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This is a protocol for a systematic review and meta-analysis of research on mental health outcomes of abortion. Does abortion increase the risk of adverse mental health outcomes? That is the central question for this review. Our review aims to inform policy and practice by locating, critically appraising, and synthesizing empirical evidence on associations between abortion and subsequent mental health outcomes. Given the controversies surrounding this topic and the complex social, political, legal, and ideological contexts in which research and reviews on abortion are conducted, it is especially important to conduct this systematic review and meta-analysis with comprehensive, rigorous, unbiased, and transparent methods. We will include a variety of study designs to enhance understanding of studies methodological strengths and weaknesses and to identify potential explanations for conflicting results. We will follow open science principles, providing access to our methods, measures, and results, and making data available for re-analysis.

Background: We examined whether experiencing more types of lifetime intimate partner violence (IPV) was independently associated with the effectiveness level of the contraceptive method women chose following an abortion. Materials and Methods: Using data on 245 women who were attending an urban hospital abortion clinic, we assessed whether women had ever experienced emotional, physical, or sexual IPV. Effectiveness of women's post-abortion contraceptive method selection was categorized into high (intrauterine device [IUD] and implant), moderate (pill, patch, ring, and shot), and low (condoms, emergency contraception, and none) effectiveness. Using multinomial logistic regression, we examined the relationship between number of types of IPV experienced and post-abortion contraceptive method effectiveness, adjusting for sociodemographics, prior abortion, having children, abortion trimester, importance of avoiding pregnancy in the next year, pre-abortion psychological distress, and effectiveness level of the contraceptive method women were planning to use before contraceptive counseling. Results: Twenty-seven percent (27%) of women experienced two or three types of IPV, 35% experienced one IPV type, and 38% experienced no IPV. Compared to women with no histories of IPV, women who experienced two or more types of IPV during their lifetimes were more likely to choose contraceptive methods with moderate effectiveness (adjusted odds ratio [AOR] = 5.23, 95% confidence interval [CI]: 1.13-24.23, p = 0.035) and high effectiveness (AOR = 5.01, 95% CI: 1.12-22.39, p = 0.035) than those with low effectiveness. Conclusion: Women who experienced two or more types of lifetime IPV selected more effective contraceptive methods post-abortion. Access to contraceptives that are not partner dependent, including long-acting reversible contraceptives (LARC), may be particularly important for women who have experienced multiple types of IPV.

This is a protocol for a systematic review and meta‐analysis of research on mental health outcomes of abortion. Does abortion increase the risk of adverse mental health outcomes? That is the central question for this review. Our review aims to inform policy and practice by locating, critically appraising, and synthesizing empirical evidence on associations between abortion and subsequent mental health outcomes. Given the controversies surrounding this topic and the complex social, political, legal, and ideological contexts in which research and reviews on abortion are conducted, it is especially important to conduct this systematic review and meta‐analysis with comprehensive, rigorous, unbiased, and transparent methods. We will include a variety of study designs to enhance understanding of studies' methodological strengths and weaknesses and to identify potential explanations for conflicting results. We will follow open science principles, providing access to our methods, measures, and results, and making data available for re‐analysis. [ABSTRACT FROM AUTHOR]

RationaleMost research in mental health and abortion has examined factors associated with post-abortion psychological health. However, research that follows women from before to after their abortion consistently finds that depressive, anxiety, and stress symptoms are highest just before an abortion compared to any time afterwards.ObjectiveThis finding suggests that studies investigating psychosocial factors related to pre-abortion mental health are warranted.MethodsThe current study uses data from 353 women seeking abortions at three community reproductive health clinics to examine predictors of pre-abortion psychological health. Drawing from three perspectives in the abortion and mental health literature, common risks, stress and coping, and sociocultural context, we conducted multivariable analyses to examine the contribution of important factors on depressive, anxiety, and stress symptoms just before an abortion, including sociodemographics, abortion characteristics, childhood adversities, recent adversities with an intimate partner, relationship context, future pregnancy desires, and perceived abortion stigma.ResultsChildhood and partner adversities, including reproductive coercion, were associated with negative mental health symptoms, as was perceived abortion stigma. Before perceived abortion stigma was entered into the model, 18.6%, 20.7%, and 16.8% of the variance in depressive, anxiety, and stress symptoms respectively, was explained. Perceived abortion stigma explained an additional 13.2%, 9.7%, and 10.7% of the variance in depressive, anxiety, and stress symptoms pre-abortion.ConclusionThis study, one of the first to focus on pre-abortion mental health as an outcome, suggests that addressing stigma among women seeking abortions may significantly lower their psychological distress.

