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Deaths associated with pregnancy outcome: A record linkage study of low income women

  • Elliot Institute

Abstract and Figures

A national study in Finland showed significantly higher death rates associated with abortion than with childbirth. Our objective was to examine this association using an American population over a longer period. California Medicaid records for 173,279 women who had an induced abortion or a delivery in 1989 were linked to death certificates for 1989 to 1997. Compared with women who delivered, those who aborted had a significantly higher age-adjusted risk of death from all causes (1.62), from suicide (2.54), and from accidents (1.82), as well as a higher relative risk of death from natural causes (1.44), including the acquired immunodeficiency syndrome (AIDS) (2.18), circulatory diseases (2.87), and cerebrovascular disease (5.46). Results are stratified by age and time. Higher death rates associated with abortion persist over time and across socioeconomic boundaries. This may be explained by self-destructive tendencies, depression, and other unhealthy behavior aggravated by the abortion experience.
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THE REDUCTION of maternal mortality rates is a
major goal of national health care initiatives. The
accuracy of maternal mortality figures has been
questioned, however, because of inadequate re-
porting mechanisms and confusion about when
a woman’s pregnancy actually contributes to the
cause of death. It is difficult, for example, to re-
liably determine whether pregnancy has con-
tributed to death resulting from tumor, stroke, or
To overcome the difficulties involved when us-
ing an a priori definition of “pregnancy-related”
deaths, researchers at Stakes, the National Re-
search and Development Centre for Welfare and
Health in Finland, undertook two important rec-
ord linkage studies.
They identified all death
certificates from 1987 to 1994 for all women
aged 15 to 49, linked them to Finland’s central-
ized Birth, Abortion, and Hospital Discharge
Registers, and examined death rates relative to
all pregnancy events among these women dur-
ing the year before their deaths.
The Stakes studies revealed remarkable vari-
ations in death rates relative to pregnancy out-
come. Women who had given birth had half
the death rate of women who had not been
pregnant in the year before death. By contrast,
women who had had an induced abortion
were 76% more likely to die than women who
had not been pregnant, 102% more likely to
die than women who miscarried, and 252%
more likely to die than women who had car-
ried to term. Compared with women who de-
livered, the age-adjusted odds ratio of dying
during the year after an induced abortion was
1.6 for death from nonviolent causes, 4.2 for
death from injuries related to accidents, 6.5
for suicide, and 14.0 for homicide.
If the findings reported by Stakes identify a
true association between mortality rates and pre-
vious pregnancy outcomes, one would expect
them to be replicable elsewhere. In addition,
Deaths Associated With Pregnancy Outcome:
A Record Linkage Study of Low Income Women*
Background. A national study in Finland showed significantly higher death rates associated
with abortion than with childbirth. Our objective was to examine this association using an
American population over a longer period.
Methods. California Medicaid records for 173,279 women who had an induced abortion or a
delivery in 1989 were linked to death certificates for 1989 to 1997.
Results. Compared with women who delivered, those who aborted had a significantly higher
age-adjusted risk of death from all causes (1.62), from suicide (2.54), and from accidents
(1.82), as well as a higher relative risk of death from natural causes (1.44), including the
acquired immunodeficiency syndrome (AIDS) (2.18), circulatory diseases (2.87), and
cerebrovascular disease (5.46). Results are stratified by age and time.
Conclusions. Higher death rates associated with abortion persist over time and across
socioeconomic boundaries. This may be explained by self-destructive tendencies, depression,
and other unhealthy behavior aggravated by the abortion experience.
From Elliot Institute, Springfield, Ill.
*Presented at the First World Congress on Women’s Health,
Berlin, Germany, March, 2001.
Reprint requests to David C. Reardon, PhD, Elliot Institute, PO
Box 7348, Springfield, IL 62791-7348.
Low-income women in California have differential rates of
death associated with childbirth and abortion that are similar
to the pattern observed in Finland.
Compared with women who give birth, those who had abor-
tions were more likely to subsequently die of suicide, acci-
dents, homicide, mental disease, and cerebrovascular dis-
Previous psychiatric history does not appear to explain the
higher relative death rates.
The differential in subsequent death rates persists over a
period of at least 8 years.
Previous pregnancy outcomes may interact with the most
recent pregnancy outcome to increase or decrease the rela-
tive risk of death.
834 August 2002 • SOUTHERN MEDICAL JOURNAL Vol. 95, No. 8
the Stakes findings raise the question of how
long the effects of previous pregnancy out-
comes on mortality rates may persist. The goals
of our study were to investigate whether the
Stakes findings would be observed in a homoge-
neous socioeconomic population and to exam-
ine any associations between pregnancy history
and subsequent mortality over a longer period.
The California Department of Health Services
(DHS) identified 249,625 women who had
received funding for either abortion or delivery
in calendar year 1989 under the state-funded
medical insurance program known as Medi-Cal.
Of this population, 194,694 were citizens whose
beneficiary identification codes could be record
linked to valid social security numbers, a provi-
sion that eliminated illegal immigrants whose
medical needs are irregularly covered by Medi-
Cal. All “short paid claim” records for these
women were obtained for 6 fiscal years begin-
ning in July 1988 and extending through June
1994 with encrypted social security numbers pro-
vided for data linkage. In addition, the social
security numbers (SSNs) linked to these patient
IDs were also linked by DHS to California death
certificates between 1989 and 1998, resulting in
the identification of 1,713 deaths. A file contain-
ing cause of death, date of death, and the appro-
priate encrypted social security number for link-
ing the two data sets was provided to our research
team. An important limitation in our study is that
we were not provided with any information re-
garding race, marital status, and parity. This
information was either not readily available in
government records or was omitted to protect
the privacy and anonymity of individual patients.
Since data were collected from government
records representing medical claims reported
by thousands of health care providers, data
integrity was carefully examined. The record
linkage to the death certificate file was carried
out by the state of California using the en-
crypted social security numbers. The linkage of
multiple events for the same individual was
done by us, using the encrypted SSN provided.
Linkage errors by SSN are not uncommon.
Therefore, we checked both our own linkages
and those done by DHS to assure that a high
quality match had been carried out. The con-
firmatory variables available on both the Medi-
Cal and death certificate files used in this
checking included the woman’s date of birth,
date of pregnancy event, and the cost of med-
ical treatment.
