This is a reshare from last fall1.

Yesterday marked three years since the Dobbs decision overturned Roe v Wade. Seems apt to reshare this one, where I interviewed the brilliant researchers behind the Turnaway Study out of UCSF. Dr. Diana Greene Foster, who designed and led the 10+ year study, published her book summarizing the findings in June 2020. When I asked her what she expected when she started writing, her response was "I thought the topic would be moot and the book would be of academic interest only."

Oh, how I wish that were true.

Here is your annual reminder that ABORTION IS HEALTHCARE…

Audio

This is a long one so feel free to skip ahead to sections focused on where abortion access connects on the stressor map, specifically: social narrative+stigma, financial stability, child care issues, intimate partner violence, and child health.

Or bounce straight to the bottom for a reminder that anti-abortion activism is NEVER really about women’s mental health (the most obvious spoiler of all spoilers).

In 2007, Dr. Diana Greene Foster was driving across the Bay Bridge and passed a poster, clearly targeted at San Francisco Bay Area feminists. The claim: “abortion harms women”. 

The same year, the Supreme Court struck down a case that would have expanded federal abortion access. Justice Kennedy wrote the majority opinion and, after reading amicus briefs with cherry-picked stories from anti-abortionists, included the statement: “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. Severe depression and loss of esteem can follow.”

Justice Kennedy had ZERO DATA to base his statement on. 

The billboard-sponsoring anti-abortionists had ZERO DATA to base their statements on. 

But these unscientific assertions weren’t simply a reflection of people ignoring data that didn’t suit their goals. In 2007, solid data on how women’s wellbeing is affected by abortion did not exist. No one had done the research cleanly enough to demonstrate or contradict the claims2. 

After listening to Kennedy and seeing those billboards, Dr. Foster, a demographer and reproductive health researcher at UCSF, had a challenge accepted! moment and set up a long-term study to fill in those data gaps. 

Quick side bar — When it comes to testing the outcomes of clinical care pathways, like abortion care, it can be damn near impossible to design a study meeting the “gold standard” in human research – a randomized controlled trial. When you cannot control or separate groups, any number of variables in the complicated lives and biology of human beings can muck up the dataset, make statistics a nightmare, and diminish any findings by adding questions around correlation versus causation3. 

The beautiful design4 of the resulting Turnaway Study managed to overcome these issues in a very cool way. Inspired by a casual observation: 

“A doctor at UCSF, who does abortions and runs the Women's Options Center, said to me, ‘I wonder what happens to people we turn away’. A light bulb went on in my head – that was the key study population. 

All the studies up to that point had problematic comparison groups – either no comparison group or only people who had abortions and were recruited from support groups, or they were based on surveys later from people who reported their abortion.

If we could follow the people who want an abortion and can't get one, and then compare them to people who did get their abortions, that would [solve for previous study design flaws].” – Dr. Diana Greene Foster

The key comparison groups clustered around a yes/no time point: 1) Near-Limit Abortions – a group of participant who sought abortions “just in time” to receive care (up to 2 weeks before gestational limit); and 2) Turnaways – a group of participants who sought abortions, were a little too late to receive care (up to 3 weeks after gestational limit), and turned away from a wanted abortion. The team then tested their study design by comparing the groups at baseline  – how do the individuals in each group compare before getting or being denied an abortion? 

“When we recruited from just over and just under the abortion limit, we could see that the study design was a success – the two groups are very similar at baseline – so when we follow them over time, the data reveal what the consequences are of being denied a wanted abortion or being able to get an abortion.” – Dr. Diana Greene Foster

On average, participants came into the study with no significant differences in any of the parameters the team would go on to measure after participants received their abortion or were turned away and carried to term. 

The longitudinal study ran for ten years5, resulted in more than 50 peer-reviewed papers and a book6 all focusing on “the effects of unwanted pregnancy on women’s lives”.

When we look at the results — in the framing of the anti-abortion claims — are women who get abortions worse off than those who do not get abortions?

Short answer: NO. 

Those who did receive abortion care had better outcomes across nearly all parameters compared to those who did not receive abortion care.

Having an abortion led to better financial outcomes, better health outcomes, better family outcomes.

Dr. Antonia Biggs, a social psychologist on Turnaway study team, who studied the stress and mental health components, summarized the decade of research this way:

“Abortion does not cause mental health harm. 

