Mental Health 101: Abortion Access
An introduction to the Turnaway Study, one of the most comprehensive assessments of mental health outcomes on women who seek abortions
Mental Health 101 is an ongoing series where I discuss a mental health concern that is common throughout pregnancy or early parenthood. I’ve previously written about “the baby blues,” the global prevalence of postpartum depression, intrusive thoughts, and postpartum psychosis.
This week I’m talking about abortion. Specifically, I discuss an innovative research program that suggests it’s the lack of access to safe abortions - rather than abortions themselves - that contribute to mental health difficulties for pregnant people.
Portland, Oregon recently became the first in the U.S. to allow city employees to take up to three days of bereavement leave if they’ve had an abortion. City employees are also allowed this leave if they’ve experienced a miscarriage, stillbirth, or other pregnancy loss, as well as the loss of any other person in their life that they care about. This is great from so many perspectives, not least of which is that our society generally fails to prioritize our grief, and when it does, it’s only for the loss of an adult legal relative. It also comes at a time when abortion rights in the U.S. are under severe threat, such as the recent Texas law that bans most abortions after six weeks, before most people even know they’re pregnant.
Major medical and health care organizations agree that abortion is a common, integral aspect of reproductive health care. According to the CDC, the abortion rate in 2018 was 11.3 abortions per 1000 women, or 189 abortions per 1000 live births. The American Psychological Association asserts that abortion is a civil right. The American Academy of Pediatrics, the American Medical Association, the Society for Adolescent Health and Medicine, the American Public Health Association, and the American College of Obstetricians and Gynecologists, among others, are in consensus that adolescents should not be compelled or required to involve a parent in their decision to have an abortion1.
There are many who experience grief after an abortion, but there are also many who do not. Often, however, the narratives around abortion focus only on the negative emotional experiences related to it, and conservative politicians have weaponized this narrative to support anti-abortion policies (such as discussing a “post-abortion syndrome” of physical and psychological consequences women face after they have an abortion). Because of this, rigorous research on the relationship between maternal mental health and abortion is essential.
For example, imagine a study that tracks drinking behaviors in women before they get pregnant versus after. Researchers then compare the drinking habits between the women in their study who got abortions with the women who did not, and their results suggest that the women who terminated their pregnancies drank more on average than the women who didn’t. I can see the conservative click-bait headline now: “ABORTIONS LEAD TO ALCHOLISM.” In reality, abortions didn’t suddenly make some women winos; it simply made them not pregnant anymore. So of course women who terminated their pregnancies probably drank more alcohol than when they were pregnant, or drank more on average than the women who stayed pregnant.
While fake, the problems with this study are not that different from real studies that compare women who seek abortions with women who don’t. These groups, for so many reasons, are not comparable because they differ in so many fundamental things - including how much they planned or wanted to be pregnant. This is just one example of the types of flaws that the American Psychological Association Task Force on Mental Health and Abortion found when they reviewed publications from 1990-2007 on the psychological effects of abortion. Many studies were methodologically flawed to the extent it was difficult to draw firm conclusions on the relationship between mental health and abortion from this existing research.
In response to these findings, the University of California San Francisco Turnaway Study was developed. From 2008-2010, this research team recruited close to a thousand women from 30 different abortion facilities in 21 states. They were specifically interested in addressing the need for adequate comparison groups in understanding the unique experiences of women who have abortions. Based on their recruitment, women in their study fell into one of three groups (numbers based on Biggs et al., 2016)2:
254 women who received an abortion in the first trimester of pregnancy (first trimester abortion group)
413 women who sought an abortion up to two weeks under a facility’s gestational limit and received an abortion (near-limit abortion group)
210 women who sought an abortion up to three weeks over a facility’s gestational limit and were turned away from receiving an abortion (turnaway group)
Participants were interviewed one week after they sought an abortion and then every six months for five years on various measures of mental and physical health, education, employment, family relationships, etc. The longitudinal nature of this study also allowed them to further compare within the turnaway group women who carried their pregnancy to full-term versus women who either had a miscarriage or received an abortion from another site.
