Monday, 9 November 2009

Guest post: Mixed bag from latest Fergusson et al article

Thanks very much to reader Captiver for permission to post her commentary on the latest Fergusson article on abortion that was released in the last couple of weeks.

The latest article from Fergusson et al on abortion and mental health, called “Reactions to abortion and subsequent mental health”, appears in this month’s (November) British Journal of Psychiatry, and though it focuses on negative outcomes for women, as its predecessor articles have also tended to do, the piece actually contains some positive news for supporters of a woman’s right to choose.

BACKGROUND

Before looking at the content of this new effort, a bit of background about the Fergusson studies. (Thanks to ALRANZ Newsletter for this info.) This is the fourth article on the 1977 cohort of women from Christchurch, New Zealand. 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 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 some positive outcomes it received less publicity. Women having abortions had advantages in terms of educational and economic outcomes.

In 2008 Fergusson wrote and editorial entitled “Abortion and mental health” published in the Psychiatric Bulletin calling for more and better research.

A third paper on the cohort in 2008 entitled “Abortion and mental health disorders: evidence from a 30-year longitudinal study” was published in the British Journal of Psychiatry. A finding was that abortion could account for only 1.5 to 5.5 per cent of the overall rate of mental disorders.

In the new paper the time line is extended to include interviews at age 30 years. Unsurprisingly, it concludes that abortion was associated with both positive and negative reactions, but goes on to reach other conclusions that are arguably not justified by the data.

POSITIVE FACTORS

1. Definitely in the positive column, the latest Fergusson et al report concludes that 90% of women who had abortions were satisfied that they had made the right decision and only 2% regretted the decision, refuting the claim by anti-abortion advocates that large numbers of women have regrets. The next time Fergusson et al is bandied about by opponents of women’s rights, this is an important figure to throw back.

2. The report doesn’t actually find a link between abortion and mental health problems as such, but between “distress about abortion” and mental health problems. Put another way, women who didn’t report “distress” about their abortion (and these reports were gathered retrospectively when the women were 30) “do not show increased risk of mental health problems.”

This raises questions about what this “distress” is? Could it relate to abortion being demonized, for instance? Indeed it could. The authors admit they don’t know: “The present data are unclear as to whether negative reactions to abortion were more common among participants who were members of communities or groups in which an unwanted pregnancy or abortion may have been viewed most negatively.” They list other limitations, including that their assessment of “abortion-related distress was based on retrospective reports obtained at age 30. Such reports may be subject to errors of reminiscence and possible recall bias.” !

The difference between the “distressed” women (with alleged subsequent mental health problems) and the women who weren’t distressed about their abortions could just as easily lead to the conclusion that more effort should be made to end the stigma surrounding abortion or that better counseling be offered women, as it could to the conclusion that abortion on grounds of mental health are questionable. Naturally, it was on this “distressed” group that media headlines were focused.

It’s also worth recalling some of the commentary with the previous Fergusson paper (why wasn’t there any this time?) One commenter made a point that relates to the purported link between “distress surrounding abortion” and negative mental health outcomes: “The modest increase in risk of mild problems might be accounted for by ‘a minority of women [for whom] abortion is a highly stressful life event which evokes distress, guilt and other negative feelings that may last for many years.’ Unfortunately, they did not identify who this minority of women might be. Research suggests that women with multiple pregnancy loss and those who have a late termination for foetal abnormality face an increased risk of mental health problems.” Again, we need to know about this “distress”.

MISSING DATA:

The report’s biggest problem, we believe, is fudging the crucial distinction between women with unwanted pregnancies who carry them to term because they choose to do so (i.e. abortion is available) and women who carry them to term because they want but cannot obtain an abortion.

Basically, as far as one can tell there is no data from the latter group in the study (it would be ethically challenging to try to include such a group, to say the least). All we learn of the unwanted pregnancies carried to term is this: “66 live births (to 52 women) following an unwanted/adverse reaction to the pregnancy”.

