Priscilla K. Coleman, PhD

Our culture is in a worrisome state when major medical journals ignore the foundation and methods of science in service to a political end. Equipped for decades with billions in grant revenue, ideological control of the academy, and agenda-driven professional organizations, scores of scientists have suspended personal and professional ethics to safeguard women’s right to end the lives of their children and suffer the concomitant effects. Biggs and colleagues are just the latest to march down this path with their JAMA Psychiatry article titled “Women’s Mental Health and Well-Being 5 Years after Being Denied an Abortion: A Prospective, Longitudinal Cohort Study.” What once appeared to be a subtle mainstream journal bias in favor of publishing results, suggesting abortion poses no threat to women’s psyches, has morphed into a peer-review process, blind to scientific deficiencies as long as the results further leftist abortion rights initiatives. These are desperate times for the pro-choice community, as they seek to block women-centered abortion laws rooted in strong empirical evidence and the voices of brave women standing up to share their post-abortion struggles. What better way than to grab bullet points from a JAMA article and flood the popular media with them? Women deserve better and here is why the latest study results have absolutely no merit and will not hold up in any court.

The study results and obvious bias

The authors compared women who received abortions just under legal gestational limits with women who wanted an abortion but were denied, because they were just over the facility gestational limit (Turnaway Group) relative to psychological outcomes. The Turnaway Group was subdivided into those who gave birth and those who obtained an abortion subsequently or miscarried. The authors summarized the results by stating “Women who were denied an abortion, in particular those who later miscarried or had an abortion elsewhere (Turnaway no-birth group), had the most elevated levels of anxiety and lowest self-esteem and life satisfaction 1 week after being denied an abortion, which quickly improved and approached levels similar to those in the other groups by 6 to 12 months.”

The authors’ objective for publishing the study is introduced in the opening line: “The idea that abortion leads to adverse psychological outcomes has been the basis for legislation mandating counseling before obtaining an abortion and other policies restricting abortion” and it is nailed down at the end of the article when they state “…there is no evidence to justify laws that require women seeking abortion to be forewarned about negative psychological responses.” As scientists we never make such sweeping conclusions based on a single study, particularly when there is an abundant literature comprised of sophisticated studies with discrepant conclusions. Courts throughout the US have concluded that women should be appraised of the risks before consenting to abortion; it is absurd that these researchers have attempted to shift the tide based on this one study.Funding was predictably secured from the David and Lucille Packard Foundation among other sources with a political agenda. As described on their website, “Our work in the United States seeks to advance reproductive health and rights for women and young people by improving access to quality comprehensive sexuality education, family planning and safe abortion care.”

The JAMA results are inconsistent with the current state of knowledge

The results of hundreds of studies published worldwide over the past three decades indicate that abortion is a substantial contributing factor to women’s mental health problems. I published a meta-analysis on the association between abortion and mental health in the British Journal of Psychiatry (BJP) in 2011. In a meta-analysis, the contribution of any particular study to the final result is based on objective scientific criteria (sample size and strength of effect). The BJP sample consisted of 22 studies and 877,297 participants. Results revealed that women who aborted experienced an 81% increased risk for mental health problems. When compared exclusively to unintended pregnancy delivered, women were found to have a 55% increased risk of experiencing mental health problems. This review offers the largest quantitative estimate of mental health risks associated with abortion currently available. Evidence of this nature has influenced informed consent legislation in many states. For example, upholding the South Dakota law in 2012, the US Court of Appeals relied upon the emerging body of data.

Methodological shortcomings in the JAMA Psychiatry article

1. Only 37.5% of women invited to take part in the study actually participated, and across the study period 42% of these dropped out, rendering the final sample comprised of under 22% of those eligible for inclusion! The 78% of women whose voices are not included were likely those who had the most serious post-abortion psychological complications. With sensitive topic research, securing a high initial consent rate and avoiding sample loss are vitally linked to the validity of the conclusions. The authors acknowledge this fact as they state “we cannot rule out the possibility that women with adverse mental health outcomes may have been less likely to participate and/or been retained.” We really can just stop here, because this is a fatal flaw.

2. In a previous article with the same data published last year in PLoS ONE, the authors noted that the sample had a high concentration of women from low socioeconomic backgrounds, obviously not representative of US women undergoing abortion today. Now we hear from the research group that “given the large number and range of recruitment facilities representing geographically diverse regions in the US (30 clinics from 21 states), and that our sample demographics are consistent with those of nationally representative samples of women seeking abortion, we believe these results are generalizable.” A sample is either representative or it is not.

3. The authors failed to reveal the specific consent to participate rates for each group. Second trimester abortions have been established as potentially more traumatizing than first trimester procedures; therefore it is likely that a significantly higher percentage of women in the first-trimester group compared to those in the second trimester group consented to participate. If the rates were comparable, why not report this? Failure to report critical information increases suspicion that this “near limit’ group is in no way representative.

4. In the Turnaway Study, women who secured abortions near the gestational limits included women for whom the legal cut off ranged from 10 to 27 weeks. There is a wealth of data indicating that women’s reasons for choosing abortion and their emotional responses to the procedure differ greatly at varying points of pregnancy. Women aborting at such widely disparate gestational ages should therefore not be lumped together, particularly when such information is available in the data.

5. The authors do not explain how the sites were actually chosen. What type of sampling plan was employed? Why were only those identified with the National Abortion Federation used? What cities were included? Which areas of the country were sampled?

6. All 4 outcome measures are shockingly simplistic with 2 variables containing only 6 items and 2 variables measured with single items. This is inexcusable given the many psychometrically sound multiple item surveys available in the literature. Further, no theoretical basis is given for the cut-score employed to determine clinically relevant cases of depression or anxiety. Well-trained behavioral science researchers should not measure complex human emotions in such a superficial manner; and ethically responsible scientists would not extrapolate from minimalistic assessments to women’s emotional reactions to one of life’s more challenging decisions.

The authors suggest that later abortions are healthier for women than childbirth when women seek abortions, obscuring the well-documented risks of late abortions to women's physical well-being in addition to the elevated psychological risks. For example, using national data, Bartlett and colleagues reported in 2004 that the relative risk of abortion-related mortality was 14.7 per 100,000 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.

Many women who make the decision to abort do so without a thorough understanding of the procedure. A number of studies have revealed that feeling misinformed or being denied relevant information often precipitates post-abortion difficulties. There is also considerable evidence that a high percentage of women walking into abortion clinics are conflicted about the choice. In a 2006 study I published with colleagues in theJournal of Medical Ethics, we found that 95% 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. Fortunately state-level legislation has responded to the needs of women, respecting the gravity of an abortion decision by mandating dissemination of accurate information on the procedure and risks involved, time to reflect on the decision, and sensitive pre-abortion counseling.

This latest study in JAMA will be aptly tossed on the dusty stack with other similarly compromised studies that have yielded results palatable to a culture fighting to normalize a procedure that will never feel natural or right to countless women. The studies will be unattended to by the average person, clinicians, and the science-savvy alike, because the results simply do not align with the lived experiences of women.