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• Published: 02 January 2024

Psychological traits and public attitudes towards abortion: the role of empathy, locus of control, and need for cognition

• Jiuqing Cheng 1 ,
• Ping Xu 2 &
• Chloe Thostenson 1  

Humanities and Social Sciences Communications volume  11 , Article number:  23 ( 2024 ) Cite this article

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In the summer of 2022, the U.S. Supreme Court overturned the historic Roe v. Wade ruling, prompting various states to put forth ballot measures regarding state-level abortion rights. While earlier studies have established associations between demographics, such as religious beliefs and political ideologies, and attitudes toward abortion, the current research delves into the role of psychological traits such as empathy, locus of control, and need for cognition. A sample of 294 U.S. adults was obtained via Amazon Mechanical Turk, and participants were asked to provide their attitudes on seven abortion scenarios. They also responded to scales measuring empathy toward the pregnant woman and the unborn, locus of control, and need for cognition. Principal Component Analysis divided abortion attitudes into two categories: traumatic abortions (e.g., pregnancies due to rape) and elective abortions (e.g., the woman does not want the child anymore). After controlling for religious belief and political ideology, the study found psychological factors accounted for substantial variation in abortion attitudes. Notably, empathy toward the pregnant woman correlated positively with abortion support across both categories, while empathy toward the unborn revealed an inverse relationship. An internal locus of control was positively linked to support for both types of abortions. Conversely, external locus of control and need for cognition only positively correlated with attitudes toward elective abortion, showing no association with traumatic abortion attitudes. Collectively, these findings underscore the significant and unique role psychological factors play in shaping public attitudes toward abortion. Implications for research and practice were discussed.

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The U.S. Supreme Court overturned the long-time landmark ruling of Roe v. Wade in 2022 summer. Debates and legal challenges regarding legal abortion in the U.S. have been heated (Felix et al., 2023 ). Furthermore, residents in several states have or will cast their vote on a ballot measure to determine abortion rights at the state level. A Gallup poll released in 2023 summer found that about one third of voters indicated that they would only vote for a candidate who shared their views on abortion (Saad, 2023 ). Therefore, it is imperative to understand people’s attitudes toward abortion. Past research on such attitudes have mainly focused on the role of political ideology and religious belief (e.g., Hess and Rueb, 2005 ); however, to our knowledge, relatively few studies have been done to examine the psychological underpinnings. Here we propose that examining the correlations between psychological factors and attitudes toward abortion has the potential to make contributions from the perspectives of both research and practice.

First, compared to attitudes in everyday life such as attitudes toward a product or brand, attitudes toward abortion are unique because it often elicits strong emotional response and conflict experience (Foster et al., 2012 ; Scott, 1989 ). Moreover, such an attitude goes beyond individual preference as it is deeply intertwined with one’s moral and religious beliefs, cultural background, and societal norms. Debate on abortion is not merely about a personal choice; it is about the definitions of life, rights, and autonomy (Osborne et al., 2022 ; Scott, 1989 ). For abortion, the contrasting views may lead to polarized opinions. In contrast, disagreements about a product or brand preference are typically less emotionally charged and do not carry the same societal weight. Therefore, given the unique nature of attitudes toward abortion as described above, it remains unclear whether psychological factors that correlate with attitudes in other areas still apply and, if so, in what capacity they do so. Additionally, as introduced below, several studies in this area employed a qualitative approach (interview). While the qualitative approach offered valuable insights into individuals’ perspectives on abortion, we aim to expand upon these findings by employing a quantitative approach. Especially, the quantitative approach allows us to explore the unique relationship between psychology and abortion attitudes after statistically controlling for other powerful factors like religious belief and political ideology. Together, a major goal of the present study is to provide initial empirical evidence for the correlations between attitudes toward abortion and certain psychological factors. We will further detail how our study might fill research gaps when introducing specific psychological factors as described below.

Second, examining the correlations between psychological factors and attitudes toward abortion may also offer practical insights. Consider the role of thinking style, for instance. The decision to pursue an abortion is imperative and often a prominently salient one, impacting not just the pregnant woman but also her family and extensive social network. Such a decision is complex and challenging due to intense feelings (e.g., conflict) and the balance between a woman’s bodily autonomy and fetal rights. From this viewpoint, there might be a correlation between attitudes toward abortion and one’s thinking style, especially their willingness to address complex and difficult issues. Past research has highlighted the connection between rational decision-making and the availability of relevant information (Shafir and LeBoeuf, 2002 ). Hence, to facilitate informed decisions, comprehensive knowledge about abortion is both essential and beneficial. The present study will examine the relationship between thinking style and abortion attitudes. Should a correlation be identified, our study would suggest individuals engage more deeply in critical thinking about the issues of abortion to enhance abortion-related education and informed decision-making.

Together, the present study aims to shed more light on the unique role of psychology in abortion attitudes, particularly in the presence of political ideology and religious belief. Specifically, we choose to examine the factors of empathy, locus of control, and thinking style (need for cognition) based on three considerations. Firstly, from a face validity perspective, the psychological constructs are predicted to exhibit a relationship with abortion attitudes. For example, the internal locus of control aligns well with the pro-choice mantra, ‘my body, my choice. Secondly, as detailed below, although these constructs have been explored in previous studies, they have only received limited attention and their relations with abortion attitudes remain inconclusive. Hence, our study aims to fill the gaps from past research by further clarifying their roles in attitudes toward abortion. Thirdly, research has indicated significant intersections between elements like cognitive style, empathy, and locus of control with various decisions, especially in health contexts (Marton et al., 2021 ; Pfattheicher et al., 2020 ; Xu and Cheng, 2021 ). These elements are tied to motivation, information analysis, and make trade-offs (Fischhoff and Broomell, 2020 ). Building on this, our study seeks to explore the applicability of these factors to the deeply sensitive and polarizing decision of abortion. On the other hand, it is worth noting that the psychological factors examined in our study are not exhaustive or driven by theoretical considerations. However, as mentioned in recent publications (Osborne et al., 2022 ; Valdez et al., 2022 ), past research on abortion attitudes with a psychological perspective is still limited. Therefore, our hope is that the present study could provide initial yet meaningful empirical evidence to exhibit the sophisticated role of psychology in attitudes toward abortion. We detail our rationales for each factor below.

Empathy refers to a variety of cognitive and affective responses, including sharing and understanding, toward others’ experiences (Pfattheicher et al., 2020 ). Previous studies have demonstrated a positive association between empathy and prosocial behaviors, such as caring for others (Moudatsou et al., 2020 ; Klimecki et al., 2016 ), as well as a reduction in conflict and stigma (Batson et al., 1997 ; Klimecki, 2019 ). Recently, Pfattheicher et al. ( 2020 ) also demonstrated that inducing empathy for the vulnerable people could promote taking preventative measures during the Covid-19 pandemic. While researchers advocated for incorporating empathy into abortion-related mental health intervention (Brown et al., 2022 ), the role of empathy in attitudes toward abortion remains understudied. Hunt ( 2019 ) investigated the impact of empathy toward pregnant women by presenting testimonial videos in which a pregnant woman described the challenges she faced due to legal abortion restrictions in Arkansas. However, this manipulation did not significantly reduce participants’ support for the abortion restrictions. Research has found that people’s views on abortion tends to be stable over time (Jelen and Wilcox, 2003 ; Pew Research Center, 2022 ). Hence, a short video used in Hunt ( 2019 ) might not be able to change people’s long-held views on abortion. Instead, we here hypothesize that the pre-existing but not temporality induced empathy play a role in abortion attitudes.

Furthermore, in addition to the empathy toward pregnant woman, it is also reasonable to assume that (some) people may feel empathy toward the unborn. For instance, interviews with Protestant religious leaders exhibited empathy toward both pregnant women and unborn (Dozier et al., 2020 ). Embree ( 1998 ) asked participants to indicate their opinions when responding to different scenarios of abortion. As a result, the study found that 64% and 17% of participants showed a moderate and strong level of empathy for the unborn, respectively. Despite the informative findings, the relationship between attitudes toward abortion and empathy toward the unborn remains unclear, particularly when taking empathy toward pregnant woman and other factors (e.g., political ideology) into account.

Together, we raise three hypotheses regarding the role of empathy as shown below.

H1a: Empathy toward pregnant woman and unborn can coexist.

H1b: People’s empathy toward pregnant woman are positively related to the support toward abortion.

H1c: People’s empathy toward unborn are negatively related to the support toward abortion.

As empathy has been highlighted in the intervention process when dealing with abortion-related mental health issues (Brown et al., 2022 ; Whitaker et al., 2015 ), we hope our findings could generate implications for future research and practice.

Locus of control

Locus of control (LOC) refers to people’s beliefs regarding whether their life outcomes are controlled and determined by their own (internal LOC) or external resources (fate, chance and/or powerful people, external LOC) (Levenson, 1981 ). Before delving into details, it is important to note that the internal and external LOC refer to different dimensions and are not mutually exclusive (Levenson, 1981 ; Reknes et al., 2019 ). For example, a person’s success may be determined by both hardworking and support from others. Regarding abortion attitudes, Sundstrom et al. ( 2018 ) analyzed interview contents and found that some women’s thoughts on pregnancy and abortion aligned with an internal locus of control (e.g., “As women, we need to take control as much as possible of our reproductive health”), while others aligned with an external locus of control (e.g., “leave it in God’s hands…we’ll just play it by ear and if I get pregnant, I get pregnant”).

The findings from Sundstrom et al. ( 2018 ) were informative and consistent with common sense. For example, at face value level, the slogan of “my body my choice” well aligns with the concept of internal LOC. However, the role of internal LOC in abortion attitudes may be more complicated. That is, religious belief may complicate the association between internal LOC and abortion attitudes. Past studies, including a meta-analysis and a study with over 20,000 participants, found a positive relationship between internal LOC and religious belief (Coursey et al., 2013 ; Falkowski, 2000 ; Iles-Caven et al., 2020 ). As noted in these articles, there are similarities between internal LOC and religious belief. For instance, religious beliefs often provide individuals with a sense of meaning, purpose, and guidance in life. Meanwhile, people higher in internal LOC are more likely to report higher levels of existential well-being and purpose in life, which can be associated with religious belief and engagement (Kim-Prieto et al., 2005 ; Krause and Hayward, 2013 ). Thus, the relationship between internal LOC and religious belief may complicate how internal LOC is involved in the abortion attitudes. Sundstrom et al. ( 2018 ) used interviews to explore the role of LOC in thoughts about abortion. However, this method might not sufficiently differentiate the influence of religious beliefs. In this study, we adopt a quantitative approach, using a classical scale to measure LOC. We aim to empirically assess the relationship between internal LOC and attitudes toward abortion, especially when accounting for religious belief. Furthermore, considering that the relationship between internal LOC and abortion attitudes might be intertwined with religious beliefs, we refrain from positing a specific hypothesis at this point.

External LOC, on the other hand, does not appear to have a significant relationship with religious belief. Additionally, a few studies found that people higher in external LOC tended to attribute outcomes to external reasons (Falkowski, 2000 ; Reknes et al., 2019 ). Building on this concept, individuals with a higher external locus of control (LOC) may be more inclined to attribute pregnancy to external factors and place less emphasis on personal responsibility. Accordingly, we predict the hypothesis below.

H2: External LOC will be positively related to the support toward abortion.

Need for cognition

Based on face validity, thinking style might pertain to one’s perception of abortion. For instance, individuals who prioritize comprehensive and empirical data might arrive at a different conclusion than those who lean on personal stories and emotional narratives. A few studies have tapped into the relationship between thinking style and attitudes toward abortion. Valdez et al. ( 2022 ) conducted qualitative interviews on abortion and employed natural language processing techniques to analyze the interviews. The study identified analytical thinking, which involved considering abortion from multiple perspectives, had a negative relationship with the number of cognitive distortions (such as polarized and rigid thinking about abortion). However, such a finding conflicted with another study by Hill ( 2004 ) where the concept of cognitive complexity (thinking beyond surface-level observations) did not correlate with attitudes toward abortion. The inconsistency might be due to methodological issues. For example, the correlations described above in Valdez et al. ( 2022 ) were derived from a small sample consisting of 16 participants. A low reliability of the cognitive complexity scale used in Hill ( 2004 ) might (partly) address the non-significant relationship. Thus, the present study will utilize the Need for Cognition scale, a widely recognized and validated instrument that measures thinking style, to examine its correlation with attitudes toward abortion in a larger sample.

Need for cognition (NFC) pertains to the inclination to derive satisfaction from and actively participate in effortful thinking (Cacioppo et al., 1984 ). Consistent with its concept, past research demonstrated that NFC was positively correlated with information seeking (Verplanken et al., 1992 ), academic achievement (Richardson et al., 2012 ), and logical reasoning performance (Ding et al., 2020 ). As for attitudes toward abortion, we hypothesize the following.

H3: There will be a positive correlation between NFC and attitudes toward abortion.

Our prediction is based on two reasons. First, NFC drives individuals to actively seek and update information and knowledge. It was discovered that acquiring a deeper understanding of abortion correlated with increased support for it (Hunt, 2019 ; Mollen et al., 2018 ). Second and relatedly, NFC was found to be negatively associated with various stereotype memories and positively related to non-prejudicial social judgments (Crawford and Skowronski, 1998 ; Curşeu and de Jong, 2017 ).

In sum, the present study aims to provide empirical evidence for the association between attitudes toward abortion and psychology by examining and clarifying the role of empathy, locus of control, and need for cognition. Past research has repeatedly found the involvement of political ideology and religious belief in abortion attitudes (e.g., Hess and Rueb, 2005 ; Holman et al., 2020 ; Jelen, 2017 ; Osborne et al., 2022 ; Prusaczyk and Hodson, 2018 ). Given their powerful and robust effect, it is crucial to gather additional empirical evidence to elucidate the distinct contribution of psychology to attitudes toward abortion, while considering the influence of political ideology and religious beliefs. Additionally, when describing attitudes toward abortion, the dichotomization of “pro-choice” and “pro-life” have been widely used for decades. However, some studies have criticized that the dichotomization oversimplified attitudes toward abortion (Hunt, 2019 ; Osborne et al., 2022 ; Rye and Underhill, 2020 ). That is, people’s views on abortion vary across different scenarios and reasons. For instance, people showed less support toward abortion with elective reasons than with traumatic reasons (Hoffmann and Johnson, 2005 ). With confirmatory analysis, Osborne et al. ( 2022 ) derived two types of abortion: traumatic (e.g., pregnancy due to rape) vs. elective (e.g., the woman does not want the child anymore). Building on prior research, the current study aims exploring potential variations in attitudes across different abortion reasons. Furthermore, we also intend to examine whether the psychological factors described above have varying associations with different types of abortion.

Participants

The study was approved by IRB before data collection. Participants were recruited from Amazon Mechanical Turk (mTurk) on October 20th, 2022. To be eligible for the study, participants must be an adult, a U.S. citizen, and have an approval rating greater than 98% in mTurk. A total of 300 participants were enrolled into the study. Each participant received $3 for compensation. Six participants did not complete at least 80% of the items and were removed from the study. Thus, the effective sample size was 294. Demographics are presented in the Results section.

Materials and procedures

Participants took an online survey developed by Qualtrics. Our study did not set a specific time restriction. Across 294 participants, the average survey completion time was 682.8 s (SD = 286.6 s). The median completion time was 595.0 s (IQR = 344.8 s). The following questionnaires were completed.

Attitudes toward abortion

Hoffmann and Johnson ( 2005 ) and Osborne et al. ( 2022 ) analyzed attitudes toward abortion with six different scenarios (scenarios a-f below) that were measured by the U.S. General Social Survey. We further added an additional item regarding underage pregnancy for two reasons. First, compared to other Western industrialized nations, the U.S. has historically had a higher rate of underage pregnancies. Additionally, underage pregnant individuals tended to have a higher likelihood of seeking abortions compared to their older counterparts (Lantos et al., 2022 ; Kearney and Levine, 2012 ; Sedgh et al., 2015 ). Second, underage pregnancy is linked to various adverse outcomes, such as increased risk during childbirth, heightened stress and depression, disruptions in education, and financial challenges (Eliner et al., 2022 ; Hodgkinson et al., 2014 ; Kearney and Levine, 2012 ). Given the significance and prevalence of underage pregnancy, we chose to include it as a scenario to understand the public’s perception. Additionally, we understood that people might feel conflict or uncertain toward one or more scenarios. Hence, instead of using binary response (yes/no format) adopted in the U.S. General Social Survey, we employed a 1 to 7 Likert scale for each scenario, with a higher score indicating stronger support for a pregnant woman to obtain legal abortion.

The seven scenarios in the present study included: (a) there is a strong chance of serious defect in the baby; (b) the woman’s own health is seriously endangered by the pregnancy; (c) the woman became pregnant as a result of rape; (d) the woman is married and does not want any more children; (e) the family has a very low income and cannot afford any more children; (f) the woman is not married and does not want to marry the man; and (g) the woman is underage.

Following the wording used to measure empathy in Pfattheicher et al. ( 2020 ), we developed six items to measure the empathy toward the pregnant woman and unborn or fetus, respectively. The scale of empathy toward pregnant woman included: (a) I am very concerned about the pregnant woman who may lose access to legal abortion; (b) I feel compassion for the pregnant women who may lose access to legal abortion; and (c) I am quite moved by the pregnant women who may lose access to legal abortion. The scale of empathy toward unborn included: (a) I am very concerned about the fetus or unborn child; (b) I feel compassion for the fetus or unborn child; and (c) I am quite moved by the fetus or unborn child. Participants rated each item on a five-point Likert scale, with 1 being strongly disagree and 5 being strongly agree. Thus, a higher score demonstrated stronger empathy toward the target. The Cronbach’s α for the scale of toward pregnant woman was 0.90 in the present study. The Cronbach’s α for the scale of toward unborn was 0.92.

The need for cognition scale (NFC, Cacioppo et al., 1984 ) intends to measure the tendency to engage into deep thinking. It has 18 items, such as “I only think as hard as I have to” and “I find satisfaction in deliberating hard and for long hours”. Participants rated each item on a five-point Likert scale, with a higher score indicating a greater tendency to enjoy deep thinking. In the present study, the reliability of this scale was 0.93.

The present study adopted Levenson multidimensional locus of control scale (Levenson, 1981 ). Across 24 items, this scale measures three dimensions of locus of control: internality (sample item: Whether or not I get to be a leader depends mostly on my ability); powerful others (sample item: I feel like what happens in my life is mostly determined by powerful people); and chance (sample item: To a great extent my life is controlled by accidental happenings). In the present study, participants rated each item on a 1 to 6 Likert scale, with a higher score indicating a stronger belief that fate was controlled by self, powerful others, or chance. The Cronbach’s α for the subscales of internality, powerful others, and chance was 0.84, 0.91, and 0.93, respectively. As shown below, there was a high agreement between powerful others and chance subscales ( r  = 0.87, p  < 0.001). Hence, we combined these two subscales to form an external locus of control composite.

Demographics

After completing the scales described above, participants were asked to report their demographic information including race, age, gender, education, annual household income, current relationship status, abortion experience, religious belief, and political ideology. Gender was coded with 1 = male, 2 = female, and 3 = other. Race was coded with 1 = White or Caucasian, 2 = Hispanic or Latinx, 3 = Black or African American, 4 = Asian or Asian American, and 5 = Other. Education was coded with six levels: 1 = Less than high school graduate, 2 = High school graduate or equivalent, 3 = Some college or associate degree, 4 = Bachelor’s degree, 5 = Master’s degree, 6 = Doctoral degree. Annual household income was categorized into 13 levels and ranged between under $9,999 and above $120,000 with increments of $9,999. Current relationship status was coded into six levels: 1 = single and not dating, 2 = single but in a relationship, 3 = married, 4 = divorced, 5 = widowed, 6 = other. For abortion experience participants were asked “For any reason, have you had an abortion?”. For this question, the answer was coded with 1 = yes and 2 = no.

Religious belief was measured with three items. The first item asked “How often do you attend religious services?” Participants selected one option out of the following: 1 = never, 2 = a few times per year, 3 = once a month, 4 = 2–3 times a month, 5 = once a week or more. The second item asked “How important is religion to you personally?” Participants rated this question on a five-point Likert point, with 5 being most important. The third question asked “How would you describe your religious denomination”. The options included 1 = Christian, 2 = Islam, 3 = Judaism, 4 = Buddhism, 5 = Hinduism, 6 = other or atheism. In the present study, the first two items were highly correlated ( r  = 0.77, p  < 0.001). Following Hunt ( 2019 ), we combined the two items to form a general religiosity composite, with a higher score indicating a stronger religious belief.

Political ideology was measured with two items: (a) Generally, how would you describe your views on most social political issues (e.g., education, religious freedom, death penalty, gender issues, etc.)? and (b) Generally, how would you describe your views on most economic political issues (e.g., minimum wage, taxes, welfare programs, etc.)? Participants rated each item with a five-point Likert scale, with 1 = strongly conservative 2 = conservative 3 = moderate 4 = liberal 5 = strongly liberal. We found a strong correlation between the two political ideology items, r  = 0.76, p  < 0.001. Hence, we combined the two items to form a general political ideology composite.

SPSS 24.0 was employed to perform all the analyses. Across 294 participants, age ranged from 21 to 79, with a mean of 40.4 and a standard deviation of 12.4. Table 1 displays the descriptive statistics for the variables of gender, race, education, annual household income, current relationship status, religious denomination, and abortion experience.

Table 2 presents the descriptive statistics of attitudes toward abortion in different scenarios, religious belief, political ideology, and the scores of the psychological scales. Similar to the results obtained from the large-scale surveys in the U.S. and New Zealand (Osborne et al., 2022 ), the support toward abortion was strong (neutral = 4) across all scenarios.

To examine the structure of attitudes toward abortion in different scenarios, a Principal Component Analysis (PCA) with a Varimax orthogonal rotation was performed on all seven scenarios. With eigenvalue ≥ 1 as the threshold, two components were generated, accounting for 81.34% of the variability. Table 3 presents the PCA results. As shown, we obtained two distinct components. The first one included the scenarios of baby defection, pregnant woman’s health being endangered, pregnancy caused by rape, and underage pregnancy. The second component included the scenarios of not wanting the child, low income, and not wanting to marry. Such a differentiation between the two components was consistent with the notion in Osborne et al. ( 2022 ). Following this paper and the face validity of the scenarios, we labeled the two components traumatic abortion and elective abortion, respectively. Accordingly, we also computed a composite score for each component by averaging the corresponding items. In line with previous research (Hoffmann and Johnson, 2005 ), the support was significantly stronger toward the traumatic abortion (mean = 5.84, SD = 1.24) than the elective abortion (mean = 4.94, SD = 1.74), t (293) = 11.51, p  < 0.001, Cohen’s d  = 0.67.

Table 4 presents the zero-order correlations between attitudes toward traumatic and elective abortions, demographics, and scores of the psychological factors. Consistent with the findings from past research (e.g., Hess and Rueb, 2005 ; Holman et al., 2020 ), a stronger religious belief was negatively related to the support toward both types of abortions. A stronger liberal ideology was positively related to the support toward both types of abortions. Additionally, empathy toward the pregnant woman was positively associated with the support toward both types of abortions whereas empathy toward unborn or fetus had an opposite effect. Based on the zero-order correlation, we did not find a significant relationship between internal locus of control and attitudes toward either type of abortion. The external locus of control (either powerful others or chance), on the other hand, was positively related to the support toward elective but not traumatic abortion. As there was a high agreement between the two external locus of control subscales ( r  = 0.87, p  < 0.001), we formed a general external locus of control composite by averaging the two items in the following regressions. Finally, need for cognition was positively related to attitudes toward elective abortion but not traumatic abortion.

While the zero-order correlations were informative, we were mindful that the Type I error might be greatly inflated due to a vast amount of repeated testing. Moreover, one goal of the study was to examine the role of psychological factors in the presence of religious belief and political ideology. Thus, we performed a hierarchical linear regression on each type of abortion, with age, gender, income, and education in the first block, religious belief and political ideology in the second block, and psychological factors in the third block. We separated the regression between the two types of abortion because the role of predictors might vary. This approach was also employed in Osborne et al. ( 2022 ). Table 5 exhibits the regression results.

As shown in Table 5 , the demographic variables of age, gender, education, and income did not account for a significant portion of the variability in attitudes toward either type of abortion. The present study added to the literature that there might not necessarily be a difference in attitudes toward abortion between males and females (Bilewicz et al., 2017 ; Jelen and Wilcox, 1997 ). By contrast, in the second block, religious belief and political ideology collectively explained a sizable portion of the variability in attitudes toward both types of abortion. In block 3, in the presence of demographic variables including religious belief and political ideology, psychological factors could still account for a significant portion of the variability.

Looking at the individual psychological predictors (for more detailed interpretations please refer to the discussion part), consistent with our hypothesis, empathy toward the pregnant woman was positively associated with the support toward both types of abortion. By contrast, empathy toward the unborn or fetus was negatively associated the support toward abortion. For the factor of locus of control, the internal locus of control was not related to any type of abortion attitudes when zero-order correlation was used (Table 4 ); yet it was positively related to abortion attitudes after all other predictors were taken into account, indicating a suppressing effect. Upon further examination, we identified two suppressors: religious belief and empathy toward the unborn. After removing these two variables, internal locus of control was no longer significant. The observed pattern reflected our previous prediction, indicating that the role of internal locus of control could be complicated by religious beliefs. External locus of control, on the other hand, was positively correlated with the support toward elective abortion. Similarly, need for cognition (NFC) also had a positive relationship with the support toward elective abortion. Neither external locus of control nor NFC had a significant correlation with attituded toward traumatic abortion. Hence, our hypotheses regarding external locus of control and NFC were partially supported. We detailed out interpretation and discussion of the results below.

The present study aimed to provide empirical evidence for the correlations between psychological factors and attitudes toward abortion. As introduced earlier, while it is common to find the involvement of psychology in everyday life attitudes and preferences, attitudes toward abortion are unique and drastically different. Given its unique nature, it lacks empirical evidence regarding whether psychological factors that interplay with attitudes in other areas still apply and, if so, in what capacity they do so. Past research has primarily focused on the role of religious belief and political ideology. Our study demonstrated a substantial involvement ( R 2 change = 0.27 and 0.24 for traumatic and elective abortion, respectively) of the psychological factors, after controlling for religious belief and political ideology. More importantly, these effects were comparable to the variability accounted for by religious belief and political ideology combined, particularly in the elective abortion category. The results highlighted the influential role of psychological factors in shaping attitudes toward abortion.

Additionally, past research has shown the interconnection between psychology and the public’s attitudes toward major societal events. For example, during the Covid-19 pandemic, while the perception of mask-wearing and/or social distancing was highly politicized, studies found that attitudes toward these preventative measures to be related to thinking style, self-control, numeracy, and working memory capacity (Steffen and Cheng, 2023 ; Xie et al., 2020 ; Xu and Cheng, 2021 ). In line with this, our study further underscored the significant influence of psychology on another pressing societal topic: abortion. In the sections below, we detail our findings and relevant implications. We are fully aware that our study was preliminary and hope it could serve as a starting point for future research and practice. We also acknowledge the limitations of our study and address them at the end.

Some past studies on empathy and abortion only considered the empathy toward the pregnant woman (e.g., Brown et al., 2022 ; Homaifar et al., 2017 ; Hunt, 2019 ; Whitaker et al., 2015 ). The present study identified two types of empathy when dealing abortion: empathy toward the pregnant woman and empathy toward the unborn. In the presence of each other, we found that greater empathy toward the pregnant woman was associated with more support toward abortion, whereas greater empathy toward the unborn or fetus was associated with less support toward abortion. Such a pattern suggested that empathy might be a source of conflict feeling. That is, when considering abortion, concerns and care toward pregnant woman and unborn could coexist, potentially leading to conflict and dilemma when people thought about abortion. While the present study examined the public’s attitudes toward abortion with a diverse sample, pregnant women might have a similar pattern of empathy and hence feel conflict and dilemma when thinking about abortion. To cope with such a conflict, it might be beneficial for a counselor to acknowledge conflicting emotions that arise from empathizing with both the unborn and the pregnant individual. Moreover, the counselor could guide the client through the process of reconciling these emotions to alleviate feelings of isolation or confusion the client may experience. Future research in the realms of mental health and counseling should consider integrating these dual empathy perspectives and empirically assess the efficacy of such therapeutic interventions.

Additionally, Hunt ( 2019 ) did not find a significant influence of empathy on abortion attitudes change when participants were exposed to testimonial videos featuring pregnant women discussing the legal obstacles they faced. The disparity between Hunt’s ( 2019 ) findings and our own could potentially be attributed to the inherent stability and longstanding nature of abortion attitudes. Research has found that people’s views on abortion tends to be stable over time (Jelen and Wilcox, 2003 ; Pew Research Center, 2022 ). As a result, it is possible that pre-existing empathy, rather than empathy induced temporarily, was the factor correlated with individuals’ perception and consideration of abortion. Our findings were consistent with this possibility. Together, our findings supported H1a to H1c. Moreover, our study shed more light on empathy by showing its association with distinct views on abortion. The results suggest that future research could investigate how different types of empathy are formed and how they influence the shaping and persuasion of abortion attitudes.

Through qualitative interviews, Sundstrom et al. ( 2018 ) unveiled individual differences in the locus of control when discussing opinions on abortion. However, these interviews might not have fully captured the interplay between internal and external locus of control and other factors involved attitudes toward abortion. To fill the gap, our study employed a quantitative approach to delve deeper into how locus of control correlated with abortion attitudes. Consistent with Levenson ( 1981 ) and Reknes et al. ( 2019 ), we found that the constructs internal locus of control and external locus of control were differentiated but not unidimensional. For internal locus of control, interestingly, we found a suppressing effect. As discussed earlier, the role of internal locus of control in abortion attitudes might be complicated. That is, on the one hand, by face validity, the internal locus of control well aligned with the concept of “my body, my choice” (Sundstrom et al., 2018 ). On the other hand, in line with past research (Coursey et al., 2013 ; Falkowski, 2000 ; Iles-Caven et al., 2020 ), our study found that internal locus of control was positively related to religious belief. Furthermore, as shown in Table 4 , internal locus of control was also positively related to the empathy toward the unborn, and such a relationship was significantly mediated by religious belief (mediation effect = 0.21, SE = 0.5, 95% CI = [0.13, 0.31]). Therefore, when using zero-order correlation, the effect of internal locus of control might be neutralized by the two opposite parts (“my body, my choice” vs. religious belief) discussed above. By contrast, in regression, the “my body, my choice” part stood out because the religiosity part was partialled out by the variables of religious belief and empathy toward the unborn.

In addition to internal locus of control, we also discovered that external locus of control was involved in abortion attitudes. Specifically, we found a positive relationship between external locus of control and support toward elective abortion (H2 was partially supported). Past research has found that locus of control is related to attribution (Falkowski, 2000 ; Reknes et al., 2019 ). Thus, our finding was in line with the notion that those with a greater level of external locus of control might be more likely to attribute unwanted pregnancy to external reasons (not personal responsibility), and hence showed more support toward abortion.

Our findings regarding locus of control suggest that individuals might simultaneously believe in personal autonomy (“my body, my choice”) while also feeling that certain life events, like unwanted pregnancies, are influenced by external factors beyond their control. This is particularly true when thinking about elective abortion. Education and counseling practices might be designed to reflect this duality. For example, materials and discussions could simultaneously emphasize the importance of personal choices and responsibilities, while also exploring societal, cultural, or circumstantial factors that might influence abortion decision. Incorporating both perspectives would allow to create a supportive environment where individuals feel seen and acknowledged in their complexities.

As introduced earlier, past research on the relationship between thinking style and abortion attitudes was inconclusive. To clarify the relationship, the present study adopted the validated need for cognition scale. Need for cognition has demonstrated its involvement in consequential events, such as political elections and the adoption of preventive measures during the Covid-19 pandemic (Sohlberg, 2019 ; Xu and Cheng, 2021 ). In the present study, we discovered that need for cognition was positively related to the support toward elective abortion. Such a finding was consistent with the notion that need for cognition was negatively related to stereotypes (Crawford and Skowronski, 1998 ; Curşeu and de Jong, 2017 ). Additionally, as need for cognition drives individuals to seek and update knowledge, our result was also in line with the finding that gaining knowledge about abortion led to more positive view on abortion (Hunt, 2019 ; Mollen et al., 2018 ). Our study implied that future research could empirically evaluate if indeed abortion knowledge mediates the relationship between need for cognition and abortion attitudes.

It is worth noting that the present study also clarified the role of need for cognition in attitudes toward abortion by examining a potential artifact. Specifically, the observed positive relationship between need for cognition and support for abortion might be an artifact, given that liberal ideology is positively correlated with both abortion attitudes and need for cognition (Young et al., 2019 ). However, as shown in our regression, the relationship between need for cognition and elective abortion remained significant in the presence of other variables, including political ideology. Thus, the finding suggested that at least part of the relationship between need for cognition and attitude toward abortion was unique and not driven by political ideology.

Our findings related to need for cognition had an implication on abortion-related education. As discussed earlier, having adequate knowledge about abortion could facilitate the support for making informed decisions. As need for cognition was found to be related to openness and motivation to seek and update information (Russo et al., 2022 ), our finding suggested that cultivating willingness to engage into critical thinking might be beneficial for education on abortion and reproductive rights. While we are fully aware that correlation does not equate to causation, our study still offers a starting point for future research and practice on abortion-related education.

Traumatic abortion vs. elective abortion

While some researchers argued that the dichotomization of “pro-choice” and “pro-life” was oversimplified, to date, only two studies have empirically examined attitude variation between different abortion scenarios (Hoffmann and Johnson, 2005 ; Osborne et al., 2022 ). Both studies demonstrated that public views on abortion can be grouped into two categories: traumatic and elective. Our research not only replicated these findings but also introduced two significant advancements. First, we incorporated a scenario addressing underage pregnancy, given its high prevalence and significance. Secondly, instead of a binary response, we employed a 7-point Likert scale, allowing us to more accurately capture potential conflicting attitudes among participants.

Furthermore, our findings revealed that the roles of external locus of control and need for cognition varied in relation to attitudes toward the two types of abortion. Interestingly, we observed that neither of these variables significantly related to attitudes toward traumatic abortion, as indicated by both zero-order correlation and regression analyses. Conceptually, the scenarios of traumatic abortion (e.g., pregnancy caused by rape; mother life endangered) tend to be more extreme and emergent than the scenarios of elective abortion. Hence, there might be less room for psychological factors, such as thinking or attribution, to function in traumatic abortion than in elective abortion. Our interpretation was also consistent with the statistical pattern between the two abortions. That is, compared to elective abortion, the standard deviation of traumatic abortion was smaller. Additionally, there were more participants rated seven on the Likert scale in the scenarios of traumatic abortion (29.6%) than in the scenarios of elective abortion (18%). Despite the difference between the two types of abortion, it is essential to acknowledge that elective abortion does not imply a stress-free experience. Both traumatic and elective abortions involve significant levels of stress and emotional challenges. While traumatic abortion scenarios can be considered more extreme, it is crucial to recognize that individuals undergoing elective abortion may also experience considerable emotional distress.

Taken together, with concrete evidence, our study demonstrated that the public’s attitude toward abortion depended on abortion reasons. Our study also implied that future research should focus on attitudes toward specific abortion scenarios rather than a holistic concept of abortion. Furthermore, the differentiation between the traumatic and elective abortions suggested the limitation and potential ineffectiveness of one-size-fits-all legislative solutions. Given the varying and often conflicting attitudes that people harbor, it would be reasonable for legislative frameworks to be flexible, adaptive, and cognizant of the different circumstances surrounding abortion. This will not only be more reflective of public opinions but also more supportive of individuals who undergo different types of abortion experiences, each of which carries its own set of emotional and psychological challenges.

Expanding findings with a quantitative approach

Some past studies employed a qualitive approach when dealing with attitudes toward abortion (e.g., Dozier et al., 2020 ; Sundstrom et al., 2018 ; Valdez et al., 2022 ; Woodruff et al., 2018 ). These investigations have provided insights and served as inspirations for our own research. However, the relationship between abortion attitudes and pertinent factors may remain somewhat opaque. This is particularly true when considering the intricate interconnectedness among these factors. The present study demonstrated that findings from qualitative studies could be extended and enriched with a quantitative approach. For instance, we utilized quantitative scales to measure empathy toward the unborn —a variable that was previously identified through interviews in the study by Dozier et al. ( 2020 ). Moreover, we further exhibited the role of empathy toward the unborn when statistically controlled other variables, including empathy toward the pregnant. Similarly, the role of internal locus of control was revealed in interviews in Sundstrom et al. ( 2018 ). With validated scales, we exhibited the correlation with internal locus of control in both types of abortion. Furthermore, by detecting and interpreting a suppressing effect, we showed the interplay between internal locus of control, religious belief, and attitude toward abortion. Thus, our study implied that using quantitative scales and analyses was a viable approach to examine attitude toward abortion and could deepen the understanding of relevant factors.

Limitations and future directions

Despite the contributions, limitations should be acknowledged as well. First and foremost, we believe our study was still in the explorative stage. The specific psychological factors tested in the present study were not exhaustive and not theoretically driven. We hope the present study could provide initial empirical evidence to show the sophisticated role of psychology in attitudes toward abortion. Future studies could use a more theoretical driven approach to examine the specific psychological involvement in abortion attitudes. For example, given the correlation between need for cognition and attitudes toward abortion, future research could further elucidate the role of thinking style in attitudes toward abortion by incorporating the Dual-Process Theory (Evans, 2008 ). The Dual-Process Theory posits that humans have two distinct systems of information processing: System 1, which is intuitive, automatic, and fast; and System 2, which is deliberate, analytical, and slower. By examining the interplay between these two systems, researchers might gain insights into how intuitive emotional responses versus more deliberate cognitive analyses influence individuals’ attitudes toward abortion. For instance, are individuals who predominantly rely on System 1 more swayed by emotive narratives or imagery related to abortion?

Second, when analyzing and discussing the results, we proposed several possible underlying mechanisms that might elucidate the relationships observed. To illustrate, we employed the concept of attribution to shed light on the role of an external locus of control, positing that individuals with a strong external locus might attribute abortion decisions to external factors or circumstances rather than personal choices. Furthermore, we suggested that the observed positive relationship between the need for cognition and abortion attitudes might be mediated through abortion knowledge. This implies that individuals with a higher need for cognition could potentially seek out more information on abortion, leading to more informed attitudes. However, while these interpretations offer potential insights, we recognize their speculative nature. It’s crucial to emphasize that our proposed mechanisms require rigorous empirical testing for validation. For example, it would be of interest to test whether indeed, gaining various types of abortion knowledge improves views of abortion.

Third, as described above, we strived to show how our findings could be potentially used in abortion-related counseling. However, we acknowledge that our study is explorative but not counseling focused. Therefore, while we believe our findings offer meaningful implications, we caution against over-extrapolating their direct applicability to counseling contexts. Future research could delve into empirically investigating how psychological factors, such as varying empathy types and loci of control, could be utilized to alleviate negative feelings associated with abortion decisions. Additionally, understanding how various psychological factors interact with cultural and social norms could further help tailor counseling approaches.

Fourth, the present study did not include an attention check item. We believe the quality of our survey could have been improved had we included one or more attention check items. However, the reliabilities of our scales were relatively high (ranged from 0.84 to 0.93). Additionally, we also replicated some major findings from previous research (e.g., the associations between attitudes toward abortion and religious belief and political ideology). Thus, we believe that overall, inattention did not affect the quality of our data. Future online surveys could consider using attention check items for quality control.

In conclusion, the present study demonstrates the unique contribution of empathy, locus of control, and need for cognition to how people perceived abortion in different scenarios. The findings suggests that attitudes toward complex moral issues like abortion are shaped by individual psychological traits and cognitive needs, in addition to societal, religious, and cultural norms. Future research could use our study as a starting point to expand on these findings, exploring other psychological traits and cognitive processes that may similarly affect perceptions of abortion and other controversial subjects.

Data availability

Data included in this project may be found in the online repository, https://doi.org/10.7910/DVN/E5AB5R .

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Cheng, J., Xu, P. & Thostenson, C. Psychological traits and public attitudes towards abortion: the role of empathy, locus of control, and need for cognition. Humanit Soc Sci Commun 11 , 23 (2024). https://doi.org/10.1057/s41599-023-02487-z

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• Published: 28 June 2021

Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol

• Foluso Ishola   ORCID: orcid.org/0000-0002-8644-0570 1 ,
• U. Vivian Ukah 1 &
• Arijit Nandi 1  

Systematic Reviews volume  10 , Article number:  192 ( 2021 ) Cite this article

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A country’s abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women’s access to and use of health services, as well as their health outcomes, is uncertain. First, there are methodological challenges to the evaluation of abortion laws, since these changes are not exogenous. Second, extant evaluations may be limited in terms of their generalizability, given variation in reforms across the abortion legality spectrum and differences in levels of implementation and enforcement cross-nationally. This systematic review aims to address this gap. Our aim is to systematically collect, evaluate, and synthesize empirical research evidence concerning the impact of abortion law reforms on women’s health services and outcomes in LMICs.

