"A mad abortion debate" by Dr Margaret Sparrow

Originally printed in The Press on 3rd March 2009, in the Perspective section. Many thanks to Dr Sparrow for permission to reproduce it here. Dr Sparrow is the national president of the Abortion Law Reform Association of New Zealand (ALRANZ). Any typographical errors are mine.

A mad abortion debate
Anti-abortionists use women's wellbeing as a pretext in their fight writes Margaret Sparrow.

In May the Appeal Court will deliberate on the lawfulness of the 98 per cent to 99 per cent [of] abortions preformed each year on mental health grounds in the long-running case brought by Right to Life New Zealand against the Abortion Supervisory Committee. Meanwhile, on a related front, abortion research in New Zealand by Professor David Fergusson and colleagues is being used selectively by anti-abortion groups to justify their contention that abortion is detrimental to mental health. All of which raises the question: how did women's psychological wellbeing become the main weapon in the war against choice?

When abortion became a public issue in the 70s, the main argument put forward by opponents was that it was morally wrong and violated the sanctity of human life. Others recognised a conflict between the rights of the foetus and the rights of the woman which weakened the absoluteness of the moral argument. This led to the creation of other reasons for opposing abortion and one of these is the argument that women must be protected from abortion because of the effect that it will have on their mental health. The concern for women's health is less than genuine and masks an underlying opposition to abortion.

The shift from bad to mad started in the 1980s with the invention of a new medical syndrome called post-abortion syndrome, first described in the United States then adopted elsewhere, but now discredited as a diagnosis. Post-abortion syndrome was regarded as a type of post-traumatic stress disorder and abortion patients were likened to Vietnam War veterans suffering combat fatigue.

While many women experience sadness, grief and a feeling of loss after an abortion, few develop a serious psychiatric illness that was not present before the abortion. Indeed, there may be psychological benefits. For many women the abortion brings relief from the stress that accompanies an unplanned and unwanted pregnancy and the abortion can be a learning experience and an opportunity to reassess priorities. The range of reactions after an abortion depends on a multitude of factors. What were the circumstances that led to the pregnancy? Was it a normal pregnancy? What sort of relationship were they in? What was the social environment in which the abortion took place?

The latter is important. Stigmatising abortion may directly contribute to negative outcomes of shame, secrecy and guilt. Anti-abortion propaganda, picketing abortion clinics and calling women murderers or baby-killers is definitely not conducive to good mental health. Furthermore, a hostile society that makes women believe that they should or will feel a particular way can create a self-fulfilling prophecy. In contrast, social and cultural messages that convey expectations of resilience may have the opposite effect.

Anecdotal evidence does not take the place of well conducted research, but unfortunately there is plenty of the former and little of the latter. Because of the public debate about abortion, US President Ronald Regan in 1987 asked his Surgeon General, Dr C. Everett Koop, to prepare a report on the public health effects of abortion. After conducting a comprehensive review of the scientific literature, Koop, regarded as a conservative on the abortion issue, concluded that the available research was inadequate to support any scientific findings about the psychological consequences of abortion. He testified that from a public health perspective the psychological risks were minuscule.

Taking some professional responsibility, the American Psychological Association (APA) convened a panel of scientific experts in 1989 to conduct its own review of the scientific literature. It concluded that severe negative reactions after legal first-trimester abortion are rare and abortion can best be understood in the framework of coping with normal life stress.

The APA convened a task force to re-examine all the literature between 1990 and 2007 (over 200 papers). In August 2008, the APA released its second report. It found that most studies, including two from Fergusson, suffered from methodological problems. It found no risk for women having a single abortion, but the evidence was less reliable and inconclusive for women having multiple abortions. Prior mental health emerged as the strongest predictor of post-abortion mental health.

So what did the New Zealand research say? The first paper in 2006 was entitled "Abortion in young women and subsequent mental health" and was published in the Journal of Child Psychology and Psychiatry. It reported a possible harmful association between abortion and mental health, but also said more research was needed.

The second paper in 2007 on the same group of women was entitled "Abortion among young women and subsequent life outcomes" and was published in the journal Perspectives on Sexual and Reproductive Health. Maybe because this reported positive outcomes it received less publicity. The researchers found women having abortions had advantages in terms of educational and economic outcomes.

Since the publication of the APA report in 2008 the researchers have published yet another paper on the same group of women, this time in the British Journal of Psychiatry entitled "Abortion and mental health disorders: evidence from a 30-year longitudinal study". In their paper the researchers admitted that abortion could account for only 1.5 per cent to 5.5 per cent of the overall rate of mental disorders. Such a low impact is consistent with the conclusion of Koop (minuscule) and the APA (rare).

Does it matter? For the women who live in South Dakota it does. Due to pressure from anti-abortionists, the state legislators have put unsubstantiated findings into law. Abortion providers in South Dakota must tell women seeking abortion they are putting themselves at risk for psychological distress and suicide, among a long list of other possible risks. Medico-legal experts say this is a serious threat to the autonomy of doctors, detrimental to the doctor-patient relationship, and a travesty of truly informed consent.

Back in New Zealand we await the Court of Appeal decision in the Right to Life case. Certifying consultants apparently believe that forcing a woman to continue an unwanted pregnancy may well pose a serious threat to her mental health which is a ground for abortion. While making women fit neatly into legal boxes, this makes a mockery of the grounds for abortion and is as good an argument as any for getting rid of them as has happened in places like Canada, and closer to home, the states of ACT and Victoria.

This mental-health fiasco is demeaning to women. What an insane choice. Go ahead and have the abortion and risk insanity, according to anti-abortionists, or don't have an abortion and risk insanity, according to the doctors. Mad if you do and mad if you don't.

Much better would be to rely on the World Health Organisation, which in 2007 defined mental health as a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.

According to this definition, women able to cope with an abortion (as most are) can regard themselves as mentally healthy.