Is abortion a health risk?

Part five of the spiked-paper ‘Defending abortion – in law and in practice’

(a) Physical health

Much evidence exists which attests to the low rate of risk to physical health associated with abortion. In 2000, the British Royal College of Obstetricians and Gynaecologists (RCOG) published an evidence-based guideline, The Care of Women Requesting Induced Abortion (1).

Based on systematic literature review, and synthesis of the best available research results, the guideline advises that women considering abortion should be given certain information on the possible complications of abortion. For example:

— Hemorrhage at the time of abortion is rare, occurring in around 1.5/1000 abortions overall. The rate is lower for early abortions (1.2/1000 at < 13 weeks gestation and 8.5/1000 at > 20 weeks).

— Uterine perforation at the time of surgical abortion is also rare. The incidence is of the order 1-4 per 1000 abortions.

— The rate of damage to the external cervix (neck of the womb) at the time of surgical abortion is no greater than one percent.

— The rate for complications is lower when abortions are performed early in pregnancy by experienced clinicians.

— Genital tract infection of varying degrees of severity, including pelvic inflammatory disease, occurs in up to 10 percent of cases. The risk is reduced when prophylactic antibiotics are given or when lower genital tract infection has been excluded by bacteriological screening.

Warren Hern, an American specialist in abortion services and author of the medical text, Abortion Practice, notes lower complication rates. In various published series, Hern reports a major complication rate (including haemorrage requiring transfusion) of 0.2 percent (2 per 1000) in second trimester abortion from 15 – 34 menstrual weeks. His 30,000 first trimester patients have experienced a major complication rate of 0.01 percent with no uterine perforations. By contrast, patients carrying pregnancy to term in the United States rountinely experience a caesarian rate of 25 to 30 percent, a major complication rate more than a hundred times greater than second or third trimester abortion and more than 2500 times greater than that experienced by first trimester abortion patients (2).

Regardless of the evidence attesting to the safety of abortion, the idea that abortion constitutes a health risk remains the subject of debate. In particular, there has been some discussion in recent years that abortion leads to future infertility, breast cancer, or psychiatric illness. Women’s concern about these conditions may have been heightened by claims made mainly by opponents of abortion.

The decreasing levels of support for opposition to all abortion has meant that anti-choice groups have developed a strategy that might be termed the ‘feminisation’ of anti-abortion argument. There has been a marked tendency for opponents of abortion to increasingly make their case on the grounds that abortion is bad for women’s health. In this kind of argument, the apparent motivation for opposition to abortion stems for concern with women’s well-being. Yet scientific evidence finds no support for these claims.

The RCOG reviewed available evidence about breast cancer for its guideline, and found that available evidence on an association between induced abortion and breast cancer is currently inconclusive. They noted, however, that the validity of the evidence gathered from studies which compare incidence of breast cancer in women who have and who have not had an abortion may be questionable, because of the reluctance of women studied to reveal whether they had an abortion.

Studies based on national registers are less prone to inaccuracy because they do not rely on subject recall. Such studies have not shown any significant association between abortion and breast cancer. The guideline therefore states that when only those studies least susceptible to bias are included, the evidence suggests that induced abortion does not increase a woman’s risk of breast cancer (3).

The RCOG guideline states that women with previous induced abortion appear to be at an increased risk of infertility in countries where abortion is illegal, but not in those where abortion is legal. It notes that published studies strongly suggest that infertility is not a consequence of induced abortion where there are no medical complications. British gynaecologist David Paintin has observed that, in so far as abortion and reduction in fertility are linked, a proportion of the one or two per thousand women who have serious abortion complications are likely to experience reduced fertility or inability to conceive again, but not in cases where there are no complications (4).

(b) Mental health

Assessments of the physical effects of abortion, and assessments of the relationship between abortion and a woman’s emotional state, must be approached differently. The key to assessing the emotional impact of abortion on a woman’s emotional state is context-dependence. Where a discussion is to be had of women’s emotional responses to abortion, attention must be focused on the social and personal situation in which abortion takes place. It therefore to makes no sense to contend that abortion has a particular, uniform mental health outcome.

