Current Affairs

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The Evidence That Abortion Improves Lives

The Turnaway Study followed women seeking abortions over ten years, comparing those who received the procedure to those who were denied. The study found that being denied an abortion had negative consequences, and women rarely regret abortions.

Professor Diana Greene Foster is the director of research at the Advancing New Standards in Reproductive Health collaborative research group at the University of California, San Francisco. She’s also the author of the book, The Turnaway Study: Ten Years, A Thousand Women, and the Consequences of Having—or Being Denied—an Abortion. It’s a remarkable piece of research that adds information to the abortion debate by looking at the lives of people who were either given abortions or denied abortions. The book follows a thousand women over a long period of time. Foster came on the Current Affairs podcast last fall to discuss the findings with editor-in-chief Nathan J. Robinson as part II of our Abortion in America series. (Part I, with Carole Joffe, about the obstacles facing those seeking abortion, can be found in transcript form here and in audio here.) This interview has been edited and condensed for grammar and clarity.

Robinson

Let’s start with the research question that you were aiming to address here. It seems that a lot of the abortion debate centers on philosophy about the moral status of the fetus. And, as I understand it, you thought that what was missing was a sensible discussion about what abortion actually means to those who seek abortions. What did you hope to understand by doing this research project?

Foster

The Turnaway Study was started with the hope of answering the question, Does abortion hurt women? The idea that abortion might harm women has been used to restrict access to abortion. And even in 2007, the Supreme Court outlawed one procedure on the basis that women would come to regret their decision and be depressed. And if you’re going to restrict access to abortion on the basis that women would regret it, then you need to know how much they are going to regret not getting an abortion. So the study really needed to be done to look at the consequences of getting an abortion versus being denied an abortion. We looked at mental health and physical health and socioeconomic well-being and life aspirations, a whole slew of outcomes that we thought would be changed by either getting a desired abortion or carrying an unwanted pregnancy to term.

Robinson

A lot of this—the idea of regret and harm—was speculative, right? There was the hypothesis that abortion would affect mental health one way or the other. But we just didn’t really have much reliable data. So preconceptions about abortion ended up governing the discussion.

Foster

That’s exactly right. No matter what side you’re on, you think there’s an effect. And we really needed to take no sides and measure this empirically.

Robinson

One of the things that comes across in the book is your desire to come up with something reliable, a natural experiment that would yield useful and valid results. How did you, as a social scientist, construct a piece of research that you thought could really yield helpful conclusions?

Foster

In an ideal study, we would randomize people to either getting an abortion or having a baby in a “blind” manner so they wouldn’t know which happened to them. Obviously, that can’t happen, and it’s not ethical. To get as close as possible to randomizing people, we went to 30 abortion facilities across the country where if you’re too late for an abortion there, no one else nearby can do an abortion later. We recruited people on either side of those gestational limits, so people who are just over the limit and just under the limit And what you really want in randomizing people is to have the two groups to have the same characteristics. You want the two groups the same at the onset, and then to study their differences over time. And that’s exactly what this study achieved. The two groups were nearly identical in terms of motivations for abortion, baseline physical health, and baseline mental health. The group that was denied was a little bit younger. And that’s because women who are younger are a little slower to recognize they’re pregnant. And a week might make the difference in being denied. But we controlled for age in these analyses, and we followed both groups over time and found that, in fact, in many ways, their outcomes did diverge over time.

Robinson

Your findings are useful to the conversation no matter where one stands. You approached this as a research scientist. The book helps us to empathize with people and to understand what is actually going on. Let’s discuss some of the factors here and what it’s like for those who are struggling to put the money together for the procedure or who are told they’re running against the clock.

