What the Supreme Court overturning Roe v. Wade could mean for women’s health
The overturn of Roe v. Wade, possibly presaged this week in the leak of a draft Supreme Court opinion, would be a development of enormous political and social consequence. Most fundamentally, however, such a ruling could almost immediately trigger tectonic change in the health and well-being of birthing people and children across the country.
We know this due to important research published in 2020 that compared the fates of women who were forced to carry pregnancies to term versus those who were provided abortions. The influential Turnaway Study, as it’s commonly referred to, found that, among other things, women who were denied an abortion endured more serious pregnancy complications, more chronic pain, and more short-term anxiety.
The Supreme Court’s decision is not final: Opinions go through many drafts, and, in theory, some of the justices could still change their minds before handing down their final decision in Dobbs v. Jackson Women’s Health Organization.
Yet if the court were to issue a ruling along the lines of what Justice Samuel Alito has drafted — as published this week by Politico — more than 20 states are expected to immediately ban abortion in most cases, with half of those having “trigger laws” already on their books (meaning abortion bans that would take effect almost immediately if Roe were overturned). In an instant, a common medical service that has been constitutionally protected for nearly half a century would be outlawed in almost half the country.
The precise effect of such a sweeping loss in abortion access is impossible to know from our vantage point in time. In many of these states, abortion access has already dwindled over the years as state legislators passed onerous restrictions aimed at forcing clinics to shut down — half-measures they could take until a conservative majority on the nation’s high court, as there is currently, could overturn Roe outright.
Many pregnant people rely on mail-order pills for abortions, and President Joe Biden’s administration has pledged to safeguard access for them (though anti-abortion states are already attempting to restrict access to those drugs). Some seeking an abortion may also travel to another state where abortion is still legal, though, because of the cost, it would likely be more privileged people who are able to take advantage of that option. Still, both options could help limit the consequences of a decision overturning Roe.
Nevertheless, it’s inevitable that more unwanted pregnancies would be carried to term if the court were to negate a federal right to abortion. Diana Greene Foster, a professor at the University of California San Francisco and the lead researcher on the Turnaway Study, which analyzed how women who received an abortion and women who were denied one were affected by that important juncture in their life, roughly estimates that between one-quarter and one-third of women with an unwanted pregnancy will bring the pregnancy to term if Roe is overturned.
Foster and her colleagues have given us a strong idea of the health, social, and economic consequences of outright abortion bans. The Turnaway Study began in 2007 and followed more than 1,000 women for five years to assess how their lives had been altered, if at all, by the provision or the denial of an abortion. Some of the women had an abortion shortly before reaching the gestational limit set by their state or provider, while others had just passed that limit and were denied an abortion as a result. The differences in the women’s experiences from that critical moment onward were the purview of the study.
“We find no evidence abortion hurts women,” Foster writes in the 2020 book The Turnaway Study that covered the research’s findings. “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.”
The mental health of women who received an abortion was better immediately after the procedure than that of women who were denied one. Their physical health fared better over the longer term. Their subsequent children developed better.
Foster presents a nuanced picture, noting, for example, that after the five-year period of the study almost none of the women who ended up carrying an unwanted pregnancy to term said that they still wished they’d had an abortion. But Foster is nevertheless unequivocal in her conclusions about what being denied an abortion meant for the women involved: “We find many ways in which women were hurt by carrying an unwanted pregnancy to term.”
The most unexpected and tragic outcome noted in the Turnaway Study was that two of the women died because of childbirth complications. It came as a shock to Foster, who wrote that she “did not expect to find even one maternal death in a study of 1,000 women.” The US maternal mortality rate is 1.7 per 10,000, meaning the odds of two women in 1,000 dying were exceedingly low.
Foster was careful not to be definitive about this finding, writing that a much larger sample size would be necessary to draw any firm conclusions about the relationship between being denied an abortion and maternal mortality. The implications remain grim, however: “This level of maternal mortality is shocking,” she wrote.
Short of death, women who are denied an abortion are more likely to have serious complications than women who received an abortion. The Turnaway Study found that 6.3 percent of the women who had given birth suffered life-threatening complications versus about 1 percent of women who had an abortion.
