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Spontaneous abortion or miscarriage may arrive as a shock to the mother as it is sudden and unexpected.
A therapeutically induced abortion is one that is done for medical purposes. In an elective abortion, the mother requests an medical termination of pregnancy (MTP) voluntarily. In both these cases, time may be available to the woman, to mentally prepare herself for the changes she is going to go through.
One in every five pregnant women has an abortion. This is quite a significant factor. In addition, there is an increased risk of abortion in developing countries in comparison to developed countries.
A Cross-Sectional Study of the Psychosocial Problems Following Abortion Sameera Kotta, Umashankar Molangur1, Rajshekhar Bipeta2, Radhika Ganesh3 House Surgeon, 1Professor of Psychiatry and Head of Department, 2Associate Professor of Psychiatry, Department of Psychiatry, 3Assistant Professor of Obstetrics and Gynecology, Gandhi Medical College and Hospital, Hyderabad, Telangana, India
Address for correspondence: Ms. Sameera Kotta, Department of Psychiatry, Gandhi Medical College and Hospital, Musheerabad, Secunderabad, Hyderabad ‑ 500 003, Telangana, India. E‑mail: [email protected]
Background: Twenty percent of pregnant women undergo an abortion. Reviews of previous studies on the effects of abortion on mental health have been inconclusive. Little research has been carried out in this direction in our country. Aims: This study aims to study the psychological effects of abortions and the associated sociodemographic and other parameters. Setting and Design: It is a cross‑sectional study, conducted in five different government hospitals of Hyderabad. Materials and Methods: After identifying the participants, an interview was conducted. First, sociodemographic and other parameters were collected by an interviewer. Then, another interviewer conducted the interview using diagnostic tools (Impact of Events Scale-Revised [IES-R] and Goldberg Health Questionnaire-12 [GHQ-12]). Analysis was carried out using SPSS software. Results: Sixty cases of spontaneous abortion, 31 therapeutic and 9 elective abortions, were collected. Overall, on GHQ-12, 57% women had no distress, 11% had typical distress, while 14% had more than typical distress, 15% had psychological distress, and 3% of them had severe distress. On IES-R, 16% women had little or no symptoms of posttraumatic stress disorder PTSD, 57% had several symptoms, while 27% of them were likely to have PTSD. Conclusions: Women who underwent elective abortion showed less distress than the other types. Those that underwent a late abortion were more likely to suffer from psychological distress than those having an early one. The medical history was a significant factor in determining the mental health outcome of the women who underwent abortion.
Key words: Abortion, India, posttraumatic stress disorder, psychosocial problems
How to cite this article: Kotta S, Molangur U, Bipeta R, Ganesh R. A cross-sectional study of the psychosocial problems following abortion. Indian J Psychiatry 2018;60:217-23.
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In an elective abortion, a woman chooses to terminate her pregnancy by virtue of her own will. They may be stable and content but have not finished their education or already have the number of children they desire. This category also includes women who have abortions because of financial difficulties or unstable relationships. Nevertheless, the discovery of the pregnancy can be a shock, and the period prior to the abortion can be distressing. The process of deciding to have an abortion can be difficult, and the reason for electing to have an abortion can affect the psychological responses after the event.
In either type of abortion, the mother may feel guilty or ashamed of herself, assuming her own actions/neglect to be the cause.
Several research studies have previously been conducted on the effects of abortion on mental health, though reviews have been inconclusive. Some studies lean toward the inference that women do have an increased risk of psychological problems following an abortion,[6-8] whereas some state outright that postabortion syndrome (an unofficial variant of posttraumatic stress disorder [PTSD]) and other long-term psychiatric effects do not exist significantly.[1,4]
There is little literature published on the mental health outcomes of women after second-trimester abortions. Awareness that the fetus has developed completely, increased bonding with the fetus, increased desire to continue the pregnancy, etc., may be reasons for more serious psychological issues arising after late abortions.
Previous studies have called for further research into related topics to gain a stronger insight into the mental health outcomes after abortions. In India, the pressure of myths and society may add to women’s distress. Contrasting between the psychological outcomes of the two types may retrieve relevant risk factors for the development of psychosocial problems in a woman postabortion. Little research has been carried out in India on the psychological health of a woman postabortion, in spite of the factors that differentiate the possible results from other countries.
Objectives 1. To assess the psychological health of women following
an MTP and a spontaneous abortion 2. To study the risk of PTSD in a woman after an abortion 3. To study the associated sociodemographic and other
MATERIALS AND METHODS
Prior approval from the Institutional Ethics Committee was taken before beginning the collection of data.
Study design This was a cross-sectional study.
Inclusion criteria Women of 18–45 years of age who have undergone an abortion were included in the study.
Exclusion criteria Women with psychiatric disorders, mental retardation, and those who do not consent were excluded from the study.
Study setting The study was conducted in the obstetrics and gynecology departments of five government hospitals in Hyderabad, which are attached to medical colleges.
Sampling The study sample included all consecutive women fulfilling inclusion criteria, who have come to the hospital for MTP or after miscarriage, during July, August, and September of 2015.
Study tools 1. Intake proforma: This was a semi-structured
questionnaire that gathered various details regarding the present abortion undergone, sociodemographic parameters, beliefs related to abortion in general, existing children, previous abortions, self-evaluation of discomfort undergone, particulars that made a lasting impact on the individual during the procedures undergone at the hospital, other health problems that may affect the patient’s mental health, and other anticipated risk factors. Previous psychiatric health and substance history of the patient were also taken into account
2. Goldberg General Health Questionnaire-12 (GHQ-12): Introduced by Goldberg, this particular scale consists of 12 questions. It is a quick, reliable, and sensitive short form. It tests for nonspecific psychiatric morbidity. The questions are rated from 1 to 4, with 1 being “Often” and 4 being “Never.” Results obtained from assessments of psychological well-being can be useful in understanding various sources of distress, as well as any predisposing factors. The score obtained is grouped into five classes, determining the distress of the patient. It focuses on two main areas: the inability to carry out normal functions and the appearance of new and distressing phenomenon
3. Impact of Events Scale-Revised (IES-R): This is a questionnaire made by Weiss and Marmar, mainly targeted at diagnosing PTSD according to the DSM-IV criteria. Items are rated from 0 (“not at all”) to 4 (“extremely”). The IES-R yields a total score (ranging from 0 to 88). The total scores may be interpreted into three groups of results. Subscale scores can also be calculated for intrusion, avoidance, and hyperarousal. The intrusion subscale includes items related to intrusive thoughts, nightmares, intrusive feelings, and imagery associated with the traumatic event. The
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avoidance subscale has eight items such as numbing of responsiveness and avoidance of feelings and situations. The new items of the hyperarousal scale added in the revised version of IES help measure hyperarousal symptoms, for example, anger and irritability, heightened startle response, difficulty concentrating, and hypervigilance.
