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• Fact sheets /
• Six out of 10 unintended pregnancies end in induced abortion.
• Abortion is a common health intervention. It is very safe when carried out using a method recommended by WHO, appropriate to the pregnancy duration and by someone with the necessary skills.
• However, around 45% of abortions are unsafe.
• Unsafe abortion is an important preventable cause of maternal deaths and morbidities. It can lead to physical and mental health complications and social and financial burdens for women, communities and health systems.
• Lack of access to safe, timely, affordable and respectful abortion care is a critical public health and human rights issue.

Around 73 million induced abortions take place worldwide each year. Six out of 10 (61%) of all unintended pregnancies, and 3 out of 10 (29%) of all pregnancies, end in induced abortion (1) .

Comprehensive abortion care is included in the list of essential health care services published by WHO in 2020. Abortion is a simple health care intervention that can be safely and effectively managed by a wide range of health workers using medication or a surgical procedure. In the first 12 weeks of pregnancy, a medical abortion can also be safely self-managed by the pregnant person outside of a health care facility (e.g. at home), in whole or in part. This requires that the woman has access to accurate information, quality medicines and support from a trained health worker (if she needs or wants it during the process).

Comprehensive abortion care includes the provision of information, abortion management and post-abortion care. It encompasses care related to miscarriage (spontaneous abortion and missed abortion), induced abortion (the deliberate interruption of an ongoing pregnancy by medical or surgical means), incomplete abortion as well as intrauterine fetal demise.

The information in this fact sheet focuses on care related to induced abortion.

Scope of the problem

When carried out using a method recommended by WHO appropriate to the pregnancy duration, and by someone with the necessary skills, abortion is a safe health care intervention (5).

However, when people with unintended pregnancies face barriers to attaining safe, timely, affordable, geographically reachable, respectful and non-discriminatory abortion care, they often resort to unsafe abortion. 1

Global estimates from 2010–2014 demonstrate that 45% of all induced abortions are unsafe. Of all unsafe abortions, one third were performed under the least safe conditions, i.e. by untrained persons using dangerous and invasive methods.  More than half of all these unsafe abortions occurred in Asia, most of them in south and central Asia. In Latin American and Africa, the majority (approximately 3 out of 4) of all abortions were unsafe. In Africa, nearly half of all abortions occurred under the least safe circumstances (3) .

Consequences of inaccessible quality abortion care

Lack of access to safe, affordable, timely and respectful abortion care, and the stigma associated with abortion, pose risks to women’s physical and mental well-being throughout the life-course.

Inaccessibility of quality abortion care risks violating a range of human rights of women and girls, including the right to life; the right to the highest attainable standard of physical and mental health; the right to benefit from scientific progress and its realization; the right to decide freely and responsibly on the number, spacing and timing of children; and the right to be free from torture, cruel, inhuman and degrading treatment and punishment.

One review from 2003–12, found that 4.7-13% of maternal deaths were linked to abortive pregnancy outcomes (4) but noted that maternal deaths due to abortion, and more specifically unsafe abortion, are often misclassified and underreported given the stigma. 

Deaths from safe abortion are negligible, <1/100 000 (5). On the other hand, in regions where unsafe abortions are common, the death rates are high, at > 200/100 000 abortions. Estimates from 2012 indicate that in developing countries alone, 7 million women per year were treated in hospital facilities for complications of unsafe abortion (6) .

Physical health risks associated with unsafe abortion include:

• incomplete abortion (failure to remove or expel all pregnancy tissue from the uterus);
• haemorrhage (heavy bleeding);
• uterine perforation (caused when the uterus is pierced by a sharp object); and
• damage to the genital tract and internal organs as a consequence of inserting dangerous objects into the vagina or anus.

Restrictive abortion regulation can cause distress and stigma, and risk constituting a violation of human rights of women and girls, including the right to privacy and the right to non-discrimination and equality, while also imposing financial burdens on women and girls. Regulations that force women to travel to attain legal care, or require mandatory counselling or waiting periods, lead to loss of income and other financial costs, and can make abortion inaccessible to women with low resources (6,8) .

Estimates from 2006 show that complications of unsafe abortions cost health systems in developing countries US$ 553 million per year for post-abortion treatments. In addition, households experienced US$ 922 million in loss of income due to long-term disability related to unsafe abortion (10) . Countries and health systems could make substantial monetary savings by providing greater access to modern contraception and quality induced abortion (8,9) .

Expanding quality abortion care

Evidence shows that restricting access to abortions does not reduce the number of abortions (1) ; however, it does affect whether the abortions that women and girls attain are safe and dignified. The proportion of unsafe abortions are significantly higher in countries with highly restrictive abortion laws than in countries with less restrictive laws (2) .

Barriers to accessing safe and respectful abortion include high costs, stigma for those seeking abortions and health care workers, and the refusal of health workers to provide an abortion based on personal conscience or religious belief. Access is further impeded by restrictive laws and requirements that are not medically justified, including criminalization of abortion, mandatory waiting periods, provision of biased information or counselling, third-party authorization and restrictions regarding the type of health care providers or facilities that can provide abortion services.

Multiple actions are needed at the legal, health system and community levels so that everyone who needs abortion care has access to it. The three cornerstones of an enabling environment for quality comprehensive abortion care are:

• respect for human rights, including a supportive framework of law and policy;
• the availability and accessibility of information; and
• a supportive, universally accessible, affordable and well functioning health system.

A well-functioning health system implies many factors, including:

• evidence-based policies;
• universal health coverage;
• the reliable supply of quality, affordable medical products and equipment;
• that an adequate number of health workers, of different types, provide abortion care at a reachable distance to patients; 
• the delivery of abortion care through a variety of approaches, e.g. care in health facilities, digital interventions and self-care approaches, allowing for choices depending on the values and preferences of the pregnant person, available resources, and the national and local context;
• that health workers are trained to provide safe and respectful abortion care, to support informed decision-making and to interpret laws and policies regulating abortion;
• that health workers are supported and protected from stigma; and
• provision of contraception to prevent unintended pregnancies.

Availability and accessibility of information implies:

• provision of evidence-based comprehensive sexuality education; and
• accurate, non-biased and evidence-based information on abortion and contraceptive methods.

WHO response

WHO provides global technical and policy guidance on the use of contraception to prevent unintended pregnancy, provision of information on abortion care, abortion management (including miscarriage, induced abortion, incomplete abortion and fetal death) and post-abortion care. In 2022, WHO published an updated, consolidated guideline on abortion care, including all WHO recommendations and best practice statements across three domains essential to the provision of abortion care: law and policy, clinical services and service delivery. 

WHO also maintains the Global Abortion Policies Database . This interactive online database contains comprehensive information on the abortion laws, policies, health standards and guidelines for all countries. 

Upon request, WHO provides technical support to countries to adapt sexual and reproductive health guidelines to specific contexts and strengthen national policies and programmes related to contraception and safe abortion care. A quality abortion care monitoring and evaluation framework is also in development.

WHO is a cosponsor of the HRP (UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction) , which carries out research on clinical care, abortion regulation, abortion stigma, as well as implementation research on community and health systems approaches to quality abortion care. It also monitors the global burden of unsafe abortion and its consequences.

1 An “unsafe abortion” is defined as a procedure for terminating a pregnancy performed by persons lacking the necessary information or skills or in an environment not in conformity with minimal medical standards, or both. The persons, skills and medical standards considered safe in the provision of abortion are different for medical and surgical abortion and by pregnancy duration. In using this definition, what is considered ‘safe’ or unsafe needs to be interpreted in line with the most current WHO technical and policy guidance (2).

(1) Bearak J, Popinchalk A, Ganatra B, Moller A-B, Tunçalp Ö, Beavin C et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019. Lancet Glob Health. 2020 Sep; 8(9):e1152-e1161. doi: 10.1016/S2214-109X(20)30315-6. 

(2) Ganatra B, Tunçalp Ö, Johnston H, Johnson BR, Gülmezoglu A, Temmerman M. From concept to measurement: Operationalizing WHO's definition of unsafe abortion. Bull World Health Organ 2014;92:155; 10.2471/BLT.14.136333.

(3) Ganatra B, Gerdts C, Rossier C, Johnson Jr B R, Tuncalp Ö, Assifi A et al. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. The Lancet. 2017 Sep.

(4) Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014 Jun; 2(6):e323-33.

(5) Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012 Feb;119(2 Pt 1):215-9. doi: 10.1097/AOG.0b013e31823fe923. PMID: 22270271.

(6) Singh S, Maddow-Zimet I. Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: a review of evidence from 26 countries. BJOG 2015; published online Aug 19. DOI:10.1111/1471-0528.13552.

(7) Coast E, Lattof SR, Meulen Rodgers YV, Moore B, Poss C. The microeconomics of abortion: A scoping review and analysis of the economic consequences for abortion care-seekers. PLoS One. 2021 Jun 9;16(6):e0252005. doi: 10.1371/journal.pone.0252005. PMID: 34106927; PMCID: PMC8189560.

(8) Lattof SR, Coast E, Rodgers YVM, Moore B, Poss C. The mesoeconomics of abortion: A scoping review and analysis of the economic effects of abortion on health systems. PLoS One. 2020 Nov 4;15(11):e0237227. doi: 10.1371/journal.pone.0237227. PMID: 33147223; PMCID: PMC7641432.

(9) Rodgers YVM, Coast E, Lattof SR, Poss C, Moore B. The macroeconomics of abortion: A scoping review and analysis of the costs and outcomes. PLoS One. 2021 May 6;16(5):e0250692. doi: 10.1371/journal.pone.0250692. PMID: 33956826; PMCID: PMC8101771.

(10). Vlassoff et al. Economic impact of unsafe abortion-related morbidity and mortality: evidence and estimation challenges. Brighton, Institute of Development Studies, 2008 (IDS Research Reports 59).

• Abortion care guideline
• Classification of abortions by safety: article in The Lancet
• Quality of care
• Maintaining essential health services during the COVID-19 outbreak
• Sexual and reproductive health and research including the Special Programme HRP

Global Abortion Policies Database

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Is Abortion Sacred?

By Jia Tolentino

Twenty years ago, when I was thirteen, I wrote an entry in my journal about abortion, which began, “I have this huge thing weighing on me.” That morning, in Bible class, which I’d attended every day since the first grade at an evangelical school, in Houston, my teacher had led us in an exercise called Agree/Disagree. He presented us with moral propositions, and we stood up and physically chose sides. “Abortion is always wrong,” he offered, and there was no disagreement. We all walked to the wall that meant “agree.”

Then I raised my hand and, according to my journal, said, “I think it is always morally wrong and absolutely murder, but if a woman is raped, I respect her right to get an abortion.” Also, I said, if a woman knew the child would face a terrible life, the child might be better off. “Dead?” the teacher asked. My classmates said I needed to go to the other side, and I did. “I felt guilty and guilty and guilty,” I wrote in my journal. “I didn’t feel like a Christian when I was on that side of the room. I felt terrible, actually. . . . But I still have that thought that if a woman was raped, she has her right. But that’s so strange—she has a right to kill what would one day be her child? That issue is irresolved in my mind and it will eat at me until I sort it out.”

I had always thought of abortion as it had been taught to me in school: it was a sin that irresponsible women committed to cover up another sin, having sex in a non-Christian manner. The moral universe was a stark battle of virtue and depravity, in which the only meaningful question about any possible action was whether or not it would be sanctioned in the eyes of God. Men were sinful, and the goodness of women was the essential bulwark against the corruption of the world. There was suffering built into this framework, but suffering was noble; justice would prevail, in the end, because God always provided for the faithful. It was these last tenets, prosperity-gospel principles that neatly erase the material causes of suffering in our history and our social policies—not only regarding abortion but so much else—which toppled for me first. By the time I went to college, I understood that I was pro-choice.

America is, in many ways, a deeply religious country—the only wealthy Western democracy in which more than half of the population claims to pray every day. (In Europe, the figure is twenty-two per cent.) Although seven out of ten American women who get abortions identify as Christian, the fight to make the procedure illegal is an almost entirely Christian phenomenon. Two-thirds of the national population and nearly ninety per cent of Congress affirm a tradition in which a teen-age girl continuing an unplanned pregnancy allowed for the salvation of the world, in which a corrupt government leader who demanded a Massacre of the Innocents almost killed the baby Jesus and damned us all in the process, and in which the Son of God entered the world as what the godless dare to call a “clump of cells.”

For centuries, most Christians believed that human personhood began months into the long course of pregnancy. It was only in the twentieth century that a dogmatic narrative, in which every pregnancy is an iteration of the same static story of creation, began both to shape American public policy and to occlude the reality of pregnancy as volatile and ambiguous—as a process in which creation and destruction run in tandem. This newer narrative helped to erase an instinctive, long-held understanding that pregnancy does not begin with the presence of a child, and only sometimes ends with one. Even within the course of the same pregnancy, a person and the fetus she carries can shift between the roles of lover and beloved, host and parasite, vessel and divinity, victim and murderer; each body is capable of extinguishing the other, although one cannot survive alone. There is no human relationship more complex, more morally unstable than this.

The idea that a fetus is not just a full human but a superior and kinglike one—a being whose survival is so paramount that another person can be legally compelled to accept harm, ruin, or death to insure it—is a recent invention. For most of history, women ended unwanted pregnancies as they needed to, taking herbal or plant-derived preparations on their own or with the help of female healers and midwives, who presided over all forms of treatment and care connected with pregnancy. They were likely enough to think that they were simply restoring their menstruation, treating a blockage of blood. Pregnancy was not confirmed until “quickening,” the point at which the pregnant person could feel fetal movement, a measurement that relied on her testimony. Then as now, there was often nothing that distinguished the result of an abortion—the body expelling fetal tissue—from a miscarriage.

Ancient records of abortifacient medicine are plentiful; ancient attempts to regulate abortion are rare. What regulations existed reflect concern with women’s behavior and marital propriety, not with fetal life. The Code of the Assura, from the eleventh century B.C.E., mandated death for married women who got abortions without consulting their husbands; when husbands beat their wives hard enough to make them miscarry, the punishment was a fine. The first known Roman prohibition on abortion dates to the second century and prescribes exile for a woman who ends her pregnancy, because “it might appear scandalous that she should be able to deny her husband of children without being punished.” Likewise, the early Christian Church opposed abortion not as an act of murder but because of its association with sexual sin. (The Bible offers ambiguous guidance on the question of when life begins: Genesis 2:7 arguably implies that it begins at first breath; Exodus 21:22-24 suggests that, in Old Testament law, a fetus was not considered a person; Jeremiah 1:5 describes God’s hand in creation even “before I formed you in the womb.” Nowhere does the Bible clearly and directly address abortion.) Augustine, in the fourth century, favored the idea that God endowed a fetus with a soul only after its body was formed—a point that Augustine placed, in line with Aristotelian tradition, somewhere between forty and eighty days into its development. “There cannot yet be a live soul in a body that lacks sensation when it is not formed in flesh, and so not yet endowed with sense,” he wrote. This was more or less the Church’s official position; it was affirmed eight centuries later by Thomas Aquinas.

In the early modern era, European attitudes began to change. The Black Death had dramatically lowered the continent’s population, and dealt a blow to most forms of economic activity; the Reformation had weakened the Church’s position as the essential intermediary between the layman and God. The social scientist Silvia Federici has argued, in her book “ Caliban and the Witch ,” that church and state waged deliberate campaigns to force women to give birth, in service of the emerging capitalist economy. “Starting in the mid-16th century, while Portuguese ships were returning from Africa with their first human cargoes, all the European governments began to impose the severest penalties against contraception, abortion, and infanticide,” Federici notes. Midwives and “wise women” were prosecuted for witchcraft, a catchall crime for deviancy from procreative sex. For the first time, male doctors began to control labor and delivery, and, Federici writes, “in the case of a medical emergency” they “prioritized the life of the fetus over that of the mother.” She goes on: “While in the Middle Ages women had been able to use various forms of contraceptives, and had exercised an undisputed control over the birthing process, from now on their wombs became public territory, controlled by men and the state.”

Martin Luther and John Calvin, the most influential figures of the Reformation, did not address abortion at any length. But Catholic doctrine started to shift, albeit slowly. In 1588, Pope Sixtus V labelled both abortion and contraception as homicide. This pronouncement was reversed three years later, by Pope Gregory XIV, who declared that abortion was only homicide if it took place after ensoulment, which he identified as occurring around twenty-four weeks into a pregnancy. Still, theologians continued to push the idea of embryonic humanity; in 1621, the physician Paolo Zacchia, an adviser to the Vatican, proclaimed that the soul was present from the moment of conception. Still, it was not until 1869 that Pope Pius IX affirmed this doctrine, proclaiming abortion at any point in pregnancy to be a sin punishable by excommunication.

When I found out I was pregnant, at the beginning of 2020, I wondered how the experience would change my understanding of life, of fetal personhood, of the morality of reproduction. It’s been years since I traded the echo chamber of evangelical Texas for the echo chamber of progressive Brooklyn, but I can still sometimes feel the old world view flickering, a photographic negative underneath my vision. I have come to believe that abortion should be universally accessible, regulated only by medical codes and ethics, and not by the criminal-justice system. Still, in passing moments, I can imagine upholding the idea that our sole task when it comes to protecting life is to end the practice of abortion; I can imagine that seeming profoundly moral and unbelievably urgent. I would only need to think of the fetus in total isolation—to imagine that it were not formed and contained by another body, and that body not formed and contained by a family, or a society, or a world.

As happens to many women, though, I became, if possible, more militant about the right to an abortion in the process of pregnancy, childbirth, and caregiving. It wasn’t just the difficult things that had this effect—the paralyzing back spasms, the ragged desperation of sleeplessness, the thundering doom that pervaded every cell in my body when I weaned my child. And it wasn’t just my newly visceral understanding of the anguish embedded in the facts of American family life. (A third of parents in one of the richest countries in the world struggle to afford diapers ; in the first few months of the pandemic , as Jeff Bezos’s net worth rose by forty-eight billion dollars, sixteen per cent of households with children did not have enough to eat.) What multiplied my commitment to abortion were the beautiful things about motherhood: in particular, the way I felt able to love my baby fully and singularly because I had chosen to give my body and life over to her. I had not been forced by law to make another person with my flesh, or to tear that flesh open to bring her into the world; I hadn’t been driven by need to give that new person away to a stranger in the hope that she would never go to bed hungry. I had been able to choose this permanent rearrangement of my existence. That volition felt sacred.

Abortion is often talked about as a grave act that requires justification, but bringing a new life into the world felt, to me, like the decision that more clearly risked being a moral mistake. The debate about abortion in America is “rooted in the largely unacknowledged premise that continuing a pregnancy is a prima facie moral good,” the pro-choice Presbyterian minister Rebecca Todd Peters writes . But childbearing, Peters notes, is a morally weighted act, one that takes place in a world of limited and unequally distributed resources. Many people who get abortions—the majority of whom are poor women who already have children—understand this perfectly well. “We ought to take the decision to continue a pregnancy far more seriously than we do,” Peters writes.

I gave birth in the middle of a pandemic that previewed a future of cross-species viral transmission exacerbated by global warming, and during a summer when ten million acres on the West Coast burned . I knew that my child would not only live in this degrading world but contribute to that degradation. (“Every year, the average American emits enough carbon to melt ten thousand tons of ice in the Antarctic ice sheets,” David Wallace-Wells writes in his book “ The Uninhabitable Earth .”) Just before COVID arrived, the science writer Meehan Crist published an essay in the London Review of Books titled “Is it OK to have a child?” (The title alludes to a question that Alexandria Ocasio-Cortez once asked in a live stream, on Instagram.) Crist details the environmental damage that we are doing, and the costs for the planet and for us and for those who will come after. Then she turns the question on its head. The idea of choosing whether or not to have a child, she writes, is predicated on a fantasy of control that “quickly begins to dissipate when we acknowledge that the conditions for human flourishing are distributed so unevenly, and that, in an age of ecological catastrophe, we face a range of possible futures in which these conditions no longer reliably exist.”

In late 2021, as Omicron brought New York to another COVID peak, a Gen Z boy in a hoodie uploaded a TikTok , captioned “yall better delete them baby names out ya notes its 60 degrees in december.” By then, my baby had become a toddler. Every night, as I set her in the crib, she chirped good night to the elephants, koalas, and tigers on the wall, and I tried not to think about extinction. My decision to have her risked, or guaranteed, additional human suffering; it opened up new chances for joy and meaning. There is unknowability in every reproductive choice.

As the German historian Barbara Duden writes in her book “ Disembodying Women ,” the early Christians believed that both the bodies that created life and the world that sustained it were proof of the “continual creative activity of God.” Women and nature were aligned, in this view, as the material sources of God’s plan. “The word nature is derived from nascitura , which means ‘birthing,’ and nature is imagined and felt to be like a pregnant womb, a matrix, a mother,” Duden writes. But, in recent decades, she notes, the natural world has begun to show its irreparable damage. The fetus has been left as a singular totem of life and divinity, to be protected, no matter the costs, even if everything else might fall.

The scholar Katie Gentile argues that, in times of cultural crisis and upheaval, the fetus functions as a “site of projected and displaced anxieties,” a “fantasy of wholeness in the face of overwhelming anxiety and an inability to have faith in a progressive, better future.” The more degraded actual life becomes on earth, the more fervently conservatives will fight to protect potential life in utero. We are locked into the destruction of the world that birthed all of us; we turn our attention, now, to the worlds—the wombs—we think we can still control.

By the time that the Catholic Church decided that abortion at any point, for any reason, was a sin, scientists had identified the biological mechanism behind human reproduction, in which a fetus develops from an embryo that develops from a zygote, the single-celled organism created by the union of egg and sperm. With this discovery, in the mid-nineteenth century, women lost the most crucial point of authority over the stories of their pregnancies. Other people would be the ones to tell us, from then on, when life began.

At the time, abortion was largely unregulated in the United States, a country founded and largely populated by Protestants. But American physicians, through the then newly formed American Medical Association, mounted a campaign to criminalize it, led by a gynecologist named Horatio Storer, who once described the typical abortion patient as a “wretch whose account with the Almighty is heaviest with guilt.” (Storer was raised Unitarian but later converted to Catholicism.) The scholars Paul Saurette and Kelly Gordon have argued that these doctors, whose profession was not as widely respected as it would later become, used abortion “as a wedge issue,” one that helped them portray their work “as morally and professionally superior to the practice of midwifery.” By 1910, abortion was illegal in every state, with exceptions only to save the life of “the mother.” (The wording of such provisions referred to all pregnant people as mothers, whether or not they had children, thus quietly inserting a presumption of fetal personhood.) A series of acts known as the Comstock laws had rendered contraception, abortifacient medicine, and information about reproductive control widely inaccessible, by criminalizing their distribution via the U.S. Postal Service. People still sought abortions, of course: in the early years of the Great Depression, there were as many as seven hundred thousand abortions annually. These underground procedures were dangerous; several thousand women died from abortions every year.

