Chapter 1: The Turnaway Study CHAPTER 1 The Turnaway Study
In the summer of 1987, President Ronald Reagan addressed the leaders of the right-to-life movement during a gathering in Washington, DC, and did what Republican presidents have been doing ever since abortion become legal in the United States.1
He promised to fight to overturn Roe v. Wade
, the 1973 Supreme Court decision that continues to rankle the Grand Old Party’s religious-right base all these decades later.
“I will not rest until a human life amendment becomes a part of our Constitution,” Reagan promised, referring to the name given to various proposed constitutional amendments introduced since 1973 that would have granted legal personhood to embryos and fetuses and effectively criminalized all abortions, sometimes without exceptions. To date, no such proposal has gone far in Congress, and Reagan clearly didn’t expect it to go far in his last years in office. Before the anti-abortion leaders ceased their applause, Reagan quickly turned the conversation to incremental attacks on abortion. “At the same time,” he said, “we must continue to search for practical steps that we can take now, even before the battle for the human life amendment is won.”
Reagan listed four steps his administration had taken, steps he believed represented “powerful examples of what can be done now to protect the lives of unborn children.” The third step on his list, however, did not address those “unborn children,” but rather the need for proof that abortion harms women.
“Growing numbers of women who’ve had abortions now say that they have been misled by inaccurate information,” he said. “Making accurate data on maternal morbidity available to women before an abortion is performed is an essential element of informed consent. I am, therefore, directing the Surgeon General to issue a comprehensive medical report on the health effects, physical and emotional, of abortion on women.”
That task fell to Surgeon General C. Everett Koop, an acclaimed pediatric surgeon who very publicly opposed abortion. The doctor had written a book and produced short films arguing that abortion would inevitably lead to forced euthanasia for seniors and people with disabilities.2
He had previously toured the country giving multimedia presentations on the evils of abortion. This is the man who was charged with finding evidence that abortion harms women. Reagan and his religious-right constituents hoped that Koop’s report would provide the basis for abortion to be legislated accordingly.
However, Koop could find no such evidence. And it wasn’t for lack of trying. As he would write in his final letter to President Reagan a year and a half later, the surgeon general reviewed more than 250 studies pertaining to the psychological impact of abortion.3
He interviewed women who’d had abortions and talked to dozens of medical, social, and philosophical groups on both sides of the debate.
Koop surprised his initial critics with his commitment to science and public health, even in the face of religious and political opposition, when he ultimately concluded that the existing data, showing either that abortion was harmful or that it wasn’t, were rife with methodological problems: “I regret, Mr. President, that in spite of a diligent review on the part of many in the Public Health Service and in the private sector, the scientific studies do not provide conclusive data about the health effects of abortion on women.”
In Koop’s 1989 letter to President Reagan, he called for more and better research of abortion’s effects, specifically a five-year prospective study analyzing all the many outcomes of sex and reproduction, including the psychological and physical effects of trying but failing to conceive; having planned and unplanned, wanted and unwanted pregnancies; and delivering, miscarrying, or aborting pregnancies. His call for better research would go unfulfilled for twenty years.
Until, that is, 2007, when my team of social scientists decided to take on a portion of what Koop had envisioned: to study the outcomes of both birth and abortion for women with unwanted pregnancies. Abortion is a medical procedure so controversial it decides elections and ruins Thanksgiving dinners. Yet it is also extremely common—between one in four and one in three women in the U.S. will have an abortion during their lifetime.4
But being common does not make it easy to study. We needed to overcome the methodological pitfalls that had discredited all the earlier studies Koop had reviewed. In particular, we needed to avoid comparisons between women who have abortions and those who have wanted pregnancies. After all, the set of circumstances that in some cases makes a pregnancy unwanted—such as poverty, poor mental health, or lack of social support—might be the primary stressor that causes poor outcomes, rather than the abortion itself. And given the difficulties brought to the fore when a woman discovers she is pregnant but doesn’t have the job, housing, family support, or other resources required to raise a child, it may not only be the unintended pregnancy that causes distress, but the life reckoning that comes when making the decision to have an abortion.
An unbiased study would focus on women who share the same circumstance of becoming pregnant and not feeling able or willing to have a baby. Pregnant women like Jessica, a 23-year-old mother of two whose previous pregnancies had exacerbated her serious health problems and who was married to a man she described as abusive and whom she wanted to leave. Or Sofia, who at 19 was in what she called a “rocky” relationship and whose family had just been evicted from their home. Then we would compare the outcomes—physical, psychological, financial, romantic, familial—of women who got the abortions they wanted, like Jessica, to women who were turned away because they were too far along, like Sofia.