Foster

Too often the abortion debate is abstract. It’s like the philosophical rights of a fetus versus a woman and not even a discussion of why a person would want to have an abortion and what it takes to get one. And that allows people to think, Oh, it’s an easy decision that people make half-heartedly and then come to regret it. In reality, it’s very difficult to get an abortion. Often just gathering the money to pay for it slows people down. We have laws that intentionally slow people down such as waiting periods or that unintentionally slow people down like forbidding insurance companies or the federal government from paying for the procedure. Other laws cause clinics to be shuttered so that people have to travel farther. We’ve made it as difficult as possible to get an abortion. Not surprisingly, some people who want it can’t get it. Right now [Note: interview was in fall 2021], the Supreme Court is considering whether to let Texas continue to ban abortion at six weeks, which has resulted in a 50 percent drop in abortions in that state. It’s very difficult to access abortion in parts of the country.

Robinson

I interviewed your colleague Carole Joffe a few weeks ago about her book Obstacle Course and the barriers that face people as they try to get the procedure. Perhaps you could talk about the lead up to either getting the abortion procedure or to being turned away. What are the typical reasons for being turned away? And what happens after someone is turned away?

Foster

What slows people down is raising money to pay for the procedure. But if you look at the statistical difference between those who were early versus late, a very large fraction of the difference is not realizing one is pregnant. So if you’re late to realize you’re pregnant, then you have to gather more money, you have to travel farther, and it takes longer to find a clinic that will do the abortion. So all of the logistical barriers snowball, and you could wonder, well, how is it possible someone wouldn’t know they were pregnant? It happens when people don’t have pregnancy symptoms. It happens when they’re young and have never been pregnant before. And it happens when people were using contraception to prevent pregnancy, which two-thirds of the women in the study were doing. And if you think you’re protected, then you’re slower to realize that you are indeed pregnant.

Robinson

There is a remarkable chart in the book that was a revelation to me. It lists the different forms of contraception and how many times you will have to use them in order to avoid pregnancy over the course of your sexually active life. The regularity, the discipline of using contraception—it’s a lot. If at no point you want to have an unintended pregnancy, it’s quite intensive.

from Diana Greene Foster, “The Turnaway Study”

Foster

That’s exactly right. It’s underappreciated. It takes a lot to prevent pregnancy. I estimate you would need over 2,000 condoms, almost 7,000 oral contraceptive pills, almost 1,000 contraceptive patches. And these calculations presume that you’ve got constant access to health insurance and healthcare providers and that you never run out of supplies before another pack comes, and that you’re a consistent user. For many people, that is not the case. In addition to access, you have to actually like this method to use it consistently over a lifetime. And lots of people don’t find methods that work for them, that don’t cause side effects, that are easy to use, that respect their desire for control over the method or privacy or desire not to have to go to a clinic all the time. So it’s really not easy. We don’t have perfect methods of birth control yet.

Robinson

Another statistics you cite in the book is that women are not pleased with the availability of the existing methods of birth control. It’s highly imperfect, right? Many methods cause side effects. It’s a conversation we don’t have enough in this country—even among those of us concerned with reproductive rights and abortion access. We assume that contraceptives are widely available. Which is kind of true. But there’s a long way to go.

Foster

Legally they look good. And then practically they don’t. For example, I did the research that showed if you give people a one year supply of a method, they’re less likely to become pregnant and less likely to have an abortion. In response, many states changed their law to allow a one-year supply of birth control. And as far as researchers can tell, nobody’s getting the benefit of that. Less than a fraction of 1 percent are actually benefiting from a law that looks good on paper but just isn’t being implemented. So there are lots of steps and they’re not all being taken.

Robinson

Why is that?

Foster

It requires huge shifts of bureaucracy. And that’s always slow. I don’t even think there’s anyone who’s particularly opposed to it. But to get all the pharmacists, insurance companies, and doctors to change, it’s just a lot of shifting that doesn’t happen quickly.

Robinson

I want to ask you the about attitudes to abortion. What are some of the findings about people’s attitudes going into the procedure?

