States across the country are tightening regulations on abortion providers in the name of protecting women's health. But a long-term study of women who sought abortions has found that those who ended their pregnancies reported slightly better health than their counterparts who requested the procedure but were denied.
The findings, reported Monday in the Annals of Internal Medicine, suggests that a woman's access to abortion may influence her health over time—providing new fodder for the highly charged debate.
"Having an abortion is not necessarily dangerous or harmful to women, but being denied one may be," said study leader Lauren Ralph, an epidemiologist at the University of California, San Francisco. "The argument that abortion is harmful to women, or that restricting access is somehow necessary to protect women's health, is not supported by our data."
An editorial that accompanied the study reminds doctors that for women, "birth always carries more risks" of illness and death compared with abortion. "The availability of safe, legal abortion is an issue for all health care providers."
The new report is part of the Turnaway Study, an initiative to explore whether there are differences in the health and well-being of women who receive an abortion in the first or second trimester and women who were denied an abortion and carried their pregnancy to term.
Researchers from UCSF's Bixby Center for Global Reproductive Health enrolled 1,132 women who sought abortions at one of 30 facilities in the United States between 2008 and 2010. Most of them completed a baseline interview about a week after visiting a clinic, and the study team checked in with them periodically over five years to ask about an array of health conditions, including asthma, high blood pressure, joint pain and diabetes.
At the end of the study, there were no indications that women who had abortions were in worse health than woman who gave birth. And when differences emerged, they favored the women who ended their pregnancies.
For instance, among women who had a first-trimester abortion, the odds of rating their own health as "fair" or "poor" declined over the course of the study. The opposite was true for women who were denied an abortion.
In their final interview, 20% of women who had a first-trimester abortion rated their health as "fair" or "poor," as did 21% of women who had a second-trimester abortion. Among women who were denied an abortion, 27% said their health was "fair" or "poor," according to the study.
Compared with a woman who had a first-trimester abortion, a woman who carried her unwanted pregnancy to term was 29% more likely to suffer chronic headaches or migraines. And compared with a woman who had a second-trimester abortion, a woman who gave birth was 45% more likely to report an increase in chronic joint pain over the course of the study.
There were no differences for chronic pain in the back, abdomen or anywhere else, nor were there differences in obesity.
"Whether the adverse outcomes observed among women who gave birth are due to term pregnancy, the birthing process itself, or parenting, the point is that reproductive life events and overall health are entwined long after delivery," Dr. Lisa S. Harris and Dr. Vanessa Dalton, both of the University of Michigan's Department of Obstetrics and Gynecology, wrote in the editorial.
Abortion opponents maintain that advocates of legalized abortion routinely downplay or deny the health risks of the procedure. A report by the Center for Arizona Policy details a litany of problems that have been reported in the medical literature, including increased risks of suicide, breast cancer, drug abuse and future miscarriages.
"This simple truth remains: Abortion harms women," the report states.
In contrast, a 2018 report from the National Academies of Sciences, Engineering and Medicine concluded that "legal abortions in the United States ... are safe and effective," and that studies that meet high standards for "rigor and lack of bias" have not shown an increased risk of physical or mental health problems.
The Supreme Court's 1973 decision in Roe vs. Wade allows states to place restrictions on abortions performed after the end of the first trimester and up through the point of fetal viability only if doing so would protect a pregnant woman's health. That principle was upheld in the 2016 decision in Whole Woman's Health vs. Hellerstedt.
Yet 24 states have tried to impose new rules on abortion providers, arguing that the strictures are needed for patient safety, according to the Guttmacher Institute. (Regulations in six of those states have been invalidated in court.)
In 2019 alone, Alabama, Georgia, Kentucky, Mississippi, Missouri and Ohio outlawed abortion during part of the first trimester. If more states follow suit, the number of women denied abortions because their pregnancies are too far along is expected to increase dramatically.
The Turnaway Study has tallied the costs of such restrictions, which already result in an estimated 4,000 women being denied wanted abortions each year.
In 2016, researchers reported that compared with women who got an abortion, those who were forced to complete their pregnancies were more likely to suffer depression or anxiety disorders five years later.
And a 2018 study found that after a woman who already had young children sought but was denied an abortion, those children were slightly more likely to miss developmental milestones.
The latest study includes one particularly bleak statistic. Two of the 161 women who were denied an abortion died of causes linked to pregnancy or childbirth. None of the women who received abortions died of pregnancy or childbirth-related causes over the following five years.
Rates of maternal death have been rising in the U.S., and it is now close to one death per 1,000 cases of childbirth, or 0.1%. That's the highest rate in the industrialized world, and it's even higher among women in the study who were denied a wanted abortion—1.2%.
It's "just a very surprising thing," Ralph said.
She acknowledged that the small size of the sample, and some uncertainty about the exact circumstances of these deaths, make the finding preliminary.
Even beyond the postpartum period, death from any cause was more common in the overall sample of abortion-seeking women than it is for American women generally. Eight of the 1,132 women who enrolled in the Turnaway Study—or 0.7% - died in the following five years. Nationally, the mortality rate for women of reproductive age is 0.0005%.
University of Rochester nursing professor Susan Groth, who also studies the long-term effect of pregnancy, noted that the women in the Turnaway Study may not be representative of U.S. women as a whole, and that they may face greater health risks for some unknown reason.
Still, she said the study's findings underscore a longstanding suspicion among many researchers: that "pregnancy is considered a 'stress test for life.'" It can reveal—and even exacerbate—a woman's health vulnerabilities that may increase her risk of future illness or early death.
If these suspicions are correct, she said, a woman who carries an unwanted pregnancy to term may suffer enduring damage that would have been avoided if she had been allowed an abortion.
When future researchers consider the "cost to reproduction" borne by women, that's something they should keep in mind, Groth said.
Journal information: Annals of Internal Medicine
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