This is when the contemporary movements for and against the right to abortion took shape. Those who favored legal abortion did not, in these years, emphasize “choice,” Daniel K. Williams notes in his book “ Defenders of the Unborn .” They emphasized protecting the health of women, protecting doctors, and preventing the births of unwanted children. Anti-abortion activists, meanwhile, argued, as their successors do, that they were defending human life and human rights. The horrors of the Second World War gave the movement a lasting analogy: “Logic would lead us from abortion to the gas chamber,” a Catholic clergyman wrote, in October, 1962.

Ultrasound imaging, invented in the nineteen-fifties, completed the transformation of pregnancy into a story that, by default, was narrated to women by other people—doctors, politicians, activists. In 1965, Life magazine published a photo essay by Lennart Nilsson called “ Drama of Life Before Birth ,” and put the image of a fetus at eighteen weeks on its cover. The photos produced an indelible, deceptive image of the fetus as an isolated being—a “spaceman,” as Nilsson wrote, floating in a void, entirely independent from the person whose body creates it. They became totems of the anti-abortion movement; Life had not disclosed that all but one had been taken of aborted fetuses, and that Nilsson had lit and posed their bodies to give the impression that they were alive.

In 1967, Colorado became the first state to allow abortion for reasons other than rape, incest, or medical emergency. A group of Protestant ministers and Jewish rabbis began operating an abortion-referral service led by the pastor of Judson Memorial Church, in Manhattan; the resulting network of pro-choice clerics eventually spanned the country, and referred an estimated four hundred and fifty thousand women to safe abortions. The evangelical magazine Christianity Today held a symposium of prominent theologians, in 1968, which resulted in a striking statement: “Whether or not the performance of an induced abortion is sinful we are not agreed, but about the necessity and permissibility for it under certain circumstances we are in accord.” Meanwhile, the priest James McHugh became the director of the National Right to Life Committee, and equated fetuses to the other vulnerable people whom faithful Christians were commanded to protect: the old, the sick, the poor. As states began to liberalize their abortion laws, the anti-abortion movement attracted followers—many of them antiwar, pro-welfare Catholics—using the language of civil rights, and adopted the label “pro-life.”

W. A. Criswell, a Dallas pastor who served as president of the Southern Baptist Convention from 1968 to 1970, said, shortly after the Supreme Court issued its decision in Roe v. Wade , that “it was only after a child was born and had life separate from his mother that it became an individual person,” and that “it has always, therefore, seemed to me that what is best for the mother and the future should be allowed.” But the Court’s decision accelerated a political and theological transformation that was already under way: by 1979, Criswell, like the S.B.C., had endorsed a hard-line anti-abortion stance. Evangelical leadership, represented by such groups as Jerry Falwell’s Moral Majority , joined with Catholics to oppose the secularization of popular culture, becoming firmly conservative—and a powerful force in Republican politics. Bible verses that express the idea of divine creation, such as Psalm 139 (“For you created my innermost being; you knit me together in my mother’s womb,” in the New International Version’s translation), became policy explanations for prohibiting abortion.

In 1984, scientists used ultrasound to detect fetal cardiac activity at around six weeks’ gestation—a discovery that has been termed a “fetal heartbeat” by the anti-abortion movement, though a six-week-old fetus hasn’t yet formed a heart, and the electrical pulses are coming from cell clusters that can be replicated in a petri dish. At six weeks, in fact, medical associations still call the fetus an embryo; as I found out in 2020, you generally can’t even schedule a doctor’s visit to confirm your condition until you’re eight weeks along.

So many things that now shape the cultural experience of pregnancy in America accept and reinforce the terms of the anti-abortion movement, often with the implicit goal of making pregnant women feel special, or encouraging them to buy things. “Your baby,” every app and article whispered to me sweetly, wrongly, many months before I intuited personhood in the being inside me, or felt that the life I was forming had moved out of a liminal realm.

I tried to learn from that liminality. Hope was always predicated on uncertainty; there would be no guarantees of safety in this or any other part of life. Pregnancy did not feel like soft blankets and stuffed bunnies—it felt cosmic and elemental, like volcanic rocks grinding, or a wild plant straining toward the sun. It was violent even as I loved it. “Even with the help of modern medicine, pregnancy still kills about 800 women every day worldwide,” the evolutionary biologist Suzanne Sadedin points out in an essay titled “War in the womb.” Many of the genes that activate during embryonic development also activate when a body has been invaded by cancer, Sadedin notes; in ectopic pregnancies, which are unviable by definition and make up one to two per cent of all pregnancies, embryos become implanted in the fallopian tube rather than the uterus, and “tunnel ferociously toward the richest nutrient source they can find.” The result, Sadedin writes, “is often a bloodbath.”

The Book of Genesis tells us that the pain of childbearing is part of the punishment women have inherited from Eve. The other part is subjugation to men: “Your desire will be for your husband and he will rule over you,” God tells Eve. Tertullian, a second-century theologian, told women, “You are the devil’s gateway: you are the unsealer of the (forbidden) tree: you are the first deserter of the divine law: you are she who persuaded him whom the devil was not valiant enough to attack.” The idea that guilt inheres in female identity persists in anti-abortion logic: anything a woman, or a girl, does with her body can justify the punishment of undesired pregnancy, including simply existing.

If I had become pregnant when I was a thirteen-year-old Texan , I would have believed that abortion was wrong, but I am sure that I would have got an abortion. For one thing, my Christian school did not allow students to be pregnant. I was aware of this, and had, even then, a faint sense that the people around me grasped, in some way, the necessity of abortion—that, even if they believed that abortion meant taking a life, they understood that it could preserve a life, too.

One need not reject the idea that life in the womb exists or that fetal life has meaning in order to favor the right to abortion; one must simply allow that everything, not just abortion, has a moral dimension, and that each pregnancy occurs in such an intricate web of systemic and individual circumstances that only the person who is pregnant could hope to evaluate the situation and make a moral decision among the options at hand. A recent survey found that one-third of Americans believe life begins at conception but also that abortion should be legal. This is the position overwhelmingly held by American Buddhists, whose religious tradition casts abortion as the taking of a human life and regards all forms of life as sacred but also warns adherents against absolutism and urges them to consider the complexity of decreasing suffering, compelling them toward compassion and respect.

There is a Buddhist ritual practiced primarily in Japan, where it is called mizuko kuyo : a ceremony of mourning for miscarriages, stillbirths, and aborted fetuses. The ritual is possibly ersatz; critics say that it fosters and preys upon women’s feelings of guilt. But the scholar William LaFleur argues, in his book “ Liquid Life ,” that it is rooted in a medieval Japanese understanding of the way the unseen world interfaces with the world of humans—in which being born and dying are both “processes rather than fixed points.” An infant was believed to have entered the human world from the realm of the gods, and move clockwise around a wheel as she grew older, eventually passing back into the spirit realm on the other side. But some infants were mizuko , or water babies: floating in fluids, ontologically unstable. These were the babies who were never born. A mizuko , whether miscarried or aborted—and the two words were similar: kaeru , to go back, and kaesu , to cause to go back—slipped back, counterclockwise, across the border to the realm of the gods.

There is a loss, I think, entailed in abortion—as there is in miscarriage, whether it occurs at eight or twelve or twenty-nine weeks. I locate this loss in the irreducible complexity of life itself, in the terrible violence and magnificence of reproduction, in the death that shimmered at the edges of my consciousness in the shattering moment that my daughter was born. This understanding might be rooted in my religious upbringing—I am sure that it is. But I wonder, now, how I would square this: that fetuses were the most precious lives in existence, and that God, in His vision, already chooses to end a quarter of them. The fact that a quarter of women, regardless of their beliefs, also decide to end pregnancies at some point in their lifetimes: are they not acting in accordance with God’s plan for them, too? ♦

More on Abortion and Roe v. Wade

In the post-Roe era, letting pregnant patients get sicker— by design .

The study that debunks most anti-abortion arguments .

Of course the Constitution has nothing to say about abortion .

How the real Jane Roe shaped the abortion wars.

Black feminists defined abortion rights as a matter of equality, not just “choice.”

Recent data suggest that taking abortion pills at home is as safe as going to a clinic. 

When abortion is criminalized, women make desperate choices .

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By Eyal Press

By Daniel Immerwahr

By Abe Streep

There’s a Better Way to Debate Abortion

Caution and epistemic humility can guide our approach.

If Justice Samuel Alito’s draft majority opinion in Dobbs v. Jackson Women’s Health Organization becomes law, we will enter a post– Roe v. Wade world in which the laws governing abortion will be legislatively decided in 50 states.

In the short term, at least, the abortion debate will become even more inflamed than it has been. Overturning Roe , after all, would be a profound change not just in the law but in many people’s lives, shattering the assumption of millions of Americans that they have a constitutional right to an abortion.

This doesn’t mean Roe was correct. For the reasons Alito lays out, I believe that Roe was a terribly misguided decision, and that a wiser course would have been for the issue of abortion to have been given a democratic outlet, allowing even the losers “the satisfaction of a fair hearing and an honest fight,” in the words of the late Justice Antonin Scalia. Instead, for nearly half a century, Roe has been the law of the land. But even those who would welcome its undoing should acknowledge that its reversal could convulse the nation.

From the December 2019 issue: The dishonesty of the abortion debate

If we are going to debate abortion in every state, given how fractured and angry America is today, we need caution and epistemic humility to guide our approach.

We can start by acknowledging the inescapable ambiguities in this staggeringly complicated moral question. No matter one’s position on abortion, each of us should recognize that those who hold views different from our own have some valid points, and that the positions we embrace raise complicated issues. That realization alone should lead us to engage in this debate with a little more tolerance and a bit less certitude.

Many of those on the pro-life side exhibit a gap between the rhetoric they employ and the conclusions they actually seem to draw. In the 1990s, I had an exchange, via fax, with a pro-life thinker. During our dialogue, I pressed him on what he believed, morally speaking , should be the legal penalty for a woman who has an abortion and a doctor who performs one.

My point was a simple one: If he believed, as he claimed, that an abortion even moments after conception is the killing of an innocent child—that the fetus, from the instant of conception, is a human being deserving of all the moral and political rights granted to your neighbor next door—then the act ought to be treated, if not as murder, at least as manslaughter. Surely, given what my interlocutor considered to be the gravity of the offense, fining the doctor and taking no action against the mother would be morally incongruent. He was understandably uncomfortable with this line of questioning, unwilling to go to the places his premises led. When it comes to abortion, few people are.

Humane pro-life advocates respond that while an abortion is the taking of a human life, the woman having the abortion has been misled by our degraded culture into denying the humanity of the child. She is a victim of misinformation; she can’t be held accountable for what she doesn’t know. I’m not unsympathetic to this argument, but I think it ultimately falls short. In other contexts, insisting that people who committed atrocities because they truly believed the people against whom they were committing atrocities were less than human should be let off the hook doesn’t carry the day. I’m struggling to understand why it would in this context.

There are other complicating matters. For example, about half of all fertilized eggs are aborted spontaneously —that is, result in miscarriage—usually before the woman knows she is pregnant. Focus on the Family, an influential Christian ministry, is emphatic : “Human life begins at fertilization.” Does this mean that when a fertilized egg is spontaneously aborted, it is comparable—biologically, morally, ethically, or in any other way—to when a 2-year-old child dies? If not, why not? There’s also the matter of those who are pro-life and contend that abortion is the killing of an innocent human being but allow for exceptions in the case of rape or incest. That is an understandable impulse but I don’t think it’s a logically sustainable one.

The pro-choice side, for its part, seldom focuses on late-term abortions. Let’s grant that late-term abortions are very rare. But the question remains: Is there any point during gestation when pro-choice advocates would say “slow down” or “stop”—and if so, on what grounds? Or do they believe, in principle, that aborting a child up to the point of delivery is a defensible and justifiable act; that an abortion procedure is, ethically speaking, the same as removing an appendix? If not, are those who are pro-choice willing to say, as do most Americans, that the procedure gets more ethically problematic the further along in a pregnancy?

Read: When a right becomes a privilege

Plenty of people who consider themselves pro-choice have over the years put on their refrigerator door sonograms of the baby they are expecting. That tells us something. So does biology. The human embryo is a human organism, with the genetic makeup of a human being. “The argument, in which thoughtful people differ, is about the moral significance and hence the proper legal status of life in its early stages,” as the columnist George Will put it.

These are not “gotcha questions”; they are ones I have struggled with for as long as I’ve thought through where I stand on abortion, and I’ve tried to remain open to corrections in my thinking. I’m not comfortable with those who are unwilling to grant any concessions to the other side or acknowledge difficulties inherent in their own position. But I’m not comfortable with my own position, either—thinking about abortion taking place on a continuum, and troubled by abortions, particularly later in pregnancy, as the child develops.

The question I can’t answer is where the moral inflection point is, when the fetus starts to have claims of its own, including the right to life. Does it depend on fetal development? If so, what aspect of fetal development? Brain waves? Feeling pain? Dreaming? The development of the spine? Viability outside the womb? Something else? Any line I might draw seems to me entirely arbitrary and capricious.

Because of that, I consider myself pro-life, but with caveats. My inability to identify a clear demarcation point—when a fetus becomes a person—argues for erring on the side of protecting the unborn. But it’s a prudential judgment, hardly a certain one.

At the same time, even if one believes that the moral needle ought to lean in the direction of protecting the unborn from abortion, that doesn’t mean one should be indifferent to the enormous burden on the woman who is carrying the child and seeks an abortion, including women who discover that their unborn child has severe birth defects. Nor does it mean that all of us who are disturbed by abortion believe it is the equivalent of killing a child after birth. In this respect, my view is similar to that of some Jewish authorities , who hold that until delivery, a fetus is considered a part of the mother’s body, although it does possess certain characteristics of a person and has value. But an early-term abortion is not equivalent to killing a young child. (Many of those who hold this position base their views in part on Exodus 21, in which a miscarriage that results from men fighting and pushing a pregnant woman is punished by a fine, but the person responsible for the miscarriage is not tried for murder.)

“There is not the slightest recognition on either side that abortion might be at the limits of our empirical and moral knowledge,” the columnist Charles Krauthammer wrote in 1985. “The problem starts with an awesome mystery: the transformation of two soulless cells into a living human being. That leads to an insoluble empirical question: How and exactly when does that occur? On that, in turn, hangs the moral issue: What are the claims of the entity undergoing that transformation?”

That strikes me as right; with abortion, we’re dealing with an awesome mystery and insoluble empirical questions. Which means that rather than hurling invective at one another and caricaturing those with whom we disagree, we should try to understand their views, acknowledge our limitations, and even show a touch of grace and empathy. In this nation, riven and pulsating with hate, that’s not the direction the debate is most likely to take. But that doesn’t excuse us from trying.

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Reproductive rights in America

7 persistent claims about abortion, fact-checked.

Jaclyn Diaz

Koko Nakajima

Nick Underwood

Anti-abortion demonstrators watch as abortion rights protestors chant in front of the U.S. Supreme Court in Washington, D.C., on May 5. Jim Watson/AFP via Getty Images hide caption

Anti-abortion demonstrators watch as abortion rights protestors chant in front of the U.S. Supreme Court in Washington, D.C., on May 5.

Since the Supreme Court's 1973 Roe v. Wade decision ruled that women have a constitutional right to end their pregnancies, proponents and opponents of abortion rights have worked to own the conversation over the issue.

In 2019, the Centers for Disease Control and Prevention reported that 629,898 legal induced abortions were reported across the United States.

Lingering claims circulate about abortion, including about the safety of it, who gets abortions and even who supports or opposes access to abortion.

Below, seven popular claims surrounding abortion get fact-checked.

According to the Pew Research Center's polls , 37% of Americans want abortion illegal in all or most cases.

But an even bigger fraction — around 6 in 10 Americans — think abortion should be legal in all or most cases.

Current abortion rates are lower than what they were in 1973 and are now less than half what they were at their peak in the early 1980s, according to the Guttmacher Institute , a reproductive health research organization that supports abortion rights.

In 2017, pregnancy rates for females age 24 or below hit their lowest recorded levels, reflecting a long-term decline in pregnancy rates among females 24 or below.

Overall, in 2017, pregnancy rates for females of reproductive age hit their lowest recorded levels, with 87 pregnancies per 1,000 females ages 15 to 44, according to the Guttmacher Institute.

The annual number of deaths related to legal induced abortion has fluctuated from year to year since 1973, according to the CDC.

An analysis of data from 2013 to 2018 showed the national case-fatality rate for legal induced abortion was 0.41 deaths per 100,000 legal induced abortions, lower than in the previous five years.

The World Health Organization said people obtaining unsafe abortions are at a higher risk of death. Annually, 4.7% to 13.2% "of maternal deaths can be attributed to unsafe abortion," the WHO said. In developing regions of the world, there are 220 deaths per 100,000 unsafe abortions.

Trans and nonbinary people have undergone abortions as well.

The Guttmacher Institute estimates in 2017 an estimated 462 to 530 transgender or nonbinary individuals in the U.S. had abortions. That same year, the CDC said, 609,095 total abortions were carried out in the country.

The Abortion Out Loud campaign has collected stories from thousands of people who have had an abortion. Included are stories from trans and nonbinary people who have had an abortion — such as Jae, who spoke their experience.

"Most abortions in 2019 took place early in gestation," according to the CDC . Nearly 93% of abortions were performed at less than 13 weeks' gestation.

Abortion pills, which can typically be used up to 10 weeks into a pregnancy, made up 54% of abortions in 2020. These pills were the primary choice in the U.S. for the first time since the Food and Drug Administration approved the abortion drug mifepristone more than 20 years ago.

State legislatures have been moving to adopt 20-week abortion bans, with abortion opponents claiming fetuses can feel pain at that point. Roughly a third of states have implemented an abortion ban around 20 weeks .

But this contradicts widely accepted medical research from 2005. This study , published in the Journal of the American Medical Association , concluded that a fetus is not capable of experiencing pain until somewhere between 29 or 30 weeks.

Researchers wrote that fetal awareness of pain requires "functional thalamocortical connections." Those thalamocortical fibers begin appearing between 23 and 30 weeks' gestational age, but the capacity for pain perception comes later.

The argument against abortion has frequently been based on religion.

Data shows that the majority of people who get an abortion have some sort of religious affiliation, according to the most recent Guttmacher Institute data , from 2014.

The Pew Research Center also shows that attitudes on whether abortion should be legal vary among evangelical Protestants, mainline Protestants and Catholics.

Roe v. Wade and the future of reproductive rights in America

Here's what could happen now that roe v. wade is overturned.

• Supreme Court
• Roe v. Wade

The facts about abortion and mental health

Scientific research from around the world shows having an abortion is not linked to mental health issues but restricting access is 

Vol. 53 No. 6 Print version: page 40

More than 50 years of international psychological research shows that having an abortion is not linked to mental health problems, but restricting access to safe, legal abortions does cause harm. Research shows people who are denied abortions have worse physical and mental health, as well as worse economic outcomes than those who seek and receive them.

Meanwhile, the same research shows getting a wanted abortion does not cause significant psychological problems, despite beliefs to the contrary. In a landmark study of more than 1,000 women across 21 states, those who were allowed to obtain an abortion were no more likely to report negative emotions, mental health symptoms, or suicidal thoughts than women who were denied an abortion.

[ Related: Frequently asked questions about abortion laws and psychology practice ]

Large longitudinal and international studies have found that obtaining a wanted abortion does not increase risk for depression, anxiety, or suicidal thoughts ( The mental health impact of receiving vs. being denied an abortion , Advancing New Standards in Reproductive Health , 2018).

“It’s important for folks to know that abortion does not cause mental health problems,” said Debra Mollen, PhD, a professor of counseling psychology at Texas Woman’s University, who studies abortion and reproductive rights. “What’s harmful are the stigma surrounding abortion, the lack of knowledge about it, and the lack of access.”

Misconceptions about abortion are also linked to lower support for it—and people deserve to have accurate information so they can make informed decisions, Mollen said (Weibe, E. R., et al., Gynecology & Obstetrics , Vol. 5, No. 9, 2015 ).

How abortion impacts mental health

The Turnaway Study , a landmark analysis of abortion from Advancing New Standards in Reproductive Health (ANSIRH) at the University of California, San Francisco, served to debunk the belief that people who get abortions experience deep regret, grief, or even posttraumatic stress disorder. Instead, the most commonly felt emotion is relief (Rocca, C. H., et al., Social Science & Medicine , Vol. 248, 2020 ).

In the study, researchers followed nearly 1,000 women across 21 states for five years to examine the similarities and differences between those who wanted and received an abortion versus those who wanted but were denied an abortion. Five years after the procedure, women who had an abortion were no more likely to report negative emotions or suicidal thoughts than women who were denied an abortion, and more than 97% of those studied said that having the abortion was the right decision (Rocca, C. H., et al., Social Science & Medicine , Vol. 248, 2020 ).

In a review of the scientific literature on abortion published 10 years earlier, an APA task force reached a similar conclusion, especially in the case of unplanned pregnancy. The task force reported that women who had an abortion in the first trimester did not face a higher risk of mental health problems than women who continued with an unplanned pregnancy ( Report of the APA Task Force on Mental Health and Abortion , 2008).

“In fact, the best predictor of a woman’s mental health after an abortion is her mental health before the abortion,” said Nancy Felipe Russo, PhD, an emeritus professor of psychology and women’s studies at Arizona State University who has spearheaded research on unwanted pregnancy, mental health, and abortion.

Another group of women—those who planned and wanted a pregnancy but terminated it during the second or third trimester because of a life-threatening birth defect—faced some psychological problems after the procedure. But those were comparable to mental health problems among women who miscarried or lost a newborn baby, and less severe than the distress among women who delivered babies with severe birth defects.

“The bottom line is that abortion in and of itself does not cause mental health issues,” said M. Antonia Biggs, PhD, a psychologist and researcher at ANSIRH and one of the leaders of the Turnaway Study.

When abortions are denied

The women in the Turnaway Study who were denied an abortion reported more anxiety symptoms and stress, lower self-esteem, and lower life satisfaction than those who received one ( JAMA Psychiatry , Vol. 74, No. 2, 2017 ). Women who proceeded with an unwanted pregnancy also subsequently had more physical health problems, including two who died from childbirth complications (Ralph, L. J., et al., Annals of Internal Medicine , Vol. 171, No. 4, 2019 ).

They faced more economic hardships, including worse credit scores, more frequent bankruptcies and evictions, and a higher chance of living in poverty. After being denied an abortion, women were also more likely to stay linked to a violent partner or to raise children alone ( The harms of denying a woman a wanted abortion , ANSIRH, 2020).

And people seeking abortions aren’t the only ones harmed when the procedure is banned.

“The children born as a result of abortion denial were not only more likely to live in poverty, but they were also more likely to experience poor bonding with their mothers,” Biggs said.

