titles for abortion research paper

Home — Blog — Topic Ideas — 50 Abortion Essay Topics: Researching Abortion-Related Subjects

50 Abortion Essay Topics: Researching Abortion-Related Subjects

Abortion remains a contentious social and political issue, with deeply held beliefs and strong emotions shaping the debate. It is a topic that has been at the forefront of public discourse for decades, sparking heated arguments and evoking a range of perspectives from individuals, organizations, and governments worldwide.

The complexity of abortion stems from its intersection with fundamental human rights, ethical principles, and societal norms. It raises questions about the sanctity of life, individual autonomy, gender equality, and public health, making it a challenging yet critically important subject to explore and analyze.

This guide provides a comprehensive overview of the significance of choosing the right abortion essay topics and abortion title ideas , offering valuable insights and practical advice for students navigating this challenging yet rewarding endeavor. By understanding the multifaceted nature of abortion and its far-reaching implications, students can make informed decisions about their topic selection, setting themselves up for success in producing well-researched, insightful, and impactful essays.

Choosing the Right Abortion Essay Topic

For students who are tasked with writing an essay on abortion, choosing the right topic is essential. A well-chosen topic can be the difference between a well-researched, insightful, and impactful piece of writing and a superficial, uninspired, and forgettable one.

This guide delves into the significance of selecting the right abortion essay topic, providing valuable insights for students embarking on this challenging yet rewarding endeavor. By understanding the multifaceted nature of abortion and its far-reaching implications, students can identify topics that align with their interests, research capabilities, and the overall objectives of their essays.

Abortion remains a contentious social and political issue, with deeply held beliefs and strong emotions shaping the debate on abortion topics . It is a topic that has been at the forefront of public discourse for decades, sparking heated arguments and evoking a range of perspectives from individuals, organizations, and governments worldwide.

List of Abortion Argumentative Essay Topics

Abortion argumentative essay topics typically revolve around the ethical, legal, and societal aspects of this controversial issue. These topics often involve debates and discussions, requiring students to present well-reasoned arguments supported by evidence and persuasive language.

• The Bodily Autonomy vs. Fetal Rights Debate: A Balancing Act
• Navigating the Ethical Labyrinth of Abortion: Life, Choice, and Consequences
• Championing Gender Equality and Reproductive Freedom in the Abortion Debate
• Considering Abortion as a Human Right
• The Impact of Abortion Stigma on Women's Mental Health and Well-being
• The Impact of Abortion Restrictions on Poverty, Inequality, and Social Disparities
• Addressing Racial and Ethnic Disparities in Abortion Access and Health Outcomes
• Analyzing the Impact of Public Opinion and Voter Attitudes on Abortion Legislation
• Discussion on Whether Abortion is a Crime
• Abortion Restrictions and Women's Economic Opportunity
• Government Intervention in Abortion Regulation
• Religion, Morality, and Abortion Attitudes
• Parental Notification and Consent Laws
• Education and Counseling for Informed Abortion Choices
• Media Representation and Abortion Perceptions

Ethical Considerations: Abortion raises profound ethical questions about the sanctity of life, personhood, and individual choice. Students can explore these ethical dilemmas by examining the moral implications of abortion, the rights of the unborn, and the role of personal conscience in decision-making.

Legal Aspects: The legal landscape surrounding abortion is constantly evolving, with varying regulations and restrictions across different jurisdictions. Students can delve into the legal aspects of abortion by analyzing the impact of laws and policies on access, safety, and the well-being of women.

Societal Impact: Abortion has a significant impact on society, influencing public health, gender equality, and social justice. Students can explore the societal implications of abortion by examining its impact on maternal health, reproductive rights, and the lives of marginalized communities.

Effective Abortion Topics for Research Paper

Research papers on abortion demand a more in-depth and comprehensive approach, requiring students to delve into historical, medical, and international perspectives on this multifaceted issue.

Medical Perspectives: The medical aspects of abortion encompass a wide range of topics, from advancements in abortion procedures to the health and safety of women undergoing the procedure. Students can explore medical perspectives by examining the evolution of abortion techniques, the impact of medical interventions on maternal health, and the role of healthcare providers in the abortion debate.

Historical Analysis: Abortion has a long and complex history, with changing attitudes, practices, and laws across different eras. Students can engage in historical analysis by examining the evolution of abortion practices in ancient civilizations, tracing the legal developments surrounding abortion, and exploring the shifting social attitudes towards abortion throughout history.

International Comparisons: Abortion laws and regulations vary widely across different countries, leading to diverse experiences and outcomes. Students can make international comparisons by examining abortion access and restrictions in different regions, analyzing the impact of varying legal frameworks on women's health and rights, and identifying best practices in abortion policies.

List of Abortion Research Paper Topics

• The Socioeconomic Factors and Racial Disparities Shaping Abortion Access
• Ethical and Social Implications of Emerging Abortion Technologies
• Abortion Stigma and Women's Mental Health
• Telemedicine and Abortion Access in Rural Areas
• International Human Rights and Abortion Access
• Reproductive Justice and Other Social Justice Issues
• Men's Role in Abortion Decision-Making
• Abortion Restrictions and Social Disparities
• Racial and Ethnic Disparities in Abortion Access
• Alternative Approaches to Abortion Regulation
• Political Ideology and Abortion Policy Debates
• Public Health Campaigns for Informed Abortion Decisions
• Abortion Services in Conflict-Affected Areas
• Healthcare Providers and Medical Ethics of Abortion
• International Cooperation on Abortion Policies

By exploring these topics and subtopics for abortion essays , students can gain a more comprehensive understanding of the multifaceted nature of the abortion debate and choose a specific focus that aligns with their interests and research objectives.

Choosing Abortion Research Paper Topics

When selecting research paper topics on abortion, it is essential to consider factors such as research feasibility, availability of credible sources, and the potential for original contributions.

Abortion is a complex and multifaceted issue that intersects with various aspects of society and individual lives. By broadening the scope of abortion-related topics, students can explore a wider range of perspectives and insights.

• Demystifying Abortion Statistics: Understanding the Global and Domestic Landscape
• Abortion and Women's Rights: A Historical and Contemporary Perspective
• Decoding the Impact of Abortion on Public Health and Social Welfare
• Unveiling the Role of Media and Public Discourse in Shaping Abortion Perceptions
• Comparative Analysis of Abortion Laws Worldwide
• Historical Evolution of Abortion Rights and Practices
• Impact of Abortion on Public Health and Maternal Mortality
• Abortion Funding and Access to Reproductive Healthcare
• Role of Misinformation and Myths in Abortion Debates
• International Perspectives on Abortion and Reproductive Freedom
• Abortion and the UN Sustainable Development Goals
• Abortion and Gender Equality in the Global Context
• Abortion and Human Rights: A Legal and Ethical Analysis
• Religious and Cultural Influences on Abortion Perceptions
• Abortion and Social Justice: Addressing Disparities and Marginalization
• Anti-abortion and Pro-choice Movements: Comparative Analysis and Impact
• Impact of Technological Advancements on Abortion Procedures and Access
• Ethical Considerations of New Abortion Technologies and Surrogacy
• Role of Advocacy and Activism in Shaping Abortion Policy and Practice
• Measuring the Effectiveness of Abortion Policy Interventions

Navigating the complex landscape of abortion-related topics can be a daunting task, but it also offers an opportunity for students to delve into a range of compelling issues and perspectives. By choosing the right topic, students can produce well-researched, insightful, and impactful essays that contribute to the ongoing dialogue on this important subject.

The 50 abortion essay ideas presented in this guide provide a starting point for exploring the intricacies of abortion and its far-reaching implications. Whether students are interested in argumentative essays that engage in ethical, legal, or societal debates or research papers that delve into medical, historical, or international perspectives, this collection offers a wealth of potential topics to ignite their curiosity and challenge their thinking.

We use cookies to personalyze your web-site experience. By continuing we’ll assume you board with our cookie policy .

• Open access
• Published: 28 June 2021

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

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

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

20k Accesses

2 Citations

3 Altmetric

Metrics details

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

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

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

Systematic review registration

PROSPERO CRD42019126927

Peer Review reports

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

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

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

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

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

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

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

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

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

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

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

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

Eligibility criteria

Types of studies.

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

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

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

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

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

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

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

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

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

Intervention

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

National constitutions;

Supreme court decisions, as well as higher court decisions;

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

Medical ethical codes; and

Regulatory standards and guidelines governing the provision of abortion.

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

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

Outcome measures

Primary outcomes.

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

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

Secondary outcomes

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

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

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

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

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

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

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

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

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

Search methods

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

Ovid MEDLINE(R) (from 1946 to present)

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

CINAHL (1973 to present); and

Web of Science (1900 to present)

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

Search strategy

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

Data collection and analysis

Data management.

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

Selection process

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

Data extraction

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

Risk of bias and quality assessment

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

Confidence in cumulative evidence

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

Data synthesis

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

Information on the differential aspects of the abortion policy reforms.

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

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

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

Potential meta-analysis

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

Analysis of subgroups

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

Sensitivity analysis

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

Meta-biases

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

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

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

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

Abbreviations

Cumulative index to nursing and allied health literature

Excerpta medica database

Low- and middle-income countries

Preferred reporting items for systematic review and meta-analysis protocols

International prospective register of systematic reviews

Ganatra B, Gerdts C, Rossier C, Johnson BR, Tuncalp O, Assifi A, et al. Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model. Lancet. 2017;390(10110):2372–81. https://doi.org/10.1016/S0140-6736(17)31794-4 .

Article   PubMed   PubMed Central   Google Scholar  

Guttmacher Institute. Induced Abortion Worldwide; Global Incidence and Trends 2018. https://www.guttmacher.org/fact-sheet/induced-abortion-worldwide . Accessed 15 Dec 2019.

Singh S, Remez L, Sedgh G, Kwok L, Onda T. Abortion worldwide 2017: uneven progress and unequal access. NewYork: Guttmacher Institute; 2018.

Book   Google Scholar  

Fusco CLB. Unsafe abortion: a serious public health issue in a poverty stricken population. Reprod Clim. 2013;2(8):2–9.

Google Scholar  

Rehnstrom Loi U, Gemzell-Danielsson K, Faxelid E, Klingberg-Allvin M. Health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data. BMC Public Health. 2015;15(1):139. https://doi.org/10.1186/s12889-015-1502-2 .

Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):E323–E33. https://doi.org/10.1016/S2214-109X(14)70227-X .

Article   PubMed   Google Scholar  

Benson J, Nicholson LA, Gaffikin L, Kinoti SN. Complications of unsafe abortion in sub-Saharan Africa: a review. Health Policy Plan. 1996;11(2):117–31. https://doi.org/10.1093/heapol/11.2.117 .

Abiodun OM, Balogun OR, Adeleke NA, Farinloye EO. Complications of unsafe abortion in South West Nigeria: a review of 96 cases. Afr J Med Med Sci. 2013;42(1):111–5.

CAS   PubMed   Google Scholar  

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. 2016;123(9):1489–98. https://doi.org/10.1111/1471-0528.13552 .

Article   CAS   PubMed   Google Scholar  

Vlassoff M, Walker D, Shearer J, Newlands D, Singh S. Estimates of health care system costs of unsafe abortion in Africa and Latin America. Int Perspect Sex Reprod Health. 2009;35(3):114–21. https://doi.org/10.1363/3511409 .

Singh S, Darroch JE. Adding it up: costs and benefits of contraceptive services. Estimates for 2012. New York: Guttmacher Institute and United Nations Population Fund; 2012.

Auger N, Bilodeau-Bertrand M, Sauve R. Abortion and infant mortality on the first day of life. Neonatology. 2016;109(2):147–53. https://doi.org/10.1159/000442279 .

Krieger N, Gruskin S, Singh N, Kiang MV, Chen JT, Waterman PD, et al. Reproductive justice & preventable deaths: state funding, family planning, abortion, and infant mortality, US 1980-2010. SSM Popul Health. 2016;2:277–93. https://doi.org/10.1016/j.ssmph.2016.03.007 .

Banaem LM, Majlessi F. A comparative study of low 5-minute Apgar scores (< 8) in newborns of wanted versus unwanted pregnancies in southern Tehran, Iran (2006-2007). J Matern Fetal Neonatal Med. 2008;21(12):898–901. https://doi.org/10.1080/14767050802372390 .

Bhandari A. Barriers in access to safe abortion services: perspectives of potential clients from a hilly district of Nepal. Trop Med Int Health. 2007;12:87.

Seid A, Yeneneh H, Sende B, Belete S, Eshete H, Fantahun M, et al. Barriers to access safe abortion services in East Shoa and Arsi Zones of Oromia Regional State, Ethiopia. J Health Dev. 2015;29(1):13–21.

Arroyave FAB, Moreno PA. A systematic bibliographical review: barriers and facilitators for access to legal abortion in low and middle income countries. Open J Prev Med. 2018;8(5):147–68. https://doi.org/10.4236/ojpm.2018.85015 .

Article   Google Scholar  

Boland R, Katzive L. Developments in laws on induced abortion: 1998-2007. Int Fam Plan Perspect. 2008;34(3):110–20. https://doi.org/10.1363/3411008 .

Lavelanet AF, Schlitt S, Johnson BR Jr, Ganatra B. Global Abortion Policies Database: a descriptive analysis of the legal categories of lawful abortion. BMC Int Health Hum Rights. 2018;18(1):44. https://doi.org/10.1186/s12914-018-0183-1 .

United Nations Population Division. Abortion policies: A global review. Major dimensions of abortion policies. 2002 [Available from: https://www.un.org/en/development/desa/population/publications/abortion/abortion-policies-2002.asp .

Johnson BR, Lavelanet AF, Schlitt S. Global abortion policies database: a new approach to strengthening knowledge on laws, policies, and human rights standards. Bmc Int Health Hum Rights. 2018;18(1):35. https://doi.org/10.1186/s12914-018-0174-2 .

Haaland MES, Haukanes H, Zulu JM, Moland KM, Michelo C, Munakampe MN, et al. Shaping the abortion policy - competing discourses on the Zambian termination of pregnancy act. Int J Equity Health. 2019;18(1):20. https://doi.org/10.1186/s12939-018-0908-8 .

Schatz JJ. Zambia’s health-worker crisis. Lancet. 2008;371(9613):638–9. https://doi.org/10.1016/S0140-6736(08)60287-1 .

Erdman JN, Johnson BR. Access to knowledge and the Global Abortion Policies Database. Int J Gynecol Obstet. 2018;142(1):120–4. https://doi.org/10.1002/ijgo.12509 .

Cleeve A, Oguttu M, Ganatra B, Atuhairwe S, Larsson EC, Makenzius M, et al. Time to act-comprehensive abortion care in east Africa. Lancet Glob Health. 2016;4(9):E601–E2. https://doi.org/10.1016/S2214-109X(16)30136-X .

Berer M, Hoggart L. Medical abortion pills have the potential to change everything about abortion. Contraception. 2018;97(2):79–81. https://doi.org/10.1016/j.contraception.2017.12.006 .

Moseson H, Shaw J, Chandrasekaran S, Kimani E, Maina J, Malisau P, et al. Contextualizing medication abortion in seven African nations: A literature review. Health Care Women Int. 2019;40(7-9):950–80. https://doi.org/10.1080/07399332.2019.1608207 .

Blystad A, Moland KM. Comparative cases of abortion laws and access to safe abortion services in sub-Saharan Africa. Trop Med Int Health. 2017;22:351.

Berer M. Abortion law and policy around the world: in search of decriminalization. Health Hum Rights. 2017;19(1):13–27.

PubMed   PubMed Central   Google Scholar  

Johnson BR, Mishra V, Lavelanet AF, Khosla R, Ganatra B. A global database of abortion laws, policies, health standards and guidelines. B World Health Organ. 2017;95(7):542–4. https://doi.org/10.2471/BLT.17.197442 .

Replogle J. Nicaragua tightens up abortion laws. Lancet. 2007;369(9555):15–6. https://doi.org/10.1016/S0140-6736(07)60011-7 .

Keogh LA, Newton D, Bayly C, McNamee K, Hardiman A, Webster A, et al. Intended and unintended consequences of abortion law reform: perspectives of abortion experts in Victoria, Australia. J Fam Plann Reprod Health Care. 2017;43(1):18–24. https://doi.org/10.1136/jfprhc-2016-101541 .

