Induced Abortion, Miscarriage, and Breast Cancer Risk of Young Women¹

Short Communications
Pregnancy Hormones, Pre-eclampsia, and Implications for Breast Cancer Risk in the Offspring¹

The Expression of Smads in Human Endometrium and Regulation and Induction in Endometrial Epithelial and Stromal Cells by Transforming Growth Factor-ß

Accepted 20 May 2003
Am J Epidemiol 2003; 158:798-806.
© 2003 by Johns Hopkins Bloomberg School of Public Health

ORIGINAL CONTRIBUTIONS

Use of Electric Bedding Devices and Risk of Breast Cancer in African-American Women

¹ Pennsylvania State University College of Medicine, Hershey, PA.
² Meharry Medical College, Nashville, TN.
³ Current address: United States Military Cancer Institute, Walter Reed Army Medical Center, Washington, DC.

Key Words: bedding and linens; blacks; breast neoplasms; case-control studies; electromagnetic fields; women
Abbreviations: CI, confidence interval; EMF(s), electromagnetic field(s); ER, estrogen receptor; SES, socioeconomic status.

Am J Epidemiol, 2003; 157:185-194.
© 2003 by Johns Hopkins Bloomberg School of Public Health

ORIGINAL CONTRIBUTIONS

Risk Factors for Ectopic Pregnancy: A Comprehensive Analysis Based on a Large Case-Control, Population-based Study in France

¹ INSERM U569, IFR69 (The French Institute of Health and Medical Research), Le Kremlin-Bicêtre, France.
² Centre Hospitalier Hôtel-Dieu, Service de Gynécologie-Obstétrique, Clermont-Ferrand, France.
³ Hôpital Antoine Béclère, Service de Gynécologie-Obstétrique, Clamart, France.
⁴ Service d’Epidémiologie et de Santé Publique, Clermont-Ferrand, France.

Key Words: abortion, induced; case-control studies; infertility, female; pregnancy, ectopic; registries; risk factors; sexually transmitted diseases; tobacco
Abbreviation: CI, confidence interval.

J. Clin. Invest. 112:973-977 (2003). doi:10.1172/JCI200319993.
©2003 by the American Society for Clinical Investigation.

Women's health and clinical trials

Women's health issues have not been entirely ignored. The well-known Framingham Heart Study, initiated in 1948, has long stood as the benchmark epidemiological study on cardiovascular health and included slightly more women than men (6). The Nurses' Health Study I and II, established in 1976 and 1989, respectively, followed large numbers of registered female nurses, initially to study the long-term use of oral contraceptives,and has been used over the years to look at other health issues, such as the correlation between low-dose aspirin administration and risk of heart attack in women. Unlike the Physicians' Health Study, the Nurses' Health Study was an observational investigation, not a more costly, randomized clinical trial(7). Like the study of male physicians, the study of female nurses evaluated predominantly white, health-conscious populations.

Is what's good for the gander good for the goose?

Until 1988, clinical trials of new drugs by the U.S. Food and Drug Administration (FDA) were routinely conducted predominantly on men (8), even though women consume approximately 80% of pharmaceuticals in the US. The results of male-only clinical trials have led to the development of diagnoses, preventive measures, and treatments that are commonly extrapolated to women, yet the reverse is rare. In 1992, a survey by the US General Accounting Office, the body responsible for the audit, evaluation, and investigation of Congressional policy and funding decisions, found that less than half of publicly available prescription drugs had been analyzed for sex-related response differences (9). A consequence of extrapolating the results of male-only clinical data to female consumers is that women were (and still are) typically prescribed dosages devised for men's average weights and metabolisms. For example, it is now known that acetaminophen, an ingredient in many pain relievers, is eliminated by the female body at approximately 60% the rate of elimination documented in men (10). The administration of drugs to women at dosages designed for men can place women at risk for overdose. Furthermore, while little is known about the effects of aspirin on heart disease in women, postmenopausal women, like men, have been encouraged to take aspirin daily. The effects of other widely used drugs, such as Valium, were never tested in randomized clinical trials with female subjects, although 2 million women per year consume this drug to control conditions such as anxiety, epilepsy, muscle spasms, and alcohol addiction.

