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Dear
Editor,
I
appreciate the opportunity Rapid Response provides to reply the new analysis of
the NLSY data regarding associations between long-term depression and outcome
of first unintended pregnancy presented by Schmiege and Russo.[1]
This study was prepared in response to our own analysis of the same data
previously published in the BMJ,[2]
with additional data published in a subsequent BMJ letter.[3]
Our original short report revealed in a single table that among married women
who had an unintended first pregnancy an average of eight years prior an
assessment of depression risk, those who had aborted their unintended pregnancy
were at a significantly higher risk of depression (OR=1.92 95% CI 1.23 to 2.97)3
than women who carried the unintended pregnancy to term, with controls
for income, education, race, age at first pregnancy and a pre-pregnancy score
for psychological state using the Rotter internal-external locus of control
scale. Stratification by marital status was a central feature of our study as
there were no significant differences between women who were unmarried at the
time of the depression assessment in regard to outcome of the first unintended
pregnancy. The significance of the marital status was discussed in companion
pieces and will be further discussed below.
The lengthy repetition of our findings above is offered to underscore
that in omitting any stratification of their results by marital status,
Schmiege and Russo have failed to offer readers a true reanalysis of the data
and findings we presented. Though they present four tables and one figure to
analyze other aspects of the data using new selection criteria, they have
failed to present the most basic evidence necessary to either refute our
confirm our prior results. Namely, they have failed to reconstruct our table
using data generated from their coding and selection rules, including
stratification by marital state and the use of our control variables. It is my
hope that in the confident spirit of openness, the authors will publicly affirm
their willingness to share their recoded data with our research team and others
so that any who are interested can more completely evaluate their new coding
approach and may also complete the final reconstruction of our table using this
potentially improved coding system.
While the study of Schmiege and Russo currently fails to directly address
our findings regarding differences in depression rate, which are most evident
among women married at the time of the depression assessment, as discussed
above, it should be noted that there are a number of other significant flaws
and weaknesses in the design, presentation, and discussion presented.
First, it should be noted that the authors’ claim in the “What we already
know” section stating “Well designed studies have not found that abortion
contributes to an increased risk of depression,” is misleading and not supported
by their discussion, their citations, or the literature. In fact, the
statistical association between abortion and higher depression rates is very
firmly established by many well designed studies.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13]
Indeed, one of the authors of the this newest
study,1 Russo, was herself the lead author of a study of 2,525 women
which revealed that women who had abortions had significantly more depression, suicidal ideation, and lower life
satisfaction than other women.13 While it is true that Russo argued
in that paper13 that this association with depression might possibly
be explained by greater exposure to experiences of violence among women who
have abortion, the act of simply proposing this hypothesis serves to
demonstrate the fact that the irrefutable evidence of an link between abortion
and depression requires explanation and further investigation. While the
hypothesis that the link between abortion and depression may be explained by
some common risk factors certainly deserves additional investigation, the more
straight-forward case for a causal link between abortion and depression is
strongly supported by the self-attribution of women who have been interviewed
about their psychological reactions to abortion[14],[15],[16],[17]
and also by clinical experience of counselors who have successfully treated
post-abortion depression.17, [18],[19]
Furthermore, as suicide is closely associated with depression, some of the best
statistical evidence for a causal link between abortion and depression is found
in large record based studies linking a dramatic increase risk of suicide[20],[21],[22],[23],
suicide attempts[24]
and suicidal ideation13 following
abortion. Case studies of suicide attempts[25],[26],[27]
directly linked to a traumatic abortion experiences
strongly support a causal interpretation of these record based findings.22
The preceding discussion of the literature is important because
uninformed readers may wrongly infer from the authors’ presentation that our NLSY
study2 is the only study linking abortion to depression. In fact, it
was simply the first study to compare
women who have had abortions to a control group of women who have
carried unintended pregnancies to term. The authors’ failure to even partially
mention this larger body of literature, including Russo’s own research, may unfortunately
lead readers to conclude that since the questions the authors’ are raising
about our own NLSY analyses are sufficient enough to prove that there is in
fact no link between abortion and depression. Certainly, this has been exactly
the impression fostered by numerous news reports sparked by the authors’ new study.
