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Science or Politics?

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Title: Science or Politics?


1
Science or Politics?
  • The Abortion Debate

2
Some Numbers
  • An estimated 38 of pregnancies world wide are
    unintended
  • Of these, about half end in abortion
  • 4/5 of women having induced abortions live in
    developing countries

3
Who is the typical abortion client?
  • In the developing world, 90 are married, and
    most already have children
  • In the United States and Canada, 75-80 are
    unmarried, half are 25 years of age or older
  • In the Netherlands, teen pregnancy rates are 1/10
    of those in the US, and abortion rates 1/8

4
The History of Fertility Regulation
  • Oldest known medical texts describing abortion in
    China about 2700 BC
  • Recipe for abortion found on an Egyptian papyrus
    scroll, dated about 1550 BC
  • Familiar practice in classical Greek and Roman
    times

5
More Recent History
  • Common procedure in 19th century Europe and North
    America
  • One American doctor in 1860 estimated that 1in 5
    pregnancies then ended in abortion another
    estimated in 1890 that 2 million abortions were
    performed every year in the US, which compares to
    1.3 million now
  • No American State had a law against abortion
    until 1821

6
More Recent History
  • The Roman Catholic Church was relatively tolerant
    of abortion before quickening up to 1869, when
    Pope Pius IX declared that ensoulment occurred at
    conception
  • Saint Augustine speculated that the fetus
    obtained a soul at the 46th day, the time in
    years it took to build the temple in Jerusalem

7
Public Attitudes to Abortion
  • Difficult to assess, but probably 10 of people
    in North America, oppose abortion for any reason,
    while 30-40 support access to abortion without
    restriction
  • Remainder express discomfort about abortion, but
    have difficulty determining what restrictions or
    rules should be imposed difference between what
    is wrong and what should be illegal

8
The Medical Profession and Abortion
  • Shortly after its formation the AMA in the mid
    1800s spoke out against abortion and
    contraception
  • Medical school curricula addressed neither until
    the 1930s
  • Nonetheless in the first half of the 20th century
    hospitals did perform abortions for a growing
    list of medical indications, usually for
    privileged clients with the appropriate
    connections

9
The Medical Profession and Abortion
  • 1950s and 1960s the therapeutic abortion
    committees appeared
  • Access however remained very inconsistent, with
    no standards or agreed upon means of making these
    decisions, which was exacerbated with the
    addition of psychiatric indications for abortions
    in the 1960s

10
Since liberalization of access
  • The post-abortion syndrome
  • Medical education and its impact on abortion
    services
  • Access to information

11
The search for a post-abortion syndrome
  • Numerous papers have examined the literature to
    determine whether or not there is any increased
    risk of psychological harm following an induced
    abortion
  • The goal would appear to be to provide support
    for limiting access to abortion, by creating the
    fear that long term serious psychological damage
    is caused by this procedure

12
  • Many careful reviews of the literature have
    failed to find any clear link between induced
    abortion and psychological distress, but there
    are exceptions, that deserve examination

13
How Can We Understand the Discrepancy?
  • Studies published since 2000 reviewed
  • Rationale
  • Reviews prior to this time generally support no
    negative impact
  • Arguments in favour of position that induced
    abortion is psychologically dangerous, criticize
    these earlier studies as being of poor quality,
    too small, and too short

14
Classification of Studies
  • Records Linkages
  • Reviews
  • Prospective Studies
  • Youth Focused Studies

15
Records Linkages
  • Finnish Record Linkage
  • published in 1996, but cited in review of 2003 as
    most important result given hard end point
    suicide, as opposed to soft measures (eg.
    Scales assessing depression, psychiatric
    morbidity)
  • Linked death by suicide with evidence of
    pregnancy and abortion in the past year
  • Rates of suicide with birth lower than age
    adjusted averages, while rates for miscarriage
    and induced abortion higher

16
Records Linkages (cont.)
  • So?
  • Deliveries much more likely to occur in the
    context of a wanted pregnancy
  • Did not separate induced abortion of wanted child
    with genetic defect from abortion for other
    reasons
  • Predictors of unwanted pregnancy not considered
    in terms of impact on subsequent health

17
Record Linkages (cont.)
  • Reardon et al (2002)
  • California Medicaid data from 1989-1997
  • Compared with women who delivered, those who
    aborted had a significantly higher risk of death
    from all causes, from suicide, and from
    accidents.
  • Concludes that
  • women with children more likely to avoid risk
    taking, or
  • that history of abortion may be marker for other
    stresses, or
  • that the higher death rate amongst aborting women
    may stem from increased stresses related to
    unresolved guilt, grief, or depression, and
    supports this latter statement by citing an
    analysis of this data that showed that
    controlling for prior psychiatric treatment in
    the year before the procedure did not affect the
    results

18
Problem?
  • Did not control for unwanted vs. wanted pregnancy
  • Prior registered psychiatric treatment in the
    year prior does not accurately reflect all
    problematic behaviour patterns such as risk
    taking
  • Statement about guilt, unresolved guilt, and
    depression not supported by any evidence
  • Issue of causality

19
Record Linkages
  • US National Longitudinal Survey of Youth
  • Assessed those with unwanted first pregnancy
  • Analysis by Reardon and Cougle (2002)
  • Married women who aborted were found to be at
    higher risk for depression as predicted by the
    CES-D than those who carried the pregnancy to
    term
  • No difference for unmarried women (trend to
    higher rates of depression in those who carried
    to term)

20
Record Linkages
  • Reardon and Cougle (cont)
  • Postulated that shame, secrecy and thought
    suppression regarding abortion caused these women
    to under report abortion, and since these
    individuals in their view are at higher risk of
    negative reactions, result was diluted

21
Record Linkages
  • US National Longitudinal Study of Youth
  • Analysis by Schmiege and Russo (2006)
  • Presented careful discussion of how they
    determined who had an unwanted pregnancy
  • Found no evidence of difference between risk of
    depression in group that delivered vs. those that
    had an abortion
  • Assessed for under-reporting by looking at groups
    known in previous studies to under-report and
    found that in those groups the result was the same

22
Why the Difference?
  • Impact of conflict of interest?
  • Pre-existing bias that is un-reported?
  • Role of expertise in interpretation of data?

