Science or Politics?

Science or Politics? The Abortion Debate

Some Numbers • An estimated 38% of pregnancies world wide are unintended • Of these, about half end in abortion • 4/5 of women having induced abortions live in developing countries

Who is the typical abortion client? • In the developing world, 90% are married, and most already have children • In the United States and Canada, 75-80% are unmarried, half are 25 years of age or older • In the Netherlands, teen pregnancy rates are 1/10 of those in the US, and abortion rates 1/8

The History of Fertility Regulation • Oldest known medical texts describing abortion in China about 2700 BC • Recipe for abortion found on an Egyptian papyrus scroll, dated about 1550 BC • Familiar practice in classical Greek and Roman times

More Recent History • Common procedure in 19th century Europe and North America • One American doctor in 1860 estimated that 1in 5 pregnancies then ended in abortion – another estimated in 1890 that 2 million abortions were performed every year in the US, which compares to 1.3 million now • No American State had a law against abortion until 1821

More Recent History • The Roman Catholic Church was relatively tolerant of abortion before “quickening” up to 1869, when Pope Pius IX declared that ensoulment occurred at conception • Saint Augustine speculated that the fetus obtained a soul at the 46th day, the time in years it took to build the temple in Jerusalem

Public Attitudes to Abortion • Difficult to assess, but probably 10% of people in North America, oppose abortion for any reason, while 30-40% support access to abortion without restriction • Remainder express discomfort about abortion, but have difficulty determining what restrictions or rules should be imposed – difference between what is wrong and what should be illegal

The Medical Profession and Abortion • Shortly after its formation the AMA in the mid 1800’s spoke out against abortion and contraception • Medical school curricula addressed neither until the 1930’s • Nonetheless in the first half of the 20th century hospitals did perform abortions for a growing list of medical indications, usually for privileged clients with the appropriate connections

The Medical Profession and Abortion • 1950’s and 1960’s the therapeutic abortion committees appeared • Access however remained very inconsistent, with no standards or agreed upon means of making these decisions, which was exacerbated with the addition of psychiatric indications for abortions in the 1960’s

Since liberalization of access • The “post-abortion syndrome” • Medical education and its impact on abortion services • Access to information

The search for a post-abortion syndrome • Numerous papers have examined the literature to determine whether or not there is any increased risk of psychological harm following an induced abortion • The goal would appear to be to provide support for limiting access to abortion, by creating the fear that long term serious psychological damage is caused by this procedure

Many careful reviews of the literature have failed to find any clear link between induced abortion and psychological distress, but there are exceptions, that deserve examination

How Can We Understand the Discrepancy? • Studies published since 2000 reviewed: • Rationale: • Reviews prior to this time generally support no negative impact • Arguments in favour of position that induced abortion is psychologically dangerous, criticize these earlier studies as being of poor quality, too small, and too short

Classification of Studies • Records Linkages • Reviews • Prospective Studies • Youth Focused Studies

Records Linkages • Finnish Record Linkage • published in 1996, but cited in review of 2003 as most important result given “hard” end point – suicide, as opposed to “soft” measures (eg. Scales assessing depression, psychiatric morbidity) • Linked death by suicide with evidence of pregnancy and abortion in the past year • Rates of suicide with birth lower than age adjusted averages, while rates for miscarriage and induced abortion higher

Records Linkages (cont.) • So? • Deliveries much more likely to occur in the context of a wanted pregnancy • Did not separate induced abortion of wanted child with genetic defect from abortion for other reasons • Predictors of unwanted pregnancy not considered in terms of impact on subsequent health

Record Linkages (cont.) • Reardon et al (2002) • California Medicaid data from 1989-1997 • Compared with women who delivered, those who aborted had a significantly higher risk of death from all causes, from suicide, and from accidents. • Concludes that: • women with children more likely to avoid risk taking, or • that history of abortion may be marker for other stresses, or • that the higher death rate amongst aborting women may stem from increased stresses related to unresolved guilt, grief, or depression, and supports this latter statement by citing an analysis of this data that showed that controlling for prior psychiatric treatment in the year before the procedure did not affect the results

Problem? • Did not control for unwanted vs. wanted pregnancy • Prior registered psychiatric treatment in the year prior does not accurately reflect all problematic behaviour patterns such as risk taking • Statement about guilt, unresolved guilt, and depression not supported by any evidence • Issue of causality

Record Linkages • US National Longitudinal Survey of Youth • Assessed those with unwanted first pregnancy • Analysis by Reardon and Cougle (2002) • Married women who aborted were found to be at higher risk for depression as predicted by the CES-D than those who carried the pregnancy to term • No difference for unmarried women (trend to higher rates of depression in those who carried to term)

Record Linkages • Reardon and Cougle (cont) • Postulated that shame, secrecy and thought suppression regarding abortion caused these women to under report abortion, and since these individuals in their view are at higher risk of negative reactions, result was diluted

Record Linkages • US National Longitudinal Study of Youth • Analysis by Schmiege and Russo (2006) • Presented careful discussion of how they determined who had an unwanted pregnancy • Found no evidence of difference between risk of depression in group that delivered vs. those that had an abortion • Assessed for under-reporting by looking at groups known in previous studies to under-report and found that in those groups the result was the same

Why the Difference? • Impact of conflict of interest? • Pre-existing bias that is un-reported? • Role of expertise in interpretation of data?