What [the Turnaway study] shows us, is that denying people access to an abortion is worse for their mental health. We found that people denied an abortion had lower self-esteem, more stress, and more symptoms of anxiety soon after being denied an abortion when compared to people able to get their wanted abortions.” — Dr. Antonia Biggs

Shove it, Justice Kennedy.

In a more nuanced take, when I spoke with Dr. Foster and Dr. Biggs, the thing that struck me most was how study participants seemed to carefully consider their array of current life stressors when making their decision to seek an abortion. They understood their current burden, they understood their restrictions and the elements of life that added too much weight and too much stress. And they understood the potential repercussions of carrying the pregnancy to term. 

Abortion was, in a way, a healthy form of self-care for them.

The heartbreaking thing that the study revealed: their feared predictions were spot on. They were right. The exact things that they worried about happening, if they carried the pregnancy to term, happened:  

“We find that, when people are making the decision about whether or not to have an abortion, the things they're most concerned about – economics, relationships, children, health – are exactly the negative outcomes we see for those who cannot get their abortion. 

People who are trying to make this decision actually understand the potential consequences, they know what carrying a pregnancy to term will mean for them.” – Dr. Diana Greene Foster

In conversation with Dr. Biggs, she added: 

“You seek abortion because you have stressors. You feel like you're not in a place to have a child.

The time of becoming pregnant with an unwanted pregnancy is inherently stressful, for all the reasons given for wanting to seek an abortion. 

By denying them abortion, we're just adding more stress. 

Abortion bans carry the messaging that, 'Okay, we don't trust you to make your own pregnancy decision.' Bans are inherently coercive in that they deny people from getting needed healthcare. Abortion bans and restrictions can add more stressors making it more difficult for people to figure out how to find and access abortion care. Traveling to another state for care increases the time and cost needed to get care and is more difficult and stressful for people with limited financial, informational, and emotional resources and social support.” – Dr. Antonia Biggs

In the last post, I included the stressor map to start the discussion around wanted pregnancies and the impacts of abortion access in the context of pregnancy loss.

I pointed out that the connections go both ways: affected by and affecting the severity of other stressors on the map7.

"It made an awful situation even worse."

Molly Dickens, PhD

·

October 15, 2024

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When I started making the connections, I kept it super simple. I honestly thought that there were some stressors that did not connect from or back to abortion access. Then I discussed the map with Dr. Biggs. She asked me to toggle between the full map and the abortion access specific map – in a “what is missing?” way --  and through that discussion, it was clear:  nearly everything is connected. 

Let’s go through some connections: 

Social narrative – Stigma + Shame

When it comes to psychological stressors, social narrative contextualizes the external challenges and could become a key differentiation point for why some individuals respond more strongly than others. 

The effects of stigma and shame (internalized stigma) on stress-related health outcomes is still understudied in the context of motherhood and maternal stress8. The Turnaway study research on the effects of perceived stigma around abortion care contributes broadly to this topic, suggesting the power of narrative shift for improving health outcomes.

Data from the Turnaway study indicates that over half of the participants seeking abortion experienced some perceived stigma from those close to them (60%) or from their community (56%). Those who classify their experience as high perceived abortion stigma at baseline had higher odds of experiencing psychological distress for years after abortion seeking, regardless of whether or not they received care. 

People who anticipate abortion stigma fared worse. 

When talking with Dr. Biggs, who led this research, she added her own post-Dobbs concerns:      

“Perceived stigma is so important when we think of mental health. 

The Turnaway study found that most people perceive that people in their community or people close to them would look down on them for seeking abortion, and prefer to keep the decision private. We know that people prefer to be selective in terms of who they want to involve in the abortion decision and are less compelled to want to disclose the decision to someone who they anticipate will be unsupportive or judgmental. This particularly holds true for young people.

When you start adding barriers to care, our research from the Burden Study finds that people are more likely to disclose that abortion decision unwantedly because they have to take days away from work or school or need to find childcare or money to pay for the care. These added obstacles make it harder to keep the abortion decision private. This study found that people who disclosed the abortion unwantedly, reported more stress, anxiety and depression.” — Dr. Antonia Biggs

To read more about how the language in the laws themselves are stigmatizing, revisit the last piece here. 

Financial stability (+ food security, job security, housing security) 

Women denied access to abortion care endure significant increases in financial hardship that persist over several years. When compared to those who received abortion care, participants denied abortions were three times more likely to be unemployed, four times more likely to be living below the poverty line, more likely to require food assistance or other public programs, and more likely to indicate that they could not afford basic living needs.  

From decades of stress research, we know the negative connections between financial stability and stress-related health outcomes. Job-loss and unemployment carries its own psychological weight.  