Yet despite what seems on its face a glaring hole, the authors conclude that “unwanted pregnancy that came to term was not associated with significant increases in mental health problems”, and from this, they go on to the question the legality of abortions performed on mental health grounds (i.e. the continuing with an unwanted pregnancy will harm the woman’s mental health). This is what they say:

“There is no evidence in this research that would suggest that unwanted pregnancies that come to term were associated with increased risks of mental health problems or that abortion mitigated the risks of mental health problems in women having unwanted pregnancy.”

Clearly, as noted, the women in their study with “unwanted/adverse reaction to” pregnancies who carried them to term had the option of choosing abortion. They did not so choose. It is very hard to see how this can be used to justify the much broader claim that being forced to carry a pregnancy to term has no mental health impact. The authors seem to be both fudging and overreaching here.

That said, supporters of a woman’s right to choose oppose laws that mandate grounds like mental health be met before a woman can have an abortion. Generally, we find ourselves defending those grounds where they are the only way women can gain access to abortion. But it is indeed a wildly unsatisfactory situation, so when studies like Fergusson’s are used to attack the mental health ground, it’s important to point out that, actually, we don’t think forcing women to jump through the many hoops that the “grounds” throw up is so great either, and what all this fighting over covariant factors and models points to is the need for women to simply have the right to choose. Period. Grounds are there as cover for politicians, they are not there for women.

FAILED DEFENSE?

In their paper, Fergusson et al use this “fudging” to defend themselves against recent U.S. studies that have criticized their earlier work. Particularly, they say, that there are two questions,

(1) “The first question focuses on whether unwanted pregnancy terminated by abortion is an adverse life event that leads to increased risks of mental health problems in women exposed to that event.” And (2) “The second causal question concerns the issue of whether any adverse consequences of unwanted pregnancy
terminated by abortion are greater or lesser than the adverse consequences of unwanted pregnancy coming to term.”

They say the American studies “committed the error of dismissing large amounts
of evidence that was relevant to answering the first question on the grounds that these data failed to address the second question.”

OK, perhaps the first question can and should be taken on its face. But unless the authors of the study themselves satisfactorily answer the second question, they surely cannot not draw conclusions about laws that use the mental health ground to justify abortions. And based on the women in their study, they cannot satisfactorily answer the second question. Thus, some of the more political conclusions the authors draw here arguably overreach their own data. I also don’t believe their defense adequately answers the U.S. critics.

WHY DOES THIS MATTER?

Aside from the obvious propagandistic use to which these endless studies are being put by those opposed to women’s reproductive rights, (we won’t add links here, but if you want to see what they’re saying, visit Family Life International blog at http://familylifenz(dot)wordpress.com/) (Copy this address into your browser and replace (dot) with an actual dot.) Fergusson seems quite interested in the official policy/statements of the Royal College of Psychiatrists. Writing in the Psychiatric Bulletin in 2008 he noted that:

“Recently, the Royal College of Psychiatrists (2008) issued a statement (Appendix) on the relationship between induced abortion and women’s mental health that reached the following conclusions:
‘The specific issue of whether or not induced abortion has harmful effects on women’s mental health remains to be fully resolved. The current research evidence base is inconclusive - some studies indicate no evidence of harm while other studies identify a range of mental disorders following abortion.’

This careful and hedged position contrasts starkly with the confident statement made by the Royal College of Psychiatrists in 1994 (Royal College of Psychiatrists, 1994):
‘The Royal College of Psychiatrists finds the risks to psychological health from termination of pregnancy in the first trimester much less than the risks associated with proceeding with a pregnancy that is clearly harming the mother’s mental health. There is no evidence in such cases of major psychiatric risk or long-lasting psychological distress.’”

Perhaps this is part of a campaign to have the College adopt as its official position a link between abortion and mental ill-health, we don’t know. It is hoped that those with expertise in this kind of statistical analysis will follow up the latest Fergusson et al paper with a rigorous critique that can be submitted to the Journal.

1 comment:

The ex-expat said...

Thanks so much to posting this. It's so much more eloquent than my argh! To the latest study.