Foster 1 29-15

Diana Greene Foster

Acting Director, Advancing New Standards in Reproductive Health. Bixby Center for Global Reproductive Health

Associate Professor, Department of Obstetrics, Gynecology and Reproductive Sciences

University of California, San Francisco

Consequences for women of receiving or being denied a wanted abortion

UCLA Bixby Center

January 29, 2015

December 2014 | Slide 2

Does abortion hurt women?

“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. Severe depression and loss of esteem can follow.”

Justice Anthony Kennedy majority decision Gonzales v. Carhart (2007)


American Psychological Association Report Mental Health and Abortion, May 2008

“The best scientific evidence published indicates that among adult women who have an unplanned pregnancy, the relative risk of mental health problems is no greater if they have a single elective first trimester abortion than if they deliver that pregnancy.”


American Psychological Association Report Mental Health and Abortion, May 2008

“The best scientific evidence published indicates that among adult women who have an unplanned pregnancy, the relative risk of mental health problems is no greater if they have a single elective first trimester abortion than if they deliver that pregnancy.”


Challenges in studying mental health and abortion

■ Incorrect or no comparison groups■ Ignore prior mental health status■Recall bias■Abortion underreporting■Conflate association with causation■Temporal precedence of abortion and

mental health outcomes■Fail to control for likely confounders■Do not use longitudinal design


Turnaway Study aim

To describe the mental health, physical health and socioeconomic consequences of receiving an abortion compared to carrying an unwanted pregnancy to term.


Turnaway Study recruitment sites

Recruit from 30 abortion providers who have the latest gestational limit within 150 miles


Turnaway Study design

■ Recruit three types of eligible women

■ Turnaways

■ Up to 3 weeks above gestational limit

■ Do NOT receive abortion

■ Near Limit Abortion Group

■ Within 2 weeks of limit

■ Receive procedure

■ First Trimester Patients

■ Receive procedure under 14 weeks gestation

■ Excludes women seeking abortion for fetal anomalies


Turnaway Study design

4 6 8 10 12 14 16 18 20 22 24 26 28 …

Site A Gestational age limit = 20

4 6 8 10 12 14 16 18 20 22 24 26 28 …

Site B Gestational age limit = 18

First trimester abortion Near Limit Abortion Turnaway


Study methods

■956 women seeking abortion between 2008 and 2010 including■156 women denied abortions who carried

to term■405 women just under limit who receive

the abortion

■Follow all women for 5 years with semi-annual telephone interviews■ Interviews conducted in English and

Spanish


What are the mental health consequences of receiving or being denied a wanted abortion?

A comparison of depression and anxiety symptom trajectories between women who had an abortion and women denied one

Foster DG, Steinberg JR, Roberts SCM, Neuhaus J, Biggs MA. In press.


Mental health assessment at first interview

Mental health measures Abortion Group TurnawaysDepression (mean) (0-24 symptoms) 3.0 3.2

Depression “case” 11% 11%

Anxiety (mean) (0-24 symptoms) 1.9 2.7*

Anxiety “case” 8% 9%

Self-esteem (mean) (1=none, 5= High) 2.8 2.5**

Significance tests compare Turnaways to Abortion Group * p<0.05, **p<.01


What post-abortion trauma syndrome might look like

0

2

4

6

8

1 week 6 months 12 months 18 months 24 months

Dep

ress

ive

and/

or A

nxie

ty

sym

ptom

sHYPOTHETICAL DATA


Depression (BSI

In the past seven days, to what extent have you felt [loneliness, loss of interest, blue, worthless, hopeless, thought of ending life]?

Predictors Coef

Turnaway ns

Months -0.17***

Ts X months ns

Months2 .005***

Ts X months2 ns

***p<.0010

2

4

6

8

1 week 6 months 1 year 18 months 2 years

Dep

ress

ive

sym

ptom

s Abortion GroupTurnaways

Controls for differences in age, race, marital status, employment, parity, and child abuse and neglect at baseline


Anxiety (BSI)

In the past seven days, to what extent have you felt [nervous, tense, scared, terror, restless, fearful] (0-24 symptoms)?

Predictors Coef

Turnaways 0.76*

Months -0.07**

Ts X mnths -0.12*

Months2 0.002*

Ts X Mths2 0.004*


0

2

4

6

8

1 week 6 months 12 months 18 months 24 months

Anx

iety

Sym

ptom

s

Abortion GroupTurnaways

*p<0.05, **p<.01


Self-esteem

In the past seven days, to what extent have you felt high self esteem? (0=not at all, 3=Moderately, 5=Extremely) Predictors Coef

Turnaway -0.27*

Months 0.02***

Ts X mnths .01*


0

1

2

3

4

5

1 week 6 months 1 year 18 months 2 years

Self

Este

em

Abortion Group

Turnaway

* p<0.05, ***p<.001


Mental Health Summary

■There is no evidence of abortion trauma syndrome within two years of having an abortion.

