Review of
"Termination of Pregnancy and Psychiatric Morbidity"

Dr. Philip G. Ney, MA, MD, FRCP(C), FRANZCP

The study by Gilchrist et al. is based on the concept of an unplanned pregnancy, but the authors make little attempt to define what this is and how it was determined. As every physician knows, people are ambivalent about the inception and conception of almost every pregnancy. There are very few people who actually put much effort into planning a pregnancy, and those are mostly people who use natural family planning methods. Most "plan" only by withdrawing contraception. A recent report of the Alan Guttmacher Institute states that "the proportion of women wanting to become pregnant is extremely low, less than 1 in 5 in industrialised countries."¹ If contracepting or not contracepting means whether the pregnancy is planned or not, then there is no basis for making statements about psychiatric sequlae of any pregnancy outcome. Many people change their mind almost in the middle of intercourse about whether they want or plan to have a baby.

The review of the literature is very biased. There are many relevant studies not cited.^{2 3} Gilchrist et al. do not summarize the references of Doane & Quigley and David et al. correctly.

Since the authors were only using major psychiatric illness classifications, it appears that they did not expect to find or look for the constellation of symptoms and signs now known as the Post_Abortion Syndrome. Post_Abortion Syndrome is now reasonably well recognised and defined, but not included in ICD _ 8.

Although the authors state this study examined a variety of pregnancy outcomes, they did not compare a live birth to a miscarriage or to a stillbirth or to an abortion. They found that the rates of miscarriage were different in the different groups. Miscarriages in the non_abortion group would tend to increase the morbidity because miscarriages do result in higher rates of both physical and psychiatric morbidity. Miscarriages in the abortion group would tend to decrease the apparent morbidity because the effects of the miscarriages are less than the effects of the abortion.

This study relied on general practitioners' assessment of psychiatric morbidity and used the not too precise catagorizations of ICD 8. They diagnosed 225 puerperal psychosis; much higher than the estimated prevalence. The authors found that only 13 of these puerperal psychosis were admitted for treatment, yet almost every case of a puerperal psychosis should be admitted. It seems family physicians were wrong in their diagnosis of puerperal psychosis by a factor of 17. It is likely they were equally out on the other psychiatric diagnosis. The authors did admit that the estimation of puerperal psychosis was too high. The authors found that there is a significantly higher rate of deliberate self_harm (DSH) following an abortion. Eighty_nine (89) % of these were overdoses, which are not difficult to diagnose. If the family physicians were better able to diagnose psychiatric morbidity of other kinds, it is likely that they might have found higher rates in the TOP group.

The authors state that the general practitioners would not have a systematic bias in diagnosing. However, since these general practitioners were referring their patients for TOP, they are less likely to see any adverse effects of a procedure they recommended. Why did the authors not include family physicians who do not make abortion referrals? Physicians of the Christian Medical and Dental Society (CMDS) Canada have a significantly lower rate of abortions and miscarriages in their practices compared to other general practitioners.

The general practitioners' follow up in this study was poor. They lost 65.6% to follow up by the end of the study from the abortion group, and 57.6% from the non_abortion group. The authors state that most of those who were lost to follow up were single, highly educated women. Other studies have shown these women are more likely to have an abortion.

Since those in the refused abortion group were probably refused because of psychiatric problems, psychiatric morbidity in the TOP group should be lower. The authors state that although the DSH was higher in the TOP group, the rates fell more rapidly than in the non_abortion group. They failed to note that the rate the TOP group fell to, i.e. 3.8 was still higher than the baseline group of the non_TOP group, 3.0.

Gilchrist et al. did not show the demographic variables in each group, but state that the data "were indirectly standardised for age, marital status, smoking habit, age at leaving full_time education, gravidity, and previous history of induced abortion at recruitment, since the comparison groups differed on these characteristics." At the end of this article they also state that "the lack of more detailed social information was, however, an important limitation, given the evidence that poor social support increases the risk of psychological morbidity after abortion." They then, to try and explain why DSH is higher in the abortion group, state, "the most likely explanation is that they were at risk because of coexisting social or psychological difficulties associated with both their decision to seek a termination and their subsequent risk of deliberate self_harm." This confusing obfuscation seems to be an attempt to deny the findings that psychiatric morbidity, apart from DSH, was not higher in the group who were refused TOP. The authors state that "risk ratios (RR) were calculated with reference to the group of those who did not request a termination." "The 95% confidence intervals (CI) were calculated using the assumption that the standard deviation of the log of relative risk is equal to the sum of the reciprocals of the observed number of cases in the two groups being compared." This is a questionable assumption, especially in view of the fact that the crude rates for psychosis are; TOP group .1 per 1000, non_TOP group .05 per 1000.

The fact that the psychiatric morbidity of the termination group was not lower than a comparison group of women who requested abortion and changed their minds, effectively demonstrates that abortion is not an effective treatment for psychiatric illness. This study also demonstrates that abortion makes psychiatric conditions of all kinds worse. Yet, without scientific or clinical support, these general practitioners used "previous or anticipated psychiatric illness" as a justification for abortion. This is a practice that the Canadian Psychiatric Association has officially deplored⁴.

¹ Gadd J. (1995, August 22). Families becoming smaller but many births still unwanted. The Globe and Mail, A8.

² Ney PG, Fung T, Wickett AR, Beaman_Dodd C. "The Effects of Pregnancy Loss on Women's Health", Social Science and Medicine, 38(9): 1193_1200, 1994.

³ Sim M, Neisser R. "Post_abortive psychosis: a report from two centers. In: The Psychological Aspects of Abortion. Mall D, Watts F (Eds.), University Publications of America, Washington: 1_13, 1979.

⁴ Smith CM. Canadian Psychiatric Association Bulletin, 13(4): 2_3, Oct. 1981.