M. Antonia Biggs et al. recently published a study on mental health and abortion showing (again) that there is negligible evidence that abortion improves mental health. In this case, it has mostly been spun in the context of undermining laws requiring physicians to explain the mental health risks of abortion to women considering one. I sent a letter to the editor of JAMA Psychiatry, where it was published, which was rejected. So instead of letting the effort go to waste I thought I might as well post it here:

A recent article in JAMA Psychiatry¹ argues, inter alia, that ‘there is no evidence to justify laws that require women seeking abortion to be forewarned about negative psychological responses.’ While the paper is a valuable contribution to the field, I must register dissent from this conclusion.

Firstly, despite the authors’ own study showing no significant difference in mental health outcomes between the relevant groups, the overall picture is more equivocal. Most pertinently, the authors introduce their study by way of a sweeping conclusion that ‘Studies finding a negative effect on women’s mental health owing to abortion have been critically refuted.’ But this is hardly the case, since some of the most widely acclaimed studies—those of Fergusson et al.^2-4—suggest precisely the opposite conclusion. The authors are surely cognisant of Fergusson’s work, yet there is not a single criticism of any of his studies in any of the references the authors here adduce (there is one brief, indirect allusion to the 2008 study, which nevertheless went unrefuted). Criticisms made almost entirely without reference to the best studies supporting the opposing view will not suffice. Moreover, they insist that their study improves on the methodological shortcomings of previous literature, omitting the facts that the specific flaws cited are addressed in Fergusson’s work, and that Fergusson offers both a more comprehensive treatment of confounding factors and a broader range of mental health disorders than do Biggs et al.

Secondly, supposing we grant the generalisability of their results, the normative conclusion still does not follow. The fact that overall rates of mental disorder may not increase after abortion does not entail that abortion does not cause mental disorder. It may be that it causes different kinds of mental disorder than does the continuation of pregnancy. The evidence does, in fact, suggest this to be the case—it is relatively uncontroversial that some psychological sequelae are abortion-specific.⁵ But then—just as women must weigh up the pros and cons of any other treatment using detailed relevant information, rather than simply being told that a treatment offers or does not offer ‘overall’ benefit—so they ought to be informed that abortion and continuation of pregnancy each confer their own separate mental health risks. This is consonant with and indeed supported by the authors’ claim that ‘women will vary in their responses to having an abortion or being denied an abortion’. The conclusion here is undermotivated.

References

1. Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women’s Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study.JAMA Psychiatry. Published online December 14, 2016.
2. 2 Fergusson, DM, Horwood LJ, Boden JM. Abortion and mental health disorders: Evidence from a 30-year longitudinal study. Br J Psychiatry. 2008; 193(6):444-51.
3. Fergusson DM, Horwood LJ, Boden JM. Reactions to abortion and subsequent mental health. Br J Psychiatry. 2009; 195(5):420-6.
4. Fergusson, DM, Horwood LJ, Boden JM. Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence. Aust N Z J Psychiatry. 2013; 47(9):819-27.
5. Astbury-Ward E. Emotional and psychological impact of abortion: a critique of the literature. J Fam Plann Reprod Health Care. 2008; 34(3):181–4.