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clinmed/2001030003v1 (April 25, 2001)
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Suicide Deaths Associated with Pregnancy Outcome

A Record Linkage Study of 173,279 Low Income American Women


David C. Reardon, Philip G. Ney, Fritz J. Scheuren,
Jesse R. Cougle, Priscilla K. Coleman, Thomas W. Strahan

Poster Presentation at the
First World Congress on Women's Mental Health 
Berlin, March 27-31, 2001 
 



ABSTRACT
Design: Record linkage study. State funded medical insurance records identifying all paid claims for abortion or delivery in 1989 were linked to the state death certificate registry.

Subjects: A population of 173,279 low income women eligible for state-funded medical insurance in California, United States, who had either an induced abortion or delivery in 1989.

Results: Aborting women who had no known live births were significantly more likely to die than women with no known history of abortion, and women with a history of both abortion and childbirth. The relative risk was highest when comparing low income women with only one known pregnancy outcome. Compared to women who delivered, those who aborted had a significantly higher age adjusted risk of dying from all causes (1.62), from suicide (2.54), and accidents (1.82), as well as a higher risk of dying from nonviolent causes (1.44). Higher suicide rates were most pronounced in the first four years. Notably, the average annual suicide rates per 100,000 in our sample, 3.0 for delivering women and 7.8 for aborting women, bracketed the national average suicide rate of 5.2 for women ages 15-44. The higher death rates were significant across an eight year period and over four of the six age groups examined.

Conclusions: The pattern of death rates associated with prior pregnancy outcomes among low income women of California are similar to the pattern previously observed among the general population of women in Finland. Moreover, the apparent beneficial effects of childbirth and/or the detrimental effects of pregnancy loss persist over many years. Abortion experience may operate as a causal factor in suicide, risk-taking, or unhealthy behaviors or it may be a marker for other stress factors that increase the likelihood of death. The results are discussed in context of related literature.


BACKGROUND

  • To overcome the difficulties involved when using an a priori definition of "pregnancy related" deaths, researchers at Stakes, the National Research and Development Centre for Welfare and Health, in Finland undertook two important record linkage studies.1,2 They identified all death certificates from 1987-1994 for all women ages 15-49 and linked them to Finland's centralized Birth, Abortion, and Hospital Discharge Registers and examined death rates relative to all pregnancy events among these women in the year prior to their deaths.
  • The Stakes studies revealed remarkable variations in death rates. Women who had given birth had half the death rate of women who had not been pregnant in the year before their deaths. By contrast, women who had an induced abortion were 76% more likely to die than women who had not been pregnant, 102% more likely to die than women who miscarried, and 252% more likely to die than women who had carried to term. Compared to women who delivered, the age adjusted odds ratio of dying in the year following an induced abortion was 1.6 for death from nonviolent causes, 4.2 for death from injuries related to accidents, 6.5 for deaths resulting from suicide, and 14.0 for deaths resulting from homicide.
  • If the findings reported by Stakes identify a true association between mortality rates and prior pregnancy outcomes, one would expect them to be replicable elsewhere. In addition, the Stakes findings raise the question of how long the effects of prior pregnancy outcomes on mortality rates may persist. The goals of our study were to investigate whether the Stakes findings would be observed in an homogenous socioeconomic population and to examine any associations between pregnancy history and subsequent mortality over a longer period of time.


METHODS

  • The California Department of Health Services (DHS) identified 249,625 women who had received funding for either an abortion or delivery in calendar year 1989 under the state-funded medical insurance program known as Medi-Cal. Of this population, 194,694 were citizens whose beneficiary identification codes could be record linked to valid social security numbers. All "short paid claim" records for these women were obtained for six fiscal years beginning in July 1988 and extending through June 1994.
  • The patient identifier codes were also linked by DHS to California death certificates between 1989 and 1998, resulting in the identification of 1713 deaths.
  • Data integrity was carefully examined. Both our own linkages and those done by DHS were checked by us to assure that a high quality match had been carried out. The confirmatory variables available on both the Medi-Cal and death certificate files employed in this checking included the woman's date of birth, gender, date of pregnancy event, and the cost of medical treatment.
  • Screening for aberrant, indeterminate, and out-of-scope data resulted in the elimination of 21,415 cases, and 419 deaths for the following reasons (1) unlinkable social security numbers, (2) the age recorded for an individual woman in the medical records and/or the death certificates could not be reasonably verified by reference to multiple records, (3) the abortion was identified as illegal or unknown (ICD-9 codes 636 and 637), (4) reported age below 13 or above 49 at the time of their first pregnancy event, (5) first delivery or induced abortion occurred after 1990, (6) the costs associated with the target pregnancy event was below $100 (suggesting only counseling for a possible procedure was received), or (7) when the first recorded pregnancy event was a miscarriage.
  • All data handling steps were blind to the pregnancy outcome. Age-adjusted relative risks and 95% confidence intervals were calculated by means of a logistic regression using age as a covariate.


