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Arguments that abortion causes women emotional harm are used to regulate abortion, particularly later procedures, in the United States. However, existing research is inconclusive. We examined women's emotions and reports of whether the abortion decision was the right one for them over the three years after having an induced abortion. We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities across the United States, selected based on having the latest gestational age limit within 150 miles. Two groups of women (n=667) were followed prospectively for three years: women having first-trimester procedures and women terminating pregnancies within two weeks under facilities' gestational age limits at the same facilities. Participants completed semiannual phone surveys to assess whether they felt that having the abortion was the right decision for them; negative emotions (regret, anger, guilt, sadness) about the abortion; and positive emotions (relief, happiness). Multivariable mixed-effects models were used to examine changes in each outcome over time, to compare the two groups, and to identify associated factors. The predicted probability of reporting that abortion was the right decision was over 99% at all time points over three years. Women with more planned pregnancies and who had more difficulty deciding to terminate the pregnancy had lower odds of reporting the abortion was the right decision (aOR=0.71 [0.60, 0.85] and 0.46 [0.36, 0.64], respectively). Both negative and positive emotions declined over time, with no differences between women having procedures near gestational age limits versus first-trimester abortions. Higher perceived community abortion stigma and lower social support were associated with more negative emotions (b=0.45 [0.31, 0.58] and b=-0.61 [-0.93, -0.29], respectively). 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. Emotional support may be beneficial for women having abortions who report intended pregnancies or difficulty deciding.
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RESEARCH ARTICLE
Decision Rightness and Emotional Responses
to Abortion in the United States: A
Longitudinal Study
Corinne H. Rocca
1
*, Katrina Kimport
1
, Sarah C. M. Roberts
1
, Heather Gould
1
,
John Neuhaus
2
, Diana G. Foster
1
1Advancing Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health,
Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of
California San Francisco, San Francisco, California, United States of America, 2Division of Biostatistics,
Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco,
California, United States of America
*roccac@obgyn.ucsf.edu
Abstract
Background
Arguments that abortion causes women emotional harm are used to regulate abortion, par-
ticularly later procedures, in the United States. However, existing research is inconclusive.
We examined womens emotions and reports of whether the abortion decision was the right
one for them over the three years after having an induced abortion.
Methods
We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities
across the United States, selected based on having the latest gestational age limit within
150 miles. Two groups of women (n=667) were followed prospectively for three years:
women having first-trimester procedures and women terminating pregnancies within two
weeks under facilitiesgestational age limits at the same facilities. Participants completed
semiannual phone surveys to assess whether they felt that having the abortion was the
right decision for them; negative emotions (regret, anger, guilt, sadness) about the abortion;
and positive emotions (relief, happiness). Multivariable mixed-effects models were used to
examine changes in each outcome over time, to compare the two groups, and to identify
associated factors.
Results
The predicted probability of reporting that abortion was the right decision was over 99% at
all time points over three years. Women with more planned pregnancies and who had more
difficulty deciding to terminate the pregnancy had lower odds of reporting the abortion was
the right decision (aOR=0.71 [0.60, 0.85] and 0.46 [0.36, 0.64], respectively). Both negative
and positive emotions declined over time, with no differences between women having pro-
cedures near gestational age limits versus first-trimester abortions. Higher perceived
PLOS ONE | DOI:10.1371/journal.pone.0128832 July 8, 2015 1/16
a11111
OPEN ACCESS
Citation: Rocca CH, Kimport K, Roberts SCM, Gould
H, Neuhaus J, Foster DG (2015) Decision Rightness
and Emotional Responses to Abortion in the United
States: A Longitudinal Study. PLoS ONE 10(7):
e0128832. doi:10.1371/journal.pone.0128832
Academic Editor: Sharon Dekel, Harvard Medical
School, UNITED STATES
Received: January 29, 2015
Accepted: April 30, 2015
Published: July 8, 2015
Copyright: © 2015 Rocca et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Data Availability Statement: The authors are not
able to provide any data beyond what is presented in
the manuscript due to restrictions that study
participants agreed to when they signed the consent
form, which was approved by the UCSF IRB. The
authors have included sufficient details in the
Methods section of the manuscript for others to
replicate the analysis in a similar setting, using a
similar study population.
Funding: This study was supported by a gift from the
Wallace Alexander Gerbode Foundation (http://
foundationcenter.org/grantmaker/gerbode/, to DGF),
a research grant from an anonymous foundation (to
community abortion stigma and lower social support were associated with more negative
emotions (b=0.45 [0.31, 0.58] and b=-0.61 [-0.93, -0.29], respectively).
Conclusions
Women experienced decreasing emotional intensity over time, and the overwhelming ma-
jority of women felt that termination was the right decision for them over three years. Emo-
tional support may be beneficial for women having abortions who report intended
pregnancies or difficulty deciding.
Introduction
Arguments about emotional harms from induced abortionincluding decision regret and in-
creasing negative emotions over timehave been leveraged to support abortion regulation in
the United States [13]. To uphold a 2007 law banning a later abortions, Justice Kennedy of
the Supreme Court stated: While we find no reliable data to measure the phenomenon, it
seems unexceptionable to conclude some women come to regret their choice to abort...[2].
In support of a state-level ban, a researcher testified that abortion carries greater risk of emo-
tional harm than childbirth[3]. Arguments about emotional harm have been used to forward
parental consent, mandatory ultrasound viewing, and waiting period legislation as well.
Despite these arguments, questions about long-term abortion regret and emotional harm
remain unresolved. While research has found that womens short-term emotions post-abor-
tion can vary substantiallywith mixed emotions being common and relief predominating
[48]fewer studies have addressed whether decision regret and negative emotions emerge
over years post-abortion. Existing longer-term studies suffer from important methodological
limitations, including being retrospective and thus vulnerable to selection and recall biases
[9,10]. The few prospective studies have found that most women report positive emotions
and satisfaction with the abortion decision years later [6,7,11,12]. But these studies have
had mixed results regarding changes in emotions, with some finding decreases in negative
emotions over time [6], and others documenting increasing negative emotions and decreas-
ing abortion decision satisfaction [7]. Interpretation is limited by small samples, high attri-
tion, and/or recruitment from single cities or facilities. Additionally, some studies were
conducted outside the US or over a decade ago and may not capture the current reality of
post-abortion emotions in the US.
Analyses of baseline data from the current study illustrated the importance of differentiating
negative emotions from decision regret. Although one-quarter of women experienced primari-
ly negative emotions over one week post-abortion, 95% still felt that the abortion was the right
decision [4]. Believing abortion was the wrong decision and experiencing negative emotions
are distinct, with the later representing a normal reaction to a significant life event, and the for-
mer being an outcome of potential public health concern, yet one that some view as inevitable
among some individuals making any decision [13]. While neither construct constitutes a men-
tal disorder, both are important for womens well-being [10].