TABLE 1. Overall Cause-Specific Risk of Death in 8 Subsequent Years for Women Whose First Pregnancy Event Was an Abortion or a Delivery (and No Subsequent Abortions)
Controlling for at Least
All Cases 1 Year Previous Psychiatric History
Number of Deaths Number of Deaths
(Rate per 100,000) (Rate per 100,000)
First First Age-Adjusted Delivery of First Abortion Age-Adjusted
Cause Pregnancy Pregnancy Relative Pregnancy and of First Relative
of Delivery Abortion Risk No Abortions Pregnancy Risk
Death (n = 83,690) (n = 50,260) (95% CI) (n = 41,956) (n = 17,472) (95% CI)
All deaths 490 (585.5) 366 (728.2) 1.30 (1.13 to 1.49)* 213 (507.7) 141 (807.0) 1.61 (1.30 to 1.99)*
Violent causes 207 (247.3) 179 (356.1) 1.43 (1.17 to 1.74)† 82 (195.4) 63 (360.6) 1.78 (1.28 to 2.47)†
Nonviolent causes 281 (335.8) 183 (364.1) 1.17 (0.97 to 1.12) 130 (309.8) 76 (435.0) 1.44 (1.08 to 1.91)**
*P < .0002.
P < .001.
**P < .013.
836 August 2002 • SOUTHERN MEDICAL JOURNAL Vol. 95, No. 8
Screening for aberrant, indeterminate, and
out-of-scope data resulted in the elimination of
21,415 cases (419 deaths) for the following rea-
sons: (1) unlinkable social security numbers,
(2) the age recorded for an individual woman
in the medical records and/or the death certifi-
cates could not be reasonably verified by refer-
ence to multiple records, (3) the abortion was
identified as illegal or unknown (ICD-9 codes
636 and 637), (4) reported age below 13 or
above 49 at the time of their first pregnancy
event, (5) first delivery or induced abortion oc-
curred after 1990, (6) the cost associated with
the target pregnancy event was below $100
(suggesting that only counseling for a possible
procedure was received), or (7) the first re-
corded pregnancy event was a miscarriage.
Our primary analysis included all women in
the sample who met the stated conditions.
Since it has been postulated, however, that
previous psychiatric problems may be a com-
mon risk factor for both abortion and shorter
longevity, we also examined the subset of
women who had their first known delivery
after July 1, 1989. This allowed us to control
for at least 1 year before psychiatric history.
All data handling steps were blind to the
pregnancy outcome. Age-adjusted relative risks
and 95% confidence intervals were calculated
by means of a logistic regression using age as a
covariate. In the secondary analysis, the number
of psychiatric claims within a year of the target
pregnancy event was also used as a covariate. In
addition, sensitivity analyses based on alternative
matching rules revealed that stricter matching
rules, eg, allowing no date of birth discrepancies
over 6 years of medical claims, would still have
produced similar results. Often, stricter rules
would have resulted in even higher odds ratios
and greater statistical significance, despite the
loss of cases. The software used for all statistical
calculations was SPSS 10.0.
Overall Analysis
The first analysis compared death rates be-
tween women whose first pregnancy event was
an abortion (average age: mean = 24.83, SD =
5.8) and women with no known history of abor-
tion who had a delivery for their first pregnancy
event (average age: mean = 25.63, SD = 5.8). As
seen in Table 1, deaths from all causes in the 8
years after the first known pregnancy outcome
were significantly higher among women with a
known history of abortion.
Disaggregated Analysis
In our second analysis, we explored the
interaction of multiple and varied pregnancy
outcomes on differential cause-specific mortal-
ity. To do this, we used all of the reproductive
history information available for the 6 years
included in our data. This time all women (n
= 8,703 including 48 deaths) with a history of
both abortion and miscarriage (and possibly
childbirth as well) were excluded to avoid con-
fusing the effects of voluntary and involuntary
pregnancy loss.
The remaining women were categorized
into five groups by experience with each preg-
nancy outcome (Table 2). Women who had
only abortion outcomes were more likely to
die overall than women in each of the other
four groups. Only in comparison to women
who had a miscarriage after a birth was this
finding not statistically significant (P < .05).
Stratification by cause of death revealed that
the abortion only group had the highest death
rate of all five groups for both natural and vio-
lent causes. The greatest number of significant
differences occurred between the abortion
only and delivery only groups.
Women in the three groups having both
delivery and pregnancy loss (abortion or mis-
carriage) had lower deaths rates than the
abortion only group for nearly every cause of
death. Lower deaths rates for these three
groups, however, would be expected since
women in these groups must necessarily have
lived long enough to have two or more preg-
Single Known Pregnancy Events
For our third analysis, we limited our com-
parison to the two most disparate groups—
births only and abortions only. To further con-
trol for the confounding factor of multiple
pregnancy outcomes, this analysis included
women with only one known pregnancy event.
The mean age was 26.39 (SD = 5.9) for women
who delivered and 25.96 (SD = 6.3) for
women who aborted.
During the 8-year period after the first preg-
nancy event, women who aborted were 62%
more likely to die (all causes) than women
who carried to term (Table 3). They were also
significantly more likely to die of nonviolent
causes, suicide, and accidents.
The greatest number of deaths were due to
nonviolent causes; therefore, these were disag-
gregated. Examination of major categories of
death from nonviolent causes revealed that
the most significant differences were in rela-
tion to deaths from AIDS and from circulatory
diseases (ICD-9 codes 390-459). Additional
analysis of those who died of circulatory dis-
eases revealed that aborting women had signif-
icantly higher rates of death from cerebrovas-
cular disease (ICD-9 codes 430-438) and other
heart diseases (ICD-9 codes 415-423, 425-429).
As shown in Table 4, stratification by 2-year
increments revealed significant differences in
the death rates during the first 2 years for over-
all deaths, deaths due to nonviolent causes, and
deaths due to violent causes. Other significant
differences were found in all but the fifth and
sixth years.
Stratification by age is shown in Table 5.
Differences were significant for four of the six
age groups. As would be expected, the risk of
death from nonviolent causes increased with
age, while the risk of death from violent causes
generally declined.
