INDUCED ABORTION AND MENTAL HEALTH A SYSTEMATIC REVIEW OF THE MENTAL HEALTH OUTCOMES OF INDUCED ABORTION, INCLUDING THEIR PREVALENCE AND ASSOCIATED FACTORS. DECEMBER 2011 Developed for the Academy of Medical Royal Colleges by National Collaborating Centre for Mental Health, London, 2011 This review was funded by the Department of Health The National Collaborating Centre for Mental Health (NCCMH) was established in 2001 at the Royal College of Psychiatrists, in partnership with the British Psychological Society. Its primary role is to develop evidence-based mental health reviews and clinical guidelines CONTENTS Steering Group Members................................................,............................................................................................05 Executive summary.......................................................................................................................................................07 1 Introduction.........................................................................................................................................................09 1.1 Background...........................................................................................................................................................................09 1.2 Terminology...........................................................................................................................................................................11 1.3 Abortion Legislation..............................................................................................................................................................11 1.4 Previous reviews: the relationship between induced abortion and mentalhealth..........................................................12 1.4.1 Recent systematic reviews..................................................................................................................................................12 1.4.2 Limitations of the research included in the previous reviews...........................................................................................14 1.4.3 Limitations in methodology of the previous reviews..........................................................................................................17 1.4.4 Summary of key findings from the APA, Charles and Coleman reviews..........................................................................18 1.5 The present review: The relationship between induced abortion and mental health....................................................19 2 Methods...............................................................................................................................................................21 2.1 The steering group................................................................................................................................................................21 2.2 Review questions..................................................................................................................................................................22 2.3 Eligibility criteria....................................................................................................................................................................22 2.4 Information sources..............................................................................................................................................................24 2.5 Study selection......................................................................................................................................................................25 2.6 Results of literature search..................................................................................................................................................25 2.7 Quality assurance.................................................................................................................................................................26 2.8 Risk of bias in individual studies.........................................................................................................................................28 2.9 Applicability to research questions......................................................................................................................................28 2.10 Data items and extraction....................................................................................................................................................30 2.10.1 Prevalence .............................................................................................................................................................................30 2.10.2 Factors associated with poor mental health.......................................................................................................................30 2.10.3 Mental health outcomes for women following abortion compared with those following a delivery............................30 2.11 Data analysis and synthesis of results.................................................................................................................................31 2.12 Grading the evidence............................................................................................................................................................32 2.13 Consultation..........................................................................................................................................................................35 3 Prevalence of mental health problems in women following an induced abortion........................................37 3.1 Review question....................................................................................................................................................................37 3.2 Studies considered...............................................................................................................................................................37 3.3 Studies that did not account for previous mental health Problems.................................................................................37 3.3.1 Study characteristics............................................................................................................................................................37 3.3.2 Findings..................................................................................................................................................................................42 3.3.3 Limitations.............................................................................................................................................................................54 3.4 Studies that account for previous mental health problems..............................................................................................56 3.4.1 Study characteristics............................................................................................................................................................56 3.4.2 Findings..................................................................................................................................................................................58 3.4.3 Limitations.............................................................................................................................................................................62 3.5 Comparison of studies that accounted for previous mental health problems and studies that did not account for previous mental health problems........................................................................................................................................63 3.6 Evidence statements............................................................................................................................................................64 A SYSTEMATIC REVIEW 4 Factors associated with mental health problems following an induced abortion.........................................65 4.1 Review question....................................................................................................................................................................65 4.2 Studies considered...............................................................................................................................................................65 4.3 Factors associated with poor mental health following an abortion.................................................................................66 4.3.1 Study characteristics............................................................................................................................................................66 4.3.2 Findings..................................................................................................................................................................................73 4.3.3 Limitations.............................................................................................................................................................................88 4.3.4 Factors associated with mental health problems following birth or pregnancy.............................................................90 4.4 Evidence statements............................................................................................................................................................90