PurposeThis study aims to assess the effects of obtaining an abortion versus being denied an abortion on self-esteem and life satisfaction.MethodsWe present the first 2.5 years of a 5-year longitudinal telephone-interview study that follows 956 women who sought an abortion from 30 facilities across the USA. We examine the self-esteem and life satisfaction trajectories of women who sought and received abortions just under the facility's gestational age limit, of women who sought and received abortions in their first trimester of pregnancy, and of women who sought abortions just beyond the facility gestational limit and were denied an abortion. We use adjusted mixed effects linear regression analyses to assess whether the trajectories of women who sought and obtained an abortion differ from those who were denied one.ResultsWomen denied an abortion initially reported lower self-esteem and life satisfaction than women who sought and obtained an abortion. For all study groups, except those who obtained first trimester abortions, self-esteem and life satisfaction improved over time. The initially lower levels of self-esteem and life satisfaction among women denied an abortion improved more rapidly reaching similar levels as those obtaining abortions at 6 months to one year after abortion seeking. For women obtaining first trimester abortions, initially higher levels of life satisfaction remained steady over time.ConclusionsThere is no evidence that abortion harms women's self-esteem or life satisfaction in the short term.

ObjectiveTo examine whether a first abortion increases risk of mental health disorders compared with a first childbirth with and without considering prepregnancy mental health and adverse exposures, childhood economic status, miscarriage history, age at first abortion or childbirth, and race or ethnicity.MethodsA cohort study compared rates of mental disorders (anxiety, mood, impulse-control, substance use, eating disorders, and suicidal ideation) among 259 women postabortion and 677 women postchildbirth aged 18-42 years at the time of interview from The National Comorbidity Survey-Replication.ResultsThe percentage of women with no, one, two, and three or more mental health disorders before their first abortion was 37.8%, 19.7%, 15.2%, and 27.3% and before their first childbirth was 57.9%, 19.6%, 9.2%, and 13.3%, respectively, indicating that women in the abortion group had more prior mental health disorders than women in the childbirth group (P

ObjectiveWe investigated whether more psychological distress before an abortion is associated with the effectiveness of contraception selected (low, moderate, or high effectiveness) at an abortion clinic visit.MethodUsing data from 253 women attending an urban abortion clinic that primarily serves low-income women, we tested the association between pre-abortion psychological distress and the effectiveness level of post-abortion contraceptive choice. Based on typical use failure rates, we classified effectiveness of contraceptive choice into three levels-low, moderate, and high effectiveness. We measured psychological distress with four validated measures of depressive, anxious, and stress symptoms, and negative affect, as well as with a global measure comprising these four measures. We used multivariable ordinal logistic regression to measure the association of each psychological distress measure with post-abortion contraceptive method effectiveness level, adjusting for sociodemographic factors, pregnancy history, trimester of abortion, and importance of avoiding pregnancy in the next year.ResultsWe found that compared to women experiencing less stress symptoms, negative affect and global psychological distress, women experiencing more stress symptoms [AOR=1.028, 95% CI: 1.001-1.050], negative affect [AOR=1.05, 95% CI: 1.01-1.09] and global psychological distress [AOR=1.46, 95% CI: 1.09-1.95] were more likely to choose more effective versus less effective methods, p