Previous Psychiatric Claims
Our fourth analysis was that of women who
had their first pregnancy event between July 1
and December 31, 1989. By limiting the analysis
to these 6 months, we were able to examine any
inpatient and outpatient psychiatric claims
women had 1 year before the target pregnancy
events. The resulting sample consisted of
17,472 women (mean age = 24.91, SD = 6.0)
whose first pregnancy event was abortion and
41,956 women (mean age = 25.48, SD = 5.8)
who had delivery as their first pregnancy event
and no history of abortion. Among these
women, number of previous psychiatric claims
was significantly correlated with overall deaths
(r [59,428] = .020, P < .0001), deaths by violent
causes (r [59,428] = .009, P < .023), and deaths
by nonviolent causes (r [59,428] = .018, P <
Logistic regression analyses were done using
number of psychiatric claims within 1 year
before the target pregnancy event and age as
covariates. The results of these analyses are
given in Tables 3, 4, and 5. In several circum-
stances, most notably deaths related to mental
illness, the relative risk of death for aborting
women compared with that of delivering
women increased after removing the effects of
previous psychiatric history.
The death rate from all causes was signifi-
cantly higher for women with a history of
TABLE 2. Detailed Cause-Specific Deaths and Death Rates in 8 Subsequent Years for Women With a History of at Least One Abortion Compared With Women Having No Known History of
Abortion, by Reproductive History
Number of Deaths
(Rate per 100,000)
(1) (2) (3) (4) (5)
Cause Delivery Abortion Abortion Followed Delivery Followed Delivery Followed *Significantly
of Death Only Only by Delivery by Abortion by Miscarriage Different Pairs
All deaths 464 (549.6) 272 (853.9) 85 (462.4) 132 (514.2) 26 (612.3) 1 & 2, 2 & 3, 2 & 4
Nonviolent causes 266 (315.1) 137 (430.1) 39 (212.2) 53 (206.4) 15 (353.3) 1 & 2, 2 & 3, 2 & 4
Violent causes 196 (232.2) 132 (414.4) 45 (244.8) 79 (307.7) 11 (259.1) 1 & 2, 2 & 3
Suicides 21 (24.9) 20 (62.8) 3 (16.3) 7 (27.3) 2 (47.1) 1 & 2
Accidents 109 (129.1) 65 (204.1) 24 (130.6) 38 (148.0) 6 (141.3) 1 & 2
Homicides 66 (78.2) 47 (147.5) 18 (97.9) 34 (132.4) 3 (70.7) 1 & 2
AIDS 22 (26.1) 21 (65.9) 4 (21.8) 11 (42.8) 4 (94.2) 1 & 2
Circulatory disease 39 (46.2) 34 (106.7) 7 (38.1) 12 (46.7) 2 (47.1) 1 & 2, 2 & 3, 2 & 4
Number of cases by group: (1) 84,420, (2) 31,854, (3) 18,383, (4) 25,673, (5) 4,246.
Mean age by group, in years: (1) 25.66, (2) 25.58, (3) 23.48, (4) 23.15, (5) 25.12.
Standard deviation of age, by group: (1) 5.8, (2) 6.0, (3) 5.1, (4) 5.0, (5) 6.0.
*Pairwise significance determined at P < .05 or less.
838 August 2002 • SOUTHERN MEDICAL JOURNAL Vol. 95, No. 8
abortion than for delivering women with no
known history of abortion (Table 1). Com-
parisons across the five possible combina-
tions of pregnancy experiences analyzed
here (Table 2) suggest that childbirth with-
out any pregnancy losses (abortion or mis-
carriage) may have a protective effect, while
abortion without any childbirth experiences
may have a deleterious effect. These effects,
over the course of a combination of preg-
nancy outcomes, may also interact.
The most pronounced differences in rela-
tive risk of death by various causes were
found between women with a history of only
one known pregnancy comparing women
who aborted and women who carried to
term (Tables 3, 4, and 5). The key finding is
that the elevated death rates associated with
women who had abortions were observed
throughout the 8 years examined. This indi-
cates that the association between abortion
and higher subsequent mortality rates previ-
ously observed in Finland is a persistent one.
Higher deaths rates after abortion may be
explained by a number of factors. Women
who have children may be more likely to
avoid risk-taking and to take better care of
their health. Alternatively, a history of abor-
tion may be a marker for other stress factors
that decrease longevity; or the higher death
rate among aborting women may stem from
increased psychologic stresses related to
unresolved guilt, grief, or depression. This
hypothesis is supported by another analysis
of this same population in which it was
found that even after controlling for previ-
ous psychiatric treatment, women who had
abortions, across all age groups, had signifi-
cantly higher rates of subsequent psychiatric
The highest relative risks (>2.5)
were related to adjustment reactions, bipo-
lar disorder, and depressive psychoses.
The findings of this study are consistent
with a substantial body of literature demon-
strating an association between abortion
and suicide.
A record-based measurement
of suicide attempts before and after abor-
tion has shown that the increase in suicide
rates among aborting women is not related
to previous suicidal behavior but is most
likely related to adverse reactions to the pro-
Pregnancy and childbirth, on the
other hand, reduce the risk of suicide.
The greater risk of fatal accidents and
homicides may result from unrecognized
suicides or increased risk-taking behavior.
