What Really Happens to Women Who are Not Denied Abortions? Best Not to Ask NY Times Journalist Joshua Lang

On June 12^th the New York Times published an article by graduate student Joshua Lang titled “What Happens to Women Who Are Denied Abortions?” Mr. Lang is currently enrolled in UC Berkley’s Joint Medical Program, a 5 year Master of Science/Medical Doctorate Program. He approached this story with training in the methods of science and medical ethics and after an hour interview with me last fall, I am certain he understood the abortion literature. Sadly, his desire to push a political agenda was apparently the most salient force behind his intellectually and scientifically dishonest piece. I spend too much of my professional energy trying to set the record straight after mainstream media outlets allow, and likely encourage, such shoddy journalism. However, in the interests of women seeking to understand abortion-related risks and to defend the high quality work of many domestic and international scientists, dismissed with a hand wave by Mr. Lang, I am once again compelled to point out the most glaring issues (detailed below.)  

1)      Early in the story, Lang notes “At the clinic, a counselor comforted S. and asked her why she had come, if anyone had coerced her into making this decision. “S. was very fortunate to have been asked about coercion; however the majority of women in this country are not afforded the luxury of sensitive questioning to insure they are making their own choice. As one who has served as an expert on several state and civil cases involving abortion, I know for a fact that this is not typical and the naïve reader is left assume that asking about pressure or coercion is standard protocol.

2)      According to Mr. Lang “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.”This statement actually indirectly affirms the strength of the published evidence regarding abortion as a risk factor for mental health problems, because the evidence presented in courts continues to trump the APA conclusions. The vast majority of research studies addressing the psychological implications of abortion do not look into a “Post-Abortion Syndrome”; they examine mental illnesses identified by mainstream professional organizations. The results of hundreds of studies published in leading peer-reviewed medicine and psychology journals over the past 3 decades indicates abortion is a substantial contributing factor in women’s mental health problems, including depression and death from suicide. Other well-established psychological difficulties associated with abortion include anxiety (including Post-Traumatic Stress Disorder), substance use disorders, and relationship problems. 

When Mr. Lang interviewed me last October, I shared the results of a meta-analysis I conducted titled “Abortion and Mental Health: A Quantitative Synthesis and Analysis of Research Published from 1995-2009” published in the British Journal of Psychiatry. Meta-analyses have much more credibility than the results of individual empirical studies or narrative reviews, such as the one conducted by the American Psychological Association in 2008.  In a meta-analysis, the contribution or weighting of any particular study to the final result is based on objective scientific criteria (sample size and strength of effect), as opposed to an individual’s opinion of what constitutes a strong study. The sample consisted of 22 studies and 877,297 participants (163,880 experienced an abortion). Results revealed that women who aborted experienced an 81% increased risk for mental health problems. When compared specifically to unintended pregnancy delivered, women were found to have a 55% increased risk of experiencing mental health problem.  The British Journal of Psychiatry has a very high Impact Factor (5.9) and it is currently the 3rd most-cited general psychiatry journal in the world. Submitted papers are extensively scrutinized by well-respected scientists and the studies published are trusted by practitioners around the globe. This review offers the largest quantitative estimate of mental health risks associated with abortion available in the world.   

3) Mr. Lang, quoting Foster reported “The unstated assumption of most new abortion restrictions — mandatory ultrasound viewing, waiting periods, mandated state ‘information 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.”  The reality is that many women who make the decision to abort do so without a thorough understanding of the procedure. Research suggests that feeling misinformed or being denied relevant information often precipitates post-abortion difficulties. Moreover, there is considerable evidence that a high percentage of women walking into abortion clinics are conflicted about the choice. In a paper published in the top-rated medical ethics journal, The Journal of Medical Ethics with colleagues, I found that 95% of a socio-demographically diverse group of women wished to be informed of all possible complications associated with drugs, surgery, and/or other forms of elective treatments, including abortion.  Women should be given sufficient time to make a comfortable decision, provided accurate information regarding risks, and they should have opportunity to ask questions in a private, individualized context.

4) Mr. Lang goes on to tell us that “Most studies on the effects of abortion compare women who have abortions with those who choose to carry their pregnancies to term.” While this is true, there is no mention of the fact that a minimum of 8 peer-reviewed journal articles have been published using unintended pregnancy delivered as a comparison group, and many additional studies have used women who have not experienced a pregnancy or had a miscarriage as a comparison group.

5) Foster’s Turnaway Study, the focus of Mr. Lang’s story is presented as superior to any existing studies. However there are glaring flaws, likely the reason that Foster has not yet successfully published a single peer-reviewed journal article from the work. Here are a few of the major problems that preclude trust in any results obtained. First, less than a third of the women who were approached to participate agreed to do so. This is unacceptable because those agreeing may have differed systematically from those who declined. Consent to participate rates should be at least 70%. Second, women who obtained or were denied abortions around the gestational limits included women for whom the legal cut off ranged from 10 weeks through the end of the second trimester or 27 weeks. This is not a variable that can be loosely defined, as there is a wealth of data indicating the psychological impact of abortion differs between first and second trimester abortions. Women aborting at such widely varying points in pregnancy cannot be lumped together.

6)  Mr. Lang states that “Women cite not recognizing their pregnancies, travel and procedure costs, insurance problems and not knowing where to find care as common reasons for delay.” Actually the best documented reason for delay is ambivalence about the decision.

7) We are also told that women 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.” Yes they are particularly vulnerable, but the primary reason is that psychological and physical risks increase exponentially with delayed abortion decisions. This brings us to perhaps the most appalling statement in the whole article. Mr. Lang quotes the lead investigator of the Turnaway Study stating even “later abortions are significantly safer than childbirth.” The riskiness of late-term abortion to women's physical well-being is not contested in the professional literature. For example, using national data, Bartlett and colleagues reported in 2002 that per 100,000 abortions, the relative risk of abortion-related mortality was 14.7 at 13–15 weeks of gestation, 29.5 at 16-20 weeks, and 76.6 at or after 21 weeks. This compares to a 12.1 rate for childbirth. Causes of death during the 2nd trimester as reported by Bartlett included hemorrhage, infection, embolism, anesthesia complications, and cardiac and cerebrovascular events.

8) As academics, politicians, and lawyers debate the post-abortion psychological and medical literature, the most expedient route to the truth is likely through women’s own voices. The woman in the story who was denied an abortion told Mr. Lang “She is more than my best friend, more than the love of my life” “She is just my whole world.” The Turnaway Study headed by a biased investigator using a seriously flawed methodology will likely silence most of these voices and perpetuate the suffering of women rushed through abortion clinics.