Investigators have defended their choice of males as research subjects on the grounds that men are cheaper and easier to study. The estrous cycle is viewed as a methodological complication during analysis that increases research costs because many more control groups are required. Researchers have also feared that the inclusion of women of childbearing age in clinical trials might endanger fetuses. FDA guidelines restricting research on women of childbearing potential were first implemented in 1977 in reaction to the birth defects resulting from thalidomide and diethylstilbestrol administrated during pregnancy, and the FDA only revised these guidelines to include this population of women in early-phase clinical trials in 1993. These protective restrictions, however, can support the portrayal of women as "walking wombs," unable or unwilling to control their fertility. These guidelines also overlooked the pharmacologic needs of many pregnant women, three-quarters of whom require drug therapy during pregnancy and currently use prescription or over-the-counter drugs for chronic conditions such as diabetes or depression(11).

The net effect of gender bias in medical research is that women are at risk for adverse drug reactions and may suffer unnecessarily and die. Such adverse reactions occur approximately twice as often in women as in men. For example, some antithrombotic agents used to break up blood clots immediately after a heart attack, while beneficial to many men, may cause significant bleeding problems in women (12). Commonly prescribed drugs used to treat high blood pressure tend to lower men's mortality from heart attack but have been shown to increase cardiac-related deaths among women (12). Emerging evidence also suggests that the effects of antidepressants can vary over the course of the menstrual cycle. Subsequently, drug dosage may be too high at some points during estrous and too low at others. Besides that, drugs developed for men and untested on women may be dangerous for women, drugs that are potentially beneficial to women may be eliminated in early phases of clinical testing when the test group does not include women and no benefits are manifest in male subjects (13). Concomitantly, while women tend to be undertreated in many areas of medicine, they are also at risk for overtreatment in the area of reproduction, such as unnecessary cesarean sections and hysterectomies (14).

Much has now been made in the US of the need to depart from the "usual male model," where testing is routinely done on males, and from the "usual white model," where test subjects are of white European origins, in medical research and health (15, 16). Researchers are now wary of developing a "usual female model," where females are assumed to conform to a unitary category of sex, and racial and ethnic differences remain unanalyized. Whereas the women's health movement of the 1970s sought to solidify sisterhood through the commonalities of female childbirth experiences, there is now an emphasis on the differing health needs of different racial and ethnic groups of women. Only very limited conclusions can be drawn about a patient's disease from her biological sex. This is revealed in the variation of disease morbidity and mortality in different ethnic populations. African-American women are, for example, more at risk for stroke, heart attack, and hypertension than European-American women. While African-American women have a lower incidence of breast cancer than European-American women, they die more often as a result. Hispanic women's rates of cervical cancer are twice as high as those of non-Hispanic white women. In addition, non-Hispanic white women have higher rates of osteoporosis than Hispanic or African-American women; however, because osteoporosis is considered a white disease in the US, African-American and Hispanic women may not be properly screened and educated about it (17).

The feminist sea change

Beginning in the late 1980s and 1990s, feminist calls for reform in federally funded biomedical research in the US were taken up by the federal government. The 1990s saw what could only be called a revolution in biomedicine for women in the US. In September 1990, the US federal government founded the Office of Research on Women's Health within the Office of the Director at the NIH. This office has two primary missions: to develop opportunities for and to support women's recruitment and reentry into, and advancement in, biomedical professions, and to ensure that research conducted and supported by the NIH adequately addresses diseases, disorders, and conditions that affect women. In 1991, the federal government announced the establishment of the Women's Health Initiative, a major 15-year research program coordinated among 40 clinical centers nationwide, in conjunction with the Department of Health and Human Services, the NIH, and the National Heart, Lung, and Blood Institute, to which $625 million was budgeted toward the study of the most common causes of death, disability, and poor quality of life in postmenopausal women. Between 1990 and 1994, Congress enacted no fewer than 25 pieces of legislation to support advancements in the understanding and management of the health of American women. The most important of these was the NIH Revitalization Act of 1993 (18). Also significant was the publication of the NIH Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical Research (19). The act reinforced existing NIH policies, with a number of major differences (see Reform of investigation without representation)(20), ranging from requiring that females and minorities be adequately represented in clinical trials to establishing new federal regulations for mammography (21, 22). In 1994, the FDA also created an Office of Women's Health, which oversees correction of gender disparities in drug research and administration policies (23).

