Original Research Article in Social Science & Medicine
Abortion history and current mental health
Examining the association of abortion history and
current mental health: A reanalysis of the National
Comorbidity Survey using a common-risk-factors
Julia R. Steinberg
University of California, San Francisco
Lawrence B. Finer
The Guttmacher Institute
Published in Social Science and Medicine, Vol.72, No. 1, pp. 72-82
Available online at Social Science and Medicine, 23 October, 2010
Abstract available from Social Science and Medicine through Science Direct
Author Correspondence: Julia R. Steinberg
Department of Obstetrics, Gynecology, and Reproductive Sciences
Bixby Center for Global Reproductive Health
University of California, San Francisco
3333 California St., Ste 335, Box 0744
San Francisco, CA 94143-0744
Key Words: Abortion, mental health, USA, women, common risk factors, pregnancy context
Abortion history and current mental health 2
Using the National Comorbidity Survey (NCS), Coleman, Coyle, Shuping and Rue (2009)
published an analysis indicating that compared to women who had never had an abortion,
women who had reported an abortion were at an increased risk of several anxiety, mood, and
substance use disorders. Here, we show that those results are not replicable. That is, using the
same data, sample, and codes as indicated by those authors, it is not possible to replicate the
simple bivariate statistics testing the relationship of ever having had an abortion to each mental
health disorder when no factors were controlled for in analyses (Table 2 in Coleman et al., 2009).
Furthermore, among women with prior pregnancies in the NCS, we investigated whether having
zero, one, or multiple abortions (abortion history) was associated with having a mood, anxiety, or
substance use disorder at the time of the interview. In doing this, we tested two competing
frameworks: the abortion-as-trauma versus the common-risk-factors approach. Our results
support the latter framework. In the bivariate context when no other factors were included in
models, abortion history was not related to having a mood disorder, but it was related to having
an anxiety or substance use disorder. When prior mental health and violence experience were
controlled in our models, no significant relation was found between abortion history and anxiety
disorders. When these same risk factors and other background factors were controlled, women
who had multiple abortions remained at an increased risk of having a substance use disorder
compared to women who had no abortions, likely because we were unable to control for other
risk factors associated with having an abortion and substance use. Policy, practice, and research
should focus on assisting women at greatest risk of having unintended pregnancies and having
poor mental health—those with violence in their lives and prior mental health problems.
Abortion history and current mental health 3
Examining the association of abortion history and current mental health: A
reanalysis of the National Comorbidity Survey using a common-risk-factors
Recently, Coleman, Coyle, Shuping and Rue (henceforth CCSR, 2009) published an
analysis finding that women who reported having had an abortion had higher rates of several
mental health disorders as diagnosed according to the guidelines of the Diagnostic and Statistical
Manual III Revised (DSM-III-R, American Psychiatric Association, 1987). These disorders
included panic disorders and attacks, post-traumatic stress disorder, agoraphobia, alcohol and
drug abuse and dependence, bipolar disorder, mania, and depression (CCSR, 2009). Using a U.S.
nationally representative data set designed to measure the prevalence and correlates of DSM-III-
R mental disorders, the National Comorbidity Survey (NCS), CCSR (2009) concluded, “The
results of this study revealed that women who have aborted are at a higher risk for a variety of
mental health problems including anxiety (panic attacks, panic disorder, agoraphobia, PTSD),
mood (bipolar disorder, major depression with and without hierarchy) and substance abuse
disorders when compared to women without a history of abortion after controls were instituted
for a wide range of personal, situational, and demographic factors” (p. 775). Here, we test the
replicability of their findings. That is using the same data, sample, and coded variables as
indicated by those authors, we examined whether the simple bivariate statistics (found in Table 2
of CCSR, 2009) presenting the relationship of ever having had an abortion to each mental health
disorder are replicable when no factors are controlled for in models. Furthermore, we test
whether having multiple, one, or no abortions is associated with having subsequent mental health
problems among ever-pregnant women when considering and not considering alternative
explanations (i.e., when controlling and not controlling for common risk factors).
