research paper against abortion

The facts about abortion and mental health

Scientific research from around the world shows having an abortion is not linked to mental health issues but restricting access is 

Vol. 53 No. 6 Print version: page 40

More than 50 years of international psychological research shows that having an abortion is not linked to mental health problems, but restricting access to safe, legal abortions does cause harm. Research shows people who are denied abortions have worse physical and mental health, as well as worse economic outcomes than those who seek and receive them.

Meanwhile, the same research shows getting a wanted abortion does not cause significant psychological problems, despite beliefs to the contrary. In a landmark study of more than 1,000 women across 21 states, those who were allowed to obtain an abortion were no more likely to report negative emotions, mental health symptoms, or suicidal thoughts than women who were denied an abortion.

[ Related: Frequently asked questions about abortion laws and psychology practice ]

Large longitudinal and international studies have found that obtaining a wanted abortion does not increase risk for depression, anxiety, or suicidal thoughts ( The mental health impact of receiving vs. being denied an abortion , Advancing New Standards in Reproductive Health , 2018).

“It’s important for folks to know that abortion does not cause mental health problems,” said Debra Mollen, PhD, a professor of counseling psychology at Texas Woman’s University, who studies abortion and reproductive rights. “What’s harmful are the stigma surrounding abortion, the lack of knowledge about it, and the lack of access.”

Misconceptions about abortion are also linked to lower support for it—and people deserve to have accurate information so they can make informed decisions, Mollen said (Weibe, E. R., et al., Gynecology & Obstetrics , Vol. 5, No. 9, 2015 ).

How abortion impacts mental health

The Turnaway Study , a landmark analysis of abortion from Advancing New Standards in Reproductive Health (ANSIRH) at the University of California, San Francisco, served to debunk the belief that people who get abortions experience deep regret, grief, or even posttraumatic stress disorder. Instead, the most commonly felt emotion is relief (Rocca, C. H., et al., Social Science & Medicine , Vol. 248, 2020 ).

In the study, researchers followed nearly 1,000 women across 21 states for five years to examine the similarities and differences between those who wanted and received an abortion versus those who wanted but were denied an abortion. Five years after the procedure, women who had an abortion were no more likely to report negative emotions or suicidal thoughts than women who were denied an abortion, and more than 97% of those studied said that having the abortion was the right decision (Rocca, C. H., et al., Social Science & Medicine , Vol. 248, 2020 ).

In a review of the scientific literature on abortion published 10 years earlier, an APA task force reached a similar conclusion, especially in the case of unplanned pregnancy. The task force reported that women who had an abortion in the first trimester did not face a higher risk of mental health problems than women who continued with an unplanned pregnancy ( Report of the APA Task Force on Mental Health and Abortion , 2008).

“In fact, the best predictor of a woman’s mental health after an abortion is her mental health before the abortion,” said Nancy Felipe Russo, PhD, an emeritus professor of psychology and women’s studies at Arizona State University who has spearheaded research on unwanted pregnancy, mental health, and abortion.

Another group of women—those who planned and wanted a pregnancy but terminated it during the second or third trimester because of a life-threatening birth defect—faced some psychological problems after the procedure. But those were comparable to mental health problems among women who miscarried or lost a newborn baby, and less severe than the distress among women who delivered babies with severe birth defects.

“The bottom line is that abortion in and of itself does not cause mental health issues,” said M. Antonia Biggs, PhD, a psychologist and researcher at ANSIRH and one of the leaders of the Turnaway Study.

When abortions are denied

The women in the Turnaway Study who were denied an abortion reported more anxiety symptoms and stress, lower self-esteem, and lower life satisfaction than those who received one ( JAMA Psychiatry , Vol. 74, No. 2, 2017 ). Women who proceeded with an unwanted pregnancy also subsequently had more physical health problems, including two who died from childbirth complications (Ralph, L. J., et al., Annals of Internal Medicine , Vol. 171, No. 4, 2019 ).

They faced more economic hardships, including worse credit scores, more frequent bankruptcies and evictions, and a higher chance of living in poverty. After being denied an abortion, women were also more likely to stay linked to a violent partner or to raise children alone ( The harms of denying a woman a wanted abortion , ANSIRH, 2020).

And people seeking abortions aren’t the only ones harmed when the procedure is banned.

“The children born as a result of abortion denial were not only more likely to live in poverty, but they were also more likely to experience poor bonding with their mothers,” Biggs said.

Other studies show that children born in such circumstances face a range of social, emotional, and mental health problems that continue into adulthood, including more psychiatric hospitalizations than their siblings or other children of planned pregnancies (David, H. P., Reproductive Health Matters , Vol. 14, No. 27, 2006 ; Dagg, P. K., American Journal of Psychiatry , Vol. 148, No. 5, 1991 ).

“Negative outcomes are not limited to minor problems that occur over a short span of time,” Russo said. “They can be severe outcomes of real concern.”

More stigma, barriers, and inequities

Given that the mental health impacts of denying abortion extend far beyond the procedure itself, it’s important to consider the issue in the larger context of society.

“Most people assume that if we’re talking about psychological ramifications, that’s about their feelings around having an abortion,” said Julie Bindeman, PsyD, a reproductive psychologist who cofounded and directs Integrative Therapy of Greater Washington, a private practice outside Washington, D.C. “But we really need to think about the compounding costs involved with even getting to that point.”

If a state bans abortions, a resident seeking one faces a new and significant set of barriers. They might incur additional costs for out-of-state travel, lodging, and childcare during the trip—all while missing wages at work. They might feel compelled to disclose the pregnancy to friends, family members, or coworkers from whom they’ve solicited help. They might be forced to wait longer for an appointment. All these challenges add up to more psychological stress.

Those new barriers could hinder anyone seeking an abortion, not just people in states restricting the procedure.

“Many people will be traveling to states with greater access to care, and that surge in demand for a limited number of appointments has the potential to impact everyone,” Biggs said.

Research has shown that people who face logistical barriers to accessing abortion care, including increased travel time or difficulty scheduling appointments, have more symptoms of stress, anxiety, and depression. A loss of autonomy—such as being forced to wait for an appointment or disclose a pregnancy—has the same effect ( Contraception , Vol. 101, No. 5, 2020 ).

Banning the procedure also stigmatizes it, and stigma harms mental health, according to findings from the Turnaway Study. Women in the study who felt they would be looked down on by friends, family, and community members if they had an abortion were much more likely to report psychological distress years later ( PLOS ONE , Vol. 15, No. 1, 2020 ).

Experts say the growing costs of obtaining an abortion will weigh much more heavily on those people with fewer economic resources.

“What we’re likely to see is an increased stratification, where those who have means and can travel will be able to obtain their abortions, and those who do not will face barriers upon barriers,” Bindeman said.

People who already struggle to pay for and access abortions—those living in poverty, people of color, people in rural areas, sexual and gender minorities, and young people, who are often bound by state-level parental consent and notification laws—are likely to be hardest hit by abortion bans.

“For all those reasons, this is a perfect storm of perpetuating continued inequities for people who are already marginalized,” said Bindeman.

Resources and support

While abortion isn’t linked to mental health problems, the challenges around obtaining one can be distressing. The following programs and organizations aid people who are seeking an abortion or want to talk about their experience.

Finding a credible health care provider

• Planned Parenthood partners with more than 600 sexual and reproductive health care centers nationwide.
• AbortionFinder.org offers a directory of verified abortion providers across the United States
• The National Abortion Federation offers an online “Find a Provider” tool and a Referral Line to help patients locate abortion providers in their region.
• Avoid “crisis pregnancy centers,” which promote misinformation intended to dissuade people from obtaining abortions. One study found that 80% of crisis pregnancy center websites contained false or misleading information (Bryan, A. G., et al., Contraception , Vol. 90, No. 6, 2014 ).

Social and emotional support

• Exhale Pro-Voice is a textline that offers peer counseling for people who have had abortions and their loved ones, as well as trainings on how to provide support after an abortion.
• Planned Parenthood ’s local, state, and regional centers offer various programming and activities for patients.
• Sister Song , the National Black Women’s Reproductive Justice Agenda , and other organizations focus on supporting people of color.

Financial support

• The National Network of Abortion Funds works with more than 80 organizations to provide funding for abortion, transportation, childcare, and other services.
• The National Abortion Federation provides referrals, case management, and financial assistance for people seeking abortions.
• Funding is also available from numerous regional, state, and local grassroots organizations, such as Jane’s Due Process , the Texas Equal Access Fund , and the Mississippi Reproductive Freedom Fund .

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Abortion is an issue that has ethical, moral, and religious considerations for many people, making it a topic that impacts all of society. Read the overview below to gain a balanced understanding of the issue and explore the previews of opinion articles that showcase many perspectives on reproductive rights.

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Abortion topic overview.

"Abortion" Opposing Viewpoints Online Collection , Gale, 2024.  

Abortion is a medical or surgical procedure to deliberately end a pregnancy. In 1973 the US Supreme Court decision in Roe v. Wade ruled that the Constitution protects the right to an abortion prior to the viability of a fetus. Until the 2022 ruling in Dobbs v. Jackson Women's Health Organization, Roe v. Wade allowed a person living in any US state to exercise the right to an abortion at their own discretion through the end of the first trimester, around the twelfth week of pregnancy. States were allowed some power to regulate abortion access during the second and third trimesters. The Dobbs ruling, however, ended the federal protections for abortion rights and returned to the states the authority to determine abortion law.

In the decades between Roe and Dobbs , activists and policy makers in many states sought to change legal protections for reproductive rights. In 2020 lawmakers in twelve states tried to use the COVID-19 pandemic as justification to temporarily ban abortion as a "nonessential service." In 2021 several states introduced new restrictions on abortion, implementing over one hundred new abortion restrictions. Though the public has consistently indicated opposition to bans on abortion, several state legislatures passed bans in anticipation of the conservative Supreme Court majority overturning the nearly fifty-year-old Roe decision. Since the decision, new abortion laws have been passed across the country, some restricting and some easing access to abortion.

  Main Ideas

• Abortion  refers to a procedure to terminate a pregnancy. The term is typically applied to a planned medical or surgical procedure.
• People who support legal access to abortion typically identify as  pro-choice , while those who support bans and heavy restrictions identify as  pro-life .
• Medical abortions can take place during the first trimester of a pregnancy. In these procedures, the patient takes a combination of drugs to induce an abortion.
• In 1973 the US Supreme Court ruled in  Roe v. Wade  that state laws banning abortion during the first trimester of pregnancy were unconstitutional. Reproductive rights advocates challenged subsequent restrictions placed on abortion in federal court.
• Passed in 1976, the Hyde Amendment forbids the use of federal funds for abortions except under cases of rape, incest, or in which continuing the pregnancy would threaten the woman's health.
• In 2022 the US Supreme Court ruled in  Dobbs v. Jackson Women's Health Organization  that the US Constitution did not guarantee the right to abortion. The decision overturned the court's previous ruling in  Roe v. Wade .
• After the  Dobbs  ruling, many states passed or implemented abortion bans or restrictions, despite continuing US public support for legal abortion. Bans have increased travel to obtain abortions to states where it remains legal and resulted in increased maternal and infant deaths in states where abortion was banned.

SUPPORT FOR AND OPPOSITION TO ABORTION

Opponents of abortion, who generally refer to themselves as  pro-life , typically object to the practice for religious or ethical reasons, contending that the procedure amounts to the killing of what they consider to be a human life. Supporters of abortion rights, who typically identify as  pro-choice , consider it an issue of human rights, asserting that individuals should be able to make medical decisions about their own bodies and lives. Both movements encompass a range of opinions on the subject. Some pro-life activists may condone abortions in cases of rape or incest, while others argue that all abortion is murder. Within the pro-choice movement, some activists contend that no restrictions should be placed on abortion, while others support laws requiring a waiting period before abortions can be performed or that minors obtain permission from their parents.

The majority of Americans oppose banning abortion altogether, with just 13 percent of respondents to a May 2022 Gallup poll indicating a belief that abortion should be illegal under all circumstances. However, the public has remained divided on the extent to which the government should be allowed to impose restrictions. A 2023 Pew Research Center poll found that 64 percent of US adults believed abortion should be legal in all or most cases, compared to 34 percent who said it should be prohibited in all or most cases. Poll results also showed a partisan divide on abortion that has widened over time, with almost 90 percent of Democrats believing abortion should be legal in all or most cases in 2022 compared to 21 percent of Republicans. According to an April 2023 report from the Pew Research Center, 54 percent of Americans said it would be very or somewhat easy to get an abortion in their area, compared to 65 percent in 2019. A further 34 percent of respondents told Pew it should be easier to have an abortion in their area, up from 26 percent in 2019.

After  Roe  was overturned, protest marches and demonstrations erupted across the United States and lasted for days, with some commentators noting the wide discrepancy between popular support for  Roe  and the court's rejection of it. While abortion has long been considered a feminist or women's rights issue, the protests highlighted its effects on all Americans regardless of gender. The  Dobbs  ruling removed precedents related to the right to privacy and the right to bodily autonomy, neither of which is specifically stated in the Constitution. However, these assumed rights have been foundational to rulings decriminalizing interracial marriage, contraception, nonprocreative sex, and same-sex marriage.

Surgical and Medical Abortions

Most abortions take place within the first trimester of pregnancy. The two types of abortion are  surgical  and  medication . The most commonly performed surgical abortion procedure is  suction abortion , also referred to as  vacuum aspiration , which involves removing tissue from the uterus through a thin tube. The procedure is less invasive than surgeries at later stages of pregnancy, which require labor to be induced. First-trimester surgical abortions performed by trained medical professionals are among the safest and simplest forms of surgery. Data from the US Centers for Disease Control and Prevention (CDC) suggests that many fewer women die from legal abortions than from childbirth or many other common procedures, leading many medical experts to conclude that abortion is safer than giving birth in the United States.

Abortions achieved with drugs instead of surgery are called  medication abortions  and are considered safe and effective until between nine and eleven weeks after the last menstrual period. The most commonly used drugs for medication abortions in the United States are mifepristone and misoprostol, taken in sequence as prescribed by a health care provider. Patients first take mifepristone (previously called RU-486), which blocks the body's natural production of progesterone, an essential pregnancy hormone. The patient takes the second pill, misoprostol, two days later. This drug causes the uterus to contract and expel the embryo. Medication abortions are different from emergency contraception, a type of birth control pill used after unprotected sexual intercourse that prevents pregnancy.

The number of medication abortions surpassed the number of surgical abortions for the first time in 2020, accounting for an estimated 54 percent of all abortions that year, according to the Guttmacher Institute. In April 2021, due in part to COVID-19's impact on providing and accessing health care services, the US Food and Drug Administration (FDA) lifted a ban on dispensing abortion medication through the mail. The decision enabled patients to access abortion without risking COVID exposure and allowed abortion providers that operate online to mail pills to more states. The FDA made this change permanent in December 2021.

Roe V. Wade

Abortions were commonly performed in the United States at the time of its founding and were not restricted by law until Connecticut passed the first anti-abortion law in 1821. Until the  Roe v. Wade  ruling in 1973 there was no federal standard for abortion laws, which were left to the discretion of state legislatures. By 1967 forty-nine states and the District of Columbia had classified abortion as a felony crime in most cases. That same year, however, Colorado passed a law that allowed women to seek voluntary abortions. Several states followed Colorado in liberalizing their abortion laws. By 1973 laws prohibiting abortions had been repealed in four states and loosened in fourteen. In states where abortions were prohibited by law, women who wished to terminate their pregnancies sought out illegal abortions provided by health care workers who risked jeopardizing their careers or by individuals without the proper skills or tools to perform the procedure safely.

In  Roe v. Wade , the Supreme Court ruled that restrictive abortion laws are unconstitutional and violate a woman's right to privacy, as implied by the due process clause of the Fourteenth Amendment. The court's decision also determined that an embryo or unviable fetus is not a person in the legal sense. The ruling established that the decision to terminate a pregnancy during the first trimester was the sole decision of the pregnant person and their physician but permitted state governments to regulate abortion during the second trimester. States could ban abortion after the fetus had reached viability, except in cases where the pregnant person's health is endangered.  Viability  refers to a fetus's ability to survive outside of the womb. The point at which viability is achieved during a pregnancy remains a topic of debate, though it is usually accepted as near the end of the second trimester, at around twenty-four weeks.

In  Doe v. Bolton , a companion case to  Roe v. Wade  decided on the same day, the Supreme Court reaffirmed its decision in  Roe v. Wade  by prohibiting laws that require admission to a hospital, approval by a hospital abortion committee, a second and third medical opinion, or legal residence in a state before an abortion can be performed. The decision also extended the definition of what posed a health threat to the pregnant person when performing a post-viability abortion by allowing a health care provider to consider such factors as the woman's age and emotional and psychological health. These two court decisions contributed to a notable decrease in mortality rates among pregnant women.

After  Roe , the Supreme Court heard several cases that challenged the ruling. In  Planned Parenthood v. Danforth  (1976), the court ruled against several restrictions imposed by Missouri's abortion laws, thus expanding access to abortion. One year later, however, the court ruled in  Maher v. Roe  that state governments could choose to deny public funds for an abortion, granting the government additional control over reproductive health care. The  Maher v. Roe  decision took advantage of the Hyde Amendment, legislation passed by Congress in 1976 that excluded abortion from the list of medical services provided and covered through Medicaid, the federal and state government program that subsidizes medical costs for patients with limited financial means.

CAMPAIGN TO OVERTURN  ROE V. WADE

Responding first to a trend in the states toward liberalizing abortion laws and later to the court's decision in  Roe v. Wade , activists founded several organizations in the late 1960s and 1970s, giving rise to a network of fervent pro-life groups. On the one-year anniversary of the  Roe  decision, approximately twenty thousand activists in Washington, DC, participated in the first March for Life, which became an annual event for anti-abortion activists. Activists also commonly hold public demonstrations outside abortion clinics, brandishing signs with disturbing images of fetuses and shouting condemnations toward people entering the buildings. In 1994 the Freedom of Access to Clinic Entrances (FACE) Act made blocking the entrances of places providing abortion counseling or services a federal offense punishable by fines and imprisonment.

Some anti-abortion activists have taken more extreme, surreptitious, or violent measures. Members of groups such as Project Veritas, for instance, have posed as patients and secretly filmed abortion providers, using the footage to create misinformation campaigns alleging unethical and criminal behavior. Anti-abortion groups also operate  crisis pregnancy centers  (CPCs), nonprofit organizations that seek to deter women from terminating unintended pregnancies. CPCs have been accused of using misleading and deceptive advertising and purposefully providing inaccurate information to stop individuals from accessing abortion services. Members of militant pro-life organizations such as Operation Rescue have committed acts of domestic terrorism, including the bombing of clinics and waging of aggressive harassment campaigns. Several doctors who provided abortions have been murdered by pro-life activists.

Meanwhile, in states where pro-life conservatives hold power, legislatures passed laws that placed additional regulations on abortion providers and had the effect of making abortion services more difficult to obtain. Some of these laws included provisions that required the examination rooms in which the procedure would be performed to be a certain size. Other laws required abortion providers and facilities to be affiliated with a hospital or located within a certain distance from a hospital. Pro-choice groups refer to these laws as Targeted Regulation (or Restriction) for Abortion Providers (TRAP) laws. The Supreme Court ruled against TRAP bills from Texas and Louisiana in  Whole Woman's Health v. Hellerstedt  (2016) and  June Medical Services, LLC v. Russo  (2020), determining that such requirements did not produce sufficient medical benefit to justify the imposition placed on women seeking abortions.

Many anti-abortion activists celebrated the election of President Donald Trump in 2016, as he had committed during his campaign to nominating pro-life judges. Anticipating a conservative majority in the Supreme Court, lawmakers in several states began advancing more restrictive anti-abortion legislation, including many laws intended to prohibit abortions before the end of the first trimester. For example, some states passed legislation outlawing abortion after a "fetal heartbeat" is detected. Reproductive health doctors consider this terminology misleading, as they describe the noise heard as the electrical activity of the ultrasound machine rather than a heartbeat produced by a functioning heart. Texas' "fetal heartbeat" law prohibited abortions after six weeks and relied on private citizens for enforcement by allowing anyone in any state to file a civil suit against any person who helps someone get an abortion in Texas. Out of fear of possible litigation, most providers in the state had ceased operations months before the Supreme Court issued its ruling in  Dobbs .

In the courts, pro-life attorneys brought challenges to  Roe  in the hopes the Supreme Court would eventually strike it down, while pro-life activists built an organized pipeline of judicial nominees. In 1982 a group of conservatives and libertarians founded the Federalist Society as a professional network that would support and promote judges who shared a similar legal vision, including the overturning of  Roe v. Wade . The Trump administration nominated several Federalist Society members as federal judges, including Supreme Court justices Neil Gorsuch, Brett Kavanaugh, and Amy Coney Barrett. As of 2023, six of the nine Supreme Court justices were members of the Federalist Society.

CRITICAL THINKING QUESTIONS

• What factors do you think prevented federal lawmakers from adding a constitutional amendment or passing a federal law establishing a national standard regarding abortion rights?
• Under what circumstances, if any, do you think state governments should restrict a person's access to abortion services? Explain your answer.
• How has the Supreme Court's 2022 overturning of abortion rights affected abortion access in the country? What do you consider to be the most significant effect of those changes?

ABORTION RIGHTS POST- ROE

The  Dobbs  ruling, which denied that the Constitution ever recognized or implied a right to abortion in the US Constitution, has had a significant impact on abortion access throughout the country. In the late 2010s, in anticipation of a conservative majority on the court, lawmakers in some states began passing legislation to safeguard the right to legal and safe abortions in the event  Roe v. Wade  was overturned. In 2019, for example, New York passed the Reproductive Health Act, which removed several restrictions, decriminalized abortion, and limited government interference with the decisions of women and their health care providers. Before  Roe 's overturning, ten states—Alaska, Arizona, California, Florida, Kansas, Massachusetts, Minnesota, Montana, New Jersey, and New Mexico—had state constitutions protecting abortion rights. As of October 2023, twenty-two states had expanded or protected access to abortion, though the governments of some of these states were challenging those protections.

Before the  Dobbs  ruling, thirteen US states had passed trigger laws that would outlaw abortion in all or most cases, but not all went into effect immediately after the decision. Some triggered the beginning of a process to ban abortion, while others triggered the ban going into effect. Some laws were blocked from taking effect while lawsuits against them moved through the courts. In some states nearly all abortions became illegal, with some not allowing exceptions in instances of rape and incest or when continuing the pregnancy could be fatal.

President Joe Biden issued an executive order aimed at protecting reproductive rights in July 2022, following the  Dobbs  ruling. The order directed federal agencies, including the FDA and the Federal Trade Commission (FTC), to develop plans to protect patient privacy, safety, and security, as well as ensure access to comprehensive and reliable medical information and medical services, including abortion and contraception. Additionally, the order created a reproductive health care task force. Despite the sweeping intentions of the executive order, the Biden administration's ability to affect abortion rights remains limited without congressional action.

Since  Dobbs , states have passed new laws either protecting or restricting abortion. State legislatures introduced 563 abortion restriction provisions, fifty of which were signed into law, and 369 abortion protection provisions, seventy-seven of which were passed. Six states also held ballot initiatives in which voters chose to protect abortion rights, reflecting the 64 percent majority of Americans who reported supporting abortion rights. As of October 2023, the Guttmacher Institute categorized six US states as "very protective" of abortion rights, with Oregon's laws identified as "most protective." An additional nine states, plus Washington, DC, had policies that protected the right to abortion but imposed some restrictions. Eight states were characterized as "restrictive" and three as "very restrictive." Fifteen states—Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Carolina, South Dakota, Texas, Tennessee, and West Virginia—had the "most restrictive" abortion policies, a significant increase from the five states with the designation in 2022.

One major point of contention between states is the ability of people to travel in order to access abortion. As of June 2023, twenty-five million people who can become pregnant had less access to legal abortion in their state than they did before the ruling, resulting in significant numbers of people traveling across state borders for the procedure. In response, so-called  shield laws , which protect abortion patents and providers from prosecution in states where abortion is illegal, have been passed in fourteen states since  Dobbs , bringing the total to fifteen states. In September 2023, lawmakers in Texas began passing measures restricting access to roadways for people on their way to an abortion appointment. In response to a federal rule allowing military personnel stationed in states where access to abortion is restricted to travel to states where abortion is legal, Senator Tommy Tuberville (R–AL) blocked the Senate from voting on military promotions, leaving several crucial high-level posts vacant for months. As of October 2023, despite pressure to relent from both sides of the aisle, Tuberville's blockade continued.

With the FDA allowing delivery of pills for medication abortion through the mail, pro-choice lawmakers and reproductive rights activists hoped that expanding access to medication abortion through telemedicine would mitigate some of the travel burden. However, in states where abortion is restricted, anti-abortion lawmakers began to explore ways of preventing the use of medication abortion. Despite a lack of medical or scientific evidence, several states passed legislation requiring doctors to inform patients that medical abortions can be interrupted or "reversed" by replacing the second pill with a dose of progesterone. Conservative states and legal groups have also pursued overturning the FDA's approval of mifepristone, one of the two drugs used in medication abortions. In April 2023 the Supreme Court ruled that mifepristone could continue to be prescribed while lawsuits continued.

In the year following  Dobbs , the US maternal death rate, already the highest among industrialized countries, rose in states where abortion access was illegal or highly restricted. According to a January 2023 report by the Gender Equity Policy Institute, pregnant people in states where abortion is banned were up to three times more likely to die during pregnancy or labor or soon after than pregnant people in less restrictive states. Of these deaths, one in seven occurred in Texas. Babies were 30 percent likelier to die during their first month of life in states with abortion bans, and teen birth rates were twice as high in abortion restriction states.

The number of abortions performed in the United States increased after the  Dobbs  decision, according to the Guttmacher Institute, which found about 511,000 abortions performed between January and June 2023, compared to 465,000 in the same period of 2020. Less restrictive states bordering more restrictive states experienced most of the increase, with Illinois providers reporting a 69 percent increase and New Mexico reporting a 220 percent increase. States with total bans or six-week bans had an estimated 114,590 fewer abortions performed within their borders, according to the research group WeCount. Experts have raised concerns that the country's remaining abortion clinics are experiencing unsustainable demand for the procedure.

More Articles

Parental involvement laws can impose harmful burdens on pregnant minors.

"They talked about making sure they did really well in school from now on, so that their abortions weren't in vain."

Francie Diep is a staff writer at Pacific Standard . In the following viewpoint, Diep argues that parental involvement laws for minors seeking abortions can be detrimental to young women's physical and mental health. Discussing a study of minors who sought a judge's approval, a process commonly referred to as judicial bypass, in lieu of obtaining parental consent, the author reveals wide variation among experiences with the process. Diep notes that judicial bypass frequently delays a minor's abortion by several weeks. Citing the experiences of study participants, the author characterizes securing judicial bypass as a humiliating experience and provides several examples of a judge or a minor's guardian ad litem demonstrating anti-abortion bias. Despite these negative experiences, the author maintains, many of the minors subjected to parental involvement laws support such restrictions on minors seeking abortions.

Parental Consent Laws Protect Teens

“According to a national study conducted by researchers associated with Guttmacher, disappointment is the most common response of parents who learn that their teen daughter is pregnant, and almost no parent responds with violence.”

Teresa S. Collett is a professor of law at the University of St. Thomas School of Law in Minneapolis.

In the following viewpoint, Collett contends that parental consent laws are constitutional and in the best interest of girls seeking abortion. Citing the likelihood that adult men are most often the fathers of school-age pregnancies, parental involvement ensures that cases of coercion and statutory rape do not go unreported. Additionally, parents are in the best position to provide health information and care for their daughters during a time of acute vulnerability and need.

Late-Term Abortions Are Cruel, Common, and Unjustified

"In one recording taken on May 2, an unidentified woman is able to schedule an abortion at 30 weeks of pregnancy, even after she says there's nothing wrong with the fetus."

Bradford Richardson is a reporter at the Washington Times .

In the following viewpoint, Richardson argues that abortion providers in New Mexico, Louisiana, and Texas frequently terminate pregnancies during the third trimester (twenty-eight to forty weeks) and employ methods that cause the fetus undue harm. Defending comments made by Donald Trump during the 2016 presidential debates, the author disputes assertions made by reproductive rights groups and media outlets that late-term abortions are performed only in special circumstances and that the procedure referred to as partial-birth abortion is not considered legitimate among US medical experts. The author commends the efforts of anti-abortion activists and organizations like the Center for Medical Progress, which made covert recordings of abortion providers, for drawing attention to medical practices employed at reproductive health clinics.

Overregulation Forces Women To Have Late-Term Abortions

"Animal advocates, as well as many scientists, are increasingly questioning the scientific validity and reliability of animal experimentation."

