EXECUTIVE SUMMARY

  There is good evidence of long-term safety after abortion. Research into subsequent reproductive outcome is reassuring with respect to infertility, ectopic pregnancy and placenta praevia. Possibly due to mechanical effects on the cervix, there is a small increased risk of miscarriage or pre-term delivery in subsequent pregnancies. There is no association between abortion and breast cancer.

  The vast majority of women have positive psychological reactions to abortion in the long term. Both the women themselves and their children display poorer outcomes when abortion is denied compared to women with wanted pregnancies that are continued.

INTRODUCTION

  In this submission, I will consider the third aspect the Select Committee is focussing on, namely evidence of long-term or acute adverse health outcomes from abortion or from the restriction of access to abortion. The first part consists of physical and psychological health outcomes after abortion, but does not cover immediate complications. The second part considers the effect on both the woman and child born after abortion is denied, again only long-term effects. I will assume that members of the Committee will have referred to the relevant sections of the 2004 Royal College of Obstetricians and Gynaecologists' guideline The care of women requesting abortion;1 this submission will not repeat these and will ensure that all possible evidence which has subsequently become available is cited. The RCOG guideline draws heavily on a review by Thorp et al2 and this too is a key piece of work that the Committee should have its attention drawn to. Finally with respect to Part 1, a recent Danish record-linkage study has shown that first trimester medical abortion, as compared to first trimester surgical abortion, is at least as safe with respect to the risks of ectopic pregnancy, miscarriage, pre-term delivery and low birth weight.3 This is an important piece of work in view of the proportion of abortions performed medically having increased to 30%.4

  With regard to mental health, it is important to state that research in this area is complex and it is very difficult always to obtain clear cut answers. With respect to women who undergo abortion, a key review is that by Zolese and Blacker.5 In Part 2 with respect to denied abortion, a key review that I have used is that by Dagg.6

  This submission will not consider abortions carried out for medical and genetic reasons which comprise only 1% of total abortions4 and have their own particular associations.

PART 1

Infertility

  1.  Genital tract infection is a recognised immediate complication of abortion. Pelvic inflammatory disease is the most severe form of genital tract infection. It is known that pelvic inflammatory disease is associated with subsequent infertility due to the Fallopian tubes becoming scarred and obstructed.

  2.  It has therefore become routine practice to carry out preventive measures during the abortion procedure to protect women from developing infection afterwards. This can be done by giving prophylactic antibiotics before a woman leaves the facility after abortion. An alternative is to screen for infection, particularly for Chlamydia trachomatis and Neisseria gonorrhoeae, and treat only the positive cases and their sexual partners. Some centres both screen and treat.

  3.  Seven studies were reviewed by the RCOG in 2004; I have not been able to identify any subsequent studies. Although two small Greek case-control studies showed a small increased risk of infertility in those who underwent an abortion, the other higher quality studies showed no such association.

  4.  There is no proven increased risk of subsequent infertility when an abortion is carried out in proper, safe medical conditions and is not complicated by pelvic inflammatory disease.

Ectopic pregnancy

  5.  Ectopic pregnancy (pregnancy outside the uterus, usually in the Fallopian tube) is a known adverse outcome following pelvic inflammatory disease. It would be plausible that the risk of having a subsequent ectopic pregnancy could be raised in women who have had induced abortions.

  6.  Nine studies were reviewed by the RCOG in 2004; I have not been able to identify any subsequent studies. Seven of these nine studies were of a case-control design and therefore prone to unreliable results. Two of the case-control studies reported a positive association; both were small studies relying on self-report of previous abortion. The other five case-control studies showed no association. The two large cohort studies which used medical records to define those who had had an abortion showed no such association.

  7.  All good quality studies show no association between abortion and subsequent ectopic pregnancy.

Placenta praevia

  8.  I was unable to identify any more recent studies since the RCOG guideline was published. A large Danish cohort study based on record linkage showed no association between abortion and placenta praevia (low-lying afterbirth).7 Previous studies, some of poor quality, had showed variable results. The Danish study should be given more weight as it is the best type of evidence that can be obtained.