Other studies show that children born in such circumstances face a range of social, emotional, and mental health problems that continue into adulthood, including more psychiatric hospitalizations than their siblings or other children of planned pregnancies (David, H. P., Reproductive Health Matters , Vol. 14, No. 27, 2006 ; Dagg, P. K., American Journal of Psychiatry , Vol. 148, No. 5, 1991 ).

“Negative outcomes are not limited to minor problems that occur over a short span of time,” Russo said. “They can be severe outcomes of real concern.”

More stigma, barriers, and inequities

Given that the mental health impacts of denying abortion extend far beyond the procedure itself, it’s important to consider the issue in the larger context of society.

“Most people assume that if we’re talking about psychological ramifications, that’s about their feelings around having an abortion,” said Julie Bindeman, PsyD, a reproductive psychologist who cofounded and directs Integrative Therapy of Greater Washington, a private practice outside Washington, D.C. “But we really need to think about the compounding costs involved with even getting to that point.”

If a state bans abortions, a resident seeking one faces a new and significant set of barriers. They might incur additional costs for out-of-state travel, lodging, and childcare during the trip—all while missing wages at work. They might feel compelled to disclose the pregnancy to friends, family members, or coworkers from whom they’ve solicited help. They might be forced to wait longer for an appointment. All these challenges add up to more psychological stress.

Those new barriers could hinder anyone seeking an abortion, not just people in states restricting the procedure.

“Many people will be traveling to states with greater access to care, and that surge in demand for a limited number of appointments has the potential to impact everyone,” Biggs said.

Research has shown that people who face logistical barriers to accessing abortion care, including increased travel time or difficulty scheduling appointments, have more symptoms of stress, anxiety, and depression. A loss of autonomy—such as being forced to wait for an appointment or disclose a pregnancy—has the same effect ( Contraception , Vol. 101, No. 5, 2020 ).

Banning the procedure also stigmatizes it, and stigma harms mental health, according to findings from the Turnaway Study. Women in the study who felt they would be looked down on by friends, family, and community members if they had an abortion were much more likely to report psychological distress years later ( PLOS ONE , Vol. 15, No. 1, 2020 ).

Experts say the growing costs of obtaining an abortion will weigh much more heavily on those people with fewer economic resources.

“What we’re likely to see is an increased stratification, where those who have means and can travel will be able to obtain their abortions, and those who do not will face barriers upon barriers,” Bindeman said.

People who already struggle to pay for and access abortions—those living in poverty, people of color, people in rural areas, sexual and gender minorities, and young people, who are often bound by state-level parental consent and notification laws—are likely to be hardest hit by abortion bans.

“For all those reasons, this is a perfect storm of perpetuating continued inequities for people who are already marginalized,” said Bindeman.

Resources and support

While abortion isn’t linked to mental health problems, the challenges around obtaining one can be distressing. The following programs and organizations aid people who are seeking an abortion or want to talk about their experience.

Finding a credible health care provider

• Planned Parenthood partners with more than 600 sexual and reproductive health care centers nationwide.
• AbortionFinder.org offers a directory of verified abortion providers across the United States
• The National Abortion Federation offers an online “Find a Provider” tool and a Referral Line to help patients locate abortion providers in their region.
• Avoid “crisis pregnancy centers,” which promote misinformation intended to dissuade people from obtaining abortions. One study found that 80% of crisis pregnancy center websites contained false or misleading information (Bryan, A. G., et al., Contraception , Vol. 90, No. 6, 2014 ).

Social and emotional support

• Exhale Pro-Voice is a textline that offers peer counseling for people who have had abortions and their loved ones, as well as trainings on how to provide support after an abortion.
• Planned Parenthood ’s local, state, and regional centers offer various programming and activities for patients.
• Sister Song , the National Black Women’s Reproductive Justice Agenda , and other organizations focus on supporting people of color.

Financial support

• The National Network of Abortion Funds works with more than 80 organizations to provide funding for abortion, transportation, childcare, and other services.
• The National Abortion Federation provides referrals, case management, and financial assistance for people seeking abortions.
• Funding is also available from numerous regional, state, and local grassroots organizations, such as Jane’s Due Process , the Texas Equal Access Fund , and the Mississippi Reproductive Freedom Fund .

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Key Facts on Abortion in the United States

Usha Ranji , Karen Diep , and Alina Salganicoff Published: Nov 21, 2023

Note: This brief was updated on January 4, 2024 to correct the description of the data collected by the federal CDC Abortion Surveillance System. On June 24, 2022, the Supreme Court issued a ruling in Dobbs v. Jackson Women’s Health Organization that overturned the constitutional right to abortion as well as the federal standards of abortion access, established by prior decisions in the cases Roe v. Wade and Planned Parenthood v. Casey . Prior to the Dobbs ruling, the federal standard was that abortions were permitted up to fetal viability. That federal standard has been eliminated, allowing states to set policies regarding the legality of abortions and establish limits. Access to and availability of abortions varies widely between states , with some states banning almost all abortions and some states protecting abortion access.

This issue brief answers some key questions about abortion in the United States and presents data collected before and new data that was published shortly after the overturn of Roe v. Wade .

What is abortion?

How safe are abortions, how often do abortions occur, who gets abortions, at what point in pregnancy do abortions occur, where do people get abortion care, how much do abortions cost, does private insurance or medicaid cover abortions, what are public opinions about abortion.

Abortion is the medical termination of a pregnancy. It is a common medical service that many women obtain at some point in their life. There are different types of abortion methods, which the National Academy of Sciences, Engineering, and Medicine (NASEM ) places in four categories:

• Medication Abortion – Medication abortion, also known as medical abortion or abortion with pills, is a pregnancy termination protocol that involves taking oral medications. There are two widely accepted protocols for medication abortion. In the U.S., the most common protocol involves taking two different drugs, Mifepristone and Misoprostol. Typically, an individual using medication abortion takes Mifepristone first, followed by misoprostol 24-48 hours later. In the U.S., the Food and Drug Administration (FDA) has approved this protocol of medication abortion for use up to the first 70 days (10 weeks) of pregnancy, and its use has been rising for years. Another medication abortion protocol uses misoprostol alone . Patients can take 800 µg (4 pills) of misoprostol sublingually or vaginally every three hours for a total of 12 pills. The regimen is also recommended for up to 70 days (10 weeks) of pregnancy, but it is not currently approved by the FDA and is more commonly used in other countries.

Guttmacher Institute estimates that in 2020, medication was used for more than half (53%) of all abortions. While medication abortion has been available in the U.S. for more than 20 years, studies have found that many adults and women of reproductive age have not heard of medication abortion. Many have confused emergency contraception ( EC ) pills with medication abortion pills, but EC does not terminate a pregnancy. EC works by delaying or inhibiting ovulation and will not affect an established pregnancy.

• Aspiration , a minimally invasive and commonly used gynecological procedure, is the most common form of procedural abortion. It can be used to conduct abortions up to 14-16 weeks of gestation. Aspiration is also commonly used in cases of early pregnancy loss (miscarriage).
• Dilation and evacuation abortions (D&E) are usually performed after the 14th week of pregnancy. The cervix is dilated, and the pregnancy tissue is evacuated using forceps or suction.
• Induction abortions are rare and conducted later in pregnancy. They involve the use of medications to induce labor and delivery of the fetus.

( Back to top )

Decades of research have shown that abortion is a very safe medical service.

Despite its strong safety profile, abortion is the most highly regulated medical service in the country and is now banned in several states. In addition to bans on abortion altogether and telehealth, many states impose other limitations on abortion that are not medically indicated, including waiting periods, ultrasound requirements, gestational age limits, and parental notification and consent requirements. These restrictions typically delay receipt of services.

• NASEM completed an exhaustive review on the safety and effectiveness of abortion care and concluded that complications from abortion are rare and occur far less frequently than during childbirth.
• NASEM also concluded that safety is enhanced when the abortion is performed earlier in the pregnancy. State level restrictions such as waiting periods, ultrasound requirements, and gestational limits that impede access and delay abortion provision likely make abortions less safe.
• When medication abortion pills, which account for the majority of abortions, are administered at 9 weeks’ gestation or less, the pregnancy is terminated successfully 99.6% of the time, with a 0.4% risk of major complications, and an associated mortality rate of less than 0.001 percent (0.00064%).
• Medication abortion pills can be provided in a clinical setting or via telehealth (without an in-person visit). Research has found that the provision of medication abortion via telehealth is as safe and effective as the provision of the pills at an in person visit.
• Studies on procedural abortions, which include aspiration and D&E, have also found that they are very safe. Research on aspiration abortions, the most common procedural method, have found the rate of major complications of less than 1%.

There are three major data sources on abortion incidence and the characteristics of people who obtain abortions in the U.S: the Centers for Disease Control and Prevention (CDC), the Guttmacher Institute, and most recently, the Society of Family Planning’s (SFP) #WeCount project.

The federal CDC Abortion Surveillance System requests data from the central health agencies of the 50 states, DC, and New York City to document the number and characteristics of women obtaining abortions. Most states collect data from facilities where abortions are provided on the demographic characteristics of patients, gestational age, and type of abortion procedure. Reporting these data to the CDC is voluntary and not all states participate in the surveillance system. Notably, California, Maryland, and New Hampshire have not reported data on abortions to the CDC system for years. CDC publishes available data from the surveillance system annually.

Guttmacher Institute , an independent research and advocacy organization, is another major source of data on abortions in the U.S. Prior to the Dobbs ruling, Guttmacher conducted the Abortion Provider Census (APC) periodically which has provided data on abortion incidence, abortion facilities, and characteristics of abortion patients. Data from this Census are based primarily on questionnaires collected from all known facilities that provide abortion in the country, information obtained from state health departments, and Guttmacher estimates for a small portion of facilities. The most recent APC reports data from 2020.

The CDC and Guttmacher data differ in terms of methods, timeframe, and completeness, but both have shown similar trends in abortion rates over the past decade. One notable difference is that Guttmacher’s study includes continuous reporting from California, D.C., Maryland, and New Hampshire, which explains at least in part the higher number of abortions in their data.

Since the Dobbs ruling, the Guttmacher Institute has established the Monthly Abortion Provision Study to track abortion volume within the formal United States health care system. This ongoing effort collects data on and provides national and state-level estimates on procedural and medication abortions while also tracking the changes in abortion volume since 2020. The Monthly Abortion Provision Study was designed to complement Guttmacher’s APC along with other data collection efforts to allow for quick snapshots of the changing abortion landscape in the United States.

Society of Family Planning’s (SFP) #WeCount is another national reporting effort that measures changes in abortion access following the Dobbs ruling. The project reports on the number of abortions per month by state and includes data on abortions provided through clinics, private practices, hospitals, and virtual-only providers. The report does not include data on self-managed abortions that are performed without clinical supervision. The most recent #WeCount report analyzes data from April 2022 to data from June 2023, marking one full year of abortion data since Dobbs. The effort represents 83% of all providers known to #WeCount who agreed to participate in their research.

This KFF issue brief uses data from the CDC, Guttmacher, and SFP as well as other research organizations.

How has the abortion rate changed over time?

For most of the decade prior to the Dobbs ruling, there was a steady decline in abortion rates nationally, but there was a slight increase in the years just before the ruling.

In their most recent national data, Guttmacher Institute reported 930,160 abortions in 2020 and a rate of 14.4 per 1,000 women. CDC reported 622,108 abortions in 2021 and a rate of 11.6 abortions per 1,000 women (excludes CA, DC, MD, NH). Guttmacher’s study showed an upward trend in abortion from 2017 to 2020 whereas CDC’s report showed an increase in abortions from 2017 to 2021 except for a slight decrease in 2020.

While most attribute the long-term decline in abortion rates to increased use of more effective methods of contraception , several states had reduced access to low- or no-cost contraceptive care as a result of reductions in the Title X network under the Trump Administration, which may have contributed to the slight rise in abortions prior to the Dobbs ruling. Other factors that may have contributed to the increase could include greater coverage under Medicaid that subsequently made abortions more affordable in some states and broader financial support from abortion funds to help individuals pay for the costs of abortion care.

Even prior to the Dobbs ruling, abortion rates varied widely between states.

National averages can mask local and more granular differences. Lower state-level abortion rates do not reflect less need. Some of the variation has been due to the wide differences in state policies, with some states historically placing restrictions on abortion that make access and availability to nearly out of reach and, on the other side, some states enshrining protections in state Constitutions and legislation.

• In 2020, the abortion rate (per 1,000 women ages 15-44) ranged from 0.1 in Missouri to 48.9 in the District of Columbia (DC). Trends also varied between states. While the national rate of abortion increased between 2017 and 2019, some states saw declines, with particularly sharp drops in states where heavy restrictions were put into place.

While the number of abortions in the U.S. dropped immediately following the Dobbs decision, new data show that the number of abortions increased overall one year following the ruling. However, the upswing obscures the declines in abortion care in states with bans.

SFP’s #WeCount estimates there were 2,200 cumulative more abortions in the year following Dobbs (July 2022 to June 2023) compared to the pre- Dobbs period (April 2022 and May 2022). Nationally, the number of abortions varied month-by-month, with the largest decrease observed in November 2022 (73,930 abortions; 8,185 fewer abortions than pre- Dobbs period ) and the largest increase in March 2023 (92,680 abortions; 10,565 more abortions than pre- Dobbs period). The states with the largest cumulative increases in the total number of abortions provided by a clinician during the 12-month period include Illinois, Florida, North Carolina, California, and New Mexico. States with abortion bans experienced the largest cumulative decreases in the number of abortions, including Texas, Georgia, Tennessee, and Louisiana (data varies by month in each state; data not shown).

States without abortion bans experienced an increase of abortions following the Dobbs ruling likely due to a combination of reasons: increased interstate travel for abortion access, expanded in-person and virtual/telehealth capacity to see patients, increased measures to protect and cover abortion care for residents and out-of-state patients, and potentially reduced abortion-related stigma as a result of community mobilization around abortion care.

However, the overall national increase in the number of abortions masks the absence and/or scarcity of abortion care in states with total abortion bans or severe restrictions. States with total bans experienced observed 94,930 fewer clinician-provided abortions a year following the ruling (data not shown). Note, this figure is an underestimate due several state policies that restricted abortion access during the pre- Dobbs period. These estimates do not include abortions that may have been performed through self-managed means.

Most of the information about people who receive abortions comes from data prior to the Dobbs ruling. In 2021, women across a range of age groups, socioeconomic status, and racial and ethnic backgrounds obtained abortions, but the majority were obtained by women who were in their twenties, low-income, and women of color.

• Women in their twenties accounted for more than half (57%) of abortions. Nearly one-third (31%) were among women in their thirties and a small share were among women in their 40s (4%) and teens (8%).
• Seven in ten abortion patients were of women of color. Black women comprised 42% of abortion recipients, White women 30% , Hispanic women 22%, and 7% women of other races/ethnicities.
• Many women who sought abortions have children. More than six in 10 (61%) abortion patients in 2021 had at least one previous birth.

The vast majority (94%) of abortions occur during the first trimester of pregnancy according to data available from before the Dobbs decision.

Before the 2022 ruling in Dobbs, there was a federal constitutional right to abortion before the pregnancy is considered to be viable, that is, can survive outside of a pregnant person’s uterus. Viability is generally considered around 24 weeks of pregnancy. Most abortions, though, occur well before the point of fetal viability.

• Data from 2021 found that more than four in ten (45%) abortions occurred by six weeks of gestation, a third (36%) occurred between seven and nine weeks, and 13% at 10-13 weeks. Just 7% of abortions occurred after the first trimester.
• Prior to the decision in the Dobbs case, almost half of states (22) had enacted laws that ban abortion at a certain gestational age. Most of these limits are in the second trimester, but some are in the first trimester, well before fetal viability. Many of these laws were blocked because they violated the federal standard established by Roe v Wade. Some states have enacted laws banning abortions after fetal cardiac activity can be detected, or around 6 weeks of pregnancy, which is often before a person knows they are pregnant. In addition to banning abortion, states can now establish pre-viability gestational restrictions because the federal standard has been overturned.

Just over half of abortions were provided at clinics that specialize in abortion care in 2020. Others were provided at clinics that offer abortion care in addition to other family planning services.

Guttmacher Institute estimated that 96% of abortions were provided at clinics and just 4% were provided in doctors’ offices or hospitals in 2020. Most clinic-based abortions were provided at clinics that specialize in providing abortion care, but many were provided at clinics that offer a wide range of other sexual and reproductive health services like contraception and STI care. Most abortions are provided by physicians. However, in 19 states and D.C., Advanced Practice Clinicians (APCs) such as Nurse Practitioners and midwives may provide medication abortions. Conversely, 31 states prohibit clinicians other than physicians from providing abortion care.

Even prior to the ruling in Dobbs , access to abortion services was very uneven across the country though. The proliferation of restrictions in many states, particularly in the South, had greatly shrunk the availability of services in some areas. In the wake of overturning Roe v. Wade , these geographic disparities are likely to widen as more states ban abortion services altogether.

Telehealth has grown as a delivery mechanism for abortion services.

While procedural abortions must be provided in a clinical setting, medication abortion can be provided in a clinical setting or via telehealth. Access to medication abortion via telehealth had been limited for many years by a Food and Drug Administration (FDA) restriction that had permitted only certified clinicians to dispense mifepristone in a health care setting. The drug could not be mailed or picked up at a retail pharmacy. However, in December 2021, the FDA permanently revised its policy and no longer requires clinicians to dispense the drug in person. Additionally, in January 2023, the FDA finalized a change that allows retail pharmacies to dispense medication abortion pills to patients with a prescription.

While some states are regulating the use of mifepristone as an abortion method, the Biden Administration has asserted that the FDA has regulatory power over all drugs, including mifepristone. This could result in future legal action as the authority of the state to regulate health care will be pitted against the authority of the federal government to regulate drugs through the FDA will be contested.

• In a telehealth abortion, the patient typically completes an online questionnaire to assess (1) confirmation of pregnancy, (2) gestational age and (3) blood type. If determined eligible by a remote clinician, the patient is mailed the medications. This model does not require an ultrasound for pregnancy dating if the patient has regular periods and is sure of the date of their last menstrual period (in line with  ACOG ’s guidelines for pregnancy dating). If the patient has irregular periods or is unsure how long they have been pregnant, they must obtain an ultrasound to confirm gestational age and rule out an ectopic pregnancy 3 and send in the images for review before receiving their medications. If the patient does not know their blood type or has Rh negative blood, the  provider  may prompt the patient to visit a nearby clinic for an injection to prevent adverse reactions between maternal and fetal blood ( RhoGAM ), The follow-up visit with a clinician can also happen via a telehealth visit.
• However, even in some of the states that have not banned abortion altogether, telehealth may not be available. Many states had established restrictions prior to the Dobbs ruling that limit the use of telehealth abortions by either requiring abortion patients to take the pills at a physical clinic, require ultrasounds for all abortions, set their own policies regarding the dispensing of the medications used for abortion care, or directly ban the use of telehealth for abortion care. As of November 2022, of the 33 states that have not banned abortion, eight had at least one of these restrictions, effectively prohibiting telehealth for medication abortion.
• Medication abortion has emerged as a major legal front in the battle over abortion access across the nation. Multiple cases have been filed in federal courts regarding aspects of the FDA’s regulation of medication abortion as well as the mailing of medications. One notable ongoing case is Alliance for Hippocratic Medicine v. FDA , where the plaintiffs are challenging the FDA’s authority and approval process for mifepristone. The plaintiffs also contend that an 1873 anti-obscenity law, the Comstock Act, prohibits the mailing of any medication used for abortion. In April 2023, a US Supreme Court ruling allowed current FDA rules to remain in effect as the case proceeds through the courts. This means that mifepristone remains available for medication abortion either in a clinic or via telehealth where state law permits.

Data from SFP’s October 2023 #WeCount report show that abortions provided by virtual-only clinics represent approximately 5% of all abortions post- Roe . The number of telehealth abortions increased 72% from a monthly average of 4,045 abortions in April and May 2022 to 6,950 abortions per month in the 12 months post- Dobbs . Nearly all of these abortions occurred in states that permit abortions.

Self-managed abortions are provided without a clinician visit.

Self-managed abortions typically involve obtaining medication abortion pills from an online pharmacy that will send the pills by mail or by purchasing the pills from a pharmacy in another country. This does not typically involve a direct consultation with a clinician either in person or via telehealth.

Research has found that prior to Dobbs , more than one in ten patients who obtained abortions at clinics had considered self-managing their abortions. This is likely to increase going forward since abortion care is not available in many states, and there have already been reports of people ordering pills from online markets outside the U.S. medical system. Tracking information on these online orders can help fill in gaps in abortion count estimates but can also be difficult. Some companies may not share data on purchases, and it would also be unclear whether patients take the abortion medication after receiving it in the mail.

The median costs of abortion services exceed $500.

Obtaining an abortion can be costly. On average, the costs are higher for abortions in the second trimester than in the first trimester. State restrictions can also raise the costs, as people may have to travel if abortions are prohibited or not available in their area. Many people pay for abortion services out of pocket, but some people can obtain assistance from local abortion funds.

• In 2021, the median costs for people paying out of pocket in the first trimester were $568 for a medication abortion and $625 for a procedural abortion. The Federal Reserve estimates that nationally about one-third of people do not have $400 on hand for unexpected expenses. For low-income people, who are more likely to need abortion care, these costs are often unaffordable.
• The costs of abortion are higher in the second trimester compared to the first, with median self-pay of $775. In the second trimester, more intensive procedures may be needed, more are likely to be conducted in a hospital setting (although still a minority), and local options are more limited in many communities that have fewer facilities. This results in additional nonmedical costs for transportation, childcare, lodging, and lost wages. nonmedical costs for transportation, childcare, lodging, and lost wages.
• Abortion funds are independent organizations that help some people pay for the costs of abortion services. Most abortion funds are regional and have connections to clinics in their area. Funds vary, but they typically provide assistance with the costs of medical care, travel, and accommodations if needed. However, they do not reach all people seeking services, and many people are not able to afford the costs of obtaining an abortion because they cannot pay for the abortion itself or cover the costs of travel, lodging or missed work.

Insurance coverage for abortion services is heavily restricted in certain private insurance plans and public programs like Medicaid and Medicare.

Private insurance covers most women of reproductive age, and states have the responsibility to regulate fully insured private plans in their state, whereas the federal government regulates self-funded plans under the Employee Retirement Income Security Act (ERISA). States can choose whether abortion coverage is included or excluded in private plans that are not self-insured.

