abortion research paper introduction

Introduction: The Politics of Abortion 50 Years after Roe

Katrina Kimport is a professor with the Department of Obstetrics, Gynecology, and Reproductive Sciences and a medical sociologist with the ANSIRH program at the University of California, San Francisco. Her research examines the (re)production of inequality in health and reproduction, with a topical focus on abortion, contraception, and pregnancy. She is the author of No Real Choice: How Culture and Politics Matter for Reproductive Autonomy (2022) and Queering Marriage: Challenging Family Formation in the United States (2014) and co-author, with Jennifer Earl, of Digitally Enabled Social Change (2011). She has published more than 75 articles in sociology, health research, and interdisciplinary journals.

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Rebecca Kreitzer is an associate professor of public policy at the University of North Carolina at Chapel Hill. Her research focuses on gendered political representation and intersectional policy inequality in the US states. Much of her research focuses on the political dynamics of reproductive health care, especially surrounding contraception and abortion. She has published dozens of articles in political science, public policy, and law journals.

[email protected]

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Katrina Kimport , Rebecca Kreitzer; Introduction: The Politics of Abortion 50 Years after Roe . J Health Polit Policy Law 1 August 2023; 48 (4): 463–484. doi: https://doi.org/10.1215/03616878-10451382

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Abortion is central to the American political landscape and a common pregnancy outcome, yet research on abortion has been siloed and marginalized in the social sciences. In an empirical analysis, the authors found only 22 articles published in this century in the top economics, political science, and sociology journals. This special issue aims to bring abortion research into a more generalist space, challenging what the authors term “the abortion research paradox,” wherein abortion research is largely absent from prominent disciplinary social science journals but flourishes in interdisciplinary and specialized journals. After discussing the misconceptions that likely contribute to abortion research siloization and the implications of this siloization for abortion research as well as social science knowledge more generally, the authors introduce the articles in this special issue. Then, in a call for continued and expanded research on abortion, the introduction to this special issue closes by offering three guiding practices for abortion scholars—both those new to the topic and those deeply familiar with it—in the hopes of building an ever-richer body of literature on abortion politics, policy, and law. The need for such a robust literature is especially acute following the US Supreme Court's June 2022 overturning of the constitutional right to abortion.

Abortion has been both siloed and marginalized in social science research. But because abortion is a perennially politically and socially contested issue as well as vital health care that one in four women in the United States will experience in their lifetime (Jones and Jerman 2022 ), it is imperative that social scientists make a change. This special issue brings together insightful voices from across disciplines to do just that—and does so at a particularly important historical moment. Fifty years after the United States Supreme Court's Roe v. Wade (1973) decision set a national standard amid disparate state policies on abortion, we again find ourselves in a country with a patchwork of laws about abortion. In Dobbs v. Jackson Women's Health Organization (2022), the Supreme Court overturned the constitutional right to abortion it had established in Roe , purportedly returning the question of legalization of abortion to the states. In the immediate aftermath of the Dobbs decision, state policies polarized, and public opinion shifted. This moment demands scholarly evaluation of where we have been, how we arrived at this moment, and what we should be attentive to in coming years. This special issue came about, in part, in response to the on-the-ground conditions of abortion in the United States.

As we argue below, the siloization of abortion research means that the social science literature broadly is not (yet) equipped to make sense of this moment, our history, and what the future holds. First, though, we make a case for the importance of political scientists, economists, and sociologists studying abortion. Then we describe the siloization of abortion research through what we call the “abortion research paradox,” wherein abortion research—despite its social and political import—is curiously absent from top disciplinary journals, even as it thrives in other publication venues that are often interdisciplinary and usually specialized. We theorize some reasons for this siloization and discuss the consequences, both for generalist knowledge and for scientific understanding of abortion. We then introduce the articles in this special issue, noting the breadth of methodological, topical, and theoretical approaches to abortion research they demonstrate. Finally, we offer three suggestions for scholars—both those new to abortion research and those already deeply familiar with it—embarking on abortion research in the hopes of building an ever-richer body of literature on abortion politics, policy, and law.

Why Abortion?

Abortion has arguably shaped the American political landscape more than any other domestic policy issue in the last 50 years. Since the Supreme Court initially established a nationwide right to abortion in Roe v. Wade (1973), debate over this right has influenced elections at just about every level of office (Abramowitz 1995 ; Cook, Hartwig, and Wilcox 1993 ; Cook, Jelen, and Wilcox 1994 ; Cook, Jelen, and Wilcox 1992 ; Paolino 1995 ; Roh and Haider-Markel 2003 ), inspired political activism (Carmines and Woods 2002 ; Killian and Wilcox 2008 ; Maxwell 2002 ; Verba, Schlozman, and Brady 1995 ) and social movements (Kretschmer 2014 ; Meyer and Staggenborg 1996 , 2008 ; Munson 2010a , Munson 2010b ; Rohlinger 2006 ; Staggenborg 1991 ), and fundamentally structured partisan politics (Adams 1997; Carsey and Layman 2006 ; Killian and Wilcox 2008 ). Position on abortion is frequently used as the litmus test for those seeking political office (Flaten 2010 ; Kreitzer and Osborn 2019 ). Opponents to legal abortion have transformed the federal judiciary (Hollis-Brusky and Parry 2021 ; Hollis-Brusky and Wilson 2020 ). Indeed, abortion is often called the quintessential “morality policy” issue (Kreitzer 2015 ; Kreitzer, Kane, and Mooney 2019 ; Mooney 2001 ; Mucciaroni, Ferraiolo, and Rubado 2019 ) and “ground zero” in the prominent culture wars that have polarized Americans (Adams 1997 ; Lewis 2017 ; Mouw and Sobel 2001 ; Wilson 2013 ). Almost fifty years after Roe v. Wade , in June 2022, the US Supreme Court overturned the constitutional right to abortion in its Dobbs v. Jackson Women's Health Organization decision, ushering in a new chapter of political engagement on abortion.

But abortion is not simply an abstract political issue; it is an extremely common pregnancy outcome. Indeed, as noted above, about one in four US women will get an abortion in her lifetime (Jones and Jerman 2022 ), although the rates of unintended pregnancy and abortion vary substantially across racial and socioeconomic groups (Dehlendorf, Harris, and Weitz 2013 ; Jones and Jerman 2022 ). Despite rampant misinformation claiming otherwise, abortion is a safe procedure (Raymond and Grimes 2012 ; Upadhyay et al. 2015 ), reduces physical health consequences and mortality (Gerdts et al. 2016 ), and does not cause mental health issues (Charles et al. 2008 ; Major et al. 2009 ) or regret (Rocca et al. 2013 , 2015 , 2020 ). Abortion also has a significant impact on people's lives beyond health outcomes. Legal abortion is associated with educational attainment (Everett et al. 2019 ; Ralph et al. 2019 ; Mølland 2016 ) as well as higher female labor force participation, and it affects men's and women's long-term earning potential (Bernstein and Jones 2019 ; Bloom et al. 2009 ; Everett et al. 2019 ; Kalist 2004 ). Access to abortion also shapes relationship satisfaction and stability (Biggs et al. 2014 ; Mauldon, Foster, and Roberts 2015 ). The preponderance of evidence, in other words, demonstrates substantial benefits and no harms to allowing pregnant people to choose abortion.

Yet access to abortion in the United States has been rapidly declining for years. Most abortion care in the United States takes place in stand-alone outpatient facilities that primarily provide reproductive health care (Jones, Witwer, and Jerman 2019 ). As antiabortion legislators in some states have advanced policies that target these facilities, the number of abortion clinics has decreased (Gerdts et al. 2022 ; Venator and Fletcher 2021 ), leaving large geographical areas lacking an abortion facility (Cartwright et al. 2018 ; Cohen and Joffe 2020 ) and thus diminishing pregnant people's ability to obtain abortion care when and where they need it.

The effects of policies regulating abortion, including those that target facilities, have been unevenly experienced, with people of color (Jones and Jerman 2022 ), people in rural areas (Bearak, Burke, and Jones 2017 ), and those who are financially struggling (Cook et al. 1999 ; Roberts et al. 2019 ) disproportionately affected. Even before the Dobbs decision overturned the constitutional right to abortion, the American landscape was characterized by ever-broadening contraception deserts (Axelson, Sealy, and McDonald-Mosley 2022 ; Barber et al. 2019 ; Kreitzer et al. 2021 ; Smith et al. 2022 ), maternity care deserts (Simpson 2020 ; Taporco et al. 2021 ; Wallace et al. 2021 ), and abortion deserts (Cartwright et al. 2018 ; Cohen and Joffe 2020 ; Engle and Freeman 2022 ; McNamara et al. 2022 ; Pleasants, Cartwright, and Upadhyay 2022 ). After Dobbs , access to abortion around the country changed in a matter of weeks. In the 100 days after Roe was overturned, at least 66 clinics closed in 15 states, with 14 of those states no longer having any abortion facilities (Kirstein et al. 2022 ). In this moment of heightened contention about an issue with a long history of social and political contestation, social scientists have a rich opportunity to contribute to scientific knowledge as well as policy and practice that affect millions of lives. This special issue steps into that opportunity.

The Abortion Research Paradox

This special issue is also motivated by what we call the abortion research paradox. As established above, abortion fundamentally shapes politics in a myriad of ways and is a very common pregnancy outcome, with research consistently demonstrating that access to abortion is consequential and beneficial to people's lives. However, social science research on abortion is rarely published in top disciplinary journals. Abortion is a topic of clear social science interest and is well suited for social science inquiry, but it is relatively underrepresented as a topic in generalist social science journals. To measure this underrepresentation empirically, we searched for original research articles about abortion in the United Sates in the top journals of political science, sociology, and economics. We identified the top three journals for each discipline by considering journal reputation within their respective discipline as well as impact factors and Google Scholar rankings. (There is room for debate about what makes a journal a “top” general interest journal, but that is beyond our scope. Whether these journals are exactly the top three is debatable; nonetheless, these are undoubtedly among the top general-interest or “flagship” disciplinary journals and thus representative of what the respective disciplines value as top scholarship.) Then we searched specified journal databases for the keyword “abortion” for articles published in this century (i.e., 2000–2021), excluding commentaries and book reviews. We found few articles about abortion: just seven in economics journals, eight in political science journals, and seven in sociology journals. We read the articles and classified each into one of three categories: articles primarily about abortion; articles about more than one aspect of reproductive health, inclusive of abortion; or articles about several policy issues, among which abortion is one ( table 1 ).

In the three top economics journals, articles about abortion focused on the relationships between abortion and crime or educational attainment, or on the impact of abortion policies on trends in the timing of first births of women (Bitler and Zavodny 2002 ; Donohue III and Levitt 2001 ; Myers 2017 ). Articles that studied abortion as one among several topics also studied “morally controversial” issues (Elías et al. 2017 ), the electoral implications of abortion (Glaeser, Ponzetto, and Shapiro 2005 ; Washington 2008 ), or contraception (Bailey 2010 ). Articles published in the three top political science journals that focused primarily on abortion evaluated judicial decision-making and legitimacy (Caldarone, Canes-Wrone, and Clark 2009 ; Zink, Spriggs, and Scott 2009 ) or public opinion (Kalla, Levine, and Broockman 2022 ; Rosenfeld, Imai, and Shapiro 2016 ). More commonly, abortion was one of several (or many) different issues analyzed, including government spending and provision of services, government help for African Americans, law enforcement, health care, education, free speech, Hatch Act restrictions, and the Clinton impeachment. The degree to which these articles are “about abortion” varies considerably. In the three top sociology journals, articles represented a slightly broader range of topics, including policy diffusion (Boyle, Kim, and Longhofer 2015 ), public opinion (Mouw and Sobel 2001 ), social movements (Ferree 2003 ), and crisis pregnancy centers (McVeigh, Crubaugh, and Estep 2017 ). Unlike in economics and political science, articles in sociology on abortion mostly focused directly on abortion.

The Journal of Health Politics, Policy and Law ( JHPPL ) would seem well positioned to publish research on abortion. Yet, even in JHPPL , abortion research is not very common. In the same time period (2000–2021), JHPPL published five articles on reproductive health: two articles on abortion (Daniels et al. 2016 ; Kimport, Johns, and Upadhyay 2018 ), one on contraception (Kreitzer et al. 2021 ), one on forced interventions on pregnant people (Paltrow and Flavin 2013 ), and one about how states could respond to the passage of the Affordable Care Act mandate regarding reproductive health (Stulberg 2013 ).

This is not to say that there is no extensive, rigorous published research on abortion in the social science literature. Interdisciplinary journals that are focused on reproductive health, such as Contraception and Perspectives on Sexual and Reproductive Health , as well as health research journals, such as the American Journal of Public Health and Social Science & Medicine , regularly published high-quality social science research on abortion during the focal time period. Research on abortion can also be found in disciplinary subfield journals. In the same time period addressed above, the Journal of Women, Politics, and Public Policy and Politics & Gender— two subfield journals focused on gender and politics—each published around 20 articles that mentioned abortion in the abstract. In practice, while this means excellent research on abortion is published, the net effect is that abortion research is siloed from other research areas in the disciplines of economics, political science, and sociology. This special issue aims to redress some of this siloization and to inspire future scholarship on abortion. Our motivation is not simply premised on quantitative counts, however. As we assert below, abortion research siloization has significant consequences for knowledge—and especially for real people's lives. First, though, we consider some of the possible reasons for this siloization.

The Origins of Siloization

We do not know why abortion research is not more commonly published in top disciplinary journals, given the topic's clear importance in key areas of focus for these disciplines, including public discourse, politics, law, family life, and health. The siloing and marginalization of abortion is likely related to several misconceptions. For one, because of social contention on the issue, peer reviewers may not have a deep understanding of abortion as a research topic, may express hostility to the topic, or may believe that abortion is exceptional in some way—a niche or ungeneralizable research topic better published in a subfield journal. Scholars themselves may share this mischaracterization of abortion. As Borgman ( 2014 ) argues about the legal arena, and as Roberts, Schroeder, and Joffe ( 2020 ) provide evidence of in medicine, abortion is regularly treated as exceptional, making it both definitional and reasonable that abortion be treated differently in the law and in health care from other medical experiences. Scholars are not immune to social patterns that exceptionalize abortion. In their peer and editor reviews, they may inappropriately—and perhaps inadvertently—draw on their social, rather than academic, knowledge. For scholars of abortion, reviews premised on social knowledge may not be constructive to strengthening the research, and additional labor may be required to educate reviewers and editors on the academic parameters of the topic, including which social assumptions about abortion are scientifically inaccurate. Comments from authors educating editors and peer reviewers on abortion research may then counterintuitively reinforce the (mis)perception that abortion research is niche and not of general interest.

Second, authors' negative experiences while trying to publish about abortion or reproductive health in top disciplinary journals may compound as scholars share information about journals. This is the case for research on gender; evidence from political science suggests that certain journals are perceived as more or less likely to publish research on gender (Brown et al. 2020 ). Such reputations, especially for venues that do not publish abortion research, may not even be rooted in negative experiences. The absence of published articles on abortion may itself dissuade scholars from submitting to a journal based on an educated guess that the journal does not welcome abortion research. Regardless of the veracity of these perceptions, certain journals may get a reputation for publishing on abortion (or not), which then may make future submissions of abortion research to those outlets more (or less) likely. After all, authors seek publication venues where they believe their research will get a robust review and is likely to be published. This pattern may be more common for some author groups than others. Research from political science suggests women are more risk averse than men when it comes to publishing strategies and less likely to submit manuscripts to journals where the perceived likelihood of successful publication is lower (Key and Sumner 2019 ). Special issues like this one are an important way for journals without a substantial track record of publishing abortion research to establish their willingness to do so.

Third, there might be a methodological bias, which unevenly intersects with some author groups. Top disciplinary journals are more likely to publish quantitative approaches rather than qualitative ones, which can result in the exclusion of women and minority scholars who are more likely to utilize mixed or qualitative methods (Teele and Thelen 2017 ). To the extent that investigations of abortion in the social sciences have utilized qualitative rather than quantitative methods, that might contribute to the underrepresentation of abortion-focused scholarship in top disciplinary journals.

Stepping back from the idiosyncrasies of peer review and methodologies, a fourth explanation for why abortion research is not more prominent in generalist social science journals may arise far earlier than the publishing process. PhD-granting departments in the social sciences may have an undersupply of scholars with expertise in reproductive health who can mentor junior scholars interested in studying abortion. (We firmly believe one need not be an expert in reproductive health to mentor junior scholars studying reproductive health, so this explanation only goes so far.) Anecdotally, we have experienced and heard many accounts of scholars who were discouraged from focusing on abortion in dissertation research because of advisors', mentors', and senior scholars' misconceptions about the topic and about the viability of a career in abortion research. In data provided to us by Key and Sumner from their analysis of the “leaky pipeline” in the publication of research on gender at top disciplinary journals in political science (Key and Sumner 2019 ), there were only nine dissertations written between 2000 and 2013 that mention abortion in the abstract, most of which are focused on judicial behavior or political party dynamics rather than focusing on abortion policy itself. If few junior scholars focus on abortion, it makes sense there may be an undersupply of cutting-edge social science research on abortion submitted to top disciplinary journals.