Data collection The patients were first identified from the hospital wards. Written consent was taken, and then a face-to-face interview was conducted by us in the language of the patient’s convenience. The objective details (status of abortion, number of previous abortions, medical history, etc.) were cross-checked in their case sheets. First, sociodemographic and other parameters were collected by an interviewer.
Then, the elements of the diagnostic tools were asked verbally by another interviewer. Thus, the interviewer did not influence the patient’s answers due to bias due to expectation of grief based on the type of abortion.
Statistical analysis The information thus obtained was entered into an MS Excel sheet (MS Excel (2013) Microsoft). Analysis was carried out using SPSS IBM Corp. Released 2013. IBM SPSS Statistics for Windows, (Version 22.0. Armonk, NY, IBM Corp). software. All the sociodemographic parameters were analyzed in simple proportions and the information from the tools (GHQ-12 and IES-R) was cross-tabulated to find the association of mental health issues in relation with sociodemographic parameters.
In the current study, we took 100 Indian women in the age group of 18–35 years. Of the 100 women, 63 (63%) were of the younger age group, 28 (28%) were of the middle age group, and nine (9%) were of the older age group.
Sixty-two (62%) women were Hindu, six (6%) were Christian, and 32 (32%) were Muslim.
All the 100 women were married and had no previous psychiatric history.
Half of the population stayed in a nuclear family and the other half in a joint or extended type of family. For the purpose of this study, joint and extended types were classified as a single category.
Twenty-six (26%) women were illiterate, nine (9%) had completed primary school, 29 (29%) had finished secondary school, 20 (20%) had finished higher secondary school, and nine (9%) were graduates. Eighty-one (81%) women were homemakers and two were unemployed. Twelve (12%) were
laborers and four (4%) were semi-skilled workers. Only one woman was a professional.
Twenty-three (23%) women were of lower middle socioeconomic status, while 77 (77%) were of the upper middle class.
Sixty (60%) cases of spontaneous abortion, 31 (31%) of therapeutic, and nine (9%) of elective abortion were collected from five different government hospitals in the city of Hyderabad.
As shown in Figure 1, the women were also asked to rate their discomfort on a scale of 1–4. Nine (9%) women claimed to have undergone no discomfort. Thirty-four (34%) reported mild discomfort, 36 (36%) moderate, and 21 (21%) felt that they underwent severe discomfort.
Everyone was asked to list the particulars that may have troubled them. As seen in Figure 2, eighty-seven (87%) women felt that there was nothing in particular that left a disturbing impact on them. Four (4%) were disturbed by the behavior of staff toward them, while six (6%) were troubled by overcrowding in the hospital. Another three (3%) were affected by excessively long waiting period before being attended to by the doctors.
After the procedure, 95 (95%) women were confined to bed rest. One woman felt that she had gone back to work too soon after her abortion. Four of them were put through other medical tests or procedures. This was not a statistically significant factor in the determination of risk of mental disease.
Seventy-three (73%) women reported no other medical history. Sixteen (16%) of them had hypertension, two (2%) had hypothyroidism, three (3%) had seizures, two (2%) had AIDS, and three (3%) had anemia. One (1%) woman had more than one problem.
Five (5%) women had a habit of drinking alcohol or toddy, whereas 95 (95%) claimed to have no substance history at all. This was not statistically significant.
The mean GHQ score for elective abortions was 5, for spontaneous abortion, it was 10.9, and 10.03 for therapeutic abortions.
Overall, as shown in Figure 3, on GHQ, 57 (57%) women had no distress. Eleven (11%) had typical distress, while 14 (14%) had more than typical distress. Fifteen (15%) had psychological distress, and three (3%) of them had severe distress.
As seen in Figure 4, the mean IES score for elective abortions was 12.22, for spontaneous type, it was 25.57, and for therapeutic abortions, it was 26.26.
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On IES, 16 (16%) women had little or no symptoms of PTSD. Fifty-seven (57%) had several symptoms, while 27 (27%) of them were likely to have PTSD. On a scale of 0–4, the mean IES intrusion score was 1.1, avoidance score was 1.4, and hyperarousal score was 0.8.
Eighty-six (86%) women had never undergone an abortion before the present one. For nine (9%) women, it was the second time, and it was the third time for another five (5%).
The mean IES and GHQ scores were marginally increased in women who had previously undergone a single abortion than those who had never had an abortion before, as depicted in Figure 5.
For the purpose of this study, an abortion which has occurred after the 20th week of pregnancy has been considered as “late” and before that as “early.”
As seen in Figure 6, the mean GHQ and IES scores are higher in later abortions than earlier ones.
As shown in Table 1, age group was a statistically significant factor in determining the type of abortion; women of 18–24 years were more likely to undergo a spontaneous or therapeutic abortion (were compelled to terminate the pregnancy), whereas women of 25–31 years were more likely to undergo an elective abortion than others. This may be because they felt that they already had enough children or voluntarily terminated their pregnancy due to the anticipation of financial difficulties.
Table 2 indicates that the number of previous living male children played an important role in the determination of type of abortion, probably because of the Indian ideology that a male child completes the family. Number of previous female children was not a significant factor.
Fifty-four (54%) women had no children before the present abortion.
There was no statistical significance between beliefs related to abortion and GHQ scores as shown in Table 3.
As shown in Table 4, there was a statistically significant relation between medical history and GHQ group that the postabortion women came under, probably because the present illness led to abortion and added to mental strain on the woman, causing the general mental health of the woman to deteriorate.
As shown in Table 5, the mean GHQ scores were least in elective type of abortion (5.00), indicating low psychological distress. They were more in therapeutic (10.03) and most in spontaneous type (10.9), which borders between low and typical psychological distress. IES intrusion and avoidance scores were also least in elective abortions and more in
Table 2: Relation between number of male children and type
Number of male children Type Elective Spontaneous Therapeutic
0 2 42 24 1 2 15 6 2 4 3 1 4 1 0 0 Total 9 60 31 P=0.001
Table 3: Relation between beliefs related to abortion and General Health Questionnaire group
Beliefs related to abortion
GHQ group Low
More than typical distress
37 8 12 9 0
Illness 3 0 0 2 0 Woman is at fault
2 1 0 0 0
Curse of God 0 0 1 1 1 Curse of Witchcraft
0 1 0 1 0
God’s wish 13 1 1 2 2 Wrong doing 2 0 0 0 0 Total 57 11 14 15 3 P=0.07. GHQ – General Health Questionnaire
Table 1: Relation between age group and type of abortion
Age group (years) Type Elective Spontaneous Therapeutic
18-24 2 41 20 25-30 4 15 9 31-35 3 4 2 Total 9 60 31 P=0.04
spontaneous and therapeutic abortions. Both intrusion and avoidance scores are slightly higher in therapeutic
Table 4: Relation between medical history and General Health Questionnaire group
GHQ group Low
None 44 6 11 11 1 Hypertension 9 2 3 2 0 Hypothyroidism 0 0 0 2 0 Seizures 3 0 0 0 0 AIDS 1 0 0 0 1 Anemia 0 2 0 0 1 More than one 0 1 0 0 0 Total 57 11 14 15 3 P=0.0001. GHQ – General Health Questionnaire
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type than spontaneous type. Mean hyperarousal score is slightly higher in spontaneous type. The mean avoidance score is higher than intrusion or hyperarousal score in woman who underwent elective abortion. Overall, women undergoing therapeutic abortion showed the highest total scores on IES.
