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.

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.