Although many studies have found an association between childhood adversities and mental health disorders, few have examined whether childhood adversities are linked to having abortions. This research investigates the association between a range of childhood adversities and risk of abortion in part to identify which adversities should be considered when examining the association between abortion and subsequent mental health. Using the U.S. National Comorbidity Survey-Replication (NCS-R), we tested the association between 10 childhood adversities and risk of 0, 1, or multiple abortions among 1511 women ages 18-41. We employed multinomial logistic regression to examine the independent association between each childhood adversity and number of subsequent abortions, controlling for sociodemographic factors, total number of pregnancies, and each adversity. Women who had experienced two or more personal safety threats, one parental mental illness, or two or more parental mental illnesses while growing up were more likely subsequently to have multiple versus no abortions [Relative Risk Ratio (RRR) = 9.87, 95% CI: 2.45-39.72; OR = 2.81, 95% CI: 1.27-6.21; RRR = 5.28, 95% CI: 1.60-17.38, respectively], and multiple versus one abortion [RRR = 13.33, 95% CI: 2.48-71.68; RRR = 2.17, 95% CI: 1.03-4.56; RRR = 3.67, 95% CI: 1.15-11.76, respectively]. Women who had experienced childhood physical abuse were more likely to have one compared to no abortions [RRR = 2.00; 1.19-3.34]. These results suggest that some childhood adversities may partially explain the association between abortion and mental health. Accordingly, they should be considered in future research examining the link between abortion and mental health.

The article discusses the broader implications of overturning Roe v Wade in June 2022, highlighting concerns beyond abortion statistics, such as maternal and infant mortality. Topics include the potential mental health repercussions of restrictive abortion policies, a study's findings on increased anxiety and depression symptoms in trigger-ban states post-Dobbs, and the importance of clinicians' awareness in states with abortion restrictions.

The proportion of abortions provided by medication in the United States and worldwide has increased greatly since the U.S. Food and Drug Administration approved mifepristone in 2000. While existing research has shown that abortion does not increase risk of mental health problems, no population-based study has examined specifically whether a procedural or medication abortion increases risk of mental health disorders. This study examined whether mental health disorders increased in the shorter and longer-term after a medication or procedural abortion. Using Danish population registers' data, we conducted a prospective cohort study in which we included 72,424 females born in Denmark between 1980 and 2006, who were ages 12 to 38 during the study period and had a first first-trimester abortion before 13 weeks gestation in 2000 to 2018. Females with no previous psychiatric diagnoses were followed from 1 year before their abortion until their first psychiatric diagnosis, December 31, 2018, emigration from Demark, or death, whichever came first. Risk of any first psychiatric disorder was defined as a recorded psychiatric diagnosis at an in- or out-patient facility from the 1 year after to more than 5 years after a medication or procedural abortion relative to the year beforehand. Results were adjusted for calendar year, age, gestational age, partner status, prior mental and physical health, childbirth history, childhood environment, and parental mental health history. Females having medication (n=37,155) and procedural abortions (n=35,269) had the same risk of any first psychiatric diagnosis in the year after their abortion relative to the year before their abortion (medication abortion adjusted incidence rate ratio [MaIRR]=1.02, 95% confidence interval [CI]: 0.93–1.12; procedural abortion adjusted incidence rate ratio [PaIRR]=0.94, 95% CI: 0.86–1.02). Moreover, as more time from the abortion passed, the risk of a psychiatric diagnoses decreased relative to the year before their abortion for each abortion method (MaIRR 1–2 years after=0.89, 95% CI: 0.80–0.98; PaIRR 1–2 years after=0.81, 95% CI: 0.88–1.05; MaIRR 2–5 years after=0.77, 95% CI: 0.71–0.84; PaIRR 2–5 years after=0.72, 95% CI: 0.67–0.78; MaIRR 5+ years after=0.58, 95% CI: 0.53–0.63; PaIRR 5+ years after=0.54, 95% CI: 0.50–0.58). Because the risk of psychiatric diagnoses was the same in the year after relative to the year before a medication and procedural abortion and the risk did not increase as more time after the abortion increased, neither abortion method increased risk of mental health disorders in the shorter or longer-term. [ABSTRACT FROM AUTHOR]

