Manifold problems in a recent New York Times article
On June 12 the New York Times published an article by graduate student Joshua Lang, “What Happens to Women Who Are Denied Abortions?” Mr Lang is currently enrolled in UC Berkley’s Joint Medical Program, a five-year Master of Science/Medical Doctorate Program. Sadly, Lang’s desire to push a political agenda was apparently the most salient force behind his shoddy piece. Like many before him, Lang tries to dismiss more than 100 peer-reviewed studies revealing an increased risk of mental health problems by focusing on one counter study that has yet to generate any peer-reviewed publications. Lang interviewed me last fall for over an hour and he clearly understood the science.
According to Mr Lang, “There is no credible research to support a ‘post-abortion syndrome’, as a report published by the American Psychological Association in 2008 made clear. Yet the notion has influenced restrictive laws in many states.” This statement actually indirectly affirms the strength of the published evidence regarding abortion as a risk factor for mental health problems, because the evidence presented in courts continues to trump the APA conclusions. The vast majority of research studies on the psychological implications of abortion do not address a “Post-Abortion Syndrome”. Instead, researchers examine abortion as a risk factor in mental illnesses that are identified by mainstream professional organizations.
The results of hundreds of studies published in leading peer-reviewed medicine and psychology journals over the past three decades indicate that abortion is a substantial contributing factor to women’s mental health problems, including depression, anxiety, substance use disorders, and suicidal thoughts and behaviors. This evidence has quite reasonably influenced informed consent legislation in many states. In upholding the South Dakota law in 2012, the US Court of Appeals relied upon this body of data.
A critique of the 2008 APA report is posted at the website of the World Expert Consortium for Abortion Research and Education (WECARE), a group of 10 credentialed scientists working to bring accurate information to a public in dire need of evidence-based facts concerning abortion.
Among dozens of other peer-reviewed studies, Lang ignores the results of a meta-analysis entitled “Abortion and Mental Health: A Quantitative Synthesis and Analysis of Research Published from 1995-2009” that I published in the British Journal of Psychiatry (BJP) in 2011. Meta-analyses have much more credibility than the results of individual empirical studies or narrative reviews, such as the APA’s 2008 report. In a meta-analysis, the contribution or weighting of any particular study to the final result is based on objective scientific criteria (sample size and strength of effect), as opposed to an individual’s opinion of what constitutes a strong study. The BJP sample consisted of 22 studies and 877,297 participants (163,880 experienced an abortion). Results revealed that women who aborted experienced an 81 percent increased risk for mental health problems. When compared specifically to unintended pregnancy delivered, women were found to have a 55 percent increased risk of experiencing mental health problems. This review offers the largest quantitative estimate of mental health risks associated with abortion available in the world.
Many women who make the decision to abort do so without a thorough understanding of the procedure. A number of peer-reviewed studies have revealed that feeling misinformed or being denied relevant information often precipitates post-abortion difficulties. Moreover, there is considerable evidence that a high percentage of women walking into abortion clinics are conflicted about the choice. In another study I published with colleagues in the Journal of Medical Ethics, we found that 95 percent of a socio-demographically diverse group of women wished to be informed of all possible complications associated with drugs, surgery, and/or other forms of elective treatments, including abortion.
Lang also offers the misleading statement that “Most studies on the effects of abortion compare women who have abortions with those who choose to carry their pregnancies to term.” This ignores the fact that a minimum of eight peer-reviewed studies have included, as a comparison group, women who had an unintended pregnancy and delivered. Many additional studies have included women who have not experienced a pregnancy or had a miscarriage as a comparison group.
Lang puts great emphasis on Diana Foster’s Turnaway Study, which is presented as superior to any existing studies. But the Turnaway Study has glaring flaws. First, less than a third of the women who were approached to participate agreed to do so. This is unacceptable, because those agreeing may have differed systematically from those who declined. Consent to participate rates should be at least 70 percent. Second, women who obtained or were denied abortions around the gestational limits included women for whom the legal cut-off ranged from 10 weeks through the end of the second trimester or 27 weeks. This is not a variable that can be loosely defined, as there is a wealth of data indicating the psychological impact of abortion differs between first and second trimester abortions. Women aborting at such widely varying points in pregnancy cannot be lumped together.
Lang states that “Women cite not recognizing their pregnancies, travel and procedure costs, insurance problems and not knowing where to find care as common reasons for delay.” Actually, the best documented reason for delay is ambivalence about the decision.
Lang also says that women seeking second-trimester abortions “tend to be particularly vulnerable, given the difficulties of finding an appropriate clinic and the higher cost of a later procedure.” Yes, they are particularly vulnerable, but the primary reason is that psychological and physical risks increase exponentially with delayed abortion decisions.
But the most appalling statement in the whole article is Lang’s quoting Foster’s claim that “later abortions are significantly safer than childbirth.” The risks of late-term abortion to women’s physical well-being are well-documented. For example, using national data, Bartlett and colleagues reported in 2004 that the relative risk of abortion-related mortality was 14.7 at 13–15 weeks of gestation, 29.5 at 16-20 weeks, and 76.6 at or after 21 weeks. This compares to a 12.1 rate for childbirth. Bartlett reported that the causes of death during the second trimester included hemorrhage, infection, embolism, anesthesia complications, and cardiac and cerebrovascular events.
As academics, politicians, and lawyers debate the post-abortion psychological and medical literature, the most expedient route to the truth is likely through women’s own voices. The woman in the story who was denied an abortion told Mr Lang about her daughter, “She is more than my best friend, more than the love of my life” “She is just my whole world.” The Turnaway Study, using a seriously-flawed methodology, will likely silence most of these voices and perpetuate the suffering of women rushed through abortion clinics.