Unfortunately, in much discussion of women’s feelings about abortion, there is a general failure to contextualise the decision to abort a pregnancy. Many reports do not consider age, marital status, wantedness of pregnancy, gestational age, previous reproductive history, or sociocultural setting. These and other characteristics can have a substantial effect on a woman’s motivation and may also influence the risk of negative psychological consequences.

The most extreme example of a de-contextualised approach to the relationship between abortion and emotion is the claim made by opponents of abortion that women suffer from ‘Post Abortion Syndrome’. In this approach, rather than paying attention to the context in which abortion decisions are made, a woman’s emotions after an abortion are pathologised as a form of mental illness.

Post-abortion syndrome (PAS) was initially described by Rue in 1981, in United States Congressional Testimony, as a variant of post-traumatic stress disorder. He claimed that psychological stressors were capable of causing post-traumatic-stress disorder and that: ‘Post-abortion syndrome (PAS) is a specific type of post-traumatic stress disorder’ (5). Subsequently, anti-abortion organisations in Britain adopted Rue’s approach, and PAS has become a feature of anti-abortion arguments in British debate (6).

According to the American Psychiatric Association (APA), post-traumatic stress disorder (PTSD) is a disabling condition ‘…following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury’ (7). Likely stressors cited by APA as examples of PTSD include military combat, violent personal assault, terrorist attack, and being held hostage. Notwithstanding the substantial difficulties associated with the PTSD diagnosis in general (8), it is quite a stretch to claim abortion as a stressor likely to induce PTSD.

One criterion for PTSD is experiencing ‘…an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone’ (9). Considering that around a third of British women will have an abortion at some point it can hardly be said that the abortion experience is outside the range of usual human experience. There has been no reported increase in public or private mental health services for women attributing their current psychological problems to abortion.

Many empirical studies have been conducted to investigate the emotional aftermath of abortion, and there is not space here to detail them all. In one example, reported in 1995 in the British Journal of Psychiatry, information was obtained about 13,261 British women, through volunteer GPs. This included age, marital status, social status and previous psychiatric and obstetric history. As a result, four comparison groups were obtained, of 6151 women who did not request abortion, 6410 who obtained an abortion, 379 who requested the operation but were refused and 37 who requested the abortion and changed their minds.

In this study, GPs were asked to record diagnoses of women they saw by grouping psychological or psychiatric disorders into three categories: major mental illness (including puerperal psychosis, schizophrenia, and manic depression), minor mental illness (depression, anxiety or other emotional disorders) and deliberate self-harm (drug overdoes, self cutting). Key findings reported were that in women with no past psychiatric histories there was no significant difference between comparison groups in rates of psychiatric illness; that women with a previous history of psychosis were more likely to experience a psychotic illness than those with no such history; and that termination of pregnancy did not appear to increase the risk (10).

In another, recent piece of research, Russo and Zierk reported findings from a US based 1992 study, which found that the wellbeing of 773 women, interviewed annually in a national sample of 5295 women, was unrelated to their abortion experience eight years earlier. The study considered many factors that can influence a woman’s emotional wellbeing, including education, employment, income, the presence of a spouse, and the number of children. Higher self-esteem was associated with having a higher income, more years of education, and fewer children.

Women who had experienced an abortion in fact had a statistically significant higher global self-esteem rating than women who had never had an abortion. This difference was even greater when comparing aborting women with women delivering unwanted pregnancies (who had the lowest self-esteem). Women who had experienced repeat abortions did not differ in self-esteem from women who had never had an abortion. In all, the evidence confirmed earlier findings that factors other than the abortion experience itself determine postabortion emotional status. Some women continually reconstruct and reinterpret past events in the light of subsequent experience and can be pressured into feeling guilt and shame long afterwards (11).

In the light of the substantial amount of evidence against the existence of Post Abortion Syndrome, it is perhaps surprising that the claim for PAS retains any credibility. In part the continued debate about whether or not there is such a syndrome can be explained by the confusing degree of variation in the ‘symptoms’ that are said to be associated with the putative condition. As already noted, Rue claimed that PAS is a form of PTSD. As such it would constitute a severe psychiatric disorder. Yet if its occurrence could be measured on this basis, it would be found to be non-existent.