Youth and Abortion • Two studies this decade – one concludes there is no evidence of increased risk for young people, the other that there is • Evidence of risk? • Record linkage study in New Zealand – delivery vs. abortion – looked at rates of psychiatric disorders, and childhood, family and other confounding factors, but did not address “wantedness”, nor identified that as a weakness of the study

Youth and Abortion • No risk? • Looked at women aged 14-21 seeking counselling for unwanted pregnancies and assessed pre and post-abortion mental distress, comparing under 18 and over 18 – no difference between groups, and evidence of decreased distress post-abortion in both • Problems – short term, no comparison with delivery

Youth and Abortion • Strongest study to date: • Zabin et al, 1989 – 360 young women who presented for pregnancy testing, and compared non-pregnant, delivery, and abortion and followed for two years • Abortion group showed no greater distress or anxiety at time of test and no more likely to experience psychological distress at 2 years • Better school performance than other two groups, and less likely to experience pregnancy and more likely to practice contraception

Other New Research on Abortion • Two Reviews – Bradshaw and Slade (2003) and Thorp et al (2003) • Thorp concluded increased risk of depression on the basis of report of suicide noted in Finnish linkage study – despite inclusion criteria that would have included studies such as Zabin et al, only reviewed a handful of studies, and used no methods to determine relative impact of findings other than favouring the finding of suicide over other “subjective measures” • Search strategy limited to “abortion” and “complications of abortion”

New Research • Bradshaw and Slade • More extensive database, broader search strategy • Cited much larger selection of studies • Concluded that “findings are generally in line with those reported in previous reviews in that most distress was reported prior to the abortion, and levels of distress decreased following abortion”

Prospective Studies • Major et al (2000) • 882 subjects assessed before procedure, immediately after procedure, and 1 month and 2 years later (dismissed by Thorp as a self-report study when it was interviewer based with validated instruments) • Found that most women did not experience psychological problems or regret their decision 2 years later, but some do – identified risk factors

Prospective Studies • Kero et al(2003) • 58 women 4 and 12 months post abortion • Majority did not experience any emotional distress following abortion • Almost all described it as a relief or a form of taking responsibility, and more than half reported only positive experiences such as mental growth and maturity • Mixed feelings were present although tended to decline over time, and about 1/5 did experience feelings of distress following the procedure • Concludes that the majority of women are able to make the complex decision about abortion without suffering any subsequent regret or negative effects

“Prospective” Studies • Lee et al (2000) • Post-natally, 220 women interviewed and relationship found between more than two abortions in past and presence of depressive symptoms at this time • Concluded that a history of previous therapeutic abortions was associated with post-natal depression

Knowledge and Abortion • What is the current climate with respect to knowledge about abortion? • Medical Education • In the early 1990’s nearly half of all graduating residents in ob-gyn in the US had never performed a first trimester abortion – by the late 1990’s this number was still 1/3

Knowledge and Abortion • Medical Education • In 1991, only 12% of US Ob-Gyn training programs routinely offered training in first trimester abortions • In the late 1990’s an expert educator in Canada estimated that only 1/3 of residents in Ob-Gyn received training in this procedure – the training objectives of the Royal College of Physicians and Surgeons of Canada require only knowledge of the procedure – not experience or expertise

Knowledge and Abortion • Writing an “Abortion Book” • Previously published primary author with international reputation • Book sent to 4 literary agents in New York with reputation as “sympathetic feminists” • One reported that she had handled a manuscript the previous year that the agent felt was excellent and 32 publishers turned it down • Another described our manuscript as excellent, but was unwilling to take it on because publishers considered the topic “toxic” • In the end – self published, and sold about 1000 copies – several very strong reviews, and placed now in numerous library collections, but no publisher or agent willing to handle a re-release

Knowledge and Abortion • When book published • Donated a copy to our hospital library, but no public or even hospital wide release notice

So What Does This Mean? • Climate in which the scientific literature is being used to advance political/social agendas without acknowledgement of this? • Climate in which the sharing of information on abortion is in part suppressed by fear of reaction?

So What Does This Mean • Need to expand reporting on conflict of interest and bias? • Rather than focusing on understanding the complex experience of women dealing with unplanned pregnancies, we are focussing on a good or bad discussion that aims at reducing access or defending acess

So What Does This Mean? • If we feel a procedure is damaging and thus should be restricted, we need to look at the impact of the procedure, and the impact if the procedure is denied which historically in the case of abortion has meant: • Illegal, unsafe abortion with high morbidity and mortality, and no less frequency than when access is more liberal • Complex issues of “Born Unwanted”

Science or Politics?