Levels M, Sluiter R, Need A. A review of abortion laws in Western-European countries. A cross-national comparison of legal developments between 1960 and 2010. Health Policy. 2014;118(1):95–104. https://doi.org/10.1016/j.healthpol.2014.06.008 .

Serbanescu F, Morris L, Stupp P, Stanescu A. The impact of recent policy changes on fertility, abortion, and contraceptive use in Romania. Stud Fam Plann. 1995;26(2):76–87. https://doi.org/10.2307/2137933 .

Henderson JT, Puri M, Blum M, Harper CC, Rana A, Gurung G, et al. Effects of Abortion Legalization in Nepal, 2001-2010. PLoS ONE. 2013;8(5):e64775. https://doi.org/10.1371/journal.pone.0064775 .

Goncalves-Pinho M, Santos JV, Costa A, Costa-Pereira A, Freitas A. The impact of a liberalisation law on legally induced abortion hospitalisations. Eur J Obstet Gynecol Reprod Biol. 2016;203:142–6. https://doi.org/10.1016/j.ejogrb.2016.05.037 .

Latt SM, Milner A, Kavanagh A. Abortion laws reform may reduce maternal mortality: an ecological study in 162 countries. BMC Women’s Health. 2019;19(1). https://doi.org/10.1186/s12905-018-0705-y .

Clarke D, Muhlrad H. Abortion laws and women’s health. IZA discussion papers 11890. Bonn: IZA Institute of Labor Economics; 2018.

Benson J, Andersen K, Samandari G. Reductions in abortion-related mortality following policy reform: evidence from Romania, South Africa and Bangladesh. Reprod Health. 2011;8(39). https://doi.org/10.1186/1742-4755-8-39 .

Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. Bmj-Brit Med J. 2015;349.

William R. Shadish, Thomas D. Cook, Donald T. Campbell. Experimental and quasi-experimental designs for generalized causal inference. Boston, New York; 2002.

Bernal JL, Cummins S, Gasparrini A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol. 2017;46(1):348–55. https://doi.org/10.1093/ije/dyw098 .

Bernal JL, Cummins S, Gasparrini A. The use of controls in interrupted time series studies of public health interventions. Int J Epidemiol. 2018;47(6):2082–93. https://doi.org/10.1093/ije/dyy135 .

Meyer BD. Natural and quasi-experiments in economics. J Bus Econ Stat. 1995;13(2):151–61.

Strumpf EC, Harper S, Kaufman JS. Fixed effects and difference in differences. In: Methods in Social Epidemiology ed. San Francisco CA: Jossey-Bass; 2017.

Abadie A, Diamond A, Hainmueller J. Synthetic control methods for comparative case studies: estimating the effect of California’s Tobacco Control Program. J Am Stat Assoc. 2010;105(490):493–505. https://doi.org/10.1198/jasa.2009.ap08746 .

Article   CAS   Google Scholar  

Abadie A, Diamond A, Hainmueller J. Comparative politics and the synthetic control method. Am J Polit Sci. 2015;59(2):495–510. https://doi.org/10.1111/ajps.12116 .

Moscoe E, Bor J, Barnighausen T. Regression discontinuity designs are underutilized in medicine, epidemiology, and public health: a review of current and best practice. Journal of Clinical Epidemiology. 2015;68(2):132–43. https://doi.org/10.1016/j.jclinepi.2014.06.021 .

Dennis A, Blanchard K, Bessenaar T. Identifying indicators for quality abortion care: a systematic literature review. J Fam Plan Reprod H. 2017;43(1):7–15. https://doi.org/10.1136/jfprhc-2015-101427 .

Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. https://doi.org/10.1186/s13643-016-0384-4 .

Jackson JL, Kuriyama A, Anton A, Choi A, Fournier JP, Geier AK, et al. The accuracy of Google Translate for abstracting data from non-English-language trials for systematic reviews. Ann Intern Med. 2019.

Reeves BC, Wells GA, Waddington H. Quasi-experimental study designs series-paper 5: a checklist for classifying studies evaluating the effects on health interventions-a taxonomy without labels. J Clin Epidemiol. 2017;89:30–42. https://doi.org/10.1016/j.jclinepi.2017.02.016 .

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6. https://doi.org/10.1136/bmj.39489.470347.AD .

Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58. https://doi.org/10.1002/sim.1186 .

Download references

Acknowledgements

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

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

Author information

Authors and affiliations.

Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Purvis Hall 1020 Pine Avenue West, Montreal, Quebec, H3A 1A2, Canada

Foluso Ishola, U. Vivian Ukah & Arijit Nandi

You can also search for this author in PubMed   Google Scholar

Contributions

FI and AN conceived and designed the protocol. FI drafted the manuscript. FI, UVU, and AN revised the manuscript and approved its final version.

Corresponding author

Correspondence to Foluso Ishola .

Ethics declarations

Ethics approval and consent to participate.

Not applicable

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1:.

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

Additional File 2:.

LMICs according to World Bank Data Catalogue. Country classification specified in the World Bank Data Catalogue to identify low- and middle-income countries

Additional File 3: Table 1

. Search strategy in Embase. Detailed search terms and filters applied to generate our search in Embase

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

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

Download citation

Received : 02 January 2020

Accepted : 08 June 2021

Published : 28 June 2021

DOI : https://doi.org/10.1186/s13643-021-01739-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Abortion law/policies; Impact
• Unsafe abortion
• Contraception

Systematic Reviews

ISSN: 2046-4053

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

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

Chapter: 1 introduction, 1 introduction.

When the Institute of Medicine (IOM) 1 issued its 1975 report on the public health impact of legalized abortion, the scientific evidence on the safety and health effects of legal abortion services was limited ( IOM, 1975 ). It had been only 2 years since the landmark Roe v. Wade decision had legalized abortion throughout the United States and nationwide data collection was just under way ( Cates et al., 2000 ; Kahn et al., 1971 ). Today, the available scientific evidence on abortion’s health effects is quite robust.

In 2016, six private foundations came together to ask the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to conduct a comprehensive review of the state of the science on the safety and quality of legal abortion services in the United States. The sponsors—The David and Lucile Packard Foundation, The Grove Foundation, The JPB Foundation, The Susan Thompson Buffett Foundation, Tara Health Foundation, and William and Flora Hewlett Foundation—asked that the review focus on the eight research questions listed in Box 1-1 .

The Committee on Reproductive Health Services: Assessing the Safety and Quality of Abortion Care in the U.S. was appointed in December 2016 to conduct the study and prepare this report. The committee included 13 individuals 2 with research or clinical experience in anesthesiology,

___________________

1 In March 2016, the IOM, the division of the National Academies of Sciences, Engineering, and Medicine focused on health and medicine, was renamed the Health and Medicine Division.

2 A 14th committee member participated for just the first 4 months of the study.

obstetrics and gynecology, nursing and midwifery, primary care, epidemiology of reproductive health, mental health, health care disparities, health care delivery and management, health law, health professional education and training, public health, quality assurance and assessment,

statistics and research methods, and women’s health policy. Brief biographies of committee members are provided in Appendix A .

This chapter describes the context for the study and the scope of the inquiry. It also presents the committee’s conceptual framework for conducting its review.

ABORTION CARE TODAY

Since the IOM first reviewed the health implications of national legalized abortion in 1975, there has been a plethora of related scientific research, including well-designed randomized controlled trials (RCTs), 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 ( Ashok et al., 2004 ; Autry et al., 2002 ; Bartlett et al., 2004 ; Borgatta, 2011 ; Borkowski et al., 2015 ; Bryant et al., 2011 ; Cates et al., 1982 ; Chen and Creinin, 2015 ; Cleland et al., 2013 ; Frick et al., 2010 ; Gary and Harrison, 2006 ; Grimes et al., 2004 ; Grossman et al., 2008 , 2011 ; Ireland et al., 2015 ; Kelly et al., 2010 ; Kulier et al., 2011 ; Lohr et al., 2008 ; Low et al., 2012 ; Mauelshagen et al., 2009 ; Ngoc et al., 2011 ; Ohannessian et al., 2016 ; Peterson et al., 1983 ; Raymond et al., 2013 ; Roblin, 2014 ; Sonalkar et al., 2017 ; Upadhyay et al., 2015 ; White et al., 2015 ; Wildschut et al., 2011 ; Woodcock, 2016 ; Zane et al., 2015 ). With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed ( Chen and Creinin, 2015 ; Jatlaoui et al., 2016 ; Lichtenberg and Paul, 2013 ). For example, the use of dilation and sharp curettage is now considered obsolete in most cases because safer alternatives, such as aspiration methods, have been developed ( Edelman et al, 1974 ; Lean et al, 1976 ; RCOG, 2015 ). The use of abortion medications in the United States began in 2000 with the approval by the U.S. Food and Drug Administration (FDA) of the drug mifepristone. In 2016, the FDA, citing extensive clinical research, updated the indications for mifepristone for medication abortion 3 up to 10 weeks’ (70 days’) gestation ( FDA, 2016 ; Woodcock, 2016 ).

Box 1-2 describes the abortion methods currently recommended by U.S. and international medical, nursing, and other health organizations that set professional standards for reproductive health care, including the American College of Obstetricians and Gynecologists (ACOG), the Society of Family Planning, the American College of Nurse-Midwifes, the National Abortion Federation (NAF), the Royal College of Obstetricians and Gynaecologists (RCOG) (in the United Kingdom), and the World

3 The terms “medication abortion” and “medical abortion” are used interchangeably in the literature.

Health Organization ( ACNM, 2011 , 2016 ; ACOG, 2013 , 2014 ; Costescu et al., 2016 ; Lichtenberg and Paul, 2013 ; NAF, 2017 ; RCOG, 2011 ; WHO, 2014 ).

A Continuum of Care

The committee views abortion care as a continuum of services, as illustrated in Figure 1-1 . For purposes of this study, it begins when a woman, who has decided to terminate a pregnancy, contacts or visits a provider seeking an abortion. The first, preabortion phase of care includes an initial clinical assessment of the woman’s overall health (e.g., physical examination, pregnancy determination, weeks of gestation, and laboratory and other testing as needed); communication of information on the risks and benefits of alternative abortion procedures and pain management options; discussion of the patient’s preferences based on desired anesthesia and weeks of gestation; discussion of postabortion contraceptive options if desired; counseling

and referral to services (if needed); and final decision making and informed consent. The next phases in the continuum are the abortion procedure itself and postabortion care, including appropriate follow-up care and provision of contraceptives (for women who opt for them).

A Note on Terminology

Important clinical terms that describe pregnancy and abortion lack consistent definition. The committee tried to be as precise as possible to avoid misinterpreting or miscommunicating the research evidence, clinical practice guidelines, and other relevant sources of information with potentially significant clinical implications. Note that this report follows Grimes and Stuart’s (2010) recommendation that weeks’ gestation be quantified using cardinal numbers (1, 2, 3...) rather than ordinal numbers (1st, 2nd, 3rd...). It is important to note, however, that these two numbering conventions are sometimes used interchangeably in the research literature despite having different meanings. For example, a woman who is 6 weeks pregnant has completed 6 weeks of pregnancy: she is in her 7th (not 6th) week of pregnancy.

This report also avoids using the term “trimester” where possible because completed weeks’ or days’ gestation is a more precise designation, and the clinical appropriateness of abortion methods does not align with specific trimesters.

Although the literature typically classifies the method of abortion as either “medical” or “surgical” abortion, the committee decided to specify methods more precisely by using the terminology defined in Box 1-2 . The term “surgical abortion” is often used by others as a catchall category that includes a variety of procedures, ranging from an aspiration to a dilation and evacuation (D&E) procedure involving sharp surgical and other instrumentation as well as deeper levels of sedation. This report avoids describing abortion procedures as “surgical” so as to characterize a method more accurately as either an aspiration or D&E. As noted in Box 1-2 , the term “induction abortion” is used to distinguish later abortions that use a

medication regimen from medication abortions performed before 10 weeks’ gestation.

See Appendix B for a glossary of the technical terms used in this report.

Regulation of Abortion Services

Abortion is among the most regulated medical procedures in the nation ( Jones et al., 2010 ; Nash et al., 2017 ). While a comprehensive legal analysis of abortion regulation is beyond the scope of this report, the committee agreed that it should consider how abortion’s unique regulatory environment relates to the safety and quality of abortion care.

In addition to the federal, state, and local rules and policies governing all medical services, numerous abortion-specific federal 4 and state laws and regulations affect the delivery of abortion services. Table 1-1 lists the abortion-specific regulations by state. The regulations range from prescribing information to be provided to women when they are counseled and setting mandatory waiting periods between counseling and the abortion procedure to those that define the clinical qualifications of abortion providers, the types of procedures they are permitted to perform, and detailed facility standards for abortion services. In addition, many states place limitations on the circumstances under which private health insurance and Medicaid can be used to pay for abortions, limiting coverage to pregnancies resulting from rape or incest or posing a medical threat to the pregnant woman’s life. Other policies prevent facilities that receive state funds from providing abortion services 5 or place restrictions on the availability of services based on the gestation of the fetus that are narrower than those established under federal law ( Guttmacher Institute, 2017h ).

Trends and Demographics

National- and state-level abortion statistics come from two primary sources: the Centers for Disease Control and Prevention’s (CDC’s) Abortion

4 Hyde Amendment (P.L. 94-439, 1976); Department of Defense Appropriations Act (P.L. 95-457, 1978); Peace Corps Provision and Foreign Assistance and Related Programs Appropriations Act (P.L. 95-481, 1978); Pregnancy Discrimination Act (P.L. 95-555, 1977); Department of the Treasury and Postal Service Appropriations Act (P.L. 98-151, 1983); FY1987 Continuing Resolution (P.L. 99-591, 1986); Dornan Amendment (P.L. 100-462, 1988); Partial-Birth Abortion Ban (P.L. 108-105, 2003); Weldon Amendment (P.L. 108-199, 2004); Patient Protection and Affordable Care Act (P.L. 111-148 as amended by P.L. 111-152, 2010).

5 Personal communication, O. Cappello, Guttmacher Institute, August 4, 2017: AZ § 15-1630, GA § 20-2-773; KS § 65-6733 and § 76-3308; KY § 311.800; LA RS § 40:1299 and RS § 4 0.1061; MO § 188.210 and § 188.215; MS § 41-41-91; ND § 14-02.3-04; OH § 5101.57; OK 63 § 1-741.1; PA 18 § 3215; TX § 285.202.

TABLE 1-1 Overview of State Abortion-Specific Regulations That May Impact Safety and Quality, as of September 1, 2017

a Excludes laws or regulations permanently or temporarily enjoined pending a court decision.

b States have abortion-specific requirements generally following the established principles of informed consent.

c The content of informed consent materials is specified in state law or developed by the state department of health.

d In-person counseling is not required for women who live more than 100 miles from an abortion provider.

e Counseling requirement is waived if the pregnancy is the result of rape or incest or the patient is younger than 15.

f Maximum distance requirement does not apply to medication abortions.

g Some states also exempt women whose physical health is at severe risk and/or in cases of fetal impairment.

h Some states have exceptions for pregnancies resulting from rape or incest, pregnancies that severely threaten women’s physical health or endanger their life, and/or in cases of fetal impairment.

SOURCES: Guttmacher Institute, 2017b , c , d , e , f , g , h , i , 2018b .

Surveillance System and the Guttmacher Institute’s Abortion Provider Census ( Jatlaoui et al., 2016 ; Jerman et al., 2016 ; Jones and Kavanaugh, 2011 ; Pazol et al., 2015 ). Both of these sources provide estimates of the number and rate of abortions, the use of different abortion methods, the characteristics of women who have abortions, and other related statistics. However, both sources have limitations.

The CDC system is a voluntary, state-reported system; 6 , 7 three states (California, Maryland, and New Hampshire) do not provide information ( CDC, 2017 ). The Guttmacher census, also voluntary, solicits information from all known abortion providers throughout the United States, including in the states that do not submit information to the CDC surveillance system. For 2014, the latest year reported by Guttmacher, 8 information was obtained directly from 58 percent of abortion providers, and data for nonrespondents were imputed ( Jones and Jerman, 2017a ). The CDC’s latest report, for abortions in 2013, includes approximately 70 percent of the abortions reported by the Guttmacher Institute for that year ( Jatlaoui et al., 2016 ).