TABLE 3. Risk of Death by Specific Causes in 8 Subsequent Years for Women With Only One Known Pregnancy (Those With an Abortion vs Those With a Delivery)
All Cases Controlling for 1-Year Previous Psychiatric History
Number of Deaths Number of Deaths
(Rate per 100,000) (Rate per 100,000)
Cause One One Age-Adjusted Delivery of First Abortion Age and Psychiatric History-
of Delivery Abortion Relative Risk Pregnancy and of First Adjusted Relative Risk
Death Only Only (95% CI) No Abortions Pregnancy (95% CI)
All causes 335 (614.7) 173 (974.6) 1.62 (1.34 to 1.94)* 213 (507.7) 141 (807.0) 1.61 (1.30 to 1.99)†
Violent causes 127 (233.0) 76 (428.2) 1.81 (1.36 to 2.41)* 82 (195.4) 63 (360.6) 1.78 (1.28 to 2.47)†
Suicide 13 (23.9) 11 (62.0) 2.54 (1.14 to 5.67)* 8 (19.1) 11 (63.0) 3.12 (1.25 to 7.78)*
Homicide 50 (91.7) 27 (152.1) 1.59 (1.00 to 2.55) 28 (66.7) 24 (137.4) 1.93 (1.11 to 3.33)*
Accident or undetermined 64 (117.4) 38 (214.1) 1.82 (1.22 to 2.73)† 46 (109.6) 28 (160.3) 1.44 (0.90 to 2.30)
Nonviolent causes 206 (378.0) 95 (535.2) 1.44 (1.13 to 1.84)† 130 (309.8) 76 (435.0) 1.44 (1.08 to 1.91)*
AIDS 20 (36.7) 14 (78.9) 2.18 (1.10 to 4.31)* 10 (23.8) 12 (68.7) 2.96 (1.28 to 6.87)*
Mental disease 11 (21.6) 7 (43.9) 2.05 (0.79 to 5.28) 6 (14.3) 8 (45.8) 3.21 (1.11 to 9.27)*
Circulatory disease 28 (51.4) 26 (146.5) 2.87 (1.68 to 4.89)† 18 (42.9) 15 (85.9) 2.00 (1.00 to 3.99)*
Cerebrovascular disease 4 (7.3) 7 (39.4) 5.46 (1.60 to 18.65)‡ 3 (7.2) 5 (28.6) 4.42 (1.06 to 18.48)*
Other heart diseases 12 (22.0) 10 (56.3) 2.59 (1.12 to 5.99)* 8 (19.1) 7 (40.1) 2.10 (0.76 to 5.82)
*P < .0001.
P < .005.
**P < .05.
P < .01.
Deaths from accidents may also be related to
higher rates of alcohol consumption
drug abuse
among aborting women. The
higher risk of death from homicide may re-
flect increased levels of anger, self-destructive
behavior, or domestic violence after abor-
The heightened risk of death from nonvio-
lent causes may reflect a decline in general
health after abortion, as reported elsewhere.
Other unhealthy behaviors linked to abortion
are increased alcohol consumption, drug
abuse, and smoking.
In regard to the unexpected finding of in-
creased deaths related to cardiovascular disease,
a substantial body of research has shown that
psychologic problems, especially depression,
increase cardiovascular morbidity and mortal-
Compared with delivering women, women
who abort have significantly higher rates of
depression an average of 10 years after their first
pregnancy event, even after controlling for previ-
ous psychologic state.
It is possible that persis-
tent emotional reactions to abortion may aggra-
vate or cause cardiovascular illnesses. Additional
investigation of this association is warranted.
Unfortunately, as in the case of the Finland
study of pregnancy-associated deaths, this data
set did not include any information on race,
marital status, or parity, all of which may be sig-
nificant variables. This limitation is partially off-
set by the fact that these data represent a homo-
geneous socioeconomic population. The fact
that it includes only low income women, who
would generally face similar stressful life events,
would tend to help control for socioeconomic
factors. By comparison, the Finland studies,
which included a heterogeneous national pop-
ulation without controls for socioeconomic fac-
tors, also revealed a trend toward substantially
higher death rates after abortion. The fact that
these large prospective record-based studies,
using different types of populations (heteroge-
neous population of Finns and a racially diverse
population of low income Americans), found
such similar results indicates that the trend in
higher death rates among aborting women is
likely to hold across racial, economic, and
national boundaries.
In addition, comparison of these results with
national data suggests that these findings are
likely to hold true across race, martial status, and
parity. The 1997 suicide rate per 100,000
American women aged 15 to 24 for all races was
3.5—3.7 for whites and 2.4 for blacks. For ages 25
to 44, the suicide rate was 6.0 for all races—6.6
TABLE 4. Risk of Specific Causes of Death in 8 Subsequent Years (in 2-Year Increments) for Women With Only One Known Pregnancy (Those With an Abortion vs Those With a Delivery
All Cases Controlling for 1-Year Previous Psychiatric History
Number of Deaths Number of Deaths
(Rate per 100,000) (Rate per 100,000)
Cause Time One One Age-Adjusted Delivery of First Abortion Age and Psychiatry History-
of Interval Delivery Abortion Relative Risk Pregnancy and of First Adjusted Relative Risk
Death (years) Only Only (95% CI) No Abortions Pregnancy (95% CI)
Overall deaths 1-2 97 (178.0) 61 (343.7) 1.95 (1.42 to 2.69) * 47 (112.0) 40 (228.9) 2.03 (1.33 to 3.10)†
3-4 84 (154.1) 42 (236.6) 1.56 (1.07 to 2.25) * 40 (95.3) 33 (188.9) 1.98 (1.25 to 3.15)†
5-6 76 (139.5) 29 (163.4) 1.19 (0.78 to 1.83) 63 (150.2) 35 (200.3) 1.35 (0.89 to 2.05)
7-8 78 (143.1) 41 (231.0) 1.64 (1.12 to 2.39)‡ 63 (150.2) 33 (188.9) 1.29 (0.84 to 1.96)
Violent causes 1-2 52 (95.4) 37 (208.5) 2.12 (1.39 to 3.23)† 19 (45.3) 23 (131.6) 2.62 (1.42 to 4.82)†
3-4 32 (58.7) 23 (129.6) 2.18 (1.28 to 3.73)† 14 (33.4) 18 (103.0) 3.00 (1.49 to 6.04)†
5-6 28 (51.4) 7 (39.4) 0.77 (0.34 to 1.76) 27 (64.4) 13 (74.4) 1.15 (0.59 to 2.24)
7-8 15 (27.5) 9 (50.7) 1.85 (0.81 to 4.23) 22 (52.4) 9 (51.5) 0.98 (0.45 to 2.13)
Nonviolent causes 1-2 45 (82.6) 24 (135.2) 1.66 (1.01 to 2.72)* 28 (66.7) 17 (97.3) 1.49 (0.81 to 2.73)
3-4 51 (93.6) 18 (101.4) 1.10 (0.64 to 1.88) 26 (62.0) 15 (85.9) 1.40 (0.74 to 2.66)
5-6 47 (86.2) 22 (123.9) 1.46 (0.88 to 2.42) 35 (83.4) 22 (125.9) 1.54 (0.90 to 2.63)
7-8 63 (115.6) 31 (174.6) 1.53 (0.99 to 2.35) 41 (97.7) 22 (125.9) 1.33 (0.79 to 2.23)
*P < .0001.