We will conduct a systematic review of the peer-reviewed literature on changes in abortion laws and women’s health services and outcomes in LMICs. We will search Medline, Embase, CINAHL, and Web of Science databases, as well as grey literature and reference lists of included studies for further relevant literature. As our goal is to draw inference on the impact of abortion law reforms, we will include quasi-experimental studies examining the impact of change in abortion laws on at least one of our outcomes of interest. We will assess the methodological quality of studies using the quasi-experimental study designs series checklist. Due to anticipated heterogeneity in policy changes, outcomes, and study designs, we will synthesize results through a narrative description.

This review will systematically appraise and synthesize the research evidence on the impact of abortion law reforms on women’s health services and outcomes in LMICs. We will examine the effect of legislative reforms and investigate the conditions that might contribute to heterogeneous effects, including whether specific groups of women are differentially affected by abortion law reforms. We will discuss gaps and future directions for research. Findings from this review could provide evidence on emerging strategies to influence policy reforms, implement abortion services and scale up accessibility.

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PROSPERO CRD42019126927

Peer Review reports

An estimated 25·1 million unsafe abortions occur each year, with 97% of these in developing countries [ 1 , 2 , 3 ]. Despite its frequency, unsafe abortion remains a major global public health challenge [ 4 , 5 ]. According to the World health Organization (WHO), nearly 8% of maternal deaths were attributed to unsafe abortion, with the majority of these occurring in developing countries [ 5 , 6 ]. Approximately 7 million women are admitted to hospitals every year due to complications from unsafe abortion such as hemorrhage, infections, septic shock, uterine and intestinal perforation, and peritonitis [ 7 , 8 , 9 ]. These often result in long-term effects such as infertility and chronic reproductive tract infections. The annual cost of treating major complications from unsafe abortion is estimated at US$ 232 million each year in developing countries [ 10 , 11 ]. The negative consequences on children’s health, well-being, and development have also been documented. Unsafe abortion increases risk of poor birth outcomes, neonatal and infant mortality [ 12 , 13 ]. Additionally, women who lack access to safe and legal abortion are often forced to continue with unwanted pregnancies, and may not seek prenatal care [ 14 ], which might increase risks of child morbidity and mortality.

Access to safe abortion services is often limited due to a wide range of barriers. Collectively, these barriers contribute to the staggering number of deaths and disabilities seen annually as a result of unsafe abortion, which are disproportionately felt in developing countries [ 15 , 16 , 17 ]. A recent systematic review on the barriers to abortion access in low- and middle-income countries (LMICs) implicated the following factors: restrictive abortion laws, lack of knowledge about abortion law or locations that provide abortion, high cost of services, judgmental provider attitudes, scarcity of facilities and medical equipment, poor training and shortage of staff, stigma on social and religious grounds, and lack of decision making power [ 17 ].

An important factor regulating access to abortion is abortion law [ 17 , 18 , 19 ]. Although abortion is a medical procedure, its legal status in many countries has been incorporated in penal codes which specify grounds in which abortion is permitted. These include prohibition in all circumstances, to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, and on request with no requirement for justification [ 18 , 19 , 20 ].

Although abortion laws in different countries are usually compared based on the grounds under which legal abortions are allowed, these comparisons rarely take into account components of the legal framework that may have strongly restrictive implications, such as regulation of facilities that are authorized to provide abortions, mandatory waiting periods, reporting requirements in cases of rape, limited choice in terms of the method of abortion, and requirements for third-party authorizations [ 19 , 21 , 22 ]. For example, the Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds. It is considered liberal, as it permits legal abortions for more indications than most countries in Sub-Saharan Africa; however, abortions must only be provided in registered hospitals, and three medical doctors—one of whom must be a specialist—must provide signatures to allow the procedure to take place [ 22 ]. Given the critical shortage of doctors in Zambia [ 23 ], this is in fact a major restriction that is only captured by a thorough analysis of the conditions under which abortion services are provided.

Additionally, abortion laws may exist outside the penal codes in some countries, where they are supplemented by health legislation and regulations such as public health statutes, reproductive health acts, court decisions, medical ethic codes, practice guidelines, and general health acts [ 18 , 19 , 24 ]. The diversity of regulatory documents may lead to conflicting directives about the grounds under which abortion is lawful [ 19 ]. For example, in Kenya and Uganda, standards and guidelines on the reduction of morbidity and mortality due to unsafe abortion supported by the constitution was contradictory to the penal code, leaving room for an ambiguous interpretation of the legal environment [ 25 ].

Regulations restricting the range of abortion methods from which women can choose, including medication abortion in particular, may also affect abortion access [ 26 , 27 ]. A literature review contextualizing medication abortion in seven African countries reported that incidence of medication abortion is low despite being a safe, effective, and low-cost abortion method, likely due to legal restrictions on access to the medications [ 27 ].

Over the past two decades, many LMICs have reformed their abortion laws [ 3 , 28 ]. Most have expanded the grounds on which abortion may be performed legally, while very few have restricted access. Countries like Uruguay, South Africa, and Portugal have amended their laws to allow abortion on request in the first trimester of pregnancy [ 29 , 30 ]. Conversely, in Nicaragua, a law to ban all abortion without any exception was introduced in 2006 [ 31 ].

Progressive reforms are expected to lead to improvements in women’s access to safe abortion and health outcomes, including reductions in the death and disabilities that accompany unsafe abortion, and reductions in stigma over the longer term [ 17 , 29 , 32 ]. However, abortion law reforms may yield different outcomes even in countries that experience similar reforms, as the legislative processes that are associated with changing abortion laws take place in highly distinct political, economic, religious, and social contexts [ 28 , 33 ]. This variation may contribute to abortion law reforms having different effects with respect to the health services and outcomes that they are hypothesized to influence [ 17 , 29 ].

Extant empirical literature has examined changes in abortion-related morbidity and mortality, contraceptive usage, fertility, and other health-related outcomes following reforms to abortion laws [ 34 , 35 , 36 , 37 ]. For example, a study in Mexico reported that a policy that decriminalized and subsidized early-term elective abortion led to substantial reductions in maternal morbidity and that this was particularly strong among vulnerable populations such as young and socioeconomically disadvantaged women [ 38 ].

To the best of our knowledge, however, the growing literature on the impact of abortion law reforms on women’s health services and outcomes has not been systematically reviewed. A study by Benson et al. evaluated evidence on the impact of abortion policy reforms on maternal death in three countries, Romania, South Africa, and Bangladesh, where reforms were immediately followed by strategies to implement abortion services, scale up accessibility, and establish complementary reproductive and maternal health services [ 39 ]. The three countries highlighted in this paper provided unique insights into implementation and practical application following law reforms, in spite of limited resources. However, the review focused only on a selection of countries that have enacted similar reforms and it is unclear if its conclusions are more widely generalizable.

Accordingly, the primary objective of this review is to summarize studies that have estimated the causal effect of a change in abortion law on women’s health services and outcomes. Additionally, we aim to examine heterogeneity in the impacts of abortion reforms, including variation across specific population sub-groups and contexts (e.g., due to variations in the intensity of enforcement and service delivery). Through this review, we aim to offer a higher-level view of the impact of abortion law reforms in LMICs, beyond what can be gained from any individual study, and to thereby highlight patterns in the evidence across studies, gaps in current research, and to identify promising programs and strategies that could be adapted and applied more broadly to increase access to safe abortion services.

The review protocol has been reported using Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 40 ] (Additional file 1 ). It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database CRD42019126927.

Eligibility criteria

Types of studies.

This review will consider quasi-experimental studies which aim to estimate the causal effect of a change in a specific law or reform and an outcome, but in which participants (in this case jurisdictions, whether countries, states/provinces, or smaller units) are not randomly assigned to treatment conditions [ 41 ]. Eligible designs include the following:

Pretest-posttest designs where the outcome is compared before and after the reform, as well as nonequivalent groups designs, such as pretest-posttest design that includes a comparison group, also known as a controlled before and after (CBA) designs.

Interrupted time series (ITS) designs where the trend of an outcome after an abortion law reform is compared to a counterfactual (i.e., trends in the outcome in the post-intervention period had the jurisdiction not enacted the reform) based on the pre-intervention trends and/or a control group [ 42 , 43 ].

Differences-in-differences (DD) designs, which compare the before vs. after change in an outcome in jurisdictions that experienced an abortion law reform to the corresponding change in the places that did not experience such a change, under the assumption of parallel trends [ 44 , 45 ].

Synthetic controls (SC) approaches, which use a weighted combination of control units that did not experience the intervention, selected to match the treated unit in its pre-intervention outcome trend, to proxy the counterfactual scenario [ 46 , 47 ].

Regression discontinuity (RD) designs, which in the case of eligibility for abortion services being determined by the value of a continuous random variable, such as age or income, would compare the distributions of post-intervention outcomes for those just above and below the threshold [ 48 ].

There is heterogeneity in the terminology and definitions used to describe quasi-experimental designs, but we will do our best to categorize studies into the above groups based on their designs, identification strategies, and assumptions.

Our focus is on quasi-experimental research because we are interested in studies evaluating the effect of population-level interventions (i.e., abortion law reform) with a design that permits inference regarding the causal effect of abortion legislation, which is not possible from other types of observational designs such as cross-sectional studies, cohort studies or case-control studies that lack an identification strategy for addressing sources of unmeasured confounding (e.g., secular trends in outcomes). We are not excluding randomized studies such as randomized controlled trials, cluster randomized trials, or stepped-wedge cluster-randomized trials; however, we do not expect to identify any relevant randomized studies given that abortion policy is unlikely to be randomly assigned. Since our objective is to provide a summary of empirical studies reporting primary research, reviews/meta-analyses, qualitative studies, editorials, letters, book reviews, correspondence, and case reports/studies will also be excluded.

Our population of interest includes women of reproductive age (15–49 years) residing in LMICs, as the policy exposure of interest applies primarily to women who have a demand for sexual and reproductive health services including abortion.

Intervention

The intervention in this study refers to a change in abortion law or policy, either from a restrictive policy to a non-restrictive or less restrictive one, or vice versa. This can, for example, include a change from abortion prohibition in all circumstances to abortion permissible in other circumstances, such as to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, or on request with no requirement for justification. It can also include the abolition of existing abortion policies or the introduction of new policies including those occurring outside the penal code, which also have legal standing, such as:

National constitutions;

Supreme court decisions, as well as higher court decisions;

Customary or religious law, such as interpretations of Muslim law;

Medical ethical codes; and

Regulatory standards and guidelines governing the provision of abortion.

We will also consider national and sub-national reforms, although we anticipate that most reforms will operate at the national level.

The comparison group represents the counterfactual scenario, specifically the level and/or trend of a particular post-intervention outcome in the treated jurisdiction that experienced an abortion law reform had it, counter to the fact, not experienced this specific intervention. Comparison groups will vary depending on the type of quasi-experimental design. These may include outcome trends after abortion reform in the same country, as in the case of an interrupted time series design without a control group, or corresponding trends in countries that did not experience a change in abortion law, as in the case of the difference-in-differences design.

Outcome measures

Primary outcomes.

Access to abortion services: There is no consensus on how to measure access but we will use the following indicators, based on the relevant literature [ 49 ]: [ 1 ] the availability of trained staff to provide care, [ 2 ] facilities are geographically accessible such as distance to providers, [ 3 ] essential equipment, supplies and medications, [ 4 ] services provided regardless of woman’s ability to pay, [ 5 ] all aspects of abortion care are explained to women, [ 6 ] whether staff offer respectful care, [ 7 ] if staff work to ensure privacy, [ 8 ] if high-quality, supportive counseling is provided, [ 9 ] if services are offered in a timely manner, and [ 10 ] if women have the opportunity to express concerns, ask questions, and receive answers.

Use of abortion services refers to induced pregnancy termination, including medication abortion and number of women treated for abortion-related complications.

Secondary outcomes

Current use of any method of contraception refers to women of reproductive age currently using any method contraceptive method.

Future use of contraception refers to women of reproductive age who are not currently using contraception but intend to do so in the future.

Demand for family planning refers to women of reproductive age who are currently using, or whose sexual partner is currently using, at least one contraceptive method.

Unmet need for family planning refers to women of reproductive age who want to stop or delay childbearing but are not using any method of contraception.

Fertility rate refers to the average number of children born to women of childbearing age.

Neonatal morbidity and mortality refer to disability or death of newborn babies within the first 28 days of life.

Maternal morbidity and mortality refer to disability or death due to complications from pregnancy or childbirth.

There will be no language, date, or year restrictions on studies included in this systematic review.

Studies have to be conducted in a low- and middle-income country. We will use the country classification specified in the World Bank Data Catalogue to identify LMICs (Additional file 2 ).

Search methods

We will perform searches for eligible peer-reviewed studies in the following electronic databases.

Ovid MEDLINE(R) (from 1946 to present)

Embase Classic+Embase on OvidSP (from 1947 to present)

CINAHL (1973 to present); and

Web of Science (1900 to present)

The reference list of included studies will be hand searched for additional potentially relevant citations. Additionally, a grey literature search for reports or working papers will be done with the help of Google and Social Science Research Network (SSRN).

Search strategy

A search strategy, based on the eligibility criteria and combining subject indexing terms (i.e., MeSH) and free-text search terms in the title and abstract fields, will be developed for each electronic database. The search strategy will combine terms related to the interventions of interest (i.e., abortion law/policy), etiology (i.e., impact/effect), and context (i.e., LMICs) and will be developed with the help of a subject matter librarian. We opted not to specify outcomes in the search strategy in order to maximize the sensitivity of our search. See Additional file 3 for a draft of our search strategy.

Data collection and analysis

Data management.

Search results from all databases will be imported into Endnote reference manager software (Version X9, Clarivate Analytics) where duplicate records will be identified and excluded using a systematic, rigorous, and reproducible method that utilizes a sequential combination of fields including author, year, title, journal, and pages. Rayyan systematic review software will be used to manage records throughout the review [ 50 ].

Selection process

Two review authors will screen titles and abstracts and apply the eligibility criteria to select studies for full-text review. Reference lists of any relevant articles identified will be screened to ensure no primary research studies are missed. Studies in a language different from English will be translated by collaborators who are fluent in the particular language. If no such expertise is identified, we will use Google Translate [ 51 ]. Full text versions of potentially relevant articles will be retrieved and assessed for inclusion based on study eligibility criteria. Discrepancies will be resolved by consensus or will involve a third reviewer as an arbitrator. The selection of studies, as well as reasons for exclusions of potentially eligible studies, will be described using a PRISMA flow chart.

Data extraction

Data extraction will be independently undertaken by two authors. At the conclusion of data extraction, these two authors will meet with the third author to resolve any discrepancies. A piloted standardized extraction form will be used to extract the following information: authors, date of publication, country of study, aim of study, policy reform year, type of policy reform, data source (surveys, medical records), years compared (before and after the reform), comparators (over time or between groups), participant characteristics (age, socioeconomic status), primary and secondary outcomes, evaluation design, methods used for statistical analysis (regression), estimates reported (means, rates, proportion), information to assess risk of bias (sensitivity analyses), sources of funding, and any potential conflicts of interest.

Risk of bias and quality assessment

Two independent reviewers with content and methodological expertise in methods for policy evaluation will assess the methodological quality of included studies using the quasi-experimental study designs series risk of bias checklist [ 52 ]. This checklist provides a list of criteria for grading the quality of quasi-experimental studies that relate directly to the intrinsic strength of the studies in inferring causality. These include [ 1 ] relevant comparison, [ 2 ] number of times outcome assessments were available, [ 3 ] intervention effect estimated by changes over time for the same or different groups, [ 4 ] control of confounding, [ 5 ] how groups of individuals or clusters were formed (time or location differences), and [ 6 ] assessment of outcome variables. Each of the following domains will be assigned a “yes,” “no,” or “possibly” bias classification. Any discrepancies will be resolved by consensus or a third reviewer with expertise in review methodology if required.

Confidence in cumulative evidence

The strength of the body of evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system [ 53 ].

Data synthesis

We anticipate that risk of bias and heterogeneity in the studies included may preclude the use of meta-analyses to describe pooled effects. This may necessitate the presentation of our main findings through a narrative description. We will synthesize the findings from the included articles according to the following key headings:

Information on the differential aspects of the abortion policy reforms.

Information on the types of study design used to assess the impact of policy reforms.

Information on main effects of abortion law reforms on primary and secondary outcomes of interest.

Information on heterogeneity in the results that might be due to differences in study designs, individual-level characteristics, and contextual factors.

Potential meta-analysis

If outcomes are reported consistently across studies, we will construct forest plots and synthesize effect estimates using meta-analysis. Statistical heterogeneity will be assessed using the I 2 test where I 2 values over 50% indicate moderate to high heterogeneity [ 54 ]. If studies are sufficiently homogenous, we will use fixed effects. However, if there is evidence of heterogeneity, a random effects model will be adopted. Summary measures, including risk ratios or differences or prevalence ratios or differences will be calculated, along with 95% confidence intervals (CI).

Analysis of subgroups

If there are sufficient numbers of included studies, we will perform sub-group analyses according to type of policy reform, geographical location and type of participant characteristics such as age groups, socioeconomic status, urban/rural status, education, or marital status to examine the evidence for heterogeneous effects of abortion laws.

Sensitivity analysis

Sensitivity analyses will be conducted if there are major differences in quality of the included articles to explore the influence of risk of bias on effect estimates.

Meta-biases

If available, studies will be compared to protocols and registers to identify potential reporting bias within studies. If appropriate and there are a sufficient number of studies included, funnel plots will be generated to determine potential publication bias.

This systematic review will synthesize current evidence on the impact of abortion law reforms on women’s health. It aims to identify which legislative reforms are effective, for which population sub-groups, and under which conditions.

Potential limitations may include the low quality of included studies as a result of suboptimal study design, invalid assumptions, lack of sensitivity analysis, imprecision of estimates, variability in results, missing data, and poor outcome measurements. Our review may also include a limited number of articles because we opted to focus on evidence from quasi-experimental study design due to the causal nature of the research question under review. Nonetheless, we will synthesize the literature, provide a critical evaluation of the quality of the evidence and discuss the potential effects of any limitations to our overall conclusions. Protocol amendments will be recorded and dated using the registration for this review on PROSPERO. We will also describe any amendments in our final manuscript.

Synthesizing available evidence on the impact of abortion law reforms represents an important step towards building our knowledge base regarding how abortion law reforms affect women’s health services and health outcomes; we will provide evidence on emerging strategies to influence policy reforms, implement abortion services, and scale up accessibility. This review will be of interest to service providers, policy makers and researchers seeking to improve women’s access to safe abortion around the world.

Abbreviations

Cumulative index to nursing and allied health literature

Excerpta medica database

Low- and middle-income countries

Preferred reporting items for systematic review and meta-analysis protocols

International prospective register of systematic reviews

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We thank Genevieve Gore, Liaison Librarian at McGill University, for her assistance with refining the research question, keywords, and Mesh terms for the preliminary search strategy.

The authors acknowledge funding from the Fonds de recherche du Quebec – Santé (FRQS) PhD doctoral awards and Canadian Institutes of Health Research (CIHR) Operating Grant, “Examining the impact of social policies on health equity” (ROH-115209).

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PRISMA-P 2015 Checklist. This checklist has been adapted for use with systematic review protocol submissions to BioMed Central journals from Table 3 in Moher D et al: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews 2015 4:1

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Ishola, F., Ukah, U.V. & Nandi, A. Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol. Syst Rev 10 , 192 (2021). https://doi.org/10.1186/s13643-021-01739-w

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Introduction: The Politics of Abortion 50 Years after Roe

Katrina Kimport is a professor with the Department of Obstetrics, Gynecology, and Reproductive Sciences and a medical sociologist with the ANSIRH program at the University of California, San Francisco. Her research examines the (re)production of inequality in health and reproduction, with a topical focus on abortion, contraception, and pregnancy. She is the author of No Real Choice: How Culture and Politics Matter for Reproductive Autonomy (2022) and Queering Marriage: Challenging Family Formation in the United States (2014) and co-author, with Jennifer Earl, of Digitally Enabled Social Change (2011). She has published more than 75 articles in sociology, health research, and interdisciplinary journals.

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Rebecca Kreitzer is an associate professor of public policy at the University of North Carolina at Chapel Hill. Her research focuses on gendered political representation and intersectional policy inequality in the US states. Much of her research focuses on the political dynamics of reproductive health care, especially surrounding contraception and abortion. She has published dozens of articles in political science, public policy, and law journals.

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Katrina Kimport , Rebecca Kreitzer; Introduction: The Politics of Abortion 50 Years after Roe . J Health Polit Policy Law 1 August 2023; 48 (4): 463–484. doi: https://doi.org/10.1215/03616878-10451382

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Abortion is central to the American political landscape and a common pregnancy outcome, yet research on abortion has been siloed and marginalized in the social sciences. In an empirical analysis, the authors found only 22 articles published in this century in the top economics, political science, and sociology journals. This special issue aims to bring abortion research into a more generalist space, challenging what the authors term “the abortion research paradox,” wherein abortion research is largely absent from prominent disciplinary social science journals but flourishes in interdisciplinary and specialized journals. After discussing the misconceptions that likely contribute to abortion research siloization and the implications of this siloization for abortion research as well as social science knowledge more generally, the authors introduce the articles in this special issue. Then, in a call for continued and expanded research on abortion, the introduction to this special issue closes by offering three guiding practices for abortion scholars—both those new to the topic and those deeply familiar with it—in the hopes of building an ever-richer body of literature on abortion politics, policy, and law. The need for such a robust literature is especially acute following the US Supreme Court's June 2022 overturning of the constitutional right to abortion.

Abortion has been both siloed and marginalized in social science research. But because abortion is a perennially politically and socially contested issue as well as vital health care that one in four women in the United States will experience in their lifetime (Jones and Jerman 2022 ), it is imperative that social scientists make a change. This special issue brings together insightful voices from across disciplines to do just that—and does so at a particularly important historical moment. Fifty years after the United States Supreme Court's Roe v. Wade (1973) decision set a national standard amid disparate state policies on abortion, we again find ourselves in a country with a patchwork of laws about abortion. In Dobbs v. Jackson Women's Health Organization (2022), the Supreme Court overturned the constitutional right to abortion it had established in Roe , purportedly returning the question of legalization of abortion to the states. In the immediate aftermath of the Dobbs decision, state policies polarized, and public opinion shifted. This moment demands scholarly evaluation of where we have been, how we arrived at this moment, and what we should be attentive to in coming years. This special issue came about, in part, in response to the on-the-ground conditions of abortion in the United States.

As we argue below, the siloization of abortion research means that the social science literature broadly is not (yet) equipped to make sense of this moment, our history, and what the future holds. First, though, we make a case for the importance of political scientists, economists, and sociologists studying abortion. Then we describe the siloization of abortion research through what we call the “abortion research paradox,” wherein abortion research—despite its social and political import—is curiously absent from top disciplinary journals, even as it thrives in other publication venues that are often interdisciplinary and usually specialized. We theorize some reasons for this siloization and discuss the consequences, both for generalist knowledge and for scientific understanding of abortion. We then introduce the articles in this special issue, noting the breadth of methodological, topical, and theoretical approaches to abortion research they demonstrate. Finally, we offer three suggestions for scholars—both those new to abortion research and those already deeply familiar with it—embarking on abortion research in the hopes of building an ever-richer body of literature on abortion politics, policy, and law.

• Why Abortion?

Abortion has arguably shaped the American political landscape more than any other domestic policy issue in the last 50 years. Since the Supreme Court initially established a nationwide right to abortion in Roe v. Wade (1973), debate over this right has influenced elections at just about every level of office (Abramowitz 1995 ; Cook, Hartwig, and Wilcox 1993 ; Cook, Jelen, and Wilcox 1994 ; Cook, Jelen, and Wilcox 1992 ; Paolino 1995 ; Roh and Haider-Markel 2003 ), inspired political activism (Carmines and Woods 2002 ; Killian and Wilcox 2008 ; Maxwell 2002 ; Verba, Schlozman, and Brady 1995 ) and social movements (Kretschmer 2014 ; Meyer and Staggenborg 1996 , 2008 ; Munson 2010a , Munson 2010b ; Rohlinger 2006 ; Staggenborg 1991 ), and fundamentally structured partisan politics (Adams 1997; Carsey and Layman 2006 ; Killian and Wilcox 2008 ). Position on abortion is frequently used as the litmus test for those seeking political office (Flaten 2010 ; Kreitzer and Osborn 2019 ). Opponents to legal abortion have transformed the federal judiciary (Hollis-Brusky and Parry 2021 ; Hollis-Brusky and Wilson 2020 ). Indeed, abortion is often called the quintessential “morality policy” issue (Kreitzer 2015 ; Kreitzer, Kane, and Mooney 2019 ; Mooney 2001 ; Mucciaroni, Ferraiolo, and Rubado 2019 ) and “ground zero” in the prominent culture wars that have polarized Americans (Adams 1997 ; Lewis 2017 ; Mouw and Sobel 2001 ; Wilson 2013 ). Almost fifty years after Roe v. Wade , in June 2022, the US Supreme Court overturned the constitutional right to abortion in its Dobbs v. Jackson Women's Health Organization decision, ushering in a new chapter of political engagement on abortion.

But abortion is not simply an abstract political issue; it is an extremely common pregnancy outcome. Indeed, as noted above, about one in four US women will get an abortion in her lifetime (Jones and Jerman 2022 ), although the rates of unintended pregnancy and abortion vary substantially across racial and socioeconomic groups (Dehlendorf, Harris, and Weitz 2013 ; Jones and Jerman 2022 ). Despite rampant misinformation claiming otherwise, abortion is a safe procedure (Raymond and Grimes 2012 ; Upadhyay et al. 2015 ), reduces physical health consequences and mortality (Gerdts et al. 2016 ), and does not cause mental health issues (Charles et al. 2008 ; Major et al. 2009 ) or regret (Rocca et al. 2013 , 2015 , 2020 ). Abortion also has a significant impact on people's lives beyond health outcomes. Legal abortion is associated with educational attainment (Everett et al. 2019 ; Ralph et al. 2019 ; Mølland 2016 ) as well as higher female labor force participation, and it affects men's and women's long-term earning potential (Bernstein and Jones 2019 ; Bloom et al. 2009 ; Everett et al. 2019 ; Kalist 2004 ). Access to abortion also shapes relationship satisfaction and stability (Biggs et al. 2014 ; Mauldon, Foster, and Roberts 2015 ). The preponderance of evidence, in other words, demonstrates substantial benefits and no harms to allowing pregnant people to choose abortion.

Yet access to abortion in the United States has been rapidly declining for years. Most abortion care in the United States takes place in stand-alone outpatient facilities that primarily provide reproductive health care (Jones, Witwer, and Jerman 2019 ). As antiabortion legislators in some states have advanced policies that target these facilities, the number of abortion clinics has decreased (Gerdts et al. 2022 ; Venator and Fletcher 2021 ), leaving large geographical areas lacking an abortion facility (Cartwright et al. 2018 ; Cohen and Joffe 2020 ) and thus diminishing pregnant people's ability to obtain abortion care when and where they need it.

The effects of policies regulating abortion, including those that target facilities, have been unevenly experienced, with people of color (Jones and Jerman 2022 ), people in rural areas (Bearak, Burke, and Jones 2017 ), and those who are financially struggling (Cook et al. 1999 ; Roberts et al. 2019 ) disproportionately affected. Even before the Dobbs decision overturned the constitutional right to abortion, the American landscape was characterized by ever-broadening contraception deserts (Axelson, Sealy, and McDonald-Mosley 2022 ; Barber et al. 2019 ; Kreitzer et al. 2021 ; Smith et al. 2022 ), maternity care deserts (Simpson 2020 ; Taporco et al. 2021 ; Wallace et al. 2021 ), and abortion deserts (Cartwright et al. 2018 ; Cohen and Joffe 2020 ; Engle and Freeman 2022 ; McNamara et al. 2022 ; Pleasants, Cartwright, and Upadhyay 2022 ). After Dobbs , access to abortion around the country changed in a matter of weeks. In the 100 days after Roe was overturned, at least 66 clinics closed in 15 states, with 14 of those states no longer having any abortion facilities (Kirstein et al. 2022 ). In this moment of heightened contention about an issue with a long history of social and political contestation, social scientists have a rich opportunity to contribute to scientific knowledge as well as policy and practice that affect millions of lives. This special issue steps into that opportunity.

• The Abortion Research Paradox

This special issue is also motivated by what we call the abortion research paradox. As established above, abortion fundamentally shapes politics in a myriad of ways and is a very common pregnancy outcome, with research consistently demonstrating that access to abortion is consequential and beneficial to people's lives. However, social science research on abortion is rarely published in top disciplinary journals. Abortion is a topic of clear social science interest and is well suited for social science inquiry, but it is relatively underrepresented as a topic in generalist social science journals. To measure this underrepresentation empirically, we searched for original research articles about abortion in the United Sates in the top journals of political science, sociology, and economics. We identified the top three journals for each discipline by considering journal reputation within their respective discipline as well as impact factors and Google Scholar rankings. (There is room for debate about what makes a journal a “top” general interest journal, but that is beyond our scope. Whether these journals are exactly the top three is debatable; nonetheless, these are undoubtedly among the top general-interest or “flagship” disciplinary journals and thus representative of what the respective disciplines value as top scholarship.) Then we searched specified journal databases for the keyword “abortion” for articles published in this century (i.e., 2000–2021), excluding commentaries and book reviews. We found few articles about abortion: just seven in economics journals, eight in political science journals, and seven in sociology journals. We read the articles and classified each into one of three categories: articles primarily about abortion; articles about more than one aspect of reproductive health, inclusive of abortion; or articles about several policy issues, among which abortion is one ( table 1 ).

In the three top economics journals, articles about abortion focused on the relationships between abortion and crime or educational attainment, or on the impact of abortion policies on trends in the timing of first births of women (Bitler and Zavodny 2002 ; Donohue III and Levitt 2001 ; Myers 2017 ). Articles that studied abortion as one among several topics also studied “morally controversial” issues (Elías et al. 2017 ), the electoral implications of abortion (Glaeser, Ponzetto, and Shapiro 2005 ; Washington 2008 ), or contraception (Bailey 2010 ). Articles published in the three top political science journals that focused primarily on abortion evaluated judicial decision-making and legitimacy (Caldarone, Canes-Wrone, and Clark 2009 ; Zink, Spriggs, and Scott 2009 ) or public opinion (Kalla, Levine, and Broockman 2022 ; Rosenfeld, Imai, and Shapiro 2016 ). More commonly, abortion was one of several (or many) different issues analyzed, including government spending and provision of services, government help for African Americans, law enforcement, health care, education, free speech, Hatch Act restrictions, and the Clinton impeachment. The degree to which these articles are “about abortion” varies considerably. In the three top sociology journals, articles represented a slightly broader range of topics, including policy diffusion (Boyle, Kim, and Longhofer 2015 ), public opinion (Mouw and Sobel 2001 ), social movements (Ferree 2003 ), and crisis pregnancy centers (McVeigh, Crubaugh, and Estep 2017 ). Unlike in economics and political science, articles in sociology on abortion mostly focused directly on abortion.

The Journal of Health Politics, Policy and Law ( JHPPL ) would seem well positioned to publish research on abortion. Yet, even in JHPPL , abortion research is not very common. In the same time period (2000–2021), JHPPL published five articles on reproductive health: two articles on abortion (Daniels et al. 2016 ; Kimport, Johns, and Upadhyay 2018 ), one on contraception (Kreitzer et al. 2021 ), one on forced interventions on pregnant people (Paltrow and Flavin 2013 ), and one about how states could respond to the passage of the Affordable Care Act mandate regarding reproductive health (Stulberg 2013 ).

This is not to say that there is no extensive, rigorous published research on abortion in the social science literature. Interdisciplinary journals that are focused on reproductive health, such as Contraception and Perspectives on Sexual and Reproductive Health , as well as health research journals, such as the American Journal of Public Health and Social Science & Medicine , regularly published high-quality social science research on abortion during the focal time period. Research on abortion can also be found in disciplinary subfield journals. In the same time period addressed above, the Journal of Women, Politics, and Public Policy and Politics & Gender— two subfield journals focused on gender and politics—each published around 20 articles that mentioned abortion in the abstract. In practice, while this means excellent research on abortion is published, the net effect is that abortion research is siloed from other research areas in the disciplines of economics, political science, and sociology. This special issue aims to redress some of this siloization and to inspire future scholarship on abortion. Our motivation is not simply premised on quantitative counts, however. As we assert below, abortion research siloization has significant consequences for knowledge—and especially for real people's lives. First, though, we consider some of the possible reasons for this siloization.

• The Origins of Siloization

We do not know why abortion research is not more commonly published in top disciplinary journals, given the topic's clear importance in key areas of focus for these disciplines, including public discourse, politics, law, family life, and health. The siloing and marginalization of abortion is likely related to several misconceptions. For one, because of social contention on the issue, peer reviewers may not have a deep understanding of abortion as a research topic, may express hostility to the topic, or may believe that abortion is exceptional in some way—a niche or ungeneralizable research topic better published in a subfield journal. Scholars themselves may share this mischaracterization of abortion. As Borgman ( 2014 ) argues about the legal arena, and as Roberts, Schroeder, and Joffe ( 2020 ) provide evidence of in medicine, abortion is regularly treated as exceptional, making it both definitional and reasonable that abortion be treated differently in the law and in health care from other medical experiences. Scholars are not immune to social patterns that exceptionalize abortion. In their peer and editor reviews, they may inappropriately—and perhaps inadvertently—draw on their social, rather than academic, knowledge. For scholars of abortion, reviews premised on social knowledge may not be constructive to strengthening the research, and additional labor may be required to educate reviewers and editors on the academic parameters of the topic, including which social assumptions about abortion are scientifically inaccurate. Comments from authors educating editors and peer reviewers on abortion research may then counterintuitively reinforce the (mis)perception that abortion research is niche and not of general interest.

Second, authors' negative experiences while trying to publish about abortion or reproductive health in top disciplinary journals may compound as scholars share information about journals. This is the case for research on gender; evidence from political science suggests that certain journals are perceived as more or less likely to publish research on gender (Brown et al. 2020 ). Such reputations, especially for venues that do not publish abortion research, may not even be rooted in negative experiences. The absence of published articles on abortion may itself dissuade scholars from submitting to a journal based on an educated guess that the journal does not welcome abortion research. Regardless of the veracity of these perceptions, certain journals may get a reputation for publishing on abortion (or not), which then may make future submissions of abortion research to those outlets more (or less) likely. After all, authors seek publication venues where they believe their research will get a robust review and is likely to be published. This pattern may be more common for some author groups than others. Research from political science suggests women are more risk averse than men when it comes to publishing strategies and less likely to submit manuscripts to journals where the perceived likelihood of successful publication is lower (Key and Sumner 2019 ). Special issues like this one are an important way for journals without a substantial track record of publishing abortion research to establish their willingness to do so.

Third, there might be a methodological bias, which unevenly intersects with some author groups. Top disciplinary journals are more likely to publish quantitative approaches rather than qualitative ones, which can result in the exclusion of women and minority scholars who are more likely to utilize mixed or qualitative methods (Teele and Thelen 2017 ). To the extent that investigations of abortion in the social sciences have utilized qualitative rather than quantitative methods, that might contribute to the underrepresentation of abortion-focused scholarship in top disciplinary journals.

Stepping back from the idiosyncrasies of peer review and methodologies, a fourth explanation for why abortion research is not more prominent in generalist social science journals may arise far earlier than the publishing process. PhD-granting departments in the social sciences may have an undersupply of scholars with expertise in reproductive health who can mentor junior scholars interested in studying abortion. (We firmly believe one need not be an expert in reproductive health to mentor junior scholars studying reproductive health, so this explanation only goes so far.) Anecdotally, we have experienced and heard many accounts of scholars who were discouraged from focusing on abortion in dissertation research because of advisors', mentors', and senior scholars' misconceptions about the topic and about the viability of a career in abortion research. In data provided to us by Key and Sumner from their analysis of the “leaky pipeline” in the publication of research on gender at top disciplinary journals in political science (Key and Sumner 2019 ), there were only nine dissertations written between 2000 and 2013 that mention abortion in the abstract, most of which are focused on judicial behavior or political party dynamics rather than focusing on abortion policy itself. If few junior scholars focus on abortion, it makes sense there may be an undersupply of cutting-edge social science research on abortion submitted to top disciplinary journals.

• The Implications of Siloization

The relative lack of scholarly attention to abortion as a social phenomenon in generalist journals has implications for general scholarship. Most concerningly, it limits our ability to understand other social phenomena for which the case of abortion is a useful entry point. For example, the case of abortion as a common, highly safe medical procedure is useful for examining medical innovations and technologies, such as telemedicine. Similarly, given the disparities in who seeks and obtains abortion care in the United States, abortion is an excellent case study for scholars interested in race, class, and gender inequality. It also holds great potential as an opportunity for exploration of public opinion and attitudes, particularly as a case of an issue whose ties to partisan politics have solidified over time and that is often—but not always—“moralized” in policy engagement (Kreitzer, Kane, and Mooney 2019 ). Additionally, there are missed opportunities to generate theory from the specifics of abortion. For example, there is ample evidence of abortion stigma and stigmatization (Hanschmidt et al. 2016 ) and of their effects on people who obtain abortions (Sorhaindo and Lavelanet 2022 ). This research is often unmoored from existing theorization on stigmatization, however, because the bulk of the stigma literature focuses on identities; and having had an abortion is not an identity the same way as, for example, being queer is. (For a notable exception to this trend, see Beynon-Jones 2017 .)

There is, it must be noted, at least one benefit of abortion research being regularly siloed within social science disciplines. The small but growing number of researchers engaged in abortion research has often had to seek mentorship and collaborations outside their disciplines. Indeed, several of the articles included in this special issue come from multidisciplinary author teams, building bridges between disciplinary literatures and pushing knowledge forward. Social scientists studying abortion regularly engage with research by clinicians and clinician-researchers, which is somewhat rare in the academy. The interdisciplinary journals noted above that regularly publish social science abortion research ( Contraception and Perspectives on Sexual and Reproductive Health ) also regularly publish clinical articles and are read by advocates and policy makers. In other words, social scientists studying abortion frequently reach audiences that include clinicians, advocates, and policy makers, marking an opportunity for social science research to influence practice.

The siloization of abortion research in the social sciences affects more than broad social science knowledge; it also dramatically shapes our understanding of abortion. When abortion researchers are largely relegated to their own spaces, they risk missing opportunities to learn from other areas of scholarship that are not related to abortion. Lacking context from other topics, abortion scholars may inaccurately understand an aspect of abortion as exceptional that is not, or they may reinvent the proverbial theoretical wheel to describe an abortion-related phenomenon that is not actually unique to abortion. For example, scholars have studied criminalized behavior for decades, offering theoretical insights and methodological best practices for research on illegal activities. With abortion now illegal in many states, abortion researchers can benefit from drawing on that extant literature to examine the implications of illegality, identifying which aspects of abortion illegality are unique and which are common to other illegal activities. Likewise, methodologically, abortion researchers can learn from other researchers of illegal activities about how to protect participants' confidentiality.

The ontological and epistemological implications for the siloization of abortion research extend beyond reproductive health. When abortion research is not part of the central discussions in economics, political science, and sociology, our understanding of health policy, politics, and law is impoverished. We thus miss opportunities to identify and address chronic health disparities and health inequities, with both conceptual and practical consequences. These oversights matter for people's lives. Following the June 2022 Dobbs decision, millions of people with the capacity of pregnancy are now barred from one key way to control fertility: abortion. The implications of scholars' failure to comprehensively grapple with the place of abortion in health policy, politics, and law are playing out in those people's lives and the lives of their loved ones.

Articles in this Special Issue

In this landscape, we offer this special issue on “The Politics of Abortion 50 Years After Roe .” We seek in this issue to illustrate some of the many ways abortion can and should be studied, with benefits not only for scholarly knowledge about abortion and its role in policy, politics, and law but also for general knowledge about health policy, politics, and law themselves.

The issue's articles represent multiple disciplines, including several articles by multidisciplinary teams. Although public health has long been a welcoming home for abortion research, authors in this special issue point to opportunities in anthropology, sociology, and political science, among other disciplines, for the study of abortion. We do not see the differences and variations among disciplinary approaches as a competition. Rather, we believe that the more diverse the body of researchers grappling with questions about abortion, abortion provision, and abortion patients, the better our collective knowledge about abortion and its role in the social landscape.

The same goes for diversity of methodological approaches. Authors in this issue employ qualitative, quantitative, and mixed methods, showcasing compelling methodological variation. There is no singular or best methodology for answering research questions about abortion. Instead, the impressive variation in methodological approaches in this special issue highlights the vast methodological opportunities for future research. A diversity of methodologies enables a diversity of research questions. Indeed, different methods can identify, generate, and respond to different research questions, enriching the literature on abortion. The methodologies represented in this issue are certainly not exhaustive, but we believe they are suggestive of future opportunities for scholarly exploration and investigation. We hope these articles will provide a road map for rich expansions of the research literature on abortion.

