Science or Politics?

1
Science or Politics?

• The Abortion Debate

2
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

3
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

4
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

5
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

6
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

7
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

8
The Medical Profession and Abortion

• Shortly after its formation the AMA in the mid
  1800s spoke out against abortion and
  contraception
• Medical school curricula addressed neither until
  the 1930s
• 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

9
The Medical Profession and Abortion

• 1950s and 1960s 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 1960s

10
Since liberalization of access

• The post-abortion syndrome
• Medical education and its impact on abortion
  services
• Access to information

11
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

12

• 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

13
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

14
Classification of Studies

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

15
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

16
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

17
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

18
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

19
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)

20
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

21
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

22
Why the Difference?

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

23
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

24
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

25
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

26
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

27
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

28
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

29
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

30
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

31
Knowledge and Abortion

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

32
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 1990s 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

33
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

34
Knowledge and Abortion

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

35
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?

36
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

37
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