“[A]dding hurdles that force women to obtain an abortion later in pregnancy—or to seek out options on their own, such as online medications of unknown quality—is bad for women’s health.”

Daniel Grossman is a professor in the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco, and director of Advancing New Standards in Reproductive Health (ANSIRH) at the Bixby Center for Global Reproductive Health.

In the following viewpoint, Grossman argues that restrictions on abortion access contribute to women delaying abortions. He explains how abortions that take place earlier in a pregnancy tend to be safer for the woman’s health than abortions performed later. He argues that women already encounter significant obstacles to obtaining the procedure without additional regulations. He contends that several restrictions prevent patients from choosing medical abortions, which are significantly less invasive than surgical abortions and could be administered by more health care providers than specific state laws allow.

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The Most Important Study in the Abortion Debate

Researchers rigorously tested the persistent notion that abortion wounds the women who seek it.

The demographer Diana Greene Foster was in Orlando last month, preparing for the end of Roe v. Wade , when Politico published a leaked draft of a majority Supreme Court opinion striking down the landmark ruling. The opinion, written by Justice Samuel Alito, would revoke the constitutional right to abortion and thus give states the ability to ban the medical procedure.

Foster, the director of the Bixby Population Sciences Research Unit at UC San Francisco, was at a meeting of abortion providers, seeking their help recruiting people for a new study . And she was racing against time. She wanted to look, she told me, “at the last person served in, say, Nebraska, compared to the first person turned away in Nebraska.” Nearly two dozen red and purple states are expected to enact stringent limits or even bans on abortion as soon as the Supreme Court strikes down Roe v. Wade , as it is poised to do. Foster intends to study women with unwanted pregnancies just before and just after the right to an abortion vanishes.

Read: When a right becomes a privilege

When Alito’s draft surfaced, Foster told me, “I was struck by how little it considered the people who would be affected. The experience of someone who’s pregnant when they do not want to be and what happens to their life is absolutely not considered in that document.” Foster’s earlier work provides detailed insight into what does happen. The landmark Turnaway Study , which she led, is a crystal ball into our post- Roe future and, I would argue, the single most important piece of academic research in American life at this moment.

The legal and political debate about abortion in recent decades has tended to focus more on the rights and experience of embryos and fetuses than the people who gestate them. And some commentators—including ones seated on the Supreme Court—have speculated that termination is not just a cruel convenience, but one that harms women too . Foster and her colleagues rigorously tested that notion. Their research demonstrates that, in general, abortion does not wound women physically, psychologically, or financially. Carrying an unwanted pregnancy to term does.

In a 2007 decision , Gonzales v. Carhart , the Supreme Court upheld a ban on one specific, uncommon abortion procedure. In his majority opinion , Justice Anthony Kennedy ventured a guess about abortion’s effect on women’s lives: “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.”

Was that really true? Activists insisted so, but social scientists were not sure . Indeed, they were not sure about a lot of things when it came to the effect of the termination of a pregnancy on a person’s life. Many papers compared individuals who had an abortion with people who carried a pregnancy to term. The problem is that those are two different groups of people; to state the obvious, most people seeking an abortion are experiencing an unplanned pregnancy, while a majority of people carrying to term intended to get pregnant.

Foster and her co-authors figured out a way to isolate the impact of abortion itself. Nearly all states bar the procedure after a certain gestational age or after the point that a fetus is considered viable outside the womb . The researchers could compare people who were “turned away” by a provider because they were too far along with people who had an abortion at the same clinics. (They did not include people who ended a pregnancy for medical reasons.) The women who got an abortion would be similar, in terms of demographics and socioeconomics, to those who were turned away; what would separate the two groups was only that some women got to the clinic on time, and some didn’t.

In time, 30 abortion providers—ones that had the latest gestational limit of any clinic within 150 miles, meaning that a person could not easily access an abortion if they were turned away—agreed to work with the researchers. They recruited nearly 1,000 women to be interviewed every six months for five years. The findings were voluminous, resulting in 50 publications and counting. They were also clear. Kennedy’s speculation was wrong: Women, as a general point, do not regret having an abortion at all.

Researchers found, among other things, that women who were denied abortions were more likely to end up living in poverty. They had worse credit scores and, even years later, were more likely to not have enough money for the basics, such as food and gas. They were more likely to be unemployed. They were more likely to go through bankruptcy or eviction. “The two groups were economically the same when they sought an abortion,” Foster told me. “One became poorer.”

Read: The calamity of unwanted motherhood

In addition, those denied a termination were more likely to be with a partner who abused them. They were more likely to end up as a single parent. They had more trouble bonding with their infants, were less likely to agree with the statement “I feel happy when my child laughs or smiles,” and were more likely to say they “feel trapped as a mother.” They experienced more anxiety and had lower self-esteem, though those effects faded in time. They were half as likely to be in a “very good” romantic relationship at two years. They were less likely to have “aspirational” life plans.

Their bodies were different too. The ones denied an abortion were in worse health, experiencing more hypertension and chronic pain. None of the women who had an abortion died from it. This is unsurprising; other research shows that the procedure has extremely low complication rates , as well as no known negative health or fertility effects . Yet in the Turnaway sample, pregnancy ended up killing two of the women who wanted a termination and did not get one.

The Turnaway Study also showed that abortion is a choice that women often make in order to take care of their family. Most of the women seeking an abortion were already mothers. In the years after they terminated a pregnancy, their kids were better off; they were more likely to hit their developmental milestones and less likely to live in poverty. Moreover, many women who had an abortion went on to have more children. Those pregnancies were much more likely to be planned, and those kids had better outcomes too.

The interviews made clear that women, far from taking a casual view of abortion, took the decision seriously. Most reported using contraception when they got pregnant, and most of the people who sought an abortion after their state’s limit simply did not realize they were pregnant until it was too late. (Many women have irregular periods, do not experience morning sickness, and do not feel fetal movement until late in the second trimester.) The women gave nuanced, compelling reasons for wanting to end their pregnancies.

Afterward, nearly all said that termination had been the right decision. At five years, only 14 percent felt any sadness about having an abortion; two in three ended up having no or very few emotions about it at all. “Relief” was the most common feeling, and an abiding one.

From the May 2022 issue: The future of abortion in a post- Roe America

The policy impact of the Turnaway research has been significant, even though it was published during a period when states have been restricting abortion access. In 2018, the Iowa Supreme Court struck down a law requiring a 72-hour waiting period between when a person seeks and has an abortion, noting that “the vast majority of abortion patients do not regret the procedure, even years later, and instead feel relief and acceptance”—a Turnaway finding. That same finding was cited by members of Chile’s constitutional court  as they allowed for the decriminalization of abortion in certain circumstances.

Yet the research has not swayed many people who advocate for abortion bans, believing that life begins at conception and that the law must prioritize the needs of the fetus. Other activists have argued that Turnaway is methodologically flawed; some women approached in the clinic waiting room declined to participate, and not all participating women completed all interviews . “The women who anticipate and experience the most negative reactions to abortion are the least likely to want to participate in interviews,” the activist David Reardon argued in a 2018 article in a Catholic Medical Association journal.

Still, four dozen papers analyzing the Turnaway Study’s findings have been published in peer-reviewed journals; the research is “the gold standard,” Emily M. Johnston, an Urban Institute health-policy expert who wasn’t involved with the project, told me. In the trajectories of women who received an abortion and those who were denied one, “we can understand the impact of abortion on women’s lives,” Foster told me. “They don’t have to represent all women seeking abortion for the findings to be valid.” And her work has been buttressed by other surveys, showing that women fear the repercussions of unplanned pregnancies for good reason and do not tend to regret having a termination. “Among the women we spoke with, they did not regret either choice,” whether that was having an abortion or carrying to term, Johnston told me. “These women were thinking about their desires for themselves, but also were thinking very thoughtfully about what kind of life they could provide for a child.”

The Turnaway study , for Foster, underscored that nobody needs the government to decide whether they need an abortion. If and when America’s highest court overturns Roe , though, an estimated 34 million women of reproductive age will lose some or all access to the procedure in the state where they live. Some people will travel to an out-of-state clinic to terminate a pregnancy; some will get pills by mail to manage their abortions at home; some will “try and do things that are less safe,” as Foster put it. Many will carry to term: The Guttmacher Institute has estimated that there will be roughly 100,000 fewer legal abortions per year post- Roe . “The question now is who is able to circumvent the law, what that costs, and who suffers from these bans,” Foster told me. “The burden of this will be disproportionately put on people who are least able to support a pregnancy and to support a child.”

Ellen Gruber Garvey: I helped women get abortions in pre- Roe America

Foster said that there is a lot we still do not know about how the end of Roe might alter the course of people’s lives—the topic of her new research. “In the Turnaway Study, people were too late to get an abortion, but they didn’t have to feel like the police were going to knock on their door,” she told me. “Now, if you’re able to find an abortion somewhere and you have a complication, do you get health care? Do you seek health care out if you’re having a miscarriage, or are you too scared? If you’re going to travel across state lines, can you tell your mother or your boss what you’re doing?”

In addition, she said that she was uncertain about the role that abortion funds —local, on-the-ground organizations that help people find, travel to, and pay for terminations—might play. “We really don’t know who is calling these hotlines,” she said. “When people call, what support do they need? What is enough, and who falls through the cracks?” She added that many people are unaware that such services exist, and might have trouble accessing them.

People are resourceful when seeking a termination and resilient when denied an abortion, Foster told me. But looking into the post- Roe future, she predicted, “There’s going to be some widespread and scary consequences just from the fact that we’ve made this common health-care practice against the law.” Foster, to her dismay, is about to have a lot more research to do.

What really drives anti-abortion beliefs? Research suggests it’s a matter of sexual strategies

Assistant Professor of Psychology, Oklahoma State University

Professor of Psychology, University of California, Los Angeles

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Many people have strong opinions about abortion – especially in the wake of the U.S. Supreme Court decision that overturned Roe v. Wade, revoking a constitutional right previously held by more than 165 million Americans.

But what really drives people’s abortion attitudes?

It’s common to hear religious, political and other ideologically driven explanations – for example, about the sanctity of life. If such beliefs were really driving anti-abortion attitudes, though, then people who oppose abortion might not support the death penalty ( many do ), and they would support social safety net measures that could save newborns’ lives ( many don’t ).

Here, we suggest a different explanation for anti-abortion attitudes – one you probably haven’t considered before – from our field of evolutionary social science .

Why do people care what strangers do?

The evolutionary coin of the realm is fitness – getting more copies of your genes into the next generation. What faraway strangers do presumably has limited impact on your own fitness. So from this perspective, it is a mystery why people in Pensacola care so strongly about what goes on in the bedrooms of Philadelphia or the Planned Parenthoods of Los Angeles.

The solution to this puzzle – and one answer to what is driving anti-abortion attitudes – lies in a conflict of sexual strategies: People vary in how opposed they are to casual sex . More “sexually restricted” people tend to shun casual sex and instead invest heavily in long-term relationships and parenting children. In contrast, more “sexually unrestricted” people tend to pursue a series of different sexual partners and are often slower to settle down.

These sexual strategies conflict in ways that affect evolutionary fitness.

The crux of this argument is that, for sexually restricted people, other people’s sexual freedoms represent threats. Consider that sexually restricted women often get married young and have children early in life. These choices are just as valid as a decision to wait, but they can also be detrimental to women’s occupational attainment and tend to leave women more economically dependent on husbands .

Other women’s sexual openness can destroy these women’s lives and livelihoods by breaking up the relationships they depend on. So sexually restricted women benefit from impeding other people’s sexual freedoms. Likewise, sexually restricted men tend to invest a lot in their children , so they benefit from prohibiting people’s sexual freedoms to preclude the high fitness costs of being cuckolded.

Benefiting from making sex more costly

According to evolutionary social science , restricted sexual strategists benefit by imposing their strategic preferences on society – by curtailing other people’s sexual freedoms.

How can restricted sexual strategists achieve this? By making casual sex more costly.

For example, banning women’s access to safe and legal abortion essentially forces them to endure the costs of bearing a child. Such hikes in the price of casual sex can deter people from having it.

This attitude is perhaps best illustrated by a statement from Mariano Azuela, a justice who opposed abortion when it came before Mexico’s Supreme Court in 2008: “I feel that a woman in some way has to live with the phenomenon of becoming pregnant . When she does not want to keep the product of the pregnancy, she still has to suffer the effects during the whole period.”

Force people to “suffer the effects” of casual sex, and fewer people will pursue it.

Also note that abortion restrictions do not increase the costs of sex equally. Women bear the costs of gestation, face the life-threatening dangers of childbirth and disproportionately bear responsibility for child care . When women are denied abortions, they are also more likely to end up in poverty and experience intimate partner violence .

No one would argue this is a conscious phenomenon. Rather, people’s strategic interests shape their attitudes in nonconscious but self-benefiting ways – a common finding in political science and evolutionary social science alike.

Resolving awkward contradictions in attitudes

An evolutionary perspective suggests that common explanations are not the genuine drivers of people’s attitudes – on either side of the abortion debate.

In fact, people’s stated religious, political and ideological explanations are often rife with awkward contradictions. For example, many who oppose abortion also oppose preventing unwanted pregnancy through access to contraception .

From an evolutionary perspective, such contradictions are easily resolved. Sexually restricted people benefit from increasing the costs of sex. That cost increases when people cannot access legal abortions or prevent unwanted pregnancy.

An evolutionary perspective also makes unique – often counterintuitive – predictions about which attitudes travel together. This view predicts that if sexually restricted people associate something with sexual freedoms, they should oppose it.

Indeed, researchers have found that sexually restricted people oppose not only abortion and birth control, but also marriage equality , because they perceive homosexuality as associated with sexual promiscuity, and recreational drugs , presumably because they associate drugs like marijuana and MDMA with casual sex. We suspect this list likely also includes transgender rights, public breastfeeding , premarital sex, what books children read (and if drag queens can read to them ), equal pay for women, and many other concerns that have yet to be tested.

No other theories we are aware of predict these strange attitudinal bedfellows.

Behind the link to religion and conservatism

This evolutionary perspective can also explain why anti-abortion attitudes are so often associated with religion and social conservatism.

Rather than thinking that religiosity causes people to be sexually restricted, this perspective suggests that a restricted sexual strategy can motivate people to become religious . Why? Several scholars have suggested that people adhere to religion in part because its teachings promote sexually restricted norms . Supporting this idea, participants in one study reported being more religious after researchers showed them photos of attractive people of their own sex – that is, potential mating rivals.

Sexually restricted people also tend to invest highly in parenting, so they stand to benefit when other people adhere to norms that benefit parents. Like religion , social conservatism prescribes parent-benefiting norms like constricting sexual freedoms and ostensibly promoting family stability. In line with this, some research suggests that people don’t simply become more conservative with age . Rather, people become more socially conservative during parenthood .

Restricting everyone to benefit yourself

There are multiple answers to any “why” question in scientific research. Ideological beliefs, personal histories and other factors certainly play a role in people’s abortion attitudes.

But so, too, do people’s sexual strategies.

This evolutionary social science research suggests that restricted sexual strategists benefit by making everyone else play by their rules. And just as Justice Thomas suggested when overturning Roe v. Wade , this group may be taking aim at birth control and marriage equality next.

• Birth control
• Contraception
• Death penalty
• Social psychology
• Evolutionary psychology
• Political views
• Social attitudes
• Abortion access
• Anti-abortion
• Abortion bans
• Access to contraception
• Dobbs v. Jackson Women’s Health Organization
• Dobbs v. Jackson
• Access to abortion

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The criminalization of abortion and surveillance of women in a post-Dobbs world

Subscribe to the center for technology innovation newsletter, jolynn dellinger and jolynn dellinger senior lecturing fellow - duke law @mindingprivacy stephanie k. pell stephanie k. pell fellow - governance studies , senior editor - lawfare.

April 18, 2024

• The authors’ new article, Body of Evidence, explores how some states are criminalizing abortion; the way medication abortion is disrupting abortion bans; the threat of prosecution faced by women who self-manage abortions with medication; and the ways modern surveillance technologies enable law enforcement investigations of abortion crimes.
• Medication abortion, which is approved by the FDA for terminating a pregnancy of up 10 weeks, accounts for 63% of abortions in the United States but currently faces a challenge before the Supreme Court.
• Meanwhile, as an array of modern technologies enable the investigation of abortion-related crimes, some states are subjecting women to the threat of prosecution for self-managing abortions.
• 11 min read

On February 16, the Alabama Supreme Court held that frozen embryos were “children” under Alabama’s Wrongful Death of a Minor Act. While this was a decision about in vitro fertilization (IVF), Alabama’s recognition of embryos as persons is simply a logical extension of the anti-abortion movement’s long-time commitment to the notion of fetal personhood, an idea now animating the post-Dobbs criminalization of reproductive care. A number of state legislatures have already granted personhood status to fertilized eggs or unborn children in utero at any stage of development.

Consistent with the anti-abortion movement’s goal of a nationwide recognition of fetal personhood, the criminalization of abortion is a tool for preventing abortions from ever occurring. In our new article, Bodies of Evidence: The Criminalization of Abortion and Surveillance of Women in a Post-Dobbs World , we explore: how ban states are criminalizing abortion; the way medication abortion is disrupting abortion bans; the threat of prosecution faced by women who self-manage abortions with medication; and the ways modern surveillance technologies enable law enforcement investigations of abortion crimes.

The criminalization of abortion is one of several strategies endorsed by the anti-abortion movement and adopted in states attempting to enforce abortion bans and defend them against circumvention by medication abortion.

Medication abortion, a two-pill regimen involving mifepristone and misoprostol, is approved by the FDA for terminating a pregnancy up to 10 weeks. While the FDA approved the use of mifepristone in 2000, the revolutionary promise of medication abortion—where a woman can receive the medication in the mail, then safely self-manage an abortion in the privacy of her own home—was not realized until the FDA permanently lifted the in-person dispensing requirement in 2021. Not surprisingly, research from the Guttmacher Institute indicates that medication abortion now accounts for 63% of abortions in the United States, up from 53% in 2020.

Because of medication abortion, pregnant people living in states that ban or severely restrict abortions have access to a form of abortion care that was not available pre-Roe. Today, pills can be moved across state lines, doctors in abortion-protective states can offer telehealth care to women in ban states, and organizations like Aid Access can mail abortion medication from overseas. It is no longer necessary for all women in ban states to travel out of state to access abortion care.

The anti-abortion movement is, of course, aware of the ways in which medication abortion can thwart abortion bans and is attacking the problem on a number of fronts. In one response to this threat, a group of anti-abortion doctors brought a lawsuit challenging both the FDA’s original approval of mifepristone in 2000 and subsequent actions in 2016 and 2021 to improve access to and availability of the drug. The goal of the lawsuit is to remove mifepristone from the U.S. market, a result that would drastically reduce access to medication abortion for all women in the United States, regardless of the state in which they live. The Fifth Circuit granted partial relief to the doctors, landing the case in front of the Supreme Court after the government’s petition for writ of certiorari was granted. The Court heard oral arguments on March 26.

While it is unwise to predict how the Court will rule on any case, a majority of justices during the oral argument seemed to express some skepticism that the doctors who brought the suit had the necessary legal standing to seek the requested relief. The Court could thus dispose of the case without ever reaching its merits.

Even if the challenge to the FDA’s treatment of mifepristone is unsuccessful, however, the case presented an opportunity for the plaintiffs to bring attention to another of the movement’s strategies—one that was raised on three separate occasions during the oral argument by Justices Alito and Thomas. This strategy concerns the Comstock Act , a federal obscenity law from 1873, virtually dormant but still on the books, that criminalizes the mailing of “[e]very article, instrument, substance, drug, medicine, or thing which is advertised or described in a manner calculated to lead another to use or apply it for producing abortion.”

A literal interpretation of this law would, at a minimum , make the mailing of any kind of abortifacient unlawful, essentially resulting in a nationwide ban on medication abortion. While the Department of Justice under the Biden administration interprets the Comstock Act narrowly, the Justice Department under a Trump administration is free to reject that interpretation. To achieve a nationwide abortion ban, the anti-abortion movement doesn’t need Congress or even the courts—it only needs Donald Trump to be elected. And while Congress could certainly repeal the Comstock Act, that is not an outcome anyone should expect in the near future.

As the anti-abortion movement pursues these strategies, another more familiar tactic for preventing women from self-managing abortion with medication is also available: the prosecution of women and those that may assist them. Although providers have historically been the primary targets of abortion laws, women have been investigated and prosecuted for pregnancy-related conduct and a variety of pregnancy outcomes, even during the Roe era. And, in 2016, when candidate Donald Trump was asked whether he thought women who sought an illegal abortion should face criminal punishment, he answered in the affirmative—“there has to be some sort of punishment.”

Some state officials , politicians, and movement leaders claim that no one intends to prosecute pregnant women for abortion crimes. Others, emboldened by the demise of Roe, have suggested that criminal punishment of pregnant women who seek or obtain abortions is logical, morally justifiable, and required to end abortion.

As we explore in our article, a number of current states’ laws—including personhood laws—provide prosecutors with the tools to investigate and prosecute women who self-manage abortion using medication and those that assist them. The decision whether to do so will generally turn on a prosecutor’s interpretation of these laws, many of which do not explicitly exempt women from prosecution, and his or her exercise of prosecutorial discretion.

Georgia, for example, has passed a personhood law. Its “ Living Infants Fairness and Equality ” Act (LIFE Act) bans abortion after six weeks, a time at which most women don’t even know they are pregnant, and states that “[i]t shall be the policy of the state of Georgia to recognize unborn children as natural persons.” It defines “natural person” as “any human being, including an unborn child,” and defines “unborn child” as “a member of the species of Homo sapiens at any stage of development who is carried in the womb.” By including “unborn child” in the definition of natural person, the LIFE Act raises the possibility that a woman who obtains or self-manages an abortion after six weeks could be charged with murder.

In Georgia, a person commits murder “when he unlawfully and with malice aforethought, either express or implied, causes the death of another human being.” No exemptions from prosecution are provided in the LIFE Act. While our article identifies some ambiguity surrounding whether a woman having or self-managing an abortion could be prosecuted for murder under Georgia’s LIFE Act, Douglas County District Attorney Ryan Leonard previously indicated that women in Georgia “should prepare for the possibility that they could be criminally prosecuted for having an abortion. . . . If you look at it from a purely legal standpoint, if you take the life of another human being, it’s murder.” This prosecutor’s statement is an example of a threat of prosecution, where a public official purposefully wields fear and uncertainty to enforce an abortion ban.

Meanwhile, an April 1 ruling by the Florida Supreme Court enabled a six-week abortion ban to take effect by May 1, replacing the current law , which bans abortion after 15 weeks. In Florida, “ [a]ny person who willfully performs, or actively participates in, a termination of pregnancy in violation” of the law before or during viability “commits a felony of the third degree, punishable” by a term of imprisonment not exceeding five years and fines. There is no exemption for pregnant women. The broad “any person” language subjects women who self-manage abortion through medication to the threat of investigation and prosecution. 1 Recognizing this possibility, Florida legislators proposed H.B.111 in October 2023, a bill that explicitly exempts pregnant women from prosecution for terminating their pregnancies: “This paragraph does not apply to the pregnant woman who terminates the pregnancy.” The bill died in subcommittee in March of this year.

Florida’s six-week ban features the same broad language prohibiting “any person” from engaging in the proscribed conduct. Accordingly, women will continue to be at risk of investigation and prosecution under the new law. There were 84,052 abortions in Florida last year , an increase of 2,000 abortions from 2022. More than 7,000 of those women came to Florida from other states. With the imposition of the six-week ban, the use of medication abortion will undoubtedly spike. Women continue to have abortions even when they are illegal.

Georgia and Florida are just two examples of states with laws that subject women to the threat of prosecution for self-managing abortions. There are also a range of laws “related to fetal remains, child abuse, felony assault or assault of an unborn child, practicing medicine without a license, or homicide and murder” that don’t even mention or outlaw abortion, but which have been used to investigate and prosecute people for conduct related to the alleged termination of their own pregnancies, even while Roe was the law of the land.

In the post-Dobbs world, prosecutors who choose to investigate women for self-managing abortions have an array of modern surveillance technologies at their disposal. In our article, we present three hypothetical scenarios involving law enforcement investigations of a single mom, a college student, and a high school student based on alleged self-managed abortions. In each of the scenarios, we attempt to illustrate what is possible based on current law and technology. We are not suggesting that these exact scenarios have occurred or will occur. But aspects of these fact patterns are consistent with cases described in If/When/How’s 2023 report documenting the ways in which women were investigated and prosecuted for conduct pertaining to self-managed abortions between 2000 and 2020, prior to the fall of Roe.

Whether abortion laws target providers, aiders and abettors, or women themselves, the criminalization of abortion necessarily involves the surveillance of women. Women’s bodies are often the so-called scene of the crime, and their personal data will, more likely than not, be evidence of the crime. The modern digital environment only amplifies the scope and harm of that surveillance. Communications with friends and family, internet searches, websites visited, purchases made, data shared with mobile apps, location, and other data generated in the course of everyday life become evidence that can be used in prosecutions against women and those that assist them in obtaining abortions.

We offer no single, silver bullet solution for the threat of surveillance and prosecution women face in a post-Dobbs world. But there are some intermediate measures that can mitigate this threat. As our research demonstrates, state laws criminalizing abortion are, on the whole, a confusing morass. They often do not unambiguously preclude the prosecution of women. Confusing statutory language coupled with the unpredictability of prosecutorial discretion creates uncertainty—which in turn curtails women’s liberty, compromises their privacy interests, and puts their health at risk . State legislators, especially those who claim that there is no intention to prosecute women, should ensure that laws clearly and explicitly exempt women from prosecution.

Another avenue that holds some promise for disrupting the threat is specifically tied to the state of Delaware, where many big platforms and technology companies are incorporated. Delaware, we argue, should join California and Washington in passing a data shield law that includes provisions specifically designed to prevent companies from turning over data sought by law enforcement organizations from ban states that are investigating abortion crimes. Such a shield law could provide one significant hurdle to law enforcement attempts to investigate and prosecute women who have abortions and those that assist them. As the chosen state of incorporation for many tech companies holding data relevant to the investigation of abortion crimes, Delaware has a unique opportunity to engage in threat mitigation.

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• Made by History

How Doctors Came to Play a Key Role in the Abortion Debate

O n June 13, The Supreme Court announced its unanimous decision in FDA vs . Alliance for Hippocratic Medicine , governing access to a critical drug used in medication (non-surgical) abortions and to manage miscarriages. The decision preserves access (for now) to the widely used drug mifepristone, currently legal in 36 states. The court decided the case on procedural grounds, concluding that the plaintiffs, a coalition of anti-abortion physicians and medical associations, lacked standing.

Reproductive-justice advocates cautioned that challenges to the availability of the drug are likely to make their way back to the court, threatening access to a medication that has proved extraordinarily safe and effective.

Yet this case goes far beyond issues of legal standing and procedure. The plaintiffs explicitly deployed their authority as doctors and medical providers to frame their interests as rooted in safety, patient care, and public health, rather than in their religious or moral opposition to abortion.

The complex history of how physicians have organized to legitimate their authority over the reproductive lives of their patients is worth examining, as it reveals how anti-abortion forces are building on a well-worn path that has been at least partially cleared by abortion-rights advocates.

The familiar claim that the decision to have an abortion should be made “between a woman and her doctor” has long been associated with abortion-rights rhetoric as a right to privacy from the state. This principle was at the heart of the Roe majority opinion authored by Justice Blackmun. The “and her doctor” part of this formulation has received less attention, but is at the heart of the argument in the mifepristone case.

Read More: Supreme Court Unanimously Strikes Down Challenge to Abortion Drug Mifepristone

Physicians’ assertions of authority over the right to terminate a pregnancy and other issues of reproductive health did not begin with Roe . As the Roe opinion noted, in the late 19th century, the American Medical Association’s Committee on Criminal Abortion had denounced abortion and asserted that it should only be permitted if “at least one respectable consulting physician” also concurred with the decision. Thus, even when physicians took positions allowing for some access to abortion, they insisted that medical professionals hold an an outsized voice in the process.

In the early 20th century, elites associated with the American Eugenics movement advocated for laws permitting states to sterilize individuals without their consent, in their efforts to rid the population of those they deemed “undesirable” or “unfit.” Doctors were again critical to this effort to supervise and legitimate curbs on reproductive freedom.

In the 1930s, a group called the American Eugenics Society organized meetings of doctors to encourage them to play an active role in the eugenic sterilization programs as an extension of their responsibility as medical professionals. Having doctors on state eugenic boards gave these sterilization schemes the aura of respectability, as they were overseen by medical professionals. As one physician explained to his colleagues at a 1937 conference on the subject, “There is no longer any doubt but that the physician has a eugenic responsibility. In any eugenic scheme of society, the physician, and particularly those concerned with preventive medicine, must play an important part. He will function most in the therapeutic measures of sterilization and birth control.” Doctors thus framed their role not only as treating individual patients but as also having authority over policy and law, especially over issues related to reproduction.