By way of brief introduction, we offer short summaries of the included articles. Baker traces the history of medication abortion in the United States, cataloging the initial approval of the two-part regimen by the Food and Drug Administration (FDA), subsequent policy debates over FDA-imposed restrictions on how medication abortion is dispensed, and the work of abortion access advocates to get medication abortion to people who need it. Weaving together accounts of health care policy, abortion advocacy, and on-the-ground activism, Baker illustrates both the unique contentions specific to abortion policy and how the history of medication abortion can be seen as a case of health care advocacy.

Two of the issue's articles focus on state-level legislative policy on abortion. Roth and Lee generate an original data set cataloging the introduction and implementation of statutes on abortion and other aspects of reproductive health at the state level in the United States monthly, from 1994 to 2022. In their descriptive analysis, the authors highlight trends in abortion legislation and the emergent pattern of state polarization around abortion. Their examination adds rich longitudinal context to contemporary analyses of reproductive health legislation, providing a valuable resource for future scholarship. Carson and Carter similarly attend to state-level legislation, zeroing in on the case of abortion policy in response to the COVID-19 pandemic to show how legislation unrelated to abortion has been opportunistically used to restrict abortion access. The authors also examine how abortion is discursively constructed as a risk to public health. This latter move, they argue, builds on previous constructions of abortion as a risk to individual health and points to a new horizon of antiabortion constructions of the meaning of abortion access.

Kim et al. and Kumar examine the implementation of US abortion policies. Kim et al. use an original data set of 20 years of state supreme court decisions to investigate factors that affect state supreme court decision-making on abortion. Their regression analysis uncovers the complex relationship between state legislatures, state supreme courts, and the voting public for the case of abortion. Kumar charts how 50 years of US abortion policy have affected global access to abortion, offering insights into the underexamined international implications of US abortion policy and into social movement advocacy that has expanded abortion access around the world.

Karlin and Joffe and Heymann et al. draw on data collected when Roe was still the law of the land to investigate phenomena that are likely to become far more common now that Roe has been overturned. Karlin and Joffe utilize interviews with 40 physicians who provide abortions to examine their perspectives on people who terminate their pregnancies outside the formal health care system—an abortion pathway whose popularity increases when abortion access constricts (Aiken et al. 2022 ). By contextualizing their findings on the contradictions physicians voiced—desiring to support reproductive autonomy but invested in physician authority—in a historical overview of how mainstream medicine has marginalized abortion provision since the early days after Roe , the authors add nuance to understandings of the “formal health care system,” its members, and the stakes faced by people bypassing this system to obtain their desired health outcome. Heymann et al. investigate a process also likely to increase in the wake of the Dobbs decision: the implementation of restrictive state-level abortion policy by unelected bureaucrats. Using the case of variances for a written transfer agreement requirement in Ohio—a requirement with no medical merit that is designed to add administrative burden to stand-alone abortion clinics—Heymann et al. demonstrate how bureaucratic discretion by political appointees can increase the administrative burden of restrictive abortion laws and thus further constrain abortion access. Together, these two articles demonstrate how pre- Roe data can point scholars to areas that merit investigation after Roe has been overturned.

Finally, using mixed methods, Buyuker et al. analyze attitudes about abortion acceptability and the Roe v. Wade Supreme Court decision, distinguishing what people think about abortion from what they know about abortion policy. In addition to providing methodological insights about survey items related to abortion attitudes, the authors expose a disconnect between how people think about abortion acceptability and their support for the Roe decision. In other words, as polarized as abortion attitudes are said to be, there is unacknowledged and largely unmeasured complexity in how the general public thinks about abortion.

Future Research on Abortion

We hope that a desire to engage in abortion research prompts scholars to read the excellent articles in this special issue. We also hope that reading these pieces inspires at least some readers to engage in abortion research. Having researched abortion for nearly three decades between us, we are delighted by the emerging interest in studying abortion, whether as a focal topic or alongside a different focus. This research is essential to our collective understanding of abortion politics, policy, and law and the many millions of people whose lives are affected by US abortion politics, policy, and law annually. In light of the limitations of the current field of abortion research, we have several suggestions for scholars of abortion, regardless of their level of familiarity with the topic.

First, know and cite the existing literature on abortion. To address the siloization of abortion research, and particularly the scarcity of abortion research published in generalist journals, scholars must be sure to build on the impressive work that has been published on the topic in specialized spaces. Moreover, becoming familiar with existing research can help scholars avoid several common pitfalls in abortion research. For example, being immersed in existing literature can help scholars avoid outdated, imprecise, or inappropriate language and terminology. Smith et al. ( 2018 ), for instance, illuminate the implications of clinicians deploying seemingly everday language around “elective” abortion. They find that it muddies the distinction between the use of “elective” colloquially and in clinical settings, contributing to the stigmatization of abortion and abortion patients. Examinations like theirs advance understanding of abortion stigmatization while highlighting for scholars the importance of being sensitive to and reflective about language. Familiarity with existing research can help scholars avoid methodological pitfalls as well, such as incomplete understanding of the organization of abortion provision. Although Planned Parenthood has brand recognition for providing abortion care, the majority of abortions in the United States are performed at independent abortion clinics. Misunderstanding the provision landscape can have consequences for some study designs.

Second, we encourage scholars of abortion to think critically about the ideological underpinnings of how their research questions and findings are framed. Academic research of all kinds, including abortion, is better when it is critical of ideologically informed premises. Abortion scholars must be careful to avoid uncritically accepting both antiabortion premises and abortion-supportive premises, especially as those premises unconsciously guide much of the public discourse on abortion. Scholars have the opportunity to use methodological tools not to find an objective truth per se but to challenge the uncontested common sense claims that frequently guide public thinking on abortion. One strategy for avoiding common framing pitfalls is to construct research and analysis to center the people most affected by abortion politics, policy, and law (Kimport and McLemore 2022 ). Another strategy is to critique what Baird and Millar ( 2019 , 2020 ) have termed the performative nature of abortion scholarship. Abortion scholarship, they note, has predominantly focused on negative aspects and effects of abortion care. Research that finds and explores affirmatively positive aspects—for instance, the joy in abortion—can crucially thicken scholarly understanding.

Third, related to our discussion above, scholars of abortion face an interesting challenge regarding how abortion is and is not exceptional. Research on abortion must attend to how abortion has been exceptionalized—and marginalized—in policy and practices. But there are also numerous instances where abortion is only one example of many. In these cases, investigation of abortion under the assumption that it is exceptional is an unnecessary limitation on the work's contribution. Scholars of abortion benefit from mastery of the literature on abortion, yet knowing this literature is not sufficient. There are important bridges from scholarship on abortion to scholarship in other areas, important conversations across and within literatures, that can yield insights both about abortion and about other topical foci.

As guest coeditors of this special issue, we are delighted by the rich and growing body of scholarship on abortion, to which the articles in this special issue represent an important addition. There is still much more work to be done. Going forward, we are eager to see future scholarship on abortion build on this work and tackle new questions.

• Acknowledgments

The authors thank Krystale Littlejohn, Jon Oberlander, Ellen Key, and Jane Sumner for their helpful feedback on earlier drafts of this article. Both authors contributed equally to this article and are listed alphabetically.

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Number of Articles about Abortion in Top Disciplinary Journals, 2000–2021

Note : AER  =  American Economic Review ; QJE  =  Quarterly Journal of Economics ; JPE  =  Journal of Political Economy ; APSR  =  American Political Science Review ; AJPS  =  American Journal of Political Science ; JOP  =  Journal of Politics ; ASR  =  American Sociological Review ; AJS  =  American Journal of Sociology ; ARS  =  Annual Review of Sociology.

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What can economic research tell us about the effect of abortion access on women’s lives?

Subscribe to the center for economic security and opportunity newsletter, caitlin knowles myers and caitlin knowles myers john g. mccullough professor of economics; co-director, middlebury initiative for data and digital methods - middlebury college @caitlin_k_myers morgan welch morgan welch senior research assistant & project coordinator - center on children and families, economic studies, brookings institution.

November 30, 2021

• 21 min read

On September 20, 2021, a group of 154 distinguished economists and researchers filed an amicus brief to the Supreme Court of the United States in advance of the Mississippi case, Dobbs v. Jackson Women’s Health Organization . For a full review of the evidence that shows how causal inference tools have been used to measure the effects of abortion access in the U.S., read the brief here .

Introduction

Dobbs v. Jackson Women’s Health Organization considers the constitutionality of a 2018 Mississippi law that prohibits women from accessing abortions after 15 weeks of pregnancy. This case is widely expected to determine the fate of Roe v. Wade as Mississippi is directly challenging the precedent set by the Supreme Court’s decisions in Roe , which protects abortion access before fetal viability (typically between 24 and 28 weeks of pregnancy). On December 1, 2021, the Supreme Court will hear oral arguments in Dobbs v. Jackson . In asking the Court to overturn Roe , the state of Mississippi offers reassurances that “there is simply no causal link between the availability of abortion and the capacity of women to act in society” 1 and hence no reason to believe that abortion access has shaped “the ability of women to participate equally in the economic and social life of the Nation” 2 as the Court had previously held.

While the debate over abortion often centers on largely intractable subjective questions of ethics and morality, in this instance the Court is being asked to consider an objective question about the causal effects of abortion access on the lives of women and their families. The field of economics affords insights into these objective questions through the application of sophisticated methodological approaches that can be used to isolate and measure the causal effects of abortion access on reproductive, social, and economic outcomes for women and their families.

Separating Correlation from Causation: The “Credibility Revolution” in Economics

To measure the causal effect of abortion on women’s lives, one must differentiate its effects from those of other forces, such as economic opportunity, social mores, the availability of contraception. Powerful statistical methodologies in the causal inference toolbox have made it possible for economists to do just that, moving beyond the maxim “correlation isn’t necessarily causation” and applying the scientific method to figure out when it is.

This year’s decision by the Economic Sciences Prize Committee recognized the contributions 3 of economists David Card, Joshua Angrist, and Guido Imbens, awarding them the Nobel Prize for their pathbreaking work developing and applying the tools of causal inference in a movement dubbed “the credibility revolution” (Angrist and Pischke, 2010). The gold standard for establishing such credibility is a well-executed randomized controlled trial – an experiment conducted in the lab or field in which treatment is randomly assigned. When economists can feasibly and ethically implement such experiments, they do. However, in the social world, this opportunity is often not available. For instance, one cannot feasibly or ethically randomly assign abortion access to some individuals but not others. Faced with this obstacle, economists turn to “natural” or “quasi” experimental methods, ones in which they are able to credibly argue that treatment is as good as randomly assigned.

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Pioneering applications of this approach include work by Angrist and Krueger (1991) leveraging variation in compulsory school attendance laws to measure the effects of schooling on earnings and work by Card and Krueger (1994) leveraging minimum wage variation across state borders to measure the effects of the minimum wages on employment outcomes. The use of these methods is now widespread, not just in economics, but in other social sciences as well. Fueled by advances in computing technology and the availability of data, quasi-experimental methodologies have become as ubiquitous as they are powerful, applied to answer questions ranging from the effects of economic shocks on civil conflict (Miguel, Sayanath, and Sergenti, 2004), to the effects of the Clean Water Act on water pollution levels (Keiser and Shapiro, 2019), and effects of access to food stamps in childhood on later life outcomes (Hoynes, Schanzenbach, Almond 2016; Bailey et al., 2020).

Research demonstrates that abortion access does, in fact, profoundly affect women’s lives by determining whether, when, and under what circumstances they become mothers.

Economists also have applied these tools to study the causal effects of abortion access. Research drawing on methods from the “credibility revolution” disentangles the effects of abortion policy from other societal and economic forces. This research demonstrates that abortion access does, in fact, profoundly affect women’s lives by determining whether, when, and under what circumstances they become mothers, outcomes which then reverberate through their lives, affecting marriage patterns, educational attainment, labor force participation, and earnings.

The Effects of Abortion Access on Women’s Reproductive, Economic, and Social Lives

Evidence of the effects of abortion legalization.

The history of abortion legalization in the United States affords both a canonical and salient example of a natural experiment. While Roe v. Wade legalized abortion in most of the country in 1973, five states—Alaska, California, Hawaii, New York, and Washington—and the District of Columbia repealed their abortion bans several years in advance of Roe . Using a methodology known as “difference-in-difference estimation,” researchers compared changes in outcomes in these “repeal states” when they lifted abortion bans to changes in outcomes in the rest of the country. They also compared changes in outcomes in the rest of the country in 1973 when Roe legalized abortion to changes in outcomes in the repeal states where abortion already was legal. This difference-in-differences methodology allows the states where abortion access is not changing to serve as a counterfactual or “control” group that accounts for other forces that were impacting fertility and women’s lives in the Roe era.

Among the first to employ this approach was a team of economists (Levine, Staiger, Kane, and Zimmerman, 1999) who estimated that the legalization of abortion in repeal states led to a 4% to 11% decline in births in those states relative to the rest of the country. Levine and his co-authors found that these fertility effects were particularly large for teens and women of color, who experienced birth rate reductions that were nearly three times greater than the overall population as a result of abortion legalization. Multiple research teams have replicated the essential finding that abortion legalization substantially impacted American fertility while extending the analysis to consider other outcomes. 4 For example, Myers (2017) found that abortion legalization reduced the number of women who became teen mothers by 34% and the number who became teen brides by 20%, and again observed effects that were even larger for Black teens. Farin, Hoehn-Velasco, and Pesko (2021) found that abortion legalization reduced maternal mortality among Black women by 30-40%, with little impact on white women, offering the explanation that where abortion was illegal, Black women were less likely to be able to access safe abortions by traveling to other states or countries or by obtaining a clandestine abortion from a trusted health care provider.

The ripple effects of abortion access on the lives of women and their families

This research, which clearly demonstrates the causal relationship between abortion access and first-order demographic and health outcomes, laid the foundation for researchers ­to measure further ripple effects through the lives of women and their families. Multiple teams of authors have extended the difference-in-differences research designs to study educational and labor market outcomes, finding that abortion legalization increased women’s education, labor force participation, occupational prestige, and earnings and that all these effects were particularly large for Black women (Angrist and Evans, 1996; Kalist, 2004; Lindo, Pineda-Torres, Pritchard, and Tajali, 2020; Jones, 2021).

Additionally, research shows that abortion access has not only had profound effects on women’s economic and social lives but has also impacted the circumstances into which children are born. Researchers using difference-in-differences research designs have found that abortion legalization reduced the number of children who were unwanted (Bitler and Zavodny, 2002a, reduced cases of child neglect and abuse (Bitler and Zavodny, 2002b; 2004), reduced the number of children who lived in poverty (Gruber, Levine, and Staiger, 1999), and improved long-run outcomes of an entire generation of children by increasing the likelihood of attending college and reducing the likelihood of living in poverty and receiving public assistance (Ananat, Gruber, Levine, and Staiger, 2009).

Access to abortion continues to be important to women’s lives

The research cited above relies on variation in abortion access from the 1970s, and much has changed in terms of both reproductive technologies and women’s lives. Recent research shows, however, that even with the social, economic, and legal shifts that have occurred over the last few decades and even with expanded access to contraception, abortion access remains relevant to women’s reproductive lives. Today, nearly half of pregnancies are unintended (Finer and Zolna, 2016). About 6% of young women (ages 15-34) experience an unintended pregnancy each year (Finer, Lindberg, and Desai, 2018), and about 1.4% of women of childbearing age obtain an abortion each year (Jones, Witwer, and Jerman, 2019). At these rates, approximately one in four women will receive an abortion in their reproductive lifetimes. The fact is clear: women continue to rely on abortion access to determine their reproductive lives.

But what about their economic and social lives? While women have made great progress in terms of their educational attainment, career trajectories, and role in society, mothers face a variety of challenges and penalties that are not adequately addressed by public policy. Following the birth of a child, it’s well documented that working mothers face a “motherhood wage penalty,” which entails lower wages than women who did not have a child (Waldfogel, 1998; Anderson, Binder, and Krause, 2002; Kelven et al., 2019). Maternity leave may combat this penalty as it allows women to return to their jobs following the birth of a child – encouraging them to remain attached to the labor force (Rossin-Slater, 2017). However, as of this writing, the U.S. only offers up to 12 weeks of unpaid leave through the FMLA, which extends coverage to less than 60% of all workers. 5 And even if a mother is able to return to work, childcare in the U.S. is costly and often inaccessible for many. Families with infants can be expected to pay around $11,000 a year for childcare and subsidies are only available for 1 in 6 children that are eligible under the federal program. 6 Without a federal paid leave policy and access to affordable childcare, the U.S. lacks the infrastructure to adequately support mothers, and especially working mothers – making the prospect of motherhood financially unworkable for some.

This is relevant when considering that the women who seek abortions tend to be low-income mothers experiencing disruptive life events. In the most recent survey of abortion patients conducted by the Guttmacher Institute, 97% are adults, 49% are living below the poverty line, 59% already have children, and 55% are experiencing a disruptive life event such as losing a job, breaking up with a partner, or falling behind on rent (Jones and Jerman, 2017a and 2017b). It is not a stretch to imagine that access to abortion could be pivotal to these women’s financial lives, and recent evidence from “The Turnaway Study” 7 provides empirical support for this supposition. In this study, an interdisciplinary team of researchers follows two groups of women who were typically seeking abortions in the second trimester: one group that arrived at abortion clinics and learned they were just over the gestational age threshold for abortions and were “turned away” and a second that was just under the threshold and were provided an abortion. Miller, Wherry, and Foster (2020) match individuals in both groups to their Experian credit reports and observe that in the months leading up to the moment they sought an abortion, financial outcomes for both groups were trending similarly. At the moment one group is turned away from a wanted abortion, however, they began to experience substantial financial distress, exhibiting a 78% increase in past-due debt and an 81% increase in public records related to bankruptcies, evictions, and court judgments.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase. Twelve states have enacted “trigger bans” designed to outlaw abortion in the immediate aftermath of a Roe reversal, while an additional 10 are considered highly likely to quickly enact new bans. 8 These bans would shutter abortion facilities across a wide swath of the American south and midwest, dramatically increasing travel distances and the logistical costs of obtaining an abortion. Economics research predicts what is likely to happen next. Multiple teams of economists have exploited natural experiments arising from mandatory waiting periods (Joyce and Kaestner, 2001; Lindo and Pineda-Torres, 2021; Myers, 2021) and provider closures (Quast, Gonzalez, and Ziemba, 2017; Fischer, Royer, and White, 2018; Lindo, Myers, Schlosser, and Cunningham, 2020; Venator and Fletcher, 2021; Myers, 2021). All have found that increases in travel distances prevent large numbers of women seeking abortions from reaching a provider and that most of these women give birth as a result. For instance, Lindo and co-authors (2020) exploit a natural experiment arising from the sudden closure of half of Texas’s abortion clinics in 2013 and find that an increase in travel distance from 0 to 100 miles results in a 25.8% decrease in abortions. Myers, Jones, and Upadhyay (2019) use these results to envision a post- Roe United States, forecasting that if Roe is overturned and the expected states begin to ban abortions, approximately 1/3 of women living in affected regions would be unable to reach an abortion provider, amounting to roughly 100,000 women in the first year alone.

Restricting, or outright eliminating, abortion access by overturning Roe v. Wade  would diminish women’s personal and economic lives, as well as the lives of their families.

Whether one’s stance on abortion access is driven by deeply held views on women’s bodily autonomy or when life begins, the decades of research using rigorous methods is clear: there is a causal link between access to abortion and whether, when, and under what circumstances women become mothers, with ripple effects throughout their lives. Access affects their education, earnings, careers, and the subsequent life outcomes for their children. In the state’s argument, Mississippi rejects the causal link between access to abortion and societal outcomes established by economists and states that the availability of abortion isn’t relevant to women’s full participation in society. Economists provide clear evidence that overturning Roe would prevent large numbers of women experiencing unintended pregnancies—many of whom are low-income and financially vulnerable mothers—from obtaining desired abortions. Restricting, or outright eliminating, that access by overturning Roe v. Wade would diminish women’s personal and economic lives, as well as the lives of their families.

Caitlin Knowles Myers did not receive financial support from any firm or person for this article. She has received financial compensation from Planned Parenthood Federation of America and the Center for Reproductive Rights for serving as an expert witness in litigation involving abortion regulations. She has not and will not receive financial compensation for her role in the amicus brief described here. Other than the aforementioned, she has not received financial support from any firm or person with a financial or political interest in this article. Caitlin Knowles Myers is not currently an officer, director, or board member of any organization with a financial or political interest in this article.

Abboud, Ali, 2019. “The Impact of Early Fertility Shocks on Women’s Fertility and Labor Market Outcomes.” Available from SSRN: https://ssrn.com/abstract=3512913

Anderson, Deborah J., Binder, Melissa, and Kate Krause, 2002. “The motherhood wage penalty: Which mothers pay it and why?” The American Economic Review 92(2). Retrieved from https://www.aeaweb.org/articles?id=10.1257/000282802320191606

Ananat, Elizabeth Oltmans, Gruber, Jonathan, Levine, Phillip and Douglas Staiger, 2009. “Abortion and Selection.” The Review of Economic Statistics 91(1). Retrieved from https://direct.mit.edu/rest/article-abstract/91/1/124/57736/Abortion-and-Selection?redirectedFrom=fulltext .

Angrist, Joshua D., and Alan B. Krueger, 1999. “Does Compulsory School Attendance Affect Schooling and Earnings?” The Quarterly Journal of Economics 106(4). Retrieved from https://doi.org/10.2307/2937954 .

Angrist, Joshua D., and William N. Evans, 1996. “Schooling and Labor Market Consequences of the 1970 State Abortion Reforms.” National Bureau of Economic Research Working Paper 5406. Retrieved from https://www.nber.org/papers/w5406 .

Angrist, Joshua D., and Jörn-Steffen Pischke, 2010. “The Credibility Revolution in Empirical Economics: How Better Research Design Is Taking the Con out of Econometrics.” Journal of Economic Perspectives 24(2). Retrieved from https://www.aeaweb.org/articles?id=10.1257/jep.24.2.3

Bailey, Martha J., Hoynes, Hilary W., Rossin-Slater, Maya and Reed Walker, 2020. “Is the Social Safety Net a Long-Term Investment? Large-Scale Evidence from the Food Stamps Program” National Bureau of Economic Research Working Paper 26942 , Retrieved from https://www.nber.org/papers/w26942

Bitler, Marianne, and Madeline Zavodny, 2002a. “Did Abortion Legalization Reduce the Number of Unwanted Children? Evidence from Adoptions.” Perspectives on Sexual and Reproductive Health, 34 (1): 25-33. Retrieved from https://www.jstor.org/stable/3030229?origin=JSTOR-pdf

Bitler, Marianne, and Madeline Zavodny, 2002b. “Child Abuse and Abortion Availability.” American Economic Review , 92 (2): 363-367. Retrieved from https://www.aeaweb.org/articles?id=10.1257/000282802320191624

Bitler, Marianne, and Madeline Zavodny, 2004. “Child Maltreatment, Abortion Availability, and Economic Conditions.” Review of Economics of the Household 2: 119-141. Retrieved from https://doi.org/10.1023/B:REHO.0000031610.36468.0e

Farin, Sherajum Monira, Hoehn-Velasco, Lauren, and Michael Pesko, 2021. “The Impact of Legal Abortion on Maternal Health: Looking to the Past to Inform the Present.” Retrieved from SSRN: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3913899

Finer, Lawrence B., and Mia R. Zolna, 2016. “Declines in Unintended Pregnancy in the United States, 2008–2011” New England Journal of Medicine 374. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26962904/

Finer, Lawrence B., Lindberg, Laura, D., and Sheila Desai. “A prospective measure of unintended pregnancy in the United States.” Contraception 98(6). Retrieved from https://pubmed.ncbi.nlm.nih.gov/29879398/

Fischer, Stefanie, Royer, Heather, and Corey White, 2017. “The Impacts of Reduced Access to Abortion and Family Planning Services on Abortion, Births, and Contraceptive Purchases.” National Bureau of Economic Research Working Paper 23634 . Retrieved from https://www.nber.org/papers/w23634

Gruber, Jonathan, Levine, Phillip, and Douglas Staiger, 1999. “Abortion Legalization and Child Living Circumstances: Who Is the ‘Marginal Child’?” Quarterly Journal of Economics 114. Retrieved from https://doi.org/10.1162/003355399556007

Guldi, Melanie, 2008. “Fertility effects of abortion and birth control pill access for minors.” Demography 45 . Retrieved from https://doi.org/10.1353/dem.0.0026

Hoynes, Hilary, Schanzenbach, Diane Whitmore, and Douglas Almond, 2016. “Long-Run Impacts of Childhood Access to the Safety Net.” American Economic Review 106(4). Retrieved from https://www.aeaweb.org/articles?id=10.1257/aer.20130375

Jones, Kelly, 2021. “At a Crossroads: The Impact of Abortion Access on Future Economic Outcomes.” American University Working Paper . Retrieved from https://doi.org/10.17606/0Q51-0R11 .

Jones, Rachel K., Witwer, Elizabeth, Jerman, Jenna, September 18, 2018. “Abortion Incidence and Service Availability in the United States, 2017.” Guttmacher Institute. Retrieved from https://www.guttmacher.org/sites/ default/files/report_pdf/abortion-inciden ce-service-availability-us-2017.

Jones Rachel K., and Janna Jerman, 2017a. ”Population group abortion rates and lifetime incidence of abortion: United States, 2008–2014.”  American Journal of Public Health 107 (12). Retrieved from https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.304042

Jones, Rachel K. and Jenna Jerman, 2017b. “Characteristics and Circumstances of U.S. Women Who Obtain Very Early and Second-Trimester Abortions.” PLoS One . Retrieved from https://pubmed.ncbi.nlm.nih.gov/28121999/

Joyce, Ted, and Robert Kaestner, 2001. “The Impact of Mandatory Waiting Periods and Parental Consent Laws on the Timing of Abortion and State of Occurrence among Adolescents in Mississippi and South Carolina.” Journal of Policy Analysis and Management 20(2) . Retrieved from https://www.jstor.org/stable/3325799 .

Kalist, David E., 2004. “Abortion and Female Labor Force Participation: Evidence Prior to Roe v. Wade.” Journal of Labor Research 25 (3) .

Keiser, David, and Joseph Shapiro, 2019. “Consequences of the Clean Water Act and the Demand for Water Quality.” The Quarterly Journal of Economics 134 (1).

Kleven, Henrik, Landais, Camille, Posch, Johanna, Steinhauer, Andreas, and Josef Zweimuleler, 2019. “Child Penalties Across Countries: Evidence and Explanations.” AEA Papers and Proceedings 109. Retrieved from https://www.aeaweb.org/articles?id=10.1257/pandp.20191078/

Levine, Phillip, Staiger, Douglas, Kane, Thomas, and David Zimmerman, 1999. “Roe v. Wade and American Fertility.” American Journal Of Public Health 89(2) . Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1508542/

Lindo, Jason M., Myers, Caitlin Knowles, Schlosser, Andrea, and Scott Cunningham, 2020. “How Far Is Too Far? New Evidence on Abortion Clinic Closures, Access, and Abortions” Journal of Human Resources 55. Retrieved from http://jhr.uwpress.org/content/55/4/1137.refs

Lindo, Jason M., Pineda-Torres, Mayra, Pritchard, David, and Hedieh Tajali, 2020. “Legal Access to Reproductive Control Technology, Women’s Education, and Earnings Approaching Retirement.” AEA Papers and Proceedings 110. Retrieved from https://www.aeaweb.org/articles?id=10.1257/pandp.20201108

Lindo, Jason M., and Mayra Pineda-Torres, 2021. “New Evidence on the Effects of Mandatory Waiting Periods for Abortion.” J ournal of Health Econ omics. Retrieved from https://pubmed.ncbi.nlm.nih.gov/34607119/

Miguel, Edward, Satyanath, Shanker, and Ernest Sergenti, 2004. “Economic Shocks and Civil Conflict: An Instrumental Variables Approach.” Journal of Political Economy 112(4). Retrieved from https://www.jstor.org/stable/10.1086/421174

Miller, Sarah, Wherry, Laura R., and Diana Greene Foster, 2020. “The Economic Consequences of Being Denied an Abortion.” National Bureau of  Economic Research, Working Paper 26662 . Retrieved from https://www.nber.org/papers/w26662 .

Myers, Caitlin Knowles, 2017. “The Power of Abortion Policy: Reexamining the Effects of Young Women’s Access to Reproductive Control” Journal of Political Economy 125(6) .  Retrieved from https://doi.org/10.1086/694293 .

Myers, Caitlin Knowles, Jones, Rachel, and Ushma Upadhyay, 2019. “Predicted changes in abortion access and incidence in a post-Roe world.” Contraception 100(5). Retrieved from https://pubmed.ncbi.nlm.nih.gov/31376381/

Myers, Caitlin Knowles, 2021. “Cooling off or Burdened? The Effects of Mandatory Waiting Periods on Abortions and Births.” IZA Institute of Labor Economics No. 14434. Retrieved from https://www.iza.org/publications/dp/14434/cooling-off-or-burdened-the-effects-of-mandatory-waiting-periods-on-abortions-and-births

Quast, Troy, Gonzalez, Fidel, and Robert Ziemba, 2017. “Abortion Facility Closings and Abortion Rates in Texas.” Inquiry: A Journal of Medical Care Organization, Provision and Financing 54 . Retrieved from https://journals.sagepub.com/doi/full/10.1177/0046958017700944

Rossin-Slater, Maya, 2017. “Maternity and Family Leave Policy.” National Bureau of Economic Research Working Paper 23069. Retrieved from https://www.nber.org/papers/w23069

Venator, Joanna, and Jason Fletcher, 2020. “Undue Burden Beyond Texas: An Analysis of Abortion Clinic Closures, Births, and Abortions in Wisconsin.” Journal of Policy Analysis and Management 40(3). Retrieved from https://doi.org/10.1002/pam.22263

Waldfogel, Jane, 1998. “The family gap for young women in the United States and Britain: Can maternity leave make a difference?” Journal of Labor Economics 16(3).

• Thomas E. Dobbs v. Jackson Women’s Health Organization. On Writ of Certiorari to the United States Court of Appeals for the Fifth Circuit, Brief in Support of Petitioners, No. 19-1392.
• Thomas E. Dobbs v. Jackson Women’s Health Organization. On Writ of Certiorari to the United States Court of Appeals for the Fifth Circuit, Brief for Petitioners, No. 19-139, Retrieved from https://www.supremecourt.gov/DocketPDF/19/19-1392/184703/20210722161332385_19-1392BriefForPetitioners.pdf
• The Nobel Prize. 2021. “Press release: The Prize in Economic Sciences 202.” Retrieved from https://www.nobelprize.org/prizes/economic-sciences/2021/press-release/
• See Angrist and Evans (1996), Gruber et al. (1999), Ananat et al. (2009), Guldi (2008), Myers (2017), Abboud (2019), Jones (2021).
• Brown, Scott, Herr, Jane, Roy, Radha , and Jacob Alex Klerman, July 2020. “Employee and Worksite Perspectives of the FMLA Who Is Eligible?” U.S. Department of Labor. Retrieved from https://www.dol.gov/sites/dolgov/files/OASP/evaluation/pdf/WHD_FMLA2018PB1WhoIsEligible_StudyBrief_Aug2020.pdf
• Whitehurst, Grover J., April 19, 2018. “What is the market price of daycare and preschool?” Brookings Institution. Retrieved from https://www.brookings.edu/research/what-is-the-market-price-of-daycare-and-preschool/; Chien, Nina, 2021. “Factsheet: Estimates of Child Care Eligibility & Receipt for Fiscal Year 2018.” U.S. Department of Health and Human Services. Retrieved from https://aspe.hhs.gov/sites/default/files/20 21-08/cy-2018-child-care-subsidy-eligibility.pdf
• Advancing New Standards in Reproductive Health (NSIRH). “The Turnaway Study.” Retrieved from https://www.ansirh.org/research/ongoing/turnaway-study.
• Center for Reproductive Rights, 2021. “What If Roe Fell?” Retrieved from https://maps.reproductiverights.org/what-if-roe-fell

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Reproductive rights in America

The movement against abortion rights is nearing its apex. but it began way before roe.

Deepa Shivaram

Activists Lori Gordon (R) and Tammie Miller (L) of Payne, Ohio, take part in the annual "March for Life" event January 22, 2002 in Washington, D.C. Alex Wong/Getty Images hide caption

Activists Lori Gordon (R) and Tammie Miller (L) of Payne, Ohio, take part in the annual "March for Life" event January 22, 2002 in Washington, D.C.

The Supreme Court ruled on Roe v. Wade in 1973, saying that access to abortion was protected in the United States.

The decision fueled the anti-abortion movement and congealed it, too. Prior to Roe , anti-abortion activists were operating on a state level, but the Supreme Court's ruling turned the movement into a national one.

In the decades before the decision, opposition to abortion was a fairly bipartisan issue. In fact, many Democrats in elected positions were likely to oppose unrestricting abortion access because many represented Catholics, who were largely opposed to abortion. But even then, it wasn't a politically charged topic.

Now, the Court appears to be on the verge of overturning the right to an abortion, bringing a movement that transformed American politics over the past half century to its apex.

In the past decade, Donald Trump was able to win the White House in no small part because he galvinized conservative evangelicals by pledging to appoint Supreme Court justices that would overturn Roe . It was a promise he fulfilled, even though Trump had previously supported abortion rights .

What conservative justices said — and didn't say — about Roe at their confirmations

But the history of organized opposition to abortion access started more than a century before Roe v. Wade , with roots in British common law.

Restricting abortion actually began with doctors

In the early days of the country, laws often reflected British common law, and when it came to abortion, the process was determined by quickening. Quickening meant the moment the pregnant person could feel the fetus move, which typically happened between the fourth and six month of pregnancy. At that time, it was the only way to truly confirm the pregnancy, so the thought of life beginning at conception wasn't a factor at all.

Ending the pregnancy after the quickening period was considered illegal, but was just a misdemeanor. And even then, it was hard to prosecute because it was only the pregnant person who could attest to whether or not the fetus had moved. Abortions were accessible and largely without stigma at this time.

Here's what could happen if Roe v. Wade is overturned

But close to the mid 1800s, some doctors, who at the time were a mostly unorganized profession, sought to separate themselves from the healers and midwives who were also performing abortions. Doctors didn't have as much medical or institutional authority as they do today, and some in the profession pushed states to pass anti-abortion laws in order to tamp down on competition. These physicians, all of whom were men and who were backed by the newly founded American Medical Association , argued that they had more knowledge on embryos and that the heightened medical knowledge was necessary to determine when life began.

It should be noted, though, that this claim of advanced knowledge didn't actually exist in the medical community. Historians note that this argument was mostly used as a way to take away women's bodily autonomy. Now, it was a doctor who could interpret their medical condition, rather than just relying on whether the pregnant individual could feel the fetus move.

Their efforts worked. By the early 1900s, every state had made abortion illegal, though there were exceptions made if the life of the pregnant person was at risk.

What happens next, in the decades leading up to Roe v. Wade ?

In terms of the movement, mostly nothing.

In these decades leading up to Roe , abortion was for the most part illegal. Because of that, seeking abortions also became extremely dangerous, particularly for low-income pregnant people and people of color , especially Black women.

In 1930, abortion was listed as the official cause of death for almost 2,700 women in the United States, though there were likely many more deaths that did not get recorded. In the 1940s when antibiotics were introduced, fewer were dying from illegal abortions, but thousands were still admitted into the hospital due to medical complications.

The political consequences of the Supreme Court's leaked draft opinion on abortion

By the middle of the 1960s, some states like Colorado liberalized their abortion laws, and anti-abortion movements started to crop up on the state level. But it was still not nationally talked about, or even politicized, the way it started to become in the 1970s.

How did the movement change after Roe v. Wade in 1973?

In a short answer, it changed a lot.

"All of a sudden, it moves from a movement in the states that are liberalizing to a nationwide movement," Jennifer Holland, a professor at the University of Oklahoma and scholar on the anti-abortion movement, tells NPR.

"They are able to point to sort of an oppressive federal government... and it really feeds into the argument that the United States is on a slippery slope toward genocide and fascism," Holland said, referring to language often used by the anti-abortion movement.

Members of a Right to Life committee holding a banner reading 'Stop the slaughter now!' and a placard reading 'The Supreme Court Injustice' during a protest, location unspecified, 1974. Peter Keegan/Getty Images hide caption

Members of a Right to Life committee holding a banner reading 'Stop the slaughter now!' and a placard reading 'The Supreme Court Injustice' during a protest, location unspecified, 1974.

Holland says that at this point, the anti-abortion movement strategically cast itself as a "rights campaign" and started to compare abortion to the Holocaust and the Dred Scott Supreme Court decision, which ruled that Black people in the U.S. did not have constitutional rights.

"With Roe , the movement is able to grasp on to a federal oppressor, as an entity that is... allowing genocide to be enacted," Holland said.

And then, the Republican Party gets involved

By the mid-1970s, the anti-abortion movement becomes far more partisan.

In 1976, the Republican Party added an anti-abortion stance in their party platform. And that's when they start to enlist more evangelicals into the anti-abortion movement, which was critical for the movement's expansion.

Through the 1980s, Republican leaders such as Ronald Reagan won in elections thanks to the anti-abortion movement. The Supreme Court also ruled on Planned Parenthood of Southeastern Pennsylvania v. Casey in 1992, making it easier for states to pass more restrictive abortion laws. By 1996, 86% of all counties in the U.S. did not have a known abortion provider.

The NPR Politics Podcast

The docket: after a half century, roe v. wade faces an uncertain future.

From the late 1990s into the early 2000s, socially conservative leaders like James Dobson start to become more critical of the Republican Party. For example, they didn't want Reagan to nominate Sandra Day O'Connor to the Supreme Court because she wasn't in line with the movement, but Reagan nominated her anyway.

"In the late 90s, you have all these big socially conservative leaders who say: no more... We don't agree in a big tent party," Holland said

"You really see the power of the anti-abortion movement to not only be a part of a party, but to really remake a party. And demand political uniformity on this issue," she said.

Through the end of the 20th century and the decades since, there's been a concerted effort from Republicans to prioritize abortion restrictions in legislation and judicial appointees. Conservative organizations such as the Federalist Society have heavily influenced who leaders like former President Trump nominate to the courts. Trump pledged to select nominees off a list provided by the group, which has in part led to the conservative supermajority on the Supreme Court today.

Former President Donald Trump galvizined support among conservative evangelicals by pledging to appoint Supreme Court justices who would overturn Roe v. Wade, even though he had previously supported abortion rights. OLIVIER DOULIERY/AFP via Getty Images hide caption

Former President Donald Trump galvizined support among conservative evangelicals by pledging to appoint Supreme Court justices who would overturn Roe v. Wade, even though he had previously supported abortion rights.

In the year 2022, where does the movement stand? How popular is banning abortion?

The Supreme Court's draft opinion that leaked Monday night effectively achieves what the anti-abortion movement has been aiming for for decades. But in public opinion, it's not a popular move at all.

Several polls from the last few years show that a majority of Americans do not support banning abortion. For example a recent poll from ABC/Washington Post shows that 54% think Roe v. Wade should be upheld and only 28% say it should be overturned; 18% said they had no opinion.

The unpopularity of overturning Roe isn't a new finding, either. Polling from CNN going back to 1989 shows that the percentage of Americans who support overturning Roe has never risen above 36%.

So right now, the Supreme Court is set to change a ruling that most Americans want to keep in place.

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What the data says about abortion in the U.S.

Pew Research Center has conducted many surveys about abortion over the years, providing a lens into Americans’ views on whether the procedure should be legal, among a host of other questions.

In a  Center survey  conducted nearly a year after the Supreme Court’s June 2022 decision that  ended the constitutional right to abortion , 62% of U.S. adults said the practice should be legal in all or most cases, while 36% said it should be illegal in all or most cases. Another survey conducted a few months before the decision showed that relatively few Americans take an absolutist view on the issue .

Find answers to common questions about abortion in America, based on data from the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, which have tracked these patterns for several decades:

How many abortions are there in the U.S. each year?

How has the number of abortions in the u.s. changed over time, what is the abortion rate among women in the u.s. how has it changed over time, what are the most common types of abortion, how many abortion providers are there in the u.s., and how has that number changed, what percentage of abortions are for women who live in a different state from the abortion provider, what are the demographics of women who have had abortions, when during pregnancy do most abortions occur, how often are there medical complications from abortion.

This compilation of data on abortion in the United States draws mainly from two sources: the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, both of which have regularly compiled national abortion data for approximately half a century, and which collect their data in different ways.