Our objective was to investigate how womens views about the decision to terminate a preg-
nancy and emotions change over three years. We also compare emotions between women hav-
ing abortions near facility gestational age limits and women having first-trimester abortions, to
elucidate whether emotions differ by gestational age. This is the first study to examine emo-
tions about abortion prospectively in a large, geographically diverse US sample.
Post-Abortion Emotions and Decision Rightness
PLOS ONE | DOI:10.1371/journal.pone.0128832 July 8, 2015 2/16
DGF), and an institutional grant from the David and
Lucile Packard Foundation (http://www.packard.org/).
The funders had no role in study design, data
collection and analysis, decision to publish, or
preparation of the manuscript.
Competing Interests: The authors have declared
that no competing interests exist.
Materials and Methods
Sample and procedures
We used data from the Turnaway Study, a longitudinal study examining the health and socio-
economic consequences of receiving or being denied termination of pregnancy in the US. Be-
tween January 2008 and December 2010, 956 women seeking abortions were recruited from 30
facilities across the US. Facilities, described elsewhere, were selected based on having the high-
est abortion gestational limit within 150 miles [14]. The gestational limits at recruitment facili-
ties ranged from ten weeks through the end of the second trimester due to clinician and facility
policy as well as state law. Although abortion has been legal in the US since 1973, law varies
greatly by state because individual states may regulate under what circumstances a woman may
obtain an abortion, including gestational limits [15].
The primary objective of the Turnaway Study is to compare outcomes of women obtaining
later abortions to women who were too far along in pregnancy to receive an abortion. In this
paper, our main group of interest was women who received abortion within two weeks prior to
the facilitys gestational age limit (Near-Limit Abortion group). We compared the Near-Limit
group to women receiving first-trimester procedures at the same facilities (First-Trimester
Abortion group) to determine whether the experiences of women having later abortions were
similar to those of women having procedures in the first trimester, when 92% of US procedures
occur [16]. We do not include the third study group, Turnaways, comprised of women present-
ing within three weeks beyond the facilitys gestational age limit who were denied abortions.
We could not assess emotions about the abortion or whether women felt the abortion was the
right decision among Turnaways because the women in this group did not have abortions.
Participant recruitment is described elsewhere [4,17]. Women presenting for pregnancy
termination were eligible if they were English- or Spanish-speaking, 15 years old, and had a
pregnancy with no known fetal anomalies. Facility staff gave potential participants the in-
formed consent form and connected them by telephone to study staff, who read a consent
script, answered questions, and obtained verbal consent over the phone. The participant gave a
signed consent form to facility staff, who faxed it to a confidential fax line to the research direc-
tor. Signed consent forms were sent via FedEx and logged and stored in the research office, sep-
arate from participant data or contact information. Administrative procedures required
confirmation of paper copy receipt of consent form before interview, which took place at one
week after consent. Written parental or guardian consent was obtained for minors seeking
abortion in states where parental consent was required for abortion care. In states where paren-
tal consent for abortion was not required by law, minors consented to participate in the study
themselves. However, in these cases, facility staff first conducted a screening to assess the mi-
nors ability to consent for herself and her understanding of the potential risks to her in the
context of her own life. Because we anticipated that relatively few women would meet Turn-
away eligibility criteria and to maximize power for primary analyses, we enrolled twice as
many participants into the reference group, Near-Limit, as into the Turnaway or First-Trimes-
ter groups.
Analyses include data from seven waves of phone interviews, conducted at baseline (approx-
imately eight days after care-seeking) and semiannually thereafter. Baseline interviews assessed
sociodemographic characteristics and pregnancy and abortion circumstances; all interviews
asked about emotions. Women received $50 gift cards after each interview. Three-year inter-
views were completed in February 2014.
Overall, 37.5% of eligible women consented to participate, and 85% of those completed
baseline interviews (n = 956). Among the Near-Limit and First-Trimester Abortion groups,
92% completed six-month interviews, and 69% were retained at three years; 93% completed at
Post-Abortion Emotions and Decision Rightness
PLOS ONE | DOI:10.1371/journal.pone.0128832 July 8, 2015 3/16
least one follow-up interview. The final sample size of participants for analyses was 667. Analy-
ses excluded the participants recruited from one site at which all but one Turnaway later ob-
tained an abortion elsewhere, because the site did not meet the intended eligibility criterion for
the study. We also excluded two Near-Limit group and one First-Trimester participant who de-
cided not to terminate their pregnancies.
Ethics Statement
The study, including consent procedures, was approved by the University of California, San
Francisco, Committee on Human Research (original approval date: 20 December 2006;
study #: 1000527).
Measures
Outcomes. Decision rightness was assessed at all interviews by asking participants wheth-
er, given the situation, the decision to have an abortion was right for them (yes, no, dont
know). For analyses, dont knowresponses were categorized together with noto be conser-
vative. Women were also asked at each interview how much they had felt each of six emotions
about the abortion (relief, happiness, regret, guilt, sadness, anger) over the last week (0 = not at
all, 1 = a little, 2 = moderately, 3 = quite a bit, 4 = extremely). The emotions examined were
drawn from the literature [68,12,18]. We used responses to the four negative emotions to
create a scale (range 016; Cronbachsα= 0.88). Similarly, responses to the two positive emo-
tions were combined into a scale (range 08; α= 0.69). To ensure that women responded about
the abortion and not the pregnancy itself, these items were preceded by emotions questions
regarding the pregnancy. At each follow-up interview, women were asked how often they
thought about the pregnancy or abortion (0 = never, 1 = rarely, 2 = sometimes, 3 = fairly often,
4 = all the time).
Independent variables. Study group included Near-Limit and First-Trimester. Time was
months from recruitment. First-Trimester group-by-time interaction terms were created to as-
sess different emotional time trends between groups.
We included baseline measures describing the circumstances of the pregnancy and abortion.
These variables were selected a priori as factors hypothesized to affect womens response to
abortion. We used the London Measure of Unplanned Pregnancy to rank pregnancy planning
level (range 012; α= 0.53) [19]. We assessed difficulty deciding to seek an abortion (0 = very
easy to 4 = very difficult). The abortion preference of the man involved in the pregnancy (MIP)
was assessed and categorized as: he wanted the abortion; he was not sure; he did not want the
abortion; he was not a part of decision-making or did not know about the pregnancy; and, for
participants volunteering the response, he left the decision up to the participant. Participants
reported whether they were currently in a relationship with the MIP. We examined the two
most common reasons for seeking abortion, coded from open-ended responses: not financially
prepared and not the right time; responses were not mutually exclusive [20]. To measure per-
ceived abortion stigma, participants indicated how much they would be looked down upon by
people in their communities if they knew they had sought an abortion (0 = not at all to 4 = ex-
tremely). Social support was assessed using six items derived from the Multidimensional Scale
of Perceived Social Support evaluating interpersonal support from family and friends (range
04; α= 0.80) [21,22]. We examined gestational age (weeks) and whether participants had re-
ceived facility counseling on whether or not to terminate the pregnancy.