Appeals to physicians to use their authority in this manner continued well after the public respectability of the American eugenics movement waned. In the 1950s and 1960s, some obstetricians and other doctors advanced similar arguments about their obligation to advocate for population control policies. Dr. C. Lee Buxton, Chief of Obstetrics and Gynecology at the Yale School of Medicine argued in a medical journal in 1966 that “the medical profession should accept a major responsibility in matters related to human reproduction as they affect the total population and the individual family.” Doctors would play a significant role in the growing population control movement , again deploying their medical expertise and authority to advance laws rooted in social control.

Read More: 'I Don't Have Faith in Doctors Anymore.' Women Say They Were Pressured Into Long-Term Birth Control

This authority was not just a legal right; by this logic it was a professional obligation that doctors could not refuse. Consequently, doctors served on state eugenics boards that oversaw systematic non-consensual sterilizations until into the 1970s. At least 60,000 documented involuntary sterilizations were approved and performed by state bodies in the 20th century.

Obstetricians like Buxton also supported the framework eventually enshrined in Roe that physicians, rather than the state, possessed the authority to determine whether a pregnancy should be terminated or carried to term. In 1970, an AMA committee revised its position opposing access to abortion but still cautioned against "mere acquiescence to the patient's demand" for an abortion, a sentiment expressed elsewhere by doctors who also supported Roe . Again, we see skepticism from medical authorities that a pregnant person be trusted to make reproductive decisions for themselves.

Most state eugenic laws were repealed by the 1970s, but non-consensual sterilizations continued under certain circumstances. Notably, the federal government continued to approve the procedure for Native American women under the auspices of the Bureau of Indian Affairs. Elsewhere, physicians, rather than state authorities, oversaw non-consensual sterilizations.

For example, in the 1970s, doctors at Los Angeles County Hospital, the teaching hospital of the USC School of Medicine, performed hundreds of tubal ligations on Mexican-origin women, many of whom later stated they never provided their consent.

Ten of these women eventually sued the hospital, naming Dr. Edward Quilligan, the Chief of ob/gyn at the time, as the defendant. The women offered heart-wrenching testimonies about the profound damage these non-consensual sterilizations caused them and their families. Quilligan told a journalist at the time (and to producers of a documentary on the case 40 years later) that he had done nothing wrong: “We were practicing good medicine.”

The judge agreed . In other words, physicians were not only entitled to abridge the reproductive autonomy of their patients, but they were also sometimes required to do so in the name of “good medicine.” Indeed, Quilligan suffered few professional repercussions and he has been honored at the highest level by prestigious medical schools and professional associations.

Read More: Abortion Rights Benefit People Who Want Kids, Too

When a group of anti-abortion medical providers incorporated as the Alliance for Hippocratic Medicine with the express purpose of filing a lawsuit to ban mifepristone, the briefs they submitted all built on this history. They too were doctors drawing on the principle valorized in Roe that decisions regarding the termination of pregnancy required their authority and involvement.

These briefs are largely free of religious and moral arguments, focusing instead on estimates of gestational development, safety of medication, and the efficacy of review processes, among others that fall under the authority of medical providers. And their language often centers on issues between a woman and her doctor, sometimes in paternalistic terms. One brief insisted that their interest in banning the drug stemmed from their ethical commitment to “protect women and girls from the documented danger of chemical abortion drugs,” against all evidence about the safety of the drugs. 

Such arguments draw on the troubling history of deference that (historically largely male) physicians have demanded to sometimes supersede the autonomy of their (female) patients.

Abortion and reproductive health providers do face significant legal, political, and personal threats for their work; their safety and professional right to practice must be protected vigorously. Nor should medical expertise and evidence-based research be dismissed. They are a vital part of reproductive health and care.

But a reliance on medical expertise need not be rooted in reflexive deference to that expertise, as Justice Blackmun envisioned. Indeed, the Women’s Health Movement of the 1970s developed approaches to reproductive health, including contraception, access to abortion, care and support during pregnancy and delivery, and child raising that demonstrated how medical expertise and reproductive autonomy can work together. Many reproductive justice groups today advocate similar practices, including advocating for legal access to self-managed abortions that do not require a physician’s involvement.

But the framing of reproductive decisions as lying “between a woman and a doctor” has opened the door for foes of reproductive autonomy to advance their arguments in the neutral language of medical authority. To secure a more expansive vision of reproductive justice will require retiring this phrase in favor of a vision of reproductive justice that does not reject medical experience or advice, but guards against any potential coercion, even when it comes bearing a white coat, to any person’s reproductive autonomy.

Emma Peterson is a recent graduate of Yale University with a degree in the History of Science, Medicine, and Public Health. Daniel Martinez HoSang is a Professor of American Studies at Yale University with a secondary appointment in the Section of the History of Medicine at Yale School of Medicine.

Made by History takes readers beyond the headlines with articles written and edited by professional historians. Learn more about Made by History at TIME here . Opinions expressed do not necessarily reflect the views of TIME editors .

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Abortion is becoming more common in primary care clinics as doctors challenge stigma.

Selena Simmons-Duffin

Elissa Nadworny

Abortion As Primary Care, I

Dr. Stephanie Arnold, who prefers bright-colored clothes instead of a white coat, meets with a patient who needs a pelvic exam. The family medicine clinic Arnold founded offers reproductive health care, including abortion, alongside all kinds of other care. “It’s a little bit of everything, which is very typical of family medicine,” she says. Elissa Nadworny/NPR hide caption

It’s a typical Tuesday at Seven Hills Family Medicine in Richmond, Va. The team — which consists of Dr. Stephanie Arnold, registered nurse Caci Young and several medical assistants — huddles to prepare for the day.

Arnold, a primary care physician, runs through the schedule. The 9 a.m. telemed appointment is for chronic condition management. At 10 a.m. there’s a diabetes follow-up. The 11 a.m. appointment is to go over lab results for potential sleep apnea, then there are appointments for knee pain and one for ADHD results review. The schedulers fit in a walk-in patient who has a suspected yeast infection.

And then, at 1 p.m., a patient who took the bus from Tennessee is scheduled for an abortion.

“It’s a little bit of everything, which is very typical of family medicine,” Arnold says. The patient from Tennessee is one of three abortion procedures Arnold will do today at this clinic, where abortion is “just in the mix,” Arnold says.

In lieu of standalone clinics offering abortions, or telehealth appointments where patients get abortion medication by mail, family doctors are offering an abortion option in a familiar setting.

This trend of primary care integrating medication or procedural abortions, usually in early pregnancy, is growing in states where abortion is legal. While there is little data on how common this is becoming, NPR heard from primary care doctors across the country who said they are expanding their practices to provide abortion care.

“There's no reason for this care to be siloed,” says Arnold, who is very public about her offerings, which include abortions up to 12 weeks of pregnancy and gender-affirming care. “I don't feel like it's any different than my management of diabetes or chronic pain or endometriosis — this is just a routine part of my day.”

More demand for training

Elizabeth Janiak of Harvard Medical School co-leads a program called ExPAND that trains primary care providers on abortion. In May, she published a paper in the journal Contraception documenting the rising demand among primary care physicians seeking abortion care training, a phenomenon she observed after Roe v. Wade was overturned.

Dr. Arnold meets with her staff at Seven Hills Family Medicine in Richmond, Va. to discuss the schedule for the day. Elissa Nadworny/NPR hide caption

Janiak estimates a very small portion of family medicine doctors in the U.S. perform abortions in their practice. She points out that even 5% of the country’s 250,000 primary care doctors is a significant number. “So we’re talking thousands and thousands of providers,” she says. Since nearly 40% of U.S. counties have no OB-GYN, Janiak says, primary care doctors can fill gaps in reproductive health care.

Michigan, Colorado, California, too

In Michigan, Dr. Allison Ruff says “when Dobbs happened, I personally felt really engaged.” She’s an associate professor at the University of Michigan and an internist, a speciality that does primary care with a focus on medically complicated adults.

Right after the decision, it was unclear whether access to abortion would be banned in Michigan. So she started reading and talking to experts about what providing abortion entailed, and what she learned surprised her.

“The medications used for abortion are safer than a lot of the medicines we use every day for other things — that was really shocking to me,” she says. “As far as riskiness goes, it's pretty small potatoes compared to some other things we learn in clinical practice every day.”

Ruff wrote a paper in November in a medical journal calling for more abortion training resources for doctors in her specialty.

“You can't just send your patient out to the abyss and say, ‘Go talk to someone else, go to Planned Parenthood and get this handled,’” Ruff says. “No, we as general internists are able to provide that spectrum of care.”

Many of the abortions provided at Seven Hills are done with medication; there's a pharmacy right in the doctor’s office. The first pill people take is mifepristone. Elissa Nadworny/NPR hide caption

In California, Dr. Sheila Attaie, a family physician in Sacramento, took advantage of that wave of interest and enthusiasm to expand access to abortion where she works.

"Everyone was emboldened after Dobbs in the blue states, and I have used that,” says Attaie, a fellow with Physicians for Reproductive Health. After advocating for years that her clinic fully integrate abortion, she says, administrators finally agreed after the Supreme Court overturned Roe v. Wade.

NPR heard similar stories from primary care doctors around the country, including in Minnesota and Pennsylvania. The doctors’ enthusiasm also came at a time when some blue states were making abortion access easier by getting rid of hurdles like waiting periods.

Integrating abortion into primary care is another way to increase access. Attaie says now, when patients find out they are pregnant, she can counsel them on all their options.

“Some folks end up scheduling for a medication abortion and some folks schedule for an initial prenatal visit — both of them happen in the same clinic at the same time, which is really great,” she says.

Normalize the care, but some keep it 'hush-hush'

But while Dr. Stephanie Arnold in Virginia advertises her abortion services on her website, talks to the press and is very public, most other primary care providers are being quiet about it.

After Attaie’s clinic integrated abortions, she says she was told by administrators that “we weren't allowed to advertise that we do it because we don't want that attention” — attention that could come with protesters or threats from people who oppose abortion. Since it’s not mentioned on the website, the main way patients discover abortion is offered is during doctor’s appointments, often when discussing birth control or sexual health.

Staff member Katie Yates preps the procedure room in Richmond. There’s one blue cushioned exam table where Dr. Arnold performs abortions, skin tag and mole removal, pelvic exams, biopsies and IUD placements. Elissa Nadworny/NPR hide caption

Attaie says she understands, but also finds the secrecy frustrating. “If we are hush-hush about all these things, how do we normalize them as health care?” she asks. “If we act in fear, how do we expect anything to be changed?”

Dr. Ben Smith, who practices family medicine in Fort Collins, Colo., can relate. And while limits on advertising may keep the number of abortions performed in his primary care clinic low — he estimates they do one to two per month — it can help free up appointments at abortion clinics nearby. That’s especially helpful in a state like Colorado, which has become a destination for people traveling from states with abortion bans.

“Every abortion that we do in primary care becomes a space for a more nationally facing organization [to] accommodate someone who is traveling from Texas, from Florida,” he says.

Pushback from anti-abortion groups

Anti-abortion rights activists oppose exactly what these physicians are trying to do: normalize abortion care. Dr. Christina Francis, an OB-GYN in Indiana who runs the American Association of Pro-life OB-GYNs, says abortion is nothing like managing a chronic condition like diabetes.

“Chemical abortion drugs end the life of my fetal patient, so that in and of itself makes it different from a diabetes drug,” she says. “But also, the complications related to a diabetes drug are not going to require an expertise that's outside of the skill set of a family medicine physician to manage.”

Francis maintains that family medicine physicians aren't qualified to provide abortion, which she opposes. “I'm not saying that family medicine physicians are not good physicians, they certainly are, but their training is not the same as OB-GYNs in these kinds of things,” she says. In her view, abortion is not part of essential health care for women. Her organization sued the federal government to try and remove abortion medication from the market, but the Supreme Court dismissed that challenge earlier this month.

Dr. Stephanie Arnold in Virginia pushes back on the idea that primary care doctors aren’t qualified to manage abortions. She points to a bulletin from the American College of OB-GYNs that says any clinician who can screen patients for eligibility can safely prescribe medication abortion, as long as they themselves can provide or refer patients for follow-up care — usually a uterine evacuation — as needed. The American Academy of Family Physicians also says it “supports access to comprehensive pregnancy and reproductive health services, including but not limited to abortion.”

“There's no reason for this care to be siloed,” says Dr. Arnold, who is very public about her offerings, which include abortions up to 12 weeks and gender affirming care. “I don't feel like it's any different than my management of diabetes or chronic pain or endometriosis.” Elissa Nadworny/NPR hide caption

Arnold says abortion has been separated from other kinds of care for political reasons, not for medical reasons. “It's just important to me to fight back against that stigma,” she says.

A history of isolation and stigma

There have long been family doctors who provided abortion and advocated for access, but it hasn’t caught on like this before, according to Mary Ziegler, a historian at the University of California, Davis who’s written extensively on the history of abortion.

Before Roe v. Wade , abortions generally happened at hospitals, she explains, but even then, not all hospitals offered them, often for religious reasons, making access across the country very uneven.

In the 1970s, abortion rights groups began focusing on the opening of freestanding abortion clinics. “On the one hand, obviously, those clinics did expand access in a lot of parts of the country. On the other hand,” Ziegler says, “they physically and symbolically isolated abortion from other health services and made them easier to stigmatize.”

Dr. Arnold meets with a patient interested in gender-affirming care in her offices in Richmond, Va. Elissa Nadworny/NPR hide caption

That isolation also made it easier for abortion clinics to be protested and lent credence to the idea that abortion was different from other forms of health care. For years, a key anti-abortion strategy was to target those clinics with regulations — known as TRAP laws, which stands for “targeted restrictions on abortion providers.” Those laws, for instance, mandate a certain width of hallways or that all doctors have admitting privileges at hospitals. TRAP laws made it hard or even impossible for clinics to operate, says Ziegler.

There have been advances that make abortion especially simple and safe, like abortion medication. But Ziegler says abortion in early pregnancy, which is when the vast majority of abortions happen, has never been medically complicated.

“What’s changed is more the willingness of primary care providers to integrate it into their practice, not their ability,” says Ziegler. “It's about the stigma changing.”

Back in Richmond, a successful patient experience

At Seven Hills Family Medicine, the staff ready the procedure room for the abortion patients. It’s the same room where mole removals, IUD placements and biopsies happen. They use the nitrous oxide, also known as laughing gas, for pain relief, and Arnold will use a hand-held SofTouch device to perform the abortions.

For the patients having procedural abortions Dr. Arnold uses what’s called a “SofTouch” device — a small, hand-held tool that creates a vacuum and allows a doctor to empty the uterus through suction. Elissa Nadworny/NPR hide caption

This is just what Arnold envisioned when she set up the practice soon after the Dobbs decision. The 37-year-old doctor, who eschews a white coat and favors brightly patterned jumpsuits, changes into scrubs before the procedures.

Liz Johnson, who was one of Arnold's primary care patients, had a medication abortion here in October 2022. Years before, she had an abortion at a specialty clinic and found it a little perfunctory. “It can feel very impersonal and fast and procedural,” she says, reflecting back on the differences between that day and her day in Arnold’s office.

She says she liked that the doctor, and staff knew her and her medical history. They checked in with her afterward to see how she was doing.

“I really appreciated the personal touch,” says Johnson, “being available and being able to text to check in.” She says the experience was so smooth she can hardly remember the details.

For Arnold, this is the way it should be.

And as a family medicine physician, this is how she wants people to understand her and her specialty. Those opposed to abortion call providers “abortionists” — that’s the word used by Supreme Court Justice Samuel Alito in the decision that overturned Roe v. Wade . Arnold says that term is used to “dehumanize” providers.

“I’m not some evil person who wants to harm people,” she says. “I am a mom and a family doctor, and I happen to provide abortion care.

“I'm a real doctor taking care of all kinds of real doctor things.”

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Home — Blog — Topic Ideas — 50 Abortion Essay Topics: Researching Abortion-Related Subjects

50 Abortion Essay Topics: Researching Abortion-Related Subjects

Abortion remains a contentious social and political issue, with deeply held beliefs and strong emotions shaping the debate. It is a topic that has been at the forefront of public discourse for decades, sparking heated arguments and evoking a range of perspectives from individuals, organizations, and governments worldwide.

The complexity of abortion stems from its intersection with fundamental human rights, ethical principles, and societal norms. It raises questions about the sanctity of life, individual autonomy, gender equality, and public health, making it a challenging yet critically important subject to explore and analyze.

This guide provides a comprehensive overview of the significance of choosing the right abortion essay topics and abortion title ideas , offering valuable insights and practical advice for students navigating this challenging yet rewarding endeavor. By understanding the multifaceted nature of abortion and its far-reaching implications, students can make informed decisions about their topic selection, setting themselves up for success in producing well-researched, insightful, and impactful essays.

Choosing the Right Abortion Essay Topic

For students who are tasked with writing an essay on abortion, choosing the right topic is essential. A well-chosen topic can be the difference between a well-researched, insightful, and impactful piece of writing and a superficial, uninspired, and forgettable one.

This guide delves into the significance of selecting the right abortion essay topic, providing valuable insights for students embarking on this challenging yet rewarding endeavor. By understanding the multifaceted nature of abortion and its far-reaching implications, students can identify topics that align with their interests, research capabilities, and the overall objectives of their essays.

Abortion remains a contentious social and political issue, with deeply held beliefs and strong emotions shaping the debate on abortion topics . It is a topic that has been at the forefront of public discourse for decades, sparking heated arguments and evoking a range of perspectives from individuals, organizations, and governments worldwide.

List of Abortion Argumentative Essay Topics

Abortion argumentative essay topics typically revolve around the ethical, legal, and societal aspects of this controversial issue. These topics often involve debates and discussions, requiring students to present well-reasoned arguments supported by evidence and persuasive language.

• The Bodily Autonomy vs. Fetal Rights Debate: A Balancing Act
• Exploring Abortion Rights: An Argumentative Analysis
• Gender Equality and Reproductive Freedom in the Abortion Debate
• Considering Abortion as a Human Right
• The Impact of Abortion Stigma on Women's Mental Health
• Abortion: A Controversial Issue
• Persuasive Speech Outline on Abortion
• Laughing Matters: Satire and the Abortion Debate
• Abortion Is Bad
• Discussion on Whether Abortion is a Crime
• Abortion Restrictions and Women's Economic Opportunity
• Government Intervention in Abortion Regulation
• Religion, Morality, and Abortion Attitudes
• Parental Notification and Consent Laws
• A Persuasive Paper on the Issue of Abortion

Ethical Considerations: Abortion raises profound ethical questions about the sanctity of life, personhood, and individual choice. Students can explore these ethical dilemmas by examining the moral implications of abortion, the rights of the unborn, and the role of personal conscience in decision-making.

Legal Aspects: The legal landscape surrounding abortion is constantly evolving, with varying regulations and restrictions across different jurisdictions. Students can delve into the legal aspects of abortion by analyzing the impact of laws and policies on access, safety, and the well-being of women.

Societal Impact: Abortion has a significant impact on society, influencing public health, gender equality, and social justice. Students can explore the societal implications of abortion by examining its impact on maternal health, reproductive rights, and the lives of marginalized communities.

Effective Abortion Topics for Research Paper

Research papers on abortion demand a more in-depth and comprehensive approach, requiring students to delve into historical, medical, and international perspectives on this multifaceted issue.

Medical Perspectives: The medical aspects of abortion encompass a wide range of topics, from advancements in abortion procedures to the health and safety of women undergoing the procedure. Students can explore medical perspectives by examining the evolution of abortion techniques, the impact of medical interventions on maternal health, and the role of healthcare providers in the abortion debate.

Historical Analysis: Abortion has a long and complex history, with changing attitudes, practices, and laws across different eras. Students can engage in historical analysis by examining the evolution of abortion practices in ancient civilizations, tracing the legal developments surrounding abortion, and exploring the shifting social attitudes towards abortion throughout history.

International Comparisons: Abortion laws and regulations vary widely across different countries, leading to diverse experiences and outcomes. Students can make international comparisons by examining abortion access and restrictions in different regions, analyzing the impact of varying legal frameworks on women's health and rights, and identifying best practices in abortion policies.

List of Abortion Research Paper Topics

• The Socioeconomic Factors and Racial Disparities Shaping Abortion Access
• Ethical and Social Implications of Emerging Abortion Technologies
• Abortion Stigma and Women's Mental Health
• Telemedicine and Abortion Access in Rural Areas
• International Human Rights and Abortion Access
• Reproductive Justice and Other Social Justice Issues
• Men's Role in Abortion Decision-Making
• Abortion Restrictions and Social Disparities
• Racial and Ethnic Disparities in Abortion Access
• Alternative Approaches to Abortion Regulation
• Political Ideology and Abortion Policy Debates
• Public Health Campaigns for Informed Abortion Decisions
• Abortion Services in Conflict-Affected Areas
• Healthcare Providers and Medical Ethics of Abortion
• International Cooperation on Abortion Policies

By exploring these topics and subtopics for abortion essays , students can gain a more comprehensive understanding of the multifaceted nature of the abortion debate and choose a specific focus that aligns with their interests and research objectives.

Choosing Abortion Research Paper Topics

When selecting research paper topics on abortion, it is essential to consider factors such as research feasibility, availability of credible sources, and the potential for original contributions.

Abortion is a complex and multifaceted issue that intersects with various aspects of society and individual lives. By broadening the scope of abortion-related topics, students can explore a wider range of perspectives and insights.

• Abortion Social Issue
• Exploring the Complexity of Abortion: Historical, Medical and Personal Perspectives
• Abortion: A Comprehensive Research
• An Examination of Abortion and its Health Implications on Women
• Abortion Introduction
• Comparative Analysis of Abortion Laws Worldwide
• Historical Evolution of Abortion Rights and Practices
• Impact of Abortion on Public Health and Maternal Mortality
• Abortion Funding and Access to Reproductive Healthcare
• Role of Misinformation and Myths in Abortion Debates
• International Perspectives on Abortion and Reproductive Freedom
• Abortion and the UN Sustainable Development Goals
• Abortion and Gender Equality in the Global Context
• Abortion and Human Rights: A Legal and Ethical Analysis
• Religious and Cultural Influences on Abortion Perceptions
• Abortion and Social Justice: Addressing Disparities and Marginalization
• Anti-abortion and Pro-choice Movements: Comparative Analysis and Impact
• Impact of Technological Advancements on Abortion Procedures and Access
• Ethical Considerations of New Abortion Technologies and Surrogacy
• Role of Advocacy and Activism in Shaping Abortion Policy and Practice
• Measuring the Effectiveness of Abortion Policy Interventions

Navigating the complex landscape of abortion-related topics can be a daunting task, but it also offers an opportunity for students to delve into a range of compelling issues and perspectives. By choosing the right topic, students can produce well-researched, insightful, and impactful essays that contribute to the ongoing dialogue on this important subject.

The 50 abortion essay ideas presented in this guide provide a starting point for exploring the intricacies of abortion and its far-reaching implications. Whether students are interested in argumentative essays that engage in ethical, legal, or societal debates or research papers that delve into medical, historical, or international perspectives, this collection offers a wealth of potential topics to ignite their curiosity and challenge their thinking.

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Abortion Facts and Statistics: What You Need to Know

Abortion overview, how common are abortions, abortions by race and ethnicity, abortions by age and gender, abortion risks and complications, early detection of pregnancy.

According to the Centers for Disease Control and Prevention (CDC), there were 629,898 abortions performed in 2019. There are many reasons why a person may end a pregnancy, such as not lacking financial preparation, issues with a partner, needing to focus on other children, and health-related reasons among others. This article will highlight key facts and statistics about abortion.

SDI Productions / Getty Images

There are two types of abortions: medication abortions and in-clinic or surgical abortions. The choice of process or procedure will depend on how far along the pregnancy is, preference, and access to abortion care services.

Medication Abortion

The availability of mifepristone in the United States has been the subject of recent legal challenges. In April 2023, a federal judge in Texas issued a ruling to suspend mifepristone's FDA approval. The case went to an appeals court and the Supreme Court, which returned the case to the appeals court.

The Supreme Court heard the case again and in June 2024, unanimously ruled to uphold wide access to mifepristone, including allowing it to be prescribed via telehealth and delivered by mail.

Medication abortion involves taking two different types of medicine: Mifeprex (mifepristone) and Cytotec (misoprostol). The Food and Drug Administration (FDA) has approved mifepristone, used together with misoprostol, for abortions for up to 10 weeks into a pregnancy (70 days or less since the first day of the last menstrual period).

The medication can be taken at home, and the process of passing the pregnancy tissue can take between four and five hours. This type of abortion is between 87% and 98% effective. Checking in with a healthcare provider afterward to confirm that the abortion was successful can include an ultrasound or a pregnancy test.

Mifepristone has a Risk Evaluation and Mitigation Strategy (REMS) program, and is only available from certified prescribers in clinics, medical offices, and hospitals or from certified pharmacies, with a prescription from a certified prescriber.

Misoprostol, on the other hand, has a little more flexibility. Your healthcare provider can give you misoprostol tablets or send a prescription to your retail pharmacy.

In-Clinic or Surgical Abortion

There are a few different types of abortion procedures performed in a clinic. The procedures typically use suction to remove pregnancy tissue from the uterus. A vacuum aspiration procedure can be performed up to 14–16 weeks after your last menstrual period.

If it's been longer than 16 weeks since your last period, a dilation and evacuation (D&E) procedure is performed. Either procedure can be performed as early as five or six weeks after your last menstrual period. In-clinic abortions are more than 99% effective.

Abortions are very common. The American College of Obstetricians and Gynecologists (ACOG) reports that 25% of all women will have an abortion before they turn 45 years old.

Though 40.2% of those who had an abortion in 2019 had not previously birthed a child, nearly 60% of all people who had gotten an abortion in that year previously had at least one live birth.

In terms of the point at which most abortions are performed, nearly 80% of abortions performed in 2019 were at or before the ninth week of pregnancy. In the same year, over 90% of abortions performed were before or by the 13th week of pregnancy.

Abortion rates differ by a number of factors, including race and ethnicity. Of all the abortions reported in 2019, Hispanic women accounted for about 21% and non-Hispanic women accounted for just over 7%. Among non-Hispanic women, White and Black women comprised 33.4% and 38.4%, respectively.

Though the percentages were similar, the abortion rate among non-Hispanic White women is 6.6 per 1,000 women and the rate for non-Hispanic Black women is 23.8 per 1,000 women.

People of different ages and genders seek out abortion care. In terms of age specifically, abortion rates have been decreasing among all age groups in recent years. Those who identified as women in their 20s accounted for the highest percentage of abortions among all legally induced abortions in the United States in 2019.

Women between the ages of 20 and 24 years old accounted for 27.6% of all abortions. Just over 29% of all abortions were to women between the ages of 25 and 29. The lowest percentages were found among women under the age of 15 and over the age of 40.

Those who identify as women seek out abortions, but so do transgender and gender-non-binary people. The Guttmacher Institute's Abortion Provider Census for 2017 reported that between 462 and 530 transgender and non-binary people had abortions in the United States.

Abortion procedures are considered safe and common. However, just like any medical procedure, there is the possibility of some risks and complications. These may include:

• An incomplete abortion : This occurs when the contents of the pregnancy in the uterus are not completely removed. It is more likely to occur during a medication abortion. Follow-up care is necessary in this case.
• Infection following procedure : Your healthcare provider may prescribe antibiotics to prevent an infection or to treat one following the procedure.
• Atypical or heavy bleeding : Though some bleeding is normal after either type of abortion, heavy bleeding or hemorrhage is not typical and requires immediate medical care.
• Organ damage : It is possible during an in-clinic abortion procedure to experience damage to your uterus or other nearby organs. Surgical procedures may be necessary to address any damage.

There is no evidence to suggest that abortions impact the risk of cancer, depression, or infertility in the future.

Some people may suspect they could be pregnant due to having sex without using birth control, using it incorrectly, or using birth control that failed to work properly. Others may suspect they're pregnant due to symptoms often experienced early in a pregnancy, such as:

• A missed menstrual period
• Feeling bloated
• Having to pee frequently
• Mood swings
• Feeling nauseous
• Tender or sore breasts

Tests can indicate whether you are pregnant (by detecting human chorionic gonadotropin, also known as hCG) within days after conception (when sperm fertilizes an egg). There are two types of pregnancy tests: an at-home urine test and a blood test.

The urine test taken at home can typically detect hCG as early as 10 days after conception. They are 99% accurate when taken as directed. A blood test taken at a healthcare provider's office can also detect it between nine and 12 days after conception.

Abortions in the United States are safe and very common. People of different ages, genders, races, and ethnicities seek out abortion care. There are two types of abortions: medication abortions and in-clinic/surgical abortions. How far along a pregnancy is, preference, and access to healthcare are all factors that influence which abortion process or procedure to use.