The 100 women who participated in this study were all married, which is a differentiating factor from some other studies related to mental health effects on abortion.[3,9]
In the present study, almost all the patients approached were ready to take part in the study. This may have been because we explained the objectives of the study before taking the interview, and most patients were interested in being evaluated and also in taking part in the greater good that would result from this study for women who undergo future abortions. Furthermore, it may be because we asked each patient for consent personally and they might have felt hesitant to deny it directly. Low participation rate (47%) was a limitation of some studies, which may have caused them to overestimate or underestimate their results.
Overall, 68 (68%) women had no or typical distress on GHQ scale, while 32 (32%) had more than usual distress. Of these 32 women, 14 (14%) had more than typical distress, while 15 (15%) had psychological distress and three (3%) had severe distress, according to the GHQ scale. This differs slightly from the review published by Coleman, wherein it is stated that there is an 81% increase in the risk of mental health problems after an abortion, and 10% of this can prove to be attributable to the abortion.
It is in concordance with the inference that any type of abortion increases the risk of psychological disorders.
The mean GHQ scores were least in elective type of abortion (5.00), indicating low psychological distress. This was probably because the abortion was a result of their own choice. They were more in therapeutic (10.03) and most in spontaneous type (10.9), which borders between low and typical psychological distress. This is in concordance to a study by Broen et al., which inferred that women who had experienced a miscarriage had more overall mental distress
after a short period of time than an induced abortion. It also stated that women who experienced induced abortion had significantly greater IES scores for avoidance than the miscarriage group, and the ones with a miscarriage had significantly higher IES intrusion scores than those with an induced abortion, the findings of which differ from the present study, in which both intrusion and avoidance scores were slightly more elevated in therapeutic type of abortion than miscarriage, although the scores for avoidance were greater than those for intrusion and hyperarousal in women with an elective abortion. This may be because in the previous study, induced and elective abortions were grouped as a single category.
Higher IES scores for therapeutic abortion might be since those with a therapeutic abortion might have had a threatened abortion before the loss of pregnancy and might have been taking extra precautions and measures to save their baby. The death of their baby in spite of taking extra care may have increased their risk for psychological disease.
Higher GHQ scores for spontaneous abortion could be because miscarriage arrives as a shock to the mother, while in therapeutic abortion, she has time to digest the fact that she will no longer be pregnant.
In the present study, 28.3% of women who had a miscarriage and 32% of those with a therapeutic abortion were likely to have PTSD, according to the IES scale. This is different from the previous finding, in which the proportion of women who were likely to have PTSD was 47.5% of those who underwent a miscarriage and 30% of those who underwent induced abortion.
Both IES intrusion and avoidance scores are slightly higher in therapeutic type than spontaneous type. Overall, women undergoing therapeutic abortion showed the highest total scores on IES. Those undergoing elective abortion showed higher avoidance scores than intrusion or hyperarousal score. This agrees with the previous study by Fergusson et al. which stated that induced abortions are associated with slightly higher risk of psychological disorders.
Coleman et al. inferred that higher symptoms of PTSD were reported in later abortions (of the second or third trimesters).
Table 5: Relation between mean scores of all scales and types of abortion Elective Spontaneous Therapeutic Total
Mean SD Mean SD Mean SD Mean SD GHQ score 5.00 3.082 10.90 5.177 10.03 6.003 10.10 5.515 IES (I) 0.11 0.333 1.15 0.755 1.19 0.749 1.07 0.782 IES (A) 1.11 0.601 1.42 0.530 1.48 0.626 1.41 0.570 IES (H) 0.259259 0.5144516 0.816667 0.7095661 0.827957 0.6673384 0.770000 0.6946081 Total IES score 12.22 9.628 25.57 10.774 26.26 11.051 24.58 11.359 IES – Impact of Events Scale; GHQ – General Health Questionnaire; SD – Standard deviation
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Nearly 52.5% and 67.4% in the early and late abortion groups, respectively, met the DSM-IV symptom criteria. This has been verified in the present study (mean GHQ and IES scores were higher in women with late abortions). This might be so because the increased time with the fetus resulted in increase in affection and bonding with it.
Women who had never been through an abortion experienced less distress than those with a single previous abortion, but those with two previous abortions showed less risk of mental disease than the rest of the population. This could be because having an abortion for the third time familiarizes the patient with the procedure, therefore decreasing the stress and fear associated with it. It has been previously stated that repeated abortion increases the risk for mental health problems than that of only a single abortion. Significantly higher distress was noticed in women with multiple abortions. This did not coincide with the present study.
All women were asked about their previous psychiatric history, to confirm that they did not have any diagnosed psychiatric disorder already, which would tamper with the results of the study.
Existing medical history was a statistically significant factor in determining GHQ scores of the patient, probably since the existing health problems added to the mental distress of the patient.
There was no statistical significance of beliefs of the woman. However, lower GHQ scores were observed in women who believed that the abortion was a part of God’s plan. Religion played no significant role in differentiating mental health between different women. This might be because the experience of an abortion is too distressing for beliefs or religion to provide much solace to a person. This does not coincide with the report of the American Psychological Association task force on mental health and abortion, which states that a woman’s experience of abortion may also vary as a function of her religious,
Figure 2: Distribution of population according to particularly impactful factors
Figure 1: Distribution of population according to discomfort undergone due to abortion
Figure 4: Total Impact of Events Scale scores of different types of abortion
Figure 3: Goldberg Health Questionnaire scores of different types of abortion
Figure 6: Comparison between early and late abortionsFigure 5: Mean scores in relation to the number of previous abortions
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spiritual, and moral beliefs and those of others in her immediate social context.
The number of existing male children was a significant factor in determining the type of abortion, i.e., women with enough male children opted voluntarily for elective abortion, though no such statistically significant factor was found for the number of existing female children. This may be a reflection of the fact that the preference for a male child still exists in India, and that many feel that a family is complete only after the birth of a male child.
In the present study, no significant difference was noticed in the IES or GHQ scores of the women who complained about prolonged waiting period, overcrowding, or misbehavior of staff toward them. This does not agree with a prior research on the administration of abortion services which suggests that counseling is often of value that distress is frequently caused by delays in deciding upon and in carrying out abortions and by unsympathetic attitudes of service providers.
Some women with existing children, undergoing abortion, were concerned that they were hospitalized and could not take care of their kids for the next few days.
Behavior of staff toward the patient, activities after the surgery, beliefs related to abortion, and substance history were all factors which were expected to be significant but were not statistically so. This may be because the event of an abortion itself is distressing and the additional factors play only a small role in causing the deterioration of mental health.
