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.

Additional Key Findings

1. The findings confirmed that women with prior psychiatric problems are worse off postabortion
2. Women with the most fragile mental health prior to an abortion, i.e., psychosis, were worse off postabortion
3. The findings indicated that among women with no prior psychiatric history, significantly higher risks of deliberate self harm were observed both after an abortion and after a refused abortion.

Additional Notes Regarding Methodology

1. All general practitioners reporting were volunteers and were not blind to condition when making their counts. The authors do not disclose the conditions under which volunteers were selected, nor the rate of volunteers among those invited to volunteer, nor any measure or attempts to grade or screen the volunteer physicians relative to age, gender, practice or attitudes regarding abortion, or any other factors which might influence the observer's judgments and reports.
2. Information was obtain only from women who volunteered and "agreed to their family doctor supplying anonymous data to the study center."
3. Following screening and risk-benefit analyses, attending physicians refused to peform abortions on 379 women.
4. An additional 321 women changed their minds after screening and consultation with their attending physicians.
5. GP's reported details every 6 months

Strengths

1. It was prospective with a large sample size

1. The study used five comparison groups

1. those whose who never requested abortion, including the combination of both those who delivered healthy babies and those who miscarried or had other adverse results;
2. those who had an induced abortion;
3. those who originally requested abortion but changed their minds after consulting with physician; and
4. those who requested termination but for whome physicians refused to perform the abortion after screening and a risk/benefit analysis.

Weaknesses

1. This study is not applicable to American experience because British abortion law is much more protective of women's health and requires a level of screening, counseling, and risk benefit analysis not normally found in the United States. In Britain, 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 instead 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 Britain 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. The protective effects of such screening are indicated by research among women who had abortions in the United States in which it was found that 64% reported feeling pressured into the abortion by other people (Rue). In addition to reducing the risk of women being pressured into unwanted abortions by third parties, two physician screening in the UK may also reduce the risk that women will have abortions in violation of their moral views, or their maternal desires, which are two of many statistically validated risk factors for subsequent psychiatric disorders.
2. No standardized measures for mental health diagnoses were employed
3. By the end of the study, the attrition rate was 65.6% for those had abortions and 57.5% for those who did not (p. 247). Such attrition rates are high and problematic. The fact that they were higher for women who had abortions, which may indicate greater psychological distress, is especially problematic. Those women who are having mental health problems that are trauma-related are precisely the most likely to be in the drop-out pool as they do not wish to go back to a doctor who might bring the incident back to mind. The authors report that "Most loss to follow-up occurred because patients left the practice of the recruiting doctor. Women no longer under observation were slightly younger, of lower parity and higher educational status, and more likely to be single than the original cohort."
4. Evaluation of the pscyhological state of patients was reported by general practitioners, not psychiatrists. The report of the study itself states: “The major disadvantages of using general practitioners’ reports were the likelihood of under-recognition and an imprecise diagnosis of psychiatric disorder” (p. 247).
5. 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. and record based research in the United States.
6. The GPs who participated in this catchment study were volunteers and no attempt was made to control for selection bias. It is possible that many, most, or all volunteered to participate in the study because of a special interest in the issue, and/or because they regularly referred for or performed abortions. The study had no blind or double blind controls and all contributing volunteers were aware of the implications of every judgement they made in preparing their reports. This study therefore falls far short of the objective quality of the record based studies done in Canada, Finland, and the United States, all of which found significantly higher rates of mental health treatments or suicide following abortion.
7. 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)
8. Data regarding prior psychiatric history in this study was reported by a local GP whose may not have had the complete patients’ health records due to lack of comprehensive record linkage in the UK.
9. This study had insufficient power to detect significant differences between those women who requested a termination and changed their minds, and those who were refused abortion.
10. Only extreme outcomes were measured – drug overdoses rather than substance abuse in general; only diagnosed PTSD but not the more prevalent sub-clinical levels of PTSD or the common practice of PTSD going undiagnosed; psychotic episodes which are rare in the population under either condition.
11. There are thousands of case studies of adult women who attribute post-trauma symptoms to their first-trimester abortions, narratives of which are being included in court cases and otherwise publicized. The vast majority of these case studies would not fit into the criteria of extreme problems counted in the Gilchrist 1995 study. Case studies may be inadequate for establishing prevalence or for comparison to the aftermath of other options for dealing with an unplanned pregnancy, but can a statistical study that would exclude those case studies be adequate?
12. Women who have miscarriages are known to have higher rates of subsequent psychological distress compared to women who deliver health children. By including women who miscarry with women who carried to term, the study fails to provide a comparison between rates of psychological illness for women who carry to term--which is of course their intent. While miscarriage is an unavoidable risk, the choice women face is between trying to carry to term and having an induced abortion. Therefore, it seems that the comparision between psychological risks of abortion and carrying to term would be relevent to both women and physicians--excluding the risks of psychiatric distress that may follow a miscarriage. While all measures are relevent, the failure to distinguish between successful delivery and miscarriages in this study may have obscured a relative risk of abortion compared to delivery.

Notes that may require further investigation

1. The study indicates that some dropouts occured due to death, but it does not indicate the distribution of deaths. Were there for example, an excess number of suicides or accidents among women who had abortions? And if so, it appears that the suicide did not count as a psychiatric treatment.