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In young women and subsequent mental health David M. Fergusson, L. John Hardwood, and Elizabeth M. Rider Christopher Health and Development Study, Christopher, New Zealand Background: The extent to which abortion has harmful consequences for mental health remains controversial. We aimed to examine the linkages between having an abortion and mental health outcomes over the interval from age 15-25 years. Methods: Data were gathered as part of the Christopher Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children.

Information was obtained on: a) the history of pregnancy/abortion for female participants over the Interval from 15-25 years; b) measures of ADSM-IV mental disorders and suicidal behavior over the Intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors. Results: Forty-one percent of women had become pregnant on at least one occasion prior to age 25, with 14. 6% having an abortion. Those having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviors and substance use disorders.

This association persisted after adjustment for confounding actors. Conclusions: The findings suggest that abortion in young women may be associated with increased risks of mental health problems. Keywords: Abortion, pregnancy, mental disorder, depression, anxiety, suicidal behavior, substance dependence. There have been ongoing debates about the Issue of abortion as a response to unwanted pregnancy. These debates have centered around a series of ethical, religious and other issues concerning the rights of the fetus and the mother in circumstances of unwanted pregnancy (Blanchard, 2002; Chem.., 2004; Major, 2003).

Although much of the debate in this rear has focused on ethical issues, it has also involved empirical concerns about the linkages between unwanted pregnancy, abortion and long-term mental health. Specifically, a number of authors have proposed that abortion may have longer-term adverse mental health effects owing to feelings of guilt, unresolved loss and lowered self-esteem (Nee, Fun, Hewlett, & Beam-Dodd, 1994; Spaceward & Rue, 1992).

These concerns have been most clearly articulated by Reardon and colleagues who claim that abortion anxiety, hostility, low self-esteem, depression and bipolar disorder (Coulee, Reardon, & Coleman, 2003; Reardon & Coulee, 2002; Reardon et al. 2003). Despite such claims, the evidence on the linkages between abortion and mental health proves to be relatively weak with some studies finding evidence of this linkage (Gigglers, Hemming, & Lindquist, 1996; Reardon & Coulee, 2002; Reardon et al. , 2003) and others failing to find such linkages (Gilchrest, Hanford, Frank, & Kay, 1995; Major et al. 2000; Pope, Adler, & Ithacan, 2001; Cabin, Hirsch, & Emerson, 1989). Furthermore, the studies in this area have been marked by a number of design limitations, including the use of selected samples, limited length of follow, retrospective reports of mental health prior to abortion, and failure to control confounding (Adler, 2000; Major et al. , 2000). Perhaps the most comprehensive analysis of this topic is provided by an analysis of the National Longitudinal Study of Youth (ONLY) reported by Coulee et al. (2003).

This analysis found that women who reported induced abortion were 65% more likely to score in the high-risk range for clinical depression than women whose pregnancies resulted in birth. This association was evident after control for a number of prospectively assessed confounder including pre-pregnancy psychological state. However, there were potential limitations of this study. First, the study failed to provide comprehensive control of pre-pregnancy factors, with the analysis being limited to the data available from the ONLY.

Second, there was evidence of substantial underreporting of abortion in the study, with an estimated 60% of those undergoing induced abortion failing to report this (Coulee et al. , 2003). A threat to study validity in this area arises from uncontrolled confounding (Major, 2003). In particular, evidence linking abortion to higher rates of subsequent mental disorder is consistent with two explanations. The first is that these associations reflect a cause and effect linkage in which exposure to abortion has adverse effects on subsequent mental health.

The alternative is that the association arises because abortion is associated with third or confounding factors that are also related to mental health outcomes. There are several potential sources of confounding relating to pre-abortion background. These include: socio-economic factors; childhood and family factors; mental health and personality factors. To date, the control of such factors in studies Publishing, 9600 Garrisoning Road, Oxford OX Q, UK and 350 Main Street, Malden, MA 02148, USA Abortion and mental health f the mental health effects of abortion has been limited.