Importance: The repercussions of abortion for mental health have been used to justify state policies that limit access to abortion in the United States. Much earlier research has relied on self-report of abortion or mental health conditions or on convenience samples. This study uses data that rely on neither.Objective: To examine whether first-trimester first abortion or first childbirth is associated with an increase in women's initiation of a first-time prescription for an antidepressant.Design, Setting, and Participants: This study linked data and identified a cohort of women from Danish population registries who were born in Denmark between January 1, 1980, and December 30, 1994. Overall, 396 397 women were included in this study; of these women, 30 834 had a first-trimester first abortion and 85 592 had a first childbirth.Main Outcomes and Measure: First-time antidepressant prescription redemptions were determined and used as indication of an episode of depression or anxiety, and incident rate ratios (IRRs) were calculated comparing women who had an abortion vs women who did not have an abortion and women who had a childbirth vs women who did not have a childbirth.Results: Of 396 397 women whose data were analyzed, 17 294 (4.4%) had a record of at least 1 first-trimester abortion and no children, 72 052 (18.2%) had at least 1 childbirth and no abortions, 13 540 (3.4%) had at least 1 abortion and 1 childbirth, and 293 511 (74.1%) had neither an abortion nor a childbirth. A total of 59 465 (15.0%) had a record of first antidepressant use. In the basic and fully adjusted models, relative to women who had not had an abortion, women who had a first abortion had a higher risk of first-time antidepressant use. However, the fully adjusted IRRs that compared women who had an abortion with women who did not have an abortion were not statistically different in the year before the abortion (IRR, 1.46; 95% CI, 1.38-1.54) and the year after the abortion (IRR, 1.54; 95% CI, 1.45-1.62) (P = .10) and decreased as time from the abortion increased (1-5 years: IRR, 1.24; 95% CI, 1.19-1.29; >5 years: IRR, 1.12; 95% CI, 1.05-1.18). The fully adjusted IRRs that compared women who gave birth with women who did not give birth were lower in the year before childbirth (IRR, 0.47; 95% CI, 0.43-0.50) compared with the year after childbirth (IRR, 0.93; 95% CI, 0.88-0.98) (P < .001) and increased as time from the childbirth increased (1-5 years: IRR, 1.52; 95% CI, 1.47-1.56; >5 years: IRR, 1.99; 95% CI, 1.91-2.09). Across all women in the sample, the strongest risk factors associated with antidepressant use in the fully adjusted model were having a previous psychiatric contact (IRR, 3.70; 95% CI, 3.62-3.78), having previously obtained an antianxiety medication (IRR, 3.03; 95% CI, 2.99-3.10), and having previously obtained antipsychotic medication (IRR, 1.88; 95% CI, 1.81-1.96).Conclusions and Relevance: Women who have abortions are more likely to use antidepressants compared with women who do not have abortions. However, additional aforementioned findings from this study support the conclusion that increased use of antidepressants is not attributable to having had an abortion but to differences in risk factors for depression. Thus, policies based on the notion that abortion harms women's mental health may be misinformed. [ABSTRACT FROM AUTHOR]

Objective: We examined whether preabortion depressive symptoms were associated with contraceptive method effectiveness level chosen among women seeking abortions.Study Design: Three-hundred and forty-seven young, low-income women 18 years or older who were seeking abortions at 3 community reproductive health clinics in Northern California were recruited to participate in a study on contraceptive decision making. We classified women into choosing low-, moderate- or high-effectiveness contraceptive methods based on typical-use failure rates. We used the Center for Epidemiologic Studies Depression scale to assess depressive symptoms as a continuous and dichotomous variable. Using the standard cutoff of 20, women who scored at or above this were considered depressed for the dichotomous measure. We used multinomial logistic regression to examine the association between preabortion depressive symptoms and contraceptive effectiveness level chosen to use after an abortion, adjusting for sociodemographics, abortion characteristics, pregnancy history, future pregnancy desires, relationship characteristics and adverse experiences.Results: After adjusting for covariates, we found that a one-unit increase in depressive symptoms was associated with a higher likelihood of choosing low- versus moderate- [adjusted odd ratio (aOR)=1.05, 95% confidence interval (CI): 1.01-1.10, p<.02] and high-effectiveness methods (aOR=1.05, 95% CI: 1.002-1.10, p<.05). Furthermore, women scoring above the cutoff for depression were more likely to choose low- versus moderate-effectiveness methods (aOR=4.56, 95% CI: 1.27-16.32, p=.02).Conclusions: More preabortion depressive symptoms were independently associated with choosing low- versus moderate- and high-effectiveness contraceptives.Implications: These findings together with other findings show that preabortion depressive symptoms do not uniformly influence effectiveness level of contraceptive method selected to use after an abortion. Reproductive health care providers should consider the impact of women's psychological symptoms on their contraceptive decision making. [ABSTRACT FROM AUTHOR]

