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. 2002 May 4;324(7345):1097.

Depression and unintended pregnancy in young women

Paper raises at least three concerns

Robert S Kahn 1
PMCID: PMC1123039  PMID: 11991923

Editor—Reardon and Cougle's paper raises at least three concerns.1

Firstly, their analyses do not address the stated hypothesis. No results indicate whether “prior psychological state is equally predictive of subsequent depression among women . . . regardless of whether they abort or carry to term.” Nevertheless, their unstated hypothesis, focused on abortion and depressive symptoms, may be the more central question.

Secondly, the final sample of women is surprisingly small. Only 421 of the initial 4463 women reported a first abortion or first unintended delivery between 1980 and 1992. Is it possible that the question in 1992 asking pregnancy intention actually referred to a much narrower time frame (that is, a delivery between the biannual surveys)? Little information is given about the abortion question; it is possible that the index unintended pregnancy defined in 1992 resulted in neither the first abortion nor the first delivery.

Thirdly, the discussion omits mention of possible residual confounding. The national longitudinal survey of youth (NLSY) uses a four item abbreviated version (NLSY Cronbach α 0.35) of Rotter's original 60 item locus of control scale, which itself is probably an inadequate proxy for prior psychological state. Furthermore, a one year measure of income may be only a modest proxy for a person's lifetime socioeconomic position.2,3 The robustness of the authors' findings could be examined with other available measures. For example, the 1980 Rosenberg self esteem scale data (NLSY Cronbach α 0.83) and the full 12 years of annual income and family size data would be stronger, though still less than optimal, tests of the hypotheses.

This criticism is not an attempt to dismiss research on the topic; rather, such important and highly contentious questions require published studies with equal degrees of rigour and transparency.

References

  • 1.Reardon DC, Cougle JR. Depression and unintended pregnancy in the national longitudinal survey of youth: a cohort study. BMJ. 2002;324:151–152. doi: 10.1136/bmj.324.7330.151. . (19 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Wolfe B, Haveman R, Ginther D, An CB. The “window problem” in studies of children's attainments: a methodological exploration. J Am Stat Assoc. 1996;91:970–982. [Google Scholar]
  • 3.Smith GD, Hart C, Blane D, Gillis C, Hawthorne V. Lifetime socioeconomic position and mortality: prospective observational study. BMJ. 1997;314:547–552. doi: 10.1136/bmj.314.7080.547. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 May 4;324(7345):1097.

Unmarried women do not show psychological harm from abortion

Steen Goddik 1

Editor—Reardon and Cougle start their paper by making unwarranted claims, which they attribute to an article by Major et al.1-1,1-2 That article in fact makes conclusions opposite to their own: Major et al state that the women experiencing psychological problems or regret after abortion are those with prior episodes of depression.1-1 Reardon and Cougle turn this on its head, trying to make it look as though prior psychological state predicts depression associated with a pregnancy, whether aborted or carried to term. Major et al, of course, claim no such thing.

Reardon and Cougle's study finds that in unmarried women levels of depression do not differ between those who abort their pregnancy and those who carry it to term,1-2 which seems to negate the push to limit access to abortion for teenagers. This might well be the most important finding in the study, as enormous effort is placed on limiting teenagers' access to abortion in the United States, where the Elliott Institute is based (www.cpcworld.org/hope-net/CPC/Elliott-Institute.html); this raises doubt about the authors' claim that they have no conflict of interest.

Certainly, this study shows that depression is not a factor in the issue of teenagers obtaining abortions. The authors seek to explain this away, but only with unsubstantiated speculations. If they have so little faith in their result why are they trying to present the study as a factual one?

References

  • 1-1.Major B, Cozzarelli C, Cooper ML, Zubek J, Richards C, Wilhite M, et al. Psychological responses of women after first-trimester abortion. Arch Gen Psychiatry. 2000;57:777–784. doi: 10.1001/archpsyc.57.8.777. [DOI] [PubMed] [Google Scholar]
  • 1-2.Reardon D, Cougle J. Depression and unintended pregnancy in the national longitudinal survey of youth: a cohort study. BMJ. 2002;324:151–152. doi: 10.1136/bmj.324.7330.151. . (19 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 May 4;324(7345):1097.

Women's marital status may not have been accurate in study

Deborah L Billings 1

Editor—Several methodological flaws in Reardon and Cougle's analysis undermine the conclusions stated.2-1 There are two in particular.

Firstly, in one study cited in the article higher scores on the Rotter scale correlated with higher depression scores. However, the scale measures locus of control; it is not a measure of depression and thus is not a valid indicator of prior psychological state or prior depression.