P < .005.
**P < .05.
P < .01.
840 August 2002 • SOUTHERN MEDICAL JOURNAL Vol. 95, No. 8
for whites and less than 3.7 for blacks.
In our sample (Table 3), the average
annual suicide rate for women with a
history of delivery was only 3.0, while it
was 7.8 for women with a history of
abortion. Our findings bracket the
national averages, regardless of race,
suggesting a strong protective effect
related to childbirth and a strong detri-
mental effect related to abortion.
Our finding that pregnancy events
may affect mortality over several years,
and may counterbalance each other
when childbirth and pregnancy loss
are both experienced, underscores
another limitation of both this study
and the Stakes studies: incomplete
obstetric histories. It appears most
likely that more complete data could
have revealed an even greater disparity
between “abortion only” and “delivery
only.” This is likely since unknown
childbirth events would have a protec-
tive effect on women otherwise identi-
fied as being in the “abortion only”
group (Table 2). Conversely, however,
unknown abortion events would tend
to inflate the association between
death and the delivery only group.
It may be that the diluting effect of
unknown previous pregnancies is
seen in the age stratification results
shown in Table 5. The level of signifi-
cance generally appears to drop with
increasing age. Indeed, in the oldest
age group, 40 to 49, not only is all sta-
tistical significance lost, but also the
relative rate of death suddenly
appears to shift in favor of those who
had an abortion. However, it is cer-
tainly true that the oldest age groups
of women will proportionally have far
more pregnancy events that are
unknown to us than the younger
women for whom the 6-year data set
captures a major portion of their
reproductive years. Our classification
of women as “abortion only” or “deliv-
ery only” would therefore be increas-
ingly inaccurate with increasing age.
The use of data sets that include com-
plete reproductive histories would
eliminate this problem.
Finally, at the request of the
California DPH, this population was
limited to only those women who had
TABLE 5. Risk of Specific Causes of Death in 8 Subsequent Years for Women With Only One Known Pregnancy (Those With an Abortion vs Those With a Delivery)
Based on Age at Time of First Pregnancy Event
All Cases Controlling for 1-Year Previous Psychiatric History
Number of Deaths Number of Deaths
(Rate per 100,000) (Rate per 100,000)
Cause Age at One One Age-Adjusted Delivery of First Abortion Age and Psychiatry History-
of First Known Delivery Abortion Relative Risk Pregnancy and of First Adjusted Relative Risk
Death Pregnancy Only Only (95% CI) No Abortions Pregnancy (95% CI)
Overall deaths 13-19 37 (636.9) 22 (866.5) 1.38 (0.81 to 2.35) 32 (494.3) 24 (703.0) 1.45 (0.85 to 2.48)
20-24 60 (346.1) 40 (692.9) 1.99 (1.33 to 2.98)* 53 (379.0) 35 (605.4) 1.60 (1.04 to 2.45)†
25-29 94 (590.2) 40 (844.8) 1.44 (1.00 to 2.09) 48 (419.3) 31 (688.9) 1.63 (1.03 to 2.56)†
30-34 80 (816.2) 38 (1389.4) 1.71 (1.16 to 2.52)* 44 (663.1) 28 (1155.6) 1.73 (1.07 to 2.79)†
35-39 46 (1050.5) 29 (2032.2) 1.93 (1.21 to 3.09)* 26 (944.1) 19 (1814.7) 1.77 (0.97 to 3.26)
40-49 18 (1444.6) 4 (739.4) 0.49 (0.17 to 1.45) 10 (1515.2) 4 (1302.9) 0.75 (0.23 to 2.47)
Violent causes 13-19 26 (447.6) 15 (590.8) 1.35 (0.71 to 2.55) 22 (339.8) 15 (439.4) 1.31 (0.68 to 2.55)
20-24 31 (178.8) 29 (502.3) 2.79 (1.68 to 4.64)** 29 (207.4) 26 (449.7) 2.17 (1.28 to 3.69)**
25-29 39 (244.9) 12 (253.4) 1.04 (0.54 to 1.98) 17 (148.5) 11 (244.4) 1.67 (0.78 to 3.57)
30-34 23 (234.6) 14 (511.9) 2.19 (1.13 to 4.26)† 9 (135.6) 7 (288.9) 2.15 (0.80 to 5.80)
35-39 7 (159.9) 6 (420.5) 2.61 (0.88 to 7.79) 4 (145.2) 3 (286.5) 1.39 (0.27 to 7.07)
40-49 1 (80.3) 0 (00.0) 1 (151.5) 1 (325.7) 1.82 (0.11 to 31.04)
Nonviolent causes 13-19 11 (189.4) 7 (275.7) 1.46 (0.56 to 3.80) 10 (154.5) 8 (234.3) 1.56 (0.61 to 3.99)
20-24 29 (167.3) 11 (190.5) 1.13 (0.57 to 2.27) 24 (171.6) 9 (155.7) 0.90 (0.42 to 1.95)
25-29 54 (339.0) 27 (570.2) 1.70 (1.07 to 2.70)† 30 (262.1) 20 (444.4) 1.66 (0.94 to 2.93)
30-34 56 (571.3) 24 (877.5) 1.54 (0.95 to 2.48) 35 (527.5) 21 (866.7) 1.62 (0.94 to 2.80)
35-39 39 (890.6) 22 (1541.7) 1.72 (1.02 to 2.92)† 22 (798.8) 15 (1,432.7) 1.74 (0.89 to 3.38)
40-49 17 (1364.4) 4 (739.4) 0.52 (0.17 to 1.55) 9 (1,363.6) 3 (977.2) 0.66 (0.18 to 2.48)
*P < .01.
P < .05.
**P < .0001.
P < .005.
a Medi-Cal funded abortion or hospital deliv-
ery in 1989. This made it impossible for us to
compare these women to a group of Medi-Cal
eligible women without any pregnancy history
or to a group of women who had miscarriages
in 1989. In future research, comparisons with
both nulliparous women and women who mis-
carry would be valuable.