The author comments on a study about the relationship between abortion and mental health published in this issue of the journal. She points out the inadequacy of the study's design which questioned whether abortion reduces mental health risks in women. She argues that women having unwanted or unintended pregnancies who choose not to seek abortions are very different from those seeking abortions for mental health reasons.

Abstract: Similar to other reviews within the last 4 years, a thorough review by the Royal College of Psychiatrists, published in December 2011, found that compared to delivery of an unintended pregnancy, abortion does not increase women''s risk of mental health problems. In contrast, a meta-analysis published in September 2011 concluded that abortion increases women''s risk of mental health problems by 81% and that 10% of mental health problems are attributable to abortions. Like others, we strongly question the quality of this meta-analysis and its conclusions. Here we detail seven errors of this meta-analysis and three significant shortcomings of the included studies because policy, practice and the public have been misinformed. These errors and shortcomings render the meta-analysis'' conclusions invalid. [Copyright &y& Elsevier]

Abstract: Using the US National Comorbidity Survey (NCS), published an analysis indicating that compared to women who had never had an abortion, women who had reported an abortion were at an increased risk of several anxiety, mood, and substance use disorders. Here, we show that those results are not replicable. That is, using the same data, sample, and codes as indicated by those authors, it is not possible to replicate the simple bivariate statistics testing the relationship of ever having had an abortion to each mental health disorder when no factors were controlled for in analyses ( in ). Furthermore, among women with prior pregnancies in the NCS, we investigated whether having zero, one, or multiple abortions (abortion history) was associated with having a mood, anxiety, or substance use disorder at the time of the interview. In doing this, we tested two competing frameworks: the abortion-as-trauma versus the common-risk-factors approach. Our results support the latter framework. In the bivariate context when no other factors were included in models, abortion history was not related to having a mood disorder, but it was related to having an anxiety or substance use disorder. When prior mental health and violence experience were controlled in our models, no significant relation was found between abortion history and anxiety disorders. When these same risk factors and other background factors were controlled, women who had multiple abortions remained at an increased risk of having a substance use disorder compared to women who had no abortions, likely because we were unable to control for other risk factors associated with having an abortion and substance use. Policy, practice, and research should focus on assisting women at greatest risk of having unintended pregnancies and having poor mental health—those with violence in their lives and prior mental health problems. [Copyright &y& Elsevier]

Using data from the United States National Survey of Family Growth (NSFG) and the National Comorbidity Survey (NCS), we conducted secondary data analyses to examine the relationship of abortion, including multiple abortions, to anxiety after first pregnancy outcome in two studies. First, when analyzing the NSFG, we found that pre-pregnancy anxiety symptoms, rape history, age at first pregnancy outcome (abortion vs. delivery), race, marital status, income, education, subsequent abortions, and subsequent deliveries accounted for a significant association initially found between first pregnancy outcome and experiencing subsequent anxiety symptoms. We then tested the relationship of abortion to clinically diagnosed generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and social anxiety disorder, using NCS data. Contrary to findings from our analyses of the NSFG, in the NCS analyses we did not find a significant relationship between first pregnancy outcome and subsequent rates of GAD, social anxiety, or PTSD. However, multiple abortions were found to be associated with much higher rates of PTSD and social anxiety; this relationship was largely explained by pre-pregnancy mental health disorders and their association with higher rates of violence. Researchers and clinicians need to learn more about the relations of violence exposure, mental health, and pregnancy outcome to avoid attributing poor mental health solely to pregnancy outcomes. [Copyright &y& Elsevier]