This study has soo many strengths. First, it is a demographically diverse sample of English or Spanish-speaking women from urban and rural environments across the U.S., including ~57% white, ~10% Black, ~20% Hispanic/Latina, and ~13% multiracial/other ethnicity participants3. Additionally, all of the women in this study wanted abortions, with the main difference being whether they had access to one, and when during their pregnancy the abortion happened. This helps us draw more accurate conclusions that any differences we see in our groups are most likely based on whether an abortion occurred or not, and when. The prospective, longitudinal nature of this study is also a strength - the researchers are examining the experiences of women right after (one week) they sought an abortion and comparing that experience with future experiences, rather than, say, asking women about their experiences years after they sought an abortion. This latter type of study is known as a retrospective study and while it can be useful, it tends to be more susceptible to things like recall bias (the inability for people to remember events accurately, or to accidentally omit important information).
Results from the Turnaway Study suggests that the mental health consequences of being denied an abortion far outweigh the consequences of choosing to have one. This is mostly because women who had an abortion, regardless of when they had it, did not differ from other women on a host of mental health consequences, including symptoms of depression, anxiety, PTSD, or rates of alcohol or drug use. In other words, having an abortion did not appear to increase one’s likelihood of having any of these experiences.
Biggs and colleagues (2016), one of the studies from the Turnaway Study team, found that one week after seeking an abortion, women who received an abortion during the first trimester reported less severe depression symptoms than those in other groups (including the near-limit abortion group and the turnaway group), though these groups did not differ in depression symptoms during later follow-ups. Additionally, one week after seeking an abortion, women in the turnaway group reported higher symptoms of anxiety, lower self-esteem, and lower life satisfaction compared to women who received an abortion. Specifically, these symptoms were higher for women who ended up either miscarrying or terminating their pregnancy at another site, with the researchers speculating that this was most likely due to the emotional difficulties related to being turned away in the first place and the psychological and financial toll these women experienced in trying to find a site elsewhere that would terminate their pregnancy. There were no differences in anxiety, depression, self-esteem, or life satisfaction across all groups by the end of the study (after five years).
Obviously one study, even one as rigorously designed as this, cannot answer all questions. There will always be the caveat in these studies that people who choose to be part of the study will differ from people who were approached and did not want to participate (e.g., such as people who felt particularly negative about their abortion seeking experience), or stopped participating at some point during the five year duration (a.k.a. attrition). While the researchers attempted to take into consideration important differences between groups in their statistical analysis (e.g., mental health history), it would be impossible to consider every single potential variable that differs between these groups that could influence the results. Understandably, we can’t randomly assign women to have abortions or to not. Additionally, there is very little empirical data on abortion access outcomes for non-cis-women.
Despite these caveats, this is one of the most methodologically rigorous studies ever to assess the psychological effects of abortion and abortion access. Their results support the idea that there are mental health benefits, not consequences, when women have control over the timing of their pregnancies. Additionally, the Turnaway Study team illustrates the immense importance of rigorous scientific work that can inform policies that affect the civil rights and reproductive health of all pregnant people.
If you want to learn more, I recommend checking out the Turnaway Study team’s website, including a fact sheet on the other harms related to denying women a wanted abortion and summaries of their many studies. You can also read a 2013 New York Times Magazine piece on their work or check out their book about their findings: The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having - or Being Denied - an Abortion.
Felice, M. E., & Boulter, S. (1996). The adolescent's right to confidential care when considering abortion. Pediatrics, 97(5), 746-751. https://pediatrics.aappublications.org/content/139/2/e20163861
Biggs, M. A., Upadhyay, U. D., McCulloch, C. E., & Foster, D. G. (2017). Women’s mental health and well-being 5 years after receiving or being denied an abortion: A prospective, longitudinal cohort study. JAMA Psychiatry, 74(2), 169-178. https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2592320?casa_token
So, it actually took me a LONG time to find the racial breakdown of participants from the Turnaway Study (maybe I was doing something wrong?) Anyway, demographic information for participants was not evident from the Biggs et al. (2017) study or their supplemental materials, but I found it from this other paper from the Turnaway Study team:
Roberts, S. C., Avalos, L. A., Sinkford, D., & Foster, D. G. (2012). Alcohol, tobacco and drug use as reasons for abortion. Alcohol and Alcoholism, 47(6), 640-648. https://academic.oup.com/alcalc/article/47/6/640/204854?login