RESULTS

  • Overall Analysis

  • The first analysis compared death rates between women with any known history of abortion (average age: M =24.19; standard deviation of age: SD=5.56) to those with no known history of abortion (M =25.64; SD=5.77). The alignment by age between the two groups was reasonably good, but different enough to warrant using age as a covariate. As seen in Table 1, deaths from all causes in the 8 years after the first known pregnancy outcome were significantly higher among women with a known history of abortion.

     (Note: Increasing the width of your browser will improve the formatting of the tables.)

Table 1: Overall cause specific risk of death in 8 subsequent years for women whose first pregnancy event was an abortion or a delivery (and no subsequent abortions).
All Cases Controlling for at Least One Year Prior Psychiatric History
Cause of death
Number of deaths

[Rate per 100,000]

Age-adjusted relative risk 

(95% CI)

Number of deaths

[Rate per 100,000]

Age-adjusted relative risk 

(95% CI)

First preg delivery 

(n=83,690)

First preg abort 

(n=50,260)

Delivery of first preg and no abortions 

(n=41,956)

Abortion of first preg 

(n=17,472)

All deaths 490 [585.5] 366 [728.2] 1.30 (1.13 to 1.49) 213 [507.7] 141 [807.0] 1.61 (1.30 to 1.99) 
Violent causes 207 [247.3] 179 [356.1] 1.43 (1.17 to 1.74) 82 [195.4] 63 [360.6] 1.78 (1.28 to 2.47)
Nonviolent causes 281 [335.8] 183 [364.1] 1.17 (0.97 to 1.12)  130 [309.8] 76 [435.0] 1.44 (1.08 to 1.91)*

* p<.013, p<.001, p=.094

  • Analysis of birth only and abortion only women with a single known pregnancy event.

  • For our second analysis, we limited our comparison to the two most disparate groups, the births only and the abortions only women. To further control for the confounding factor of multiple pregnancy outcomes, this analysis included women with only one known pregnancy event. The mean age for women who delivered was 26.39 (SD=5.85) and 25.96 (SD=6.26) for women who aborted.

    As shown in Table 2, stratification by two-year increments revealed significant differences in the death rates during the first two years for overall deaths, deaths due to nonviolent causes, and deaths due to violent causes. Other significant differences were found in all but the fifth and sixth years.
     


Table 2: Risk of specific causes of death in 8 subsequent years (in 2 year increments) for women with only one known pregnancy, those with an abortion compared to those with a delivery.
All Cases Controlling for 1 Year Prior Psychiatric History
Cause of death
Time interval

( years)

Number of deaths

[rate per 100,000]

Age-adjusted relative risk

(95% CI)

Number of deaths

[rate per 100,000]

Age & Psych History adjusted relative risk

(95% CI)

One delivery only 
One abortion only
Delivery of first preg and no abortions Abortion of first preg
Overall deaths 1-2 97 [178.0] 61 [343.7] 1.95 (1.42 to 2.69)  47 [112.0] 40 [228.9] 2.03 (1.33 to 3.10)
3-4 84 [154.1] 42 [236.6] 1.56 (1.07 to 2.25) * 40 [95.3] 33 [188.9] 1.98 (1.25 to 3.15)
5-6 76 [139.5] 29 [163.4] 1.19 (0.78 to 1.83)  63 [150.2] 35 [200.3] 1.35 (0.89 to 2.05)
7-8 78 [143.1] 41 [231.0] 1.64 (1.12 to 2.39)  63 [150.2] 33 [188.9] 1.29 (0.84 to 1.96)
Violent causes 1-2 52 [95.4] 37 [208.5] 2.12 (1.39 to 3.23)  19 [45.3] 23 [131.6] 2.62 (1.42 to 4.82)
3-4 32 [58.7] 23 [129.6] 2.18 (1.28 to 3.73)  14 [33.4] 18 [103.0] 3.00 (1.49 to 6.04)
5-6 28 [51.4] 7 [39.4] 0.77 (0.34 to 1.76) 27 [64.4] 13 [74.4] 1.15 (0.59 to 2.24)
7-8 15 [27.5] 9 [50.7] 1.85 (0.81 to 4.23) 22 [52.4] 9 [51.5] 0.98 (0.45 to 2.13)
Non-violent causes 1-2 45[82.6] 24 [135.2] 1.66 (1.01 to 2.72) * 28 [66.7] 17 [97.3] 1.49 (0.81 to 2.73)
3-4 51 [93.6] 18 [101.4] 1.10 (0.64 to 1.88) 26 [62.0] 15 [85.9] 1.40 (0.74 to 2.66)
5-6 47 [86.2] 22 [123.9] 1.46 (0.88 to 2.42) 35 [83.4] 22 [125.9] 1.54 (0.90 to 2.63)
7-8 63 [115.6] 31 [174.6] 1.53 (0.99 to 2.35) 41 [97.7] 22 [125.9] 1.33 (0.79 to 2.23)