Sociodemographic characteristics included age (years), self-reported race/ethnicity (non-La-
tina white, non-Latina black, Latina, other), prior abortion(s), and number of children raising
(0, 1, 2). We included participants mothers education as a proxy for socioeconomic status;
Post-Abortion Emotions and Decision Rightness
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we did not use income or education due to the young age of many participants. We assessed
school/employment status (in school only, employed only, both, neither) and history of depres-
sion, using questions from the Composite International Diagnostic Interview [23]. Women
who had ever felt sad, depressed, or lost interest in most things for 2 weeks, and this seriously
interfered with daily activities, were considered to have a history of depression.
Analyses
To investigate baseline differences between the participant groups, we fit bivariable regression
models, including random facility effects to account for the clustering of participants within fa-
cilities [24]. Depending on the measurement of the characteristic, we used a linear, logistic,
multinomial logistic, or ordinal logistic model.
Our overall approach to longitudinal analyses examining changes in abortion decision
rightness and in emotions was mixed-effects regression, including random intercepts for facili-
ty and for participant in each model to account for clustering. Random time effects allowing
changes in outcomes over time (or trajectories) to differ across participants were included if
they significantly improved model fit based on likelihood ratio tests. Similarly, for each model,
we sought appropriate functional forms for time by adding quadratic and cubic terms and as-
sessing the statistical significance of the added terms. Interaction terms between study group
and time were also included in each model to assess differences in trajectories of outcomes be-
tween Near-Limit and First-Trimester participants. Models also included the a priori selected
baseline variables thought to affect response to abortion.
Specifically, to assess changes in abortion decision rightness over three years, examine study
group differences, and identify associated variables, we used a logistic mixed-effects model
with random time effects. Quadratic time terms were not included because they did not im-
prove model fit. We calculated the predicted probability of reporting that abortion was the
right decision at a given time using the average individual-level intercepts and trajectories from
this model (e.g. random effects equal to zero), with mean-centered covariables equal to zero
[25]. We also examined how often women thought about the abortion with a multivariable lin-
ear mixed-effects model.
Then, to assess negative emotions, we first used linear mixed-effects regression, including
random time effects and quadratic and cubic time terms. Based on this model, we created a di-
chotomous variable of experiencing an increase of over a point in negative emotions over three
years. We then fit logistic mixed-effects models with increasing trajectoryas the outcome to
assess associated factors. A linear mixed-effects model with random time effects and quadratic
and cubic time terms was also fit to assess positive emotions.
We performed attrition analyses to examine differential loss-to-follow-up. We conducted
sensitivity analyses assessing whether differential enrollment of eligible women across facilities
affected our results, repeating analyses including only sites that recruited >50% of eligible
women. Also, because the gestational limit for providing abortions fell in or near the first tri-
mester for seven facilities, 14% of Near-Limit group participants received abortions in the first-
trimester. We thus repeated analyses excluding these seven sites to see if results were consistent.
We also repeated analyses including participants from the one excluded recruitment site to see
if results were consistent. Stata v.13 was used (College Station, TX, US).
Results
On average, participants were 25 years old at baseline (Table 1). Approximately one-third were
white, one-third black, 21% Latina and 13% other races. Sixty-two percent were raising chil-
dren, and 14% had a history of depression. Over 53% reported that the decision to seek the
Post-Abortion Emotions and Decision Rightness
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Table 1. Participant characteristics, by study group: percentages and p-values, Turnaway Study (n = 667)
Near-Limit Abortion First-Trimester Abortion p Total
(n = 413) (n = 254) (n = 667)
Sociodemographics
Age, mean years (range: 1446
a
) 24.9 25.9 0.041 25.3
Race/ethnicity
White 32.0 39.0 0.033 34.6
Black 31.7 31.5 31.6
Latina 21.1 21.3 21.4
Other 15.3 8.3 12.6
Maternal education
<High school 12.4 20.5 0.024 15.4
High school 35.8 35.8 35.8
Some college, technical school 15.0 9.8 13.0
College graduate 26.6 28.4 27.3
Missing 10.2 5.5 8.4
Children
0 36.4 40.6 0.668 38.0
1 30.3 24.8 28.2
2+ 33.3 34.7 33.8
Prior abortion 46.5 46.6 0.891 46.6
School/employment
Neither 33.2 23.7 0.013 29.6
In school only 12.6 12.7 12.6
Employed only 40.4 41.5 40.8
Both 13.8 22.1 17.0
History of depression 12.8 14.1 0.227 14.1
Pregnancy Circumstances
Pregnancy planning, mean score (range:012) 2.7 2.6 0.380 2.7
Difculty deciding to seek abortion
Very easy 10.4 16.9 <0.001 12.9
Somewhat easy 15.7 22.1 18.1
Neither easy nor difcult 15.7 14.6 15.3
Somewhat difcult 27.1 26.8 26.8
Very difcult 31.0 19.7 26.7
In relationship with MIP 58.8 58.7 0.986 58.8
Abortion preference of MIP (ref: Wanted)
Wanted 21.1 31.9 0.025 25.2
Not sure 21.6 19.7 18.9
Did not want 21.1 18.9 20.3
Not involved 17.7 16.9 18.9
Left it up to participant 18.5 12.6 16.2
Abortion Circumstances
Gestational age, mean weeks (range: 329) 19.7 7.6 <0.001 15.1
Reason for abortion: Financial 43.6 35.0 0.030 40.3
Reason for abortion: Not the right time 34.8 38.6 0.323 36.2
Perceived abortion stigma
Not at all 38.9 41.0 0.412 39.7
A little 14.2 13.7 14.0
(Continued)
Post-Abortion Emotions and Decision Rightness
PLOS ONE | DOI:10.1371/journal.pone.0128832 July 8, 2015 6/16
abortion was difficult or very difficult. Mean pregnancy planning scores were low, at 2.7 on the
012 scale.
Compared to the Near-Limit group, the First-Trimester group was on average older and in-
cluded a higher proportion of white women. First-Trimester participants were more likely to be
both in school and employed and had had less difficulty deciding to seek abortion. They were
more likely to report that the man involved in the pregnancy had wanted the abortion and
were less likely to have sought abortion for financial reasons. By study design, gestational ages
were lower in the First-Trimester group (mean = 8 weeks) than in the Near-Limit group
(mean = 20 weeks).
