Thursday, June 14, 2007

Ipas Briefing Paper- Mental Health and Abortion

Mental Health and Abortion

Twenty countries around the world allow for abortion to preserve a woman’s mental health (Center for Reproductive Rights). This briefing paper provides an overview of how mental health is defined, relevant guidance from international organizations and professional bodies, information on mental health and abortion, and experience of providers in applying a mental health indication for abortion.

What is mental health?
Authoritative conceptions of mental health have resisted fixed definitions. Scholars from different cultures have defined mental health in various ways, including "subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualization of one’s intellectual and emotional potential" (World Health Organization) According to a report of the United States Surgeon General,
Mental health refers to the successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity. Mental health is indispensable to personal well-being, family and interpersonal relationships, and contribution to community or society (emphasis added), (U.S. Department of Health and Human Services).

The World Health Organization’s definition of health, which includes mental health, encompasses a variety of factors. As defined by the WHO Constitution, health is "not merely the absence of disease or infirmity," but rather, "a state of complete physical, mental and social well-being." Mental health under this definition is "broader than a lack of mental disorders" (World Health Organization).

A multitude of factors contribute to one’s state of mental health. Mental well-being is "influenced by age, gender, race, and culture as well as additional facets of diversity that can be found within all of these population groups" (World Health Organization). According to the WHO, there is evidence that mental health disorders are influenced by socioeconomic status and other factors such as urbanization, poverty and technological change. Sexism and racism can also contribute to poor mental health. Women in particular are at risk for mental health disorders as they "continue to bear the burden of responsibility associated with being wives, mothers, educators and careers of others," (World Health Organization) while they are increasingly responsible for generating income for the family.

How is a woman’s mental health affected by unwanted pregnancy and abortion?
Studies have indicated that the impact of safe, legal abortion on women’s mental health is largely positive. According to the American Psychological Association, the ability of women to make decisions about their own childbearing is necessary for their health—including mental health—as well as for the health of their families (American Psychological Association). Abortion has been found to have a positive impact to women’s well being, due to "abortion’s important role in controlling fertility … and its relationship to coping resources" (Russo NF, Zierk KL). Studies have found that the most prominent emotional response of most women to first-trimester abortions is relief (Planned Parenthood Federation of America).

Research on the impact of denying a woman an abortion and thereby forcing her to continue with an unwanted pregnancy has pointed to a detrimental impact upon a woman’s mental health. Transition to parenthood can involve risk to mental health and this risk is oftentimes heightened when the pregnancy is unplanned (Schmiege, Sarah and Russo, Nancy Felipe). Delivering a first unwanted pregnancy has been associated with risk factors for depression such as lower education and income and larger family size (Schmiege, Sarah and Russo, Nancy Felipe). Studies have shown that women’s risk for depressive symptoms is higher among women with young children and increases with number of children (Schmiege, Sarah and Russo, Nancy Felipe).

The mental health impact of continued unwanted pregnancy has been particularly emphasized by legal authorities. In the decision of Karen Noelia Llantoy Huamán v. Peru, the Human Rights Committee acknowledged the negative mental health impact of denying a woman with an anencephalic pregnancy access to abortion. The Committee describes the psychological effect upon the claimant in the case as a violation of her human right to be free of cruel, inhuman and degrading treatment – which includes freedom from mental suffering. In the seminal case that made abortion legal for all American women, Roe v. Wade, Justice Harry Blackmun discussed the impact of denying a woman an abortion, with a particular emphasis on her mental health.

Justice Blackmun writes,
"The detriment that the State would impose upon the pregnant woman by denying this choice [to terminate a pregnancy] altogether is apparent. Specific and direct harm medically diagnosable even in early pregnancy may be involved. Maternity, or additional offspring, may force upon the woman a distressful life and future. Psychological harm may be imminent. Mental and physical health may be taxed by child care. There is also the distress, for all concerned, associated with the unwanted child, and there is the problem of bringing a child into a family already unable, psychologically and otherwise, to care for it. In other cases, as in this one, the additional difficulties and continuing stigma of unwed motherhood may be involved. …"
Scientific research on the mental health impact of abortion has been skewed by unfounded claims by anti-abortion activists wishing to reduce women’s access to safe abortion. These assertions state that women who choose abortion suffer from emotional trauma as a result – a condition that has been labeled "post-abortion trauma," or "post-abortion stress disorder" (Planned Parenthood Federation of America).

The claims of emotional trauma following abortion are primarily based on flawed studies of self-selected women who had abortion, but regarded abortion as an immoral choice (David, Henry P.). Further, poor mental health outcomes that are reported may be due, in part, to the stigmatization and shame that some women experience with abortion (Russo NF, Zierk KL). A review of studies found that "the weight of the evidence is that legal abortion as a resolution to an unwanted pregnancy, particularly in the first trimester, does not create psychological hazards for most women undergoing the procedure" (Adler, N., et. al.). The best available studies on the psychological responses to abortion in the United States—where safe and legal abortion is available—indicate that severe negative reactions are infrequent (Adler, N., et. al.), and less frequent than with childbirth (Adler, N., et. al.).


