Restricting reproductive care takes a toll on women – as seen in the United States. But what does this have to do with suicide rates? A whole lot, it seems.
In recent years, a woman’s right to choose has been under attack. June 2022 saw a massive upheaval to reproductive care in the USA with the overturning of Roe vs. Wade by the American Supreme Court. The decision abolished the federal right to abortion and severely restricted reproductive care in numerous US-states. While most European countries allow elective pregnancy terminations during the first trimester (and also at later stages, if the mother’s health is in danger), access is nevertheless often limited, especially by dwindling numbers of doctors willing to perform such procedures. This might be the results of anti-abortion protesters actively harassing patients and providers – a movement which seems to have gained steam in various countries. In some European countries, abortion is already effectively banned.
The victim of restricted reproductive care, no matter where: women’s mental health. It is in no way astonishing that women who seek to terminate their pregnancy and are subsequently denied an abortion suffer from more stress and anxiety than those who are granted their wish. Now a study suggests that this stress might even push up suicide rates among women of reproductive age. “Stress is a key contributor to mental health burden and a major driver of increased suicide risk”, study author Ran Barzilay explains. “We found that this particular stressor – restriction to abortion – affects women of a specific age in a specific cause of death, which is suicide.”
To test their hypothesis that restricted abortion access would be associated with higher suicide rates among reproductive-aged women, Barzilay and his team conducted a difference-in-difference analysis using American state level data from 1974 to 2016, covering the entire population of adult women in the US during this timeframe. They analyzed the annual suicide rates, both in their target group and in a control group of women of post reproductive age before and after legislations restricting abortion access – so called Targeted Regulation of Abortion Providers (TRAP) laws – were enforced. Furthermore, they compared those numbers to broad suicide trends and to rates in states without such restrictions.
21 states enforced at least one TRAP law between 1974 and 2016. In the whole timeframe, suicide rates ranged from 1.4–25.6/100,000 women in the target group (aged 20–34 years), and 2.7–33.2/100,000 women in the control group (aged 45–64 years). Without any TRAP laws in place, the annual state level suicide death rate averaged at 5.5/100,000 for the target group. After enforcement of a TRAP law that rate increased by 5.81 %. This change, however, could only be found in the target group; no effect could be seen among 45–64-year-old women.
For comparison, the researchers also did the same analysis of another common cause of death in that age-group, which was death by a motor vehicle crash (rate: 2.4–42.9/100,000). As expected, this rate remained unaffected by the introduction of TRAP laws. According to the researchers, this demonstrates that their finding was specific to their target group and the specific cause of death. Co-author Jonathan Zandberg summed up the findings once again: “Comparatively, women who experience the shock of this type of restrictive legislation had a significant increase in suicide rates.”
The findings seem quite sound, as the researchers also controlled for potential confounders such as economic factors, political climate as well as year and state fixed effects. An additional strength of the study: the authors tested for existing pre-trends in the affected states and among the two groups. If suicide numbers were already increasing before enactment of a TRAP law, this would undermine the validity of the result and point to another root cause. However, no such pre-trends were found.
The conclusion is mainly limited by relying on observational, state-level data and lacking access to individual data. Assessing the association between restrictions and anxiety, stress and suicidal ideation among the individual women was not possible. The authors also point out that no data on the proportion of suicides that specifically occurred among pregnant women exists. Therefore, the researchers’ findings do not prove without doubt that restricting abortion access causes suicide rates to increase; instead, they highlight the need for studies that identify the exact mechanisms through which restricted reproductive care could affect suicide risk. Also, their findings might not generalize to other countries, as the nature of the abortion debate in the US is quite unique.
Nevertheless, the researchers see important clinical, political and ethical implications in their findings. “Clinicians should be cognizant of the additional stress that restricted access to reproductive care engenders”, they write. Recognizing this link could change how health care providers approach suicide risk classification in affected patients. “This association is robust – and it has nothing to do with politics”, says Barzilay. “It’s all backed by the data.”
Image source: Fran Jacquier, Unsplash
