The obstetrics and mental health care fields have significant crossover. Women with unintended, undesired, or medically complex pregnancies are at greater risk of adverse mental health outcomes, which have the capacity to create long-lasting and intergenerational ripple effects within their larger family unit. Given the frequency with which women seek pregnancy terminations, the numerous factors that influence care accessibility, and the serious repercussions that stem from insufficient use of evidence-based care surrounding pregnancy termination, women are at risk of experiencing a range of mental health outcomes based on their experiences around pregnancy termination.
Key points
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Abortion is essential health care.
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The denial of abortion care is associated with heightened anxiety symptoms, lower self-esteem, and financial burdens when compared to those who received an abortion.
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Abortion stigma increases the risk for adverse psychological outcomes including post-traumatic stress disorder.
Introduction
This article seeks to lay the foundation for pregnancy termination within the field of obstetrics—it (1) lays forth the legal precedents that have influenced abortion care access and presents abortion care access as a political determinant of health; (2) highlights the fields’ current knowledge on the relation between abortion and women’s mental health; and (3) proposes evidence-based strategies for engaging with obstetrics patients throughout the pregnancy termination process. The goal of this work is to provide a foundation for clinicians to better understand the complexities of women’s abortion care needs and how they intersect with patients’ mental health; it aims to extend the goal of abortion care to not only protect women’s autonomy, but to position clinicians as advocates for women’s mental health and health care satisfaction. To begin, vignettes are presented to highlight the clinical complexity of pregnancy termination, the decision-making process, the intertwinement of women’s mental health, and the diversity with which patients approach this health care need.
Samantha is a 22-year-old G1P0 who has just learned of her pregnancy. She is in a relationship with a partner, however, she has not yet told him of the pregnancy. She starts graduate school in 2 months and does not wish to be pregnant at this time. On ultrasound, the fetus measures 8 weeks. The state in which she resides does not allow abortion after 6 weeks gestation. She is currently on financial aid and does not have the means to travel for an abortion. She has significant stress related to how she will find the finances and transportation to travel for an abortion.
Elizabeth is a 34-year-old G2P1001 who is currently 13 weeks pregnant. During her first trimester ultrasound, she is diagnosed with fetal anencephaly. She has suffered 3 years of infertility and was so excited to finally become pregnant. She has a history of anxiety and depression and knows that, despite her strong desire for this pregnancy, she cannot mentally continue this pregnancy and desires an abortion. She schedules an appointment with her obstetrician to discuss her options.
Natasha is a 26-year-old G0 who was raped by an acquaintance 5 weeks ago. She took a home pregnancy test today that resulted positive. She “does not believe in abortion” but cannott imagine being pregnant with a baby that was the result of rape and with someone who is not a life partner. She desires to proceed with abortion.
Discussion
Legal Precedents for Abortion Care Access
In 1973, the US Supreme Court codified the right to abortion under the constitutional protection of privacy in Roe v Wade. In response to growing state-level abortion restrictions, the court ruled in Planned Parenthood v. Casey that states could not enact legislation that would place an “undue burden” on the fundamental privacy related right to abortion. In June 2022, the Supreme Court of the United States issued a landmark decision in Dobbs v. Jackson Women’s Health Organization, which held that the Constitution of the United States does not confer a right to abortion. The court’s decision overruled both Roe v. Wade (1973) and Planned Parenthood v. Casey (1992), returning regulatory and legislative power to individual states regarding women’s access to abortion care.
Many professional organizations spoke out against the decision, highlighting the Dobbs decision’s potential for adverse effects on US women and families. The American Psychiatric Association stated, “By dismantling nearly 50 years of legal precedent, the Court has jeopardized the physical and mental health of millions of American women and undermined the privacy of the physician-patient relationship… today’s ruling will put many pregnant women and their families into life-threatening and/or traumatic situations.” The American College of Obstetricians and Gynecologists stated, “Abortion is a safe, essential part of comprehensive health care, and just like any other safe and effective medical intervention, it must be available equitably to people, no matter their race, socioeconomic status, or where they reside.”
