Recent evidence suggests induced abortion may be associated with later psychiatric disorders in young women. Reference Cougle, Reardon and Coleman1–Reference Pedersen3 Such findings may question one of the main orthodoxies underpinning legalised abortion, that of preventing adverse psychiatric outcomes after an unwanted pregnancy. Reference Fergusson, Horwood and Ridder2 It has been observed that the associations can be explained by previous depression or drug misuse, or that the rates of psychiatric morbidity reported after abortion are no different than expected in young women of childbearing age. Reference Gilchrist, Hannaford, Frank and Kay4–Reference Schmiege and Russo7 Alternatively, psychiatric disorders after abortion may be a result of the experience of pregnancy loss in general, rather than being specific to induced abortion. Miscarriage and pregnancy are associated with significant psychiatric morbidity. Anxiety, depression and substance use disorders are associated with miscarriage, Reference Neugebauer8 and the risk of severe psychosis increases for some women during pregnancy. Reference Brockington9 To date, no population study has directly compared psychiatric outcomes in women after abortion and miscarriage. This study used prospective data to examine the associations between pregnancy loss, whether from induced abortion or spontaneous miscarriage, and a range of DSM–IV 10 psychiatric disorders assessed at age 21 years.
Data was taken from the Mater-University of Queensland study of pregnancy and its outcomes (MUSP), Reference Najman, Bor, O'Callaghan, Williams, Aird and Shuttlewood11 a 21-year prospective birth cohort study that investigates the health and behaviour of mother–child pairs. The baseline female cohort (n=3474) were born between 1981 and 1984 at a major metropolitan public hospital in Brisbane, Australia. Mother–daughter pairs were subsequently reassessed at 6 months, 5, 14, and 21 years after birth. During the 21-year follow-up, over the years 2000–2004, all the original mother–child pairs were recontacted; however, resource constraints limited our ability to interview people residing outside of the greater Brisbane area and the 7-year gap between follow-ups made it difficult to regain contact with some. There were few who refused to participate. No social or other characteristics were used to screen inclusion, although there was a modest over-representation of disadvantage in women lost to follow-up (online Table DS1). At 21-year follow-up, 1988 female children (57.2% of the baseline cohort), now young women, were interviewed. Of these, 61.5% (n=1223) had complete data on lifetime pregnancy outcomes, psychiatric diagnoses at age 21 and covariates from birth, 14 and 21 years. Ethical approval for each phase was obtained from the University of Queensland.
Measurement of psychiatric disorders
At 21-year follow-up, the lifetime version of the Composite International Diagnostic Interview computerised version (CIDI– Auto, version 2.1) 12 was used to assess psychiatric disorders. The CIDI has been found to have good reliability and validity. Reference Andrews and Peters13 The study reports six DSM–IV 10 disorders: total affective and anxiety disorders; alcohol, cannabis and other illicit drug use and dependence disorders, as well as nicotine withdrawal and dependence disorders. The age at first onset of disorder and disorders occurring within the previous 12 months were used. Although we had intended to explore associations between pregnancy outcomes and specific psychiatric disorders such as psychosis, only 21 women met DSM–IV criteria for any psychosis. We were, therefore, unable to undertake meaningful analysis of the influence of pregnancy outcomes on psychotic disorders.
Measurement of pregnancy outcomes
Women reported the number of previous pregnancies, abortions, miscarriages and births they had experienced by age 21. We created a variable which incorporated all four possibilities (never pregnant, live birth only, ever had an abortion and ever miscarried) (Fig. 1). Seventeen women had both an abortion and miscarriage: for the analysis, six women who had miscarried two or three times were coded to miscarriage, five women who had had two abortions were coded to abortion, and the remaining six women with one abortion and one miscarriage were randomly assigned to either the abortion or miscarriage group. Those with missing data in any of the questions were excluded.
Confounders included maternal and familial factors, measures related to pre-existing behaviour problems and substance misuse, as well as demographic characteristics of the young women.