Taxation without representation

Much of the impetus for the women's health movement came from the feminist idea that women should get their fair share of research dollars, both as researchers and as research subjects. Attention was drawn to the failure to include women in publically funded research. Quite appropriately, many people supported the idea that since women pay taxes that contribute to federally funded health research, they deserve to derive benefit from that research. Simply taking women seriously as researchers and including them as research subjects in areas other than reproduction - a base-line liberal approach - has had a tremendous impact on medicine. The reforms have been simple in their conception - inquiry should include female subjects - but dramatic in their realization: the right of females to be included in basic medical research is now secured by federal law.

Beyond the liberal approach to gender equity in biomedical research, which emphasizes equal attention to the health needs of men and women, a reconceptualizing of sex-related differences in the human body has been crucial to advances in women's health(24). When the General Accounting Office reviewed NIH policies in 1989, there was still no uniform definition of research specific to women's health. Medical researchers had long assumed that the phrase "women's health" referred to reproductive health - involving attention to birthing, contraception, abortion, breast and uterine cancer, premenstrual syndrome, and other maladies distinctively female. Definitions of women's health now treat the whole array of women's distinctive biology. Florence Haseltine, founder of the Society for Advancement of Women’s Health Research and a powerhouse for reform at the NIH, has identified this shift from reproductive health to more general female health issues as being crucial for ongoing reforms in women’s health research (25). The NIH now defines women’s health research as the study of diseases unique to women (such as breast cancer), or diseases with a higher prevalence in women than in men (such as osteoporosis), or diseases that present differently in women than in men (such as heart disease). Working from this conceptual base, the Women’s Health Initiative has focused attention on the prevention of osteoporosis in addition to the leading causes of death in women: cardiovascular disease and breast and colon cancer. The NIH Office of Research on Women’s Health has also funded understudied areas of research, including women’s occupational health, sex-related differences in autoimmune diseases, and female urologic health.

Critics of the Women’s Health Initiative

Not everyone, of course, agrees that women’s health requires special attention. Critics deny that it has been improper to leave women out of randomized clinical trials, such as the MRFIT studies. According to this view, since men die from heart disease at earlier ages than women, they are an appropriate group for study (26). The Women’s Health Initiative currently receives approximately 6% of the NIH annual budget, and critics charge that the funds earmarked for the study of female-specific disorders is excessive. They argue that 13% of the NIH annual budget is already devoted to health issues directly related to women, while only 6.5% of the budget contributes to the study of diseases unique to men. Their trump card is that the life expectancy of an American female, at 78.6 years, substantially outstrips that of the American male, at 71.8 years, suggesting that women are currently well cared for.

Other critics deny that feminism has now adequately addressed women’s health in medical research and charge that the Women’s Health Initiative and the poorly funded Office of Research on Women’s Health are merely efforts to diffuse the explosive politics surrounding federal funding of women’s health research (12). What is equal or fair in this instance? Is the solution to equalize spending on men’s and women’s health research? One could argue that research that uses the male body as the norm serves men better even when fewer dollars are spent on male-specific diseases. One might also argue that the greater role of women in human reproduction warrants more research on female reproductive health. But surely the goal of US biomedical research is to study both men and women of various classes, races, and backgrounds to maximize their long-term health and well-being.

A call for broader reform: beyond the biomedical model

Feminist reform within the NIH has been critical in improving health care for women. But some feminists suggest that it may not be enough simply to include women in clinical studies already in progress or to take into account their distinctive physiology. Study populations can be reconfigured and women’s diseases can be given research priority within existing medical practices, they claim, without dramatically improving women’s health. These feminists contrast the dominant "biomedical" model of research with a "community" or "social" model of the investigation and evaluation of women’s health. They challenge approaches that focus narrowly on disease management and biochemical processes in organ systems, cells, or genes (27). Broad social models that seek to ground health in the community do not ignore genetic or biological aspects of health — certainly the genetic components of Tay-Sachs disease, sickle-cell anemia, cystic fibrosis, and ß-thalassemia require study. Nor do advocates of the community or social models deny the importance of personal lifestyle (attention to nutrition, exercise, relaxation, and restraint from smoking and drug abuse). They do, however, see as equally important an understanding of how health and disease are affected by an individual’s daily life, access to medical care, economic standing, and relation to his or her community. Advocates of relating health and disease to broader social factors see health as embedded in communities, not restricted to individual bodies.