The CDC data that is highlighted in this post comes from the agency’s “abortion surveillance” reports, which have been published annually since 1974 (and which have included data from 1969). Its figures from 1973 through 1996 include data from all 50 states, the District of Columbia and New York City – 52 “reporting areas” in all. Since 1997, the CDC’s totals have lacked data from some states (most notably California) for the years that those states did not report data to the agency. The four reporting areas that did not submit data to the CDC in 2021 – California, Maryland, New Hampshire and New Jersey – accounted for approximately 25% of all legal induced abortions in the U.S. in 2020, according to Guttmacher’s data. Most states, though,  do  have data in the reports, and the figures for the vast majority of them came from each state’s central health agency, while for some states, the figures came from hospitals and other medical facilities.

Discussion of CDC abortion data involving women’s state of residence, marital status, race, ethnicity, age, abortion history and the number of previous live births excludes the low share of abortions where that information was not supplied. Read the methodology for the CDC’s latest abortion surveillance report , which includes data from 2021, for more details. Previous reports can be found at  stacks.cdc.gov  by entering “abortion surveillance” into the search box.

For the numbers of deaths caused by induced abortions in 1963 and 1965, this analysis looks at reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. In computing those figures, we excluded abortions listed in the report under the categories “spontaneous or unspecified” or as “other.” (“Spontaneous abortion” is another way of referring to miscarriages.)

Guttmacher data in this post comes from national surveys of abortion providers that Guttmacher has conducted 19 times since 1973. Guttmacher compiles its figures after contacting every known provider of abortions – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, and it provides estimates for abortion providers that don’t respond to its inquiries. (In 2020, the last year for which it has released data on the number of abortions in the U.S., it used estimates for 12% of abortions.) For most of the 2000s, Guttmacher has conducted these national surveys every three years, each time getting abortion data for the prior two years. For each interim year, Guttmacher has calculated estimates based on trends from its own figures and from other data.

The latest full summary of Guttmacher data came in the institute’s report titled “Abortion Incidence and Service Availability in the United States, 2020.” It includes figures for 2020 and 2019 and estimates for 2018. The report includes a methods section.

In addition, this post uses data from StatPearls, an online health care resource, on complications from abortion.

An exact answer is hard to come by. The CDC and the Guttmacher Institute have each tried to measure this for around half a century, but they use different methods and publish different figures.

The last year for which the CDC reported a yearly national total for abortions is 2021. It found there were 625,978 abortions in the District of Columbia and the 46 states with available data that year, up from 597,355 in those states and D.C. in 2020. The corresponding figure for 2019 was 607,720.

The last year for which Guttmacher reported a yearly national total was 2020. It said there were 930,160 abortions that year in all 50 states and the District of Columbia, compared with 916,460 in 2019.

• How the CDC gets its data: It compiles figures that are voluntarily reported by states’ central health agencies, including separate figures for New York City and the District of Columbia. Its latest totals do not include figures from California, Maryland, New Hampshire or New Jersey, which did not report data to the CDC. ( Read the methodology from the latest CDC report .)
• How Guttmacher gets its data: It compiles its figures after contacting every known abortion provider – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, then provides estimates for abortion providers that don’t respond. Guttmacher’s figures are higher than the CDC’s in part because they include data (and in some instances, estimates) from all 50 states. ( Read the institute’s latest full report and methodology .)

While the Guttmacher Institute supports abortion rights, its empirical data on abortions in the U.S. has been widely cited by  groups  and  publications  across the political spectrum, including by a  number of those  that  disagree with its positions .

These estimates from Guttmacher and the CDC are results of multiyear efforts to collect data on abortion across the U.S. Last year, Guttmacher also began publishing less precise estimates every few months , based on a much smaller sample of providers.

The figures reported by these organizations include only legal induced abortions conducted by clinics, hospitals or physicians’ offices, or those that make use of abortion pills dispensed from certified facilities such as clinics or physicians’ offices. They do not account for the use of abortion pills that were obtained  outside of clinical settings .

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The annual number of U.S. abortions rose for years after Roe v. Wade legalized the procedure in 1973, reaching its highest levels around the late 1980s and early 1990s, according to both the CDC and Guttmacher. Since then, abortions have generally decreased at what a CDC analysis called  “a slow yet steady pace.”

Guttmacher says the number of abortions occurring in the U.S. in 2020 was 40% lower than it was in 1991. According to the CDC, the number was 36% lower in 2021 than in 1991, looking just at the District of Columbia and the 46 states that reported both of those years.

(The corresponding line graph shows the long-term trend in the number of legal abortions reported by both organizations. To allow for consistent comparisons over time, the CDC figures in the chart have been adjusted to ensure that the same states are counted from one year to the next. Using that approach, the CDC figure for 2021 is 622,108 legal abortions.)

There have been occasional breaks in this long-term pattern of decline – during the middle of the first decade of the 2000s, and then again in the late 2010s. The CDC reported modest 1% and 2% increases in abortions in 2018 and 2019, and then, after a 2% decrease in 2020, a 5% increase in 2021. Guttmacher reported an 8% increase over the three-year period from 2017 to 2020.

As noted above, these figures do not include abortions that use pills obtained outside of clinical settings.

Guttmacher says that in 2020 there were 14.4 abortions in the U.S. per 1,000 women ages 15 to 44. Its data shows that the rate of abortions among women has generally been declining in the U.S. since 1981, when it reported there were 29.3 abortions per 1,000 women in that age range.

The CDC says that in 2021, there were 11.6 abortions in the U.S. per 1,000 women ages 15 to 44. (That figure excludes data from California, the District of Columbia, Maryland, New Hampshire and New Jersey.) Like Guttmacher’s data, the CDC’s figures also suggest a general decline in the abortion rate over time. In 1980, when the CDC reported on all 50 states and D.C., it said there were 25 abortions per 1,000 women ages 15 to 44.

That said, both Guttmacher and the CDC say there were slight increases in the rate of abortions during the late 2010s and early 2020s. Guttmacher says the abortion rate per 1,000 women ages 15 to 44 rose from 13.5 in 2017 to 14.4 in 2020. The CDC says it rose from 11.2 per 1,000 in 2017 to 11.4 in 2019, before falling back to 11.1 in 2020 and then rising again to 11.6 in 2021. (The CDC’s figures for those years exclude data from California, D.C., Maryland, New Hampshire and New Jersey.)

The CDC broadly divides abortions into two categories: surgical abortions and medication abortions, which involve pills. Since the Food and Drug Administration first approved abortion pills in 2000, their use has increased over time as a share of abortions nationally, according to both the CDC and Guttmacher.

The majority of abortions in the U.S. now involve pills, according to both the CDC and Guttmacher. The CDC says 56% of U.S. abortions in 2021 involved pills, up from 53% in 2020 and 44% in 2019. Its figures for 2021 include the District of Columbia and 44 states that provided this data; its figures for 2020 include D.C. and 44 states (though not all of the same states as in 2021), and its figures for 2019 include D.C. and 45 states.

Guttmacher, which measures this every three years, says 53% of U.S. abortions involved pills in 2020, up from 39% in 2017.

Two pills commonly used together for medication abortions are mifepristone, which, taken first, blocks hormones that support a pregnancy, and misoprostol, which then causes the uterus to empty. According to the FDA, medication abortions are safe  until 10 weeks into pregnancy.

Surgical abortions conducted  during the first trimester  of pregnancy typically use a suction process, while the relatively few surgical abortions that occur  during the second trimester  of a pregnancy typically use a process called dilation and evacuation, according to the UCLA School of Medicine.

In 2020, there were 1,603 facilities in the U.S. that provided abortions,  according to Guttmacher . This included 807 clinics, 530 hospitals and 266 physicians’ offices.

While clinics make up half of the facilities that provide abortions, they are the sites where the vast majority (96%) of abortions are administered, either through procedures or the distribution of pills, according to Guttmacher’s 2020 data. (This includes 54% of abortions that are administered at specialized abortion clinics and 43% at nonspecialized clinics.) Hospitals made up 33% of the facilities that provided abortions in 2020 but accounted for only 3% of abortions that year, while just 1% of abortions were conducted by physicians’ offices.

Looking just at clinics – that is, the total number of specialized abortion clinics and nonspecialized clinics in the U.S. – Guttmacher found the total virtually unchanged between 2017 (808 clinics) and 2020 (807 clinics). However, there were regional differences. In the Midwest, the number of clinics that provide abortions increased by 11% during those years, and in the West by 6%. The number of clinics  decreased  during those years by 9% in the Northeast and 3% in the South.

The total number of abortion providers has declined dramatically since the 1980s. In 1982, according to Guttmacher, there were 2,908 facilities providing abortions in the U.S., including 789 clinics, 1,405 hospitals and 714 physicians’ offices.

The CDC does not track the number of abortion providers.

In the District of Columbia and the 46 states that provided abortion and residency information to the CDC in 2021, 10.9% of all abortions were performed on women known to live outside the state where the abortion occurred – slightly higher than the percentage in 2020 (9.7%). That year, D.C. and 46 states (though not the same ones as in 2021) reported abortion and residency data. (The total number of abortions used in these calculations included figures for women with both known and unknown residential status.)

The share of reported abortions performed on women outside their state of residence was much higher before the 1973 Roe decision that stopped states from banning abortion. In 1972, 41% of all abortions in D.C. and the 20 states that provided this information to the CDC that year were performed on women outside their state of residence. In 1973, the corresponding figure was 21% in the District of Columbia and the 41 states that provided this information, and in 1974 it was 11% in D.C. and the 43 states that provided data.

In the District of Columbia and the 46 states that reported age data to  the CDC in 2021, the majority of women who had abortions (57%) were in their 20s, while about three-in-ten (31%) were in their 30s. Teens ages 13 to 19 accounted for 8% of those who had abortions, while women ages 40 to 44 accounted for about 4%.

The vast majority of women who had abortions in 2021 were unmarried (87%), while married women accounted for 13%, according to  the CDC , which had data on this from 37 states.

In the District of Columbia, New York City (but not the rest of New York) and the 31 states that reported racial and ethnic data on abortion to  the CDC , 42% of all women who had abortions in 2021 were non-Hispanic Black, while 30% were non-Hispanic White, 22% were Hispanic and 6% were of other races.

Looking at abortion rates among those ages 15 to 44, there were 28.6 abortions per 1,000 non-Hispanic Black women in 2021; 12.3 abortions per 1,000 Hispanic women; 6.4 abortions per 1,000 non-Hispanic White women; and 9.2 abortions per 1,000 women of other races, the  CDC reported  from those same 31 states, D.C. and New York City.

For 57% of U.S. women who had induced abortions in 2021, it was the first time they had ever had one,  according to the CDC.  For nearly a quarter (24%), it was their second abortion. For 11% of women who had an abortion that year, it was their third, and for 8% it was their fourth or more. These CDC figures include data from 41 states and New York City, but not the rest of New York.

Nearly four-in-ten women who had abortions in 2021 (39%) had no previous live births at the time they had an abortion,  according to the CDC . Almost a quarter (24%) of women who had abortions in 2021 had one previous live birth, 20% had two previous live births, 10% had three, and 7% had four or more previous live births. These CDC figures include data from 41 states and New York City, but not the rest of New York.

The vast majority of abortions occur during the first trimester of a pregnancy. In 2021, 93% of abortions occurred during the first trimester – that is, at or before 13 weeks of gestation,  according to the CDC . An additional 6% occurred between 14 and 20 weeks of pregnancy, and about 1% were performed at 21 weeks or more of gestation. These CDC figures include data from 40 states and New York City, but not the rest of New York.

About 2% of all abortions in the U.S. involve some type of complication for the woman , according to an article in StatPearls, an online health care resource. “Most complications are considered minor such as pain, bleeding, infection and post-anesthesia complications,” according to the article.

The CDC calculates  case-fatality rates for women from induced abortions – that is, how many women die from abortion-related complications, for every 100,000 legal abortions that occur in the U.S .  The rate was lowest during the most recent period examined by the agency (2013 to 2020), when there were 0.45 deaths to women per 100,000 legal induced abortions. The case-fatality rate reported by the CDC was highest during the first period examined by the agency (1973 to 1977), when it was 2.09 deaths to women per 100,000 legal induced abortions. During the five-year periods in between, the figure ranged from 0.52 (from 1993 to 1997) to 0.78 (from 1978 to 1982).

The CDC calculates death rates by five-year and seven-year periods because of year-to-year fluctuation in the numbers and due to the relatively low number of women who die from legal induced abortions.

In 2020, the last year for which the CDC has information , six women in the U.S. died due to complications from induced abortions. Four women died in this way in 2019, two in 2018, and three in 2017. (These deaths all followed legal abortions.) Since 1990, the annual number of deaths among women due to legal induced abortion has ranged from two to 12.

The annual number of reported deaths from induced abortions (legal and illegal) tended to be higher in the 1980s, when it ranged from nine to 16, and from 1972 to 1979, when it ranged from 13 to 63. One driver of the decline was the drop in deaths from illegal abortions. There were 39 deaths from illegal abortions in 1972, the last full year before Roe v. Wade. The total fell to 19 in 1973 and to single digits or zero every year after that. (The number of deaths from legal abortions has also declined since then, though with some slight variation over time.)

The number of deaths from induced abortions was considerably higher in the 1960s than afterward. For instance, there were 119 deaths from induced abortions in  1963  and 99 in  1965 , according to reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. The CDC is a division of Health and Human Services.

Note: This is an update of a post originally published May 27, 2022, and first updated June 24, 2022.

Support for legal abortion is widespread in many countries, especially in Europe

Nearly a year after roe’s demise, americans’ views of abortion access increasingly vary by where they live, by more than two-to-one, americans say medication abortion should be legal in their state, most latinos say democrats care about them and work hard for their vote, far fewer say so of gop, positive views of supreme court decline sharply following abortion ruling, most popular.

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The Most Important Study in the Abortion Debate

Researchers rigorously tested the persistent notion that abortion wounds the women who seek it.

The demographer Diana Greene Foster was in Orlando last month, preparing for the end of Roe v. Wade , when Politico published a leaked draft of a majority Supreme Court opinion striking down the landmark ruling. The opinion, written by Justice Samuel Alito, would revoke the constitutional right to abortion and thus give states the ability to ban the medical procedure.

Foster, the director of the Bixby Population Sciences Research Unit at UC San Francisco, was at a meeting of abortion providers, seeking their help recruiting people for a new study . And she was racing against time. She wanted to look, she told me, “at the last person served in, say, Nebraska, compared to the first person turned away in Nebraska.” Nearly two dozen red and purple states are expected to enact stringent limits or even bans on abortion as soon as the Supreme Court strikes down Roe v. Wade , as it is poised to do. Foster intends to study women with unwanted pregnancies just before and just after the right to an abortion vanishes.

Read: When a right becomes a privilege

When Alito’s draft surfaced, Foster told me, “I was struck by how little it considered the people who would be affected. The experience of someone who’s pregnant when they do not want to be and what happens to their life is absolutely not considered in that document.” Foster’s earlier work provides detailed insight into what does happen. The landmark Turnaway Study , which she led, is a crystal ball into our post- Roe future and, I would argue, the single most important piece of academic research in American life at this moment.

The legal and political debate about abortion in recent decades has tended to focus more on the rights and experience of embryos and fetuses than the people who gestate them. And some commentators—including ones seated on the Supreme Court—have speculated that termination is not just a cruel convenience, but one that harms women too . Foster and her colleagues rigorously tested that notion. Their research demonstrates that, in general, abortion does not wound women physically, psychologically, or financially. Carrying an unwanted pregnancy to term does.

In a 2007 decision , Gonzales v. Carhart , the Supreme Court upheld a ban on one specific, uncommon abortion procedure. In his majority opinion , Justice Anthony Kennedy ventured a guess about abortion’s effect on women’s lives: “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained,” he wrote. “Severe depression and loss of esteem can follow.”

Was that really true? Activists insisted so, but social scientists were not sure . Indeed, they were not sure about a lot of things when it came to the effect of the termination of a pregnancy on a person’s life. Many papers compared individuals who had an abortion with people who carried a pregnancy to term. The problem is that those are two different groups of people; to state the obvious, most people seeking an abortion are experiencing an unplanned pregnancy, while a majority of people carrying to term intended to get pregnant.

Foster and her co-authors figured out a way to isolate the impact of abortion itself. Nearly all states bar the procedure after a certain gestational age or after the point that a fetus is considered viable outside the womb . The researchers could compare people who were “turned away” by a provider because they were too far along with people who had an abortion at the same clinics. (They did not include people who ended a pregnancy for medical reasons.) The women who got an abortion would be similar, in terms of demographics and socioeconomics, to those who were turned away; what would separate the two groups was only that some women got to the clinic on time, and some didn’t.

In time, 30 abortion providers—ones that had the latest gestational limit of any clinic within 150 miles, meaning that a person could not easily access an abortion if they were turned away—agreed to work with the researchers. They recruited nearly 1,000 women to be interviewed every six months for five years. The findings were voluminous, resulting in 50 publications and counting. They were also clear. Kennedy’s speculation was wrong: Women, as a general point, do not regret having an abortion at all.

Researchers found, among other things, that women who were denied abortions were more likely to end up living in poverty. They had worse credit scores and, even years later, were more likely to not have enough money for the basics, such as food and gas. They were more likely to be unemployed. They were more likely to go through bankruptcy or eviction. “The two groups were economically the same when they sought an abortion,” Foster told me. “One became poorer.”

Read: The calamity of unwanted motherhood

In addition, those denied a termination were more likely to be with a partner who abused them. They were more likely to end up as a single parent. They had more trouble bonding with their infants, were less likely to agree with the statement “I feel happy when my child laughs or smiles,” and were more likely to say they “feel trapped as a mother.” They experienced more anxiety and had lower self-esteem, though those effects faded in time. They were half as likely to be in a “very good” romantic relationship at two years. They were less likely to have “aspirational” life plans.

Their bodies were different too. The ones denied an abortion were in worse health, experiencing more hypertension and chronic pain. None of the women who had an abortion died from it. This is unsurprising; other research shows that the procedure has extremely low complication rates , as well as no known negative health or fertility effects . Yet in the Turnaway sample, pregnancy ended up killing two of the women who wanted a termination and did not get one.

The Turnaway Study also showed that abortion is a choice that women often make in order to take care of their family. Most of the women seeking an abortion were already mothers. In the years after they terminated a pregnancy, their kids were better off; they were more likely to hit their developmental milestones and less likely to live in poverty. Moreover, many women who had an abortion went on to have more children. Those pregnancies were much more likely to be planned, and those kids had better outcomes too.

The interviews made clear that women, far from taking a casual view of abortion, took the decision seriously. Most reported using contraception when they got pregnant, and most of the people who sought an abortion after their state’s limit simply did not realize they were pregnant until it was too late. (Many women have irregular periods, do not experience morning sickness, and do not feel fetal movement until late in the second trimester.) The women gave nuanced, compelling reasons for wanting to end their pregnancies.

Afterward, nearly all said that termination had been the right decision. At five years, only 14 percent felt any sadness about having an abortion; two in three ended up having no or very few emotions about it at all. “Relief” was the most common feeling, and an abiding one.

From the May 2022 issue: The future of abortion in a post- Roe America

The policy impact of the Turnaway research has been significant, even though it was published during a period when states have been restricting abortion access. In 2018, the Iowa Supreme Court struck down a law requiring a 72-hour waiting period between when a person seeks and has an abortion, noting that “the vast majority of abortion patients do not regret the procedure, even years later, and instead feel relief and acceptance”—a Turnaway finding. That same finding was cited by members of Chile’s constitutional court  as they allowed for the decriminalization of abortion in certain circumstances.

Yet the research has not swayed many people who advocate for abortion bans, believing that life begins at conception and that the law must prioritize the needs of the fetus. Other activists have argued that Turnaway is methodologically flawed; some women approached in the clinic waiting room declined to participate, and not all participating women completed all interviews . “The women who anticipate and experience the most negative reactions to abortion are the least likely to want to participate in interviews,” the activist David Reardon argued in a 2018 article in a Catholic Medical Association journal.

Still, four dozen papers analyzing the Turnaway Study’s findings have been published in peer-reviewed journals; the research is “the gold standard,” Emily M. Johnston, an Urban Institute health-policy expert who wasn’t involved with the project, told me. In the trajectories of women who received an abortion and those who were denied one, “we can understand the impact of abortion on women’s lives,” Foster told me. “They don’t have to represent all women seeking abortion for the findings to be valid.” And her work has been buttressed by other surveys, showing that women fear the repercussions of unplanned pregnancies for good reason and do not tend to regret having a termination. “Among the women we spoke with, they did not regret either choice,” whether that was having an abortion or carrying to term, Johnston told me. “These women were thinking about their desires for themselves, but also were thinking very thoughtfully about what kind of life they could provide for a child.”

The Turnaway study , for Foster, underscored that nobody needs the government to decide whether they need an abortion. If and when America’s highest court overturns Roe , though, an estimated 34 million women of reproductive age will lose some or all access to the procedure in the state where they live. Some people will travel to an out-of-state clinic to terminate a pregnancy; some will get pills by mail to manage their abortions at home; some will “try and do things that are less safe,” as Foster put it. Many will carry to term: The Guttmacher Institute has estimated that there will be roughly 100,000 fewer legal abortions per year post- Roe . “The question now is who is able to circumvent the law, what that costs, and who suffers from these bans,” Foster told me. “The burden of this will be disproportionately put on people who are least able to support a pregnancy and to support a child.”

Ellen Gruber Garvey: I helped women get abortions in pre- Roe America

Foster said that there is a lot we still do not know about how the end of Roe might alter the course of people’s lives—the topic of her new research. “In the Turnaway Study, people were too late to get an abortion, but they didn’t have to feel like the police were going to knock on their door,” she told me. “Now, if you’re able to find an abortion somewhere and you have a complication, do you get health care? Do you seek health care out if you’re having a miscarriage, or are you too scared? If you’re going to travel across state lines, can you tell your mother or your boss what you’re doing?”

In addition, she said that she was uncertain about the role that abortion funds —local, on-the-ground organizations that help people find, travel to, and pay for terminations—might play. “We really don’t know who is calling these hotlines,” she said. “When people call, what support do they need? What is enough, and who falls through the cracks?” She added that many people are unaware that such services exist, and might have trouble accessing them.

People are resourceful when seeking a termination and resilient when denied an abortion, Foster told me. But looking into the post- Roe future, she predicted, “There’s going to be some widespread and scary consequences just from the fact that we’ve made this common health-care practice against the law.” Foster, to her dismay, is about to have a lot more research to do.

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• Joan Andrews (in Earl and Kathleen Essex collection) Earl W. Essex (1919-1992) was a Pennsylvania attorney and pro-life activist. He and his wife, Kathleen (1938-2004) provided financial support for Catholic, pro-life activist Joan Andrews following her 1986 arrest following an anti-abortion sit-in at The Ladies' Center, a women's health clinic that provided abortions, in Pensacola, Florida. The Earl and Kathleen Essex collection on Joan Andrews contains clippings documenting Andrews' participation in abortion clinic protests; photographs of Andrews; legal documents relating to Andrews' 1986 arrest following a protest at The Ladies' Center in Pensacola, Florida; correspondence between Earl Essex and Andrews' lawyer, Stephen Anthony Flynn regarding financial support for Andrews' defense; and letters Andrews wrote to the Essexes during her imprisonment.
• Nicole Armenta This collection consists of pro- and anti-abortion brochures, posters, reports, and other printed material that Armenta assembled while writing her undergraduate thesis at Harvard/Radcliffe in 1995.
• Bill Baird (b. 1932) Reproductive rights pioneer Bill Baird, a 1955 graduate of Brooklyn College, served in the United States Army (1955-1957) and worked for Sandoz and Emko pharmaceutical companies (1957-1964). In 1963 he began distributing birth control foam in the New York area, and in 1964 established the Parents' Aid Society in Hempstead, New York. A "Plan Van" also distributed contraception in poorer neighborhoods. During the 1960s he was repeatedly arrested for distributing information about birth control and abortion. Convicted in 1967 for providing contraception to a female college student at Boston University, Baird's appeal culminated in the historic 1972 Supreme Court decision, Eisenstadt v. Baird, which established the right of unmarried persons to possess contraception. In 1978, with his clinic under constant threat, Baird wrote the nation's first clinic self-defense manual. The following year his Hempstead clinic was firebombed, with fifty people inside it. Two other Supreme Court cases, Baird v. Bellotti (1976) and Baird v. Bellotti (1979), gave minors the right to abortion without parental consent. With the escalation of anti-abortion violence at clinics nationwide, Baird worked with Father Frank Pavone, co-founder of Priests for Life, to create a document calling for an end to inflammatory rhetoric and violence; signed in 2002, it was distributed nationwide. Throughout his career, he has lectured widely and demonstrated for abortion and reproductive rights. As of 2015, he serves as co-director, with Joni Scott Baird of the Pro Choice League.
• Thea Rossi Barron Attorney Thea Rossi Barron worked with physician and pro-life advocate Mildred Jefferson (1926-2010) as the first lobbyist hired by the National Right to Life Committee in 1976. In 1979 Barron returned to private practice and continued to represent Jefferson in her role as president of the Right to Life Crusade.
• Bass and Howes, Inc. As the former national campaign director for ERAmerica and a lobbyist for the Planned Parenthood Federation of America, Marie Bass and Joanne Howes brought together over thirty years of experience to form the public policy and public affairs consulting firm Bass and Howes, Inc. While it operated largely in a male-dominated field, Bass and Howes came to be centrally involved in most of the key women's policy issues of the 1980s and 1990s, including reproductive rights, women's health, family and medical leave, domestic violence, and women in politics.
• Birth Control League of Massachusetts The League was established in 1916 to disseminate birth control information in the state of Massachusetts. Collection includes correspondence, articles, and state statutes concerning the early legal difficulties of the League. Correspondents include Blanche (Ames) Ames and Margaret Sanger.
• Boston Association for Childbirth Education The Boston Association for Childbirth Education (BACE) was incorporated in 1958, although its founders had begun meeting as early as 1953 to discuss how best to reform obstetrical and maternity care and to disseminate information about natural childbirth. Some of the early educators were Justine Kelliher, Abigail Avery, and Sylvia D. Sawin. In seeking to further the acquisition and application of information concerning family-centered maternity care and breastfeeding, BACE sponsored studies, held workshops and classes, published newsletters and other printed material, and collaborated with the International Childbirth Education Association.
• Boston N.O.W. A chapter of the National Organization for Women (NOW), Boston NOW brings a feminist voice and vision to a wide variety of issues addressing the economic, political, social, and personal dynamics that affect women's everyday lives. The members of Boston NOW have played a key role in shaping public discourse and policy in Massachusetts through political and legislative activities. They work to educate the public through rallies, forums, workshops, and demonstrations.
• Boston Women's Health Book Collective The Boston Women's Health Book Collective began in 1969 when a small group of women gathered after a workshop on women and their bodies at a Boston-area female liberation conference to talk about some crucial health issues and to confront a medical establishment viewed as paternalistic and condescending. Perhaps best known for their pioneering handbook Our Bodies, Ourselves (1971 and subsequent editions and international adaptations), the Collective helped to create worldwide networks of women involved in health education and advocacy. See also, Boston Women's Health Book Collective, Additional Records .
• Marjorie Braude (1924-2005) A psychiatrist, advocate for women's health care issues, and activist against domestic violence, Marjorie Braude advocated gender equality in medical research, sought to ensure women's access to abortions, supported the introduction of the abortion pill into the American market, and was editor of Women, Power, and Therapy . She also held a landmark conference on domestic violence in Los Angeles in 1994 and was an activist, writer, and speaker on women's medical and psychological issues.
• Mary Steichen Calderone (1904-1998) Calderone was a physician and leader in public health, birth control and sex education. A compelling speaker, she was especially popular with youthful audiences who appreciated her candid no-nonsense factual replies to their questions. Dr. Calderone spearheaded a virtual revolution in liberalizing U. S. attitudes toward sex education and as a result, became the target of extremist groups. See also four collections of additional papers for Calderone: MC 622 , 73-150--81-M35 , 83-M129 , and 83-M184 .
• Florence Clothier (1903-1987) A psychiatrist and author, Clothier was director of the Planned Parenthood League of Massachusetts (1945-1957) and served as League president (1953-1956) before becoming assistant to the president of Vassar College, her alma mater, in 1957. She was also president of the Greater Fall River Committee for Family Planning and a board member of the Euthanasia Educational Council.
• Mary Dent Crisp (1923-2007) A fervent supporter of the Equal Rights Amendment and of abortion rights, Crisp was an active member of the Republican Party, first on the local and then on the national level, for over twenty years. In 1977, she was elected co-chair of the Republican National Committee, and served until 1980. At the 1980 Republican Convention, she spoke out against the platform committee’s decision to oppose the Equal Rights Amendment and also protested the party's opposition to the federal funding of abortion. In 1989, after the Supreme Court restricted federal funding for abortion, Crisp co-founded and served as chair and spokesperson for the National Republican Coalition for Choice.
• Sarah Thomas Curwood (1916-1990) A sociologist, professor, lecturer, and tree farmer, Sarah Thomas Curwood graduated from Cornell University in 1937 and went on to attend Boston University (Ed.M. 1947) and Radcliffe College (Ph.D. 1956). Curwood taught early childhood education at the Harvard Graduate School of Education (1952-1955) as well as other institutions. From 1968 to 1969, she was the Head Start regional training officer for New Hampshire and Vermont. She was also a consultant for many organizations including the Massachusetts Committee on Children and Youth and Volt Information Services Head Start Planned Variations Program in Buffalo, New York. In addition to her professional activities, Curwood served on the boards or as a trustee of the Massachusetts Mothers' Health Council, Planned Parenthood League of Massachusetts, the Eliot-Pearson School of Tufts University, Region One of the Girl Scouts of the USA, and the American Friends Service Committee in Philadelphia.
• Mildred Emeline Danforth (b. ca. 1900) Danforth worked as a librarian and teacher and served in the Women's Army Corps during World War II. This collection includes Danforth's anti-abortion writings and cartoons, letters, and lists of anti-abortion groups nationwide.
• Mary Ware Dennett (1872-1947) A suffragist, pacifist, artisan, and advocate of birth control and sex education, Mary Coffin (Ware) Dennett was a founder of the National Birth Control League, director of the Voluntary Parenthood League, and editor of the Birth Control Herald. See also Additional Papers of Mary Ware Dennett .
• Jennifer M. Donnally The collection consists of recordings of interviews conducted by Jennifer M. Donnally with people active in the pro-life movement in Massachusetts; interview use agreements; biographical information on interviewees; and transcripts of some interviews, including one with Mildred Jefferson. Interviews were conducted as research for Donnally's PhD dissertation, The Politics of Abortion and the Rise of the New Right .
• Bette L. Ellis Ellis has been active in the pro-life movement in Rapid City, S.D. The collection, spanning the 1970s and 1980s, includes research papers by Ellis relating to the pro-life movement and the role of propaganda; letters to the editor; and pro-life advertisements.
• Morris Leopold Ernst (1888-1976) Ernst was a lawyer who represented physician Hannah Stone in United States v. One Package of Pessaries, a successful legal action against the U.S. government, which had seized some contraceptives shipped to Stone from Japan.
• Family Planning Oral History Project Interviews From 1973 to 1977, the Schlesinger Library carried on an oral history project, funded by two two-year grants from the Rockefeller Foundation, on the role of women in the family planning movement. The project concentrated first on the birth control movement and then on abortion law reform. This collection contains tapes and transcripts of the 24 oral histories. The interviews discuss the family background, education, marriage, children, and careers of the interviewees. See also the Project Records , which contain research materials collection by the interviewers, consisting of printed and manuscript material and photographs.
• Feminist Ephemera Collection This collection consists of feminist flyers, pamphlets, directories, statements, bibliographies, curricula, programs, invitations, manifestos, articles, catalogs, and other printed materials. The collection includes materials on abortion, birth control, and other women’s health concerns.
• Wanda Kay Franz (b. 1943) Wanda Kay Franz, an associate professor of family resources at West Virginia University and a specialist in child development, has been active in the pro-life movement, publishing and speaking widely against abortion.
• Sarah Merry Bradley Gamble (1898-1984) Sarah Gamble and her husband, Clarence James Gamble (1894-1966) were active in the birth control movement in the U.S. and internationally. Clarence (Princeton, 1914; Harvard Medical School, M.D. 1920) founded a maternal health clinic in Cincinnati, Ohio, in 1929, taught at the Harvard Medical School, and was a researcher at the Harvard School of Public Health. Beginning in 1952, the Gambles traveled around the world, working with doctors and social workers to set up family planning clinics. In 1957 they founded the Pathfinder Fund to promote and support this work.
• Charlotte Perkins Gilman (1860-1935) A socialist and deist, Gilman was an independent thinker, author, and speaker who was an intellectual leader of the women's movement from the late 1890s through the mid-1920s. An advocate of economic independence for women, Gilman considered the ballot of secondary importance. Her interests ranged from sensible dress for women, physical fitness, more rational domestic architecture, and professionalized housework, to birth control, Freud, and immigrants. This collection and other Gilman collections have been digitized. Please see the Charlotte Perkins Gilman research guide for more information about accessing the digitized materials.
• Ellen McCormack [in the Jane H. Gilroy collection] An active member of the pro-life movement since 1969, Jane Gilroy published numerous scholarly and popular articles on the movement. She served as vice-chairman and secretary for the 1976 presidential campaign of Ellen McCormack, who ran on an exclusively pro-life platform, and authored a book on the campaign, A Shared Vision: The 1976 Ellen McCormack Presidential Campaign (2010). Gilroy was a founding member and president of the Long Island Chapter of University Faculty for Life. The collection contains mailings, press releases, speeches by McCormack, and clippings from local and national newspapers documenting the 1976 United States presidential campaign of Ellen Cullen McCormack, a Democratic candidate who ran on a pro-life platform.
• Patricia Gold (b. 1935) Patricia Gold was involved in the women's liberation movement in the Boston, Mass., area and active in a number of organizations, including the Massachusetts Organization to Repeal Abortion Laws (MORAL), local chapters of the National Organization for Women, and the Massachusetts Women's Political Caucus. A nurse in Watertown, Mass., she served on the Health Task Force of the Governor's Commission on the Status of Women and was co-chair of Boston NOW's Abortion and Birth Control Task Force.
• Debra Haffner Co-founder and executive director of the Religious Institute, Debra Haffner is a graduate of Wesleyan University, Yale University School of Medicine (MPH), and Union Theological Seminary (MDiv). She is an ordained Unitarian Universalist minister and worked for Planned Parenthood of Metropolitan Washington before becoming chief executive officer of the Sexuality Information and Education Council of the United States (SIECUS) from 1988 to 2000. In 2001 she co-founded the Religious Institute, a multifaith organization advocating sexual health, education, and justice in faith communities and society. She is the author of several guides for congregations on sexuality, a college sexuality education textbook, and books for parents on raising sexually healthy children.
• Louise Kapp Howe Louise Kapp Howe was the author of Moments on Maple Avenue: The Reality of Abortion (1984). This collection includes research material in preparation for her book, typed drafts of the book, and audiotapes of an unnamed conference on abortion.
• Institute for Women's Policy Research The Institute for Women's Policy Research was founded in 1987 by Heidi Hartmann, a pioneering feminist economist and recipient of a MacArthur Fellowship Award. A leading think-tank on women's issues, the Institute develops comprehensive, women-focused, policy-oriented research on employment, education and economic change; democracy and society; poverty, welfare, and income security; work and family; and health and safety.
• Mildred Jefferson (1926-2010) A surgeon and national spokesperson for the pro-life movement, Jefferson became involved in the pro-life movement in 1970. She was a founding member of the Value of Life Committee (VOLCOM) in Massachusetts and subsequently helped formed Massachusetts Citizens for Life (MCFL), which was incorporated in 1973. MCFL's efforts led to the founding of the National Right to Life Committee (NRTLC), an umbrella organization comprising 50 state-run organizations and more than 3000 local chapters. Jefferson served on the boards and held prominent positions within each organization, including VOLCOM's board of governors; NRTLC president (1975-1978), and MCFL president (2007). She also served as president of the Right to Life Crusade, Inc., which she founded in 1978, and played an active role in several allied organizations, including Americans United for Life, American Life League, and Black Americans for Life.
• Norma J. Kane Norma J. Kane was a member of St. Clare of Assisi Church in the Bronx, New York and was co-director of the St. Clare of Assisi Pro-Life Group, which she helped found in 1997. The pro-life collection of Norma J. Kane contains meeting notes and agendas of the St. Clare of Assisi Pro-Life Group; St. Clare of Assisi Pro-Life Group fundraising and outreach materials; and pro-life pamphlets, fliers, and clippings collected by Kane.
• Lawrence Lader (b. 1919) Author and activist Lawrence Lader has written extensively on abortion rights and family planning in the United States. He was founding chair of the National Association for the Repeal of Abortion Laws (now the National Abortion and Reproductive Rights Action League) in 1969 and was instrumental in the campaign that produced the 1970 New York State law legalizing abortion. Beginning in 1976 he served as president of the Abortion Rights Mobilization, and has worked for the introduction of RU 486 (also known as the “abortion pill”) to the United States.
• Lucile Lord-Heinstein (1903-1997) A gynecologist and birth control advocate (Tufts College Medical School, M.D., 1927), Lord-Heinstein was on the staff of the New England Hospital for Women, Physician-In-Charge of the Mothers' Health Office in Salem, MA, and a marriage and family counselor.
• Kristin Luker Professor of sociology at the University of California, Berkeley, Kristin Luker is the author of five books, many of them on abortion and teenage pregnancy. This collection includes printed material, largely from pro-life and teenage abstinence groups, collected by Luker in the course of her research; printed material from pro-choice groups such as Sex Information and Education Council of the U.S. and Catholics for a Free Choice; transcripts of interviews by Luker, mostly with pro-life activists; and correspondence of Lena Clarke Phelan, abortion reform activist, from viewers after an appearance on the Louis Lomax television show.
• Massachusetts NOW The Massachusetts Chapter of the National Organization for Women (NOW) was organized in early 1973 as a way to link and support the activities of all local chapters in the state. Mass. NOW has helped to change Massachusetts laws regarding economic and workplace equality, reproductive rights, racial diversity in employment, equal civil rights regardless of sexual orientation, and violence against women.
• Norma McCorvey and Roe v. Wade [in Joshua Prager collection] In 1970, Norma McCorvey became the anonymous plaintiff, known as "Jane Roe" in Coffee and Weddington's class action suit challenging Texas abortion laws. The suit led to the 1973 Supreme Court decision legalizing abortion in the first trimester of pregnancy, Roe v. Wade. Norma McCorvey gave birth to her third child, known as the "Roe Baby," in 1970 before her case reached the Supreme Court. McCorvey remained anonymous to the public for her role in the case until the 1980s, when she began taking a larger role in the pro-choice movement, counseling women and attending pro-choice rallies. In 1995, McCorvey was baptized by Philip "Flip" Benham, an evangelical minister and director of Operation Rescue. After her baptism, McCorvey joined the pro-life movement and founded the Roe No More Ministry. McCorvey converted to Catholicism in 1998. The collection documents the personal and professional life of Norma McCorvey, as well as the history and the aftermath of the 1973 Roe v. Wade Supreme Court decision.
• Edna Rankin McKinnon (1893-1978) A birth control advocate, McKinnon worked with the Margaret Sanger Research Bureau (1936-1947) establishing birth control clinics around the country; was Executive Director of the Planned Parenthood Association, Chicago area (1947-1957); and was a field worker for the Pathfinder Fund, a private organization for international family planning (1958-1966).
• Emily Hartshorne Mudd (1898-1998) Emily Borie (Hartshorne) Mudd was a marriage counselor, advocate for family planning, researcher, and educator (University of Pennsylvania, M.S.W., 1936, Ph.D., 1950). Mudd became counselor and then executive director of the newly founded Marriage Council of Philadelphia (MCP) in the early 1930s. The MCP affiliated with the University of Pennsylvania School of Medicine in 1952; in 1956 Mudd became the first woman full professor in the medical school.
• NARAL Pro-Choice America Formerly known as the National Association for the Repeal of Abortion Laws, the National Abortion Rights Action League, and the National Abortion and Reproductive Rights Action League, NARAL Pro-Choice America was founded in 1969 and engages in political action and advocacy efforts to oppose restrictions on abortion and fight for reproductive freedom.
• NARAL Pro-Choice Massachusetts The Massachusetts Organization for the Repeal of Abortion Laws (MORAL) was incorporated on September 11, 1972, as the Massachusetts state affiliate for National Association for the Repeal of Abortion Laws (NARAL). MORAL was a non-profit political organization whose purpose was to develop and sustain a constituency which utilized the political process to protect a woman's right to a legal abortion.
• National Abortion Rights Action League A national lobbying and membership organization devoted first to obtaining, and later to maintaining, the availability of safe, legal abortions. See also NARAL Additional Records .
• National Abortion Rights Action League, State affiliates newsletter collection Formed in 1969, the National Abortion Rights Action League (NARAL) was the first national gathering of grassroots activists advocating the repeal of state abortion laws. The collection consists of NARAL affiliate newsletters and newsletters of unaffiliated groups/organizations in the United States.
• National Organization for Women The National Organization for Women was formed on June 30, 1966. The Statement of Purpose declares that "the time has come to confront, with concrete action, the conditions that now prevent women from enjoying the equality of opportunity and freedom of choice which is their right, as individual Americans, and as human beings." In June 1986, after a series of abortion clinic arsons and bombings, NOW, the Delaware Women's Health Organization, and the Pensacola Ladies Center filed a complaint against Joseph Scheidler, the Pro-Life Action Network, and other individuals and organizations of the "pro-life" movement. Within this collection, Series XLI: Reproductive Rights: NOW v. Scheidler, 1975-1998, 2002 contains records relating to the suit.
• Obscenity Trials Collection This collection consists of court records and other materials from New York City concerning obscenity charges brought against Charles Manches and Charles McCabe by Anthony Comstock of the New York Society for the Suppression of Vice. Manches was charged with sale of contraceptives and McCabe with the sale of an obscene pamphlet.
• Katherine Brownell Oettinger (b. 1903) Oettinger was a social worker, dean, and government official. In 1965, she was the first public official to speak out in favor of family planning and in 1968 was appointed to the newly created position of Dey Assistant Secretary for Population and Family Planning. She retired from the federal government in 1970. In the international arena, Oettinger was a U.S. representative on international bodies, and a delegate to international conferences, on social welfare, family planning, and child welfare. Since leaving government, Oettinger has served as a consultant in population and family planning for a number of organizations; she has also lectured at many colleges and universities.
• Harriet F. Pilpel (b. 1911) Harriet Fleishl Pilpel was a lawyer who specialized in family and marriage law, birth control, copyright and literary property, and civil liberties. See also Harriet F. Pilpel, Oral History Interview (Please note: Written permission of Eleanor J. Piel is required to access the interview.)
• Pro-life movement collection This collection consists of mailings, pamphlets, and ephemera produced by pro-life organizations between 1988 and 2017.
• Pro-life movement newsletter and periodical collection This collection includes pro-life movement newsletters and periodicals for which the Schlesinger Library holds three or fewer issues. Newsletters were created by state-wide pro-life groups, individuals, "crisis" pregnancy centers and religious groups between 1972 and 2009.
• Martha Ragsdale Ragland (1906-1996) A civic worker, political campaigner, and advocate of civil rights, birth control, and women's rights, Martha (Ragsdale) Ragland helped organize Planned Parenthood groups at the local and state levels in the 1930s and early 1940s, and in 1938 organized a speaking tour for Margaret Sanger in Tennessee. She held offices in the League of Women Voters at the local, state, and national levels and worked for better housing and health services, tax equalization, and reform of the Tennessee constitution. In 1948 Ragland headed the women's division of the Democratic Party in the general election and chaired the women's division in the Estes Kefauver (1948) and Albert Gore (1952) campaigns for the U.S. Senate. A delegate to the Democratic National Convention and member of the platform committee (1952), she was also a member of the Democratic National Committee (1952-1956).
• Janice G. Raymond (b. 1943) Radical lesbian activist, professor, and author Janice G. Raymond received a BA in English literature from Salve Regina College in 1965, an MA in religious studies from Andover Newton Theological School (1971), and a PhD in ethics and society from Boston College (1977). She joined the faculty at the University of Massachusetts Amherst in 1978, retiring as Professor of Women's Studies and Medical Ethics in 2002. From 2000 to 2007, she served as adjunct professor of International Health at Boston University's School of Public Health. From 1994 to 2007, Raymond was the Co-Executive Director of the Coalition Against Trafficking in Women (CATW), and continues to serve on their board of directors. This collection includes correspondence, writings, talks, reports, etc., documenting Raymond's work as an author and advocate. Some materials document Raymond's views on transsexuality and reproductive technologies, but the majority of materials represent her work as a member of the Coalition Against Trafficking in Women (CATW), often in close collaboration with Dorchen Leidholdt and H. Patricia Hynes, lobbying for legislation and mounting public awareness campaigns in an effort to end sexual exploitation and human trafficking.
• Reproductive Health Technologies Project The Reproductive Health Technologies Project (RHTP), co-founded in 1988 by Marie Bass and Joanne Howes, began as an informal group of scientists, clinicians, policy makers, and activists working together to advance public understanding of the French "abortion pill" RU 486, and other forms of the drug mifepristone. The Project became an independent non-profit 501 (c) (3) organization (1992) and in 1998 became focused on educating a wider audience on the methods of non-surgical medical abortions, such as the drugs mifepristone and methotrexate. The Project ceased in 2017. The records of the Reproductive Health Technologies Project document the organization's efforts to educate the American public about a variety of birth control methods and to influence the public perception of reproductive health and freedom. The records in this collection highlight the Reproductive Health Technologies Project's work on emergency contraception and RU 486; intrauterine devices; oral contraception; Policy, Advocacy, Legislation, & the Media (PALM) workshops; non-surgical medical abortions; reproductive genetic technologies, such as egg donations and in vitro fertilization; and microbicides and the prevention of sexually transmitted diseases.
• Barbara Rochelle Barbara Rochelle has studied and collected material by and about the pro-life movement in the United States. This collection includes an Army of God manual detailing various ways of curtailing the functioning of abortion clinics (ca. 1992), pamphlets handed out at Atlanta (Ga.) area clinics (1988-1990), and an advertising supplement by the Human Life Alliance of Minnesota Education Fund (1997).
• Barbara Seaman (b. 1935) Barbara Rosner Seaman (Oberlin, B.A. 1956) was a feminist and author, a columnist and contributing editor at Ladies' Home Journal (1965-1969), a child care and education editor at Family Circle (1970-1973), and the author of articles and reviews in numerous newspapers and magazines. The author of The Doctors' Case Against the Pill , Free and Female , and Women and the Crisis in Sex Hormones , she was cited for her part in seeing that appropriate written warnings to patients accompany each prescription. See also Additional Papers of Barbara Seaman .
• Sybil Shainwald An attorney and expert in women's health law, Sybil Shainwald graduated from the College of William and Mary (B.A. 1948), Columbia University (M.A. 1972) and New York Law School (J.D. 1976). She has litigated thousands of cases involving drugs and medical devices that have injured women and their offspring, including DES (Diethylstilbesterol); the Dalkon Shield Intrauterine Device; silicone breast implants; Parlodel, a drug to suppress lactation; and Norplant, a contraceptive device. She has also served as co-counsel in cases involving other product liability actions. Shainwald was chair of the board of directors of the National Women's Health Network and served on the boards of the Consumer Interest Research Institute and the Hysterectomy Educational Resources and Services Foundation. See also Additional Papers of Sybil Shainwald .
• Ruth Proskauer Smith (1907-2010) An advocate of family planning and legal abortion, Smith began her career in 1946 as a field worker for the Planned Parenthood League of Massachusetts, where she later served as executive secretary. Moving to New York, she administered the family planning service at Mount Sinai Hospital (1953-55) and was executive director of the Human Betterment Association for Voluntary Sterilization (1955-64) and the Association for the Study of Abortion (1964-66). In 1967 she helped organize the National Association for Repeal of Abortion Laws (now the National Abortion Rights Action League), and in 1970, as a member of the Abortion Rights Association of New York, Smith worked to implement a new state law legalizing abortion.
• Society for Humane Abortion The Society for Humane Abortion was founded by Patricia Maginnis in 1962 as the Citizens Committee for Humane Abortion Laws. The name was changed in 1964, and the society was incorporated in California as a non-profit educational organization in 1965. Endorsing "elective abortion," SHA supported the repeal of all abortion laws, sponsored symposia on abortion procedures for physicians, maintained a post-abortion care center, and was active in public education. It was disbanded in 1975. See also Additional Records of the Society for Humane Abortion .
• Robert D. Spencer Robert D. Spencer practiced general medicine in Ashland, Pa., and was willing to perform abortions before the procedure was legalized. This collection includes letters to Spencer from women or their husbands or boyfriends requesting his assistance in obtaining abortions, as well as some letters from women who had had abortions.
• Hilda Crosby Standish (1902-2005) Standish was a physician and lecturer on family planning. She became medical director of the first birth control clinic in Connecticut, which opened in July 1935; birth control was then illegal in Connecticut and most other states.
• Joseph R. Stanton (in the Julie A. Grimstad Papers) Julie A. Grimstad is a licensed practical nurse and volunteer patient advocate and is also a pro-life writer whose areas of interest are euthanasia, assisted suicide and patient advocacy. The Julie A. Grimstad collection on Joseph R. Stanton contains materials relating to Grimstad's unpublished book on Stanton, "Profound Obligation; Highest Privilege": Dr. Joseph R. Stanton and the Prolife Movement . Materials include an incomplete draft of the book; letters from Stanton and his wife, Mary, to Grimstad; biographical information about Stanton; correspondence with Stanton's colleagues about Stanton and the proposed book; and research files containing reprints of articles by and clippings about Stanton, many annotated by Stanton.
• Joseph R. Stanton Activist and historian of the pro-life movement, Dr. Joseph R. Stanton, attended Boston College and Yale School of Medicine and became an associate clinical professor of medicine at Tufts University School of Medicine. After the legalization of abortion in New York in 1970, Dr. Stanton became actively involved in the fledgling pro-life movement and helped to found the Value of Life Committee (VOLCOM), a non-denominational, grass-roots organization; and the Massachusetts Citizens for Life which was incorporated in 1973, four days after the Roe v. Wade decision. Stanton collected volumes of press clippings, books, printed materials from pro-life organizations, and other materials about life issues and the people and organizations working for and against legalized abortion and euthanasia. In the 1990s, Stanton entrusted his library and archival materials to the religious institute of the Sisters of Life, an order of nuns which actively support the Roman Catholic Church's doctrine on life. The Dr. Joseph R. Stanton Human Life Issues Library and Resource Center was dedicated on October 12, 1996.
• Felicia Hance Stewart (1943-2006) Stewart was an obstetrician, gynecologist, and advocate for women's access to emergency contraception and abortion services. The co-author of multiple books about gynecology and family planning, Stewart practiced medicine in Sacramento and San Francisco. From 1994 to 1996 she served as deputy assistant secretary for population affairs in the U.S. Dept. of Health and Human Services, where she helped formulate and implement domestic and international policies on family planning. She later served as director of the Reproductive Health Programs at the Henry J. Kaiser Family Foundation (1996-1999) and as co-director of the Center for Reproductive Health Research and Policy at the University of California, San Francisco (1999-2004). Perhaps best known for her research which established the efficacy and safety of the emergency contraceptive known as "Plan B," she also led the successful legal effort that allows qualified nurses and midwives to perform abortions in California.
• Therese Hester Vaughn (b. 1930) Pro-life activist Therese Hester Vaughn attended the University of Minnesota Duluth for two years and worked as a licensed practical nurse at St. Mary's Hospital in the pediatrics department from 1958 to 1970. Beginning in the 1970s, Vaughn dedicated her time to being a wife and mother and became involved in the pro-life movement. She was Telechain Chairwoman of Minnesota Citizens Concerned for Life, Chairwoman of the Daughters of Isabella Pro-Life Committee, director of Duluth BirthRight, and a Pro-Life Information Network Information Specialist. She also served as the 8th Congressional District Chairwoman for the Republican Party of Minnesota. The papers of Therese Hester Vaughn contain pro-life pamphlets, fliers, newsletters, catalogs, and clippings collected by Vaughn. Also included is a small amount of correspondence with other pro-life activists and letters from Vaughn written to government officials and companies advancing the pro-life agenda. Materials also document Vaughn's Catholic faith and her stance against euthanasia.
• Linda J. Wharton Attorney and professor Linda J. Wharton was born in Camden, New Jersey, in 1955. She received a BA from Bryn Mawr College and a JD from Rutgers Law School. From 1989 to 1997, she served as the managing attorney at the Women's Law Project in Philadelphia, Pennsylvania. She was co-lead counsel in Planned Parenthood v. Casey, a lawsuit that went to the Supreme Court in 1992 and reaffirmed the constitutionality of abortion.
• Ellen Willis (1941-2006) Journalist and feminist Ellen Willis was a founder of Redstockings, a radical feminist group begun in 1969, and, in the 1980s, of No More Nice Girls, a street theater and protest group that focused on abortion rights. A professor of journalism at New York University, Willis was known for her political essays which appeared in The Nation , Dissent , and elsewhere, as well as for her writings on rock music which were published in Rolling Stone , the New Yorker , and the Village Voice . Her books included Beginning to See the Light: Pieces of a Decade (1981), No More Nice Girls: Countercultural Essays (1992), and Don't Think, Smile! Notes on a Decade of Denial (1999).
• Elizabeth C. Winship (b. 1921) Beginning in 1963, Winship wrote an advice column for teenagers, "Ask Beth," after it was suggested to her by an editor at the Boston Globe . In 1970 the Los Angeles Times Syndicate, which at its peak had seventy subscribing newspapers, picked up "Ask Beth." In addition to her column, Winship tackled various health and sexuality issues in numerous publications, including Ask Beth: You Can't Ask Your Mother (1972) and Human Sexuality (1988). She regularly spoke with high school students, parents, and community groups on the topic of teenage sexual behavior and was also a consultant for a variety of family life educational programs.
• Mary Winter Winter was a pro-life activist who founded People Concerned for the Unborn Child in southwestern Pennsylvania. She also served on the Advisory Board of Feminists for Life. This collection includes speeches, testimony, and clippings concerning abortion and pro-life issues.
• Women's Community Health Center (Cambridge, Mass.) The Women's Community Health Center in Cambridge, Mass., was incorporated in February 1974 as a women-owned and women-controlled health center. Initially staff offered self-help programs and gynecological services, and by May 1975 they were performing first trimester abortions. Other educational programs centered upon sexuality, menopause, and natural birth control, and WCHC literature was translated into Spanish and Portuguese. The WCHC operated on a suggested fee system of payment, and funding was often dependent upon contributions from supporters.
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The Morning