Limitations Due to the cross-sectional nature of the study, we could not establish the cause–effect relationship. Since the study involved women from a single city, generalizability may be difficult.
Women who underwent elective abortion seemed to far better on all scales than the other two types. This type was more likely to be opted by women who had existing male children. Therapeutic abortion candidates had higher mean IES scores, whereas spontaneous abortions were associated with marginally higher GHQ scores. Women undergoing a late abortion were more likely to suffer from psychological distress than those having an early one. Medical history was a significant factor determining the mental outcome of the patient.
Suggestions 1. Further studies could be conducted to evaluate specific
risk factors for mental disease postabortion 2. Women undergoing elective abortion could be
3. Families can be more strongly advised to undergo vasectomy rather than tubectomy
4. Women who have lost their fetus/baby could be kept in separate wards.
Acknowledgment We thank Prof. Lakshman Rao, Head, department of Community Medicine, Osmania Medical College, Hyderabad, India and Prof. N. Nageswara Rao, Head, department of Psychiatry, SVR Ruia Hospital, Tirupati, India for their guidance. We sincerely thank Dr. Sameer Valsangkar, Senior Resident, department of Community Medicine, Gandhi Medical College, Hyderabad, India for the help with statistical analysis. We also thank the faculty of the various hospitals that granted permission to conduct this study.
Financial support and sponsorship This study was funded by ICMR, New Delhi as a part of STS scholarship (Reference ID: 2015-01298).
Conflicts of interest There are no conflicts of interest.
1. Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A, et al. Induced abortion: Incidence and trends worldwide from 1995 to 2008. Lancet 2012;379:625-32.
2. Broen AN, Moum T, Bödtker AS, Ekeberg O. Psychological impact on women of miscarriage versus induced abortion: A 2-year follow-up study. Psychosom Med 2004;66:265-71.
3. Broen AN, Moum T, Bødtker AS, Ekeberg O. The course of mental health after miscarriage and induced abortion: A longitudinal, five-year follow-up study. BMC Med 2005;3:18.
4. Charles VE, Polis CB, Sridhara SK, Blum RW. Abortion and long-term mental health outcomes: A systematic review of the evidence. Contraception 2008;78:436-50.
5. Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C. Report of the APA task force on mental health and abortion. http://www. apa.org/pi/wpo/mental-health-abortion-report.pdf. [Last accessed on 2016 July 03).
6. Fergusson DM, Horwood LJ, Boden JM. Abortion and mental health disorders: Evidence from a 30-year longitudinal study. Br J Psychiatry 2008;193:444-51.
7. Dingle K, Alati R, Clavarino A, Najman JM, Williams GM. Pregnancy loss and psychiatric disorders in young women: An Australian birth cohort study. Br J Psychiatry 2008;193:455-60.
8. Coleman PK. Abortion and mental health: Quantitative synthesis and analysis of research published 1995-2009. Br J Psychiatry 2011;199:180-6.
9. Coleman PK, Coyle CT, Rue VM. Late-term elective abortion and susceptibility to posttraumatic stress symptoms. J Pregnancy 2010;2010:130519.
10. Goldberg DP, Blackwell B. Psychiatric illness in general practice. A detailed study using a new method of case identification. Br Med J 1970;1:439-43.
11. Weiss DS, Marmar CR. The impact of event scale-revised. In: Wilson JP, Keane TM, editors. Assessing Psychological Trauma and PTSD: A Practitioner’s Handbook. New York: Guilford Press; 1997. p. 399-411.
12. Freeman EW, Rickels K, Huggins GR, Garcia CR, Polin J. Emotional distress patterns among women having first or repeat abortions. Obstet Gynecol 1980;55:630-6.
13. Illsley R, Hall MH. Psychosocial aspects of abortion. Bull World Health Organ 1976;53:93-106.
Socioeconomic Outcomes of Women Who Receive and Women Who Are Denied Wanted Abortions in the United States
Diana Greene Foster, PhD, M. Antonia Biggs, PhD, Lauren Ralph, PhD, MPH, Caitlin Gerdts, PhD, MHS, Sarah Roberts, DrPH, and M. Maria Glymour, ScD, MS
Objectives. To determine the socioeconomic consequences of receipt versus denial of
Methods.Womenwho presented for abortion just before or after the gestational age
limit of 30 abortion facilities across the United States between 2008 and 2010 were
recruited and followed for 5 years via semiannual telephone interviews. Using mixed
effects models, we evaluated socioeconomic outcomes for 813 women by receipt or
denial of abortion care.
Results. In analyses that adjusted for the few baseline differences, women denied
abortions who gave birth had higher odds of poverty 6 months after denial (adjusted
odds ratio [AOR] = 3.77; P< .001) than did women who received abortions; women denied abortions were also more likely to be in poverty for 4 years after denial of
abortion. Sixmonths after denial of abortion, womenwere less likely to be employed full
time (AOR=0.37; P= .001) andweremore likely to receive public assistance (AOR=6.26;
P < .001) than were women who obtained abortions, differences that remained signif- icant for 4 years.
Conclusions. Women denied an abortion were more likely than were women
who received an abortion to experience economic hardship and insecurity lasting
years. Laws that restrict access to abortion may result in worsened economic out-
comes for women. (Am J Public Health. 2018;108:407–413. doi:10.2105/AJPH.2017.
Since 2011, hundreds of state-level re-strictions on abortion have been imple- mented in the United States. Little is known about the socioeconomic consequences for women and families if women are not able to obtain a wanted abortion. When women are asked why they want to end a pregnancy, the most common reasons are financial—in particular, not having enough money to raise a child or support another child.1–3 Yet no research has evaluated the economic conse- quences for US women of being unable to terminate an unwanted pregnancy and car- rying the pregnancy to term.
The lack of evidence about the socio- economic consequences of barriers to abortion services is largely the result of methodological challenges related to study design and the identification of appropriate
comparison groups.4–6 Given that preexist- ing economic difficulties contribute to a woman’s decision to terminate a preg- nancy, studies that compare socioeconomic outcomes of women who receive abortion services to women who do not choose to terminate a pregnancy may not identify the effects of abortion, but instead may reflect the characteristics that lead women either to seek abortions or carry a pregnancy to term, such as poverty, lack of education, and younger age.7,8
We aimed to examine the effects of re- ceiving versus being denied awanted abortion on women’s socioeconomic well-being by following a group of women who all sought abortions, some of whom were denied ser- vices. Facility and state-imposed gestational age limits restrict abortion for women whose pregnancies are past the limit. Women who request services immediately before a facility’s gestational limit are potentially similar to women who seek services immediately after the limit, but women in the former group receive the abortion whereas the latter do not. Gestational limit thresholds provide a quasi-experiment that can reveal the con- sequences of denial of abortion services on household structure, employment, income, use of public assistance, and poverty in the 5 years after seeking abortion.