In crude data, approximately 95% of women completing each follow-up interview reported
that having the abortion was the right decision for them. Based on the mixed-effects model,
which accounts for attrition and baseline characteristics and allows for individual variation in
trajectories over time, the predicted probability of the average participant reporting that the
abortion was the right decision was >99% across all times, with an increase over three years
(adjusted odds ratio [aOR] = 1.05 per month, 95% confidence interval [CI] [1.00, 1.08]) (Fig 1
and Table 2). Women whose pregnancies had been more planned and who had greater difficul-
ty deciding to seek abortion reported lower levels of decision rightness (aOR = 0.72 [0.60, 0.85]
and aOR = 0.48 [0.36, 0.64], respectively), as did Latinas (aOR = 0.31 [0.13, 0.74], versus
white). Women both in school and employed at baseline were more likely to report that abor-
tion was right than those neither in school nor employed (aOR = 3.23 [1.06, 9.81]). Women re-
porting that the man involved in the pregnancy was not a part of the decision-making process
had greater feelings of decision rightness than women whose partners did not want or were not
sure if they wanted to terminate the pregnancy.
Women thought about the abortion less frequently over time (b = -0.019 [-0.023, -0.016]
per month), with no differences between study groups (data not shown). At six months post-
abortion, participants on average thought about the abortion sometimes(mean = 1.8, range
04); by three years, they thought about it rarely(mean = 1.2, range 04).
The average negative emotions score (range 016) among Near-Limits declined from 3.9 at
baseline to 1.8 at three years (Fig 2 and Table 3). There were no differences in initial level nor
change over time in negative emotions for the First-Trimester group compared to Near-Limits
(from 3.7 at baseline to 2.2 at three years).
Over the three years post-abortion, women who had pregnancies that were more planned
(b = 0.29 [0.17, 0.42]), who had greater difficulty deciding to seek abortion (b = 0.77 [0.61,
0.92]), and who perceived more community abortion stigma (b = 0.45 [0.31, 0.58]) reported
more negative emotions (Table 3). Women with more social support (b = -0.61 [-0.93, -0.29])
and who had had a prior abortion (b = -0.58 [-1.00, -0.16]) reported fewer negative emotions.
Approximately 6% of women experienced an increase of at least a point in negative emotions
Table 1. (Continued)
Near-Limit Abortion First-Trimester Abortion p Total
(n = 413) (n = 254) (n = 667)
Moderately 14.5 16.5 15.2
Quite a bit 13.0 12.5 12.8
Extremely 19.5 16.5 18.3
Social support, mean score (range:04) 3.2 3.2 0.869 3.2
Received counseling at facility 70.1 70.0 0.776 70.0
a
One participant aged 14 was recruited before the minimum age was changed to 15.
doi:10.1371/journal.pone.0128832.t001
Post-Abortion Emotions and Decision Rightness
PLOS ONE | DOI:10.1371/journal.pone.0128832 July 8, 2015 7/16
over three years. No baseline factors were significantly associated with having an increasing tra-
jectory of negative emotions (data not shown). Women expressing more negative emotions
about the abortion at baseline experienced steeper declines over time (subject-specific slope-in-
tercept correlation = -0.27 [-0.41, -0.12]).
For positive emotions about the abortion, average scores (range 08) in the Near-Limit
group declined from 3.8 at baseline to 1.8 at three years (Fig 3, data not shown). Scores for the
First-Trimester group declined from 3.7 at baseline to 1.4 at three years, reflecting a trajectory
no different than for Near-Limits. Women with more planned pregnancies (b = -0.09 [-0.17,
-0.01]) and who had more difficulty deciding to terminate (b = -0.36 [-0.46, -0.27]) experienced
lower levels of happiness and relief. Older women (b = 0.03 [0.01, 0.06] per year) reported
more positive emotions, as did black women (b = 0.35 [0.03, 0.68]) and women of other races
(b = 0.52 [0.11, 0.93]), compared to white women.
Loss-to-follow-up did not differ by study group, sociodemographic characteristics, nor
baseline decision rightness or negative emotions. However, women feeling more relief and hap-
piness at baseline were less likely to be lost (mean score 3.8 for those maintained versus 3.0 for
those lost, p = 0.03).
When repeating analyses among sites with >50% participation and, separately, among sites
with all Near-Limit participants having abortions in the second trimester, results generally re-
mained unchanged, with wider confidence intervals, as expected with smaller sample sizes. The
only substantive difference was that, among sites with >50% participation, having a history of
depression was significantly associated with lower odds of decision rightness (aOR = 0.25
[0.080.78]). Results were unchanged when including participants recruited from the one ex-
cluded site.
Fig 1. Mean predicted probability of reporting that abortion was the right decision over three years
after an abortion. The line represents the trajectory of the average participant (average intercept and slope),
based on a multivariable mixed-effects model of reporting that abortion was the right decision, with mean-
centered covariables equal to zero.
doi:10.1371/journal.pone.0128832.g001
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Table 2. Abortion decision rightness over 3 years post-abortion: adjusted odds ratios from a multivar-
iable logistic mixed-effects regression model (n = 650).
Abortion was the right decision
Adjusted Odds Ratio 95% CI
Months 1.05*1.001.08
First-Trimester group 1.58 0.703.55
First-Trimester*months interaction 0.99 0.951.03
Pregnancy Circumstances
Pregnancy planning score 0.72*** 0.600.85
Difculty deciding to seek abortion 0.48*** 0.360.64
In relationship with MIP 0.80 0.411.60
Abortion preference of MIP (ref: Wanted)
Not sure 0.58 0.241.44
Did not want 0.65 0.261.61
Not involved 1.920.665.61
Left decision up to participant 0.86 0.302.44
Abortion Circumstances
Reasons for abortion
Financial 0.91 0.491.71
Not the right time 1.01 0.512.01
Perceived abortion stigma 0.84 0.691.02
Social support 1.43 0.902.30
Received counseling at facility 0.82 0.411.63
Sociodemographics
Age 1.06 1.001.14
Race/ethnicity (ref: White)
Black 0.68 0.291.59
Latina 0.31**0.130.74
Other 2.09 0.617.09
Maternal education (ref: <High school)
High school 1.63 0.624.24
Some college, technical school 0.69 0.232.06
College graduate 0.83 0.312.22
Children (ref: 0)
1 1.05 0.472.32
2+ 0.86 0.372.00
Prior abortion 1.23 0.642.37
School/employment (ref: Neither)
In school only 1.60 0.544.68
Employed only 1.43 0.683.03
Both 3.23*1.069.81
History of depression 0.52 0.221.19
***p.001.
**p.01.
*p.05.
Different from Otherat p.01.
Different from Not sureand Did not wantat p.05.
Note: Effect estimates are based on 3,758 observations of 650 women (mean 5.8 observations/woman).
doi:10.1371/journal.pone.0128832.t002
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Discussion
Arguments that abortion causes women emotional harm, and that women come to regret abor-
tions they decided to have, are used to shape public opinion and advance legislation restricting
access to abortion in the US. Existing studies suffer from shortcomings, leaving the question of
womens post-abortion emotions unresolved. Using three years of data from the Turnaway
Study, we addressed many limitations of prior studies to comprehensively investigate womens
decisional rightness and emotions post-abortion.