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... Comparisons have been made to each of the following: the general population of women, 77,195 women who have never been pregnant, 94 women with no reported history of abortion, 74,84,85,91,92,94,95,100,101 women giving birth, 30,69,71-73, 75-77,81,83,86-90,94,97-99,102 women giving birth to a first pregnancy, 69,86,113 women having miscarriages or other involuntary losses, 81,88,91,94,[195][196][197] women experiencing both births and pregnancy loss (abortions or miscarriages), 69,82,107 women giving birth to unintended pregnancies, 69,72,75,76,86,90,92,98 and women denied abortions. 179,198 Together, these findings show that women with a history of abortion are statistically more likely to experience significantly more mental health issues relative to every comparison group that has been examined. ...
... Acting on that premise, many researchers have chosen to simultaneously compare women who abort to multiple other groups whenever the data allow it. 72,88,92,94 By contrast, Charles et al., 6 have argued that the only "appropriate" comparison group for AMH studies is to women who have "unwanted deliveries." But this argument is weak for three major reasons. ...
... This is important since significantly different outcome patterns have been observed relative to multiple pregnancy outcomes and their sequences, including both multiple losses and losses followed or preceded by live births. 88,94 While comparisons of first pregnancy outcomes are valuable, it should be noted that it is a very poor methodological choice to include in the group of women experiencing a "first live birth" women who are known to have had one or more abortions before their first live birth or between the birth and the date of the mental health assessment. 69,107 Unfortunately, these flawed studies 69,82,107,[208][209][210] ignore the extensive evidence showing that a history of pregnancy loss (abortion or miscarriage) is associated with higher rates of mental health problems during subsequent pregnancies. ...
Full-text available
The abortion and mental health controversy is driven by two different perspectives regarding how best to interpret accepted facts. When interpreting the data, abortion and mental health proponents are inclined to emphasize risks associated with abortion, whereas abortion and mental health minimalists emphasize pre-existing risk factors as the primary explanation for the correlations with more negative outcomes. Still, both sides agree that (a) abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; (b) the abortion experience directly contributes to mental health problems for at least some women; (c) there are risk factors, such as pre-existing mental illness, that identify women at greatest risk of mental health problems after an abortion; and (d) it is impossible to conduct research in this field in a manner that can definitively identify the extent to which any mental illnesses following abortion can be reliably attributed to abortion in and of itself. The areas of disagreement, which are more nuanced, are addressed at length. Obstacles in the way of research and further consensus include (a) multiple pathways for abortion and mental health risks, (b) concurrent positive and negative reactions, (c) indeterminate time frames and degrees of reactions, (d) poorly defined terms, (e) multiple factors of causation, and (f) inherent preconceptions based on ideology and disproportionate exposure to different types of women. Recommendations for collaboration include (a) mixed research teams, (b) co-design of national longitudinal prospective studies accessible to any researcher, (c) better adherence to data sharing and re-analysis standards, and (d) attention to a broader list of research questions.
... Cougle and Reardon's United States National Longitudinal Study of Youth (NLSY) study found that eight years after pregnancy, married women who had an abortion were 65 percent more likely to score in the high-risk range for clinical depression than those who gave birth (Reardon, 2002) [15]. Reardon also studied psychiatric admissions up to four years after abortion and childbirth (Reardon et al., 2003). ...
... It found the abortion group had significantly more admissions for depression (both single episode and recurrent), for bipolar and for adjustment disorders. Another study also looked at the NLSY data and claimed the evidence that having an abortion led to a higher risk of depression than giving birth (Schmiege& Russo, 2005) [16]. ...
Full-text available
This review intends to provide brief data about the psychological consequences of induced unsafe abortion. The data were collected from different articles, journals, guidelines and related published materials. Emerging data report 30% of women worldwide who practiced abortion experience negative and persistent psychological distress afterward. It is estimated that there are 3.27 million pregnancies in Ethiopia every year, of which approximately 500,000 ends in either spontaneous or unsafely induced abortion. Reasons for seeking abortion are socioeconomic concerns (including poverty, no support from the partner, and disruption of education or employment); family-building preferences (including the need to postpone childbearing or achieve a healthy spacing between births); relationship problems with the husband or partner; risks to maternal or fetal health; and pregnancy resulting from rape or incest; poor access to contraceptives and contraceptive failure. Smoking, drug abuse, eating disorder, depression, anxiety disorders, attempted suicide, guilt, regret, nightmare, decreased self-esteem, and worry about not being able to conceive again were the psychological consequences of abortion.
... Eighteen studies conducted in the USA related to causality loop PPM and 17 to causality loop TRC. Those too, varied in designs: twelve systematic reviews (Adams & Nelson, 2008;Asaria et al., 2007;DeZern & Guinan, 2014;Hague, 2009;Hecht, 2002;Schane et al., 2010;Shaw et al., 2016;Shields, 2002;Smith et al., 2009;Torre, 2015;van Doorslaer et al., 2000;Zamzaireen et al., 2018), four randomized clinical trials (Amemori et al., 2011;Ickovics et al., 2007;Kolu et al., 2012;McMahon et al., 2011), one histopathology screening (Lima et al., 2016); fifteen retrospective population-based case control or linkage studies (Anderson et al., 2004;Bernstein et al., 2000;Dasenbrock et al., 2018;Deneux-Tharaux et al., 2005;Selvan et al., 2019;Kawakita et al., 2016;Kozhimannil et al., 2013;Lisonkova et al., 2017;Marshall et al., 2001;Reardon et al., 2002;Russell et al., 2007;Patel et al., 2004;Pesch et al., 2012;Underwood et al., 2007;Vintzileos et al., 2000), and three cross-section surveys (Long et al., 2011;Miller et al., 1999;Weinstein et al., 2004)-covering patient populations of 3,996,495 (PPM loop) and 307,554 (TRC loop). Table 1 shows the map of study-distribution per country and per causality loops. ...