Both data collection systems report descriptive statistics on women who have abortions and the types of abortion provided, although they define demographic variables and procedure types differently. Nevertheless, in the aggregate, the trends in abortion utilization reported by the CDC and Guttmacher closely mirror each other—indicating decreasing rates of abortion, an increasing proportion of medication abortions, and the vast majority of abortions (90 percent) occurring by 13 weeks’ gestation (see Figures 1-2 and 1-3 ) ( Jatlaoui et al., 2016 ; Jones and Jerman, 2017a ). 9 Both data sources are used in this chapter’s brief review of trends in abortions and throughout the report.

Trends in the Number and Rate of Abortions

The number and rate of abortions have changed considerably during the decades following national legalization in 1973. In the immediate years after

6 In most states, hospitals, facilities, and physicians are required by law to report abortion data to a central health agency. These agencies submit the aggregate utilization data to the CDC ( Guttmacher Institute, 2018a ).

7 New York City and the District of Columbia also report data to the CDC.

8 Guttmacher researchers estimate that the census undercounts the number of abortions performed in the United States by about 5 percent (i.e., 51,725 abortions provided by 2,069 obstetrician/gynecologist [OB/GYN] physicians). The estimate is based on a survey of a random sample of OB/GYN physicians. The survey did not include other physician specialties and other types of clinicians.

9 A full-term pregnancy is 40 weeks.

national legalization, both the number and rate 10 of legal abortions steadily increased ( Bracken et al., 1982 ; Guttmacher Institute, 2017a ; Pazol et al., 2015 ; Strauss et al., 2007 ) (see Figure 1-2 ). The abortion rate peaked in the

10 Reported abortion rates are for females aged 15 to 44.

1980s, and the trend then reversed, a decline that has continued for more than three decades ( Guttmacher Institute, 2017a ; Jones and Kavanaugh, 2011 ; Pazol et al., 2015 ; Strauss et al., 2007 ). Between 1980 and 2014, the abortion rate among U.S. women fell by more than half, from 29.3 to 14.6 per 1,000 women ( Finer and Henshaw, 2003 ; Guttmacher Institute, 2017a ; Jones and Jerman, 2017a ) (see Figure 1-2 ). In 2014, the most recent year for which data are available, the aggregate number of abortions reached a low of 926,190 after peaking at nearly 1.6 million in 1990 ( Finer and Henshaw, 2003 ; Jones and Jerman, 2017a ). The reason for the decline is not fully understood but has been attributed to several factors, including the increasing use of contraceptives, especially long-acting methods (e.g., intrauterine devices and implants); historic declines in the rate of unintended pregnancy; and increasing numbers of state regulations resulting in limited access to abortion services ( Finer and Zolna, 2016 ; Jerman et al., 2017 ; Jones and Jerman, 2017a ; Kost, 2015 ; Strauss et al., 2007 ).

Weeks’ Gestation

Length of gestation—measured as the amount of time since the first day of the last menstrual period—is the primary factor in deciding what abortion procedure is most appropriate ( ACOG, 2014 ). Since national legalization, most abortions in the United States have been performed in early pregnancy (≤13 weeks) ( Cates et al., 2000 ; CDC, 1983 ; Elam-Evans et al., 2003 ; Jatlaoui et al., 2016 ; Jones and Jerman, 2017a ; Koonin and Smith, 1993 ; Lawson et al., 1989 ; Pazol et al., 2015 ; Strauss et al., 2007 ). CDC surveillance reports indicate that since at least 1992 (when detailed data on early abortions were first collected), the vast majority of abortions in the United States were early-gestation procedures ( Jatlaoui et al., 2016 ; Strauss et al., 2007 ); this was the case for approximately 92 percent of all abortions in 2013 ( Jatlaoui et al., 2016 ). With such technological advances as highly sensitive pregnancy tests and medication abortion, procedures are being performed at increasingly earlier gestational stages. According to the CDC, the percentage of early abortions performed ≤6 weeks’ gestation increased by 16 percent from 2004 to 2013 ( Jatlaoui et al., 2016 ); in 2013, 38 percent of early abortions occurred ≤6 weeks ( Jatlaoui et al., 2016 ). The proportion of early-gestation abortions occurring ≤6 weeks is expected to increase even further as the use of medication abortions becomes more widespread ( Jones and Boonstra, 2016 ; Pazol et al., 2012 ).

Figure 1-3 shows the proportion of abortions in nonhospital settings by weeks’ gestation in 2014 ( Jones and Jerman, 2017a ).

Abortion Methods

Aspiration is the abortion method most commonly used in the United States, accounting for almost 68 percent of all abortions performed in 2013 ( Jatlaoui et al., 2016 ). 11 Its use, however, is likely to decline as the use of medication abortion increases. The percentage of abortions performed by the medication method rose an estimated 110 percent between 2004 and 2013, from 10.6 to 22.3 percent ( Jatlaoui et al., 2016 ). In 2014, approximately 45 percent of abortions performed up to 9 weeks’ gestation were medication abortions, up from 36 percent in 2011 ( Jones and Jerman, 2017a ).

Fewer than 9 percent of abortions are performed after 13 weeks’ gestation; most of these are D&E procedures ( Jatlaoui et al., 2016 ). Induction abortion is the most infrequently used of all abortion methods, accounting for approximately 2 percent of all abortions at 14 weeks’ gestation or later in 2013 ( Jatlaoui et al., 2016 ).

Characteristics of Women Who Have Abortions

The most detailed sociodemographic statistics on women who have had an abortion in the United States are provided by the Guttmacher Institute’s Abortion Patient Survey. Respondents to the 2014/2015 survey included more than 8,000 women who had had an abortion in 1 of 87 outpatient (nonhospital) facilities across the United States in 2014 ( Jerman et al., 2016 ; Jones and Jerman, 2017b ). 12 Table 1-2 provides selected findings from this survey. Although women who had an abortion in a hospital setting are excluded from these statistics, the data represent an estimated 95 percent of all abortions provided (see Figure 1-3 ).

The Guttmacher survey found that most women who had had an abortion were under age 30 (72 percent) and were unmarried (86 percent) ( Jones and Jerman, 2017b ). Women seeking an abortion were far more likely to be poor or low-income: the household income of 49 percent was below the federal poverty level (FPL), and that of 26 percent was 100 to 199 percent of the FPL ( Jerman et al., 2016 ). In comparison, the

11 CDC surveillance reports use the catchall category of “curettage” to refer to nonmedical abortion methods. The committee assumed that the CDC’s curettage estimates before 13 weeks’ gestation refer to aspiration procedures and that its curettage estimates after 13 weeks’ gestation referred to D&E procedures.

12 Participating facilities were randomly selected and excluded hospitals. All other types of facilities were included if they had provided at least 30 abortions in 2011 ( Jerman et al., 2016 ). Jerman and colleagues report that logistical challenges precluded including hospital patients in the survey. The researchers believe that the exclusion of hospitals did not bias the survey sample, noting that hospitals accounted for only 4 percent of all abortions in 2011.

TABLE 1-2 Characteristics of Women Who Had an Abortion in an Outpatient Setting in 2014, by Percent

NOTE: Percentages may not sum to 100 because of rounding.

SOURCES: (a) Jones and Jerman, 2017b (n = 8,098); (b) Jerman et al., 2016 (n = 8,380).

corresponding percentages among all women aged 15 to 49 are 16 and 18 percent. 13 Women who had had an abortion were also more likely to be women of color 14 (61.0 percent); overall, half of women who had had an abortion were either black (24.8 percent) or Hispanic (24.5 percent) ( Jones and Jerman, 2017b ). This distribution is similar to the racial and ethnic distribution of women with household income below 200 percent of the FPL, 49 percent of whom are either black (20 percent) or Hispanic (29 percent). 15 Poor women and women of color are also more likely than others to experience an unintended pregnancy ( Finer and Henshaw, 2006 ; Finer et al., 2006 ; Jones and Kavanaugh, 2011 ).

Many women who have an abortion have previously experienced pregnancy or childbirth. Among respondents to the Guttmacher survey, 59.3 percent had given birth at least once, and 44.8 percent had had a prior abortion ( Jerman et al., 2016 ; Jones and Jerman, 2017b ).

While precise estimates of health insurance coverage of abortion are not available, numerous regulations limit coverage. As noted in Table 1-1 , 33 states prohibit public payers from paying for abortions and other states have laws that either prohibit health insurance exchange plans (25 states) or private insurance plans (11 states) sold in the state from covering or paying for abortions, with few exceptions. 16 In the Guttmacher survey, only 14 percent of respondents had paid for the procedure using private insurance coverage, and despite the disproportionately high rate of poverty and low income among those who had had an abortion, only 22 percent reported that Medicaid was the method of payment for their abortion. In 2015, 39 percent of the 25 million women lived in households that earned less than 200 percent of the FPL in the United States were enrolled in Medicaid, and 36 percent had private insurance ( Ranji et al., 2017 ).

Number of Clinics Providing Abortion Care

As noted earlier, the vast majority of abortions are performed in nonhospital settings—either an abortion clinic (59 percent) or a clinic offering a variety of medical services (36 percent) ( Jones and Jerman, 2017a ) (see Figure 1-4 ). Although hospitals account for almost 40 percent of facilities offering abortion care, they provide less than 5 percent of abortions overall.

13 Calculation by the committee based on estimates from Annual Social and Economic Supplement (ASEC) to the Current Population Survey (CPS) .

14 Includes all nonwhite race and ethnicity categories in Table 1-2 . Data were collected via self-administered questionnaire ( Jones and Jerman, 2017b ).

15 Calculation by the committee based on estimates from Annual Social and Economic Supplement (ASEC) to the Current Population Survey (CPS) .

16 Some states have exceptions for pregnancies resulting from rape or incest, pregnancies that endanger the woman’s life or severely threaten her health, and in cases of fetal impairment.

The overall number of nonhospital facilities providing abortions—especially specialty abortion clinics—is declining. The greatest proportional decline is in states that have enacted abortion-specific regulations ( Jones and Jerman, 2017a ). In 2014, there were 272 abortion clinics in the United States, 17 percent fewer than in 2011. The greatest decline (26 percent) was among large clinics with annual caseloads of 1,000–4,999 patients and clinics in the Midwest (22 percent) and the South (13 percent). In 2014, approximately 39 percent of U.S. women aged 15 to 44 resided in a U.S. county without an abortion provider (90 percent of counties overall) ( Jones and Jerman, 2017a ). Twenty-five states have five or fewer abortion clinics; five states have one abortion clinic ( Jones and Jerman, 2017a ). A recent analysis 17 by Guttmacher evaluated geographic disparities in access to abortion by calculating the distance between women of reproductive age (15 to 44) and the nearest abortion-providing facility in 2014 ( Bearak et al., 2017 ). Figure 1-5 highlights the median distance to the nearest facility by county.

17 The analysis was limited to facilities that provided at least 400 abortions per year and those affiliated with Planned Parenthood that performed at least 1 abortion during the period of analysis.

The majority of facilities offer early medication and aspiration abortions. In 2014, 87 percent of nonhospital facilities provided early medication abortions; 23 percent of all nonhospital facilities offered this type of abortion ( Jones and Jerman, 2017a ). Fewer facilities offer later-gestation procedures, and availability decreases as gestation increases. In 2012, 95 percent of all abortion facilities offered abortions at 8 weeks’ gestation, 72 percent at 12 weeks’ gestation, 34 percent at 20 weeks’ gestation, and 16 percent at 24 weeks’ gestation ( Jerman and Jones, 2014 ).

STUDY APPROACH

Conceptual framework.

The committee’s approach to this study built on two foundational developments in the understanding and evaluation of the quality of health

care services: Donabedian’s (1980) structure-process-outcome framework and the IOM’s (2001) six dimensions of quality health care. Figure 1-6 illustrates the committee’s adaptation of these concepts for this study’s assessment of abortion care in the United States.

Structure-Process-Outcome Framework

In seminal work published almost 40 years ago, Donabedian (1980) proposed that the quality of health care be assessed by examining its structure, process, and outcomes ( Donabedian, 1980 ):

• Structure refers to organizational factors that may create the potential for good quality. In abortion care, such structural factors as the availability of trained staff and the characteristics of the clinical setting may ensure—or inhibit—the capacity for quality.
• Process refers to what is done to and for the patient. Its assessment assumes that the services patients receive should be evidence based and correlated with patients’ desired outcomes—for example, an early and complete abortion for women who wish to terminate an unintended pregnancy.
• Outcomes are the end results of care—the effects of the intervention on the health and well-being of the patient. Does the procedure achieve its objective? Does it lead to serious health risks in the short or long term?

Six Dimensions of Health Care Quality

The landmark IOM report Crossing the Quality Chasm: A New Health System for the 21st Century ( IOM, 2001 ) identifies six dimensions of health care quality—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The articulation of these six dimensions has guided public and private efforts to improve U.S. health care delivery at the local, state, and national levels since that report was published ( AHRQ, 2016 ).

In addition, as with other health care services, women should expect that the abortion care they receive meets well-established standards for objectivity, transparency, and scientific rigor ( IOM, 2011a , b ).

Two of the IOM’s six dimensions—safety and effectiveness—are particularly salient to the present study. Assessing both involves making relative judgments. There are no universally agreed-upon thresholds for defining care as “safe” versus “unsafe” or “effective” versus “not effective,” and decisions about safety and effectiveness have a great deal to do with the context of the clinical scenario. Thus, the committee’s frame of reference for evaluating safety, effectiveness, and other quality domains is of necessity a

relative one—one that entails not only comparing the alternative abortion methods but also comparing these methods with other health care services and with risks associated with not achieving the desired outcome.

Safety—avoiding injury to patients—is often assessed by measuring the incidence and severity of complications and other adverse events associated with receiving a specific procedure. If infrequent, a complication may be characterized as “rare”—a term that lacks consistent definition. In this report, “rare” is used to describe outcomes that affect fewer than 1 percent of patients. Complications are considered “serious” if they result in a blood transfusion, surgery, or hospitalization.

Note also that the term “effectiveness” is used differently in this report depending on the context. As noted in Box 1-3 , effectiveness as an attribute of quality refers to providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively). Elsewhere in this report, effectiveness denotes the clinical effectiveness of a procedure, that

is, the successful completion of an abortion without the need for a follow-up aspiration.

Finding and Assessing the Evidence

The committee deliberated during four in-person meetings and numerous teleconferences between January 2017 and December 2017. On March 24, 2017, the committee hosted a public workshop at the Keck Center of the National Academies of Sciences, Engineering, and Medicine in Washington, DC. The workshop included presentations from three speakers on topics related to facility standards and the safety of outpatient procedures. Appendix C contains the workshop agenda.

Several committee workgroups were formed to find and assess the quality of the available evidence and to draft summary materials for the full committee’s review. The workgroups conducted in-depth reviews of the epidemiology of abortions, including rates of complications and mortality, the safety and effectiveness of alternative abortion methods, professional standards and methods for performing all aspects of abortion care (as described in Figure 1-1 ), the short- and long-term physical and mental health effects of having an abortion; and the safety and quality implications of abortion-specific regulations on abortion.

The committee focused on finding reliable, scientific information reflecting contemporary U.S. abortion practices. An extensive body of research on abortion has been conducted outside the United States. A substantial proportion of this literature concerns the delivery of abortion care in countries where socioeconomic conditions, culture, population health, health care resources, and/or the health care system are markedly different from their U.S. counterparts. Studies from other countries were excluded from this review if the committee judged those factors to be relevant to the health outcomes being assessed.

The committee considered evidence from randomized controlled trials comparing two or more approaches to abortion care; systematic reviews; meta-analyses; retrospective cohort studies, case control studies, and other types of observational studies; and patient and provider surveys (see Box 1-4 ).

An extensive literature documents the biases common in published research on the effectiveness of health care services ( Altman et al., 2001 ; Glasziou et al., 2008 ; Hopewell et al., 2008 ; Ioannidis et al., 2004 ; IOM, 2011a , b ; Plint et al., 2006 ; Sackett, 1979 ; von Elm et al., 2007 ). Thus, the committee prioritized the available research according to conventional principles of evidence-based medicine intended to reduce the risk of bias in a study’s conclusions, such as how subjects were allocated to different types of abortion care, the comparability of study populations, controls

for confounding factors, how outcome assessments were conducted, the completeness of outcome reporting, the representativeness of the study population compared with the general U.S. population, and the degree to which statistical analyses helped reduce bias ( IOM, 2011b ). Applying these principles is particularly important with respect to understanding abortion’s

long-term health effects, an area in which the relevant literature is vulnerable to bias (as discussed in Chapter 4 ).

