Thirty-one years after the Supreme Court issued its landmark Roe vs. Wade decision, the argument about abortion remains one of the most acrimonious in America today.
Scores of studies published during the last three decades attempt to determine scientifically the effects of what may be the nation's most common medical procedure.
Priscilla Coleman, a researcher at Bowling Green State University, is among a small group of investigators looking for scientific answers to a question swaddled in layers of moral, religious, and political belief.
Ninety percent of U.S. abortions occur in the first trimester, when the health risks to the women are minuscule, according to the Alan Guttmacher Institute, a nonprofit organization with offices in Washington and New York City. The institute focuses on reproductive health issues and may be the only research group cited favorably by all sides in the debate.
A Guttmacher survey of all U.S. abortion providers found that 1.31 million women had abortions in 2000. This is a decline from a high of 1.6 million abortions yearly in the early 1990s. Still, the institute estimates, at that rate 35 percent of American women will have an abortion by age 45.
Since abortion was legalized on Jan. 22, 1973, abortion-associated deaths plummeted, the institute reports. In 1965, before any states liberalized abortion laws, 200 women died as a result of the illegal procedure. Today, about 10 women die each year from abortions, mostly because of complications of anesthesia or from hemorrhage.
But do the hundreds of thousands of women who opt for abortion each year open themselves to risk?
It depends on the woman, Dr. Coleman said.
“People who decide to have an abortion, are comfortable with it, have social support for it ... the majority of women will not have a problem. Most women, at this point in the understanding of the literature ... are not harmed psychologically.”
But, she said, many studies show that 10 percent of women who have abortions do have problems.
“It's that 10 percent with a common procedure that just keeps nudging at me,” she said. “I think that's a group we really need to look at more closely. Ten percent of 1.3 million women. How could we ignore that? If it was any other medical procedure it would get more attention,” Dr. Coleman said.
“I consider myself pro-choice,” said Nancy Russo, an Arizona State University researcher who studies abortion and other women's issues, “but as far as I'm concerned, whether or not an abortion creates psychological difficulties is not relevant ... it means you give proper informed consent and you deal with it.”
In fact, Dr. Russo argues that the continuing effort to stigmatize abortion is creating some of the effects researchers may be finding.
“All of this stuff is a campaign to manipulate the women's appraisal [of their abortions].It's not about the research. It's misrepresentation of what we know. It's the manipulative and cunning campaign,” she said.
With such contentious debate among scientists, it's no wonder that scientific journals publishing research on abortion catch a share of the flak.
This summer, Dr. Coleman was co-author of a study published in Canada's most prestigious medical journal. The study compared psychiatric hospitalizations among 15,000 women who had abortions to the number of such hospitalizations among 41,000 women who gave birth. None of the women had been treated for a psychiatric illness in the year before their pregnancy. All of the data came from MediCal, California's Medicaid program.
In that study, women who had abortions were far more likely to be hospitalized for psychiatric illness during the four years after their pregnancy. Although only 1.5 percent of the women who had abortions were admitted for psychiatric treatment during the four years examined, their rate of hospitalization was considerably higher than the birth group. Among those 41,000 women, 0.7 percent were hospitalized for mental-health problems.
Within 90 days of the abortion or birth, women who had abortions had a rate of psychiatric admission 160 percent higher than women who gave birth. At the four-year mark, women who had abortions were 50 percent more likely to be admitted for psychiatric treatment.
Canadian Medical Association Journal editors also published a critique of the above study by Brenda Major, a professor at the University of California, Santa Barbara.
Her main criticism involved the distinction between coincidence and cause. Simply noting a correlation between abortion and psychiatric admissions fails to identify a cause, she said.
“It is just as plausible that the direction of causality is reversed ... that psychiatric problems cause women who become pregnant to feel less capable of raising a child and to terminate their pregnancy.”
Or perhaps a third variable, undetected in the study, was at fault. The MediCal data did not indicate whether the women were in stable relationships, for instance. Nor did the MediCal data show education levels.
Despite the journal's attempt at balance, criticism of the publication was swift and furious, said CMAJ editor John Hoey. Letter writers attacked both the article and Dr. Major's response.
