What Happens to Women Who Are Denied Abortions?

http://www.nytimes.com/2013/06/16/magazine/study-women-denied-abortions.html?pagewanted=1&_r=1&hp&pagewanted=all&

By JOSHUA LANG

Published: June 12, 2013 807 Comments

S. arrived alone at a Planned Parenthood in Richmond, Calif., four days before Christmas. As she filled out her paperwork, she looked at the women around her. Nearly all had someone with them; S. wondered if they also felt terrible about themselves or if having someone along made things easier. She began to cry quietly. She kept reminding herself that she felt secure in her decision. “I knew that that was going to be the right-wrong thing to do,” she told me later. “I was ready for it.”

After S. urinated in a cup, she was led into a small room. She texted one of her sisters, “Do you think God would forgive me if I were to murder my unborn child?” It was the first time anyone in her family knew she was pregnant.

“Where are you?” her sister asked. “Are you O.K.?”

“I’m at Planned Parenthood, about to have an abortion.”

“God knows your heart, and I understand that you are not ready,” her sister texted back. “I think God will understand.”

The pregnancy had crept up on S. She was a strong believer in birth control — in high school she was selected to help teach sex education. But having been celibate for months and strapped for cash, she stopped taking the pill. Then an ex-boyfriend came around. For months after, she had only a little spotting, but because her periods are typically light, she didn’t think much of it at first. Then she started to worry. “I used to press on my stomach really hard thinking maybe it would make my period come,” she said.

Around Thanksgiving in 2011, S., then 24, took her first pregnancy test — a home kit from Longs Drugs. S. (her first initial) lived alone, with her dog and her parrot, and it was late at night when she read the results. She stared into space, past the plastic stick. She’d never been pregnant before. “I cried. I was heartbroken.” Her ex had begun a new relationship, and she knew he wouldn’t be there to support her or a child. She was working five part-time jobs to keep herself afloat and still didn’t always have enough money for proper meals. How could she feed a baby? She kept the news to herself and made an appointment at Planned Parenthood.

At the clinic, a counselor comforted S. and asked her why she had come, if anyone had coerced her into making this decision. No, S. explained, she was simply not ready to have a child. The woman asked how far along she thought she might be. S. estimated that she was about three months pregnant.

In the exam room, a technician asked her to lie down. She did an ultrasound, sliding the instrument across S.’s stomach: “Oh . . . it shows here that you are a little further along.” She repeated the exam. S., she estimated, was nearly 20 weeks pregnant, too far along for this Planned Parenthood clinic. S. felt numb: “I was thinking, If it is too late here, it is probably too late other places. . . . And I was like, Oh, my God, now what?”

Planned Parenthood gave S. a packet of information, including two pieces of paper — one green, for adoption, and one yellow, for other abortion providers. S. still wanted to have an abortion. She called a clinic in Oakland and took the first available appointment, just after Christmas. “I was a ticking time bomb, running out of days,” she told me. On the Internet, another of S.’s sisters also found a place called First Resort, which provided abortion counseling. S. didn’t know that First Resort’s president once said that “abortion is never the right answer.” (A spokeswoman for First Resort says that while the organization “takes no public stand on legalized abortion,” it “does not provide abortions or abortion referrals.”)

S. went to First Resort the day before her appointment in Oakland, unsure what to expect. It provided a free ultrasound. The nurse asked S. if she wanted to see the baby and turned the monitor toward her: “Look! Your baby is smiling at you.” S. was shaken, convinced she also saw the baby smiling. The nurse told her that she was at least a week further along than the Planned Parenthood estimate (ultrasound estimates can be off by several days either way). S. sobbed all the way to her car and called the clinic in Oakland, giving it the First Resort estimate. If it was correct, they told her, she would be past its deadline. S. never made it to the Oakland clinic and in a matter of days gave up looking for another clinic that could perform a later procedure. She was out of gas money, hadn’t eaten a decent meal in weeks and resigned herself to the fact that, no matter what she wanted or how it would affect her life, she was going to have a baby.

When Diana Greene Foster, a demographer and an associate professor of obstetrics and gynecology at the University of California, San Francisco, first began studying women who were turned away from abortion clinics, she was struck by how little data there were. A few clinics kept records, but no one had compiled them nationally. And there was no research on how these women fared over time. What, Foster wondered, were the consequences of having to carry an unwanted pregnancy to term? Did it take a higher psychological or economic toll than having an abortion? Or was the reverse true — did the new baby make up for any social or financial difficulties?