• Prior to the Dobbs ruling, several states had enacted private plan restrictions and banned abortion coverage from ACA Marketplace plans. Currently, there are 11 states that have policies restricting abortion coverage in private plans and 26 that ban coverage in any Marketplace plans. Since the Dobbs ruling, some of these states have also banned the provision of abortion services altogether.
• A handful of states ( 9 ), however, have enacted laws that require private plans to cover abortion.
• The Medicaid program covers approximately one in five women of reproductive age and four in ten who are low-income. For decades, the Hyde Amendment has banned the use of federal funds for abortion in Medicaid and other public programs unless the pregnancy is a result of rape, incest, or it endangers the woman’s life.
• States have the option to use state-only funds to cover abortions under other circumstances for women on Medicaid, which 16 states do currently. However, more than half (56% ) of women covered by Medicaid live in Hyde states.
• According to a Guttmacher Institute survey of patients in the year prior to the Dobbs ruling, a quarter (26%) of abortion patients in the study used Medicaid to pay for abortion services, 11% used private insurance, and 60% paid out of pocket. People in states with more restrictive abortion policies were less likely to use Medicaid or private insurance and more likely to pay out of pocket compared to people living in less restrictive states.
• Federal law also restricts abortion funding under the Indian Health Service, Medicare, and the Children’s Health Insurance Program. Over the years, language similar to that in the Hyde Amendment has been incorporated into a range of other federal programs that provide or pay for health services to women including: the military’s TRICARE program, federal prisons, the Peace Corps, and the Federal Employees Health Benefits Program.

National polls have consistently found that a majority of the public did not want to see Roe v . Wade overturned and that most people feel that abortion is a personal medical decision. The public also strongly opposes the criminalization of abortion both among people who get abortion and the clinicians who provide abortion services. Nearly three quarters of adults (74%) and 79% of reproductive age women say that obtaining an abortion should be a personal choice rather than regulated by law (data not shown). For example, two-thirds of the public are concerned that bans on abortion may lead to unnecessary health problems for people experiencing pregnancy complications.

Additional KFF resources:

Abortion in the US Dashboard

Access and Coverage of Abortion Services

Issue Brief: Abortion at SCOTUS: Dobbs v. Jackson Women’s Health

Issue Brief: State Actions to Protect and Expand Access to Abortion Services

Policy Watch: A Year After Dobbs: Policies Restricting Access to Abortion in States Even Where It’s Not Banned

Policy Watch: Employer Coverage of Travel Costs for Out-of-State Abortion

Issue Brief: Exclusion of Abortion Coverage from Employer-Sponsored Health Plans

Interactive: How State Policies Shape Access to Abortion Coverage

Medication Abortion

Issue Brief: Legal Challenges to the FDA Approval of Medication Abortion Pills

Infographic: The Availability and Use of Medication Abortion Care

Fact Sheet: The Availability and Use of Medication Abortion

Issue Brief: The Intersection of State and Federal Policies on Access to Medication Abortion Via Telehealth

Public Opinion on Abortion

Web Event: Americans’ Knowledge and Attitudes About Abortion Access and The Pending Supreme Court Ruling

KFF Health Tracking Poll: Early 2023 Update On Public Awareness On Abortion and Emergency Contraception

KFF Health Tracking Poll: Views on and Knowledge about Abortion in Wake of Leaked Supreme Court Opinion

Other Resources on Women’s Health

Interactive: State Profiles for Women’s Health

Interactive: State Health Facts on Women’s Health Indicators

Homepage: Women’s Health Policy

• Women's Health Policy
• Access to Care

Also of Interest

• The Availability and Use of Medication Abortion
• State Actions to Protect and Expand Access to Abortion Services
• Legal Challenges to State Abortion Bans Since the Dobbs Decision
• Legal Challenges to the FDA Approval of Medication Abortion Pills
• Employer Coverage of Travel Costs for Out-of-State Abortion
• Abortion in the United States Dashboard

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• America’s Abortion Quandary

1. Americans’ views on whether, and in what circumstances, abortion should be legal

Table of contents.

• Abortion at various stages of pregnancy 
• Abortion and circumstances of pregnancy 
• Parental notification for minors seeking abortion
• Penalties for abortions performed illegally 
• Public views of what would change the number of abortions in the U.S.
• A majority of Americans say women should have more say in setting abortion policy in the U.S.
• How do certain arguments about abortion resonate with Americans?
• In their own words: How Americans feel about abortion 
• Personal connections to abortion 
• Religion’s impact on views about abortion
• Acknowledgments
• The American Trends Panel survey methodology

As the long-running debate over abortion reaches another  key moment at the Supreme Court  and in  state legislatures across the country , a majority of U.S. adults continue to say that abortion should be legal in all or most cases. About six-in-ten Americans (61%) say abortion should be legal in “all” or “most” cases, while 37% think abortion should be  illegal  in all or most cases. These views have changed little over the past several years: In 2019, for example, 61% of adults said abortion should be legal in all or most cases, while 38% said it should be illegal in all or most cases.    Most respondents in the new survey took one of the middle options when first asked about their views on abortion, saying either that abortion should be legal in  most  cases (36%) or illegal in  most  cases (27%). 

Respondents who said abortion should either be legal in  all  cases or illegal in  all  cases received a follow-up question asking whether there should be any exceptions to such laws. Overall, 25% of adults initially said abortion should be legal in all cases, but about a quarter of this group (6% of all U.S. adults) went on to say that there should be some exceptions when abortion should be against the law.

One-in-ten adults initially answered that abortion should be illegal in all cases, but about one-in-five of these respondents (2% of all U.S. adults) followed up by saying that there are some exceptions when abortion should be permitted. 

Altogether, seven-in-ten Americans say abortion should be legal in some cases and illegal in others, including 42% who say abortion should be generally legal, but with some exceptions, and 29% who say it should be generally illegal, except in certain cases. Much smaller shares take absolutist views when it comes to the legality of abortion in the U.S., maintaining that abortion should be legal in all cases with no exceptions (19%) or illegal in all circumstances (8%). 

There is a modest gender gap in views of whether abortion should be legal, with women slightly more likely than men to say abortion should be legal in all cases or in all cases but with some exceptions (63% vs. 58%). 

Younger adults are considerably more likely than older adults to say abortion should be legal: Three-quarters of adults under 30 (74%) say abortion should be generally legal, including 30% who say it should be legal in all cases without exception. 

But there is an even larger gap in views toward abortion by partisanship: 80% of Democrats and Democratic-leaning independents say abortion should be legal in all or most cases, compared with 38% of Republicans and GOP leaners.  Previous Center research  has shown this gap widening over the past 15 years. 

Still, while partisans diverge in views of whether abortion should mostly be legal or illegal, most Democrats and Republicans do not view abortion in absolutist terms. Just 13% of Republicans say abortion should be against the law in all cases without exception; 47% say it should be illegal with some exceptions. And while three-in-ten Democrats say abortion should be permitted in all circumstances, half say it should mostly be legal – but with some exceptions. 

There also are sizable divisions within both partisan coalitions by ideology. For instance, while a majority of moderate and liberal Republicans say abortion should mostly be legal (60%), just 27% of conservative Republicans say the same. Among Democrats, self-described liberals are twice as apt as moderates and conservatives to say abortion should be legal in all cases without exception (42% vs. 20%).

Regardless of partisan affiliation, adults who say they personally know someone who has had an abortion – such as a friend, relative or themselves – are more likely to say abortion should be legal than those who say they do not know anyone who had an abortion.

Views toward abortion also vary considerably by religious affiliation – specifically among large Christian subgroups and religiously unaffiliated Americans. 

For example, roughly three-quarters of White evangelical Protestants say abortion should be illegal in all or most cases. This is far higher than the share of White non-evangelical Protestants (38%) or Black Protestants (28%) who say the same. 

Despite  Catholic teaching on abortion , a slim majority of U.S. Catholics (56%) say abortion should be legal. This includes 13% who say it should be legal in all cases without exception, and 43% who say it should be legal, but with some exceptions. 

Compared with Christians, religiously unaffiliated adults are far more likely to say abortion should be legal overall – and significantly more inclined to say it should be legal in all cases without exception. Within this group, atheists stand out: 97% say abortion should be legal, including 53% who say it should be legal in all cases without exception. Agnostics and those who describe their religion as “nothing in particular” also overwhelmingly say that abortion should be legal, but they are more likely than atheists to say there are some circumstances when abortion should be against the law.

Although the survey was conducted among Americans of many religious backgrounds, including Jews, Muslims, Buddhists and Hindus, it did not obtain enough respondents from non-Christian groups to report separately on their responses.

As a  growing number of states  debate legislation to restrict abortion – often after a certain stage of pregnancy – Americans express complex views about when   abortion should generally be legal and when it should be against the law. Overall, a majority of adults (56%) say that how long a woman has been pregnant should matter in determining when abortion should be legal, while far fewer (14%) say that this should  not  be a factor. An additional one-quarter of the public says that abortion should either be legal (19%) or illegal (8%) in all circumstances without exception; these respondents did not receive this question.

Among men and women, Republicans and Democrats, and Christians and religious “nones” who do not take absolutist positions about abortion on either side of the debate, the prevailing view is that the stage of the pregnancy should be a factor in determining whether abortion should be legal.

Americans broadly are more likely to favor restrictions on abortion later in pregnancy than earlier in pregnancy. Many adults also say the legality of abortion depends on other factors at every stage of pregnancy. 

Overall, a plurality of adults (44%) say that abortion should be legal six weeks into a pregnancy, which is about when cardiac activity (sometimes called a fetal heartbeat) may be detected and before many women know they are pregnant; this includes 19% of adults who say abortion should be legal in all cases without exception, as well as 25% of adults who say it should be legal at that point in a pregnancy. An additional 7% say abortion generally should be legal in most cases, but that the stage of the pregnancy should not matter in determining legality. 1

One-in-five Americans (21%) say abortion should be  illegal  at six weeks. This includes 8% of adults who say abortion should be illegal in all cases without exception as well as 12% of adults who say that abortion should be illegal at this point. Additionally, 6% say abortion should be illegal in most cases and how long a woman has been pregnant should not matter in determining abortion’s legality. Nearly one-in-five respondents, when asked whether abortion should be legal six weeks into a pregnancy, say “it depends.” 

Americans are more divided about what should be permitted 14 weeks into a pregnancy – roughly at the end of the first trimester – although still, more people say abortion should be legal at this stage (34%) than illegal (27%), and about one-in-five say “it depends.”

Fewer adults say abortion should be legal 24 weeks into a pregnancy – about when a healthy fetus could survive outside the womb with medical care. At this stage, 22% of adults say abortion should be legal, while nearly twice as many (43%) say it should be  illegal . Again, about one-in-five adults (18%) say whether abortion should be legal at 24 weeks depends on other factors. 

Respondents who said that abortion should be illegal 24 weeks into a pregnancy or that “it depends” were asked a follow-up question about whether abortion at that point should be legal if the pregnant woman’s life is in danger or the baby would be born with severe disabilities. Most who received this question say abortion in these circumstances should be legal (54%) or that it depends on other factors (40%). Just 4% of this group maintained that abortion should be illegal in this case.

This pattern in views of abortion – whereby more favor greater restrictions on abortion as a pregnancy progresses – is evident across a variety of demographic and political groups. 

Democrats are far more likely than Republicans to say that abortion should be legal at each of the three stages of pregnancy asked about on the survey. For example, while 26% of Republicans say abortion should be legal at six weeks of pregnancy, more than twice as many Democrats say the same (61%). Similarly, while about a third of Democrats say abortion should be legal at 24 weeks of pregnancy, just 8% of Republicans say the same. 

However, neither Republicans nor Democrats uniformly express absolutist views about abortion throughout a pregnancy. Republicans are divided on abortion at six weeks: Roughly a quarter say it should be legal (26%), while a similar share say it depends (24%). A third say it should be illegal. 

Democrats are divided about whether abortion should be legal or illegal at 24 weeks, with 34% saying it should be legal, 29% saying it should be illegal, and 21% saying it depends. 

There also is considerable division among each partisan group by ideology. At six weeks of pregnancy, just one-in-five conservative Republicans (19%) say that abortion should be legal; moderate and liberal Republicans are twice as likely as their conservative counterparts to say this (39%). 

At the same time, about half of liberal Democrats (48%) say abortion at 24 weeks should be legal, while 17% say it should be illegal. Among conservative and moderate Democrats, the pattern is reversed: A plurality (39%) say abortion at this stage should be illegal, while 24% say it should be legal. 

Christian adults are far less likely than religiously unaffiliated Americans to say abortion should be legal at each stage of pregnancy.  

Among Protestants, White evangelicals stand out for their opposition to abortion. At six weeks of pregnancy, for example, 44% say abortion should be illegal, compared with 17% of White non-evangelical Protestants and 15% of Black Protestants. This pattern also is evident at 14 and 24 weeks of pregnancy, when half or more of White evangelicals say abortion should be illegal.

At six weeks, a plurality of Catholics (41%) say abortion should be legal, while smaller shares say it depends or it should be illegal. But by 24 weeks, about half of Catholics (49%) say abortion should be illegal. 

Among adults who are religiously unaffiliated, atheists stand out for their views. They are the only group in which a sizable majority says abortion should be  legal  at each point in a pregnancy. Even at 24 weeks, 62% of self-described atheists say abortion should be legal, compared with smaller shares of agnostics (43%) and those who say their religion is “nothing in particular” (31%). 

As is the case with adults overall, most religiously affiliated and religiously unaffiliated adults who originally say that abortion should be illegal or “it depends” at 24 weeks go on to say either it should be legal or it depends if the pregnant woman’s life is in danger or the baby would be born with severe disabilities. Few (4% and 5%, respectively) say abortion should be illegal at 24 weeks in these situations.

The stage of the pregnancy is not the only factor that shapes people’s views of when abortion should be legal. Sizable majorities of U.S. adults say that abortion should be legal if the pregnancy threatens the life or health of the pregnant woman (73%) or if pregnancy is the result of rape (69%). 

There is less consensus when it comes to circumstances in which a baby may be born with severe disabilities or health problems: 53% of Americans overall say abortion should be legal in such circumstances, including 19% who say abortion should be legal in all cases and 35% who say there are some situations where abortions should be illegal, but that it should be legal in this specific type of case. A quarter of adults say “it depends” in this situation, and about one-in-five say it should be illegal (10% who say illegal in this specific circumstance and 8% who say illegal in all circumstances). 

There are sizable divides between and among partisans when it comes to views of abortion in these situations. Overall, Republicans are less likely than Democrats to say abortion should be legal in each of the three circumstances outlined in the survey. However, both partisan groups are less likely to say abortion should be legal when the baby may be born with severe disabilities or health problems than when the woman’s life is in danger or the pregnancy is the result of rape. 

Just as there are wide gaps among Republicans by ideology on whether how long a woman has been pregnant should be a factor in determining abortion’s legality, there are large gaps when it comes to circumstances in which abortions should be legal. For example, while a clear majority of moderate and liberal Republicans (71%) say abortion should be permitted when the pregnancy is the result of rape, conservative Republicans are more divided. About half (48%) say it should be legal in this situation, while 29% say it should be illegal and 21% say it depends.

The ideological gaps among Democrats are slightly less pronounced. Most Democrats say abortion should be legal in each of the three circumstances – just to varying degrees. While 77% of liberal Democrats say abortion should be legal if a baby will be born with severe disabilities or health problems, for example, a smaller majority of conservative and moderate Democrats (60%) say the same. 

White evangelical Protestants again stand out for their views on abortion in various circumstances; they are far less likely than White non-evangelical or Black Protestants to say abortion should be legal across each of the three circumstances described in the survey. 

While about half of White evangelical Protestants (51%) say abortion should be legal if a pregnancy threatens the woman’s life or health, clear majorities of other Protestant groups and Catholics say this should be the case. The same pattern holds in views of whether abortion should be legal if the pregnancy is the result of rape. Most White non-evangelical Protestants (75%), Black Protestants (71%) and Catholics (66%) say abortion should be permitted in this instance, while White evangelicals are more divided: 40% say it should be legal, while 34% say it should be  illegal  and about a quarter say it depends. 

Mirroring the pattern seen among adults overall, opinions are more varied about a situation where a baby might be born with severe disabilities or health issues. For instance, half of Catholics say abortion should be legal in such cases, while 21% say it should be illegal and 27% say it depends on the situation. 

Most religiously unaffiliated adults – including overwhelming majorities of self-described atheists – say abortion should be legal in each of the three circumstances. 

Seven-in-ten U.S. adults say that doctors or other health care providers should be required to notify a parent or legal guardian if the pregnant woman seeking an abortion is under 18, while 28% say they should not be required to do so.  

Women are slightly less likely than men to say this should be a requirement (67% vs. 74%). And younger adults are far less likely than those who are older to say a parent or guardian should be notified before a doctor performs an abortion on a pregnant woman who is under 18. In fact, about half of adults ages 18 to 24 (53%) say a doctor should  not  be required to notify a parent. By contrast, 64% of adults ages 25 to 29 say doctors  should  be required to notify parents of minors seeking an abortion, as do 68% of adults ages 30 to 49 and 78% of those 50 and older. 

A large majority of Republicans (85%) say that a doctor should be required to notify the parents of a minor before an abortion, though conservative Republicans are somewhat more likely than moderate and liberal Republicans to take this position (90% vs. 77%). 

The ideological divide is even more pronounced among Democrats. Overall, a slim majority of Democrats (57%) say a parent should be notified in this circumstance, but while 72% of conservative and moderate Democrats hold this view, just 39% of liberal Democrats agree. 

By and large, most Protestant (81%) and Catholic (78%) adults say doctors should be required to notify parents of minors before an abortion. But religiously unaffiliated Americans are more divided. Majorities of both atheists (71%) and agnostics (58%) say doctors should  not  be required to notify parents of minors seeking an abortion, while six-in-ten of those who describe their religion as “nothing in particular” say such notification should be required. 

Americans are divided over who should be penalized – and what that penalty should be – in a situation where an abortion occurs illegally. 

Overall, a 60% majority of adults say that if a doctor or provider performs an abortion in a situation where it is illegal, they should face a penalty. But there is less agreement when it comes to others who may have been involved in the procedure. 

While about half of the public (47%) says a woman who has an illegal abortion should face a penalty, a nearly identical share (50%) says she should not. And adults are more likely to say people who help find and schedule or pay for an abortion in a situation where it is illegal should  not  face a penalty than they are to say they should.

Views about penalties are closely correlated with overall attitudes about whether abortion should be legal or illegal. For example, just 20% of adults who say abortion should be legal in all cases without exception think doctors or providers should face a penalty if an abortion were carried out in a situation where it was illegal. This compares with 91% of those who think abortion should be illegal in all cases without exceptions. Still, regardless of how they feel about whether abortion should be legal or not, Americans are more likely to say a doctor or provider should face a penalty compared with others involved in the procedure. 

Among those who say medical providers and/or women should face penalties for illegal abortions, there is no consensus about whether they should get jail time or a less severe punishment. Among U.S. adults overall, 14% say women should serve jail time if they have an abortion in a situation where it is illegal, while 16% say they should receive a fine or community service and 17% say they are not sure what the penalty should be. 

A somewhat larger share of Americans (25%) say doctors or other medical providers should face jail time for providing illegal abortion services, while 18% say they should face fines or community service and 17% are not sure. About three-in-ten U.S. adults (31%) say doctors should lose their medical license if they perform an abortion in a situation where it is illegal.

Men are more likely than women to favor penalties for the woman or doctor in situations where abortion is illegal. About half of men (52%) say women should face a penalty, while just 43% of women say the same. Similarly, about two-thirds of men (64%) say a doctor should face a penalty, while 56% of women agree.

Republicans are considerably more likely than Democrats to say both women and doctors should face penalties – including jail time. For example, 21% of Republicans say the woman who had the abortion should face jail time, and 40% say this about the doctor who performed the abortion. Among Democrats, far smaller shares say the woman (8%) or doctor (13%) should serve jail time.  

White evangelical Protestants are more likely than other Protestant groups to favor penalties for abortions in situations where they are illegal. Fully 24% say the woman who had the abortion should serve time in jail, compared with just 12% of White non-evangelical Protestants or Black Protestants. And while about half of White evangelicals (48%) say doctors who perform illegal abortions should serve jail time, just 26% of White non-evangelical Protestants and 18% of Black Protestants share this view.

• Only respondents who said that abortion should be legal in some cases but not others and that how long a woman has been pregnant should matter in determining whether abortion should be legal received questions about abortion’s legality at specific points in the pregnancy.  ↩

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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.

• Historical Abortion Law Timeline: 1850 to Today

Follow the journey of abortion law in the United States — from criminalization in the late 1800s to legalization in the early 1970s — and the ongoing battles for abortion access.

1847: Formation of the American Medical Association (AMA)

In 1847, doctors banded together to form the AMA. It became the male-dominated authority on medical practices. The AMA scrutinized reproductive health care workers, like midwives and nurses, and the obstetric  services they provided were phased out. 

AMA members believed they should have the power to decide when an abortion could be legally performed. At the same time, the AMA was composed of physicians who lacked expertise in pregnancy and reproductive health.

• AMA members launched a full-fledged criminalization campaign against abortion and female abortion providers. State legislatures moved to ban abortion.

1880s: Criminalization and Vilification

This backlash kicked off a “century of criminalization,” which was ended by Roe v. Wade in 1973 (see below).

Laws restricting abortion access became the norm. 

By 1880, all states had laws to restrict abortion — with exceptions in some states if a doctor said the abortion was needed to save the life or health of the patient, or for therapeutic reasons . 

As abortion became criminalized, the stigma surrounding it grew.

1910: Abortion Bans Nationwide

By 1910 , abortion was not only restricted but outright illegal at every stage in pregnancy in every state in the country. These abortion bans had some exceptions in instances to save the patient’s life — a decision that only doctors, 95% of whom were men , had the power to make.

By this time, America had experienced several decades of increased immigration. Worried about losing their hold on the country, white men in power supported abortion bans as a way to get upper-class white women to have more children.

1930: Deaths from Illegal, Unsafe Abortions

Criminalizing abortion sent the practice underground, which resulted in a high death toll. 

Unsafe, illegal abortion was the cause of death for nearly 2,700 women in 1930 — almost one out of every five (18%) of recorded maternal deaths that year, according to the Guttmacher Institute .

1955: Conference on Abortion Legalization

In response to increasingly alarming media coverage of unsafe, illegal abortions, Planned Parenthood held a first-of-its-kind conference on the issue of abortion.

The doctors who attended the national conference on abortion made the bold move to publicly call for abortion law reform. 

Conference attendees said that laws should be rewritten to allow doctors greater latitude to provide abortion services, which would improve public health and access to reproductive health care for people of different economic circumstances.

1962: Thalidomide

In the late 1950s and early ’60s, thousands of pregnant women took a drug called thalidomide to ease pregnancy symptoms. The problem: It was found to cause severe birth defects. 

In 1962, a pregnant TV host who ingested thalidomide could not obtain a legal abortion in the United States. The media tracked her journey to get an abortion in Sweden, and 52% of Americans supported her.

The thalidomide fallout brought greater support for abortion law reform.

1964 : Association for the Study of Abortion (ASA)

In 1964, abortion law reform activists registered their first national group: the Association for the Study of Abortion (ASA).

Planned Parenthood joined doctors and laypeople leading the ASA in advocating for abortion law reforms and for studies that would advance abortion procedure safety.

In a strategic move to incrementally increase abortion access, the ASA advocated only for " medically necessary " abortions. But members of the larger abortion law reform movement wanted a full repeal to legalize abortion for all people.

