Women’s mental health: Unwanted pregnancy

To the Editor

The question of whether termination of pregnancy is associated with an increased risk of mental health problems has attracted the interest of psychiatrists. However, studies conducted in countries where termination of pregnancy is lawful have proven inconclusive on the matter.

One longitudinal study showed that women who had had terminations had rates of mental health problems which were 30% higher than that of other pregnancy outcomes (pregnancy loss, live birth following unwanted pregnancy or a pregnancy having an initial adverse reaction, and other live births). The conditions most associated with termination included anxiety disorders and substance abuse disorders. Nonetheless, the overall effects of termination on mental disorders rated in this cohort were as small as 1.5 – 5.5% (Ferguson et al., 2008). A more recent prospective population-based cohort study showed that a single first-trimester termination does not correlate with worsening of mental health in adolescents and women. The authors also observed that any propensity towards mental health disorders in adolescents and women who have a termination predates the termination and makes termination more likely (Munk-Olsen et al., 2011).

Despite numerous studies of the risk of mental health problems associated with termination published in the English language over the last ten years, consensus has not been achieved. To fill the gap the Academy of Medical Royal Colleges requested a systematic review, which was carried out by the National Collaborating Centre for Mental Health (NCCMH) and the Royal College of Psychiatrists. The results of this review, published in December 2011 (Academy of Medical Royal Colleges, 2011), showed that having an unwanted pregnancy was associated with an increased risk of mental health problems. However, the rates of mental health problems for women with an unwanted pregnancy are the same whether they have a termination or give birth. Further, women who have had mental health problems before the termination of pregnancy are at a greater risk of mental health problems after the termination. Some other factors may be associated with increased rates of post-termination mental health problems, such as women having a negative attitude towards terminations in general, being under pressure from their partners to have a termination, or experiencing other stressful life events. Therefore, termination is not itself a predictor of mental health problems, but rather, having an unwanted pregnancy.

The results of this systematic review have shifted the focus of interest onto unwanted pregnancy. Women’s mental health might benefit from psychiatrists refocusing their attention on addressing issues related to the occurrence of unwanted pregnancy. Further, unintended pregnancy at a very young age is a likely indicator of parental abuse and/or neglect. These adolescents are at a high risk for repeated victimisation and clinicians must consider whether they have an obligation to report the situation to child protection authorities (Stotland, 2011). Data from the National Comorbidity Survey found that adult women with multiple terminations also have high rates of violence in their lives (Steinberg and Russo, 2008). Consequently, it appears evident that psychiatric practice and research should focus on assisting women who are at the greatest risk of having unwanted pregnancies, particularly those with prior mental health problems, and violence in their lives.