Full-text available
A bid is made to measure health as a value. Continuous and conceptual variables pertaining to healthcare distribution, expenses and outcomes are obtained from 70 studies presenting 4,245,866 patient-population from Finland and 4,304,049 from the USA—clustered for three periods: biennium, lustrum, decade. Two causality loops are sampled per country of interest: prematurity–perinatal mortality (PPM), tobacco consumption–respiratory cancer (TRC). Both in Finland and the USA, attribute risk for hypothyroidism, autoimmune disorders, and cardiomyopathy outstage other predictors of perinatal mortality. Diabetes mellitus, diabetes insipidus, obesity, and urinary tract infections are increasingly dominating PPM risks in the USA. Perinatal and maternal mortality ratios are consistently lower in Finland (RR 1.8–4.35). The mean duration of NICU-stay among the surviving and non-surviving low-weight infants is higher in Finland (RR 1.3–3.0). Regardless the term, cost of one NICU-day is 36–53-fold higher in the USA. The state-sponsored prenatal care is 2.58 times more consumed in Finland where the cost of basic prenatal care (excluding childbirth expenses) is 1.6 times lower. Low income is a substantial contributor to tobacco smoking (OR 5.0–15.6)—with a stronger connection (RR 3.56) in the USA. The US mortality rates from active smoking (R 1.5) and nicotine consumption by non-smoking means (RR 2.22) are higher even when the leading death predictors (COPD, Fanconi anemia, thromboembolism, TP53 gene mutation, KRAS mutation) are significantly higher in Finland (RR 2.57–12.85). High asthma rates among the US smokers (RR 4.21) are distinct predictors of poor survival rates from lung cancer—also reflected in higher Tiffeneau-Pinelli index reduction (RR 3.96). Delays in detection of respiratory cancer inversely relate to the survival rates (r =− 0.56). Where results are chaotic, data are assessed through holomorphic operation, each domain as complex-valued function of differentiable variable(s). Under the Riemannian and Finsler reasoning, each variable is a manifold in a spatial unit where tangent sits with the fourth root of differential expression. Such indexing could interprete functional relationships between healthcare value, demand elasticity, attributable or relative risk, prognosis—in the non-cohort samples, as suggested by the following equation matrix: R = ( [η (t) η (t’)/δ (t−t’) ]−D¹xμ r − D¹[μ xr + μ r x] − D²x(1 − λ s) + D²[λ xs + λ s x])ik (lj Rjikl ll). Due to its inherent dissonance property enabling data triangulation in infinitesimal points, Euclidean reasoning may help devise comprehensive healthcare index to predict perinatal and tobacco mortality. Findings of this study suggest that health value is higher in Finland. The need for health policy reform in the USA is warranted.
... This data gap is particularly problematic for the category of natural or induced fetal losses for two reasons. First, research has indicated that pregnant women who do not successfully carry to term may be at significantly greater risk of premature mortality, often from emotional or social factors such as suicide or violence whether the fetal loss was by induced abortion or a spontaneous loss [5,6]. Second, the loss of fully 1/3 of all pregnancies, nearly half of them for unknown causes, has a significant impact on the Total Fertility Rate (TFR) of the nation. ...
Background The current measuring metric and reporting methods for assessing maternal mortality are seriously flawed. Evidence-based prevention strategies require consistently reported surveillance data and validated measurement metrics.Main BodyThe denominator of live births used in the maternal mortality ratio reinforces the mistaken notion that all maternal deaths are consequent to a live birth and, at the same time, inappropriately inflates the value of the ratio for subpopulations of women with the highest percentage of pregnancies ending in outcomes other than a live birth. Inadequate methods for identifying induced or spontaneous abortion complications assure that most maternal deaths associated with those pregnancy outcomes are unlikely to be attributed. Absent the ability to identify all maternal deaths, and without the ability to differentiate those deaths by specific pregnancy outcomes, existing variations in pregnancy outcome-specific maternal deaths are masked by the use of an aggregated (all outcome) numerator. Under these circumstances, clear and accurate data is not available to inform evidence-based preventive strategies. As the result, algorithms applied for analyzing maternal mortality data may return distorted results.Conclusion Improvement in the effectiveness of maternal mortality surveillance will require: mandatory certification of all fetal losses; linkage of death, birth and all fetal loss (induced and natural) certificates; modification of the structure of the overall maternal mortality ratio to enable pregnancy outcome-specific ratio calculations; development of the appropriate ICD codes which are specific to induced and spontaneous abortions; education for providers on identifying and reporting early pregnancy losses; and, flexible information systems and methods which integrate these capabilities and inform users.
... For example, in Texas, as part of a mandated counseling law, women are given a booklet warning them that they are at increased risk of becoming suicidal if they choose abortion (2). This view is supported by several studies in the United States and one in Finland finding that abortion increases a woman's risk for suicidal ideation, suicide attempts (3), and suicide (4)(5)(6)(7). However, these studies suffer from some serious methodological shortcomings (8) that limit the validity of their results. ...
Objective: The aim of this study was to assess the effects of receiving compared with being denied an abortion on women's experiences of suicidal ideation over 5 years. Method: The authors recruited 956 women from 30 U.S. abortion facilities. Women were interviewed by telephone 1 week after their abortion visit, then every 6 months for 5 years. Women who received near-limit abortions were compared with women who were denied an abortion and carried their pregnancies to term (turnaway-birth group). Women completed the suicidal ideation items on the Brief Symptom Interview (BSI) and the Patient Health Questionnaire (PHQ-9). The Sheehan Suicidality Tracking Scale was used to assess imminent suicidality. Adjusted mixed-effects regression analyses accounting for clustering by site and individual were used to assess whether levels and trajectories of suicidality differed by group. Results: One week after abortion seeking, 1.9% of the near-limit group and 1.3% of the turnaway-birth group reported any suicidal ideation symptoms on the BSI. Over the 5-year study period, the proportion of women with any suicidal ideation symptoms on the BSI declined significantly to 0.25% for women in the near-limit group and nonsignificantly to 0.21% for those in the turnaway-birth group. In four out of 7,247 observations (0.06%), women reported being imminently suicidal. There was no statistically significant differential loss to follow-up by baseline report of suicidal ideation or history of depression or anxiety. There were no statistically significant group differences on any suicidal ideation outcome over the 5-year study period. Conclusions: Levels of suicidal ideation were similarly low between women who had abortions and women who were denied abortions. Policies requiring that women be warned that they are at increased risk of becoming suicidal if they choose abortion are not evidence based.