Young women's early life and family background
Symptoms of anxiety and depression experienced by the young women's mothers during pregnancy were assessed using the two seven-item sub-scales of the Delusions-Symptoms-States Inventory (DSSI). Reference Bedford and Foulds14 The depression sub-scale strongly correlates with DSM–IV major depressive disorder. Reference Spence, Najman, Bor, O'Callaghan and Williams15 Mothers were classified as anxious or depressed if they reported four or more symptoms. Maternal smoking was assessed pre-pregnancy and at birth. At 14-year follow-up, mothers indicated if they lived with the young women's biological father, lived alone or with others. Mother–child communication was measured with a problem communication sub-scale from the Parent–Adolescent Communication Scale (PACS). Reference Barnes and Olson16 Family socio-economic status was assessed by yearly family income and maternal education at baseline.
At age 14, we used maternal reports of the young women's delinquent/aggressive behaviour from the Achenbach's Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR) anxious/depressed sub-scale. Reference Achenbach17 The checklists are widely used, standardised scales that are reliable, valid indicators of problem behaviour. Reference Achenbach, Howell, McConaughy and Stanger18 At 14, the young women were asked to define their overall school performance (average or below and above average).
At age 21, participants were asked whether they used cannabis and the age this was initiated. Participants were also asked the age at which they first had sexual intercourse, women reporting no sexual intercourse were excluded. A history of exposure to sexual violence or child sexual abuse and the age this first occurred was obtained with items from the Los Angeles epidemiologic catchment area project. Reference Sorenson, Stein, Siegel, Golding and Burnam19 Child sexual abuse was defined as unwanted sexual contact before 16 years of age with a person 5 or more years their senior. Young women were also asked if they had ever been raped.
Demographic factors at age 21
Demographic factors included age, marital status, age of leaving the family home, living arrangements (parents/relatives, renter, boarder or owner) and education level at age 21.
Chi-squared tests and logistic regression were used to explore the bivariate associations of pregnancy outcomes and each DSM–IV disorder. We then fitted multivariate logistic models on a restricted sample of young women (n=1223) with complete data for each DSM–IV disorder separately. Associations with each disorder were adjusted consecutively for maternal and family factors at baseline and 14-year follow-up (model 1), adolescent behaviour problems at 14 (model 2), adolescent behaviour reported at 21 (model 3) and concurrent demographic factors (model 4). Clearly non-significant factors (P>0.1 or those with unstable estimates as assessed by large standard errors) were removed. Each model was reassessed until only significant effects (P<0.05) remained. This was undertaken separately for each of the six DSM–IV disorders. Unadjusted and adjusted odds ratios (OR) and 95% confidence intervals were used to estimate the association between pregnancy outcomes and each disorder compared with the never pregnant group. All pairwise pregnancy outcome comparisons were undertaken with each of the fully adjusted models.
A series of sensitivity analyses were done to further explore the timing of the associations and effects of substance misuse, behaviour problems and psychiatric morbidity that possibly preceded pregnancy loss. Factors such as adolescent cigarette smoking, alcohol consumption and anxious/depressed and aggressive/delinquent behaviour were excluded from the model as these are possible causal factors associated with later psychiatric morbidity. Six separate sensitivity analyses were conducted:
(a) current (12-month) diagnoses were used instead of lifetime diagnoses;
and exclusion of women who reported:
(b) both a miscarriage and abortion;
(c) giving birth and pregnancy loss either as an abortion or miscarriage or both;
(d) smoking, drinking alcohol or anxious/depressed problem behaviours at 14 years;
(e) aggressive/delinquent behaviours at 14 years; and
(f) onset of a particular DSM–IV disorder at or before the age of sexual debut.
Finally, we used inverse probability weighting Reference Hogan, Roy and Korkontzelou20 to determine whether loss to follow-up affected the validity of our findings. This was done for the six DSM–IV diagnoses both lifetime and current (12-month) disorders. Analyses were carried out using SPSS version 15.0 and STATA version 9.0 on Windows.
Overall, 1223 young women had complete data. By about 20 years (s.d.=0.83) 943 reported never being pregnant and 280 (22.9%) reported one or more pregnancies. Over a quarter of those pregnant (26.8%, n=75; 6.1% of the sample) had complex lifetime pregnancy histories with two or three outcomes (Fig. 1).