The Implications of Siloization

The relative lack of scholarly attention to abortion as a social phenomenon in generalist journals has implications for general scholarship. Most concerningly, it limits our ability to understand other social phenomena for which the case of abortion is a useful entry point. For example, the case of abortion as a common, highly safe medical procedure is useful for examining medical innovations and technologies, such as telemedicine. Similarly, given the disparities in who seeks and obtains abortion care in the United States, abortion is an excellent case study for scholars interested in race, class, and gender inequality. It also holds great potential as an opportunity for exploration of public opinion and attitudes, particularly as a case of an issue whose ties to partisan politics have solidified over time and that is often—but not always—“moralized” in policy engagement (Kreitzer, Kane, and Mooney 2019 ). Additionally, there are missed opportunities to generate theory from the specifics of abortion. For example, there is ample evidence of abortion stigma and stigmatization (Hanschmidt et al. 2016 ) and of their effects on people who obtain abortions (Sorhaindo and Lavelanet 2022 ). This research is often unmoored from existing theorization on stigmatization, however, because the bulk of the stigma literature focuses on identities; and having had an abortion is not an identity the same way as, for example, being queer is. (For a notable exception to this trend, see Beynon-Jones 2017 .)

There is, it must be noted, at least one benefit of abortion research being regularly siloed within social science disciplines. The small but growing number of researchers engaged in abortion research has often had to seek mentorship and collaborations outside their disciplines. Indeed, several of the articles included in this special issue come from multidisciplinary author teams, building bridges between disciplinary literatures and pushing knowledge forward. Social scientists studying abortion regularly engage with research by clinicians and clinician-researchers, which is somewhat rare in the academy. The interdisciplinary journals noted above that regularly publish social science abortion research ( Contraception and Perspectives on Sexual and Reproductive Health ) also regularly publish clinical articles and are read by advocates and policy makers. In other words, social scientists studying abortion frequently reach audiences that include clinicians, advocates, and policy makers, marking an opportunity for social science research to influence practice.

The siloization of abortion research in the social sciences affects more than broad social science knowledge; it also dramatically shapes our understanding of abortion. When abortion researchers are largely relegated to their own spaces, they risk missing opportunities to learn from other areas of scholarship that are not related to abortion. Lacking context from other topics, abortion scholars may inaccurately understand an aspect of abortion as exceptional that is not, or they may reinvent the proverbial theoretical wheel to describe an abortion-related phenomenon that is not actually unique to abortion. For example, scholars have studied criminalized behavior for decades, offering theoretical insights and methodological best practices for research on illegal activities. With abortion now illegal in many states, abortion researchers can benefit from drawing on that extant literature to examine the implications of illegality, identifying which aspects of abortion illegality are unique and which are common to other illegal activities. Likewise, methodologically, abortion researchers can learn from other researchers of illegal activities about how to protect participants' confidentiality.

The ontological and epistemological implications for the siloization of abortion research extend beyond reproductive health. When abortion research is not part of the central discussions in economics, political science, and sociology, our understanding of health policy, politics, and law is impoverished. We thus miss opportunities to identify and address chronic health disparities and health inequities, with both conceptual and practical consequences. These oversights matter for people's lives. Following the June 2022 Dobbs decision, millions of people with the capacity of pregnancy are now barred from one key way to control fertility: abortion. The implications of scholars' failure to comprehensively grapple with the place of abortion in health policy, politics, and law are playing out in those people's lives and the lives of their loved ones.

Articles in this Special Issue

In this landscape, we offer this special issue on “The Politics of Abortion 50 Years After Roe .” We seek in this issue to illustrate some of the many ways abortion can and should be studied, with benefits not only for scholarly knowledge about abortion and its role in policy, politics, and law but also for general knowledge about health policy, politics, and law themselves.

The issue's articles represent multiple disciplines, including several articles by multidisciplinary teams. Although public health has long been a welcoming home for abortion research, authors in this special issue point to opportunities in anthropology, sociology, and political science, among other disciplines, for the study of abortion. We do not see the differences and variations among disciplinary approaches as a competition. Rather, we believe that the more diverse the body of researchers grappling with questions about abortion, abortion provision, and abortion patients, the better our collective knowledge about abortion and its role in the social landscape.

The same goes for diversity of methodological approaches. Authors in this issue employ qualitative, quantitative, and mixed methods, showcasing compelling methodological variation. There is no singular or best methodology for answering research questions about abortion. Instead, the impressive variation in methodological approaches in this special issue highlights the vast methodological opportunities for future research. A diversity of methodologies enables a diversity of research questions. Indeed, different methods can identify, generate, and respond to different research questions, enriching the literature on abortion. The methodologies represented in this issue are certainly not exhaustive, but we believe they are suggestive of future opportunities for scholarly exploration and investigation. We hope these articles will provide a road map for rich expansions of the research literature on abortion.

By way of brief introduction, we offer short summaries of the included articles. Baker traces the history of medication abortion in the United States, cataloging the initial approval of the two-part regimen by the Food and Drug Administration (FDA), subsequent policy debates over FDA-imposed restrictions on how medication abortion is dispensed, and the work of abortion access advocates to get medication abortion to people who need it. Weaving together accounts of health care policy, abortion advocacy, and on-the-ground activism, Baker illustrates both the unique contentions specific to abortion policy and how the history of medication abortion can be seen as a case of health care advocacy.

Two of the issue's articles focus on state-level legislative policy on abortion. Roth and Lee generate an original data set cataloging the introduction and implementation of statutes on abortion and other aspects of reproductive health at the state level in the United States monthly, from 1994 to 2022. In their descriptive analysis, the authors highlight trends in abortion legislation and the emergent pattern of state polarization around abortion. Their examination adds rich longitudinal context to contemporary analyses of reproductive health legislation, providing a valuable resource for future scholarship. Carson and Carter similarly attend to state-level legislation, zeroing in on the case of abortion policy in response to the COVID-19 pandemic to show how legislation unrelated to abortion has been opportunistically used to restrict abortion access. The authors also examine how abortion is discursively constructed as a risk to public health. This latter move, they argue, builds on previous constructions of abortion as a risk to individual health and points to a new horizon of antiabortion constructions of the meaning of abortion access.

Kim et al. and Kumar examine the implementation of US abortion policies. Kim et al. use an original data set of 20 years of state supreme court decisions to investigate factors that affect state supreme court decision-making on abortion. Their regression analysis uncovers the complex relationship between state legislatures, state supreme courts, and the voting public for the case of abortion. Kumar charts how 50 years of US abortion policy have affected global access to abortion, offering insights into the underexamined international implications of US abortion policy and into social movement advocacy that has expanded abortion access around the world.

Karlin and Joffe and Heymann et al. draw on data collected when Roe was still the law of the land to investigate phenomena that are likely to become far more common now that Roe has been overturned. Karlin and Joffe utilize interviews with 40 physicians who provide abortions to examine their perspectives on people who terminate their pregnancies outside the formal health care system—an abortion pathway whose popularity increases when abortion access constricts (Aiken et al. 2022 ). By contextualizing their findings on the contradictions physicians voiced—desiring to support reproductive autonomy but invested in physician authority—in a historical overview of how mainstream medicine has marginalized abortion provision since the early days after Roe , the authors add nuance to understandings of the “formal health care system,” its members, and the stakes faced by people bypassing this system to obtain their desired health outcome. Heymann et al. investigate a process also likely to increase in the wake of the Dobbs decision: the implementation of restrictive state-level abortion policy by unelected bureaucrats. Using the case of variances for a written transfer agreement requirement in Ohio—a requirement with no medical merit that is designed to add administrative burden to stand-alone abortion clinics—Heymann et al. demonstrate how bureaucratic discretion by political appointees can increase the administrative burden of restrictive abortion laws and thus further constrain abortion access. Together, these two articles demonstrate how pre- Roe data can point scholars to areas that merit investigation after Roe has been overturned.

Finally, using mixed methods, Buyuker et al. analyze attitudes about abortion acceptability and the Roe v. Wade Supreme Court decision, distinguishing what people think about abortion from what they know about abortion policy. In addition to providing methodological insights about survey items related to abortion attitudes, the authors expose a disconnect between how people think about abortion acceptability and their support for the Roe decision. In other words, as polarized as abortion attitudes are said to be, there is unacknowledged and largely unmeasured complexity in how the general public thinks about abortion.

Future Research on Abortion

We hope that a desire to engage in abortion research prompts scholars to read the excellent articles in this special issue. We also hope that reading these pieces inspires at least some readers to engage in abortion research. Having researched abortion for nearly three decades between us, we are delighted by the emerging interest in studying abortion, whether as a focal topic or alongside a different focus. This research is essential to our collective understanding of abortion politics, policy, and law and the many millions of people whose lives are affected by US abortion politics, policy, and law annually. In light of the limitations of the current field of abortion research, we have several suggestions for scholars of abortion, regardless of their level of familiarity with the topic.

First, know and cite the existing literature on abortion. To address the siloization of abortion research, and particularly the scarcity of abortion research published in generalist journals, scholars must be sure to build on the impressive work that has been published on the topic in specialized spaces. Moreover, becoming familiar with existing research can help scholars avoid several common pitfalls in abortion research. For example, being immersed in existing literature can help scholars avoid outdated, imprecise, or inappropriate language and terminology. Smith et al. ( 2018 ), for instance, illuminate the implications of clinicians deploying seemingly everday language around “elective” abortion. They find that it muddies the distinction between the use of “elective” colloquially and in clinical settings, contributing to the stigmatization of abortion and abortion patients. Examinations like theirs advance understanding of abortion stigmatization while highlighting for scholars the importance of being sensitive to and reflective about language. Familiarity with existing research can help scholars avoid methodological pitfalls as well, such as incomplete understanding of the organization of abortion provision. Although Planned Parenthood has brand recognition for providing abortion care, the majority of abortions in the United States are performed at independent abortion clinics. Misunderstanding the provision landscape can have consequences for some study designs.

Second, we encourage scholars of abortion to think critically about the ideological underpinnings of how their research questions and findings are framed. Academic research of all kinds, including abortion, is better when it is critical of ideologically informed premises. Abortion scholars must be careful to avoid uncritically accepting both antiabortion premises and abortion-supportive premises, especially as those premises unconsciously guide much of the public discourse on abortion. Scholars have the opportunity to use methodological tools not to find an objective truth per se but to challenge the uncontested common sense claims that frequently guide public thinking on abortion. One strategy for avoiding common framing pitfalls is to construct research and analysis to center the people most affected by abortion politics, policy, and law (Kimport and McLemore 2022 ). Another strategy is to critique what Baird and Millar ( 2019 , 2020 ) have termed the performative nature of abortion scholarship. Abortion scholarship, they note, has predominantly focused on negative aspects and effects of abortion care. Research that finds and explores affirmatively positive aspects—for instance, the joy in abortion—can crucially thicken scholarly understanding.

Third, related to our discussion above, scholars of abortion face an interesting challenge regarding how abortion is and is not exceptional. Research on abortion must attend to how abortion has been exceptionalized—and marginalized—in policy and practices. But there are also numerous instances where abortion is only one example of many. In these cases, investigation of abortion under the assumption that it is exceptional is an unnecessary limitation on the work's contribution. Scholars of abortion benefit from mastery of the literature on abortion, yet knowing this literature is not sufficient. There are important bridges from scholarship on abortion to scholarship in other areas, important conversations across and within literatures, that can yield insights both about abortion and about other topical foci.

As guest coeditors of this special issue, we are delighted by the rich and growing body of scholarship on abortion, to which the articles in this special issue represent an important addition. There is still much more work to be done. Going forward, we are eager to see future scholarship on abortion build on this work and tackle new questions.

Acknowledgments

The authors thank Krystale Littlejohn, Jon Oberlander, Ellen Key, and Jane Sumner for their helpful feedback on earlier drafts of this article. Both authors contributed equally to this article and are listed alphabetically.

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Data & Figures

Number of Articles about Abortion in Top Disciplinary Journals, 2000–2021

Note : AER = American Economic Review ; QJE = Quarterly Journal of Economics ; JPE = Journal of Political Economy ; APSR = American Political Science Review ; AJPS = American Journal of Political Science ; JOP = Journal of Politics ; ASR = American Sociological Review ; AJS = American Journal of Sociology ; ARS = Annual Review of Sociology.

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What can economic research tell us about the effect of abortion access on women’s lives?

Subscribe to the center for economic security and opportunity newsletter, caitlin knowles myers and caitlin knowles myers john g. mccullough professor of economics; co-director, middlebury initiative for data and digital methods - middlebury college @caitlin_k_myers morgan welch morgan welch senior research assistant & project coordinator - center on children and families, economic studies, brookings institution.

November 30, 2021

21 min read

On September 20, 2021, a group of 154 distinguished economists and researchers filed an amicus brief to the Supreme Court of the United States in advance of the Mississippi case, Dobbs v. Jackson Women’s Health Organization . For a full review of the evidence that shows how causal inference tools have been used to measure the effects of abortion access in the U.S., read the brief here .

Introduction

Dobbs v. Jackson Women’s Health Organization considers the constitutionality of a 2018 Mississippi law that prohibits women from accessing abortions after 15 weeks of pregnancy. This case is widely expected to determine the fate of Roe v. Wade as Mississippi is directly challenging the precedent set by the Supreme Court’s decisions in Roe , which protects abortion access before fetal viability (typically between 24 and 28 weeks of pregnancy). On December 1, 2021, the Supreme Court will hear oral arguments in Dobbs v. Jackson . In asking the Court to overturn Roe , the state of Mississippi offers reassurances that “there is simply no causal link between the availability of abortion and the capacity of women to act in society” 1 and hence no reason to believe that abortion access has shaped “the ability of women to participate equally in the economic and social life of the Nation” 2 as the Court had previously held.

While the debate over abortion often centers on largely intractable subjective questions of ethics and morality, in this instance the Court is being asked to consider an objective question about the causal effects of abortion access on the lives of women and their families. The field of economics affords insights into these objective questions through the application of sophisticated methodological approaches that can be used to isolate and measure the causal effects of abortion access on reproductive, social, and economic outcomes for women and their families.

Separating Correlation from Causation: The “Credibility Revolution” in Economics

To measure the causal effect of abortion on women’s lives, one must differentiate its effects from those of other forces, such as economic opportunity, social mores, the availability of contraception. Powerful statistical methodologies in the causal inference toolbox have made it possible for economists to do just that, moving beyond the maxim “correlation isn’t necessarily causation” and applying the scientific method to figure out when it is.

This year’s decision by the Economic Sciences Prize Committee recognized the contributions 3 of economists David Card, Joshua Angrist, and Guido Imbens, awarding them the Nobel Prize for their pathbreaking work developing and applying the tools of causal inference in a movement dubbed “the credibility revolution” (Angrist and Pischke, 2010). The gold standard for establishing such credibility is a well-executed randomized controlled trial – an experiment conducted in the lab or field in which treatment is randomly assigned. When economists can feasibly and ethically implement such experiments, they do. However, in the social world, this opportunity is often not available. For instance, one cannot feasibly or ethically randomly assign abortion access to some individuals but not others. Faced with this obstacle, economists turn to “natural” or “quasi” experimental methods, ones in which they are able to credibly argue that treatment is as good as randomly assigned.

The Effects of Abortion Access on Women’s Reproductive, Economic, and Social Lives

Evidence of the effects of abortion legalization.

The history of abortion legalization in the United States affords both a canonical and salient example of a natural experiment. While Roe v. Wade legalized abortion in most of the country in 1973, five states—Alaska, California, Hawaii, New York, and Washington—and the District of Columbia repealed their abortion bans several years in advance of Roe . Using a methodology known as “difference-in-difference estimation,” researchers compared changes in outcomes in these “repeal states” when they lifted abortion bans to changes in outcomes in the rest of the country. They also compared changes in outcomes in the rest of the country in 1973 when Roe legalized abortion to changes in outcomes in the repeal states where abortion already was legal. This difference-in-differences methodology allows the states where abortion access is not changing to serve as a counterfactual or “control” group that accounts for other forces that were impacting fertility and women’s lives in the Roe era.

Among the first to employ this approach was a team of economists (Levine, Staiger, Kane, and Zimmerman, 1999) who estimated that the legalization of abortion in repeal states led to a 4% to 11% decline in births in those states relative to the rest of the country. Levine and his co-authors found that these fertility effects were particularly large for teens and women of color, who experienced birth rate reductions that were nearly three times greater than the overall population as a result of abortion legalization. Multiple research teams have replicated the essential finding that abortion legalization substantially impacted American fertility while extending the analysis to consider other outcomes. 4 For example, Myers (2017) found that abortion legalization reduced the number of women who became teen mothers by 34% and the number who became teen brides by 20%, and again observed effects that were even larger for Black teens. Farin, Hoehn-Velasco, and Pesko (2021) found that abortion legalization reduced maternal mortality among Black women by 30-40%, with little impact on white women, offering the explanation that where abortion was illegal, Black women were less likely to be able to access safe abortions by traveling to other states or countries or by obtaining a clandestine abortion from a trusted health care provider.

The ripple effects of abortion access on the lives of women and their families

This research, which clearly demonstrates the causal relationship between abortion access and first-order demographic and health outcomes, laid the foundation for researchers to measure further ripple effects through the lives of women and their families. Multiple teams of authors have extended the difference-in-differences research designs to study educational and labor market outcomes, finding that abortion legalization increased women’s education, labor force participation, occupational prestige, and earnings and that all these effects were particularly large for Black women (Angrist and Evans, 1996; Kalist, 2004; Lindo, Pineda-Torres, Pritchard, and Tajali, 2020; Jones, 2021).

Additionally, research shows that abortion access has not only had profound effects on women’s economic and social lives but has also impacted the circumstances into which children are born. Researchers using difference-in-differences research designs have found that abortion legalization reduced the number of children who were unwanted (Bitler and Zavodny, 2002a, reduced cases of child neglect and abuse (Bitler and Zavodny, 2002b; 2004), reduced the number of children who lived in poverty (Gruber, Levine, and Staiger, 1999), and improved long-run outcomes of an entire generation of children by increasing the likelihood of attending college and reducing the likelihood of living in poverty and receiving public assistance (Ananat, Gruber, Levine, and Staiger, 2009).