*p<.05, p<.01, p<.005, p<.0001

  • As seen in Table 3, during the eight year period following the first pregnancy event, women who aborted had 62 percent more likely to die from all causes than women who carried to term. They were also significantly more likely to die from nonviolent causes, suicide, and accidents.

 

Table 3: Risk of death by specific causes in 8 subsequent years for women with only one known pregnancy, those with an abortion compared to those with a delivery.
All Cases Controlling for 1 Year Prior Psychiatric History
Cause 

of 

death

Number of deaths

[rate per 100,000]

Age-adjusted relative risk

(95% CI)

Number of deaths

[rate per 100,000]

Age & Psych History adjusted relative risk

(95% CI)

One delivery only One abortion only Delivery of first preg and no abortions Abortion of first preg
All causes 335 [614.7] 173 [974.6] 1.62 (1.34 to 1.94)  213 [507.7] 141 [807.0] 1.61 (1.30 to 1.99)
Violent causes 127 [233.0] 76 [428.2] 1.81 (1.36 to 2.41)  82 [195.4] 63 [360.6] 1.78 (1.28 to 2.47)
Suicide 13 [23.9] 11 [62.0] 2.54 (1.14 to 5.67)*  8 [19.1] 11 [63.0] 3.12 (1.25 to 7.78)*
Homicide 50 [91.7] 27 [152.1] 1.59 (1.00 to 2.55)  28 [66.7] 24 [137.4] 1.93 (1.11 to 3.33)*
Accident or undetermined 64 [117.4] 38 [214.1] 1.82 (1.22 to 2.73)  46 [109.6] 28 [160.3] 1.44 (0.90 to 2.30)
Nonviolent causes 206 [378.0] 95 [535.2] 1.44 (1.13 to 1.84)  130 [309.8] 76 [435.0] 1.44 (1.08 to 1.91)*
Aids 20 [36.7] 14 [78.9] 2.18 (1.10 to 4.31)*  10 [23.8] 12 [68.7] 2.96 (1.28 to 6.87)*
Mental disease 11 [21.6] 7 [43.9]
2.05 (0.79 to 5.28)
6 [14.3]
8 [45.8]
3.21 (1.11 to 9.27)*
Circulatory disease 28 [51.4] 26 [146.5] 2.87 (1.68 to 4.89)  18 [42.9] 15 [85.9] 2.00 (1.00 to 3.99)*
Cerebrovascular disease 4 [7.3] 7 [39.4] 5.46 (1.60 to 18.65) 3 [7.2] 5 [28.6] 4.42 (1.06 to 18.48)*
Other heart diseases 12 [22.0] 10 [56.3] 2.59 (1.12 to 5.99)*  8 [19.1] 7 [40.1] 2.10 (0.76 to 5.82)

*p<.05, p<.01, p<.005, p<.0001
 

  • Stratification by age is shown in Table 4. Differences were significant for four of the six age groups. As would be expected, the risk of death from nonviolent causes increased with age while the risk of death from violent causes generally declined.
Table 4: Risk of specific causes of death in 8 subsequent years for women with only one known pregnancy, those with an abortion compared to those with a delivery, based on age at the time of the first pregnancy event.
All Cases Controlling for 1 Year Prior Psychiatric History
Cause of death Age at first known pregnancy Number of deaths

[rate per 100,000]

Age-adjusted relative risk 

(95% CI)

Number of deaths

[rate per 100,000]

Age & Psych adjusted relative risk 

(95% CI)

