Postpartum psychiatric episodes are often linked to prior abortions or miscarriages, yet also often overlooked

Because women are at increased risk of mental health issues during the postpartum period (1-4), this is an important topic of interest for many researchers and practitioners. For example, in a recent issue of the Annals of Emergency Medicine a medical records-based study of Ontario’s health administration revealed that 11.7% of women who had recently given birth sought repeat emergency department (ED) care for psychiatric symptoms within 30 days of their first ED visit (1). The analysis included controls for twenty risk factors, among which the highest adjusted relative risk was reported to be a history of prior psychiatric admissions [1.46; 95% confidence interval (CI): 1.28–1.68].

Another recent medical registry study from Denmark also investigated the risk of a first time postpartum psychiatric episodes among women experiencing a first live birth controlling for age, family history of psychiatric disorders, personal history of psychiatric disorders, and a high polygenic score for a genetic trait indicating an elevated risk of mood disorders and postpartum psychiatric episodes (2). A previous history of psychiatric disorders was the strongest risk factor, reported as a hazard ratio (6.53; 95% CI: 4.78–8.97).

These studies have two things in common. First, both agreed that a personal history of prior mental health treatments was the strongest predictor of a need for psychiatric care in the postpartum period. Secondly, both record-based studies could have, should have, but did not consider the effects of prior pregnancy loss on postpartum mental health.

This commentary begins with an argument for the position that every investigation of risk factors for mental health issues, especially in the postpartum period, should always include consideration of women’s entire reproductive histories. Whenever possible, such investigations should control for the number of pregnancy losses, the type of pregnancy losses, and the timing of the first loss relative to the first mental health treatment. Secondly, we will explore other examples and possible reasons why these important risk factors are frequently ignored or even obscured.

Pregnancy loss is an important risk factor for mental health issues, especially in the postpartum period

Clinical experience (5-8) and self-reports (5,6,9) reveal that unresolved grief over prior abortion(s) may often be aroused and aggravated during subsequent pregnancies. Especially in the postpartum period, when there are also many hormonal changes, new mothers may experience dissonance between the joys of a newborn child and unresolved grief over the child(ren) they can never hold (4,6,9).

For example, in a retrospective survey of 260 women with a history of abortion, 49% reported that the birth of a subsequent child triggered a worsening of negative feelings surrounding the prior loss (6). Additionally, in a cross-sectional study of 198 women recruited during their first-year pediatric well-child visit who completed the Semi-structured Clinical Interview for DSM Disorders (SCID), the women who had experienced a prior pregnancy loss (either natural or induced) were more likely than those who had not to be diagnosed with major depression and anxiety disorders (4). Moreover, there was a dose effect, with women who had multiple pregnancy losses more likely to be diagnosed with either major depression and/or post-traumatic stress disorder compared to those with only one pregnancy loss (4). A similar dose effect was also reported in an analysis of the National Longitudinal Study of Adolescent to Adult Health (Add Health). After controlling for 25 confounding factors, including prior mental health and exposures to violence, this Add Health study found that each exposure to abortion was associated with a 23% increased risk of subsequent mental health disorders (10). In addition, the women who reported aborting a wanted child experienced a 122% higher rate of depression and a 244% higher rate of suicidality (11). Similarly, in a prospective study of 212 first-time mothers recruited at the time of their deliveries for a postpartum evaluation three to six months later, there was a sixfold increased risk of postpartum psychiatric episodes among women with a history of abortion (12).

In our own examination of medical records for 1.5 million Medicaid beneficiaries in the United States, we examined the risk of mental health treatments among women experiencing a first live birth (3). Overall, after adjusting for prior mental health, age, race, and the year of the first live birth, exposure to a prior pregnancy loss had a significant independent effect on the rate of postpartum psychiatric treatments [adjusted odds ratio (OR) 1.27, 95% CI: 1.25–1.29] within 6 months of a first live birth. This elevated risk was most pronounced within the first 90 days postpartum (42% higher risk) and for inpatient treatments (83% higher risk). Differences between the two groups became even more evident when the data was analyzed relative to the timing of a first mental treatment before, after, or between the conception of a first pregnancy loss and a first live birth. Most notably, 99.97% of the women who experienced both a history of pregnancy loss and their first mental health treatment in the year preceding their first live birth necessitated postpartum mental health care (adjusted OR >999). Among women whose first mental health treatment occurred between their first estimated conception date of their first live birth (a period which includes both the time of pregnancy and the time between a pregnancy loss and a first live birth) the adjusted OR was 13.39 (95% CI: 13.16–13.62). This suggests that mental health events that may be triggered by a first pregnancy are at greater risk of being re-triggered following a subsequent live birth. That interpretation is strengthened by the additional finding that among only those women with a history of pregnancy loss, those whose first mental health treatment occurred between conception of the lost pregnancy and first live birth were over seven times more likely to require postpartum psychiatric care (adjusted OR 7.25; 95% CI: 6.95–7.56).