METHODS We used data from the Turnaway Study,
a 5-year, longitudinal study of women who presented for abortion care at 1 of 30 facilities throughout the United States between 2008 and 2010. Gestational limits at the study fa- cilities ranged from the end of the first tri- mester to the end of the second. Each facility had the latest gestation age limit of any providerwithin 150miles.9 Study participants were pregnant women with no known fetal anomalies or demise who spoke English or Spanish and were aged 15 years or older. Participants were enrolled into 3 study groups
ABOUT THE AUTHORS Diana Greene Foster, M. Antonia Biggs, Lauren Ralph, Sarah Roberts, and M. Maria Glymour are with University of California, San Francisco. Caitlin Gerdts is with Ibis Reproductive Health, Oakland, CA.
Correspondence should be sent toDianaGreene Foster, PhD, 1330Broadway, Suite 1100,Oakland,CA94612 (e-mail: diana. [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
This article was accepted November 15, 2017. doi: 10.2105/AJPH.2017.304247
March 2018, Vol 108, No. 3 AJPH Foster et al. Peer Reviewed Research 407
in a 2-to-1-to-1 ratio on the basis of ultra- sound dating of gestational age relative to each facility’s limit: (1) near limits presented for abortion up to 2 weeks under the facility’s gestational age limit and obtained wanted abortions, (2) turnaways presented for abor- tion up to 3 weeks over a facility’s limit and were denied abortions, and (3) first trimesters received abortions at gestations up to 14 weeks. The unequal study groups reflect fewer women meeting the criteria for the turnaway group.
Study participants completed a baseline telephone interview 1 week after either re- ceiving or being denied an abortion and follow-up interviews by phone every 6 months for 5 years. Other studies from the Turnaway Study have examined the effect of abortion received and denied on outcomes including mental health,10 emotions,11
physical health,12 violence,13 and achieve- ment of 1-year plans.14 To our knowledge, this is the first to examine socioeconomic outcomes.
Outcome Measures Household structure variables included
household size and whether the woman was livingwith adult familymembers, with amale partner, or without either a male partner or adult family members. Three employment outcomes were assessed: full-time employ- ment, part-time employment, and not employed. We evaluated 3 outcomes related to past-month receipt of public assistance from Special Supplemental Nutrition Pro- gram for Women, Infants, and Children (WIC), Temporary Assistance for Needy Families (TANF), and Supplemental Nutri- tional Assistance Program (SNAP), also known as food stamps. We assessed access to health insurance as a binary indicator for having either private or public health insurance.
Outcomes related to financial security included personal monthly income from employment, child support, and government assistance; household monthly income of all adults living with the respondent who share expenses; poverty, a binary indicator for household income at or below 100% of that specific year’s US Census Bureau federal poverty level (FPL) based on household composition and income15; and subjective
poverty, a dichotomous indicator that the woman reported that she did not always have enough money to meet basic living needs such as food, housing, and transportation in the month before the interview.
Analysis The quasi-experiment established by
abortion facility gestational limits allowed a comparison of socioeconomic outcomes between those who received an abortion and those who were denied. As some women in the turnaway group had an abortion or miscarriage subsequent to being turned away, the turnaway group was divided into birth and no birth for analysis purposes. Compar- ing the near-limit abortion group to the turnaway–birth group is the primary com- parison for this analysis—a comparison that identifies the effect of receiving an abortion versus carrying an unwanted pregnancy to term. We compared turnaway–no births to near limits; if turnaway–no births are more similar to the turnaway–births, this would suggest that characteristics associated with presenting late to an abortion facility predict subsequent socioeconomic outcomes. If turnaway–no births are more similar to the near-limit abortion group, this would sug- gest that carrying an unwanted pregnancy to term is the cause of changes in subsequent socioeconomic outcomes. The comparison of the first-trimester group to the near-limit group assesses whether women who present for an abortion earlier in pregnancy, at a gestation when the majority of abortions occur nationally, have a different socio- economic trajectory than do women who present later.
Because the gestational limits of facilities vary such that a woman could obtain an abortion at the same gestation at one site that she would be denied at another, and because within sites, women who received versus were denied were only a few weeks different in gestation, we expected the near-limit and turnaway groups to be similar at the baseline interview (1week after seeking abortion).We empirically assessed this by comparing base- line characteristics between near limits and turnaway–births and turnaway–no births with linear and logistic mixed effects models to account for clustering of individuals by facility.
Longitudinal analyses used multivariate mixed effects linear and logistic regression models with random intercepts for both re- cruitment facility and individual. In the models, we measured time in months since the mean expected date of delivery, 4.4 months after recruitment, because we ex- pected socioeconomic trajectories to diverge after the birth of a child. Models included a main effect of study group, continuous time in months, and an interaction between study group and months (interpreted as the differ- ence between study groups in rate of change in the outcome). In all longitudinal models, we adjusted for baseline age, parity, and the baseline value of the dependent variable. Ability to report household income was as- sociated with household structure—women living with adult relatives, such as parents, were less likely to know their household income. Therefore, we also controlled for household type at baseline (living with a partner or spouse, with adult family members, or other) to remove systematic bias in household income reporting models in which household structure was not an outcome. In graphs, we presented predicted values derived fromour adjustedmodels by time since seeking abortion from6months to 5 years. For baseline values, we plotted predicted values at baseline, with control for age, parity, and household structure. We assessed differences in predicted probabilities of outcomes at 6-month intervals by using postestimation margins commands.
To examine the effect of denial of abor- tion, regardless of whether the woman re- ceived an abortion elsewhere, we present supplementary intent-to-treat (ITT) analyses comparing near limits women to all turnaway women. In this supplementary analysis, we used instrumental variables analyses to esti- mate the effects of giving birth associated with being denied an abortion, comparing the near-limits women to all turnaway women and accounting for the fraction of turnaway women who either miscarried or obtained an abortion at another facility (Appendix A, available as a supplement to the online version of this article at http://www.ajph.org, pro- vides detailed methods description and the results of ITT and treatment-on-treated [TOT] analyses). All analyses were conducted in Stata version 14.0 (StataCorp LP, College Station, TX).
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RESULTS Among eligible women approached for
study participation, 37.5% (n = 1132) con- sented to take part in the 5-year study. Among those who consented, 85% (n= 956) com- pleted the baseline interview. Participa- tion did not differ between near-limit and turnaway–birth groups. Ninety-two percent of participants who completed the baseline interview were retained at the 6-month follow-up interview and an average of 95% were retained at each subsequent 6-month interview. Of women interviewed at base- line, 58% were retained at the 5-year follow-up, with no differential loss to follow-up between study groups through 5 years.
A total of 452 women were recruited into the near-limit abortion group, 231 women to the turnaway group, and 273 women to the first-trimester group. We removed 76 par- ticipants from 1 facility with a gestational limit of 10 weeks from the analysis because more than 90% of turnaways from that facility in the study ultimately received abortions else- where. We excluded an additional 2 partic- ipants in the near-limit abortion group and 1 in the first-trimester group from analyses because they later reported that they had not had the abortion. Among women in the turnaway group, 5 experienced a miscarriage or stillbirth and 44 received an abortion at a different facility subsequent to being turned away; these women constitute the turnaway– no birth group. Sixty-four of the remaining women completed only the first interview and did not provide follow-up data, bringing the total for this analysis to 813. The final counts by study group include 382 women in the near- limit abortion group, 146 in the turnaway–birth group (including 15 who placed their child for adoption), 45 in the turnaway–no birth group, and 240 in the first trimester group.