Access to abortion continues to be important to women’s lives

The research cited above relies on variation in abortion access from the 1970s, and much has changed in terms of both reproductive technologies and women’s lives. Recent research shows, however, that even with the social, economic, and legal shifts that have occurred over the last few decades and even with expanded access to contraception, abortion access remains relevant to women’s reproductive lives. Today, nearly half of pregnancies are unintended (Finer and Zolna, 2016). About 6% of young women (ages 15-34) experience an unintended pregnancy each year (Finer, Lindberg, and Desai, 2018), and about 1.4% of women of childbearing age obtain an abortion each year (Jones, Witwer, and Jerman, 2019). At these rates, approximately one in four women will receive an abortion in their reproductive lifetimes. The fact is clear: women continue to rely on abortion access to determine their reproductive lives.

But what about their economic and social lives? While women have made great progress in terms of their educational attainment, career trajectories, and role in society, mothers face a variety of challenges and penalties that are not adequately addressed by public policy. Following the birth of a child, it’s well documented that working mothers face a “motherhood wage penalty,” which entails lower wages than women who did not have a child (Waldfogel, 1998; Anderson, Binder, and Krause, 2002; Kelven et al., 2019). Maternity leave may combat this penalty as it allows women to return to their jobs following the birth of a child – encouraging them to remain attached to the labor force (Rossin-Slater, 2017). However, as of this writing, the U.S. only offers up to 12 weeks of unpaid leave through the FMLA, which extends coverage to less than 60% of all workers. 5 And even if a mother is able to return to work, childcare in the U.S. is costly and often inaccessible for many. Families with infants can be expected to pay around $11,000 a year for childcare and subsidies are only available for 1 in 6 children that are eligible under the federal program. 6 Without a federal paid leave policy and access to affordable childcare, the U.S. lacks the infrastructure to adequately support mothers, and especially working mothers – making the prospect of motherhood financially unworkable for some.

This is relevant when considering that the women who seek abortions tend to be low-income mothers experiencing disruptive life events. In the most recent survey of abortion patients conducted by the Guttmacher Institute, 97% are adults, 49% are living below the poverty line, 59% already have children, and 55% are experiencing a disruptive life event such as losing a job, breaking up with a partner, or falling behind on rent (Jones and Jerman, 2017a and 2017b). It is not a stretch to imagine that access to abortion could be pivotal to these women’s financial lives, and recent evidence from “The Turnaway Study” 7 provides empirical support for this supposition. In this study, an interdisciplinary team of researchers follows two groups of women who were typically seeking abortions in the second trimester: one group that arrived at abortion clinics and learned they were just over the gestational age threshold for abortions and were “turned away” and a second that was just under the threshold and were provided an abortion. Miller, Wherry, and Foster (2020) match individuals in both groups to their Experian credit reports and observe that in the months leading up to the moment they sought an abortion, financial outcomes for both groups were trending similarly. At the moment one group is turned away from a wanted abortion, however, they began to experience substantial financial distress, exhibiting a 78% increase in past-due debt and an 81% increase in public records related to bankruptcies, evictions, and court judgments.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase. Twelve states have enacted “trigger bans” designed to outlaw abortion in the immediate aftermath of a Roe reversal, while an additional 10 are considered highly likely to quickly enact new bans. 8 These bans would shutter abortion facilities across a wide swath of the American south and midwest, dramatically increasing travel distances and the logistical costs of obtaining an abortion. Economics research predicts what is likely to happen next. Multiple teams of economists have exploited natural experiments arising from mandatory waiting periods (Joyce and Kaestner, 2001; Lindo and Pineda-Torres, 2021; Myers, 2021) and provider closures (Quast, Gonzalez, and Ziemba, 2017; Fischer, Royer, and White, 2018; Lindo, Myers, Schlosser, and Cunningham, 2020; Venator and Fletcher, 2021; Myers, 2021). All have found that increases in travel distances prevent large numbers of women seeking abortions from reaching a provider and that most of these women give birth as a result. For instance, Lindo and co-authors (2020) exploit a natural experiment arising from the sudden closure of half of Texas’s abortion clinics in 2013 and find that an increase in travel distance from 0 to 100 miles results in a 25.8% decrease in abortions. Myers, Jones, and Upadhyay (2019) use these results to envision a post- Roe United States, forecasting that if Roe is overturned and the expected states begin to ban abortions, approximately 1/3 of women living in affected regions would be unable to reach an abortion provider, amounting to roughly 100,000 women in the first year alone.

Restricting, or outright eliminating, abortion access by overturning Roe v. Wade would diminish women’s personal and economic lives, as well as the lives of their families.

Whether one’s stance on abortion access is driven by deeply held views on women’s bodily autonomy or when life begins, the decades of research using rigorous methods is clear: there is a causal link between access to abortion and whether, when, and under what circumstances women become mothers, with ripple effects throughout their lives. Access affects their education, earnings, careers, and the subsequent life outcomes for their children. In the state’s argument, Mississippi rejects the causal link between access to abortion and societal outcomes established by economists and states that the availability of abortion isn’t relevant to women’s full participation in society. Economists provide clear evidence that overturning Roe would prevent large numbers of women experiencing unintended pregnancies—many of whom are low-income and financially vulnerable mothers—from obtaining desired abortions. Restricting, or outright eliminating, that access by overturning Roe v. Wade would diminish women’s personal and economic lives, as well as the lives of their families.

Caitlin Knowles Myers did not receive financial support from any firm or person for this article. She has received financial compensation from Planned Parenthood Federation of America and the Center for Reproductive Rights for serving as an expert witness in litigation involving abortion regulations. She has not and will not receive financial compensation for her role in the amicus brief described here. Other than the aforementioned, she has not received financial support from any firm or person with a financial or political interest in this article. Caitlin Knowles Myers is not currently an officer, director, or board member of any organization with a financial or political interest in this article.

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Lindo, Jason M., Myers, Caitlin Knowles, Schlosser, Andrea, and Scott Cunningham, 2020. “How Far Is Too Far? New Evidence on Abortion Clinic Closures, Access, and Abortions” Journal of Human Resources 55. Retrieved from http://jhr.uwpress.org/content/55/4/1137.refs

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See Angrist and Evans (1996), Gruber et al. (1999), Ananat et al. (2009), Guldi (2008), Myers (2017), Abboud (2019), Jones (2021).
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Whitehurst, Grover J., April 19, 2018. “What is the market price of daycare and preschool?” Brookings Institution. Retrieved from https://www.brookings.edu/research/what-is-the-market-price-of-daycare-and-preschool/; Chien, Nina, 2021. “Factsheet: Estimates of Child Care Eligibility & Receipt for Fiscal Year 2018.” U.S. Department of Health and Human Services. Retrieved from https://aspe.hhs.gov/sites/default/files/20 21-08/cy-2018-child-care-subsidy-eligibility.pdf
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Published: 15 February 2024

Effectiveness and safety of telehealth medication abortion in the USA

Ushma D. Upadhyay ORCID: orcid.org/0000-0002-2731-2157 1 ,
Leah R. Koenig 1 , 2 ,
Karen Meckstroth 1 ,
Jennifer Ko 1 ,
Ena Suseth Valladares 3 &
M. Antonia Biggs 1

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Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 μg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2–98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6–99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.

Genomic data in the All of Us Research Program

The All of Us Research Program Genomics Investigators

Digital twins in medicine

R. Laubenbacher, B. Mehrad, … N. Trayanova

An overview of clinical decision support systems: benefits, risks, and strategies for success

Reed T. Sutton, David Pincock, … Karen I. Kroeker

In 2021, the US Food and Drug Administration (FDA) removed the in-person dispensing requirement on mifepristone, the first drug used in a medication abortion. This ruling allowed clinicians to begin offering a ‘no-test’ telehealth model of medication abortion care. Clinicians could now offer entirely remote consultations, using the patient’s self-reported medical history instead of ultrasonography or other tests to screen for medical eligibility.

Moving abortion out of the clinic reduced travel, cost and stigma-related barriers and increased convenience for patients 1 , 2 . While telehealth abortion is usually conducted through synchronous communication, with a real-time scheduled videoconference appointment with the patient, some virtual clinics rely on entirely asynchronous communication, using secure text messaging without a scheduled interaction. Follow-up for both models is usually asynchronous, through secure text messaging.

This expansion of services became critical after the June 2022 Supreme Court Dobbs v. Jackson Women’s Health Organization decision allowed states to ban abortion. In states such as Illinois, Kansas and Colorado, where abortion remained legal but neighboring states banned abortion, clinics experienced large increases in patient volume 3 . Telehealth became vital to meeting increased demand by reducing appointment waiting times and serving patients from states with abortion bans 4 . Some individuals from US states with an abortion ban use methods such as mail forwarding and mailing medications to a friend or Post Office box close to the border in states where abortion is permitted, minimizing the travel required 5 . Additionally, some clinicians have begun to use the legal protections of their state’s “shield laws” to provide medication abortion via telehealth to patients in banned states 6 .

However, access to mifepristone for medication abortion has been under threat, with a federal court ruling to reverse FDA regulatory approvals of mifepristone, including the 2021 decision that allowed telehealth for abortion to continue even after the pandemic. This ruling was issued despite multiple FDA reviews and abundant evidence demonstrating the effectiveness and safety of mifepristone 7 . According to the mifepristone label, 97.4% of 16,794 patients in US clinical trials of in-person medication abortion had a complete abortion and less than 0.5% had a serious adverse event 8 .

While decades of evidence support the effectiveness and safety of mifepristone provided in person, the evidence supporting no-test direct-to-patient telehealth abortion is more limited. Before 2021, US research on the effectiveness and safety of telehealth abortion was limited to clinic-to-clinic 9 , 10 , 11 or direct-to-patient models that required pre-abortion ultrasonography or other tests 12 . To date, only five US studies have examined the outcomes of no-test direct-to-patient telehealth abortion models; four of these had small (fewer than 350) samples of patients receiving such care; thus, they were underpowered to examine outcomes as rare as serious adverse events 13 , 14 , 15 , 16 . The fifth study was a retrospective examination of no-test medication abortion provided either in-person or by telehealth and mail. Among 3,779 medication abortions, 95% were complete without procedural intervention and 0.5% experienced a serious adverse event. Effectiveness and safety were similar whether medications were dispensed in-person or by mail 17 , 18 . However, this study did not report the effectiveness and safety outcomes of asynchronous telehealth abortion.

In this study, we used data from the California Home Abortion by Telehealth (CHAT) study to follow a large sample of patients across the US from three virtual clinics to estimate the effectiveness and safety of medication abortion care provided via telehealth. Clinicians provided telehealth abortion care via either synchronous (video) or asynchronous (secure text messaging) methods. They screened patients using a published, standardized no-test protocol, primarily relying on patient medical history to assess medical eligibility 19 . Patients who had any risk factors for or symptoms of ectopic pregnancy or were potentially beyond the gestational limit of the virtual clinic were referred for pre-abortion ultrasonography. Eligible patients received 200 mg mifepristone and 800 or 1,600 μg buccal or vaginal misoprostol via mail order pharmacy. Outcome data were collected by scheduled follow-up interactions conducted remotely 3–7 days after intake and again 2–4 weeks after medication administration (Fig. 1 ). Our primary aim was to assess the effectiveness and safety of telehealth medication abortion care. Our secondary aim was to compare effectiveness and safety outcomes between synchronous and asynchronous models of telehealth.

Timing and content of the electronic medical records and survey data analyzed in the CHAT study.

We received electronic medical records for 6,974 encounters. Among those, 6,154 patients met the eligibility criteria and had abortion medications dispensed to them in 20 states and Washington, DC. We excluded cases where the patient took neither mifepristone nor misoprostol ( n = 120) leaving 6,034 patients in the analytical sample (Fig. 2 ). Among these, 1,600 patients provided supplementary self-reported data on their outcomes via surveys (Extended Data Table 1 ).

Patient flow chart depicting the exclusion criteria.

All patients were pregnant and seeking abortion. Half (50.3%) were 30 years or older and 4.6% were aged under 20 years (Table 1 ). Race, ethnicity or ethnic grouping was unknown for one-third (34.3%) of patients because one of the clinics did not record these data in their medical records for the first half of the study period. Among the subsample with known race, ethnicity or ethnic grouping, nearly two-thirds (62.7%) were white. Most (84.3%) patients had pregnancy durations under 7 weeks (≤49 days). Medical records did not document patient sex or gender.

Overall, 72.3% of patients received asynchronous care. Among patients of the clinic that offered asynchronous care but allowed patients to request a phone or video call, 0.3% requested a call with the provider. Patients who were younger (100.0% for 16–18 years, 79.3% for 18–19 years), Asian, Native Hawaiian or Pacific Islander (82.3%), Middle Eastern or North African (80.0%), living in an urban area (72.7%) and who had pregnancy durations over 56 days (74.8% for 50–56 days, 99.6% for 57–63 days and 100.0% for 64–70 days) were more likely to have received asynchronous care.

Of the sample, 76% (4,613 of 6,034) of cases had any follow-up contact with the virtual clinic or by surveys (Fig. 2 ). Abortion outcomes were known (ascertained using a test or the patient’s history) for 74% (4,454 of 6,034) of the analytical sample. There were few sociodemographic characteristics associated with unknown outcomes. Outcomes were less likely to be known for American Indian or Alaska Native patients (57.1%), Middle Eastern or North African patients (64.0%), patients with a previous birth (70.4%), patients with a pregnancy duration of 57–63 days (66.7%) and 64–70 days (68.4%), and patients receiving asynchronous care (69.6%) (Extended Data Table 2 ). Among patients with unknown outcomes, two requested abortion pill reversal after they took mifepristone but before misoprostol. Both were advised that evidence-based reversal treatment does not exist and referred to urgent in-person care. No further information on their outcomes was available.

Effectiveness

Overall, results from both the complete case analysis and the imputed models found that 97.7% (95% confidence interval (CI) = 97.2–98.1%) of abortions were complete without a subsequent known intervention or ongoing pregnancy after initial treatment (Table 2 and Extended Data Table 3 ). The effectiveness of synchronous and asynchronous telehealth was similar; in the complete case analysis effectiveness was 98.3% (95% CI = 97.5–99.0%) in the synchronous group and 97.4% (95% CI = 96.9–98.0%) in the asynchronous group. In the final imputed analysis, effectiveness was 98.3% (95% CI = 97.7–99.0%) in the synchronous group and 97.4% (95% CI = 96.9–98.0%) in the asynchronous group. Effectiveness also did not differ according to patient age, pregnancy duration, race, ethnicity or ethnic grouping, urbanicity, previous birth, previous abortion or whether the patient had screening ultrasonography.

Among the 2.3% (95% CI = 1.9–2.8%) of patients whose abortion was not initially complete, 0.56% were treated with more than 200 mg mifepristone, more than 1,600 μg misoprostol or other uterotonic medication to complete the abortion, 1.4% were treated with an aspiration or other abortion procedure, 0.16% were treated for an ectopic pregnancy and 0.94% had a confirmed or suspected continuing pregnancy (Table 3 ).

Overall, six (0.16%) patients had ectopic pregnancies; three (0.12%) were suspected ectopic pregnancies treated with methotrexate; one (0.07%) was an ectopic pregnancy treated with an unknown treatment; one (0.12%) was a cesarean scar ectopic pregnancy treated with an unknown treatment; and one (0.09%) was a ruptured ectopic pregnancy treated with a salpingectomy.

Overall, the rate of abortions that were not followed by a serious adverse event was 99.7% (95% CI = 99.5–99.8%) in the complete case analysis and 99.8% (95% CI = 99.6–99.9%) in the final imputed model (Table 2 and Extended Data Table 3 ). Safety was similar between patients who received synchronous and asynchronous care; in the complete case analysis, the safety rate was 99.7% (95% CI = 99.4–100.0%) in the synchronous group and 99.6% (95% CI = 99.4–99.9%) in the asynchronous group. In the final imputed model, safety was 99.8% (95% CI = 99.5–100.0%) among synchronous patients and 99.7% (95% CI = 99.6–99.9%) among asynchronous patients. In the final imputed models, safety was lower among Black or African American patients (99.3%, 95% CI = 98.7–100.0%) than among white patients (99.8%, 95% CI = 97.0–100.0%). No other factors were significantly associated with reduced safety.

Among the 0.25% of patients who experienced a serious adverse event, 0.10% received blood transfusions and 0.02% had abdominal surgery to treat a ruptured ectopic pregnancy; 0.17% of patients had hospital admissions requiring overnight stays. Among the ten (0.17%) hospital admissions, four (0.12%) received inpatient aspiration procedures, two (0.10%) were treated for infection and received an aspiration, one (0.09%) involved a blood transfusion and aspiration, one (0.09%) underwent surgery to treat a ruptured ectopic pregnancy, one (0.08%) was treated with intravenous antibiotics and one (0.09%) had a uterine infection treated with unknown treatment.

Other outcomes

Overall, 1.3% (95% CI = 1.1–1.6%) of abortions were followed by a known emergency department visit, 38.3% of which resulted in no treatment. Emergency department visits were similar between synchronous patients (1.2%, 95% CI = 0.7–1.7%) and asynchronous patients (1.4%, 95% CI = 1.0–1.7%). We identified no cases where, at the subsequent follow-up, it was determined that the abortion occurred beyond 70 days’ gestation.

Sensitivity analyses

The first sensitivity analysis, where we conservatively categorized the 25 patients who were referred to in-person care and were subsequently lost to follow-up as requiring additional intervention to complete the abortion, resulted in effectiveness rates that were not significantly different from the primary analysis; overall 97.1% (95% CI = 96.5–97.6%), with 98.1% (95% CI = 97.3–98.8%) among synchronous patients and 96.7% (95% CI = 96.0–97.3%) among asynchronous patients.

