The harms of imposing barriers to abortion care on people's psychological well‐being

The assumption that abortion is detrimental to pregnant people's mental health has long been used to justify policies that restrict or ban legal access to abortion. Such policies often include implementing total abortion bans, banning certain types of abortion procedures, setting gestational limits, mandated waiting period and counseling laws, among others. While these policies claim that they will protect people's mental health by denying them access to abortion or forcing them to wait, they ignore the large body of evidence demonstrating that abortion in itself does not cause mental health harm, and that the restrictions themselves might harm pregnant people's mental health.

The US Turnaway Study is one of the most robust investigations assessing whether abortion causes mental health harm ¹ . This longitudinal cohort study examined the consequences of having or being denied an abortion on pregnant people's psychological, physical and financial well‐being. From 2008‐2010, we recruited 956 participants at 30 abortion facilities across 21 US states who had abortions just below a facility's gestational limit, and compared their psychological, physical and socioeconomic outcomes to people denied abortion because they were just above a facility's limit and carried their pregnancies to term. Using a structured telephone interview tool, we interviewed participants one week after having or being denied abortion and then every six months for five years. Using validated measures, we mapped people's mental health trajectories over this five‐year period.

The Turnaway Study improves on prior studies by utilizing a prospective design and an appropriate comparison group. Its two main study groups were similar at baseline on key background characteristics that could confound the relationship between abortion and mental health. In particular, they were comparable with respect to pre‐pregnancy history of child abuse and neglect, mental health diagnoses, and drug or problem alcohol use. Other studies have been methodologically limited by relying on comparison groups that differ from the abortion group on key background characteristics, such as people with wanted pregnancies or who are not pregnant. These studies ignore the reality that people seek abortion due to reasons related to their financial, relationship, and mental health circumstances ² , all of which can result in key baseline differences that impact their mental health trajectories. The use of such flawed comparison groups have led authors to erroneously conclude that the abortion, rather than other factors – such as pre‐existing mental health conditions and trauma – are the source of adverse mental health outcomes.

The Turnaway Study, which accounted for these background characteristics, found no evidence of mental health harm due to abortion. It was the people who were denied access to abortion who had worse mental health, at least initially. For the first six months after being denied abortion, they reported more stress and symptoms of anxiety, and lower self‐esteem than those who got their wanted abortion, while reporting similar levels of depression, post‐traumatic stress, and suicidal ideation ¹ , ³ , ⁴ , ⁵ , ⁶ . Both study groups – whether they had or were denied abortion – experienced heightened psychological distress around the time they were seeking abortion, which gradually improved over time. While the study concluded that abortion is not harmful to people's mental health, it did find that the people most vulnerable to experiencing post‐abortion‐seeking psychological distress were those with a history of mental health conditions, perceived abortion stigma, and history of trauma or abuse ¹ , ⁵ .

What's more, when we examined the effects of abortion denial on other outcomes, such as people's socioeconomic and physical well‐being, those who were denied abortion fared worse ¹ . When compared to those who had an abortion, they experienced an increase in household poverty, were less likely to have enough money to cover basic living expenses such as food, housing and transportation, had lower credit scores as well as more debt, bankruptcies and evictions. These adverse outcomes extended onto participants’ children. Children of people denied abortion were more likely to live in poverty and less likely to achieve key developmental milestones, while children born due to abortion denial were more likely to experience poor maternal bonding.

Being denied abortion and then giving birth was also associated with greater physical health risks than having abortion, including experiencing life‐threatening complications such as eclampsia and postpartum hemorrhage, chronic headaches or migraines, joint pain, and gestational hypertension, as well as death (two people denied abortion tragically died following delivery, whereas no people died from abortion) ¹ .

The Turnaway Study findings provided robust evidence demonstrating that abortion denial is more harmful to people's mental and physical health and financial well‐being, than having an abortion. These findings also prompted a need to identify the factors that might contribute to elevated levels of anxiety and depression symptoms at the time of abortion seeking.

The Burden Study aimed to explore whether abortion restrictions and other barriers might be one source of the heightened psychological distress when seeking an abortion ⁷ , ⁸ . In this cross‐sectional study, we surveyed 784 people seeking abortion care at four facilities located in the states of California, Illinois and New Mexico – all states with protected access to abortion. We selected these states because they allowed us to capture the experiences of people who traveled from other states with more restricted access to abortion care.

We found that 58% of participants experienced delays accessing abortion care, most often due to the costs of care‐seeking (45%), as well as access barriers (43%) and travel time (35%). Furthermore, as many as 42% reported incurring catastrophic health expenditures, meaning that their out‐of‐pocket costs to pay for abortion‐related medical care and travel were so high as to hinder their household's ability to pay for basic living needs such as food and housing. Over one‐quarter (27%) of participants reported having to tell someone about the abortion decision unwantedly, due to the many logistical constraints that they endured trying to obtain care ⁷ , ⁹ .

In analyses adjusting for pre‐pregnancy mental health history and other background characteristics, participants who experienced delays, unwanted disclosure about the abortion, and catastrophic health expenditures reported more symptoms of anxiety, depression and stress ⁷ , ⁸ , ⁹ . While the cross‐sectional design limited our ability to determine the direction of these relationships, these findings suggest that facing obstacles to abortion care may be harmful to people's psychological and financial well‐being.

This research adds to the body of evidence demonstrating that policies claiming to protect pregnant people's mental health by restricting their access to abortion are not evidence‐based. It is critical that policy‐makers understand the long‐standing impact of abortion restrictions on people's psychological, physical and financial well‐being, as well as the rippling impacts that these policies are likely to have on the financial and psychological well‐being of their children.