The Most Important Study in the Abortion Debate

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The Most Important Study in the Abortion Debate
The Most Important Study in the Abortion Debate


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

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

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

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

In a 2007 decision, Gonzales v. Carhart, the Supreme Court upheld a ban on one specific, uncommon abortion procedure. In his majority opinion, Justice Anthony Kennedy ventured a guess about abortion’s effect on women’s lives: and sustained, ”he wrote. “Severe depression and loss of esteem can follow.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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