On 2014 Aug 12, David Reardon commented:

The association between PTSD and preterm birth revealed by Yonkers et al¹ is unfortunately marred by the failure to control for a common risk factor for both PTSD and pre-term birth: induced abortion.

For example, a recent systematic review and meta-analysis of 37 qualifying studies found that the risk of preterm birth rose 36% after a single induced abortion and 93% after two or more induced abortions.^2  The risk of low birth weight deliveries also rose 35% after a single abortion and 72% after two or more abortions.

Regarding PTSD, a study of 155 women presenting for abortion found that the presence of PTSD symptoms had increased 61 percent at three month post-abortion evaluation.^3   Yet another study, interviewing women a few hours after their abortions and again six weeks later, reported that 38% of the women had PTSD symptomatology.^4   Another study which interviewed 217 American women seeking general health care found that 65 percent reported multiple symptoms of PTSD which they self-attributed to their abortions, with slightly over 14 percent reporting all the symptoms necessary for a clinical diagnosis of PTSD.^5

In light of these other studies, Yonker's finding of some correlation between PTSD and preterm births is not surprising. But lacking any segregation of results relative to history of induced abortion, this study fails to tease out whether PTSD itself contributes to the risk of premature birth or whether PTSD is simply a marker for a history of abortion which may have contributed to physiological changes that increase the risk of preterm birth.

The above concerns were submitted as a letter to the editor of JAMA Psychiatry but it was rejected because it "did not receive a high enough priority rating for publication."

I also contacted the lead author, Dr. Yonkers, by email inquiring whether prior pregnancy loss information had been collected, suggesting it may have in impact on her results. In her reply she stated that the history of induced abortions and spontaneous miscarriages had been collected, but that they had chosen to not use that data in their analysis. I replied with citations to the studies listed below showing that abortion is associated with both PTSD and preterm births and urged her to conduct an additional analysis to stratify the into these four categories: (1) no reported prior pregnancy loss; (2) 1 miscarriage, 0 abortion; (3) 0 miscarriage, 1 abortion; (4)more than one reported pregnancy loss.

Whether Dr. Yonkers bothered to take a look at what the data might show is unknown. But her response, in full was "Please stop emailing me. Abortion is safe and legal." That suggests that even if she did look at the data as I had requested, she is not going to share the results with us . . . especially if they are in agreement with the trend in the studies I have indicated.

Unfortunately, the passions surrounding the abortion issue appear to limit how deeply some researchers are willing to look at the data. Dr. Yonkers is not unique in this regard. Other researchers have similarly rejected requests for reanalysis considering pregnancy loss history, and especially any stratification of results relative to pregnancy loss.⁶ Given the trend already seen in the few studies that do so, there is ample reason to be concerned that many researchers are afraid that publishing results that might be seen as "criticizing" abortion may either lead to these results being exploited by "anti-choice zealots" or may expose the researcher to being accused of such zealotry. The possibility that this chilling effect is so strong that researchers will refuse to consider additional analyses when studies, like those I cited herein, clearly support the need for doing so is deeply concerning.

If we allow the political and emotional gravitas surrounding the word "abortion" to become a barrier to simply analyzing our data from every direction, then we are choosing to give priority to ideologies rather than scientific inquiry. Analyses should be done to show what the data reveals however it is sliced. Interpretations of those results may be disputed, or tentative, or subject to reconsideration based on future research findings. But future research cannot even be defined if we refuse to publish analyses regarding the data that is already at hand.

In my view, every study which deals with the overlap between reproductive health and mental health should show results that are stratified relative to women's exposure to both natural pregnancy losses and induced pregnancy losses. Only in this way can we begin to more clearly distinguish the roles that may be played by psychological causes, physiological states, or both.

References

1) Yonkers KA, Smith MV, Forray A, Epperson CN, Costello D, Lin H, Belanger K. Pregnant Women With Posttraumatic Stress Disorder and Risk of Preterm Birth. JAMA Psychiatry. 2014 Jun 11. doi: 10.1001/jamapsychiatry.2014.558.

2) Shah PS, Zao J. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analysis. BJOG 2009;116:1425-1442.

3) Sharain Suliman et. al., “Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation,” BMC Psychiatry 2007, 7:24.

4) Rousset, C. Brulfert, N. Séjourné, N. Goutaudier & H. Chabrol Posttraumatic Stress Disorder and psychological distress following medical and surgical abortion. C. Journal of Reproductive and Infant Psychology, (2011) Volume 29(5), 506-517.

5) Rue VM, Coleman PK, Rue JJ, Reardon DC. Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Med Sci Monit, 2004 10(10): SR5-16.

6) Munk-Olsen T, Gasse C, Laursen TM. Prevalence of antidepressant use and contacts with psychiatrists and psychologists in pregnant and postpartum women. Acta Psychiatr Scand. 2011 Nov 25. doi: 10.1111/j.1600-0447.2011.01784.x.

