Policies based on the notion that undergoing an abortion causes or increases women's risk of suicide attempts are misinformed, according to the results of a 17-year-long observational study including more than half a million 18 to 36-year-old Danish women who had a first, first-trimester abortion, published in The Lancet Psychiatry journal. The study is the first to compare the risk of women attempting suicide before and after an abortion.
Although women in the study who had abortions had a higher risk of first-time non-fatal suicide attempts, a closer look at the data suggests this cannot be attributed to the abortion itself. Instead, pre-existing mental health problems (which were more common in women having abortions than in women not having abortions) were associated with the increased risk of attempted suicide.
"The view that having an abortion leads to suicidal thoughts, plans, or even suicide attempts has been used to inform abortion policies in some regions of the world, particularly laws requiring women seeking the procedure be informed of this view," says lead author Dr Julia R. Steinberg from the University of Maryland, College Park, USA. "The evidence from our study does not support this notion." 
Previous research on abortion and suicidal ideation has not considered prior mental health, has had low participation and high attrition rates, or has relied on self-reporting of abortion (and suicidal ideation). The new study is the first to address these limitations. It is also the first to examine rates and relative risk of first non-fatal suicide attempts in the year before an abortion, as well as the year after, and as more time from the abortion increases, allowing researchers to unpick whether abortions are a contributing factor.
The authors examined data from 523,380 Danish women aged 18 to 36 years. They compared the risk of non-fatal suicide attempts associated with a first abortion relative to having no abortion between January 2000 and December 2016, and examined whether the risk of suicide attempts changed before and after the abortion. In their fully adjusted model, they adjusted for age, calendar year, women's history of childbirth, mental health, and physical health, their parents' mental health, and their parents' socioeconomic status.
The authors only considered data related to non-fatal suicide attempts and first first-trimester abortions, not multiple abortions nor abortions beyond the first trimester. They excluded women under 18 because consent from parents or legal guardians is required for an abortion before this age.
Of the women included in the study, 9% (48,990/523,380 women) had at least one first-trimester abortion. In addition, overall in the group, 2% (10,216/523,380 women) had a suicide attempt during the seventeen-year study period.
For the women who had an abortion, there were similar unadjusted rates of suicide attempts in the year before and after the abortion - 8.9 attempts in every 1,000 women in the year before an abortion, and 8.6 attempts in every 1,000 women in the year after the abortion.
Over time, the unadjusted rate of suicide attempts decreased to 4.6 attempts in every 1,000 women per year between one to five years after an abortion, and to 2.2 in every 1,000 women per year after five or more years - similar to the rate of 2 per 1,000 women per year for women who did not have an abortion during the study period.
"Five years after an abortion, the unadjusted rate of first-time suicide attempts reduces to the same rate as in women who have not had an abortion, countering the notion of 'post-abortion syndrome', in which it is hypothesised that the effects are not experienced until a long time afterwards," says Dr Steinberg. 
This pattern of similar increased incidence rate of suicide attempt in the year before and after an abortion, compared with women who had no abortion, persisted but the association was attenuated after adjusting for age, calendar year, women's history of childbirth, mental health, and physical health, their parents' mental health, and their parents' socioeconomic status. The risk decreased as more time from the abortion increased. This indicates that the abortion could not be causing or increasing women's risk of suicide attempts.
The strongest risk factors for attempting suicide were having previous contact with a psychiatric service, previous use of antidepressant medication, previous use of antianxiety medication and previous use of antipsychotic medication.
"Our findings suggest that when a woman is seeking advice and care surrounding an abortion, it could be appropriate to screen for mental health issues in order to pick up on pre-existing problems and to prevent future ones occurring," says Dr Trine Munk-Olsen from Aarhus University, Denmark. 
The authors note that in Denmark abortions can be accessed legally, and so it is not clear whether the results generalise to other contexts, particularly where access to abortion is legally restricted. They also note that not all women with mental health problems may seek help, therefore, the effect of previous mental health problems may be underestimated.
Writing in a linked Comment, Dr Jenneke van Ditzhuijzen from the University of Amsterdam, Netherlands, says: "The increased risk of non-fatal suicide attempts in women who have had an abortion might be related to other co-occurring risk factors around the time of the unwanted pregnancy and abortion, such as intimate partner violence, unstable relationships, or other negative life events, for which Steinberg and colleagues could not adjust."
She continues: "This does not mean that having an abortion is an indication that women are going through a difficult time, or that the symptoms of mental disorders are attributable to the abortion, but rather that some women are at an elevated risk of multiple adversities at a certain period in their life, which could include an unwanted pregnancy and abortion."
NOTES TO EDITORS
This study was funded by the Society of Family Planning, the American Foundation for Suicide Prevention, and The Lundbeck Foundation Initiative for Integrative Psychiatric Research. It was conducted by researchers from the University of Maryland, Aarhus University, Aarhus University Hospital, The Lundbeck Foundation Initiative for Integrative Psychiatric Research and the University of California, San Francisco.
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