Women's Mental Health After Abortion: A Literature Review

Introduction

According to Steinberg, Tschann, Fergerson, and Harper (2016), a significant percentage of women in the United States procure "an abortion before the age of 45" (p. 63). The authors indicate that this percentage could be as high as 30%. Despite this prevalence, abortion remains one of the most controversial issues in contemporary society. As a consequence of the controversy surrounding this issue, many myths have emerged around the subject — particularly regarding the connection between abortion and both physical and mental health. According to Steinberg, Tschann, Fergerson, and Harper (2016), most of the myths propagated on this front are not evidence-based. For this reason, there is a need to explore available scientific research regarding the impact that abortion has on the health and wellbeing of women, specifically mental health. The present review seeks to answer the question: how does abortion affect mental health? The relevance of a review of this nature cannot be overstated, given the large percentage of women who procure an abortion at some point in their lives.

Prior to 1969, no meaningful data on abortion was being collected in the United States. The Centers for Disease Control and Prevention had not yet commenced the documentation of abortion rates and occurrences; that surveillance began in 1969 (Centers for Disease Control and Prevention, 2021). To a large extent, no standard definition of abortion exists, and numerous definitions have been proposed in attempts to conceptualize the term in diverse contexts. However, from a legal standpoint, "abortion is defined as an intervention performed by a licensed clinician within the limits of state regulations, that is intended to terminate a suspected or known ongoing intrauterine pregnancy and that does not result in a live birth" (Centers for Disease Control and Prevention, 2021). This is the definition embraced throughout this review.

Various abortion procedures are commonly performed. The most common are the use of pills and vacuum aspiration (Johnson, 2021). Whereas the former involves the ingestion of a prescription pill — typically mifepristone — the latter involves the removal of the pregnancy via gentle suction. Both approaches depend on the stage of pregnancy. For instance, the use of pills is most appropriate during the early stages of pregnancy, whereas vacuum aspiration is typically used in later stages, including the second trimester.

According to the American Psychological Association (2018), "there are numerous reasons for a woman to seek an abortion." Exploring these factors requires engagement with relevant sociological concepts, including conflict theory, critical race theory, and cultural theory.

When it comes to conflict theory, the focus is on tensions arising from the uneven distribution of power, status, and resources in society — a framework originally proposed by Karl Marx. From a conflict theory perspective, abortion may be pursued as a consequence of competition for limited resources, particularly economic pressures that motivate the decision. This perspective is reinforced by the finding that, as Yazdkhasti, Pourreza, Pirak, and Abdi (2015) point out, unintended pregnancies can have negative consequences on economic and financial fronts, placing "appreciable socioeconomic burden on individuals and society" (p. 12). For women who are unsure of how to provide for an unborn child, procuring an abortion may appear to be the most rational course of action. Notably, the authors estimate that up to 50% of pregnancies in the United States could be classified as unwanted.

With regard to critical race theory, the most prominent factor is the institutionalization of racial discrimination — the idea that various procedures, rules, regulations, and laws in the country are skewed in favor of some racial groups, making differential outcomes by race largely inevitable (Ziegler, 2020). According to Cohen (2008), African American women tend to have a higher rate of abortion than their white counterparts — approximately five times more likely to procure an abortion. Consistent with critical race theory, Cohen (2008) argues that "these higher unintended pregnancy rates reflect the particular difficulties that many women in minority communities face in accessing high-quality contraceptive services and in using their chosen method of birth control consistently and effectively over long periods of time."

Finally, the issue of abortion can also be assessed through the lens of cultural ideology, which relates to the beliefs and viewpoints rooted in culture that specific groups or classes hold. Over the last few decades, the United States has moved toward reproductive choice — meaning that, unlike several decades ago, most citizens now have access to abortion services that could be deemed high quality. This shift accelerated following the landmark 1973 Supreme Court decision that effectively legalized abortion while permitting states to impose certain restrictions, resulting in a broader ideological shift regarding access to abortion services.

Abortion and Mental Health

It is important to note at the outset that there appear to be conflicting findings across studies about the impact of abortion on mental health. Whereas some studies indicate that abortion is linked to a wide range of psychological problems — including negative feelings, depression, and post-traumatic stress disorder (PTSD) — others have found no evidence of psychological distress among women who have procured an abortion. Reardon (2018) best captures this standoff by pointing out that "the abortion and mental health controversy is driven by two different perspectives regarding how best to interpret accepted facts" (p. 21).