Women seeking abortion reported eco- nomic hardships at the time of abortion seeking—half (51%) were living below 100% of the federal poverty level; 3 quarters (76%) reported not having enough money to cover housing, transportation, and food. Most (63%) already had children. Recruitment of participants above and below the gesta- tional limit at each clinic resulted in similar turnaway–birth and near-limit abortion groups. There were no differences by study
group in race, education, or marital status at baseline (Table 1). However, there were age, parity, family structure, and income reporting differences between the turnaway–birth and near-limit groups.Compared withwomen in the near-limits group, those in the turnaway– birth group were more likely to be aged younger than 20 years (30%vs 16%;P= .001), less likely to have children (54% vs 67%; P= .007), more likely to be unemployed (60% vs 45%; P= .002), more likely to be living with other adult family members (49% vs 36%; P= .024), and less likely to re- port household income at baseline (60% vs 73%; P= .004). The association between turnaway–births and missing data on income was largely eliminated by adjustment for household composition, age, and parity (ad- justed P= .205). Reporting of household income improved over time—85% reported their household income at 5 years with no difference by study group. First-trimester par- ticipants had higher household incomes and were less likely to be living in poverty thanwere women in the near-limit or turnaway groups. Turnaway–no birth participants were more similar to near-limit women than to turnaway– births, including a similar, lower gestational age, which may have permitted them to find abortion services elsewhere.
Changes in Household Structure Household size and composition dif-
fered by study group over time (Table 2). Turnaway–births had more people (B= 1.00; 95% confidence interval [CI] = 0.78, 1.22) in their household than near limits at the 6-month interview, which occurred an av- erage of 1.6 months after the expected date of delivery. The difference in household size slowly narrowed over 5 years as women ceased living with adult family members. Turnaway–birth and near-limit women had similar odds of living with a male partner throughout the 5-year follow-up. By 5 years, women in the turnaway–birth group were more likely than were those in the near-limit group to be raising children alone without adult family members or a male partner (47% vs 39%; P= .040).
Changes in Employment Over 5 years, women in the near-limit
group gradually increased full-time
employment—from 40% working full time at 6 months to more than 50% at 5 years. At 6 months, only 30% of women in the turnaway–birth group were working full time, significantly lower than those in the near-limit group (adjusted odds ratio [AOR] =0.37; 95% CI= 0.20, 0.68; Table 2). Women in the turnaway–birth group in- creased full-time employment relative to those in the near-limit group over time so that by 4 years, there was no statistically significant difference between groups. Participants in the turnaway–birth group had more than 3 times the odds of not working at 6 months com- pared with those in the near-limit group (AOR=3.06; 95% CI= 1.78, 5.25), a dif- ference that was no longer statistically significant by 3 years.
Public Assistance and Health Insurance
Turnaway–births had 6-times-higher odds of receiving TANF (AOR=6.26; 95% CI = 2.63, 14.88) at 6 months, when slightly more than 15% of turnaway–births but less than 8% of near limits were receiving TANF (Table 2). Receipt of TANF decreased over time for both groups; by 5 years, the dif- ference between near limits and turnaway– births was no longer statistically significant. At 6 months, one third (33%) of near limits and 44% of turnaway–births received food assistance (SNAP), a significantly higher odds of receipt among turnaway–births (AOR= 2.54; 95% CI = 1.45, 4.44) that remained statistically significant across the 5 years. At 6months, 8% of near limits and 50% of turnaway–births were receiving WIC benefits, an AOR of 48 (95% CI = 21, 109). The difference remained significant over 2 years despite substantial decreases in turnaway–birth WIC receipt over the time period. Turnaway–births were more likely than near-limit women to have health in- surance at 6 months (AOR= 2.54; 95% CI = 1.48, 4.36) but did not retain this advantage after 1 year.
Changes in Income and Poverty Personal income was lower among turn-
away–births compared with near limits at 6 months (–$175; 95% CI= $–342, $–8) but differed little from near limits for the rest of the study period (Table 2). There were no
March 2018, Vol 108, No. 3 AJPH Foster et al. Peer Reviewed Research 409
differences in household income between turnaway–births and near limits at 6 months or over time, but, because of increases in household size, turnaway–births were more
likely to live in poverty. Turnaway–births’ average household incomewas at 110% of the FPL compared with 144% among near limits at 6 months with 61% of turnaway–births and
45% of near limits below the FPL. At 6 months, turnaway–births had almost 4-times- higher odds of being below the FPL (AOR= 3.77; 95% CI= 1.96, 7.25), a difference
TABLE 1—Characteristics of Study Participants Who Completed More Than 1 Interview, by Study Group: United States, 2008–2016
Near-Limit Abortion (n = 382), Mean 6SD or %
First-Trimester Abortion (n = 240), Mean 6SD or %
Turnaway–Birth (n = 146),
Mean 6SD or %
Turnaway–No Birth (n = 45),
Mean 6SD or % Total (n = 813), Mean 6SD or %
Gestational age, weeks 19.9 64.1 7.8 62.4 23.4 63.4 19.3 64.0 16.9 67.0
15–19 16 15 30* 20 18
20–24 40 28 34* 42 35
25–51 44 57 36* 38 46
White 32 40* 25 38 33
Black 32 32 35 31 33
Hispanic/Latina 21 20 27 16 21
Other 15 8* 14 16 13
Nulliparous 33 36 46* 40 37
Highest level of education
< high school 18 16 23 18 18 High school or GED 34 30 36 24 33
Associates, some college, or technical school 41 43 35 49 41
College 7 11 6 9 8
Single, never married 80 76 84 78 79
Married 8 11 10 4 9
Separated, divorced, widowed 12 13 6 18 12
Full time 34 42 22 29 34
Part time 21 23 18 20 21
Not employed 45 35* 60* 51 45
Living with adult family members 36 24* 49* 40 35
Living with spouse or partner 25 32 22 20 26
Living without male partner or family 38 44 29* 40 38
No. of people in the household 3.7 61.8 3.3 61.6* 3.9 61.9 3.6 61.6 3.6 61.7
Income and poverty
Personal monthly income, $ 891 6861 1337 61281* 743 6973 935 6821 996 61040
Household monthly income, $ (n = 586) 1758 61461 2502 62384* 1700 61649 2166 62517 2007 61915
Not reporting household income 27 23 40* 36 28
Not enough money to make ends meet 78 70 83 73 76
Below FPL 57 40* 56 52 51
Receives TANF assistance 12 5* 12 11 10
Receives WIC assistance 14 13 18 11 14
Receives food stamps 31 26 34 40 31
Health insurance 69 69 75 67 70
Note. FPL = federal poverty level15; GED=general equivalency diploma; TANF = Temporary Assistance for Needy Families; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
*P < .05 compared with near-limit abortion group; differences assessed by using mixed effects linear or logistic regression to account for clustering of observations by recruitment facility.