For example, both Reuters[28]
and WebMD[29]
headlined their stories inspired by this study definitively declaring, without any
qualifications, “Abortion Does Not Raise Depression Risk.” The articles
themselves also and included reporting which reflected numerous other overgeneralizations that go far beyond
the data presented.
Specifically regarding the authors’ new analysis, it is first important
to note that their results do not contradict ours; indeed, they do not even
attempt to reconstruct our analysis in regard to stratification by marital
status using their recoded coded data. Even what they do report, as noted by
Schmiege and Russo, can easily be reconciled with our own findings since any differences
in results “can primarily be explained by differences in coding of key
variables and sample selection.”1
While the authors argue that their coding of key variables and
redefinition of the parameters for sample selection are superior, I am
skeptical of this claim. From what they have reported, the first questionable decision
they made in recoding the data was the choice to eliminate from the sample
women who had abortions who had subsequently indicated that they had wanted
their pregnancies at some point before they decided to have an abortion.
Ambivalence about pregnancy and abortion is common. I do not doubt that there
was a group of women who had swings in “wanting” their pregnancies, which ended
in a decision against keeping the pregnancy. Indeed, ambivalent swings from wanting
to unwanting a pregnancy is well-known risk factor for emotional turmoil after
an abortion.[30]
For example, research by Husfeldt and colleagues found that 44% of
participants experienced doubts about a decision to abort upon confirmation of
their pregnancies, while 30% continued to have doubts on the day of their
abortions.[31]
Eliminating this subset of women may significantly bias the analysis by
eliminating a class of women who have abortions who may be at highest risk of
post-abortion depression. Moreover, as the authors note on the last page of
their discussion, in most cases the classification of wantedness was made many
years after the abortion and may therefore reflect a certain amount of recall
bias. Bottom line: these women did in fact have abortions, so they belong in
the abortion column. However, I do agree that in a larger data set with
better "real time" measures of intended and wantedness, it would be
very appropriate to run a separate comparison of women who aborted originally
wanted pregnancies with women who aborted pregnancies that were not originally
wanted. This data set is simply not so robust, however.
Secondly, the authors increased the percentage of control cases
identified at risk of depression by deciding to include in the control group
women who carried their first pregnancy to term but then had a subsequent
abortion. This is very problematic since the measure of depression occurred,
on average, eight years after the first pregnancy. In other words, the authors
have statistically added any depression associated with abortions of second or
third pregnancies to the control group of who delivered a first unintended
pregnancy. Indeed, there is some evidence that women who have an abortion
after giving birth to living children are at greater risk of emotional sequelae
compared to women without children.[32],[33]
Comparing the mental health of women who aborted a first unintended pregnancy
to a group including women who aborted subsequent pregnancies simply does not
help to clarify interpretation of the data. Instead, it only serves to muddy
the data and increase the likelihood that any statistical comparisons will not
detect significant results.
Our own decision to exclude from the control group women with a
subsequent abortion was intended to reduce the confounding effects of multiple
pregnancies. Indeed, our restriction of focus on the outcome of first
unintended pregnancies was entirely driven by the fact that it is extremely
difficult to control for multiple pregnancy experiences, especially with such a
limited data set. One can well make the case that in addition to eliminating
cases which had subsequent abortions we should also have eliminated cases where
women had subsequent unintended pregnancies. Or, most ideally, to eliminate
the many confounding effects of multiple pregnancies with different outcomes
and different levels of wantedness, one could limit the comparison to women who
never had a second pregnancy. Unfortunately, such a restrictive approach would
have severely limited the number of cases that could be drawn from the data set
and would also have made results even less generalizable since most women will
have multiple pregnancies. Still, narrowing the inclusion criteria in such a
fashion would have been far more rational than expanding the criteria, as
Schmiege and Russo have done to add women exposed to abortion to the control
group of women who did not abort their first pregnancy.