■There is a short term elevated risk of anxiety and low self-esteem among women denied wanted abortions.

■ In terms of mental health, women are resilient to both abortion and unwanted childbirth.


But what about the emotional responses to having an abortion?

Rocca CH, Kimport K, Roberts SCM, Gould H, Neuhaus J, Foster DG. Decision rightness and emotional responses to pregnancy termination in the United States: a longitudinal study. Under Review.


Outcome Measures

■Relief, happiness, regret, guilt, sadness, anger (Likert scale)■About becoming pregnant■About the abortion

■Emotional response groups (negative, positive, low, mixed)

■Negative emotional response (yes, no)

■Abortion was the right decision (yes, no)


Positive 35%

Negative24%

Low23%

Mixed18%

Emotions after the Abortion, 1 week

Emotional Response GroupsAll participants obtaining an abortion


Abortion was right decision, 1 week

Abortion was the right decision

97%

Among all participants obtaining an abortion


Abortion was right decision, 1 week

Among women with a negative emotional response

Among women expressing any regret

90% 93%

Abortion was the right decision


Emotion groups over 2 years

0%

20%

40%

60%

80%

100%

0 6 12 18 24

% o

f par

ticip

ants

Months since abortion

NegativeMixedLowPositive


Why do women have abortions?

Biggs MA, Gould H, Foster DG. Understanding why women seek abortions in the US. BMC Women’s Health. 2013; 13:29.


Reasons for wanting to terminate a pregnancy

1. Not financially prepared 40%2. Not the right time for a baby 36%3. Partner-related reasons 31%4. Need to focus on other children 29%5. Interferes with future opportunities 20%6. Not emotionally prepared 19%7. Health related reasons 12%8. Want a better life for the baby than she could provide 12%9. Not independent or mature enough for a baby 7%10.Influences from family or friends 5%


Reasons for wanting to terminate a pregnancy

1. Not financially prepared 40%2. Not the right time for a baby 36%3. Partner-related reasons 31%4. Need to focus on other children 29%5. Interferes with future opportunities 20%6. Not emotionally prepared 19%7. Health related reasons 12%8. Want a better life for the baby than she could provide 12%9. Not independent or mature enough for a baby 7%10.Influences from family or friends 5%


What are the socioeconomic consequences of receiving or being denied a wanted abortion?


Financial reasons for abortion

■ 4 in 10 women cite financial reasons“[It was] all financial, me not having a job, living off death benefits, dealing with my 14 year old son. I didn't have money to buy a baby spoon.” 42 year old from the Dakotas

“[My husband and I] haven't had jobs in awhile and I don't want to go back to living with other people. If we had another child it would be undue burden on our financial situation.” 28 year old from California

“I’m unemployed, no health insurance, and could not qualify for any government-assisted aid, and even if my fiancé decided to hurry up and get married, I still wouldn't have been covered under his health insurance for that.” 32 year old from Illinois

“I don't have enough money to support a child and I don't want to have to get support from the government.” 19 year old from Washington


Household size

1

1.5

2

2.5

3

3.5

4

4.5

8 days 0.5 years 1 year 1.5 years 2 years 2.5 years


Living alone with children

0%

10%

20%

30%

40%

50%

60%

70%



No differences

■Living with the man involved in the pregnancy

■Living with adult family members


Full time employment

0%

10%

20%

30%

40%

50%

60%

70%



Household income below the poverty level

0%

10%

20%

30%

40%

50%

60%

70%


Near Limit AbortionParenting TurnawayNon-Parenting TurnawayFirst Trimester Abortion


No differences

■Part time employment■Household income


Temporary Assistance to Needy Families (TANF)

0%

10%

20%

30%

40%

50%

60%

70%



Food Stamps

0%

10%

20%

30%

40%

50%

60%

70%



Women’s Infants and Children (WIC) receipt

0%

10%

20%

30%

40%

50%

60%

70%



Conclusions

■ Large and significant differences in the economic trajectories; women denied abortions faced more hardships than women receiving abortions.

■ Public assistance programs mitigate the loss of full-time employment for women denied an abortion who then parent the child.

■ Public assistance was not sufficient to support the increase in household size due to the new baby, and households of parenting women were more likely to drop below the poverty level.

■ Being denied a wanted abortion is associated with a large increase in the chance that the woman will be raising her children alone, not with family or a male partner.


What happens to women’s relationships with the man involved and to intimate partner violence?

