of death was more than six times greater among women who had never been pregnant compared with those who only had birth(s). Increased risks of death were 45%, 114% and 191% for 1, 2 and 3 abortions, respectively, compared with no abortions after controlling for other reproductive outcomes and last pregnancy age.