Secondly, women included in the sample were categorised in the analysis according to marital status in 1992, yet data regarding first abortion or first unintended delivery are taken from 1980-92, with abortions and deliveries on average occurring between 1984 and 1986. Marital status in 1992 was not necessarily the marital status of women included in the sample during their first abortion or first unintended delivery. Thus basing the analysis and conclusions on the categories of married versus unmarried women is invalid and is not meaningful.

Given these observations, more rigorous analysis of the data is needed before any conclusions can be drawn about the link between depression and unintended pregnancy and marital status.

References

  • 2-1.Reardon DC, Cougle JR. Depression and unintended pregnancy in the national longitudinal survey of youth: a cohort study. BMJ. 2002;324:151–152. doi: 10.1136/bmj.324.7330.151. . (19 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 May 4;324(7345):1097.

Readers should bear in mind potential conflict of interest

Dallas A Blanchard 1

Editor—Reardon and Cougle claim no conflict of interest in their paper.3-1 However, the principal author (Reardon) is a professional anti-abortionist and the funding organisation for which he works has as its primary aim propagandising against abortion. Therefore the sampling, the methods, the statistics, and the conclusions should be rigorously evaluated.

References

  • 3-1.Reardon DC, Cougle JR. Depression and unintended pregnancy in the national longitudinal survey of youth: a cohort study. BMJ. 2002;324:151–152. doi: 10.1136/bmj.324.7330.151. . (19 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 May 4;324(7345):1097.

Authors' reply

David C Reardon 1,2, Jesse R Cougle 1,2

Editor—Longer versions of our replies to the above letters have been posted as rapid responses (bmj.com/cgi/eletters/324/7330/151#top); the shorter versions are given here.

With regard to Kahn's comments, review of the variables showed that the cases of abortion were properly identified but many cases of unintended first deliveries were missed. We apologise for this error. To correct this problem we obtained details regarding intention for delivered pregnancies over all years.4-1 The table shows the corrected results, which are within the confidence limits of our original results.

Table.

Women scoring in range for high risk of depression (CES depression score >15) who had their first abortion or unintended childbirth between 1980 and 1992

Women with unintended births but no subsequent abortions
Women who had an abortion
Adjusted odds ratio (95% CI)4-150
Total No (%) at high risk Total No (%) at high risk
Unmarried† 253 91 (36) 129 37 (29) 0.88 (0.54 to 1.43)
Married† 530 101 (19) 164 43 (26) 1.92 (1.23 to 2.97)
 In first marriage 443 78 (18) 131 35 (27) 2.23 (1.36 to 3.64)
All women 783 192 (25) 293 80 (27) 1.39 (1.02 to 1.90)
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4-150

Adjusted for family income, education, race, age at first pregnancy, and 1979 Rotter score. †When CES depression questionnaire was administered in 1992. 

A more careful reading of our remarks and Major et al's study will show Goddik that our statements are correct. Also, Goddik misapplies the finding regarding unmarried women to teenagers. Our study does not examine marital status at the time of the pregnancy. We segregated women on marital status at the time that depression was measured in 1992. Contrary to Billings's complaint, this is a valid and meaningful control for social support in that key year, 1992, since marital status is associated with depression rates.

No study is without weaknesses. In ours, the Rotter scale is admittedly an imperfect measure of psychiatric state before pregnancy, but it does correlate to depression in our study as well as those of others. Our findings are at least sufficient to cast doubt on the prevailing hypotheses that unintended deliveries are more harmful to emotional health than abortion and that any subsequent differences associated with outcome of pregnancy can be explained entirely by prior mental state.

We have never seen political or moral views on abortion identified as a conflict of interest in any of hundreds of studies published on abortion. If Blanchard is recommending a change in this custom he would more credibly begin by identifying his own association to the National Abortion Federation as a conflict of interest.4-2 It is a matter of public record that one of us specialises in research on post-abortion adjustments and rejects the notion that abortion is a harmless panacea.4-3,4-4 That opinion, like the present study's findings, is consistent with the literature.4-5

Every study should be carefully scrutinised; we claim no exception to this rule. Fortunately, the national longitudinal survey of youth is publicly available and our analyses can be readily replicated.

References

  • 4-1.Joyce TJ, Kaestner R, Korenman S. The effect of pregnancy intention on child development. Demography. 2000;37:83–94. [PubMed] [Google Scholar]
  • 4-2.Blanchard DA. Religious violence and the far right: an update. 18th Annual National Abortion Federation conference, 1994.
  • 4-3.Reardon DC. Aborted women, silent no more. Chicago, IL: Loyola University Press; 1986. [Google Scholar]
  • 4-4.Burke T, Reardon DC. Forbidden grief: the unspoken pain of abortion. Springfield, IL: Acorn Books; 2002. [Google Scholar]
  • 4-5.Strahan TW. Detrimental effects of abortion: an annotated bibliography with commentary. Springfield, IL: Acorn Books; 1996. [Google Scholar]

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