1966 : Trial of the San Francisco Nine  

Nine well-respected doctors were sued in California for performing abortions on women who had been exposed to rubella, a disease known to cause birth defects. 

Doctors across the country came to the defense of the San Francisco Nine, including the deans of 128 medical schools. 

This resulted in one of the first abortion reform measures in the United States. California amended its prohibition on abortion to allow hospital committees to approve requests for abortion.

1969: NARAL Established

The National Association for the Repeal of Abortion Laws (NARAL) was established in Chicago at the First National Conference on Abortion Laws.

NARAL was the first national group created solely to campaign for the legalization of abortion, marking the start of direct action to repeal abortion bans.

Late 1960s and early 1970s: Abortion Reform

By the late 1960s, a nationwide effort was underway to reform abortion laws in nearly every state. 

Health care providers, advocates, clergy members, and the legal community lobbied state legislatures and went to court to overturn statutes that had been in place since before the turn of the century. 

Between 1967 and 1973, four states — Alaska, Hawaii, New York, and Washington — repealed their abortion bans entirely, while 13 others enacted reforms that expanded exceptions. Instead of just allowing for abortion to save the patient’s life, they now allowed it in instances where a pregnancy was dangerous for the physical or mental health of a patient, fetal abnormalities, and when the pregnancy resulted from rape or incest.

1970: Legal Abortion in New York

In 1970, New York state legalized abortion . One day after that law took effect, a Planned Parenthood health center in Syracuse became the the first Planned Parenthood health center to provide abortion services, and the first free-standing abortion center nationwide. 

In the first two years after abortion was legalized in New York, two-thirds of the abortions performed in the state were on patients who had traveled from other states  — most of which still outlawed abortion. At the time, other states that had legalized abortion required patients to be state residents.

1973: Roe v. Wade

In a landmark decision, the U.S. Supreme Court ruled that the due process clause of the 14th Amendment to the Constitution protects the right to abortion. 

In particular, the Supreme Court recognized for the first time that the constitutional right to privacy “is broad enough to encompass a woman’s decision whether or not to terminate her pregnancy.”

Roe v. Wade protected the right to abortion in all 50 states, making abortion services safer and more accessible throughout the country. The decision also set a legal precedent that affected dozens of subsequent Supreme Court cases.

1976: Hyde Amendment Put Into Place

The Hyde Amendment is a discriminatory and racist policy that prevents federal dollars from being used in government insurance programs like Medicaid for abortion services (except in instances of incest, rape, or life-threatening risk to the pregnant person). 

The legislation was created by Rep. Henry Hyde. “I would certainly like to prevent, if I could legally, anybody having an abortion: a rich woman, a middle class woman, or a poor woman,” he said. “Unfortunately, the only vehicle available is the [Medicaid] bill.”

Because of centuries of systemic racism and bias, Medicaid disproportionately serves Black, Latino, and LGBTQ+ communities — people who already face other barriers to care and economic opportunity.

Despite the federal law, 16 states currently include abortion in their Medicaid programs using state funds. (The remaining 34 states and the District of Columbia do not have abortion coverage in their Medicaid programs due to the Hyde Amendment).

Thanks in large part to the advocacy of reproductive justice organizations, in 2021 the Biden-Harris administration became the first administration in decades to exclude the Hyde Amendment from its presidential budget.

1984: Global Gag Rule

Former President Ronald Reagan introduced the Mexico City policy, otherwise known as the global gag rule, in 1984. 

The global gag rule prevents foreign organizations that receive U.S. health aid from providing information on and referrals for abortions or advocating for abortion access.

Every president since Reagan who supports abortion access has rescinded the global gag rule, while every president since Reagan who opposes abortion access has reinstated it. That includes President Donald Trump , who not only reinstated it, but expanded the global gag rule to make it even more harmful.

1992: Planned Parenthood of Southeastern Pennsylvania v. Casey

This landmark case reaffirmed that the Constitution protects the right to abortion.

However, Casey created an “undue burden” framework, under which laws restricting access to abortion would be judged. This framework made it more difficult to challenge laws that were less than absolute prohibitions on abortion — requiring challenges to show that a law has the purpose or effect of placing a substantial obstacle in the path of a patient seeking an abortion.

Following Casey , state politicians passed numerous medically unnecessary abortion restrictions across the country which courts have found do not impose an undue burden.

2007: Gonzales v. Carhart and Gonzales v. Planned Parenthood Federation of America

The Supreme Court upheld the first federal legislation to criminalize abortion , allowing Congress to ban certain second-trimester abortion procedures — which are sometimes the safest and best way to protect a patient’s health.

Because the legislation does not contain an exception for the patient’s health, the Supreme Court effectively overruled a key component of Roe v. Wade : that the patient’s health must be of paramount concern in laws that restrict abortion access.

2016: Whole Woman's Health v. Hellerstedt

The Supreme Court ruled that two Texas abortion restrictions were unconstitutional because they would shut down most abortion providers in the state and impose an “undue burden” on access to safe, legal abortion in Texas.

2020: June Medical Services v. Russo

On June 29, 2020 — in June Medical Services v. Russo — the Supreme Court struck down a medically unnecessary law that was nearly identical to the one it had struck down in Whole Woman’s Health . This law would have made abortion virtually inaccessible in Louisiana.

Four justices dissented, and it was the last time Ruth Bader Ginsburg had a chance to rule on abortion access before she died later that year. Ginsburg was replaced by Amy Coney Barrett — who is one of three Supreme Court justices nominated by Donald Trump.

2021: Texas Six-Week Ban

On Sept. 1, 2021, Texas implemented a dangerous law called S.B. 8. which bans abortion at approximately six weeks of pregnancy — before many people even know they’re pregnant. 

The AMA denounced the Texas abortion ban, but the Supreme Court allowed it to take effect.

Where We’re Headed 

This history of abortion laws and court decisions provides important context to the road ahead.

Right now, 80% of Americans want abortion to be legal. 

On December 1, 2021 , the Supreme Court will hear oral arguments in Dobbs v. Jackson Women’s Health Organization — a case about a Mississippi ban on abortion at 15 weeks that’s a direct challenge to Roe v. Wade . The state of Mississippi not only has asked the Supreme Court to allow a pre- viability abortion ban, in violation of one of the core tenets of Roe v. Wade , but also has asked the Supreme Court to overrule Roe and Casey entirely.

The Supreme Court will issue a decision in Dobbs v. Jackson Women’s Health Organization by the end of June 2022. If Roe is overturned or its protections are dismantled, then the laws governing abortion will fall to individual state governments. Many people of reproductive age will lose access to safe, legal abortion in the United States.

No matter what happens, Planned Parenthood will continue to fight to uphold access to safe, legal abortion.

Abortion Access

• Roe v. Wade Overturned: How the Supreme Court Let Politicians Outlaw Abortion
• Federal and State Bans and Restrictions on Abortion
• Types of State Attacks on Abortion
• The State of Emergency for Women's Health
• Timeline of Attacks on Abortion: 2009–2021

The History of Abortion in America

Abortion has been legal for much of American history. Learn how.

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Abortion - List of Free Essay Examples And Topic Ideas

Abortion is a highly contentious issue with significant moral, legal, and social implications. Essays on abortion could explore the various aspects of the debate including the ethical dimensions, the legal frameworks governing abortion, and the social attitudes surrounding it. They might delve into historical changes in public opinion, the different arguments presented by pro-life and pro-choice advocates, and the impact of legal rulings on the accessibility and safety of abortion services. Discussions could also explore the intersection of abortion with issues like gender equality, religious freedom, and medical ethics. We have collected a large number of free essay examples about Abortion you can find at Papersowl. You can use our samples for inspiration to write your own essay, research paper, or just to explore a new topic for yourself.

Issue of Sex-Selective Abortion

Sex-selective abortion is the practice of ending a pregnancy due to the predicted gender of the baby. It has been occurring for centeriues in many countries many people believe that males are more valuable than females. This practice has been happening in many Asian countries but even in the US many Asians still hold strong to those beliefs. Due to these beleifs there is a huge shift in sex ratio in Asian countries. People are using the technology to determine […]

Abortion and Women’s Rights

In spite of women's activist desires, the matter of conceptive decision in the United States was not settled in 1973 by the important Supreme Court choice on account of Roe v. Wade. From the beginning there was animal-like restriction by the Catholic Church. Anyway, in the course of at least the last 20 years, the too early or soon birth discussion has changed into a definitely spellbound, meaningful debate between two differentiating societal talks that are moored to the problems […]

Women’s Rights in the United States in the 1970s

In the 1940’s-1960’s, there was a blurred distinction between clinical and sexual exams within the medical field (Wendy Kline, She’s Beautiful When She’s Angry). For example, many male doctors would provide pelvic exams as a means to teach women sex instruction, and were taught to assert their power over their patients. This led to women instituting new training programs for proper examinations, creating a more gentle and greatly-respected method of examining women and their bodies. There was also an increase […]

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Abortion: a Woman’s Choice

Women have long been criticized in every aspect of their lives. They have even little to no choice about how to live their lives. Much like, abortion, which is the termination of a pregnancy after, accompanied by, resulting in, or closely followed by the death of the embryo or fetus. It has been one of the most sensitive topics, society sees it as a murderous act. On, January 22, 1973, the Supreme Court ruled on making the availability of abortion […]

Abortion: the most Debated Topic

There is no question that abortion is one of the most debated topics of the last 50 years. Women all over the United States tend to feel passionately over one side or the other, either pro-choice or anti-abortion. Not one to shy away from controversial subjects, I chose this topic to shed light on both sides of the ethical and moral decision of this important issue surrounding a termination of pregnancy. There is no question the gravity of this decision, […]

Women’s Rights to Choose

Every person in the United States is granted inalienable rights, whether it be to practice their own religion or vote, which should include autonomy over their own bodies.  A woman should have the right to choose what she does with her own body, and in 1973 that became a possibility for American women.  In 1973 Roe v. Wade made it possible for women to legally choose to terminate unwanted pregnancies within their first two trimesters.  The government finally took into […]

Don Marquis’s View on Abortion

Don Marquis begins his argument of abortion being immoral by mentioning the pro-choice premise, which was that the statement of a fetus is never a person being too narrow. It's too narrow because if the fetus is never a person, then what would be the difference of a 9-month-old fetus and a newborn baby? That would just mean that infanticide isn't considered murder because a 9-month-old fetus and newborn weren't ever considered to be a person. Marquis further mentions that […]

Effects of Abortion on Young Women

Abortion is defined as the deliberate termination of a human pregnancy. It is a controversial conversation that most people avoid having.  Abortion is different than most issues in politics, because it directly impacts women, rather than men. Young women being targeted over the last forty-five years, has changed the way the public views abortion and what it does to women. A rise in physical complications, mental health problems, and the modern wave of feminism are the effects of legalized abortion […]

The Murder of Innocence

Abortion is a new generation's way of shrugging off accountability of their action at the cost of human life agreeing to the first revision to the structure that says we have the proper way to give of discourse. Me personally for one beyond any doubt that most of us would agree to the reality that ready to say and do what we need and select. For it is our choice to control of speech our conclusions. In connection, moms at […]

The History of Abortion

The history of abortion' is more complex than most people realize. There has been a lot of debate in the past few years about abortion being murder/not murder. Abortion has become illegal in most states. There are several women who believe in "pro-choice" which means they want to have a choice taking care of the baby. I, personally, believe abortion is murder. You are killing a fetus that is going to be born within months and they don't have a […]

Abortion: Go or no Go

Premature birth ends a pregnancy by killing an actual existence yet the mother isn't accused of homicide. Is this right? Shockingly, this has happened roughly twenty million times in the previous twenty years. Tragically, in South Africa, an unborn human has been slaughtered lawfully because of the nation's insufficient laws! The enemy of a honest unprotected human is a killer, accordingly, the individual merits the discipline proportional to a killer by law. Premature birth on interest just gives a mother […]

Abotion: Right or Wrong

When does a person learn right from wrong?  Is someone that knows right from wrong, different from someone who does not? These questions bring up the topic of the difference between a "Human" and a "Person". A human would be of human genetics and have a certain build. On the other hand, a human can also not be a person at certain points in the stage of life. If you can distinguish right from wrong, and are able to make […]

Let’s Talk about my Abortion Article

Why is something that requires two people, almost always considered the woman's problem? Every answer to this question is different, more aggressive in some cases, but it narrows down to basic human rights. Now you may be asking "What the hell is she talking about?" and I can assure you, we will get to that. I'd like for you to first put yourself in a situation: You're given a puppy, yet you're allergic to dogs and absolutely do not have […]

Debates on Abortion Theme

Abortion has proved to be a highly controversial topic in religion, politics, and even ethics. Its debate has caused division between factions with some supporting and others opposing its practice. This issue has also landed in the realm of philosophy where several ethicists have tried to explain why they think the method should either be supported or opposed. This essay looks at the works of Judith Thomson and Don Marquis as a representation of both sides of arguments (advocates and […]

Abortion on Teens should be Abolished

Am sure we have all heard of the girl meets boy story, where the girl falls in love with the boy despite receiving plenty of warnings and criticism from any person who has ever mattered in the girl's life. Everything is merry and life is good for the girl until one day she realizes she has missed her period and rushes to her man's home telling herself that everything will be okay. Reality checks in, hard, when the boy declines […]

The Mother and Abortion

For Gwendolyn Brooks, writing poetry that would be considered out of the ordinary and frowned upon was a common theme for her. Her widespread knowledge on subjects like race, ethnicity, gender, and even abortion placed this African American poet apart from many others. Like many poets, Brooks based many of her works on her own life experiences. Although it's unclear whether or not Brooks had an abortion herself, she creates hints and provokes strong feelings towards the issue, revealing the […]

An Issue of Women’s Reproductive Rights

We hold these truths to be self-evident: that men and women are created equal (Elizabeth Cady Stanton). In America this has been the basis of what our nation stands for. It is stated that every citizen has the right to equality that shall not be stripped away, in many cases that is not true. Whether man or women you should possess the same rights, but more often than not the women's rights are taken away. There are many instances in […]

What is Abortion

Every year, approximately 40-50 million abortions are conducted. That's about 125,000 little human beings being vacuumed, sucked out, and dissolved, everyday. That's 1 baby being aborted every 26 seconds. As of 58% of Americans think abortion should be legal.. Only 37% thinks it should be illegal in all, Or most cases. Abortion should be eliminated because it is murder, gives women mental health issues, and can cause high risks in the mother's future baby's health. There are two different types […]

The Complex Debate: Exploring Abortion Laws and their Implications

There has been a disputed discussion in history among religious, political, ethical, moral and practical grounds when it comes to the case about abortion. Abortion law forbids, allows, limits and governs the availability of abortion. Abortion laws alter to a high degree by country. For example, three countries in Latin America and two others in Europe ban the act of abortion altogether. In other countries like the United Kingdom contains the abortion act of 1967 that clarifies and prescribes abortion […]

My Beliefs on Abortion

Society today condones the killing of a life, they call it abortion, but I will try to show you why this is wrong.  Life begins at conception.  The Bible provides proof that God knew us before we were even formed.  This provides truth that what is inside a woman's body is a human life. I believe that when you decide to have an abortion, you are deciding to kill an innocent baby.  Whether you're doing it because the baby may […]

Research on Abortion Issues

The raging battle for women's rights can be found in almost every avenue of American culture. Whether it be in the workplace, in the government, in churches, or within families, females are fighting for their freedom to control their own lives. They want to work in whichever field they desire, to love whomever they want, and to make decisions for themselves. One of the biggest cases in the quarrel for feminism is the legalization of abortion. Women argue that it […]

Reasons the Constitution of Texas should be Rewritten

The constitution of Texas was written in 1876 but this constitution is not successful in this modern time. Rules and set of protocols which are written in this constitution are not valid for urban Texas these rules need to be amended. From the time of the adoption of this constitution, a total number of 653 amendments were proposed and out of these 653 a total of 474 amendments were approved by the voters and 179 were rejected. Some ?urrent political […]

Get Rid of Abortion or Not?

The world includes a huge variety of people who share different beliefs and morals, however, the Bible states that no one should judge others. One is supposed to respect another for whom they are as a person. The people in this world are beginning to divide because of the debate concerning if abortion is right, or if it is wrong. People identifying themselves to be pro-choice are in support of abortion because they believe a woman should be allowed to […]

Abortion Issues in Modern World

Premature birth alludes to the end of a pregnancy by evacuating or removing the baby or fetus from the uterus before it is prepared for birth. There are two noteworthy types of premature birth: unconstrained, which is regularly alluded to as an unsuccessful labor or the intentional fetus removal, which is frequently instigated fetus removal. The term fetus removal is normally used to allude to the prompted premature birth, and this is the premature birth, which has been loaded up […]

My Understanding of Abortion

Life has a beginning and an end and every individual knows this, as much as they may not want to know or understand it. An abortion, however, brings a thought to many people within our modern society: Is a baby alive before it is born? There are many ways to look at this but scientist have found out that there is an age of viability, where a baby is considered alive after a certain period of a woman's pregnancy. Before […]

Potential Factors that Influence Abortion

When it comes to women and unplanned pregnancies, there are alternatives other than abortions that a woman can use who and go for who isn't interested in having a child. Adoptions could be one of those alternatives; however, some women can't bear the thought of actually carrying a child. Therefore, they turn to their only option which is the abortion. For women, there are several reasons that may lead to them wanting to have an abortion. According to Stacey (2018), […]

The Status of Women’s Sexual and Reproductive Rights

The consequences of sexual behaviour between women and men have driven a desire and determination of women to control their fertility, yet in an environment in which anti-choice legislators and organizations do not protect women's reproductive rights, there is an ongoing dispute on who decides the fate of such rights. The status of women's sexual and reproductive rights remains controversial and while there have been many attempts to gain such basic human right, the fight for reproductive freedoms remains intense. […]

Abortion and Fathers Rights

In this section I will be focusing on the fathers' situation before and after conception, and bring out arguments how he could effectively avoid becoming a parent in any way (biological, bearer of financial costs, emotional). The father after conception has no alternatives left, unlike the mother has. She is in a position that can terminate the pregnancy by opting for an abortion, or she can carry out (or at least try to) the pregnancy until the end. The father […]

Abstinence only Vs. Abortion Rates

If an individual decides to have premarital sex and becomes pregnant it is likely that they will be shamed by someone no matter what decision they make.  If they decide to keep the baby they will be shamed.  If they decided to put the baby up for adoption they will be shamed.  If they decide to get an abortion they will be shamed.  Although the United States of America was founded on the ideas of freedom of religion and the […]

Why Abortion should be Illegal

Abortion is an issue in today’s society, people that agree or disagree about taking an innocent life away. Even though women now have the legal right to decide what to do with their bodies and to decide whether to end a baby’s life, there are options other than abortions. Each and every life is valuable, and babies should be able to experience a future ahead of them. Abortions should be illegal. Making abortion illegal could allow children to live a […]

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Frequently Asked Questions

Why abortion is legal.

Due to the outcome of a Supreme Court hearing, abortion is completely legal. In 1973, the Supreme Court's ruling on Roe vs Wade provided people legal access to abortion across the entire country. While legal, some doctors will not perform abortions.

How Abortion Affects Economy?

Women who have access to legal abortion will have the ability to continue their education and careers. Women denied an abortion because of gestational limits are more than 80% more likely to experience bankruptcy or face eviction.

Where Abortion is Illegal?

Abortion is legal in the entire country of the US, but some states have restrictions based on gestational status, fetal fatal conditions, and even rape. Other countries around the world have different laws and some have completely outlawed abortion, including Honduras, the Dominican Republic, and El Salvador.

Will Abortion Affect Health?

Women who have an abortion by a medical professional are at no risk for future pregnancies and there are no risks to overall health. Abortions do not increase any risk of breast cancer or have any effect on fertility.

Is Abortion Morally Justifiable?

This will depend on the person and their beliefs. Many women find abortion to be moral and a choice they are allowed to make in regards to their own bodies. Some religions have a strict stance on abortion and deem it immoral, regardless of the reason.

How To Write an Essay About Abortion

Introduction to the topic of abortion.

Abortion is a deeply complex and often controversial topic, encompassing a range of ethical, legal, and social issues. In your essay's introduction, it is important to define abortion and the various viewpoints and ethical considerations surrounding it. This introduction should establish the scope of your essay, whether you are focusing on the moral arguments, the legal aspects, the impact on individuals and society, or a combination of these. Your introduction should set a respectful and scholarly tone, acknowledging the sensitivity of the topic and the diverse opinions held by different groups.

Developing a Balanced Argument

The body of your essay should be dedicated to presenting a balanced and well-reasoned argument. Whether your essay is persuasive, analytical, or exploratory in nature, each paragraph should focus on a specific aspect of the abortion debate. This could include the ethical implications of abortion, the legal history and current laws regarding abortion in different regions, the psychological and physical effects on individuals, or the societal impacts. It's crucial to back up your points with evidence, such as statistical data, legal texts, ethical theories, medical research, and sociological studies. Addressing counterarguments is also important to show that you have considered multiple viewpoints and to strengthen your own argument.

Exploring Ethical and Societal Implications

An essay on abortion should also delve into the ethical dilemmas and societal implications surrounding the topic. This might involve discussing the moral philosophies related to the right to life, bodily autonomy, and the definition of personhood. The societal perspective might include the impact of abortion laws on different socio-economic groups, public health considerations, and the role of education and family planning. This section of your essay should challenge readers to think critically about their own values and the role of societal norms and laws in shaping the abortion debate.

Concluding the Discussion

In your conclusion, bring together all the threads of your argument, emphasizing the complexity of the abortion debate. This is your final opportunity to reinforce your main points and leave a lasting impression on your readers. Reflect on the broader implications of the debate and the ongoing challenges in finding a consensus in such a polarized issue. You might also offer recommendations for future policy, research, or public discourse. Remember, a strong conclusion doesn't just restate what has been said; it provides closure and offers new insights, prompting readers to continue thinking about the topic long after they have finished reading your essay.

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How Biden’s abortion stance has shifted over the years

Since the Supreme Court overturned Roe v. Wade nearly two years ago, abortion has become a top campaign issue. Since then, President Biden has vociferously defended the right to choose an abortion and attacked former president Donald Trump , the presumptive GOP nominee, for eroding reproductive rights.

It might come as a surprise that Biden once opposed abortion and believed that Roe was wrongly decided. Here is how Biden’s stance on abortion has evolved over the decades.

June 1974: He doesn’t think a woman has ‘the sole right to say what should happen to her body’

I don’t think that a woman has the sole right to say what should happen to her body. — Profile in "Washingtonian" magazine, June 1, 1974

Just the year before, on Jan. 5, 1973, Biden had been sworn in as a senator. Later that month, the Supreme Court issued its landmark 7-2 ruling in Roe v. Wade, which protected the right to an abortion.