23
Youth and Abortion
  • Two studies this decade one concludes there is
    no evidence of increased risk for young people,
    the other that there is
  • Evidence of risk?
  • Record linkage study in New Zealand delivery
    vs. abortion looked at rates of psychiatric
    disorders, and childhood, family and other
    confounding factors, but did not address
    wantedness, nor identified that as a weakness
    of the study

24
Youth and Abortion
  • No risk?
  • Looked at women aged 14-21 seeking counselling
    for unwanted pregnancies and assessed pre and
    post-abortion mental distress, comparing under 18
    and over 18 no difference between groups, and
    evidence of decreased distress post-abortion in
    both
  • Problems short term, no comparison with delivery

25
Youth and Abortion
  • Strongest study to date
  • Zabin et al, 1989 360 young women who presented
    for pregnancy testing, and compared non-pregnant,
    delivery, and abortion and followed for two years
  • Abortion group showed no greater distress or
    anxiety at time of test and no more likely to
    experience psychological distress at 2 years
  • Better school performance than other two groups,
    and less likely to experience pregnancy and more
    likely to practice contraception

26
Other New Research on Abortion
  • Two Reviews Bradshaw and Slade (2003) and Thorp
    et al (2003)
  • Thorp concluded increased risk of depression on
    the basis of report of suicide noted in Finnish
    linkage study despite inclusion criteria that
    would have included studies such as Zabin et al,
    only reviewed a handful of studies, and used no
    methods to determine relative impact of findings
    other than favouring the finding of suicide over
    other subjective measures
  • Search strategy limited to abortion and
    complications of abortion

27
New Research
  • Bradshaw and Slade
  • More extensive database, broader search strategy
  • Cited much larger selection of studies
  • Concluded that findings are generally in line
    with those reported in previous reviews in that
    most distress was reported prior to the abortion,
    and levels of distress decreased following
    abortion

28
Prospective Studies
  • Major et al (2000)
  • 882 subjects assessed before procedure,
    immediately after procedure, and 1 month and 2
    years later (dismissed by Thorp as a self-report
    study when it was interviewer based with
    validated instruments)
  • Found that most women did not experience
    psychological problems or regret their decision 2
    years later, but some do identified risk factors

29
Prospective Studies
  • Kero et al(2003)
  • 58 women 4 and 12 months post abortion
  • Majority did not experience any emotional
    distress following abortion
  • Almost all described it as a relief or a form of
    taking responsibility, and more than half
    reported only positive experiences such as mental
    growth and maturity
  • Mixed feelings were present although tended to
    decline over time, and about 1/5 did experience
    feelings of distress following the procedure
  • Concludes that the majority of women are able to
    make the complex decision about abortion without
    suffering any subsequent regret or negative
    effects

30
Prospective Studies
  • Lee et al (2000)
  • Post-natally, 220 women interviewed and
    relationship found between more than two
    abortions in past and presence of depressive
    symptoms at this time
  • Concluded that a history of previous therapeutic
    abortions was associated with post-natal
    depression

31
Knowledge and Abortion
  • What is the current climate with respect to
    knowledge about abortion?
  • Medical Education
  • In the early 1990s nearly half of all graduating
    residents in ob-gyn in the US had never performed
    a first trimester abortion by the late 1990s
    this number was still 1/3

32
Knowledge and Abortion
  • Medical Education
  • In 1991, only 12 of US Ob-Gyn training programs
    routinely offered training in first trimester
    abortions
  • In the late 1990s an expert educator in Canada
    estimated that only 1/3 of residents in Ob-Gyn
    received training in this procedure the
    training objectives of the Royal College of
    Physicians and Surgeons of Canada require only
    knowledge of the procedure not experience or
    expertise

33
Knowledge and Abortion
  • Writing an Abortion Book
  • Previously published primary author with
    international reputation
  • Book sent to 4 literary agents in New York with
    reputation as sympathetic feminists
  • One reported that she had handled a manuscript
    the previous year that the agent felt was
    excellent and 32 publishers turned it down
  • Another described our manuscript as excellent,
    but was unwilling to take it on because
    publishers considered the topic toxic
  • In the end self published, and sold about 1000
    copies several very strong reviews, and placed
    now in numerous library collections, but no
    publisher or agent willing to handle a re-release

34
Knowledge and Abortion
  • When book published
  • Donated a copy to our hospital library, but no
    public or even hospital wide release notice

35
So What Does This Mean?
  • Climate in which the scientific literature is
    being used to advance political/social agendas
    without acknowledgement of this?
  • Climate in which the sharing of information on
    abortion is in part suppressed by fear of
    reaction?

36
So What Does This Mean
  • Need to expand reporting on conflict of interest
    and bias?
  • Rather than focusing on understanding the complex
    experience of women dealing with unplanned
    pregnancies, we are focussing on a good or bad
    discussion that aims at reducing access or
    defending acess

37
So What Does This Mean?
  • If we feel a procedure is damaging and thus
    should be restricted, we need to look at the
    impact of the procedure, and the impact if the
    procedure is denied which historically in the
    case of abortion has meant
  • Illegal, unsafe abortion with high morbidity and
    mortality, and no less frequency than when access
    is more liberal
  • Complex issues of Born Unwanted
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