Abortion and mental health: A longitudinal study of common mental disorders among women who terminated an unwanted pregnancy

In the last decade there has been renewed interest in the question whether termination of an unwanted pregnancy is linked to subsequent mental health disorders. Most research in this field is characterized by methodological limitations, and conclusions often remain disputable. To offer insight in the mental health of women who have abortions, both before and after the pregnancy termination, a prospective longitudinal cohort study was conducted, the “Dutch Abortion and Mental Health Study” (DAMHS). This study was designed in a similar way as the large scale Dutch population study into mental health, the “Netherlands Mental Health Survey and Incidence Study-2” (NEMESIS-2). Women (n=325 at baseline) who had an abortion were interviewed three times over the course of five years, and these were compared to similar data of women who did not have an abortion (n=1902 at baseline), from NEMESIS-2. Prevalence, incidence and recurrence of mental disorders were measured with the Composite International Diagnostic Interview (CIDI) version 3.0. The disorders were mood disorders (major depression, dysthymia, bipolar disorder), anxiety disorders (panic disorder, agoraphobia, social phobia, specific phobia, generalized anxiety disorder), childhood impulse control disorders (ADHD, conduct disorder, oppositional defiant disorder), substance abuse (alcohol/drug abuse and dependence), and antisocial personality disorder. Various sociodemographics, vulnerability factors (e.g., childhood abuse), and variables related to the unwanted pregnancy, the abortion, and the decision process (e.g., multiple abortions, pregnancy duration, decision difficulty, and emotional burden) were measured. In the studies looking at incidence and recurrence, women in DAMHS were matched one-to-one using Coarsened Exact Matching (CEM) to women in the reference group on confounding background variables related to both abortion and mental health. Compared to the NEMESIS-2 reference cohort, DAMHS women more often had experienced mental disorders in the past. The risk on the incidence of mental disorders was however not increased for DAMHS, compared to the reference cohort. Women with a psychiatric history experienced a more stressful pre- and postabortion period, and within this group the risk on recurrent mental disorders was slightly elevated (marginally significant) on the short term (2,5 to 3 years), but not on the long term (5 to 6 years). Previous mental disorders were a consistent risk factor, as well as other negative life events and having an unstable relationship with the conception partner. This study does not support the idea that the life event of the termination of an unwanted pregnancy ‘causes’ mental disorders. When post-abortion mental disorders do occur, they are mostly related to vulnerability factors. In this type of research, it is important that psychiatric history is taken into account, as it may explain associations between abortion and post-abortion mental health. It seems highly clinically relevant that future research focuses on reproductive events and choices in the lives of those women who are most at risk for having an abortion and/ or an unwanted pregnancy: women with mental disorders. In abortion care practice, clinicians could be extra attentive to underlying pre-existing mental health problems