What questions should be considered in assessing whether a woman’s continued pregnancy is a risk to her mental health?
The particular circumstances of a woman’s pregnancy, together with factors that affect her overall mental health, influence the degree to which a continued pregnancy is a risk. Research has found that a woman’s response to pregnancy depends on factors such as whether a pregnancy was planned, whether the woman has adequate resources to care for a child, whether the partner is supportive, and whether there is an indication of genetic abnormality (Adler, N., et. al.). Other psychological studies have shown that the outcome of stressful life events, such as unwanted pregnancy, depend on what is identified by leading psychologists as "coping resources." These resources have been identified as factors such as employment, income, education and marital status (Russo NF, Zierk KL).

Doctors in Great Britain usually consider social circumstances in interpreting the mental health indication in British abortion law. The British abortion law allows for abortion when (among other circumstances) "the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family." In England and Wales, according to a 1997 report, 97.6% of abortions were performed under these grounds (Information & Statistics Division). Most medical doctors in Great Britain apply the World Health Organization definition of health when assessing the impact of the pregnancy on the mental health of the woman or her children.

As reported in 2000 by the Royal College of Obstetricians and Gynaecologists,
The WHO definition of ‘health’ is ‘a state of physical and mental well-being, not merely an absence of disease or infirmity.’ Most doctors apply this broad definition of health in interpreting the Abortion Act. Thus, to meet the terms of the Act, a woman need not have a psychiatric illness when she makes her abortion request but there must be factors that would threaten her mental health if the pregnancy were to continue. Thus, the abortion is not carried out for social reasons although a woman’s social circumstances may be taken into account in assessing the risks to her health.

Conclusion
This briefing paper has reviewed information and guidance from a range of international sources, the scientific literature, and practical experience in the provision of services where the law permits abortion for mental health reasons. In considering the inclusion and interpretation of a mental health indication for abortion, policymakers and health care providers should recognize the potential risks of compelling women to continue unwanted pregnancies that would have negative mental health consequences, as well as the individual and social benefits for many women and their families of permitting abortion for mental health reasons.

Resources

Adler, N., et. al., Psychological Factors in Abortion - A Review, Am Psychol. 1992 Oct;47(10):1194-204.

Adler, Nancy E. (1989). University of California at San Francisco, Statement on Behalf of the American Psychological Association Before the Human Resources and Intergovernmental Relations Subcommittee of the Committee on Governmental Operations, U.S. House of Representatives: 130-140.

American Psychological Association, APA Briefing Paper on the Impact of Abortion on Women, available at http://www.rcrc.org/pdf/APA%20document.pdf.

Center for Reproductive Rights, The World’s Abortion Laws, April 2005, available at http://www.reproductiverights.org/pub_fac_abortion_laws.html.

David, Henry P., Abortion and Mental Health, prepared for presentation at the 28th International Congress of Psychology, Beijing, China (2004).

Information & Statistics Division. Abortion statistics 1996 & 1997 (1998) ISD Scotland Health Briefing Edingburgh as cited in Royal College of Obstetricians and Gynaecologists, The Care of Women Requesting Induced Abortion (March 2000).

Karen Noelia Llantoy Huamán v. Peru, Communication No. 1153/2003, UN Doc. CCPR/C/85/D/1153/2003 (2005), para. 6.2, 6.3.

Planned Parenthood Federation of America, The Emotional Effects of Induced Abortion (2001), available at http://www.plannedparenthood.org/pp2/portal/files/portal/medicalinfo/abortion/fact-010600-emoteff.xml.

Roe v. Wade, 410 U.S. 113 (1973).

Royal College of Obstetricians and Gynaecologists, The Care of Women Requesting Induced Abortion, March 2000, available at http://www.nelh.nhs.uk/guidelinesdb/html/front/InducedAbortion.html.

Russo NF, Zierk KL. "Abortion, childbearing, and women’s well-being." Professional Psychology: Research and Practice, 1992, 23(4): 269-280.

Schmiege, Sarah and Russo, Nancy Felipe, Depression and unwanted first pregnancy: longitudinal cohort study, British Medical Journal 331,7528 (December 2005): 1303-1306.

U.S. Department of Health and Human Services, Mental Health, A Report of the Surgeon General, Executive Summary (1999), available at http://www.surgeongeneral.gov/library/mentalhealth/home.html.

United Kingdom, The Abortion Act 1967, as amended by the Human Fertilization and Embryology Act of 1990.

World Health Organization, The World Health Report 2001 – Mental Health: New Understanding New Hope, Chapter 1: A public health approach to mental health (2001) available at http://www.who.int/whr/2001/en/index.html.

This briefing paper was prepared by Patty Skuster, J.D., M.P.P., Policy Associate at Ipas, an international non-governmental organization that has worked for over three decades to increase women’s ability to exercise their sexual and reproductive rights and to reduce deaths and injuries of women from unsafe abortion.

April 2006

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