Though abortions are considered very safe, risks and complications are as possible as they are with any medical procedure. Taking note of any common early pregnancy symptoms and confirming pregnancy with an at-home or blood test can help detect pregnancy in the early weeks.

Food and Drug Administration. Questions and answers on mifepristone for medical termination of pregnancy through ten weeks gestation .

Planned Parenthood. The abortion pill .

Planned Parenthood. How does the abortion pill work?

Planned Parenthood. In-clinic abortion .

American College of Obstetricians and Gynecologists. Abortion care .

Kortsmit K. Abortion surveillance — united states, 2019 .  MMWR Surveill Summ . 2021;70.

Jones RK, Witwer E, Jerman J. Transgender abortion patients and the provision of transgender-specific care at non-hospital facilities that provide abortions .  Contraception: X . 2020;2:100019. doi: 10.1016/j.conx.2020.100019

Planned Parenthood. Pregnancy month by month .

Cleveland Clinic. Pregnancy tests .

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Pro-Choice Does Not Mean Pro-Abortion: An Argument for Abortion Rights Featuring the Rev. Carlton Veazey

Since the Supreme Court’s historic 1973 decision in Roe v. Wade , the issue of a woman’s right to an abortion has fostered one of the most contentious moral and political debates in America. Opponents of abortion rights argue that life begins at conception – making abortion tantamount to homicide. Abortion rights advocates, in contrast, maintain that women have a right to decide what happens to their bodies – sometimes without any restrictions.

To explore the case for abortion rights, the Pew Forum turns to the Rev. Carlton W. Veazey, who for more than a decade has been president of the Religious Coalition for Reproductive Choice. Based in Washington, D.C., the coalition advocates for reproductive choice and religious freedom on behalf of about 40 religious groups and organizations. Prior to joining the coalition, Veazey spent 33 years as a pastor at Zion Baptist Church in Washington, D.C.

A counterargument explaining the case against abortion rights is made by the Rev. J. Daniel Mindling, professor of moral theology at Mount St. Mary’s Seminary.

Featuring: The Rev. Carlton W. Veazey, President, Religious Coalition for Reproductive Choice

Interviewer: David Masci, Senior Research Fellow, Pew Forum on Religion & Public Life

Question & Answer

Can you explain how your Christian faith informs your views in support of abortion rights?

I grew up in a Christian home. My father was a Baptist minister for many years in Memphis, Tenn. One of the things that he instilled in me – I used to hear it so much – was free will, free will, free will. It was ingrained in me that you have the ability to make choices. You have the ability to decide what you want to do. You are responsible for your decisions, but God has given you that responsibility, that option to make decisions.

I had firsthand experience of seeing black women and poor women being disproportionately impacted by the fact that they had no choices about an unintended pregnancy, even if it would damage their health or cause great hardship in their family. And I remember some of them being maimed in back-alley abortions; some of them died. There was no legal choice before Roe v. Wade .

But in this day and time, we have a clearer understanding that men and women are moral agents and equipped to make decisions about even the most difficult and complex matters. We must ensure a woman can determine when and whether to have children according to her own conscience and religious beliefs and without governmental interference or coercion. We must also ensure that women have the resources to have a healthy, safe pregnancy, if that is their decision, and that women and families have the resources to raise a child with security.

The right to choose has changed and expanded over the years since Roe v. Wade . We now speak of reproductive justice – and that includes comprehensive sex education, family planning and contraception, adequate medical care, a safe environment, the ability to continue a pregnancy and the resources that make that choice possible. That is my moral framework.

You talk about free will, and as a Christian you believe in free will. But you also said that God gave us free will and gave us the opportunity to make right and wrong choices. Why do you believe that abortion can, at least in some instances, be the right choice?

Dan Maguire, a former Jesuit priest and professor of moral theology and ethics at Marquette University, says that to have a child can be a sacred choice, but to not have a child can also be a sacred choice.

And these choices revolve around circumstances and issues – like whether a person is old enough to care for a child or whether a woman already has more children than she can care for. Also, remember that medical circumstances are the reason many women have an abortion – for example, if they are having chemotherapy for cancer or have a life-threatening chronic illness – and most later-term abortions occur because of fetal abnormalities that will result in stillbirth or the death of the child. These are difficult decisions; they’re moral decisions, sometimes requiring a woman to decide if she will risk her life for a pregnancy.

Abortion is a very serious decision and each decision depends on circumstances. That’s why I tell people: I am not pro-abortion, I am pro-choice. And that’s an important distinction.

You’ve talked about the right of a woman to make a choice. Does the fetus have any rights?

First, let me say that the religious, pro-choice position is based on respect for human life, including potential life and existing life.

But I do not believe that life as we know it starts at conception. I am troubled by the implications of a fetus having legal rights because that could pit the fetus against the woman carrying the fetus; for example, if the woman needed a medical procedure, the law could require the fetus to be considered separately and equally.

From a religious perspective, it’s more important to consider the moral issues involved in making a decision about abortion. Also, it’s important to remember that religious traditions have very different ideas about the status of the fetus. Roman Catholic doctrine regards a fertilized egg as a human being. Judaism holds that life begins with the first breath.

What about at the very end of a woman’s pregnancy? Does a fetus acquire rights after the point of viability, when it can survive outside the womb? Or let me ask it another way: Assuming a woman is healthy and her fetus is healthy, should the woman be able to terminate her pregnancy until the end of her pregnancy?

There’s an assumption that a woman would end a viable pregnancy carelessly or without a reason. The facts don’t bear this out. Most abortions are performed in the first 12 weeks of pregnancy. Late abortions are virtually always performed for the most serious medical and health reasons, including saving the woman’s life.

But what if such a case came before you? If you were that woman’s pastor, what would you say?

I would talk to her in a helpful, positive, respectful way and help her discuss what was troubling her. I would suggest alternatives such as adoption.

Let me shift gears a little bit. Many Americans have said they favor a compromise, or reaching a middle-ground policy, on abortion. Do you sympathize with this desire and do you think that both sides should compromise to end this rancorous debate?

I have been to more middle-ground and common-ground meetings than I can remember and I’ve never been to one where we walked out with any decision.

That being said, I think that we all should agree that abortion should be rare. How do we do that? We do that by providing comprehensive sex education in schools and in religious congregations and by ensuring that there is accurate information about contraception and that contraception is available. Unfortunately, the U.S. Congress has not been willing to pass a bill to fund comprehensive sex education, but they are willing to put a lot of money into failed and harmful abstinence-only programs that often rely on scare tactics and inaccurate information.

Former Surgeon General David Satcher has shown that abstinence-only programs do not work and that we should provide young people with the information to protect themselves. Education that stresses abstinence and provides accurate information about contraception will reduce the abortion rate. That is the ground that I stand on. I would say that here is a way we can work together to reduce the need for abortions.

Abortion has become central to what many people call the “culture wars.” Some consider it to be the most contentious moral issue in America today. Why do many Catholics, evangelical Christians and other people of faith disagree with you?

I was raised to respect differing views so the rigid views against abortion are hard for me to understand. I will often tell someone on the other side, “I respect you. I may disagree with your theological perspective, but I respect your views. But I think it’s totally arrogant for you to tell me that I need to believe what you believe.” It’s not that I think we should not try to win each other over. But we have to respect people’s different religious beliefs.

But what about people who believe that life begins at conception and that terminating a pregnancy is murder? For them, it may not just be about respecting or tolerating each other’s viewpoints; they believe this is an issue of life or death. What do you say to people who make that kind of argument?

I would say that they have a right to their beliefs, as do I. I would try to explain that my views are grounded in my religion, as are theirs. I believe that we must ensure that women are treated with dignity and respect and that women are able to follow the dictates of their conscience – and that includes their reproductive decisions. Ultimately, it is the government’s responsibility to ensure that women have the ability to make decisions of conscience and have access to reproductive health services.

Some in the anti-abortion camp contend that the existence of legalized abortion is a sign of the self-centeredness and selfishness of our age. Is there any validity to this view?

Although abortion is a very difficult decision, it can be the most responsible decision a person can make when faced with an unintended pregnancy or a pregnancy that will have serious health consequences.

Depending on the circumstances, it might be selfish to bring a child into the world. You know, a lot of people say, “You must bring this child into the world.” They are 100 percent supportive while the child is in the womb. As soon as the child is born, they abort the child in other ways. They abort a child through lack of health care, lack of education, lack of housing, and through poverty, which can drive a child into drugs or the criminal justice system.

So is it selfish to bring children into the world and not care for them? I think the other side can be very selfish by neglecting the children we have already. For all practical purposes, children whom we are neglecting are being aborted.

This transcript has been edited for clarity, spelling and grammar.

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Global Abortion Access After Roe

In the past thirty years, sixty countries have expanded access to abortion care as an underpinning of maternal health. The 2022 U.S. Supreme Court decision overturning Roe v. Wade made the United States the fourth country ever to decrease access to abortion—and the world took notice. Some countries have since reinforced protections for abortion care, while others have moved to further restrict it.

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• Onikepe Owolabi Director of International Research, Guttmacher Institute
• Patty Skuster Reproductive Health Law Policy Researcher and Consultant, University of Pennsylvania

Globally, there is broad medical consensus that access to safe abortion and reproductive care saves womens’ lives. And nations around the world have acknowledged this fact, expanding access to reproductive health services over the past three decades.

Still, in 2022, the U.S. Supreme Court overturned Roe v. Wade , taking away nearly 50 years of constitutional protections for abortion care and making the United States one of just four countries to roll back access to abortion.

And what the U.S. does, matters. This decision has - and could continue to - spark action in other countries, for both those that want to restrict abortion care and those that want to protect it.

My name is Gabrielle Sierra and this is Why It Matters. Today, why abortion is a public health issue and how the United States’ ruling could play out globally.

Onikepe OWOLABI: Public health aims to promote and protect the health of all people and all communities. Even though abortion has been typically politicized, it's important to note that abortion is basic healthcare and ties into bodily autonomy and thus public health.  

This is Onikepe Owolabi. She’s a physician epidemiologist and the director of international research at the Guttmacher Institute, a research and policy NGO focused on reproductive health.

OWOLABI: When you think of reproductive care, it's supposed to be care across the spectrum that caters to all the needs of people, and in this space, an abortion is a complete health intervention. And if reproductive health really aims to ensure complete physical, mental, and social well-being, and not merely the absence of disease, then abortion is a key part of care that we should provide to women. 

So what does reproductive care entail? 

Reproductive care includes access to prenatal services, safe childbirth, and contraception, which prevents pregnancy from happening in the first place. Contraceptives like Plan B and IUDs are often conflated with abortion, and, in recent years, some lawmakers in the U.S. have even tried to ban these birth control methods in their state legislatures.

Reproductive care also encompasses legal and safe abortion, which is different from contraception. And in the last thirty years, more than sixty countries have liberalized their abortion laws. And over the past twenty, maternal mortality has declined by over 30 percent, potentially putting the world on track to meeting a core UN Sustainable Development Goal which seeks to “ensure universal access to sexual and reproductive health-care services” by 2030.

OWOLABI: Safe abortions are extremely safe and extremely effective, with very, very low prevalence of complications, in an adequate environment, or even when a woman takes medication abortion at the right dose, the right prescription, and she has access to healthcare system, it's extremely effective. And when women don't have access to safe abortion care, they simply will typically seek out unsafe abortions. Abortions have happened for many generations, and so it's not like, oh, they don't have access, and then they don't do anything about it, and this is why all the data we have shows that the abortion rates in countries where the laws are restricted and in countries where the laws are liberal are pretty similar to each other. The only thing that changes is the process of the abortion, and thus the woman's outcome.

But according to the Center for Reproductive Rights, 40 percent of women worldwide live in countries with restrictive abortion laws. And each year, the World Health Organization estimates that 39,000 women and girls still die from the consequences of unsafe abortions. 

OWOLABI: The evidence we have from countries like Latin America, including Mexico, and countries like Nepal, where the abortion law has been liberalized, suggests very clearly to us that when abortion laws are changed and more women have access to safe abortion, we see reductions in some of the worst outcomes of unsafe abortion, so hemorrhage, sepsis, perforation of the uterus, we see those go down in hospital admissions dramatically. In fact, if you look at some of the evidence available from Southeast Asia, they will often tell you that you just don't see severe complications of abortions go down, you see maternal mortality reduce dramatically, because unsafe abortions are a major cause of maternal mortality in many of these contexts, they're often amongst the most marginalized, and when you're able to increase access to safe abortions, it basically takes away a very easily preventable cause of maternal mortality.

Because abortion is highly stigmatized, many women and health-care providers don’t report the procedure, which then makes data limited. This has led some experts to believe that deaths and complications from unsafe abortions are undercounted.

This theme could play out increasingly in the U.S. too, where women in some states could soon face legal action for admitting to having an abortion.

Gabrielle SIERRA: Can you give me a quick breakdown of why are we talking about this today? What's the current landscape of abortion policy in the U.S.?

Patty SKUSTER: So for nearly 50 years, the U.S. had a constitutionally protected right to abortion under Roe v. Wade .

This is Patty Skuster. She teaches about global abortion law and reproductive rights at the University of Pennsylvania and works with the World Health Organization on abortion law implementation.

SKUSTER: There are a lot of different contours around that. But basically, before viability, abortion was legal in the U.S., no matter what state you were in, there were a lot of other restrictions, but that was the baseline.

https://youtu.be/-U25RwoLXlA?si=SJiwT_2_JLENW802&t=85

The Nation Speaks: The supreme court really ever since 1973, has said that there’s a right to choose abortion before fetal viability. Which usually comes somewhere between the 22nd and 24th week of pregnancy.

https://youtu.be/Bhw-87pi-tA?si=nHRKu47YIP6M7Si2&t=71

KETV NewsWatch 7: Fetal viability addresses whether a pregnancy is expected to continue developing normally, and addresses whether a fetus might survive outside of the uterus.

In 2021, the last year before the overturning of Roe v. Wade , the Center for Disease Control and Prevention reported that less than 1 percent of U.S. abortions occurred after 21 weeks. The timeframe for viability varies around the world, but many countries are in the same ballpark as the United States.

SKUSTER: In 2022, we had the Dobbs decision where the U.S. Supreme Court removed the right to abortion for Americans, basically from the interpretation of the constitution that they had. And then that enabled states across the country to make abortion illegal.

https://www.youtube.com/watch?v=74b4OBBESCE   

WFAA: Real time reaction to the high courts decision overturning Roe v. Wade , striking down the constitutional right to abortion, leaving that decision for states to decide.

https://youtu.be/weRVOvLXvok?si=eXLnes5OrRyvqYyn&t=43

ABC News: “ Roe was on a collision course with the constitution from the day it was decided.” Alito wrote, “It is time to heed the constitution and return the issue of abortion to the people's elected representatives.”

SKUSTER: Legally, there's been tons of litigation. The Supreme Court just heard a case on the FDA's approval of abortion pills. And so we're in a real legal quagmire now following the Dobbs decision but with the range of abortion legality across the country.

SIERRA: How does abortion access in the U.S. compare globally? Are we that unique in our policies? Does anyone have similar policies?

SKUSTER: Where we're really, really an outlier is looking at trends. Globally, we've seen massive undeniable trends toward loosening of restrictions on abortion, towards steps toward making abortion more available, making more abortions legal, while a very small handful, including the U.S., have made their abortion laws more restrictive.

Alongside the United States, Nicaragua, El Salvador, and Poland have decreased access to abortion.

SKUSTER: But then also, particularly with Nicaragua and El Salvador, we can see a rise of authoritarianism. And I think we're starting to understand the links between restrictive abortion laws, restricting rights of women, restricting gender equality and links to authoritarianism. But I also think kinda putting the U.S. with its retrogression on abortion in the context, so the world really illuminates, kind of, the authoritarian danger. Not to go too far afield, but that's happening in the U.S. When we see ourselves in the company of Nicaragua, El Salvador specifically, which also have repressive governments, we can see there are very clear connections between wanting to roll back women's rights, roll back rights to abortion, and establish a government that has a tremendous amount of power. 

The United States, of course, is a leading global democracy which has an outsized role in global health efforts. The U.S. directs $13 billion in funding for global health each year - and this means that the U.S. can decide what money goes where, including with a program called PEPFAR.

SKUSTER: PEPFAR is the funding to combat the AIDS crisis around the world. It's actually a President George W. Bush program that promotes treatment for HIV, reductions in HIV. And so PEPFAR has been successful in reducing transmission and AIDS rates around the world and is really the largest chunk of global health funding that the U.S. has given to countries primarily in Africa, Asia and Latin America. However, the U.S. has had an anti-abortion global health policy since the '70s, right after Roe v. Wade . The U.S. restricted its funding to say that no U.S. foreign assistance can go for abortion. But the Dobbs decision really sets more of a tone of the U.S. as being very against abortion across the world.

T here are two major pieces of policy that restrict U.S. funds for abortion overseas. The first is the Helms Amendment, which prohibits the use of U.S. aid to pay for abortions, abortion research, or abortion lobbying. It was passed by Congress in 1973 before being signed by President Richard Nixon. The second is the global gag rule, commonly known as the Mexico City policy, which went even further than the Helms Amendment by requiring foreign NGOs to certify that they would not perform or actively promote abortion as a method of family planning. President Ronald Reagan implemented that rule in 1985 to prevent organizations that receive U.S. global health funds from using any foreign aid money for abortion-related purposes. Every Republican president since has supported the global gag rule, and every Democratic president has rolled it back.

And this pattern continues. One of Donald Trump’s first acts as president was to reinstate and expand the global gag rule, policies that President Joe Biden rescinded soon after taking office.

SKUSTER: So all of the money that the U.S. gives to lower and middle-income countries around the world, the Helms Amendment says none of that funding can be used for abortion. And so even in countries, for example, Ethiopia, which is a big recipient of U.S., foreign assistance, abortion is legal in Ethiopia, the U.S. gives a lot of funding for various programs on reproductive health, but none of that can be used for abortion. And so the result of that is not only reducing the availability of funds for abortion, but then also stigmatizing abortion, “Abortion is different than other healthcare services.” And so while the U.S. has had an important role in promoting reproductive health, it's always been problematic from an abortion rights perspective. It really sends that message through the Helms Amendment.

SIERRA: Do other governments restrict foreign aid dollars on abortion like the U.S. does because of Helms or the global gag rule?

SKUSTER: No. We are in fact, the only donor government that has an explicit restriction on funding for abortion. That's not to say every government funds abortion. Some governments might have other priorities, but we are the only one that restricts funding for abortion. And that's important because the U.S., as I mentioned, is the largest funder of reproductive health around the world. And so by carving out abortion, which is a key part of reproductive health, of course, really has an impact not only on programming, but also reinforces abortion stigma and forms an impression of abortion as being this other thing when in fact it is an essential part of reproductive healthcare.

We’ll be back after a quick break.  

SIERRA: How influential is the United States with regard to abortion policy in other countries?

SKUSTER: It's undeniable that the U.S. is a highly influential country in many different ways, including in the way that courts decide things here in the U.S. The decision of Roe v. Wade was based on legal precedent going back a couple decades before Roe , but basically said reproductive rights have to do with privacy, have to do with the right of someone to decide what to do with themselves during pregnancy. And that was a real novel argument, but we've seen it kind of seep into other places, including international human rights law, where the committee that oversees a treaty on civil and political rights at the UN started to recognize abortion as an issue of the right to privacy. 

SIERRA: Have other countries seized on Dobbs to enforce their own abortion bans?

OWOLABI: We have seen that the U.S. is really impactful, because since the Supreme Court Dobbs decision in 2022 when they reversed Roe v. Wade , we have already started to see ripple effects globally. And the Dobbs decision has been cited in multiple other regressive laws, including Uganda's anti-LGBTQIA law, in Nigeria in the bid to roll back the Safe Abortion Act in Lagos State. It has also been cited in Kenyan courts as a reason not to push forward with a more liberal abortion law, because when Dobbs was repealed, they said, "Well, if the USA, they've backtracked and they made a bad decision, why should we make progress?" And so, the impact of the U.S. decisions on abortion is affecting countries globally, and empowering people to make decisions that really affect the human rights of women and girls all around the world.

SIERRA: So then let me ask you this - can U.S. law be used as a basis for law abroad?

SKUSTER: Judges and justices can and often do look to other courts in deciding law. I've seen it firsthand in drafting legislation. When someone's drafting legislation, they might say, "Okay, how does the U.S. do it?" And so legislators very deliberately might look around the world to see, I've played this role at how do we draft abortion laws? Well, let's look at how other countries do it. And judges do the same thing explicitly or not explicitly. And so it's not that unusual, but to really directly cite it and use the same analysis in that robust way, certainly was unusual.

SIERRA: So perhaps it's fair to say that decisions like Dobbs are at least politically useful for leaders around the world who are seeking to block abortion access in their own countries.

SKUSTER: Yeah. It's sort of putting a very influential tool in the toolbox of repressive regimes. And on the non-legal influence piece of it, when you criminalize abortion, you're really stigmatizing it. You're saying this thing is criminal. And so the fact that the U.S. has now said, "Okay, we're going to allow criminalization of abortion," really helps deem it something bad. And when you stigmatize it, you treat it as people who have it as bad people, even though it's totally common, and it's usually women who are having abortions.

But not all countries are using Dobbs to restrict abortion. In some nations, Dobbs has had the opposite effect, with the law serving as motivation for enshrining abortion protections.

https://youtu.be/kISgBA7f9nU?si=KQf31F7icFoYwJbC&t=14

Guardian News: I’ve got to tell you I think it’s a big step backwards.

https://youtu.be/-lT7n5EhMhs?si=dD3fEq_BDvT2vzUz&t=4

Global News: The judgment coming out of the United States is an attack on women's freedom, and quite frankly it's an attack on everyone's freedoms and rights.

https://youtu.be/_YiSvpZ6w7I?si=VJrLzCbfm8YPkD1g

CBS News: In a historic move, France has become the only country to guarantee abortion as a constitutional right.

https://youtu.be/KjQDl1ZhtmU?si=GIV5JX48tAWHdbl0&t=75

Emmanuel Macron/Guardian News: ( Translation) This is why I wish for the inscription of this guaranteed liberty to access to abortion in the chart of fundamental rights of the European Union.

SKUSTER: Abortion was legal in France before, but here they're saying, "Okay, let's change the constitution and make abortion a right." And so in the same way that we're seeing the same types of votes in U.S. states where, when given the opportunity for a population of a state to vote on the constitutionality of abortion, even in I think Kansas was the first one, even in states that are conservative, we see the popular vote is supportive of abortion rights. And that happened in France and spurred on by Dobbs . Dobbs has really brought abortion, to the forefront, and really the realization that we don't want to go backwards.

And this ripple effect of support for abortion access extends into access to reproductive care as well, where both abortion pills and contraceptives like IUDs and Plan B are becoming more widespread options for women.

OWOLABI: There are some things that have made abortion care safer, and what I'm referring to is medication abortion pills. And so, since the development and marketing of misoprostol and mifepristone, which is a combination often used for self-managed medication abortion, it has been easier for many women to get access to safe abortions. It's also been easier to do something called task shifting, or task sharing, in many countries, which means to take abortion care from being the sole preserve of a physician or an obstetrician gynecologist, and to allow mid-level or other cadres of staff, including nurses, midwives, and physician assistants, to provide this care. And it is important to recognize that task sharing, especially with the availability of medication abortion pills, has the potential to expand access for many women, self-managed or in conjunction with providers, and to really make abortion safer globally.

Even in a country like Honduras, which has one of the toughest abortion laws in the world, there is momentum behind the decriminalization of non-abortion related reproductive care. This March, the President of Honduras, Xiomara Castro, signed an executive order ending the country’s ban on the use and sale of emergency contraceptives like Plan B.

SIERRA: Do you think we will continue to see ripples from Dobbs ?

OWOLABI: I do think so. I think we will likely continue to see ripples from Dobbs , because the United States has established itself as a very influential country, both politically, and it is also one of the largest funders of development in many countries. It funds many maternal reproductive health programs, and like we've seen over time, every time something happens in our policy space, it affects the direct funding countries get. But beyond the direct funding they get, it affects the policy environment. The impact of Dobbs is likely to be felt in all low income countries, but many countries are at a point where they're in an election period so they're changing their governments. We hope that the Dobbs decision does not embolden conservative governments to try to backtrack on legislative progress that has already been made.

This November, a seemingly divisive choice on abortion will loom large in the minds of many American voters. Around a dozen states may have abortion-related ballot items this fall, and the issue motivated voters to come out in droves in 2022. Many analysts believe it could be an issue that defines the 2024 election.

But the stakes of the election go far beyond U.S. borders.

SIERRA: What’s at stake for these issues in the 2024 election?

SKUSTER: Certainly, directly from a policy perspective, the global gag rule is the real direct thing that is of great concern. We've seen when the global gag rule is on, organizations really shy away from any type of abortion work at all. And there are some examples of where coalitions working for liberalization of abortion laws have shrunk under the global gag rule because organizations weren't allowed to participate in advocacy on abortion. And so that, we would expect, would be one of the things that a Republican, that a Trump Administration would do in the first act, but then also, kind of thinking about appointing judges, potentially appointing justices. And here's where I'm seeing the connections between gender equality, LGBTQ rights, abortion rights, all of these rights. All of our rights, every one of our rights is really at stake when we're looking forward to the next election.

Most OB-GYNs say the overturning of Roe v. Wade has worsened their ability to manage pregnancy-related emergencies, and a majority of them say they are concerned about their own legal risk when making decisions about patient care. If doctors are unable to provide necessary care based on legal restrictions, that could put many womens’ lives in danger. And that’s scary, especially when one in four women in the United States are expected to have an abortion during their lifetime.

How the United States views abortion access matters globally, and with a pivotal American election on the horizon, the way the country moves forward could affect the trajectory of how reproductive rights and services are provided globally for years to come.

Our interns this semester were amazing, and we wish them the best of luck on their future endeavors. So, as is tradition, here they are to read us out!

For resources used in this episode and more information, visit CFR.org/whyitmatters and take a look at the show notes. If you ever have any questions or suggestions or just want to chat with us, email at [email protected] or you can hit us up on X, better known as Twitter at @CFR_org .

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There is broad medical consensus that access to safe abortion and reproductive care saves womens’ lives. While the United States has been a world leader and major funder of foreign health initiatives for decades, on this issue it is moving in the opposite direction of global trends. Some experts now fear that the overturning of Roe v. Wade, a landmark decision that established the constitutional right to abortion for nearly fifty years in the United States, could prove a useful tool for countries seeking to limit or decrease access to abortion, such as Nigeria, which cited the Dobbs ruling as a reason to rollback its Safe Abortion Act in Lagos State. But it could also provoke the opposite effect, serving as motivation for abortion protections in countries such as France, which has since enshrined the right to abortion in its constitution. 

Mariel Ferragamo, “ Roe’s Repeal Inspires Global Abortion Rollbacks in Other Countries ,” Think Global Health

Women and Foreign Policy Program Staff, “ Abortion Law: Global Comparisons ”

From Our Guests

Onikepe Owolabi, Ann Biddlecom, and Hannah S. Whitehead, “ Health Systems’ Capacity to Provide Post-abortion Care: a Multicountry Analysis Using Signal Functions ,” Lancet Global Health

Patty Skuster, Heidi Moseson, and Jamila Perritt, “ Self-Managed Abortion: Aligning Law and Policy With Medical Evidence ,” International Journal of Gynecology and Obstetrics  

Patty Skuster, “ Countering the Anti-Science of Abortion Regulation ,” American Journal of Public Health

“ Abortion Care Guideline ,” World Health Organization

Daniela Santamariña, Brittany Shammas, and Aaron Steckelberg, “ The Most Common Abortion Procedures and When They Occur ,” Washington Post

“ The World’s Abortion Laws ,” Center for Reproductive Rights

“ Tracking Abortion Bans Across the Country ,” New York Times

Watch and Listen

“ Abortion Rights Rollback in US Could Ripple Across Globe ,” Voice of America

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Article by Women and Foreign Policy Program Staff March 7, 2024 Women and Foreign Policy Program

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In Brief by Claire Klobucista July 28, 2021

Good News Emerges About a Malaria Vaccine

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via Council of Councils May 25, 2023

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The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities

The abortion and mental health controversy is driven by two different perspectives regarding how best to interpret accepted facts. When interpreting the data, abortion and mental health proponents are inclined to emphasize risks associated with abortion, whereas abortion and mental health minimalists emphasize pre-existing risk factors as the primary explanation for the correlations with more negative outcomes. Still, both sides agree that (a) abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; (b) the abortion experience directly contributes to mental health problems for at least some women; (c) there are risk factors, such as pre-existing mental illness, that identify women at greatest risk of mental health problems after an abortion; and (d) it is impossible to conduct research in this field in a manner that can definitively identify the extent to which any mental illnesses following abortion can be reliably attributed to abortion in and of itself. The areas of disagreement, which are more nuanced, are addressed at length. Obstacles in the way of research and further consensus include (a) multiple pathways for abortion and mental health risks, (b) concurrent positive and negative reactions, (c) indeterminate time frames and degrees of reactions, (d) poorly defined terms, (e) multiple factors of causation, and (f) inherent preconceptions based on ideology and disproportionate exposure to different types of women. Recommendations for collaboration include (a) mixed research teams, (b) co-design of national longitudinal prospective studies accessible to any researcher, (c) better adherence to data sharing and re-analysis standards, and (d) attention to a broader list of research questions.