Biden’s personal struggle with the issue of abortion, as a devout Catholic, was evident early on in his political career. In 1974, he said he opposed a constitutional amendment banning abortion, reportedly telling a group of antiabortion activists in January that year that he did not have the right to force his personal or religious views upon others.

However, in one of his first profiles as a young senator, Biden also told Washingtonian magazine that he did not agree with the Supreme Court’s ruling on Roe and that he believed women did not have “the sole right” over what should happen to their bodies .

“But when it comes to issues like abortion, amnesty, and acid, I’m about as liberal as your grandmother,” Biden said in the piece published June 1974. “I don’t like the Supreme Court decision on abortion. I think it went too far.”

March 1982: He votes with Republicans to allow states to bypass Roe

I’m probably a victim, or a product, however you want to phrase it, of my background. — March 11, 1982

Biden was one of two Democrats on the Senate Judiciary Committee to vote with Republicans in favor of the Hatch Amendment, which would allow Congress and the states to bypass Roe v. Wade and restrict abortion. The amendment, proposed by then-Sen. Orrin G. Hatch (R-Utah), would have declared “that the Constitution does not secure the right to an abortion.”

At the time, Biden cited his Catholic faith and said it was “the single most difficult vote I’ve cast as a U.S. senator.” Despite his supportive vote, Biden expressed reservations about the amendment and said he reserved the right to vote differently on the floor, according to a Morning Call report at the time .

The amendment never received a vote on the Senate floor in 1982. Hatch introduced a similar version of the amendment the following year, but Biden voted against it in 1983.

April 1994: He says those opposed to abortion ‘should not be compelled to pay for them’

… those of us who are opposed to abortion should not be compelled to pay for them. — April 7, 1994

In a letter to a Delaware constituent — who had written then-Sen. Biden to ask, “Please don’t force me to pay for abortions against my conscience” — Biden emphasized his long history of voting against federal funding of abortions.

“I will continue to abide by the same principle that has guided me throughout my 21 years in the Senate: those of us who are opposed to abortion should not be compelled to pay for them,” Biden wrote, according to a copy of the letter obtained by NBC News . “As you may know, I have consistently — on no fewer than 50 occasions — voted against federal funding of abortions.”

March 2006: ‘I do not view abortion as a choice and a right’

I’m a little bit of an odd man out in my party … I do not view abortion as a choice and a right. — "Texas Monthly" interview, March 2006

Biden told Texas Monthly in 2006 that he had “made everybody angry” when it came to the issue of abortion, noting that he voted against funding for abortion as well as against restricting a woman’s right to have an abortion under Roe v. Wade.

He said his stance on abortion — which he did not view “as a choice and a right” — made him an “odd man out” in the Democratic Party.

“I think [abortion is] always a tragedy, and I think that it should be rare and safe, and I think we should be focusing on how to limit the number of abortions,” Biden said. “The fact of the matter is, I’ve never known of a woman having an abortion say ‘By the way, I feel like having an abortion.’ It’s always a tragic decision made. Always a difficult decision. And I think we should focus on how to deal with women not wanting abortion.”

April 2007: He calls reconciling abortion policy with his faith ‘the biggest dilemma’

I’m a practicing Catholic, and it is the biggest dilemma for me in terms of comporting my religious and cultural views with my political responsibility. — NBC's "Meet the Press" interview, April 2007

Biden’s internal struggle on the issue of abortion was on display again when in an interview on NBC’s “Meet the Press,” he spoke about the difficulty of reconciling his faith with his “political responsibility.”

Biden acknowledged that he supported a ban on late-term abortions but said he had changed his mind on the constitutionality of Roe v. Wade.

“ Roe v. Wade is as close to where we’re going to be able to get as a society that incorporates the general lines of debate within Christendom, Judaism and other faiths, where it basically says there is a sliding scale relating to viability of a fetus,” Biden said. “It does encompass, I’ve come to conclude, the only means by which — in this heterogeneous society of ours — we can reach some general accommodation on what is a religiously charged and a publicly charged debate.”

October 2012: He says he accepts that ‘life begins at conception,’ but ‘I just refuse to impose that on others’

Life begins at conception. … I just refuse to impose to impose that on others. — Vice presidential debate, October 11, 2012

Biden, who was then Barack Obama’s running mate, sparred with then-Rep. Paul D. Ryan (R-Wis.), GOP candidate Mitt Romney’s running mate, on abortion during a vice-presidential debate . Both Ryan and Biden said they recognized the Catholic Church’s position that life begins at conception. Biden, however, said he did not want to impose that on others.

“That’s the church’s judgment. I accept it in my personal life, but I refuse to impose it on equally devout Christians and Muslims and Jews. I just refuse to impose that on others,” Biden said.

Biden also noted Ryan had in the past argued that it would still be a crime to have an abortion even in the case of rape or incest.

“I just fundamentally disagree with that,” Biden said.

June 2019: He reverses support for Hyde Amendment

Circumstances have changed. — Speech at DNC's African American Leadership Council summit in Atlanta, June 6, 2019

Biden, a candidate in a crowded Democratic presidential primary, abruptly reversed his decades-long support for the Hyde Amendment, which banned federal funding for abortions.

After days of criticism over his support for the amendment — a sharp contrast with the rest of the Democratic field — Biden announced his change during a speech at the Democratic National Committee’s African American Leadership Council summit in Atlanta.

He told the crowd that in an environment where the Roe v. Wade decision on abortion was under attack in Republican-held states, he could no longer support a policy that limited funding.

“We’ve seen state after state including Georgia passing extreme laws,” Biden said. “It’s clear that these folks are going to stop at nothing to get rid of Roe .”

“Circumstances have changed,” he added.

June 2020: He vows to ‘protect women’s constitutional right to choose’

We will protect women’s constitutional right to choose. — Video remarks to Planned Parenthood Action Fund, June 15, 2020

Biden, the presumptive 2020 Democratic presidential nominee at this point, is endorsed by Planned Parenthood Action Fund . In recorded remarks, Biden says he is “proud to stand” with the group and vows to protect a woman’s right to choose — though he does not state the word abortion.

“It’s a simple proposition: Health care is a right not dependent on race, gender, income or Zip code. As president, I’m going to do everything in my power to expand access to quality, affordable health care for women, especially women of color,” Biden says in the video. “We will protect women’s constitutional right to choose. I’m proud to stand with you in this fight.”

January 2021: He signs health-care executive orders to ‘undo the damage Trump has done’

Basically, the best way to describe them, [is] to undo the damage Trump has done. — Oval Office remarks, January 28, 2021

Days after taking office as president, Biden signed two executive orders — one to expand access to affordable health care and another to reverse the restrictions on abortion access put in place by President Donald Trump’s administration.

“Basically, the best way to describe them, [is] to undo the damage Trump has done,” Biden said, emphasizing that he was not initiating any new laws.

“This is going back to what the situation was prior to [Trump’s] executive order,” Biden said. “And the second order I’m signing relates to protecting women’s health at home and abroad, and it reinstates the changes that were made … making it harder for women to have access to affordable health care as it relates to reproductive rights.”

May 2022: He says the right to choose an abortion is ‘fundamental’

I believe that a woman’s right to choose is fundamental, Roe has been the law of the land for almost fifty years, and basic fairness and the stability of our law demand that it not be overturned. — White House statement, May 3, 2022

In response to the leak of a Supreme Court draft opinion that suggested the Supreme Court was poised to overturn Roe v. Wade, Biden issued a statement that emphasized his support for a woman’s “fundamental” right to choose.

Biden noted that he had directed his Gender Policy Council and the White House Counsel’s Office to prepare options for “when any ruling is issued.” If the Supreme Court were to overturn Roe, he added, he called on voters and elected officials “at all levels” to protect the right to choose.

“We will need more pro-choice senators and a pro-choice majority in the House to adopt legislation that codifies Roe, which I will work to pass and sign into law,” he said.

June 2022: He calls on Congress to codify abortion rights after Supreme Court overturns Roe

This is a sad day for the country. — White House remarks, June 24, 2022

Shortly after the Supreme Court issued a decision that overturned Roe, Biden spoke from the White House, forcefully defending the right to choose an abortion and calling on Congress to codify abortion rights.

“This is a sad day for the country, in my view, but it doesn’t mean the fight’s over,” Biden said. “Let me very clear and unambiguous: The only way we can secure a woman’s right to choose, a balance that existed, is for Congress to restore the protections of Roe v. Wade as federal law.”

Biden declared that, during the upcoming midterm elections, “Roe is on the ballot.”

“Personal freedoms are on the ballot. The right to privacy, liberty, equality — they’re all on the ballot,” he added.

January 2024: He expands contraception, abortion protections through executive orders

I believe Roe v. Wade was right. — White House remarks, January 22, 2024

On what would have been the 51st anniversary of Roe v. Wade , Biden signed executive orders that would ensure expanded access to contraception, abortion medication and emergency abortions at hospitals.

In remarks at the White House, Biden blasted Republican lawmakers for continuing to push national abortion bans after the Supreme Court had ripped a “fundamental right” away from so many Americans. GOP lawmakers, he noted, were also trying to stop pregnant individuals from traveling to a different state to receive abortion care — or, in the case of one state, threatening to prosecute people who helped family members travel for that reason.

“That means even if you live in a state where the extremist Republicans are not running the show, your right to choose, your right to privacy would still be at risk if this law was passed — any of these were passed nationally,” Biden said. “Folks, this is what it looks like when the right to privacy is under attack. These extreme laws have no place — no place in the United States of America.”

Matt Viser and Colby Itkowitz contributed to this report.

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• Copy URL https://www.pbs.org/newshour/health/bitter-battle-over-abortion-complicates-enforcement-of-new-law-designed-to-protect-pregnant-workers

Bitter battle over abortion complicates enforcement of new law designed to protect pregnant workers

NEW YORK (AP) — Victoria Cornejo Barrera thought the legal helpline for workers sounded too good to be true.

A month earlier, Cornejo Barrera had been forced to take leave from her job as head custodian at a South Carolina high school after she turned in a doctor’s note asking to be exempt from tasks like climbing ladders and lifting more than 20 pounds because she was pregnant.

She spent a month crying and blaming herself for thinking she could keep her job while pregnant. She used up all her accumulated paid time off because she couldn’t afford to go without a paycheck. Then she got a notice from human resources saying she would have to start paying $600 a month to stay on health insurance while on unpaid leave.

“I was feeling so guilty. I was feeling like my pregnancy was the problem,” Cornejo Barrera said.

Searching for help online, she came across the website run by the legal advocacy organization A Better Balance, explaining about a federal law called the Pregnant Workers Fairness Act that entitled her to the types of accommodations she had been seeking. It had gone into effect in June 2023, a month before she was pushed out of her job.

Was the law really on her side? Cornejo Barrera called the helpline.

A new law’s complicated first year

Nearly 500 workers in similar circumstances have contacted the helpline in the year since the implementation of the Pregnant Workers Fairness Act, which strengthens the rights of workers to seek accommodations for pregnancy-related needs. The experiences of those workers tell a complicated story about the impact of a new law that is still unfamiliar to many employers, according to a report released Tuesday by A Better Balance, the organization that spearheaded a decade-long campaign for the law, which Congress finally passed in December 2022.

Most of those workers swiftly obtained accommodation after learning about their rights and invoking them with their employers, said Dina Bakst, co-founder and co-president of A Better Balance. But many women confronted employers who didn’t know about the law, misunderstood its scope or simply refused to comply, according to the report.

READ MORE: New York judge blocks amendment barring discrimination on gender identity and pregnancy outcomes

A bitter legal battle over whether the law covers abortion is further complicating its enforcement.

The dispute centers on Equal Employment Opportunity Commission regulations that took effect Tuesday detailing how employers should comply with the law, and which included abortion among the pregnancy-related conditions that entitle workers to time off and other accommodations.

On Monday, a federal judge in Louisiana temporarily prohibited the EEOC from enforcing the abortion provision of its rules against employers located in Louisiana and Mississippi, or against the U.S. Conference of Catholic Bishops and three other religious groups that filed a consolidated lawsuit against the EEOC, arguing that the abortion provision is an illegal interpretation of the Pregnant Workers Fairness Act.

Another judge in Arkansas last week dismissed a similar lawsuit filed by Republican attorneys general from 17 states, but Arkansas Attorney General Tim Griffin, who is leading the case, said he is considering legal options to continue pursuing the challenge.

That lawsuit had asked the judge to suspend the EEOC rules in their entirety, a prospect that the American Civil Liberties Union and the National Women’s Law Center, along with more than 20 labor and women’s advocacy groups, warned in amicus briefs could thwart the successful implementation of law. The EEOC’s rules, for example, make clear that employers cannot delay requests by asking pregnant workers for onerous paperwork to back claims of common pregnancy-related limitations such as morning sickness or back pain.

Although the pregnant workers law would remain in place even without the EEOC rules, advocates say it’s a badly needed tool for settling disputes and training employers on compliance. According to A Better Balance, one out of seven workers who contacted its helpline since the law took effect said their employers had ordered them to take leave rather than grant them reasonable accommodations.

Cornejo Barrera was among them, but her employer reversed the decision after she sent her human resources department a letter invoking her rights. Within two days, she shared language from the Pregnant Workers Fairness Act with her supervisor, who then told her she could return to work immediately.

Raquel Robinson, a telecommunication specialist in Ohio, also ultimately prevailed in a similar confrontation with her company. After her daughter was born in October 2022, Robinson was diagnosed with postpartum depression.

“Mentally, I just was not in a good place where I felt like I was good enough to be my daughter’s mom,” she said.

After Robinson’s disability leave ended in July 2023, her therapist told her she was entitled to work from home under the new law. But her company resisted her request for more than a month.

Robinson reached out to A Better Balance for help and the company relented.

Other workers are still fighting to be protected under the law. The EEOC says it has received 1,869 charges so far citing violations of the Pregnant Workers Fairness Act and has resolved more than 450, though it has not provided details on the cases.

The abortion issue complicates the law

The law’s passage in 2022 came after years of campaigning by advocacy groups and women in low-wage jobs who shared stories of being denied even basic accommodations. But Republican lawmakers and conservative religious leaders who had overwhelmingly supported the Pregnant Workers Fairness Act were furious when the EEOC rules explicitly included abortion.

READ MORE: Research uncovers link between hormone and severe morning sickness during pregnancy

Citing numerous court rulings, the EEOC in its regulations said it was conforming to decades of legal precedent establishing that pregnancy-related discrimination laws include abortion.

Mylissa Farmer, the woman at the center of a federal investigation of two hospitals who refused to provide her with an emergency abortion, said her ordeal shows why the Pregnant Workers Fairness Act must include abortion.

Farmer sought emergency treatment after her water broke early at 17 weeks of pregnancy in August 2022. Doctors at hospitals in Missouri and Kansas told Farmer her fetus would not survive, that her amniotic fluid had emptied and that she was at risk for serious infection or losing her uterus but they refused to provide an abortion. She and her husband traveled for hours while she was in labor before a clinic in Illinois provided her with an abortion.

Farmer, who was working a low-wage job as a sales representative, said her supervisor repeatedly contacted her during her ordeal to pressure her to return to work. She said her doctor recommended she take two weeks off to recover but she returned to work after two days because she was afraid of getting fired. But she ended up facing discipline after absences to cope with the physical and mental trauma of losing her pregnancy.

“I was just not able to get the care that I needed at the time and it made it really difficult to even deal with the emotional loss of what we were going through,” said Farmer, who is being represented by the National Women’s Law Center in a complaint to the Centers for Medicare and Medicaid Services.

The Associated Press’ women in the workforce and state government coverage receives financial support from Pivotal Ventures. AP is solely responsible for all content. Find AP’s standards for working with philanthropies, a list of supporters and funded coverage areas at AP.org.

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Princeton Legal Journal

The First Amendment and the Abortion Rights Debate

Sofia Cipriano

4 Prin.L.J.F. 12

Following Dobbs v. Jackson ’s (2022) reversal of Roe v. Wade (1973) — and the subsequent revocation of federal abortion protection — activists and scholars have begun to reconsider how to best ground abortion rights in the Constitution. In the past year, numerous Jewish rights groups have attempted to overturn state abortion bans by arguing that abortion rights are protected by various state constitutions’ free exercise clauses — and, by extension, the First Amendment of the U.S. Constitution. While reframing the abortion rights debate as a question of religious freedom is undoubtedly strategic, the Free Exercise Clause is not the only place to locate abortion rights: the Establishment Clause also warrants further investigation. 

Roe anchored abortion rights in the right to privacy — an unenumerated right with a long history of legal recognition. In various cases spanning the past two centuries, t he Supreme Court located the right to privacy in the First, Fourth, Fifth, Ninth, and Fourteenth Amendments . Roe classified abortion as a fundamental right protected by strict scrutiny, meaning that states could only regulate abortion in the face of a “compelling government interest” and must narrowly tailor legislation to that end. As such, Roe ’s trimester framework prevented states from placing burdens on abortion access in the first few months of pregnancy. After the fetus crosses the viability line — the point at which the fetus can survive outside the womb  — states could pass laws regulating abortion, as the Court found that   “the potentiality of human life”  constitutes a “compelling” interest. Planned Parenthood of Southeastern Pennsylvania v. Casey (1992) later replaced strict scrutiny with the weaker “undue burden” standard, giving states greater leeway to restrict abortion access. Dobbs v. Jackson overturned both Roe and Casey , leaving abortion regulations up to individual states. 

While Roe constituted an essential step forward in terms of abortion rights, weaknesses in its argumentation made it more susceptible to attacks by skeptics of substantive due process. Roe argues that the unenumerated right to abortion is implied by the unenumerated right to privacy — a chain of logic which twice removes abortion rights from the Constitution’s language. Moreover, Roe’s trimester framework was unclear and flawed from the beginning, lacking substantial scientific rationale. As medicine becomes more and more advanced, the arbitrariness of the viability line has grown increasingly apparent.  

As abortion rights supporters have looked for alternative constitutional justifications for abortion rights, the First Amendment has become increasingly more visible. Certain religious groups — particularly Jewish groups — have argued that they have a right to abortion care. In Generation to Generation Inc v. Florida , a religious rights group argued that Florida’s abortion ban (HB 5) constituted a violation of the Florida State Constitution: “In Jewish law, abortion is required if necessary to protect the health, mental or physical well-being of the woman, or for many other reasons not permitted under the Act. As such, the Act prohibits Jewish women from practicing their faith free of government intrusion and thus violates their privacy rights and religious freedom.” Similar cases have arisen in Indiana and Texas. Absent constitutional protection of abortion rights, the Christian religious majorities in many states may unjustly impose their moral and ethical code on other groups, implying an unconstitutional religious hierarchy. 

Cases like Generation to Generation Inc v. Florida may also trigger heightened scrutiny status in higher courts; The Religious Freedom Restoration Act (1993) places strict scrutiny on cases which “burden any aspect of religious observance or practice.”

But framing the issue as one of Free Exercise does not interact with major objections to abortion rights. Anti-abortion advocates contend that abortion is tantamount to murder. An anti-abortion advocate may argue that just as religious rituals involving human sacrifice are illegal, so abortion ought to be illegal. Anti-abortion advocates may be able to argue that abortion bans hold up against strict scrutiny since “preserving potential life” constitutes a “compelling interest.”

The question of when life begins—which is fundamentally a moral and religious question—is both essential to the abortion debate and often ignored by left-leaning activists. For select Christian advocacy groups (as well as other anti-abortion groups) who believe that life begins at conception, abortion bans are a deeply moral issue. Abortion bans which operate under the logic that abortion is murder essentially legislate a definition of when life begins, which is problematic from a First Amendment perspective; the Establishment Clause of the First Amendment prevents the government from intervening in religious debates. While numerous legal thinkers have associated the abortion debate with the First Amendment, this argument has not been fully litigated. As an amicus brief filed in Dobbs by the Freedom From Religion Foundation, Center for Inquiry, and American Atheists  points out, anti-abortion rhetoric is explicitly religious: “There is hardly a secular veil to the religious intent and positions of individuals, churches, and state actors in their attempts to limit access to abortion.” Justice Stevens located a similar issue with anti-abortion rhetoric in his concurring opinion in Webster v. Reproductive Health Services (1989) , stating: “I am persuaded that the absence of any secular purpose for the legislative declarations that life begins at conception and that conception occurs at fertilization makes the relevant portion of the preamble invalid under the Establishment Clause of the First Amendment to the Federal Constitution.” Judges who justify their judicial decisions on abortion using similar rhetoric blur the line between church and state. 

Framing the abortion debate around religious freedom would thus address the two main categories of arguments made by anti-abortion activists: arguments centered around issues with substantive due process and moral objections to abortion. 

Conservatives may maintain, however, that legalizing abortion on the federal level is an Establishment Clause violation to begin with, since the government would essentially be imposing a federal position on abortion. Many anti-abortion advocates favor leaving abortion rights up to individual states. However, in the absence of recognized federal, constitutional protection of abortion rights, states will ban abortion. Protecting religious freedom of the individual is of the utmost importance  — the United States government must actively intervene in order to uphold the line between church and state. Protecting abortion rights would allow everyone in the United States to act in accordance with their own moral and religious perspectives on abortion. 

Reframing the abortion rights debate as a question of religious freedom is the most viable path forward. Anchoring abortion rights in the Establishment Clause would ensure Americans have the right to maintain their own personal and religious beliefs regarding the question of when life begins. In the short term, however, litigants could take advantage of Establishment Clauses in state constitutions. Yet, given the swing of the Court towards expanding religious freedom protections at the time of writing, Free Exercise arguments may prove better at securing citizens a right to an abortion. 

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The Safety and Quality of Abortion Care in the United States (2018)

Chapter: 5 conclusions, 5 conclusions.

This report provides a comprehensive review of the state of the science on the safety and quality of abortion services in the United States. The committee was charged with answering eight specific research questions. This chapter presents the committee’s conclusions by responding individually to each question. The research findings that are the basis for these conclusions are presented in the previous chapters. The committee was also asked to offer recommendations regarding the eight questions. However, the committee decided that its conclusions regarding the safety and quality of U.S. abortion care responded comprehensively to the scope of this study. Therefore, the committee does not offer recommendations for specific actions to be taken by policy makers, health care providers, and others.

1. What types of legal abortion services are available in the United States? What is the evidence regarding which services are appropriate under different clinical circumstances (e.g., based on patient medical conditions such as previous cesarean section, obesity, gestational age)?

Four legal abortion methods—medication, 1 aspiration, dilation and evacuation (D&E), and induction—are used in the United States. Length of gestation—measured as the amount of time since the first day of the last

___________________

1 The terms “medication abortion” and “medical abortion” are used interchangeably in the literature. This report uses “medication abortion” to describe the U.S. Food and Drug Administration (FDA)-approved prescription drug regimen used up to 10 weeks’ gestation.

menstrual period—is the primary factor in deciding what abortion procedure is the most appropriate. Both medication and aspiration abortions are used up to 10 weeks’ gestation. Aspiration procedures may be used up to 14 to 16 weeks’ gestation.