Our study design is what social scientists call a natural experiment, where randomness in access to a program or a service allows researchers to compare people who received it and people who didn’t. A classic example is a lottery that determines which people get health insurance, as was done in Oregon in the rollout of an expansion in Medicaid.5
Obviously, it would be unethical to randomly deny women wanted abortions for the sake of science. But women are denied abortions all the time in the United States—sometimes because they cannot afford one and, sometimes (for at least 4,000 women per year) because there are no clinics nearby that perform abortions at their gestation.6
The strength of the Turnaway Study’s design is that women just above and just below the gestational limit are women facing the same circumstances—sometimes just a few days determines whether a woman can access abortion. Any divergences in their outcomes are likely a result of whether they received their wanted abortion. Over the course of three years, 2008 through 2010, we recruited more than 1,000 pregnant women from the waiting rooms of 30 abortion facilities in 21 states. Facilities set their gestational limits to reflect their doctors’ level of comfort and ability, as well as to comply with state law. Because most of the facilities we chose have limits in the second trimester but more than 90% of women in the U.S. have abortions in the first trimester, we also recruited first-trimester patients, who would represent a more typical abortion experience. At each site, for every woman denied the abortion, we recruited two women who received an abortion just under the gestational limit and one who received an abortion in the first trimester.
We interviewed these women by phone twice a year for up to five years—through both easy and difficult recoveries from abortion and birth. We asked about their emotions and mental health, their physical health, their life goals and financial well-being, and the health and development of their children. For those denied abortions, we followed some who continued their search for another clinic that could provide their abortion. The great majority (70%) of those turned away carried the pregnancy to term, and we asked them about their childbirth and subsequent decisions about parenting. We examined nearly every aspect of how receiving or being denied an abortion affected these women’s lives and the lives of their families. We gathered data about why women want to end their pregnancies and how hard it is to get an abortion in the U.S. We had study participants take us back to the day of their abortions, to the protesters they encountered, to the ultrasound images of embryos or fetuses that some state laws required their doctors to offer to show them. We wanted to learn how these experiences affected women’s long-term emotions about their abortion. We documented their physical health and how it changed with pregnancy, abortion, and birth and in the years that followed. We analyzed the role of men in abortion-related decision-making and how the outcome of the pregnancy affected women’s romantic relationships. A team of UCSF researchers used the latest statistical techniques to analyze data from thousands of interviews, often collaborating with scientists across the country. Launching the Turnaway Study
I would not have been able to carry out the Turnaway Study on my own. As you will see, I had help from many other people from the beginning. In 2007, when I first conceived of the study, Sandy Stonesifer was working as the assistant to the chief of the family planning division at San Francisco General Hospital. I needed to conduct a pilot study to see if women faced with the news that they would not be able to get an abortion would be willing to sign up for a study about their outcomes. Sandy offered to run down the hall to the Women’s Options Center to try to recruit women deemed too late to receive an abortion. When the pilot proved successful, Sandy took over the job of managing the study and finding other abortion facilities that would help direct their patients and their turnaways to our small study team. So Sandy and I embarked on a series of abortion-clinic tours. We visited a clinic in Fargo, North Dakota, in the middle of a massive snowstorm in February. Come sweltering July we were touring clinics in Texas. Clinic staff welcomed us out of the snow and heat and into their communities. Many clinic workers seemed enthusiastic about our mission to understand the experiences of both the women they serve and those they’re unable to serve. Everyone we visited was proud of their clinic.
Some clinics were architecturally beautiful, like one in Atlanta that featured a high-peaked trellised wooden ceiling above its waiting room. Others were rather spare, like one in a converted auto mechanic shop in the Midwest. A few clinics we visited displayed feminist-themed décor—posters urging patients and accompaniers to vote or telling them that “good women have abortions.” Most of the clinics we toured seemed like ordinary health care clinics designed by the same architect who designed all the public schools I attended as a kid in Maryland—who apparently believed that no kid should get to see natural light while at school. But in the case of abortion clinics, the fortress is designed to keep protesters out instead of occupants in. Security is a big deal in these buildings. Some abortion doctors wear bulletproof vests to work.7
At the time we did these tours, between 2007 and 2010, violence at clinics was less common than it was in the 1980s and ’90s, when blockades and violent attacks on clinics and providers surged in America.8
Most facilities we went to were just busy medical clinics. Roughly half of those we visited had protesters, but the protesters usually just stood there peacefully and did not talk to the women going in.9
Only a few facilities had loud and aggressive protesters.
In the ten years since we toured the clinics, incidences of harassment, threats, and violence have increased substantially.10
Clinic bombings and shootings occur, and sometimes they’re fatal. Most recently, in 2015 three people were murdered at a Planned Parenthood clinic in Colorado Springs, Colorado.11
But the fact that the national media most often pays attention to abortion clinics when there’s a mass shooting or a bombing creates a misperception that abortion facilities are constantly under violent attack. The media focus on protesters contributes to the perception that abortion is a political act rather than the provision of routine health care.