Another difficulty in evaluating this new study is that the author’s
post-1979 analysis, which was intended to parallel our analysis which used the 1979
Rotter control variable, identified 38% fewer cases of women exceeding the depression
cutoff score. We reported 196 cases among delivering women to their 111 cases,
and 80 cases above the cutoff for women who aborted compared to their
identification of 55 cases.3 Having not yet had an opportunity to
examine the researchers’ data, I have no idea how coding changes resulted in
such a significant drop in the number of cases identified by the authors. In
any event, this loss of cases would clearly reduce statistical power and
therefore serves to increase the probability that their study would find no
significant results.
Another problem with the authors’ paper revolves around a secondary
analysis concerning the very high rate of non-reported abortions in the NLSY
data set. Compared with national averages, only 40% of the expected number of
abortions are reported by women interviewed in the NLSY. [34]
As noted in our original short report, since shame, secrecy, and thought
suppression regarding an abortion are all associated with greater postabortion
depression, anxiety, and hostility,[35]
the fact that 60% of abortions are concealed from NLSY interviewers would
almost certainly dilute our ability to accurately measure the association
between abortion and depression. While Schmiege and Russo do not call readers
attention to the 60% concealment rate, they do attempt to address the questions
raised by the high concealment problem by undertaking an examination of
depression scores relative to whether or not women completed a private abortion
history assessment. The fundamental, unaddressed problem with this approach is
that it assumes that only those women who did not turn in the abortion history
assessment were engaged in concealing past abortions. Absent evidence to the
contrary, willingness to accept and return an abortion history card does not
demonstrate a willingness to fully disclose one’s abortion history. Furthermore,
the authors’ conclusion that women who are prone to depression are more likely
than women not prone to depression to complete an abortion history card and
report an abortion is not supported by a reasonable explanation for why women
would behave in this way. Are there actually any studies showing that persons
prone to depression are more willing to disclose past abortions? A citation to
this effect would be most helpful. Even if it were true, as they claim, that
“women who are willing to disclose abortion are also more willing to disclose
stigmatizing mental health problems, such as depression,” the converse does not
necessarily follow: namely, that women who are unwilling to disclose abortions experience
less depression.
In my reading of this study, the only contribution the authors actually make
to an understanding of our earlier published results is found in their identification
of the fact that by electing to use a control variable for psychological state
before the first pregnancy, the 1979 Rotter scale, we lost 80 percent of the
teenage pregnancies, due to the age distribution of the NLSY cohort prior to
1980. The authors are therefore correct that our findings may not be
generalizable to minors. If we had noticed this at the time, we would have
eliminated all cases of teen pregnancies and thereby narrowed our conclusions. But
nothing in the authors’ paper reverses our findings regarding the group of
women that were selected. At most, it simply narrows our findings to mostly non-teenage
women, a group which makes up the majority of women who have abortions.
At this point it is useful to recap the importance of our findings in
regard to marital status. In short, we found nearly a doubling of risk for
depression among married women at the time of the depression assessment who
aborted an unintended first pregnancy an average of eight years previously as
compared to married women who carried a first unintended pregnancy to term.
This doubling of risk was found after removing the effects of education, race,
age at first pregnancy, and pre-pregnancy psychological state as measured by 1979
administered Rotter score.3 As noted, our results for unmarried
women were not significant. In other words, we found that women who aborted a
first unintended pregnancy and were still single an average of eight years
later had a similar risk for depression compared to single mothers who gave
birth to a first unintended pregnancy—even though they were not faced with the
same challenges of being a single parent.. While single women who had
abortions had a very similar depression rate compared to married women who had
aborted their first pregnancy, among women who delivered their unintended first
pregnancy, those who were unmarried in 1992 were twice as likely to be at risk
of depression compared to those who were married. In other words, abortion
did not reduce the risk of depression for any of the groups we examined, but
marriage did – unless the married woman had previously aborted her first
unintended pregnancy. As shown in the table reproduced below, when cases for
married and unmarried women are combined, the association between abortion and
depression is statistically significant, but not strongly. It would therefore
be expected that the kinds of changes in coding employed by Schmiege and Russo
discussed above would easily dissolve the significance found for all women.
This is why a reanalysis using the control variables we employed with
stratification for marital status is particularly important, since the more
robust significance found in the comparison for married women may well have
persisted even after their realignment of classification rules.
