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. 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, 66% sample attrition was reported for women who terminated their pregnancies.
4. Evaluation of the pscyhological state of patients was reported by general practitioners, not psychiatrists, and therefore the reports of the GP's, as acknowledged by the authors, is likely to have resulted in an “underrecognition of and an imprecise diagnosis of psychiatric disorder(s).” (page 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. 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.