The committee’s literature search strategy is described in Appendix D .

ORGANIZATION OF THE REPORT

Chapter 2 of this report describes the continuum of abortion care including current abortion methods (question 1 in the committee’s statement of task [ Box 1-1 ]); reviews the evidence on factors affecting their safety and quality, including expected side effects and possible complications (questions 2 and 3), necessary safeguards to manage medical emergencies (question 6), and provision of pain management (question 7); and presents the evidence on the types of facilities or facility factors necessary to provide safe and effective abortion care (question 4).

Chapter 3 summarizes the clinical skills that are integral to safe and high-quality abortion care according to the recommendations of leading national professional organizations and abortion training curricula (question 5).

Chapter 4 reviews research examining the long-term health effects of undergoing an abortion (question 2).

Finally, Chapter 5 presents the committee’s conclusions regarding the findings presented in the previous chapters, responding to each of the questions posed in the statement of task. Findings are statements of scientific evidence. The report’s conclusions are the committee’s inferences, interpretations, or generalizations drawn from the evidence.

ACNM (American College of Nurse-Midwives). 2011. Position statement: Reproductive health choices . http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000087/Reproductive_Choices.pdf (accessed August 1, 2017).

ACNM. 2016. Position statement: Access to comprehensive sexual and reproductive health care services . http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000087/Access-to-Comprehensive-Sexual-and-Reproductive-Health-Care-Services-FINAL-04-12-17.pdf (accessed August 1, 2017).

ACOG (American College of Obstetricians and Gynecologists). 2013. Practice Bulletin No. 135: Second-trimester abortion. Obstetrics & Gynecology 121(6):1394–1406.

ACOG. 2014. Practice Bulletin No. 143: Medical management of first-trimester abortion (reaffirmed). Obstetrics & Gynecology 123(3):676–692.

AHRQ (Agency for Healthcare Research and Quality). 2016. The six domains of health care quality. https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html (accessed May 3, 2017).

Altman, D. G., K. F. Schulz, D. Moher, M. Egger, F. Davidoff, D. Elbourne, P. C. Gøtzsche, and T. Lang. 2001. The revised CONSORT statement for reporting randomized trials: Explanation and elaboration. Annals of Internal Medicine 134(8):663–694.

Ashok, P. W., A. Templeton, P. T. Wagaarachchi, and G. M. Flett. 2004. Midtrimester medical termination of pregnancy: A review of 1002 consecutive cases. Contraception 69(1):51–58.

Autry, A. M., E. C. Hayes, G. F. Jacobson, and R. S. Kirby. 2002. A comparison of medical induction and dilation and evacuation for second-trimester abortion. American Journal of Obstetrics and Gynecology 187(2):393–397.

Bartlett, L. A., C. J. Berg, H. B. Shulman, S. B. Zane, C. A. Green, S. Whitehead, and H. K. Atrash. 2004. Risk factors for legal induced abortion-related mortality in the United States. Obstetrics & Gynecology 103(4):729–737.

Bearak, J. M., K. L. Burke, and R. K. Jones. 2017. Disparities and change over time in distance women would need to travel to have an abortion in the USA: A spatial analysis. The Lancet Public Health 2(11):e493–e500.

Borgatta, L. 2011. Labor induction termination of pregnancy. Global library for women’s medicine . https://www.glowm.com/section_view/heading/Labor%20Induction%20Termination%20of%20Pregnancy/item/443 (accessed September 13, 2017).

Borkowski, L., J. Strasser, A. Allina, and S. Wood. 2015. Medication abortion. Overview of research & policy in the United States . http://publichealth.gwu.edu/sites/default/files/Medication_Abortion_white_paper.pdf (accessed January 25, 2017).

Bracken, M. B., D. H. Freeman, Jr., and K. Hellenbrand. 1982. Hospitalization for medical-legal and other abortions in the United States 1970–1977. American Journal of Public Health 72(1):30–37.

Bryant, A. G., D. A. Grimes, J. M. Garrett, and G. S. Stuart. 2011. Second-trimester abortion for fetal anomalies or fetal death: Labor induction compared with dilation and evacuation. Obstetrics & Gynecology 117(4):788–792.

Cates, Jr., W., K. F. Schulz, D. A. Grimes, A. J. Horowitz, F. A. Lyon, F. H. Kravitz, and M. J. Frisch. 1982. Dilatation and evacuation procedures and second-trimester abortions. The role of physician skill and hospital setting. Journal of the American medical Association 248(5):559–563.

Cates, Jr., W., D. A. Grimes, and K. F. Schulz. 2000. Abortion surveillance at CDC: Creating public health light out of political heat. American Journal of Preventive Medicine 19(1, Suppl. 1):12–17.

CDC (Centers for Disease Control and Prevention). 1983. Surveillance summary abortion surveillance: Preliminary analysis, 1979–1980—United States. MMWR Weekly 32(5): 62–64. https://www.cdc.gov/mmwr/preview/mmwrhtml/00001243.htm (accessed September 18, 2017).

CDC. 2017. CDC’s abortion surveillance system FAQs . https://www.cdc.gov/reproductivehealth/data_stats/abortion.htm (accessed June 22, 2017).

Chen, M. J., and M. D. Creinin. 2015. Mifepristone with buccal misoprostol for medical abortion: A systematic review. Obstetrics & Gynecology 126(1):12–21.

Cleland, K., M. D. Creinin, D. Nucatola, M. Nshom, and J. Trussell. 2013. Significant adverse events and outcomes after medical abortion. Obstetrics & Gynecology 121(1):166–171.

Costescu, D., E. Guilbert, J. Bernardin, A. Black, S. Dunn, B. Fitzsimmons, W. V. Norman, H. Pymar, J. Soon, K. Trouton, M. S. Wagner, and E. Wiebe. 2016. Medical abortion. Journal of Obstetrics and Gynaecology Canada 38(4):366–389.

Donabedian, A. 1980. The definition of quality and approaches to its assessment. In Explorations in quality assessment and monitoring. Vol. 1. Ann Arbor, MI: Health Administration Press.

Edelman, D. A., W. E. Brenner, and G. S. Berger. 1974. The effectiveness and complications of abortion by dilatation and vacuum aspiration versus dilatation and rigid metal curettage. American Journal of Obstetrics and Gynecology 119(4):473–480.

Elam-Evans, L. D., L. T. Strauss, J. Herndon, W. Y. Parker, S. V. Bowens, S. Zane, and C. J. Berg. 2003. Abortion surveillance—United States, 2000. MMWR Surveillance Summaries 52(SS-12):1–32. https://www.cdc.gov/mmwr/preview/mmwrhtml/ss5212a1.htm (accessed September 18, 2017).

FDA (U.S. Food and Drug Administration). 2016. MIFEPREX ® : Highligh ts of prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/020687s020lbl.pdf (accessed September 11, 2017).

Finer, L. B., and S. K. Henshaw. 2003. Abortion incidence and services in the United States in 2000. Perspectives on Sexual and Reproductive Health 35(1):6–15.

Finer, L. B., and S. K. Henshaw. 2006. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health 38(2):90–96.

Finer, L. B., and M. R. Zolna. 2016. Declines in unintended pregnancy in the United States, 2008–2011. New England Journal of Medicine 374(9):843–852.

Finer, L. B., L. F. Frohwirth, L. A. Dauphinee, S. Singh, and A. M. Moore. 2006. Timing of steps and reasons for delays in obtaining abortions in the United States. Contraception 74(4):334–344.

Frick, A. C., E. A. Drey, J. T. Diedrich, and J. E. Steinauer. 2010. Effect of prior cesarean delivery on risk of second-trimester surgical abortion complications. Obstetrics & Gynecology 115(4):760–764.

Gary, M. M., and D. J. Harrison. 2006. Analysis of severe adverse events related to the use of mifepristone as an abortifacient. Annals of Pharmacotherapy 40(2):191–197.

Glasziou, P., E. Meats, C. Heneghan, and S. Shepperd. 2008. What is missing from descriptions of treatment in trials and reviews? British Medical Journal 336(7659):1472–1474.

Grimes, D. A., and G. Stuart. 2010. Abortion jabberwocky: The need for better terminology. Contraception 81(2):93–96.

Grimes, D. A., S. M. Smith, and A. D. Witham. 2004. Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: A pilot randomised controlled trial. British Journal of Obstetrics & Gynaecology 111(2):148–153.

Grossman, D., K. Blanchard, and P. Blumenthal. 2008. Complications after second trimester surgical and medical abortion. Reproductive Health Matters 16(31 Suppl.):173–182.

Grossman, D., K. Grindlay, T. Buchacker, K. Lane, and K. Blanchard. 2011. Effectiveness and acceptability of medical abortion provided through telemedicine. Obstetrics & Gynecology 118(2 Pt. 1):296–303.

Guttmacher Institute. 2017a. Fact sheet: Induced abortion in the United States. https://www.guttmacher.org/fact-sheet/induced-abortion-united-states (accessed November 10, 2017).

Guttmacher Institute. 2017b. Bans on specific abortion methods used after the first trimester. https://www.guttmacher.org/state-policy/explore/bans-specific-abortion-methods-used-after-first-trimester (accessed September 12, 2017).

Guttmacher Institute. 2017c. Counseling and waiting periods for abortion. https://www.guttmacher.org/state-policy/explore/counseling-and-waiting-periods-abortion (accessed September 12, 2017).

Guttmacher Institute. 2017d. Medication abortion. https://www.guttmacher.org/state-policy/explore/medication-abortion (accessed September 12, 2017).

Guttmacher Institute. 2017e. An overview of abortion laws. https://www.guttmacher.org/state-policy/explore/overview-abortion-laws (accessed September 12, 2017).

Guttmacher Institute. 2017f. Requirements for ultrasound. https://www.guttmacher.org/state-policy/explore/requirements-ultrasound (accessed September 12, 2017).

Guttmacher Institute. 2017g. State funding of abortion under Medicaid. https://www.guttmacher.org/state-policy/explore/state-funding-abortion-under-medicaid (accessed September 12, 2017).

Guttmacher Institute. 2017h. State policies on later abortions. https://www.guttmacher.org/state-policy/explore/state-policies-later-abortions (accessed September 12, 2017).

Guttmacher Institute. 2017i. Targeted regulation of abortion providers. https://www.guttmacher.org/state-policy/explore/targeted-regulation-abortion-providers (accessed September 12, 2017).

Guttmacher Institute. 2018a. Abortion reporting requirements. https://www.guttmacher.org/state-policy/explore/abortion-reporting-requirements (accessed January 22, 2018).

Guttmacher Institute. 2018b. Restricting insurance coverage of abortion. https://www.guttmacher.org/state-policy/explore/restricting-insurance-coverage-abortion (accessed January 24, 2018).

Hopewell, S., M. Clarke, D. Moher, E. Wager, P. Middleton, D. G. Altman, K. F. Schulz, and the CONSORT Group. 2008. CONSORT for reporting randomized controlled trials in journal and conference abstracts: Explanation and elaboration. PLoS Medicine 5(1):e20.

Ioannidis, J. P., S. J. Evans, P. C. Gøtzsche, R. T. O’Neill, D. G. Altman, K. Schulz, D. Moher, and the CONSORT Group. 2004. Better reporting of harms in randomized trials: An extension of the CONSORT statement. Annals of Internal Medicine 141(10):781–788.

IOM (Institute of Medicine). 1975. Legalized abortion and the public health . Washington, DC: National Academy Press.

IOM. 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

IOM. 2011a. Clinical practice guidelines we can trust. Washington, DC: The National Academies Press.

IOM. 2011b. Finding what works in health care: Standards for systematic reviews. Washington, DC: The National Academies Press.

Ireland, L. D., M. Gatter, and A. Y. Chen. 2015. Medical compared with surgical abortion for effective pregnancy termination in the first trimester. Obstetrics & Gynecology 126(1):22–28.

Jatlaoui, T. C., A. Ewing, M. G. Mandel, K. B. Simmons, D. B. Suchdev, D. J. Jamieson, and K. Pazol. 2016. Abortion surveillance—United States, 2013. MMWR Surveillance Summaries 65(No. SS-12):1–44.

Jerman, J., and R. K. Jones. 2014. Secondary measures of access to abortion services in the United States, 2011 and 2012: Gestational age limits, cost, and harassment. Women’s Health Issues 24(4): e419–e424.

Jerman J., R. K. Jones, and T. Onda. 2016. Characteristics of U.S. abortion patients in 2014 and changes since 2008 . https://www.guttmacher.org/sites/default/files/report_pdf/characteristics-us-abortion-patients-2014.pdf (accessed October 17, 2016).

Jerman, J., L. Frohwirth, M. L. Kavanaugh, and N. Blades. 2017. Barriers to abortion care and their consequences for patients traveling for services: Qualitative findings from two states. Perspectives on Sexual and Reproductive Health 49(2):95–102.

Jones, R. K., and H. D. Boonstra. 2016. The public health implications of the FDA update to the medication abortion label. New York: Guttmacher Institute. https://www.guttmacher.org/article/2016/06/public-health-implications-fda-update-medication-abortion-label (accessed October 27, 2017).

Jones, R. K., and J. Jerman. 2017a. Abortion incidence and service availability in the United States, 2014. Perspectives on Sexual and Reproductive Health 49(1):1–11.

Jones, R. K., and J. Jerman. 2017b. Characteristics and circumstances of U.S. women who obtain very early and second trimester abortions. PLoS One 12(1):e0169969.

Jones, R. K., and M. L. Kavanaugh. 2011. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstetrics & Gynecology 117(6):1358–1366.

Jones, R. K., L. B. Finer, and S. Singh. 2010. Characteristics of U.S. abortion patients, 2008. New York: Guttmacher Institute.

Kahn, J. B., J. P. Bourne, J. D. Asher, and C. W. Tyler. 1971. Technical reports: Surveillance of abortions in hospitals in the United States, 1970. HSMHA Health Reports 86(5):423–430.

Kelly, T., J. Suddes, D. Howel, J. Hewison, and S. Robson. 2010. Comparing medical versus surgical termination of pregnancy at 13–20 weeks of gestation: A randomised controlled trial. British Journal of Obstetrics & Gynaecology 117(12): 1512–1520.

Koonin, L. M., and J. C. Smith. 1993. Abortion surveillance—United States, 1990. MMWR Surveillance Summaries 42(SS-6):29–57. https://www.cdc.gov/mmwr/preview/mmwrhtml/00031585.htm (accessed September 18, 2017).

Kost, K. 2015. Unintended pregnancy rates at the state level: Estimates for 2010 and trends since 2002. New York: Guttmacher Institute.

Kulier, R., N. Kapp, A. M. Gulmezoglu, G. J. Hofmeyr, L. Cheng, and A. Campana. 2011. Medical methods for first trimester abortion. The Cochrane Database of Systematic Reviews (11):CD002855.

Lawson, H. W., H. K. Atrash, A. F. Saftlas, L. M. Koonin, M. Ramick, and J. C. Smith. 1989. Abortion surveillance, United States, 1984–1985. MMWR Surveillance Summaries 38(SS-2):11–15. https://www.cdc.gov/Mmwr/preview/mmwrhtml/00001467.htm (accessed September 18, 2017).

Lean, T. H., D. Vengadasalam, S. Pachauri, and E. R. Miller. 1976. A comparison of D & C and vacuum aspiration for performing first trimester abortion. International Journal of Gynecology and Obstetrics 14(6):481–486.

Lichtenberg, E. S., and M. Paul. 2013. Surgical abortion prior to 7 weeks of gestation. Contraception 88(1):7–17.

Lohr, A. P., J. L. Hayes, and K. Gemzell Danielsson. 2008. Surgical versus medical methods for second trimester induced abortion. Cochrane Database of Systematic Reviews (1):CD006714.

Low, N., M. Mueller, H. A. Van Vliet, and N. Kapp. 2012. Perioperative antibiotics to prevent infection after first-trimester abortion. Cochrane Database of Systematic Reviews (3):CD005217.

Mauelshagen, A., L. C. Sadler, H. Roberts, M. Harilall, and C. M. Farquhar. 2009. Audit of short term outcomes of surgical and medical second trimester termination of pregnancy. Reproductive Health 6(1):16.