“It’s not that the study was so hard to do,” Foster says. But no one had done it before. Since Roe v. Wade was decided in 1973, the debate over abortion has focused primarily on the ramifications of having one. The abortion rights community maintains that abortion is safe, both physically and psychologically — a position most scientists endorse. Those on the anti-abortion side argue that abortion is immoral, can cause a fetus pain and leads to long-lasting negative physical and psychological effects in the women who have the procedure. There is no credible research to support a “post-abortion syndrome,” as a report published by the American Psychological Association in 2008 made clear. Yet the notion has influenced restrictive laws in many states. In Alabama, women who seek an abortion must have an ultrasound and be offered the option to view the image; in South Dakota, women must wait at least 72 hours after a consultation with a doctor before having the procedure. “The unstated assumption of most new abortion restrictions — mandatory ultrasound viewing, waiting periods, mandated state ‘information,’ ” Foster says, “is that women don’t know what they are doing when they try to terminate a pregnancy. Or they can’t make a decision they won’t regret.” Lost in the controversy, however, is the flip side of the question. What, Foster wondered, could the women who did not have the abortions they sought tell us about the women who did?

Most studies on the effects of abortion compare women who have abortions with those who choose to carry their pregnancies to term. It is like comparing people who are divorced with people who stay married, instead of people who get the divorce they want with the people who don’t. Foster saw this as a fundamental flaw. By choosing the right comparison groups — women who obtain abortions just before the gestational deadline versus women who miss that deadline and are turned away — Foster hoped to paint a more accurate picture. Do the physical, psychological and socioeconomic outcomes for these two groups of women differ? Which is safer for them, abortion or childbirth? Which causes more depression and anxiety? “I tried to measure all the ways in which I thought having a baby might make you worse off,” Foster says, “and the ways in which having a baby might make you better off, and the same with having an abortion.”

Foster began by gathering data locally. She ran the study out of her office at U.C.S.F. (I am a student in the U.C. Berkeley-U.C.S.F. Joint Medical Program but did not know Foster before reporting this article.) When the counselors at a nearby abortion clinic received a woman who was too far along to terminate her pregnancy, they called Foster, who would run over and arrange to interview the patient. Given the stigma attached to seeking an abortion later in pregnancy, Foster expected that many women would be reluctant to be part of her study. But four out of five women agreed to participate. “Sometimes, if you tell them that their experience is valuable, that it might help other people in their situation, they will come through,” she says.

Initially, Foster’s study was confined to women whose pregnancies were in a narrow band of time on either side of this particular clinic’s gestational limit — two weeks under or three weeks over. (In California, state law allows an abortion up to what a physician considers viability, but clinics can set their own limits.) Eventually Foster received multiple foundation grants that allowed her to hire additional staff and recruit more subjects. The study, which is ongoing, encompasses 30 clinics from 21 states across the country. The clinics’ gestational limits vary from 10 weeks to the end of the second trimester, with a vast majority falling in the second trimester, typically defined as Weeks 14 to 26 of pregnancy. Women turned away from these “last stop” clinics had no other options within 150 miles. Of some 3,000 women who were asked to participate, 956 have completed a baseline interview and agreed to follow-up interviews every six months. Of those women, 452 were within two weeks of their facility’s cutoff and received an abortion, and 231 missed the cutoff by up to three weeks and were turned away. About 20 percent of the turnaways received an abortion elsewhere. Foster compared the remaining women who carried their pregnancies to term with the near-limit abortion patients. (The 273 other women in the study received a first-trimester abortion and acted as a control group. In the United States, 88 percent of abortions occur in the first 12 weeks, and Foster wanted to be sure that the near-limit abortion patients did not differ significantly in their outcomes from first-trimester abortion patients.) Of the turnaways in Foster’s study who gave birth, 9 percent eventually put their children up for adoption.