However, proponents of PAS tend to shift in their writings from a definition of the PAS ‘symptoms’ where the proposed comparison with PTSD is made clear, to a much broader collection of ‘symptoms’ that could perhaps more accurately be described as negative feelings (12). Rue has listed a wide range of feelings, and forms of behavior that he argues might be evident in women who have had an abortion. These include feelings of helplessness, hopelessness, sadness, sorrow, lowered self-esteem, distrust, regret, relationship disruption, communication impairment and/or restriction and self condemnation.

Associating this broad range of ‘symptoms’ with a diagnosis of PAS opens the door to claims that that large numbers of women may suffer from the syndrome. As the ‘diagnostic criteria’ for PAS become broader, it is easier to claim that many women may suffer from the ‘syndrome’. A link between mild and severe psychological responses is generated: all become less serious versions of the same response. Feelings a woman might have after abortion, such as sadness or regret, are seen as a less serious version of a psychiatric disorder.

If an accurate assessment of the psychological effects of abortion is to be made, an approach which combines psychiatric illness with negative feeling is unacceptable. As Stotland argued in a 1992 Commentary in the Journal of the American Medical Association, a symptom or a feeling is not equivalent to a disease (13). Some women who undergo abortion experience feelings of sadness, regret and loss, but this does not mean they are suffering from an illness.

In sum, for the vast majority of women, an abortion of an unwanted pregnancy will be followed by a mixture of emotions, with a predominance of positive feelings and relief. The time of greatest stress is likely to be before the abortion decision is made.

Evidence from the research literature suggests that, in the aggregate, legal abortion of an unwanted pregnancy does not pose a psychological hazard for most women. They tend to cope successfully and go on with their lives. There is no credible evidence for the existence of a post-abortion syndrome.

Ann Furedi is director of communications at the British Pregnancy Advisory Service (BPAS).

Dr Ellie Lee is lecturer in sociology at the University of Southampton, UK, and co-ordinator of Pro-Choice Forum.

(1) RCOG. 2000. The Care of Women Requesting Abortion, Evidence-based Guideline No. 7. RCOG Press: London.

(2) Hern, Warren. 2000. Personal Communication to Ellie Lee.

(3) RCOG. 2000. The Care of Women Requesting Abortion, Evidence-based Guideline No. 7. RCOG Press: London.

(4) Paintin, David. 1997. Twenty Questions About Abortion Answered. London: Birth Control Trust.

(5) Doherty, P. (ed.). 1995. Post-Abortion Syndrome: Its Wide Ramifications. Dublin: Four Courts Press.

(6) Lee, E. ‘Post-abortion syndrome: reinventing abortion as a social problem’. In Best, J. (Ed.). Spreading Social Problems: Studies in the Cross-National Diffusion of Social Problems Claims. Hawthorne, NY: Aldine de Gruyter (In Press).

(7) David, H. 1997. ‘Post-Abortion Psychological Responses’. In Ketting, Evert and Smit, J. (eds). Abortion Matters: Proceedings of the 1996 Amsterdam Conference.

(8) Lee, Ellie. 2001, ‘The Invention of PTSD’

(9) APA. 1980. Diagnostic and Statistical Manual of Mental Disorders (III), American Psychiatric Association, Washington DC: 250-1)

(10) Gilchrist et al. 1995. ‘Termination of Pregnancy and Psychiatric Morbidity’. British Journal of Psychiatry 167: 243-8.

(11) Russo, N. F. and Zierk, K. L. 1992. ‘Abortion, childbearing and women’s well-being. Professional Psychology: Research and Practice 23: 269-80.

(12) Lee, E. ‘Post-abortion syndrome: reinventing abortion as a social problem’. In Best, J. (Ed.). Spreading Social Problems: Studies in the Cross-National Diffusion of Social Problems Claims. Hawthorne, NY: Aldine de Gruyter (In Press).

(13) Stotland, Nada L. 1992. ‘The Myth of Abortion Trauma Syndrome’. Journal of the American Medical Association 268: 2078-9.