In the second sensitivity analysis modeling effectiveness, we considered patients as having complete abortions regardless of the amount of misoprostol they received, which is consistent with the Medical Abortion Reporting of Efficacy (MARE) guidelines 20 . (Total misoprostol dosages according to pregnancy duration are reported in Extended Data Table 4 .) This also resulted in effectiveness rates that were not significantly different from the primary analysis: 97.9% (95% CI = 97.4–98.3%) overall, 98.4% (95% CI = 97.8–99.0%) among patients who received synchronous care and 97.7% (95% CI = 97.1–98.2%) among patients who received asynchronous care.

The third sensitivity analysis, where we examined effectiveness and safety only among the subsample of patients with supplementary self-reported data on their outcomes via surveys in addition to standard clinical follow-up ( n = 1,600), resulted in effectiveness rates that were not significantly different from the primary analysis: 96.7% (95% CI = 95.7–97.6%), with 97.1% (95% CI = 95.6–98.6%) among those who received synchronous care and 96.4% (95% CI = 95.2–97.6%) among those who received asynchronous care. This sensitivity analysis resulted in a similar safety rate of 99.3% (95% CI = 98.9–99.7%), and rates of 99.4% (95% CI = 98.7–100.0%) among those who received synchronous care versus 99.3% (95% CI = 98.8–99.8%) of those who received asynchronous care.

In the fourth sensitivity analysis, we conducted delta-adjusted pattern-mixture modeling to examine the potential impact of loss to follow-up on the observed results (Extended Data Table 5 ). Across a range of delta values, we found that the results were largely consistent with the main analysis. Under an extreme scenario in which those with unknown outcomes had ten times the odds of an incomplete abortion or serious adverse event, effectiveness for the entire sample would be 93.3% (95% CI = 92.1–94.5%) and safety would be 98.9% (95% CI = 98.3–99.4%). Under this scenario, effectiveness would be higher in the synchronous group than the asynchronous group, but there would be no differences in safety. Under the opposite and also extreme scenario in which those with unknown outcomes had ten times lower odds of an incomplete abortion, effectiveness would be 98.2% (95% CI = 97.9–98.6%) and safety would be 99.7% (95% CI = 99.6–99.9%), with no significant differences in effectiveness and safety between synchronous and asynchronous groups.

In this large prospective cohort study, telehealth medication abortion provided primarily without tests was effective and safe. The overall 98% effectiveness rate of our primary analysis, and the effectiveness rates from the sensitivity analyses, were similar to previous large US studies of in-person medication abortion care, which found rates of 95–98% 21 , 22 , 23 , 24 . The serious adverse event rate of 0.25% and ectopic pregnancy rate of 0.14% were also similar to previous studies of in-person medication abortion care, which found adverse event rates of 0.2–0.5%, and ectopic pregnancy rates of 0.2% 8 , 23 , 24 , 25 . Both effectiveness and safety rates were similar to the rates for medication abortions with in-person screening tests as published on the FDA label (Fig. 3 ) 8 .

The gray bars represent published estimates from the FDA label for in-person dispensing of mifepristone; the blue bars represent the rates found in the CHAT study. Estimates for the CHAT study were calculated using marginal estimates from logistic regression analyses conducted on n = 6,034 patients. The published estimates of in-person dispensing represent the published rates drawn from the FDA label for mifepristone in 2016. The 95% CIs are represented by the black error bars.

The effectiveness and safety rates found in this study are consistent with, although slightly lower than, those found in studies of no-test telehealth abortion in other countries. A national study in the UK, which included 18,435 telehealth medication abortions, found that 99% were complete without intervention and serious adverse events occurred in 0.02% (refs. 26 , 27 , 28 ). This higher documented effectiveness rate may be explained by the lack of routine follow-up after medication abortion care in the UK; additional interventions that patients may receive may not be systematically reported to the original abortion provider.

The rates in our study are also similar to the effectiveness and safety rates documented from self-managed medication abortion models (defined as using abortion pills to end a pregnancy outside of the formal healthcare system), in the USA 29 and internationally, including in contexts where abortion is legally restricted 30 , 31 .

The effectiveness rates for both synchronous and asynchronous services were very high and similar to in-person care. These findings have important implications for service delivery and health equity. Synchronous models with videoconferencing require strong Internet connectivity. Asynchronous models can be accessed using more types of devices; they may be more private, require shorter waiting times and can be more easily integrated into work or home schedules because no appointment is needed 32 , 33 , 34 . Offering patients a choice between synchronous and asynchronous care is consistent with patient-centered care and may increase access for people historically excluded from healthcare, particularly those living in rural areas or those who live far from an abortion-providing facility 1 , 35 , 36 .

We used a more conservative definition of effectiveness than recommended by the MARE guidelines 20 but used in previous studies 17 , 37 . Our definition included an additional 22 patients who received a second medication abortion (mifepristone plus misoprostol) or more than one additional dose of misoprostol. In the context of telehealth and in the wake of the Dobbs decision, patients living in states that have banned abortions may experience more barriers to procedural treatment for incomplete abortion and thus be more likely to obtain additional medications to complete the abortion. Therefore, our definition of effectiveness may better account for patient experience.

While safety was over 99% among all ethnic groups, Black patients had significantly higher rates of serious adverse events than white patients. This finding is consistent with research showing higher rates of adverse obstetric outcomes among Black patients. Growing consensus finds that these disparities in obstetric health are rooted in implicit biases and structural racism 38 , 39 .

This analysis provides an initial picture of the real-world effectiveness and safety of a rapidly expanding model of abortion care among a large US cohort. However, this analysis has several limitations. One is the lack of clinic-level variation in synchronous and asynchronous models, which may limit generalizability. However, each virtual clinic had multiple providers offering care, thereby increasing variation within each clinic and thus the generalizability of our findings. For example, different providers may use different thresholds or criteria for when to refer patients to in-person care for an ultrasound or exam, which may impact effectiveness rates. This natural variation strengthens the premise that these results could be applied to other providers offering synchronous or asynchronous care. While there was no direct comparison group, we were able to compare our results to widely accepted rates in the published literature using standardized guidelines for measuring medication abortion outcomes.

Additionally, we identified no cases of unexpected pregnancy durations beyond 70 days. This is surprising given that a previous study of no-test medication abortion found a rate of 0.38% 17 . This lack of evidence may be due to underreporting. Although most patients can accurately assess their pregnancy duration 40 , 41 , patients who later learned that they provided a date of last menstrual period that underestimated their pregnancies may have felt that they could be held responsible and thus not reported it to the virtual clinic, particularly if it resulted in an abortion beyond 70 days.

Finally, another limitation is the follow-up rate; at 74% it was similar or higher than other studies on abortion 17 , 31 , 42 , 43 ; attrition may have introduced selection bias given that some groups had lower follow-ups than others. In particular, we observed lower follow-up rates in the asynchronous group than the synchronous group. Telehealth is a less medicalized healthcare model, and asynchronous care even less so; those who opt for it may prefer a more autonomous experience. This differential follow-up may overestimate effectiveness and safety rates for asynchronous patients if those with concerning symptoms seek additional care without informing the virtual clinic. On the other hand, it might underestimate effectiveness rates if patients who have a negative pregnancy test or clear signs of complete abortion do not feel that they must report their outcome back to the virtual clinic. We attempted to limit this potential bias with multiple imputation. We also explored this limitation through a sensitivity analysis simulating higher and lower odds of incomplete abortions and serious adverse events among those lost to follow-up relative to those with known outcomes. This analysis demonstrated that differences in effectiveness between synchronous and asynchronous groups could reach significance under extreme scenarios, but differences in safety remained nonsignificant in all scenarios tested.

These findings provide evidence that telehealth for abortion is effective and safe, with rates similar to in-person care. Additionally, synchronous and asynchronous care are comparably effective and safe. Although telehealth models cannot serve the needs and preferences of everyone, such as those who do not have electronic devices or those who are beyond the first trimester of pregnancy, offering people telehealth options has the potential to expand access to abortion care. These results are reassuring as more clinicians begin to provide telehealth abortion care to patients in US states with a ban, under the legal protections of their state’s shield laws. At the same time, 11 states continue to permit abortion but have prohibitions on no-test telehealth abortion ( https://www.rhites.org/state-based-resources ). This study demonstrates that policies that restrict telehealth abortion owing to concerns or claims about effectiveness or safety need to be revisited and revised to ensure equitable access to this essential healthcare service.

The CHAT study was approved by the University of California, San Francisco institutional review board (no. 20-32951) and registered with ClinicalTrials.gov (registration: NCT04432792 ). We used Strengthening the Reporting of Observational studies in Epidemiology guidelines to design and report the results of this study. All survey respondents provided consent to participate in the research.

Data source and study cohort

The CHAT study followed the patients of three US virtual abortion clinics: Choix (which opened in October 2020); Hey Jane (which opened in January 2021); and Abortion on Demand (which opened in April 2021). These virtual clinics were selected because they were among the first to open in the USA after the FDA temporarily suspended the in-person dispensing requirement during the COVID-19 emergency, and because they operated in states with large populations.

Medication protocols included 200 mg mifepristone orally and 800 µg misoprostol buccally or vaginally for pregnancy durations less than 63 days or 1,600 µg for pregnancy durations of 63 or more days. Care was provided based on a published protocol 19 by nurse practitioners, nurse midwives, physician assistants and physicians who specialize in abortion care. Clinics offered synchronous (video) or asynchronous (secure text messaging) telehealth abortion with mail order pharmacy delivery. One clinic offered only synchronous medication abortion care, one offered only asynchronous care and one offered asynchronous care with an option to have a phone or video call with the provider if preferred. Patients learned about the services through Web searches, social media or referrals.

During the study period, one clinic offered abortion care up to 56 days (8 weeks) of pregnancy, whereas the two other clinics offered it up to 70 days (10 weeks). As per the published protocol, patients were evaluated for medical eligibility based on the reported medical history. Pregnancy duration at intake was primarily based on self-reported date of last menstrual period or by ultrasonography, if available. Some patients had already had ultrasonography before contacting the virtual clinic. Additionally, patients were referred for pre-abortion ultrasonography if they had any risk factors for, or symptoms of, ectopic pregnancy 19 or were potentially beyond the gestational limit of the virtual clinic. Some of these patients returned to the virtual clinic after their eligibility was confirmed by ultrasonography and obtained a telehealth abortion; thus, they were included in the study. Others opted for in-person care and thus were excluded.

Each clinic had two scheduled follow-up interactions. The first confirmed medication administration and assessed symptoms of complete abortion 3–7 days after intake. The second was a low-sensitivity pregnancy test at 2 weeks or a high-sensitivity test at 4 weeks after medication administration. Follow-up interactions were conducted by text messaging, secure messaging or telephone. At each scheduled follow-up, clinicians made up to four attempts to contact patients. Clinicians referred patients to in-person care if any adverse event or incomplete abortion was suspected and outcomes of care were documented whenever possible.

For this analysis, we evaluated data collected from two sources, both imported into REDCap 44 . We obtained anonymized medical record data of consecutive patients receiving care from the participating virtual clinics between April 2021 and January 2022.

Additionally, each virtual clinic invited all patients seen between June 2021 and January 2022 to enroll in three surveys about their abortion experience, including any additional treatments received. After providing electronic informed consent, participants completed a baseline survey on the date of the intake, which included sociodemographic characteristics and medical history. Participants completed a second survey 3–7 days after the intake, to assess medication administration, additional medical care and any adverse events, and a final survey 4 weeks after the intake to assess additional medical care and adverse events (Fig. 1 ). The survey sample was powered to assess the acceptability of telehealth (published separately 2 ); thus, we aimed to collect complete sets of surveys from 1,600 participants. Survey participants received a US$50 electronic debit card on completion of all three surveys.

The primary outcomes were effectiveness and safety based on standard definitions in previous studies 17 , 24 , 37 , 45 . We generally followed the MARE guidelines for reporting outcomes 20 . We defined effectiveness as the proportion of medication abortions that were complete after initial treatment with 200 mg mifepristone and 1,600 µg or less of misoprostol without known subsequent intervention. Abortions were not considered complete if (1) the patient had an aspiration, dilation and evacuation, other procedure or surgical intervention to complete the abortion; (2) the patient received more than 200 mg mifepristone, more than 1,600 µg misoprostol, or a uterotonic medication to complete the abortion; (3) the patient received treatment for suspected or confirmed ectopic pregnancy; or (4) the patient had a continuing pregnancy confirmed by ultrasonography or suspected at last contact. While MARE guidelines define effectiveness as successful expulsion of pregnancy without the need for procedural intervention, we chose a more conservative definition, recognizing that patients may view the need to have what constitutes a second medication abortion treatment as a failure of the medication abortion protocol.

We defined safety using standardized definitions from the Procedural Abortion Incident Reporting and Surveillance Framework 45 and Standardizing Abortion Research Outcomes protocol 46 as the proportion of abortions that were not followed by a known abortion-related serious adverse event. Serious adverse events included: blood transfusion; abdominal surgery (including salpingectomy, laparotomy and laparoscopy to treat an ectopic pregnancy); hospital admission requiring overnight stay; or death.

Effectiveness and safety outcomes were determined from all information collected in the medical records and surveys. Abortion completion was determined based on the virtual clinic’s designation, either using a test (urine pregnancy test, ultrasonography or serum human chorionic gonadotrophin) or using the patient’s medical history (using a checklist reflecting symptoms of complete abortion) without further contact related to the abortion for at least 6 weeks after the intake visit. Patients without outcomes noted in the medical records were determined to have complete abortions if they completed a survey at least 28 days after screening and did not report an intervention or ongoing pregnancy.

Secondary outcomes included the number of cases where, at the subsequent follow-up, it was determined that at intake the patient had been beyond 70 days’ gestation. We also evaluated rates of suspected or confirmed ectopic pregnancy and emergency department visits.

We examined the categorical covariates reflecting participant age at abortion intake in years (16–17 years, 18–19 years, 20–24 years, 25–29 years, 30–34 years and 35 years or older), and pregnancy duration in days at abortion intake (less than 35 days, 35–49 days, 50–56 days, 57–63 days, 64–70 days or unknown). We also included a measure of race, ethnicity or ethnic grouping indicated by participants on an intake form or in the surveys (American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, Black or African American, Middle Eastern or North African, White, Multiracial or Unknown). We included binary covariates for urbanicity (suburban or rural versus urban), whether the patient had a previous abortion, whether the patient had a previous birth and whether the patient had confirmatory pre-abortion ultrasonography.

The key exposure was a binary measure reflecting whether the patient received care synchronously (video) or asynchronously (secure text messaging).

Statistical analysis

The study was powered to detect differences in the rarest primary outcome, that is, serious adverse events. We aimed to have outcome data from 4,202 patients. The study was designed to detect a difference of 0.4% or more in the rate of serious adverse events compared to 0.5%, the rate for in-person medication abortions as published in the FDA label 8 , with 90% power and a two-sided alpha of 0.05. With a final sample size of 4,454, the study had more than 90% power to detect a difference of 2% or more in the effectiveness rate compared to the 3% rate for in-person medication abortions as published on the FDA label 8 .

We described the characteristics of the overall sample and the subsample of patients who completed the surveys. We examined the extent of loss to follow-up and whether loss to follow-up differed between those who obtained synchronous and asynchronous care. We then conducted multiple imputation by chained equations to account for missing covariate and outcome data with 100 replications for primary regression analyses, assuming that missing data were related to observed patient and abortion characteristics. Multiple imputation by chained equations iteratively impute missing data using predictive models based on other variables in the dataset, and accounts for statistical uncertainty in the imputations 47 . Imputation models included patient age, urbanicity, whether the patient obtained screening ultrasonography, whether the patient obtained synchronous or asynchronous telehealth care, whether the patient participated in CHAT surveys, virtual clinics, and whether the patient used an abortion fund to pay for any portion of their abortion.

We developed logistic regression models for all effectiveness and safety outcomes. We used multivariable models for outcomes n > 15, adjusting for a binary measure of whether the patient received screening via synchronous or asynchronous methods. These models were also adjusted for baseline patient and abortion characteristics, including patient age, race, ethnicity or ethnic grouping, and pregnancy duration. We included binary measures reflecting whether the patient had a previous abortion or birth, and whether the patient had pre-abortion ultrasonography 21 . For rare outcomes ( n < 15), we used unadjusted logistic regression models.

We calculated marginal estimates, the corresponding 95% CIs and P values from the logistic regression results to estimate the predicted probability of each effectiveness and safety outcome. Primary estimates came from logistic regression analyses performed on imputed data. P values correspond to a Wald test in the logistic regressions, comparing each group to the reference group. We then compared results with published estimates of effectiveness and safety. All statistical tests were two-tailed with significance set at 0.05. All analyses were conducted using Stata v.17.0 (StataCorp LLC).

We conducted several sensitivity analyses to assess the robustness of our findings. First, we replicated the effectiveness analysis, assuming that patients who were referred to in-person care after taking the medications and were then lost to follow-up required further intervention to complete the abortion. Second, we replicated the effectiveness analysis by categorizing all patients who received any additional misoprostol as completed abortions. This is consistent with the MARE guidelines and previous studies 26 , 48 , which classified patients who received more than 1,600 μg of misoprostol (more than two doses) as successful abortions. Third, we examined both effectiveness and safety outcomes only among the subsample of patients who completed the surveys to evaluate whether the main findings held true among this sample with supplementary self-reported data on their outcomes. Finally, to test how robust our results were to the follow-up rates, we used delta-adjusted pattern-mixture model imputation 49 to simulate the outcomes under different assumptions regarding patients with missing outcome data, hypothesizing results if they had lower or higher odds of incomplete abortion or serious adverse events than those with outcome data.

Reporting summary

Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article.