Women scoring in range for high risk
of depression (CES depression score >15) who had their first abortion or
unintended childbirth between 1980 and 1992
|
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Women with unintended births
but no subsequent abortions
|
Women who had an abortion Adjusted
odds ratio
|
|
|
|
|
Total
|
No (%) at high risk
|
Total
|
No (%) at high risk
|
Adjusted odds ratio (95% CI)*
|
|
|
Unmarried†
|
253
|
91 (36)
|
129
|
37 (29)
|
0.88 (0.54 to 1.43)
|
|
|
Married†
|
530
|
101 (19)
|
164
|
43 (26)
|
1.92 (1.23 to 2.97)
|
|
|
In first marriage
|
443
|
78 (18)
|
131
|
35 (27)
|
2.23 (1.36 to 3.64)
|
|
|
All
women
|
783
|
192 (25)
|
293
|
80 (27)
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1.39 (1.02 to 1.90)
|
|
|
*Adjusted for family income,
education, race, age at first pregnancy, and 1979 Rotter score. †When CES
depression questionnaire was administered in 1992.
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|
This brings us to still another problem. The authors observe that given
their selection criteria, women who gave birth to an unintended pregnancy prior
to 1980 had significantly higher risk of depression compared to women who
reported aborting their first pregnancy prior to 1980 and compared to women who
had a first unintended pregnancy after 1980, whether they carried to term or
had abortions (Table 1).1 For reasons not discussed, the authors
decided in this case to report these results without any controls for age,
race, income, or education, much less marital status, which proved to be so
important in our own analysis. This omission of all control variables is especially
odd since several control variables are used in Table 2. 1 Unfortunately
this inconsistent use of control variables should have been avoided since it
might arouse the suspicion of some readers that the authors have selectively
used or omitted control variables to produce results which would most appear to
support their hypotheses.
Yet another problem with the authors pre-1980 sample is that it heavily
loaded with women who were younger at the time of there first pregnancy and
older at the time of the depression assessment in 1992. Comparing these women
to the post-1980 group is very problematic without any controls for age.
Moreover, interpretation of these results is further complicated by the fact
that women in the NLSY under age 20 at the time of their pregnancies have the
highest concealment rate for abortion among all age groups.34 It is
therefore impossible to know how many women classified as having delivered
their first unintended pregnancy prior to 1980 actually had a prior, unreported
abortion. The importance of this confounding effect is underscored by
literature which demonstrates that many women who have abortions, especially
minors, will become pregnant again, within two years, [36],[37],[38]
and many will then carry the subsequent pregnancy to term. Therefore, in their
discussion of this data point, the authors not only fail to control for
available confounding variables, such as age, they also miss the opportunity to
discuss how their findings should be cautiously interpreted in light of the
NLSY high concealment rates.
A more accurate evaluation of the points raised above will be possible
once others have had a chance to more carefully understand and evaluate the new
coding system employed by Schmiege and Russo. As Russo, is a honored member of
the American Psychological Association (APA), I am confident the authors will
publicly confirm their willingness to share their recoded data with myself and
other researchers as required by rules for sharing data set forth by the APA.[39]
As stated above, at a minimum the newly coded data must be used to reconstruct
of our original table stratified by marital status.
This brings me back to the original purpose of our study which was to
investigate the hypothesis that the previously observed increased risk of
depression following abortion might be inconsequential compared to equal or
higher rates of depression that might be associated with giving birth to an
unintended child.4 While our original short report did not provide
room for this discussion, I will offer it here.