NAF (National Abortion Federation). 2017. 2017 Clinical policy guidelines for abortion care . Washington, DC: NAF.

Nash, E., R. B. Gold, L. Mohammed, O. Cappello, and Z. Ansari-Thomas. 2017. Laws affecting reproductive health and rights: State policy trends at midyear, 2017 . Washington, DC: Guttmacher Institute. https://www.guttmacher.org/article/2017/07/laws-affecting-reproductive-health-and-rights-state-policy-trends-midyear-2017 (accessed September 21, 2017).

Ngoc, N. T., T. Shochet, S. Raghavan, J. Blum, N. T. Nga, N. T. Minh, V. Q. Phan, B. Winikoff. 2011. Mifepristone and misoprostol compared with misoprostol alone for second-trimester abortion: A randomized controlled trial. Obstetrics & Gynecology 118(3):601–608.

Ohannessian, A., K. Baumstarck, J. Maruani, E. Cohen-Solal, P. Auquier, and A. Agostini. 2016. Mifepristone and misoprostol for cervical ripening in surgical abortion between 12 and 14 weeks of gestation: A randomized controlled trial. European Journal of Obstetrics & Gynecology and Reproductive Biology 201:151–155.

Pazol, K., A. A. Creanga, and S. B. Zane. 2012. Trends in use of medical abortion in the United States: Reanalysis of surveillance data from the Centers for Disease Control and Prevention, 2001–2008. Contraception 86(6):746–751.

Pazol, K., A. A. Creanga, and D. J. Jamieson. 2015. Abortion surveillance—United States, 2012. Morbidity and Mortality Weekly Report 64(SS-10):1–40.

Peterson, W. F., F. N. Berry, M. R. Grace, and C. L. Gulbranson. 1983. Second-trimester abortion by dilatation and evacuation: An analysis of 11,747 cases. Obstetrics & Gynecology 62(2):185–190.

Plint, A. C., D. Moher, A. Morrison, K. Schulz, D. G. Altman, C. Hill, and I. Gaboury. 2006. Does the CONSORT checklist improve the quality of reports of randomised controlled trials? A systematic review. Medical Journal of Australia 185(5):263–267.

Ranji, U., A. Salganicoff, L. Sobel, C. Rosenzweig, and I. Gomez. 2017. Financing family planning services for low-income women: The role of public programs. https://www.kff.org/womens-health-policy/issue-brief/financing-family-planning-services-for-low-income-women-the-role-of-public-programs (accessed September 9, 2017).

Raymond, E. G., C. Shannon, M. A. Weaver, and B. Winikoff. 2013. First-trimester medical abortion with mifepristone 200 mg and misoprostol: A systematic review. Contraception 87(1):26–37.

RCOG (Royal College of Obstetricians and Gynaecologists). 2011. The care of women requesting induced abortion (Evidence-based clinical guideline number 7). London, UK: RCOG Press. https://www.rcog.org.uk/globalassets/documents/guidelines/abortion-guideline_web_1.pdf (accessed July 27, 2017).

RCOG. 2015. Best practice in comprehensive abortion care (Best practice paper no. 2). London, UK: RCOG Press. https://www.rcog.org.uk/globalassets/documents/guidelines/best-practice-papers/best-practice-paper-2.pdf (accessed September 11, 2017).

Roblin, P. 2014. Vacuum aspiration. In Abortion care, edited by S. Rowlands. Cambridge, UK: Cambridge University Press.

Sackett, D. L. 1979. Bias in analytic research. Journal of Chronic Diseases 32(1–2):51–63.

Sonalkar, S., S. N. Ogden, L. K. Tran, and A. Y. Chen. 2017. Comparison of complications associated with induction by misoprostol versus dilation and evacuation for second-trimester abortion. International Journal of Gynaecology & Obstetrics 138(3):272–275.

Strauss, L. T., S. B. Gamble, W. Y. Parker, D. A. Cook, S. B. Zane, and S. Hamdan. 2007. Abortion surveillance—United States, 2004. MMWR Surveillance Summaries 56 (SS-12):1–33.

Upadhyay, U. D., S. Desai, V. Zlidar, T. A. Weitz, D. Grossman, P. Anderson, and D. Taylor. 2015. Incidence of emergency department visits and complications after abortion. Obstetrics & Gynecology 125(1):175–183.

von Elm, E., D. G. Altman, M. Egger, S. J. Pocock, P. C. Gøtzsche, and J. P. Vandenbrouke. 2007. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. PLoS Medicine 4(10):e296.

White, K., E. Carroll, and D. Grossman. 2015. Complications from first-trimester aspiration abortion: A systematic review of the literature. Contraception 92(5):422–438.

WHO (World Health Organization). 2012. Safe abortion: Technical and policy guidance for health systems (Second edition). http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf (accessed September 12, 2017).

WHO. 2014. Clinical practice handbook for safe abortion. Geneva, Switzerland: WHO Press. http://apps.who.int/iris/bitstream/10665/97415/1/9789241548717_eng.pdf?ua=1&ua=1 (accessed November 15, 2016).

Wildschut, H., M. I. Both, S. Medema, E. Thomee, M. F. Wildhagen, and N. Kapp. 2011. Medical methods for mid-trimester termination of pregnancy. The Cochrane Database of Systematic Reviews (1):Cd005216.

Woodcock, J. 2016. Letter from the director of the FDA Center for Drug Evaluation and Research to Donna Harrison, Gene Rudd, and Penny Young Nance. Re: Docket No. FDA-2002-P-0364. Silver Spring, MD: FDA.

Zane, S., A. A. Creanga, C. J. Berg, K. Pazol, D. B. Suchdev, D. J. Jamieson, and W. M. Callaghan. 2015. Abortion-related mortality in the United States: 1998–2010. Obstetrics & Gynecology 126(2):258–265.

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.

Welcome to OpenBook!

You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

Do you want to take a quick tour of the OpenBook's features?

Show this book's table of contents , where you can jump to any chapter by name.

...or use these buttons to go back to the previous chapter or skip to the next one.

Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

Switch between the Original Pages , where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

To search the entire text of this book, type in your search term here and press Enter .

Share a link to this book page on your preferred social network or via email.

View our suggested citation for this chapter.

Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

Get Email Updates

Do you enjoy reading reports from the Academies online for free ? Sign up for email notifications and we'll let you know about new publications in your areas of interest when they're released.

• Services Paper editing services Paper proofreading Business papers Philosophy papers Write my paper Term papers for sale Term paper help Academic term papers Buy research papers College writing services Paper writing help Student papers Original term papers Research paper help Nursing papers for sale Psychology papers Economics papers Medical papers Blog

159 Abortion Research Paper Topics: Creative Ideas List

Abortion is a very controversial issue discussed in different panels all over the world. Because of how vast the topic of abortion is, many interesting research papers can be written about it. For many students, picking the right topic to build their abortion thesis on can seem complicated, and finding the right topic is the bedrock to writing an excellent essay. This article aims at exposing all students to interesting abortion research topics that will help them write high-quality and in-depth research papers on abortion for their university programs. Abortion is simply a medical procedure that intentionally ends a pregnancy before a fetus is born. There are a lot of opinions about abortion, with some opposing it, stating various religious or ethical reasons why it is wrong. Those who support it do that with human rights and medical backing.

What Makes a Good Abortion Thesis Paper?

The first step to writing your essay is picking the right topic, but after you do that, there is a structure to put your thoughts into writing to deliver the best quality thesis paper. This section highlights how to outline and arrange your ideas to produce a good paper at the end. Follow the below outline when writing your abortion essay.

Before Beginning the Paper

Don’t just start writing immediately, do the below pre-writing activities first

Select a Topic : As mentioned above, an essential part of writing an essay is picking the right topic. The right topic should be interesting to you and appeal to your readers. State your Argument : Now that you know the abortion topic you want to write on, what is your argument? Are you going to oppose or support the issue? Your answer will help build a research paper on the topic. Conduct a Research : without proper research, you might end up misinforming your audience. Take time out to dig deep and find evidence that backs up your research. Organize your References : Your references need to be credible. The evidence shows you have done research to back your thesis.

Writing the Paper

After completing your pre-writing exercises, it is time to write your essay properly. Use this as a guideline.

• The Introduction : your Introduction should aim at grabbing the reader’s interest and ensuring that they are interested enough to read the rest of your paper. The opening is what starts the report. It also lets the reader know that your paper is worth reading.
• The Body : The body is the main section of the paper. This is where you present your actual writing. Here you state each idea and back it up with evidence. Your tone, style, and grammar must be concise, making your paper interesting enough for your professor to read. Do not miss out on any detail here. You are allowed to be as descriptive as you want.
• Conclusion : Here, you summarize the main points of your paper and highlight what you would like the reader to remember from reading your work.

Many students find writing a research paper challenging. Following the above structure will help you write a proper essay that will guarantee the best scores. Now that you know how to write a great paper, here are some good topics to help you begin. Before you get acquainted with our perfect list, remember you always have an opportunity to buy a custom research paper from our team of professional helpers. Just c ontact us with a “ do my research paper ” request and get a top grade.

 Abortion Topics for Research Paper

Abortion is a topic that has different opinions and conversations. These are some topics you can explore when writing about abortion.

• Explore the possible side effects of abortion.
• Medical reasons for abortions.
• Different religions and their stands on abortion.
• Why the government should ban abortion
• History of abortion.
• The abortion procedure explained.
• General misinformation about abortion.
• What other gender-borne concerns can be connected to abortion?
• Considering that the legislators who pass pro-life regulations are male, can abortion be considered reproductive control?
• The Problems of Abortion in Modern Society.
• Pro-life and Pro-choice Sides of Abortion. Who is right?
• Is Africa ready to embrace abortion?
• Abortion and virtue ethics.
• Legalizing Abortion: Advantages and Justification.
• Legalization of Abortion for Underage Girls.
• Abortion as a Crime and the Fight Against It
• Teenage Pregnancy, Abortion and Sex Education.
• Abortion in Ireland: Law and Public Opinion.
• The Safety and Quality of Abortion Care in Canada.
• Abortion: An Unsolvable Dilemma?
• Abortion: Premeditated Murder or a Reasonable Way Out?
• Abortion: Strengths and Limitations
• Is the abortion rate declining? What are the factors contributing to it?
• Abortion is legal but is it ethical?
• The upward trend and demand for abortion in the United States.
• What is abortion counseling, and who should provide it?

Essay Topics on Abortions

To write a proper essay on abortion, you need to look at different perspectives before deciding on your topic. Here are some essay topics that explore different perspectives of the abortion discussion.

• Has the legalization of abortion played any part in reducing crime rates in the United States?
• How Have Abortion Laws Changed Around the World?
• How Has Abortion and Birth Control Affected the 20th and 21st Century?
• Who Should Decide the Legality of Abortion?
• Why Has Abortion Created Serious Debates and Controversies Among the Mainline?
• Should the Right to Have an abortion lay on the woman alone?
• Why Should Abortion Remain Legal and With Limitations?
• Historically, what were the main reasons women of various titles abort children?
• What were the methods used for abortion before the development of modern medicine?
• Is the history of abortion relevant to the contemporary debate? Why or why not?
• Understanding the risks of teenage abortion.
• Is Self-Defense Abortion Permissible?
• Should women have the right to abortion if serious handicaps are detected in their children?
• Third-trimester abortions: Are they ever morally permissible?
• Is it immoral to force a woman to carry a pregnancy to term against her will?
• Who can teenagers talk to if they want to get an abortion?
• Some medical effects of abortion on the woman’s body.
• How lack of resources affects the occurrences of unsafe abortions in developing countries.
• Is a woman who has had an abortion considered a mother?
• Republican and Democratic views on abortion.
• The roles religion plays in the social discussion and perception of abortion.
• Is abortion about women’s health, or is it a choice of convenience?
• What does early and late abortion mean?
• Who has more rights when it concerns abortion, and why?
• Should health insurance cover abortions?
• Abortion and how it affects adoptions.
• Why do teenagers need consent from a parent before having an abortion?
• In cases of incest, is abortion morally right?
• Abortion is always wrong. Explain
• How do we reduce the rate of abortion in the United States while keeping abortion safe and accessible to all women?
• What are the rights of a fetus?
• The effects of repeated abortions on future pregnancies.
• Abortion rights and patriarchy.
• The perception of abortion in different cultures.
• Why do the abortion policies differ per state in the United States?

Abortion Argumentative Topics

Everyone has a different view about abortion, which sometimes leads to intelligent arguments. Some topics that can present your points argumentatively include:

• Moral and ethical arguments concerning abortion.
• Abortion laws and how it contradicts women’s fundamental human rights.
• What are the pros and cons of having an abortion?
• Under what circumstances should abortion be considered?
• The abortion and mental health controversy.
• Abortion in older women. Is it safe?
• The rights of a father in the abortion decision.
• Christianity and abortion.
• Who should have the final say on abortion? The woman, the hospital, or the government?
• Cultural arguments surrounding abortion.
• Examine the generation gap in abortion support.
• How accessible is abortion in Africa?
• Mental health consequences of refused abortions.
• Is abortion a mortal sin?
• Why is there a stigma surrounding abortion?
• Abortions due to medical mistakes, should there be legal actions?
• Do mothers regret their actions after abortion?
• A cross-study of abortion laws in Malawi.
• Side effects of illegal abortions.
• The role of parents in the minor’s decision to abort.
• When is the best time to have an abortion?
• Psychiatric aspects of abortion.

Abortion Research Questions

There are many complex ethical, moral, legal, and religious perspectives concerning abortion. Some interesting questions you can research include:

• Should Abortions be legal?
• In what countries are abortions legal?
• How does abortion relate to mental health?
• What issues are agreeable reasons for abortions?
• Does rape justify abortion?
• Will abortion affect subsequent pregnancies?
• What are the abortion laws surrounding teenagers?
• Why is abortion such a controversial issue?
• What are the current laws regarding abortion?
• What do women want from abortion services?
• Has abortion been politicized?
• Why is abortion still illegal in some countries?
• Why is abortion such a controversial issue worldwide?

College Research Topics about Abortion

College students are responsible for writing clear and concise research papers built on good topics. The following are some interesting topics college students can write on.

• The Physiological effects of having an abortion
• Controversies surrounding abortion.
• A critical look at the United States laws concerning abortion?
• Common misconceptions about abortion.
• What is incomplete abortion, and how does it affects the woman’s health?
• Abortion amongst teenagers and adolescents.
• Understanding induced abortion.
• The process of legalization of abortion in Japan.
• When is abortion denied?
• The adverse effects of self-induced abortions.
• Post-abortion complications as a result of visiting illegal abortion centers.
• Childhood trauma and its connection to women seeking an abortion.
• What is a post-abortion syndrome?
• Understanding why some women opt for abortion.
• Barriers to access to abortion
• Different abortion methods, pros, and cons.
• Do the fathers have their say in abortion?
• Abortion laws and restrictions. A cross-examination of The United States and India.
• Clandestine abortion and all it entails.
• Abortion laws around the world: progress and pushbacks.
• Abortion and how it is linked to population growth and reduction.
• Looking at the punishment for abortion in countries where they ate illegal.
• Is abortion immoral?
• Should the rights of the unborn be more important than the mothers?
• What are the medical arguments for and against abortion?
• The evolution of abortion laws.
• What are the changes people opposing abortion are trying to effect?
• What changes are those supporting abortion trying to effect?
• What are the cultural arguments for and against abortion?
• History of the anti-abortion movement.
• Why do various religions have different views on abortion?
• Would a complete abortion ban be a correct solution from a religious viewpoint? Why or why not?
• When applied to abortion, what are the different ethical notions?
• What would be some negative consequences of an abortion ban?
• Why is abortion considered to be a feminist issue?
• Illegal abortions in India, and how it affects the girl child.
• Post-abortion discussion: How to avoid a repeat case of unwanted pregnancy.