A recent analysis from the Turnaway study focused on women who were just under the gestational limit of a clinic and received an abortion and those who had first trimester abortions to examine trends in decisional rightness and negative and positive emotions over 5 years after the abortion. Specifically, Rocca et al. (in press) analyzed these data and found that women were overwhemingly sure of their decision: 95% felt their decision was the right one at each assessment after their abortion, and the predicted probability of abortion being the right decision was 99% at 5 years afterwards. Relief was the most common emotion felt by women, and negative emotions or decision regret did not emerge over time. These results and others from studies conducted globally counter assertions by abortion opponents that women are not certain of their decisions, or that women regret or have mainly negative emotions about their abortions if not in the short run then after a long period of time. This commentary addresses not only these findings but also relevant U.S. abortion policies based on these unsubstantiated claims. Policies should not be based on the notions that women are unsure of their decision, come to regret, it or have negative emotions because there is no evidence to support these claims. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Does Abortion Reduce the Mental Health Risks of Unwanted or Unintended Pregnancy? A Re-appraisal of the Evidence," by D. M. Fergusson, L. J. Horwood, and J. M. Boden in an issue.

Abstract: Background: Some abortion policies in the U.S. are based on the notion that abortion harms women’s mental health. The American Psychological Association (APA) Task Force on Abortion and Mental Health concluded that first-trimester abortions do not harm women’s mental health. However, the APA task force does not make conclusions regarding later abortions (second trimester or beyond) and mental health. This paper critically evaluates studies on later abortion and mental health in order to inform both policy and practice. Method: Using guidelines outlined by , post 1989 quantitative studies on later abortion and mental health were evaluated on the following qualities: 1) composition of comparison groups, 2) how prior mental health was assessed, and 3) whether common risk factors were controlled for in analyses if a significant relationship between abortion and mental health was found. Studies were evaluated with respect to the claim that later abortions harm women’s mental health. Results: Eleven quantitative studies that compared the mental health of women having later abortions (for reasons of fetal anomaly) with other groups were evaluated. Findings differed depending on the comparison group. No studies considered the role of prepregnancy mental health, and one study considered whether factors common among women having later abortions and mental health problems drove the association between later abortion and mental health. Conclusion: Policies based on the notion that later abortions (because of fetal anomaly) harm women''s mental health are unwarranted. Because research suggests that most women who have later abortions do so for reasons other than fetal anomaly, future investigations should examine women’s psychological experiences around later abortions. [Copyright &y& Elsevier]

Abstract: Stigmatization is a deeply contextual, dynamic social process; stigma from abortion is the discrediting of individuals as a result of their association with abortion. Abortion stigma is under-researched and under-theorized, and the few existing studies focus only on women who have had abortions. We build on this work, drawing from the social science literature to describe three groups whom we posit are affected by abortion stigma: Women who have had abortions, individuals who work in facilities that provide abortion, and supporters of women who have had abortions, including partners, family, and friends, as well as abortion researchers and advocates. Although these groups are not homogeneous, some common experiences within the groups—and differences between the groups—help to illuminate how people manage abortion stigma and begin to reveal the roots of this stigma itself. We discuss five reasons why abortion is stigmatized, beginning with the rationale identified by Kumar, Hessini, and Mitchell: The violation of female ideals of sexuality and motherhood. We then suggest additional causes of abortion stigma, including attributing personhood to the fetus, legal restrictions, the idea that abortion is dirty or unhealthy, and the use of stigma as a tool for anti-abortion efforts. Although not exhaustive, these causes of abortion stigma illustrate how it is made manifest for affected groups. Understanding abortion stigma will inform strategies to reduce it, which has direct implications for improving access to care and better health for those whom stigma affects. [Copyright &y& Elsevier]