Women in this study overwhelmingly felt that the decision was the right one for them: at all
time points over three years, 95% of participants reported abortion was the right decision, with
the typical participant having a >99% chance of reporting the abortion decision was right for
her. Women also experienced reduced emotional intensity over time: the feelings of relief and
happiness experienced shortly after the abortion tended to subside, as did negative emotions.
Notably, we found no differences in emotional trajectories or decision rightness between
women having earlier versus later procedures. Important to womens reports were social fac-
tors surrounding the pregnancy and termination-seeking. Having had difficulty deciding to
terminate the pregnancy, and reporting higher pregnancy planning levels, were strongly associ-
ated with negative emotions and lower decision rightness, while being in school and working at
the time of the pregnancy was associated with far higher feelings of decision rightness. Com-
munity stigma and lower social support were associated with negative emotions.
Strengths and limitations
Analyses included data collected through three years post-abortion. Participant follow-up to
five years is ongoing; future analyses will explore how changing circumstances of womens lives
affect feelings about the abortion further into the future.
Fig 2. Mean predicted negative emotions scores over three years after an abortion. Lines represent the
trajectory of the average participant (average intercept and slope), based on a multivariable mixed-effects
model of negative emotions, with mean-centered covariables equal to zero.
doi:10.1371/journal.pone.0128832.g002
Post-Abortion Emotions and Decision Rightness
PLOS ONE | DOI:10.1371/journal.pone.0128832 July 8, 2015 10 / 16
Table 3. Negative emotions (regret, anger, sadness, guilt) over 3 years post-abortion: adjusted coefficients from a multivariable linear mixed-ef-
fects model (n = 650).
Negative Emotions, range: 016
Adjusted Coefcient 95% CI
Time
Months -0.21*** -0.28 -0.14
Months-squared 0.009*** 0.0050.013
Months-cubed -0.001*** -0.001 -0.001
Study Group (ref: Near-Limit)
First-Trimester -0.21 -0.760.34
Study Group by Time Interactions
First-Trimester*months 0.02 -0.080.13
First-Trimester*months-squared -0.002 -0.0090.005
First-Trimester*months-cubed 0.001 -0.0010.001
Pregnancy Circumstances
Pregnancy planning score 0.29*** 0.170.42
Difculty deciding to seek abortion 0.77*** 0.610.92
In relationship with MIP 0.05 -0.370.47
Abortion preference of MIP (ref: Wanted)
Not sure 0.01 -0.590.61
Did not want 0.18 -0.430.78
Not involved 0.19 -0.420.81
Left decision up to participant 0.12 -0.510.76
Abortion Circumstances
Reasons for abortion
Financial 0.15 -0.250.56
Not the right time -0.18 -0.610.24
Perceived abortion stigma 0.45*** 0.310.58
Social support -0.61*** -0.93 -0.29
Received counseling at facility 0.34 -0.090.78
Sociodemographics
Age 0.01 -0.040.05
Race/ethnicity (ref: White)
Black 0.15 -0.380.68
Latina 0.47 -0.111.06
Other -0.06 -0.730.61
Maternal education (ref: <High school)
High school 0.01 -0.610.63
Some college, technical school 0.09 -0.660.84
College graduate -0.01 -0.650.65
Children (ref: 0)
1 -0.09 -0.600.42
2+ 0.01 -0.540.55
Prior abortion -0.58** -1.00 -0.16
School/employment (ref: Neither)
In school only -0.33 -1.030.37
Employed only -0.33 -0.820.17
Both -0.58 -1.230.06
(Continued)
Post-Abortion Emotions and Decision Rightness
PLOS ONE | DOI:10.1371/journal.pone.0128832 July 8, 2015 11 / 16
Because no formal measures of abortion emotions exist, the scales we used may not have
validly captured womens emotions. Although the emotions we examined were similar to those
assessed in prior studies [6,7,12], they were not necessarily the most relevant aspects of the
abortion experience. Relief and happiness may be most relevant directly after an abortion and
less relevant over years. In particular, research has found that the positive sentiments women
report over time post-abortion included maturity, deeper self-knowledge, and strengthened
self-esteem [6]. In addition, social expectations that abortion ought to be emotionally difficult
might have led to increased reporting of negative emotions post-abortion [26]. Asking partici-
pants biannually about their emotions and how often they thought about the abortion may
have led to higher reported levels of all outcomes than otherwise would have existed.
We were unable to assess the effects of continuously measured gestational age on outcomes
due to the study design, by which Near-Limit participants were recruited within two weeks of
facility gestational limits. While this design achieved comparability between the Near-Limit
Table 3. (Continued)
Negative Emotions, range: 016
Adjusted Coefcient 95% CI
History of depression 0.55 -0.031.14
***p.001.
**p.01.
*p.05.
Note: Effect estimates are based on 3,754 observations of 650 women (mean 5.8 observations/woman).
doi:10.1371/journal.pone.0128832.t003
Fig 3. Mean predicted positive emotions scores over three years after an abortion. Lines represent the
trajectory of the average participant (average intercept and slope), based on a multivariable mixed-effects
model of positive emotions, with mean-centered covariables equal to zero.
doi:10.1371/journal.pone.0128832.g003
Post-Abortion Emotions and Decision Rightness
PLOS ONE | DOI:10.1371/journal.pone.0128832 July 8, 2015 12 / 16
and Turnaway groups, it resulted in little within-site variation in gestational ages by group.
Thus, facility-level factors associated with a facilitys gestational limit, such as state abortion re-
strictions and community sentiment about abortion, are confounded with individual-level
abortion gestational age. That 86% of Near-Limit participants had the abortion after the first
trimester, and that results did not differ when removing sites with low gestational cut-points,
suggest that findings can validly be interpreted as showing a lack of differences in outcomes be-
tween women having first-trimester versus later abortions.
Finally, the relatively low participation rate might raise concerns about selection bias. In a
review of high-impact public health journals, 63% of prospective studies reported no recruit-
ment information; those that did had participation rates as low as 20% [27]. Another proposed
that published participation rates are biased, with studies with lower participation less likely to
report participation [28]. 38% enrollment for a five-year study asking women about a stigma-
tized health service is within the range of other large-scale prospective studies. Importantly,
with the exception of being poorer, women in this sample were demographically similar to US
women with unintended pregnancies [29]. Also, women experienced a range of emotions at en-
rollment: approximately two-thirds expressed sadness and over one-third felt some regret [4].
We have no reason to believe that women would select into the study based on how these emo-
tions would evolve over three years.