Data availability

The datasets analyzed during this study are not publicly available because the patients who underwent an abortion did not consent to sharing their data beyond the primary researchers and because the legal status of abortion care is continually changing. The de-identified, individual-level data used to reach the study conclusions are available to qualified investigators from the corresponding author. Requesters must include a description of their research project, the qualifications of the research team, whether the analysis has institutional review board approval and how the results will be disseminated. Requesters must also sign a data use agreement to (1) use the data only for research purposes, (2) not attempt to re-identify the data or contact the study participants, (3) secure the data using appropriate computer technology and (4) destroy the data after the analyses are completed. Responses can be expected within 1 month of a request.

Code availability

Data analyses were carried out using Stata v.17.0 (StataCorp LLC) as specified in the Methods . The code is available on GitHub ( https://github.com/Upadhyay-Lab ).

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Acknowledgements

We thank M. Cervantes, L. Shin, K. Song, A. Becker and L. Peters for their contributions to data collection and management and other input on the CHAT study. We also thank C. Adam, M. Adam, K. Baron, S. Bussmann, L. Coplon, L. Dubey, L. DuBois, K. Freedman, G. Izarra, J. Phifer and A. Wagner for their support with data acquisition. We thank E. Wells and F. Coeytaux for their early input on study design, and E. Raymond for thoughtful guidance on classifying adverse events. We thank W. J. Boscardin for his input on pattern-mixture modeling. The CHAT study was supported by the BaSe Family Fund, the Erik E. and Edith H. Bergstrom Foundation, the Isabel Allende Foundation, Jess Jacobs, the Kahle/Austin Foundation, the Lisa and Douglas Goldman Fund, Preston-Werner Ventures (all to U.D.U.) and a Resource Allocation Program Award from the University of California, San Francisco National Center of Excellence in Women’s Health (to M.A.B.). L.R.K. was funded in part by a training grant from the National Institute of Child Health and Human Development of the National Institutes of Health under award no. F31HD111277 for the duration of the study. The funders had no role in study design, data collection and analysis, the writing of the manuscript or the decision to submit the manuscript for publication.

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Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA

Ushma D. Upadhyay, Leah R. Koenig, Karen Meckstroth, Jennifer Ko & M. Antonia Biggs

Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA

Leah R. Koenig

California Latinas for Reproductive Justice, Los Angeles, CA, USA

Ena Suseth Valladares

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Contributions

U.D.U. obtained the funding for the study. U.D.U., L.R.K., E.S.V. and K.M. conceptualized and designed the study. L.R.K. conducted the data analysis. U.D.U. supervised the data analysis. J.K. provided management and administration for the study. U.D.U., L.R.K. and M.A.B. drafted the manuscript. All authors interpreted the data, reviewed the manuscript drafts, provided substantive input on its content and approved the final version of the manuscript. U.D.U. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Corresponding author

Correspondence to Ushma D. Upadhyay .

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Competing interests.

K.M. reports receiving personal fees from Danco Laboratories, a distributor of mifepristone, for staffing a US Food and Drug Administration-mandated expert hotline. The other authors declare no competing interests.

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Nature Medicine thanks Alimu Dayimu and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. Primary Handling Editor: Sonia Muliyil and Jennifer Sargent, in collaboration with the Nature Medicine team.

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Upadhyay, U.D., Koenig, L.R., Meckstroth, K. et al. Effectiveness and safety of telehealth medication abortion in the USA. Nat Med (2024). https://doi.org/10.1038/s41591-024-02834-w

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Abortion Research Paper: Example, Outline, & Topics

The long-standing debate surrounding abortion has many opponents and advocates. Groups known as Pro-Choice and Pro-Life argue which approach is better, with no easy solution in sight. This ethical complexity is what makes abortion a popular topic for argumentative writing. As a student, you need to tackle it appropriately.

Our specialists will write a custom essay specially for you!

The picture shows statistics regarding the legal status of abortion.

If this task sounds daunting, read this guide by our custom-writing experts to get excellent writing tips on handling this assignment. You will also find here:

abortion topics and prompts,
a research paper outline,
a free essay sample.
🤔 Why Is Abortion a Good Topic?
☑️ Research Paper Prompts
👨‍⚕️ Abortion Research Questions
📚 Research Topics
🔬 Before You Start
✍️ Step-by-Step Writing Guide

📋 Abortion Research Paper Example

🔍 references, 🤔 why is abortion a good research topic.

Abortion studies are a vast area of research and analysis. It touches upon numerous domains of life, such as politics, medicine, religion, ethics, and human rights perspectives.

Like gun control or euthanasia, the abortion debate offers no evident answers to what kind of regulation is preferable. According to a recent survey, 61% of US adults are in favor of abortion , while 37% think it should be illegal. The arguments from both sides make sense, and there is no “yes-no” solution.

All this makes investigating the abortion debate a valuable exercise to hone your critical analysis skills. It will teach you to back up your claims with sound evidence while giving credit to counterarguments. Besides, expanding the body of abortion research is beneficial for the American community and women’s rights.

☑️ Abortion Research Paper Prompts

The first step to writing a successful paper is choosing an appropriate topic. Abortion is surrounded by numerous legal, medical, ethical, and social debates. That’s why the choice of ideas is virtually endless.

Just in 1 hour! We will write you a plagiarism-free paper in hardly more than 1 hour

Don’t know where to start? Check out the prompts and creative titles below.

Should Abortion Be Legal: Research Paper Prompt

You can approach this question from several perspectives. For example, propose a new legal framework for regulating eligibility for abortion. Some states allow the procedure under certain circumstances, such as a threat to a woman’s health. Should it be made legal in less extreme situations, too?

Anti-Abortion Research Paper Prompt

The legal status of abortions is still disputed in many countries. The procedure’s most ardent opponents are Catholic religious groups. In an anti-abortion paper, you may list ethical or faith-based claims. Focus on the right-to-life arguments and give scientific evidence regarding embryo’s rights.

Abortion and Embryonic Stem Cell Research Prompt

Stem cell research is a dubious issue that faces strong opposition from ethical and religious activists. Here are some great ideas for an essay on this topic:

Start by explaining what stem cells are.
Outline the arguments for and against their use in research.
Link this discussion to the status of abortion.

Abortion Law Research Paper Prompt

If you get an abortion-related assignment in your Legal Studies class, it’s better to take a legislative approach to this issue. Here’s what you can do:

Receive a plagiarism-free paper tailored to your instructions. Cut 20% off your first order!

Study the evolution of abortion laws in the US or other countries.
Pinpoint legal gaps.
Focus on the laws’ strengths and weaknesses.

Abortion Breast Cancer Research Prompt

Increasing research evidence shows the link between abortion and breast cancer development . Find scholarly articles proving or refuting this idea and formulate a strong argument on this subject. Argue it with credible external evidence.

Abortion Ethics Research Paper Prompt

Here, you can focus on the significance of the discussion’s ethical dimension. People who are against abortion often cite the ethics of killing an embryo. You can discuss this issue by quoting famous thinkers and the latest medical research. Be sure to support your argument with sound evidence.

👨‍⚕️ Questions about Abortion for Research Paper

How does technology reframe the abortion debate ?
Is there new ethics of abortion in the 21 st century?
How did the abortion debate progress before the Roe v. Wade decision?
How is the abortion debate currently being shaped on social media?
How do abortion rights advocates conceptualize the meaning of life ?
Can the abortion debate be called a culture war?
What are women’s constitutional abortion rights ?
How does abortion reshape the concept of a person?
How does the abortion debate fit in the post-Socialist transition framework of the European community?
Where does the abortion debate stand in the politics of sexuality?

📚 Abortion Topics for Research Paper

The changing legal rhetoric of abortion in the US .
Constructing abortion as a legal problem .
Regendering of the US’ abortion problem .
Evolution of public attitudes to abortion in the US.
Choice vs. coercion in the abortion debate.
Abortion and sin in Catholicism.
Artificial wombs as an innovative solution to the abortion debate.
Religious belief vs. reason in the abortion debate.
Introduction of pregnant women’s perspectives into the abortion debate: dealing with fetal abnormalities .
The role of ultrasound images in the evolution of women’s abortion intentions.

🔬 Research Papers on Abortions: Before You Start

Before discussing how to write an abortion paper, let’s focus on the pre-writing steps necessary for a stellar work. Here are the main points to consider.

The picture explains the difference between qualitative and quantitative research design.

Abortion Research Design

Before you start exploring your topic, you need to choose between a qualitative and quantitative research design:

💬 Qualitative studies focus on words and present the attitudes and subjective meanings assigned to the concept of abortion by respondents.

Get an originally-written paper according to your instructions!

🧪 Quantitative studies , in turn, focus on numbers and statistics. They analyze objective evidence and avoid subjective interpretations.

Pick a research design based on your research skills and the data you’re planning to analyze:

If you plan to gain insight into people’s opinions, attitudes, and life experiences related to abortion, it’s better to go for an interview and qualitative analysis.
If you have a survey and want to focus on descriptive statistics, it’s better to stick to quantitative methods .

Abortion Research Paper Outline Format

Next, it’s time to choose the format of your paper’s outline. As a rule, students use one of the 3 approaches:

You can learn more about these formats from our article on how to write an outline .

Choosing Headings & Subheadings

A strong title can save your paper, while a poor one can immediately kill the readers’ interest. That’s why we recommend you not to underestimate the importance of formulating an attention-grabbing, exciting heading for your text.

Here are our best tips to make your title and subheadings effective:

A good title needs to be brief. It’s up to 5 words, as a rule. Subheadings can be longer, as they give a more extended explanation of the content.
Don’t be redundant. Make sure the subheadings are not duplicating each other.
Mind the format. For instance, if your paper is in the APA format, you need to use proper font size and indentation. No numbering of headings and subheadings is necessary as in the outline. Ensure the reader understands the hierarchy with the help of heading level distinctions.

Components of an Effective Outline

According to academic writing conventions, a good outline should follow 4 essential principles:

Parallelism . All components of your outline need to have a similar grammatical structure. For example, if you choose infinitives to denote actions, stick to them and don’t mix them with nouns and gerunds.
Coordination . Divide your work into chunks with equal importance. This way, you will allocate as much weight to one point as to all the others. Your outline’s sections of similar hierarchy should have equal significance.
Subordination . The subheadings contained within one heading of a higher order should all be connected to the paper’s title.
Division . The minimum number of subheadings in each outline heading should be 2. If you have only one point under a heading, it’s worth adding another one.

Use this list of principles as a cheat sheet while creating your outline, and you’re sure to end up with well-organized and structured research!

Abortion Research Paper Outline Example

To recap and illustrate everything we’ve just discussed, let’s have a look at this sample abortion outline. We’ve made it in the decimal format following all effective outlining principles—check it out!

History of abortion laws in the USA.
Problem: recent legal changes challenge Roe vs. Wade .
Thesis statement: the right to abortion should be preserved as a constitutional right
The fundamental human right to decide what to do with their body.
Legal abortions are safer.
Fetuses don’t feel pain at the early stages of development.
Abortion is murder.
Fetuses are unborn people who feel pain at later stages.
Abortion causes lifelong psychological trauma for the woman.
Roe vs. Wade is a pro-choice case.
The constitutional right to privacy and bodily integrity.
Conclusion.

✍️ Abortion Research Paper: How to Write

Now, let’s proceed to write the paper itself. We will cover all the steps, starting with introduction writing rules and ending with the body and conclusion essentials.

Abortion Introduction: Research Paper Tips

When you begin writing an abortion paper, it’s vital to introduce the reader to the debate and key terminology. Start by describing a broader issue and steadily narrow the argument to the scope of your paper. The intro typically contains the key figures or facts that would show your topic’s significance.

For example, suppose you plan to discuss the ethical side of abortion. In this case, it’s better to structure the paper like this:

Start by outlining the issue of abortion as a whole.
Introduce the arguments of pro-choice advocates, saying that this side of the debate focuses on the woman’s right to remove the fetus from her body or leave it.
Cite the latest research evidence about fetuses as living organisms, proceeding to debate abortion ethics.
End your introduction with a concise thesis statement .

The picture shows parts of an introduction in an abortion research paper.

Thesis on Abortion for a Research Paper

The final part of your introduction is a thesis—a single claim that formulates your paper’s main idea. Experienced readers and college professors often focus on the thesis statement’s quality to decide whether the text is worth reading further. So, make sure you dedicate enough effort to formulate the abortion research paper thesis well!

Don’t know how to do it? These pro tips will surely help you write a great thesis:

Abortion Research Paper Body

Now, it’s time to proceed to the main body of your paper. It should expand on the main idea in more detail, explaining the details and weighing the evidence for and against your argument.

The secret of effective writing is to go paragraph by paragraph . Your essay’s body will have around 2-5 of them, and the quality of each one determines the value of the whole text.

Here are the 4 easy steps that can help you excel in writing the main part of your essay:

Start each paragraph with a topic sentence. It functions as a mini-thesis statement and communicates the paragraph’s main idea.
Then, expand it with additional facts and evidence. It’s better to back that information with external sources, showing that it’s not your guesswork. Make sure you properly analyze the citations and show how they fit into your broader research.
A paragraph should end with a concise wrap-up. Write a concluding sentence restating the topic sentence or a transition linking to the next section.

Research Papers on Abortions: Conclusion

The conclusion of an abortion paper also plays a major role in the overall impression that your paper will produce. So, how do you make it interesting?

Instead of simply restating the thesis and enumerating your points, it’s better to do the following:

Focus on the broader implications of the issue you’ve just discussed.
Mention your study’s limitations and point out some directions for further research.
It’s also a good idea to include a call to action , which can help create a sense of urgency in the readers.

Abortion Articles for Research Paper & Other Sources

Every research paper ends with “works cited” or a reference page enumerating the sources used for the assignment. A rule of thumb is to cite credible, authoritative publications from governmental organizations and NGOs and academic articles from peer-reviewed journals. These sources will make your research more competent and professional, supporting your viewpoint with objective scientific information.

Here are some databases that can supply top-quality data to back the abortion-related claims in a research paper:

Feel free to check these databases for studies related to your subject. It’s best to conduct preliminary research to see whether your topic has enough supporting evidence. Also, make sure there are plenty of new studies to back your arguments! Abortion is a fast-changing field of research, so it’s best only to use publications no more than 5 years old.

To learn more about credible research sources, check out our guide on choosing reliable websites .

We’ve taught you all you need to write a well-researched and thoughtful abortion paper. Finally, we want to give you an example of an essay on the topic “ Should Abortion Rights Be Preserved? ” Check it out to gain inspiration.

Now you know all the details of abortion paper writing. Use our tips to choose a topic, develop sound arguments, and impress your professor with a stellar piece on this debatable subject!

❓ Abortion Research Paper FAQs

First, you need to pick a debatable topic about abortion and develop a thesis statement on that subject.
Next, choose the arguments to support your claim and use external evidence to back them up.
End the paper with a concise wrap-up.
Begin your introduction with a catchy fact or shocking statistics on the issue of abortion.
Ask a rhetorical question to boost your readers’ interest.
Cite a famous person’s words about the pros and cons of legal abortion.

To compose a strong opening for your abortion essay, make sure to provide some background and context for further discussion. Explain why the debate about abortions is so acute and what the roots of the problem are.

There are many interesting topics related to abortion, spanning the areas of sociology, ethics, and medicine. You can focus on the progression of the abortion debate along with civil rights or discuss abortion from a feminist perspective.

You can choose between qualitative and quantitative approaches for your abortion research. Hold a survey among women and report the findings of your qualitative study in a short report. Or, you can measure factual information in numbers and conduct quantitative research.

The Ultimate Guide to Writing a Research Paper: Grammarly
Scholarly Articles on Abortion: Gale
Unintended Pregnancy and Abortion Worldwide: Guttmacher Institute
Why Abortion Should Be Legal: News 24
Pro and Con: Abortion: Britannica
Organizing Academic Research Papers: The Introduction: Sacred Heart University
How to Write a Thesis Statement for a Research Paper: Steps and Examples: Research.com
Abortion: American Psychological Association
Writing a Research Paper: University of Wisconsin-Madison
Writing a Research Paper: Purdue University
A Process Approach to Writing Research Papers: University of California, Berkeley
What Is Qualitative vs. Quantitative Study?: Grand Canyon University
Decimal Outlines: Texas A&M University
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How to Write Abortion Research Paper Homework?

Table of Contents

Looking for easy tips on how to write a research paper on abortion? We’ve got you covered!

Abortion is probably the most controversial subject in modern society. It includes a number of complex questions concerning ethical, moral, legal, medical, philosophical, and religious issues related to the deliberate ending of pregnancy before normal childbirth.

Public opinions are polarized; they have strong feelings for or against this subject. That’s why writing a good abortion research paper with work cited requires in-depth research of existing literature. Students have to find a decent amount of relevant arguments (statistics, facts) about positive and negative aspects of the problem and create a convincing piece.

Abortion research paper specifics

Abortion research paper is a piece of academic writing based on original research performed by a writer. The author’s task is to analyze and interpret research findings on a particular topic.

Although research paper assignments may vary widely, there are two common types – analytical and argumentative.

In argumentative essay students have to establish their position in a thesis statement and convince their audience to adopt this point of view.
In analytical essay students state a research question, take a neutral stance on a topic, presenting information in a form of well-supported critical analysis without persuading the audience to adopt any particular point of view.

Thorough writing a college research paper on the subject is critical – it can help students develop their own opinions and build a strong argument.

Research paper on abortion: writing hints & tips

Abortion is among political and moral issues on which Americans are genuinely split. Their opinions on this controversial issue remain unchanged since 1995. There are two primary moral and legal questions related to the abortion debate, which divides public opinion for generations:

Are abortions morally wrong?
Should they be legal or banned?

Although these questions seem straightforward, they are more complex than students think. There are two separate camps. People who favor the “pro-choice” stance support the right of women to choose whether she carries a pregnancy to term or not. They think that abortions are acceptable.