Abortion politics in 2024.

Four key points to help you make sense of the current debate.

By David Leonhardt

No American president has done as much to restrict abortion as Donald Trump. When he was running in 2016, he promised to appoint Supreme Court justices who would overturn Roe v. Wade, and his three nominees helped do precisely that in the 2022 Dobbs decision. Twenty-one states have since enacted tight restrictions. Yesterday, Arizona’s highest court reinstated an 1864 law that bans nearly all abortions.

These laws have proven to be unpopular. When abortion access has appeared on the ballot since 2022, it has consistently won, even in red states like Kansas, Kentucky and Montana. A Wall Street Journal poll last month found that abortion stood out from immigration, inflation and foreign wars as the only major issue on which most voters trusted President Biden more than Trump.

All of this helps explains why Trump has tried to reduce his vulnerability on the issue — and why the Biden campaign is already running advertisements about abortion. “Donald Trump did this,” reads the onscreen text at the end of an ad released this week. It focuses on a Texas woman who nearly died during a miscarriage after a hospital refused to treat her.

Trump released his own video this week, meant to serve as his defining statement on the issue. He said that states should be free to set their own laws, which is the post-Dobbs status quo. In so doing, he tried to distance himself from his past support for a federal ban.

This back-and-forth will be a theme of the 2024 campaign. Democrats will try to focus voters on abortion, while many Republicans will try to shift attention elsewhere. Today’s newsletter offers four key points to help you make sense of the debate.

The four points

1. The politics of abortion have changed.

Before Dobbs, polls suggested that the issue didn’t offer a big political advantage to either party. Most voters favored both significant access to abortion and significant restrictions, which put them to the left of Republican politicians and to the right of Democratic politicians.

But Dobbs — and the reality of statewide bans, as opposed to the mere prospect of them — altered public opinion. Gallup’s polls suggest that almost 10 percent of Americans on net switched from an anti-abortion position to a position favoring abortion access:

Americans’ attitudes on abortion

Do you think abortions should be:

Legal under any

circumstance

Legal only under

certain circumstances

Illegal in all

circumstances

2. Democrats still have a challenge: salience.

In the 2022 midterms, several high-profile Democratic candidates highlighted their Republican opponents’ role in restricting abortion access. Stacey Abrams in Georgia and Beto O’Rourke in Texas were among them. So was Nan Whaley, the Democratic candidate for governor in Ohio. “We think it is the issue,” Whaley said.

It wasn’t. These candidates all lost by substantial margins. Nationwide, not a single Republican governor or senator has lost a re-election bid since the Dobbs decision. In House elections, the decision may have played a decisive role in a small number of races.

How could this be? In today’s polarized atmosphere, most voters have already made up their minds. “There’s no one issue in this day and age that can be a silver bullet,” Danielle Deiseroth, executive director of Data for Progress, a left-leaning research firm, told me.

If anything, Democrats may have a harder time focusing attention on abortion in a presidential election, when a larger portion of the electorate doesn’t follow politics closely and prioritizes pocketbook issues. Some of these voters are Black and Hispanic working-class Americans who tend to care less about abortion policy than white voters, Rachel Cohen of Vox has written .

3. Trump’s has his own problem: suburban swing voters.

Democrats who tried to run on abortion in the 2022 midterms were trying to oust incumbent Republicans. Biden has an easier job this year: He’s trying to reassemble a winning coalition.

His 2020 coalition included many college graduates — and women — in metropolitan areas like Philadelphia, Detroit, Atlanta and Phoenix, who allowed him to win swing states. Abortion access is popular with these voters, Deiseroth notes, especially when framed in terms of freedom and government overreach.

A recent poll found that only about one in four independents blame Trump for recent abortion bans. Biden hopes to increase that share — and win back people who voted for him four years ago.

4. Trump hopes voters ignore the past.

Trump’s latest position on the issue is a middle ground for Republicans, in favor of Dobbs but implicitly against a new federal law restricting abortion. This stance is meant to suggest that voting for him won’t lead to new laws forbidding abortion. That may be true (if he were to veto a Republican-passed federal ban, which he didn’t promise in his video). Yet it also ignores some important facts.

As president again, Trump could appoint dozens more federal judges who would interpret existing laws to reduce access. And Trump is effectively asking voters to ignore his first-term record. He remains arguably the most important opponent of abortion access in American history.

Biden condemned the Arizona abortion decision as “cruel” and “extreme.”

“I’m pretty pro-life, but I think it should be the woman’s choice”: Read the mixed responses of Arizonans to the ruling.

Trump’s abortion stance is designed to look moderate , Times Opinion’s Jamelle Bouie writes.

Trump’s contempt for weakness is toxic to the pro-life movement , which promises protections to the most vulnerable, Times Opinion’s Ross Douthat writes.

THE LATEST NEWS

The Japanese prime minister, Fumio Kishida, is on a state visit to Washington. The U.S. and Japan are expected to further integrate their militaries to counter China.

David Cameron, the British foreign secretary and former prime minister, met with Trump at Mar-a-Lago .

A bipartisan group of lawmakers plans to introduce a bill in Congress today that would limit troops’ exposure to blasts from weapons that can cause brain injuries.

Congress passed legislation to get food to children from low-income homes over the summer break. Nearly half of Republican-led states are yet to join the program.

More on Politics

An appeals court judge rejected another attempt by Trump to delay his criminal case in Manhattan. The trial is set to start Monday.

A judge ordered Trump’s lawyers to redact the name of witnesses from a public filing in the classified documents case. The special counsel, Jack Smith, expressed concern for their safety .

A Florida woman who stole the diary of Ashley Biden, the president’s daughter, and helped sell it to a right-wing group was sentenced to a month in prison .

The U.S. is now almost evenly divided between Democrats and Republicans, a Pew report says. More voters have shifted toward the Republican Party.

“A reality distortion bubble”: America isn’t as divided as many people think, Jim VandeHei and Mike Allen write for Axios .

Israel-Hamas War

Iran is smuggling weapons to Palestinians in the West Bank to stoke unrest, according to Iranian, Israeli and U.S. officials.

Benjamin Netanyahu reaffirmed that Israel would invade the crowded city of Rafah in southern Gaza. “No force in the world will stop us,” he said in a speech to military recruits.

At the top U.N. court, Germany rejected an accusation from Nicaragua that it had aided genocide by shipping arms to Israel. It said most of the equipment was nonlethal.

The U.S. defense secretary, Lloyd Austin, told a Senate committee that the Pentagon had no evidence that Israel was carrying out a genocide in Gaza.

Turkey said it would limit exports to Israel until there’s a cease-fire in Gaza. Israel threatened to retaliate.

England’s health service restricted medical gender transition for minors after a four-year review cast doubt on the treatment’s benefits. Several other European countries have similar rules.

Europe’s top human rights court ruled that Switzerland violated its citizens’ rights by not doing enough to stop climate change .

Ireland is now led by its youngest ever prime minister: the 37-year-old Simon Harris .

Ukraine’s military has turned to drones from China after models sent by Silicon Valley start-ups failed in combat, The Wall Street Journal reports.

Other Big Stories

The parents of a teenager who shot to death four fellow students at a Michigan high school each received 10 to 15 years in prison .

The total solar eclipse delayed some Islamic communities’ declaration of Eid al-Fitr , the celebration that marks the end of Ramadan.

The E.P.A. will require utilities to remove “forever chemicals” from tap water. The chemicals identified are linked to cancer.

Benjamin Netanyahu must step down and leave Israel’s war in Gaza to someone who can win it, Bret Stephens writes.

The U.S. economy has been far more successful at recovering from the Covid shock than from the 2008 financial crisis, Paul Krugman argues.

Here are columns by Thomas Friedman on an exit strategy for Israel in Gaza and Thomas Edsall on Trump and the politics of intimidation .

MORNING READS

Passion projects: A lab in France is famous for its medical discoveries. Some of its staff are also excelling in another field: music .

Cure-all? People claim that apple cider vinegar can help you lose weight and clear acne. The science is more nuanced .

Guns, machetes and food poisoning: Read about what one man encountered when he ran the length of Africa .

Eclipse: Internet traffic dropped by 40 percent or more in the path of totality.

Space: Rising temperatures make it harder for researchers to collect meteorites in Antarctica.

Lives Lived: Peter Higgs predicted the existence of a new particle, sparking a half-century search that culminated with a Nobel Prize. The particle — the Higgs boson — was named after him. Higgs died at 94 .

College basketball: The men’s national title game between UConn and Purdue averaged 14.8 million viewers , four million fewer than the women’s game.

Stepping down: The Stanford women’s basketball coach Tara VanDerveer, who holds the record for most wins in college basketball, announced her retirement .

M.L.B.: The Baltimore Orioles will promote Jackson Holliday , considered the best prospect in baseball, to the major leagues.

ARTS AND IDEAS

Dr. Jane’s Dream: Next year, sometime around World Chimpanzee Day — July 14 — “Dr. Jane’s Dream” will open its doors. The cultural complex, between Mount Kilimanjaro and Serengeti National Park in Tanzania, will celebrate the English primatologist Jane Goodall, who turned 90 last week.

Read more about it, and about Goodall’s career .

More on culture

Donna Dennis is a trailblazer of installation art who has long been overlooked. Some of her work is being exhibited at O’Flaherty’s in Manhattan.

Conan O’Brien returned to “The Tonight Show” for the first time in 14 years.

THE MORNING RECOMMENDS …

Bake budget-friendly cheesy chicken and mushroom pasta .

Exercise even when you’re experiencing allergies .

Buy a robot vacuum (they can work).

Find a good raincoat for spring showers.

Drink from an insulated tumbler .

Download these apps before visiting a national park.

Here is today’s Spelling Bee . Yesterday’s pangram was hangable .

And here are today’s Mini Crossword , Wordle , Sudoku , Connections and Strands .

Thanks for spending part of your morning with The Times. See you tomorrow.— David

Sign up here to get this newsletter in your inbox . Reach our team at [email protected] .

David Leonhardt runs The Morning , The Times’s flagship daily newsletter. Since joining The Times in 1999, he has been an economics columnist, opinion columnist, head of the Washington bureau and founding editor of the Upshot section, among other roles. More about David Leonhardt

Don’t Be Fooled By Trump’s Failure to Endorse a Nationwide Abortion Ban

F ormer President Donald Trump announced on Truth Social that he favors state control over abortion law and policy and declined to endorse a nationwide ban. He also claimed that the Supreme Court’s overturning of  Roe v. Wade  in  Dobbs v. Jackson Women’s Health Organization  was favored by “all legal scholars” on “both sides.” Abortion is “where everybody wanted it, from a legal standpoint,” according to Trump.

All of this is patently false, of course. Decades of legal scholarship and advocacy support the federal constitutional right to abortion that Dobbs eliminated. Some scholars who support legal abortion as a matter of policy have criticized the result the Court reached in  Roe , but they are in the minority. Others have critiqued the  reasoning  of  Roe v. Wade . Some, like Ruth Bader Ginsburg , prefer the equality rationale of  Planned Parenthood v. Casey   (1992), where the Court noted the central importance of reproductive freedom to women’s ability to participate fully and equally in the social, political, and economic life of the nation. But the notion that all or most legal scholars wanted the Court to obliterate the right to choose abortion is ludicrous.

No one should be fooled by Trump’s failure to endorse any of the proposed nationwide abortion bans, a move designed to appear “moderate” and lull voters into a false sense of complacency. Make no mistake: a second Trump administration will empower an anti-abortion movement determined to make abortion illegal everywhere. Even if Republicans do not take over Congress, there are plans in place to make medication abortion unavailable and to resurrect the 1873 Comstock Act, an archaic anti-vice law, to ban abortion nationwide. Proponents of fetal personhood, which defines an embryo as a legal person from the moment of fertilization, will be closer to realizing their goal, threatening not only abortion and miscarriage care but also IVF and common forms of contraception. Trump promotes the grotesque lie that Democrats want to “execute babies” to distract from his own party’s extremism.

Trump peddles these false and misleading claims because he understands that the truth about abortion endangers his candidacy and Republicans generally. Far from ending the controversy, returning abortion to the states already has led to outcomes wildly out of step with public opinion. Doctors and hospitals routinely deny patients basic medical care, including miscarriage treatment, because they are not close enough to death to have their rights outweigh those of an embryo or fetus. State laws with no or ineffective exceptions force children, survivors of rape and incest, and people with nonviable fetuses to carry pregnancies regardless of the consequences to their health and future fertility. Maternal health deserts multiply because doctors fear criminal and civil liability. Abortion bans exacerbate a maternal and infant mortality crisis that makes pregnancy a mortal danger to American women— especially Black women , who are almost three times more likely to die from pregnancy and childbirth than their white counterparts.

Read More: How Louisiana Has Become a Microcosm of the Abortion Access Fight

Even people with qualms about abortion in theory don’t favor these horrific results in fact. Recent polling from Gallup and Axios respectively reveals supermajority popular opposition to total and near-total bans on abortion, and majority support , even among Republicans, for keeping the government out of reproductive health care decisions altogether. Every ballot initiative since Dobbs has been resolved in favor of abortion rights and access. In fact, abortion motivates Americans to turn out and vote for candidates who support reproductive freedom.

Perhaps the most pernicious of Trump’s lies is that returning abortion to the states is a victory for democracy. Depriving people of the right to make the most basic decisions about their bodies and lives is deeply undemocratic and a hallmark of authoritarian regimes worldwide. Extreme abortion bans and fetal personhood laws pass  despite  popular opposition because of unchecked partisan gerrymandering that gives Republicans supermajorities. Even the most conservative lawmakers live in fear of a primary challenge from the right if they support any exceptions, however minor and ineffective, to total abortion bans. Trump says abortion law after Dobbs is “all about the will of the people.” But in fact, Republicans are scrambling to take decisions about abortion out of the people’s hands by preventing referenda from reaching the ballot, protecting state courts that defy public opinion from accountability for their decisions, and disenfranchising voters.

The GOP has long used abortion to secure the support of voters to promote a much broader right-wing agenda. Trump, as promised, packed the federal judiciary with jurists who would destroy the government’s ability to regulate corporations, combat climate change and political corruption, enact sensible gun-safety laws, provide for affordable health care, expand opportunities for women and people of color, fight discrimination, protect the rights of workers and immigrants, ask the wealthy to pay their fair share in taxes, and so on. The problem is that a majority of Americans actually support each of the policies the Right is determined to undo. To remain in power, Republicans must undermine democratic institutions and practices. Partisan and racial gerrymandering, voter suppression, and the evisceration of campaign finance regulation and voting rights laws are longstanding strategies; more recently, election denialism, insurrection, political violence, and white supremacist resurgence—all fomented by Trump—place democracy and the rule of law in mortal danger. All of this is at stake in Trump’s ultimate lie: his claim to be a champion of democracy rather than the architect of its demise.

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Trump Could Use the 1873 Comstock Act to Ban Abortion Nationwide. Here’s How.

Legal scholar mary ziegler explains how another “zombie law” eviscerating civil liberties is stalking the land..

Julianne McShane

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Mother Jones; Getty

Last week, in a bid to clarify his historically nebulous stance on abortion, Donald Trump said that if reelected, he intends to leave abortion rights “to the states,” seemingly contradicting his prior stance in favor of a 16-week national ban.  

But Mary Ziegler , a law professor at UC Davis and leading abortion historian, thinks that a complete ban could be on the agenda for a future Trump administration—and the vehicle for it would be the Comstock Act , a 19th-century anti-obscenity law still on the books. Ziegler and other legal experts warn the law could be marshaled to ban all abortions—even in blue states that protect abortion rights—and possibly even contraception and gender-affirming care, while circumventing the democratic process. 

Let’s start with a quick history lesson. In 1873, Congress passed the Comstock Act, which bars the mailing of “ every article or thing designed, adapted, or intended for producing abortion, or for any indecent or immoral use.” It was named after anti-vice crusader Anthony Comstock, a Civil War veteran molded by his strict Puritan upbringing who was obsessed with enforcing a culture of sexual purity, which was his mission as a special agent of the US Post Office after the eponymous law was passed. His views on abortion, though, were more nuanced than what the text of the law might suggest: He believed abortion should be permissible to protect a woman’s life.

The act was challenged, narrowed, and broadly seen as irrelevant in the decades after Comstock’s 1915 death, but recently, anti-abortion conservatives have suggested deploying it to skirt the wide support that exists for abortion rights nationwide. They “argue that every abortion involves an item that’s put in the mail or transported by common carrier,” Ziegler said, “and that if there’s this effective mailing ban, that is a de facto ban on [abortion] procedures, full stop.” That would mean a ban on medication and procedural, in-clinic abortions—and, as the health policy research organization KFF, formerly known as the Kaiser Family Foundation, points out in a policy brief, enforcement of the Comstock Act could also affect the treatment of miscarriages and other OB-GYN care.

Anti-abortion activists took that argument to the Supreme Court last month to drastically restrict access to mifepristone, one of the two pills used in medication abortion, which research has shown has continued to grow in popularity since the FDA allowed them to be prescribed virtually and sent by mail starting in December 2021.  Project 2025 , an initiative led by dozens of conservative groups and spearheaded by the Heritage Foundation, repeatedly cited the Comstock Act—by its statute numbers, not by name—throughout “Mandate for Leadership,” its blueprint for Trump’s next term. Given Comstock, it stated, “the Department of Justice in the next conservative administration should therefore announce its intent to enforce federal law against providers and distributors of [abortion] pills.” Jonathan Mitchell, the conservative lawyer behind the Texas abortion ban, told the New York Times in February, “We don’t need a federal ban when we have Comstock on the books,” cautioning Trump and anti-abortion groups to keep quiet about the Comstock Act until after the election. Trump appears to be following these orders and hasn’t publicly addressed whether he’d enforce Comstock if reelected. (His campaign also didn’t respond to repeated questions about that from Mother Jones .)  

These efforts ignore the fact that medication abortion is safe and effective —including when it’s prescribed virtually and mailed to patients —and that polling by the Pew Research Center shows the majority of Americans disapprove of Dobbs and support legal abortion in all or most circumstances. But as Ziegler  writes in a forthcoming Yale Law Journal article on the history of the Comstock Act, co-authored with Yale law professor Reva Siegel,  “Comstock revival has emerged as a tool to create an abortion ban that would be unachievable in democratic politics—and a vehicle for Republican surrogates to demand a national ban that it would be too politically risky for candidates to assert in their own voices.” 

I spoke with Ziegler—who has written six books on the history of abortion and the law in the US— about the Comstock Act, the problems with the right’s reading of it today, Democrats’ strategies (or lack thereof) to resist it, and what the law’s possible revival reveals about the risks posed by similar centuries-old “zombie laws” that could come back to haunt us. Our conversation has been edited for length and clarity.

What was Comstock supposed to accomplish when it was passed back in 1873? 

The Comstock Act was passed by a group of people who saw themselves as deeply concerned with sexual purity. This was a period when many Americans were moving to cities; when people from all over the world were immigrating to the United States; when women were campaigning for the right to vote in a way that they really hadn’t before. And this was causing something of a moral panic, particularly among white Protestant well-to-do men who believed that cities were changing the way people, their children, and wives, were behaving. Comstock himself had become particularly concerned about pornography, which he’d been exposed to during the Civil War. But he thought the problem was broader than that. He thought that a broad array of materials—from sex toys to medical textbooks to great works of literature—were all incentivizing people to have impure sex. And this was a concern, I would say, in a different way for women and other female-identified folks because they could get pregnant. But Comstock was concerned with the debauching of boys as well as girls. 

Contraception and abortion came into the picture because Comstock believed they made these forms of illicit sex possible. He called them “incentives to crime,” meaning that if you knew you could have this kind of illicit sex without a pregnancy, you’d be more likely to engage in it if you were female. At the time, the law wasn’t very clear about what obscenity meant. No one had really been regulating contraception much at all. Abortion laws were very new and untested, particularly insofar as early pregnancy was concerned. So the Comstock Act basically was designed to stamp out illicit sex…and it spawned a bigger movement. It was not the end of the story. It was sort of the beginning.

You write that “revivalists selectively quote the Comstock law to construct it as an abortion ban, rather than recognizing that the law Congress enacted was a broad obscenity statute, and remains so today.” Can you say more about the problem with their reading of the law? And how does understanding it as an obscenity statute, rather than a plain and simple abortion ban, complicate its application today?

Their argument to the Supreme Court is essentially, “This is the way to a nationwide abortion ban that isn’t about the Constitution, that isn’t about our values, and that isn’t about politics.” It’s sort of a way to give the anti-abortion movement what it wants…and in part, I think this cherry-picking is problematic because if the statute has a plain meaning, it covers much more than abortion. 

The other problem…is that I don’t think the statute has a plain meaning. The word “abortion” didn’t have a plain meaning in 1873. [In her paper, Ziegler noted that, at the time, abortion often referred to miscarriages.] I don’t think it has a plain meaning today. And if the statute is ambiguous, then what you’re doing is imposing a 21st-century reading of the statute as a ban they would never enact, which it is not. Reading the text—it’s doing something very different.

You write that when Comstock was passed, “Congress was enacting a law that would be flatly unconstitutional today.” How so, and why do you think we aren’t seeing more Democrats mobilizing to resist it? 

The Comstock Act applies not only to items but to speech. Even in the mifepristone Supreme Court case , Clarence Thomas asked, “Wouldn’t information about this pill be illegal under the Comstock Act?” So a lot of speech was covered by the Comstock Act—that’s one potential dimension of a challenge. There are also due process questions about what the heck the terms in the Comstock Act mean. I think the term “abortion” is ambiguous because anti-abortion leaders have contested its meaning and have offered literally dozens of definitions and state laws that vary from place to place. 

But there are other terms that I would imagine anyone would agree are vague—like, the statute says you can’t mail items. What does that mean? Does that mean medical textbooks? Does that mean Viagra? Does that mean drugs for gender-affirming care? Does that mean methotrexate, because you could theoretically use it as an abortifacient? Does it mean vaccines? So there are also due process questions raised because you can’t criminally punish someone for violating the rules when they don’t know what the rules are. 

There is an interesting interplay between the litigation groups, which really don’t want Democrats going full tilt on the argument that Comstock is going to function as an abortion ban. They think that’s a ridiculous argument legally and don’t want to give it more momentum by having everyone believe that conservatives are right about how the Comstock Act operates. They don’t want that before the Supreme Court weighs in, because they could, in theory, adopt this theory of the Comstock Act. At the same time, Democrats are aware that there’s a real political threat in not discussing Comstock. 

So my guess is that after the mifepristone case is resolved, you’ll see a more forceful response from Democrats who’ve been trying to balance not wanting to give conservatives a leg up in the conservative Supreme Court, where they already have an advantage, and not leaving voters in the dark about the threat Comstock poses. I don’t know if they’ve been striking the right balance. Essentially, litigation is pulling one way and the politics are pulling another way.

I didn’t realize this until I read what you wrote, but there was no mention of Comstock in the Supreme Court’s 2022 Dobbs ruling to overturn Roe v. Wade —or even in the privacy-related decisions that flowed from Roe . But a couple of the justices brought it up in the case they heard last month seeking to restrict medication abortion. Why do you think the right didn’t invoke Comstock sooner? Why are they doing it now? 

I mean, it’s not a great idea politically to bring it up now, right? I would sort of pose the question of, why would you bring it up at all? [ Laughs .]

Politically, it seems pretty disastrous. I mean, Anthony Comstock was a very strange, troubled man who introduced a law that raised grave First Amendment and equal protection concerns, which was enforced against his political enemies in ways that swept in a lot of stuff unrelated to abortion. And you have conservatives for decades spending time creating a single-issue anti-abortion movement, saying, “We are not the sex police. We are not coming for contraception. We are not worried about women voting. We are not concerned about sex outside of marriage. That’s just not our thing. We’re worried about the rights of the unborn here.” So invoking Comstock really undermines that message because Comstock is unambiguously about more than abortion. 

The other thing is that enforcing it would have been unconstitutional under Roe . So there was no point in bringing it up. T here was both a pretty high political cost of invoking Comstock and not much upside. The other thing that’s important to mention is if you’re thinking of the anti-abortion movement as a single-issue movement, for a long time, its game plan was a constitutional personhood amendment. That was the end goal. And to get a constitutional amendment, you need to win hearts and minds. You need to convince a majority of Americans that you’re right. And invoking the Comstock Act is not going to help you with that. I think we’ve seen a little bit of a pivot since Dobbs toward imagining that fetal personhood will come from a judicial decision from the US Supreme Court, not from a constitutional amendment. If your goal is to win via the courts, you don’t need to care as much about whether voters are with you—or not. So I think to some degree, the invocation of the Comstock Act tells you that the anti-abortion movement has been moving away from strategies that focus on winning in elections and instead on strategies that are taking the issue away from voters and putting it in the hands of people who are not accountable to voters. 

You raised earlier the question of what exactly Comstock could regulate. Would the question of what it regulates ultimately depend on how the Department of Justice enforces it?

Absolutely. We don’t know a lot about how it would be interpreted. Contraceptives, I think, would be on the table, because we know that a lot of abortion opponents believe that at least IUDs, the birth control pill, and the morning-after pill are abortifacients. If Comstock is interpreted as an abortion ban, you would have some contraceptives potentially swept in—emergency contraceptives are the most likely. I mean, we don’t know, right? Because the law is very vague, and it would depend on what the Trump Justice Department’s priorities will be. We know that in Project 2025 , the priority has been people who manufacture pills and abortion providers who have been called out as prosecution targets. But what actually happens would be left a lot to the prosecutorial discretion of the Justice Department.

The recent ruling from the Arizona Supreme Court reignites this question of “zombie laws” like Comstock and how they can come back to haunt us. I read a piece in the Washington Post that laid out some of these discriminatory laws that are still on the books: 13 states have laws that ban same-sex marriage, and another dozen states ban sodomy. How likely is it that we could see laws like those revived, given that Clarence Thomas has called for overruling the decisions keeping them at bay? Are there other disturbing zombie laws we should be aware of?

Any of what you could imagine as “morals laws” are still on the books. The dynamic, essentially, was the same with Comstock, which is that at a certain point everyone said, “Well, that’s Comstockery,” which meant Victorian, antiquated, prudish. And no one really thought they would be enforced. But then repealing them felt weird because that somehow seemed to be saying, “This kind of sex is OK.” It felt very different for legislators to say, “Well, we don’t want to repeal this ban on sodomy because that makes it seem like we’re saying sodomy is good. But we’re not going to enforce it because that would make us seem like we’re engaging in Comstockery.”

Then you had other people, Democrats essentially, saying over and over again, “Maybe we don’t need to repeal this stuff because it’s not going to be enforced anyway.” And it’s not that they thought it was OK, or they didn’t want to be seen as opposing those things, but rather that they had other priorities. So you would have these zombie laws left on the books time after time because people were prioritizing other things. One of the lessons, obviously, is that that’s a stupid idea—if a law looks dangerous in theory, it can become dangerous in practice. 

If Comstock were enforced, could it pave the way for the formal recognition of fetal personhood? And conversely, could states that explicitly protect abortion rights—like New York or California—challenge Comstock’s enforcement? 