Mauldon J, Foster DG, Roberts SCM. Effect of Abortion vs. Carrying to Term on a Woman’s Relationship with the Man Involved in the Pregnancy. Perspectives on Sexual and Reproductive Health 2015 47(1).

Roberts SCM, Biggs MA, Chibber KS, Gould H, Rocca CH, Foster DG. Risk of Violence from the Man Involved in the Pregnancy after Receiving or Being Denied an Abortion. BMC Medicine September 2014.


Romantic relationship with the man involved

00.10.20.30.40.50.60.70.80.9

1

1 week 6months

12months

18months

24months

Prob

abili

ty

Near Limit AbortionGroupTurnaway Births


Ongoing contact with the man involved

0.00.10.20.30.40.50.60.70.80.91.0

1 week 6months

12months

18months

24months

Prob

abili

ty

Near Limit AbortionGroupTurnaway Births


Prevalence of violence among women seeking abortion

■One in twenty women seeking abortion reported physical violence from the man involved in the pregnancy in the six months prior to seeking an abortion.

■One in thirty women reported psychological violence in the previous six months.


Intimate partner violence and abortion

■Women who have abortions experience a decrease in physical violence from the man involved in the pregnancy.

■Women who carry to term experience no decrease in physical violence.

“It is very, very difficult to find a job when you're pregnant, to keep a job when you're pregnant, and to find or maintain a job with a baby especially if your partner …doesn't want to help. So … domestic violence skyrockets because you're … financially dependent on your partner because you have to be home with the kid … Where you're like, oh no … I can't be homeless with this kid … I need him for money type of thing, … Pregnancy is an incredibly scary thing especially if you cannot trust the person you're with.”


What happens to women’s existing children when they receive or are denied a wanted abortion?

Foster and Biggs. In progress.


Existing children as a reason for abortion

Number of previous children under age 5(whose mother completed 6 month interview)

Near Limit Abortion 186Turnaway Parenting 55Turnaway Not Parenting 27First Trimester Abortion 101

■The majority of women in the U.S. who have abortions are already mothers.

■45% of mothers give their desire to care for existing children as a reason for terminating a pregnancy.


No differences

■ Injuries in the past 6 months■Residency with the mother■Caregiving ■Asthma


Child development (PEDS: DM)

0.0

1.0

2.0

expressivelanguage

fine motor grossmotor

receptivelanguage

self help socialemotional

TurnawayChildren better off

TurnawayChildren worse off

Existing children to women denied an abortion have 4% lower scores across all six domains of child development (p<0.05) compared to children whose mother received a wanted abortion


Conclusions

There are measurable impairments to the development of children whose mothers had unwanted births compared to children whose mothers had abortions.


Implications of the Turnaway Study

■Abortion does not hurt women.■Women who carry unwanted pregnancies

to term may need additional support.■Women can make decisions that are right

for themselves and their families.


What can we learn from a Global Turnaway Study?

■Who is unable to get a legal abortion and why?■What happens to these women -- who finds safe

abortions, who has unsafe procedures and who carries to term?

■What are the health and socioeconomic consequences of legal abortion compared to illegal abortion and childbirth?


Global Turnaway Studies

■Phase 1: Surveillance of abortion denials through surveys of abortion patients■Data collection: December 2012 to June 2013■Collect incidence of abortion and abortion denial, reasons

for turning patients away, demographics, willingness to participate in a hypothetical future study

■Phase 2: Interview 10-20 women denied abortion 2 months later■Data collection: September 2013 to September 2014■Conduct open ended interviews, determine whether

women are carrying to term or finding safe or unsafe abortions


Global Turnaway Studies

■Phase 3: A prospective longitudinal quantitative cohort study with women who receive and women who are denied wanted abortions■Can this methodology yield a prospective study of

women who go on to seek illegal abortions?


Denial of Abortion in Legal Settings

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

other reasonsgestational age

Bangladesh data from Singh, Hossain et al, International Perspectives 2012

s


Reported pregnancy outcomes after denial of legal abortion

Abortion(reporting complications)

Carry to term Miscarriage

Tunisia 9 4

Nepal 12 (2) 12 1

South Africa 6 2

Colombia 5 3

Bangladesh 9 (3) 11 1


Delay in recognizing pregnancy

• Lack of symptoms

• Irregular periods

• Using contraception

• Postpartum

• Negative pregnancy test

• Symptoms similar to existing health conditions

• Nulliparous (United States)

1-“I didn’t know that I was pregnant until yesterday [at 22 weeks] as I was taking birth control. I had a baby a few months ago and went onto the pill…I didn’t get my period after going onto the pill and the pharmacist told me that it was normal not to get a period for up to 4 months after having a baby. I only found out because I went in for a gynecologist appointment and the doctor felt my stomach and said “Are you pregnant?” There must be someone who can help me. They do it up to 24 weeks in the UK… The government is basically forcing me to get a backstreet abortion.” South Africa