There are many reasons women are turned away from an abortion clinic — lack of funds (many insurance plans don’t cover abortion) or obesity (excess weight can make the procedure more complicated) — but most simply arrive too late. Women cite not recognizing their pregnancies, travel and procedure costs, insurance problems and not knowing where to find care as common reasons for delay. These are the women for whom “society has the absolute least sympathy,” Foster acknowledges. While a majority of Americans (53 percent) agree with Roe, many of those who support abortion rights draw the line at later stages of pregnancy. And the law reflects this view. Roe v. Wade guarantees a woman’s right to abortion only up to the “viability” of a fetus, with exceptions for danger to a woman’s health. (Viability varies depending on the medical expert you ask, typically at 23 weeks or more.) But the widespread discomfort with abortions near viability is reflected in recent bans on so-called partial-birth abortions. And many clinics, reacting to state law, set their own gestational limits — often 20 to 22 weeks — making later-term abortion more difficult to find in some states than in others. (In the U.S., 87 percent of counties have no abortion provider at all.)

“Usually the only difference between making it and not is just realizing you are pregnant,” Foster says. “If you’re late, abortion gets much harder to find. All the logistic concerns snowball — money, travel, support.” Women who seek abortions tend, in general, to be less well off than those who don’t, and those seeking second-trimester abortions tend to be “particularly vulnerable,” given the difficulties of finding an appropriate clinic and the higher cost of a later procedure.

As the argument that abortion harms women gains political traction, it is especially critical to look at how turnaways fare. “All past studies of women denied abortion in the United States have been hospital-specific and local, focusing on a brief amount of time, without a control group,” says Roger Rochat, former director of the division of reproductive health at the C.D.C. and a professor of global health and epidemiology at Emory University. “Foster’s turnaway study had a sample across the United States that she followed over a long period of time. It is the best science we have ever done on the subject. ”

Foster’s study does have a precedent — of a sort. In 1957, Czechoslovakia liberalized its abortion laws, while maintaining significant restrictions. Women were required to apply to an abortion commission and could be denied for a host of reasons — if they were past 12 weeks’ gestation, presented “false or insufficient” reasons or had had an abortion too recently. Women denied by the first commission could appeal to regional review boards. Some were denied twice and thus carried their pregnancies to term.

An eminent American psychologist, Henry David, took note of this and embarked on a pioneering study. Between 1961 and 1963, 24,989 Czech women applied for abortions; 638 of the applications were denied after initial application and appeal. With a team of Czech colleagues, David enrolled 220 of the women who were twice denied the abortion they sought and 220 women who never pursued an abortion. For the next 35 years, he followed their children, making regular inquiries and comparisons between the two groups.

The first results examined the children at age 9. David reported that the children born of unwanted pregnancies had significant disadvantages. They were breast-fed for shorter periods; were slightly but consistently overweight; had more instances of acute illness and lower grades in Czech. They seemed less capable in socially demanding situations; they were less popular among peers and teachers and even, if sons, with their own mothers. David concluded that “the child of a woman denied abortion appears to be born into a potentially handicapping situation.” After David published his first round of data, Czechoslovakia made first-trimester abortion available on demand.

In the course of interviewing the mothers about their children, David’s research suggested that whether the mother wanted the child was a significant predictor of the child’s future negative qualities, independent of the effect of the mother’s personality. But he did not have a proper control group to determine if a child’s unwantedness rather than a poor family environment was the source of the trouble. David called it “the Achilles’ heel” of his work.

Foster’s study, by contrast, seeks to isolate the impact of abortion by comparing two groups of very similar women: there are few differences in their educational and socioeconomic backgrounds, and they all sought an abortion. Only 6.6 percent of near-limit patients in the study and 5.6 percent of turnaways finished college (18 percent of adult American women have a bachelor’s degree). One in 10 were on welfare, and approximately 80 percent reported not having enough money to meet basic living needs. A majority, in both groups, already had at least one child.

Foster hoped that their similarities would allow her to answer more fully how abortion affects women’s mental health and emotional states. The A.P.A. report from 2008 concluded that, among adult women with unplanned pregnancies, the “relative risk of mental-health problems is no greater if [women] have a single elective first-trimester abortion than if they delivered the pregnancy.” But it did not go beyond the first trimester. It also noted the “complexity of women and their circumstances” and suggested that further study was needed to “disentangle confounding factors and establish relative risks of abortion compared to its alternatives.”

Foster saw that most abortion studies failed to acknowledge that women seeking abortions are likely to have mixed emotions — regret, anger, happiness, relief. They also often failed to separate the reaction to pregnancy from the reaction to the abortion. She has designed her study to do both, relying on a series of questions and periodic interviews, and initial results, to be published in the fall, show that the emotion that predominates right after an abortion is relief.