Mifepristone, sold under the brand name Mifeprex, is the only medication specifically approved by the FDA for use in medication abortion. The drug’s distribution has been restricted under the requirements of the FDA Risk Evaluation and Mitigation Strategy program since 2011—it may be dispensed only to patients in clinics, hospitals, or medical offices under the supervision of a certified prescriber. To become a certified prescriber, eligible clinicians must register with the drug’s distributor, Danco Laboratories, and meet certain requirements. Retail pharmacies are prohibited from distributing the drug.

When abortion by aspiration is no longer feasible, D&E and induction methods are used. D&E is the superior method; in comparison, inductions are more painful for women, take significantly more time, and are more costly. However, D&Es are not always available to women. The procedure is illegal in Mississippi 2 and West Virginia 3 (both states allow exceptions in cases of life endangerment or severe physical health risk to the woman). Elsewhere, access to the procedure is limited because many obstetrician/gynecologists (OB/GYNs) and other physicians lack the requisite training to perform D&Es. Physicians’ access to D&E training is very limited or nonexistent in many areas of the country.

Few women are medically ineligible for abortion. There are, however, specific contraindications to using mifepristone for a medication abortion or induction. The drug should not be used for women with confirmed or suspected ectopic pregnancy or undiagnosed adnexal mass; an intrauterine device in place; chronic adrenal failure; concurrent long-term systemic corticosteroid therapy; hemorrhagic disorders or concurrent anticoagulant therapy; allergy to mifepristone, misoprostol, or other prostaglandins; or inherited porphyrias.

Obesity is not a risk factor for women who undergo medication or aspiration abortions (including with the use of moderate intravenous sedation). Research on the association between obesity and complications during a D&E abortion is less certain—particularly for women with Class III obesity (body mass index ≥40) after 14 weeks’ gestation.

A history of a prior cesarean delivery is not a risk factor for women undergoing medication or aspiration abortions, but it may be associated

2 Mississippi Unborn Child Protection from Dismemberment Abortion Act, Mississippi HB 519, Reg. Sess. 2015–2016 (2016).

3 Unborn Child Protection from Dismemberment Abortion Act, West Virginia SB 10, Reg. Sess. 2015–2016 (2016).

with an increased risk of complications during D&E abortions, particularly for women with multiple cesarean deliveries. Because induction abortions are so rare, it is difficult to determine definitively whether a prior cesarean delivery increases the risk of complications. The available research suggests no association.

2. What is the evidence on the physical and mental health risks of these different abortion interventions?

Abortion has been investigated for its potential long-term effects on future childbearing and pregnancy outcomes, risk of breast cancer, mental health disorders, and premature death. The committee found that much of the published literature on these topics does not meet scientific standards for rigorous, unbiased research. Reliable research uses documented records of a prior abortion, analyzes comparable study and control groups, and controls for confounding variables shown to affect the outcome of interest.

Physical health effects The committee identified high-quality research on numerous outcomes of interest and concludes that having an abortion does not increase a woman’s risk of secondary infertility, pregnancy-related hypertensive disorders, abnormal placentation (after a D&E abortion), preterm birth, or breast cancer. Although rare, the risk of very preterm birth (<28 weeks’ gestation) in a woman’s first birth was found to be associated with having two or more prior aspiration abortions compared with first births among women with no abortion history; the risk appears to be associated with the number of prior abortions. Preterm birth is associated with pregnancy spacing after an abortion: it is more likely if the interval between abortion and conception is less than 6 months (this is also true of pregnancy spacing in general). The committee did not find well-designed research on abortion’s association with future ectopic pregnancy, miscarriage or stillbirth, or long-term mortality. Findings on hemorrhage during a subsequent pregnancy are inconclusive.

Mental health effects The committee identified a wide array of research on whether abortion increases women’s risk of depression, anxiety, and/or posttraumatic stress disorder and concludes that having an abortion does not increase a woman’s risk of these mental health disorders.

3. What is the evidence on the safety and quality of medical and surgical abortion care?

Safety The clinical evidence clearly shows that legal abortions in the United States—whether by medication, aspiration, D&E, or induction—are

safe and effective. Serious complications are rare. But the risk of a serious complication increases with weeks’ gestation. As the number of weeks increases, the invasiveness of the required procedure and the need for deeper levels of sedation also increase.

Quality Health care quality is a multidimensional concept. Six attributes of health care quality—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—were central to the committee’s review of the quality of abortion care. Table 5-1 details the committee’s conclusions regarding each of these quality attributes. Overall, the committee concludes that the quality of abortion care depends to a great extent on where women live. In many parts of the country, state regulations have created barriers to optimizing each dimension of quality care. The quality of care is optimal when the care is based on current evidence and when trained clinicians are available to provide abortion services.

4. What is the evidence on the minimum characteristics of clinical facilities necessary to effectively and safely provide the different types of abortion interventions?

Most abortions can be provided safely in office-based settings. No special equipment or emergency arrangements are required for medication abortions. For other abortion methods, the minimum facility characteristics depend on the level of sedation that is used. Aspiration abortions are performed safely in office and clinic settings. If moderate sedation is used, the facility should have emergency resuscitation equipment and an emergency transfer plan, as well as equipment to monitor oxygen saturation, heart rate, and blood pressure. For D&Es that involve deep sedation or general anesthesia, the facility should be similarly equipped and also have equipment to provide general anesthesia and monitor ventilation.

Women with severe systemic disease require special measures if they desire or need deep sedation or general anesthesia. These women require further clinical assessment and should have their abortion in an accredited ambulatory surgery center or hospital.

5. What is the evidence on what clinical skills are necessary for health care providers to safely perform the various components of abortion care, including pregnancy determination, counseling, gestational age assessment, medication dispensing, procedure performance, patient monitoring, and follow-up assessment and care?

Required skills All abortion procedures require competent providers skilled in patient preparation (education, counseling, and informed consent);

TABLE 5-1 Does Abortion Care in the United States Meet the Six Attributes of Quality Health Care?

a These attributes of quality health care were first proposed by the Institute of Medicine’s Committee on Quality of Health Care in America in the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century.

b Elsewhere in this report, effectiveness refers to the successful completion of the abortion without the need for a follow-up aspiration.

clinical assessment (confirming intrauterine pregnancy, determining gestation, taking a relevant medical history, and physical examination); pain management; identification and management of expected side effects and serious complications; and contraceptive counseling and provision. To provide medication abortions, the clinician should be skilled in all these areas. To provide aspiration abortions, the clinician should also be skilled in the technical aspects of an aspiration procedure. To provide D&E abortions, the clinician needs the relevant surgical expertise and sufficient caseload to maintain the requisite surgical skills. To provide induction abortions, the clinician requires the skills needed for managing labor and delivery.

Clinicians that have the necessary competencies Both trained physicians (OB/GYNs, family medicine physicians, and other physicians) and advanced practice clinicians (APCs) (physician assistants, certified nurse-midwives, and nurse practitioners) can provide medication and aspiration abortions safely and effectively. OB/GYNs, family medicine physicians, and other physicians with appropriate training and experience can perform D&E abortions. Induction abortions can be provided by clinicians (OB/GYNs,

family medicine physicians, and certified nurse-midwives) with training in managing labor and delivery.

The extensive body of research documenting the safety of abortion care in the United States reflects the outcomes of abortions provided by thousands of individual clinicians. The use of sedation and anesthesia may require special expertise. If moderate sedation is used, it is essential to have a nurse or other qualified clinical staff—in addition to the person performing the abortion—available to monitor the patient, as is the case for any other medical procedure. Deep sedation and general anesthesia require the expertise of an anesthesiologist or certified registered nurse anesthetist to ensure patient safety.

6. What safeguards are necessary to manage medical emergencies arising from abortion interventions?

The key safeguards—for abortions and all outpatient procedures—are whether the facility has the appropriate equipment, personnel, and emergency transfer plan to address any complications that might occur. No special equipment or emergency arrangements are required for medication abortions; however, clinics should provide a 24-hour clinician-staffed telephone line and have a plan to provide emergency care to patients after hours. If moderate sedation is used during an aspiration abortion, the facility should have emergency resuscitation equipment and an emergency transfer plan, as well as equipment to monitor oxygen saturation, heart rate, and blood pressure. D&Es that involve deep sedation or general anesthesia should be provided in similarly equipped facilities that also have equipment to monitor ventilation.

The committee found no evidence indicating that clinicians that perform abortions require hospital privileges to ensure a safe outcome for the patient. Providers should, however, be able to provide or arrange for patient access or transfer to medical facilities equipped to provide blood transfusions, surgical intervention, and resuscitation, if necessary.

7. What is the evidence on the safe provision of pain management for abortion care?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended to reduce the discomfort of pain and cramping during a medication abortion. Some women still report high levels of pain, and researchers are exploring new ways to provide prophylactic pain management for medication abortion. The pharmaceutical options for pain management during aspiration, D&E, and induction abortions range from local anesthesia, to minimal sedation/anxiolysis, to moderate sedation/analgesia, to deep sedation/

analgesia, to general anesthesia. Along this continuum, the physiological effects of sedation have increasing clinical implications and, depending on the depth of sedation, may require special equipment and personnel to ensure the patient’s safety. The greatest risk of using sedative agents is respiratory depression. The vast majority of abortion patients are healthy and medically eligible for all levels of sedation in office-based settings. As noted above (see Questions 4 and 6), if sedation is used, the facility should be appropriately equipped and staffed.

8. What are the research gaps associated with the provision of safe, high-quality care from pre- to postabortion?

The committee’s overarching task was to assess the safety and quality of abortion care in the United States. As noted in the introduction to this chapter, the committee decided that its findings and conclusions fully respond to this charge. The committee concludes that legal abortions are safe and effective. Safety and quality are optimized when the abortion is performed as early in pregnancy as possible. Quality requires that care be respectful of individual patient preferences, needs, and values so that patient values guide all clinical decisions.

The committee did not identify gaps in research that raise concerns about these conclusions and does not offer recommendations for specific actions to be taken by policy makers, health care providers, and others.

The following are the committee’s observations about questions that merit further investigation.

Limitation of Mifepristone distribution As noted above, mifepristone, sold under the brand name Mifeprex, is the only medication approved by the FDA for use in medication abortion. Extensive clinical research has demonstrated its safety and effectiveness using the FDA-recommended regimen. Furthermore, few women have contraindications to medication abortion. Nevertheless, as noted earlier, the FDA REMS restricts the distribution of mifepristone. Research is needed on how the limited distribution of mifepristone under the REMS process impacts dimensions of quality, including timeliness, patient-centeredness, and equity. In addition, little is known about pharmacist and patient perspectives on pharmacy dispensing of mifepristone and the potential for direct-to-patient models through telemedicine.

Pain management There is insufficient evidence to identify the optimal approach to minimizing the pain women experience during an aspiration procedure without sedation. Paracervical blocks are effective in decreasing procedural pain, but the administration of the block itself is painful, and

even with the block, women report experiencing moderate to significant pain. More research is needed to learn how best to reduce the pain women experience during abortion procedures.

Research on prophylactic pain management for women undergoing medication abortions is also needed. Although NSAIDs reduce the pain of cramping, women still report high levels of pain.

Availability of providers APCs can provide medication and aspiration abortions safely and effectively, but the committee did not find research assessing whether APCs can also be trained to perform D&Es.

Addressing the needs of women of lower income Women who have abortions are disproportionately poor and at risk for interpersonal and other types of violence. Yet little is known about the extent to which they receive needed social and psychological supports when seeking abortion care or how best to meet those needs. More research is needed to assess the need for support services and to define best clinical practice for providing those services.

Abortion is a legal medical procedure that has been provided to millions of American women. Since the Institute of Medicine first reviewed the health implications of national legalized abortion in 1975, there has been a plethora of related scientific research, including well-designed randomized clinical trials, systematic reviews, and epidemiological studies examining abortion care. This research has focused on examining the relative safety of abortion methods and the appropriateness of methods for different clinical circumstances. With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed.

The Safety and Quality of Abortion Care in the United States offers a comprehensive review of the current state of the science related to the provision of safe, high-quality abortion services in the United States. This report considers 8 research questions and presents conclusions, including gaps in research.

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The People Who Dismantled Affirmative Action Have a New Strategy to Crush Racial Justice

Last summer, in Students for Fair Admissions v. Harvard College , the Supreme Court’s conservative supermajority struck down race-conscious admission programs adopted by Harvard College and the University of North Carolina as violations of the 14 th Amendment’s equal protection clause. In doing so, the court’s conservative supermajority both ignored that the Framers of the 14 th Amendment were the originators of affirmative action and turned a blind eye to entrenched racial inequalities that make a mockery of the constitutional promise of equal citizenship. Now, Edward Blum, who was behind the attack on affirmative action in the SFFA case, and other conservative litigants intent on blocking racial justice efforts have a new strategy: remake the nation’s oldest federal civil rights law, the Civil Rights Act of 1866, into a weapon to challenge private efforts to ameliorate systemic racial discrimination and to redress the racial wealth gap.

Last week, in American Alliance for Equal Rights v. Fearless Fund Management , a divided panel of the U.S. Court of Appeals for the 11 th Circuit became the first federal court of appeals to place its imprimatur on Blum’s new tactic. In a 2–1 ruling, the court of appeals held that Fearless Fund’s grant program to provide capital funding to small businesses run by Black women violated a key federal civil rights statute that dates back to the Civil Rights Act of 1866. Known as Section 1981, this law guarantees the equal right to make and enforce contracts.

The court’s opinion, written by Judge Kevin Newsom and joined by Judge Robert Luck, both Donald Trump appointees, held that Fearless Fund’s privately financed effort to rectify the near-total exclusion of Black women from venture capital and ensure that women of color have access to the resources they need to enjoy economic freedom and succeed in business was an unlawful form of racial discrimination. Adopting a strict colorblind reading of Section 1981, Newsom insisted that permitting a grant program open only to Black women “would be anathema to the principles that underlie all antidiscrimination provisions” and preliminarily enjoined its operation.

Newsom’s majority opinion works hard to portray the result as compelled by settled legal principles, but make no mistake, Fearless Fund is a big deal: It perverts a landmark civil rights statute aimed at guaranteeing basic rights of economic citizenship to Black Americans and redressing the long shadow of enslavement, and it creates new barriers to efforts to ensure racial inclusion. Never mind that eradicating racial subordination and guaranteeing economic justice lie at the very core of Section 1981. The two Trump-appointed jurists in the majority effectively read these fundamental precepts out of the statute, holding that Black-owned companies cannot put their own private money into the work of redressing the racial wealth gap and helping to ensure the success of Black-owned companies. According to the court of appeals, Fearless Fund’s grant program must be available to white-owned businesses as well.

The colorblind reading of Section 1981 advanced by Newson’s majority opinion is profoundly antitextual. The Civil Rights Act of 1866 was intentionally written in a race-conscious manner. The act declares that citizens “of every race and color … shall have the same right … to make and enforce contracts, to sue, be parties, and give evidence, to inherit, purchase, lease, sell, hold, and convey real and personal property, and to full and equal benefit of all laws and proceedings for the security of person and property, as is enjoyed by white citizens.” Recognizing that enslaved Black Americans never had rights to contract and property—rights essential to equal citizenship—Congress used sweeping language to ensure that persons of “every race and color” would “enjoy” the same economic freedoms as “white citizens.” The statute is not aimed at the use or consideration of race at all; instead, it uses the rights of white citizens as a baseline to guarantee to Black Americans rights of economic citizenship that white citizens have long taken for granted. Newsom quotes the relevant statutory language, but pays the text lip service.

Congress chose this text for good reason: The Reconstruction-era Civil Rights Act was critical to enforcing the 13 th Amendment, eradicating badges of slavery and ensuring that Black Americans freed from bondage were entitled to basic economic rights and enjoyment of the fruits of their labor. It came in direct response to former enslavers seeking to impose new forms of servitude and reduce Black Americans to serfdom. With these new race-conscious protections, the Reconstruction-era Civil Rights Act’s Framers insisted, “all features of slavery which are oppressive in their character, which extinguish the rights of free citizens, and which unlawfully control their liberty shall be abolished and destroyed forever.” The Fearless Fund ruling perverts the statute’s roots in securing economic justice, even as it forbids Black-led businesses from using their own money to ameliorate systemic patterns of economic exclusion and inequality.

The Congress that enacted the Civil Rights Act of 1866 knew that private efforts were crucial to racial and economic uplift. One of the singular successes of Reconstruction was the creation of the nation’s first schools and colleges for Black Americans in the South , spurred by charitable giving by abolitionists and others who devoted significant resources to education in recognition that knowledge is power. In throwing up new roadblocks to the use of private money to redress racial and economic inequality, the Fearless Fund ruling is both deeply antitextual and antihistorical.

Fearless Fund will be far from the last word on the meaning of Section 1981. As other courts consider Ed Blum’s conservative effort to rewrite that critical act, they should remember that the Civil Rights Act of 1866 sought to redress continuing badges of enslavement and to make economic justice a reality. Reconstruction’s great constitutional transformations were race-conscious to the core. In passing statutes like the Civil Rights Act of 1866, Congress understood the need for far-reaching remedies to rectify centuries of racial enslavement, oppression, and violence and to ensure some measure of economic justice to Black Americans. Getting this history right is essential to exposing the glaring flaws in conservative rulings, like Fearless Fund , and to addressing the next wave of coming cases seeking to roll back racial justice efforts.

Highlights From the Supreme Court’s Abortion Pill Ruling

The justices unanimously rejected a bid to sharply curtail access to a widely available abortion pill, finding that the plaintiffs did not have standing to sue.

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Abbie VanSickle

The Supreme Court, for now, upholds access to a widely available abortion pill.

The Supreme Court on Thursday maintained access to a widely available abortion pill, rejecting a bid from a group of anti-abortion organizations and doctors to undo the Food and Drug Administration’s approval of the drug.

In a unanimous decision , written by Justice Brett M. Kavanaugh, the court held that the anti-abortion groups lacked a direct stake in the dispute, a requirement to challenge the F.D.A.’s approval of the pill, mifepristone.

“The plaintiffs do not prescribe or use mifepristone,” Justice Kavanaugh wrote. “And F.D.A. is not requiring them to do or refrain from doing anything.”

He added, “A plaintiff ’s desire to make a drug less available for others does not establish standing to sue.”

The case originally sought to erase the F.D.A.’s approval of mifepristone. But by the time it reached the Supreme Court, the question had been narrowed to whether the agency had acted legally in 2016 and 2021, when it broadened distribution of the pill, eventually including telemedicine and mail options.

The ruling handed a muted victory to abortion rights groups. Even as they praised the decision for averting severe restrictions on the availability of the pill, they warned that the outcome could be short-lived.

Anti-abortion groups vowed to press ahead, promising that the fight was far from over and raising the possibility that other plaintiffs, states in particular, would mount challenges to the drug.

The ruling did not affect separate restrictions on the pill in more than a dozen states that have passed near-total bans on abortion since the court eliminated a constitutional right to the procedure in Dobbs v. Jackson Women’s Health Organization. (The bans do not distinguish between medication and surgical abortion.)

Access to abortion remains broadly popular, and ever since the court overturned Roe v. Wade two years ago, prompting some states to swiftly enact bans, the issue has been a major focus of political campaigns. Democrats have succeeded in galvanizing voters to defeat anti-abortion measures and plan to highlight abortion rights in the November elections.

By dodging a ruling on the substance of the case, the justices avoided delivering a clear, substantive win to either political party or a decision they could use to motivate their base.

President Biden said in a statement that the “decision does not change the fact that the fight for reproductive freedom continues.”

He added, “It does not change the fact that the Supreme Court overturned Roe v. Wade two years ago, and women lost a fundamental freedom.”

The Biden campaign also raised concerns that the ruling would not be enough to protect access to abortion medication if former President Donald J. Trump wins a second term, saying his administration would move to enforce new restrictions through executive action.

Mr. Trump had wrestled with what position to take on abortion access after the Supreme Court, whose conservative supermajority he appointed, overturned the Roe v. Wade landmark abortion-rights case. Several weeks ago, he said it was up to states to set their own policies .

His campaign suggested he staked out a similar position on the abortion pill ruling, without addressing how his administration would handle regulation of the drug. “The Supreme Court has unanimously decided 9-0; the matter is settled,” Danielle Alvarez, a Trump spokeswoman, said.

Abortion rights groups cautioned that the ruling only maintained the status quo.

“The anti-abortion movement sees how critical abortion pills are in this post-Roe world, and they are hell bent on cutting off access,” Nancy Northup, the president of the Center for Reproductive Rights, said in a statement.

Erin Hawley, senior counsel for Alliance Defending Freedom, the conservative legal organization that represented the plaintiffs, suggested that the case could be revived through three Republican-led states, Idaho, Kansas and Missouri, which had intervened as plaintiffs at the lower court level.

“We are grateful that three states stand ready to hold the F.D.A. accountable for jeopardizing the health and safety of women and girls across this country,” Ms. Hawley said in a statement.

Mifepristone, part of a two-drug regimen, is used in nearly two-thirds of abortions in the United States. Many studies have found the pill to be safe , and years of research have shown that serious complications are rare.

After the F.D.A. loosened restrictions on the drug’s availability during the pandemic, allowing for it to be prescribed online or sent by mail, its use only increased. A rising number of medication abortions are prescribed by telemedicine. By one count , about one in six abortions, or around 14,000 a month, happened via telehealth from July through September 2023.

Medication abortion has become a practical form of abortion for women in states where the procedure is banned. Clinicians, protected by so-called shield laws in several states where abortion is legal, have mailed pills to women based in states with bans.

Justice Kavanaugh focused part of the majority opinion on why the justices disagreed with rulings by lower courts, which all determined the groups had standing to bring the case.

Citing Justice Antonin Scalia, Justice Kavanaugh wrote that to bring a suit, a plaintiff first must answer a basic question: “What’s it to you?”

Plaintiffs must show “a predictable chain of events leading from the government action to the asserted injury,” Justice Kavanaugh wrote.

In this instance, he wrote, the doctors and medical associations trying to challenge F.D.A.’s regulation failed to show an actual injury because the plaintiffs did not include people actually involved with the pill, such as doctors who prescribed mifepristone or pregnant women who took it.

The plaintiffs’ claims that they have “sincere legal, moral, ideological, and policy objections to mifepristone being prescribed and used by others” do not meet the threshold of standing to sue, Justice Kavanaugh wrote.

The justices also rejected an argument by the anti-abortion doctors that they had standing to sue because they could be required to provide emergency abortions against their conscience.

Federal conscience laws already protect doctors from being required to perform abortions or other treatment that violates their consciences, and none of the doctors had shown otherwise, Justice Kavanaugh wrote.

In a concurring opinion, Justice Clarence Thomas noted that he supported the decision “in full,” but cautioned that the court should take a limited view of when to allow organizations to claim standing on behalf of their members.