Comstock is interestingly not about fetal personhood—I mean, Anthony Comstock would occasionally call abortion “antenatal murder,” but it was mostly about sex for him. Sex was the main problem, and abortion was an issue because it let people have sex. It wasn’t that abortion was an issue because of fetal protection. Comstock, if anything, was more worked up about things like dildos than he was about abortion to begin with. Reviving the Comstock Act would be an abortion ban, but the history and language of the statute aren’t fetal protective in the same way at all. From the anti-abortion movement standpoint, Comstock is clearly a stopgap solution because they want recognition that fetuses are persons. That is what leaders of the movement call the new North Star, the new kind of fight that replaced the fight to get rid of Roe v. Wade . 

It would certainly move the needle in terms of making abortion harder. Because if the Comstock Act were being enforced, it would preempt state laws that protect abortion rights, and states that have ballot initiatives, and states that have other protective legislation. And I think that’s a really important point for people to sit with for a minute. Because if you don’t like Joe Biden, and you are planning on staying home, and you think that that’s going to be okay if you support abortion rights because you live in a state that either has, had, or will have a ballot initiative, that ignores the fact that the Trump could get elected, enforce the Comstock Act as a ban, and override whatever protections are in your state. 

Trump has never said he’s not going to do that—you have a lot of former Trump officials who have been going around essentially promising that he is going to enforce the Comstock Act as a ban. The Trump campaign has never disavowed those claims, never really even addressed those claims. I don’t know that that’s what’s going to happen, but at least it’s a reasonable concern to have, given that Trump has done nothing to discourage those concerns.

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Hope for Women Facing Abortion Movement Lies

Planned Parenthood’s annual report shows a peak into a post Roe era.  Hugh Brown joins Trending with Timmerie to discuss. (2:49) A front line look at what’s happening in Virginia after the overturning of pro-abortion Roe v. Wade. (15:46) Get involved in the pro-life fight in your state.  (25:56) Britain’s National Health Services commissions research by pediatrician Dr. Hilary Cass exposing the damage and lack of evidence for transitioning minors to a trans identity.  Author J.K. Rowling takes shots at Daniel Radcliffe and Emma Watson over pro LGBTQ support. (41:15)

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2333 Everyone, man and woman, should acknowledge and accept his sexual identity . Physical, moral, and spiritual difference and complementarity are oriented toward the goods of marriage and the flourishing of family life. The harmony of the couple and of society depends in part on the way in which the complementarity, needs, and mutual support between the sexes are lived out.

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The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities

The abortion and mental health controversy is driven by two different perspectives regarding how best to interpret accepted facts. When interpreting the data, abortion and mental health proponents are inclined to emphasize risks associated with abortion, whereas abortion and mental health minimalists emphasize pre-existing risk factors as the primary explanation for the correlations with more negative outcomes. Still, both sides agree that (a) abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; (b) the abortion experience directly contributes to mental health problems for at least some women; (c) there are risk factors, such as pre-existing mental illness, that identify women at greatest risk of mental health problems after an abortion; and (d) it is impossible to conduct research in this field in a manner that can definitively identify the extent to which any mental illnesses following abortion can be reliably attributed to abortion in and of itself. The areas of disagreement, which are more nuanced, are addressed at length. Obstacles in the way of research and further consensus include (a) multiple pathways for abortion and mental health risks, (b) concurrent positive and negative reactions, (c) indeterminate time frames and degrees of reactions, (d) poorly defined terms, (e) multiple factors of causation, and (f) inherent preconceptions based on ideology and disproportionate exposure to different types of women. Recommendations for collaboration include (a) mixed research teams, (b) co-design of national longitudinal prospective studies accessible to any researcher, (c) better adherence to data sharing and re-analysis standards, and (d) attention to a broader list of research questions.

Introduction

In 1992, the Journal of Social Issues dedicated an entire issue to the psychological effects of induced abortion. In an overview of the contributors’ papers, the editor, Dr Gregory Wilmoth, concluded,

There is now virtually no disagreement among researchers that some women experience negative psychological reactions postabortion. Instead the disagreement concerns the following: (1) The prevalence of women who have these experiences …, (2) The severity of these negative reactions …, (3) The definition of what severity of negative reactions constitutes a public health or mental health problem …, [and] (4) The classification of severe reactions … 1

Twenty-six years later, the body of literature has grown. Today, there are many additional areas of agreement, but the areas of disagreement have also grown.

As with most controversies, the abortion and mental health (AMH) controversy is driven by at least two different perspectives regarding how best to interpret accepted facts. A useful parallel is found in the debate over climate change. On the fringes of the climate change controversy are non-experts who hold an extreme position of either total denial or total credulity. But it is far more common for skeptics to acknowledge that fossil fuels make some contribution to global warming while still arguing that these effects are not as extreme global warming proponents contend. 2 This group may be described as global warming minimalists. Their normal pattern is to interpret the data in a way that minimizes the potential threat. By contrast, global warming proponents may be more likely to interpret the data in ways that emphasize the potential risks.

Similarly, in regard to the AMH controversy, there are both AMH minimalists and AMH proponents. The experts from both groups can report similar findings from the same data but will do so in ways that seem to either minimize or emphasize the negative outcomes associated with abortion. It should be carefully noted that there is actually a broad spectrum of expert views regarding the AMH link. 3 While each researcher and expert has likely developed carefully considered and nuanced opinions, these have not been completely disclosed and cannot be cataloged in regard to every issue discussed herein. Still, broadly speaking, it is evident that both expert reviews and the authors of individual studies appear to generally support either the view that (a) the mental health effects associated with abortion are minimal and within the expected range for the women seeking abortions 4 – 10 or (b) the effects are significant enough to justify more research dollars, and better screening and counseling in order to reduce the number of adverse outcomes. 11 – 19 In addressing this conflict, it is not my intention to pigeonhole any particular expert’s viewpoint at any location on the spectrum of views regarding AMH.

In writing this review, I have tried to be as objective and fair as possible. Yet, as discussed later, since my own informed opinion is also influenced by my own experiences and preconceptions, full disclosure requires that I acknowledge at the outset that I fit most closely under the category of an AMH proponent. That said, my goal is not to dismiss or disprove the viewpoint of “the other side,” but rather to understand and engage with it in a manner that will contribute to a respectful “transformational dialogue” that will help to “crystalize the areas of agreement and disagreement along with opportunities for collaboration.” 20 In this regard, it is my great hope that those who disagree with my analysis and conclusions herein will use the publication of this review as an opportunity to publish responses and reviews that address the issues raised with additional depth from their perspectives.

The method I used for this review was to carefully examine previous literature reviews regarding mental health effects associated with legal abortion that have been published since 2005. 4 – 10 , 12 – 19 , 21 , 22 In that sense, this article may be considered a review of reviews of the literature on AMH. In addition, I studied the references cited in these various reviews in order to further my effort to more completely identify (a) areas of agreement and disagreement, (b) the underlying reasons for disagreements, and (c) opportunities to collaborate in light of the current literature.

This undertaking is intended to advance more than just an academic discussion, however. Research has shown that women considering abortion have a high degree of desire for information on “all possible complications,” including rare risks. 23 Therefore, an updated and more complete understanding of the literature can and should better prepare physicians and mental healthcare providers with more accurate and helpful information for advising and counseling women before or after an abortion. For example, better screening for risk factors should help to identify women who may benefit from additional pre- or post-abortion counseling 24 – 38 and may also help to prevent cases of women being pressured into unwanted abortions. In addition, more complete insights may help mental health counselors to be more aware and sensitive to providing the counseling services that women want and need.

This review is organized into three sections. The first examines major areas of agreement and offers a synthesis of the findings from major studies. The second section investigates the obstacles to building a consensus between AMH minimalists and AMH proponents, including institutional and ideological biases, research obstacles, poorly defined terms, and similar issues that contribute to the disparity in the conclusions most emphasized by each side. The third section provides recommendations for collaborative research based on the insights gained from the first two sections, addressing such issues as data sharing, mixed research teams, and how to maximize the value of longitudinal prospective studies.

Areas of agreement

Abortion contributes to negative outcomes for at least some women.

The 2008 report of the American Psychological Association’s (APA) Task Force on Mental Health and Abortion (TFMHA) concluded that “it is clear that some women do experience sadness, grief, and feelings of loss following termination of a pregnancy, and some experience clinically significant disorders, including depression and anxiety.” 4 Indeed, task force chair Brenda Major et al.’s 39 own research had reported that 2 years after their abortions, 1.5% of the remnant participating in her case series (38% of the 1177 eligible women, after dropouts) had all the symptoms for abortion-specific post-traumatic stress disorder (PTSD). In addition, she found that compared to their 1-month post-abortion assessments, at 2 years the participating remnant had significantly rising rates of depression and negative reactions and lowering rates of positive reactions, relief, and decision satisfaction. 39

The fact that some women do have maladjustments is most specifically documented in case studies developed by post-abortion counselors successfully treating women with maladjustments, including counselors working from a pro-choice perspective 40 – 44 as well as from those working from a pro-life perspective. 45 – 47

Even one of the harshest critics of the “myth” of abortion trauma, psychiatrist Nada L Stotland, 40 subsequently reported her own clinical experience treating a patient whose miscarriage triggered a mental health crisis arising from unresolved issues regarding a prior abortion. Stotland, who later served as president of the American Psychiatric Association, subsequently began to recommend screening of prospective abortion patients for risk factors in order to guide decision counseling and identify additional counseling needs. 31

Some groups of women are predictably at greater risk of negative outcomes

There is a strong research-based consensus that there are numerous risk factors that can be used to identify which women are at greatest risk of negative psychological outcomes following one or more abortions. Indeed, the TFMHA concluded that one of the few areas of research which can be most effectively studied is in regard to efforts to “identify those women who might be more or less likely than others to show adverse or positive psychological outcomes following an abortion.” 4

The TFMHA itself identified at least 15 risk factors for increased risk of negative reactions. While the TFMHA did not report on the percentage of women exhibiting each risk factor, Table 1 provides ranges of the incidence of each TFMHA risk factor as reported in the literature. The incidence rates shown in Table 1 clearly suggest that the majority of women seeking abortion have one or more of the TFMHA identified risk factors. Since exposure to multiple abortions is one of the risk factors, that risk factor alone applies to approximately half of all women having abortions, at least in the United States. 64

Risk factors for mental health problems after an abortion identified by the American Psychological Association’s Task Force on Mental Health and Abortion (TFMHA) in 2008.

Notably, the TFMHA list used here is one of the shortest that has been developed. A similar, but longer list is published in the text book on abortion most highly recommended by the National Abortion Federation. 66 A more recent systematic search of the literature for risk factors associated with elevated rates of psychological problems after abortion cataloged 119 peer reviewed studies identifying 146 individual risk factors which the author grouped into 12 clusters. 35 Yet another major review of risk factors identified risk factors from 63 studies which were grouped into two major categories. 25 The first category includes 22 risk factors related to conflicts or defects in the decision-making process , for example, feeling pressured to abort, conflicting maternal desires and moral beliefs, and inadequate pre-abortion counseling. The second category contains 25 risk factors related to psychological or developmental limitations , such as pre-existing mental health issues, lack of social support, and prior pregnancy loss. 25

The ability to identify women who are at greater risk of negative reactions has resulted in numerous recommendations for abortion providers to screen for these risk factors in order to provide additional counseling both before an abortion, including decision-making counseling, and after an abortion. 24 , 25 , 31 , 66 – 68

Notably, while there is no dispute regarding the abundance of research identifying risk factors, there is little if any research identifying which women, if any, acquire any mental health benefits from abortion compared to carrying a pregnancy to term, even if the pregnancy was unintended or unwanted. 17

All AMH studies have inherent limitations

It is impossible to conduct randomized double-blind studies to investigate abortion-associated outcomes. Such studies would require random selection of women to have abortions.

Notably, the very same fact that would make such a study unethical—forcing a group of women to have abortions—actually occurs in the real world wherein some women feel pressured or even forced into unwanted abortions by their partners, parents, employers, doctors, or other significant persons. 25 , 45 This problem with coerced abortions highlights one of the major difficulties involved in AMH research: any sample based entirely on self-selection (voluntary participation) no longer represents the full population of women actually having abortions. Indeed, since feeling pressured to abort is a major risk factor, the practice of excluding women aborting intended pregnancies from AMH studies 39 , 69 makes the results from such studies less generalizable to the actual population of all women having abortions.

This is just one of many difficulties which makes it truly impossible to conduct any AMH study that does not have significant methodological weaknesses. As a result, the “true prevalence” and intensity of the negative effects associated with abortion can never be known with any great certainty. Noting this problem, the TFMHA review concurred with the view that the complexity of this field “raises the question of whether empirical science is capable of informing understanding of the mental health implications of and public policy related to abortion,” admitting that many research “questions cannot be definitively answered through empirical research because they are not pragmatically or ethically possible.” 4

Despite study limitations, statistically significant risks are regularly identified

While every observational study can be criticized for methodological weaknesses, it is also nonetheless true that is still possible to discover meaningful and actionable results. For example, research demonstrating elevated rates of mental health problems among women who feel pressured to abort contrary to their moral beliefs is generalizable to that specific subset of women. So while it is important to never generalize to all women who have abortions, insights can be gained from nearly any study when the results are properly narrowed to the limits of the population studied. 70

Figure 1 shows the odds ratios (ORs) and 95% confidence interval (95% CI) for risks associated with abortion in all major studies published since 1995 organized by class of symptoms. 17 , 30 , 67 , 69 , 71 – 102

Relative risk of abortion relative to each study’s comparison groups.

While there are disagreements on how to best interpret these findings (to be discussed later), the findings themselves are not disputed. The results are organized into six sets: all classes of symptoms (segregated by inpatient and outpatient treatments when separately reported); depression and depression-related symptoms such as bipolar disorder; anxiety; substance use disorders (segregated by type of substance use when identified); and other disorders. Each row identifies the study reporting the results; the numeric relative risk (or OR) and CIs (also shown as a range in the forest plot); the participation rate of eligible women (after deducting refusals and dropouts) when identifiable; the group to whom the aborting women are being compared in the study; the forest plot; and an abbreviated description of the specific outcome, symptom, diagnostic scale, and/or time frame to which the statistic applies. Comparison groups include women carrying an unintended pregnancy to term, women delivering a child, women delivering a first pregnancy, women with no known history of abortion, women with any other pregnancy outcome other than abortion, and women not pregnant during the period studied.

What is most notable from Figure 1 is that the trend in results, including those reported by questionnaire and record linkage studies, is consistent. All but three odds ratios are above 1. In most cases, the lower 95% CI is also above 1, signifying statistical significance. Moreover, even among studies showing no significant difference (when the lower 95% CI is less than 1.0), the upper 95% CI is always above 1 and overlaps the statistically significant CIs of other studies.

This overlap is very important. For example, as can be seen in the depression grouping in Figure 1 , the overlap of the 95% CIs in the findings of Schmiege & Russo 2005 and Cougle 2003 (both using different sampling rules for the same data set) demonstrates that there is no actual contradiction in the findings of these two studies. Whenever there is overlap in the CIs, this tells us that the variation in the respective relative risks reported by each study is within the expected range of variation given the limits of each study’s statistical power. Since findings only contradict each other when there is no overlap in the CIs, it is clear from Figure 1 that the minority of studies without statistically significant findings do not contradict the findings of studies with statistically significant findings. Claims to the contrary 69 ignore the relevance of CIs and also the fact that studies with low statistical power are easily prone to Type II errors resulting in false negatives.

The risk of such false negatives is increased when there is also any risk of sample bias. In regard to abortion research, the risk of sample bias is especially high since questions about abortion are frequently associated with feelings of shame. 22 , 59 The resulting selection bias due to self-censure and the high dropout rates of women at greatest risk of negative reactions also contributes to the misclassification of women concealing a history of abortion as non-aborters. In addition, some researchers choose to exclude groups such as women who abort wanted pregnancies, 69 have later term abortions, or have other risk factors for more negative reactions ( Table 1 ) and these methodological choices will also tend to shift results below statistical significance.

Despite these problems, the trend in findings, as shown in Figure 1 , is very clear. Women who abort are at higher risk of many mental health problems.

This conclusion is strengthened by the variety of the study designs that have been conducted. Collectively, these studies examine a wide variety of different comparison groups, explore a diverse set of outcome variables, employ a large variety of control variables, and report on numerous outcomes over different time frames and/or at a variety of cross sections of time. Collectively, they reveal the following:

• (a) There are no findings of mental health benefits associated with abortion. (These would be signified by the entire 95% confidence line being below 1.0.)
• (b) The association between abortion and higher rates of anxiety, depression, substance use, traumatic symptoms, sleep disorders, and other negative outcomes is statistically significant in most analyses.
• (c) The minority of analyses that do not show statistically significant higher rates of negative outcomes do not contradict those that do. (Shown by the upper bound of the 95% confidence overlapping the lower 95% CI of the statistically significant studies.)

A number of recent studies have also reported the population attributable risk (PAR) associated with abortion. This statistic estimates the percentage of an outcome that may be attributed to exposure to an abortion experience after statistically removing the effects associated with the available control variables.

Fergusson was the first to report PARs identified in a prospective longitudinal cohort studied from birth to 30 years of age in New Zealand. He reported that the attributable risk ranged from 1.5% to 5.5%, but did not identify the PAR of specific mental health effects nor provide the CIs. 75 Specific outcome PAR risks were also calculated by Coleman 15 in her meta-analysis, but these were reported without CIs. These are shown in Figure 2 along with PAR estimates with 95% CIs that have been reported in three other studies. 94 , 101 , 103

Population attributable fraction and 95% CI.

Of particular interest is a 2016 study by Sullins using the National Longitudinal Study of Adolescent to Adult Health that provided three models of analyses, including controls for 25 confounding factors. In addition, he conducted a fixed-effects regression analysis controlling for within-person variations to control “for all unobserved or unmeasured variance that may covary with abortion and/or mental health.” 94 Sullins’ lagged models, employed as additional means of examining effects of prior mental illness, confirmed that the risks associated with abortion cannot be fully explained by prior mental disorders. He also identified a dose effect, with each exposure to abortion (up to the four) associated with a 23 percent (95% CI, 1.16–1.30) increased of relative risk of subsequent mental disorders.

Collectively, the findings shown in Figure 2 suggest that substance use disorders appear to be most strongly attributable to abortion. Put another way, assessments of substance use (perhaps indicating self-medicating behavior) may be one of the more sensitive measures of difficulties adjusting to post-abortion. 96 Conversely, at least some research has shown that other outcomes, such as variations in self-esteem, may be unaffected, or only weakly associated with abortion. 38 Alternatively, some outcomes may appear to be less strongly associated with abortion because women are receiving successful treatment, such as medication for depression or anxiety, that would obviously suppress these associations with abortion.

Prior mental health and co-occurring factors explain at least part of the effects

As shown in Table 1 , a history of mental health problems is a risk factor for higher rates of mental health problems following abortion as compared to women without a history of mental health problems. This association has been known since at least 1973 when a case series identified several pre-existing mental health factors that could be used to identify the women who were most likely to experience subsequent psychopathology. 32 The authors of that study recommended that a low-cost computer scored Minnesota Multiphasic Personality Inventory assessment could effectively identify women who could benefit from additional pre- and post-abortion counseling.

Both AMH proponents and AMH minimalists agree that prior health is a major factor in explaining the negative reactions observed post-abortion. There are differences, however, in how proponents and minimalists distinguish, interpret, and emphasize the interactions between prior mental health, the abortion experience, and subsequent mental health.

AMH proponents see poor prior mental health as contributing to the risk that a woman (a) may become pregnant in problematic circumstances; (b) may be more vulnerable to pressure or manipulation to have an abortion contrary to personal preference, maternal desires, or moral ideals; and (c) may have fewer or weakened coping skills with which to process post-abortion stresses. In addition, from the perspective of abortion as a potential stressor, women exposed to prior traumatic experiences may be more predisposed to experiencing abortion as another traumatic experience.

In contrast, AMH minimalists tend to interpret the evidence that a high percentage of women having abortions have prior mental health issues as the primary explanation for higher rates of mental illness observed after abortion. 5 , 7 , 104 , 105 From this perspective, women with mental health problems are more likely to engage in risk-taking behavior and to experience more problematic pregnancies and are more likely to choose abortion. It is also hypothesized that pregnant women with pre-existing mental health problems may be more inclined to choose abortion because they recognize that they are likely to fare worse if they deliver and try to raise an unplanned child. 106 , 107 The higher rates of mental health issues following abortion, therefore, may be mostly explained as just a continuation of pre-existing mental health problems rather than a direct and independent cause of mental illness. While a few minimalists suggest that the underlying cause of mental health problems observed after abortion can be entirely explained by prior mental health defects or co-occurring stressors, 30 , 82 I have been unable to find any researchers who have denied that abortion can contribute to mental health problems.

A closely related issue is that a history of being physically and/or sexually abused is a co-occurring risk factor for both mental health problems and abortion. 92 , 94 , 108 – 110 Obviously, both sides agree that trauma from prior abuse can harm mental health. Also, at least from the clinical perspective of AMH proponents treating women with a history of both abortion and abuse, a history of abuse may increase the vulnerability of women consenting to unwanted abortions.

The differences between AMH minimalists and proponents on these issues will be more thoroughly discussed later. At this point, it is sufficient to note that both sides agree that poor prior mental health is a major predictor of higher rates of mental health problems after an abortion. Moreover, both sides agree that there should be mental health screening of women seeking abortion 24 – 30 , 32 – 38 , 58 precisely because the “abortion care setting may be an important intervention point for mental health screening and referrals” 30 due to the higher concentration of women with previous and subsequent mental health issues. At the very least, a history of abortion is a useful marker for identifying women at greater risk of mental health problems and a corresponding elevated risk of a variety of related chronic illnesses 111 and reduced longevity. 112 , 113

A summary of agreements with difference in emphasis

Table 2 summarizes specific factual propositions to which the vast majority of both AMH minimalists and AMH proponents would agree. As indicated in the table, each side may typically emphasize some points over others and might underemphasize, reluctantly admit, or even evade discussion of some of these propositions. Still, while some may quibble over the exact formulation of any particular proposition in Table 2 , the underlying consensus relative to each proposition is easily discernible in the body of references by both sides cited in this review.

Variations in emphasis on conclusions generally shared by AMH minimalists and AMH proponents.

AMH: abortion and mental health.

In summary, the consensus of expert opinion, including that of both AMH proponents and minimalists, is that (a) a history of abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; (b) the abortion experience can directly contribute to mental health problems in some women; (c) there are risk factors, including pre-existing vulnerability to mental illness, which can be used to identify the women who are at greatest risk of mental health problems following an abortion; and (d) it is impossible to conduct research in this field in a manner that can definitively identify the extent of any mental illnesses following abortion, much less than the proportion of disorders that can be reliably attributed solely to abortion itself.

Obstacles in the way of research, understanding, and consensus

Facts are facts. But there is plenty of room for disagreement regarding which facts are generalizable, much less on how to best synthesize and interpret sets of facts, especially when there are flaws in the research and gaps in what one would want to know. Indeed, the greater the ideological differences between people regarding any question, the easier it is to disagree about what the available evidence really means. As shown in Table 2 , even areas around which there is a fundamental agreement by experts under sworn testimony may appear muddied by shifts of emphasis and the insertion of nuances that may be technically true but misleading to non-experts who imagine there are simple, global answers.

For example, the same APA task force which produced the list of risk factors shown in Table 1 did not highlight these findings in their press releases with a recommendation for screening. Instead, the centerpiece of their press release 114 was the report’s conclusion that “the relative risk of mental health problems among adult women who have a single , legal, first-trimester abortion of an unwanted pregnancy for nontherapeutic reasons is no greater than the risk among women who deliver an unwanted pregnancy” 7 (italics added).

This statement was widely reported as the APA officially concluding that abortion has no mental health risks. But as shown in Table 1 , this reassuring conclusion was actually couched in nuances which make it applicable to only a minority of women undergoing abortions on any given day. It excludes the 48%–52% of women who already have a history of one or more abortions, 64 the 18% of abortion patients who are minors, 115 the 11% of patients beyond the first trimester, 116 the 7% aborting for therapeutic reasons regarding their own health or concerns about the health of the fetus, 117 and the 11%–64% whose pregnancies are wanted, were planned, or for which women developed an attachment despite their problematic circumstances. 38 , 50 , 51

The above example demonstrates that the same set of facts, presented and interpreted by AMH minimalists in a way that suggests that few women face any risk of negative reactions to abortion, could also have been worded by AMH proponents in a way that would have underscored a conclusion that most women having abortions are at greater risk compared to the minority who have no risk factors.

This points to one of the greatest hindrances in the advance of knowledge: the tendency to use nuances to dodge direct engagement with the ideas, evidence, and arguments which threaten one’s own preconceptions.

Therefore, one of the purposes of the following discussion is to invite direct engagement and thoughtful responses to the specific obstacles identified below.

Intrinsic biases in the assessment of evidence are nearly impossible to avoid

Everyone, even the most “objective” scholar, has developed shortcuts in their thinking and beliefs. These shortcuts (or biases) help us to (a) be more efficient in drawing conclusions and making decisions and also (b) be more consistent in how we perceive ourselves and reality, or conversely, to avoid the stress of cognitive dissonance which occurs when some fact or experience clashes with our core beliefs and values.

Our biases are not just personal. They also have a communal element. We tend to adopt the biases of our peers for several practical reasons. First, by adopting the opinion of our peers as our own, we are embracing a collective wisdom that frees us from the need to deeply research and consider every idea on our own. Second, the more completely our beliefs are aligned within our community of peers, the less we will face conflict and suspicion. Obviously, there is never perfect alignment or cessation of independent thinking. But the tendency to accept the “conventional truths” of one’s peers as “fact” is a very real phenomenon.

The impact of biases among academics on the interpretation of data and suppression of contrary opinions has been well documented. 118 – 123 For example, identical studies, for which the results are the only difference, are more likely to be lauded or condemned 122 – 125 by peer reviewers when the results confirm or conflict with the reviewer’s own biases. In the fields of psychology and psychiatry, such confirmatory bias may contribute to the promotion or suppression of research findings that favor liberal causes. 125 – 128 In one study, only one-fourth of reviewers noted a major methodological problem in a fake study that agreed with their preconceptions, while 72% quickly raised an objection about the problem when presented with a nearly identical fake study in which the results challenged their preconceptions. 123 The only way to eliminate result-based bias, the author suggests, would be to solicit reviews only on the relevance of a study’s methodology, withholding the actual results and discussion of results, since the latter are the actual drivers of confirmatory bias. 123

While much of the confirmatory bias observed in peer reviewers may be unconscious, 129 at least one survey of 800 research psychologists found high rates of admissions that they or their colleagues would openly and knowingly discriminate against conservative views when providing peer review (34.2%), awarding grants (37.9%), or making hiring decisions (44.1%). 130 The authors noted that this admission of conscious ideological bias was likely just the tip of the iceberg compared to confirmatory bias since “[i]t is easier to detect bias in materials that oppose one’s beliefs than in material that supports it. 124 Work that supports liberal politics may thus seem unremarkable, whereas work that supports conservatism is seen as improperly ideological.” 130

In addition to blocking publication of good research, ideological and confirmatory bias may also contribute to poorly designed studies and/or carelessly interpreted findings that advance a preferred viewpoint. 118 , 126 , 131 – 133

Social psychologist Jonathan Haidt, a self-proclaimed liberal specializing in the foundations of morality and ideology, has argued that that the vast majority of psychologists are united by the “sacred values” of a “tribal-moral community” which is politically aligned with the liberal left. 134 This shared moral superiority, 129 he says, both “binds and blinds” their community. 134 The risk of “blindness” occurs because the lack of sufficient political diversity predisposes the community of psychologists to “embrace science whenever it supports their sacred values, but they’ll ditch it or distort it as soon as it threatens a sacred value.” 134

In regard to the abortion, mental health controversy, studies by AMH minimalists tend to be written in a way that minimizes any disruption of the core pro-choice aspiration that abortion is a civil right that advances the welfare of women. 135 The research on confirmatory bias discussed above, therefore, suggests that studies by AMH proponents are more likely to be unfavorably reviewed and rejected. 136

An excellent example of this result-based bias was the four rejections reported by David Fergusson, former director of the Christchurch Health and Development Study, which followed 1265 children born in Christchurch, New Zealand, for over 30 years. 137 Fergusson, a self-proclaimed pro-choice atheist, believed that his data would help to prove that AMH proponents were wrong. 137 But when he ran his analyses, he found that even after controlling for numerous factors, abortion was indeed independently associated with a two-to threefold increased risk of depression, anxiety, suicidal behaviors, and substance abuse disorders. 17 , 138 Though his findings were opposite to his preconceptions, he submitted them for pubication anyway. It was then that he ran into a wall of ideologically driven rejections and was even asked by the New Zealand government’s Abortion Supervisory Committee to withhold the results. 137

Similarly, Ann Speckhard, 139 another pro-choice AMH proponent and an associate professor of psychiatry at Georgetown University Medical School, has complained,

Politics have also stood in the way of good research being conducted to examine psychological responses in a nationally representative sample to all pregnancy outcomes: live birth, miscarriage, induced abortion, and stillbirth (and perhaps even including adoption). I offered in 1987 to our National Center for Health Statistics a simple mechanism for collecting such data via a short interview to be attached to an already existing survey—but fear of the answers—on both sides of the issue staunchly squelched the idea.

The problem is that even trained scientists struggle with being purely objective—especially regarding issues that may touch one’s own core beliefs, values, and experiences. What makes Fergusson’s experience particularly unique is that he chose to publish his findings even though they contradicted his own worldview. How many other researchers, expecting to prove mental health benefits from abortion but finding the opposite, might be tempted to withhold their findings, or worse, to redesign their study in ways that would obfuscate their results in order to declare that a lack of statistically significant results “proved” that there was no need to look further? This concern is heightened by the refusal of AMH minimalists to allow examination of their data by AMH proponents, 140 as will be discussed in more detail later.

Just as lawyers are taught to never ask a question at trial to which you do not already know the answer, researchers engaged in any field where there are “adversarial” positions may often be hesitant to cooperate in a mutual pursuit of objective truth. 141 This fear of admitting the validity of “the other side’s” concerns is also reflected in the admission by pro-choice feminists that they are afraid to publicize the existence of their own post-abortion counseling programs. 44 , 142

These concerns regarding bias surrounding AMH issues are further heightened by the fact that many professional organizations, including the APA, have taken official political positions defending abortion as a “civil right.” 135 In defense of that political position, Nancy Russo, a member of the APA’s TFMHA, has stated that “whether or not an abortion creates psychological difficulties is not relevant” 143 and has been a proponent of the APA taking a pro-active role in aggressively attacking the credibility of studies by AMH proponents. 144 The problem with professional organizations taking a political position on abortion is that any subsequent acknowledgment of negative mental health effects linked to abortion might then embarrass the APA, and/or other professional organizations that have committed themselves to the agenda of defending abortion as a civil right, and thereby creates an ideological obstacle in objectively evaluating new evidence.

There are different rates of exposure to the highest risk and lowest risk archetypes

This leads us to an important and perhaps closely related observation. It is not only political, philosophical, or ideological beliefs that contribute to the AMH controversy. Conflicts in the perceiving AMH controversy are also colored by direct and indirect personal experiences . The fact that pro-choice feminists are more focused on feelings of relief and other liberating aspects of having a right to abortion 3 may be accurately representing their own positive personal experiences. Conversely, anti-abortion conservatives, who presume that AMH problems are common, may be accurately representing their own relative rate of exposure to negative experiences. 3

Support for this hypothesis is found in a study based on structured interviews of women following their abortions conducted by Mary Zimmerman 48 in which she found that approximately half of the women she interviewed could be classified as “affiliated” (more goal oriented, more educated, less dependent on the approval of others, and more likely to abort for their own self-interest) and the other half as “disaffiliated” (less career oriented, less educated, more dependent on the approval of others, and more likely to abort to please others). When she interviewed her sample 6 weeks after their abortions, Zimmerman 48 found that only 26% of “affiliated” women were struggling with “troubled thoughts” about their abortions compared to 74% of “disaffiliated” women, a threefold increase. A similar disparity relative to personality types was observed by Major et al. 145

It is reasonable to assume that friends and associates of highly educated research psychologists are more likely to be skewed toward the “affiliated” than the “disaffiliated.” If so, the personal experience of such AMH skeptics may be dominated by the observation that they and their closest friends have generally coped well with any exposure to abortions.

Conversely, AMH proponents, especially those who directly meet and counsel women having problems dealing with past abortion 45 may have little or no experience with women who have had positive abortion experiences. The concentrated experience of meeting with scores or hundreds of women struggling with past abortions would understandably incline AMH proponents to believe that negative experiences with abortion are more common than positive ones. 146

In short, applying the general rule that people (including scientists) tend to look for and believe data that confirm their preconceptions, and are disproportionately skeptical of data that conflict with their preconceptions, both AMH skeptics and AMH proponents are at risk of preferentially interpreting their personal exposure to abortion’s risks and benefits as applicable to the general population.

While women having abortions will fall across the entire spectrum of risk factors, it is useful for this review to consider two hypothetical women at opposite ends of any risk-benefits analysis: (a) “Allie All-Risks,” the worst possible candidate for an abortion and (b) “Betsy Best-Case,” with no known risk factors:

• “Allie All-Risks” is 15 years old. A victim of verbal, emotional, and physical abuse, including three incidents of sexual molestation, she has low self-esteem with bouts of anxiety, depression, and suicidal ideation. While her parents are not regular churchgoers, she attended a Catholic grade school, believes in God, and believes abortion is the killing of a baby. She is not a good student and has no concrete career goals. She has always wanted to be a mother, loves babies, and fantasizes about how she will find fulfillment in giving the love to her children that she never received from her own mother. Given Allie’s yearnings for escape, acceptance, and true love, she is vulnerable to the seductions of a 22-year-old womanizer with whom she falls madly in love and aspires to a happy future. When she learns she is pregnant, her initial reaction is excitement. While not planned, the pregnancy is welcomed. She believes she can now start building a family with her lover. But this fantasy is immediately crushed when he tells her that they can’t afford it, that neither of them are ready for it, and that if she decides to continue the pregnancy, he will leave her. She feels she has no choice. She can’t imagine losing him. In addition, her parents would be furious and insist on an abortion, too. Allie’s initial excitement at being pregnant is replaced by despair. Indeed, given her need to please others, she gives in with barely a complaint. Her mild protests about “their choice” go unnoticed. The day of the abortion she whispers: “Good bye. I don’t want to do this to you. But I don’t have a choice.” Immediately after the abortion, Allie feels a mild relief that the dreaded procedure is now behind her and hopes her boyfriend will be content, but alongside that relief are feelings of emptiness and loss that seem to grow stronger with every passing week. She begins to have obsessive thoughts. Her baby is no longer in her body, but it is constantly in her thoughts.
• “Betsy Best-Case” is 32 years old. She has no history of mental illness and has a good family life. Her parents were both well-educated secularists. They preach education, hard work, and honest success as the only ethical standards Betsy needs to guide her. Betsy is popular, has many friends, and has always had high career aspirations, toward which, with grit, she has proudly made good progress. Even as a child, Betsy had little or no interest in being a mother. Married to her career, she now has even less interest in maternity. Having successfully used birth control since she was 15, when her mother got her an IUD, Betsy is shocked when she realizes she is pregnant. But contraceptive failures happen. Her decision to abort is immediate and made without any emotional conflict. When she flips through the state mandated informed consent booklet given to her at the abortion clinic, the pictures of developing fetuses have no effect. Betsy has seen similar photos many times in the past. She has a strong philosophical belief, based on years of engagement in minor abortion debates, that the value of being a “person” is not based on biological features but rather on the development of a psychological, purpose-filled, self-actualized human being far beyond anything to which a 9-week-old fetus could yet lay claim. Betsy is not surprised when her abortion is completed without drama or even a tinge of angst. She thinks of it rarely. The only negative feelings ever associated with it come when she hears the right of women to choose abortion attacked by self-righteous busybodies who should know better.

Hopefully, any reader can see and respect that the Allie and Betsy’s abortion experiences are very different. One is focused on her loss and the other on how her abortion helped her to avoid any loss. Given these differences, it would be unfair to them try to interpret their abortion experiences from within a single ideological framework. Similarly, the women who reside at different places along the wide spectrum between the extreme poles of Allie and Betsy are also very different and unique.

We will employ Allie and Betsy in our discussion later in this review. But for now, let them simply stand as examples of why AMH skeptics may, from personal experience, presume that Betsy is “typical” of abortion patients, while AMH proponents may presume that Allie is more “typical.” This difference in regard to how each side of the AMH controversy views the “typical” abortion patient is likely to impact how they interpret AMH research in their efforts to describe the experience of “most” women.

There are multiple pathways for AMH risks

Despite the convenience of standard diagnostic criteria, mental illnesses do not necessarily fit into neat, single classifications with distinct and exclusive symptoms arising from a single cause for each illness. 147 As noted in one review of the psychiatric complications of abortion,

A psychiatric complication is a disturbance that occurs as an outcome that is precipitated or at least favored by a previous event …. Every psychiatric outcome is of a multi-factorial origin. Predisposing factors including polygenic influence and precipitating factors such as stressful events are involved in this outcome; in addition, there are modulating, both risk and protective, factors. The impact of the events depends on how they are perceived, on psychological defense mechanisms put into action (unconscious to a great extent) and on the coping style. 18 (Emphasis added)

An abortion does not occur in isolation from interrelated personal, familial, and social conditions that influence the experience of becoming pregnant, the reaction to discovery of the pregnancy, and the abortion decision. These factors will also affect women’s post-abortion adjustments, including adjusting to the memory of the abortion itself, potential changes in relationships associated with the abortion, and whether this experience can be shared or must be kept secret. These are all parts of the abortion experience. Therefore, the mental health effects of abortion cannot be properly limited to the day on which the surgical or medical abortion takes place. The entirety of the abortion experience, including the weeks before and after it, must be considered.

Moreover, there is no reason to believe that there is a single model for understanding, much less predicting, all of the psychological reactions to the abortion experience. Miller alone identified and tested six models for interpreting psychological responses to abortion and concluded that

theoretical approaches that emphasize unitary affective responses to abortion, such as feelings of shame or guilt, loss or depression, and relief may be missing an important broader picture. To some extent what appears to happen following abortion involves not so much a unitary as a broad, multidimensional affective response. 148

The APA’s TFMHA proposed four models: (a) abortion as a traumatic experience, (b) abortion within a stress and coping perspective, (c) abortion within a socio-cultural context, and (d) abortion as associated with co-occurring risk factors. 7 Additional models could be built on biological responses, 149 , 150 attachment theory, 151 – 154 bereavement, 153 , 155 – 158 complicated, prolonged or impacted grief, 159 – 163 ambiguous loss, 156 , 161 , 164 – 167 or within a paradigm of psychological responses to miscarriage. 74 , 168 – 170

The complexity of considering so many models, or pathways, combined with the multiplicity of symptoms women attribute to their abortions, 45 contributes to discord in the literature produced by AMH proponents and AMH minimalists.

When there is no agreement on what outcomes are relevant or what theoretical pathways should be investigated, there are countless reasons to disagree about both (a) the adequacy of any specific studies and (b) how any specific set of findings should be best interpreted.

Women may simultaneously experience both positive and negative reactions

The act of undergoing an abortion can be both a stress reliever and a stress inducer. 171 It may relieve one’s immediate pressures and concerns while also leaving behind issues that may require attention immediately or at a future date. Positive and negative feelings can co-exist and frequently do. 38 , 39 , 48 , 50 , 166 , 172

In one study,

Almost one-half also had parallel feelings of guilt, as they regarded the abortion as a violation of their ethical values. The majority of the sample expressed relief while simultaneously experiencing the termination of the pregnancy as a loss coupled with feelings of grief/emptiness. 166

Another study found that 56% of women chose both positive and negative words to describe their upcoming abortion, 33% chose only negative words, and only 11% chose only positive words. 62 The women at greatest risk of experiencing negative reactions immediately and in the short term following an abortion are those who feel most conflicted about the decision to abort or have other pre-existing risk factors. 39 , 45 , 82 , 173

Applying this insight to our polar extremes, Annie All-Risks would be more likely to experience strong negative feelings more profoundly than her feelings of relief, whereas Betsy Best-Case would be more likely to focus on her relief than any doubts or reservations. Moreover, because Annie has low expectations for coping well (itself a TFMHA risk factor), she may be less likely to agree to participate in a follow-up study. The faster she can get out of the abortion clinic without talking to anyone, the better. Conversely, Betsy is confident that her decision is right and will improve her life and is therefore much more likely to participate.

What “most women” experience cannot be reliably measured

As will be further discussed later, the fact that positive and negative feelings can co-exist makes it difficult, and potentially misleading, to describe any single reaction to abortion as the “most common,” given the fact that (a) it is very rare for women to have a single reaction and (b) typically, over half of women asked to participate surveys regarding their abortion experiences refuse or drop out. Obviously, it is impossible to know what the most common reaction of women is based on surveys of only a minority of self-selected women.