Controversial Abortion Research Paper Topics

Abortion is one of the most controversial subjects in modern society, and there are many strong feelings for or against this topic. Some controversial abortion topics you can build on include:

• How has the rise of women’s rights affected abortion rates in The United States?
• What is late-term abortion?
• What is the difference between the morality and legality of abortion?
• When is abortion the right option?
• Why women should be able to have an abortion whenever they please.
• Canada and China have no legal restrictions on abortion. Any woman in these countries can get an abortion whenever she pleases. Should there be any restrictions on abortion? If not, why not? If so, what should those restrictions be and why?
• Does life begin at conception?
• Should we consider the fetus a separate being, or is it a part of its mother?
• What is a better option: abort an unplanned pregnancy or have the child neglected after birth?
• Adoption as an alternative to Abortion: Discuss
• How has legalizing abortion impacted the birth rate?
• Discuss the abortion debate and human rights.
• Why does the public support for legal termination of pregnancy remain high?
• Should men be allowed to discuss the termination of pregnancy?
• How race, poverty, and choice affect the abortion rate.
• Abortion vs. using embryos for research and IVF: Evaluate
• Should an aborting woman go through forced sterilization?
• Should birth control be considered as wrong as abortions?
• Why is it hard for some women to have an abortion even if something is wrong with a fetus?
• Why do many married couples have abortions?
• Is it better to have an abortion or give birth and place a baby in the orphanage?
• Is abortion a simple operation, or is it a severe psychological trauma for women?
• A woman’s life before and after abortion: what changes exactly?
• Canadian Abortion Laws and Women’s Rights.
• Debate on Abortion: Ethics and Principles.

Writing Help For Your Saviour

The success of an essay is first determined by the topic you write on. But picking the topic is not the only important factor. You are also required to write a detailed and concise essay. With all the workload of a college student, it might be tough to deliver your best when you write an essay. Sometimes, you should allow experts and professionals from different disciplines to provide thesis help and write the perfect essay. We provide custom research papers that can be delivered to you fast. Our team of writers consists of University graduates, professors, and teachers who can write essays suitable for undergraduate and Ph.D. students alike. Our research paper services are affordable, secure, and easily accessed by everyone online. 

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

Terms & Conditions Loyalty Program Privacy Policy Money-Back Policy

Copyright © 2013-2024 MyPaperDone.com

About Abortion

Narrow the topic.

• Articles & Videos
• MLA Citation This link opens in a new window
• APA Citation This link opens in a new window

• Is abortion immoral?
• How can Roe v. Wade be overturned?
• Should the "right of conscience" regulation apply to pharmacists?
• Should the rights of the unborn be more important than the rights of the mother?
• Is abortion justifiable after a rape?
• Is the fight against Planned Parenthood justified?
• Is partial birth abortion infanticide?
• Should Planned Parenthood be funded by the government?
• Next: Library Resources >>
• Last Updated: Feb 6, 2024 11:38 AM
• URL: https://libguides.broward.edu/abortion

• MJC Library & Learning Center
• Research Guides
• Abortion Research

Start Learning About Your Topic

Create research questions to focus your topic, featured current news, find articles in library databases, find web resources, find books in the library catalog, cite your sources, key search words.

Use the words below to search for useful information in books and articles .

• birth control
• pro-choice movement
• pro-life movement
• reproductive rights
• Roe v. Wade
• Dobbs v. Jackson Women's Health Organization (Dobbs v. Jackson)

Background Reading:

It's important to begin your research learning something about your subject; in fact, you won't be able to create a focused, manageable thesis unless you already know something about your topic.

This step is important so that you will:

• Begin building your core knowledge about your topic
• Be able to put your topic in context
• Create research questions that drive your search for information
• Create a list of search terms that will help you find relevant information
• Know if the information you’re finding is relevant and useful

If you're working from off campus , you'll be prompted to sign in if you aren't already logged in to your MJC email or Canvas. If you are prompted to sign in, use the same credentials you use for email and Canvas. 

Most current background reading 

• Issues and Controversies: Should Women in the United States Have Access to Abortion? June 2022 article (written after the Supreme Court overturned Roe v Wade) that explores both sides of the abortion debate.
• Access World News: Abortion The most recent news and opinion on abortion from US newspapers.

More sources for background information

• CQ Researcher Online This link opens in a new window Original, comprehensive reporting and analysis on issues in the news. Check the dates of results to be sure they are sufficiently current.
• Gale eBooks This link opens in a new window Authoritative background reading from specialized encyclopedias (a year or more old, so not good for the latest developments).
• Gale In Context: Global Issues This link opens in a new window Best database for exploring the topic from a global point of view.

Choose the questions below that you find most interesting or appropriate for your assignment.

• Why is abortion such a controversial issue?
• What are the medical arguments for and against abortion?
• What are the religious arguments for and against abortion?
• What are the political arguments for and against abortion?
• What are the cultural arguments for and against abortion?
• What is the history of laws concerning abortion?
• What are the current laws about abortion?
• How are those who oppose access to abortion trying to affect change?
• How are those who support access to abortion trying to affect change?
• Based on what I have learned from my research, what do I think about the issue of abortion?
• State-by-State Abortion Laws Updated regularly by the Guttmacher Institute
• What the Data Says About Abortion in the U.S. From the Pew Research Center in June 2022, a look at the most recent available data about abortion from sources other than public opinion surveys.

Latest News on Abortion from Google News

All of these resources are free for MJC students, faculty, & staff.

• Gale Databases This link opens in a new window Search over 35 databases simultaneously that cover almost any topic you need to research at MJC. Gale databases include articles previously published in journals, magazines, newspapers, books, and other media outlets.
• EBSCOhost Databases This link opens in a new window Search 22 databases simultaneously that cover almost any topic you need to research at MJC. EBSCO databases include articles previously published in journals, magazines, newspapers, books, and other media outlets.
• Facts on File Databases This link opens in a new window Facts on File databases include: Issues & Controversies , Issues & Controversies in History , Today's Science , and World News Digest .
• MEDLINE Complete This link opens in a new window This database provides access to top-tier biomedical and health journals, making it an essential resource for doctors, nurses, health professionals and researchers engaged in clinical care, public health, and health policy development.
• Access World News This link opens in a new window Search the full-text of editions of record for local, regional, and national U.S. newspapers as well as full-text content of key international sources. This is your source for The Modesto Bee from January 1989 to the present. Also includes in-depth special reports and hot topics from around the country. To access The Modesto Bee , limit your search to that publication. more... less... Watch this short video to learn how to find The Modesto Bee .

Browse Featured Web Sites:

• American Association of Pro-Life Obstetricians and Gynecologists Medical information and anti-abortion rights advocacy.
• American Congress of Obstetricians and Gynecologists Use the key term "abortion" in the search box on this site for links to reports and statistics.
• Guttmacher Institute Statistics and policy papers with a world-wide focus from a "research and policy organization committed to advancing sexual and reproductive health and rights worldwide."
• NARAL Pro-Choice America This group advocates for pro-abortion rights legislation. Current information abortion laws in the U.S.
• National Right to Life Committee This group advocates for anti-abortion rights legislation in the U.S.

Why Use Books:

Use books to read broad overviews and detailed discussions of your topic. You can also use books to find  primary sources , which are often published together in collections.  

Where Do I Find Books?

You'll use the library catalog to search for books, ebooks, articles, and more.  

What if MJC Doesn't Have What I Need?

If you need materials (books, articles, recordings, videos, etc.) that you cannot find in the library catalog , use our  interlibrary loan service .

Your instructor should tell you which citation style they want you to use. Click on the appropriate link below to learn how to format your paper and cite your sources according to a particular style.

• Chicago Style
• ASA & Other Citation Styles
• Last Updated: Feb 14, 2024 12:41 PM
• URL: https://libguides.mjc.edu/abortion

Except where otherwise noted, this work is licensed under CC BY-SA 4.0 and CC BY-NC 4.0 Licenses .

Abortion Research Paper: Example, Outline, & Topics

The long-standing debate surrounding abortion has many opponents and advocates. Groups known as Pro-Choice and Pro-Life argue which approach is better, with no easy solution in sight. This ethical complexity is what makes abortion a popular topic for argumentative writing. As a student, you need to tackle it appropriately.

Our specialists will write a custom essay specially for you!

If this task sounds daunting, read this guide by our custom-writing experts to get excellent writing tips on handling this assignment. You will also find here:

• abortion topics and prompts,
• a research paper outline,
• a free essay sample.
• 🤔 Why Is Abortion a Good Topic?
• ☑️ Research Paper Prompts
• 👨‍⚕️ Abortion Research Questions
• 📚 Research Topics
• 🔬 Before You Start
• ✍️ Step-by-Step Writing Guide

📋 Abortion Research Paper Example

🔍 references, 🤔 why is abortion a good research topic.

Abortion studies are a vast area of research and analysis. It touches upon numerous domains of life, such as politics, medicine, religion, ethics, and human rights perspectives.

Like gun control or euthanasia, the abortion debate offers no evident answers to what kind of regulation is preferable. According to a recent survey, 61% of US adults are in favor of abortion , while 37% think it should be illegal. The arguments from both sides make sense, and there is no “yes-no” solution.

All this makes investigating the abortion debate a valuable exercise to hone your critical analysis skills. It will teach you to back up your claims with sound evidence while giving credit to counterarguments. Besides, expanding the body of abortion research is beneficial for the American community and women’s rights.

☑️ Abortion Research Paper Prompts

The first step to writing a successful paper is choosing an appropriate topic. Abortion is surrounded by numerous legal, medical, ethical, and social debates. That’s why the choice of ideas is virtually endless.

Just in 1 hour! We will write you a plagiarism-free paper in hardly more than 1 hour

Don’t know where to start? Check out the prompts and creative titles below.

Should Abortion Be Legal: Research Paper Prompt 

You can approach this question from several perspectives. For example, propose a new legal framework for regulating eligibility for abortion. Some states allow the procedure under certain circumstances, such as a threat to a woman’s health. Should it be made legal in less extreme situations, too?

Anti-Abortion Research Paper Prompt

The legal status of abortions is still disputed in many countries. The procedure’s most ardent opponents are Catholic religious groups. In an anti-abortion paper, you may list ethical or faith-based claims. Focus on the right-to-life arguments and give scientific evidence regarding embryo’s rights.

Abortion and Embryonic Stem Cell Research Prompt   

Stem cell research is a dubious issue that faces strong opposition from ethical and religious activists. Here are some great ideas for an essay on this topic:

• Start by explaining what stem cells are.
• Outline the arguments for and against their use in research.
• Link this discussion to the status of abortion.

Abortion Law Research Paper Prompt

If you get an abortion-related assignment in your Legal Studies class, it’s better to take a legislative approach to this issue. Here’s what you can do:

Receive a plagiarism-free paper tailored to your instructions. Cut 20% off your first order!

• Study the evolution of abortion laws in the US or other countries.
• Pinpoint legal gaps.
• Focus on the laws’ strengths and weaknesses.

Abortion Breast Cancer Research Prompt

Increasing research evidence shows the link between abortion and breast cancer development . Find scholarly articles proving or refuting this idea and formulate a strong argument on this subject. Argue it with credible external evidence.

Abortion Ethics Research Paper Prompt 

Here, you can focus on the significance of the discussion’s ethical dimension. People who are against abortion often cite the ethics of killing an embryo. You can discuss this issue by quoting famous thinkers and the latest medical research. Be sure to support your argument with sound evidence.

👨‍⚕️ Questions about Abortion for Research Paper

• How does technology reframe the abortion debate ?
• Is there new ethics of abortion in the 21 st century?
• How did the abortion debate progress before the Roe v. Wade decision?
• How is the abortion debate currently being shaped on social media?
• How do abortion rights advocates conceptualize the meaning of life ?
• Can the abortion debate be called a culture war?
• What are women’s constitutional abortion rights ?
• How does abortion reshape the concept of a person?
• How does the abortion debate fit in the post-Socialist transition framework of the European community?
• Where does the abortion debate stand in the politics of sexuality?

📚 Abortion Topics for Research Paper

• The changing legal rhetoric of abortion in the US .
• Constructing abortion as a legal problem .
• Regendering of the US’ abortion problem .
• Evolution of public attitudes to abortion in the US.
• Choice vs. coercion in the abortion debate.
• Abortion and sin in Catholicism.
• Artificial wombs as an innovative solution to the abortion debate.
• Religious belief vs. reason in the abortion debate.
• Introduction of pregnant women’s perspectives into the abortion debate: dealing with fetal abnormalities .
• The role of ultrasound images in the evolution of women’s abortion intentions.

🔬 Research Papers on Abortions: Before You Start

Before discussing how to write an abortion paper, let’s focus on the pre-writing steps necessary for a stellar work. Here are the main points to consider.

Abortion Research Design 

Before you start exploring your topic, you need to choose between a qualitative and quantitative research design:

💬 Qualitative studies focus on words and present the attitudes and subjective meanings assigned to the concept of abortion by respondents.

Get an originally-written paper according to your instructions!

🧪 Quantitative studies , in turn, focus on numbers and statistics. They analyze objective evidence and avoid subjective interpretations.  

Pick a research design based on your research skills and the data you’re planning to analyze:

• If you plan to gain insight into people’s opinions, attitudes, and life experiences related to abortion, it’s better to go for an interview and qualitative analysis.
• If you have a survey and want to focus on descriptive statistics, it’s better to stick to quantitative methods .

Abortion Research Paper Outline Format

Next, it’s time to choose the format of your paper’s outline. As a rule, students use one of the 3 approaches:

You can learn more about these formats from our article on how to write an outline .

Choosing Headings & Subheadings

A strong title can save your paper, while a poor one can immediately kill the readers’ interest. That’s why we recommend you not to underestimate the importance of formulating an attention-grabbing, exciting heading for your text.

Here are our best tips to make your title and subheadings effective:

• A good title needs to be brief. It’s up to 5 words, as a rule. Subheadings can be longer, as they give a more extended explanation of the content.
• Don’t be redundant. Make sure the subheadings are not duplicating each other.
• Mind the format. For instance, if your paper is in the APA format, you need to use proper font size and indentation. No numbering of headings and subheadings is necessary as in the outline. Ensure the reader understands the hierarchy with the help of heading level distinctions.

Components of an Effective Outline

According to academic writing conventions, a good outline should follow 4 essential principles:

• Parallelism . All components of your outline need to have a similar grammatical structure. For example, if you choose infinitives to denote actions, stick to them and don’t mix them with nouns and gerunds.
• Coordination . Divide your work into chunks with equal importance. This way, you will allocate as much weight to one point as to all the others. Your outline’s sections of similar hierarchy should have equal significance.
• Subordination . The subheadings contained within one heading of a higher order should all be connected to the paper’s title.
• Division . The minimum number of subheadings in each outline heading should be 2. If you have only one point under a heading, it’s worth adding another one.

Use this list of principles as a cheat sheet while creating your outline, and you’re sure to end up with well-organized and structured research!

Abortion Research Paper Outline Example

To recap and illustrate everything we’ve just discussed, let’s have a look at this sample abortion outline. We’ve made it in the decimal format following all effective outlining principles—check it out!

• History of abortion laws in the USA.
• Problem: recent legal changes challenge Roe vs. Wade .
• Thesis statement: the right to abortion should be preserved as a constitutional right
• The fundamental human right to decide what to do with their body.
• Legal abortions are safer.
• Fetuses don’t feel pain at the early stages of development.
• Abortion is murder.
• Fetuses are unborn people who feel pain at later stages.
• Abortion causes lifelong psychological trauma for the woman.
• Roe vs. Wade is a pro-choice case.
• The constitutional right to privacy and bodily integrity.
• Conclusion.

✍️ Abortion Research Paper: How to Write

Now, let’s proceed to write the paper itself. We will cover all the steps, starting with introduction writing rules and ending with the body and conclusion essentials.

Abortion Introduction: Research Paper Tips  

When you begin writing an abortion paper, it’s vital to introduce the reader to the debate and key terminology. Start by describing a broader issue and steadily narrow the argument to the scope of your paper. The intro typically contains the key figures or facts that would show your topic’s significance.

For example, suppose you plan to discuss the ethical side of abortion. In this case, it’s better to structure the paper like this:

• Start by outlining the issue of abortion as a whole.
• Introduce the arguments of pro-choice advocates, saying that this side of the debate focuses on the woman’s right to remove the fetus from her body or leave it.
• Cite the latest research evidence about fetuses as living organisms, proceeding to debate abortion ethics.
• End your introduction with a concise thesis statement .

Thesis on Abortion for a Research Paper

The final part of your introduction is a thesis—a single claim that formulates your paper’s main idea. Experienced readers and college professors often focus on the thesis statement’s quality to decide whether the text is worth reading further. So, make sure you dedicate enough effort to formulate the abortion research paper thesis well!