Reasons for abortion

• Financial concerns about raising a/another child• Desire to stay in school• Poor relationship/marital conflict• Need to take care of existing children• Age• Influence of others• Health reasons (Tunisia)• Don’t want child outside marriage (Tunisia)• Can’t afford another girl child (Nepal)

2-“I felt like I should keep it when other people started to shout at me saying it would be a sin to [abort]. After that I kept thinking about it and my child lost weight because she was unable to drink my milk and then I thought, would I be able to educate them as it would be difficult to educate them all? We have to educate daughters more than sons because I had to face so many hardships as I was not educated. So I thought I would not be able to educate them and I also felt like what we would do with 3 children?” Nepal


Delay in seeking abortion care

• Inefficient and/or malevolent referral system• Need time to make the decision

• Need time to gather money

• Didn’t know where to go (Colombia)

• Want to find out sex (Nepal)

• Needed to work (Nepal and Bangladesh)

• Did not recognize ongoing pregnancy after medication abortion (Nepal)

3-“She told me to come to see her in one month. I was willing, and I went back a month later. She did a sonogram and then told me to go to [Hospital 2]. I went there and they sent me to the [Hospital 3], because I was taking [an anticoagulant medication]. There, they sent me back [Hospital 2]. There, they did a new sonogram and sent be back to [Hospital 3], and from there they sent me to [Hospital 4]. They made me come and go, until the fetus was big enough. In sum, during this period of time, they really fooled me” Tunisia


Reason for denial of abortion

• Advanced gestational age

• Not having enough money

• Medical contraindications (Tunisia)

• Too early in pregnancy (S Africa)

• Doctor not in or available (S Africa, Tunisia)

• Bureaucratic (Colombia, Tunisia)

4. “The doctor was ready to terminate my pregnancy but then I didn’t have money so I asked him if I could visit him on the next day. Then he said ‘ok’ so… on the next day I went there with my brother-in-law but then he said that the baby couldn’t be aborted. I was disappointed then… [the doctor] had agreed to abort the baby. But on the next day it seemed like pregnancy had crossed its time. On the next day, the doctor told me that they could terminate the pregnancy below 12 weeks. But on that day my mine had crossed 12 weeks. Then I felt sad” Nepal


Provider knowledge and behavior

• Staff knowledge of correct contraindications for abortion and safety of abortion versus childbirth

• Attitudes and behavior (counseling against the procedure, judgmental behavior)

• Role of abortion champions/guides

• Conscientious objection

• Provider motivations for harm reduction

5. “...In that place, I felt that I deserved this, that’s all… I felt that I only got what I deserved. For example, in the doctor’s language, when she talked, you felt, how can I explain, you felt what she was thinking, and excuse the word, but it was humiliating.” Tunisia


Experiences of being denied care

• Fear

• Resignation

• Seeking illegal care

6-“Knowing that I can no longer do anything, I feel powerless. There is very little time left before I have the baby. I have no power, I’m scared … scared of what is going to happen. I don’t have a job. I don’t have a way to give it stability; I don’t feel like I am able to. I don’t have money. I had a few ideas for a different life. I won’t be able to study.” Colombia


Acknowledgements

This study was supported by research and institutional grants from the Wallace Alexander Gerbode Foundation, the David and Lucile Packard Foundation, the William and Flora Hewlett Foundation, the Society for Family Planning, and an anonymous foundation.


Global Turnaway Study researchers

UCSF: Caitlin Gerdts, Heidi Moseson, Sarah Raifman, Divya Vohra, Heather Gould, Rana Barar

Dr. Teresa DePineresDr. Selma HajriDr. Jane HarriesDr. Altaf Hossain Dr. Mahesh Puri


US Turnaway Study researchers

■M. Antonia Biggs, Social Psychology ■Diana Greene Foster, Demography■Caitlin Gerdts, Epidemiology■Heather Gould, Public Health■E. Angel James, Nursing■Katrina Kimport, Sociology■Lauren Ralph, Epidemiology■Sarah Roberts, Public Health ■Corinne Rocca, Epidemiology ■Ushma Upadhyay, Public Health


Turnaway Study Team

Principal InvestigatorDiana Foster, PhD

Project DirectorRana Barar, MPH

Research CoordinatorHeather Gould, MPH

Project CoordinatorDebbie Nguyen

InterviewersBrenly RowlandMattie Boehler-TatmanIvette Gomez

Also thanks toJanine Carpenter Selena PhippsUndine Darney Claire SchreiberMichaela Ferrari Danielle SinkfordJay Fraser Sandy StonesiferJohn Neuhaus Elisette Weiss

Education

Foster 1 29-15