When she looked at more objective measures of mental health over time — rates of depression and anxiety — she also found no correlation between having an abortion and increased symptoms. In a working paper based on her study, Foster notes that “women’s depression and anxiety symptoms either remained steady or decreased over the two-year period after receiving an abortion,” and that in fact, “initial and subsequent levels of depressive symptoms were similar” between those who received an abortion and those who were turned away. Turnaways did, however, suffer from higher levels of anxiety, but six months out, there were no appreciable differences between the two groups.

Where the turnaways had more significant negative outcomes was in their physical health and economic stability. Because new mothers are eligible for government programs, Foster thought that they might have better health over time. But women in the turnaway group suffered more ill effects, including higher rates of hypertension and chronic pelvic pain (though Foster cannot say whether turnaways face greater risk from pregnancy than an average woman). Even “later abortions are significantly safer than childbirth,” she says, “and we see that through lower complications and low incidence of chronic conditions.” (In the National Right to Life’s five-part response to preliminary findings of Foster’s study, which were presented at the American Public Health Association conference last year, the group noted that the ill effects of abortion — future miscarriage, breast cancer, infertility — may become apparent only later. Reputable research does not support such claims.)

Economically, the results are even more striking. Adjusting for any previous differences between the two groups, women denied abortion were three times as likely to end up below the federal poverty line two years later. Having a child is expensive, and many mothers have trouble holding down a job while caring for an infant. Had the turnaways not had access to public assistance for women with newborns, Foster says, they would have experienced greater hardship.

Though S. is not part of Foster’s turnaway study, she is in many ways typical. The same month that she realized she would be having her baby, she was confronted with a host of financial hurdles. She couldn’t move in with her parents because they’d lost their home to foreclosure. By late March, S., exhausted by the pregnancy, had stopped working. Everyone moved into her older sister’s house — a three-bedroom, one-bathroom — where now seven people would be living. There was a family meeting. S. and her baby would take one room; her sister’s daughter would move into the small playroom; the parents would move into the garage. Their parents brought 20 years of belongings with them; S. sold, gave away or threw out everything she could but brought her parrot and her dog.

S., who had never seriously considered adoption, was overwhelmed when Baby S., a healthy girl, was born in May 2012. “It was like, whoa!” S. recalled. “That first night was terrible. I was tired, and she was so hungry, and she had a very loud cry. They don’t tell you how hard it is to nurse your baby. You don’t know how painful it is for something to eat off you, and it’s pulling your skin.” She developed plugged ducts, a condition in which the breasts become painfully engorged with milk.

It’s not unusual for new mothers to have trouble breast feeding, but S. felt overwhelmed in other ways too. “This baby is such a crybaby, and I didn’t know what was going on,” she said. “I felt like she didn’t love me, like maybe she was mad at me.” S. watched bitterly as her family members held a contented Baby S. When S. held her, the baby would begin to cry. It went on like that for weeks. S. sometimes buried her head in her pillow, crying, when the baby cried. “Her tone was negative,” one of S.’s sisters remembers. “She would become angry, saying she wished the baby would shut up.”

S. wanted to be a good mother, so she kept trying to nurse even when she began to develop sores on her breasts. Perhaps because of S.’s difficulty breast-feeding, Baby S. wasn’t gaining weight. Her physician threatened to call social services. Through a federal program — Women, Infants and Children (W.I.C.) — S. found a lactation consultant, who rented her a breast pump and provided her with information on baby formula. Once she stopped breast-feeding, Baby S. began to gain weight.

One day, when Baby S. was nearly 3 months old, S. left her on a pillow at the center of her bed while she went to the bathroom. She was gone for about a minute. When she came back, Baby S. was on the floor, lying face up, whimpering softly. S. and her mother took the baby to the hospital. It turned out nothing was wrong, but like many new parents in that situation, S. was terrified. The thought of losing Baby S. made her sick. From that point on, she no longer buried herself under the pillow when her baby cried. She didn’t let Baby S. out of her sight.

S. now says that Baby S. is the best thing that ever happened to her. “She is more than my best friend, more than the love of my life,” S. told me, glowingly. There were white spit-up stains on her green top. “She is just my whole world.”

When I told Foster S.’s story, she wasn’t surprised that S. ended up bonding with her baby. “That would be consistent with our study,” Foster said. “About 5 percent of the women, after they have had the baby, still wish they hadn’t. And the rest of them adjust.” S.’s experience is also consistent with one of the most striking statistics from Henry David’s Czech study. David found that nine years after being denied abortions, 38 percent of women said they never sought one in the first place.