This study has several features that strengthen the validity of findings. Our use of prospec-
tive data helped to reduce recall and selection biases, and we are unaware of other studies pro-
spectively assessing decision rightness and emotions up to three years. Our sample was
relatively large, and participants were recruited from diverse geographic locations and across
gestational ages, improving generalizability. Only 7% of women were lost-to-follow-up
completely after baseline, and our statistical approach accounted for attrition and individual
variation in outcomes. Much prior research on post-abortion emotions has been conducted in
Europe, where abortion is a viewed differently than in the US; research on US women is an
important contribution.
Interpretation
Results from this study suggest that claims that many women experience abortion decision re-
gret are likely unfounded. The random slope model we fit allowed for individual variability in
decision rightness trajectory: some women have lower predicted values of the outcome and
others higher values. The typical participant, however, had >99% chance of reporting that the
abortion was right for her over three years, and her negative emotions subsided over time.
These findings differ from those of the only other large-scale US prospective study, which
found that negative emotions increased, and satisfaction with the abortion decision decreased
slightly, over two years [7]. Differences in results may be due to differences in outcome mea-
sures used, geographic context (one US city in the prior study), time (1993 in the prior study)
or attrition (50% in the prior study) [7].
The patterns of emotions found in this studyreduced negative and positive emotions over
time after an abortionindicate a general trend of declining emotional intensity. Various di-
mensions of psychological welfare, including emotions, are important to womens well-being
after an abortion [10]. Yet no consensus on the meaning of experiencing negative emotions
post-abortion exists, and its importance is unclear. Certainly, experiencing feelings of guilt or re-
gret in the short-term after an abortion is not a mental health problem; in fact, such emotions
are a normal part of making a life decision that many women in this study found to be difficult
[30]. However, increases in negative emotions over time may be indicative of difficulty coping
with an abortion, which is a concern for womens well-being. Our results of declining emotional
Post-Abortion Emotions and Decision Rightness
PLOS ONE | DOI:10.1371/journal.pone.0128832 July 8, 2015 13 / 16
intensity are consistent with Turnaway Study analyses assessing other aspects of psychological
well-being, finding steady or improving levels of self-esteem, life satisfaction, stress, social sup-
port, stress, substance use, and symptoms of depression and anxiety over time post-abortion
[21,3134]. The high probability of reporting that the abortion decision was right over all time
points is further evidence of emotional coping. Decision regret has been documented among pa-
tients undergoing other medical procedures, including sterilization [35], breast cancer treat-
ments [36], and heart surgery [37], as well as among women making other major non-medical
life decisions (e.g. marriage, employment), indicating that some level of regret is not unique to
abortion[13].
Finally, that higher community abortion stigma was associated with negative emotions
and that having more social support, which may mitigate stigma, was associated with fewer
negative emotionshighlights that social context matters for womens emotions after an abor-
tion [38]. Consistent with prior studies [4,26,39,40], our findings also point to the significance
of the decision-making process to post-abortion emotions.
Conclusions
In the three years after terminating a pregnancy, women tended to cope well emotionally.
Women overwhelmingly felt abortion was the right decision in both the short-term and over
three years, and the intensity of emotions and frequency of thinking about the abortion de-
clined over time. Yet high coping and resilience were not observed among all individuals: those
with more intended pregnancies and difficulty making the abortion decision experienced
poorer emotional outcomes after an abortion. Individualized counseling for women having dif-
ficulty with the abortion decision might help improve their emotional welfare over time [41].
Efforts to combat stigma may also support the emotional well-being of women
terminating pregnancies.
Acknowledgments
The authors thank Rana Barar and Sandy Stonesifer for study coordination and management;
Mattie Boehler-Tatman, Janine Carpenter, Undine Darney, Ivette Gomez, Selena Phipps,
Brenly Rowland, Claire Schreiber, Danielle Sinkford, and C. Emily Hendrick for conducting in-
terviews; Michaela Ferrari, Debbie Nguyen and Elisette Weiss for project support; Jay Fraser
for database assistance; and all the participating providers for their assistance with recruitment.
Author Contributions
Conceived and designed the experiments: DGF. Performed the experiments: DGF HG. Ana-
lyzed the data: CHR. Contributed reagents/materials/analysis tools: CHR SCMR JN DGF.
Wrote the paper: CHR KK SCMR HG JN DGF. Served as PI: DGF. Interpreted results: CHR
KK SCMR DGF. Provided statistical support: JN.
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... Women whose voices were not represented are logically among those with the most significant mental health complications, because revisiting the experience may have been perceived as too stressful or traumatic (Adler, 1976;Söderberg et al., 1998a). In one of the Turnaway studies led by Rocca et al. (2015), the investigators noted that participants most likely to be retained had among the highest rates of relief at baseline; whereas those with the lowest levels of relief at baseline were most likely to drop out before the 3rd year decision satisfaction measure was administered. There is a myriad of other ways the non-participants may have been distinct from the participants, creating a biased sample. ...
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We explore abortion access, abortion experiences, and abortion stigma. We emphasize global perspectives on abortion diversity and the relationship between pregnancy norms and expectations, abortion stigma, and practical constraints on reproductive freedom. Evolutionary psychological, clinical psychological, and social-psychological perspectives illuminate how abortion decisions are shaped by strategies to optimize survival and success, support services that emphasize the costs and risks of pregnancy termination, and pronatalist norms and punishment of departures from those expectations. We call for future abortion research that integrates multiple subfields in psychology and is rooted in an intention to effect public policy and social change that promotes reproductive autonomy.
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Objective We compared perceived stress between women traveling 50 or fewer miles and more than 50 miles for abortion care. Secondary objectives were to compare individual-level stigma and hardship scores in patients by distance traveled to the clinic. Methods We performed a cross-sectional study of patients presenting for care at an independent abortion clinic in southern Illinois. Participants completed a self-administered, tablet computer-based survey asking about their experiences seeking abortion, including the Perceived Stress Scale (PSS) and Individual Level Abortion Stigma (ILAS) scale. We created a composite score to characterize patient hardship regarding abortion care (range, 0–4). We examined responses stratified by the patients’ self-reported one-way distance traveled to the clinic (group 1, ≤50 miles; group 2, >50 miles). Results A total of 308 women completed the survey. There was no significant difference in mean PSS scores (p = .71) or median ILAS scores (p = .40) between groups. A majority of the cohort reported moderate or high stress (68.2%). The median hardship score was significantly higher in the greater than 50 mile group (median, 1 [interquartile range, 0–2] vs. 2 [interquartile range 1–3]; p < .001). Patients who traveled more than 50 miles reported difficulties related to missing work (58.3%), delays in obtaining an abortion owing to financial costs (35.7%), lodging (13.9%), and transportation (11.3%). Conclusions There was no difference in PSS or ILAS scores by distance traveled among patients seeking an abortion; however, patients who traveled more than 50 miles had a higher hardship score, suggesting greater difficulty accessing abortion. The most common difficulties encountered included missing time from work and financial costs associated with the abortion.