People who take the strict religious “pro-life” stance think that abortions are always wrong because the fetus has rights and we should treat it the same way as any other human being.

If you have to write an argumentative research paper, you must choose either “pro-life” or “pro-choice” stance and develop a convincing argument to persuade readers.

If your research paper is analytical, you should examine both sides of the issue, evaluate the most important arguments, provide a balanced overview of both approaches, analyzing their weak and strong points.

Religion plays a great role in the debate but there are a lot of non-religious issues. Here are the most important ethical and legal issues, involving the rights of women and the rights of a fetus.

Is fetus a human being and does it have the basic legal right to live?
Does life begin at conception?
Should we consider the fetus a separate being or is it a part of its mother?
Does the fetus’ right to life have a priority over the woman’s right to control her body?
Under what circumstances is it acceptable to terminate the fetus’ life?
Can the removing of a fetus be considered as a murder?
Is it better to abort an unwanted child or allow it to be neglected by parents?
Can adoption be alternative to termination of pregnancy?
Is it possible to find a balance between the rights of a mother and those of a fetus?

A lot of arguments in favor of this procedure are based on respect for women’s reproductive rights.

“Pro-choice” camp argues that a woman is a person with her own rights and not a fetus’ carrier.

They say that governmental or religious authorities shouldn’t limit a woman’s right to control her own body. Besides, the fetus can’t be regarded as a separate entity because it can’t exist outside a woman’s womb.

Opponents of this procedure speak about respect for all forms of life, fetus’ right to life, and argue that it is actually the kill of an innocent human being.

Best abortion research paper topics

The first step in writing a research paper is selecting a good manageable topic that interests you and defining a research question or a thesis statement.

Wondering where to find powerful abortion research paper topics? Here is a short list of interesting ideas. Feel free to pick any of them for creating your own writings. You may also use them as a source of inspiration and further research of a specific issue.

Impact of legalizing abortions on the birth rate.
How terminations of pregnancies are regulated around the world.
How termination of pregnancy is considered within moral terms.
Analyze regional differences in Americans’ attitude to termination of pregnancy.
Examine the generation gap in abortion support.
Feminist beliefs and abortion rights supporters.
What is the future of abortion politics?
Give an overview of the legislation on the termination of pregnancies around the world.
The medical complications of pregnancy termination.
Discuss the abortion debate and human rights.
How having an abortion affects a woman’s life.
Will the abortion debate ever end?
How can we reduce the demand for termination of pregnancy?
Moral aspects of pregnancy termination.
Legal aspects of the abortion conflict.
Should termination of pregnancy be treated as a health issue?
Electoral politics and termination of pregnancy.
Is the termination of pregnancy a human issue or a gender issue?
Philosophical aspects of the abortion debate.
Liberal views on the termination of pregnancy.
Abortion demographics: race, poverty, and choice.
Why does the public support for legal termination of pregnancy remains high?
Should men be allowed to discuss the termination of pregnancy?
Is the abortion a “women’s only” issue?
Woman’s mental health after abortion.

How to write an abortion research paper outline?

Now let’s discuss how to write an abortion research paper outline. First, you have to write a thesis statement that summarizes the main point of your paper and outlines supporting points. The thesis will help you organize your structure and ensure that you stay focused while working on your project. Make a thesis statement strong, specific, and arguable.

After defining the thesis statement, you need to brainstorm ideas that are supporting the thesis in the best way. When it comes to the level of detail in an outline, you should take into account the length of a college project. You should choose the most suitable subtopics and arrange them logically. Decide which order is the most effective in arguing your thesis. Your paper should include at least 3 parts: an introduction, main body, and conclusion.

Have a look at simple abortion research paper outline example .

Introduction

Hook sentence
Thesis statement
Transition to Main Body
History of abortion
Abortion demographics in countries where it is legal
Impact of legal termination of pregnancy on women’s life and health
Negative consequences of illegal termination of pregnancy
What measures should be taken to reduce the number of abortions?
Transition to Conclusion
Unexpected twist or a final argument
Food for thought

Academic writing is very challenging, especially if it involves complex controversial topics . Writing an abortion research paper is a time-consuming and arduous task, which involves a lot of researching, reading, writing, revising, rewriting, editing, and proofreading. Make sure you are ready to create several drafts and then improve the content and style to make your paper perfect.

We hope that our quick tips will help you get started. But if you are new to academic writing, a good idea is to find well-written abortion research paper examples. Read and analyze them to have a better idea about proper paper structure, academic writing style, references, and different approaches to organizing thoughts.

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Where to Start to Get the Right Environment Essay Topic

The Safety and Quality of Abortion Care in the United States (2018)

Chapter: 5 conclusions, 5 conclusions.

This report provides a comprehensive review of the state of the science on the safety and quality of abortion services in the United States. The committee was charged with answering eight specific research questions. This chapter presents the committee’s conclusions by responding individually to each question. The research findings that are the basis for these conclusions are presented in the previous chapters. The committee was also asked to offer recommendations regarding the eight questions. However, the committee decided that its conclusions regarding the safety and quality of U.S. abortion care responded comprehensively to the scope of this study. Therefore, the committee does not offer recommendations for specific actions to be taken by policy makers, health care providers, and others.

1. What types of legal abortion services are available in the United States? What is the evidence regarding which services are appropriate under different clinical circumstances (e.g., based on patient medical conditions such as previous cesarean section, obesity, gestational age)?

Four legal abortion methods—medication, 1 aspiration, dilation and evacuation (D&E), and induction—are used in the United States. Length of gestation—measured as the amount of time since the first day of the last

___________________

1 The terms “medication abortion” and “medical abortion” are used interchangeably in the literature. This report uses “medication abortion” to describe the U.S. Food and Drug Administration (FDA)-approved prescription drug regimen used up to 10 weeks’ gestation.

menstrual period—is the primary factor in deciding what abortion procedure is the most appropriate. Both medication and aspiration abortions are used up to 10 weeks’ gestation. Aspiration procedures may be used up to 14 to 16 weeks’ gestation.

Mifepristone, sold under the brand name Mifeprex, is the only medication specifically approved by the FDA for use in medication abortion. The drug’s distribution has been restricted under the requirements of the FDA Risk Evaluation and Mitigation Strategy program since 2011—it may be dispensed only to patients in clinics, hospitals, or medical offices under the supervision of a certified prescriber. To become a certified prescriber, eligible clinicians must register with the drug’s distributor, Danco Laboratories, and meet certain requirements. Retail pharmacies are prohibited from distributing the drug.

When abortion by aspiration is no longer feasible, D&E and induction methods are used. D&E is the superior method; in comparison, inductions are more painful for women, take significantly more time, and are more costly. However, D&Es are not always available to women. The procedure is illegal in Mississippi 2 and West Virginia 3 (both states allow exceptions in cases of life endangerment or severe physical health risk to the woman). Elsewhere, access to the procedure is limited because many obstetrician/gynecologists (OB/GYNs) and other physicians lack the requisite training to perform D&Es. Physicians’ access to D&E training is very limited or nonexistent in many areas of the country.

Few women are medically ineligible for abortion. There are, however, specific contraindications to using mifepristone for a medication abortion or induction. The drug should not be used for women with confirmed or suspected ectopic pregnancy or undiagnosed adnexal mass; an intrauterine device in place; chronic adrenal failure; concurrent long-term systemic corticosteroid therapy; hemorrhagic disorders or concurrent anticoagulant therapy; allergy to mifepristone, misoprostol, or other prostaglandins; or inherited porphyrias.

Obesity is not a risk factor for women who undergo medication or aspiration abortions (including with the use of moderate intravenous sedation). Research on the association between obesity and complications during a D&E abortion is less certain—particularly for women with Class III obesity (body mass index ≥40) after 14 weeks’ gestation.

A history of a prior cesarean delivery is not a risk factor for women undergoing medication or aspiration abortions, but it may be associated

2 Mississippi Unborn Child Protection from Dismemberment Abortion Act, Mississippi HB 519, Reg. Sess. 2015–2016 (2016).

3 Unborn Child Protection from Dismemberment Abortion Act, West Virginia SB 10, Reg. Sess. 2015–2016 (2016).

with an increased risk of complications during D&E abortions, particularly for women with multiple cesarean deliveries. Because induction abortions are so rare, it is difficult to determine definitively whether a prior cesarean delivery increases the risk of complications. The available research suggests no association.

2. What is the evidence on the physical and mental health risks of these different abortion interventions?

Abortion has been investigated for its potential long-term effects on future childbearing and pregnancy outcomes, risk of breast cancer, mental health disorders, and premature death. The committee found that much of the published literature on these topics does not meet scientific standards for rigorous, unbiased research. Reliable research uses documented records of a prior abortion, analyzes comparable study and control groups, and controls for confounding variables shown to affect the outcome of interest.

Physical health effects The committee identified high-quality research on numerous outcomes of interest and concludes that having an abortion does not increase a woman’s risk of secondary infertility, pregnancy-related hypertensive disorders, abnormal placentation (after a D&E abortion), preterm birth, or breast cancer. Although rare, the risk of very preterm birth (<28 weeks’ gestation) in a woman’s first birth was found to be associated with having two or more prior aspiration abortions compared with first births among women with no abortion history; the risk appears to be associated with the number of prior abortions. Preterm birth is associated with pregnancy spacing after an abortion: it is more likely if the interval between abortion and conception is less than 6 months (this is also true of pregnancy spacing in general). The committee did not find well-designed research on abortion’s association with future ectopic pregnancy, miscarriage or stillbirth, or long-term mortality. Findings on hemorrhage during a subsequent pregnancy are inconclusive.

Mental health effects The committee identified a wide array of research on whether abortion increases women’s risk of depression, anxiety, and/or posttraumatic stress disorder and concludes that having an abortion does not increase a woman’s risk of these mental health disorders.

3. What is the evidence on the safety and quality of medical and surgical abortion care?

Safety The clinical evidence clearly shows that legal abortions in the United States—whether by medication, aspiration, D&E, or induction—are

safe and effective. Serious complications are rare. But the risk of a serious complication increases with weeks’ gestation. As the number of weeks increases, the invasiveness of the required procedure and the need for deeper levels of sedation also increase.

Quality Health care quality is a multidimensional concept. Six attributes of health care quality—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—were central to the committee’s review of the quality of abortion care. Table 5-1 details the committee’s conclusions regarding each of these quality attributes. Overall, the committee concludes that the quality of abortion care depends to a great extent on where women live. In many parts of the country, state regulations have created barriers to optimizing each dimension of quality care. The quality of care is optimal when the care is based on current evidence and when trained clinicians are available to provide abortion services.

4. What is the evidence on the minimum characteristics of clinical facilities necessary to effectively and safely provide the different types of abortion interventions?

Most abortions can be provided safely in office-based settings. No special equipment or emergency arrangements are required for medication abortions. For other abortion methods, the minimum facility characteristics depend on the level of sedation that is used. Aspiration abortions are performed safely in office and clinic settings. If moderate sedation is used, the facility should have emergency resuscitation equipment and an emergency transfer plan, as well as equipment to monitor oxygen saturation, heart rate, and blood pressure. For D&Es that involve deep sedation or general anesthesia, the facility should be similarly equipped and also have equipment to provide general anesthesia and monitor ventilation.

Women with severe systemic disease require special measures if they desire or need deep sedation or general anesthesia. These women require further clinical assessment and should have their abortion in an accredited ambulatory surgery center or hospital.

5. What is the evidence on what clinical skills are necessary for health care providers to safely perform the various components of abortion care, including pregnancy determination, counseling, gestational age assessment, medication dispensing, procedure performance, patient monitoring, and follow-up assessment and care?

Required skills All abortion procedures require competent providers skilled in patient preparation (education, counseling, and informed consent);

TABLE 5-1 Does Abortion Care in the United States Meet the Six Attributes of Quality Health Care?

a These attributes of quality health care were first proposed by the Institute of Medicine’s Committee on Quality of Health Care in America in the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century.

b Elsewhere in this report, effectiveness refers to the successful completion of the abortion without the need for a follow-up aspiration.

clinical assessment (confirming intrauterine pregnancy, determining gestation, taking a relevant medical history, and physical examination); pain management; identification and management of expected side effects and serious complications; and contraceptive counseling and provision. To provide medication abortions, the clinician should be skilled in all these areas. To provide aspiration abortions, the clinician should also be skilled in the technical aspects of an aspiration procedure. To provide D&E abortions, the clinician needs the relevant surgical expertise and sufficient caseload to maintain the requisite surgical skills. To provide induction abortions, the clinician requires the skills needed for managing labor and delivery.

Clinicians that have the necessary competencies Both trained physicians (OB/GYNs, family medicine physicians, and other physicians) and advanced practice clinicians (APCs) (physician assistants, certified nurse-midwives, and nurse practitioners) can provide medication and aspiration abortions safely and effectively. OB/GYNs, family medicine physicians, and other physicians with appropriate training and experience can perform D&E abortions. Induction abortions can be provided by clinicians (OB/GYNs,

family medicine physicians, and certified nurse-midwives) with training in managing labor and delivery.

The extensive body of research documenting the safety of abortion care in the United States reflects the outcomes of abortions provided by thousands of individual clinicians. The use of sedation and anesthesia may require special expertise. If moderate sedation is used, it is essential to have a nurse or other qualified clinical staff—in addition to the person performing the abortion—available to monitor the patient, as is the case for any other medical procedure. Deep sedation and general anesthesia require the expertise of an anesthesiologist or certified registered nurse anesthetist to ensure patient safety.

6. What safeguards are necessary to manage medical emergencies arising from abortion interventions?

The key safeguards—for abortions and all outpatient procedures—are whether the facility has the appropriate equipment, personnel, and emergency transfer plan to address any complications that might occur. No special equipment or emergency arrangements are required for medication abortions; however, clinics should provide a 24-hour clinician-staffed telephone line and have a plan to provide emergency care to patients after hours. If moderate sedation is used during an aspiration abortion, the facility should have emergency resuscitation equipment and an emergency transfer plan, as well as equipment to monitor oxygen saturation, heart rate, and blood pressure. D&Es that involve deep sedation or general anesthesia should be provided in similarly equipped facilities that also have equipment to monitor ventilation.

The committee found no evidence indicating that clinicians that perform abortions require hospital privileges to ensure a safe outcome for the patient. Providers should, however, be able to provide or arrange for patient access or transfer to medical facilities equipped to provide blood transfusions, surgical intervention, and resuscitation, if necessary.

7. What is the evidence on the safe provision of pain management for abortion care?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended to reduce the discomfort of pain and cramping during a medication abortion. Some women still report high levels of pain, and researchers are exploring new ways to provide prophylactic pain management for medication abortion. The pharmaceutical options for pain management during aspiration, D&E, and induction abortions range from local anesthesia, to minimal sedation/anxiolysis, to moderate sedation/analgesia, to deep sedation/

analgesia, to general anesthesia. Along this continuum, the physiological effects of sedation have increasing clinical implications and, depending on the depth of sedation, may require special equipment and personnel to ensure the patient’s safety. The greatest risk of using sedative agents is respiratory depression. The vast majority of abortion patients are healthy and medically eligible for all levels of sedation in office-based settings. As noted above (see Questions 4 and 6), if sedation is used, the facility should be appropriately equipped and staffed.

8. What are the research gaps associated with the provision of safe, high-quality care from pre- to postabortion?

The committee’s overarching task was to assess the safety and quality of abortion care in the United States. As noted in the introduction to this chapter, the committee decided that its findings and conclusions fully respond to this charge. The committee concludes that legal abortions are safe and effective. Safety and quality are optimized when the abortion is performed as early in pregnancy as possible. Quality requires that care be respectful of individual patient preferences, needs, and values so that patient values guide all clinical decisions.

The committee did not identify gaps in research that raise concerns about these conclusions and does not offer recommendations for specific actions to be taken by policy makers, health care providers, and others.

The following are the committee’s observations about questions that merit further investigation.

Limitation of Mifepristone distribution As noted above, mifepristone, sold under the brand name Mifeprex, is the only medication approved by the FDA for use in medication abortion. Extensive clinical research has demonstrated its safety and effectiveness using the FDA-recommended regimen. Furthermore, few women have contraindications to medication abortion. Nevertheless, as noted earlier, the FDA REMS restricts the distribution of mifepristone. Research is needed on how the limited distribution of mifepristone under the REMS process impacts dimensions of quality, including timeliness, patient-centeredness, and equity. In addition, little is known about pharmacist and patient perspectives on pharmacy dispensing of mifepristone and the potential for direct-to-patient models through telemedicine.

Pain management There is insufficient evidence to identify the optimal approach to minimizing the pain women experience during an aspiration procedure without sedation. Paracervical blocks are effective in decreasing procedural pain, but the administration of the block itself is painful, and

even with the block, women report experiencing moderate to significant pain. More research is needed to learn how best to reduce the pain women experience during abortion procedures.

Research on prophylactic pain management for women undergoing medication abortions is also needed. Although NSAIDs reduce the pain of cramping, women still report high levels of pain.

Availability of providers APCs can provide medication and aspiration abortions safely and effectively, but the committee did not find research assessing whether APCs can also be trained to perform D&Es.

Addressing the needs of women of lower income Women who have abortions are disproportionately poor and at risk for interpersonal and other types of violence. Yet little is known about the extent to which they receive needed social and psychological supports when seeking abortion care or how best to meet those needs. More research is needed to assess the need for support services and to define best clinical practice for providing those services.

Abortion is a legal medical procedure that has been provided to millions of American women. Since the Institute of Medicine first reviewed the health implications of national legalized abortion in 1975, there has been a plethora of related scientific research, including well-designed randomized clinical trials, systematic reviews, and epidemiological studies examining abortion care. This research has focused on examining the relative safety of abortion methods and the appropriateness of methods for different clinical circumstances. With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed.