Introduction

In 1992, the Journal of Social Issues dedicated an entire issue to the psychological effects of induced abortion. In an overview of the contributors’ papers, the editor, Dr Gregory Wilmoth, concluded,

There is now virtually no disagreement among researchers that some women experience negative psychological reactions postabortion. Instead the disagreement concerns the following: (1) The prevalence of women who have these experiences …, (2) The severity of these negative reactions …, (3) The definition of what severity of negative reactions constitutes a public health or mental health problem …, [and] (4) The classification of severe reactions … 1

Twenty-six years later, the body of literature has grown. Today, there are many additional areas of agreement, but the areas of disagreement have also grown.

As with most controversies, the abortion and mental health (AMH) controversy is driven by at least two different perspectives regarding how best to interpret accepted facts. A useful parallel is found in the debate over climate change. On the fringes of the climate change controversy are non-experts who hold an extreme position of either total denial or total credulity. But it is far more common for skeptics to acknowledge that fossil fuels make some contribution to global warming while still arguing that these effects are not as extreme global warming proponents contend. 2 This group may be described as global warming minimalists. Their normal pattern is to interpret the data in a way that minimizes the potential threat. By contrast, global warming proponents may be more likely to interpret the data in ways that emphasize the potential risks.

Similarly, in regard to the AMH controversy, there are both AMH minimalists and AMH proponents. The experts from both groups can report similar findings from the same data but will do so in ways that seem to either minimize or emphasize the negative outcomes associated with abortion. It should be carefully noted that there is actually a broad spectrum of expert views regarding the AMH link. 3 While each researcher and expert has likely developed carefully considered and nuanced opinions, these have not been completely disclosed and cannot be cataloged in regard to every issue discussed herein. Still, broadly speaking, it is evident that both expert reviews and the authors of individual studies appear to generally support either the view that (a) the mental health effects associated with abortion are minimal and within the expected range for the women seeking abortions 4 – 10 or (b) the effects are significant enough to justify more research dollars, and better screening and counseling in order to reduce the number of adverse outcomes. 11 – 19 In addressing this conflict, it is not my intention to pigeonhole any particular expert’s viewpoint at any location on the spectrum of views regarding AMH.

In writing this review, I have tried to be as objective and fair as possible. Yet, as discussed later, since my own informed opinion is also influenced by my own experiences and preconceptions, full disclosure requires that I acknowledge at the outset that I fit most closely under the category of an AMH proponent. That said, my goal is not to dismiss or disprove the viewpoint of “the other side,” but rather to understand and engage with it in a manner that will contribute to a respectful “transformational dialogue” that will help to “crystalize the areas of agreement and disagreement along with opportunities for collaboration.” 20 In this regard, it is my great hope that those who disagree with my analysis and conclusions herein will use the publication of this review as an opportunity to publish responses and reviews that address the issues raised with additional depth from their perspectives.

The method I used for this review was to carefully examine previous literature reviews regarding mental health effects associated with legal abortion that have been published since 2005. 4 – 10 , 12 – 19 , 21 , 22 In that sense, this article may be considered a review of reviews of the literature on AMH. In addition, I studied the references cited in these various reviews in order to further my effort to more completely identify (a) areas of agreement and disagreement, (b) the underlying reasons for disagreements, and (c) opportunities to collaborate in light of the current literature.

This undertaking is intended to advance more than just an academic discussion, however. Research has shown that women considering abortion have a high degree of desire for information on “all possible complications,” including rare risks. 23 Therefore, an updated and more complete understanding of the literature can and should better prepare physicians and mental healthcare providers with more accurate and helpful information for advising and counseling women before or after an abortion. For example, better screening for risk factors should help to identify women who may benefit from additional pre- or post-abortion counseling 24 – 38 and may also help to prevent cases of women being pressured into unwanted abortions. In addition, more complete insights may help mental health counselors to be more aware and sensitive to providing the counseling services that women want and need.

This review is organized into three sections. The first examines major areas of agreement and offers a synthesis of the findings from major studies. The second section investigates the obstacles to building a consensus between AMH minimalists and AMH proponents, including institutional and ideological biases, research obstacles, poorly defined terms, and similar issues that contribute to the disparity in the conclusions most emphasized by each side. The third section provides recommendations for collaborative research based on the insights gained from the first two sections, addressing such issues as data sharing, mixed research teams, and how to maximize the value of longitudinal prospective studies.

Areas of agreement

Abortion contributes to negative outcomes for at least some women.

The 2008 report of the American Psychological Association’s (APA) Task Force on Mental Health and Abortion (TFMHA) concluded that “it is clear that some women do experience sadness, grief, and feelings of loss following termination of a pregnancy, and some experience clinically significant disorders, including depression and anxiety.” 4 Indeed, task force chair Brenda Major et al.’s 39 own research had reported that 2 years after their abortions, 1.5% of the remnant participating in her case series (38% of the 1177 eligible women, after dropouts) had all the symptoms for abortion-specific post-traumatic stress disorder (PTSD). In addition, she found that compared to their 1-month post-abortion assessments, at 2 years the participating remnant had significantly rising rates of depression and negative reactions and lowering rates of positive reactions, relief, and decision satisfaction. 39

The fact that some women do have maladjustments is most specifically documented in case studies developed by post-abortion counselors successfully treating women with maladjustments, including counselors working from a pro-choice perspective 40 – 44 as well as from those working from a pro-life perspective. 45 – 47

Even one of the harshest critics of the “myth” of abortion trauma, psychiatrist Nada L Stotland, 40 subsequently reported her own clinical experience treating a patient whose miscarriage triggered a mental health crisis arising from unresolved issues regarding a prior abortion. Stotland, who later served as president of the American Psychiatric Association, subsequently began to recommend screening of prospective abortion patients for risk factors in order to guide decision counseling and identify additional counseling needs. 31

Some groups of women are predictably at greater risk of negative outcomes

There is a strong research-based consensus that there are numerous risk factors that can be used to identify which women are at greatest risk of negative psychological outcomes following one or more abortions. Indeed, the TFMHA concluded that one of the few areas of research which can be most effectively studied is in regard to efforts to “identify those women who might be more or less likely than others to show adverse or positive psychological outcomes following an abortion.” 4

The TFMHA itself identified at least 15 risk factors for increased risk of negative reactions. While the TFMHA did not report on the percentage of women exhibiting each risk factor, Table 1 provides ranges of the incidence of each TFMHA risk factor as reported in the literature. The incidence rates shown in Table 1 clearly suggest that the majority of women seeking abortion have one or more of the TFMHA identified risk factors. Since exposure to multiple abortions is one of the risk factors, that risk factor alone applies to approximately half of all women having abortions, at least in the United States. 64

Risk factors for mental health problems after an abortion identified by the American Psychological Association’s Task Force on Mental Health and Abortion (TFMHA) in 2008.

Notably, the TFMHA list used here is one of the shortest that has been developed. A similar, but longer list is published in the text book on abortion most highly recommended by the National Abortion Federation. 66 A more recent systematic search of the literature for risk factors associated with elevated rates of psychological problems after abortion cataloged 119 peer reviewed studies identifying 146 individual risk factors which the author grouped into 12 clusters. 35 Yet another major review of risk factors identified risk factors from 63 studies which were grouped into two major categories. 25 The first category includes 22 risk factors related to conflicts or defects in the decision-making process , for example, feeling pressured to abort, conflicting maternal desires and moral beliefs, and inadequate pre-abortion counseling. The second category contains 25 risk factors related to psychological or developmental limitations , such as pre-existing mental health issues, lack of social support, and prior pregnancy loss. 25

The ability to identify women who are at greater risk of negative reactions has resulted in numerous recommendations for abortion providers to screen for these risk factors in order to provide additional counseling both before an abortion, including decision-making counseling, and after an abortion. 24 , 25 , 31 , 66 – 68

Notably, while there is no dispute regarding the abundance of research identifying risk factors, there is little if any research identifying which women, if any, acquire any mental health benefits from abortion compared to carrying a pregnancy to term, even if the pregnancy was unintended or unwanted. 17

All AMH studies have inherent limitations

It is impossible to conduct randomized double-blind studies to investigate abortion-associated outcomes. Such studies would require random selection of women to have abortions.

Notably, the very same fact that would make such a study unethical—forcing a group of women to have abortions—actually occurs in the real world wherein some women feel pressured or even forced into unwanted abortions by their partners, parents, employers, doctors, or other significant persons. 25 , 45 This problem with coerced abortions highlights one of the major difficulties involved in AMH research: any sample based entirely on self-selection (voluntary participation) no longer represents the full population of women actually having abortions. Indeed, since feeling pressured to abort is a major risk factor, the practice of excluding women aborting intended pregnancies from AMH studies 39 , 69 makes the results from such studies less generalizable to the actual population of all women having abortions.

This is just one of many difficulties which makes it truly impossible to conduct any AMH study that does not have significant methodological weaknesses. As a result, the “true prevalence” and intensity of the negative effects associated with abortion can never be known with any great certainty. Noting this problem, the TFMHA review concurred with the view that the complexity of this field “raises the question of whether empirical science is capable of informing understanding of the mental health implications of and public policy related to abortion,” admitting that many research “questions cannot be definitively answered through empirical research because they are not pragmatically or ethically possible.” 4

Despite study limitations, statistically significant risks are regularly identified

While every observational study can be criticized for methodological weaknesses, it is also nonetheless true that is still possible to discover meaningful and actionable results. For example, research demonstrating elevated rates of mental health problems among women who feel pressured to abort contrary to their moral beliefs is generalizable to that specific subset of women. So while it is important to never generalize to all women who have abortions, insights can be gained from nearly any study when the results are properly narrowed to the limits of the population studied. 70

Figure 1 shows the odds ratios (ORs) and 95% confidence interval (95% CI) for risks associated with abortion in all major studies published since 1995 organized by class of symptoms. 17 , 30 , 67 , 69 , 71 – 102

Relative risk of abortion relative to each study’s comparison groups.

While there are disagreements on how to best interpret these findings (to be discussed later), the findings themselves are not disputed. The results are organized into six sets: all classes of symptoms (segregated by inpatient and outpatient treatments when separately reported); depression and depression-related symptoms such as bipolar disorder; anxiety; substance use disorders (segregated by type of substance use when identified); and other disorders. Each row identifies the study reporting the results; the numeric relative risk (or OR) and CIs (also shown as a range in the forest plot); the participation rate of eligible women (after deducting refusals and dropouts) when identifiable; the group to whom the aborting women are being compared in the study; the forest plot; and an abbreviated description of the specific outcome, symptom, diagnostic scale, and/or time frame to which the statistic applies. Comparison groups include women carrying an unintended pregnancy to term, women delivering a child, women delivering a first pregnancy, women with no known history of abortion, women with any other pregnancy outcome other than abortion, and women not pregnant during the period studied.

What is most notable from Figure 1 is that the trend in results, including those reported by questionnaire and record linkage studies, is consistent. All but three odds ratios are above 1. In most cases, the lower 95% CI is also above 1, signifying statistical significance. Moreover, even among studies showing no significant difference (when the lower 95% CI is less than 1.0), the upper 95% CI is always above 1 and overlaps the statistically significant CIs of other studies.

This overlap is very important. For example, as can be seen in the depression grouping in Figure 1 , the overlap of the 95% CIs in the findings of Schmiege & Russo 2005 and Cougle 2003 (both using different sampling rules for the same data set) demonstrates that there is no actual contradiction in the findings of these two studies. Whenever there is overlap in the CIs, this tells us that the variation in the respective relative risks reported by each study is within the expected range of variation given the limits of each study’s statistical power. Since findings only contradict each other when there is no overlap in the CIs, it is clear from Figure 1 that the minority of studies without statistically significant findings do not contradict the findings of studies with statistically significant findings. Claims to the contrary 69 ignore the relevance of CIs and also the fact that studies with low statistical power are easily prone to Type II errors resulting in false negatives.

The risk of such false negatives is increased when there is also any risk of sample bias. In regard to abortion research, the risk of sample bias is especially high since questions about abortion are frequently associated with feelings of shame. 22 , 59 The resulting selection bias due to self-censure and the high dropout rates of women at greatest risk of negative reactions also contributes to the misclassification of women concealing a history of abortion as non-aborters. In addition, some researchers choose to exclude groups such as women who abort wanted pregnancies, 69 have later term abortions, or have other risk factors for more negative reactions ( Table 1 ) and these methodological choices will also tend to shift results below statistical significance.

Despite these problems, the trend in findings, as shown in Figure 1 , is very clear. Women who abort are at higher risk of many mental health problems.

This conclusion is strengthened by the variety of the study designs that have been conducted. Collectively, these studies examine a wide variety of different comparison groups, explore a diverse set of outcome variables, employ a large variety of control variables, and report on numerous outcomes over different time frames and/or at a variety of cross sections of time. Collectively, they reveal the following:

• (a) There are no findings of mental health benefits associated with abortion. (These would be signified by the entire 95% confidence line being below 1.0.)
• (b) The association between abortion and higher rates of anxiety, depression, substance use, traumatic symptoms, sleep disorders, and other negative outcomes is statistically significant in most analyses.
• (c) The minority of analyses that do not show statistically significant higher rates of negative outcomes do not contradict those that do. (Shown by the upper bound of the 95% confidence overlapping the lower 95% CI of the statistically significant studies.)

A number of recent studies have also reported the population attributable risk (PAR) associated with abortion. This statistic estimates the percentage of an outcome that may be attributed to exposure to an abortion experience after statistically removing the effects associated with the available control variables.

Fergusson was the first to report PARs identified in a prospective longitudinal cohort studied from birth to 30 years of age in New Zealand. He reported that the attributable risk ranged from 1.5% to 5.5%, but did not identify the PAR of specific mental health effects nor provide the CIs. 75 Specific outcome PAR risks were also calculated by Coleman 15 in her meta-analysis, but these were reported without CIs. These are shown in Figure 2 along with PAR estimates with 95% CIs that have been reported in three other studies. 94 , 101 , 103

Population attributable fraction and 95% CI.

Of particular interest is a 2016 study by Sullins using the National Longitudinal Study of Adolescent to Adult Health that provided three models of analyses, including controls for 25 confounding factors. In addition, he conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” 94 Sullins’ lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. He also identified a dose effect, with each exposure to abortion (up to the four) associated with a 23 percent (95% CI, 1.16–1.30) increased of relative risk of subsequent mental disorders.

Collectively, the findings shown in Figure 2 suggest that substance use disorders appear to be most strongly attributable to abortion. Put another way, assessments of substance use (perhaps indicating self-medicating behavior) may be one of the more sensitive measures of difficulties adjusting to post-abortion. 96 Conversely, at least some research has shown that other outcomes, such as variations in self-esteem, may be unaffected, or only weakly associated with abortion. 38 Alternatively, some outcomes may appear to be less strongly associated with abortion because women are receiving successful treatment, such as medication for depression or anxiety, that would obviously suppress these associations with abortion.

Prior mental health and co-occurring factors explain at least part of the effects

As shown in Table 1 , a history of mental health problems is a risk factor for higher rates of mental health problems following abortion as compared to women without a history of mental health problems. This association has been known since at least 1973 when a case series identified several pre-existing mental health factors that could be used to identify the women who were most likely to experience subsequent psychopathology. 32 The authors of that study recommended that a low-cost computer scored Minnesota Multiphasic Personality Inventory assessment could effectively identify women who could benefit from additional pre- and post-abortion counseling.

Both AMH proponents and AMH minimalists agree that prior health is a major factor in explaining the negative reactions observed post-abortion. There are differences, however, in how proponents and minimalists distinguish, interpret, and emphasize the interactions between prior mental health, the abortion experience, and subsequent mental health.

AMH proponents see poor prior mental health as contributing to the risk that a woman (a) may become pregnant in problematic circumstances; (b) may be more vulnerable to pressure or manipulation to have an abortion contrary to personal preference, maternal desires, or moral ideals; and (c) may have fewer or weakened coping skills with which to process post-abortion stresses. In addition, from the perspective of abortion as a potential stressor, women exposed to prior traumatic experiences may be more predisposed to experiencing abortion as another traumatic experience.

In contrast, AMH minimalists tend to interpret the evidence that a high percentage of women having abortions have prior mental health issues as the primary explanation for higher rates of mental illness observed after abortion. 5 , 7 , 104 , 105 From this perspective, women with mental health problems are more likely to engage in risk-taking behavior and to experience more problematic pregnancies and are more likely to choose abortion. It is also hypothesized that pregnant women with pre-existing mental health problems may be more inclined to choose abortion because they recognize that they are likely to fare worse if they deliver and try to raise an unplanned child. 106 , 107 The higher rates of mental health issues following abortion, therefore, may be mostly explained as just a continuation of pre-existing mental health problems rather than a direct and independent cause of mental illness. While a few minimalists suggest that the underlying cause of mental health problems observed after abortion can be entirely explained by prior mental health defects or co-occurring stressors, 30 , 82 I have been unable to find any researchers who have denied that abortion can contribute to mental health problems.

A closely related issue is that a history of being physically and/or sexually abused is a co-occurring risk factor for both mental health problems and abortion. 92 , 94 , 108 – 110 Obviously, both sides agree that trauma from prior abuse can harm mental health. Also, at least from the clinical perspective of AMH proponents treating women with a history of both abortion and abuse, a history of abuse may increase the vulnerability of women consenting to unwanted abortions.

The differences between AMH minimalists and proponents on these issues will be more thoroughly discussed later. At this point, it is sufficient to note that both sides agree that poor prior mental health is a major predictor of higher rates of mental health problems after an abortion. Moreover, both sides agree that there should be mental health screening of women seeking abortion 24 – 30 , 32 – 38 , 58 precisely because the “abortion care setting may be an important intervention point for mental health screening and referrals” 30 due to the higher concentration of women with previous and subsequent mental health issues. At the very least, a history of abortion is a useful marker for identifying women at greater risk of mental health problems and a corresponding elevated risk of a variety of related chronic illnesses 111 and reduced longevity. 112 , 113

A summary of agreements with difference in emphasis

Table 2 summarizes specific factual propositions to which the vast majority of both AMH minimalists and AMH proponents would agree. As indicated in the table, each side may typically emphasize some points over others and might underemphasize, reluctantly admit, or even evade discussion of some of these propositions. Still, while some may quibble over the exact formulation of any particular proposition in Table 2 , the underlying consensus relative to each proposition is easily discernible in the body of references by both sides cited in this review.

Variations in emphasis on conclusions generally shared by AMH minimalists and AMH proponents.

AMH: abortion and mental health.

In summary, the consensus of expert opinion, including that of both AMH proponents and minimalists, is that (a) a history of abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; (b) the abortion experience can directly contribute to mental health problems in some women; (c) there are risk factors, including pre-existing vulnerability to mental illness, which can be used to identify the women who are at greatest risk of mental health problems following an abortion; and (d) it is impossible to conduct research in this field in a manner that can definitively identify the extent of any mental illnesses following abortion, much less than the proportion of disorders that can be reliably attributed solely to abortion itself.

Obstacles in the way of research, understanding, and consensus

Facts are facts. But there is plenty of room for disagreement regarding which facts are generalizable, much less on how to best synthesize and interpret sets of facts, especially when there are flaws in the research and gaps in what one would want to know. Indeed, the greater the ideological differences between people regarding any question, the easier it is to disagree about what the available evidence really means. As shown in Table 2 , even areas around which there is a fundamental agreement by experts under sworn testimony may appear muddied by shifts of emphasis and the insertion of nuances that may be technically true but misleading to non-experts who imagine there are simple, global answers.

For example, the same APA task force which produced the list of risk factors shown in Table 1 did not highlight these findings in their press releases with a recommendation for screening. Instead, the centerpiece of their press release 114 was the report’s conclusion that “the relative risk of mental health problems among adult women who have a single , legal, first-trimester abortion of an unwanted pregnancy for nontherapeutic reasons is no greater than the risk among women who deliver an unwanted pregnancy” 7 (italics added).

This statement was widely reported as the APA officially concluding that abortion has no mental health risks. But as shown in Table 1 , this reassuring conclusion was actually couched in nuances which make it applicable to only a minority of women undergoing abortions on any given day. It excludes the 48%–52% of women who already have a history of one or more abortions, 64 the 18% of abortion patients who are minors, 115 the 11% of patients beyond the first trimester, 116 the 7% aborting for therapeutic reasons regarding their own health or concerns about the health of the fetus, 117 and the 11%–64% whose pregnancies are wanted, were planned, or for which women developed an attachment despite their problematic circumstances. 38 , 50 , 51

The above example demonstrates that the same set of facts, presented and interpreted by AMH minimalists in a way that suggests that few women face any risk of negative reactions to abortion, could also have been worded by AMH proponents in a way that would have underscored a conclusion that most women having abortions are at greater risk compared to the minority who have no risk factors.

This points to one of the greatest hindrances in the advance of knowledge: the tendency to use nuances to dodge direct engagement with the ideas, evidence, and arguments which threaten one’s own preconceptions.

Therefore, one of the purposes of the following discussion is to invite direct engagement and thoughtful responses to the specific obstacles identified below.

Intrinsic biases in the assessment of evidence are nearly impossible to avoid

Everyone, even the most “objective” scholar, has developed shortcuts in their thinking and beliefs. These shortcuts (or biases) help us to (a) be more efficient in drawing conclusions and making decisions and also (b) be more consistent in how we perceive ourselves and reality, or conversely, to avoid the stress of cognitive dissonance which occurs when some fact or experience clashes with our core beliefs and values.

Our biases are not just personal. They also have a communal element. We tend to adopt the biases of our peers for several practical reasons. First, by adopting the opinion of our peers as our own, we are embracing a collective wisdom that frees us from the need to deeply research and consider every idea on our own. Second, the more completely our beliefs are aligned within our community of peers, the less we will face conflict and suspicion. Obviously, there is never perfect alignment or cessation of independent thinking. But the tendency to accept the “conventional truths” of one’s peers as “fact” is a very real phenomenon.

The impact of biases among academics on the interpretation of data and suppression of contrary opinions has been well documented. 118 – 123 For example, identical studies, for which the results are the only difference, are more likely to be lauded or condemned 122 – 125 by peer reviewers when the results confirm or conflict with the reviewer’s own biases. In the fields of psychology and psychiatry, such confirmatory bias may contribute to the promotion or suppression of research findings that favor liberal causes. 125 – 128 In one study, only one-fourth of reviewers noted a major methodological problem in a fake study that agreed with their preconceptions, while 72% quickly raised an objection about the problem when presented with a nearly identical fake study in which the results challenged their preconceptions. 123 The only way to eliminate result-based bias, the author suggests, would be to solicit reviews only on the relevance of a study’s methodology, withholding the actual results and discussion of results, since the latter are the actual drivers of confirmatory bias. 123

While much of the confirmatory bias observed in peer reviewers may be unconscious, 129 at least one survey of 800 research psychologists found high rates of admissions that they or their colleagues would openly and knowingly discriminate against conservative views when providing peer review (34.2%), awarding grants (37.9%), or making hiring decisions (44.1%). 130 The authors noted that this admission of conscious ideological bias was likely just the tip of the iceberg compared to confirmatory bias since “[i]t is easier to detect bias in materials that oppose one’s beliefs than in material that supports it. 124 Work that supports liberal politics may thus seem unremarkable, whereas work that supports conservatism is seen as improperly ideological.” 130

In addition to blocking publication of good research, ideological and confirmatory bias may also contribute to poorly designed studies and/or carelessly interpreted findings that advance a preferred viewpoint. 118 , 126 , 131 – 133

Social psychologist Jonathan Haidt, a self-proclaimed liberal specializing in the foundations of morality and ideology, has argued that that the vast majority of psychologists are united by the “sacred values” of a “tribal-moral community” which is politically aligned with the liberal left. 134 This shared moral superiority, 129 he says, both “binds and blinds” their community. 134 The risk of “blindness” occurs because the lack of sufficient political diversity predisposes the community of psychologists to “embrace science whenever it supports their sacred values, but they’ll ditch it or distort it as soon as it threatens a sacred value.” 134

In regard to the abortion, mental health controversy, studies by AMH minimalists tend to be written in a way that minimizes any disruption of the core pro-choice aspiration that abortion is a civil right that advances the welfare of women. 135 The research on confirmatory bias discussed above, therefore, suggests that studies by AMH proponents are more likely to be unfavorably reviewed and rejected. 136

An excellent example of this result-based bias was the four rejections reported by David Fergusson, former director of the Christchurch Health and Development Study, which followed 1265 children born in Christchurch, New Zealand, for over 30 years. 137 Fergusson, a self-proclaimed pro-choice atheist, believed that his data would help to prove that AMH proponents were wrong. 137 But when he ran his analyses, he found that even after controlling for numerous factors, abortion was indeed independently associated with a two-to threefold increased risk of depression, anxiety, suicidal behaviors, and substance abuse disorders. 17 , 138 Though his findings were opposite to his preconceptions, he submitted them for pubication anyway. It was then that he ran into a wall of ideologically driven rejections and was even asked by the New Zealand government’s Abortion Supervisory Committee to withhold the results. 137

Similarly, Ann Speckhard, 139 another pro-choice AMH proponent and an associate professor of psychiatry at Georgetown University Medical School, has complained,

Politics have also stood in the way of good research being conducted to examine psychological responses in a nationally representative sample to all pregnancy outcomes: live birth, miscarriage, induced abortion, and stillbirth (and perhaps even including adoption). I offered in 1987 to our National Center for Health Statistics a simple mechanism for collecting such data via a short interview to be attached to an already existing survey—but fear of the answers—on both sides of the issue staunchly squelched the idea.

The problem is that even trained scientists struggle with being purely objective—especially regarding issues that may touch one’s own core beliefs, values, and experiences. What makes Fergusson’s experience particularly unique is that he chose to publish his findings even though they contradicted his own worldview. How many other researchers, expecting to prove mental health benefits from abortion but finding the opposite, might be tempted to withhold their findings, or worse, to redesign their study in ways that would obfuscate their results in order to declare that a lack of statistically significant results “proved” that there was no need to look further? This concern is heightened by the refusal of AMH minimalists to allow examination of their data by AMH proponents, 140 as will be discussed in more detail later.

Just as lawyers are taught to never ask a question at trial to which you do not already know the answer, researchers engaged in any field where there are “adversarial” positions may often be hesitant to cooperate in a mutual pursuit of objective truth. 141 This fear of admitting the validity of “the other side’s” concerns is also reflected in the admission by pro-choice feminists that they are afraid to publicize the existence of their own post-abortion counseling programs. 44 , 142

These concerns regarding bias surrounding AMH issues are further heightened by the fact that many professional organizations, including the APA, have taken official political positions defending abortion as a “civil right.” 135 In defense of that political position, Nancy Russo, a member of the APA’s TFMHA, has stated that “whether or not an abortion creates psychological difficulties is not relevant” 143 and has been a proponent of the APA taking a pro-active role in aggressively attacking the credibility of studies by AMH proponents. 144 The problem with professional organizations taking a political position on abortion is that any subsequent acknowledgment of negative mental health effects linked to abortion might then embarrass the APA, and/or other professional organizations that have committed themselves to the agenda of defending abortion as a civil right, and thereby creates an ideological obstacle in objectively evaluating new evidence.

There are different rates of exposure to the highest risk and lowest risk archetypes

This leads us to an important and perhaps closely related observation. It is not only political, philosophical, or ideological beliefs that contribute to the AMH controversy. Conflicts in the perceiving AMH controversy are also colored by direct and indirect personal experiences . The fact that pro-choice feminists are more focused on feelings of relief and other liberating aspects of having a right to abortion 3 may be accurately representing their own positive personal experiences. Conversely, anti-abortion conservatives, who presume that AMH problems are common, may be accurately representing their own relative rate of exposure to negative experiences. 3

Support for this hypothesis is found in a study based on structured interviews of women following their abortions conducted by Mary Zimmerman 48 in which she found that approximately half of the women she interviewed could be classified as “affiliated” (more goal oriented, more educated, less dependent on the approval of others, and more likely to abort for their own self-interest) and the other half as “disaffiliated” (less career oriented, less educated, more dependent on the approval of others, and more likely to abort to please others). When she interviewed her sample 6 weeks after their abortions, Zimmerman 48 found that only 26% of “affiliated” women were struggling with “troubled thoughts” about their abortions compared to 74% of “disaffiliated” women, a threefold increase. A similar disparity relative to personality types was observed by Major et al. 145

It is reasonable to assume that friends and associates of highly educated research psychologists are more likely to be skewed toward the “affiliated” than the “disaffiliated.” If so, the personal experience of such AMH skeptics may be dominated by the observation that they and their closest friends have generally coped well with any exposure to abortions.

