In the JournalsPerspective

Abortion does not increase women's suicide risk

Julia R. Steinberg

Although women who have had an abortion have a higher risk for nonfatal suicide attempts, the abortion itself is not the cause, according to results of a longitudinal cohort study published in Lancet Psychiatry.

“There are 12 states that inform women seeking abortions that abortion increases or may increase their risk for suicidal ideation or mental health problems,” Julia R. Steinberg, PhD, assistant professor in the department of family science at the University of Maryland, told Healio Psychiatry. “Abortion does not cause or increase women's risk for suicide attempts.”

According to Steinberg and colleagues, certain restrictive abortion policies in the United States are based on a link between suicidal ideation and abortion, but much prior related research relied on self-report, had low participation rates and did not consider confounding factors. In the present study, the researchers obtained data from 523,280 women born in Denmark between 1980 and 1998. They used a survival analysis to examine the risk for first suicide attempt or self-harm associated with a first abortion compared with no abortion, as well as Poisson regression to examine incidence rate ratios. They also investigated whether the risk of suicide attempts changed before and after the abortion and adjusted for several factors, including age and parental mental health.

Steinberg and colleagues reported that 48,990 (9.4%) women had at least one first-trimester abortion, and 10,216 (2%) had a suicide attempt during the study period. Among the 48,990 women who had an abortion, 1,402 (2.9%) had a first suicide attempt following the first abortion. Using a model that adjusted for all covariates, the researchers found that the risk for first-time nonfatal suicide attempts was similar in the year before an abortion (incidence rate ratio [IRR] = 2.46; 95% CI, 2.22-2.72) and the year after an abortion (IRR = 2.54; 95% CI, 2.29-2.81) compared with women who had not had an abortion. The risk decreased with increasing time since the abortion, they noted.

“We should not be telling women seeking abortions that abortion may increase their risk for suicidal ideation or mental health problems, nor should mental health professionals tell or suggest to women that an abortion is the reason for any mental health problems a woman may be experiencing,” Steinberg said. “We should consider integrating mental health screenings into the abortion care setting because women having abortions are more likely to have pre-existing mental health problems.”

In a related editorial, Jenneke van Ditzhuijzen, PhD, of the University of Amsterdam, described these findings as, “a welcome addition to the academic literature.”

“Steinberg and colleagues correctly limit their analyses to first-time abortions and first-time suicide attempts; although this decreases external validity, it is a necessary step to establish causal effects and ensure temporal order,” van Ditzhuijzen wrote. – by Joe Gramigna

Disclosures: Steinberg reports serving as a scientific expert on abortion and mental health in four legal challenges to state laws in the U.S. All other authors report no relevant financial disclosures.

Julia R. Steinberg

Although women who have had an abortion have a higher risk for nonfatal suicide attempts, the abortion itself is not the cause, according to results of a longitudinal cohort study published in Lancet Psychiatry.

“There are 12 states that inform women seeking abortions that abortion increases or may increase their risk for suicidal ideation or mental health problems,” Julia R. Steinberg, PhD, assistant professor in the department of family science at the University of Maryland, told Healio Psychiatry. “Abortion does not cause or increase women's risk for suicide attempts.”

According to Steinberg and colleagues, certain restrictive abortion policies in the United States are based on a link between suicidal ideation and abortion, but much prior related research relied on self-report, had low participation rates and did not consider confounding factors. In the present study, the researchers obtained data from 523,280 women born in Denmark between 1980 and 1998. They used a survival analysis to examine the risk for first suicide attempt or self-harm associated with a first abortion compared with no abortion, as well as Poisson regression to examine incidence rate ratios. They also investigated whether the risk of suicide attempts changed before and after the abortion and adjusted for several factors, including age and parental mental health.

Steinberg and colleagues reported that 48,990 (9.4%) women had at least one first-trimester abortion, and 10,216 (2%) had a suicide attempt during the study period. Among the 48,990 women who had an abortion, 1,402 (2.9%) had a first suicide attempt following the first abortion. Using a model that adjusted for all covariates, the researchers found that the risk for first-time nonfatal suicide attempts was similar in the year before an abortion (incidence rate ratio [IRR] = 2.46; 95% CI, 2.22-2.72) and the year after an abortion (IRR = 2.54; 95% CI, 2.29-2.81) compared with women who had not had an abortion. The risk decreased with increasing time since the abortion, they noted.

“We should not be telling women seeking abortions that abortion may increase their risk for suicidal ideation or mental health problems, nor should mental health professionals tell or suggest to women that an abortion is the reason for any mental health problems a woman may be experiencing,” Steinberg said. “We should consider integrating mental health screenings into the abortion care setting because women having abortions are more likely to have pre-existing mental health problems.”

In a related editorial, Jenneke van Ditzhuijzen, PhD, of the University of Amsterdam, described these findings as, “a welcome addition to the academic literature.”

“Steinberg and colleagues correctly limit their analyses to first-time abortions and first-time suicide attempts; although this decreases external validity, it is a necessary step to establish causal effects and ensure temporal order,” van Ditzhuijzen wrote. – by Joe Gramigna

Disclosures: Steinberg reports serving as a scientific expert on abortion and mental health in four legal challenges to state laws in the U.S. All other authors report no relevant financial disclosures.

    Perspective
    M. Antonia Biggs

    M. Antonia Biggs

    Steinberg and colleagues’ recent Lancet Psychiatry publication provides new rigorous evidence confirming that abortion does not increase people’s risk of engaging in non-fatal suicide attempts. The authors take advantage of Danish registry data to prospectively demonstrate that among the nearly 50,000 adults having an abortion in Denmark, the incidence rate ratios of non-fatal suicide attempts were the same in the year before and after the abortion. Consistent with other studies,1-4 these findings confirm that factors such as mental health history are the most strongly associated with experiencing suicidal thoughts and behaviors, not the abortion. Steinberg et al.’s study adds to the growing body of evidence demonstrating that abortion does not increase women’s risk of experiencing adverse psychological outcomes.3-7 Importantly, this study calls in to question current state-level policies in the U.S. that require providers to tell their patients that abortion results in an increased risk of suicidal ideation, suicide or other mental health problems, before they are allowed to provide the abortion care their patients desire.  It seems imperative to revise current laws that mandate pre-abortion counseling on this basis, and to ensure that any information we give people regarding the effects of abortion on their mental health be based on good evidence.

    References:

    Biggs MA, et al. American Journal of Psychiatry. 2018;doi:10.1176/appi.ajp.2018.18010091.

    Biggs MA, et al. JAMA Psychiatry. 2017;doi:10.1001/jamapsychiatry.2016.3478.

    Charles VE, et al. Contraception. 2008;doi:10.1016/j.contraception.2008.07.005.

    Major B, et al. American Psychologist. 2009;doi:10.1037/a0017497.

    National Collaborating Centre for Mental Health at the Royal College of Psychiatrists. Induced abortion and mental health: a systematic review of the mental health outcomes of induced abortion, including their prevalence and associated factors. London: Royal College of Psychiatrists; 2011.

    Steinberg JR, et al. Obstetrics and Gynecology. 2014;doi:10.1097/AOG.0000000000000092.

    Steinberg JR, et al. The American Journal of Orthopsychiatry. 2011;doi:10.1111/j.1939-0025.2011.01088.x.

    • M. Antonia Biggs, PhD
    • Social psychologist researcher,
      Advancing New Standards in Reproductive Health,
      Bixby Center for Global Reproductive Health
      Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco

    Disclosures: Biggs reports no relevant financial disclosures.