What brought about change at the NIH?

It is commonly assumed that increasing the number of female physicians is sufficient to bring about change in medical theories and practices with respect to women (28). Increasing the number of women in the medical profession is, of course, important. The NIH Office of Research on Women’s Health has rightly set women’s recruitment and reentry into, and retention in, biomedical careers as one of its goals. But to see this as the decisive factor in promoting better health care for women oversimplifies and depoliticizes a complex cultural process. It is not just women but feminists — both men and women — inside and outside the medical field who have driven reform in medical research policies. The changes discussed here in the study and practice of medicine in the US have resulted from a multidimensional process of social change that has included (a) a broadly based women’s movement; (b) fundamental changes in attitudes toward women; (c) the collaboration of men opposed to the apparent inequality in research policies; (d) the institutionalization of academic research on women and gender in universities; (e) strong congressional lobbies on emotional issues such as breast cancer research; (f) a reasonably strong economy; and (g) action by Congress to legislate gender equality in health research. The same forces and changes that successfully increased the number of women in the medical profession have also facilitated a change in attitudes and policies regarding the conduct of research relating to women’s health. The reform of gender-related medical research may now serve as a model for correcting gender bias in other sciences. Most importantly, including an analysis of significant sexual differences in biomedical research has facilitated the development of reliable databases upon which physicians and other health professionals can base informed clinical decisions and health recommendations for both women and men.

Sidebar 1 http://www.jci.org/content/vol112/issue7/images/data/973/DC1/JCI0319993sb1.jpg

Footnotes

Conflict of interest: The author has declared that no conflict of interest exists.

Nonstandard abbreviations used: Multiple Risk Factor Intervention Trial (MRFIT); Food and Drug Administration (FDA).