  9.  The literature on a possible association between abortion and subsequent placenta praevia is conflicting but one high quality study shows no association. There is no proven association.

Miscarriage

  10.  It is recognised that during abortion the cervix (neck of the womb) may be damaged. It has been hypothesised that such injury could make it less competent in subsequent pregnancies and so less able to "hold a pregnancy in".

  11.  I was unable to identify any more recent studies since the RCOG guideline was published. The literature is conflicting in this area. Two cohort and three case-control studies published prior to 1999 found no association. However two more recent studies have shown a positive association between abortion and subsequent miscarriage; 8, 9.

  12.  It is now thought that abortion may be associated with a small risk of subsequent miscarriage. Women requesting abortion should be informed of this as stated in Recommendation 16.8 of the RCOG guideline.

Pre-term delivery

  13.  In the same way as for miscarriage, after fetal viability, an incompetent cervix could increase the risk of pre-term delivery (premature birth) in subsequent pregnancies.

  14.  The RCOG guideline identified 26 studies on this topic. Some of the cohort studies showed no association. However, three more recent large cohort studies all showed positive associations between pre-term delivery or low birth weight babies, which can be taken as a surrogate marker for pre-term delivery. Among those studies that suggest a significant association between abortion and pre-term delivery the increase in risk is estimated to be between 30% and two-fold. Since the publication of the RCOG guideline, there has been a French case-control paper on very pre-term delivery (defined as between 22 and 32 weeks' gestation). 10 This study showed a 50% increase in risk of very pre-term delivery in women who had a history of induced abortion compared with those who had no such history. Recently there has been as very large Finnish record linkage study published which shows no association between previous abortion and pre-term delivery or low birth weight babies. 11

  15.  The conclusion must be therefore that there is conflicting evidence that abortion is associated with subsequent pre-term delivery and final conclusions on this are not possible. The potential risk should be mentioned to women requesting abortion, as stated in Recommendation 16.8 of the RCOG guideline.

Breast cancer

  16.  There have been many emotive views expressed on this subject, with whole web sites devoted to it (see http://www.bcpinstitute.org/brochure.htm and http://www.abortionbreastcancer.com/abc.html ). There is a proliferation of "fact" sheets, many criticising the 2004 Lancet meta-analysis.

  17.  A major worldwide meta-analysis published in the Lancet in 2004 showed no association between abortion and breast cancer. 12 More than 20 case-control studies have been published on this topic, some of which show a positive association. However, case-control studies are subject to recall bias, with more under-reporting of abortion in the controls than the cases. There are also at least nine prospective cohort studies which are more likely to give reliable results: these show no association or a negative association. Recall bias does not occur in record-linkage studies in which study subject data are present in databases; there are now seven such studies published, all of which show no association. 13-19 Two recent cohort studies of high quality also show no association. 20, 21

  18.  It is very important that the evidence is looked at objectively and scientifically. There are many studies to refer to, but care must be taken to give proper weight to the high quality studies. It can be stated with confidence that no association exists between abortion and breast cancer.

Mental health

  19.  The vast majority of women have positive reactions to abortion in the long-term and only a small minority express any degree of regret.

  20.  There is widespread misinformation on this subject with politically-motivated activists insisting that there is a condition called "postabortion traumatic stress syndrome" (see for instance http://www.afterabortion.org). This so-called condition does not exist and is not recognised by national or international bodies of psychiatrists. 22

  21.  Serious psychotic illness occurs less often after abortion than after childbirth. 23

  22.  The majority of women undergoing abortion appear to make a good subsequent adjustment.5 The unintended pregnancy is a time of crisis in a woman's life that is resolved once the abortion has taken place. A US study which followed women for two years post-abortion, showed that 301 of 418 women (72%) were satisfied with their decision; 69% said they would have the abortion again; 72% reported more benefit than harm from their abortion; and 80% were not depressed24. A US study of over 5,000 women followed for eight years after abortion concluded that there was no independent relationship between abortion and women's well-being. 25

  23.  There are well-recognised predictors of poor mental outcomes and women displaying these can be targeted for pregnancy options counselling. 24, 26-35

  24.  Five of the six studies cited in the RCOG guideline show higher rates of psychiatric symptomatology/morbidity after abortion when compared to delivery of a child. The symptoms/diagnoses range from psychological depression scoring, attempted suicide, suicide and admission to psychiatric hospital. The sixth study, from the UK, showed no difference in total psychiatric disorders, but deliberate self-harm was more common in the abortion group compared to the abortion refused group.