A further class of factors that may also confound the association may relate to the woman’s circumstances at the time of pregnancy, including age, the planning of pregnancy, and the stability of partnerships (Adler, 1992; Major, 2003). In most studies to date, comparisons have been made between those who became pregnant but did not seek abortion and those who became pregnant and sought an abortion. Those women who were not (yet) pregnant were excluded from the analysis.

Whilst it may seem intuitively reasonable to exclude the not pregnant group from analysis, the omission f this group leads too problem of interpretation. In particular, the finding that rates of mental health problems are higher amongst those women having abortions than those women becoming pregnant and not seeking abortion is consistent with two quite different interpretations. First, the results are consistent with the view that exposure to abortion leads to an increased susceptibility to subsequent mental health problems.

However, the alternative explanation is that pregnancy without abortion is beneficial for mental health. To distinguish between these alternatives requires that results for the not pregnant group are included in analysis o provide a reference by which the direction of association may be determined. Against this background, this paper reports an analysis of the linkages between abortion in young women aged 15-25 and subsequent mental health in a birth cohort of young women studied to the age of 25.

The specific aims of this analysis were: 1. To examine the extent to which mental health outcomes in the interval 15-25 years varied between the three pregnancy status groups: not pregnant by age 25; pregnant no abortion; pregnant abortion. 2. To adjust any association between mental health outcomes and pregnancy status groups for confounding pre-pregnancy factors, including social background, childhood and family history; mental health and personality factors. 3.

To use the results of a covariate adjustment method to estimate the adjusted rates of mental pregnant groups relative to rates of mental disorders in the pregnant abortion group. Methods The data used in this analysis were gathered over the course of the Christopher Health and Development Study (CADS). The CADS is a longitudinal study of a birth cohort of 1265 children born in the Christopher (NZ) urban region who have been studied from birth to age 25 years. The present analysis is based on the cohort of female participants for whom information on pregnancy history and mental health 17 outcomes was available.

The sample sizes used in the analysis range between 506 and 520 depending on the timing of assessment of pregnancy history and mental health. These samples represent between 80% and 83% of the original cohort of 630 females. All data were collected only on the basis of signed consent from research participants. The study had ethical approval from the Canterbury Ethics Committee. Pregnancy and abortion 15-20 years In New Zealand, the provision of legal abortion is determined by the Contraception, Sterilization and

Abortion Act, 1977 and overseen by the Abortion Supervisory Committee. The Act requires that certain criteria are met before allowing a woman to undergo a legal abortion. Firstly, women must approach their doctor and are then referred to specialist consultants. Two certifying consultants must then agree: 1) that the pregnancy would seriously harm the life, physical or mental health of the woman or baby; or 2) that the pregnancy is the result of incest; or 3) that the woman is severely mentally handicapped.

An abortion will also be considered on the basis of age, or when the pregnancy is the result of rape. Abortions in New Zealand are free, and legal for all ages, and parental consent is not required for women under the age of 16. Counseling is required for all women considering an abortion (Ministry of Health, 1998). Sample members were interviewed at ages 15, 16, 18, 21 and 25 about pregnancy and abortion occurring since the previous assessment. These reports showed that by age twenty five, 205 women (41% of the cohort) (14. %) reported seeking and obtaining an abortion at least once. In total there were 422 pregnancies reported prior to age 25. Of these, 90 were terminated. To crystallite self-report data, the duty estimates were compared with officially recorded pregnancy and abortion statistics for New Zealand (Abortion Supervisory Committee, 2002). These comparisons suggested some underreporting of abortion. The observed rate of abortion by age 25 in the cohort (178 per 1,000) was 81% of the rate expected based on population figures (220 per 1 ,OOH).

This difference was statistically significant (P < . 05). Mental health 15-25 years At ages 16, 18, 21 and 25 years, participants were questioned about mental health issues since the previous assessment using questionnaires based on the Diagnostic Interview Schedule for Children (DISC) Costello, Edelbrock, Kalas, Kessler, & Klaric, 1982) at age 16 years and the Composite International Diagnostic Interview (CIDI) (World Health Organization, 1993) at ages 18-25 years, supplemented by additional measures.

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