This insight also underscores the difficulty of making any generalizations regarding prevalence rates from any study involving volunteer participation or questionnaires. Broadly speaking, there are three groups of women: (a) those with no regrets or negative feelings, (b) those with deep regrets and profound negative feelings, and (c) those with a mix of feelings, including contradictory feelings. As discussed above, the best evidence indicates that women with the most negative feelings are least likely to agree to participate in studies initiated at abortion clinics. But it also follows that women with no regrets are unlikely to be represented in studies of women seeking post-abortion counseling. Both of these factors underscore that it is impossible to accurately measure how “most” women react to their abortion experience when participation in research is voluntary.

The degree of reactions can widely vary and there is no reasonable cutoff for concern

Not all negative emotions constitute a diagnosable mental illness. Therefore, the fact that only a minority of women have diagnosable mental illnesses following abortion does not preclude the possibility that a majority experience negative emotional reactions.

Structured interviews of women who received abortions at participating clinics reveal that the majority report at least one negative emotion that they attribute to their abortions. 48 , 172 Given the relatively high rate of women refusing to participate in these follow-up studies, it is likely that the actual percentage of women having at least some negative reactions is well over half. 174 Similarly, retrospective questionnaires of women also reveal that over half attribute at least some negative reactions to their abortions. 50

The opinion that negative reactions are experienced by the majority of abortion patients is also shared by a number of abortion providers, such as Poppemna and Henderson: 175

Sorrow, quite apart from the sense of shame, is exhibited in some way by virtually every woman for whom I’ve performed an abortion, and that’s 20,000 as of 1995. The sorrow is revealed by the fact that most women cry at some point during the experience …. The grieving process may last from several days to several years.

Similarly, Julius Fogel, who as both a psychiatrist and OB-GYN and as a pioneer of abortion rights performed tens of thousands of abortion, testified that while abortion may be necessary and generally beneficial, it always exacts a psychological price:

Every woman—whatever her age, background or sexuality—has a trauma at destroying a pregnancy. A level of humanness is touched. This is a part of her own life. When she destroys a pregnancy, she is destroying herself. There is no way it can be innocuous. One is dealing with the life force. It is totally beside the point whether or not you think a life is there. You cannot deny that something is being created and that this creation is physically happening … Often the trauma may sink into the unconscious and never surface in the woman’s lifetime. But it is not as harmless and casual an event as many in the pro-abortion crowd insist. A psychological price is paid. It may be alienation; it may be a pushing away from human warmth, perhaps a hardening of the maternal instinct. Something happens on the deeper levels of a woman’s consciousness when she destroys a pregnancy. I know that as a psychiatrist. 176 , 177

This distinction between negative reactions and diagnosable mental illness is another important reason why AMH proponents and minimalists appear to disagree more than they really do. When AMH proponents make statements about “most women” which imply that negative reactions are common, they are including women who attribute any negative reactions to their abortions even if the reactions fall short of fitting a standard diagnosable illness. 45 Conversely, when AMH minimalists insist that “most women” do not experience mental illness due to their abortions, they are excluding the women who have negative feelings, even if unresolved and disturbing, on the grounds that (a) the symptoms do not rise above the threshold necessary to diagnose a clinically significant mental illness and (b) the symptoms cannot be strictly attributed to the abortion experience alone. 7

In short, if pressed, both sides would agree that the best evidence indicates that most women do experience at least some negative feelings related to their abortion experiences. Yet at the same time, the majority do not experience mental illnesses (as defined by standard diagnostic criteria) that can be solely attributed to their abortions.

This brings us to a more general problem regarding the claim that “the majority” of women experiencing relief following their abortions. 178 , 179 For women who do have strong negative feelings, such global denials of their personal experience may be demeaning. Even if these women’s negative reactions fall short of being classified as mental illnesses, it is reasonable for them to take offense at the AMH minimalist’s assertion that abortion does not involve any emotional risks, much less that the only women troubled by abortion are those who already had prior emotional problems. 180 In short, publicity suggesting that abortion has no psychological effects may have the unintended effect of making women who do struggle with a past abortion feel like “freaks” who are unable to handle their abortions as easily as “everyone else.” 45

Even if it could be proven that 99% of women who had abortions experienced more benefit than harm, that would still not justify ignoring the 1% who experienced more harm than good. Majorities matter in elections. But in regard to medical ethics and public policy, negative reactions are important among even a minority of patients … especially when it is possible to screen for risk factors that identify the patients at greatest risk of adverse reactions.

Negative reactions may manifest themselves over a very long time frame

Most studies can only capture evidence spanning very limited timeframes. In the 1960s and 1970s, most studies of emotional reactions after abortion were based on volunteer samples limited to a few hours, days, or weeks after the abortion. These studies typically found negative outcomes in the range of 10%–20% of their volunteer samples. Early reactions, however, are not necessarily predictive of longer range reactions. 38 Subsequent studies revealed that the percentage of women experiencing negative reactions increases with time, along with a significant drop in decision satisfaction and feelings of relief. 39 , 148

For example, in a study led by TFMHA chair Brenda Major, volunteers interviewed at an abortion clinic reported a significant decline in their Brief Symptom Inventory Depression scores 1–2 h after their abortions (T2, 62% decline) compared to their scores an hour before their abortions (T1, asking women to rate their depression for the month prior to the abortion). But at the 1-month follow-up (T3), depression scores rose 91% above their post-abortion (T2) score and continued to get higher, up to 118% at the 2-year follow-up (T4). 39 Notably, this study had a 30% dropout at the 1-month follow-up (T3) and a 50% dropout at the 2-year follow-up (T4). In addition, the self-selection bias of this volunteer sample was further magnified by the study protocol that also excluded women aborting an intended pregnancy or a second trimester pregnancy, two of the risk categories for elevated risk of negative reactions.

The fact that negative reactions may unfold over a long period of time is also evident from retrospective surveys. For example, one survey of women seeking post-abortion counseling found that only 24% claimed they had always been aware of negative feelings regarding their abortions. Of the remainder, less than half reported “doubts or negative feelings” within the first 3 years, while 100% were experiencing negative feelings by the time they sought post-abortion counseling. 45 A similar survey found that 70% of women seeking post-abortion counseling reported that there had been a time after their abortions when they would have denied having any negative feelings. 181 The first appearance of negative emotions may occur even as late as menopause. 182

It is likely that there are patterns relative to which women are at greater risk of experiencing early negative reactions and those who are likely to experience later reactions. Zimmerman, for example, found that 74% of “disaffiliated” women were struggling with negative thoughts about their abortions, three times the rate reported by “affiliated” women. 48 Thus, it is easy to predict that our archetype Annie All-Risks would likely be among those who would have immediate negative reactions. After all, she felt coerced into aborting an unplanned but welcomed pregnancy against her maternal preferences and moral beliefs. In addition, given her history of abuse and psychological problems, her coping skills were already stretched to the limit prior to her abortion.

Similarly, it is also easy to imagine that Betsy Best-Case would cope well in the immediate hours, days, months, and even years after her abortion. She freely chose to abort a pregnancy that was both unintended and unwanted for rational reasons. She also had strong coping skills and could easily compartmentalize any “socially induced” doubts into the “deeper levels” of her consciousness.

Clinical experience indicates, however, that there is no certainty that Betsy will always remain symptom free. Subsequent reproductive events such as miscarriage, infertility, or even a wanted birth may unexpectedly trigger existential crises deeply intertwined with a nearly forgotten abortion experience. 24 , 37 , 40 , 45 Similarly, life events that trigger introspection such as the death of a loved one, or a later religious conversion, may trigger a redefinition of past choices and experiences in a way that may include obsessive guilt and self-condemnation. 45 An example of a “perfect decision” being reinterpreted as a woman’s worst decision is found in this posting at a post-abortion counseling site:

I had an abortion when I was 22 years old. Now it is haunting me. I think about it every day of my life. I have so much regret. I wish I could turn the clock and undo my mistakes. I am not coping. The guilt is too much. At that time the decision was perfect. But now it kills me day by day. Please help me. I don’t trust anyone with this secret.

AMH minimalists might reasonably argue that it is the subsequent trigger, the miscarriage, or religious conversion, that is the “true cause” of later distress. But efforts to apportion blame for the “true cause” of distress over a prior abortion simply disrespects the real experience of women who seek, desire, or need post-abortion counseling. Whatever the trigger, whatever the contributing factors, the internal turmoil over a past abortion is centered on, or at least intertwines with, the abortion and will not be resolved by pretending the abortion is not part of the problem.

Based on reports of clinical experience, we would hypothesize that delayed reactions are most frequently triggered by (a) subsequent reproductive experiences, including reproductive difficulties and (b) experiences that lead to introspection and reevaluation of one’s overall life course or moral integrity. 45 Conversely, the more risk factors that are present, especially feelings of coercion and attachment combined with weakened coping skills, are predictive of more immediate negative reactions.

The great variability in the time frame for negative reactions greatly complicates the interpretation of studies examining limited time frames, and even those covering long time frames but at infrequent intervals. For example, two studies examined Center for Epidemiological Studies depression scores (CES-D) collected by the National Longitudinal Study of Youth (NLSY) an average of 8 years after an abortion. 69 , 86 But the NLSY was not designed to study reproductive or mental health and had a very high concealment rate regarding past abortions. Moreover, the single year in which depression was evaluated in the NLSY could only provide a bit of cross-sectional information about the women surveyed. While the passage of time may have helped to identify some delayed reactions, it would also miss cases where women have gone through a healing or recovery process during the 8 years (on average) for which there was no data. Moreover, the NLSY’s single measure for current depression, the CES-D, did not account for women who were being successfully treated for depression with medication.

In short, questionnaires which lack abortion-specific retrospective questions such as “Did you ever experience significant negative feelings about a past abortion?” followed by questions regarding the timeline for each type of mental health outcome being studied 45 , 50 , 183 are simply capturing cross-sectional data. Cross-sectional data regarding current symptoms will simply miss symptoms that have ceased, either due to medication, counseling, or by the healing effects of time or a replacement pregnancy. It will also miss symptoms that may be delayed beyond the date of the assessment. As a result, data from general prospective studies like the NLSY simply cannot tell us anything about the “true prevalence rate” of depression associated with abortion.

The weakness of such general purpose prospective studies also explains why AMH proponents and AMH minimalists can look at the same data and come to different conclusions. For example, the first analysis of NLSY CES-D scores relative to women with a history of abortion found that depression was highest among married women with a history of abortion (OR = 1.92; 95% CI = 1.24–2.97) and among women in their first marriage in particular (OR = 2.23; 95% CI = 1.36–3.74). 184 Since CES-D scores did not significantly vary among unmarried women, the combined results for all women (OR = 1.39; 95% CI = 1.02–1.90) were barely significant. 184 The significance of marital status may indicate that abortion-related depression after an average of 8 years may be triggered by subsequent pregnancies in marriage. In any event, given the weakness of this data set, it was a trivial matter for AMH minimalists 69 to use different selection criteria, excluding a subgroup of women at greatest risk of negative reactions to abortion, in order to shift the lower 95% CI for all women below 1 (OR = 1.19; 95% CI: 0.85–1.66) in their reanalysis of the NLSY data. Notably, their analysis also excluded results segregated by marital status, the finding most significant in the earlier study. Based on these weaknesses, it was simply misleading for Schmiege and Russo 69 to interpret their reanalysis as conclusive evidence that abortion does not contribute to the risk of depression in some women. Their overreaching conclusions were particularly unjustified in light of the fact that the NLSY data set was also tainted with a 60% concealment rate regarding past abortions 185 and the CES-D scale inquired about only depression in the prior week and was administered in only once, an average of 8 years after the abortions.

In summary, the efforts to estimate the prevalence rate of negative reactions to abortion are complicated by (a) the wide variety of reactions, (b) the existence of both early and delayed reactions, (c) a wide variety of triggers for delayed reactions, and (d) the prospect that in any assessment years after the abortion, a number of women who previously had significant reactions may have experienced full or partial recovery by the time of that assessment. Each of these factors would tend to skew the results of any prevalence estimates based on questionnaires toward underestimating the total lifetime risks.

Self-censure and defense mechanisms contribute to underreporting of sequelae

Data collected to investigate reactions to abortion may also be distorted by any number of defense mechanisms. Avoidance, denial, repression, suppression, intellectualization, rationalization, projection, splitting, and reaction formation may all contribute to the conscious or unconscious underreporting of symptoms attributable to unresolved abortion issues.

Active defense mechanisms are also the most likely explanation for selection bias and the high rate of concealing abortion history found in national longitudinal studies. Typically, respondents will report under half, and as few as 30%, of the number of abortions expected compared to age-adjusted national data on abortion rates. 106 , 185 , 186

In case series studies, where women are first contacted while at the abortion provider and asked to participate in a follow-up evaluation, both the initial refusal and subsequent dropouts usually exceed 50%. 39 , 187 In the Turnaway study, for example, only 37.5% of women asked to participate agreed, and of those who agreed 15% immediately dropped out before the first baseline interview, approximately 8 days after the abortion. 179 The study continued with phone interviews every 6 months for 5 years. Women were rewarded with a US$50 gift card each time they completed an interview. But despite this motivation, by the end of the 3 years, only 27% of the eligible women were participating, and this dropped to only 18% at the 5-year assessment. 188 Given this high rate of self-censure, the researchers’ conclusion that “Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years” 179 clearly overstates what the Turnaway data can actually reveal. Unfortunately, the authors’ overgeneralized conclusion inspired many newspaper headlines which definitively proclaimed that the overwhelming majority of women are glad they had their abortions. 178 , 189 But if the researchers’ conclusions had been more accurately narrowed to describe their actual pool of respondents, the abstract should have read, “Of the 27% of eligible women participating at a three year assessment, the overwhelming majority felt that termination was the right decision for them.” That single clarification would have helped even the most pro-choice reporter to recognize that the views of a self-selected minority of volunteers (27%) simply cannot tell us what the “majority of women” feel and think. What “most women” experience is simply unknown when the majority of women are refusing to share their thoughts and feelings at any given time.

Avoidance, and other defense mechanisms, clearly works. Research has shown that the subset of women who anticipate the most difficulty dealing well with their abortions are right; they do have higher rates of negative reactions. 56 It is therefore natural for women who anticipate more negative reactions to avoid follow-up surveys that may aggravate those negative feelings. Indeed, one reproductive history survey that included as the last query, “Answering this survey has been emotionally difficult or disturbing,” found that women admitting a history of abortion were significantly more likely to feel disturbed by participating in the survey. 183 This finding is especially important relative to research designs that rely on waves of multiple interviews over time. Clearly, women who feel more stress at one wave may be more likely to decline to participate again in subsequent waves.

These findings are consistent with studies showing that women refusing to participate in follow-up studies are likely at greater risk of negative reactions to their abortions. 174 , 190 While one study has asserted that the women dropping out are not significantly different than subjects retained, 39 this conclusion was based on demographic comparisons, not on comparison of the presence of risk factors that are more predictive of negative reactions. The authors’ refusal to allow reanalysis of their data 140 also diminishes the reliability of their conclusions.

Notably, the act of avoiding a post-abortion evaluation may itself be evidence of a post-traumatic stress response. A study of 246 employees exposed to an industrial explosion revealed that those employees who were most resistant to a psychological checkup following the explosion had the highest rates and most severe cases of PTSD. Without repetitive outreach and the leverage of an employer mandate for undergoing post-traumatic assessments, 42% of the PTSD cases would not have been identified, including 64% of the most severe PTSD cases. 191 In the subsequent clinical treatment of these subjects, the author noted that “In the clinical analysis of the psychological resistance [to the initial assessment] among the 26 subjects with high PTSS-30 scores, their resistance was mainly found to reflect avoidance behavior, withdrawal, and social isolation.” 191

Our understanding of defense mechanisms also suggests there may be cases where the denial of a link between abortion and abortion-specific symptoms is evidence of both avoidant behavior and an elevated risk of mental illness. It seems likely that defense mechanisms may contribute to a significant underreporting of negative reactions, especially in survey responses. Conversely, questionnaire-based reports may also lead to the exaggerated rating of some positive reactions due to splitting or reaction formation. In these cases, women trying to focus on the positive may respond in ways that may anticipate, or even inflate, the positive feelings they want to feel while “rounding down” negative reactions which they want to escape or deny.

The statistical impact of defense mechanisms is also double edged. First, self-censure, dropouts, and concealment of past abortions are all likely to suppress measurements of the prevalence rate of mental illnesses among those volunteers admitting to a past abortion. Second, comparison groups that include women who conceal their history of abortion (who are most likely to have AMH effects) are likely to have inflated prevalence rates for mental illness due to the misclassification of women with a history of abortion into the comparison group of women who, according to the study design, have not been exposed to abortion. 184 Both problems suggest that odd ratios and prevalence rates based on studies relying on voluntary self-reporting of abortions will most likely be skewed toward underestimating the true risks associated with abortion.

It is also worth noting that defense mechanisms may also impede the ability of women to receive good follow-up care. In a survey of women reporting that they sought post-abortion counseling from a psychologist, psychiatrist, social worker, or other professional counselor, 58% reported that the counseling was not helpful. 45 Many reported that their therapists simply refused to seriously consider abortions as significant. This phenomenon may be at least partially due to defense mechanisms employed by healthcare professional professionals themselves. Many therapists may have unresolved issues with their own history with abortions; others may be loath to reconsider the wisdom of their advice to previous patients, reassuring them that abortion was a good; still others may have ideological commitments to abortion rights which conflict with their ability to trust their patient’s self-assessments, and some may simply have an uncritical confidence in the widely spread, but exaggerated claim, that “there is no evidence that abortion has any mental health risks.” This is yet another reason why better research and training regarding how abortion may contribute to problems for “ at least some women ” is important to prepare healthcare workers to be more sensitive and open to providing informed care. 45

There is no perfect control group; yet all comparison groups provide insights

Since it is impossible to randomly assign women to different groups to be exposed to abortion or not, there are no true control groups in relation to abortion among humans. Given this limitation, comparisons to other groups of women who have not been exposed to abortion are the only option. While no comparison group is perfect, 192 – 194 nearly every comparison can be useful for teasing out patterns that may help to inform patients and caregivers regarding the many varieties of abortion experiences.

Comparisons have been made to each of the following: the general population of women, 77 , 195 women who have never been pregnant, 94 women with no reported history of abortion, 74 , 84 , 85 , 91 , 92 , 94 , 95 , 100 , 101 women giving birth, 30 , 69 , 71 – 73 , 75 – 77 , 81 , 83 , 86 – 90 , 94 , 97 – 99 , 102 women giving birth to a first pregnancy, 69 , 86 , 113 women having miscarriages or other involuntary losses, 81 , 88 , 91 , 94 , 195 – 197 women experiencing both births and pregnancy loss (abortions or miscarriages), 69 , 82 , 107 women giving birth to unintended pregnancies, 69 , 72 , 75 , 76 , 86 , 90 , 92 , 98 and women denied abortions. 179 , 198 Together, these findings show that women with a history of abortion are statistically more likely to experience significantly more mental health issues relative to every comparison group that has been examined.

Notably, most of these comparisons are based on general-purpose longitudinal cohort studies. As discussed previously, due to the temporal limits, cross-sectional data, self-selection bias, concealment, and the misclassification of women with an abortion history into the comparison groups, the results of these studies most certainly skew toward underestimating the true relative risks between the groups compared. Still, while every choice for a comparison group is imperfect, 192 , 193 below we will argue that there are valid insights that can be gained by every comparison. Acting on that premise, many researchers have chosen to simultaneously compare women who abort to multiple other groups whenever the data allow it. 72 , 88 , 92 , 94

By contrast, Charles et al., 6 have argued that the only “appropriate” comparison group for AMH studies is to women who have “unwanted deliveries.” But this argument is weak for three major reasons.

First, the efforts to define and evaluate what constitutes an “unintended” or “unwanted” pregnancy are themselves imprecise, rendering any study based on such a flawed definition imprecise. 15 , 199 Moreover, not intending to become pregnant at a particular time in one’s life is very different than not wanting a child. Indeed, over half of unintended pregnancies are carried to term, accounting for approximately 37% of all births. 200 Conversely, among women having abortions, the evidence suggests that between 30% and 63% of aborted pregnancies were intended, wanted, welcomed, or involved significant emotional attachment. 48 , 50 , 51 , 148 , 172 In short, both groups (women having abortions and women carrying unintended pregnancies to term) encompass a huge variation in intentionality, wantedness, and attachment to their pregnancies.

Second, as Romans 192 has convincingly argued, the differences in women who choose to carry an unintended pregnancy to term and those who abort are simply immeasurable. No conceivable comparison between the two groups can control for all the possible variations between them. Still, as both the TFMHA 4 and Fergusson et al. 193 have argued, even imperfect comparisons have and can continue to yield valuable insights regarding the differences between the women who cope well and those who cope poorly. While such findings cannot tell us what “most women” experience, they can tell us how different subgroups of women compare to each other. These findings are meaningful and actionable since they should be used to guide pre-abortion screening and counseling and post-abortion care 25 and for informed consent procedures. 23

Third, the argument for discounting studies that lack information on pregnancy intention appears to have been advanced primarily as an excuse to denigrate the majority of studies on AMH. This charge is supported by the fact the “quality scale” created by Charles et al. 6 required deducting two of the five possible quality points from any study using any control group other than women carrying unwanted pregnancies to term.

The highly biased and subjective application of Charles et al.’s quality scale is demonstrated by the fact that they rated studies published by AMH minimalists 69 , 92 , 201 using exactly the same national longitudinal data sets as AMH proponents 72 , 86 , 101 consistently higher in quality. Moreover, Charles et al.’s quality scale totally ignored the problem of high concealment, misclassification, and drop-out rates in the very same studies they rated as better. Thus, by ignoring issues related to selection bias, the Charles et al. contrived ranking scale identified just four studies as “very good”—even though three of these had concealment rates of 60% or higher, 185 and the fourth had a dropout rate of 65%. 76 Meanwhile, their skewed scale allowed them to rank as “poor” or “very poor” literally all record linkage studies, which by their nature have no concealment or selection bias , 81 , 87 , 89 , 97 , 196 even though these same studies revealed some of the strongest associations between AMH problems.

The fact that Charles et al.’s study quality scale was deliberately skewed to serve the AMH minimalists’ perspective is perhaps best demonstrated by the fact that when the very same record linkage studies rated as poor by Charles et al. are rated using the Newcastle-Ottawa Quality Assessment Scale (NOQAS) for cohort studies, 202 a standard and widely used assessment tool across all disciplines, all receive very high scores, 8 or 9, on the NOQAS 9-point scale for quality. 203

In response to Charles et al.’s argument that the only appropriate comparison group is to women carrying unintended pregnancies to term, the following arguments are made in defense of other comparison groups. I argue that, while no comparison is perfect, every option for a comparison group can be a useful tool in developing a multidimensional perspective on the complexity of AMH issues.

First, comparisons to women with a history of abortion and the general population of women provide a useful baseline, especially when combined with comparisons to women who miscarry or carry to term. For example, a record linkage in Finland revealed that the age-adjusted risk of death within a year of pregnancy outcome was 5.5 per 100,000 deliveries, 16.5 per 100,000 miscarriages, and 33.8 per 100,000 abortions, compared to 11.8 per 100,000 age-adjusted women years for the general population of women not pregnant in the prior year. 196 A similar record linkage study of the population of Denmark revealed a dose effect, with the risk of death increasing by 45%, 114%, and 191% with exposure to one, two, or three abortions, respectively. 112 Yet another record linkage study examining attempted suicide rates before and after pregnancies revealed declining rates of suicide attempts after both delivery and miscarriage, but a sharp increase in attempted suicide following abortion, as seen in Figure 3 . 81

Suicide attempt rates per 100,000 women before and after designated pregnancy outcome.

Source: Morgan et al. 81

Comparisons to women who have never been pregnant (nulligravida) are especially important when the aborting women have no live born children. 74 , 92 , 94 , 113 , 204 Indeed, this is an important comparison since an abortion of a first pregnancy is essentially an effort to return a woman to her never been pregnant state. Differences between childless women with a history of one or more abortions and those without any history of pregnancy may provide valuable insights into the effects of an interrupted pregnancy on women’s emotional and physical health.

Another important comparison is between women who have induced abortions and women who miscarry. Both have experienced the effects of pregnancy, which may produce long-lasting changes to the brain, 150 , 205 , 206 and maternal attachment. 151 , 152 , 154 , 207 While the physiological processes of natural miscarriage and induced abortion are different, there may be similarities in the recovery process. Moreover, this comparison may allow insights into the psychological differences between intentionally choosing the end of a pregnancy versus an unintended loss, both of which may be experienced as a form of disenfranchised grief. 45 , 161 Arguably, examining the differences between miscarriage and abortion may be the most relevant and important comparison. 203

Comparisons to women giving birth are also meaningful. Just as a comparison to a never pregnant woman attempts to estimate how closely induced abortion achieves the goal of “turning back the clock” to the point before the woman became pregnant, a comparison to a delivering woman seeks to estimate how a woman’s mental health would fare if she chooses to “move into” the group of women giving birth.

Comparisons between women aborting a first pregnancy and women carrying a first pregnancy to its natural conclusion (birth, miscarriage, or neo-natal loss) are extremely valuable. By excluding the confounding effects of multiple pregnancy outcomes, these studies offer at least a small window on the effects associated with exposure to a single pregnancy outcome. Moreover, they are the proper starting point for investigating the interactions between multiple pregnancy outcomes. This is important since significantly different outcome patterns have been observed relative to multiple pregnancy outcomes and their sequences, including both multiple losses and losses followed or preceded by live births. 88 , 94

While comparisons of first pregnancy outcomes are valuable, it should be noted that it is a very poor methodological choice to include in the group of women experiencing a “first live birth” women who are known to have had one or more abortions before their first live birth or between the birth and the date of the mental health assessment. 69 , 107 Unfortunately, these flawed studies 69 , 82 , 107 , 208 – 210 ignore the extensive evidence showing that a history of pregnancy loss (abortion or miscarriage) is associated with higher rates of mental health problems during subsequent pregnancies. 78 , 80 , 99 , 100 , 170 , 211 – 226 By adulterating the “control” group of women having a “first live birth” with women who also have a history of one or more abortion and/or miscarriages, the resulting analyses clearly confound rather than clarify the differences between abortion, miscarriage, and childbirth, shifting the known negative effects associated with prior pregnancy losses into results associated with a first childbirth. 69 , 82 , 107 , 208 – 210 Arguably, this confounding methodology has been specifically employed by AMH minimalists precisely with the intent of producing results that obfuscate the mental health effects associated with abortion while inflating the effects associated with childbirth. 141 , 227

As will be discussed further, we recommend that the best practice for all studies examining the interactions between mental and reproductive health is to include stratification of results by the order and number of exposures to births, abortions, miscarriages, and other pregnancy losses. 94 , 141 , 227 Otherwise, the effects of different pregnancy outcomes are likely to be obscured rather than clarified.

In addition, we would note that the argument of Charles et al. for discounting studies that lack controls for pregnancy intention may do a major disservice to both women considering abortion and their caregivers. For all the reasons given above, the best evidence indicates that reasonable patients may consider any and all of the comparisons discussed above to be of value in their efforts to evaluate the potential risks and benefits of an abortion in their own personal circumstance 23 , 25

Finally, it has been argued that the differences between women who abort and those who do not are so extreme that the only meaningful comparison is between women who abort and women who sought but were denied an abortion. 194 While this comparison might be informative, it is clearly not a perfect comparison since the reasons why women may end up being denied an abortion are also likely to make these women significantly different than the average woman seeking and obtaining an abortion. Moreover, since in most countries where abortion is legal, very few women are denied an abortion undertaking such studies may be impractical. Indeed, the only set data set using this control group is the so-called Turnaway Study. Indeed, the argument that this is the only valid comparison group appears to be made in an attempt to dismiss all other research in favor of this single data set. But there are many problems with the Turnaway Study data set. 198 The most damning is the problem of self-censure. Over 70% of women approached to participate in this study refused, even after they were promised payments for participating, plus, nearly half of those who did participate subsequently dropped out. 198 This high refusal rate alone renders the Turn-Away Study data meaningless in terms of drawing any conclusions regarding the general population of women seeking or having abortions, and that is just one of many major flaws in the Turnaway Study methodology and execution. 198

Poorly defined terms produce misleading conclusions: unwanted, relief, and more

Unfortunately, a great deal of the literature on AMH revolves around poorly defined terms. The resulting lack of precision and nuance contribute to AMH minimalists and AMH proponents talking past each other and contributes to overgeneralizations regarding research findings, especially in the press releases and position papers of pro-choice and anti-abortion activists.

As previously discussed, one common overgeneralization is the assertion that abortions typically involve “unwanted” pregnancies. A closer look, however, reveals that many aborted pregnancies, perhaps the majority, occur for planned, partially wanted, or initially welcomed pregnancies. 48 , 50 , 51 , 148 , 172 By “welcomed” pregnancies, I mean pregnancies which were not planned in advance but to which the woman was open or naturally inclined to accept and embrace if only she had received the support of her partner, family, or others. 45 , 181 , 228

Attempts to define “unwanted” pregnancies are also complicated by the fact that many women report a divide between their emotional and intellectual responses when they first discover they are pregnant. Emotionally, they may be excited that a new life is growing inside them and may fantasize about having the child. But at the same time, their logical side may be immediately convinced that abortion is their only pragmatic choice. 45 The pregnancy may therefore be simultaneously “emotionally wanted” and “logically unwanted.”

Based on both clinical experience and case series studies, 173 we hypothesize that many delayed reactions to abortion stem from the psychological conflicts that arise when emotions are suppressed in favor of pragmatic choices. In such cases, forward-looking women with strong defense mechanisms are likely to cope well with their choice for many years. But if this coping is achieved by suppressed emotions, this may consume energy and may even fuel maladaptive behaviors, like substance use and sleep disorders. Any connection between these symptoms and underlying abortion associated conflicts may not be recognized until some subsequent event or stress compels a reexamination of unresolved maternal attachments or the woman’s moral priorities.

One measure of openness to having a child, seldom addressed in AMH studies, is desire for children at some later date. A high level of desire for future children suggests that an aborted pregnancy was most likely problematic due to specific circumstance or lack of sufficient social support. Among a sample of women seeking counseling for post-abortion distress, 64% felt “forced by outside circumstance” to have an abortion and 83% indicated they would have carried to term if significant others in their lives had encouraged delivery. 181 While statistics gathered from women contacting post-abortion recovery programs may be not representative of the general population of women, these findings demonstrate that labeling these aborted pregnancies as “unwanted” does not reflect the experience of the women who subsequently do seek post-abortion help.

Given the wide variation in levels of intention or openness to pregnancy, much more extensive data on intention 199 , 228 and attachment 207 are required to draw any conclusions regarding the mental health effects of abortion relative to various levels of women’s attachment, intention, and outcome preferences.

A second poorly defined variable is “relief.” AMH minimalists have frequently asserted that the most common reaction to abortion is relief. 4 But “relief” is a very broad term. A woman reporting “relief” may be referring to (a) relief that she will not have a baby, (b) relief that a dreaded medical procedure is now behind her, (c) relief that her parents will not discover she was pregnant, (d) relief that her partner will finally stop harassing her to have an abortion, or (e) any number of other reasons for feeling a reduction in stress.

But as indicated earlier, abortion can be both a stress reliever and a stress creator. The many declarations by AMH minimalists that “relief” is the most common reaction to abortion tend to distract the public from the fact that the vast majority of women reporting relief are also reporting a host of negative feelings at the same time. 39 , 50 , 62

Similarly, claims that “the most common reaction” to abortion is relief is also misleading because it falsely suggests that a truly representative sample of all women having abortions have been queried about their most prominent and common reactions. But in fact, all the case series studies assessing “relief” have self-censure and dropout rates exceeding 50%. 39 , 59 When only a minority of women agree to report on their reactions to an abortion, these studies cannot reliably tell us anything about the majority of women. This is especially true if the self-selection bias is toward women who expect to feel more relief because their abortion decision is more consistent with their own desires and preferences, while those who refuse to participate anticipate and do experience more negative reactions. 174 , 190 , 191

Another misleading factor is that relief is most often reported as a single variable whereas negative reactions are often averaged together. For example, one of the most frequently cited case-series reporting that women felt “more relief than either positive or negative emotions” was based on comparing the results of a single question regarding relief to an average of six scores (“sad,” “disappointed,” “guilty,” “blue,” “low,” and “feelings of loss”) chosen to represent negative emotions and an average of three scores (“happy,” “pleased” and “satisfied”) chosen to represent positive emotions (excluding relief). 39 This methodology was highly problematic.

While it would be interesting to see score distributions for each reaction separately, 45 how can a variety of emotions be “averaged” together in any meaningful way? For example, if a score of 1 (corresponding to “not at all” on the Likert-type scale used) is equivalent to 0% of the relevant emotion and a 5 (“a great deal”) is 100% of that emotion, averaging six emotion scores together presumes that a rating of 3 (50%) for “disappointed” is truly equivalent to twice a rating of 2 (25%) for “feelings of loss” and half the value of a rating of 5 for “guilty.”

But what makes this averaging process even more suspect is that the least common negative reaction (“disappointed,” perhaps) would dilute the entire average of negative reactions, concealing the frequency of the more common reactions (“guilty,” perhaps). Most importantly, while the most common negative and positive reactions were diluted by this “averaging” process, the “relief” score was not subject to the dilution by averaging with any of the other positive emotions.

Yet another problem with the authors’ conclusion 39 was their presumption that the six negative reactions they asked about are actually the most common negative reactions. But three of the six negative reactions (“sad,” “blue,” “low”) appear nearly synonymous. The similarity of these three may have been deliberate in order to boost the reliability score for the authors’ scale. One of the remaining choices, “disappointed,” is simply odd, rather bland, and perhaps disinviting as it is not a term that has been reported in interviews with women reporting negative reactions to abortion. 45 , 172 , 173 , 181 While the assessments of “guilty” and “feelings of loss” were appropriate, it would have been more illuminating to report these separately rather than in an “average” of negative emotions.

In any event, averaging emotion scores is problematic and in this case the choice of the six negative feelings chosen to be averaged together failed to include many of the negative emotions most commonly reported in surveys of the women who seek post-abortion counseling, including sorrow, shame, remorse, emptiness, anger, loneliness, confusion, feigned happiness, loss of confidence, and despair. 45

Despite the many limitations regarding the claim that “relief” is more common than negative reactions, it is notable that the same researchers also found that between the 3-month and 2-year post-abortion assessments, both relief scores and positive emotions decreased significantly while the average for negative emotions increased. 39 In other words, even with a self-selected sample of women most likely to have more positive reactions, those positive emotions declined and negative emotions increased within the first 2 years. If that trend continued over 20 years, the finding that the “most common reaction” to abortion was relief may not have held up over a longer period of time.

Similar problems apply to the widely reported claim that most women are satisfied with their decisions to abort. 179 In this case, the self-selection bias was profound, with only 27% of the eligible women participating at the date of their first assessment. In addition, this “finding” was based on a binary yes or no response to a single question: “Given your situation, was your decision to have an abortion right for you?” This question clearly invited reaction formation and splitting. Additional questions, such as, “If you had received support from others, would you have preferred to have carried to term?” would have provided deeper insight into the participants’ true preferences.

Despite the problems with their methodology and self-selected sample, these researchers’ confident assertion that the vast majority of women are satisfied with their abortions generated bold headlines. 189 But these misleading headlines were clearly based on poor science. 198 Similar questions, posed to a different self-selected sample of women seeking post-abortion counseling, reveal that 98% of that sample of women regret their abortions. 45 These resuts are contradictoruy because neither of the two samples just cited represent the general population of women having abortions. Given the fact that so many women refuse to respond to questionnaires about their abortions, it is impossible to ever be certain what “the majority” of women feel or think about their past abortions at any given time, much less through their entire lifetimes.

If there is any consistency in the evidence, it is in regard to the finding that satisfaction declines and regrets increase over time. 38 , 39 , 45 Therefore, the existing data for claims regarding high levels of relief and decision satisfaction are highly questionable in the short term and meaningless in regard to predicting feelings in the long term.

Is abortion the sole cause, a contributing cause, or never a cause of mental health problems? Or is this question just a distraction from helping women?

Normally, the burden of proving that any proposed medical treatment produces real benefits which outweigh any risks associated with the procedure falls on the proponents of the treatment. 229 Indeed, proponents of a treatment are also tasked with the obligation of proving not only specific benefits but also with identifying the symptoms and circumstances for which the treatment has been proven to be beneficial and those cases for which it might be contraindicated. After all, no treatment is a panacea. Even highly successful elective treatments such as Lasik are contraindicated for 20%–30% of patients considering the surgery. 230

Evidence-based medicine is centered on the idea that there must be real evidence of benefits that outweigh the risks associated with a medical intervention. But there are no statistically validated medical studies showing that women facing any specific disease or fetal anomaly fare better if they have an abortion compared to similar women who allow the pregnancy to continue to a natural outcome. 17 , 231 , 232 Nor is there evidence of any mental health benefits. 17 , 25 As a result, in approaching a risk–benefits assessment, there are literally no studies to place in the benefits column of an evidence-based risk–benefits analysis. Conversely, there are literally hundreds of studies with statistically significant risks (both physical and mental) associated with abortion which must be considered in weighing abortion’s potential risks against the patient’s hoped for benefits. 11 , 112 , 113 , 232 , 233 See, for example, the references to Table 1 .

In this regard, induced abortion is an anomaly. It is the only medical treatment for which the principles of evidence-based medicine are routinely ignored, not for medical reasons, but by appeals to abortion being a fundamental civil right 135 or a public policy tool for population control. 25 From these vantage points, there has arisen an a priori premise that abortion should presumed to be safe and beneficial. Therefore, according to defenders of abortion, the burden of proving the safety and efficacy of abortion is no longer on them. Instead, abortion skeptics must prove that abortion is the sole and direct cause of harm to women—and not just a few unfortunate women, but a large proportion of women. 4 , 6 , 57

This difference in evaluating abortion compared to other medical treatments was at the center of a Planned Parenthood suit challenging a South Dakota statute requiring abortion providers to inform women of research regarding psychological risks associated with abortion. Abortion providers argued that there was not yet enough proof that abortion was the “direct cause” of the statistically significant higher risks of mental illness, including suicide, following abortion. Therefore, they argued, disclosing the findings of these studies to women might unnecessarily frighten their patients. 234 But the Eighth Circuit United States Federal Court of Appeals rejected Planned Parenthood’s argument, ruling that it was a standard practice in medicine to “recognize a strongly correlated adverse outcome as a ‘risk’, even while further studies are being conducted to investigate which factors play causal roles.” 234 The court went on to add that Planned Parenthood’s “contravention of that standard practice” had no legal merit since “there is no constitutional requirement to invert the traditional understanding of ‘risk’ by requiring, where abortion is involved, that conclusive understanding of causation be obtained first.” 234

This appellate court’s ruling is consistent with idea that “risk,” by definition, includes uncertainty—otherwise, it would not be a “risk” but rather a “certainty.” Therefore, the question of whether a statistically significant risk is solely due to abortion, partially due to abortion, or only incidentally associated with abortion is itself just another of the uncertainties about the procedure, and therefore a true risk about which patients should be informed. 25

The court’s decision favoring disclosure of all risks, even when causality is challenged by proponents of the procedure, is in line with the preferences reported by 95% of women considering elective medical procedures, to be informed of “all possible complications.” 23 From a feminist perspective, the right of each individual woman to evaluate for herself whether a statistically significant risk is incidental or causal would also appear be central to the protection of each woman’s personal liberty. Indeed, the United Nation’s Fourth World Conference on Women’s Declaration and Platform for Action, which specifically addressed the issue of unsafe abortions, urged every government to

Take all appropriate measures to eliminate harmful, medically unnecessary or coercive medical interventions, as well as inappropriate medication and over-medication of women, and ensure that all women are fully informed of their options, including likely benefits and potential side-effects, by properly trained personnel. 235 (Emphasis added)

For the reasons above, the claim that the higher incidence rates of mental health problems associated with abortion are most likely “spurious” 105 has no bearing on informed consent. Only after full disclosure can each patient judge the relevance of such information for herself.

These challenges are also irrelevant to the obligation of the treating clinician to screen for the risk factors associated with higher rates of negative outcomes associated with abortion. 23 , 25 After all, even if abortion proponents could prove that 100% of all the negative effects associated with abortion are causally due to common risk factors, the finding that abortion is consistently associated with higher rates of mental health problems 15 , 57 , 82 , 89 , 94 is still an actionable marker that can and should be used to identify women who may benefit from referrals for additional counseling. 26 , 27 , 30 , 32 – 34 , 36 – 39

Still, the question of causation is worthy of additional attention. One approach for judging causality is to apply the nine criteria Bradford-Hill proposed to identify the causal role that occupational and lifestyle factors may play in the development of diseases, such as cancer. These include temporal sequence, strength of association, consistency, specificity, biological gradient (dose–effect), biologic rationale, coherence, experimental evidence, and analogous evidence. 236 Applying the Bradford-Hill criteria to the AMH question, Fergusson, a pro-choice proponent, concluded that “the weight of the evidence favors the view that abortion has a small causal effect on the mental health problem.” 75

It should be noted, however, that the Bradford-Hill criteria were developed to evaluate contributing factors for physiological diseases. Bradford-Hill therefore ignored a type of evidence for causality which is unique to psychological diseases, namely, self-aware attribution of causal pathways. For example, the evidence of a woman who says, “After the death of my child, I drank more heavily to dull the pain,” is a conscious identification of cause and effect regarding her own mental state and behaviors.