Don’t know how to do it? These pro tips will surely help you write a great thesis:

Abortion Research Paper Body

Now, it’s time to proceed to the main body of your paper. It should expand on the main idea in more detail, explaining the details and weighing the evidence for and against your argument.

The secret of effective writing is to go paragraph by paragraph . Your essay’s body will have around 2-5 of them, and the quality of each one determines the value of the whole text.

Here are the 4 easy steps that can help you excel in writing the main part of your essay:

• Start each paragraph with a topic sentence. It functions as a mini-thesis statement and communicates the paragraph’s main idea.
• Then, expand it with additional facts and evidence. It’s better to back that information with external sources, showing that it’s not your guesswork. Make sure you properly analyze the citations and show how they fit into your broader research.
• A paragraph should end with a concise wrap-up. Write a concluding sentence restating the topic sentence or a transition linking to the next section.

Research Papers on Abortions: Conclusion

The conclusion of an abortion paper also plays a major role in the overall impression that your paper will produce. So, how do you make it interesting?

Instead of simply restating the thesis and enumerating your points, it’s better to do the following:

• Focus on the broader implications of the issue you’ve just discussed.
• Mention your study’s limitations and point out some directions for further research.
• It’s also a good idea to include a call to action , which can help create a sense of urgency in the readers.

Abortion Articles for Research Paper & Other Sources

Every research paper ends with “works cited” or a reference page enumerating the sources used for the assignment. A rule of thumb is to cite credible, authoritative publications from governmental organizations and NGOs and academic articles from peer-reviewed journals. These sources will make your research more competent and professional, supporting your viewpoint with objective scientific information.

Here are some databases that can supply top-quality data to back the abortion-related claims in a research paper:

Feel free to check these databases for studies related to your subject. It’s best to conduct preliminary research to see whether your topic has enough supporting evidence. Also, make sure there are plenty of new studies to back your arguments! Abortion is a fast-changing field of research, so it’s best only to use publications no more than 5 years old.

To learn more about credible research sources, check out our guide on choosing reliable websites .

We’ve taught you all you need to write a well-researched and thoughtful abortion paper. Finally, we want to give you an example of an essay on the topic “ Should Abortion Rights Be Preserved? ” Check it out to gain inspiration.

Now you know all the details of abortion paper writing. Use our tips to choose a topic, develop sound arguments, and impress your professor with a stellar piece on this debatable subject!

❓ Abortion Research Paper FAQs

• First, you need to pick a debatable topic about abortion and develop a thesis statement on that subject.
• Next, choose the arguments to support your claim and use external evidence to back them up.
• End the paper with a concise wrap-up.
• Begin your introduction with a catchy fact or shocking statistics on the issue of abortion.
• Ask a rhetorical question to boost your readers’ interest.
• Cite a famous person’s words about the pros and cons of legal abortion.

To compose a strong opening for your abortion essay, make sure to provide some background and context for further discussion. Explain why the debate about abortions is so acute and what the roots of the problem are.

There are many interesting topics related to abortion, spanning the areas of sociology, ethics, and medicine. You can focus on the progression of the abortion debate along with civil rights or discuss abortion from a feminist perspective.

You can choose between qualitative and quantitative approaches for your abortion research. Hold a survey among women and report the findings of your qualitative study in a short report. Or, you can measure factual information in numbers and conduct quantitative research.

• The Ultimate Guide to Writing a Research Paper: Grammarly
• Scholarly Articles on Abortion: Gale
• Unintended Pregnancy and Abortion Worldwide: Guttmacher Institute
• Why Abortion Should Be Legal: News 24
• Pro and Con: Abortion: Britannica
• Organizing Academic Research Papers: The Introduction: Sacred Heart University
• How to Write a Thesis Statement for a Research Paper: Steps and Examples: Research.com
• Abortion: American Psychological Association
• Writing a Research Paper: University of Wisconsin-Madison
• Writing a Research Paper: Purdue University
• A Process Approach to Writing Research Papers: University of California, Berkeley
• What Is Qualitative vs. Quantitative Study?: Grand Canyon University
• Decimal Outlines: Texas A&M University
• Share to Facebook
• Share to Twitter
• Share to LinkedIn
• Share to email

What is the most important part of any essay or research paper? Of course, it’s the thesis statement—a sentence that expresses the paper’s main idea and guides the readers through your arguments. But where do you place the thesis? You’ve probably answered, “in the introduction.” However, that’s not all of...

If you’re a student, you’ve heard about a formal essay: a factual, research-based paper written in 3rd person. Most students have to produce dozens of them during their educational career.  Writing a formal essay may not be the easiest task. But fear not: our custom-writing team is here to guide...

Rhetorical analysis is never a simple task. This essay type requires you to analyze rhetorical devices in a text and review them from different perspectives. Such an assignment can be a part of an AP Lang exam or a college home task. Either way, you will need a solid outline...

Narrative essays are unlike anything you wrote throughout your academic career. Instead of writing a formal paper, you need to tell a story. Familiar elements such as evidence and arguments are replaced with exposition and character development. The importance of writing an outline for an essay like this is hard...

Discourse is the way people talk about any specific topic. It’s also the way in which language is used to convey social and historical meanings. Discourse analysis is the process that helps to understand the underlying message of what is being said. Sounds interesting? Keep reading to learn more.  This in...

A précis is a brief synopsis of a written piece. It is used to summarize and analyze a text’s main points. If you need to write a précis for a research paper or the AP Lang exam, you’ve come to the right place. In this comprehensive guide by Custom-Writing.org, you’ll...

A synthesis essay requires you to work with multiple sources. You combine the information gathered from them to present a well-rounded argument on a topic. Are you looking for the ultimate guide on synthesis essay writing? You’ve come to the right place! In this guide by our custom writing team,...

Do you know how to make your essay stand out? One of the easiest ways is to start your introduction with a catchy hook. A hook is a phrase or a sentence that helps to grab the reader’s attention. After reading this article by Custom-Writing.org, you will be able to...

A critical analysis essay is an academic paper that requires a thorough examination of theoretical concepts and ideas. It includes a comparison of facts, differentiation between evidence and argument, and identification of biases. Crafting a good paper can be a daunting experience, but it will be much easier if you...

Critical thinking is the process of evaluating and analyzing information. People who use it in everyday life are open to different opinions. They rely on reason and logic when making conclusions about certain issues. A critical thinking essay shows how your thoughts change as you research your topic. This type...

Process analysis is an explanation of how something works or happens. Want to know more? Read the following article prepared by our custom writing specialists and learn about: process analysis and its typesa process analysis outline tipsfree examples and other tips that might be helpful for your college assignment So,...

A visual analysis essay is an academic paper type that history and art students often deal with. It consists of a detailed description of an image or object. It can also include an interpretation or an argument that is supported by visual evidence. In this article, our custom writing experts...

Read our research on: Abortion | Podcasts | Election 2024

Regions & Countries

Key facts about the abortion debate in america.

The U.S. Supreme Court’s June 2022 ruling to overturn Roe v. Wade – the decision that had guaranteed a constitutional right to an abortion for nearly 50 years – has shifted the legal battle over abortion to the states, with some prohibiting the procedure and others moving to safeguard it.

As the nation’s post-Roe chapter begins, here are key facts about Americans’ views on abortion, based on two Pew Research Center polls: one conducted from June 25-July 4 , just after this year’s high court ruling, and one conducted in March , before an earlier leaked draft of the opinion became public.

This analysis primarily draws from two Pew Research Center surveys, one surveying 10,441 U.S. adults conducted March 7-13, 2022, and another surveying 6,174 U.S. adults conducted June 27-July 4, 2022. Here are the questions used for the March survey , along with responses, and the questions used for the survey from June and July , along with responses.

Everyone who took part in these surveys is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories.  Read more about the ATP’s methodology .

A majority of the U.S. public disapproves of the Supreme Court’s decision to overturn Roe. About six-in-ten adults (57%) disapprove of the court’s decision that the U.S. Constitution does not guarantee a right to abortion and that abortion laws can be set by states, including 43% who strongly disapprove, according to the summer survey. About four-in-ten (41%) approve, including 25% who strongly approve.

About eight-in-ten Democrats and Democratic-leaning independents (82%) disapprove of the court’s decision, including nearly two-thirds (66%) who strongly disapprove. Most Republicans and GOP leaners (70%) approve , including 48% who strongly approve.

Most women (62%) disapprove of the decision to end the federal right to an abortion. More than twice as many women strongly disapprove of the court’s decision (47%) as strongly approve of it (21%). Opinion among men is more divided: 52% disapprove (37% strongly), while 47% approve (28% strongly).

About six-in-ten Americans (62%) say abortion should be legal in all or most cases, according to the summer survey – little changed since the March survey conducted just before the ruling. That includes 29% of Americans who say it should be legal in all cases and 33% who say it should be legal in most cases. About a third of U.S. adults (36%) say abortion should be illegal in all (8%) or most (28%) cases.

Generally, Americans’ views of whether abortion should be legal remained relatively unchanged in the past few years , though support fluctuated somewhat in previous decades.

Relatively few Americans take an absolutist view on the legality of abortion – either supporting or opposing it at all times, regardless of circumstances. The March survey found that support or opposition to abortion varies substantially depending on such circumstances as when an abortion takes place during a pregnancy, whether the pregnancy is life-threatening or whether a baby would have severe health problems.

While Republicans’ and Democrats’ views on the legality of abortion have long differed, the 46 percentage point partisan gap today is considerably larger than it was in the recent past, according to the survey conducted after the court’s ruling. The wider gap has been largely driven by Democrats: Today, 84% of Democrats say abortion should be legal in all or most cases, up from 72% in 2016 and 63% in 2007. Republicans’ views have shown far less change over time: Currently, 38% of Republicans say abortion should be legal in all or most cases, nearly identical to the 39% who said this in 2007.

However, the partisan divisions over whether abortion should generally be legal tell only part of the story. According to the March survey, sizable shares of Democrats favor restrictions on abortion under certain circumstances, while majorities of Republicans favor abortion being legal in some situations , such as in cases of rape or when the pregnancy is life-threatening.

There are wide religious divides in views of whether abortion should be legal , the summer survey found. An overwhelming share of religiously unaffiliated adults (83%) say abortion should be legal in all or most cases, as do six-in-ten Catholics. Protestants are divided in their views: 48% say it should be legal in all or most cases, while 50% say it should be illegal in all or most cases. Majorities of Black Protestants (71%) and White non-evangelical Protestants (61%) take the position that abortion should be legal in all or most cases, while about three-quarters of White evangelicals (73%) say it should be illegal in all (20%) or most cases (53%).

In the March survey, 72% of White evangelicals said that the statement “human life begins at conception, so a fetus is a person with rights” reflected their views extremely or very well . That’s much greater than the share of White non-evangelical Protestants (32%), Black Protestants (38%) and Catholics (44%) who said the same. Overall, 38% of Americans said that statement matched their views extremely or very well.

Catholics, meanwhile, are divided along religious and political lines in their attitudes about abortion, according to the same survey. Catholics who attend Mass regularly are among the country’s strongest opponents of abortion being legal, and they are also more likely than those who attend less frequently to believe that life begins at conception and that a fetus has rights. Catholic Republicans, meanwhile, are far more conservative on a range of abortion questions than are Catholic Democrats.

Women (66%) are more likely than men (57%) to say abortion should be legal in most or all cases, according to the survey conducted after the court’s ruling.

More than half of U.S. adults – including 60% of women and 51% of men – said in March that women should have a greater say than men in setting abortion policy . Just 3% of U.S. adults said men should have more influence over abortion policy than women, with the remainder (39%) saying women and men should have equal say.

The March survey also found that by some measures, women report being closer to the abortion issue than men . For example, women were more likely than men to say they had given “a lot” of thought to issues around abortion prior to taking the survey (40% vs. 30%). They were also considerably more likely than men to say they personally knew someone (such as a close friend, family member or themselves) who had had an abortion (66% vs. 51%) – a gender gap that was evident across age groups, political parties and religious groups.

Relatively few Americans view the morality of abortion in stark terms , the March survey found. Overall, just 7% of all U.S. adults say having an abortion is morally acceptable in all cases, and 13% say it is morally wrong in all cases. A third say that having an abortion is morally wrong in most cases, while about a quarter (24%) say it is morally acceptable in most cases. An additional 21% do not consider having an abortion a moral issue.

Among Republicans, most (68%) say that having an abortion is morally wrong either in most (48%) or all cases (20%). Only about three-in-ten Democrats (29%) hold a similar view. Instead, about four-in-ten Democrats say having an abortion is morally  acceptable  in most (32%) or all (11%) cases, while an additional 28% say it is not a moral issue. 

White evangelical Protestants overwhelmingly say having an abortion is morally wrong in most (51%) or all cases (30%). A slim majority of Catholics (53%) also view having an abortion as morally wrong, but many also say it is morally acceptable in most (24%) or all cases (4%), or that it is not a moral issue (17%). Among religiously unaffiliated Americans, about three-quarters see having an abortion as morally acceptable (45%) or not a moral issue (32%).

Sign up for our weekly newsletter

Fresh data delivered Saturday mornings

Public Opinion on Abortion

Majority in u.s. say abortion should be legal in some cases, illegal in others, three-in-ten or more democrats and republicans don’t agree with their party on abortion, partisanship a bigger factor than geography in views of abortion access locally, most popular.

About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• 26 March 2024

Abortion-pill challenge provokes doubt from US Supreme Court

• Mariana Lenharo

You can also search for this author in PubMed   Google Scholar

People in favour of abortion rights rally in front of the US Supreme Court on the day that justices heard arguments over access to abortion pill mifepristone. Credit: Drew Angerer/AFP via Getty

Members of the US Supreme Court expressed scepticism today about arguments from a group of anti-abortion organizations and physicians seeking to restrict use of the abortion drug mifepristone in the United States. The group is challenging the decision by the US Food and Drug Administration (FDA) to expand access to the medication.

The court’s nine justices must decide whether the challengers are qualified to bring suit in the first place — in legal terms, whether the challengers have standing. If they do, then the justices will then determine whether the FDA’s actions to facilitate access to mifepristone are valid. A decision is expected to be made in June.

Changes made by the agency over the past eight years allowed the drug to be used until ten weeks of pregnancy, rather than the previous limit of seven weeks. The changes also relaxed the requirement that the drug be dispensed only in person, allowing it to be sent through the mail. If the court invalidates those actions, mifepristone access would be restricted nationwide. In 2022, the Supreme Court reversed Roe v. Wade , the decision that legalized abortion nationally.

US lawsuit threatens access to abortion drug: the science behind the case

Eva Temkin, a lawyer specializing in FDA regulatory issues at the law firm Paul Hastings, who is based in Washington DC, notes that the justices seemed particularly sceptical that the plaintiffs had standing. The court didn’t focus much on the appropriateness of the FDA’s actions, she says. “I am very hopeful that the Supreme Court was not immersed in those issues as much because they recognized how outrageous it would be to find the FDA scientific judgment here was not exercised appropriately.”

Reproductive-health researchers say that the case has no scientific merit, because mifepristone has been shown to be safe and effective. They also say that a ruling against the FDA would undermine the agency’s authority to regulate medicines . Mifepristone, which the FDA approved in 2000, is used in combination with the drug misoprostol to induce an abortion. Endorsed by the American College of Obstetricians and Gynecologists, the pairing is the most commonly prescribed regimen for medication abortion in the United States, where 63% of abortions in 2023 were carried out using pills.

A question of standing

During oral arguments today, justices questioned the anti-abortion group’s allegation that the physicians it represents could be affected by the widespread access to mifepristone. Emergency-room doctors, the group says, might have to treat people who experience complications as a result of a medication abortion. Treating the after-effects of a therapy to which they have ethical objections would cause emotional suffering and distress, the group says.

Justice Ketanji Brown Jackson said at the hearing she worried that there was a “significant mismatch” between the alleged harm done by widespread mifepristone access and the effects of rolling back that access. “The obvious common-sense remedy would be to provide them with an exemption, that they don’t have to participate in this procedure,” she added. Existing federal and state laws already allow health-care providers to refuse to perform abortion-related care, noted solicitor general Elizabeth Prelogar, who was representing the US government at the hearing.

“This case seems like a prime example of turning what could be a small lawsuit into a nationwide legislative assembly on an FDA rule,” said justice Neil Gorsuch.

