MONOLOGUE 33

Why don't we know more about the long-term effects of abortion?

By Annalee Newitz

Though abortion is one of the most contested medical practices in U.S. history, we know shockingly little about how this simple outpatient procedure affects women. There are almost no scientific studies on what happens to women who receive abortions, and even fewer on what happens to women who are unable to get them. The American government regulates access to abortion, but ironically doesn't fund studies on the procedure through the National Institutes of Health (NIH) or the Centers for Disease Control (CDC). That means that most abortion policies in the U.S. are not based on scientific evidence from medical studies.

To find out why, we talked to the University of California at San Francisco'sTracy Weitz, who for the past decade has run a program at UCSF called Advancing New Standards in Reproductive Health (ANSIRH). The group, funded entirely by private donors, has done some of the only comprehensive studies in the U.S. about abortion in the medical system. Weitz told us what she and her colleagues have found.

ANSIRH was founded at the medical school in 2002 for scientists and doctors who wanted to research abortion and other reproductive health issues. They publish all their results specifically to help policy makers base regulations on rigorous, scientific studies.

The worst study ever done on abortion

In several states, including Kansas, Michigan, Nebraska, North Carolina, South Dakota, Texas, Utah and West Virginia, "informed consent" laws require health care providers to tell women seeking an abortion that the procedure can lead to mental illness. These laws are based in part on a 2009study by psychology researcher Priscilla Coleman, who found a higher incidence of depression and other psychological disorders among women who had abortions.

Since that time, many scientists — including Weitz herself — have published papers showing how Coleman's research methods were flawed. She made the basic "correlation does not equal causation" error, said Weitz. "You may have higher rates of depression in the population of women who choose abortion, but that's part of why they choose abortion. You can't make a causality argument, but that's what these studies try to do."

To combat poorly-designed studies like Coleman's, ANSIRH has just completed a five-year study on the long-term health effects of abortion on women. They're currently analyzing their data, and will have results to report later this year.

The questions that science can't ask

There are no studies on what happens to women's health when they want abortions but are denied them. Weitz says that's partly because gathering that data would be almost impossible. Women can be denied abortions in multiple ways. "It could be health care providers denying it to them," she said, or it could be that they go to an abortion clinic but their pregnancies are so far along that the clinic says it can't handle the procedure.

"The only way to do it would be to track a general population and ask them what their experience was when they sought abortions," she mused. But even that would be difficult, because often women aren't willing to admit they wanted abortions. Besides, Weitz added, women's perspectives on unwanted pregnancies change once they've actually had their children. "It was unintended, they didn't want it, but then the child is there and they love their children." It would be hard to ask women in that position about having an unwanted child, since they have ultimately come to want it.

"Another question we're interested in is how many women don't even contemplate an abortion because the social stigma is so great in their communities," Weitz said. "If they lived in a different world, would they have had an abortion?" Again, this is a question that's almost impossible to answer.

But there is one data set that gives us hard numbers on how much social environment affects whether women will get an abortion.

How many unwanted babies are born when abortion is taken away?

In North Carolina, researchers can track very precisely what happens to women when access to abortion is taken away. That state separates medicaid funds for abortion into its own special fund, and the fund has been cut off at various points over the years. So researchers can pore over data that shows how many abortions women get when money is available for them, vs. when it isn't. For many women, coming up with $500 to get an abortion in time (ideally, the first 3 months of pregnancy) is impossible. So lack of funding means lack of access, period.

In a scientific analysis of the data, researchers found that "3 out of 10 pregnancies that would have been terminated were carried to term among low income black women" who were the main recipients of the medicare funds. Those are fairly extraordinary numbers. They suggest that 3 out of 10 women who were already struggling financially would be saddled with the additional expense of rearing children.

While we don't have data on what happens to women who are denied abortion, we do have a great deal of data on what happens to people in the long term when they struggle financially. Their health suffers tremendously, and they are prone to depression.

How should abortion fit into health care?

Questions around how abortion should be funded are part of a larger issue: How does abortion fit into the medical system? This sounds like an odd question, but it's what doctors have to ask about most procedures that are more complicated than taking your blood pressure. Is abortion such a difficult medical undertaking that it needs to be done by a specialist at an abortion clinic, for example? Currently, most states say yes. In California, for example, only doctors are allowed to perform abortions and most often they're done at specialized clinics.

Placing all these limitations on who can do abortions and where means that women often don't have access to abortions in time. As Weitz put it, every week that a woman waits to get an abortion — whether because she needs a doctor's appointment, is raising $500, or has to travel to a far-away clinic — makes the operation more difficult.

But what if women could get safe abortions in their doctor's offices, from nurse practitioners? This would certainly help women get abortions in time far more often. ANSIRH did a 4-year study in California asking this very question. They gathered data on the feasibility of training physicians, nurse practitioners, even midwives to perform abortions. As a medical procedure, Weitz explained, abortions are relatively simple — from a purely medical standpoint, a first term abortion is roughly equivalent to having your wisdom teeth pulled. ANSIRH's researchers found that a variety of healthcare providers could be trained relatively quickly to provide abortions, and that this would be a very cost-effective way to provide safer abortions to a greater number of women. Currently, their research is being used by policy makers in California who are contemplating a law that would allow a greater range of clinicians to give abortions.

What should scientists really be researching if they want to understand how abortion affects women?

Weitz has spent much of her career researching questions that most scientists and funding organizations won't touch. But there is a lot more she'd like to know.

"I think the real question of interest is what social and economic resources do women need to make the child bearing decisions they want," she said. She continued:

Some women don't want to be pregnant because it's not the right time in their lives, and that's a very affirmative decision. Then there are women [at abortion clinics] because they don't have enough money, they don't have a place to live. Those women are not making an affirmative choice — they're making a survival choice. [In the context of social justice] we need to be asking more than, "Did they get the abortion?" but "What kinds of policies could be in place to help women make the decision they truly want?" We've forgotten to think about that group of women because this is so politicized. But what would allow women to make a genuine choice, to have the families they want and to parent their kids in healthy communities? In a rational society, that's what we'd be asking.

Weitz gets to the heart of what "choice" really means for women. In our current political climate, pundits lump "choice" in with "abortion." But understood rationally, as Weitz would have it, choice means setting up a social system where women never have to terminate pregnancies for survival reasons. They shouldn't fear living on the streets, without resources, just because they want children.

One of the greatest investments women make, both financially and emotionally, is in their kids. But we live in a nation that provides almost no assistance to low-income women who want to be mothers. As long as this is the case, women will never truly be making a free choice about whether to give birth.