The Mental Cost of Being Denied an Abortion

Shortly after the Supreme Court draft opinion was leaked that indicated the possible overturning of Roe v. Wade, the American Psychological Association reaffirmed its opinion that restricting abortion was “likely to lead to mental health harms,” a growing concern as some states rush to pass laws that would prohibit abortion.

But anti-abortion groups have long argued that abortion is what harms a woman’s mental health, a claim that contradicts credible research.

While unwanted pregnancy can produce feelings of distress, regardless of whether a woman has an abortion or not, landmark research known as the Turnaway study found that women who were denied an abortion had more psychological problems in the short term than those who received one, and also experienced more long-term physical and financial problems.

What happens to the women who are turned away?

When examining how women are affected by abortion restrictions, the Turnaway study — while not without its limitations — is the most comprehensive available, and analyses of its data have been published in numerous peer-reviewed journals.

The study recruited nearly 1,000 women at 30 abortion clinics around the country between 2008 and 2010. The researchers then compared the outcomes of those who were denied an abortion (because they were just over the gestational limit in their state) with those who were permitted to have the procedure, and followed both sets of women for five years.

The women who were denied abortions were initially more likely to experience higher levels of anxiety, lower life satisfaction and lower self-esteem compared with those who could obtain abortions — distress that “may be a response to being denied an abortion, as well as other social and emotional challenges faced on discovery of unwanted pregnancy and abortion seeking,” the study said.

After about six months, however, those differences disappeared. In fact, the mental health of both groups eventually improved, which indicates that the study participants were emotionally resilient, said Diana Greene Foster, a professor in the department of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco, and lead investigator of the Turnaway study.

“The experience of having an unwanted pregnancy is really disruptive,” she added. But “over time people do better — regardless of whether they got their abortion or not.”

The physical and financial harms of being denied an abortion, however, lasted for years. Women who were denied an abortion and gave birth reported more chronic headaches or migraines, joint pain and gestational hypertension compared with those who had an abortion. They also reported more life-threatening complications like eclampsia and postpartum hemorrhage, and burdens that included higher exposure to domestic violence and increased poverty.

Ann, a 28-year-old in California who was not part of the Turnaway study, said she didn’t realize she was pregnant until well into the second trimester, shortly after graduating from college. She wanted to have an abortion but just missed the legal cutoff in her state.

After speaking with her obstetrician, “I remember going to the bathroom and sobbing,” said Ann, who asked to be referred to by a first name to protect her family’s privacy.

During her pregnancy, Ann suffered from severe pre-eclampsia that ended in seizures and an emergency C-section. “I deeply feel like I never want to get pregnant again just because of how traumatic the experience itself was,” she said.

Limitations of the Turnaway study

Even though the Turnaway study was rigorous in its design, it cannot be used to generalize for all women seeking abortions — or all experiences with unwanted pregnancy.

Turnaway excluded women with a fetal diagnosis or maternal health problems, for example, and most of the women denied abortions were in the second trimester.

In addition, the Turnaway study did not include women who never made it to an abortion clinic — in other words, the women who were the most isolated, financially and socially.

Some abortion opponents are dismissive of the Turnaway study because of its participation rate. In a 2018 paper published in SAGE Open Medicine, for example, the anti-abortion activist David C. Reardon criticized Turnaway, in part because only about 37 percent of the more than 3,000 women who were asked to participate agreed to do so, and throughout the five-year study some of the women dropped out.

Women who anticipate the most difficulty with their abortions may not wish to share their thoughts and feelings about it, he wrote, and may want “to avoid follow-up surveys that may aggravate those negative feelings.”

Dr. Foster acknowledged that the subject of abortion or unwanted pregnancy isn’t always easy to talk about, but said there was no evidence that the women in their study skewed toward having rosier views on abortion. And with regard to the participation rate, she added, a study like this is time-consuming — not everyone will want to commit for a five-year period.

“We actually take pride in our retention rate,” Dr. Foster said. “We only lost 5 percent of people from survey to survey.”

How does abortion affect mental health?

Decades of research show that one of the most reliable predictors of mental health after an abortion is the condition of a woman’s mental health before pregnancy.

For example, a study led by Julia R. Steinberg, an associate professor at the University of Maryland, College Park, compared women who gave birth to those who had abortions and found that when women’s pre-existing mental health disorders were taken into account, having an abortion was not associated with anxiety, mood, impulse control or eating disorders, nor were abortions predictive of suicidal ideation.

Additionally, the Turnaway study found that those who had abortions were no worse off mentally than those who did not, and the procedure did not increase women’s risk for post-traumatic stress.

Even so, some anti-abortion groups believe that getting an abortion can be more harmful to a woman’s mental health than being denied one.

“Grief and a feeling of not being fully informed is consistent throughout my clients who report having had an abortion,” Robin Atkins, a licensed mental health counselor who leads the mental health section of the American Association of Pro-Life Obstetricians and Gynecologists, said in an email.

Among women who have an abortion, an analysis of Turnaway data published in 2020 found that five years post-abortion, 84 percent had either primarily positive emotions or no emotions whatsoever about their abortion decision, while 6 percent expressed primarily negative emotions.

The stress of seeking an abortion

The decision to seek an abortion can be emotionally taxing, regardless of whether someone decides to do it or not.

An analysis of Turnaway data published in 2020, led by M. Antonia Biggs, an associate professor in the department of obstetrics, gynecology and reproductive sciences​ at the University of California, San Francisco, found that most people considering abortion perceived some stigma — they felt people in their community or people they were close to would look down on them if they knew they had sought an abortion — and this stigma was associated with psychological distress years later.

Another of Dr. Biggs’s studies, also published in 2020, surveyed 784 people seeking abortion at four facilities in three U.S. states. The women who encountered logistical problems, like spending time trying to seek care, scheduling an appointment or traveling — as well as those who felt forced to wait to have the abortion or to tell other people about their pregnancy — were more likely to have symptoms of stress, anxiety and depression.

Having reproductive autonomy “is extremely important in terms of protecting someone’s mental health and well-being,” Dr. Biggs said.

The more women are denied abortions, experts say, the bigger some of these obstacles might become.

In 2017, Catherine Sullivan was 17 weeks pregnant when she learned that her baby was missing an X chromosome, the result of a rare genetic disorder called Turner Syndrome.

The doctor presented termination as an option. But in Anchorage, where she lived, she could not find a provider who was willing or able to perform the procedure. She began calling clinics in different states and finally located one in Colorado. The cost, $10,000 out of pocket, was out of reach.

“I went through five or six weeks of absolute torture,” Ms. Sullivan recalled. Eventually, at 22 weeks, her daughter died in utero and was delivered at a hospital.

“I am still working through the PTSD of being denied the choice of how to end my pregnancy,” said Ms. Sullivan, 39. “And I still feel shame about having wanted an abortion for this child that I wanted so much.”

Not having the option only caused her “further pain, further anguish, further grief,” she said. “And none of that had to happen.”