Sandy left after a couple of years to bring her excellent management skills to Washington, DC, and I recruited Rana Barar, a Columbia University–trained expert in reproductive health research management, to direct the increasingly complicated study logistics. She expanded the number of recruiting clinics and oversaw a growing team of interviewers and database developers that collected data from 7,851 interviews. We eventually chose 30 recruitment sites that had the latest gestational limit within 150 miles—if a woman was too late for one of these clinics, no clinic nearby could provide her abortion. At each site, one staff person was responsible for approaching women and asking them if they would be interested in participating in a nationwide study of women seeking abortion services. Many of these designated recruiters were initially skeptical that someone who was denied care would stick around long enough to hear about a study and, more to the point, that they would agree to anything, given that they were being turned away. It was the recruiting success of Dr. Drey’s Women’s Options Center, where 70% of women agreed to participate, that gave the point people at the other clinic sites the courage to approach women. As Tammi Kromenaker, the point person in Fargo, North Dakota, would tell women, “It’s your chance to have your story heard.” The Women of the Turnaway Study
The women who agreed to participate in this study closely resemble the profile of women who get abortions nationally.12
Just over a third (37%) were white and not Latina, just under a third (29%) were African American, one in five (21%) were Latina, 4% were American Indian, and 3% were Asian American. Similar to abortion patients nationwide, more than half of the women (60%) were in their twenties at the time of the abortion. Almost one in five (18%) were teenagers, and just over one in five (22%) were 30 or older. Half were living in poverty, although women seeking abortion later in pregnancy were more likely to be poor—40% of those in the first trimester and 57% of those who sought abortions just above or below the clinic gestational limit.13
There are economically privileged women in the study as well. Roughly a quarter of the study participants were middle-class or wealthier, had private health insurance, and reported that they often or always have enough money. Women of all ethnic and economic backgrounds seek abortions.
They came from more than 40 states across the country to the clinics in 21 states where we recruited, from Maine to Florida, Washington to Texas. Sixty percent had children, and 45% had experienced a prior abortion. Sixty-one percent were in a current romantic relationship with the man with whom they became pregnant; 39% reported that the man was a friend, ex-partner, or acquaintance, or that they had no relationship with him. One in five women reported a history of sexual assault or rape; 11 women (1%) were pregnant as a result of rape.
Where the women in this study differ from the national profile of women getting abortions is in how far along many of them were in their pregnancies. Again, roughly 90% of women in America who have abortions do so in the first trimester (13 weeks and under), and only 1% do so after 20 weeks of pregnancy. But in the Turnaway Study, 25% of the women were in the first trimester, 30% were between 14 and 19 weeks, and 45% were 20 weeks or later. This gives us extremely important data on the most politically vulnerable and least socially accepted abortion patients.
I decided to exclude from the study women who were terminating pregnancies because of a known fetal anomaly or because of their own severe immediate health risks. My rationale was that the law allows providers to terminate pregnancies after viability in cases like these. Therefore, if I had recruited these patients, I probably would have had to remove them from the analyses because they might only end up in one study group—those getting their wanted abortions and not in the group of women who were denied. This would defeat the concept of the study design, where women are similar on both sides of the gestational limit. In retrospect, I wish I had included them, if only to analyze their data separately. Very little is known about women’s experiences and the emotional consequences of terminating a wanted pregnancy for reasons related to fetal or maternal health. Based on previous research showing that women who aborted wanted pregnancies due to fetal anomaly anticipate more difficulty coping immediately after the abortion, women might have more distress after an abortion for fetal anomaly or maternal health than after aborting an unwanted pregnancy.14
But before we leap to saying that abortion for those reasons results in poor outcomes, we would want to know about distress and coping after carrying such a pregnancy to term. It would also have been interesting to look at whether those women had subsequent, healthier pregnancies and how their emotional health fared in the long run. Further study is needed in these areas. Our Findings
We find no evidence that abortion hurts women. For every outcome we analyzed, women who received an abortion were either the same or, more frequently, better off than women who were denied an abortion. Their physical health was better. Their employment and financial situations were better. Their mental health was initially better and eventually the same. They had more aspirational plans for the coming year. They had a greater chance of having a wanted pregnancy and being in a good romantic relationship years down the road. And the children they already had were better off, too.
We find many ways in which women were hurt by carrying an unwanted pregnancy to term. Continued pregnancy and childbirth is associated with large physical health risks, so great that two women in our study died from childbirth-related causes. Many others experienced complications from delivery and, extending over the next five years, increased chronic head and joint pain, hypertension, and poorer self-rated overall health. In the short run, women experienced increased anxiety and loss of life satisfaction after being denied an abortion, and those with violent partners found it difficult to extricate themselves after the birth. Over the next several years, women who were denied abortions experienced economic hardships not experienced by women who received their wanted abortions.