Associations between pregnancy and psychiatric disorders
The unadjusted odds of having a lifetime psychiatric or substance use disorder were highest among women reporting a pregnancy loss and lowest among women who never had a pregnancy or gave birth; women with a nicotine disorder were the exception. Women with a history of abortion or miscarriage were twice as likely to meet criteria for alcohol, cannabis, other illicit drug use, depressive or anxiety disorder compared with those who were never pregnant or who had given birth (Table 1). Young women who became pregnant regardless of outcome had similarly high odds of having a lifetime tobacco dependency compared with never pregnant women.
|Lifetime DSM—IV disorders||Never pregnanta (n=943)||Live birth (n=97)||Abortion (n=101)||Miscarriage (n=82)||P b|
|Nicotine (withdrawal and dependence) (n=198)|
|OR (95% CI)c||1.0||2.6 (1.6-4.3)||4.0 (2.5-6.3)||3.7 (2.2-6.1)|
|Alcohol (misuse and dependence) (n=214)|
|OR (95% CI)||1.0||1.2 (0.7-2.1)||3.2 (2.1-5.0)||2.4 (1.5-4.1)|
|Cannabis (misuse and dependence) (n=172)|
|OR (95% CI)||1.0||1.5 (0.8-2.7)||3.7 (2.3-6.0)||2.8 (1.6-4.7)|
|Other illicit substance used (misuse and dependence) (n=93)|
|OR (95% CI)||1.0||1.2 (0.5-2.8)||4.8 (2.8-8.4)||3.6 (1.9-7.0)|
|OR (95% CI)||1.0||1.2 (0.8-1.9)||2.5 (1.6-3.8)||2.3 (1.4-3.6)|
|OR (95% CI)||1.0||1.6 (1.1-2.5)||2.5 (1.6-3.7)||2.7 (1.7-4.2)|
Adjustment for confounding
Online Table DS2 shows associations between pregnancy outcomes and a number of potential confounding factors. Pregnancy outcomes were associated with greater social and economic disadvantage, family instability, alcohol and cigarette use, aggressive/delinquent behaviours, early sexual intercourse and poorer educational outcomes at both age 14 and 21. There were only modest differences between women reporting an abortion and those with a history of miscarriage or birth.
Table 2 shows the multivariable logistic regression analyses. Women reporting a pregnancy were twice as likely to develop a tobacco dependency, with the association being slightly attenuated by adjustment for maternal and family factors and adolescent behaviour. Women who reported an abortion had twice the odds of having an alcohol disorder and nearly four times the odds of an illicit drug use disorder (excluding cannabis). Also, those reporting an abortion had an increased risk of affective disorder, although this association bordered significance after adjustment for 21-year demographic factors. Women who reported a miscarriage had a similarly high risk of developing an illicit drug use disorder, but not affective or alcohol disorders, as women reporting an abortion.