Among the studies linking abortion to negative mental health outcomes, a 2011 study found that women who had procured an abortion had a higher likelihood of struggling with mental health issues (Coleman, 2018). More specifically, women who had procured an abortion had an 81% higher likelihood of experiencing significant mental health changes following the abortion. The mental health issues likely to be presented included depression and anxiety, and women who had had an abortion were more likely to abuse marijuana and/or alcohol than those who had not (Coleman, 2018). The author argues that these results call into question studies finding no link, stating that "the results revealed a moderate to highly increased risk of mental health problems after abortion" (Coleman, 2018, p. 180).

In another study incorporating a large sample of more than 8,000 women, those who had had an abortion at some point in their lives presented with a significantly higher risk of mental health disorders, even after accounting for relevant sociodemographic differences (Sullins, 2016). Mental health outcomes examined in this study included suicidal ideation, anxiety disorder, and depression. Similarly, Kulathilaka, Hanwella, and Silva (2016) found that "abortion is associated with moderate to high risk of psychological problems such as depression, use of alcohol or marijuana, anxiety, and suicidal behaviors" (p. 28).

However, other studies deny or substantially qualify the link between abortion and negative mental health outcomes. According to the American Psychological Association (2018), a comprehensive review of recent scientific literature clearly indicates that "the relative risk of mental health problems following a single elective first-trimester abortion is no greater than the risk associated with carrying that pregnancy to term." Ditzhuijzen, Have, Graff, Nijnatten, and Vollebergh (2017) similarly indicate that no recent credible research has established a link between mental disorders and abortion. In a study by Steinberg, McCulloch, and Adler (2014), no statistically significant link was found between the procurement of an abortion and the subsequent development of mental health concerns such as suicidal ideation and anxiety. The authors argue that advocacy groups pushing to outlaw abortion have claimed a negative psychological impact, but that the available scientific evidence does not support these viewpoints. Furthermore, in one systematic review, Charles, Polis, Sridhara, and Blum (2008) concluded that in most high-quality studies — those without significant methodological flaws — no scientifically significant link between abortion and adverse mental health outcomes has been observed.

Reconciling the Conflicting Findings

The seemingly conflicting findings described above appear to stem from a single phenomenon: co-occurring factors. As the American Psychological Association (2018) points out, whether or not a woman experiences negative mental health outcomes following an abortion may be determined by co-occurring risk factors. More specifically, "among women who do experience mental health issues, these issues may be related to co-occurring risk factors that predispose a woman to multiple unwanted pregnancies and mental health problems" (American Psychological Association, 2018). This assertion is further supported by Ditzhuijzen, Have, Graff, Nijnatten, and Vollebergh (2017), who found that mental disorders following the procurement of an abortion were linked to prior mental health problems and relationship difficulties.

Another co-occurring factor is the difficulty with which the decision to procure an abortion was made. In one study assessing women's emotions shortly after an abortion, emotional state was found to be largely dependent upon how difficult the decision-making process had been (Rocca, Kimport, Gould, and Foster, 2013). Women who had struggled with the decision were more likely to experience negative feelings a few days after the abortion than those whose decision was more straightforward. Biggs, Upadhyay, McCulloch, and Foster (2017) similarly found that adverse mental health outcomes following abortion could be triggered by exposure to other traumatic life events and a history of mental health conditions.

Stigma represents yet another important co-occurring risk factor. According to Biggs, Rowland, McCulloch, and Foster (2016), most women who exhibit signs of distress following an abortion report that their distress was largely triggered by negative connotations about abortion and fear of shame and disgrace. As the authors note, "some women who experienced distress after an abortion reported that seeing protestors at the clinic had triggered their symptoms" (Biggs, Rowland, McCulloch, and Foster, 2016, p. 97).

Conclusion

In the final analysis, overwhelming evidence has emerged indicating that there is no direct causal link between abortion and the development of mental disorders among women who procure one. Abortion, by itself, does not appear to have any inherent impact on a woman's mental health. It is worth noting that this conclusion differs substantially from this reviewer's prior assumptions about the association between abortion and women's mental health. For instance, the assumption had been that a woman who procures an abortion would likely experience intense negative feelings in the short term, which could then develop into major depressive symptoms — an assumption rooted in the view of abortion as involving the intentional destruction of life. Available evidence, however, points to co-occurring risk factors as the actual drivers of post-abortion negative feelings and adverse mental health outcomes. Efforts to minimize the risk of mental or psychological disorders following the procurement of an abortion should therefore focus squarely on addressing these co-occurring risk factors rather than treating abortion itself as the cause.