References

1. Healy, B. 1991. Women’s health, public welfare. JAMA. 266:566-568.[CrossRef][Medline]
2. Final report on the aspirin component of the ongoing Physicians’ Health Study. Steering Committee of the Physicians’ Health Study Research Group. N. Engl. J. Med. 321:129-135.
3. Multiple risk factor intervention trial. Risk factor changes and mortality results. Multiple Risk Factor Intervention Trial Research Group. JAMA. 248:1465-1477.
4. Shock, N.W., et al. 1984. Normal human aging: the Baltimore Longitudinal Study of Aging. NIH Publication no. 84-2450. Washington, DC, USA. 399 pp..
5. Rosser, S. 1994. Women’s health: missing from U.S. medicine. Indiana University Press. Bloomington, Indiana, USA. 213 pp..
6. Dawber, T.R., Meadors, G.F., and Moore, F.E.J. 1951. Epidemiological approaches to heart disease: the Framingham Study. Am. J. Public Health. 41:279-286.
7. Johnson, T., and Fee, E. 1997. Women’s health research. In Women’s health research: a medical and policy primer. F. Haseltine and B. Jacobson, editors. Health Press International. Washington, DC, USA. 3–26..
8. Sherman, L.A., Temple, R., and Merkatz, R.B. 1995. Women in clinical trials: an FDA perspective. Science. 269:793-795.[Medline]
9. US General Accounting Office, Women’s health: FDA needs to ensure more study of gender differences in prescription drug testing, 1992, GAO/HRD-93-17..
10. Merkatz, R. et al.1993. Women in clinical trials of new drugs. N. Engl. J. Med. 329:292-296.[Free Full Text]
11. Gender disparities in clinical decision making. Council on Ethical and Judicial Affairs, American Medical Association. JAMA. 266:559-562.
12. Nechas, E., and Foley, D. 1994. Unequal treatment: what you don’t know about how women are mistreated by the medical community. Simon & Schuster Inc. New York, New York, USA. 272 pp..
13. Johnson, T., and Fee, E. 1994. Women’s participation in clinical research: from protectionism to access. In Women and health research: ethical and legal issues of including women in clinical studies. Volume 2. A. Mastroianni, R. Faden, and D. Federman, editors. National Academy Press. Washington, DC, USA. 1–10..
14. Norsigian, J. 1993. Women and national health care reform: a progressive feminist agenda. J. Women’s Health (Larchmt.). 2:91-94.
15. Ruzek, S., Olesen, V., and Clarke, A., editors. 1997. Women’s health: complexities and differences. Ohio State University Press. Columbus, Ohio, USA. 689 pp..
16. Doyal, L. 1995. What makes women sick: gender and the political economy of health. Rutgers University Press. New Brunswick, New Jersey, USA. 280 pp..
17. Gamble, V., and Blustein, B. 1994. Racial differentials in medical care. In Women and health research: ethical and legal issues of including women in clinical studies. Volume 2. A. Mastroianni, R. Faden, and D. Federman, editors. National Academy Press. Washington, DC, USA. 174–191..
18. National Institutes of Health Revitalization Act of 1993. Public Law 103-43. June 10..
19. Notice of the "NIH Guidelines on the Inclusion of WomenMinorities as Subjects in Clinical Research." Federal record. 59(Part VIII):14508-14513.
20. NIH Department of Heath and Human Services. 2000. Monitoring adherence to the NIH policy on the inclusion of women and minorities. 103 pp..
21. Primmer, L. 1997. Women’s health research. Congressional action and legislative gains: 1990-1994. In Women’s health research: a medical and policy primer. F. Haseltine and B. Jacobson, editors. Health Press International. Washington, DC, USA. 301–330..
22. Office of the Director, NIH. 1999. Agenda for research on women’s health for the 21^st century. Volume 1, Executive summary. National Institutes of Health. Bethesda, Maryland, USA. 137 pp..
23. Merkatz, R., and Summers, E. 1997. Including women in clinical trials: policy changes at the Food and Drug Administration. In Women’s health research: a medical and policy primer. F. Haseltine and B. Jacobson, editors. Health Press International. Washington, DC, USA. 265–284..
24. Institute of Medicine (U.S.), Committee on Understanding the Biology of Sex and Gender Differences. 2001. Exploring the biological contributions to human health: does sex matter? National Academy Press. Washington, DC, USA. 267 pp..
25. Haseltine, F. 1997. Foreword. In Women’s health research: a medical and policy primer. F. Haseltine and B. Jacobson, editors. Health Press. Washington, DC, USA. xiii–xviii..
26. Holden, C. 1997. Women not shortchanged in trials? Science. 275:1571-1573.[Medline]
27. Krieger, N., and Fee, E. 1994. Women’s health, politics, and power: essays on sex/gender, medicine, and public health. N. Krieger and E. Fee, editors. Baywood Publishing Co. Amityville, New York, USA. 376 pp..
28. Schiebinger, L. 1999. Has feminism changed science? Harvard University Press. Cambridge, Massachusetts, USA. 252 pp..
    

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    http:// newsvote.bbc.co.uk/mpapps/pagetools/print/news.bbc.co.uk/2/hi/health/3431817.stm
    Mon, 26 Jan 2004
    
    Abortion 'no breast cancer link'
    Having an abortion does not increase a woman's risk of developing breast cancer, researchers have found. A study of just under 4,000 women by doctors at Sweden's Karolinska Institute found no link between terminations and the disease. Some studies have suggested abortions could increase the risk of cancer, but many experts say the evidence is weak.
     
    Last week three MPs sent out their own survey to UK doctors in a bid to examine the potential link. There is no proven link between abortion and the risk of breast cancer.
    Christine Fogg, Breast Cancer Care Researchers identified 1,759 women who had given birth between 1973 and 1991 and then gone on to develop breast cancer by comparing data from the Swedish Medical Birth Register and the Swedish Cancer Register.  They then looked at the same number of cases from the birth register who had not gone on to develop cancer. All had been asked if they had previously had any abortions while receiving maternity care. Researchers found 383 of those who went on to develop breast cancer and 473 of those who did not had had at least one abortion, suggesting terminating a pregnancy was not linked with an increased risk of breast cancer.  In fact, women who had had at least one abortion had a reduced risk of breast cancer compared to those who had none.
    