|DSM—IV disorders at 21-year follow-up, OR (95% CI)|
|Model||Nicotine||Alcohol||Cannabis||Other illicit substance use||Affective||Anxiety|
|1. Adjusted for early life and family factorsa,b|
|Live birth||2.7 (1.6-4.5)||1.1 (0.6-1.9)||1.3 (0.7-2.3)||1.4 (0.6-3.3)||1.0 (0.6-1.7)||1.4 (0.9-2.1)|
|Abortion||4.0 (2.5-6.4)||2.8 (1.8-4.4)||3.3 (2.1-5.4)||5.8 (3.3-10.4)||2.2 (1.4-3.5)||2.0 (1.3-3.1)|
|Miscarriage||3.6 (2.1-6.2)||2.2 (1.3-3.7)||2.5 (1.5-4.4)||4.1 (2.1-8.2)||2.1 (1.3-3.5)||2.3 (1.4-3.6)|
|2. Adjusted for previous significant factors and adolescent behavioura,c|
|Live birth||2.4 (1.4-4.1)||0.8 (0.5-1.5)||1.0 (0.6-2.0)||1.1 (0.4-2.8)||0.9 (0.5-1.5)||1.2 (0.8-1.9)|
|Abortion||3.3 (2.0-5.4)||2.3 (1.4-3.8)||2.6 (1.6-4.3)||4.4 (2.4-8.0)||1.9 (1.2-3.0)||1.8 (1.2-2.8)|
|Miscarriage||3.1 (1.8-5.4)||1.9 (1.1-3.2)||2.1 (1.2-3.8)||4.0 (2.0-8.1)||2.0 (1.2-3.4)||2.1 (1.3-3.4)|
|3. Adjusted for previous significant factors and adolescent factors reported at 21a,c,d|
|Live birth||2.4 (1.4-4.2)||0.8 (0.4-1.5)||0.8 (0.4-1.4)||1.0 (0.4-2.6)||0.8 (0.5-1.4)||1.1 (0.7-1.8)|
|Abortion||2.6 (1.6-4.3)||2.0 (1.2-3.3)||1.7 (1.0-2.8)||3.6 (2.0-6.7)||1.7 (1.1-2.7)||1.5 (1.0-2.5)|
|Miscarriage||2.3 (1.3-4.3)||1.5 (0.8-2.7)||1.5 (0.8-2.6)||2.6 (1.2-5.4)||1.7 (1.0-3.0)||1.7 (1.0-2.9)|
|4. Fully adjusted for previous significant factors and child's demographic factors reported at 21-year follow-upa,e|
|Live birth||2.1 (1.2-3.8)||0.9 (0.5-1.7)||0.8 (0.4-1.5)||1.0 (0.4-2.6)||0.7 (0.4-1.2)||1.0 (0.6-1.6)|
|Abortion||2.5 (1.5-4.2)||2.1 (1.3-3.5)||1.5 (0.9-2.5)||3.6 (2.0-6.7)||1.5 (0.9-2.4)||1.5 (1.0-2.4)|
|Miscarriage||2.1 (1.2-3.9)||1.7 (0.9-3.1)||1.4 (0.8-2.5)||2.6 (1.2-5.4)||1.4 (0.8-2.4)||1.5 (0.9-2.5)|
Comparison testing of pregnancy outcomes
For all psychiatric outcomes, except for tobacco dependence, pairwise comparisons show that risk did not vary significantly between the never pregnant and live birth groups (P>0.15) and importantly, between women reporting either a miscarriage or abortion (P>0.40). Young women reporting a pregnancy regardless of outcome were at least twice as likely to have a tobacco dependency disorder as never pregnant women (P<0.02) and the risk of disorder did not vary between pregnancy outcomes (P>0.64). Women reporting a pregnancy loss were at increased risk of affective disorders, irrespective of whether the loss was due to abortion (P=0.02) or miscarriage (P=0.05). Those reporting having an abortion were also more likely to develop an alcohol disorder (P=0.02) or an illicit drug use disorder (P=0.02), although not a cannabis disorder, than women giving birth (online Table DS3).
In this birth cohort study, DSM–IV diagnoses and pregnancy outcomes were concurrently measured, making the direction of the associations difficult to determine. Therefore a series of six sensitivity analyses were undertaken. When we excluded women with complex pregnancy outcomes (17 participants reporting both an abortion and miscarriage and 68 reporting one or more types of pregnancy loss as well as a birth) there was no substantial change to our results, with the exception of the association between abortion and anxiety disorder, which became significant (OR=1.6, 95% CI 1.1–2.7) when individuals with abortion and miscarriage were removed, although the same was not seen when women reporting at least one birth and pregnancy loss were removed. Exclusion of participants reporting cigarette and alcohol use, anxious/depressed behaviour and aggressive/delinquent behaviour at 14 yielded similar results to those presented in Table 2.
As timing of the pregnancy was not recorded, young women reporting onset of a disorder at or before the age of their debut sexual intercourse were excluded. The majority of young women had onset of DSM–IV depression (55.8%, n=192) and anxiety (87.6%, n=366) before they started having sexual intercourse. Removal of those with early onset strengthened associations between abortion and depression (OR=1.9, 95% CI 1.1–3.3) and all the pregnancy outcomes and anxiety (OR=2.9, 95% CI 1.2–6.7). The remaining results were essentially unchanged from those reported in Table 2 (online Table DS4).