Abortion opponents often accuse women seeking abortions of being misinformed, irresponsible, or amoral. In fact, as the Turnaway Study results make clear, women make thoughtful, well-considered decisions about whether to have an abortion. When asked why they want to end a pregnancy, women give specific and personal reasons. And their fears are borne out in the experiences of women who carry unwanted pregnancies to term. Women seeking abortions worry that they cannot afford to raise a baby, and we find that women denied abortions are more likely to live in poverty. They worry that their relationship isn’t strong enough to support a child, and we find that relationships with the man involved dissolve regardless of whether they carry the pregnancy to term or have an abortion. They worry about not being able to take care of their existing children, and we find evidence that women’s children do worse on several measures of health and development when women carry an unwanted pregnancy to term than when they receive an abortion. The Turnaway Study brings powerful evidence about the ability of women to foresee consequences and make decisions that are best for their lives and families. Women’s Stories
In this book, you’ll see how women’s lives are changed when they receive a wanted abortion and when they are turned away. The consequences reach far beyond one pregnancy to shape the direction of their lives and their children’s. The data—measurable quantitative outcomes faced by women who receive abortions versus women who are denied them, such as symptoms of depression, income levels, and cases of hypertension—don’t tell the whole story. To get a deeper understanding of the lived experiences of the women in the study, you need to hear from the women themselves. My colleague Heather Gould conducted in-depth interviews with 31 women—28 who were randomly selected from those who had completed five years of interviews, two who had placed children for adoption, and one who had completed the surveys in Spanish. You’ll hear from most of these 31 women (referred to by pseudonyms) and in particular ten whom I have selected to tell their whole stories. I picked them for the strength of their voices and the breadth of their experiences.
In their own words, these women will tell you about their unwanted pregnancies. Some will recount the abortions they were able to have, whether early or late in their pregnancies. Others will tell you about the babies they birthed, which some chose to parent and others chose to place for adoption. You’ll hear from a woman who is smart and ambitious but also young, barely 20 when we first meet her, and rationalizes that a two-year joint cell phone contract should lock her in a relationship with a man who fills their home with cigarette smoke and aggravates her crippling asthma, who hurts her and who forces her into sex. As you will see, it takes facing the reality of an accidental pregnancy to set her on a more independent path. You will hear from the partygoing store clerk turned Christian-café owner whose life changes when she falls in love with her steakhouse waiter. She’s too far along for an abortion in her city. She could travel more than 250 miles to get a later abortion; in fact, her family insists she do just that. But she resists and experiences isolation, depression, and, eventually, happiness, with the birth of her son. These stories and the many others included here show that our reproductive lives are complex. Women who have abortions also have wanted pregnancies; women who place children for adoption later decide to raise a child.
Ten women cannot represent the nearly one million people who have abortions each year. But the ten stories from women in the Turnaway Study do give some insight into the personal experiences of women seeking abortion. I have changed their names and identifying details, but the words are theirs, taken and condensed from the interview transcripts. The stories appear between chapters, presented in order of increasing gestational age at the time each woman enrolled in this study. It’s probably not a coincidence that the woman with the earliest abortion also has one of the least complicated stories. Not being poor, sick, unsupported, or conflicted about her decision probably helped Amy seek an abortion earlier than the other women you’ll hear from. I think Amy’s is the ideal story to start with because she shows that unwanted pregnancies can happen to anyone. Amy is nurturing, funny, kind, and feels grateful for her “extravagant, wonderful ordinary life.” It doesn’t take a life in crisis to need an abortion. Over 30-plus years of trying to avoid pregnancy, accidents can happen. They can even happen more than once. Amy’s situation is happy and stable, and having an abortion helped her preserve that. The abortion is a part of how Amy handled her life and planned her family. She and her husband had a child already, and they didn’t want another. She’d tried adoption once and knew it wasn’t for her.
Amy’s experience is an example of what the bioethicist Katie Watson calls, in her excellent book, Scarlet A
, an “ordinary abortion.”15
Abortion-rights advocates often hold up the extreme cases—the woman with a violent partner, the woman with a life-threatening illness, the 14-year-old girl raped by a relative, the woman whose fetus wouldn’t survive more than a few moments after birth. The motivation might be to try to evoke sympathy for someone in such dire circumstances. But the message communicated may be that abortion is an extreme remedy for an extreme situation. Instead, as Amy shows, abortion can be a normal part of planning a family and living a meaningful life. Extreme cases do occur and should also receive our sympathy, but the story of abortion is overwhelmingly one of people in ordinary circumstances wanting to have some control over their bodies, their childbearing, and their lives.