One delivery only  One abortion only  Delivery of first preg and no abortions Abortion of first preg
Overall deaths 13-19 37 [636.9] 22 [866.5] 1.38 (0.81 to 2.35) 32 [494.3] 24 [703.0] 1.45 (0.85 to 2.48)
20-24 60 [346.1] 40 [692.9] 1.99 (1.33 to 2.98) 53 [379.0] 35 [605.4] 1.60 (1.04 to 2.45)*
25-29 94 [590.2] 40 [844.8] 1.44 (1.00 to 2.09) 48 [419.3] 31 [688.9] 1.63 (1.03 to 2.56)*
30-34 80 [816.2] 38 [1389.4] 1.71 (1.16 to 2.52)  44 [663.1] 28 [1155.6] 1.73 (1.07 to 2.79)*
35-39 46 [1050.5] 29 [2032.2] 1.93 (1.21 to 3.09)  26 [944.1] 19 [1814.7] 1.77 (0.97 to 3.26)
40-49 18 [1444.6] 4 [739.4] 0.49 (0.17 to 1.45) 10 [1515.2] 4 [1302.9] 0.75 (0.23 to 2.47)
Violent causes 13-19 26 [447.6] 15 [590.8] 1.35 (0.71 to 2.55) 22 [339.8] 15 [439.4] 1.31 (0.68 to 2.55)
20-24 31 [178.8] 29 [502.3] 2.79 (1.68 to 4.64) 29 [207.4] 26 [449.7] 2.17 (1.28 to 3.69)
25-29 39 [244.9] 12 [253.4] 1.04 (0.54 to 1.98) 17 [148.5] 11 [244.4] 1.67 (0.78 to 3.57)
30-34 23 [234.6] 14 [511.9] 2.19 (1.13 to 4.26)* 9 [135.6] 7 [288.9] 2.15 (0.80 to 5.80)
35-39 7 [159.9] 6 [420.5] 2.61 (0.88 to 7.79) 4 [145.2] 3 [286.5] 1.39 (0.27 to 7.07)
40-49 1 [80.3] 0 [00.0] -- 1 [151.5] 1 [325.7] 1.82 (0.11 to 31.04)
Non-violent causes 13-19 11 [189.4] 7 [275.7] 1.46 (0.56 to 3.80) 10 [154.5] 8 [234.3] 1.56 (0.61 to 3.99)
20-24 29 [167.3] 11 [190.5] 1.13 (0.57 to 2.27) 24 [171.6] 9 [155.7] 0.90 (0.42 to 1.95)
25-29 54 [339.0] 27 [570.2] 1.70 (1.07 to 2.70)* 30 [262.1] 20 [444.4] 1.66 (0.94 to 2.93)
30-34 56 [571.3] 24 [877.5] 1.54 (0.95 to 2.48) 35 [527.5] 21 [866.7] 1.62 (0.94 to 2.80)
35-39 39 [890.6] 22 [1541.7] 1.72 (1.02 to 2.92)* 22 [798.8] 15 [1,432.7] 1.74 (0.89 to 3.38)
40-49 17 [1364.4] 4 [739.4] 0.52 (0.17 to 1.55) 9 [1,363.6] 3 [977.2] 0.66 (0.18 to 2.48)

*p<.05, p<.01, p<.005, p<.0001

  • Analysis controlling for prior psychiatric claims.

  • Our fourth analysis used a sample of women who had their first pregnancy events between July 1 and December 31 of 1989. By limiting the analysis to these six months, we were able to examine any inpatient and outpatient psychiatric claims women had one year prior to the target pregnancy events. The resulting sample consisted of 17,472 women (age: M=24.91, SD=6.0) whose first pregnancy events were abortions and 41,956 women (age: M=25.48, SD=5.8) who had deliveries as their first pregnancy events and no history of abortion. Among these women, number of prior psychiatric claims was significantly correlated with overall deaths (r(59428)=.020, p<.0001), deaths by violent causes (r(59428)=.009, p<.023), and deaths by non-violent causes (r(59428)=.018, p<.0001).

    Logistic regression analyses were carried out using number of psychiatric claims within one year prior to the target pregnancy event and age as covariates. The results of these analyses are given in Tables 1 - 4. In several circumstances, most notably deaths related to mental illness, the relative risk of death for aborting women compared to delivering women increased after removing the effect of prior psychiatric history.

    Among women who had psychiatric claims during the year prior to their first pregnancy event, 846 were aborting and 1,140 were non-aborting. Of the 19 women who died by suicide, 11 had aborted the target pregnancy event and 8 carried to term. Two women (one aborting and one non-aborting) from the analysis had prior psychiatric claims and death by suicide.