Indeed, in the psychological sciences, it has been a traditional practice to begin any investigation of mental illness by first listening to those individuals who claim they have a psychological problem. After carefully listening to a “sick” population, psychologists can then map the range of reported symptoms and then build hypothesis regarding the contributing factors and causal pathways which can then be explored by surveys of the general population. This was the approach AMH proponents used in their initial investigations of women seeking post-abortion counseling. 45 , 171 , 181 Because these samples were based on women experiencing post-abortion issues, they were likely skewed toward the Allie All-Risks archetype. Still, because they were focused on developing a profile of the women having post-abortion issues, this was a valid starting point for identifying the most common complaints and recurring patterns.

By contrast, most AMH minimalists have tested their hypotheses using surveys of women contacted at abortion clinics. These survey instruments appear to have been developed with little or no attention to the complaints of the women who reported post-abortion mental health crises. Moreover, because these surveys are implemented in cooperation with abortion providers, in a stressful situation during which less than half of the women agree to participate, it is likely that these self-selected samples skew toward the Betsy Best-Case archetype. 39 , 237

Even though AMH minimalists and proponents approach their research from different perspectives, the results from both sides consistently show that at least a minority of women experience mental health problems that they attribute, at least in part, to their abortions. While not included in the Bradford-Hill criteria, when it comes to mental health issues, the fact that so many intelligent, self-aware women attribute specific patterns of emotional distress to their history of abortion is one of the strongest pieces of evidence that abortion directly contributes to mental health problems. The same is true with regard to mental health associated with miscarriage. The validity of this evidence is further strengthened by the professional assessment of both pro-choice therapists 40 – 44 and pro-life therapists 45 – 47 who also attest to the causal connection.

Similarly, the clinical evidence that women struggling with post-abortion mental health issues improve following treatment focused on their abortion loss 40 , 46 , 238 – 240 also supports the conclusion that abortion can cause, trigger, or exacerbate psychological illness. After all, a successful treatment is evidence in favor of a correct diagnosis.

As previously noted, self-attribution is not perfect evidence. Defense mechanisms often operate by obscuring the “true cause” of one’s mental distress. But we would argue that the bias of defense mechanisms would be toward underreporting of effects truly associated with an abortion rather than toward false attribution of unrelated effects to past abortions.

That is not to say that pre-existing mental health issues cannot become intermingled with an abortion. To the contrary, clinical experience shows that abortion can become such a significant stressor in a woman’s life that other pre-existing issues can become enmeshed in the abortion and its aftermath. Pre-existing substance abuse, for example, may become intensified in the abortion aftermath, but it would be a self-deception to blame the abortion entirely for such substance abuse. On the contrary, once the issues become intermeshed, progress in dealing with underlying issues will be hindered by a failure to address the intermingled abortion issues.

Similarly, even in cases where suicide notes specifically attribute a woman’s final act of despair to her recent abortion, 241 other pre-existing factors may also contribute to these tragedies. In short, while it would be absurd and insulting to deny that abortion at least contributes to such suicides, it would be a mistake to assume that abortion is the sole cause of suicide or any other specific mental illness.

As stated previously, abortion does not occur in isolation from interrelated personal, familial, and social conditions that influence the experience and mental health of each individual. Moreover, there are likely a multiplicity of different pathways for effects to manifest either in the near or longer term. 18 In general then, abortion is most likely a contributing factor to the manifestation of problems rather than the sole factor . It may be trigger latent issues, intensify or complicate existing issues, interact with pre-existing issues to create new issues, or contribute in any number of ways unique to any particular individual’s susceptibilities and prior and subsequent life stresses.

In summary, there is incontrovertible evidence that abortion contributes to mental health problems, both directly and indirectly. Based on reports of clinical experience, it would appear that abortion can be the primary cause for mental health issues in some women. But it may also trigger, intensify, prolong, or complicate pre-existing mental health issues. Still, for the sake of argument, assuming AMH minimalists are right in their assumption that abortion itself is never the “sole cause” of mental health problems, there is still no reasonable doubt that abortion contributes to mental health issues in some women.

Finally, it should be emphasized that the difficulties involved in proving causality cut both ways. The burden of proving the efficacy and safety of abortion falls on abortion providers. To date, they have failed to provide any evidence, much less proof, that abortion is the sole and direct cause of any health benefits for women in general, or even for specific subgroups of women. 193 , 232 Nor have they shown that the benefits women hope to obtain through abortion are proportionate to or greater than the significantly elevated rates of negative outcomes associated with abortion. In this regard, abortion continues to be an experimental treatment, one for which they hoped for benefits are unproven. And with no proven benefits, the risks–benefits ratio is unknown even for those women without any known risk factors.

Is it reasonable to attribute all negative effects to pre-existing factors?

There is no longer any dispute regarding the fact that, on average, women with a history of abortion have higher rates of mental illness compared to similar women without a history of abortion. But AMH minimalists frame this admission in the context of arguing that this is most likely due to pre-existing mental health issues. 5 , 6 , 242 In other words, they argue that a higher percentage of aborting women were “already emotionally broken” to begin with. Therefore, higher rates of mental illness following abortion are just a continuation of pre-existing mental frailty.

This argument is indistinguishable from the centuries-old accusation of personal defects applied to “hysterics,” “malingerers,” “cowards” and others who exhibit traumatic reactions. 45 , 243 This blame-their-weakness argument is just a corollary to the assertion that higher quality, more emotionally stable people simply do not break under such circumstances.

In courtrooms, this line of arguments is known as the thin skull, or eggshell skull, defense. It asserts that a defendant should not be held accountable for injuries that would not have been suffered if the plaintiff had not been predisposed to injury due to pre-existing physical or emotional defects. Notably, the thin skull defense has been rejected in most legal jurisdictions. Even if the damages of the “frail” plaintiff are greater than they would be for a healthier person, jurists have ruled, the defendant is still liable for the greater damages because

a defendant who negligently inflicts injury on another takes the injured party as he finds her , which means it is not a defense that some other person of greater strength, constitution, or emotional makeup might have been less injured, or differently injured, or quicker to recover. 244 (Emphasis added)

Applying the thin skull legal analysis to abortion, this means that a physician who fails to screen for known risk factors, such as prior mental illness, before recommending or performing an abortion is guilty of negligence if the woman suffers any subsequent mental health problems because it is precisely the obligation of the physician to treat the woman “as he finds her.”

In short, the argument that negative effects may be mostly due to pre-existing mental health problems simply strengthens the argument for better pre-abortion screening for this and other risk factors. 12 , 25 , 26 , 32 Conversely, it does not at all support the presumption that abortion is safe or likely beneficial to most women, much less all.

The “broken women” argument has also been used by AMH minimalists to argue that the emotionally fragile women having abortions would most likely face as many or more mental health problems if they were denied abortion. 245 But again, this argument is based entirely on conjecture. While only a few studies have examined the mental health of women denied abortions, none have found any significant mental health benefits compared to other groups of women. 76 , 188

Still another AMH minimalist argument is that women with prior mental illness may instinctively know they are less likely to cope well with an unwanted pregnancy, so the higher rate of abortion among women with mental illness is actually a sign of these women choosing abortion wisely. 106 , 107 Again, this is entirely speculation. It ignores the likelihood that mentally ill women, especially those with a history of being abused, may simply be more susceptible to being pressured into unwanted abortions 45 like Allie All-Risks. Moreover, it ignores the ethical obligation of caregivers to discourage, rather than enable, patterns of behavior that may be self-destructive.

Rather than just assume that mentally ill women are wisely inspired to choose abortion more often than mentally healthy women, would it not be best to screen women seeking abortions for mental illness so women can be counseled in a manner that more fully addresses their needs in the context of their mental illness? 25 , 36 As previously noted, while abortion may relieve some stresses, it may also create new ones.

Moreover, bearing children may actually contribute to mental health improvements through direct biological effect, 150 , 205 , 206 by expanding and strengthening interpersonal relationships with the child(ren) and others, 151 , 152 , 154 , 207 or by behavioral adaptations that may replace risk-taking with self-improving behaviors. These benefits may also apply to bearing unplanned children. Indeed, given how common unplanned pregnancies are throughout the millennia, it could be argued that female biology has evolved mechanisms in order to adapt and adjust to unexpected pregnancies.

In short, the argument that higher rates of mental illness following abortion are simply due to mentally ill women being wise enough to choose abortion more often is simply not supported by any statistically validated research. Instead, the opposite argument, that giving birth is more likely to produce mental health benefits, is more plausible and better supported by actual data.

It should also be noted that while we are aware of only one record linkage study examining mental health effects for women without any history of mental health issues , that study (by AMH minimalists) revealed that a history of abortion was associated with a significantly increased risk (risk ratio (RR) = 1.18; 95% CI = 1.03–1.37) of postpartum depression after a first live birth. 80

Closely related to the pre-existing mental illness issue is the finding that women with a history of abortion also have higher rates of abuse and violence in their lives. According to this argument, violence 106 , 110 or childhood adversities, 106 not abortion, are the most likely cause of higher rates of mental illness among women with a history of abortion. This hypothesis is contradicted, however, by studies which have shown that there are higher rates of mental illness associated with abortion even after controlling for violence. 94 , 109 More importantly, it is a mistake to engage in either/or arguments; a both/and approach is both more likely and more productive. Clearly, a history of abuse contributes to a heightened risk of both pregnancy and abortion, especially abortions to satisfy the demands of others. At the same time, clinical experience reveals that issues related to abuse and abortion can become deeply entangled. Efforts to treat based on an either/or attribution are most likely to be frustrated. Progress is most likely to be made when both the abuse and abortion experiences are holistically addressed. 45

While it important to study the interactions between exposure to violence and abortion on mental health, it is also important to consider that there may be two-way interactions. Surveys of women entering into post-abortion counseling reveal high percentages reporting elevated feelings of anger (81%), rage (52%), more easily lost temper (59%), and more violent behavior when angered (47%) following their abortions, which can obviously increase incidence rates of subsequent intimate partner violence. 45 Moreover, in the same sample, in which 56% reported suicidal feelings and 28% reported attempting suicide (with over half trying more than once), there are case studies of women “pushing the buttons” of a violent partner because they believed they did not “deserve to live.” 45 This escalation of violence following abortion may help to explain the elevated rate of homicide among women with a history of abortion. 88 , 232 , 246 For these reasons, given the multiple pathways for interactions between abortion and violence, studies that fail to distinguish between violence before and following abortion are methodologically flawed. 110 , 247

While prior abuse and mental health problems receive the most blame for why women with a history of abortion have higher rates of mental illness, a few AMH minimalists insist that the blame for mental illness following abortion can always be shifted to other risk factors. 248 For example, when Steinberg et al. 30 found that substance abuse rates were significantly associated with abortion even after controlling for dozens of other risk factors, they dismissed their own findings with the assertion that these effects are most likely due to as yet unidentified common risk factors.

In response, AMH proponents argue that (a) the burden of proving safety and effectiveness is on the proponents of a medical treatment and (b) given the weight of the evidence, it is far more logical to accept that abortion is at least a contributing factor that may work in concert with any number of other contributing factors.

In addition, denying that abortion directly contributes to mental health problems is illogical given the fact that so many of the risk factors identified by AMH minimalists themselves (see Table 1 ) are specifically part of the abortion experience. These include feeling pressured to abort by others; negative moral views of abortion; low expectation of coping well after an abortion; ambivalence about the abortion decision; and feelings of attachment or commitment to a pregnancy that is meaningful or wanted. 25 , 35 , 249

In other words, given what we know of the risk factors associated with mental illness after abortion, many of them are directly enmeshed in the abortion experience; they are not fully independent of the pregnancy and abortion experience. Therefore, even to the degree that mental illnesses can be associated with common risk factors for both unintended pregnancy and abortion, such as a history of sexual abuse, the intermeshing of elevated risk for pregnancy, abortion, and mental health issues precludes the conclusion that abortion does not contribute in any way to the observed problems. The only support for that argument comes from ideology, not from any statistically validated studies. For example, an incest victim may be at greater risk of a high school pregnancy with the first boyfriend that she imagines will be able to free her from an abusive step-father. 250 She may also be at greater risk to being pressured into an unwanted abortion. While it would be a mistake to blame the abortion for all of her subsequent mental health problems, even if a subsequent suicide note focuses on the abortion, it is ludicrous to assert that her abortion did not contribute to her problems. Moreover, it is also evident that the failure of healthcare providers to identify the risk factors that made her a poor candidate for abortion missed an opportunity to assist her in using her pregnancy to break a cycle of exploitation and trauma.

Finally, it should be noted that AMH minimalists frequently cite studies showing that women who deliver an unintended pregnancy have more subsequent problems than women who only have intended pregnancies. 248 From this base of evidence, they argue that since women who deliver unintended pregnancies have more problems, with mental health and otherwise, it follows that access to abortion helps to reduce the problems associated with unintended pregnancies. But this argument falsely presumes that abortion puts women who have unintended pregnancies back into the category of women who have never had an unintended pregnancy, and that all intended pregnancies are carried to term. But there are not just two groups: (a) women with “perfect” reproductive lives and (b) women with a history of unintended pregnancies. There is a third group, (c) women who have had abortions, who may fare worse than either of the other two groups.

While AMH proponents do not dispute that on average women with unintended pregnancies may face more problems than women who have perfect reproductive lives, it appears likely that they still have fewer problems than women who abort. Indeed, as previously discussed, not a single study has found evidence that the mental health of women who deliver an unintended pregnancy is worse than that of women who have abortions. 69 , 72 , 75 , 76 , 86 , 90 , 92 , 98 , 188 To the contrary, the only statistically significant findings indicate that women who abort are likely to have more mental health problems than those who deliver their unintended pregnancies. 17

The controversy over abortion related PTSD is more political than scientific

AMH minimalists often reserve the greatest scorn for statements made by AMH proponents that abortion can be a traumatic experience that may contribute to PTSD. 4 , 251 , 252 But this opposition seems to be driven more by a desire to silence abortion skeptics than to honestly report on the connections between abortion and traumatic reactions as revealed in the literature.

First, it is notable that all pregnancy outcomes are associated with some PTSD risk. Both vaginal and cesarean deliveries can be experienced as traumatic with a corresponding risk of PTSD. 225 , 253 – 255 Miscarriage and other natural pregnancy losses are also consistently associated with increased risk of PTSD. 170 , 222 , 256 – 258 It should therefore come as no surprise that induced abortion is also consistently found to be associated with the onset of PTSD symptoms. 21 , 39 , 50 , 60 , 170 , 225 , 259 – 269 Notably, a history of induced abortion is also a risk factor for the onset of PTSD following subsequent pregnancy outcomes, 170 , 225 , 260 , 270 so the effects of abortion may not always be immediate but may be triggered by subsequent deliveries or natural losses, or even subsequent non-pregnancy-related events. 271 These findings are consistent with the insight that multiple traumas and related life experiences may contribute to the triggering of PTSD symptoms.

Given the weight of the many statistically validated studies cited above, much less than the reports of clinicians and women who attribute PTSD symptoms to their abortions, it seems evident that the effort of a few AMH minimalists to categorically deny that abortion can contribute to traumatic reactions is driven by ideological considerations, not science. That said, it should also be noted that not all women will experience abortion as traumatic. Moreover, the susceptibility of individuals to experience PTSD symptoms can also vary based on many other pre-existing factors, including biological differences. So the risk of individual women will vary, as it does for every type of psychological reaction. Still, when even the chair of the APA’s TFMHA has reported identifying abortion-specific cases of PTSD in one of her own studies, 39 the claim that abortion trauma is a “myth” advanced purely for the purposes of anti-abortion propaganda it itself nothing more than pro-abortion propaganda. 252

The evidence is clear that some women do experience abortion as a trauma. The prevalence rates and pre-existing risk factors may continue to be disputed, but the fact that abortion contributes to PTSD symptoms in at least a small number of women is a settled issue.

Recommendations for research and collaboration

Good research is essential for both healthcare providers and patients. Better information about the risks and benefits associated with abortion should contribute to better screening, better risk–benefit assessments, and better disclosures to patients, 23 that will help to shape the expectations of patients and those who advise them. Better information will also improve the identification of at risk patients who may benefit from referrals to post-abortion counseling.

As previously discussed, while the ideological divides between AMH minimalists and proponents will continue to shape how each side interprets the data, these differing viewpoints actually provide an opportunity for improving the collection of useful data, analyses of the available data, and more thorough interpretations of research findings. Therefore, healthcare providers and patients would be better served by AMH minimalists and AMH proponents both bringing their various perspectives to bear on research efforts in a more cooperative fashion.

Whenever possible, research teams should include both AMH minimalists and AMH proponents. Such cooperation would improve methodologies by better addressing the differing concerns of each perspective at the time of the study design. Collaboration in the writing of introductions and conclusions to such studies would also be improved by bringing balance to both perspectives and by reducing the tendency to overgeneralize results of specific analyses.

More specific opportunities for collaboration and better research are discussed below.

Expanding the research goals

A major problem with abortion research and reviews is a failure to address all of the relevant questions which need to be asked, investigated, and answered. For example, the team from the National Collaborating Center for Mental Health (NCCMH) that wrote a review of AMH issues for the Academy of Medical Royal Colleges in 2011 strictly limited their investigation to only three questions: “(1) How prevalent are mental health problems in women who have an induced abortion? (2) What factors are associated with poor mental health outcomes following an induced abortion? (3) Are mental health problems more common in women who have an induced abortion when compared with women who deliver an unwanted pregnancy?” 5 Most notably, the NCCMH team chose to ignore the question specifically posed for it to investigate in the 2008 Royal College of Psychiatrists position statement on abortion, namely, “whether there is evidence for psychiatric indications for abortion” 272 (emphasis added). Given the lack of any evidence for psychiatric indications for abortion, it seems likely that the NCCMH decided to ignore this question because it echoed previous allegations that UK law was not being followed in regard to limiting abortion to cases where there are therapeutic benefits. 273

Many additional questions were raised during the consultation process when the NCCMH team invited comments and suggestions from experts. But all of these questions were summarily rejected by the NCCMH team as being “beyond the scope” of their review, even though they acknowledged that many of these other questions were equally important to the three questions they had chosen. 274 Indeed, a reading of the consultation report, which was effectively the peer review given to the paper, reveals general dissatisfaction with the three questions chosen by the NCCMH team and with many of their choices in methodology and overstatement or understatement in their conclusions. The consultation report anticipated the many criticisms of the final report 19 , 275 and revealed that NCCMH team was not very responsive to the issues and concerns raised during this peer review. Arguably, the NCCMH team’s unstated mission was to protect the status quo, and so they limited themselves to questions and methodological choices that would allow them to achieve that predetermined goal.

The following is a list of some key research questions that should be addressed in future studies and reviews. It was developed, in part, by using the NCCMH consultation report as a starting point: 274

• How prevalent are mental health problems in women who carry unplanned pregnancies to term compared to women who deliver wanted pregnancies, to women who have no children, and to women who have abortions?
• Given that women may experience a range of reactions in the near term and over a period of many years, what are the cumulative rates of negative reactions over a long period of time (including a minimum of 30 years) and what are the temporal, cross-sectional prevalence rates relative to various risk factors that may contribute to these temporal differences?
• Among women who do experience negative emotional reactions (not limited to mental illness) which they attribute to their abortions, what reactions are reported?
• What treatments are most effective?
• What statistically validated indicators predict when the mental health risks of continuing a pregnancy are greater than if the pregnancies were aborted?
• What statistically validated risk factors predict negative outcomes following one abortion, two abortions, and three or more abortions compared to each available comparison group?
• What factors, if any, are associated with improved mental health following abortion compared to similar women who carry a similarly problematic pregnancy to term?
• Among women with pre-existing mental health issues, what factors predict a likelihood that abortion may contribute to a reduction in mental health problems (intensity, duration, and number of mental health issues), and what factors predict a likelihood that abortion may contribute to an increase in mental health problems?
• Among women without pre-existing mental health issues, what factors predict a likelihood that abortion may protect good mental health, and what factors predict a likelihood that abortion may contribute to subsequent mental health problems?
• Is presenting for an abortion, or a history of abortion, a meaningful diagnostic marker for higher rates of mental illness and related problems that can be timely addressed by appropriate offers of care?
• In evaluating the risk–benefits profile of a specific patient, what criteria should be met in order to reach an evidence-based conclusion that the benefits of abortion are most likely to exceed the risks?
• In cases of pregnancy following rape or incest, what are the short- and long-term mental health effects associated with each of the following outcomes: (a) abortion, (b) miscarriage or stillbirth, (c) childbirth and adoption, and (d) childbirth and raising the child?
• Is abortion associated with an increase in rapid repeat pregnancies, that is, “replacement pregnancies?” If so, what portion are delivered, aborted, or miscarried?
• Does a history of abortion contribute to the strengthening or weakening of the woman’s relationships with her partner and/or others?
• What are the mental health effects of the abortion experience, if any, on men?
• What are the mental health and developmental effects of the abortion experience, if any, on previously born children and/or subsequently born children?
• Does a history of abortion contribute to or hinder bonding and parenting of previous and/or subsequently born children?

National prospective longitudinal studies specific to reproductive and mental health

While a number of analyses have been published based on longitudinal studies, none of these studies were designed to specifically investigate the intersection between AMH issues. The need for better longitudinal studies to investigate AMH has been recognized in other major reviews, 4 , 24 , 274 yet the call for such research has not yet been heeded.

We recommend that the value of such longitudinal studies would be vastly increased by expanding the goal of data collection to encompass not just mental health effects associated with abortion but also with all reproductive health issues from first menses to menopause. This would assist in research related to infertility, miscarriage, assisted reproductive technologies, postpartum reactions, premenstrual syndrome, and more. And given the interactions with multiple pregnancy outcomes already seen in AMH research, 88 , 94 , 170 , 203 comprehensive reproductive health histories are needed in any case.

Most importantly, the design and management of such studies should include both AMH minimalists and AMH proponents. An explicit objective should be ensuring that every line of questioning either side considers important is included. When both sides contribute to the design of such studies and have equal access to the same data, concerns about suppressed findings or incomplete analyses will be dramatically reduced … at least after re-analyses. When both sides have equal access to better data, it is more likely that the areas of consensus will increase.

The value of longitudinal studies would also be enhanced by seeking the consent of participants to link their medical records to their questionnaires. This would be most helpful given the fact that many women are reluctant to reveal abortion information even in responding to a confidential questionnaire. Since women’s willingness to share data may vary over time, this request for record linkage should perhaps be offered multiple times over the course of the longitudinal study. While many will likely refuse this option, the refusal to permit record linkage is itself a data point for analyzing patterns associated with concealment and dropout. Along the same lines, at each wave there should be included a query regarding the level of stress associated with completing the questionnaire. 183 This may also help to better understand and estimate the effects of women subsequently dropping out.

Finally, it should be noted that it has already been shown that there may be significant differences in women’s experiences relative to different cultures and nationalites. 50 Therefore, it is highly recommended that longitudinal studies to comprehensively investigate the intersections between mental and reproductive health should be funded in multiple countries.

Data sharing for re-analyses should be rule rather than the exception

It is precisely because data can be selectively analyzed and interpreted to produce slanted results, 131 – 133 that data should be made available for re-analyses by third parties. 276 Data sharing also reduces the costs of research and magnifies the contribution volunteers make to science by making their non-identifying information accessible to more scientists, which presumably most volunteers would prefer as their participation is generally intended to help science in general, not specific research teams. Most importantly, data sharing enhances confidence in the reliability of research findings, especially when related to controversial issues. Unfortunately, though many publications and professional organizations encourage or require post-publication sharing of data, in practice many researchers across many disciplines evade data sharing. 277

Support for data sharing, at least in theory, is found in the APA’s ethics rule 8.14, which states that following publication of their results, research psychologists should share the data for reanalysis by others. 278 But this principle has been frequently ignored, 279 – 281 especially in regard to abortion research. For example, the chair of the APA’s own TFMHA, Brenda Major, has repeatedly refused to allow data she collected on abortion patients to be subject to reanalysis by AMH proponents. She even refused to comply with a request for the data from the US Department of Health and Human Services, even though the study was funded by that agency. 140

Such data hoarding undermines confidence not only in the published findings of a specific study but also diminishes the value of syntheses or reviews relying on those unverified findings.

Data sharing is especially important when the process of collecting data may be blocked by ideological litmus tests. For example, abortion providers are naturally unlikely to cooperate with studies initiated by AMH proponents who they perceive as opponents of their work. On the contrary, they have frequently cooperated with AMH minimalists—precisely because of their shared ideology. Implicit in granting that cooperation may be the expectation that pro-choice researchers will not report any findings that may contribute to anti-abortion rhetoric. Conversely, many post-abortion counseling programs may also limit their cooperation to AMH proponents whom they perceive as most accepting and supportive of the issues raised by their clientele. 88

In both cases, the ideological alignments required to collect data may create biases in the design, analysis, and reporting of results. This does not mean that meaningful results cannot be obtained. But it does mean that such results should always be presumed to reflect sample and investigator biases until the findings have been confirmed in reanalyses conducted by investigators of all perspectives. It is only through equal access to the data that consensus will grow around results which survive reanalyses. It is also through this process that new research objectives will be better identified in response to these reanalyses.

Responsiveness to requests for additional analyses

In many cases, legal restrictions (government or contractual) may bar the sharing of underlying data. In such cases, reasonable requests for additional information, tables, and reanalyses should be honored through personal communication, publication of a response, or, if a major reanalysis is required, in publication of a subsequent paper. Such cooperation is especially important in regard to data sets that have access restrictions, such as those collected by government agencies.

For example, the centralized medical records of Denmark have provided some of the best record linkage studies in the world. However, when it comes to mental health effects associated with abortion, there is strong evidence that significant findings are being suppressed for ideological reasons. The arguments and evidence for this assertion are given below.

In 2011, Munk-Olsen et al. 82 published an analysis of Danish medical records to investigate first time psychiatric contact in the first year following a first abortion or first delivery. The analyses revealed that women who aborted had double the risk of psychiatric contact (OR = 2.18). But this finding was discounted by the finding that aborting women also had higher rates of outpatient psychiatric contact in the 9 months prior to their abortions (including the time they were pregnant) compared to the 9 months prior to a live birth. Munk-Olsen later conceded that this mixture of pre-conception time and pregnancy time created a baseline that “may not be directly compatible.” 227 But this was just one of many major weaknesses in the design and reporting of this highly criticized study. 282

Another methodological problem was the decision to include women who had one or more abortions prior to their first delivery into the delivery group. This decision is especially problematic since a history of abortion is significantly associated with higher rates of mental illness during and after subsequent pregnancies. 78 , 80 , 99 , 170 , 197 , 217 Notably, when Munk-Olsen was asked to provide a simple count of the number of women in her analyses who had both abortions and deliveries and the percentage of those who had psychiatric contact, she refused this and all other requests for more details. 227

Before examining the inconsistencies revealed in subsequent Munk-Olsen et al. 82 studies, it is relevant to compare her abortion study to three very similar record linkage studies conducted by AMH proponents conducted a decade earlier. These prior studies examined the differences between abortion and delivery in regard to inpatient psychiatric treatments, 89 outpatient psychiatric treatments, 97 and sleep disorders. 87 The designs of those studies were superior to Munk-Olsen’s in several respects: (a) in each case, controls for prior psychiatric inpatient treatment were employed for a longer period of time, a 12- to 18-month period prior to the estimated date of conception for each woman; (b) there was complete segregation of women relative to exposure to abortion; (c) mental health outcomes were reported showing variations relative to different age groups; and (d) results were shown over multiple time periods: 0–90 days, 0–180 days, first year, second year, third year, fourth year, and 0–4 years.

Normally, one would expect Munk-Olsen to have at least replicated, if not improved on, the methodology employed in these prior record linkage studies. Instead, the methodological choices she made severely narrowed the range of her investigation. Studies that are narrowly drawn can only support narrow conclusions. This is especially true since Munk-Olsen also excluded any analyses of the effects of multiple abortions, which are known to be associated with even higher rates of negative reactions 94 , 112 and also make up the majority of all abortions being performed. 64

Concerns about selective reporting are heighted by the fact that Munk-Olsen subsequently published numerous studies on mental health associated with childbirth in which, once again, she refused requests to supply data for findings associated with abortion. For example, using the same data set, Munk-Olsen published findings that reported

• Psychiatric treatment following delivery was associated with a fourfold increased risk of a diagnosis of bipolar disorders within the next 15 years; 283
• Rates of antidepressant use and mental health treatments 12 months prior to childbirth and 12 months after; 208
• Elevated rates of psychiatric disorders following miscarriage or stillbirth; 217
• Rates of postpartum depression following delivery of IVF pregnancies; 284
• Rates of primary care treatments before, during, and after pregnancies in which women experienced postpartum psychiatric episodes; 210
• Average monthly rates of psychological treatment and prescriptions before and after childbirth. 209

In each of these cases, her analyses and conclusions were flawed by the failure to address the effects of prior fetal loss, which are known to increase the risk of psychiatric disorders during and after subsequent pregnancies. 78 , 170 , 212 , 225 , 285 , 286

While in most cases she simply omitted abortion history from her analyses, 208 – 210 , 283 in two cases she used abortion history as a control variable 217 , 284 but omitted any statistics showing how this control affected the results. Clearly, the only reason to use abortion history as a control is if it has a significant independent effect on mental health outcomes.

The possibility that Munk-Olsen simply overlooked these opportunities to report on effects associated with abortion is disproven by the fact that in each case Munk-Olsen rejected both published 141 , 227 and unpublished requests for details relative to the effects of abortion on the outcomes studied. Even a request for a simple count of the number of women exposed to abortion in each of Munk-Olsen’s comparison groups was refused. 141

All of the above factors give credence to the concern that there is a selective withholding of results, by Munk-Olsen and other AMH minimalists. Moreover, given the evidence that abortion and miscarriage impacts mental health during subsequent pregnancies, 78 , 80 , 99 , 170 , 197 , 203 , 212 – 221 it is clear that every study examining the intersection between mental and reproductive health may be misleading if it fails to include analyses associated with pregnancy loss. Without such analyses, effects associated with pregnancy loss may be wrongly attributed to childbirth.

For example, there is strong evidence from both record linkage 89 , 97 and case-matched studies 287 that a history of abortion is associated with a threefold increase in bipolar disorder. Therefore, Munk-Olsen et al.’s 283 decision to exclude analyses related to fetal loss from her study of bipolar disorders following postpartum depression severely undermines her conclusion that this negative outcome is due to childbirth alone precisely because she chose to ignore, or at least not publish, findings associated with fetal loss.

The combination of Munk-Olsen’s failure to publish these results without being asked, combined with her refusal to respond to requests for reanalysis, 141 , 227 strongly suggests a pattern of selective reporting and obfuscation. If the additional analyses requested actually supported her previous assertion that prior mental health fully explains the higher rates of mental illness seen among women who have aborted 82 , 107 it seems clear that she should be rushing to publish these requested analyses precisely to silence skeptics.

In short, whenever either AMH minimalists or AMH proponents refuse to respond to queries for reanalyses of published findings, they are increasing distrust and weakening the credibility of all conclusions based on their previously published research. This creates real obstacles in the advance of evidence-based medicine, informed consent practices, and ultimately in the medical care of women. The advance of scientific investigations into reproductive mental health can only be enhanced by generously responding to requests for details and re-analyses that clarify the interpretation of published findings.

Recommendations for editors and peer reviewers

As previously discussed, there is strong evidence that individual biases may unfairly bias editors and reviewers against findings that challenge their preconceived notions. 118 – 123 Biases against “conservative” viewpoints, which may attach to the AMH controversy, are especially common. 125 – 128 , 130

Editors should guard against this bias by seeking a mix of peer reviewers, including both AMH minimalists and AMH proponents. For reasons discussed previously, while recognizing that every study in this area will have methodological weaknesses and that no sample can be perfect, editors should be blind to the results and focus their evaluation of peer review comments on the appropriateness and adequacy of the methodology and study sample. Editors should be alert to criticisms that appear to reflect a reviewer’s bias against results which support an undesired conclusion, especially when the methodology employed is comparable to studies that would be accepted for publication in any other field of research.

A good test of bias is to simply imagine that the results were flipped, 123 with the ORs showing benefits to abortion compared to delivering an unwanted pregnancy, for example. If the reviewer’s or editors reactions to the paper would most likely have been in the opposite direction, that reaction is obviously driven by a bias for preferred results.

Editors and peer reviewers should also strive to ensure that all studies relating to the intersection of mental and reproductive health include, whenever possible, analyses that delineate findings relative to exposure to all prior pregnancy outcomes, including both natural pregnancy losses and induced abortions. 141 , 227 This is important for several reasons. First, there is consensus even among AMH minimalists that better data are needed on the effects of pregnancy loss on mental health. 4 , 274 Second, there is clear and convincing evidence that exposure to pregnancy losses (both natural and induced) may have a significant impact on women’s health during and after subsequent pregnancies and at other times in women’s lives. 80 , 88 , 94 , 99 , 112 , 170 , 212 , 285

When data on abortion and miscarriage history are available, but not included in published findings, this raises concerns about concealment of findings that the authors may be afraid will bolster the position of their ideological rivals. 141 , 227 Alert reviewers and editors should routinely ask researchers to include in their tables of results analyses relevant to the number of exposures to abortion and natural pregnancy losses. Without such requests (a) the literature will continue to be deprived of meaningful data and (b) selective reporting may falsely attribute negative mental health issues to childbirth.

Limitations

The purpose of this review of the medical literature on AMH was to examine the areas of agreement and disagreement, the reasons for disagreement, and the opportunities for improved research and collaboration. The method I used began with a review of reviews published since 2005 4 – 10 , 12 – 19 , 21 , 22 and an examination of the studies cited in these reviews.

Given the difficulties previously discussed in conducting any conclusive studies, the breadth of issues examined in this review, and the range of theories and opinions of the authors of the reviews and studies examined, it is out of the scope of this, or any, review to fully address every view or concern. With that limitation in mind, however, this review does catalog a broader range of relevant issues than any previous reviews. In doing so, this review does not offer the last word on the AMH controversy. Instead, it seeks to expand and continue the conversation, inviting more detailed responses, criticism, and elaboration regarding the issues identified herein.

While there will continue to be differences of opinion between AMH minimalists and AMH proponents, there is sufficient common ground upon which to build future efforts to improve research and meaningful re-analyses. Common ground exists regarding the very basic fact that at least some women do have significant mental health issues that are caused, triggered, aggravated, or complicated by their abortion experience. In many cases, this may be due to feeling pressured into an abortion or choosing an abortion without sufficient attention to maternal desires or moral beliefs that may make it difficult to reconcile one’s choice with one’s self-identity.

There is also common ground regarding the fact that risk factors identifying women who are at greater risk, including a history of prior mental illness, can be used to identify women who may benefit from more pre-abortion and post-abortion counseling. Additional research regarding risk factors, and indicators identifying when abortion may be most likely to produce the benefits sought by women without negative consequences, can and should be conducted through major longitudinal prospective studies.

Finally, there is common ground on the need for better research. That fact alone is a strong argument for mixed research teams, collaboration in the design of longitudinal studies available for analysis by any researcher (without ideological screenings), data sharing and more responsive cooperation in responding to requests for reanalysis. All of these steps will help to provide healthcare workers with more accurate information for screening, risk–benefits assessments, and for offering better care and information to women both before and after abortion and other reproductive events.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: D.C.R.’s efforts were funded as part of his regular duties as Director of Research with the Elliot Institute.

CBS interviewed an abortion opponent in Arizona and didn't disclose her close ties to Kari Lake

Beyond “abortion rights opponent,” Merissa Hamilton is also a right-wing operative who has worked with Lake, run for office herself, and pushed false election-fraud claims

Special Programs Abortion Rights & Reproductive Health

Written by Helena Hind

Research contributions from John Whitehouse

Published 04/18/24 11:45 AM EDT

Once again , a national broadcast outlet has failed to adequately identify a conservative man-on-the-street source in its television coverage. This time, CBS News omitted any mention of an Arizona activist’s well-documented working relationship with Arizona Senate candidate and election denier Kari Lake.

During a report on Arizona Republicans blocking another effort to repeal Arizona’s near-total abortion ban, CBS News featured a soundbite from Merissa Hamilton, identifying her only as an abortion rights opponent.

“We need to save freedom in our state,” said Hamilton. “We need to save our constitution. Our rights are under threat every single day.”

Citation From the April 17, 2024, edition of CBS'  CBS Evening News with Norah O'Donnell 

Beyond being an “abortion rights opponent,” Hamilton has an illustrious career as both a right-wing operative and a political candidate.

Last May, prior to Lake’s October announcement about her Senate run, the  Trump ally   named Hamilton to lead a ballot-chasing operation, because, in Lake’s words, “we cannot allow them to steal another election from we the people.”

One Arizona journalist described her as “Kari Lake’s right-hand gal.”

Ironically, CBS was ideally positioned to ask an interesting question: What does a hardline anti-abortion activist think about Lake suddenly opposing Arizona's 1864 anti-abortion law after championing it as recently as 2022?

The answer could have been revealing, especially considering Hamilton’s relationship with Lake. Instead of actual insight, all the CBS audience received was more banal anti-abortion talking points from Hamilton.

The New York Times similarly quoted Hamilton without making the connection to Lake, but the paper at least noted her position as president of an activist group in Arizona, EZAZ.

In 2020, Hamilton ran for mayor of Phoenix and ultimately lost to the incumbent candidate by a large margin. During the campaign, an investigative report from The Arizona Republic revealed Hamilton’s membership in a private Facebook group filled with far-right conspiracy theories and hateful rhetoric against Muslims and LGBTQ people, which drew condemnation from the Human Rights Campaign.

After her failed mayoral bid, Hamilton worked as a national grassroots director for FreedomWorks, a right-wing nonprofit that once bolstered the rise of the tea party movement and is now affiliated with Project 2025.

In May 2023, Lake tapped Hamilton to head her ballot-chasing initiative.

From the Arizona Mirror :

A day after a judge shot down her challenge to the results of the 2022 governor’s race, Kari Lake called a press conference to make a “big announcement.”  But that announcement wasn’t that the failed 2022 Arizona gubernatorial candidate was  launching a bid for U.S. Senator or that she’s appealing the case, although she said she has plans to take it all the way to the U.S. Supreme Court. Instead, Lake announced that she’s starting a ballot chasing initiative, an effort to keep track of Republicans and independents on Arizona’s early voting list and make sure they actually cast their ballots, and to register new voters.  … Lake bragged that she had millions of dollars committed and thousands of people on board for the ballot chasing initiative, to be led by conservative activist Merissa Hamilton.

The “Kari Lake War Room” X (formerly Twitter) account hyped the partnership between Lake and Hamilton, claiming that the two “are building the greatest election apparatus in Arizona history.”

In addition to Lake's well-documented election denial — which includes denying the results of her ill-fated Arizona gubernatorial bid in 2022 — the candidate has a history of flip-flopping. Most recently, she was called out for backtracking  in her previous endorsement of Arizona’s 19th-century abortion ban.

Since cozying up to Lake, Hamilton has made local headlines for her own partisan antics.

According to SanTan Sun News, Hamilton caused chaos and confusion at a Chandler, Arizona, city council meeting after posting a misleading video to her 25,000 X followers urging them to stop a supposed “road diet” effort in Chandler.

“That transportation approach [was] not up for consideration in Chandler,” according to the Sun.

Hamilton has also used her social media following to bolster right-wing claims of election fraud and legitimize Lake’s platform of election denialism.

From an Arizona Republic op-ed :

The polls weren’t even closed in Arizona before members of the MAGA Nation started complaining that the fix was in on Tuesday’s election. Cue Kari Lake’s right-hand gal, Merissa Hamilton, who was there, video camera in hand, at the Paradise Valley Unified School District headquarters, where a drop box closed at 4:30 p.m. on Tuesday. As advertised. “ABSOLUTE CHAOS ON ELECTION DAY IN @MARICOPACOUNTY (AGAIN),” Hamilton breathlessly announced, in a social media post that had more than a half a million views. “Per dozens of voters @RecordersOffice told people they could vote until 7 pm. @PV It closed @ 4:30. Several voters say they can’t vote now. We’ve talked to hundreds of voters tonight to redirect them to new locations.” … Naturally, the leader of the band picked up the refrain. “The courts in Arizona have a chance to make this right,” U.S. Senate candidate Kari Lake replied, ensuring that Hamilton’s message reached her 1.6 million followers. “I hope they don’t screw it up. Our republic can not withstand much more of this.”