Some would use these data as justification to further restrict abortion — women rarely regret having a child, even one they thought they didn’t want. But as Katie Watson, a bioethicist at Northwestern University’s Feinberg School of Medicine, points out, we tell ourselves certain stories for a reason. “It’s psychologically in our interest to tell a positive story and move forward,” she says. “It’s wonderfully functional for women who have children to be glad they have them and for women who did not have children to enjoy the opportunities that afforded them.”

Yet it is still true that being denied an abortion resulted in some measurable negative effects for S. She had to give up work and her apartment, and her precarious finances became more precarious. When women seek abortion, you have to ask yourself, Foster says, what is the alternative they are trying to avoid? And how might the life of a turnaway look if she’d had the abortion she sought? “You would need to look at the people who managed to get the abortion and find whether a woman who started out similarly is now in school, building a stable relationship, career or, possibly, that later she had a baby she was ready for.”

Talking with Foster, I was reminded of a woman I met at a “last resort” clinic in New Mexico. J., as I will call her, lived in Kansas with her partner and teenage son. She was 38, one of the long-term unemployed, and struggling to support the child she had. She thought she was too old to become pregnant. When she missed her period, she and her partner drove to a nearby abortion clinic, in Oklahoma, knowing that they couldn’t afford another baby. The clinic estimated that J. was five weeks pregnant, but when they tried to perform an abortion, the procedure was not successful.

Two weeks later, J. and her partner went to a more specialized clinic in Tulsa and were told that J. was actually 23 weeks pregnant, past the clinic’s gestational limit. J. cried in the parking lot. She and her partner drove to Texas, where she missed the gestational limit again. Finally, in New Mexico, J. was able to terminate her pregnancy. A month later J. got a job operating heavy machinery at a manufacturing plant for $15 an hour. She had been applying for the past six months. If she had had the baby, she said, she wouldn’t have been able to take the job. “They wouldn’t have even looked at me.”

Given some of the negative outcomes for turnaways, Foster’s study raises an uncomfortable question: Is abortion a social good? Steven D. Levitt, a University of Chicago economist and co-author of the book “Freakonomics,” famously argued that the passage of Roe v. Wade led directly to a sharp drop in crime during the early ’90s: women who were able to plan their families gave birth to better-adjusted children. The study was widely criticized, but the extent to which it was discussed shows the intensity of the desire to understand abortion’s effect on society. “It’s offensive,” Foster said of the Levitt study. “Let people have abortions or they will breed criminals?” If there is a social good to abortion, Foster prefers to frame that good in terms of positive alternatives. “Maybe women know what is in their own and their family’s best interest,” she said. “They may be making a choice that they believe is better for their physical and mental health and material well-being. And they may be making a decision that they believe is better for their kids — the kids they already have and/or the kids they would like to have when the time is right.”

S.’s baby turned 1 on May 13. She still qualifies for W.I.C. benefits and is still living with her sibling and parents, working two days a week. Of her living arrangement, S. says: “We have had family talks and pretty much come to the conclusion that we are trying to move by the end of the year. But we haven’t really found a place to go.” What will happen when she leaves her sister’s house and she has to support herself and her baby? And what about Baby S.? Will Henry David be right that being “born unwanted” is a predictor of poor development?

There is a chance, of course, that S. and her baby will thrive. How Foster’s turnaway subjects will be affected long-term is still unclear. In assessing how women like S. and J. fare over time, Foster plans to look at several variables: mother-child bonding; whether women who carry unwanted pregnancies to term face lasting economic difficulties; how the children of turnaways compare with children who are born later to women who once had abortions. The purpose of Foster’s study is not to set policy by suggesting new or uniform gestational limits. She notes, however, that there are ways to reduce the number of women seeking abortion at an advanced gestational age by improving access to reproductive health care. But Foster sees herself as a scientist, not an advocate. She did not set out, she says, to disprove that abortion is harmful. “If abortion hurts women,” she says, “I definitely want to know.”

Joshua Lang is a student in the U.C. Berkeley-U.C.S.F. Joint Medical Program.

Editor: Sheila Glaser

A version of this article appeared in print on June 16, 2013, on page MM42 of the Sunday Magazine with the headline: Unintentional Motherhood.