Foster

We have so stigmatized abortion that people can think that abortion is wrong in general and know that in their own circumstance, it was the right thing to do. And so you can be opposed to abortion on some level but make exceptions for the circumstances that you find yourself in. And so that happens somewhat. Mostly people are supportive of the right to abortion. About 20 percent said that they thought abortion was morally wrong. But nearly all thought it should be legal. So it requires some nuance to understand that other people deserve the same amount of compassion as you feel toward yourself when you’re facing an unwanted pregnancy.

Robinson

There are many different explanations for why people get abortions.

Foster

We asked people their reasons for wanting to end the pregnancy. We asked it open-endedly. And then people gave us many reasons. And we went and categorized them. We found that our answers strongly reflect the same answers given on national surveys about this topic.

Finances are the most common, with about 40 percent of people saying that it’s not the right time or circumstances to have a child or another child. People give partner-related reasons, including that the partner is abusive, the partner wouldn’t be a good father, the relationship isn’t strong enough. As you alluded, many people say they want to focus on taking care of the children they already have. People give a range of reasons.

What’s super interesting about the reasons people give is that when you ask a woman seeking an abortion why they don’t want to have a baby, the reasons given strongly predict what happens to people who are denied. So, if you say you can’t afford to have a baby, you become poor if you are denied an abortion. Others say that the relationship with the man involved in the pregnancy isn’t strong enough. And we see that those relationships dissolve regardless of whether they have the baby or have an abortion. They say they want to take care of the children they already have. And we see that their existing children do worse, both in terms of having enough money to pay for their food and housing, but also in their attainment of developmental milestones.

So people are thoughtful when they’re trying to decide what to do with an unwanted pregnancy. They’re weighing all of their aspirations with their responsibilities and trying to decide what’s right. And, in fact, their decision-making is so astute that they strongly predict the results that we find in this study.

Robinson

Wow. It seems like the partner-related factors are often not discussed enough. It’s not just abusive situations. It’s also the fact that if you go through with the pregnancy, the partner is going to be in your life in some capacity for a very long time. It’s almost impossible to sever relations with the person. Signing up to have a child is just an immense change in people’s lives in so many ways.

Foster

That’s right. In fact, we find that relationships with the man are actually aren’t actually more likely to continue. The chance that you’re in a romantic relationship with the man involved doesn’t change whether people receive an abortion or are denied. But what does change is what you mentioned, which is ongoing contact with the man. So a woman continues to be exposed to the man involved in the pregnancy. Rates of domestic violence plummet for people who receive their abortions and are level for people who are denied. And the difference there is that the ones who got the abortion are able to extricate themselves from unhealthy relationships, and the people who carry that pregnancy to term continue to be exposed to that man. It doesn’t make the romantic relationship last but it does result in ongoing contact.

Robinson

This seems completely left out of the conversation a lot. There’s this phrase “abortion except in the cases of rape or incest,” as if those are the only cases in which we could be talking about some kind of abusive situation. To force a woman to go through with a pregnancy, even if the pregnancy is the result of a consensual sexual encounter, is to potentially force someone to maintain contact with an abusive partner.

Foster

Yes. That isn’t the majority experience, but it happens. It’s hard to say what the acceptable reasons for abortion are. Yes, this one pregnancy wasn’t rape or incest. But yes, it also involved continuing abuse. And then there are other people who have other reasons. Raising a child without enough money to pay for food and housing is not a good outcome. Do we make exceptions for that? And what about a woman with preexisting health conditions where she feels like she’s not physically strong enough to go through with pregnancy? Maybe we should make an exception for that. And, you know, I don’t know how to make a list of only the acceptable reasons. And what the study shows is that people have their reasons, and they’re right, and so we don’t have to decide for them what the good reasons are.

Robinson

What Gloria Steinem said about the book and its relationship to democracy—I think that’s a really interesting word to invoke in a study about abortion rights. [Steinem: “If you read only one book about democracy, The Turnaway Study should be it. Why? Because without the power to make decisions about our own bodies, there is no democracy.”] What we really are talking about is who makes a particular decision. Is it the person most affected or is it the legislature? You identify that the way people make this decision is really quite sophisticated and accurate.