A sensitivity analysis using current (12-month) DSM–IV disorders was conducted to better account for the temporal sequence of pregnancy outcomes, psychiatric and substance use disorders. The findings were not substantially different from Table 2, except the association between abortion and current affective disorder became significant (OR=1.9, 95% CI 1.1–3.2) (online Table DS5).
There was significant loss to follow-up between the 14- and 21-year surveys. To determine if loss to follow-up at 21 years affected the validity of our findings, we conducted a sensitivity analysis using inverse probability weights Reference Hogan, Roy and Korkontzelou20 modelling the probability of having missing data at age 21. Relevant variables available at baseline were included in an exploratory regression model to determine whether individuals remaining in the study significantly differed from those lost to follow-up. Loss to follow-up at age 21 was predicted by being the child of a teenage mother (OR=1.8, 95% CI 1.5–2.0) who smoked (OR=1.4, 95% CI 1.3–1.7) and reported anxiety symptoms during pregnancy (OR=1.4, 95% CI 1.2–1.7) (online Table DS1). When weights using factors that predicted missing data at age 21 were included in all adjusted models, the results were virtually the same as those presented here, except the association between lifetime alcohol dependency and miscarriage became significant (OR=1.9, 95% CI 1.1–3.5) (online Table DS5).
This study found that young women with a lifetime history of either abortion or miscarriage were at increased risk of tobacco dependence and illicit drug use (excluding cannabis) compared with women who had never been pregnant. Women who gave birth were also at similar increased risk of tobacco dependence. However, it appears that pregnancy and parenting tasks may discourage young women from heavy drug and alcohol use. Reference Jaffee, Caspi, Moffitt, Belsky and Silva21 Women who had an abortion were twice as likely as women who were never pregnant or who gave birth to have an alcohol disorder and current affective disorder. Associations remained robust after adjustment for a range of confounders and a series of sensitivity analyses.
Two prospective longitudinal studies, one from New Zealand Reference Fergusson, Horwood and Ridder2 and the other from Norway, Reference Pedersen3 used standardised psychiatric interviews to examine a range of psychiatric and substance use disorders following abortion. Both found evidence of a causal association between abortion and later psychiatric and substance use disorders after controlling for a wide range of pre-pregnancy factors including pre-existing mental health. The New Zealand birth cohort study followed 506 women and found those reporting an abortion before age 21 had significantly higher rates of depression, anxiety, alcohol and illicit drug use by age 25 compared with women who had never been pregnant or women who had given birth. Reference Fergusson, Horwood and Ridder2 The Norwegian study followed 769 young women from age 15 to 27 and found abortion before age 20 was associated with later nicotine dependence, alcohol, cannabis and other illicit drug use in women having no stable relationship with the biological father. Reference Pedersen3 Our study found that women having an abortion had an increased risk of both lifetime and current DSM–IV diagnoses of alcohol, illicit substance use and current affective disorders but women giving birth had no such increased risk, except for tobacco dependency. Contrary to Pedersen, Reference Pedersen3 we found no association between abortion and cannabis disorder.
