Gilchrist

Abstract

Gilchrist AC, Hannaford PC, Frank P, Kay CR. Termination of pregnancy and psychiatric morbidity. Br J Psychiatry. 1995;167:243-248.

BACKGROUND. We investigated whether reported psychiatric morbidity was increased after termination of pregnancy compared with other outcomes of an unplanned pregnancy.

METHOD. This was a prospective cohort study of 13,261 women with an unplanned pregnancy. Psychiatric morbidity reported by GPs after the conclusion of the pregnancy was compared in four groups: women who had a termination of pregnancy (6410), women who did not request a termination (6151), women who were refused a termination (379), and women who changed their minds before the termination was performed (321).

RESULTS. Rates of total reported psychiatric disorder were no higher after termination of pregnancy than after childbirth. Women with a previous history of psychiatric illness were most at risk of disorder after the end of their pregnancy, whatever its outcome. Women without a previous history of psychosis had an apparently lower risk of psychosis after termination than postpartum (relative risk RR = 0.4, 95% confidence interval CI = 0.3-0.7), but rates of psychosis leading to hospital admission were similar. In women with no previous history of psychiatric illness, deliberate self-harm (DSH) was more common in those who had a termination (RR 1.7, 95% CI 1.1-2.6), or who were refused a termination (RR 2.9, 95% CI 1.3-6.3).

CONCLUSIONS. The findings on DSH are probably explicable by confounding variables, such as adverse social factors, associated both with the request for termination and with subsequent self-harm. No overall increase in reported psychiatric morbidity was found.

Strengths

1. It was prospective with a large sample size
2. affirmed that women with prior psychiatric problems are worse off postabortion
3. affirmed that women with no prior psychiatric history, had significantly higher risks of deliberate self harm (though this was also elevated for women refused abortion)
4. affirmed that women with the most fragile mental health, i.e., psychosis, were worse off postabortion
5. the study used four comparison groups

1. no termination
2. termination
3. requested termination and changed mind
4. requested termination but were refused

Weaknesses

1. General Practitioners evaluated the patients, and are thus less likely to accurately diagnose psychiatric disorders (“underrecognition of and an imprecise diagnosis of psychiatric disorder” p. 247)

1. No standardized measures for mental health diagnoses were employed

1. By the end of the study, 66% sample attrition was reported for women who terminated their pregnancies

1. The GPs who participated in this catchment study were volunteers and no attempt was made to control for selection bias

1. Data re prior psychiatric history was conveyed by the local GP whose patients’ health records were likely incomplete due to lack of record linkage

1. Insufficient power to detect significant differences between those women who requested a termination and changed their minds, and those who were refused abortion.

1. Research has indicated that women who have negative abortion reactions are less likely to return to the physician who referred or performed the abortion, perhaps out of shame or resentments or to avoid an association which may remind them of an abortion they are trying to forget. (Find citation)

1. The findings are inconsistent with record based research in Canada which found that 24% of women who had abortions subsequently made visits to psychiatrists compared to 3% in the general population. Report of the Committee on the Abortion Law, RF Badgley et al, (Ottawa:Supply and Services, 1977) pp. 313-321 and record based research in the United States.

1. British abortion law is much more protective of women's health and would tend to reduce psychological injuries by protecting women from feeling pressured into unwanted abortions which violate their free choice, their moral views, or their maternal desires. A study of women who had abortions in the United States, for example, found that 64% reported feeling pressured into the abortion by other people. (Rue) In Britain, however, before an abortion is performed two medical doctors have to evaluate the patient and both agree that the risks of abortion are less than the risk associated with childbirth. Such screening and risk benefit analysis is not typically found in the American context where abortion is generally provided on request with little or no screening or risk benefit analysis. It seems likely that this process of screening by two physicians in Britian may better serve to identify and protect women who are being pressured into unwanted abortions and would therefore reduce the risk of severe negative psychological reactions among this group of women for whom an unwanted abortion is highly likely to result in psychological trauma.