Interestingly, the difference in poverty rates starts to disappear around the fourth year following the abortion or abortion denial. But, the sample size has dropped to a tricky level that could have affected statistical significance, AND:  

“You have to consider the lost income for all those years. 

If you've earned less for the past four years, you've accumulated less. Poverty is a measure of income, it's not a measure of wealth.” – Dr. Diana Greene Foster

Child care issues

After abortion denial, women are more likely to be raising the child on their own, without support from a partner or family.

In addition, while not directly quantified in the Turnaway study, I do see where the stress of child care issues may come into abortion care and potential stress-related health outcomes. Just a quick (not comprehensive) overview:

Child care relates to unwanted disclosure and internalizing the stigma of abortion seeking. 

Child care relates to financial security (increased with abortion denial).

Child care relates to job loss (increased with abortion denial). 

Child care relates to staying with an abusive partner and may play a role when abortion care is denied.  

Child care relates to eviction and housing insecurity (increased with abortion denial).

Child care relates to the mental load of abortion logistics. 

Just leaving this one here to tackle later. 

Intimate Partner Violence

Women’s physical and mental health is directly affected by being in abusive relationships and the negative health outcomes are often associated with the stress of those situations.

Issues related to the relationship associated with the pregnancy ranked high as a reason for seeking an abortion. With concerns about partner violence included.  As Dr. Foster explained: 

“A third of people say that their decision to have an abortion has to do with their relationship with the man involved. [It's about] one in 20 who are in a relationship that is actually violent. 

Those bad relationships tend to dissolve at an equal rate for all groups. But if you are denied abortion, you end up staying in contact with the man. People who had violent relationships have continued contact. It's continued exposure.” – Dr. Diana Greene Foster

Women who experience intimate partner violence are at a higher risk for depression and post-traumatic stress disorder. Psychological abuse can be more damaging than physical. 

Again, those seeking abortions have clear, valid reasons for seeking care. They know what their bodies and their brains could endure and could no longer endure. The data backed up the validity of the pre-abortion concerns, those who received abortion care had a reduced risk of violence, the “Turnaways” who gave birth, did not9. 

PTSD as a diagnosis feels especially worrisome when considering the differences between the two groups. If you cannot fully separate yourself from your abuser, the trauma might not be POST Traumatic Stress, it might be CONTINUOUS Traumatic Stress. 

“The disproportionate harm to people's mental health is not really about the abortion, but all the other things that are happening at the time – previous mental health conditions, people who are in violent relationships. 

Those who are able to have an abortion are less likely to be tethered to those violent partners compared to those who are able to get their wanted abortion.” – Dr. Antonia Biggs

Fully distancing yourself from someone who is abusive, as a way to preserve your own mental health, must be seen as a valid and critical reason for receiving abortion care. 

Child health

I honestly had taken the connection to child health issues off the first version of the abortion access map and put it back on when Dr. Biggs pointed out something pretty darn obvious that relates to the circular nature of how child health affects parental health affects child health:

“We do know that the children born after being denied an abortion are more likely to live in poverty. We know that when [a child] lives in poverty, they’re more likely to live in unsafe environments, they’re less likely to reach developmental milestones, they’re less likely to have access to health care. So this is definitely connected to child health issues.

When an abortion is denied, we have to consider – now there's a child, what happens to that child?” — Dr. Antonia Biggs

A majority of the women seeking abortions are already mothers. So the “what happens to the children?” outcomes relate to ALL the children in the house, regardless of whether or not they are born after a wanted abortion is carried to term. Those existing children show worse child development in households of abortion denial compared to those in households where abortion care was accessed.

Those who received their abortions were more likely to have children later. Children born to women who received a prior abortion showed better maternal bonding than those born from abortion denial.

Here is a stark truth that you will never hear anti-abortionists admit – abortion allows for healthier children. 

But maybe it’s not really about the children either:

“What the study reveals is that we have no respect, as a country, for low income parents. Whether they have a wanted pregnancy or not, our social safety net doesn’t care if kids have an equal opportunity. If the parents are poor, the kids will likely experience childhoods of intense stress. That's appalling and it has nothing to do with abortion.” — Dr. Diana Greene Foster

This was never about abortion and mental health

Now that we have evidence, loads and loads of data, demonstrating the opposite to those 2007 claims, has the “feminist” anti-abortion message changed?

“Abortion policies are one of those few areas where anti-abortion advocates claim to care about people's mental health, yet these same policies are likely having the opposite effect.