On 2014 Aug 12, David Reardon commented:

The association between PTSD and preterm birth revealed by Yonkers et al¹ is unfortunately marred by the failure to control for a common risk factor for both PTSD and pre-term birth: induced abortion.

For example, a recent systematic review and meta-analysis of 37 qualifying studies found that the risk of preterm birth rose 36% after a single induced abortion and 93% after two or more induced abortions.^2  The risk of low birth weight deliveries also rose 35% after a single abortion and 72% after two or more abortions.

Regarding PTSD, a study of 155 women presenting for abortion found that the presence of PTSD symptoms had increased 61 percent at three month post-abortion evaluation.^3   Yet another study, interviewing women a few hours after their abortions and again six weeks later, reported that 38% of the women had PTSD symptomatology.^4   Another study which interviewed 217 American women seeking general health care found that 65 percent reported multiple symptoms of PTSD which they self-attributed to their abortions, with slightly over 14 percent reporting all the symptoms necessary for a clinical diagnosis of PTSD.^5

In light of these other studies, Yonker's finding of some correlation between PTSD and preterm births is not surprising. But lacking any segregation of results relative to history of induced abortion, this study fails to tease out whether PTSD itself contributes to the risk of premature birth or whether PTSD is simply a marker for a history of abortion which may have contributed to physiological changes that increase the risk of preterm birth.

The above concerns were submitted as a letter to the editor of JAMA Psychiatry but it was rejected because it "did not receive a high enough priority rating for publication."

I also contacted the lead author, Dr. Yonkers, by email inquiring whether prior pregnancy loss information had been collected, suggesting it may have in impact on her results. In her reply she stated that the history of induced abortions and spontaneous miscarriages had been collected, but that they had chosen to not use that data in their analysis. I replied with citations to the studies listed below showing that abortion is associated with both PTSD and preterm births and urged her to conduct an additional analysis to stratify the into these four categories: (1) no reported prior pregnancy loss; (2) 1 miscarriage, 0 abortion; (3) 0 miscarriage, 1 abortion; (4)more than one reported pregnancy loss.

Whether Dr. Yonkers bothered to take a look at what the data might show is unknown. But her response, in full was "Please stop emailing me. Abortion is safe and legal." That suggests that even if she did look at the data as I had requested, she is not going to share the results with us . . . especially if they are in agreement with the trend in the studies I have indicated.

Unfortunately, the passions surrounding the abortion issue appear to limit how deeply some researchers are willing to look at the data. Dr. Yonkers is not unique in this regard. Other researchers have similarly rejected requests for reanalysis considering pregnancy loss history, and especially any stratification of results relative to pregnancy loss.⁶ Given the trend already seen in the few studies that do so, there is ample reason to be concerned that many researchers are afraid that publishing results that might be seen as "criticizing" abortion may either lead to these results being exploited by "anti-choice zealots" or may expose the researcher to being accused of such zealotry. The possibility that this chilling effect is so strong that researchers will refuse to consider additional analyses when studies, like those I cited herein, clearly support the need for doing so is deeply concerning.

If we allow the political and emotional gravitas surrounding the word "abortion" to become a barrier to simply analyzing our data from every direction, then we are choosing to give priority to ideologies rather than scientific inquiry. Analyses should be done to show what the data reveals however it is sliced. Interpretations of those results may be disputed, or tentative, or subject to reconsideration based on future research findings. But future research cannot even be defined if we refuse to publish analyses regarding the data that is already at hand.

In my view, every study which deals with the overlap between reproductive health and mental health should show results that are stratified relative to women's exposure to both natural pregnancy losses and induced pregnancy losses. Only in this way can we begin to more clearly distinguish the roles that may be played by psychological causes, physiological states, or both.

References

1) Yonkers KA, Smith MV, Forray A, Epperson CN, Costello D, Lin H, Belanger K. Pregnant Women With Posttraumatic Stress Disorder and Risk of Preterm Birth. JAMA Psychiatry. 2014 Jun 11. doi: 10.1001/jamapsychiatry.2014.558.

2) Shah PS, Zao J. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analysis. BJOG 2009;116:1425-1442.

3) Sharain Suliman et. al., “Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation,” BMC Psychiatry 2007, 7:24.

4) Rousset, C. Brulfert, N. Séjourné, N. Goutaudier & H. Chabrol Posttraumatic Stress Disorder and psychological distress following medical and surgical abortion. C. Journal of Reproductive and Infant Psychology, (2011) Volume 29(5), 506-517.

5) Rue VM, Coleman PK, Rue JJ, Reardon DC. Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Med Sci Monit, 2004 10(10): SR5-16.

6) Munk-Olsen T, Gasse C, Laursen TM. Prevalence of antidepressant use and contacts with psychiatrists and psychologists in pregnant and postpartum women. Acta Psychiatr Scand. 2011 Nov 25. doi: 10.1111/j.1600-0447.2011.01784.x.