But some justices expressed sympathy for the anti-abortion group’s arguments. “Maybe what [the FDA] did was perfectly lawful,” said justice Samuel Alito. “But shouldn’t somebody be able to challenge that in court?”

Retracted studies

The case started in 2022, when the anti-abortion group filed a suit against the FDA, claiming that the drug’s approval in 2000 — and subsequent decisions that facilitated access to the drug — had “potentially serious and life-threatening effects on women and girls”.

Influential abortion-pill studies retracted: the science behind the decision

In 2023, the judge overseeing the case, Matthew Kacsmaryk of the US District Court for the Northern District of Texas, ruled in favour of the plaintiffs, invalidating mifepristone’s FDA approval. But the Supreme Court put the ruling on hold, which allowed mifepristone to remain on the market while the case was being appealed.

In his decision, Kacsmaryk relied on problematic studies to question mifepristone’s safety . Two papers 1 , 2 he cited were retracted in February because of problems with its study design and methodology, as well as errors in data analysis, among other issues. The prevailing scientific literature 3 , 4 contradicts the papers that Kacsmaryk cited.

Later that year, the US Court of Appeals for the Fifth Circuit ruled that mifepristone should remain an approved drug but invalidated the FDA’s actions to make it more accessible. The Supreme Court’s stay on Kacsmaryk’s ruling meant that the Fifth Circuit decision didn’t take effect immediately.

Hanging in the balance

If the Supreme Court decides that the anti-abortion group has no standing, the case might be dismissed, Temkin says. If, however, it agrees with the Fifth Circuit judges, the resulting rollback in mifepristone accessibility would especially affect pregnant people who seek abortion care later in their pregnancy, as well as those who would have difficulty attending an in-person appointment with an abortion provider.

Restricting mifepristone use could also have implications for drug development in general, Temkin says. The Fifth Circuit called for a cumbersome and unprecedented standard for drug approval. If the Supreme Court follows that lead, “that would create delays, that would create inefficiencies and costs and would ultimately undermine patient access to scientifically appropriate medicines”, Temkin says.

Such a decision “would have nothing to do with science or medicine or protecting the health of pregnant people”, says Heidi Moseson, an epidemiologist at Ibis Reproductive Health, a global research organization that supports abortion rights, who is based in Oakland, California.

doi: https://doi.org/10.1038/d41586-024-00938-4

Studnicki, J. et al. Health Serv. Res. Manag. Epidemiol . 8 , 23333928211053965 (2021); retraction 11 , 23333928231216699 (2024).

Article   PubMed   Google Scholar  

Studnicki, J. et al. Health Serv. Res. Manag. Epidemiol . 9 , 23333928221103107 (2022); retraction 11 , 23333928231216699 (2024).

Upadhyay, U. D. et al. Obstet. Gynecol. 125 , 175–183 (2015).

Raymond, E. G., Shannon, C., Weaver, M. A. & Winikoff, B. Contraception 87 , 26–37 (2013).

Download references

Reprints and permissions

Related Articles

• Public health

Sam Bankman-Fried sentencing: crypto-funded researchers grapple with FTX collapse

News 28 MAR 24

News 27 FEB 24

I took my case to Nepal’s highest court to improve conservation

Career Q&A 12 FEB 24

The future of at-home molecular testing

Outlook 21 MAR 24

Google AI could soon use a person’s cough to diagnose disease

News 21 MAR 24

‘Woah, this is affecting me’: why I’m fighting racial inequality in prostate-cancer research

Career Q&A 20 MAR 24

Postdoctoral Scholar - PHAST Alzheimer

Memphis, Tennessee

The University of Tennessee Health Science Center (UTHSC)

Postdoctoral Associate- Neurodevelopmental Disease

Houston, Texas (US)

Baylor College of Medicine (BCM)

Supervisory Bioinformatics Specialist, CTG Program Head

National Institutes of Health (NIH) National Library of Medicine (NLM) National Center for Biotechnology Information (NCBI) Information Engineering...

Washington D.C. (US)

National Library of Medicine, National Center for Biotechnology Information

Postdoc Research Associates in Single Cell Multi-Omics Analysis and Molecular Biology

The Cao Lab at UT Dallas is seeking for two highly motivated postdocs in Single Cell Multi-Omics Analysis and Molecular Biology to join us.

Dallas, Texas (US)

the Department of Bioengineering, UT Dallas

Expression of Interest – Marie Skłodowska-Curie Actions – Postdoctoral Fellowships 2024 (MSCA-PF)

Academic institutions in Brittany are looking for excellent postdoctoral researchers willing to apply for a Marie S. Curie Postdoctoral Fellowship.

France (FR)

Plateforme projets européens (2PE) -Bretagne

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Help | Advanced Search

Computer Science > Computer Vision and Pattern Recognition

Title: motion inversion for video customization.

Abstract: In this research, we present a novel approach to motion customization in video generation, addressing the widespread gap in the thorough exploration of motion representation within video generative models. Recognizing the unique challenges posed by video's spatiotemporal nature, our method introduces Motion Embeddings, a set of explicit, temporally coherent one-dimensional embeddings derived from a given video. These embeddings are designed to integrate seamlessly with the temporal transformer modules of video diffusion models, modulating self-attention computations across frames without compromising spatial integrity. Our approach offers a compact and efficient solution to motion representation and enables complex manipulations of motion characteristics through vector arithmetic in the embedding space. Furthermore, we identify the Temporal Discrepancy in video generative models, which refers to variations in how different motion modules process temporal relationships between frames. We leverage this understanding to optimize the integration of our motion embeddings. Our contributions include the introduction of a tailored motion embedding for customization tasks, insights into the temporal processing differences in video models, and a demonstration of the practical advantages and effectiveness of our method through extensive experiments.

Submission history

Access paper:.

• HTML (experimental)
• Other Formats

References & Citations

• Google Scholar
• Semantic Scholar

BibTeX formatted citation

Bibliographic and Citation Tools

Code, data and media associated with this article, recommenders and search tools.

• Institution

arXivLabs: experimental projects with community collaborators

arXivLabs is a framework that allows collaborators to develop and share new arXiv features directly on our website.

Both individuals and organizations that work with arXivLabs have embraced and accepted our values of openness, community, excellence, and user data privacy. arXiv is committed to these values and only works with partners that adhere to them.

Have an idea for a project that will add value for arXiv's community? Learn more about arXivLabs .

For more audio journalism and storytelling, download New York Times Audio , a new iOS app available for news subscribers.

• March 29, 2024   •   48:42 Hamas Took Her, and Still Has Her Husband
• March 28, 2024   •   33:40 The Newest Tech Start-Up Billionaire? Donald Trump.
• March 27, 2024   •   28:06 Democrats’ Plan to Save the Republican House Speaker
• March 26, 2024   •   29:13 The United States vs. the iPhone
• March 25, 2024   •   25:59 A Terrorist Attack in Russia
• March 24, 2024   •   21:39 The Sunday Read: ‘My Goldendoodle Spent a Week at Some Luxury Dog ‘Hotels.’ I Tagged Along.’
• March 22, 2024   •   35:30 Chuck Schumer on His Campaign to Oust Israel’s Leader
• March 21, 2024   •   27:18 The Caitlin Clark Phenomenon
• March 20, 2024   •   25:58 The Bombshell Case That Will Transform the Housing Market
• March 19, 2024   •   27:29 Trump’s Plan to Take Away Biden’s Biggest Advantage
• March 18, 2024   •   23:18 Your Car May Be Spying on You
• March 17, 2024 The Sunday Read: ‘Sure, It Won an Oscar. But Is It Criterion?’

Hamas Took Her, and Still Has Her Husband

The story of one family at the center of the war in gaza..

• Share full article

Hosted by Sabrina Tavernise

Produced by Lynsea Garrison and Mooj Zadie

With Rikki Novetsky and Shannon Lin

Edited by Michael Benoist

Original music by Marion Lozano ,  Dan Powell ,  Diane Wong and Elisheba Ittoop

Engineered by Alyssa Moxley

Listen and follow The Daily Apple Podcasts | Spotify | Amazon Music

Warning: this episode contains descriptions of violence.

It’s been nearly six months since the Hamas-led attacks on Israel, when militants took more than 200 hostages into Gaza.

In a village called Nir Oz, near the border, one quarter of residents were either killed or taken hostage. Yocheved Lifshitz and her husband, Oded Lifshitz, were among those taken.

Today, Yocheved and her daughter Sharone tell their story.

On today’s episode

Yocheved Lifshitz, a former hostage.

Sharone Lifschitz, daughter of Yocheved and Oded Lifshitz.

Background reading

Yocheved Lifshitz was beaten and held in tunnels built by Hamas for 17 days.

There are a lot of ways to listen to The Daily. Here’s how.

We aim to make transcripts available the next workday after an episode’s publication. You can find them at the top of the page.

Fact-checking by Susan Lee .

Additional music by Oded Lifshitz.

Translations by Gabby Sobelman .

Special thanks to Menachem Rosenberg, Gershom Gorenberg , Gabby Sobelman , Yotam Shabtie, and Patrick Kingsley .

The Daily is made by Rachel Quester, Lynsea Garrison, Clare Toeniskoetter, Paige Cowett, Michael Simon Johnson, Brad Fisher, Chris Wood, Jessica Cheung, Stella Tan, Alexandra Leigh Young, Lisa Chow, Eric Krupke, Marc Georges, Luke Vander Ploeg, M.J. Davis Lin, Dan Powell, Sydney Harper, Mike Benoist, Liz O. Baylen, Asthaa Chaturvedi, Rachelle Bonja, Diana Nguyen, Marion Lozano, Corey Schreppel, Rob Szypko, Elisheba Ittoop, Mooj Zadie, Patricia Willens, Rowan Niemisto, Jody Becker, Rikki Novetsky, John Ketchum, Nina Feldman, Will Reid, Carlos Prieto, Ben Calhoun, Susan Lee, Lexie Diao, Mary Wilson, Alex Stern, Dan Farrell, Sophia Lanman, Shannon Lin, Diane Wong, Devon Taylor, Alyssa Moxley, Summer Thomad, Olivia Natt, Daniel Ramirez and Brendan Klinkenberg.

Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly. Special thanks to Sam Dolnick, Paula Szuchman, Lisa Tobin, Larissa Anderson, Julia Simon, Sofia Milan, Mahima Chablani, Elizabeth Davis-Moorer, Jeffrey Miranda, Renan Borelli, Maddy Masiello, Isabella Anderson and Nina Lassam.

Advertisement

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• SAGE Open Med

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.

Doctors can do more to help prevent gun violence, USF paper says

• Sam Ogozalek Times staff

Doctors can do more to help prevent gun violence and offer counseling on firearms safety, according to a review by University of South Florida researchers, including a medical student who survived the 2018 mass shooting at Marjory Stoneman Douglas High School in Parkland.

The review, published in February in the journal Advances in Pediatrics, noted that many doctors believe they should talk to patients about firearms, but often don’t because of time constraints, a lack of training and discomfort with the topic.

In Florida, a law passed in 2011 limited what questions doctors could ask patients about guns. But a federal appeals court found the restrictions to be unconstitutional and struck them down six years later.

The law “had a very chilling effect I think for a lot of providers,” said Cameron Nereim, one of the review’s authors and an assistant professor of pediatrics at USF who focuses on patients ages 12 to 25 in Tampa.

The review noted that the American Medical Association calls gun violence a public health crisis and firearm-related injuries were the leading cause of death for U.S. children in 2020, surpassing motor vehicle crashes.

Doctors can ask patients about whether guns are kept at home and if they are locked, unloaded and separated from ammunition, according to the review.

USF medical student Nikhita Nookala, who survived the shooting at Marjory Stoneman Douglas High School and covered it as a reporter at The Eagle Eye, the school’s student newspaper, contributed to the review.

The Tampa Bay Times spoke with Nereim and Nookala about their work, which was published with two other authors from North Carolina and Texas medical centers.

The interviews have been edited for clarity and length.

What are the major takeaways you hope physicians get from this paper?

Nookala: It’s important to assess patients’ risks and to see if you can do some harm reduction in terms of encouraging safe storage or just telling kids to be careful around guns.

It doesn’t have to be super political. It’s just about children’s safety at the end of the day.

The paper noted some of the major barriers to physicians counseling on firearms safety are the lack of formal training, lack of confidence that patients will follow their recommendations and low perceived self-efficacy. Are there any ways to address that?

Nereim: I think there are. ... One of the things is how do we do a better job of incorporating this into our training, whether that’s while you’re going through your residency program, while you’re going through your medical school, making sure these things are actually being plugged into our curricula.

Keep up with Tampa Bay’s top headlines

Subscribe to our free DayStarter newsletter

You’re all signed up!

Want more of our free, weekly newsletters in your inbox? Let’s get started.

Is there a particular stage of education where you think this would be best emphasized?

Nereim: I think medical school, before students have even differentiated in terms of what specialty or subspecialty they’ll be choosing, that’s a great opportunity to make sure we’re relaying this information.

In school so far, have people talked about gun violence as a public health issue?

Nookala: Everyone acknowledges that it’s become a problem and it’s getting worse. I think a lot of people feel very helpless because it’s something that is hard to bring up.

You’re not accusing someone of “You don’t store your gun safely, you’re putting your child in danger.” ... You want to (tread) the line of “Oh, you have guns in the home, that’s fine, are you storing them safely, are (you) using gun locks?”

It’s just small things that you can remind people, nicely, without discouraging them from coming back.

During routine visits, do you ask patients or patients’ parents whether there are guns in the home, if they are locked, securely unloaded (and) separated from ammunition?

Nereim: Yes, we do.

With the ongoing mental health crisis that’s involving young people ... I think it becomes even more critical that we do our due diligence and we ask those questions about things like firearm ownership ... how ammunition is being stored, what level of training the family members or the kids themselves have in terms of actually using these objects.

How do those conversations normally go for you? Are they difficult?

Nereim: When you’re able to successfully create that nonjudgemental space ... the vast majority of patients and families are really receptive to the questions we’re asking.

Do you ask patients more often than not? Or do you ask their parents?

Nereim: I tend to do both.

Do you ask firearm-related questions in every visit with a patient, or do you only ask them with someone who would be considered high risk?

Nereim: I wouldn’t say we ask it at every visit. I think we’re getting better at making this more a universal thing that we’re screening for, in the same way that 15, 20 years ago we would make sure at every visit we’re asking “Are you wearing your safety helmet if you’re riding your bike? Are you buckling your seat belt if you’re riding in a car?” We’re moving in that direction.

It happens a lot more consistently in these higher-risk situations, so if you have a patient who’s experiencing mood symptoms, depression or maybe even anger, irritability, impulsive behaviors.

(The paper suggested) that physicians can link those at risk of gun violence to other programs that offer support in the community. Do you do that regularly? How common is that?

Nereim: It’s extremely common. ... In the space where I work, probably anywhere from 50 to 70% of patients may have some significant social need. ... A lot of young people confide in me that they’re fearful just to be outside and to be walking in the place where they live because there have been times where they’ve heard gunshots. Or they know there was a shooting that occurred in that same square, that same block.

As you can imagine, when you have these kinds of social needs that manifest over time, there can be pretty major health consequences.

Why is this research important to you?

Nookala: In the aftermath of the (Marjory Stoneman Douglas High School) shooting, the focus was on Parkland, and Parkland became this beacon of gun violence prevention. But the reality is that outside of that one incident, which was horrible, gun violence doesn’t really occur in cities like Parkland every day. It occurs in cities like Tampa every day in marginalized communities. … The focus needs to be shifted back to that.

Training to be a doctor, I wanted to know more about ways you could make changes on an interpersonal level with your patients without being involved in these really political movements that oftentimes (are) just kind of doing nothing or (do) a little something and it gets reversed a few years later. It’s frustrating to watch that.

Nereim: Violence leads to more violence. The only really, truly effective way for us to move forward as a society is we just have to realize that prevention is incredibly important. … I just don’t think we can ignore the role this is playing in the lives of our patients and their families.

Sam Ogozalek is a reporter covering the healthcare system and mental health. He can be reached at [email protected].

MORE FOR YOU

• Advertisement

ONLY AVAILABLE FOR SUBSCRIBERS

The Tampa Bay Times e-Newspaper is a digital replica of the printed paper seven days a week that is available to read on desktop, mobile, and our app for subscribers only. To enjoy the e-Newspaper every day, please subscribe.