INTERPRETATION

  • Our findings were consistent with the pattern identified in Finland.
  • The key finding of this study is that the differential in death rates between women who had abortions and those who gave birth was observed throughout the eight years examined. This indicates that the factors underlying this discrepancy are persistent ones. For example, low income women who have children may be more likely to avoid risk-taking and to take better care of their health. In addition, a history of abortion may be a marker for other stress factors that decrease longevity in this low income population.
  • Higher deaths rates following abortion may stem from increased psychological stresses related to unresolved guilt, grief, or depression. In another analysis of this same population, we found that women who had abortions had significantly higher rates of psychiatric admission over a four year period across all age groups.5 The overall adjusted relative risk of psychiatric hospitalization for aborting versus delivering women, controlling for age, months eligibility, psychiatric history, and obstetric history, declined steadily from the high of 4.26 at 90 days post-pregnancy event to 1.67 in the fourth year. The highest relative risks were related to adjustment reactions, bipolar disorder, and depressive psychoses.
  • Prior psychiatric history does not appear to explain the observed effects. Controlling for the number of psychiatric treatments prior to the pregnancy revealed that significant differences in the death rates could not be explained by this variable. In some cases, as in the case of suicide, the relative risk of death actually increased when controlling for prior psychiatric history.
  • The findings of this study are consistent with a large body of literature linking abortion to an increased risk of unhealthy behaviors. For example, there is a substantial body of literature demonstrating an association between abortion and suicide.6-12 Pregnancy and childbirth, on the other hand, reduce the risk of suicide.14-16
  • An important record based measure of suicide attempts before and after abortion has shown that the increase in subsequent suicide attempts among aborting women is not predicted by prior suicidal attempts. The authors concluded that the several fold increase in suicide attempts among aborting women is most likely related to adverse reactions to the abortion.13
  • The greater risk of fatal accidents and homicides may result from unrecognized suicides or increased risk-taking behavior.6, 10, 17 Deaths from accidents may also be related to higher rates of alcohol consumption18-22 or drug abuse21-28 among aborting women. Several studies have controlled for prior substance abuse and found a significant connection between abortion and subsequent substance abuse.9, 28, 29 Other record based studies have also found an increased number of treatments for accidental injury among women with a history of abortion.30,31 The higher risk of death from homicide may reflect increased levels of anger, self-destructive behavior, and domestic violence following abortion.32-38
  • The heightened risk of death from nonviolent causes may reflect a decline in general health following abortion as reported elsewhere.39-41 Unresolved grief following an abortion may lead to an increase in anxiety, sleeping disorders, eating disorders, and promiscuity.9, 29, 42 Other unhealthy behaviors linked to abortion are increased alcohol consumption,18-22 drug abuse,21-28 and smoking.21, 22, 43-52
  • Research linking depression, anxiety, and other psychological conditions with cardiovascular diseases 53-57 may explain the strong association between abortion and deaths related to circulatory and cerebrovascular disease.
  • The persistence of higher death rates over a long period of time may be explained by the observation that negative psychological reactions to abortion may be long lasting or delayed.6,9,17, 40,58
  • Unfortunately, as in the case of the Finland study of pregnancy associated deaths,1 our data did not include any information on race, marital status, or parity. This additional data is difficult or impossible to obtain in American record based studies due to privacy safeguards and the lack of reliable methods for linking central registries.
  • Our data did have the benefit, however, of representing a homogenous socioeconomic population. The fact that it includes only low income women, who would generally face similar stressful life events, would tend to help control for many confounding factors. However, the limitation of these data to low income women precludes generalization to all socioeconomic classes of American women.
  • Comparison of these results to national data underscores the importance of additional research. For example, the 1997 suicide rate per 100,000 American women ages 15-24 was 3.5 for all races, 3.7 for whites and 2.4 for blacks. For ages 25-44, the suicide rate was 6.0 for all races, 6.6 for whites and under 3.7 for blacks.4 In our sample (Table 2) the average annual suicide rate for low income women with a history of delivery was only 3.0 while it was 7.8 for low income women with a history of abortion, bracketing the national averages regardless of race. This suggests that the protective effect related of childbirth and/or the detrimental effect related to abortion observed in this study would be unlikely to disappear with controls for race.
  • This is the second large record based study demonstrating higher death rates among women with a history of abortion. It does not appear that prior psychiatric state can explain the observed effect. It is known that even after controlling for prior psychiatric condition, aborting women score higher on depression scales (an average of eight years after their abortions) compared to women who carried unintended pregnancies to term.
  • Additional research examining the effects of prior pregnancy outcome on women's mental health and mortality rates is warranted.

  •  

     

    Funding: Elliot Institute

    Conflict of interests: None
     

Contact Information

David C. Reardon, Ph.D.
Elliot Institute
PO Box 7348
Springfield, IL 62791 USA
(217) 525-8202

You can download a copy of this poster presentation by title and author at

http://clinmed.netprints.org/

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