  25.  A recent study from New Zealand looking at 15-25 year olds having abortions showed positive associations with subsequent depression, anxiety, suicidal behaviour and substance abuse. 36

  26.  It should be carefully noted that women who seek abortion are not representative of the general population. They are more prone to mental health problems, 37 social problems such as intimate partner violence38 and other problems such as drug misuse. 39 They do not necessarily have the same psychosocial characteristics as often used comparator groups of women who choose to continue their pregnancies. Most studies, not surprisingly, cannot make comparisons with how the women were before they became pregnant. Therefore these associations with mental health problems are not necessarily casual and probably reflect continuation of pre-existing conditions.

PART 2

Effect of denied abortion on the woman herself

  27.  Around 40% of women who are refused abortion will later obtain it elsewhere, some paying privately. 40-42

  28.  The majority of women denied abortion who continue with the pregnancy, raise the child themselves with relatively few children put up for adoption.6

  29.  Swedish psychiatrists studied 249 women whose applications for abortion were refused by the National Board of Health in 1948 under the terms of the Abortion Act 1938 as amended in 1946. 43 Follow up was carried out at 7-11 years. Of these women, 46 attempted to procure an abortion illegally. Thirty had given up their child for adoption or permanent care by someone else. Sixty (24%) continued to display signs of mental illness and poor adjustment at follow up. One hundred and thirty one (53%) had finally adjusted themselves after a lengthy period of mental disturbance and emotional strain.

  30.  In an English study around the time of the passage of the Abortion Act, 34% of women who were forced to continue with their pregnancy regretted that the pregnancy had not been terminated when interviewed one to three years later and admitted to frequent feelings of resentment towards the child. 40 A Scottish comparative study carried out at around the same time found that the outcome at 15 months for women requesting abortion was better in those granted an abortion than in those refused. 44

  31.  There is not much recent data as laws and practices have liberalised in many part of the world. However a recent paper from Hong Kong, where appreciable numbers of women are considered not to have sufficient grounds for abortion, is a salutary reminder about the potential negative effects on women of denying them abortion. 45 Seventy three women were asked how they would react if their abortion was refused. Most said they would seek abortion elsewhere, if necessary in the private sector or illegally. Only four women said they would continue the pregnancy. Two women said they would commit suicide.

Effect of denied abortion on the child born

  32.  There is a significant negative effect on children born after denied abortion which is long-lasting and involves diverse psychological and social components.

  33.  In a classic study from Sweden, 120 children born after abortion was refused in the years 1939-41 compared with matched controls were followed up to age 21.46 The researchers found that the cases had a more insecure childhood, being more likely to be placed in a foster home or a children's home. The cases also had more psychiatric care, more childhood delinquency, more early marriages and in the females more young motherhood than the controls. Fewer of the cases continued beyond secondary education.

  34.  Another Swedish study with even more rigorous matching of controls followed 90 such children born after refused abortion in 1960 until the age of 15. 47 The cases had poorer school performance, more neurotic and psychosomatic symptoms and more likelihood of being registered with social services than the controls.

  35.  The Prague study is the most ambitious study of this type. The researchers followed 220 children born in 1961—1963 to women twice denied abortion for the same pregnancy (appeal rejected) until age 35. 48, 49 Czechoslovak abortion law had been liberalised in 1957. The cases were less likely to be breast fed, had more acute illness, had more behavioural problems and poorer school performance than the controls. When in their 20s, the cases showed an ongoing propensity for social problems, more job dissatisfaction, fewer friends, more criminality and more registration for drug or alcohol problems.

REFERENCES

1  RCOG. The care of women requesting induced abortion: Evidence-based Guideline No 7. Second ed London: Royal College of Obstetricians and Gynaecologists; 2004.