    'Taboo subject'
    Dr Gunnar Larfors, who led the research, said: "We have looked at some 4,000 journals from maternity centres in which women have responded to standardised questions about abortions, among other things, and have not found any correlation between abortions and increased risk of breast cancer. "In fact, aborted pregnancies had some preventive effect in our study."  It has been known for some time that pregnancy had a preventive effect against breast cancer, although it is not yet clear why this is the case. Mr Larfors said abortion was still a taboo subject, so if women on the street were asked, they might be unlikely to admit that had had one. But he said a woman who had suffered from breast cancer was asked about previous abortions would probably answer truthfully. He added: "This can skew the results to make it seem as if breast cancer is tied to abortion.
    "In our study all women had answered the same question before developing breast cancer."
    
    'Scare stories'
    Breast cancer campaigners urged women not to be unduly worried.  Christine Fogg, joint chief executive of Breast Cancer Care, said: "Current research has consistently failed to show any link between induced or spontaneous abortions and breast cancer risk."  She said "scare stories" which claimed to show a link increased the anxiety of many women.
    "We want to reassure women that there is no proven link between abortion and  the risk of breast cancer and that age remains the strongest risk factor for breast cancer."
    Following the concerns raised last week, Professor Joel Brind, from City University of New York, who claims his findings suggest a link between abortion and breast cancer after being invited by pro-life campaigners Life, is to speak to MPs on Wednesday.
    Story from BBC NEWS: http://news.bbc.co.uk/go/pr/fr/-/2/hi/health/3431817.stm
    
    

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    ProLife View Point
    

    CMAJ • July 22, 2003; 169 (2)
    © 2003 Canadian Medical Association or its licensors

    Letters/ Correspondance
    

    Abortion perils debated

    by Shauna C. Hollingshead

    Medical Student, University of Alberta, Edmonton, Alta., Canadian Physicians for Life

    In response to those who have taken issue with CMAJ over publication of the article by David Reardon and associates,¹ I would like to point out that in medical ethics the concept of informed consent is of paramount importance. Regardless of one's opinions about the abortion issue, educating patients about the benefits and risks of an intervention is integral to good medicine. Thus, physicians should be willing to inform their patients of the risks associated with abortion. Aside from the usual risks associated with a surgical procedure, these include increased risks of psychiatric illness,¹ future preterm birth² and breast cancer.^3,4

    I commend CMAJ for refusing to allow politics to trump the scientific progress of women's health care.

    Shauna C. Hollingshead Medical Student University of Alberta Edmonton, Alta. Canadian Physicians for Life

    References

    1. Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low-income women following abortion and childbirth. CMAJ 2003;168(10):1253-6.[Abstract/Free Full Text]
    2. Henriet L, Kaminski M. Impact of induced abortions on subsequent pregnancy outcome: the 1995 French national perinatal survey. Br J Obstet Gynaecol 2001;108:1036-42.
    3. Brind J, Chincilli VM, Severs WB, Summy-Long J. Induced abortion as an independent risk factor for breast cancer: a comprehensive review and meta-analysis.J Epidemiol Community Health 1996; 50:481-96.[Abstract]
    4. Daling JR, Malone KE, Voigt LF, White E, Weiss NS. Risk of breast cancer among young women: relationship to abortion. J Nat Cancer Instit 1994;86:1584-92.[Abstract]

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    CMAJ • July 22, 2003; 169 (2)
    © 2003 Canadian Medical Association or its licensors
    

    Editorial Français à la page suivante

    Unwanted results: the ethics of controversial research

    The recent publication of a study on psychiatric admission rates among low-income women after abortion and childbirth¹ has elicited a barrage of letters to CMAJ of a pitch that we do not frequently encounter (page 101).² We are chided for publishing flawed research and told that we should be ashamed of publishing the "opinions" of self-evidently biased researchers. We are accused of doing a disservice to women, medicine and the Journal, of failing to conduct proper peer review, and of not adequately scrutinizing the credentials of the authors.