As anticipated, “trigger laws” (abortion restrictions meant to be enacted if Roe was to be overturned) rapidly went into effect, with almost half of US states severely restricting abortion access, specifically based on gestational age. More anti-abortion legislation continued to go into effect. Numerous states have enacted severe restrictions of abortion, either through bans on access or through highly restrictive policies that make care challenging to access. Another way that such access is denied in some States is by criminalizing abortion care and thus putting the licenses and livelihoods of clinicians in legal jeopardy. Currently, 26 states have banned or severely restricted accessibility. Now, nearly 30% of reproductive-aged women live in states that have substantially reduced their capacity to access abortion care. Such bans have a profound and disproportionate impact on women’s physical and mental health, making access to safe, necessary, and time sensitive medical care challenging and burdensome.
Post-Dobbs Abortion Care Access: A Political Determinant of Health
In the case of the Dobbs decision, restrictive reproductive health policies function as a political determinant of health by disproportionately impacting patients who identify as non-White, who are confronted with socioeconomic struggles, and who reside in geographic regions with health care clinician shortages (herein referred to as “marginalized communities”). Political determinants of health are the policies and programs that systematically create unjust and inequitable health experiences by establishing and sustaining positions of social power and resources in such a way that benefits dominant groups while harming persons from more marginalized communities. Within perinatal health systems, such determinants of health create avoidable and inequitable differences among patients based on their social positioning, including inequitable access to high-quality obstetric care, higher rates of perinatal morbidity and mortality, and systematic differences in long-term familial wellbeing.
Since the time of the Dobbs decision, health clinicians and researchers have expressed serious concern that health and social consequences will be felt most deeply by patients from marginalized communities who were already experiencing poorer access to quality prenatal care and contraceptive care. , , Indeed, science suggests that women who confront increased barriers to desired abortion care are also significantly more likely to experience stress, anxiety, and depression and when the pregnancy continues, this can also result in adverse pregnancy outcomes such as preterm births. Women who experience stigma during their pursuit of abortion care additionally indicated adverse mental health outcomes. Critically, among states with greater restrictions on abortion access, many represent larger populations of patients of color, low-income patients, and communities with health care provider shortages. This creates stark inequities in the types of perinatal patients who can access evidence-based, life-saving obstetric care.
Thus, political determinants of health create a health care system in which marginalized communities of women are positioned within communities in a manner that prohibits ease of access to high-quality, evidence-based health care. Nearly 30% of women who obtain abortions identify as Black, 25% identify as Latinx, and 39% identify as White. Seventy five percent (75%) live at or below the poverty level. Nearly 60% are already parenting other children. In this light, not only is access to abortion care a political determinant of mental health, but it is also a political determinant of perinatal health equity, given that such restrictions are associated with disproportionate harm to perinatal patients from marginalized communities who already experience poorer outcomes due to systemic racism, discriminatory practices, and economic injustice. Women without sufficient resources have much fewer care options and may be forced to either sustain an unwanted pregnancy, or pursue abortion strategies that place them at increased risk of physical harm and legal ramifications.
Abortion and Women’s Mental Health
Psychological effects of pregnancy termination have been debated for decades. However, many studies that have informed the abortion and mental health controversy are now recognized as poor quality. Much of what we now know about abortion and mental health is informed by work conducted within the Turnaway Study. The Turnaway Study is the largest and longest study of the psychosocial effects of abortion versus childbirth. From 2008 to 2010, a research group from University of California San Francisco (UCSF) recruited 1000 women who sought abortions from 30 abortion facilities around the country. Some patients received abortions because they presented for care within the gestational limit of the clinic, but some were “turned away,” and then had to continue the pregnancy to term because they had presented past the gestational limit. The research team interviewed participants by phone over 5 years, ending in January 2016. The interviews covered various topics including physical and mental health, employment, educational attainment, relationship status, contraceptive use, and emotions about pregnancy and abortion. Participants were interviewed every 6 months about these topics. Over the course of the project, the researchers conducted nearly 8000 interviews.