Conversely, AMH proponents, especially those who directly meet and counsel women having problems dealing with past abortion 45 may have little or no experience with women who have had positive abortion experiences. The concentrated experience of meeting with scores or hundreds of women struggling with past abortions would understandably incline AMH proponents to believe that negative experiences with abortion are more common than positive ones. 146

In short, applying the general rule that people (including scientists) tend to look for and believe data that confirm their preconceptions, and are disproportionately skeptical of data that conflict with their preconceptions, both AMH skeptics and AMH proponents are at risk of preferentially interpreting their personal exposure to abortion’s risks and benefits as applicable to the general population.

While women having abortions will fall across the entire spectrum of risk factors, it is useful for this review to consider two hypothetical women at opposite ends of any risk-benefits analysis: (a) “Allie All-Risks,” the worst possible candidate for an abortion and (b) “Betsy Best-Case,” with no known risk factors:

• “Allie All-Risks” is 15 years old. A victim of verbal, emotional, and physical abuse, including three incidents of sexual molestation, she has low self-esteem with bouts of anxiety, depression, and suicidal ideation. While her parents are not regular churchgoers, she attended a Catholic grade school, believes in God, and believes abortion is the killing of a baby. She is not a good student and has no concrete career goals. She has always wanted to be a mother, loves babies, and fantasizes about how she will find fulfillment in giving the love to her children that she never received from her own mother. Given Allie’s yearnings for escape, acceptance, and true love, she is vulnerable to the seductions of a 22-year-old womanizer with whom she falls madly in love and aspires to a happy future. When she learns she is pregnant, her initial reaction is excitement. While not planned, the pregnancy is welcomed. She believes she can now start building a family with her lover. But this fantasy is immediately crushed when he tells her that they can’t afford it, that neither of them are ready for it, and that if she decides to continue the pregnancy, he will leave her. She feels she has no choice. She can’t imagine losing him. In addition, her parents would be furious and insist on an abortion, too. Allie’s initial excitement at being pregnant is replaced by despair. Indeed, given her need to please others, she gives in with barely a complaint. Her mild protests about “their choice” go unnoticed. The day of the abortion she whispers: “Good bye. I don’t want to do this to you. But I don’t have a choice.” Immediately after the abortion, Allie feels a mild relief that the dreaded procedure is now behind her and hopes her boyfriend will be content, but alongside that relief are feelings of emptiness and loss that seem to grow stronger with every passing week. She begins to have obsessive thoughts. Her baby is no longer in her body, but it is constantly in her thoughts.
• “Betsy Best-Case” is 32 years old. She has no history of mental illness and has a good family life. Her parents were both well-educated secularists. They preach education, hard work, and honest success as the only ethical standards Betsy needs to guide her. Betsy is popular, has many friends, and has always had high career aspirations, toward which, with grit, she has proudly made good progress. Even as a child, Betsy had little or no interest in being a mother. Married to her career, she now has even less interest in maternity. Having successfully used birth control since she was 15, when her mother got her an IUD, Betsy is shocked when she realizes she is pregnant. But contraceptive failures happen. Her decision to abort is immediate and made without any emotional conflict. When she flips through the state mandated informed consent booklet given to her at the abortion clinic, the pictures of developing fetuses have no effect. Betsy has seen similar photos many times in the past. She has a strong philosophical belief, based on years of engagement in minor abortion debates, that the value of being a “person” is not based on biological features but rather on the development of a psychological, purpose-filled, self-actualized human being far beyond anything to which a 9-week-old fetus could yet lay claim. Betsy is not surprised when her abortion is completed without drama or even a tinge of angst. She thinks of it rarely. The only negative feelings ever associated with it come when she hears the right of women to choose abortion attacked by self-righteous busybodies who should know better.

Hopefully, any reader can see and respect that the Allie and Betsy’s abortion experiences are very different. One is focused on her loss and the other on how her abortion helped her to avoid any loss. Given these differences, it would be unfair to them try to interpret their abortion experiences from within a single ideological framework. Similarly, the women who reside at different places along the wide spectrum between the extreme poles of Allie and Betsy are also very different and unique.

We will employ Allie and Betsy in our discussion later in this review. But for now, let them simply stand as examples of why AMH skeptics may, from personal experience, presume that Betsy is “typical” of abortion patients, while AMH proponents may presume that Allie is more “typical.” This difference in regard to how each side of the AMH controversy views the “typical” abortion patient is likely to impact how they interpret AMH research in their efforts to describe the experience of “most” women.

There are multiple pathways for AMH risks

Despite the convenience of standard diagnostic criteria, mental illnesses do not necessarily fit into neat, single classifications with distinct and exclusive symptoms arising from a single cause for each illness. 147 As noted in one review of the psychiatric complications of abortion,

A psychiatric complication is a disturbance that occurs as an outcome that is precipitated or at least favored by a previous event …. Every psychiatric outcome is of a multi-factorial origin. Predisposing factors including polygenic influence and precipitating factors such as stressful events are involved in this outcome; in addition, there are modulating, both risk and protective, factors. The impact of the events depends on how they are perceived, on psychological defense mechanisms put into action (unconscious to a great extent) and on the coping style. 18 (Emphasis added)

An abortion does not occur in isolation from interrelated personal, familial, and social conditions that influence the experience of becoming pregnant, the reaction to discovery of the pregnancy, and the abortion decision. These factors will also affect women’s post-abortion adjustments, including adjusting to the memory of the abortion itself, potential changes in relationships associated with the abortion, and whether this experience can be shared or must be kept secret. These are all parts of the abortion experience. Therefore, the mental health effects of abortion cannot be properly limited to the day on which the surgical or medical abortion takes place. The entirety of the abortion experience, including the weeks before and after it, must be considered.

Moreover, there is no reason to believe that there is a single model for understanding, much less predicting, all of the psychological reactions to the abortion experience. Miller alone identified and tested six models for interpreting psychological responses to abortion and concluded that

theoretical approaches that emphasize unitary affective responses to abortion, such as feelings of shame or guilt, loss or depression, and relief may be missing an important broader picture. To some extent what appears to happen following abortion involves not so much a unitary as a broad, multidimensional affective response. 148

The APA’s TFMHA proposed four models: (a) abortion as a traumatic experience, (b) abortion within a stress and coping perspective, (c) abortion within a socio-cultural context, and (d) abortion as associated with co-occurring risk factors. 7 Additional models could be built on biological responses, 149 , 150 attachment theory, 151 – 154 bereavement, 153 , 155 – 158 complicated, prolonged or impacted grief, 159 – 163 ambiguous loss, 156 , 161 , 164 – 167 or within a paradigm of psychological responses to miscarriage. 74 , 168 – 170

The complexity of considering so many models, or pathways, combined with the multiplicity of symptoms women attribute to their abortions, 45 contributes to discord in the literature produced by AMH proponents and AMH minimalists.

When there is no agreement on what outcomes are relevant or what theoretical pathways should be investigated, there are countless reasons to disagree about both (a) the adequacy of any specific studies and (b) how any specific set of findings should be best interpreted.

Women may simultaneously experience both positive and negative reactions

The act of undergoing an abortion can be both a stress reliever and a stress inducer. 171 It may relieve one’s immediate pressures and concerns while also leaving behind issues that may require attention immediately or at a future date. Positive and negative feelings can co-exist and frequently do. 38 , 39 , 48 , 50 , 166 , 172

In one study,

Almost one-half also had parallel feelings of guilt, as they regarded the abortion as a violation of their ethical values. The majority of the sample expressed relief while simultaneously experiencing the termination of the pregnancy as a loss coupled with feelings of grief/emptiness. 166

Another study found that 56% of women chose both positive and negative words to describe their upcoming abortion, 33% chose only negative words, and only 11% chose only positive words. 62 The women at greatest risk of experiencing negative reactions immediately and in the short term following an abortion are those who feel most conflicted about the decision to abort or have other pre-existing risk factors. 39 , 45 , 82 , 173

Applying this insight to our polar extremes, Annie All-Risks would be more likely to experience strong negative feelings more profoundly than her feelings of relief, whereas Betsy Best-Case would be more likely to focus on her relief than any doubts or reservations. Moreover, because Annie has low expectations for coping well (itself a TFMHA risk factor), she may be less likely to agree to participate in a follow-up study. The faster she can get out of the abortion clinic without talking to anyone, the better. Conversely, Betsy is confident that her decision is right and will improve her life and is therefore much more likely to participate.

What “most women” experience cannot be reliably measured

As will be further discussed later, the fact that positive and negative feelings can co-exist makes it difficult, and potentially misleading, to describe any single reaction to abortion as the “most common,” given the fact that (a) it is very rare for women to have a single reaction and (b) typically, over half of women asked to participate surveys regarding their abortion experiences refuse or drop out. Obviously, it is impossible to know what the most common reaction of women is based on surveys of only a minority of self-selected women.

This insight also underscores the difficulty of making any generalizations regarding prevalence rates from any study involving volunteer participation or questionnaires. Broadly speaking, there are three groups of women: (a) those with no regrets or negative feelings, (b) those with deep regrets and profound negative feelings, and (c) those with a mix of feelings, including contradictory feelings. As discussed above, the best evidence indicates that women with the most negative feelings are least likely to agree to participate in studies initiated at abortion clinics. But it also follows that women with no regrets are unlikely to be represented in studies of women seeking post-abortion counseling. Both of these factors underscore that it is impossible to accurately measure how “most” women react to their abortion experience when participation in research is voluntary.

The degree of reactions can widely vary and there is no reasonable cutoff for concern

Not all negative emotions constitute a diagnosable mental illness. Therefore, the fact that only a minority of women have diagnosable mental illnesses following abortion does not preclude the possibility that a majority experience negative emotional reactions.

Structured interviews of women who received abortions at participating clinics reveal that the majority report at least one negative emotion that they attribute to their abortions. 48 , 172 Given the relatively high rate of women refusing to participate in these follow-up studies, it is likely that the actual percentage of women having at least some negative reactions is well over half. 174 Similarly, retrospective questionnaires of women also reveal that over half attribute at least some negative reactions to their abortions. 50

The opinion that negative reactions are experienced by the majority of abortion patients is also shared by a number of abortion providers, such as Poppemna and Henderson: 175

Sorrow, quite apart from the sense of shame, is exhibited in some way by virtually every woman for whom I’ve performed an abortion, and that’s 20,000 as of 1995. The sorrow is revealed by the fact that most women cry at some point during the experience …. The grieving process may last from several days to several years.

Similarly, Julius Fogel, who as both a psychiatrist and OB-GYN and as a pioneer of abortion rights performed tens of thousands of abortion, testified that while abortion may be necessary and generally beneficial, it always exacts a psychological price:

Every woman—whatever her age, background or sexuality—has a trauma at destroying a pregnancy. A level of humanness is touched. This is a part of her own life. When she destroys a pregnancy, she is destroying herself. There is no way it can be innocuous. One is dealing with the life force. It is totally beside the point whether or not you think a life is there. You cannot deny that something is being created and that this creation is physically happening … Often the trauma may sink into the unconscious and never surface in the woman’s lifetime. But it is not as harmless and casual an event as many in the pro-abortion crowd insist. A psychological price is paid. It may be alienation; it may be a pushing away from human warmth, perhaps a hardening of the maternal instinct. Something happens on the deeper levels of a woman’s consciousness when she destroys a pregnancy. I know that as a psychiatrist. 176 , 177

This distinction between negative reactions and diagnosable mental illness is another important reason why AMH proponents and minimalists appear to disagree more than they really do. When AMH proponents make statements about “most women” which imply that negative reactions are common, they are including women who attribute any negative reactions to their abortions even if the reactions fall short of fitting a standard diagnosable illness. 45 Conversely, when AMH minimalists insist that “most women” do not experience mental illness due to their abortions, they are excluding the women who have negative feelings, even if unresolved and disturbing, on the grounds that (a) the symptoms do not rise above the threshold necessary to diagnose a clinically significant mental illness and (b) the symptoms cannot be strictly attributed to the abortion experience alone. 7

In short, if pressed, both sides would agree that the best evidence indicates that most women do experience at least some negative feelings related to their abortion experiences. Yet at the same time, the majority do not experience mental illnesses (as defined by standard diagnostic criteria) that can be solely attributed to their abortions.

This brings us to a more general problem regarding the claim that “the majority” of women experiencing relief following their abortions. 178 , 179 For women who do have strong negative feelings, such global denials of their personal experience may be demeaning. Even if these women’s negative reactions fall short of being classified as mental illnesses, it is reasonable for them to take offense at the AMH minimalist’s assertion that abortion does not involve any emotional risks, much less that the only women troubled by abortion are those who already had prior emotional problems. 180 In short, publicity suggesting that abortion has no psychological effects may have the unintended effect of making women who do struggle with a past abortion feel like “freaks” who are unable to handle their abortions as easily as “everyone else.” 45

Even if it could be proven that 99% of women who had abortions experienced more benefit than harm, that would still not justify ignoring the 1% who experienced more harm than good. Majorities matter in elections. But in regard to medical ethics and public policy, negative reactions are important among even a minority of patients … especially when it is possible to screen for risk factors that identify the patients at greatest risk of adverse reactions.

Negative reactions may manifest themselves over a very long time frame

Most studies can only capture evidence spanning very limited timeframes. In the 1960s and 1970s, most studies of emotional reactions after abortion were based on volunteer samples limited to a few hours, days, or weeks after the abortion. These studies typically found negative outcomes in the range of 10%–20% of their volunteer samples. Early reactions, however, are not necessarily predictive of longer range reactions. 38 Subsequent studies revealed that the percentage of women experiencing negative reactions increases with time, along with a significant drop in decision satisfaction and feelings of relief. 39 , 148

For example, in a study led by TFMHA chair Brenda Major, volunteers interviewed at an abortion clinic reported a significant decline in their Brief Symptom Inventory Depression scores 1–2 h after their abortions (T2, 62% decline) compared to their scores an hour before their abortions (T1, asking women to rate their depression for the month prior to the abortion). But at the 1-month follow-up (T3), depression scores rose 91% above their post-abortion (T2) score and continued to get higher, up to 118% at the 2-year follow-up (T4). 39 Notably, this study had a 30% dropout at the 1-month follow-up (T3) and a 50% dropout at the 2-year follow-up (T4). In addition, the self-selection bias of this volunteer sample was further magnified by the study protocol that also excluded women aborting an intended pregnancy or a second trimester pregnancy, two of the risk categories for elevated risk of negative reactions.

The fact that negative reactions may unfold over a long period of time is also evident from retrospective surveys. For example, one survey of women seeking post-abortion counseling found that only 24% claimed they had always been aware of negative feelings regarding their abortions. Of the remainder, less than half reported “doubts or negative feelings” within the first 3 years, while 100% were experiencing negative feelings by the time they sought post-abortion counseling. 45 A similar survey found that 70% of women seeking post-abortion counseling reported that there had been a time after their abortions when they would have denied having any negative feelings. 181 The first appearance of negative emotions may occur even as late as menopause. 182

It is likely that there are patterns relative to which women are at greater risk of experiencing early negative reactions and those who are likely to experience later reactions. Zimmerman, for example, found that 74% of “disaffiliated” women were struggling with negative thoughts about their abortions, three times the rate reported by “affiliated” women. 48 Thus, it is easy to predict that our archetype Annie All-Risks would likely be among those who would have immediate negative reactions. After all, she felt coerced into aborting an unplanned but welcomed pregnancy against her maternal preferences and moral beliefs. In addition, given her history of abuse and psychological problems, her coping skills were already stretched to the limit prior to her abortion.

Similarly, it is also easy to imagine that Betsy Best-Case would cope well in the immediate hours, days, months, and even years after her abortion. She freely chose to abort a pregnancy that was both unintended and unwanted for rational reasons. She also had strong coping skills and could easily compartmentalize any “socially induced” doubts into the “deeper levels” of her consciousness.

Clinical experience indicates, however, that there is no certainty that Betsy will always remain symptom free. Subsequent reproductive events such as miscarriage, infertility, or even a wanted birth may unexpectedly trigger existential crises deeply intertwined with a nearly forgotten abortion experience. 24 , 37 , 40 , 45 Similarly, life events that trigger introspection such as the death of a loved one, or a later religious conversion, may trigger a redefinition of past choices and experiences in a way that may include obsessive guilt and self-condemnation. 45 An example of a “perfect decision” being reinterpreted as a woman’s worst decision is found in this posting at a post-abortion counseling site:

I had an abortion when I was 22 years old. Now it is haunting me. I think about it every day of my life. I have so much regret. I wish I could turn the clock and undo my mistakes. I am not coping. The guilt is too much. At that time the decision was perfect. But now it kills me day by day. Please help me. I don’t trust anyone with this secret.

AMH minimalists might reasonably argue that it is the subsequent trigger, the miscarriage, or religious conversion, that is the “true cause” of later distress. But efforts to apportion blame for the “true cause” of distress over a prior abortion simply disrespects the real experience of women who seek, desire, or need post-abortion counseling. Whatever the trigger, whatever the contributing factors, the internal turmoil over a past abortion is centered on, or at least intertwines with, the abortion and will not be resolved by pretending the abortion is not part of the problem.

Based on reports of clinical experience, we would hypothesize that delayed reactions are most frequently triggered by (a) subsequent reproductive experiences, including reproductive difficulties and (b) experiences that lead to introspection and reevaluation of one’s overall life course or moral integrity. 45 Conversely, the more risk factors that are present, especially feelings of coercion and attachment combined with weakened coping skills, are predictive of more immediate negative reactions.

The great variability in the time frame for negative reactions greatly complicates the interpretation of studies examining limited time frames, and even those covering long time frames but at infrequent intervals. For example, two studies examined Center for Epidemiological Studies depression scores (CES-D) collected by the National Longitudinal Study of Youth (NLSY) an average of 8 years after an abortion. 69 , 86 But the NLSY was not designed to study reproductive or mental health and had a very high concealment rate regarding past abortions. Moreover, the single year in which depression was evaluated in the NLSY could only provide a bit of cross-sectional information about the women surveyed. While the passage of time may have helped to identify some delayed reactions, it would also miss cases where women have gone through a healing or recovery process during the 8 years (on average) for which there was no data. Moreover, the NLSY’s single measure for current depression, the CES-D, did not account for women who were being successfully treated for depression with medication.

In short, questionnaires which lack abortion-specific retrospective questions such as “Did you ever experience significant negative feelings about a past abortion?” followed by questions regarding the timeline for each type of mental health outcome being studied 45 , 50 , 183 are simply capturing cross-sectional data. Cross-sectional data regarding current symptoms will simply miss symptoms that have ceased, either due to medication, counseling, or by the healing effects of time or a replacement pregnancy. It will also miss symptoms that may be delayed beyond the date of the assessment. As a result, data from general prospective studies like the NLSY simply cannot tell us anything about the “true prevalence rate” of depression associated with abortion.

The weakness of such general purpose prospective studies also explains why AMH proponents and AMH minimalists can look at the same data and come to different conclusions. For example, the first analysis of NLSY CES-D scores relative to women with a history of abortion found that depression was highest among married women with a history of abortion (OR = 1.92; 95% CI = 1.24–2.97) and among women in their first marriage in particular (OR = 2.23; 95% CI = 1.36–3.74). 184 Since CES-D scores did not significantly vary among unmarried women, the combined results for all women (OR = 1.39; 95% CI = 1.02–1.90) were barely significant. 184 The significance of marital status may indicate that abortion-related depression after an average of 8 years may be triggered by subsequent pregnancies in marriage. In any event, given the weakness of this data set, it was a trivial matter for AMH minimalists 69 to use different selection criteria, excluding a subgroup of women at greatest risk of negative reactions to abortion, in order to shift the lower 95% CI for all women below 1 (OR = 1.19; 95% CI: 0.85–1.66) in their reanalysis of the NLSY data. Notably, their analysis also excluded results segregated by marital status, the finding most significant in the earlier study. Based on these weaknesses, it was simply misleading for Schmiege and Russo 69 to interpret their reanalysis as conclusive evidence that abortion does not contribute to the risk of depression in some women. Their overreaching conclusions were particularly unjustified in light of the fact that the NLSY data set was also tainted with a 60% concealment rate regarding past abortions 185 and the CES-D scale inquired about only depression in the prior week and was administered in only once, an average of 8 years after the abortions.

In summary, the efforts to estimate the prevalence rate of negative reactions to abortion are complicated by (a) the wide variety of reactions, (b) the existence of both early and delayed reactions, (c) a wide variety of triggers for delayed reactions, and (d) the prospect that in any assessment years after the abortion, a number of women who previously had significant reactions may have experienced full or partial recovery by the time of that assessment. Each of these factors would tend to skew the results of any prevalence estimates based on questionnaires toward underestimating the total lifetime risks.

Self-censure and defense mechanisms contribute to underreporting of sequelae

Data collected to investigate reactions to abortion may also be distorted by any number of defense mechanisms. Avoidance, denial, repression, suppression, intellectualization, rationalization, projection, splitting, and reaction formation may all contribute to the conscious or unconscious underreporting of symptoms attributable to unresolved abortion issues.

Active defense mechanisms are also the most likely explanation for selection bias and the high rate of concealing abortion history found in national longitudinal studies. Typically, respondents will report under half, and as few as 30%, of the number of abortions expected compared to age-adjusted national data on abortion rates. 106 , 185 , 186

In case series studies, where women are first contacted while at the abortion provider and asked to participate in a follow-up evaluation, both the initial refusal and subsequent dropouts usually exceed 50%. 39 , 187 In the Turnaway study, for example, only 37.5% of women asked to participate agreed, and of those who agreed 15% immediately dropped out before the first baseline interview, approximately 8 days after the abortion. 179 The study continued with phone interviews every 6 months for 5 years. Women were rewarded with a US$50 gift card each time they completed an interview. But despite this motivation, by the end of the 3 years, only 27% of the eligible women were participating, and this dropped to only 18% at the 5-year assessment. 188 Given this high rate of self-censure, the researchers’ conclusion that “Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years” 179 clearly overstates what the Turnaway data can actually reveal. Unfortunately, the authors’ overgeneralized conclusion inspired many newspaper headlines which definitively proclaimed that the overwhelming majority of women are glad they had their abortions. 178 , 189 But if the researchers’ conclusions had been more accurately narrowed to describe their actual pool of respondents, the abstract should have read, “Of the 27% of eligible women participating at a three year assessment, the overwhelming majority felt that termination was the right decision for them.” That single clarification would have helped even the most pro-choice reporter to recognize that the views of a self-selected minority of volunteers (27%) simply cannot tell us what the “majority of women” feel and think. What “most women” experience is simply unknown when the majority of women are refusing to share their thoughts and feelings at any given time.

Avoidance, and other defense mechanisms, clearly works. Research has shown that the subset of women who anticipate the most difficulty dealing well with their abortions are right; they do have higher rates of negative reactions. 56 It is therefore natural for women who anticipate more negative reactions to avoid follow-up surveys that may aggravate those negative feelings. Indeed, one reproductive history survey that included as the last query, “Answering this survey has been emotionally difficult or disturbing,” found that women admitting a history of abortion were significantly more likely to feel disturbed by participating in the survey. 183 This finding is especially important relative to research designs that rely on waves of multiple interviews over time. Clearly, women who feel more stress at one wave may be more likely to decline to participate again in subsequent waves.

These findings are consistent with studies showing that women refusing to participate in follow-up studies are likely at greater risk of negative reactions to their abortions. 174 , 190 While one study has asserted that the women dropping out are not significantly different than subjects retained, 39 this conclusion was based on demographic comparisons, not on comparison of the presence of risk factors that are more predictive of negative reactions. The authors’ refusal to allow reanalysis of their data 140 also diminishes the reliability of their conclusions.

Notably, the act of avoiding a post-abortion evaluation may itself be evidence of a post-traumatic stress response. A study of 246 employees exposed to an industrial explosion revealed that those employees who were most resistant to a psychological checkup following the explosion had the highest rates and most severe cases of PTSD. Without repetitive outreach and the leverage of an employer mandate for undergoing post-traumatic assessments, 42% of the PTSD cases would not have been identified, including 64% of the most severe PTSD cases. 191 In the subsequent clinical treatment of these subjects, the author noted that “In the clinical analysis of the psychological resistance [to the initial assessment] among the 26 subjects with high PTSS-30 scores, their resistance was mainly found to reflect avoidance behavior, withdrawal, and social isolation.” 191

Our understanding of defense mechanisms also suggests there may be cases where the denial of a link between abortion and abortion-specific symptoms is evidence of both avoidant behavior and an elevated risk of mental illness. It seems likely that defense mechanisms may contribute to a significant underreporting of negative reactions, especially in survey responses. Conversely, questionnaire-based reports may also lead to the exaggerated rating of some positive reactions due to splitting or reaction formation. In these cases, women trying to focus on the positive may respond in ways that may anticipate, or even inflate, the positive feelings they want to feel while “rounding down” negative reactions which they want to escape or deny.

The statistical impact of defense mechanisms is also double edged. First, self-censure, dropouts, and concealment of past abortions are all likely to suppress measurements of the prevalence rate of mental illnesses among those volunteers admitting to a past abortion. Second, comparison groups that include women who conceal their history of abortion (who are most likely to have AMH effects) are likely to have inflated prevalence rates for mental illness due to the misclassification of women with a history of abortion into the comparison group of women who, according to the study design, have not been exposed to abortion. 184 Both problems suggest that odd ratios and prevalence rates based on studies relying on voluntary self-reporting of abortions will most likely be skewed toward underestimating the true risks associated with abortion.

It is also worth noting that defense mechanisms may also impede the ability of women to receive good follow-up care. In a survey of women reporting that they sought post-abortion counseling from a psychologist, psychiatrist, social worker, or other professional counselor, 58% reported that the counseling was not helpful. 45 Many reported that their therapists simply refused to seriously consider abortions as significant. This phenomenon may be at least partially due to defense mechanisms employed by healthcare professional professionals themselves. Many therapists may have unresolved issues with their own history with abortions; others may be loath to reconsider the wisdom of their advice to previous patients, reassuring them that abortion was a good; still others may have ideological commitments to abortion rights which conflict with their ability to trust their patient’s self-assessments, and some may simply have an uncritical confidence in the widely spread, but exaggerated claim, that “there is no evidence that abortion has any mental health risks.” This is yet another reason why better research and training regarding how abortion may contribute to problems for “ at least some women ” is important to prepare healthcare workers to be more sensitive and open to providing informed care. 45

There is no perfect control group; yet all comparison groups provide insights

Since it is impossible to randomly assign women to different groups to be exposed to abortion or not, there are no true control groups in relation to abortion among humans. Given this limitation, comparisons to other groups of women who have not been exposed to abortion are the only option. While no comparison group is perfect, 192 – 194 nearly every comparison can be useful for teasing out patterns that may help to inform patients and caregivers regarding the many varieties of abortion experiences.

Comparisons have been made to each of the following: the general population of women, 77 , 195 women who have never been pregnant, 94 women with no reported history of abortion, 74 , 84 , 85 , 91 , 92 , 94 , 95 , 100 , 101 women giving birth, 30 , 69 , 71 – 73 , 75 – 77 , 81 , 83 , 86 – 90 , 94 , 97 – 99 , 102 women giving birth to a first pregnancy, 69 , 86 , 113 women having miscarriages or other involuntary losses, 81 , 88 , 91 , 94 , 195 – 197 women experiencing both births and pregnancy loss (abortions or miscarriages), 69 , 82 , 107 women giving birth to unintended pregnancies, 69 , 72 , 75 , 76 , 86 , 90 , 92 , 98 and women denied abortions. 179 , 198 Together, these findings show that women with a history of abortion are statistically more likely to experience significantly more mental health issues relative to every comparison group that has been examined.

Notably, most of these comparisons are based on general-purpose longitudinal cohort studies. As discussed previously, due to the temporal limits, cross-sectional data, self-selection bias, concealment, and the misclassification of women with an abortion history into the comparison groups, the results of these studies most certainly skew toward underestimating the true relative risks between the groups compared. Still, while every choice for a comparison group is imperfect, 192 , 193 below we will argue that there are valid insights that can be gained by every comparison. Acting on that premise, many researchers have chosen to simultaneously compare women who abort to multiple other groups whenever the data allow it. 72 , 88 , 92 , 94

By contrast, Charles et al., 6 have argued that the only “appropriate” comparison group for AMH studies is to women who have “unwanted deliveries.” But this argument is weak for three major reasons.