“They all used the same kind of rhetoric, not discussing the science, but the politics of the medical journal. I think that was a little surprising,” Dr. Hoey said.
While Dr. Coleman's studies consistently tally a number of negative effects of abortion in a small percentage of abortions, other researchers fail to find the same cause-and-effect relationship.
Dr. Russo looked at data from 5,295 women interviewed annually from 1979 to 1987 in the National Longitudinal Study of Youth, conducted by Ohio State University. Among these women, 773 had at least one abortion. The survey also evaluated the women's self-esteem in 1980 and 1987.
Dr. Russo's analysis, published in 1992, found that the biggest predictor of well-being in 1987 was not abortion in the intervening years, but a low self-esteem score in 1980. Women with the lowest self-esteem scores were those with unwanted births.
A study by Dr. Major published in 2000 in the Archives for General Psychiatry followed 442 women for two years.
The study began with 882 women whose levels of depression and self-esteem were assessed one hour before their abortions. Two years after their abortion, 442 of the original 882 were reassessed for self-esteem, depression, and perceptions of the abortion's harm or benefit.
Dr. Major concluded that most women - 72 percent - were satisfied with their decision to abort, and 69 percent said they would make the same decision if they had to do it over again. In addition, 72 percent said the abortion was of more benefit than harm, and 80 percent reported no depression. In addition, self-esteem measures rose for many women post-abortion as well.
Dr. Major found that the best predictor of post-abortion depression was an elevated level of distress before the abortion, a conclusion that other studies have reached as well.
Not surprisingly, abortion opponents have criticized these studies.
Dr. Coleman points to the number of women who apparently dropped out of Dr. Major's study before it was completed. Some 50 percent of the 882 women who began the study did not participate in the two-year follow up.
“What's that going to tell you?” Dr. Coleman said. She said those most likely to consent to continue the study are those least affected by abortion. She cited a 1998 European study that reported that women with negative post-abortion experiences were least willing to participate in abortion research.
Further, Dr. Coleman faulted both of the above studies for their use of self-esteem as an indicator of well-being.
“Self-esteem doesn't tend to fluctuate based on life events. It develops slowly over time. Overall, I wouldn't expect it to change much,” she said.
Although Dr. Coleman and Dr. Russo both have used data from the National Youth Longitudinal Survey, it has weaknesses as well. Because it relies on self-reporting, there's no way to be sure of its accuracy, particularly because some studies show half of all women will conceal their abortion history.
Dr. Coleman said using the MediCal data allowed her to avoid the problem with concealment, because abortions are part of the MediCal record.
Dr. Coleman has used MediCal data in a number of studies showing a injurious effect of abortion. Probably the most chilling one appeared in the Southern Medical Journal in 1995.
It showed women who aborted were 62 percent more likely to die from any cause in the eight years after pregnancy than women who carried their pregnancies to term.
The abortion group had an 81 percent higher rate of violent death, a 154 percent higher suicide rate, a 446 percent higher rate of cerebrovascular disease, and a 187 percent higher rate of circulatory disease.
“They should be embarrassed putting that out there,” responds Dr. Russo. “Some of these Medicare populations, do you ever look at the circumstances of these women's lives? They're drug abusers. They're alcoholics. They have seven or eight and six abortions. It means these women have horrible life experiences. It doesn't help us to help these women by trying to attribute their problems to abortion.”
In her own studies, Dr. Russo said, the most important predictor of depression or distress is not abortion, but violence. When studies control for a history of violence or a violent partner, the negative effects of abortion disappear.
But Dr. Coleman says it isn't clear whether abortion is the only or even the primary cause of the negative effects her studies reveal. In fact, the decision to abort may be part of a package.
“There are a whole lot of factors that lead up to the decision, a whole lot of lifestyle circumstances, and that can be predictive,'' she said.
“So when you look at the negative effects, what are you really looking at? Is it a product of their choice? Or are they experiencing depression or whatever because they were battered? Or because of the abortion? It's hard to tease apart.”
First Published January 22, 2004, 2:04 p.m.