    The abortion debate is so highly charged that a state of respectful listening on either side is almost impossible to achieve. This debate is conducted publicly in religious, ideological and political terms: forms of discourse in which detachment is rare. But we do seem to have the idea in medicine that science offers us a more dispassionate means of analysis. To consider abortion as a health issue, indeed as a medical "procedure," is to remove it from metaphysical and moral argument and to place it in a pragmatic realm where one deals in terms such as safety, equity of access, outcomes and risk–benefit ratios, and where the prevailing ethical discourse, when it is evoked, uses secular words like autonomy and patient choice.

    Hence, perhaps the thing that is most offensive to some of our correspondents is the apparent co-opting of the medical view by persons they believe to be unqualified — or disqualified. The attack in our letters column is largely an ad hominem objection to the authors' ideological biases and credentials. There are two questions here: first, does ideological bias necessarily taint research? Second, are those who publish research responsible for its ultimate uses?

    The answer to the first must be that opinion can of course cloud analysis. In light of the passion surrounding the subject of abortion we subjected this paper to especially cautious review and revision. We also recognized that research in this field is difficult to execute. Randomized trials are out of the question, and so one must rely on observational data, with all the difficulties of controlling for confounding variables. But the hypothesis that abortion (or childbirth) might have a psychological impact is not unreasonable, and to desist from posing a question because one may obtain an unwanted answer is hardly scientific. If we disqualified these researchers from presenting their data, we could never hear from authors with pro-choice views, either.

    The phrase used by Deborah Stone³ in her classic text on public policy — "No number is innocent" — might be read as saying that every statistical analysis is guilty of serving one political agenda or another. A softer interpretation is that quantitative analysis is always subject to contextual influences. Biases and expectations, pre-existing knowledge and methodologic habits all influence what kinds of hypotheses are tested and how. Ultimately, our measurements are delimited by what can be measured, and by what we choose to measure. Feminist critiques have frequently pointed out the failure of mainstream health research to "count women in," whether in randomized controlled trials or in economic analyses of health reforms.⁴ When researchers do attempt to amass quantitative evidence in women's health the ideological stakes are high: evidence is trailing rather far behind politics. Thus, the values of self-care and patient empowerment exemplified by breast self-examination gave rise to a similar outcry against unwanted results published in this journal.^5,6,7 But if it is true that more explicit research into women's health issues will point the way to better care, better outcomes and more equity in access, we cannot toss out data any time we don't like their implications. Nor can we leap from a single observational study to public policy. We must allow the gradual and honest accumulation of further evidence to confirm or contradict what we think we know.

    Which brings us to the second question: Should we deny the publication of a study because it might be applied by one or the other side of a factionalized debate? It strikes us that the results of the study by Reardon and colleagues are neutral: they could be "used" to further the argument that abortion is undesirable; or to support arguments for better post-abortion counselling and support. We cannot second-guess such interpretations without unfairly imposing our own values on the research we choose to publish. — CMAJ

    References

    1. Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low-income women following abortion and childbirth. CMAJ 2003;168(10):1253-6. [Abstract/Free Full Text]
    2. Abortion perils debated [letters]. See exchange of Letters in: CMAJ 2003; 169 (2): 101-3.[Free Full Text]
    3. Stone D. The policy paradox: the art of political decision-making. Revised ed. New York: W.W. Norton & Company; 2001.
    4. Armstrong P. The impact of health reform on women: a cautionary tale [lecture]. Available: www.fedcan.ca/english/policyandadvocacy/breakfastonthehill/breakfast-healthcare.cfm (accessed 2003 Jun 30).
    5. Baxter N, with the Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer? CMAJ 2001;164(13):1837-46.[Abstract/Free Full Text]
    6. Breast cross-examination [editorial]. CMAJ 2001;165(3): 261. [Free Full Text]
    7. Lerner BH. When statistics provide unsatisfying answers: revisiting the breast self-examination controversy [editorial]. CMAJ 2002;166(2):199-201. [Free Full Text]
    
    

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