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
abortion.
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.
304247)
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
AJPH RESEARCH
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).
AJPH RESEARCH
408 Research Peer Reviewed Foster et al. AJPH March 2018, Vol 108, No. 3
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
AJPH RESEARCH
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
Characteristics
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
Age, y
15–19 16 15 30* 20 18
20–24 40 28 34* 42 35
25–51 44 57 36* 38 46
Race/ethnicity
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
Marital status
Single, never married 80 76 84 78 79
Married 8 11 10 4 9
Separated, divorced, widowed 12 13 6 18 12
Employment
Full time 34 42 22 29 34
Part time 21 23 18 20 21
Not employed 45 35* 60* 51 45
Household structure
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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410 Research Peer Reviewed Foster et al. AJPH March 2018, Vol 108, No. 3
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
Characteristic
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)
Household structure
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).
AJPH RESEARCH
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
30
35
40
45
50
55
60
65
1 week 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Years
Pe
rc
en
t
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
AJPH RESEARCH
412 Research Peer Reviewed Foster et al. AJPH March 2018, Vol 108, No. 3
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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