In a follow-up study of 442 women who had abortions, researchers tracked
depression scores using the Brief Symptom Inventory (BSI) one hour post-abortion,
one month post-abortion, and two years post-abortion.4,5 At
the two year follow-up, approximately 50% of the women either refused to
participate in the follow-up evaluation or could not be contacted. Among those
who did participate in the two year post-abortion assessment, depression scores
were significantly higher than their one hour post-abortion scores, though
higher one hour post-abortion scores were also significantly predictive of
higher depression scores two years later. 5 In addition to these
important findings, the researchers found that 24.5% of the women remaining in
their sample at the two-year followup had scores above the cutoff for clinical
depression on the BSI depression scale.5 Curiously, rather than
registering alarm, the researchers’ erroneously asserted that the depression
rate detected in their study was only slightly over that of American women in
general by reference to a study of national prevalence conducted by Blazer,
Kessler, McGonagle, and Swartz,[40]
which indicated a 20% lifetime prevalence rate of major depression among women
15-35 years of age. The reason this was assertion was erroneous is that the researchers
mistakenly compared their scores for depression in the most recent month to
Blazer’s findings regarding lifetime prevalence rates. Fortunately,
Blazer’s group also reported the prevalence of current (30 day) major
depression for females aged 15-24 and 25-34, as 8.2% and 4.3% respectively.40
Thus, when the proper comparison is made for most recent month depression rates,
these follow-up abortion studies4,5 actually found that depression
rates two years after abortion were 3 to 5 times higher among women who have
had an abortion compared to the general population of similarly aged women.
In my opinion, this finding that one-fourth of women two years after
their abortion had high depression scores should have motivated the researchers
to encourage more detailed pre-abortion screening and post-abortion counseling.
But curiously, the authors appeared to generally dismiss the importance of
their own findings on the basis of the hypothesis that giving birth to an
unwanted pregnancy would likely incur equal or greater psychological price, 4
a theme echoed by Schmiege and Russo.1
This is an extremely important hypothesis, but it is also a hypothesis, which
up to that point, had never been tested. In the most recent, comprehensive
review of the literature on emotional reactions to abortion and future research
priorities,[41]
the absence of studies examining psychological adjustment following an
unintended pregnancy using control groups (comparing those who abort to those
who carry to term) is identified as a major shortcoming of the existing
literature. Our original study appears to be the first to employ this very
appropriate control group.1 We have continued to pursue this
direction with two other studies that have compared the psychological wellbeing
of women who carry unintended pregnancies to term with women who have abortions:
one finding higher risk of long-term generalized anxiety disorder among women
who abort[42]
and the other finding higher rates of substance abuse.[43]
While the observation of higher rates of depression, anxiety, and
substance abuse among women who have had abortions compared to similar women
who have carried unintended pregnancies to term is itself significant, the body
of research using these control groups is admittedly very sparse. But even if
these studies did not produce evidence of significantly higher adverse effects
associated with abortion, what is most telling is that they have failed to
produce any evidence of the benefits widely claimed for abortion. Indeed, it
is most remarkable that even though Schmiege and Russo themselves fail to find
any statistically significant benefit in reduced risk of depression associated
with abortion--despite their best efforts to reconfigure the selection
criteria--they instead proclaim that “Abortion may be indirectly associated
with a lower risk of depression through beneficial effects on education,
income, and control of family size.” This statement has been welcomed by
reporters covering this study as an affirmation of commonly held assumptions,
but in fact it is based on nothing more than hopeful inferences. Indeed, our
analysis of the same data, after controlling for education and income,
demonstrates there is no indirect beneficial effect on reducing depression.
Furthermore, at least for women who subsequently marry, abortion is
significantly associated with an increased risk of depression. When
interpreted in the light of the large body of literature discussed earlier,
this positive association does not appear to be incidental and nothing
presented in Schmiege’s and Russo’s analysis contradicts this finding.
In fact, the NLSY is a very weak sample for studying psychological
adjustments of abortion. Not only does it have a 60% concealment rate, but only
a few questions related to psychological state and reproductive health are
collected, and these are collected only once every several years because the
NLSY is actually designed to study labor experiences, not health. That it
includes any health variables is fortunate, but those it does have are only
sufficient to catch a hint of what women who have abortions actually
experience. The possibility of using the NLSY for abortion research was first
identified by Nancy Russo, a co-author of the present study.1 In her
first analysis of the NLSY, Russo examined of self-esteem scores collected at
two points in the NLSY cycle.[44]
In that study, Russo concluded that that the lack of any statistically
significant decline in self-esteem among women admitting having had an abortion
compared to delivering women proved that abortion does not have “a substantial
and important impact on women’s well-being.” However, none of the major
inadequacies of the NLSY data set, in particular the high concealment rate,
were discussed. Indeed, Russo instead assured readers that the NLSY contained
sufficient “size and variability in the critical variables” to detect any
negative health effects of abortion and therefore her finding of no negative
impact on self-esteem provided a solid basis for concluding that there are not
significant negative effects of abortion on women’s “well-being.”
