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

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  • 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
suicide.
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.
1,2
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*
DAVID C. REARDON, PhD, PHILIP G. NEY, MD, FRITZ SCHEUREN, PhD, JESSE COUGLE, MSc,
PRISCILLA K. COLEMAN, PhD, and THOMAS W. STRAHAN, JD, Springfield, Ill
ABSTRACT
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.
KEY POINTS
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-
ease.
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
Reardon et al DEATHS ASSOCIATED WITH PREGNANCY OUTCOME 835
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.
MATERIALS AND METHODS
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.
3
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.
RESULTS
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-
nancies.
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
Reardon et al DEATHS ASSOCIATED WITH PREGNANCY OUTCOME 837
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 <
.0001).
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.
DISCUSSION
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
admissions.
4
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.
5-11
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-
cedure.
12
Pregnancy and childbirth, on the
other hand, reduce the risk of suicide.
13-15
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.
Reardon et al DEATHS ASSOCIATED WITH PREGNANCY OUTCOME 839
Deaths from accidents may also be related to
higher rates of alcohol consumption
16-20
or
drug abuse
21-26
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-
tion.
27,28
The heightened risk of death from nonvio-
lent causes may reflect a decline in general
health after abortion, as reported elsewhere.
29-31
Other unhealthy behaviors linked to abortion
are increased alcohol consumption, drug
abuse, and smoking.
32-40
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-
ity.
41-44
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.
45,46
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.
47
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.
Reardon et al DEATHS ASSOCIATED WITH PREGNANCY OUTCOME 841
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. ...
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... 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). ...
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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.
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No strong temporal associations were found between the occurrence of stressful life events and the onset of alcohol problems.
Article
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.