Suicide in Pregnancy is much rarer now ‘thanks to legal abortion’

Published: Thursday, March 21, 2013

Article by Dr Peadar O'Grady, Consultant Child and Adolescent Psychiatrist and member of Doctors for Choice

It is important in discussing the relevance of suicide in the current abortion debate that good medical practice does not come second place to legal arrangements for certification. Maternal mental health matters because of the effects on the mother of mental distress, self-harm and the catastrophe of a completed suicide, but also because of the devastating effects any and all of these can have on any children involved. It is often observed that during pregnancy the incidence of mental health problems and suicidal ideas is high but the risk of completed suicide is lower than usual for comparable women. Even so, because the total of maternal deaths in pregnancy is low, suicide is still one of the top 4 causes of maternal deaths in developed countries.

Groups at higher risk of suicide are those with an unwanted pregnancy, particularly teenage mothers and those on low incomes. In its 2009 report on Maternal Mental Health, the UN's World Health Organisation (WHO) has highlighted the increased risk of mental health problems in, 'unintended pregnancy especially among adolescent women'. The WHO emphasises the further risk from factors such as poverty and lack of support, 'in contexts in which there are strong, gendered role restrictions on women including lack of reproductive rights'. 'Reproductive rights' for women means the right to decide whether or not they want to have children and, if so, how many and when.  To be vindicated this right requires access to abortion services but also access to good quality obstetric, contraceptive and STD services as well as sex education and information. In his 2011 journal article 'Suicidal Mothers', Salvatore Gentile agreed that maternal suicide attempts during pregnancy were increased where there was: 'teen age, unplanned pregnancy, unmarried status or recent divorce, unemployment, and difficult access to safe abortion service(s).'

It has also been observed that suicide in pregnancy (and the year after delivery, known as the 'puerperium') has become much less common with access to legal abortion services. Professor Robert Kendell summarised this conclusion in the title of his 1991 review in the British Medical Journal: 'Suicide in pregnancy and the puerperium, much rarer now: thanks to contraception, legal abortion and less punitive attitudes'. It is therefore clear from the WHO and peer-reviewed research that restricting access to abortion, that is, denying women 'the right to choose', raises the risk of suicide in pregnancy.

Despite this the opposing notion that choosing an abortion increases the risk of mental health problems, and even suicide, persists. This false conclusion is a misreading (often deliberate and repeated) of the fact that there is often a higher incidence of mental health problems found in people who have had abortions than among those giving birth. However 'correlation is not causation'. When previous mental health and unwanted pregnancy are taken into account there is no higher rate after an abortion. This makes abortion a 'risk indicator' rather than a 'risk mediator'. As we have seen the likely mediators are unwanted pregnancy and previous mental health problems. It is also well known that, following abortion, mental health problems are more common where the woman has had a negative attitude to abortion before and a negative reaction after, especially when she has been under pressure to have an abortion. The 'right to choose' must be without pressure to choose a certain way. Good counselling and practical support before and after this decision is the key to supporting women with unwanted pregnancies.

A similar example of prejudice clouding judgement is the observation that LGBT individuals are at higher risk of mental health problems. One conclusion (by many of the same fundamentalist Christians who populate the anti-choice lobby) is that homosexual or transgendered people should be 'cured' from this presumed 'disease'. The modern psychiatric approach, based on evidence, has been to reject the notion of homosexuality or transgender as diseases by identifying the high incidence of bullying and discrimination as causative factors, or 'risk mediators', for mental health problems in this group. 

When the allegation, that abortion leads to mental health problems or suicide, is systematically investigated, it is found to be false. In the US the American Psychological Association in 2008 found there was no credible evidence that choosing to have an abortion raised the risk of mental health problems. In the UK the National Collaborating Centre for Mental Health's review in 2011 reached the same conclusion. Where there the choice of legal abortion services is available there is no increase in suicide (or mental health problems) caused by choosing an abortion with informed consent.

Anti-choice proponents have emphasised that 'Abortion is not a treatment for suicide' and ignored the fact that there is no such narrowly-defined thing as a 'treatment' for suicide. However, abortion, for those who choose it with proper supports, can be as much a 'treatment' for the risk of suicide as blood pressure tablets are a 'treatment' for the risk of a heart attack. Both can be preventive, lowering the impact of a relevant risk factor; that is, the distress of an unwanted pregnancy and high blood pressure respectively. The 'treatment' for unwanted pregnancy is 'non-directive counselling' and the 'treatment' for suicidal risk in unwanted pregnancy is 'risk-reduction', which includes facilitating the choice of accessing abortion services.

In Ireland, abortion, and even access to information on abortion, is heavily restricted with a criminal sanction, confirming the 'punitive attitude' Prof Kendell referred to over 20 years ago. Women are forced to travel, usually alone or with a very restricted support network because of the costs of travel. As a result, in this Irish context, the restriction of access to abortion services is mediated by restrictions on travel. The following groups, whose ability to travel is compromised, are therefore at an increased risk of restricted access to abortion and hence at an increased risk of suicide:

• Women too sick to travel
• Adolescents and young women 
• Women with young children
• Migrant women
• Women with Disabilities
• Women with no or low incomes
• Women whose pregnancy, involves a fatal foetal malformation
• Women pregnant as the result of rape or child sexual abuse.

The obvious solution to these risk factors is to end the unnecessary, dangerous, and, for the most part, ineffective legal restrictions on abortion services. This is the very successful approach taken in Canada for the last 25 years. Abortion there is subject to healthcare guidelines and not criminal law; just like every other medical service. It is an ongoing absurdity that pregnant women are in some way considered to be exceptions to the usual rules of capacity to make a decision.

It seems likely however that, instead of the Canadian model, emergency legislation in Ireland will deal only with the risk to just some of those whose ability to travel is restricted. The 'need' to distinguish between, and medically certify, a risk to the life, as opposed to the health, of pregnant women has put an emphasis on suicide that shows little concern for either crisis pregnancy or suicide.

In summary, in terms of mental health concerns, it is important to stress that unwanted pregnancy and previous trauma or mental health problems are the most relevant risk factors for mental health in pregnancy and that women on low incomes and child and adolescent mothers are at particular risk; the focus should be on care and support. Restriction of access to abortion increases suicide risk and supported choice reduces suicide risk. While there is no medical need for aspecial legal framework for abortion, doctors are perfectly capable of certifying the need to support a woman's choice of abortion services to reduce her risk of mental health problems and suicide.

Doctors for Choice is an organisation of doctors who wish to promote choice in reproductive healthcare. This means advocating for informed consent as the basis for decision making within the doctor-patient relationship. The NWCI and Doctors for Choice recently organised a Seminar on "Abortion - The Lives and Health of Women", see presentations from the seminar.