Foster

It’s a very personal decision. And I don’t think it would be possible for someone else to make that decision for someone else, to take into account all of the factors that people are weighing when they’re trying to make this decision.

Robinson

One of the central contributions of this study is that it follows women over time—either after they had the procedure or were turned away. One of your headline findings here is that regret really is a minor exception. For the most part, as I understand it, women who are granted the procedure really do feel as if it was the correct choice for them.

Foster

Our most famous statistic is that over 95 percent of people who received their abortion feel like it was the right decision over time. And that actually trends up toward 99 percent by the end of the five years that we followed people. And if you ask who feels like it wasn’t the right decision, it’s people who said that it was an extremely difficult decision at the onset. So that’s not surprising. People who had a hard time deciding are slightly more likely to question their decision later. But even among that group of people who say it was hard, they trend toward saying it was the right decision over time. I think a lot of people just don’t understand how complicated people’s lives are and how much else goes on. So people who received their abortions did a lot over the five years. They got different jobs, they finished school, they sometimes had other children. And so their life isn’t spent just dwelling on this unwanted pregnancy that happened five years ago. One woman said to us, “The only time I think about it is when you call me for these interviews.”

Robinson

Another finding is that those who are turned away are forced to follow through with the pregnancy. They do tend to have the life outcomes that they predicted they would have because those factors are quite real. But it is also the case that over time they do feel that they are … glad they went through with the pregnancy?

Foster

Just like we asked people who had an abortion whether that was the right decision, we asked the people who were denied the abortion whether they still wish they could have had the abortion. And one week later, 65 percent of them still wish they could have an abortion. It’s about more than one in ten who say it after the child is born, and that goes down to about 4 percent by the five-year mark. And those who are particularly likely to say, I still wish I could have had an abortion, are the people who placed a child for adoption. So very few people chose to place the child for adoption. And those who did were more likely to say that they still wish they could have had the abortion. So if you’re raising a child, it’s one thing to say, I wish I could have had an abortion. Most people are resilient, they are caring for that child, they’re the best parents they can be.

And one thing that we ask people is about their emotional connection to the child. So we asked a British scale called the Postpartum Bonding Questionnaire. It’s 12 items about how you feel about your child, things like, my baby is the most beautiful baby in the world, or my baby stresses me out, they’re there on both sides. And we ask both groups, those who were denied an abortion and carried that pregnancy to term, versus the women who got their abortion and chose to carry a subsequent pregnancy to term within the five years. The difference in these two sets of kids is whether there is an emotional benefit to being able to control the timing of your births. We see that the women who got their unwanted abortions had pregnancies under better circumstances later, and they actually showed better bonding with that child than the women who were denied an abortion. I don’t want to give the wrong impression. It’s not that everyone who was denied an abortion didn’t bond with the child, it’s just that the chance of poor bonding was greater for those unwanted pregnancies than when women had control over the outcomes of their pregnancies.

Robinson

It seems like both groups kind of come to terms with life as it turned out, which I suppose is consistent with what we know about human beings. But when you look at the group of women who were turned away, you did, in fact, find that it would have, on a number of indicators, been better for them if they had been able to have a pregnancy under circumstances of their choosing.

Foster

Yes, exactly. By recruiting a whole bunch of people at the same point in life—they’re having an unwanted pregnancy, some receive the abortion, some don’t—it’s like getting to look at the road that wasn’t taken by analyzing the data for so many people, knowing that the two groups were the same at the onset. And we find a couple major areas where the women who are denied abortions are worse off.

One is in their physical health. And this is consistent with the medical literature that carrying a pregnancy to term and giving birth is much more physically risky than having an abortion, even abortion in the first or second trimester.

The other is socioeconomic well-being. So people say they can’t afford to have a child, and when they’re denied an abortion, they’re much more likely to live below the federal poverty level than if they had received an abortion. And that’s because full-time employment drops. And although public assistance increases, it’s just not enough to make up for the loss of employment.