The Turnaway study showed that having an abortion (chosen by the patient), does not harm a patient’s mental health. Rather, the denial of desired abortion care is associated with heightened anxiety symptoms and lower self-esteem and life satisfaction and financial burdens when compared to those who received an abortion. Women who have a prior history of a mental health condition or have experienced trauma are at greater risk of experiencing negative mental health outcomes when denied a wanted abortion. ,
There is other evidence that suggests poor psychological outcomes after termination of pregnancy, but these studies are low quality and most have been discredited. Specifically, some studies compare women with unplanned pregnancies to women planning ongoing pregnancies. Experiencing an unplanned/unwanted pregnancy may involve emotional distress due to strained relationships, financial difficulties, or other life stressors. Studies suggesting that abortion is associated with poor psychological outcomes did not analyze the effect of these confounders and how they may contribute to psychological distress. Reviews of such studies show that mental health outcomes following an unwanted pregnancy are similar regardless of whether the woman continues with the pregnancy and gives birth or terminates the pregnancy. The occurrence of the unwanted pregnancy itself is the risk factor that can lead to poor physical and psychological outcomes, not the outcome of the pregnancy.
As part of the Turnaway Study, 3 groups of women were screened for post-traumatic stress disorder (PTSD) at 8 days after their visit to an abortion clinic and then every 6 months over 4 years. The 3 groups included women who (1) received a first-trimester abortion, (2) received an abortion near the facility’s gestational limit and therefore later in pregnancy, and (3) were denied an abortion and gave birth because they presented after the facility’s gestational limit. The researchers controlled for potential confounding factors (including age, marital status, and history of child abuse, sexual assault, and/or psychiatric disorders), and the analyses found that the baseline risk of PTSD was comparable for the 3 groups. Therefore, no matter the outcome of the unplanned, unwanted pregnancy—namely whether or not patients underwent abortions—the prevalence of PTSD did not differ. Critically, while the topic of abortion care is hotly debated across the United States, including concern for psychological wellbeing of women who undergo abortions, present research has found that among women who received abortions, relief remained the most predominant emotion, even 5 years post abortion.
Access to Abortion and Traumatic Stress
The Turnaway study estimates that more than 4000 women are denied wanted abortions due to facilities’ gestational limits every year. This study was performed before the Dobbs decision. As more states pass gestational age-based restrictive legislation in a post-Dobbs landscape, many more will undoubtedly be affected. The Dobbs decision has resulted in lack of access to abortion care for millions of pregnant people, and this will have profound physical and mental health consequences, the full effects of which may not be realized for years to come. For example, there is the possibility of additional stress and trauma related to female autonomy, patient safety, and pregnancy termination. The psychological sequelae of carrying a forced pregnancy to term will lead to an even greater burden of maternal mental illness, exacerbating the already existing maternal mental health crisis. The already existing impacts of social determinants of health for marginalized and underserved communities will be further compounded by the medical, financial, and psycho-social burdens of the unwanted and/or unplanned pregnancies.
The effects of diminished bodily autonomy and restricted access to other supports and resources create a heightened risk for maternal stress, which is well known to be a contributing factor to adverse pregnancy outcomes such as preterm delivery. Research indicates that women denied an abortion had almost 4 times greater odds of a household income below the federal poverty level and 3 times greater odds of being unemployed. There was an increased likelihood that women did not have financial resources to cover basic family necessities like food, housing, and transportation, if they were denied an abortion. Women unable to terminate unwanted or unplanned pregnancies were more likely to be forced to stay in contact with violent partners; thus, putting them and their families at greater risk for physical and mental traumas than if they received the abortion. Additionally, continuing an unwanted pregnancy and giving birth is associated with more serious health problems than abortion. This situation may also adversely affect a person’s decision regarding a planned/wanted pregnancy at a later more appropriate time for themself. All of these factors increase the risk of adverse psychological outcomes including acute stress disorder (ASD) and post-traumatic stress (PTS)/PTSD.