2  Thorp JM, Hartmann KE, Shadigian E. Long-term physical and psychological health consequences of induced abortion: review of the evidence. Obstet Gynecol Surv 2002; 58: 67-79.

3  Virk J, Zhang J, Olsen J. Medical abortion and the risk of subsequent adverse pregnancy outcomes. New Eng J Med 2007; 357:648-653.

4  Anonymous. Abortion statistics, England and Wales: 2006. London: Department of Health; 2007.

5  Zolese G, Blacker CVR. The psychological complications of therapeutic abortion. British Journal of Psychiatry 1992; 160:742-749.

6  Dagg PKB. The psychological sequelae of therapeutic abortion—denied and completed. American Journal of Psychiatry 1991; 148:578-585.

7  Zhou W, Nielsen GL, Larsen H, Olsen J. Induced abortion and placental complications in the subsequent pregnancy. Acta Obstetrica et Gynaecologica Scandinavica 2001; 80:1115-1120.

8  Zhou W, Olsen J, Nielsen GL, Sabroe S. Risk of miscarriage following induced abortion is only increased with short interpregnancy interval. J Obstet Gynaecol 2000; 20:49-54.

9  Sun Y, Che Y, Gao E, Olsen J, Zhou W. Induced abortion and risk of subsequent miscarriage. International Journal of Epidemiology 2003; 32:449-454.

10  Moreau S, Kaminski M, Ancel PY, Bouyer J, Escande B, Thiriez G. Previous induced abortions and the risk of very preterm delivery: results of the EPIPAGE study. BJOG 2005; 112:430-437.

11  Raatikainen K, Heiskanen N, Heinonen S. Induced abortion: not an independent risk factor for pregnancy outcome. Annals of Epidemiology 2006; 16:587-592.

12  Collaborative group on hormonal factors in breast cancer. Breast cancer and abortion: collaborative reanalysis of data from 53 epidemiological studies, including 83 000 women with breast cancer from 16 countries. Lancet 2004; 363:1007-1016.

13  Lindefors Harris B, Eklund G, Meirik O, Rutqvist LE, Wiklund K. Risk of cancer of the breast after legal abortion during first trimester:a Swedish register study. BMJ 1989; 299:1430-1432.

14  Melbye M, Wohlfahrt J, Olsen JH, Frisch M, Westergaard T, Helweg-Larsen K et al. Induced abortion and the risk of breast cancer. New England Journal of Medicine 1997; 336:81-85.

15  Lazovich DA, Thompson JA, Mink PJ, Sellers TA, Anderson KE. Induced abortion and breast cancer risk. Epidemiology 2000; 11:76-80.

16  Goldacre MJ, Kurina LM, Seagroatt VF, Yeates D. Abortion and breast cancer: a case-control record linkage study. Journal of Epidemiology & Community Health 2001; 55:336-337.

17  Erlandsson G, Montgomery SM, Cnattingius S, Ekbom A. Abortions and breast cancer: record-based case-control study. Int J Cancer 2003; 103:676-679.

18  Lash TL, Fink AK. Null association between pregnancy termination and breast cancer in a registry-based study of parous women. Int J Cancer 2004; 110:443-448.

19  Brewster DH, Stockton DL, Dobbie R, Bull D, Beral V. Risk of breast cancer after miscarriage or induced abortion: a Scottish record linkage case-control study. J Epidemiol Community Health 2005; 59:283-287.

20  Reeves GK, Kan S-W, Key T, Tjnneland A, Olsen A, Overvad K. Breast cancer risk in relation to abortion: results from the EPIC study. Int J Cancer 2006; 119:1741-1745.

21  Michels KB, Xue F, Colditz GA, Willett WC. Induced and spontaneous abortion and incidence of breast cancer among young women: a prospective cohort study. Arch Intern Med 2007; 167:814-820.

22  Stotland NL. The myth of the abortion trauma syndrome. JAMA 1992; 268:2078-2079.

23  Brewer C. Incidence of post-abortion psychosis: a prospective study. BMJ 1977; 1:476-477.

24  Major B, Cozzarelli C, Cooper L, Zubek J, Richards C, Wilhite M et al. Psychological responses of women after first-trimester abortion. Arch Gen Psychiatry 2000; 57:777-784.