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that persisted through 4 years (Figure 1). Throughout the period between 1 and 5 years after seeking an abortion, turnaway–birth women were more likely than near limits to report subjective poverty—not having enough money to cover basic living expenses (Appendix B, available as a supplement to the online version of this article at http://www.ajph.org).
Intent-to-Treat Analyses Both ITT and TOT effect estimates
showed similar results as the primary analyses (Appendix A). In ITT analyses, we combined the turnaway–birth and turnaway–no birth groups into 1 turnaway group and compared them to near limits; we excluded first
trimesters (Appendix A, Table A, available as a supplement to the online version of this article at http://www.ajph.org). The ITT estimates assessed the effect of turning a woman away from a requested abortion, regardless ofwhether she subsequently carried the pregnancy to term. The TOT estimates described the effect of carrying a pregnancy to term for thosewomenwho did so as a result of being denied an abortion. Both ITT and TOT estimates indicated that economic hardship is associated with denial of abortion services. As expected, given that more than three quarters of turnaway women carried their pregnancies to term, ITT and TOT effect estimates were similar. For all out- comes, the difference between near limits and
turnaway–births was similar or greater than that betweennear limits and all turnaways (Appendix A, Tables B and C, available as a supplement to the online version of this article at http://www. ajph.org). Appendix A, Figure A (available as a supplement to the online version of this article at http://www.ajph.org) shows trends in selected ITTandTOToutcomesby receipt versus denial of abortion services in the United States.
DISCUSSION Many women seeking abortion face
economic hardship; half live below the FPL and three quarters struggle to pay for food, housing, and transportation. Denial of
TABLE 2—Effect of Receiving or Being Denied a Wanted Abortion on Public Assistance, Health Insurance, and Household Structure Over 5 Years, With Control for Baseline Study Group Differences: United States, 2008–2016
Near Limit (Ref) First Trimester Turnaway–Birth
Turnaway–No Birth Months
First Trimester · Month
Turnaway– Birth · Month
Turnaway–No Birth · Month
Public assistance and health
insurance, AOR (95% CI)
Receipt of WIC,a 1 1.23 (0.53, 2.85) 47.86 (21.04, 108.91) 2.16 (0.48, 9.83) 1.04 (0.99, 1.09) 0.97 (0.90, 1.05) 0.89 (0.83, 0.95) 0.90 (0.77, 1.05)
Receipt of TANF 1 0.56 (0.23, 1.37) 6.26 (2.63, 14.88) 0.03 (0.00, 0.48) 0.98 (0.97, 0.99) 1.01 (0.995, 1.04) 0.99 (0.97, 1.01) 1.06 (1.001, 1.13)
Receipt of food stamps 1 0.77 (0.46, 1.26) 2.54 (1.45, 4.44) 0.92 (0.34, 2.46) 1.01 (1.002, 1.01) 1.00 (0.99, 1.01) 1.00 (0.99, 1.01) 0.99 (0.97, 1.01)
Health insurance 1 0.87 (0.56, 1.36) 2.54 (1.48, 4.36) 1.55 (0.64, 3.73) 1.02 (1.01, 1.03) 1.01 (0.995, 1.02) 0.97 (0.96, 0.99) 1.01 (0.98, 1.03)
Resides with family,
AOR (95% CI)
1 0.69 (0.39, 1.23) 1.96 (1.01, 3.82) 0.74 (0.24, 2.28) 0.98 (0.97, 0.99) 1.01 (0.999, 1.02) 0.97 (0.96, 0.98) 0.99 (0.96, 1.01)
Resides with a male
partner, AOR (95% CI)
1 0.88 (0.48, 1.62) 1.05 (0.51, 2.16) 1.50 (0.47, 4.82) 1.02 (1.01, 1.03) 1.01 (0.99, 1.02) 1.00 (0.99, 1.02) 1.05 (1.02, 1.07)
Resides without adult
family or male partner,
AOR (95% CI)
1 1.45 (0.84, 2.49) 0.55 (0.29, 1.06) 1.26 (0.45, 3.49) 1.00 (0.99, 1.01) 0.98 (0.97, 0.995) 1.02 (1.01, 1.04) 0.96 (0.94, 0.98)
No. of people in the
household, B (95%CI)
0 –0.11 (–0.29, 0.08) 1.00 (0.78, 1.22) –0.34 (–0.70, 0.02) 0.001 (–0.001, 0.004) 0.00 (–0.003, 0.01) –0.01 (–0.02, –0.01) 0.01 (–0.003, 0.02)
Employment, AOR (95% CI)
Full time 1 1.01 (0.62, 1.66) 0.37 (0.20, 0.68) 0.98 (0.38, 2.51) 1.02 (1.01, 1.03) 0.99 (0.98, 1.001) 1.01 (0.997, 1.02) 1.02 (1.001, 1.04)
Part time 1 1.27 (0.84, 1.92) 0.71 (0.43, 1.17) 1.87 (0.85, 4.07) 0.99 (0.98, 0.996) 1.01 (0.996, 1.02) 1.02 (1.01, 1.03) 0.98 (0.96, 1.003)
Not working 1 0.78 (0.49, 1.25) 3.06 (1.78, 5.25) 0.51 (0.20, 1.33) 0.99 (0.99, 0.998) 1.00 (0.99, 1.01) 0.98 (0.97, 0.99) 0.98 (0.96, 1.01)
Income and poverty
Personal income, B (95% CI) 0 104.51 (–38.11, 247.14) –175.08 (–342.03, –8.12) –54.22 (–325.16, 216.73) 9.88 (7.13, 12.63) –2.18 (–6.62, 2.27) 2.44 (–2.88, 7.75) 6.79 (–2.08, 15.67)
Household income,b B (95% CI) 0 148.81 (–131.28, 428.90) –91.63 (–435.17, 251.91) –240.05 (–795.96, 315.86) 16.08 (10.65, 21.51) 0.73 (–7.93, 9.40) –3.19 (–13.83, 7.45) 19.1 (1.35, 36.86)
Below the FPL,b AOR (95% CI) 1 0.85 (0.50, 1.45) 3.77 (1.96, 7.25) 1.10 (0.38, 3.20) 1.00 (0.99, 1.01) 1.01 (0.997, 1.03) 0.99 (0.97, 1.01) 0.99 (0.96, 1.02)
Percentage of FPL,b B (95%CI) 0 0.13 (–0.05, 0.32) –0.34 (–0.57, –0.12) –0.05 (–0.41, 0.31) 0.00 (0.0001, 0.01) 0.00 (–0.01, 0.002) 0.00 (–0.005, 0.01) 0.01 (–0.001, 0.02)
Subjective poverty, AOR (95% CI) 1 0.71 (0.46, 1.12) 1.54 (0.88, 2.68) 2.27 (0.91, 5.64) 0.98 (0.97, 0.99) 1.01 (0.998, 1.03) 1.01 (0.99, 1.03) 0.97 (0.94, 0.999)
Note. AOR=adjusted odds ratio; CI = confidence interval; FPL = federal poverty level15; TANF = Temporary Assistance for Needy Families; WIC = Special SupplementalNutrition Program forWomen, Infants, andChildren. n = 813women, 6373observations exceptWIC (n = 812women and 2273 observations) and household income and poverty measures (n = 762 women and 4980 observations). All models were adjusted for baseline age, parity, household structure, and the baseline value of the dependent variable. Study group coefficients and AORs indicate the difference 4.4months after receipt or denial of abortion services. For consistency with the 6-mo increments of our interviews and of the predicted values, we report these as occurring at 6 months in the text of the article. Months refers to the change over time for near limits. Study Group · Month shows how change for that group differs from that of near limits. Estimates presented are AORs for binary outcomes and Bs for continuous outcomes. aModel for receipt of assistance from the WIC program is limited to the first 2 years of the study because of rapidly declining participation over time. bBaseline value is FPL coded as a 3-part categorical variable (below 100% FPL, at or above 100% FPL, missing FPL).
