Letters

Suicides after pregnancy

Mental health may deteriorate as a direct effect of induced abortion

Editor–Mika Gissler and colleagues state that suicides occur more commonly after induced abortion than after a pregnancy resulting in live birth.¹ We linked admissions for miscarriage, induced abortion, and normal delivery to admissions for suicide attempts in our health authority (population 408 000) during 1991-5 (table 1).

The age standardised relative risk of admission for attempted suicide compared with the non-gestational female population (ages 15-49) followed a similar pattern to that reported for mortality from suicide¹: it was 2.17 (95% confidence interval 1.45 to 3.24, P<0.001) for women admitted for miscarriage, 1.92 (1.29 to 2.88, P<0.001) for those admitted for induced abortion, and 0.94 (0.73 to 1.20, NS) for those admitted for normal delivery.

The age adjusted relative risk of suicide admission for women admitted for miscarriage compared with women admitted for normal delivery was 2.84 (1.67 to 4.81, P<0.001) before the event and 2.29 (1.13 to 4.65, P<0.05) afterwards. For induced abortion the relative risk was 1.72 (0.92 to 3.17, NS) before and 3.25 (1.79 to 5.91, P<0.001) afterwards. The non-significant increase in the induced abortion group before the event could be explained by the fact that six (46%) admissions for attempted suicide occurred within 90 days of the termination. In these cases, attempted suicide may be a consequence of the pregnancy rather than a feature of underlying mental illness. In the miscarriage group three (17%) admissions for attempted suicide occurred within 90 days before the miscarriage compared with none in the normal delivery group.

The increased risk of suicide after an induced abortion may therefore be a consequence of the procedure itself. The non-significant increase in admissions before an induced abortion is possibly explained by factors relating to the pregnancy. Hence this group of women in general does not seem to be at increased risk of suicide. Interestingly, this does not seem to be the case for women who miscarry spontaneously; their suicide rate is greater before miscarriage and reduced afterwards.

Our data suggest that a deterioration in mental health may be a consequential side effect of induced abortion. Furthermore, poor mental health, as measured by suicide admission rates, seems unlikely to predispose to abortion. The relation between mental health and miscarriage, however, requires further investigation.

Christopher Ll Morgan, Research officer,^a Marc Evans, Research registrar,^a John R Peters, Consultant physician,^a Craig Currie, Research officer ^b

^a Department of Medicine, University Hospital of Wales, Heath Park, Cardiff CF4 4XW, ^b Department of Public Health Medicine, Bro Taf Health Authority, Temple of Peace and Health, Cardiff CF1 3NW

1. Gissler M, Hemminki E, Lönnqvist J. Suicides after pregnancy in Finland, 1987-94: register linkage study.BMJ 1996;313:1431-4. (7 December.) [Abstract/Free Full Text]

Study did not show association between induced abortion and suicide

Editor–Mika Gissler and colleagues' study of suicide after pregnancy in Finland includes a brief but thoughtful discussion of the relation among pregnancy, class, social support, and risk of depression and suicide.¹ Their abstract, however, oversimplifies their findings and misses the point: they found an association between pregnancy and suicide, not induced abortion and suicide. Without a comparison of pregnancies ending in induced versus spontaneous abortion or induced abortion versus delivery, an association between induced abortion and suicide remains conjectural.

Sally Mitchison, Consultant psychiatrist ^c

^c Cherry Knowle Hospital, Sunderland SR2 0NB

1. Gissler M, Hemminki E, Lönnqvist J. Suicides after pregnancy in Finland, 1987-94: register linkage study.BMJ 1996;313:1431-4. (7 December.)

Authors' reply

Editor–In our paper we gave two explanations for women's increased risk of suicide after induced abortion: either induced abortion has negative effects on mental health or both induced abortion and suicide have common risk factors. The findings of Christopher Ll Morgan and colleagues do not support the hypothesis that women having induced abortions are more suicidal or have more external risk factors before their pregnancy. However, their data do not exclude the possibility that the (unwanted) pregnancy is the common cause both for the abortion and later for suicide, as Sally Mitchison suggests. This hypothesis is supported by Morgan and colleagues' findings of an increase in admissions for attempted suicide before the induced abortion. It is important, however, to remember that an attempted suicide is different from suicide, as epidemiological research shows. To verify that hypothesis we should compare women with unwanted pregnancies having and not having an induced abortion. We do not have such data; neither, so far as far as we know, has such a study been carried out. An explanation for Morgan and colleagues' findings regarding miscarriages and suicide may be that miscarriages often repeat themselves. Thus what seems to be a suicide attempt before a miscarriage may be an attempt after a previous miscarriage. Regardless of the aetiology, our study indicates that some women are at risk of suicide after an induced abortion. Overall, suicide is rare among women who have had an abortion, and for many women abortion may be an answer to their current problems and a relief. But some need special support, and it is the task of healthcare staff to be sensitive and to identify those women. Rather than being a relief, an abortion for them may be additional proof of their worthlessness and might contribute to suicidality and to the decision to commit suicide. Abortion services should also be organised to ease psychological consequences and regrets.

Mika Gissler, Researcher,^d Elina Hemminki, Research professor,^d Jouko Lönnqvist, Research professor ^e

^d Unit of Statistics, Registers and Information Systems, National Research and Development Centre for Welfare and Health (STAKES), PO 220, 00531 Helsinki, Finland, ^e National Public Health Institute, Department of Mental Health, 00300 Helsinki

This article has been cited by other articles:

• Reardon, D. C., Cougle, J. R., Rue, V. M., Shuping, M. W., Coleman, P. K., Ney, P. G. (2003). Psychiatric admissions of low-income women following abortion and childbirth. CMAJ 168: 1253-1256 [Abstract] [Full text]  
• Cagnacci, A., Volpe, A. (2001). Is voluntary abortion a seasonal disorder of mood?. Hum Reprod 16: 1748-1752 [Abstract] [Full text]