The case returned the issue of abortion to the Supreme Court, even as the conservative majority had declared, in overturning Roe v. Wade, that it would cede the question of access “to the people and their elected representatives.”

Its decision on Thursday appeared to vindicate that promise, although the court will soon decide another major case on abortion , involving a clash between federal law and tightened state restrictions.

The abortion pill case, F.D.A. v. Alliance for Hippocratic Medicine, reflected a new front in the fierce fight over abortion.

In the fall of 2022, an umbrella group of anti-abortion medical organizations, along with several doctors, challenged the F.D.A.’s approval of mifepristone more than two decades ago. In a preliminary ruling, a federal judge in Texas, Matthew J. Kacsmaryk, said that the F.D.A.’s approval of the drug should be suspended, removing mifepristone from the market.

Judge Kacsmaryk, a Trump appointee, joined the federal bench after years litigating at a conservative religious freedom firm, First Liberty Institute.

An appeals court, in New Orleans, overturned the part of Judge Kacsmaryk’s ruling that invalidated the F.D.A.’s approval of the pill, but it imposed certain restrictions on its distribution. Those restrictions included prohibiting the medication from being sent by mail or prescribed by telemedicine.

Maggie Haberman and Lisa Lerer contributed reporting from New York.

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The page where we keep track of the term’s decisions shows the justices have quite a few major decisions left to go, including on emergency abortions, whether former President Trump is immune from prosecution and whether cities can punish homeless people for sleeping in public spaces when there’s no other available shelter. Usually the court aims to rule on all its cases by the end of June.

Kate Zernike

Abortion rights groups celebrate the win, but fear ‘we are far from out of the woods.’

Medical groups and supporters of abortion rights hailed the Supreme Court’s rejection of the challenge to medication abortion, but with a heavy dose of caution.

“We are far from out of the woods,” said Cecile Richards, a former president of Planned Parenthood and now a leader of American Bridge, a group aligned with Democrats.

While the court on Thursday threw out the challenge from the Alliance for Hippocratic Medicine, attorneys general in three Republican-led states — Idaho, Missouri, and Kansas — are leading similar challenges that are likely to end up before the court.

And while the decision means that medication abortion will continue to be available at some pharmacies and by mail in states where abortion is legal, it does not change the fact that the pills remain illegal in the 14 states that ban abortion.

“Unfortunately, the attacks on abortion pills will not stop here — the anti-abortion movement sees how critical abortion pills are in this post-Roe world, and they are hellbent on cutting off access,” Nancy Northup, the president of the Center for Reproductive Rights, said in a statement. “In the end, this ruling is not a ‘win’ for abortion — it just maintains the status quo, which is a dire public health crisis.”

Abortion rights supporters argued that the challenge should never have ended up before the high court, because it was based on what many described as “junk science.” Two of the studies that anti-abortion groups had submitted to the court arguing that pills caused medical harm were retracted by medical journals.

Abortion rights and leading medical groups argue that the pills are “safer than Tylenol.”

“Decades of clinical research have proven mifepristone to be safe and effective, and its strong track record of millions of patient uses confirms that data,” Dr. Stella Dantas, president of the American College of Obstetricians and Gynecologists, said in a statement. “As the unanimous decision from the court makes clear in no uncertain terms, the people who brought this case were driven solely by a desire to impose their views on others and make it harder for patients to access safe, effective abortion care when they need it.”

Democratic leaders urged voters to stay energized to protect abortion rights, an issue that has driven gains for the party since the Supreme Court overturned Roe v. Wade two years ago. In a call with reporters, Julie Chavez Rodriguez, President Biden’s campaign manager, noted that the challenge to the abortion pills happened because of that decision by the court, which removed federal protections for abortion, and that the court overturned Roe v. Wade only because former President Donald J. Trump appointed three conservative justices.

She and Mini Timmaraju, the president of Reproductive Freedom for All, noted that Project 2025, drafted by groups supporting Mr. Trump, included a plan for him to direct the Food and Drug Administration to remove its approval of abortion pills. Trump allies are also pushing the revival of the Comstock Act, a 19th century anti-vice law, to prohibit mailing the pills even in states that allow abortion.

“We are going to be reminding Americans of all that’s at stake for reproductive freedom not just today, but on the debate stage — and every single day leading up to the election,” Ms. Chavez Rodriguez said. The campaign is planning abortion rights rallies on the anniversary of the court’s decision overturning Roe on June 24, which is three days before President Biden and Mr. Trump meet for their first debate before November’s election.

Read the Court’s Decision to Uphold Access to Abortion Pill

The Supreme Court upheld access to a widely available abortion pill, rejecting a bid from a group of anti-abortion organizations and doctors to unravel the Food and Drug Administration’s approval of the pill.

Elizabeth Dias

Anti-abortion activists press ahead after the loss: ‘We’ll be back.’

Anti-abortion stalwarts expressed widespread disappointment over the Supreme Court’s decision to uphold access to a widely available abortion pill, even as they vowed that their fight was far from over.

“We still have work to do,” said Erin Hawley, a lawyer for the Alliance Defending Freedom who argued the case. “A.D.F. is encouraged and hopeful that the F.D.A. will be held to account.”

She expressed hope that the court left room for legal action to continue for three states — Idaho, Kansas, and Missouri. In the long arc of anti-abortion activism, court losses historically can become victories as the lawyers and activists adapt their strategies and hone their arguments. Future challenges could consider alternative standing arguments, Ms. Hawley said.

“We stand with our allies, Attorneys General Raúl Labrador, Kris Kobach and Andrew Bailey, fighting to hold government bureaucrats accountable for betraying women and children,” Katie Daniel, the state policy director for Susan B. Anthony Pro-Life America, said in a statement, referring to Republican attorneys general in those states.

Activists continued to push their message, dismissed by mainstream scientists, that the abortion pill is harmful to women. Some, like Students for Life, attempted to pivot toward future unconventional legal arguments, like arguing against abortion on environmental grounds.

“The Biden Administration allowed distribution of Chemical Abortion Pills in a way that exposes women to injury, infertility, and death, as well as empowers abusers and created abortion water pollution,” Kristan Hawkins, the group’s president, said in a statement. “We’ll be back.”

Their eyes are also fixed on a remaining case about whether hospital emergency rooms are required to provide abortions in urgent situations, like if a woman’s life is in jeopardy. The Supreme Court is expected to decide that case this term.

Pam Belluck

Major medical groups praised the ruling. The American College of Obstetricians and Gynecologists said in a statement that it was relieved to know that “patients and clinicians across the country will continue to have access to mifepristone for medication abortion and miscarriage management.”

The president of the American Medical Association, Dr. Bobby Mukkamala, citing an association between restricted access to safe and legal abortion and higher rates of maternal morbidity and mortality, said the A.M.A. would continue to support access to “safe and effective reproductive health care against the ongoing threats of interference in the practice of medicine.”

The case is likely to be revived with three states as plaintiffs.

The Supreme Court’s decision on Thursday to dismissing one effort to curtail access to abortion pills did not eliminate the possibility that other plaintiffs would continue to mount challenges to the medication that is used in a majority of abortions in the country.

The lawsuit before the Supreme Court was rejected because the justices unanimously ruled that the plaintiffs — a group of anti-abortion doctors and organizations — did not have standing to sue because they could not show they had been harmed by the availability of abortion pills.

But the case is likely to be revived with different plaintiffs: three Republican-led states that months ago petitioned successfully to join the case at the lower court level.

Late last year, the states — Missouri, Idaho and Kansas — were granted status to be plaintiffs by Judge Matthew J. Kacsmaryk of the U.S. District Court for the Northern District of Texas, an appointee of President Donald J. Trump who heard the original lawsuit and who openly opposes abortion access . When the case was accepted by the Supreme Court, the justices denied the three states’ request to intervene as plaintiffs at that level.

But anti-abortion groups say the three states will likely now return to the district court and resurrect the attempt to restrict access to the medication, mifepristone.

In a statement on Thursday, SBA Pro-Life America, an anti-abortion group said: “The case returns to district court where the pro-life states of Idaho, Kansas and Missouri are seeking to take up the challenge based on harms suffered by women in their states.”

Questions of legal standing would be different for the states than they were for the anti-abortion doctors and medical groups, who claimed that they were injured by occasionally having to treat women who came to emergency rooms after taking abortion pills. The states would say they have been harmed because the federal government’s regulations allowing access to mifepristone have flouted state restrictions on abortion access.

“I would expect the litigation to continue with those states raising different standing arguments than made by our doctors,” Erin Hawley, a lawyer who represented the anti-abortion medical plaintiffs in the Supreme Court case, said Thursday.

The decision will also fuel efforts to restrict abortion pills in other ways. One recent example involved Louisiana classifying abortion pills as Schedule IV drugs, a category of controlled substances with some potential for abuse or dependence that includes Ambien, Valium and Xanax, among others. The categorization is contrary to medical evidence, and because Louisiana already bans most abortions, abortion rights activists and legal scholars said that in practice, the measure might not prevent many abortions among Louisiana women.

But on a political level, the new law in Louisiana supports the claim by critics that abortion pills are dangerous. And abortion-rights supporters say that such laws can create confusion among patients about what access is available to them, which might deter some from seeking abortions.

On the abortion rights side, the Supreme Court decision will likely embolden efforts to provide abortion access for women in the states with bans and restrictions. These include telemedicine abortion services, which continue to grow and have helped make medication the method used for nearly two-thirds of abortions in the United States.

There will also likely be greater use of shield laws , which allow doctors and abortion providers in states where it is legal to prescribe and mail pills to women in states with bans and restrictions, without requiring the women to travel out of state. Such laws have been enacted in seven states so far.

Maggie Haberman

Donald J. Trump had suggested in April to Time Magazine that he had “pretty strong views” on how a second administration would regulate the abortion pill mifepristone and that a plan would come in a matter of days. But that plan never came, and a spokeswoman last month suggested Trump was waiting for a Supreme Court ruling in a case related to mifepristone access. “The Supreme Court has unanimously decided 9-0. The matter is settled,” said Danielle Alvarez, a Trump spokeswoman.

Trump wrestled with what position to take after the Supreme Court, whose conservative supermajority he appointed, overturned the Roe v. Wade landmark abortion-rights case. Several weeks ago, he said it was up to states to set their own policies.

Status quo ruling may help Republicans minimize a political disadvantage.

The Supreme Court’s decision to uphold access to a widely available abortion pill frustrated antiabortion activists. But it allowed Republicans to dodge a potentially toxic issue in the midst of a tight presidential race.

Medication abortion remains broadly popular: A series of surveys have found that a majority of Americans support access to medication abortion, though the public is split over whether it should be available without a prescription.

A ruling limiting access to the medication would have given Democrats another way to hammer their opponents on an issue that’s become politically damaging for Republican politicians.

Since the Supreme Court decision that overturned Roe v. Wade in 2022, Republican candidates have struggled to reconcile their party’s decades-old opposition to abortion rights with the issue’s shifting political reality.

Donald J. Trump has notably refused to state his position on abortion medication, promising in April to release a policy on the issue “over the next week.”

On Thursday, his campaign tried to move past the issue and turn attention back to Mr. Biden.

“The Supreme Court has unanimously decided 9-0. The matter is settled,” said Danielle Alvarez, a senior adviser to the Trump campaign. “This election is about correcting the weakness, failures and dishonesty of the Biden crime family.”

Mr. Trump said that Republicans needed to improve their messaging on the issue in meetings with congressional Republicans on Capitol Hill after the decision. He urged his party to avoid discussion of bans at a specific number of weeks and instead leave the issue to the voters, according to a person in the room.

But the next president will have the power to restrict the drug or even criminalize it nationwide, through agencies like the Justice Department and Health and Human Services.

Allies of Mr. Trump and officials who served in his administration have suggested proposals that would enforce the Comstock Act , a long-dormant law from 1873, to criminalize the shipping of any materials used in an abortion — including abortion pills.

On a call with reporters, supporters of President Biden’s campaign said Mr. Trump would impose a national ban on medication abortion through executive action, pointing to policy plans released by his allies that would reverse the F.D.A.’s approval of the drug. Aides said that Mr. Biden plans to address the issue at the first presidential debate, scheduled for later this month, contrasting his support for abortion rights with Mr. Trump’s position that the policy should be left for states to decide.

“Trump and his allies are laying the groundwork to ban medication abortion nationwide,” said Mini Timmaraju, the chief executive of Reproductive Freedom for All, an abortion rights organization. She blamed the former president — who appointed three of the court’s conservative justices — for overturning Roe v. Wade, which established the constitutional right to abortion, in 2022.

The ruling is unlikely to end efforts by the antiabortion movement to restrict abortion medication. Missouri, Kansas and Idaho, all states with Republican attorneys general, remain parties in the lower court case and could try to revive the litigation as new plaintiffs.

Maggie Haberman contributed reporting.

Eileen Sullivan

The attorney general, Merrick B. Garland, said he was gratified by the Supreme Court’s decision. “The Department of Justice is committed to protecting reproductive freedom. We will continue to use every tool at our disposal to protect women’s access to mifepristone and other lawful reproductive care,” he said in a statement.

The company that makes generic mifepristone, GenBioPro, said it expected that “politically motivated attacks” on the drug would continue. “Mifepristone is safe, effective, and essential health care,” Evan Masingill, the chief executive of GenBioPro, said in a statement. “We remain committed to lawfully making our evidence-based, essential medications available in the United States and will continue to use all legal and regulatory tools at our disposal to protect access to mifepristone.”

Christina Jewett

The pharmaceutical industry is familiar with lawsuits against federal officials over policies it views as too restrictive. But it regarded this challenge over the abortion pill as potentially destabilizing, since companies rely on F.D.A. approval decisions to be final. Jim Stansel, the general counsel of the pharmaceutical lobby PhRMA, issued a statement to that effect: “We are pleased to see today’s decision from the U.S. Supreme Court which helps provide innovative biopharmaceutical companies the certainty needed to bring future medicines to patients.”

Adam Liptak

The ruling has nothing to do with the pills’ safety or morality.

The Supreme Court’s unanimous decision ensuring access to an abortion pill took no position on its safety or morality. Instead, Justice Brett M. Kavanaugh, writing for the court, focused entirely on standing. That is the legal doctrine that requires plaintiffs to show that they have suffered direct and concrete injuries in order to sue.

Justice Antonin Scalia, who died in 2016, once succinctly summarized the standing doctrine, saying it requires plaintiffs to answer this question: “What’s it to you?”

The plaintiffs in the case, doctors and medical associations who oppose abortion, had no good answer to that question, Justice Kavanaugh wrote.

Their main theory was that there was a statistical possibility that some doctors may at some point work in an emergency room and have to treat patients suffering from complications after taking the pill, subjecting the doctors to “enormous stress and pressure” and making them choose between their consciences and their professional obligations.

Justice Kavanaugh rejected that reasoning. “The plaintiff doctors and medical associations are unregulated parties who seek to challenge F.DA.’s regulation of others,” he wrote.

“Specifically, F.D.A.’s regulations apply to doctors prescribing mifepristone and to pregnant women taking mifepristone,” he wrote. “But the plaintiff doctors and medical associations do not prescribe or use mifepristone. And F.D.A. has not required the plaintiffs to do anything or to refrain from doing anything.”

It was significant, he wrote, that so-called conscience protections in federal law ensured that the plaintiffs never have to perform abortions or deal with possible complications from them.

The standing doctrine can mean that some legal questions never get answered in federal court, Justice Kavanaugh wrote. “Some issues,” he wrote, “may be left to the political and democratic processes.”

There are other avenues to try to limit the availability of the pills, he added.

“Citizens and doctors who object to what the law allows others to do may always take their concerns to the executive and legislative branches and seek greater regulatory or legislative restrictions on certain activities,” he wrote. That statement echoed a sentiment in the court’s 2022 decision overturning Roe v. Wade, which said the issue of abortion should be left to the elected branches.

Standing is a neutral legal principle that applies to the right and left alike, Chief Justice John G. Roberts Jr. wrote in an influential 1993 law review article while he was a lawyer in private practice.

“It restricts the right of conservative public interest groups to challenge liberal agency action or inaction,” he wrote, “just as it restricts the right of liberal public interest groups to challenge conservative agency action or inaction.”

Walter Dellinger , a former acting U.S. solicitor general, once said a rigorous approach to standing was consistent with Chief Justice Roberts’s statement at his confirmation hearings that judges should aspire to be umpires, whose only job is to call balls and strikes.

“Before any judge begins calling balls and strikes,” Mr. Dellinger said, “he must first make sure the batter at the plate is an actual player and not just a fan who ran on the field.”

The Biden campaign is arguing that the ruling is not enough to protect access to abortion medication if Donald J. Trump wins a second term, saying his administration would move to enforce new restrictions through executive action. “Trump and his allies are laying the groundwork to ban medication abortion nationwide,” said Mini Timmaraju, the president of Reproductive Freedom for All, on a press call hosted by the campaign.

Nearly 50 years ago, Dr. Étienne-Émile Baulieu came up with an idea for an “unpregnancy pill” that he thought would transform reproductive health care, allowing women to avoid surgery, act earlier and carry out their decisions in private. Read more about his eventful life , including his teenage days in the French Resistance.

Erin Hawley, the Alliance Defending Freedom lawyer who argued to restrict the pill, stressed that the Supreme Court ruled only on the standing of her clients, while noting that three states — Idaho, Kansas and Missouri — have also mounted challenges. “They didn’t get to the merits,” she said on a call with reporters. “Those merits will hopefully be at issue later on as the states may move forward.”

Legal scholars had feared that a ruling invalidating the approval of mifepristone could undercut the F.D.A.’s authority in deciding which medications are safe and effective. This decision, for now, puts those fears to rest.

It was an epic fight to make abortion pills legal in the United States in the first place. That fight was led by women’s rights groups, because drug companies were afraid of opposition from anti-abortion groups. Much of the effort was thanks to Peg Yorkin, a feminist leader who was early on dismissed as a “Hollywood wife.” You can read about her here .

Mifepristone is the drug formerly known as RU-486, first legalized in France in 1988. With anti-abortion groups in the United States fiercely opposing the efforts of women’s rights groups to bring the pills to the United States, it took 12 more years — until 2000 — for the F.D.A. to approve the use of the pills in this country.

There is still another major abortion case that the Supreme Court has not yet decided. That one is about whether emergency rooms in hospitals are required to provide abortions in urgent situations, like if a woman’s life is in jeopardy.

Mifepristone -- the first pill taken in the two-drug medication abortion regimen -- is approved by the F.D.A. for use through 10 weeks of pregnancy. But physicians and other abortion providers in the United States can legally use medical discretion to prescribe it through 12 weeks of pregnancy, the time frame recommended by the World Health Organization, since there is scientific evidence that abortion pills are safe within that time frame. (An earlier version of this update misstated the time period mifepristone can be used.)

Cecile Richards, the former president of Planned Parenthood, noted that the decision does not rule out future challenges. She added that states were continuing to make medication abortion harder to get; Lousiana recently criminalized possession of abortion pills. “I know from years of experience that women will do anything to end a pregnancy that they don’t want, and I fear that what the Supreme Court is doing, and anti-abortion politicians, they’re just making it more difficult, more costly, and threatening women’s health and their lives,” she said.

The decision will likely further galvanize efforts to provide access to abortion to women in states with bans or severe restrictions. Among the most powerful efforts has been shield laws, enacted so far in seven states that support abortion rights, which allow doctors and other abortion providers in shield law states to prescribe and mail abortion pills to women in states with abortion bans, without the women having to travel out of their states. Currently about 8,000 women a month are being provided access to abortion this way.

Justice Kavanaugh relies on so-called conscience protections in federal law, saying that doctors “shall not be required to provide treatment or assistance that would violate the doctors’ religious beliefs or moral convictions.”

And the Church Amendments more broadly provide that doctors shall not be required to provide treatment or assistance that would violate the doctors' religious beliefs or moral convictions. Most if not all States have conscience laws to the same effect.

Allison McCann

Out-of-state travel for abortions — either to have a procedure or obtain abortion pills — more than doubled in 2023 compared with 2019, and made up nearly a fifth of all recorded abortions. The Supreme Court decision allows the pills to remain available to patients traveling from states with bans.

The decision turned on standing, a doctrine grounded in the Constitution’s requirement that federal courts decide only concrete cases and controversies.

The standing requirement can leave a gap. It means, Justice Kavanaugh wrote, “that the federal courts may never need to decide some contested legal questions.”

And the standing requirement means that the federal courts may never need to decide some contested legal questions : “Our system of government leaves many crucial decisions to the political processes," where democratic debate can occur and a wide variety of interests and views can be weighed.

The decision will fuel efforts on the anti-abortion side to restrict abortion pills in other ways. One recent example involved Louisiana classifying abortion pills as Schedule IV drugs, a category that suggested they were dangerous or addictive substances, contrary to medical evidence .

Erin Hawley, a lawyer at the Alliance Defending Freedom and wife of Senator Josh Hawley, Republican of Missouri, was the lawyer who argued against the abortion pill. She represents the ideals of womanhood many in the anti-abortion and conservative Christian movement seek to elevate.

Even before the court’s decision in Dobbs allowed states to ban abortion, anti-abortion groups were pushing red states to restrict abortion pills, aware that they could become a workaround if abortion were banned. Read more here .

Amy Schoenfeld Walker

Yes, abortion pills are safe. Here’s what studies have shown.

The heart of the case against the abortion pill mifepristone is a claim that the pill is dangerous. Anti-abortion groups wrote in their complaint that the pill, taken with the abortion medication misoprostol, “causes significant injuries and harms to pregnant women and girls.”

Their claim is based on five studies, including two that a publisher retracted in February for using incorrect factual assumptions and misleading data presentation. Two other cited studies looked at the pill’s safety outside the 12-week window typically used in the United States. An author of the fifth cited study has said his team’s work was misinterpreted by the plaintiffs.

The claim also contradicts the large scientific record on the safety of the pills. A New York Times review last year found that more than 100 scientific studies, spanning continents and decades, concluded that a regimen of mifepristone and misoprostol is a safe and effective method for patients who want to end a pregnancy in the first trimester.

“There may be a political fight here, but there’s not a lot of scientific ambiguity about the safety and effectiveness of this product,” said Dr. Caleb Alexander, a professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health, and a co-director of the Center for Drug Safety and Effectiveness.

More recent research published provides more evidence of the pill’s safety.

Researchers found that taking abortion pills prescribed through telemedicine and received by mail is as safe and effective as when the pills are obtained by visiting a clinician. They looked at the experience of more than 6,000 patients using telemedicine abortion organizations that served 20 states and Washington, D.C. The researchers conducted the study in the months after the federal government allowed abortion pills to be mailed, from April 2021 to January 2022.

More than 99 percent of patients who took the pills had no serious complications. These uncommon complications can include hospitalizations, blood transfusions or major surgeries.

Are Abortion Pills Safe? Here’s the Evidence.

The Times reviewed 101 studies of medication abortion, spanning continents and decades. All concluded that the pills are a safe method for terminating a pregnancy.