Physical violence during pregnancy can have negative impact on health status of mother and fetus. Hence, the current study was done to determine the prevalence and determinants of physical violence and its impact on birth outcomes during pregnancy in India. We have analyzed the most recent National Family Health Survey 4 data (NFHS-4) gathered from Demographic Health Survey (DHS) program. Stratification (urban/rural) and clustering (villages/census enumeration blocks [CEBs]) in the sample design was accounted using svyset command. In total, 62,165 ever pregnant women aged 15 to 49 years were included. Prevalence of physical violence during pregnancy in India was 3.3%. Husband/partner (2.7%) was the person most commonly responsible. Women who were widowed/separated/divorced (aPR = 1.88), belonging to the poorest quantile (aPR = 2.32), women who were employed (aPR = 1.42), women in the Southern states (aPR = 3.24), and women whose husband/partner has lesser educational qualification (adjusted prevalence ratio [aPR] = 2.02) had significantly higher prevalence of physical violence during pregnancy ( p < .001). Women who faced physical violence had significantly higher proportion of miscarriage (4.3%), abortion (3.3%), and stillbirth (1.1%) when compared with women who did not face any violence (4.1% had miscarriage, 1.8% had abortion, and 0.5% had stillbirth; p < .001). These findings show the importance of providing general supportive measures and strengthen the existing punitive legislations to prevent the violence during pregnancy.
Full-text available
In this chapter, the focus will be on studying the consequences of various types of violent experiences on women’s health. It also opens possibilities of exploring the correlations that may exist between violent experiences and health. It explores the increasing and serious healthcare needs for those being abused within their intimate relationships. The practitioner should note that the victims can include children, the elderly and individuals currently married or engaged to be married. From the available studies, it is not very clear as to how much domestic violence contributes to pregnancy complications, antepartum hospitalization or low birth weight. It is also not very well known as to how much of these complications can be attributed to domestic violence. Therefore, there are little data on the public health impact and benefits of eliminating domestic violence during pregnancy and postpartum.
Objective: To investigate the risks of attempted and completed suicide in women who experienced a stillbirth or abortion within 1 year postnatally and compared this risks with that in women who experienced a live birth. Design: A nested case-control study. Setting: Linking three nationwide population-based datasets in Taiwan: National Health Insurance Research Database, National Birth Registry, and National Death Registry. Sample: 485 and 350 cases of attempted and completed, respectively, were identified during 2001-2011; for each case, 10 controls were randomly selected and matched to the cases according to the age and year of delivery. Methods: Conditional logistic regression. Main outcome measures: Attempted and completed suicidal statuses were determined. Results: The rates of attempted suicide increased in the women who experienced foetal loss. The risk of completed suicide was higher in women who experienced a stillbirth (adjusted odds ratio (aOR)=5.2; 95% confidence interval (CI)=1.77-15.32), miscarriage (aOR=3.81; 95% CI=2.81-5.15), or termination of pregnancy (aOR=3.12; 95% CI=1.77-5.5) than in those who had a live birth. Furthermore, the risk of attempted suicide was significantly higher in women who experienced a miscarriage (aOR=2.1; 95% CI=1.66-2.65) or termination of pregnancy (aOR=2.5; 95% CI=1.63-3.82). In addition to marital and educational statuses, psychological illness increased the risk of suicidal behaviour. Conclusions: The risk of suicide might increase in women who experienced foetal loss within 1 year postnatally. Healthcare professionals and family members should enhance their sensitivity to care for possible mental distress, particularly for women who have experienced a stillbirth. This article is protected by copyright. All rights reserved.
Editor-Mika Gissler and colleagues state that suicides occur more commonly after induced abortion than after a pregnancy resulting in live birth.1 We linked admissions for miscarriage, induced abortion, and normal delivery to admissions for suicide attempts in our health authority (population 408 000) during 1991-5 (table 1). Table 1 Frequency of admissions (rate per 1000 population) for attempted suicide by pregnancy event in women aged 15-49 in South Glamorgan Health Authority, 1991-5
What do professional psychologists need to know to treat women who once had an abortion? Analyses of responses from 2,525 women revealed that women who reported an abortion were more likely than others to report symptoms of depression and lower life satisfaction. However, they were also more likely to experience rape, childhood physical and sexual abuse, and a violent partner. When history of abuse, partner characteristics, and background variables were controlled, abortion was not related to poorer mental health. This underscores the need to explore the effects of violence in women's lives to avoid misattributing psychological distress to abortion experiences. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Thesis (Ph. D.)--University of Minnesota, 1985. Includes bibliographical references (leaves 202-206).
A study of 576 pregnant women, whose previous pregnancy had been terminated by legally induced abortion, has shown that the rate of pregnancy and delivery complications could not be correlated with the interval between the abortion and the subsequent pregnancy, nor with the gestational age at the time of abortion, nor the number of previous induced abortions. Neither was the abortion technique found to correlate with the frequency of complications in a subsequent pregnancy. It was found, however, that more infants with a birth weight below 2 501 grams were born to women whose cervical canal during abortion had been dilated more than 12 mm, and by women who had been submitted to récurettage. The latter group also demonstrated a higher frequency of retained placenta or placental tissue.
7,270 pregnant women were registered prospectively with the purpose of evaluating if there were an increased risk of pregnancy and delivery complications in women who had previously had a pregnancy terminated by legally induced abortion. The patient material was classified according to the termination of the previous pregnancy - legally induced abortion, spontaneous abortion or stillbirth, live birth - or to whether there had been no previous pregnancy. The group of women whose previous pregnancy had been terminated by a legally induced abortion differed from one or more of the other groups with regard to age, number of previous pregnancies and their outcome, previous illnesses, previous gynecological operations, medication during pregnancy, smoking habits and socio-economic status. These factors were all correlated with low birth weight and/or short gestational age. These variables must be taken into consideration in an investigation of risk of pregnancy and delivery complications following legally induced abortion.
No strong temporal associations were found between the occurrence of stressful life events and the onset of alcohol problems.
A study of 197 women referred for termination of pregnancy on psychiatric grounds was undertaken from February 1974 to May 1975 at a specially established clinic in the Department of Psychiatry, Groote Schuur Hospital, Cape Town. The personal, social and specifically psychiatric information collected from this study, which included both women who were refused and those granted termination on psychiatric grounds, was analysed. We gained enough data to focus on the psychosocial and 'hard' psychiatric data, to statistically compare the two groups, and to isolate variables which appeared to have influenced decision-making. Eighty per cent of the women were followed up for 12 - 18 months.