The Safety and Quality of Abortion Care in the United States offers a comprehensive review of the current state of the science related to the provision of safe, high-quality abortion services in the United States. This report considers 8 research questions and presents conclusions, including gaps in research.

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The Editorial Board

The Persistent Threat to Abortion Rights

An illustration of a woman lifting a huge mifepristone pill on her back.

By The Editorial Board

The editorial board is a group of opinion journalists whose views are informed by expertise, research, debate and certain longstanding values . It is separate from the newsroom.

The Supreme Court this week heard the first major challenge to abortion rights since it struck down Roe v. Wade two years ago — an attempt to severely limit access to mifepristone, the most commonly used abortion pill in the country, by a group of doctors who are morally opposed to the practice.

The justices seem prepared to throw out the lawsuit. During oral arguments, they questioned whether the doctors had suffered the harm necessary to bring the suit in the first place.

But that should come as small comfort to anyone concerned for the future of reproductive freedom in America. Judges at the state and federal levels are ready to further restrict reproductive options and health care access. The presumptive Republican nominee for president, Donald Trump, has indicated support for a 15-week national abortion ban. And while the Supreme Court, in overturning Roe, ostensibly left it to each state to decide abortion policy, several states have gone against the will of their voters on abortion or tried to block ballot measures that would protect abortion rights. Anti-abortion forces may have had a tough week in the Supreme Court, but they remain focused on playing and winning a longer game.

Even potential victories for reproductive freedom may prove short-lived: The mifepristone case, for instance, is far from dead. Another plaintiff could bring the same case and have it considered on the merits, a possibility Justice Samuel Alito raised during oral arguments.

“Is there anybody who could challenge in court the lawfulness of what the F.D.A. did here?” he asked the solicitor general, Elizabeth Prelogar. Such a challenge would be exceptionally weak, given that the F.D.A. provided substantial support for its approval and regulatory guidance on the use of mifepristone, but the right-wing justices on the Roberts court may be willing to hear it again anyway. The justices have already illustrated their hostility to the authority of administrative agencies, and that hostility may persist even in the face of overwhelming scientific evidence.

Then there is the Comstock Act, a 151-year-old federal law that anti-abortion activists are trying to revive to block the mailing of mifepristone and other abortion medication. During the oral arguments this week, Justices Alito and Clarence Thomas repeatedly expressed their openness to the use of the law, which was pushed by an anti-vice crusader decades before women won the right to vote. If anti-abortion activists can get themselves before a sympathetic court and secure a national injunction on this medication being mailed, they may well be able to block access to abortion throughout the country, including in states where it is legal.

However the mifepristone case turns out, the threats to reproductive rights the justices unleashed by overturning Roe go much further.

The anti-abortion movement is pursuing its aims on many legal fronts. One focus of intense activity is so-called fetal-personhood laws , which endow fetuses (and, in some cases, even fertilized eggs) with the same legal rights as living, breathing human beings. Last month, Alabama’s Supreme Court ruled that frozen embryos created through in vitro fertilization were to be protected as “extrauterine children,” relying in part on an 1872 state law. That sent lawmakers in Alabama scrambling to protect a procedure that is highly popular among Republicans and Democrats alike. Three weeks after the court ruling, they passed a law protecting patients and doctors who perform I.V.F. procedures from legal liability.

Fetal-personhood laws can also be used to target access to birth control, embryonic stem cell research and even women who suffer miscarriages.

In eliminating a woman’s constitutional right to choose what happens in her own body, the Supreme Court claimed to be respecting the democratic process by allowing state legislatures to determine whether abortion should be legal and what, if any, limits should be placed on it. Roe v. Wade had been “egregiously wrong” to wrest a fraught public debate from the American public, Justice Alito wrote in the majority opinion for Dobbs v. Jackson Women’s Health in 2022. It was “time to heed the Constitution and return the issue of abortion to the people’s elected representatives.”

Instead of being settled at the state level, less than two years since the Dobbs ruling, the issue of abortion has returned to the court and is likely to continue to do so for the foreseeable future.

The Dobbs ruling has forced a new public debate on abortion and galvanized Americans’ support for it, which has been strong for decades. Since 1975, a majority of Americans have supported legal abortion in some or all cases, according to polling by Gallup , and that support has increased slightly since Dobbs. The percentage of Americans who think abortion should be illegal in all cases has gone down.

Since Roe was overturned in 2022, in every state where reproductive rights have been on the ballot, from Vermont to Kentucky, the abortion rights side has won . This past Tuesday, the same day that the court heard the mifepristone case, voters in Alabama elected to the state legislature a Democrat who ran on a platform of protecting access to abortion and I.V.F. The candidate, Marilyn Lands, lost her race in 2022 by seven points; she won this week by 25 points.

There are limits to the state-by-state approach when it comes to protecting bodily autonomy. Some states don’t allow ballot initiatives of the type that have led to abortion rights victories elsewhere. In Ohio and other states, lawmakers have sought to block or overturn attempts by voters to protect abortion rights, and anti-abortion lawmakers in several states have sought to prosecute anyone who helps a woman travel to another state to get an abortion.

In short, there is no silver bullet for reproductive rights. The judiciary is no haven, not as long as the current Supreme Court majority holds; state and lower federal courts aren’t much better, going by the Alabama I.V.F. ruling and the decisions that pushed the mifepristone case to the Supreme Court. At the same time, voter support for reproductive rights won’t make a difference if they can’t use ballot measures to make that support known.

That is why any successful strategy to protect or restore abortion rights must understand reproductive rights and representative democracy as inextricably linked.

That means understanding the stakes of the elections in November. If Mr. Trump’s party wins solid control of the House and Senate, this could put Americans’ reproductive rights at further risk, especially if Republicans first decide to do away with the filibuster. That would lower the threshold for passing legislation such as a 15-week abortion ban , which Mr. Trump seems likely to support .

Voters will be faced with a stark choice: the choice of whether to protect not just reproductive rights but true equality for women.

Source photograph by Getty Images.

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Sex Reprod Health Matters
v.28(1); 2020

Language: English | French | Spanish

Abortion knowledge, attitudes and experiences among adolescent girls: a review of the literature

Cecilia espinoza.

a Ipas Senior Advocacy Advisor, Ipas, Chapel Hill, North Carolina, USA

Ghazaleh Samandari

b Independent consultant, Ipas, Chapel Hill, North Carolina, USA

Kathryn Andersen

c Chief Scientific and Technical Officer, Ipas, Chapel Hill, North Carolina, USA

Adolescent girls comprise a considerable proportion of annual abortion deaths, worldwide, with 15% of all unsafe abortions taking place among girls under 20 years of age. Despite recent global attention to the health and welfare of adolescent girls, little is known about their abortion experience, particularly of those under the age of 15 years. This review examines existing peer-reviewed and grey literature on abortion-related experiences of adolescent girls, paying particular attention to girls ages 10–14. In December 2019, the authors conducted a comprehensive search of five major online resource databases, using a two-part keyword search strategy for articles from 2003 to 2019. Of the original 3,100+ articles, 1,228 were individually screened and 35 retained for inclusion in the analysis. Findings show that while adolescent girls may have knowledge of abortion in general, they lack specific knowledge of sources of care and delay care-seeking due to the fear of stigma, lack of resources and provider bias. Adolescent girls do not experience higher rates of physical complications compared to older cohorts, but they are at risk of psychosocial harm. For girls ages 10–14, abortion experience may be compounded by pregnancy due to sexual abuse or transactional sex, and they face even more barriers to care than older adolescents in terms of provider bias and lack of agency. Adolescents have unique needs and experiences around abortion, which should be accounted for in programming and advocacy. Adolescent girls need information about safe abortion at an early age and a responsive and stigma-free health system.

Résumé

Dans le monde, les adolescentes représentent une proportion considérable des décès annuels dus à l’avortement, avec 15% de tous les avortements à risque étant pratiqués sur des filles âgées de moins de 20 ans. En dépit de l’attention mondiale récemment accordée à la santé et au bien-être des adolescentes, on sait peu de choses de leur expérience de l’avortement, en particulier pour celles qui ont moins de 15 ans. Cette analyse examine les publications à comité de lecture et la littérature grise sur l’expérience des adolescentes en rapport avec l’avortement, en s’intéressant particulièrement aux filles âgées de 10 à 14 ans. En décembre 2019, les auteurs ont réalisé une recherche exhaustive de cinq bases de données majeures de ressources en ligne, à l’aide d’une stratégie de recherche par mot clé en deux parties pour les articles de 2003 à 2019. Sur les plus de 3100 articles, 1228 ont été sélectionnés individuellement et 35 retenus pour être inclus dans l’analyse. Les conclusions montrent que si les adolescentes peuvent avoir des connaissances générales sur l’avortement, elles manquent de renseignements précis sur les sources de soins et retardent la demande de soins par crainte de la stigmatisation, manque de ressources et préjugés des prestataires. Les adolescentes ne connaissent pas de taux plus élevés de complications physiques que des cohortes plus âgées, mais elles risquent des dommages psychosociaux. Chez les filles âgées de 10 à 14 ans, l’expérience de l’avortement peut être aggravée par le fait que la grossesse était due à un abus sexuel ou à des relations sexuelles transactionnelles, et elles rencontrent des obstacles encore plus nombreux pour obtenir des soins que les adolescentes plus âgées, du point de vue des préjugés des prestataires et du manque de pouvoir. Les adolescents ont des besoins et des expériences uniques autour de l’avortement, dont il faudrait tenir compte dans la programmation et le plaidoyer. Les adolescentes ont besoin d’informations sur l’avortement sûr à un âge précoce ainsi que d’un système de santé réactif et qui ne les stigmatise pas.

Un considerable porcentaje de muertes anuales atribuibles al aborto ocurre entre adolescentes a nivel mundial, ya que el 15% de todos los abortos inseguros ocurren entre niñas menores de 20 años. A pesar de la atención mundial reciente a la salud y el bienestar de las adolescentes, no se sabe mucho sobre su experiencia de aborto, en particular entre aquéllas menores de 15 años. Esta revisión examina la literatura existente revisada por pares y la literatura gris sobre las experiencias de las adolescentes con relación al aborto, y presta particular atención a niñas entre 10 y 14 años. En diciembre de 2019, los autores realizaron una búsqueda integral en cinco principales bases de datos de recursos en línea, utilizando una estrategia de búsqueda con palabras clave de dos partes de artículos publicados entre los años 2003 y 2019. De los 3,100+ artículos originales, 1,228 fueron examinados individualmente y 35 fueron retenidos para su inclusión en el análisis. Los hallazgos muestran que, aunque las adolescentes tengan conocimientos generales del aborto, carecen de conocimientos específicos sobre las fuentes de servicios y retrasan la búsqueda de atención por temor al estigma, falta de recursos y prejuicios del personal de salud. Las adolescentes no presentan mayores tasas de complicaciones físicas comparadas con grupos de mujeres de edad más avanzada, pero corren riesgo de sufrir daños psicosociales. La experiencia de aborto de niñas entre 10 y 14 años podría verse agravada en casos de embarazo producido por abuso sexual o sexo transaccional; además, estas niñas enfrentan aun más barreras para obtener servicios que las adolescentes mayores, por los prejuicios del personal de salud y la falta de agencia. Las adolescentes tienen necesidades y experiencias únicas con relación al aborto, las cuales deben tomarse en consideración en los programas y en las actividades de promoción y defensa. Las adolescentes necesitan información sobre el aborto seguro a temprana edad y un sistema de salud receptivo y libre de estigma.

Each year, an estimated 3.2 million unsafe abortions (defined as a pregnancy termination performed either by a person lacking the necessary skills or in an environment lacking adequate medical standards) take place among adolescent girls ages 15–19. This number accounts for almost 15% of the total global incidence of unsafe abortion (22 million), and abortion-related mortality among young girls and women accounts for nearly one-third of abortion-related deaths worldwide. 1 Despite recently increased commitments to adolescent reproductive health, our understanding of their abortion experiences is limited. Furthermore, the focus of policy and programmatic attention remains primarily on adolescents ages 15–19, leaving a substantial gap in our understanding of the sexual and reproductive experiences of adolescents ages 10–14. 2–4 Girls in this category comprise a large and growing segment of the population, particularly in highly impoverished regions of the world (estimated at 545 million in 2015). 5 A parallel increase in the age of marriage in many contexts has extended the period of premarital fertility, which further exposes young adolescents to the risk of unintended pregnancy resulting in unsafe abortion. 6–8 Moreover, the majority of unsafe abortion incidence is concentrated in low- and middle-income countries (LMIC) where the 10–14-year-old population is proportionally largest, and where many countries have restrictive abortion laws. 9 , 10

The potential for sexual and reproductive harm among adolescents is a present and growing threat, yet our understanding of abortion in this group is insufficient to properly address their needs through programmatic and policy interventions. The purpose of this literature review is to explore abortion-related knowledge, attitudes and experiences of adolescent girls, paying particular attention to those ages 10–14.

This literature review focused on the abortion knowledge, experiences and attitudes of younger (10–14 years) and older (15–19 years) adolescents from LMIC (as defined by the World Bank). 11

Data sources

We conducted a systematic search of five online resource databases: PubMed, Global Health, Embase, POPLINE and Google Scholar, between June 2018 and December 2019. In addition, we searched websites of organisations that do sexual and reproductive health work with adolescents to locate any additional grey literature. These organisations included Ipas, International Planned Parenthood Federation, Guttmacher Institute, Marie Stopes International and EngenderHealth. We also conducted a general search of the Google search engine to locate any additional grey literature sources.

Search strategy

The search covered the time frame between 2003 and 2019 and was run simultaneously by GS and CE. Databases were searched using a two-part keyword search strategy. The first set of search terms focused on limiting the age group of target populations to only adolescents and included “Adolesc”* OR “young” OR “youth”* OR “girl”* OR “very young girl”* OR “very young adolesc”* OR “adolescent health services”* OR “child” OR “pregnancy in adolescence”. The second set of search terms related to abortion experience and included “Abortion” OR “termination of pregnancy” OR “pregnancy termination” OR “menstrual regulation” OR “postabortion” OR “abortion, induced”OR “abortion applicants”. These terms were used in combination with “tiab” and “MeSH” settings to maximise the identification of keywords in indexed articles in the databases.

Selection criteria

The search included all English, Spanish and French language † peer-reviewed publications of either quantitative or qualitative nature related to the abortion knowledge, attitudes or experience of adolescents ages 10–19. The search was restricted to articles that included findings from adolescents 19 years or younger years of age, meaning articles that included women from older age groups were included so long as data were segregated by age groups and findings for adolescents under 20 years of age could be differentiated from that of older women. The primary focus of this review is on adolescents from low- to middle-income countries.

Articles were excluded if they did not include findings from primary data collection or original secondary analysis of a primary data source, if they did not include data on the abortion experience, knowledge or attitudes of adolescents under the age of 20 years or did not come from an LMIC, with one exception: given that data on younger adolescents are sparse, if a study included segregated data on 10–14-year-olds, it was included in the review regardless of the LMIC status of the sample.

Screening and selection

We conducted screening and selection using the PRISMA guidelines ( Figure 1 ). 12 The search yielded over 3,100 articles, many of which included either duplicate articles of studies pertaining to clinical findings not suitable for the topic of this review (such as unrelated obstetric outcomes). The screening process was multi-stage, whereby first we removed all duplicates and clearly irrelevant articles (for example articles that pertained to highly technical obstetric procedures). We then performed an initial screening based on the abstracts retrieved in the first stage of the search. In this first pass, the reviewer erred on the side of inclusion, so as not to accidentally omit articles that may have provided relevant data in full-text form. After the initial abstract review, we conducted a third screening of full-text articles; only studies for which the full text was available either in English, French or Spanish were retained (as these were the working languages of the authors). Each article was then reviewed for quality by GS and CE using the critical appraisal skills programme checklist for both quantitative and qualitative studies. 13

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PRISMA screening process

Data abstraction and analysis

The articles were abstracted in terms of their publication details (authors, date, title, etc.), geographic scope, purpose, study design, population, methods and main findings. The articles were coded by hand into thematic areas that emerged from initial reading and organisation of the articles. The themes evolved over the course of coding, and the final list of themes included abortion knowledge and attitudes, comparative abortion rates for adolescents versus older women, reasons for abortion, the timing of abortion and postabortion care, sources and methods of abortion, experiences with formal health providers, the experience of complications of abortion, and psychosocial outcomes of abortion. Articles could be assigned more than one code and thus may appear under more than one thematic area.

A total of 35 articles were included in this review ( Table 1 ); five were qualitative, one used mixed methods, and the rest ( n = 29) were quantitative. Twenty-three of the articles were from Sub-Saharan Africa (e.g. Cote d’Ivoire = 1, the Democratic Republic of Congo = 1, Ethiopia = 4, Ghana = 1, Kenya = 2, Malawi = 3, Nigeria = 5, South Africa = 1, Uganda = 1 and Zambia = 1), 6 from Asia (e.g. Bangladesh = 1, India = 1 Japan = 1, Nepal = 1 Thailand = 2) and 6 from the Americas (Brazil = 3, Guadeloupe = 1, Mexico = 2). Sample sizes for the study ranged considerably depending on the method (quantitative versus qualitative) and the focus and design of the study; the largest study involved a national health records review (115,490 live birth records reviewed quantitatively in Thailand) while the smallest was an exploratory qualitative study of 16 girls in Malawi. The results of the study are presented in terms of two broad categories: knowledge/attitudes towards abortion and abortion experience. The category of abortion experience is further divided into abortion rates (comparing <19 girls with other age groups), reasons for abortion, timing and methods used for abortion, complications of abortion, experiences with providers, and psycho-social outcomes. Within these categories, there may be a combination of results pertaining to 15–19 and 10–14-year-old adolescents.