As stated earlier, the adverse maternal mental health effects of abortion restrictions may be particularly acute among communities that have historically been marginalized, oppressed, or harmed within health care systems. Black and indigenous women, for example, bear the wounds of intergenerational and historical trauma at the hands of the obstetric care system, such as lack of reproductive bodily autonomy, inhumane treatment, and non-consensual use as research and clinical subjects. Further, Black and indigenous women also experience the brunt of poor perinatal health outcomes; they experience higher rates of adverse antenatal health, infant health outcomes, and pregnancy-related mortality. In some communities, carrying a pregnancy to term is statistically more dangerous to a woman’s health than is an abortion. For example, in her testimony to the House Judiciary Committee, Professor Michelle Goodwin cited that a Black woman in the state of Mississippi is “118 times more likely to die by carrying a pregnancy to term than by having an abortion.” Such inequities are not exclusively the result of race-based discrimination, however. Critically, perinatal health inequities are intersectional in nature and frequently occur at the intersection of race, income, and geography, as well as other categories of social power, creating a spectrum of health and disease by way of access to timely and high-quality health care. Studies show that Black women are less likely to have access to high-quality health care facilities due to geographic location of health providers, barriers to transportation, affordability, and childcare, as well as a well-deserved mistrust of the medical system. Limited access to abortion care, as a result, functions as, yet another, barrier to fundamental reproductive health care and can negatively impact harmful patterns in women’s wellbeing.
A well-known and unintended consequence of the existing abortion restriction environment is loss of privacy in that travel to another state for abortion care will result in the person having to communicate their plans to various other persons and communities including family and workplace. This can result in loss of self-esteem, shame, and can aggravate the already existing stresses associated with the decision. If a complication occurs after the person has had an abortion in another state, there will be additional mental health burdens regarding decisions about seeking further treatment, or not.
Supporting Mothers Throughout the Decision-Making Process Content
Not only does the Dobbs decision impact women’s abortion care accessibility, but it also impacts women’s ability to receive ongoing support and evidence-based information on abortion care itself, further exacerbating their perceived stigma, lack of knowledge, and risk for psychological distress in the decision-making process. Abortion stigma is associated with higher odds of experiencing psychological distress years later. , As more abortion restrictions occur, more abortion stigma will follow, which will put people at risk for adverse psychological outcomes including PTSD. Thus, it is important to consider strategies for patient support throughout the decision-making process to decrease one’s risk of emotional trauma related to pregnancy complications and unwanted pregnancies, given that the likelihood of abortion-related trauma increases as the availability of resources continues to diminish.
Physicians can implement a trauma-informed approach to care for patients with medically complex or unwanted pregnancies, by implementing several key strategies. Key trauma-informed strategies involve the promotion of (1) Patient Safety; (2) Trustworthiness and Transparency; (3) Peer Support; (4) Ongoing Collaboration; (5) Empowerment and Resiliency; and (6) Cultural Humility. , Promoting ongoing physical and psychological safety throughout the care process is paramount. This includes ensuring access to evidence-based, timely, and sensitive care procedures and educational information. At each stage of the decision-making process, clinicians should aim to foster an ongoing collaboration with patients, such that patients can feel safe discussing a full range of care options. Clinician transparency and enhanced patient screening techniques may help to identify patients who would benefit from pre-abortion and post-abortion counseling, as well as patients who are being pressured to make an abortion-related decision that does not align with their own preferences. Further, to promote patients’ empowerment and autonomy, they should be provided with sufficient information and health education to make informed decisions about their conditions and care. Patients’ pre-existing support networks, health literacy, and available community resources are all strengths that can be drawn upon for support. These supports vary by patient, however, it is important for clinicians to discuss a range of support options that patients can effectively draw on, if they so choose. Each patient’s unique lived experiences, cultural background, and community network will influence the ways in which women prefer to navigate the decision-making process related to abortion care.
Facilitating Mental Health Integration into the Abortion-Care Discussion
It is critically imperative that clinicians assess and evaluate the mental well-being of patients who access and/or who are denied abortion care so that appropriate resources can be offered in a timely fashion to those requiring intervention for psychiatric symptoms because the best predictor of a person’s mental health after an abortion is their mental health prior to the intervention. Screening for risk factors after an abortion will aid in ensuring appropriate and timely mental health support for this who might require such interventions ( Box 1 ). Within the context of abortion care and mental health, 2 primary diagnoses may occur as result of abortion-related trauma: Acute Stress Disorder (ASD) and PTSD.