First, the efforts to define and evaluate what constitutes an “unintended” or “unwanted” pregnancy are themselves imprecise, rendering any study based on such a flawed definition imprecise. 15 , 199 Moreover, not intending to become pregnant at a particular time in one’s life is very different than not wanting a child. Indeed, over half of unintended pregnancies are carried to term, accounting for approximately 37% of all births. 200 Conversely, among women having abortions, the evidence suggests that between 30% and 63% of aborted pregnancies were intended, wanted, welcomed, or involved significant emotional attachment. 48 , 50 , 51 , 148 , 172 In short, both groups (women having abortions and women carrying unintended pregnancies to term) encompass a huge variation in intentionality, wantedness, and attachment to their pregnancies.

Second, as Romans 192 has convincingly argued, the differences in women who choose to carry an unintended pregnancy to term and those who abort are simply immeasurable. No conceivable comparison between the two groups can control for all the possible variations between them. Still, as both the TFMHA 4 and Fergusson et al. 193 have argued, even imperfect comparisons have and can continue to yield valuable insights regarding the differences between the women who cope well and those who cope poorly. While such findings cannot tell us what “most women” experience, they can tell us how different subgroups of women compare to each other. These findings are meaningful and actionable since they should be used to guide pre-abortion screening and counseling and post-abortion care 25 and for informed consent procedures. 23

Third, the argument for discounting studies that lack information on pregnancy intention appears to have been advanced primarily as an excuse to denigrate the majority of studies on AMH. This charge is supported by the fact the “quality scale” created by Charles et al. 6 required deducting two of the five possible quality points from any study using any control group other than women carrying unwanted pregnancies to term.

The highly biased and subjective application of Charles et al.’s quality scale is demonstrated by the fact that they rated studies published by AMH minimalists 69 , 92 , 201 using exactly the same national longitudinal data sets as AMH proponents 72 , 86 , 101 consistently higher in quality. Moreover, Charles et al.’s quality scale totally ignored the problem of high concealment, misclassification, and drop-out rates in the very same studies they rated as better. Thus, by ignoring issues related to selection bias, the Charles et al. contrived ranking scale identified just four studies as “very good”—even though three of these had concealment rates of 60% or higher, 185 and the fourth had a dropout rate of 65%. 76 Meanwhile, their skewed scale allowed them to rank as “poor” or “very poor” literally all record linkage studies, which by their nature have no concealment or selection bias , 81 , 87 , 89 , 97 , 196 even though these same studies revealed some of the strongest associations between AMH problems.

The fact that Charles et al.’s study quality scale was deliberately skewed to serve the AMH minimalists’ perspective is perhaps best demonstrated by the fact that when the very same record linkage studies rated as poor by Charles et al. are rated using the Newcastle-Ottawa Quality Assessment Scale (NOQAS) for cohort studies, 202 a standard and widely used assessment tool across all disciplines, all receive very high scores, 8 or 9, on the NOQAS 9-point scale for quality. 203

In response to Charles et al.’s argument that the only appropriate comparison group is to women carrying unintended pregnancies to term, the following arguments are made in defense of other comparison groups. I argue that, while no comparison is perfect, every option for a comparison group can be a useful tool in developing a multidimensional perspective on the complexity of AMH issues.

First, comparisons to women with a history of abortion and the general population of women provide a useful baseline, especially when combined with comparisons to women who miscarry or carry to term. For example, a record linkage in Finland revealed that the age-adjusted risk of death within a year of pregnancy outcome was 5.5 per 100,000 deliveries, 16.5 per 100,000 miscarriages, and 33.8 per 100,000 abortions, compared to 11.8 per 100,000 age-adjusted women years for the general population of women not pregnant in the prior year. 196 A similar record linkage study of the population of Denmark revealed a dose effect, with the risk of death increasing by 45%, 114%, and 191% with exposure to one, two, or three abortions, respectively. 112 Yet another record linkage study examining attempted suicide rates before and after pregnancies revealed declining rates of suicide attempts after both delivery and miscarriage, but a sharp increase in attempted suicide following abortion, as seen in Figure 3 . 81

Suicide attempt rates per 100,000 women before and after designated pregnancy outcome.

Source: Morgan et al. 81

Comparisons to women who have never been pregnant (nulligravida) are especially important when the aborting women have no live born children. 74 , 92 , 94 , 113 , 204 Indeed, this is an important comparison since an abortion of a first pregnancy is essentially an effort to return a woman to her never been pregnant state. Differences between childless women with a history of one or more abortions and those without any history of pregnancy may provide valuable insights into the effects of an interrupted pregnancy on women’s emotional and physical health.

Another important comparison is between women who have induced abortions and women who miscarry. Both have experienced the effects of pregnancy, which may produce long-lasting changes to the brain, 150 , 205 , 206 and maternal attachment. 151 , 152 , 154 , 207 While the physiological processes of natural miscarriage and induced abortion are different, there may be similarities in the recovery process. Moreover, this comparison may allow insights into the psychological differences between intentionally choosing the end of a pregnancy versus an unintended loss, both of which may be experienced as a form of disenfranchised grief. 45 , 161 Arguably, examining the differences between miscarriage and abortion may be the most relevant and important comparison. 203

Comparisons to women giving birth are also meaningful. Just as a comparison to a never pregnant woman attempts to estimate how closely induced abortion achieves the goal of “turning back the clock” to the point before the woman became pregnant, a comparison to a delivering woman seeks to estimate how a woman’s mental health would fare if she chooses to “move into” the group of women giving birth.

Comparisons between women aborting a first pregnancy and women carrying a first pregnancy to its natural conclusion (birth, miscarriage, or neo-natal loss) are extremely valuable. By excluding the confounding effects of multiple pregnancy outcomes, these studies offer at least a small window on the effects associated with exposure to a single pregnancy outcome. Moreover, they are the proper starting point for investigating the interactions between multiple pregnancy outcomes. This is important since significantly different outcome patterns have been observed relative to multiple pregnancy outcomes and their sequences, including both multiple losses and losses followed or preceded by live births. 88 , 94

While comparisons of first pregnancy outcomes are valuable, it should be noted that it is a very poor methodological choice to include in the group of women experiencing a “first live birth” women who are known to have had one or more abortions before their first live birth or between the birth and the date of the mental health assessment. 69 , 107 Unfortunately, these flawed studies 69 , 82 , 107 , 208 – 210 ignore the extensive evidence showing that a history of pregnancy loss (abortion or miscarriage) is associated with higher rates of mental health problems during subsequent pregnancies. 78 , 80 , 99 , 100 , 170 , 211 – 226 By adulterating the “control” group of women having a “first live birth” with women who also have a history of one or more abortion and/or miscarriages, the resulting analyses clearly confound rather than clarify the differences between abortion, miscarriage, and childbirth, shifting the known negative effects associated with prior pregnancy losses into results associated with a first childbirth. 69 , 82 , 107 , 208 – 210 Arguably, this confounding methodology has been specifically employed by AMH minimalists precisely with the intent of producing results that obfuscate the mental health effects associated with abortion while inflating the effects associated with childbirth. 141 , 227

As will be discussed further, we recommend that the best practice for all studies examining the interactions between mental and reproductive health is to include stratification of results by the order and number of exposures to births, abortions, miscarriages, and other pregnancy losses. 94 , 141 , 227 Otherwise, the effects of different pregnancy outcomes are likely to be obscured rather than clarified.

In addition, we would note that the argument of Charles et al. for discounting studies that lack controls for pregnancy intention may do a major disservice to both women considering abortion and their caregivers. For all the reasons given above, the best evidence indicates that reasonable patients may consider any and all of the comparisons discussed above to be of value in their efforts to evaluate the potential risks and benefits of an abortion in their own personal circumstance 23 , 25

Finally, it has been argued that the differences between women who abort and those who do not are so extreme that the only meaningful comparison is between women who abort and women who sought but were denied an abortion. 194 While this comparison might be informative, it is clearly not a perfect comparison since the reasons why women may end up being denied an abortion are also likely to make these women significantly different than the average woman seeking and obtaining an abortion. Moreover, since in most countries where abortion is legal, very few women are denied an abortion undertaking such studies may be impractical. Indeed, the only set data set using this control group is the so-called Turnaway Study. Indeed, the argument that this is the only valid comparison group appears to be made in an attempt to dismiss all other research in favor of this single data set. But there are many problems with the Turnaway Study data set. 198 The most damning is the problem of self-censure. Over 70% of women approached to participate in this study refused, even after they were promised payments for participating, plus, nearly half of those who did participate subsequently dropped out. 198 This high refusal rate alone renders the Turn-Away Study data meaningless in terms of drawing any conclusions regarding the general population of women seeking or having abortions, and that is just one of many major flaws in the Turnaway Study methodology and execution. 198

Poorly defined terms produce misleading conclusions: unwanted, relief, and more

Unfortunately, a great deal of the literature on AMH revolves around poorly defined terms. The resulting lack of precision and nuance contribute to AMH minimalists and AMH proponents talking past each other and contributes to overgeneralizations regarding research findings, especially in the press releases and position papers of pro-choice and anti-abortion activists.

As previously discussed, one common overgeneralization is the assertion that abortions typically involve “unwanted” pregnancies. A closer look, however, reveals that many aborted pregnancies, perhaps the majority, occur for planned, partially wanted, or initially welcomed pregnancies. 48 , 50 , 51 , 148 , 172 By “welcomed” pregnancies, I mean pregnancies which were not planned in advance but to which the woman was open or naturally inclined to accept and embrace if only she had received the support of her partner, family, or others. 45 , 181 , 228

Attempts to define “unwanted” pregnancies are also complicated by the fact that many women report a divide between their emotional and intellectual responses when they first discover they are pregnant. Emotionally, they may be excited that a new life is growing inside them and may fantasize about having the child. But at the same time, their logical side may be immediately convinced that abortion is their only pragmatic choice. 45 The pregnancy may therefore be simultaneously “emotionally wanted” and “logically unwanted.”

Based on both clinical experience and case series studies, 173 we hypothesize that many delayed reactions to abortion stem from the psychological conflicts that arise when emotions are suppressed in favor of pragmatic choices. In such cases, forward-looking women with strong defense mechanisms are likely to cope well with their choice for many years. But if this coping is achieved by suppressed emotions, this may consume energy and may even fuel maladaptive behaviors, like substance use and sleep disorders. Any connection between these symptoms and underlying abortion associated conflicts may not be recognized until some subsequent event or stress compels a reexamination of unresolved maternal attachments or the woman’s moral priorities.

One measure of openness to having a child, seldom addressed in AMH studies, is desire for children at some later date. A high level of desire for future children suggests that an aborted pregnancy was most likely problematic due to specific circumstance or lack of sufficient social support. Among a sample of women seeking counseling for post-abortion distress, 64% felt “forced by outside circumstance” to have an abortion and 83% indicated they would have carried to term if significant others in their lives had encouraged delivery. 181 While statistics gathered from women contacting post-abortion recovery programs may be not representative of the general population of women, these findings demonstrate that labeling these aborted pregnancies as “unwanted” does not reflect the experience of the women who subsequently do seek post-abortion help.

Given the wide variation in levels of intention or openness to pregnancy, much more extensive data on intention 199 , 228 and attachment 207 are required to draw any conclusions regarding the mental health effects of abortion relative to various levels of women’s attachment, intention, and outcome preferences.

A second poorly defined variable is “relief.” AMH minimalists have frequently asserted that the most common reaction to abortion is relief. 4 But “relief” is a very broad term. A woman reporting “relief” may be referring to (a) relief that she will not have a baby, (b) relief that a dreaded medical procedure is now behind her, (c) relief that her parents will not discover she was pregnant, (d) relief that her partner will finally stop harassing her to have an abortion, or (e) any number of other reasons for feeling a reduction in stress.

But as indicated earlier, abortion can be both a stress reliever and a stress creator. The many declarations by AMH minimalists that “relief” is the most common reaction to abortion tend to distract the public from the fact that the vast majority of women reporting relief are also reporting a host of negative feelings at the same time. 39 , 50 , 62

Similarly, claims that “the most common reaction” to abortion is relief is also misleading because it falsely suggests that a truly representative sample of all women having abortions have been queried about their most prominent and common reactions. But in fact, all the case series studies assessing “relief” have self-censure and dropout rates exceeding 50%. 39 , 59 When only a minority of women agree to report on their reactions to an abortion, these studies cannot reliably tell us anything about the majority of women. This is especially true if the self-selection bias is toward women who expect to feel more relief because their abortion decision is more consistent with their own desires and preferences, while those who refuse to participate anticipate and do experience more negative reactions. 174 , 190 , 191

Another misleading factor is that relief is most often reported as a single variable whereas negative reactions are often averaged together. For example, one of the most frequently cited case-series reporting that women felt “more relief than either positive or negative emotions” was based on comparing the results of a single question regarding relief to an average of six scores (“sad,” “disappointed,” “guilty,” “blue,” “low,” and “feelings of loss”) chosen to represent negative emotions and an average of three scores (“happy,” “pleased” and “satisfied”) chosen to represent positive emotions (excluding relief). 39 This methodology was highly problematic.

While it would be interesting to see score distributions for each reaction separately, 45 how can a variety of emotions be “averaged” together in any meaningful way? For example, if a score of 1 (corresponding to “not at all” on the Likert-type scale used) is equivalent to 0% of the relevant emotion and a 5 (“a great deal”) is 100% of that emotion, averaging six emotion scores together presumes that a rating of 3 (50%) for “disappointed” is truly equivalent to twice a rating of 2 (25%) for “feelings of loss” and half the value of a rating of 5 for “guilty.”

But what makes this averaging process even more suspect is that the least common negative reaction (“disappointed,” perhaps) would dilute the entire average of negative reactions, concealing the frequency of the more common reactions (“guilty,” perhaps). Most importantly, while the most common negative and positive reactions were diluted by this “averaging” process, the “relief” score was not subject to the dilution by averaging with any of the other positive emotions.

Yet another problem with the authors’ conclusion 39 was their presumption that the six negative reactions they asked about are actually the most common negative reactions. But three of the six negative reactions (“sad,” “blue,” “low”) appear nearly synonymous. The similarity of these three may have been deliberate in order to boost the reliability score for the authors’ scale. One of the remaining choices, “disappointed,” is simply odd, rather bland, and perhaps disinviting as it is not a term that has been reported in interviews with women reporting negative reactions to abortion. 45 , 172 , 173 , 181 While the assessments of “guilty” and “feelings of loss” were appropriate, it would have been more illuminating to report these separately rather than in an “average” of negative emotions.

In any event, averaging emotion scores is problematic and in this case the choice of the six negative feelings chosen to be averaged together failed to include many of the negative emotions most commonly reported in surveys of the women who seek post-abortion counseling, including sorrow, shame, remorse, emptiness, anger, loneliness, confusion, feigned happiness, loss of confidence, and despair. 45

Despite the many limitations regarding the claim that “relief” is more common than negative reactions, it is notable that the same researchers also found that between the 3-month and 2-year post-abortion assessments, both relief scores and positive emotions decreased significantly while the average for negative emotions increased. 39 In other words, even with a self-selected sample of women most likely to have more positive reactions, those positive emotions declined and negative emotions increased within the first 2 years. If that trend continued over 20 years, the finding that the “most common reaction” to abortion was relief may not have held up over a longer period of time.

Similar problems apply to the widely reported claim that most women are satisfied with their decisions to abort. 179 In this case, the self-selection bias was profound, with only 27% of the eligible women participating at the date of their first assessment. In addition, this “finding” was based on a binary yes or no response to a single question: “Given your situation, was your decision to have an abortion right for you?” This question clearly invited reaction formation and splitting. Additional questions, such as, “If you had received support from others, would you have preferred to have carried to term?” would have provided deeper insight into the participants’ true preferences.

Despite the problems with their methodology and self-selected sample, these researchers’ confident assertion that the vast majority of women are satisfied with their abortions generated bold headlines. 189 But these misleading headlines were clearly based on poor science. 198 Similar questions, posed to a different self-selected sample of women seeking post-abortion counseling, reveal that 98% of that sample of women regret their abortions. 45 These resuts are contradictoruy because neither of the two samples just cited represent the general population of women having abortions. Given the fact that so many women refuse to respond to questionnaires about their abortions, it is impossible to ever be certain what “the majority” of women feel or think about their past abortions at any given time, much less through their entire lifetimes.

If there is any consistency in the evidence, it is in regard to the finding that satisfaction declines and regrets increase over time. 38 , 39 , 45 Therefore, the existing data for claims regarding high levels of relief and decision satisfaction are highly questionable in the short term and meaningless in regard to predicting feelings in the long term.

Is abortion the sole cause, a contributing cause, or never a cause of mental health problems? Or is this question just a distraction from helping women?

Normally, the burden of proving that any proposed medical treatment produces real benefits which outweigh any risks associated with the procedure falls on the proponents of the treatment. 229 Indeed, proponents of a treatment are also tasked with the obligation of proving not only specific benefits but also with identifying the symptoms and circumstances for which the treatment has been proven to be beneficial and those cases for which it might be contraindicated. After all, no treatment is a panacea. Even highly successful elective treatments such as Lasik are contraindicated for 20%–30% of patients considering the surgery. 230

Evidence-based medicine is centered on the idea that there must be real evidence of benefits that outweigh the risks associated with a medical intervention. But there are no statistically validated medical studies showing that women facing any specific disease or fetal anomaly fare better if they have an abortion compared to similar women who allow the pregnancy to continue to a natural outcome. 17 , 231 , 232 Nor is there evidence of any mental health benefits. 17 , 25 As a result, in approaching a risk–benefits assessment, there are literally no studies to place in the benefits column of an evidence-based risk–benefits analysis. Conversely, there are literally hundreds of studies with statistically significant risks (both physical and mental) associated with abortion which must be considered in weighing abortion’s potential risks against the patient’s hoped for benefits. 11 , 112 , 113 , 232 , 233 See, for example, the references to Table 1 .

In this regard, induced abortion is an anomaly. It is the only medical treatment for which the principles of evidence-based medicine are routinely ignored, not for medical reasons, but by appeals to abortion being a fundamental civil right 135 or a public policy tool for population control. 25 From these vantage points, there has arisen an a priori premise that abortion should presumed to be safe and beneficial. Therefore, according to defenders of abortion, the burden of proving the safety and efficacy of abortion is no longer on them. Instead, abortion skeptics must prove that abortion is the sole and direct cause of harm to women—and not just a few unfortunate women, but a large proportion of women. 4 , 6 , 57

This difference in evaluating abortion compared to other medical treatments was at the center of a Planned Parenthood suit challenging a South Dakota statute requiring abortion providers to inform women of research regarding psychological risks associated with abortion. Abortion providers argued that there was not yet enough proof that abortion was the “direct cause” of the statistically significant higher risks of mental illness, including suicide, following abortion. Therefore, they argued, disclosing the findings of these studies to women might unnecessarily frighten their patients. 234 But the Eighth Circuit United States Federal Court of Appeals rejected Planned Parenthood’s argument, ruling that it was a standard practice in medicine to “recognize a strongly correlated adverse outcome as a ‘risk’, even while further studies are being conducted to investigate which factors play causal roles.” 234 The court went on to add that Planned Parenthood’s “contravention of that standard practice” had no legal merit since “there is no constitutional requirement to invert the traditional understanding of ‘risk’ by requiring, where abortion is involved, that conclusive understanding of causation be obtained first.” 234

This appellate court’s ruling is consistent with idea that “risk,” by definition, includes uncertainty—otherwise, it would not be a “risk” but rather a “certainty.” Therefore, the question of whether a statistically significant risk is solely due to abortion, partially due to abortion, or only incidentally associated with abortion is itself just another of the uncertainties about the procedure, and therefore a true risk about which patients should be informed. 25

The court’s decision favoring disclosure of all risks, even when causality is challenged by proponents of the procedure, is in line with the preferences reported by 95% of women considering elective medical procedures, to be informed of “all possible complications.” 23 From a feminist perspective, the right of each individual woman to evaluate for herself whether a statistically significant risk is incidental or causal would also appear be central to the protection of each woman’s personal liberty. Indeed, the United Nation’s Fourth World Conference on Women’s Declaration and Platform for Action, which specifically addressed the issue of unsafe abortions, urged every government to

Take all appropriate measures to eliminate harmful, medically unnecessary or coercive medical interventions, as well as inappropriate medication and over-medication of women, and ensure that all women are fully informed of their options, including likely benefits and potential side-effects, by properly trained personnel. 235 (Emphasis added)

For the reasons above, the claim that the higher incidence rates of mental health problems associated with abortion are most likely “spurious” 105 has no bearing on informed consent. Only after full disclosure can each patient judge the relevance of such information for herself.

These challenges are also irrelevant to the obligation of the treating clinician to screen for the risk factors associated with higher rates of negative outcomes associated with abortion. 23 , 25 After all, even if abortion proponents could prove that 100% of all the negative effects associated with abortion are causally due to common risk factors, the finding that abortion is consistently associated with higher rates of mental health problems 15 , 57 , 82 , 89 , 94 is still an actionable marker that can and should be used to identify women who may benefit from referrals for additional counseling. 26 , 27 , 30 , 32 – 34 , 36 – 39

Still, the question of causation is worthy of additional attention. One approach for judging causality is to apply the nine criteria Bradford-Hill proposed to identify the causal role that occupational and lifestyle factors may play in the development of diseases, such as cancer. These include temporal sequence, strength of association, consistency, specificity, biological gradient (dose–effect), biologic rationale, coherence, experimental evidence, and analogous evidence. 236 Applying the Bradford-Hill criteria to the AMH question, Fergusson, a pro-choice proponent, concluded that “the weight of the evidence favors the view that abortion has a small causal effect on the mental health problem.” 75

It should be noted, however, that the Bradford-Hill criteria were developed to evaluate contributing factors for physiological diseases. Bradford-Hill therefore ignored a type of evidence for causality which is unique to psychological diseases, namely, self-aware attribution of causal pathways. For example, the evidence of a woman who says, “After the death of my child, I drank more heavily to dull the pain,” is a conscious identification of cause and effect regarding her own mental state and behaviors.

Indeed, in the psychological sciences, it has been a traditional practice to begin any investigation of mental illness by first listening to those individuals who claim they have a psychological problem. After carefully listening to a “sick” population, psychologists can then map the range of reported symptoms and then build hypothesis regarding the contributing factors and causal pathways which can then be explored by surveys of the general population. This was the approach AMH proponents used in their initial investigations of women seeking post-abortion counseling. 45 , 171 , 181 Because these samples were based on women experiencing post-abortion issues, they were likely skewed toward the Allie All-Risks archetype. Still, because they were focused on developing a profile of the women having post-abortion issues, this was a valid starting point for identifying the most common complaints and recurring patterns.

By contrast, most AMH minimalists have tested their hypotheses using surveys of women contacted at abortion clinics. These survey instruments appear to have been developed with little or no attention to the complaints of the women who reported post-abortion mental health crises. Moreover, because these surveys are implemented in cooperation with abortion providers, in a stressful situation during which less than half of the women agree to participate, it is likely that these self-selected samples skew toward the Betsy Best-Case archetype. 39 , 237

Even though AMH minimalists and proponents approach their research from different perspectives, the results from both sides consistently show that at least a minority of women experience mental health problems that they attribute, at least in part, to their abortions. While not included in the Bradford-Hill criteria, when it comes to mental health issues, the fact that so many intelligent, self-aware women attribute specific patterns of emotional distress to their history of abortion is one of the strongest pieces of evidence that abortion directly contributes to mental health problems. The same is true with regard to mental health associated with miscarriage. The validity of this evidence is further strengthened by the professional assessment of both pro-choice therapists 40 – 44 and pro-life therapists 45 – 47 who also attest to the causal connection.

Similarly, the clinical evidence that women struggling with post-abortion mental health issues improve following treatment focused on their abortion loss 40 , 46 , 238 – 240 also supports the conclusion that abortion can cause, trigger, or exacerbate psychological illness. After all, a successful treatment is evidence in favor of a correct diagnosis.

As previously noted, self-attribution is not perfect evidence. Defense mechanisms often operate by obscuring the “true cause” of one’s mental distress. But we would argue that the bias of defense mechanisms would be toward underreporting of effects truly associated with an abortion rather than toward false attribution of unrelated effects to past abortions.

That is not to say that pre-existing mental health issues cannot become intermingled with an abortion. To the contrary, clinical experience shows that abortion can become such a significant stressor in a woman’s life that other pre-existing issues can become enmeshed in the abortion and its aftermath. Pre-existing substance abuse, for example, may become intensified in the abortion aftermath, but it would be a self-deception to blame the abortion entirely for such substance abuse. On the contrary, once the issues become intermeshed, progress in dealing with underlying issues will be hindered by a failure to address the intermingled abortion issues.

Similarly, even in cases where suicide notes specifically attribute a woman’s final act of despair to her recent abortion, 241 other pre-existing factors may also contribute to these tragedies. In short, while it would be absurd and insulting to deny that abortion at least contributes to such suicides, it would be a mistake to assume that abortion is the sole cause of suicide or any other specific mental illness.

As stated previously, abortion does not occur in isolation from interrelated personal, familial, and social conditions that influence the experience and mental health of each individual. Moreover, there are likely a multiplicity of different pathways for effects to manifest either in the near or longer term. 18 In general then, abortion is most likely a contributing factor to the manifestation of problems rather than the sole factor . It may be trigger latent issues, intensify or complicate existing issues, interact with pre-existing issues to create new issues, or contribute in any number of ways unique to any particular individual’s susceptibilities and prior and subsequent life stresses.

In summary, there is incontrovertible evidence that abortion contributes to mental health problems, both directly and indirectly. Based on reports of clinical experience, it would appear that abortion can be the primary cause for mental health issues in some women. But it may also trigger, intensify, prolong, or complicate pre-existing mental health issues. Still, for the sake of argument, assuming AMH minimalists are right in their assumption that abortion itself is never the “sole cause” of mental health problems, there is still no reasonable doubt that abortion contributes to mental health issues in some women.

Finally, it should be emphasized that the difficulties involved in proving causality cut both ways. The burden of proving the efficacy and safety of abortion falls on abortion providers. To date, they have failed to provide any evidence, much less proof, that abortion is the sole and direct cause of any health benefits for women in general, or even for specific subgroups of women. 193 , 232 Nor have they shown that the benefits women hope to obtain through abortion are proportionate to or greater than the significantly elevated rates of negative outcomes associated with abortion. In this regard, abortion continues to be an experimental treatment, one for which they hoped for benefits are unproven. And with no proven benefits, the risks–benefits ratio is unknown even for those women without any known risk factors.

Is it reasonable to attribute all negative effects to pre-existing factors?

There is no longer any dispute regarding the fact that, on average, women with a history of abortion have higher rates of mental illness compared to similar women without a history of abortion. But AMH minimalists frame this admission in the context of arguing that this is most likely due to pre-existing mental health issues. 5 , 6 , 242 In other words, they argue that a higher percentage of aborting women were “already emotionally broken” to begin with. Therefore, higher rates of mental illness following abortion are just a continuation of pre-existing mental frailty.

This argument is indistinguishable from the centuries-old accusation of personal defects applied to “hysterics,” “malingerers,” “cowards” and others who exhibit traumatic reactions. 45 , 243 This blame-their-weakness argument is just a corollary to the assertion that higher quality, more emotionally stable people simply do not break under such circumstances.

In courtrooms, this line of arguments is known as the thin skull, or eggshell skull, defense. It asserts that a defendant should not be held accountable for injuries that would not have been suffered if the plaintiff had not been predisposed to injury due to pre-existing physical or emotional defects. Notably, the thin skull defense has been rejected in most legal jurisdictions. Even if the damages of the “frail” plaintiff are greater than they would be for a healthier person, jurists have ruled, the defendant is still liable for the greater damages because

a defendant who negligently inflicts injury on another takes the injured party as he finds her , which means it is not a defense that some other person of greater strength, constitution, or emotional makeup might have been less injured, or differently injured, or quicker to recover. 244 (Emphasis added)

Applying the thin skull legal analysis to abortion, this means that a physician who fails to screen for known risk factors, such as prior mental illness, before recommending or performing an abortion is guilty of negligence if the woman suffers any subsequent mental health problems because it is precisely the obligation of the physician to treat the woman “as he finds her.”

In short, the argument that negative effects may be mostly due to pre-existing mental health problems simply strengthens the argument for better pre-abortion screening for this and other risk factors. 12 , 25 , 26 , 32 Conversely, it does not at all support the presumption that abortion is safe or likely beneficial to most women, much less all.