Abortion knowledge and attitudes

Five studies in this review examined the knowledge and attitudes of adolescents around the termination of pregnancy. Although adolescents are cognisant of abortion as a service, their knowledge of legality, methods of termination and access points for abortion are low. Among a sample of 10–19-year-old secondary school girls in Lagos, Nigeria, 83% had knowledge of abortion as a topic and 10–14-year-olds were more likely to know legal indications and methods of abortion than those ages 15–19. 14 In Ethiopia, 63% of adolescents were aware that abortion is safe in some cases, but few could name the indications for legal abortion. 15 An internet survey of students from two technical schools in Brazil showed that the knowledge of abortion methods among 12–14-year-olds was lower than that among 15–16-year-olds (29% vs 40%, respectively). 16 Among 16–20-year-old girls in the Democratic Republic of Congo (DRC), 46% knew of a place to obtain an abortion, 71% knew of someone who had had an illegal abortion, and most were able to name at least one health consequence of illegal abortion (death, infertility, infection and bleeding were the most commonly cited). 17

Attitudes towards abortion among young adolescents are fairly conservative. In Brazil, legal termination of pregnancy was supported by only 56% of male and female adolescent (12–21-years-old) respondents in a school-based study. 16 In Nigeria, younger adolescents (10–14-years-old) were less accepting of abortion than older adolescents (15–19-years-old). 14 In a study of 13–19-year-old males and females in Kenya, most participants disagreed with the use of abortion in the case of unwanted pregnancy and girls were significantly more likely to disagree with abortion than boys (91% vs 87%, respectively; p = 0.007) 18 In the Democratic Republic of Congo, where at the time of the study abortion was only legal to save a woman’s life, 76% of student respondents (16–20 years) were opposed to illegal abortion. 17

Comparative abortion rates/ratios among adolescents vs older groups

Nine studies in this review examined the rates or ratios of abortion among young/very young adolescents compared to older groups of women. In Bangladesh, one study showed a higher abortion ratio among adolescents <18 than 18–19-year-olds (44 vs 23 per 1,000 births, respectively; p < 0.001) and unmarried adolescents were 35 times as likely as married adolescents to abort (20 vs 733 abortions per 1,000 births; p < 0.001). 19 In Thailand, the probability of abortion was significantly higher among 10–14-year-olds than among 20–24-year-olds (OR = 1.18, p < 0.001), while in 15–19-year-olds the probability of abortion is reduced (OR = 0.65, p < 0.001). 20 In another study in the same setting, Thai girls ages 10–14 had nearly double the ratio of unsafe abortion compared to 15–19-year-olds (1,089 vs 602 unsafe abortions per 100,000 live births, respectively). 21 In Brazil, 20% of sexually active 12–14-year-old girls and 27% of 15–19-year-olds reported having had a prior abortion. 22 When adjusting for levels of sexual activity in Ethiopia, 15–19-year-old girls had higher rates of legal abortion than any other age group (64%). 23 In Nepal, however, women ages 20–34 were significantly more likely to report an induced abortion compared to those under 20 years (OR: 5.54; 95% CI: 2.87–10.72). 24

In Malawi, girls ages 10–19 comprised 20–28% of all abortions, second only to the 20–24 age group. 25 , 26 Among all 10–19-year-olds, unmarried adolescents were 11 times as likely to terminate a pregnancy as married girls ( p < 0.05) and among all unmarried women, adolescents (10–19 years) had higher rates of abortion (34%) than women aged 20–24 (12%) or women 25+ (20%; p < 0.05). 26 In a study in India, the majority of those seeking abortions were under 20 years of age (56%), 38% of whom were girls under the age of 16. 27 In Mexico, among 10–14-year-old girls the percentage of all live births ending in abortion rose from 13.6% in 2000 to 16.3% in 2010 while percentages for 15–19-year-old girls remained between 10% and 11% (descriptive abortion rates rose across all other age groups in that same period; however, no significance tests were presented). 28

Reasons for abortion

Nine studies solicited reasons why adolescents sought to terminate a pregnancy which included: the desire to continue education or to protect future aspirations; to avoid the stigma of teenage pregnancy; poverty; health; rape; incest or transactional sex.

In Zambia, girls <19 who had induced abortion did so to continue schooling and protect future aspirations. 29 These findings were echoed in Bangladesh, Brazil, South Africa and Guadeloupe. 19 , 22 , 30 , 31 A study of post-abortion care patients aged less than 19 in Malawi found that 87% were sexually assaulted by someone familiar to them, while another 3% had exchanged sex for money or clothes. 18 In South Africa and Zambia adolescents seeking abortion did so due to experiences of sexual violence (i.e. rape or incest); the South African cohort also reported fears of physical trauma due to childbirth as a reason for abortion. 30 , 31 Baba et al., in Japan, also showed that girls 10–14 were more likely to experience pregnancy due to rape or incest than older adolescents. 32 In Nigeria, adolescents who had undergone abortion were significantly more likely to have experienced transactional or forced sex. 33

Another salient reason for abortion among adolescents was fear of reprisal for getting pregnant outside of marriage or being too young to become a mother, often perpetuated by parents or members of the community. A study of unmarried pregnant adolescents in Uganda found that many girls who sought abortion felt they had to do it to “save face” for their parents; and in some contexts, such as in Mexico, girls reported that parents forced them to seek abortions. 28 , 34 Dahlback et al., in Zambia, and Ramakeula et al., in South Africa, confirmed that girls consider pregnancy shameful and stigmatising for themselves and their families, often leading them to undergo an unsafe abortion. 29 , 30 Poverty and fear for the girls’ maternal health were also important factors in abortion-seeking in a number of contexts including Nigeria and Bangladesh. 19 , 33

Timing of abortion and post-abortion care

Once the decision has been made to terminate a pregnancy, adolescents are more likely to delay the timing of abortion and post-abortion care. The studies with data on the timing of abortion showed that the majority of girls seek abortion in the second trimester and that they are more likely to delay abortion when compared to women in older cohorts.

In a study of girls less than 19 years old in India, 72% sought an abortion in the second trimester. 27 Similarly, in Guadeloupe, 55% of adolescents less than 18 years old reported seeking an abortion after nine weeks of amenorrhoea. 31 Three studies, in Japan, Ethiopia and Nigeria, showed that when compared to older groups of women, girls younger than 19 were more likely to delay abortion until the second trimester. In Nigeria, 45% of girls ages 10–18 sought a second-trimester abortion compared with 30% of women in older groups. 35 In Ethiopia, girls younger than 19 had more than double the odds of aborting in the second trimester, when compared to women aged 25 or older (OR = 2.64% CI: 1.23–5.68). 36 In a study of post-abortion care for patients ages 12–19 in Kenya, adolescents were more likely than older women to have undergone a second-trimester abortion. 37

Sources and methods of abortion

In the 10 studies that examined sources and methods of care among adolescents, the use of herbal or chemical concoctions or foreign objects inserted in the vagina was common, as was the use of traditional healers.

Ahmed et al., in Bangladesh, showed that 57% of abortion attempts among adolescents were performed by traditional healers (defined as persons in the community who provide treatment for abortion but have no formal training). 19 In Zambia, Dahlbeck et al. found that the majority of unsafe abortions (not defined by authors) among adolescents (76%) took place at home, with 47% performed by traditional healers. 29 In Cote d’Ivoire adolescents primarily self-prescribe medication (not medical abortion, but rather other over-the-counter medications) (70%) as the first attempt at termination, followed, in case of failure, by traditional healers (56.4%), then healthcare practitioners only at the third attempt (85.7%). 38 In Ethiopia, half of the adolescents reported attempting abortion at home while the other half terminated at a health centre. 39

Four studies in Brazil, Cote d’Ivoire, Ghana, and Zambia reported the unsafe methods used by adolescents for abortion: ingestion of herbs and roots or over-the-counter drugs like Chloroquine, Panadol and Cafernol; foreign objects such as Nescafe, ground glass, or herbs, sticks or leaves inserted into the vagina; and blunt force trauma to the stomach. These methods may have been in the context of a self-induced abortion or one presided over by a traditional healer. 16 , 29 , 38 , 40

In Nigeria, lack of access to adequate medical personnel, facilities and equipment were predictors of illegal abortion among girls ages 14–21. 41 High cost of safe abortion service fees and distrust in the health care providers were also cited as barriers to accessing safe abortion in Ghana. 42

Experiences with formal health care providers

Three studies showed that adolescents experience bias from health care providers and fear their reprisal, which may make them less likely to seek abortion at a formal health care facility. In Ghana, adolescents under the age of 20 (44%) were the least likely to obtain care from trained abortion providers when compared to women ages 20–29 (57%) or women 30 and older (65%). 40 When controlling for demographic and economic factors and the knowledge of abortion legality, adolescent girls still had a 77% lower odds of a safe abortion compared to women 30 and older. 5 In another study in Ghana, girls perceived providers as being hostile and did not trust providers or facilities to maintain their privacy or confidentiality. 40 In Malawi, girls undergoing abortion identified fear of abuse by health providers as one of the main sources of psychological distress during the abortion process. 43 In Mexico, adolescent girls who sought abortion care on their own (as opposed to with an accompanying adult) were refused abortion counselling and care. 44

Complications of unsafe abortion

Eleven studies in this review addressed the rate and types of complications among adolescent girls undergoing induced abortion, showing that while young adolescents comprise a disproportionate number of unsafe abortions, their risk of complications during abortion as compared to older women is inconclusive.

In Nigeria, adolescents ages 16–20 accounted for 29% of all unsafe abortions (the highest for any age group). 45 Two studies in Kenya and Malawi showed that adolescents were between 2 and 3.5 times more likely to experience mechanical injuries due to abortion than women in older groups (significant findings in each case). 26 , 46 In Cote d’Ivoire, complications among adolescents (11–19 years) were significantly associated with either self-induced abortions or abortions performed by traditional healers. 38 In Nigeria and South Africa, abortion was a leading cause of death among adolescents under the age of 19. 35 , 41 In Mexico, younger adolescents had a considerably lower rate of hospitalisation due to abortion when compared to older adolescents (0.3 vs 7.6 per 1,000 girls, respectively). 28

A South African study of comparative rates of death, or complications due to abortion, found that despite the high rates of abortion among adolescents, adolescents are not at an increased risk of death as compared to women in older groups. 47 An analysis of secondary data in Ethiopia also showed no increased risk of complications for 15–19-year-olds compared to older women. 23 However, Aung et. Al, in Thailand, found that when compared to older age groups, adolescents ages 10–19 had the highest burden of non-fatal morbidity due to complications from unsafe abortion. 21

Psycho-social outcomes of abortion

Five studies in this review touched on the psychosocial outcomes (i.e., depression, anxiety, low self-esteem, etc.) of the abortion process on adolescent girls. In Uganda, Zambia and South Africa, young girls who experienced abortion (specifically unmarried girls) describe facing rejection or denial of paternity by partners during pregnancy, being afraid of bringing shame to their families and fearing stigma from being pregnant out of wedlock. In some cases, particularly among younger adolescents, the pregnancy itself may be a result of rape or incest, which further complicates psychosocial outcomes for girls. 29 , 30 , 34 In Malawi, girls ages 14–19 reported a great deal of psychological distress prior to abortion due to fear of parents discovering the pregnancy, being forced to leave school, judgement for an out-of-wedlock pregnancy, and abuse from providers, all of which contributed to delay in care-seeking. After the abortion, girls reported feelings of guilt stemming from their religious beliefs and grief around the loss of the child (which they may have kept under better circumstances). 43 In Guadeloupe, 43.3% of girls reported psychological problems linked to abortion, mainly due to distress over the deterioration of their relationship with their parents. 31

This review highlights a number of important areas of abortion care that are specific to adolescents, and some differences between adolescents ages 10–14 and other age cohorts. Results show that girls aged 10–14 differ from older cohorts in that they are less accepting of abortion, they have a higher ratio of abortion (both safe and unsafe), and they are more likely to experience pregnancy leading to abortion as a result of rape or incest than older adolescents. Distinctions in younger versus older adolescent knowledge of abortion legality are not clear, as the two studies in Nigeria and Brazil gave conflicting results in the level of knowledge between the two cohorts.

Adolescents give a number of reasons for seeking an abortion, primary among them being their desire to continue their studies or to protect their future prospects from the burdens of early motherhood. This is particularly true among younger adolescents, many of whom are not married and are still attending school full time. Other common reasons include the shame and stigma of teen pregnancy/motherhood, poverty and pressure from their families. In the case of younger adolescents, the pregnancy is likely due to rape, incest or transactional sex, which further motivates a pregnancy termination. These reflect many of the same reasons that women around the world give for seeking an abortion; the main difference being that older women emphasise limiting childbearing as the main motivation for abortion. 48

When compared to older cohorts of women, adolescents consistently tend to delay an abortion into the second trimester, due to fear and shame around the pregnancy, limited knowledge of and access to safe abortion services, delayed recognition of pregnancy status, and fear of health providers. When adolescents do eventually attempt an abortion, the majority try to self-induce with ingested herbal/chemical concoctions or insertion of objects into the vagina, or by seeing traditional healers. Adolescents’ knowledge, resources and mobility to access health care are more limited compared to cohorts of older women; these reasons have been shown to limit general healthcare-seeking behaviour among adolescents, in particular around sexual and reproductive health needs (i.e. contraceptives, antenatal care, etc.), and exacerbate delays in seeking abortion care. 49–51

Adolescents cite strong provider bias and lack of privacy and confidentiality by formal health care workers as the main reasons why they do not seek care from formal health providers. 52 Studies of providers have shown that they can be judgmental, openly hostile or even deny care to adolescent girls seeking abortions. 53 , 54 Furthermore, providers, even those trained in youth-friendly services, may not be protecting girls’ privacy and confidentiality to the extent necessary. These barriers echo those commonly cited in the context of general adolescent sexual and reproductive health care and point to a pattern of bias against girls seeking any type of sexual health care. 55

Although adolescent girls comprise a disproportionate number of women seeking unsafe abortions, they do not necessarily suffer higher rates of complications or maternal mortality than older women. In some of the studies reviewed here, there was evidence of significantly higher rates of mechanical injury (i.e. cut or perforation) among adolescents than among older cohorts, but there were no significant differences in maternal mortality between these groups. However, complications stemming from unsafe abortion are one of the leading causes of death among adolescent girls in LMIC, which may be due to the fact that adolescents tend to delay abortion care until the second trimester. 1

There are several limitations to this review, which should be noted when using the results. First, out of the 208 prospective articles, we were only able to locate 131 full-text versions for review due to resource constraints. This may present bias in the findings due to the omission of 77 potential articles. Furthermore, this review examines findings from a variety of LMIC; however, adolescents in each context have unique personal, social or environmental characteristics that determine their abortion experience. While this review provides a global overview of abortion among adolescents, it is not generalisable to all settings.

There are several ways to improve the delivery of care and knowledge to adolescents, particularly 10–14-year-olds. This group is typically still enrolled in school, which provides a promising entry point for education on and access to safe abortion knowledge and services. Although the subject of abortion may be taboo in some contexts, comprehensive sexual education has been shown to have positive outcomes on youth sexual behaviour, including delaying sex and using contraceptives in some countries, both of which could reduce the risk of unsafe abortion. 56 As adolescents are subject to parental control, interventions aimed at very young adolescents must recognise the role of the parents in abortion decision-making and work to reduce barriers to communication within the child–parent dyad. 57

Pregnancy among 10–14-year-olds is likely due to rape, incest or coerced transactional sex. Implementers and providers must recognise the added trauma of sexual violence that a girl may face and ensure that they are not only receiving adequate and appropriate abortion care but that the underlying sexual violence is also addressed. Trauma-informed care and counselling must also adjust for the fact that for girls, the perpetrator may be her accompanying adult or immediate caregiver. 58 Furthermore, even though adolescents are not at greater risk of psychosocial maladjustment following abortion, the event may still be emotionally significant and require sensitive care. 59 Providers of abortion care may require more intensive training and patient-centred feedback is needed as part of the follow-up performance improvement loop to overcome biases against adolescent patients.

Conclusions

This review highlights several aspects of abortion programming and policy planning for adolescent girls. Many adolescents lack basic knowledge of puberty or sexual and reproductive health, which increases their chances of missing signs of pregnancy and delaying abortion until the second trimester. 5 Sexuality education that is comprehensive and that provides information on puberty and pregnancy, is essential.

Only a handful of the almost 800 studies screened for this paper either focused on or segmented data by adolescents ages 10–14. Researchers should include 10–14-year-olds as a focus of sexual health and abortion studies, examining the types of information and support needed by this group and the most effective ways in which to deliver services, given their unique constellation of issues.

Adolescent girls experience abortion differently than older women and have specific needs for and obstacles to seeking abortion care. By emphasising the unique experiences of these sub-groups of abortion patients, this review may enable programmers and practitioners to build more inclusive, thoughtful and responsive abortion care for the most vulnerable populations around the world.

† The authors are fluent in these three languages and included them in the search to maximise inclusion of articles from low- and middle-income countries.

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The Safety and Quality of Abortion Care in the United States (2018)

1. What types of legal abortion services are available in the United States? What is the evidence regarding which services are appropriate under different clinical circumstances (e.g., based on patient medical conditions such as previous cesarean section, obesity, gestational age)?

2. What is the evidence on the physical and mental health risks of these different abortion interventions?

3. What is the evidence on the safety and quality of medical and surgical abortion care?

4. What is the evidence on the minimum characteristics of clinical facilities necessary to effectively and safely provide the different types of abortion interventions?

6. What safeguards are necessary to manage medical emergencies arising from abortion interventions?

7. What is the evidence on the safe provision of pain management for abortion care?

8. What are the research gaps associated with the provision of safe, high-quality care from pre- to postabortion?

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The Persistent Threat to Abortion Rights