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Objective: Many U.S. states mandate counseling and a waiting period before abortion, which often necessitates two separate clinic visits. These laws purport to ensure individuals are certain about their abortion decision. We examined whether exposure to these laws is associated with increased decision certainty. Methods: The Google Ads Abortion Access Study is a prospective study of pregnant people considering abortion recruited when searching online using abortion care-related keywords. Eligible participants, who represented all 50 U.S. states, completed baseline and 4-week follow-up surveys. We measured decision certainty using the Decisional Conflict Scale (scores range from 0 to 100; higher scores reflect lower certainty). We used a multivariable linear mixed model to examine the association between living in states with waiting periods, two-visit requirements, or both and changes in decision certainty. We also compared baseline, follow-up, and changes in decision certainty by whether the pregnancy was ongoing or not at follow-up. Results: The analytic sample included 750 participants who contributed relevant baseline and follow-up data. At follow-up, 396 participants had an abortion, and 354 had not. There was no significant increase in decision certainty for participants in states with waiting period laws (mean change score -1.0, 95% CI -2.8 to 2.8). In adjusted models, still seeking an abortion at 4-week follow-up was associated with decreased certainty (mean change score 8.05, 95% CI 5.13-10.97). Those still seeking abortion had significantly lower certainty (baseline score 28.8 and follow-up score 32.2) than those who had obtained an abortion (baseline score 21.8 and follow-up score 20.1, P<.01). Conclusion: Decision certainty is relatively high and stable over time among those who had had an abortion. Living in a state with a waiting period or two-visit requirement is not associated with increased decision certainty.
Article
Puntos para una lectura rápida •El objetivo fundamental ante la solicitud de la interrupción voluntaria de embarazo es asegurar que el derecho legalmente reconocido tenga lugar de forma efectiva, sin barreras en el acceso. •La interrupción voluntaria de embarazo no se ha relacionado con perjuicios sobre la salud mental, pero las personas involucradas en el proceso tienen un papel relevante en las potenciales consecuencias. •Es necesario confirmar y datar la gestación, valorar posibles complicaciones precoces, actualizar la lista de problemas de salud y recoger una historia ginecoobstétrica básica. •Se debe prestar especial atención a las mujeres más vulnerables, en las que las barreras de acceso al sistema sanitario y los problemas de salud asociados son más importantes. •Valorar posibles situaciones de violencia de género, ofrecer anticoncepción desde el día de la intervención y recomendar cribado de cáncer de cérvix si lo precisa son actividades preventivas pertinentes en esta consulta. •Conocer los principales procedimientos de aborto inducido, contraindicaciones y síntomas habituales tras la interrupción voluntaria de embarazo permiten resolver dudas iniciales, facilitar la decisión y ayudar a reconocer precozmente posibles complicaciones.
Article
In this paper I analyse the written testimonies submitted by pro-choice Irish women to the government in advance of the Referendum to Repeal the Eighth Amendment in May 2018. These testimonies are all in favour of legal reform to allow abortion access. However, the women’s narratives are far from homogeneous in how they view abortion and how they present their abortion histories. Some offer a categorically pro-choice position with unapologetic calls for the liberatory potential of abortion in society to be recognized. Others, however, are far more cautious, far more conciliatory. Here, drawing on a powerful set of normative expectations around femininity, sexuality, class and family, such pro-choice women invoke a particular cultural meaning of abortion that, paradoxically perhaps, calls for the end to prohibitions on abortion while simultaneously provoking certain anti-abortion sentiments in detailing their individual abortion histories. I also suggest that adopting a defensive, almost apologetic endorsement of abortion may have significant anti-abortion side-effects in restricting future access to reproductive rights. Instead, what is called for, from a pro-choice advocacy perspective, is developing a culture of outspokenness around abortion to counter further anti-abortion inroads into women’s reproductive lives.
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Background Examining women’s stress and social support following denial and receipt of abortion furthers understanding of the effects of unwanted childbearing and abortion on women’s well-being. This study investigated perceived stress and emotional social support over time among women who were denied wanted abortions and who received abortions, and compared outcomes between the groups. Methods The Turnaway Study is a prospective cohort study of women who sought abortions at 30 abortion facilities across the United States, and follows women via semiannual phone interviews for five years. Participants include 956 English or Spanish speaking women aged 15 and over who sought abortions between 2008 and 2010 and whose gestation in pregnancy fit one of three groups: women who presented up to three weeks beyond a facility’s gestational age limit and were denied an abortion; women presenting within two weeks below the limit who received an abortion; and women who received a first trimester abortion. The outcomes were modified versions of the Perceived Stress Scale and the Multidimensional Scale of Perceived Social Support. Longitudinal mixed effects models were used to assess differences in outcomes between study groups over 30 months. Results Women denied abortions initially had higher perceived stress than women receiving abortions near gestational age limits (1.0 unit difference on 0-16 scale, P = 0.003). Women receiving first-trimester abortions initially had lower perceived stress than women receiving abortions near gestational age limits (0.6 difference, P = 0.045). By six months, all groups’ levels of perceived stress were similar, and levels remained similar through 30 months. Emotional social support scores did not differ among women receiving abortions near gestational limits versus women denied abortions or women having first trimester abortions initially or over time. Conclusions Soon after being denied abortions, women experienced higher perceived stress than women who received abortions. The study found no longer-term differences in perceived stress or emotional social support between women who received versus were denied abortions.
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This study aims to assess the effects of obtaining an abortion versus being denied an abortion on self-esteem and life satisfaction. We present the first 2.5 years of a 5-year longitudinal telephone-interview study that follows 956 women who sought an abortion from 30 facilities across the USA. We examine the self-esteem and life satisfaction trajectories of women who sought and received abortions just under the facility's gestational age limit, of women who sought and received abortions in their first trimester of pregnancy, and of women who sought abortions just beyond the facility gestational limit and were denied an abortion. We use adjusted mixed effects linear regression analyses to assess whether the trajectories of women who sought and obtained an abortion differ from those who were denied one. Women denied an abortion initially reported lower self-esteem and life satisfaction than women who sought and obtained an abortion. For all study groups, except those who obtained first trimester abortions, self-esteem and life satisfaction improved over time. The initially lower levels of self-esteem and life satisfaction among women denied an abortion improved more rapidly reaching similar levels as those obtaining abortions at 6 months to one year after abortion seeking. For women obtaining first trimester abortions, initially higher levels of life satisfaction remained steady over time. There is no evidence that abortion harms women's self-esteem or life satisfaction in the short term.