March 2018, Vol 108, No. 3 AJPH Foster et al. Peer Reviewed Research 411
abortion services exacerbates this hardship. We found large and statistically significant differences in the socioeconomic trajectories of women who were denied wanted abor- tions compared with women who received abortions—with women denied abortions facing more economic hardships—even after we accounted for baseline differences. Dif- ferences over time in employment, poverty, and receipt of public assistance suggest that public assistance programs served an impor- tant role in mitigating the loss of full-time employment for women denied an abortion. However, public assistance was not sufficient to support the increase in household size resulting from a new baby, and did not keep households of women denied an abortion from living in poverty. Differences in economic outcomes gradually converged over the 5 years. At the time of seeking an abortion, more than aquarter of allwomen in the studywere living in a household as the only adult with children, and this increased significantly forwomenwhowere denied an abortion, indicating that the burden of raising a child often falls to women alone rather than to couples or an extended family.
Strengths and Limitations This study had several notable strengths
that distinguish it from past research and address the major evidence gap regarding the
economic consequences of policies regulating access to abortion. By studying women who wanted an abortion and comparing women who arrived just before the gestational age limit to women who arrived just after, we removed the major confounding factors re- lated to whether a pregnancy was unwanted. This design enabled us to isolate the effects of receiving a wanted abortion, separate from need or desire to receive an abortion. Our results are robust to several different analytic approaches, confirming that the economic hardship comes not from being denied an abortion itself but from carrying the un- wanted pregnancy to term.
Second, ourmodels controlled for baseline values of each outcome variable. Ideally, this baseline value would have been measured before women learned whether they could obtain an abortion. However, our baseline values were measured 1 week after receipt or denial of abortion. To the extent that women had already reacted to impending parenthood by enrolling in public assistance programs, stopping full-time work, or reporting income inadequacy in the week after being denied an abortion, controlling for these baseline values will underestimate the impact of being denied an abortion.
This study had several limitations. A substantial fraction of women did not know their total household income, particularly at
baseline. This missingness was highly associ- ated with household composition—women who lived with adult family members (often parents) were less likely to know their total household income than women who were the sole adult in the household. To account for this, we controlled for household structure at first interview, which had no missingness, resulting in unbiased estimates, assuming that income values were missing at random conditional on household structure.16 The participation rate in this study was 37.5%, within the range of other large-scale pro- spective studies with 5 years of follow-up.17
Participation was not associated with our main comparison of interest (receipt vs denial of abortion). For ease of interpretation, we have used linear models of trends to sum- marize patterns that are probably not perfectly linear.
Finally, despite our quasi-experimental design, there were differences in economic well-being at baseline between study groups; we controlled for these differences in our models. Consistent with the literature showing that young age and nulliparity are associated with delay in recognition of pregnancy,18–20 we found differences in age and parity by study group. The finding that turnaway–births were less likely to be employed at baseline is consistentwith reports of lower past-month personal income among this group at baseline, likely ruling out the possibility that women had stopped working within the week once they learned they were going to carry a pregnancy to term. We controlled for differences in employment at baseline, yet we still foundmarked differences in trajectories of poverty and public assistance over time between women who received abortions and those who did not. Child support was too low to measure as an in- dependent outcome but was included in household income.
Public Health Implications Given the dynamic and intergenerational
relationship between poverty and health, our finding of the close link between obtaining abortion care and subsequent poverty is important for providers and policymakers. The majority of women in the study were living in poverty at baseline, and carrying the unwanted pregnancy to term led to almost
1 week 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Near limit First trimester Turnaway–birth Turnaway–no birth
Note. Model adjusted for baseline age, parity, household structure, and the baseline value of household poverty. One-week values are given for reference. Remaining outcomes can be found in Appendix B, available as a supplement to the online version of this article at http://www.ajph.org. Unshaded areas represent time periods in which the turnaway–birth group are significantly different (P< .05, based on a postestimation test) from the near-limit abortion group.
FIGURE 1—Trends in Household Poverty for 5 Years After Receipt or Denial of Abortion: United States, 2008–2016
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a 4-fold increase in the odds that a woman’s household income was below the FPL. Re- strictions on abortion that prevent women from obtaining wanted abortions may result in reductions in full-time employment, in- creased incidence of poverty, more women raising children alone, and greater reliance on public assistance. The net result may have serious adverse economic consequences for women and children. Laws that impose a gestational limit for abortion or otherwise restrict access to abortion will result in worsened economic outcomes for women.
CONTRIBUTORS D. Greene Foster contributed to study concept, design, funding, and supervision. D. Greene Foster, M. A. Biggs, L.Ralph, andS.Roberts drafted the article.D.GreeneFoster, L. Ralph, S. Roberts, and M.M. Glymour performed statistical analysis. All authors performed analysis or in- terpretation of data and critical revision of the article for important intellectual content.
ACKNOWLEDGMENTS This study was supported by research and institutional grants from theWallace Alexander Gerbode Foundation, the David and Lucile Packard Foundation, The William and Flora Hewlett Foundation, and an anonymous foundation.
The authors thank Jane Mauldon and an anonymous reviewer for analysis advice; Rana Barar, Heather Gould, and Sandy Stonesifer for study coordination and man- agement; Mattie Boehler-Tatman, Janine Carpenter, Undine Darney, Ivette Gomez, Selena Phipps, Brenly Rowland, Claire Schreiber, and Danielle Sinkford for conducting interviews;Michaela Ferrari,DebbieNguyen, JasminePowell, andElisetteWeiss for project support; and Jay Fraser for database assistance.
Note. The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, re- view, or approval of the article; and decision to submit the article for publication.
HUMAN PARTICIPANT PROTECTION The Turnaway Study was approved by the University of California, San Francisco, Committee on Human Research.
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