And I actually have a quote from a woman in the study who was denied an abortion and she carried the pregnancy to term and then she couldn’t raise the child because her life was just chaos. And she had a lot of domestic violence in her home. So her mother adopted the child because she just couldn’t care for the child. But after trying to raise the child for a year, what she said to us was that it’s very, very difficult to find a job when you’re pregnant, to keep a job when you’re pregnant, and to 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. Pregnancy is an incredibly scary thing if you cannot trust the person you’re with.

Robinson

And people may have fewer options in their choice of partner as well. So the initial question you set out to answer was, Does abortion hurt women? And the answer is no. But the other question, Does not having an abortion hurt women?—the answer to that question is yes.

Foster

We looked at mental health over time. And we found that depression was somewhat elevated at the time of seeking an abortion and went down over time. Likewise, it does so with the people who are denied. There isn’t a difference in depression. And so there is no evidence (in terms of post-traumatic stress, suicidality, anxiety, depression) that getting an abortion hurts women. Those who got abortions have outcomes that improved over time. But those who were denied had elevated anxiety, lower self-esteem, and lower life satisfaction at the onset. And this is during the time when they’re acclimating to the news that they’re going to have a baby that they weren’t ready for. Over time, their mental health findings actually look like the people who got the abortion. The story in terms of the difference between the groups is not in mental health; mental health-wise, people are resilient. Instead, the big differences are in physical health and socioeconomic well being. And then one other area that we didn’t touch on yet is people’s life aspirations, the goals they’re setting for themselves. And there, we see that people who were denied an abortion are just less likely to set aspirational plans for the future and less likely to achieve them. And this is because they’re scaling back what they can do, because they realize that they’re going to be caring for a child, a child that they probably weren’t ready for. And the life aspirations also include the finding that people denied an abortion are less likely to have an intended pregnancy later. So carrying this pregnancy to term makes it less likely that they’ll be in a high-quality relationship and have a child under better circumstances later.

Robinson

When people say they are having an abortion because they are not ready, I take it to mean that they want to finish school or advance their career past some certain point. But people who have abortions tend to have planned pregnancies later.

Foster

Yes. The rate is something about 7 percent per year have an intended pregnancy later if they received that abortion, and something like 2 percent if they were denied, so that’s over each year. That’s a pretty big difference. And so it can’t be said that making someone carry an unwanted pregnancy to term is pro-baby because in fact it may result in fewer intended babies later.

Robinson

Right. There’s all this panic over the declining birth rate in the United States and how we want more babies. Let’s get to the implications of this for the abortion policy debate. I take it one of the major ones is probably that regardless of our conversation on the moral status of the fetus philosophically, we have to understand that when we are talking about the question of criminalizing or legalizing abortion, we’re talking about the level of access to abortion and the obstacle course that professor Joffe talked about. We are either choosing to make people’s lives objectively better according to their own desires or choosing to impose a significant cost on them in many ways.

Foster

The focus on maternal rights versus fetal rights is missing a bigger picture. It’s not a philosophical debate alone. You can have your own viewpoint on that, but there are many people involved: the child that could be born from that pregnancy, the woman’s existing children, the future children, her partner. And it’s just more complicated. And I think rather than abstraction and moralizing, we need to look at the actual impacts on peoples’ lives.

Robinson

In the book you have many first-person testimonies from people in their own voices. The reader can actually understand what we are really talking about when we’re having this debate. We’re talking about what happens in the lives of human beings who will either go down one path or the other.

Foster

I am very quantitative. I love to compare the statistics. And that’s normally how I approach things. But I know that data alone is not the whole picture here. I knew that we needed to talk to people and hear from them, in their own words, what the experience was like, and to understand their circumstances, how they view them, and what unfolded over time. So the book profiles 10 women selected at random. And they’re from the study. My colleague and I asked them some very general questions like, What were you thinking at the time you were making this decision? What happened next? And these narratives unfolded to show that there’s so much nuance in peoples’ lives. It does humanize the experience of people, I think.

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