Abortion history and current mental health 4
Abortion as a traumatic experience
Various conceptual frameworks for understanding how having an abortion may relate to
subsequent mental health have been hypothesized (see Major, Appelbaum, Beckman, Dutton,
Russo, & West, 2009 for a review). Coleman and colleagues conceptualize having an abortion as
a traumatic experience leading to mental health problems (e.g., CCSR, 2009; Reardon, 1987;
Reardon, Strahan, Thorp, & Shuping, 2004; Rue, Coleman, Rue, & Reardon, 2004). This
framework contends that having an abortion, independent of other life circumstances, is a
traumatic experience with consequences similar to other traumatic experiences, such as rape or
war. Support for this framework originally came from qualitative interviews with women who
were recruited because they deemed a prior abortion experience as highly stressful (Speckhard &
Mufel, 2003; Speckhard & Rue, 1992, 1993). More recently, quantitative studies, including the
one described in great detail here, have offered evidence for this framework (for a review, see
Major et al., 2009, the American Psychological Association [APA], 2008, or Robinson, Stotland,
Russo, Lang, & Occhiogrosso, 2009).
While published studies other than CCSR (2009) claim that having an abortion is a
precursor to poor mental health, many other studies and reviews have not found this (for a
review, see APA, 2008; also see Charles, Polis, Sridhara, & Blum, 2008; Major et al., 2009;
Robinson et al., 2009). It may appear, therefore, that there is a scientific debate in which some
research studies find support for abortion as a cause of psychological problems, while other
studies do not. Unfortunately, this debate is a false one, because many studies claiming to find
support that abortion causes poor mental health frequently suffer from several methodological
limitations, such as 1) using inappropriate comparison groups, 2) failing to control for prior
Abortion history and current mental health 5
mental health, and 3) not considering alternative explanations (Charles et al., 2008; Robinson et
al., 2009; Steinberg & Russo, 2009; Major et al., 2009). More importantly, in some cases,
findings simply have not been replicable (e.g., see Russo & Schmiege, 2005). For example, using
the same data, same sample, and correct coding, Russo and Schmiege (2005) could not replicate
the findings of Cougle and Reardon (2002). Thus, the first analysis here will test whether the
findings of CCSR (2009) are replicable using the same dataset, same sample, and same coding.
Abortion within a stress and coping model
Instead of conceptualizing having an abortion as a traumatic experience, others
conceptualize it as a potential stressor, similar to other possible life stressors. This and other
related frameworks emphasize the variability in women’s experiences following an abortion,
acknowledging that some women will have negative psychological outcomes following an
abortion (Major et al., 2009; Adler et al., 1990, 1992). However, at the aggregate level, many
studies and reviews of the literature find that most women do not have psychological problems
following an abortion (Adler et al., 1990, 1992; Charles et al., 2008; Major et al., 2009;
Robinson et al., 2009). Women likely to have negative psychological outcomes following an
abortion are those least apt to cope with any stressful life event including giving birth to an
unwanted pregnancy. Because the work using the stress and coping perspective has focused on
explaining psychological variation among women having abortions (e.g., Cozzarelli, Major,
Karrasch, & Fuegen, 2000; Cozzarelli, Sumer, & Major, 1998; Major & Gramzow, 1999; Major,
Cozzarelli, Cooper, Zubek, Richards, Wilhite et al., 2000; Major, Richards, Cooper, Cozzarelli,
& Zubek, 1998), much of this research emphasizes the immediate circumstances and context
surrounding the abortion, such as pregnancy intention, social support, expectations for coping
Abortion history and current mental health 6
with abortion, emotions or mental health before the procedure, and influence of protestors, in
understanding psychological adjustment after an abortion. While this work seeks to understand
what explains psychological adjustment to an abortion, it does not compare the psychological
adjustment of women having an abortion to women having other pregnancy outcomes.
