We commend Jalanko et al.1 for taking advantage of Finnish registry data to answer important policy-relevant questions. However, a fatal flaw in their analysis calls into question the validity of its findings Furthermore, their results conflict with every rigorous study and review examining the effects of abortion on women's mental health outcomes, including suicidal behaviors and alcohol-related problems.2 It is critical that studies comparing the mental health outcomes of women following abortion and childbirth to never-pregnant women account for selection into these groups, particularly women's pre-pregnancy mental and physical health and substance use. Women who have abortions have a higher incidence of pre-pregnancy mental health conditions than women without a history of abortion2,3 and the reasons women seek abortion– financial, the desire to end an abusive relationship, and heavy alcohol and drug use4—can affect women's mental health post-abortion. However, Jalanko et al.1 failed to control for these pre-disposing factors. The higher rates of pre-pregnancy psychiatric illness and substance use disorders among the teenagers who became pregnant,5 likely explains the incongruity of their findings with the latest evidence. Without controls for these factors, it is not possible to attribute the outcomes to the abortion or pregnancy. Given that these are registry data, the authors likely had access to women's pre-pregnancy mental health and substance use history, and thus should have accounted for these variables. Not including controls for these factors raises serious questions about the legitimacy of the study findings.
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