Robinson et al.
Harv Rev PsychiatryAugust 2009
Public data sets based on surveys or interviews often in- volve retrospective reporting of the variables used in sam-ple selection. The use of retrospective reports of women whohad an abortion years earlier is problematic. Recall bias canaffect any individual’s perspective on a historical event.
Mood-relatedmemoryeffectsmayalsobiasrecallofboththeabortion experience and the timing of previous psychiatricepisodes—especiallyifmanyyearshavepassed.
Laterfeel-ings about an abortion may be inﬂuenced by subsequent re-productive experiences, failure to recall the circumstancesleading to the decision to abort, current depression relatedto stressful life events, or the effects of public campaignsattributing psychological problems to abortion.Findings from designs that use sampling exclusion asa means of controlling for preexisting mental health prob-lems should be generalized only with caution. In additionto applying only to women with no history of the partic-ular problem being studied, arguably such designs differ-entially advantage the delivery group by eliminating thewomen most vulnerable to the chronic stress of dealing withan unwanted child from the study sample. In choosing asample, and if the goal is to generalize to all abortions, itis important to ensure that abortions occurring after theﬁrst trimester are not overrepresented. Delay in seekingabortion may be related to inadequate coping mechanisms,more ambivalence, less social support, barriers to access,poor maternal health, and detection of fetal abnormalities(whichmayinvolveterminatingawantedpregnancy).Inad-dition, methods used to perform second trimester abortionsmay involve more pain.
Previous adversity, including mental disorder, is morelikely to be found among women with repeated unwantedpregnancies, whatever their outcome
—which createsproblems for studies that ﬁrst identify a target pregnancyoutcome (abortion vs. delivery) and then differentially ex-clude women with subsequent abortions from only the de-livery group. In effect, this practice differentially excludeswomen with preexisting mental disorders from the deliverygroup, artiﬁcially elevating the proﬁle of women who givebirth.Sometimes such studies focus on the woman’s ﬁrst preg-nancy(asopposedtoaﬁrstpregnancythatoccursduringthetime frame of the study that could actually be a later preg-nancy for the woman herself). Note that while understand-ing the mental health consequences of abortion on the ﬁrstpregnancy is an appropriate research question, generaliz-ing the results to later pregnancy outcomes, when a womanmay be older and in a different life stage, is not warranted.
Selection of Comparison Groups
Some studies of abortion fail to use a comparison group,or use as a comparison group other women in general
orwomen who have never been pregnant,
who have deliv-ered(withthewantednessofthepregnancyunspeciﬁed)buthaveneverhadanabortion,
who had a spontaneous abortion,
or who have deliveredfollowing wanted pregnancies. The indications, regulations,or circumstances regarding other medical procedures arenot comparable to those associated with a voluntary, elec-tive abortion. In particular, comparing women who have un-wanted pregnancies or who are forced by circumstances toterminate a pregnancy to those who are pleased to be preg-nant and are able to deliver a full-term wanted pregnancywill clearly bias the outcome. At a minimum, the appropri-atecomparisongroupforassessingrelativerisksofnegativemental health outcomes of such abortions is women whocarry
pregnancies to term. An unwanted preg-nancy is different from an unplanned pregnancy, which mayend up being wanted or unwanted. Women with unwantedpregnancies are more likely to suffer from a number of co-occurring life stressors, including childhood adversity, rela-tionship problems, exposure to violence, ﬁnancial problems,andpoorcopingcapacity,allofwhichcontributetoemotionaldistress.
These factors increase the risk of poormental health, whether or not a woman has an abortion.
Analysis of Relevant Variables
The prevalence and incidence of abortion, childbearing, andmental disorder vary with basic demographic variables, in-cluding age, race/ethnicity, education, income, marital sta-tus, and parental status (including timing, spacing, andnumber of children). The need to control for such variableswould seem obvious. As can be seen in Table 1 (presentedbelow in section on “Assessment of Clinically Relevant Lit-erature”),however,evenstudieswithclinicallyrelevantout-come measures may lack the most basic of controls.
Previous psychiatric history.
Many studies attribute post-abortion mental states to the abortion experience withoutproviding adequate control for pre-abortion mental states—even though the literature suggests that previous psychi-atric history is the most consistent predictor of psychiatricdisorders following abortion.
Previous psychiatric his-tory may itself be associated with the occurrence of un-wanted pregnancy. Symptoms of depression can interferewith a woman’s ability to refuse intercourse, use contracep-tion, or negotiate for a partner’s use of a condom. Mania andhypomania are frequently associated with promiscuous orimpulsive sexual behavior. Psychotic disorders leave manysufferersvulnerabletosexualexploitation,asdoalcoholandsubstance abuse.
Preexisting, co-occurring, and subsequent conditions.
Studiesthat do not take into account preexisting or co-occurring