The above findings represent strong evidence that a history of pregnancy loss is associated with elevated risk of postpartum psychiatric events. That is also consistent with a larger body of literature showing that both miscarriage and abortion are consistently associated with higher rates of mental health disorders (9). While experts disagree when, if ever, abortion is the sole and direct cause of any specific mental illnesses, there is no longer any dispute regarding the fact that pregnancy loss can contribute to mental illness as a trigger or exacerbating factor of affective disorders, self-destructive behaviors, substance use disorders, eating disorders and complicated or impacted grief (6,9,10,13). Additionally, studies controlling for prior mental health have consistently shown that the post-abortion differences in mental health cannot be fully explained by prior mental health (3,10,11,13-15). A causal interpretation of the link between abortion and mental health issues is further supported by both the reports of self-aware women (5,6,9,16) and the clinical successes of mental health counselors, on both sides of the abortion debate, whose treatments focused on grief and guilt issues flowing from these pregnancy losses have been shown to alleviate the presenting mental health issues (5-8,16-18). If a treatment protocol works, the diagnostic hypothesis of a causal connection is most likely correct.

While any pregnancy loss may trigger the grief process, social norms and higher levels of self-blame may make it more difficult to complete the grief process after an induced abortion (6). This may help to explain a recent finding that psychiatric treatment rates increase significantly more after an abortion than after a natural loss (15).

In addition, it is clear that women who agree to abortions contrary to their own preferences and values, generally due to pressures to abort from other people or circumstances, are most likely to attribute negative mental health outcomes to their abortions (9,19,20). The best evidence indicates that this subgroup may include nearly 70% of women with a history of induced abortion (9,19).

Obstacles to and examples of missed or misleading research opportunities

There is little dispute over the fact that miscarriage and other natural losses can contribute to mental health issues. So, one might expect that a medically induced miscarriage would share at least some of the same risks. But the highly politicized environment surrounding induced abortion seems to have created an exaggerated need to deny that induced abortion can have any negative impact on women (9). In my own experience, as the author of over 50 papers related to abortion, journal editors and peer reviewers are often disinclined to accept, review, or to judge on equal terms any submission that threatens the prevailing narrative that abortion is solely a boon to women’s health and free of any and all risks. Whether other researchers fail to include abortion related results because they fear such biases in the path of publication, or because they simply do not want to provide statistical evidence that might add weight to the arguments of abortion critics, it is clear that many researchers have deliberately avoided including analyses controlling for abortion and natural pregnancy losses when they could and should have been considered.

For example, despite both private and public attempts to encourage such analyses, a number of prominent Danish studies of reproductive mental health have carefully excluded any consideration of pregnancy loss (21). In one rare exception, Danish researches investigating the effects of miscarriage on subsequent mental health, included a history of abortion as a covariate, but this was noted only in a footnote and all details regarding the degree of this observed effect were withheld (22), both from the publication and in a refusal of this author’s direct request for additional details.

The concern that there may be selective reporting of abortion related results is elevated further by a reanalysis of one of the few Danish studies investigating abortion and mental health (23). In the original analyses, post-abortion mental health effects over just one and three months periods were compared to the average rate of mental health treatments in the nine months preceding an abortion (24). The difference in the elevated rates of psychological treatment pre- and post-abortion was, for the most part, not statistically significant when examined using these short and dissimilar time periods. This led the Danish authors to conclude that the higher rate of psychiatric treatments following abortion, compared to childbirth, were entirely due to pre-existing mental health differences (24). But in my own reanalysis of their published data of the cumulative rate of mental health treatments revealed that, compared to the average monthly rate of first time mental health treatments in the nine months prior to abortion, there was a significantly higher average monthly rate of mental health treatments in the first nine months after an abortion (OR 1.12; 95% CI: 1.02–1.22), and an even greater difference when the average was extended over the first twelve months post-abortion (OR 1.49; 95% CI: 1.37–1.63) (23). This finding is consistent with the evidence that many negative reactions to abortion can be triggered by anniversary reactions or delayed until the exhaustion of coping mechanisms (6,9). In addition, this reanalysis of the Danish abortion study also revealed that there was an 87% increased risk, from pre- to post-abortion, for a diagnosis of personality or behavioral disorders (OR 1.87; 95% CI: 1.48–2.36) and a 60% increased risk of neurotic, stress related, or somatoform disorders (OR 1.60; 95% CI: 1.41–1.81).

It is difficult to imagine that the Danish research team failed to notice the above noted differences if their data had been examined over the entire twelve months of post-abortion data they study examined, or even over nine months, a period of time equal to the timeframe they chose for their pre-abortion benchmark. That is why, at least for this writer, there is a lurking suspicion that abortion related results are being ignored or suppressed in research regarding women’s mental health due to the political biases of authors, reviewers, and/or journal editors (9).

Recommendation

The best evidence indicates that while prior mental health is the strongest risk factor for postpartum psychiatric episodes, a history of pregnancy loss is one of the next most significant risk factors, especially in specific circumstances where the timing of the pregnancy loss and prior mental health issues appear to reinforce and magnify the risk of a postpartum psychiatric episode. Political concerns about documenting mental health risks associated with abortion, miscarriage, or any other form of pregnancy loss, should not dissuade or impede research related to the intersection of reproductive and mental health. Wherever possible, all studies of risk factors for mental health issues should include consideration of women’s full reproductive health history, including pregnancy losses. Additional research should also investigate if there are different effects associated with therapeutic abortions.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Public Health and Emergency. The article has undergone external peer review.

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-48/prf

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-48/coif). D.C.R. reports support from Elliot Institute and consulting fees from Charlotte Lozier Institute. D.C.R. is an advocate for post-abortion healing programs for women injured by unwanted abortions. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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