While I would strenuously disagree with Russo’s claim that the NLSY is a
sufficiently sensitive tool for reaching definitive conclusions regarding the potential
risks and benefits of abortion,44 I do agree it provides at least a
few useful variables that can be used to get a glimpse at how at least some
women may adjust to abortion and the birth of unintended pregnancy. Indeed, it
is precisely because the NLSY is a very imperfect research tool that Schmiege
and Russo’s approach, as well as our own, is subject to so much second
guessing. If this current disagreement regarding analytic methods and conclusions
proves anything, it proves the need for a far better data set that would be
made available to a larger number of researchers for a much deeper and
conclusive analysis than is currently possible.
Therefore, while I don’t expect Schmiege and Russo to embrace the
criticisms I have raised above, it is my sincere hope that they, and anyone
else interested in the issue of women’s health, will embrace our recommendation9,41
for federal funding of major longitudinal cohort study carefully designed to
fully examine the associations between obstetric history and emotional
well-being. A properly designed study with annual assessments and interviews that
would be made available to all researchers, much as is currently done with the
NLSY, would enable researchers to gauge the interactions among mental health
and childbirth, parenting, adoption, abortion and miscarriage of wanted,
unwanted, planned, and mistimed pregnancies. In addition, this collection of
data would allow researchers to better investigate the effects and interactions
of marriage, divorce, single parenting, multiple partners, domestic violence,
PMS and menstrual irregularities, contraceptive practices, and similar factors
related to reproductive and mental health and to wide variety of psychological,
medical, and social issues that are uniquely related to women.
Even if Schmiege and Russo were to object to everything else I have
written above, I am optimistic that they will agree to the importance of a
longitudinal study such as we have described. Such a study will finally
produce the comprehensive data needed to reach incontrovertible conclusions
regarding the positive and negative health effects of unintended pregnancies
and abortion and deserves the support of all researchers interested in women’s
health.
CITATIONS
(Links to full articles are provided where known)
[1]
Schmiege S, Russo NF. Depression and unwanted first pregnancy: longitudinal
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[4] Major B, Cozzarelli C, Cooper ML et al: Psychological
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777-84.
[5] Cozzarelli, C., Major, B., Karrasch, A., &
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picketing. Basic and Applied Social Psychology, 2000;22:265-275.
[6] Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman
PK, Ney PG. Psychiatric admissions of low income women following abortion and
childbirth. Can Med Assoc J. 2003; 168(10):1253-7. http://www.cmaj.ca/cgi/reprint/168/10/1253
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[8]
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[10]
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[11] Soderberg H, Janzon L, Sjoberg NO: Emotional distress
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[12]
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[13] Russo N, Denious JE. Violence in the lives of women
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[14]
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[16]
Congleton, G. & Calhoun, L. (1993). Post-abortion perceptions: A comparison
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[17] Burke T, Reardon DC. Forbidden grief: the unspoken
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[18]
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[19]
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[21] Gissler M, Berg C, Bouvier-Colle MH, Buekens P.
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[25] Tischler C, Adolescent suicide attempts following
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[26] Greenglass ER. Therapeutic abortion and psychiatric
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[27] Garfinkle B, Hoberman H, Parsons J, Walker J. Stress,
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[30]
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[31]
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[32] Lask B. Short‑term Psychiatric Sequelae to
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[33] Peppers LG, “Grief and Elective Abortion:
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Sorrow, ed. Kenneth J. Doka (Lexington Books: Lexington MA, 1989), pp.135‑146.
[34] Jones EF, Forrest JD: Under reporting of abortion in
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[35] Major B, Gramzow RH. Abortion as stigma: cognitive
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[36]
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[37]
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[38]
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[40]
Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution
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[41] Coleman PK, Reardon DC, Strahan T, Cougle JR. The
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The Reality of Post Abortion Trauma
