New from the Journals: A Brief Overview of Current Literature on Women's Health

By Rachel Walden — December 2, 2008

A quick summary of a few papers in the recent medical literature:

Ford J, Grewal J, Mikolajczyk R, Meikle S, Zhang J. Primary cesarean delivery among parous women in the United States, 1990-2003. Obstet Gynecol. 2008 Dec;112(6):1235-41.

This paper used U.S. birth certificate data from 1990-2003 to figure out how many women who had previously given birth vaginally had a first-time c-section (of a single infant) during a subsequent birth. Most existing literature focuses on c-sections for first deliveries or repeat c-sections. The authors found primary cesarean rates of 7.1% in 1990, 6.6% in 1996, and a steady increase to 9.3% in 2003. They found this general trend across geographic areas, despite variations from 4-17% between regions. An increased c-section rate with increasing maternal age was also observed.

Hall AG, Khoury AJ, Lopez ED, Lisovicz N, Avis-Williams A, Mitra A. Breast cancer fatalism: the role of women’s perceptions of the health care system. J Health Care Poor Underserved. 2008 Nov;19(4):1321-35.

Data from a 2003 survey of 1,050 Mississippi women at least 40 years old was analyzed for the women’s breast cancer knowledge, attitudes, and behavior (excluding women who had previously had breast cancer). The women indicated whether they believed a diagnosis of breast cancer represented a “death sentence;” the authors express concern that this “fatalism” may contribute to women from marginalized populations not seeking breast cancer screening and often presenting with advanced-stage breast cancer.

The authors report the following findings:

  • “Older women, African American women, and women with no college education were more likely than younger women, White non-Hispanic women, and women with a college education to agree that breast cancer was a death sentence.”
  • “Women who rated their quality of care as fair/poor and women who believed that physicians hid information from patients of their race were twice as likely as other women to agree that breast cancer was a death sentence.”
  • “Women who believed that breast cancer could not be cured if found early and that treatment could be worse than the disease were more than twice as likely as other women to have fatalistic attitudes.”

It is no big surprise here that women who received limited or poor health care, who believed they couldn’t afford treatment, and who believed treatment would not be effective would be less optimistic upon receiving a breast cancer diagnosis. The authors express hope that their research will be used to “suggest strategies for addressing fatalistic beliefs towards breast cancer and for improving attitudes towards breast screening and treatment, particularly among vulnerable women,” and encourage incorporating “positive survival experiences” into health promotion and education programs. They also call for health care systems to “work towards improving overall perceptions of the delivery systems.”

In other words, these women’s “fatalistic” attitudes are not so much the inherent problem, but a reasonable reaction to the problematic economic and other factors that discourage them from seeking care in the first place.

Fergusson DM, Horwood LJ, Boden JM. Abortion and mental health disorders: evidence from a 30-year longitudinal study. Br J Psychiatry. 2008 Dec;193(6):444-51.

Yes, it’s another study on abortion and mental health. In this case, the authors followed women in New Zealand over time, and from about ages 15-30 they reported their pregnancy histories and also completed mental health assessments.

As usual, I’m cautious about the findings because there is a bit of a “chicken and egg” problem with studies of this nature – which came first, having an abortion, or existing mental health or other struggles? If a woman is experiencing distress, is it because she had an abortion, or because she has had to cope with an unwanted pregnancy?

It’s not terribly surprising, however, that the authors found higher rates of mental health concerns among those who had abortions, those who lost pregnancies, and those who experienced unwanted pregnancies that were carried to term (compared with those who did not become pregnant); those who gave birth following a wanted pregnancy showed no increased rates of any mental health concerns.

After 5 years, those who had abortions and those who lost a pregnancy were still more likely to have mental health concerns. However, the authors explain: “Although exposure to abortion was associated with significant increases in risks of mental health problems, the overall effects of abortion on mental health proved to be small. Estimates of the attributable fraction suggested that exposure to abortion accounted for 1.5–5.5% of the overall rates of mental disorder in this cohort.”

The authors note that there may be unknown factors they failed to account for. Of particular concern but not well addressed in the paper is that in New Zealand, for women of any age, two certifying consultants must agree that the pregnancy will seriously harm a woman’s physical or mental health in order for the procedure to be legal. The authors do not attempt to analyze how this legal status or cultural expectations may have affected the respondents reports of mental health issues. They have not examined, for example, whether a woman who obtains a legal abortion based on mental health concerns might be more likely to feel compelled to report mental health problems when surveyed on these two issues together. Studies such as this one also fail to reflect or address the expectation that women faced with a wanted pregnancy may be socially expected to report associated happiness or emotional well-being (similar to difficulties in recognizing and acknowledging post-partum depression).

The authors conclude:

“Specifically, the results do not support strong pro-life positions that claim that abortion has large and devastating effects on the mental health of women. Neither do the results support strong pro-choice positions that imply that abortion is without any mental health effects. In general, the results lead to a middle-of-the-road position that, for some women, abortion is likely to be a stressful and traumatic life event which places those exposed to it at modestly increased risk of a range of common mental health problems.”

I’m not personally aware of many “strong pro-choice” folks who claim that all abortions are always without mental health effects. Most seem to believe that stressful and mental health factors may contribute to the abortion choice in the first place and some women may have mental health concerns after abortion (as they may after pregnancy loss or birth), but that the decision should remain a woman’s choice to make.  Just as important, the potential mental health concerns related to unwanted pregnancy should be examined.

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