A landmark study tracks the lasting effect of having an abortion — or being denied one

Though it's impossible to know exactly what will happen to abortion access if Roe v. Wade is overturned, demographer Diana Greene Foster does know what happens when someone is denied an abortion. She documented it in her groundbreaking yearslong research project, The Turnaway Study and her findings provide insight into the ways getting an abortion – or being denied one – affects a person's mental health and economic wellbeing.

For over 10 years, Dr. Foster and her team of researchers tracked the experiences of women who'd received abortions or who had been denied them because of clinic policies on gestational age limits.

The research team regularly interviewed each of nearly 1,000 study participants for five years and found those who'd been denied abortion experienced worse economic and mental health outcomes than the cohort that received care. And 95% of study participants who received an abortion said they made the right decision.

The idea for the Turnaway Study emerged from a 2007 Supreme Court abortion case, Gonzales v. Carhart. In the majority opinion upholding a ban on a specific procedure used rarely in later abortions, Justice Anthony Kennedy speculated that abortions led to poor mental health. "While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained," he wrote. "Severe depression and loss of esteem can follow."

Kennedy's speculation — and admitted lack of evidence — captured Foster's attention, "because you can't make policy based on assumptions of what seems reasonable without talking to a representative sample of people who actually wanted an abortion," she said. The Turnaway Study fact-checked the justice's guess, finding that not having a wanted abortion was more likely to lead to the mental health outcomes he'd described than having one.

The study concluded in 2016, and didn't assess the effects of existing abortion restrictions on patients, or anticipate a future in which Roe v. Wade is overturned. It also didn't address the experiences of transgender and nonbinary people seeking abortion care, who Foster suspects may face even more significant access barriers than the women who were turned away.

Foster spoke with NPR's Short Wave about the study and its relevance today.

This interview has been edited for length and clarity.

Who participated in The Turnaway Study? How did they compare to people who typically seek abortions?

The sample ended up looking very closely like the population of people who seek abortions nationally. So 60% of the women were already mothers. About half were in their 20s, which is typical. About three-quarters were already below the federal poverty level at the time they were seeking an abortion.

The only real difference is that they tended to be later in pregnancy because we recruited them right up near the gestational limit. And I think I had an idea before I started this study, that people seeking abortion later in pregnancy would somehow be different... And that turned out to be completely false. The people who seek abortions later in pregnancy were not substantively different from the people seeking abortion earlier, with the exception that they tended to have been a lot later in realizing they were pregnant....

What did you learn about the lives of women who were denied abortions after five years of follow-up conversations?

We see a couple of areas where their lives dramatically diverge in outcomes [from women who got abortions]. The first is health. Consistent with the medical literature, carrying a pregnancy to term and delivering a child is much more physically risky than having an abortion, even a later abortion. We see much more severe physical health complications from birth, including most tragically, two women who died after delivery — one died of an infection and one died of a very common pregnancy complication.

The other area that we see big differences is in socioeconomic well-being. This is not just about poverty, although we see that people who are denied abortions are more likely to live in households where there just isn't enough money for basic living needs... And they're more likely to be raising children alone if they are denied the abortion than if they receive one. They're equally likely to be in a relationship, whether they received or were denied an abortion.

But those who receive the abortion report that their relationship is higher quality. So it's changing fundamental aspects of people's lives, including their chance at having children later under better circumstances.

And what did you find for those women who were able to get an abortion?

We see better mental health initially for the people who receive an abortion compared to those who are denied it and for both groups, improving mental health over time. And I think that's because the experience of having an unwanted pregnancy is associated with serious anxiety and distress. And over time, people improve...

Abortion doesn't cause depression or anxiety, but people could have an emotional reaction to having had an abortion. And so we asked people about six emotions... happiness, sadness, regret, relief, anger and guilt... And what we learned is that positive emotions outweigh negative emotions, but a substantial number of people do have negative emotions about it.

People can experience the emotion regret and still feel like they made the right decision about having an abortion. So: "I regret that I was in the position where I needed an abortion. But given that I was, I'm glad I had it." And they can feel sad, and sad is different than depressed. So people have a range of emotional responses, and over time, people say that having strong positive emotions and strong negative emotions, both of those reduce over time, and people tell us that they stop thinking about abortion. One woman told us "I only think about it when you call me for these interviews."

So this idea that somehow this event is disrupting people's lives forever — that is not accurate for the vast majority of people. This is something that people say they needed to do, and they did it and moved on with their lives.

Did you see any differences among women who had the support of their family, friends or community in their decision?

My colleague, social psychologist Antonia Biggs, analyzed the mental health data ... to narrow in on who actually is experiencing some mental health distress over time, and it's disproportionately those who report that they experience a lot of stigma around abortion. But I should note it's rare, and the much bigger predictor of poor mental health is a history of childhood abuse and neglect.

What impact did being denied an abortion have on families who already had children?

I think it's often surprising to people who don't think about abortion very much that people who seek abortions are often already parents. Sixty percent of people nationally who have abortions are already mothers, and they give as a reason for wanting to have an abortion that they need to take care of the kids they already have. And when we look at the well-being of those existing children, we see differences based on whether their mom received or was denied an abortion for their subsequent pregnancy. So those kids whose mothers were denied abortions are less likely to achieve developmental milestones such as language and gross motor, fine motor skills.

What does this research add to the discussion of Roe v. Wade?

The Turnaway Study was not designed with this moment in mind, because in my worst nightmares, I did not imagine that we would see an end of Roe so quickly. But what The Turnaway Study shows is that people who become pregnant and are unable to get a safe, legal abortion in their state, those that carry the pregnancy to term will experience long-term physical health and economic harm. We haven't become a more generous country that supports low-income mothers. And so those outcomes are still the outcomes that that people will experience when they are denied a wanted abortion.

What The Turnaway Study doesn't answer about the current time is that many people will manage to circumvent their state laws and they won't carry that pregnancy to term and they'll travel to nearby or faraway states or they'll order medication abortion pills online and they'll manage to get an abortion. And some people will try dangerous things and potentially harm themselves. And so we really don't know the full effect of this decision.

NPR's Rebecca Ramirez produced the audio version of this interview for Short Wave.

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