NCCMH Draft

http://www.rcpsych.ac.uk/default.aspx

Missing Points That Should Be Mentioned

• There is no evidence when, if ever, allowing a pregnancy to continue poses significantly greater mental health risks than abortion. Therefore, there is no evidence to when abortion may be legal under British law. A conclusion of equal risk does not satisfy the requirements of British law which allow for abortion only when the risks of allowing the pregnancy to continue are greater than the risks associated with abortion.

• There is no call for funding of a proper longitudinal study.

• Very similar, but subtly different, there is no evidence when, if ever, abortion is beneficial.

• The section on risk factors is very incomplete. "Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment" identifies many more which have been shown to be statistically significant.

• Since prior psychological problems are a predictor of elevated rates of psychiatric treatment following abortion, seeking an abortion is a marker for elevated needs for psychiatric care. Women with a prior history of psychiatric care should be advised that abortion will not reduce this need and may be associated with a need for additional mental health care and that they should not delay seeking it. They may also be scheduled for routine psychological followup care.

• Regarding the prior psychological problems question, that does not dismiss the importance of these studies, it underscores the need for screening. These comments regarding the Munk-Olsen study apply in general to all studies which find elevated rates of psychological treatment preceding abortion:

• Unfortunately, the authors did not segregate their results to determine if the particular women who sought counseling prior to their abortion subsequently fared better or worse than those who did not. Did pre-abortion mental health screening/counseling (1) reduce subsequent risk of mental health treatment, or (2) was it a risk factor predicting that the same women would require higher rates of subsequent mental health treatment?

• If (1) is true, then pre-abortion mental health treatments may be an important preventative measure which should be encouraged. If (2) is true, women with a history of seeking mental health care prior to an abortion might be advised to continue seeking mental health treatment.

• Just as presenting for abortion leads to counseling for better contraception use, presenting for abortion should lead to counseling regarding substance abuse, depression, and other psychological disorders associated with abortion. Whether or not abortion is a direct cause of these problems, is a question of interest but even a negative answer does not reduce the importance of using abortion as a screening factor to identify women who may need help in areas of trouble clearly associated with abortion. For many, the crisis pregnancy and abortion may provide an opening to be receptive to counseling about turning their life around and getting off of drugs, for example. At the very least, for many women abortion is a stepping stone on a downward path. This should be pointed out in counseling with preventative counseling programs integrated into and recommended following the abortion.

• Similarly, while many may argue about whether abortion causes mental illness, there is no doubt that many women experiencing mental illness have had abortions and their abortions are wrapped into their self-perception. Many do, will, and always will, blame circumstances, people, and experiences related to their abortions for much of their grief and problems. This is why clinicians should always inquire about past pregnancy losses, including abortion, to give women permission to discuss these issues. Efforts to focus on the argument that abortion is not the "sole" cause of any particular problem are consumed with political rather than patient-centered medical concerns. Even if abortion is not the cause of depression, the fact that many women attribute their depression to abortion should be respected. Moreover, there is a growing body of clinical experience and literature showing that when abortion issues are addressed in counseling, women do improve. Therefore, this report should encourage clinicians to bring up pregnancy loss issues in counseling to give women permission to address any possible concerns or unresolved issues.

Observations

• They have examined mental health problems in the totality of those giving birth as to compared to those having abortion and they do in fact find an increased risk of mental health problems in the abortion group (lower when prior mental health is controlled but higher than in the general population). They disagree with the APA on the latter saying on page 85 in the discussion - "Although these 17 findings confirm the APA review findings, the included studies for this review 18 do not show that the rates for post-abortion mental health problems amongst 19 women with no history of mental health problems occurs at the same level as 20 that of women in the general population."

• Since post natal depression receives a lot of publicity will we now be able to speak of post abortion mental health problems since the risk is the same after abortion and delivery of an unwanted pregnancy and higher in comparison to all women giving birth?

• I think their statement that apart from abortion for foetal anomaly all abortions are on unwanted pregnancies is wrong – many women feel pressured by partners or family to have an abortion, many are ambivalent about it.

• It is good that they make recommendations for recognising abortion related problems and offering treatment. This seems to me to be a recognition that there is an issue worthy of concern.

• On page 78 (section 5.4.2.5) it states that the Fergusson 2008 study does not find an increase in the number of mental health problems ((RR 0.79, CI 0.51-1.23 ) nor of substance misuse. They point out that the comparison was not made by Fergusson but that they were provided with data that enabled this calculation. Presenting the data that they recalculated on its own completely contradicts the results in the paper itself.

• It is extraordinary that of the four studies mentioned in this section 5.4 (abortion when wantedness in examined) all 4 found some mental health problem associated with abortion (Steinberger anxiety after 2 abortions, Gilchrist an increase in self harm, Cougle anxiety and Fergusson of all mental health problems and substance misuse) yet out of that they managed to say that there were no psychiatric problems following abortion as compared to delivery of an unwanted pregnancy.

Check

• Do they address the finding that multiple abortions are associated with more problems?
• It also appears that they gave inadequate attention to substance use issues.

Rawlinson Report

According to the RCOP draft report:

The Rawlinson Report (1994) held the view that there was no psychiatric justification for abortion and that the procedure puts women at risk of psychiatric illness without alleviating previous suffering.

Citation: The Rawlinson Report: The Physical and Psycho-Social effects of Abortion in Women (1994) A Report by the Commission of Inquiry into the Operation and Consequences of The Abortion Act. London: Her Majesty‟s Stationary Office.

Here is the RCOP response from 1994.

The RCOP's claim that they were misquoted is inaccurate. This is another example of the shifting from the question of "when is abortion beneficial" to the claim that "it is likely less harmful."

The Rawlinson report gave a summary of the RCOP's testimony and response to questions asked. It was no a quote of what they stated but rather a summary of what they admitted they could not state. In other words, the summary was 100% accurate in stating that evidence presented by RCOP revealed that "there are no psychiatric indications for abortion."

In other words, there is no evidence when abortion is therapeutically indicated as a treatment which should be recommended to women because it has been shown to be effective in protecting or improving women's mental health. There are no therapeutic indications. Instead, abortion is being simply made available to women on their own self-recommendation in the hope that it will be beneficial.

What bothered the the Royal College is that the Rawlinson report accurately noted the fact that there is no medical indication for recommending abortion without the usual equivocations. If they had any indications, they would have stated so in their response. For example, they would have asserted that abortion is medically indicated for a bi-polar woman faced with an unwanted pregnancy, but there is statistically validated evidence to support such a claim.

So the RCOG letter of response shifts from the the actual claim of fact to offer a new assertion, which has not been disproved, namely that "the risks to psychological health from the termination of pregnancy in the first trimester are much less than the risks associated with proceeding with a pregnancy which is clearly harming the mother's mental health."

Notably, this statement has a huge qualifying clause. Indeed, they fail to give any means of determining when and how often a pregnancy is clearly harming a mother's mental health. So this qualifier essentially makes the whole statement meaningless from the viewpoint of evidence based medicine. After all, there are no studies comparing women whose pregnancies were clearly harming their mental health who had abortions versus those who did not.

Regarding the statement on p61 which they contest, while it is clear that they did not say those words but it also evident that in the course of questioning by the panel the RCOP representatives were unable to, and admitted that, they were unable to identify any psychiatric indications for abortion, which to the panel translated into there being no psychiatric justification for abortion.

Brenda Major