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Access to high quality abortion care is essential to women's health, as evidenced by the dramatic decrease in pregnancy-related morbidity and mortality since the legalization of abortion in the United States, and by high rates of maternal death and complications in those countries where abortion is still provided under unsafe conditions. The past two decades have brought important advances in abortion care as well as increasing cross-disciplinary use of abortion technologies in women's health care. Abortion is an important option for pregnant women who have serious medical conditions or fetal abnormalities, and fetal reduction techniques are now well-integrated into infertility treatment to reduce the risks of multiple pregnancies resulting from assisted reproductive technologies. Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care is the textbook of the National Abortion Federation, and serves as the standard, evidence-based reference text in abortion care. This state-of-the-art textbook provides a comprehensive overview of the public health implications of unsafe abortion and reviews the best surgical and medical practices for pregnancy termination, as well as managing ectopic and other abnormal pregnancies. Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care is the leading source for a comprehensive understanding of issues related to unintended and abnormal pregnancy. This textbook: Is authored by internationally-known leaders in women's health care; Addresses unintended pregnancy and abortion from historical, legal, public health, clinical, and quality care perspectives; Includes chapters on pregnancy loss, ectopic pregnancy, gestational trophoblastic disease, and multifetal pregnancy reduction; Covers treatment of pregnancies in the first and second trimester by both medical and surgical techniques; and provides resources for clinical, scientific, and social support for the abortion provider and patient.
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Problem/condition: Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States. Reporting period covered: 2010. Description of system: Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). The reporting areas provide this information voluntarily. For 2010, data were received from 49 reporting areas. For the purpose of trend analysis, abortion data were evaluated from the 46 areas that reported data every year during 2001-2010. Census and natality data, respectively, were used to calculate abortion rates (number of abortions per 1,000 women) and ratios (number of abortions per 1,000 live births). Results: A total of 765,651 abortions were reported to CDC for 2010. Of these abortions, 753,065 (98.4%) were from the 46 reporting areas that provided data every year during 2001-2010. Among these same 46 reporting areas, the abortion rate for 2010 was 14.6 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 228 abortions per 1,000 live births. Compared with 2009, the total number and rate of reported abortions for 2010 decreased 3% and reached the lowest levels for the entire period of analysis (2001-2010); the abortion ratio was stable, changing only 0.4%. From 2001 to 2010, the total number, rate, and ratio of reported abortions decreased 9%, 10%, and 8%, respectively. Given the 3% decrease from 2009 to 2010 in the total number and rate of reported abortions, in combination with the 5% decrease that had occurred in the previous year from 2008 to 2009, the overall decrease for both measures was greater during 2006-2010 than during 2001-2005, despite the annual variations that resulted in no net decrease during 2006-2008. In 2010 and throughout the period of analysis, women in their 20s accounted for the majority of abortions and had the highest abortion rates, whereas women in their 30s and older accounted for a much smaller percentage of abortions and had lower abortion rates. In 2010, women aged 20-24 and 25-29 years accounted for 32.9% and 24.5% of all abortions, respectively, and had abortion rates of 26.7 and 20.2 abortions per 1,000 women aged 20-24 and 25-29 years, respectively. In contrast, women aged 30-34, 35-39, and ≥40 years accounted for 15.3%, 8.9%, and 3.4% of all abortions, respectively, and had abortion rates of 13.2, 7.6, and 2.8 abortions per 1,000 women aged 30-34 years, 35-39 years, ≥40 years, respectively. Throughout the period of analysis, abortion rates decreased among women aged 20-24 and 25-29 years, whereas they increased among women aged ≥40 years. In 2010, adolescents aged 15-19 years accounted for 14.6% of all abortions and had an abortion rate of 11.7 abortions per 1,000 adolescents aged 15-19 years. Throughout the period of analysis, the percentage of all abortions accounted for by adolescents and the adolescent abortion rate decreased. In contrast to the percentage distribution of abortions and abortion rates by age, abortion ratios in 2010 and throughout the entire period of analysis were highest among adolescents and lowest among women aged 30-39 years. Abortion ratios decreased from 2001 to 2010 for women in all age groups except for those aged <15 years, for whom they increased. In 2010, most (65.9%) abortions were performed at ≤8 weeks' gestation, and 91.9% were performed at ≤13 weeks' gestation. Few abortions (6.9%) were performed at 14-20 weeks' gestation, and even fewer (1.2%) were performed at ≥21 weeks' gestation. From 2001 to 2010, the percentage of all abortions performed at ≤8 weeks' gestation increased 10%, whereas the percentage performed at >13 weeks' decreased 10%. Moreover, among abortions performed at ≤13 weeks' gestation, the distribution shifted toward earlier gestational ages, with the percentage of these abortions performed at ≤6 weeks' gestation increasing 36%. In 2010, a total of 72.4% of abortions were performed by curettage at ≤13 weeks' gestation, 17.7% were performed by early medical abortion (a nonsurgical abortion at ≤8 weeks' gestation), and 8.3% were performed by curettage at >13 weeks' gestation. Among abortions that were performed at ≤8 weeks' gestation, and thus were eligible for early medical abortion on the basis of gestational age, 26.5% were completed by this method. From 2009 to 2010, the use of early medical abortion increased 13%. Deaths of women associated with complications from abortions for 2010 are being investigated under CDC's Pregnancy Mortality Surveillance System. In 2009, the most recent year for which data were available, eight women were identified to have died as a result of complications from known legal induced abortions. No reported deaths were associated with illegal induced abortions. Interpretation: Among the 46 areas that reported data every year during 2001-2010, the gradual decrease that had occurred during previous decades in the total number and rate of reported abortions continued through 2005, whereas year-to-year variation from 2006 to 2008 resulted in no net change during this later period. However, the large decreases that occurred both from 2008 to 2009 and from 2009 to 2010 resulted in a greater overall decrease during 2006-2010 as compared with 2001-2005 and the lowest number and rate of reported abortions for the entire period of analysis. Public health actions: Unintended pregnancy is the major contributor to abortion. Because unintended pregnancies are rare among women who use the most effective methods of reversible contraception, increasing access to and use of these methods can help further reduce the number of abortions performed in the United States. The data in this report can help program planners and policy makers identify groups of women at greatest risk for unintended pregnancy and help guide and evaluate prevention efforts.
Article
This study prospectively assesses the mental health outcomes among women seeking abortions, by comparing women having later abortions with women denied abortions, up to 2 years post-abortion seeking. We present the first 2 years of a 5-year telephone interview study that is following 956 women who sought an abortion from 30 facilities throughout the USA. We use adjusted linear mixed-effects regression analyses to assess whether symptoms of depression and anxiety, as measured by the Brief Symptom Inventory-short form and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, differ over time among women denied an abortion due to advanced gestational age, compared with women who received abortions. Baseline predicted mean depressive symptom scores for women denied abortion (3.07) were similar to women receiving an abortion just below the gestational limit (2.86). Depressive symptoms declined over time, with no difference between groups. Initial predicted mean anxiety symptoms were higher among women denied care (2.59) than among women who had an abortion just below the gestational limit (1.91). Anxiety levels in the two groups declined and converged after 1 year. Women who received an abortion had similar or lower levels of depression and anxiety than women denied an abortion. Our findings do not support the notion that abortion is a cause of mental health problems.