Even before Dobbs, many of the restrictions on abortion – the mandated waiting period laws, the mandated counseling laws, the gestational limit bans –  are rooted in the idea that they will protect people from the mental health harm of abortion.

That idea itself is rooted in misogynistic ideals, reminiscent of when “hysteria” was first conceived – claiming that women are “crazy” and can't make their own decisions, so they need to be controlled and told what to do. 

We recently witnessed the unsupported claim that abortion leads to mental health harm in the suit against the FDA filed by Judge Kaczmaryk, the Texas judge, whose attempt to invalidate the FDA’s approval of mifepristone. While he claimed that having an abortion will increase people’s risk of experiencing mental illness, the best available evidence does not support that. 

The idea that ‘abortion harms people's mental health’ is prevalent. And, despite the evidence against it, we haven't been able to get rid of that idea.10” – Dr. Antonia Biggs 

So, maybe this means we have leverage to push for better mental health services?  

Ahhhh, if only… 

“We have terrible access to mental health services everywhere. People living on incomes and those without health insurance have even worse access. But I don't think any of this has to do with whether or not [anti-abortionists] actually care [about mental health].  Their strategy adds to the public confusion about the evidence regarding abortion and mental health, and it contributes to the spread of misinformation about whether or not abortion is going to cause a mental health crisis.” — Dr. Antonia Biggs

SOLUTIONS? 

First, I need to point out one anti-abortion “solution” that is not a solution – carrying to term and then putting up the child for adoption.

The better word for this is relinquishment. 

“I see adoption as a systemic failure to care for families and to put a value on motherhood.”

– Dr. Gretchen Sisson, UCSF researcher, author of Relinquished: The Politics of Adoption and the Privilege of American Motherhood. 

Relinquishing a child does not solve for the stress related to carrying an unwanted pregnancy to term because it adds different elements of stress… but I’ll explore that one later. 

Overall, in the context of both unwanted and wanted pregnancies, the interconnected nature of this stressor node suggests that abortion bans are a key stressor in the lives of anyone with a uterus while abortion access is a broad stress-reducing solution11. 

When considering the reality of post-Dobbs America, if the goal is healthy women and healthy children, we have a range of opportunities to decrease the severity of the stress related to abortion bans:

We need a more robust social safety net. 

We need accessible, affordable childcare. 

We need some form of guaranteed basic income (e.g. child tax credit) to allow for better financial stability. 

We need paid leave and protection from pregnancy/parenting discrimination in the workplace. 

We need accessible and culturally competent perinatal care.

Pick a thing on the map and FIX IT, it's all connected.

“The same states that ban abortion have appalling policies towards parenting and childbirth. If they want to support people to carry the pregnancy to term, it's completely unethical to not support them in their pregnancy and childrearing.” – Dr. Antonia Biggs

If you are forcing us to live in a state (or a country!) that does not respect our ability to make choices around if and when and how we build our families, addressing any one of those connection points will reduce the stress of your abortion bans. 

Because, the stress of abortion bans, especially in the context of America’s systemic failures, IS harming women’s mental health. 

But, again, this was never really about women’s mental health.

If you made it all the way down here, it means that maybe you’re finding some value in these words. If so, can I ask a favor?

This is a beast of a project, and while I have no plans to paywall, feeling the support from readers (it’s so hard to tell who is actually finding value in this!) means so much to me for the road ahead.

If you don’t already, please consider subscribing. If you do already subscribe, please consider bumping up to a paid subscription or sharing. Your generous support will facilitate the growth of the project… and be much appreciated!

Two cups of coffee for Molly

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2025 update — Stephanie H. Murray highlighted a study in her newsletter Family Stuff showing that rates of IPV increased up to 10% in counties with severe abortion restriction —

Family Stuff

Couples Who Vote Together Stay Together, and Other Interesting New Research

A note for newcomers: Welcome! This is a weekly round-up of newly published research on demography, family policy, and other family stuff. Some of the studies included here may be pre-prints or working papers and have not yet been peer reviewed. And while I have done my best to summarize their findings accurately, in the words of Ebenezer Scrooge, “I am…

Read more

7 months ago · 18 likes · 16 comments · Stephanie H. Murray

(with thanks to Cathy Reisenwitz for pointing this one out. I missed it tucked away at the bottom of her newsletter last week!)

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If this issue moves you, see all things Jessica Valenti :

Abortion, Every Day

All things abortion. Feminist commentary & community.

By Jessica Valenti