Common risk factors approach
In contrast to the stress and coping framework, the common-risk-factors approach
compares the psychological outcomes of women having abortions with those having other
pregnancy outcomes, emphasizing the role of sociodemographic, structural, and other risk factors
in explaining post-abortion and post-pregnancy mental health. Often, the factors considered in
this perspective go beyond the immediate pregnancy context and encompass distal factors such
as socioeconomic status, violence history, or prior mental health. Previous research shows that
these factors are associated with having an abortion (Fisher, Singh, Shuper, Carey, Otchet,
MacLean-Brine et al., 2005; García-Moreno & Stöckl, 2009; García-Moreno, Jansen, Ellsberg,
Heise, & Watts, 2005; Jones, Darroch, & Henshaw, 2002; Russo & Denious, 2001, 1998;
Steinberg, Becker, & Henderson, in press; Steinberg & Russo, 2008; Taft & Watson, 2008) as
well as with mental health problems (Breslau, Kendler, Su, Gaxiola-Agilar, & Kessler, 2005;
Neumann, Houskamp, Pollock, Briere, 1996; Kessler, McGonagle, Zhao, Nelson, Hughes,
Eshleman et al., 1994; Kessler, Davis, & Kendler, 1997). Therefore, it is important to control for
these factors when examining how abortion, compared to other pregnancy outcomes, relates to
subsequent mental health, as some studies do (e.g., Russo & Denious, 1998, 2001; Steinberg &
Russo, 2008; Steinberg et al., in press; Taft & Watson, 2008). When analyses do not control for
these risk factors, the relationship of pregnancy outcome (abortion versus other pregnancy
Abortion history and current mental health 7
outcomes) and mental health may be significant, as depicted in Figure 1, because of common
risk factors. When risk factors are accounted for in analyses, however, this framework posits that
the relationship of abortion and mental health will not be significant (or at least will be
significantly reduced). That is, if a relationship between abortion and mental health is found, it is
likely to be spurious or driven by factors associated with both having an abortion and mental
health. In the second part of our study, we provide analyses with and without controlling for risk
Comparing the stress and coping model and common risk factors approach
The latter two perspectives, abortion within a stress and coping model and the common-
risk-factors approach, are not competing, but rather complementary. They ask and answer
different questions, shedding light from different angles on how pregnancy outcomes, and
particularly abortion, relate to subsequent mental health. The stress and coping perspective aims
to understand the contextual factors and immediate psychological mechanisms of coping with an
abortion, while the common-risk-factors perspective aims to test whether women who have
abortions are at an increased risk of subsequent mental health problems compared to women with
other pregnancy outcomes (usually women choosing to give birth). Another difference between
these two frameworks has been the methodologies used. Studies using the stress and coping
perspective usually involve data collected prospectively and designed to assess the current
coping and personal resources, relationship characteristics, and mental health among women
having abortions, while many studies using the common-risk-factors approach are secondary
data analyses of large data sets collected for purposes other than examining the relation between
abortion and mental health.
Abortion history and current mental health 8
In understanding the mental health sequelae of women having abortions compared to
women having other pregnancy outcomes, it is important to consider immediate circumstances
such as coping, personal, and economic resources, pregnancy intention, and social support, along
with other more distal risk factors such as violence history, prior mental health, and
sociodemographic characteristics. However, when using secondary data (as is the case when
using the common-risk-factors approach), often the immediate circumstances are not available.
Thus, research using the common-risk-factors approach has focused on more distal factors, such
as violence experience, rather than the immediate pregnancy context.
The CCSR (2009) study and our reanalysis are based on a secondary data analysis, so we
do not have immediate contextual factors such as pregnancy intention, personal or economic
resources, or relationship factors at the time of the abortion or other pregnancy outcomes.
Moreover, we compare women who have abortions to other groups of women. Therefore, we
draw mainly from the common-risk-factors framework, contending that distal factors related to
having an abortion are also related to having poor mental health.
In Analysis Set 2, we test whether the data fit the abortion-as-trauma framework or the
common-risk-factors perspective. According to the abortion-as-trauma framework, the relation
between abortion and mental health should be significant with and without controlling for other
risk factors. According to the common-risk-factors framework, if a relation between abortion and
mental health is found when no risk factors are controlled for in analyses, it is because of
common risk factors among women having abortions and women having mental health
problems. Therefore, when we control for these other factors, the relationship of abortion and
mental health should no longer be significant (or at least significantly reduced). Before doing
Abortion history and current mental health 39
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