The US Surgeon General made the recommendation in 1989 that a five-year longitudinal cohort study was necessary to provide data about the health effects of an elective termination on women. To rise to this challenge, the Turnaway Study was launched at the University of California, San Francisco Bixby Center for Global Reproductive Health. This prospective, longitudinal study recruited women from 30 abortion facilities in 21 states from 2008 to 2010 with the purpose of tracking their psychological well-being (Biggs et al, 2016). The researchers interviewed this population of women twice a year over five years, resulting in 11 interview waves.

The 956 participants were divided into groups in terms of the outcomes of their visits to the abortion clinic. The first group consisted of women who had successfully undergone an elective pregnancy termination because they were at least 2 weeks under the facility’s gestational limit (near-limit group, n=452). The second group included women who sought an abortion, but were denied because they were up to 3 weeks beyond the gestational limit of the facility (turnaway group, n=231). This turnaway group was further divided into those who ended up receiving care elsewhere or had a miscarriage (no-birth group, n=70) and those who gave birth (birth group, n=161) (The latter group included women who gave birth and put their child up for adoption). The third group were women who received a first-trimester elective termination (first-trimester group, n=273). Each interview included two empirically-validated measures of depression, two measures of anxiety, one measure of self-esteem, and one measure of life satisfaction. The researchers controlled for potential confounding factors, such as age, race, marital status, history of child abuse, history of a mood disorder, and drug abuse.

When the trajectory of depressive symptoms was compared between groups, women with first-trimester or near-limit terminations experienced fewer initial symptoms than women in the turnaway groups; in all groups, overall depressive symptoms declined over time. In terms of anxiety, the women in the turnaway-no-birth group and the turnaway-birth group had more immediate symptoms than those who received an elective termination. Furthermore, the women in both of the turnaway groups had lower levels of self-esteem levels and life satisfaction at baseline.  The study lost 42% of their study population by the end of the five years, so it is possible that women with adverse mental health outcomes (who may be more likely to drop the study) may have been missing from the final results.

In summary, women who had an elective termination demonstrated more positive mental health outcomes initially compared to the women who were initially denied an abortion.  Furthermore, depressive and anxiety symptoms decreased and levels of self-esteem and satisfaction with life increased over the five years of the study for both women who received an abortion and those who were denied care (see figures below).  The results found no evidence that women who successfully terminated their pregnancy had a heightened risk of developing depression, anxiety, low self-esteem, or less life satisfaction immediately following the termination or up to five years after.

Figures 1 & 2 from Biggs et al. 2016

This is the first study since the Surgeon General’s recommendation to follow this specific population of women for five years or longer and the first to use appropriate comparison groups. Prior studies compared women who had received an elective termination to women who had experienced a miscarriage or to women who had successfully carried a pregnancy to term; however, as the researchers point out, this is not an adequate comparison because there could be very different confounding factors at play for women who choose to carry a pregnancy and women who elect to terminate, especially in terms of their mental health and motivation. A previous report released from the Turnaway Study in 2013 tracked the participant’s motivations for wanting to undergo an abortion. While 64% of the women reported multiple reasons, the four primary reasons included finances (40%), timing (36%), partner-related reasons (31%), and the need to focus on other children (29%) (Biggs et al, 2013).

Given the lack of scientifically rigorous studies examining the effects of terminating a pregnancy, the work of the Turnaway Study is pivotal and will provide invaluable information regarding the psychological effects of abortion.  Although abortion is a legal medical procedure in the United States, the belief that abortion is associated with adverse psychological outcomes has been the basis for legislation and policies which restrict access to abortion.  Nine states currently require that women seeking an abortion receive counseling regarding the negative emotional effects she may experience after an abortion (Guttmacher Institute). The Turnaway Study provides us with information that is geographically diverse and highly representative of the United States, diligently follows women at 11 time points over 5 years, and uses strong, nuanced comparisons between the women who participated.

 

Lauren Claypoole, BA

 

Biggs et al. Women’s Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study. JAMA Psychiatry. Published online December 14, 2016.

Biggs et al. Understanding why women seek abortions in the US. BMC Women’s Health 2013 13:29.

For more information on the Turnaway Study: http://www.ansirh.org/research/turnaway-study