Despite this, our findings challenge the existing evidence of a causal link between nicotine, Reference Pedersen3 other illicit drug use, alcohol use disorders and abortion. Reference Fergusson, Horwood and Ridder2 Pairwise comparisons found that pregnancy outcomes were all equally associated with tobacco dependence; abortion and miscarriage exhibited similar associations with lifetime and current other illicit drug and lifetime alcohol use disorders. To date, no population-based study has compared adverse risk of psychiatric and substance use disorders in women reporting miscarriage and induced abortion. This study is the first large longitudinal cohort that has found a similar pattern of increased risk of alcohol and other illicit drug use disorders in women reporting either abortion or miscarriage compared with women who were never pregnant or had given birth. The findings suggest that the poor outcomes reported for women who had an induced abortion may be associated with pregnancy loss rather than simply the experience of abortion. Induced abortion and miscarriage are both stressful life events that have been shown to lead to anxiety, sadness and grief Reference Major, Cozzarelli, Cooper, Zubek, Richards, Wilhite and Gramzow5,Reference Klier, Geller and Ritsher22 and, for some women, serious depression and substance use disorders. Reference Klier, Geller and Ritsher22–Reference Martino, Collins, Ellickson and Klein24 Although we were not able to fully explain the mechanisms behind these associations, a number of possible pathways were explored in sensitivity analyses. Early heavy alcohol, illicit drug use and depression have been linked to risky sexual activity, unwanted pregnancies and pregnancy complications, Reference Martino, Collins, Ellickson and Klein24,Reference Ramrakha, Caspi, Dickson, Moffitt and Paul25 and could be on the causal pathway leading to both pregnancy loss and adverse psychiatric outcomes. After taking these factors into account and removing early onset disorders our findings remained robust. This suggests that our results were unlikely to be explained by reverse causality. Pregnancy loss and substance misuse may have shared risk factors. Unplanned pregnancy commonly co-occurs with individual and social risk factors such as early sexual activity, poor school performance, cigarette smoking, alcohol and illicit drug taking and behaviour problems. Reference Jaffee, Caspi, Moffitt, Belsky and Silva21,Reference Martino, Collins, Ellickson and Klein24,Reference Fergusson, Boden and Horwood26 Although we may have not been able to control for all confounding, associations in our study remained robust after adjustment for a wide range of such potential confounding factors. Finally, pregnancy loss may be directly associated with an increased risk of later substance misuse, particularly if alcohol and illicit drugs are used to decrease emotional responses to the loss. Reference Fergusson, Horwood and Ridder2,Reference Pedersen3,Reference Bradshaw and Slade27–Reference Broen, Moum, Bödtker and Ekeberg29 Future longitudinal studies are needed to better understand the relationship of pregnancy loss with adverse psychiatric outcomes in young women.
This study has a number of limitations. Contextual information related to circumstances of the pregnancy loss were not collected, so we could not account for associated factors such as reasons to abort, support received and gestational age at the time of the pregnancy loss. We had no access to medical records to investigate whether specific circumstances surrounding the termination, the timing of termination or other pregnancy-related events would confound associations between pregnancy loss and psychiatric disorders. Concern about possible underreporting of abortion has been raised. Reference Fergusson, Horwood and Ridder2,Reference Reardon and Cougle30 Data on abortion history was collected from a self-reported survey, and Jones & Kost Reference Jones and Kost31 found this method provides a more accurate abortion history than face-to-face interview. Women may have misclassified induced abortions as miscarriages; however, this appears unlikely as the reported rate of miscarriage was no higher than expected. Reference de Vaus32 It is also possible that the use of retrospective recall and concurrent assessment of pregnancy outcomes and DSM–IV disorders introduced some bias in our findings, although sensitivity analysis using more recent onset psychiatric disorders produced the same results as those shown in our main analysis. The high rate of attrition between the 14- and 21-year follow-up raised the possibility of bias in estimation of the magnitude of risk. Weighted analysis, which adjusted for factors associated with attrition at age 21, was not substantially different from the reported findings, which suggests that attrition bias is unlikely to have produced bias in our results. Finally, ours is a study of young women whose ages ranged from 18 to 23 years and therefore our results should not be generalised to older women or women of all ages.
Our study found that young women had similar increased risks of lifetime and current tobacco use, alcohol dependency and illicit substance use, although not cannabis, after an abortion or miscarriage compared with women who had never been pregnant. These associations may relate to common factors associated with pregnancy loss or early pregnancy, rather than being caused by the experience of induced abortion.
The authors wish to thank the Mater-University of Queensland Study of Pregnancy (MUSP) principal investigators for access to the data, the MUSP21 data collection team, as well as all the mothers and child participants over the 21 years of the MUSP project. The core study has been funded primarily by the National Health and Medical Research Council of Australia (NHMRC). NHMRC also funded A.C. (Capacity Building Grant), R.A. (NHMRC Career Development Award in Population Health, ID: 519721) and K.D. (NHMRC Public Health Postgraduate Research Scholarship, ID: 351654). The views expressed in the article are those of the authors and not necessarily those of any funding body.