Women who were denied an abortion also saw a higher risk of gestational hypertension, which increases their risk for cardiovascular disease later in life. The study found that 9.4 percent of women who gave birth experienced hypertension during the pregnancy versus 4.2 percent of women who had second-trimester abortions and 1.9 percent of those who had first-trimester abortions.
The women who gave birth also experienced slightly higher rates of chronic head pain and joint pain afterward. On self-reported health, a metric shown to be a strong indicator of future health and mortality, 27 percent of women who carried their pregnancies to term after being denied an abortion said they were in fair or poor health versus 21 percent of women who had second-trimester abortions and 20 percent of women who had an abortion in the first trimester.
“To the extent that there were differences in health outcomes,” Foster wrote, “they were all to the detriment of women who gave birth.”
Foster writes with some derision about the patronizing attitudes of anti-abortion legislators who have warned of dire mental health consequences, depression and even suicide, for women who receive abortions.
Her study discovered a very different reality: “We found no mental health harm from having an abortion.”
In fact, she elaborates elsewhere, “The most common emotional response to having had an abortion is none.” Two-thirds of the women in the study who had an abortion said they had no or very few emotions after five years; 95 percent of the women said the decision was the right one for them, a share that increased gradually over the five years. Only 14 percent of the women said they still felt sadness after five years, and only 17 percent said they felt guilt.
The women who reported difficulty deciding about an abortion before ultimately getting one were the ones that had more negative emotions, as did women who live in communities that look down on abortion and women with less social support.
Instead, the main mental health effect the Turnaway Study measured was that women who were denied an abortion experienced higher rates of anxiety and lower self-esteem in the initial weeks and months after being turned away. On those metrics, they began catching up to the women who received an abortion by six months, and by a year, the differences between the two groups of women had evaporated.
Like those who had abortions, the women who were denied them came to be content with their situation, Foster noted. The share who said they still wished they had gotten the abortion dropped from 65 percent one week after being denied an abortion to 7 percent by their child’s first birthday.
Ultimately, the study detected no long-term differences between the two groups in the rates of depression, PTSD, self-esteem, life satisfaction, drug abuse, or sexual abuse.
The effect of denial of abortion access extended beyond the women involved to their children, both those they already had and those who were born out of an unwanted pregnancy.
Most of the women seeking abortions in the Turnaway Study were already mothers, as is often the case nationally. Being turned away for the procedure led to the women’s existing children living in circumstances more precarious for their financial and physical well-being. They were more likely to live in poverty at some point over the next five years (72 percent versus 55 percent of the children of women who received their desired abortion) and more likely to live with adults who had trouble paying for food and housing (86 percent versus 70 percent).
The ripple effects were also felt in the relationships between women who were denied abortions and the children born out of that unwanted pregnancy. Those women were much more likely to answer survey questions in a way that signaled a failure to emotionally bond with their new baby than the women who received an abortion and went on to have another baby later in their lives.
“Scientific literature on child development shows an association between poor parent-child attachment and children’s long-term psychological and developmental outcomes,” Foster wrote.
The findings of the Turnaway Study add to that body of research. Children whose mothers were denied an abortion were less likely to accomplish fine motor, gross motor, receptive language, expressive language, self-help, and social-emotional developmental milestones on time than the children of women who did receive an abortion. It was a small but noteworthy difference: 73 percent versus 77 percent.
Foster ended her book contemplating the Turnaway Study’s findings and the possibility of a world in which Roe v. Wade was overturned, which seemed plausible in the summer of 2020 after Donald Trump named two highly conservative justices to the Supreme Court. Across the inquiries that made up her and her colleagues’ landmark project, they found a profound impact when abortions are denied. Those aftershocks touched every part of a person’s life.
If the Supreme Court hands down the ruling signaled in Alito’s draft, many more women across the United States will have to live with those consequences.
“For those women,” Foster wrote in what may prove to be the twilight of Roe v. Wade, “all the burdens outlined in this book — worse physical health, reduced life aspirations, higher exposure to domestic violence, increased poverty, a lowered chance of having a wanted pregnancy, worse outcomes for their other children — will result.”