25  Russo NF, Zierk KL. Abortion, childbearing and women's well-being. Professional Psychology, Research and Practice 1992; 23:269-280.

26  Ford CV, Castelnuovo-Tedesco P, Long KD. Abortion: is it a therapeutic procedure in psychiatry? JAMA 1971; 218:1173-1178.

27  Friedman CM, Greenspan R, Mittleman F. The decision-making process and the outcome of therapeutic abortion. Am J Psychiatry 1974; 131:1332-1337.

28  Lask B. Short-term psychiatric sequelae to therapeutic termination of pregnancy. Br J Psychiatry 1975; 126:173-177.

29  Payne EC, Kravitz AR, Notman MT, Anderson JV. Outcome following therapeutic abortion. Arch Gen Psychiatry 1976; 33:725-733.

30  Belsey EM, Greer HS, Lal S, Lewis SC, Beard RW. Predictive factors in emotional response to abortion: King's termination study IV. Social Science & Medicine 1977; 11:71-82.

31  Shusterman LR. Predicting the psychological consequences of abortion. Social Science & Medicine 1979; 13A:683-689.

32  Ashton JR. The psychological outcome of induced abortion. BJOG 1980; 87:1115-1122.

33  Moseley DT, Follingstad DR, Harley H, Heckel RV. Psychological factors that predict reaction to abortion. J Clinical Psychol 1981; 37:276-279.

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

35  Broen AN, Moum T, Bdtker AS, Ekeberg ½. Predictors of anxiety and depression following pregnancy termination: a longitudinal five-year follow-up study. Acta Obstetricia et Gynecologica Scandinavica 2006; 85:317-323.

36  Fergusson DM, Horwood LJ, Ridder EM. Abortion in young women and subsequent mental health. J Child Psychology and Psychiatry 2006; 47:16-24.

37  Blumenfield M. Psychological factors involved in request for elective abortions. J Clin Psychiatry 1978; 39:17-25.

38  Rowlands S. More than one abortion. J Fam Plann Reprod Health Care 2007; 33:155-158.

39  Martino SC, Collins RL, Ellickson PL, Klein DJ. Exploring the link between substance use and abortion: the roles of unconventionality and unplanned pregnancy. Perspectives on Sexual and Reproductive Health 2006; 38:66-75.

40  Pare CMB, Raven H. Follow-up of patients referred for termination of pregnancy. Lancet 1970; 1:635-638.

41  Beazley JM, Haeri AD. Termination of pregnancy refused. Lancet 1971; 1:1059-1061.

42  Hunton RB. Patients denied abortion at a private early pregnancy termination service in Auckland. NZ Med J 1977; 85:424-425.

43  Höök K. Refused abortion. Acta Psychiatrica Scandinavica 1963; 39 Suppl 168:1-156.

44  McCance C, Olley PC, Edward V. Long-term psychiatric follow-up. In: Horobin.G, editor. Experience with abortion: a case study of North-East Scotland. Cambridge: CUP; 1973. 245-300.

45  Yung PB, Chan LY, Lau TK. Reasons for requesting pregnancy termination and attitude of women when request is being refused: a face-to-face interview study. Australian & New Zealand Journal of Obstetrics & Gynaecology 2006; 46:68-69.

46  Forssman H, Thuwe I. One hundred and twenty children born after application for therapeutic abortion refused. Acta Psychiatrica et Neurologica Scandinavica 1966; 42:71-88.

47  Blomberg S. Influence of maternal distress during pregnancy on postnatal development. Acta Psychiatrica et Neurologica Scandinavica 1980; 62:405-417.

48  Matejcek Z, Dytrych Z, Schuller V. Children born from unwanted pregnancies. Acta Psychiatrica et Neurologica Scandinavica 1978; 57:67-90.

49  David HP, Dytrych Z, Matejcek Z. Born unwanted: observations from the Prague study. American Psychologist 2003; 58:224-229.

September 2007