The “broken women” argument has also been used by AMH minimalists to argue that the emotionally fragile women having abortions would most likely face as many or more mental health problems if they were denied abortion. 245 But again, this argument is based entirely on conjecture. While only a few studies have examined the mental health of women denied abortions, none have found any significant mental health benefits compared to other groups of women. 76 , 188

Still another AMH minimalist argument is that women with prior mental illness may instinctively know they are less likely to cope well with an unwanted pregnancy, so the higher rate of abortion among women with mental illness is actually a sign of these women choosing abortion wisely. 106 , 107 Again, this is entirely speculation. It ignores the likelihood that mentally ill women, especially those with a history of being abused, may simply be more susceptible to being pressured into unwanted abortions 45 like Allie All-Risks. Moreover, it ignores the ethical obligation of caregivers to discourage, rather than enable, patterns of behavior that may be self-destructive.

Rather than just assume that mentally ill women are wisely inspired to choose abortion more often than mentally healthy women, would it not be best to screen women seeking abortions for mental illness so women can be counseled in a manner that more fully addresses their needs in the context of their mental illness? 25 , 36 As previously noted, while abortion may relieve some stresses, it may also create new ones.

Moreover, bearing children may actually contribute to mental health improvements through direct biological effect, 150 , 205 , 206 by expanding and strengthening interpersonal relationships with the child(ren) and others, 151 , 152 , 154 , 207 or by behavioral adaptations that may replace risk-taking with self-improving behaviors. These benefits may also apply to bearing unplanned children. Indeed, given how common unplanned pregnancies are throughout the millennia, it could be argued that female biology has evolved mechanisms in order to adapt and adjust to unexpected pregnancies.

In short, the argument that higher rates of mental illness following abortion are simply due to mentally ill women being wise enough to choose abortion more often is simply not supported by any statistically validated research. Instead, the opposite argument, that giving birth is more likely to produce mental health benefits, is more plausible and better supported by actual data.

It should also be noted that while we are aware of only one record linkage study examining mental health effects for women without any history of mental health issues , that study (by AMH minimalists) revealed that a history of abortion was associated with a significantly increased risk (risk ratio (RR) = 1.18; 95% CI = 1.03–1.37) of postpartum depression after a first live birth. 80

Closely related to the pre-existing mental illness issue is the finding that women with a history of abortion also have higher rates of abuse and violence in their lives. According to this argument, violence 106 , 110 or childhood adversities, 106 not abortion, are the most likely cause of higher rates of mental illness among women with a history of abortion. This hypothesis is contradicted, however, by studies which have shown that there are higher rates of mental illness associated with abortion even after controlling for violence. 94 , 109 More importantly, it is a mistake to engage in either/or arguments; a both/and approach is both more likely and more productive. Clearly, a history of abuse contributes to a heightened risk of both pregnancy and abortion, especially abortions to satisfy the demands of others. At the same time, clinical experience reveals that issues related to abuse and abortion can become deeply entangled. Efforts to treat based on an either/or attribution are most likely to be frustrated. Progress is most likely to be made when both the abuse and abortion experiences are holistically addressed. 45

While it important to study the interactions between exposure to violence and abortion on mental health, it is also important to consider that there may be two-way interactions. Surveys of women entering into post-abortion counseling reveal high percentages reporting elevated feelings of anger (81%), rage (52%), more easily lost temper (59%), and more violent behavior when angered (47%) following their abortions, which can obviously increase incidence rates of subsequent intimate partner violence. 45 Moreover, in the same sample, in which 56% reported suicidal feelings and 28% reported attempting suicide (with over half trying more than once), there are case studies of women “pushing the buttons” of a violent partner because they believed they did not “deserve to live.” 45 This escalation of violence following abortion may help to explain the elevated rate of homicide among women with a history of abortion. 88 , 232 , 246 For these reasons, given the multiple pathways for interactions between abortion and violence, studies that fail to distinguish between violence before and following abortion are methodologically flawed. 110 , 247

While prior abuse and mental health problems receive the most blame for why women with a history of abortion have higher rates of mental illness, a few AMH minimalists insist that the blame for mental illness following abortion can always be shifted to other risk factors. 248 For example, when Steinberg et al. 30 found that substance abuse rates were significantly associated with abortion even after controlling for dozens of other risk factors, they dismissed their own findings with the assertion that these effects are most likely due to as yet unidentified common risk factors.

In response, AMH proponents argue that (a) the burden of proving safety and effectiveness is on the proponents of a medical treatment and (b) given the weight of the evidence, it is far more logical to accept that abortion is at least a contributing factor that may work in concert with any number of other contributing factors.

In addition, denying that abortion directly contributes to mental health problems is illogical given the fact that so many of the risk factors identified by AMH minimalists themselves (see Table 1 ) are specifically part of the abortion experience. These include feeling pressured to abort by others; negative moral views of abortion; low expectation of coping well after an abortion; ambivalence about the abortion decision; and feelings of attachment or commitment to a pregnancy that is meaningful or wanted. 25 , 35 , 249

In other words, given what we know of the risk factors associated with mental illness after abortion, many of them are directly enmeshed in the abortion experience; they are not fully independent of the pregnancy and abortion experience. Therefore, even to the degree that mental illnesses can be associated with common risk factors for both unintended pregnancy and abortion, such as a history of sexual abuse, the intermeshing of elevated risk for pregnancy, abortion, and mental health issues precludes the conclusion that abortion does not contribute in any way to the observed problems. The only support for that argument comes from ideology, not from any statistically validated studies. For example, an incest victim may be at greater risk of a high school pregnancy with the first boyfriend that she imagines will be able to free her from an abusive step-father. 250 She may also be at greater risk to being pressured into an unwanted abortion. While it would be a mistake to blame the abortion for all of her subsequent mental health problems, even if a subsequent suicide note focuses on the abortion, it is ludicrous to assert that her abortion did not contribute to her problems. Moreover, it is also evident that the failure of healthcare providers to identify the risk factors that made her a poor candidate for abortion missed an opportunity to assist her in using her pregnancy to break a cycle of exploitation and trauma.

Finally, it should be noted that AMH minimalists frequently cite studies showing that women who deliver an unintended pregnancy have more subsequent problems than women who only have intended pregnancies. 248 From this base of evidence, they argue that since women who deliver unintended pregnancies have more problems, with mental health and otherwise, it follows that access to abortion helps to reduce the problems associated with unintended pregnancies. But this argument falsely presumes that abortion puts women who have unintended pregnancies back into the category of women who have never had an unintended pregnancy, and that all intended pregnancies are carried to term. But there are not just two groups: (a) women with “perfect” reproductive lives and (b) women with a history of unintended pregnancies. There is a third group, (c) women who have had abortions, who may fare worse than either of the other two groups.

While AMH proponents do not dispute that on average women with unintended pregnancies may face more problems than women who have perfect reproductive lives, it appears likely that they still have fewer problems than women who abort. Indeed, as previously discussed, not a single study has found evidence that the mental health of women who deliver an unintended pregnancy is worse than that of women who have abortions. 69 , 72 , 75 , 76 , 86 , 90 , 92 , 98 , 188 To the contrary, the only statistically significant findings indicate that women who abort are likely to have more mental health problems than those who deliver their unintended pregnancies. 17

The controversy over abortion related PTSD is more political than scientific

AMH minimalists often reserve the greatest scorn for statements made by AMH proponents that abortion can be a traumatic experience that may contribute to PTSD. 4 , 251 , 252 But this opposition seems to be driven more by a desire to silence abortion skeptics than to honestly report on the connections between abortion and traumatic reactions as revealed in the literature.

First, it is notable that all pregnancy outcomes are associated with some PTSD risk. Both vaginal and cesarean deliveries can be experienced as traumatic with a corresponding risk of PTSD. 225 , 253 – 255 Miscarriage and other natural pregnancy losses are also consistently associated with increased risk of PTSD. 170 , 222 , 256 – 258 It should therefore come as no surprise that induced abortion is also consistently found to be associated with the onset of PTSD symptoms. 21 , 39 , 50 , 60 , 170 , 225 , 259 – 269 Notably, a history of induced abortion is also a risk factor for the onset of PTSD following subsequent pregnancy outcomes, 170 , 225 , 260 , 270 so the effects of abortion may not always be immediate but may be triggered by subsequent deliveries or natural losses, or even subsequent non-pregnancy-related events. 271 These findings are consistent with the insight that multiple traumas and related life experiences may contribute to the triggering of PTSD symptoms.

Given the weight of the many statistically validated studies cited above, much less than the reports of clinicians and women who attribute PTSD symptoms to their abortions, it seems evident that the effort of a few AMH minimalists to categorically deny that abortion can contribute to traumatic reactions is driven by ideological considerations, not science. That said, it should also be noted that not all women will experience abortion as traumatic. Moreover, the susceptibility of individuals to experience PTSD symptoms can also vary based on many other pre-existing factors, including biological differences. So the risk of individual women will vary, as it does for every type of psychological reaction. Still, when even the chair of the APA’s TFMHA has reported identifying abortion-specific cases of PTSD in one of her own studies, 39 the claim that abortion trauma is a “myth” advanced purely for the purposes of anti-abortion propaganda it itself nothing more than pro-abortion propaganda. 252

The evidence is clear that some women do experience abortion as a trauma. The prevalence rates and pre-existing risk factors may continue to be disputed, but the fact that abortion contributes to PTSD symptoms in at least a small number of women is a settled issue.

Recommendations for research and collaboration

Good research is essential for both healthcare providers and patients. Better information about the risks and benefits associated with abortion should contribute to better screening, better risk–benefit assessments, and better disclosures to patients, 23 that will help to shape the expectations of patients and those who advise them. Better information will also improve the identification of at risk patients who may benefit from referrals to post-abortion counseling.

As previously discussed, while the ideological divides between AMH minimalists and proponents will continue to shape how each side interprets the data, these differing viewpoints actually provide an opportunity for improving the collection of useful data, analyses of the available data, and more thorough interpretations of research findings. Therefore, healthcare providers and patients would be better served by AMH minimalists and AMH proponents both bringing their various perspectives to bear on research efforts in a more cooperative fashion.

Whenever possible, research teams should include both AMH minimalists and AMH proponents. Such cooperation would improve methodologies by better addressing the differing concerns of each perspective at the time of the study design. Collaboration in the writing of introductions and conclusions to such studies would also be improved by bringing balance to both perspectives and by reducing the tendency to overgeneralize results of specific analyses.

More specific opportunities for collaboration and better research are discussed below.

Expanding the research goals

A major problem with abortion research and reviews is a failure to address all of the relevant questions which need to be asked, investigated, and answered. For example, the team from the National Collaborating Center for Mental Health (NCCMH) that wrote a review of AMH issues for the Academy of Medical Royal Colleges in 2011 strictly limited their investigation to only three questions: “(1) How prevalent are mental health problems in women who have an induced abortion? (2) What factors are associated with poor mental health outcomes following an induced abortion? (3) Are mental health problems more common in women who have an induced abortion when compared with women who deliver an unwanted pregnancy?” 5 Most notably, the NCCMH team chose to ignore the question specifically posed for it to investigate in the 2008 Royal College of Psychiatrists position statement on abortion, namely, “whether there is evidence for psychiatric indications for abortion” 272 (emphasis added). Given the lack of any evidence for psychiatric indications for abortion, it seems likely that the NCCMH decided to ignore this question because it echoed previous allegations that UK law was not being followed in regard to limiting abortion to cases where there are therapeutic benefits. 273

Many additional questions were raised during the consultation process when the NCCMH team invited comments and suggestions from experts. But all of these questions were summarily rejected by the NCCMH team as being “beyond the scope” of their review, even though they acknowledged that many of these other questions were equally important to the three questions they had chosen. 274 Indeed, a reading of the consultation report, which was effectively the peer review given to the paper, reveals general dissatisfaction with the three questions chosen by the NCCMH team and with many of their choices in methodology and overstatement or understatement in their conclusions. The consultation report anticipated the many criticisms of the final report 19 , 275 and revealed that NCCMH team was not very responsive to the issues and concerns raised during this peer review. Arguably, the NCCMH team’s unstated mission was to protect the status quo, and so they limited themselves to questions and methodological choices that would allow them to achieve that predetermined goal.

The following is a list of some key research questions that should be addressed in future studies and reviews. It was developed, in part, by using the NCCMH consultation report as a starting point: 274

• How prevalent are mental health problems in women who carry unplanned pregnancies to term compared to women who deliver wanted pregnancies, to women who have no children, and to women who have abortions?
• Given that women may experience a range of reactions in the near term and over a period of many years, what are the cumulative rates of negative reactions over a long period of time (including a minimum of 30 years) and what are the temporal, cross-sectional prevalence rates relative to various risk factors that may contribute to these temporal differences?
• Among women who do experience negative emotional reactions (not limited to mental illness) which they attribute to their abortions, what reactions are reported?
• What treatments are most effective?
• What statistically validated indicators predict when the mental health risks of continuing a pregnancy are greater than if the pregnancies were aborted?
• What statistically validated risk factors predict negative outcomes following one abortion, two abortions, and three or more abortions compared to each available comparison group?
• What factors, if any, are associated with improved mental health following abortion compared to similar women who carry a similarly problematic pregnancy to term?
• Among women with pre-existing mental health issues, what factors predict a likelihood that abortion may contribute to a reduction in mental health problems (intensity, duration, and number of mental health issues), and what factors predict a likelihood that abortion may contribute to an increase in mental health problems?
• Among women without pre-existing mental health issues, what factors predict a likelihood that abortion may protect good mental health, and what factors predict a likelihood that abortion may contribute to subsequent mental health problems?
• Is presenting for an abortion, or a history of abortion, a meaningful diagnostic marker for higher rates of mental illness and related problems that can be timely addressed by appropriate offers of care?
• In evaluating the risk–benefits profile of a specific patient, what criteria should be met in order to reach an evidence-based conclusion that the benefits of abortion are most likely to exceed the risks?
• In cases of pregnancy following rape or incest, what are the short- and long-term mental health effects associated with each of the following outcomes: (a) abortion, (b) miscarriage or stillbirth, (c) childbirth and adoption, and (d) childbirth and raising the child?
• Is abortion associated with an increase in rapid repeat pregnancies, that is, “replacement pregnancies?” If so, what portion are delivered, aborted, or miscarried?
• Does a history of abortion contribute to the strengthening or weakening of the woman’s relationships with her partner and/or others?
• What are the mental health effects of the abortion experience, if any, on men?
• What are the mental health and developmental effects of the abortion experience, if any, on previously born children and/or subsequently born children?
• Does a history of abortion contribute to or hinder bonding and parenting of previous and/or subsequently born children?

National prospective longitudinal studies specific to reproductive and mental health

While a number of analyses have been published based on longitudinal studies, none of these studies were designed to specifically investigate the intersection between AMH issues. The need for better longitudinal studies to investigate AMH has been recognized in other major reviews, 4 , 24 , 274 yet the call for such research has not yet been heeded.

We recommend that the value of such longitudinal studies would be vastly increased by expanding the goal of data collection to encompass not just mental health effects associated with abortion but also with all reproductive health issues from first menses to menopause. This would assist in research related to infertility, miscarriage, assisted reproductive technologies, postpartum reactions, premenstrual syndrome, and more. And given the interactions with multiple pregnancy outcomes already seen in AMH research, 88 , 94 , 170 , 203 comprehensive reproductive health histories are needed in any case.

Most importantly, the design and management of such studies should include both AMH minimalists and AMH proponents. An explicit objective should be ensuring that every line of questioning either side considers important is included. When both sides contribute to the design of such studies and have equal access to the same data, concerns about suppressed findings or incomplete analyses will be dramatically reduced … at least after re-analyses. When both sides have equal access to better data, it is more likely that the areas of consensus will increase.

The value of longitudinal studies would also be enhanced by seeking the consent of participants to link their medical records to their questionnaires. This would be most helpful given the fact that many women are reluctant to reveal abortion information even in responding to a confidential questionnaire. Since women’s willingness to share data may vary over time, this request for record linkage should perhaps be offered multiple times over the course of the longitudinal study. While many will likely refuse this option, the refusal to permit record linkage is itself a data point for analyzing patterns associated with concealment and dropout. Along the same lines, at each wave there should be included a query regarding the level of stress associated with completing the questionnaire. 183 This may also help to better understand and estimate the effects of women subsequently dropping out.

Finally, it should be noted that it has already been shown that there may be significant differences in women’s experiences relative to different cultures and nationalites. 50 Therefore, it is highly recommended that longitudinal studies to comprehensively investigate the intersections between mental and reproductive health should be funded in multiple countries.

Data sharing for re-analyses should be rule rather than the exception

It is precisely because data can be selectively analyzed and interpreted to produce slanted results, 131 – 133 that data should be made available for re-analyses by third parties. 276 Data sharing also reduces the costs of research and magnifies the contribution volunteers make to science by making their non-identifying information accessible to more scientists, which presumably most volunteers would prefer as their participation is generally intended to help science in general, not specific research teams. Most importantly, data sharing enhances confidence in the reliability of research findings, especially when related to controversial issues. Unfortunately, though many publications and professional organizations encourage or require post-publication sharing of data, in practice many researchers across many disciplines evade data sharing. 277

Support for data sharing, at least in theory, is found in the APA’s ethics rule 8.14, which states that following publication of their results, research psychologists should share the data for reanalysis by others. 278 But this principle has been frequently ignored, 279 – 281 especially in regard to abortion research. For example, the chair of the APA’s own TFMHA, Brenda Major, has repeatedly refused to allow data she collected on abortion patients to be subject to reanalysis by AMH proponents. She even refused to comply with a request for the data from the US Department of Health and Human Services, even though the study was funded by that agency. 140

Such data hoarding undermines confidence not only in the published findings of a specific study but also diminishes the value of syntheses or reviews relying on those unverified findings.

Data sharing is especially important when the process of collecting data may be blocked by ideological litmus tests. For example, abortion providers are naturally unlikely to cooperate with studies initiated by AMH proponents who they perceive as opponents of their work. On the contrary, they have frequently cooperated with AMH minimalists—precisely because of their shared ideology. Implicit in granting that cooperation may be the expectation that pro-choice researchers will not report any findings that may contribute to anti-abortion rhetoric. Conversely, many post-abortion counseling programs may also limit their cooperation to AMH proponents whom they perceive as most accepting and supportive of the issues raised by their clientele. 88

In both cases, the ideological alignments required to collect data may create biases in the design, analysis, and reporting of results. This does not mean that meaningful results cannot be obtained. But it does mean that such results should always be presumed to reflect sample and investigator biases until the findings have been confirmed in reanalyses conducted by investigators of all perspectives. It is only through equal access to the data that consensus will grow around results which survive reanalyses. It is also through this process that new research objectives will be better identified in response to these reanalyses.

Responsiveness to requests for additional analyses

In many cases, legal restrictions (government or contractual) may bar the sharing of underlying data. In such cases, reasonable requests for additional information, tables, and reanalyses should be honored through personal communication, publication of a response, or, if a major reanalysis is required, in publication of a subsequent paper. Such cooperation is especially important in regard to data sets that have access restrictions, such as those collected by government agencies.

For example, the centralized medical records of Denmark have provided some of the best record linkage studies in the world. However, when it comes to mental health effects associated with abortion, there is strong evidence that significant findings are being suppressed for ideological reasons. The arguments and evidence for this assertion are given below.

In 2011, Munk-Olsen et al. 82 published an analysis of Danish medical records to investigate first time psychiatric contact in the first year following a first abortion or first delivery. The analyses revealed that women who aborted had double the risk of psychiatric contact (OR = 2.18). But this finding was discounted by the finding that aborting women also had higher rates of outpatient psychiatric contact in the 9 months prior to their abortions (including the time they were pregnant) compared to the 9 months prior to a live birth. Munk-Olsen later conceded that this mixture of pre-conception time and pregnancy time created a baseline that “may not be directly compatible.” 227 But this was just one of many major weaknesses in the design and reporting of this highly criticized study. 282

Another methodological problem was the decision to include women who had one or more abortions prior to their first delivery into the delivery group. This decision is especially problematic since a history of abortion is significantly associated with higher rates of mental illness during and after subsequent pregnancies. 78 , 80 , 99 , 170 , 197 , 217 Notably, when Munk-Olsen was asked to provide a simple count of the number of women in her analyses who had both abortions and deliveries and the percentage of those who had psychiatric contact, she refused this and all other requests for more details. 227

Before examining the inconsistencies revealed in subsequent Munk-Olsen et al. 82 studies, it is relevant to compare her abortion study to three very similar record linkage studies conducted by AMH proponents conducted a decade earlier. These prior studies examined the differences between abortion and delivery in regard to inpatient psychiatric treatments, 89 outpatient psychiatric treatments, 97 and sleep disorders. 87 The designs of those studies were superior to Munk-Olsen’s in several respects: (a) in each case, controls for prior psychiatric inpatient treatment were employed for a longer period of time, a 12- to 18-month period prior to the estimated date of conception for each woman; (b) there was complete segregation of women relative to exposure to abortion; (c) mental health outcomes were reported showing variations relative to different age groups; and (d) results were shown over multiple time periods: 0–90 days, 0–180 days, first year, second year, third year, fourth year, and 0–4 years.

Normally, one would expect Munk-Olsen to have at least replicated, if not improved on, the methodology employed in these prior record linkage studies. Instead, the methodological choices she made severely narrowed the range of her investigation. Studies that are narrowly drawn can only support narrow conclusions. This is especially true since Munk-Olsen also excluded any analyses of the effects of multiple abortions, which are known to be associated with even higher rates of negative reactions 94 , 112 and also make up the majority of all abortions being performed. 64

Concerns about selective reporting are heighted by the fact that Munk-Olsen subsequently published numerous studies on mental health associated with childbirth in which, once again, she refused requests to supply data for findings associated with abortion. For example, using the same data set, Munk-Olsen published findings that reported

• Psychiatric treatment following delivery was associated with a fourfold increased risk of a diagnosis of bipolar disorders within the next 15 years; 283
• Rates of antidepressant use and mental health treatments 12 months prior to childbirth and 12 months after; 208
• Elevated rates of psychiatric disorders following miscarriage or stillbirth; 217
• Rates of postpartum depression following delivery of IVF pregnancies; 284
• Rates of primary care treatments before, during, and after pregnancies in which women experienced postpartum psychiatric episodes; 210
• Average monthly rates of psychological treatment and prescriptions before and after childbirth. 209

In each of these cases, her analyses and conclusions were flawed by the failure to address the effects of prior fetal loss, which are known to increase the risk of psychiatric disorders during and after subsequent pregnancies. 78 , 170 , 212 , 225 , 285 , 286

While in most cases she simply omitted abortion history from her analyses, 208 – 210 , 283 in two cases she used abortion history as a control variable 217 , 284 but omitted any statistics showing how this control affected the results. Clearly, the only reason to use abortion history as a control is if it has a significant independent effect on mental health outcomes.

The possibility that Munk-Olsen simply overlooked these opportunities to report on effects associated with abortion is disproven by the fact that in each case Munk-Olsen rejected both published 141 , 227 and unpublished requests for details relative to the effects of abortion on the outcomes studied. Even a request for a simple count of the number of women exposed to abortion in each of Munk-Olsen’s comparison groups was refused. 141

All of the above factors give credence to the concern that there is a selective withholding of results, by Munk-Olsen and other AMH minimalists. Moreover, given the evidence that abortion and miscarriage impacts mental health during subsequent pregnancies, 78 , 80 , 99 , 170 , 197 , 203 , 212 – 221 it is clear that every study examining the intersection between mental and reproductive health may be misleading if it fails to include analyses associated with pregnancy loss. Without such analyses, effects associated with pregnancy loss may be wrongly attributed to childbirth.

For example, there is strong evidence from both record linkage 89 , 97 and case-matched studies 287 that a history of abortion is associated with a threefold increase in bipolar disorder. Therefore, Munk-Olsen et al.’s 283 decision to exclude analyses related to fetal loss from her study of bipolar disorders following postpartum depression severely undermines her conclusion that this negative outcome is due to childbirth alone precisely because she chose to ignore, or at least not publish, findings associated with fetal loss.

The combination of Munk-Olsen’s failure to publish these results without being asked, combined with her refusal to respond to requests for reanalysis, 141 , 227 strongly suggests a pattern of selective reporting and obfuscation. If the additional analyses requested actually supported her previous assertion that prior mental health fully explains the higher rates of mental illness seen among women who have aborted 82 , 107 it seems clear that she should be rushing to publish these requested analyses precisely to silence skeptics.

In short, whenever either AMH minimalists or AMH proponents refuse to respond to queries for reanalyses of published findings, they are increasing distrust and weakening the credibility of all conclusions based on their previously published research. This creates real obstacles in the advance of evidence-based medicine, informed consent practices, and ultimately in the medical care of women. The advance of scientific investigations into reproductive mental health can only be enhanced by generously responding to requests for details and re-analyses that clarify the interpretation of published findings.

Recommendations for editors and peer reviewers

As previously discussed, there is strong evidence that individual biases may unfairly bias editors and reviewers against findings that challenge their preconceived notions. 118 – 123 Biases against “conservative” viewpoints, which may attach to the AMH controversy, are especially common. 125 – 128 , 130

Editors should guard against this bias by seeking a mix of peer reviewers, including both AMH minimalists and AMH proponents. For reasons discussed previously, while recognizing that every study in this area will have methodological weaknesses and that no sample can be perfect, editors should be blind to the results and focus their evaluation of peer review comments on the appropriateness and adequacy of the methodology and study sample. Editors should be alert to criticisms that appear to reflect a reviewer’s bias against results which support an undesired conclusion, especially when the methodology employed is comparable to studies that would be accepted for publication in any other field of research.

A good test of bias is to simply imagine that the results were flipped, 123 with the ORs showing benefits to abortion compared to delivering an unwanted pregnancy, for example. If the reviewer’s or editors reactions to the paper would most likely have been in the opposite direction, that reaction is obviously driven by a bias for preferred results.

Editors and peer reviewers should also strive to ensure that all studies relating to the intersection of mental and reproductive health include, whenever possible, analyses that delineate findings relative to exposure to all prior pregnancy outcomes, including both natural pregnancy losses and induced abortions. 141 , 227 This is important for several reasons. First, there is consensus even among AMH minimalists that better data are needed on the effects of pregnancy loss on mental health. 4 , 274 Second, there is clear and convincing evidence that exposure to pregnancy losses (both natural and induced) may have a significant impact on women’s health during and after subsequent pregnancies and at other times in women’s lives. 80 , 88 , 94 , 99 , 112 , 170 , 212 , 285

When data on abortion and miscarriage history are available, but not included in published findings, this raises concerns about concealment of findings that the authors may be afraid will bolster the position of their ideological rivals. 141 , 227 Alert reviewers and editors should routinely ask researchers to include in their tables of results analyses relevant to the number of exposures to abortion and natural pregnancy losses. Without such requests (a) the literature will continue to be deprived of meaningful data and (b) selective reporting may falsely attribute negative mental health issues to childbirth.

Limitations

The purpose of this review of the medical literature on AMH was to examine the areas of agreement and disagreement, the reasons for disagreement, and the opportunities for improved research and collaboration. The method I used began with a review of reviews published since 2005 4 – 10 , 12 – 19 , 21 , 22 and an examination of the studies cited in these reviews.

Given the difficulties previously discussed in conducting any conclusive studies, the breadth of issues examined in this review, and the range of theories and opinions of the authors of the reviews and studies examined, it is out of the scope of this, or any, review to fully address every view or concern. With that limitation in mind, however, this review does catalog a broader range of relevant issues than any previous reviews. In doing so, this review does not offer the last word on the AMH controversy. Instead, it seeks to expand and continue the conversation, inviting more detailed responses, criticism, and elaboration regarding the issues identified herein.

While there will continue to be differences of opinion between AMH minimalists and AMH proponents, there is sufficient common ground upon which to build future efforts to improve research and meaningful re-analyses. Common ground exists regarding the very basic fact that at least some women do have significant mental health issues that are caused, triggered, aggravated, or complicated by their abortion experience. In many cases, this may be due to feeling pressured into an abortion or choosing an abortion without sufficient attention to maternal desires or moral beliefs that may make it difficult to reconcile one’s choice with one’s self-identity.

There is also common ground regarding the fact that risk factors identifying women who are at greater risk, including a history of prior mental illness, can be used to identify women who may benefit from more pre-abortion and post-abortion counseling. Additional research regarding risk factors, and indicators identifying when abortion may be most likely to produce the benefits sought by women without negative consequences, can and should be conducted through major longitudinal prospective studies.

Finally, there is common ground on the need for better research. That fact alone is a strong argument for mixed research teams, collaboration in the design of longitudinal studies available for analysis by any researcher (without ideological screenings), data sharing and more responsive cooperation in responding to requests for reanalysis. All of these steps will help to provide healthcare workers with more accurate information for screening, risk–benefits assessments, and for offering better care and information to women both before and after abortion and other reproductive events.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: D.C.R.’s efforts were funded as part of his regular duties as Director of Research with the Elliot Institute.