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.
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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.
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