The authors have declared that no competing interests exist.
Conceived and designed the experiments: DGF. Performed the experiments: DGF HG. Analyzed the data: CHR. Contributed reagents/materials/analysis tools: CHR SCMR JN DGF. Wrote the paper: CHR KK SCMR HG JN DGF. Served as PI: DGF. Interpreted results: CHR KK SCMR DGF. Provided statistical support: JN.
Arguments that abortion causes women emotional harm are used to regulate abortion, particularly later procedures, in the United States. However, existing research is inconclusive. We examined women’s emotions and reports of whether the abortion decision was the right one for them over the three years after having an induced abortion.
We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities across the United States, selected based on having the latest gestational age limit within 150 miles. Two groups of women (n=667) were followed prospectively for three years: women having first-trimester procedures and women terminating pregnancies within two weeks under facilities’ gestational age limits at the same facilities. Participants completed semiannual phone surveys to assess whether they felt that having the abortion was the right decision for them; negative emotions (regret, anger, guilt, sadness) about the abortion; and positive emotions (relief, happiness). Multivariable mixed-effects models were used to examine changes in each outcome over time, to compare the two groups, and to identify associated factors.
The predicted probability of reporting that abortion was the right decision was over 99% at all time points over three years. Women with more planned pregnancies and who had more difficulty deciding to terminate the pregnancy had lower odds of reporting the abortion was the right decision (aOR=0.71 [0.60, 0.85] and 0.46 [0.36, 0.64], respectively). Both negative and positive emotions declined over time, with no differences between women having procedures near gestational age limits versus first-trimester abortions. Higher perceived community abortion stigma and lower social support were associated with more negative emotions (b=0.45 [0.31, 0.58] and b=-0.61 [-0.93, -0.29], respectively).
Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years. Emotional support may be beneficial for women having abortions who report intended pregnancies or difficulty deciding.
Arguments about emotional harms from induced abortion—including decision regret and increasing negative emotions over time—have been leveraged to support abortion regulation in the United States [
Despite these arguments, questions about long-term abortion regret and emotional harm remain unresolved. While research has found that women’s short-term emotions post-abortion can vary substantially—with mixed emotions being common and relief predominating [
Analyses of baseline data from the current study illustrated the importance of differentiating negative emotions from decision regret. Although one-quarter of women experienced primarily negative emotions over one week post-abortion, 95% still felt that the abortion was the right decision [
Our objective was to investigate how women’s views about the decision to terminate a pregnancy and emotions change over three years. We also compare emotions between women having abortions near facility gestational age limits and women having first-trimester abortions, to elucidate whether emotions differ by gestational age. This is the first study to examine emotions about abortion prospectively in a large, geographically diverse US sample.
We used data from the
The primary objective of the
Participant recruitment is described elsewhere [
Analyses include data from seven waves of phone interviews, conducted at baseline (approximately eight days after care-seeking) and semiannually thereafter. Baseline interviews assessed sociodemographic characteristics and pregnancy and abortion circumstances; all interviews asked about emotions. Women received $50 gift cards after each interview. Three-year interviews were completed in February 2014.
Overall, 37.5% of eligible women consented to participate, and 85% of those completed baseline interviews (n = 956). Among the
The study, including consent procedures, was approved by the University of California, San Francisco, Committee on Human Research (original approval date: 20 December 2006; study #: 10–00527).
We included baseline measures describing the circumstances of the pregnancy and abortion. These variables were selected
Sociodemographic characteristics included age (years), self-reported
To investigate baseline differences between the participant groups, we fit bivariable regression models, including random facility effects to account for the clustering of participants within facilities [
Our overall approach to longitudinal analyses examining changes in abortion decision rightness and in emotions was mixed-effects regression, including random intercepts for facility and for participant in each model to account for clustering. Random time effects allowing changes in outcomes over time (or trajectories) to differ across participants were included if they significantly improved model fit based on likelihood ratio tests. Similarly, for each model, we sought appropriate functional forms for time by adding quadratic and cubic terms and assessing the statistical significance of the added terms. Interaction terms between study group and time were also included in each model to assess differences in trajectories of outcomes between
Specifically, to assess changes in abortion decision rightness over three years, examine study group differences, and identify associated variables, we used a logistic mixed-effects model with random time effects. Quadratic time terms were not included because they did not improve model fit. We calculated the predicted probability of reporting that abortion was the right decision at a given time using the average individual-level intercepts and trajectories from this model (e.g. random effects equal to zero), with mean-centered covariables equal to zero [
Then, to assess negative emotions, we first used linear mixed-effects regression, including random time effects and quadratic and cubic time terms. Based on this model, we created a dichotomous variable of experiencing an increase of over a point in negative emotions over three years. We then fit logistic mixed-effects models with “increasing trajectory” as the outcome to assess associated factors. A linear mixed-effects model with random time effects and quadratic and cubic time terms was also fit to assess positive emotions.
We performed attrition analyses to examine differential loss-to-follow-up. We conducted sensitivity analyses assessing whether differential enrollment of eligible women across facilities affected our results, repeating analyses including only sites that recruited >50% of eligible women. Also, because the gestational limit for providing abortions fell in or near the first trimester for seven facilities, 14% of
On average, participants were 25 years old at baseline (
Near-Limit Abortion | First-Trimester Abortion | p | Total | |
---|---|---|---|---|
(n = 413) | (n = 254) | (n = 667) | ||
24.9 | 25.9 | 0.041 | 25.3 | |
White | 32.0 | 39.0 | 0.033 | 34.6 |
Black | 31.7 | 31.5 | 31.6 | |
Latina | 21.1 | 21.3 | 21.4 | |
Other | 15.3 | 8.3 | 12.6 | |
<High school | 12.4 | 20.5 | 0.024 | 15.4 |
High school | 35.8 | 35.8 | 35.8 | |
Some college, technical school | 15.0 | 9.8 | 13.0 | |
≥College graduate | 26.6 | 28.4 | 27.3 | |
|
10.2 | 5.5 | 8.4 | |
0 | 36.4 | 40.6 | 0.668 | 38.0 |
1 | 30.3 | 24.8 | 28.2 | |
2+ | 33.3 | 34.7 | 33.8 | |
46.5 | 46.6 | 0.891 | 46.6 | |
Neither | 33.2 | 23.7 | 0.013 | 29.6 |
In school only | 12.6 | 12.7 | 12.6 | |
Employed only | 40.4 | 41.5 | 40.8 | |
Both | 13.8 | 22.1 | 17.0 | |
12.8 | 14.1 | 0.227 | 14.1 | |
2.7 | 2.6 | 0.380 | 2.7 | |
Very easy | 10.4 | 16.9 | <0.001 | 12.9 |
Somewhat easy | 15.7 | 22.1 | 18.1 | |
Neither easy nor difficult | 15.7 | 14.6 | 15.3 | |
Somewhat difficult | 27.1 | 26.8 | 26.8 | |
Very difficult | 31.0 | 19.7 | 26.7 | |
58.8 | 58.7 | 0.986 | 58.8 | |
Wanted | 21.1 | 31.9 | 0.025 | 25.2 |
Not sure | 21.6 | 19.7 | 18.9 | |
Did not want | 21.1 | 18.9 | 20.3 | |
Not involved | 17.7 | 16.9 | 18.9 | |
Left it up to participant | 18.5 | 12.6 | 16.2 | |
19.7 | 7.6 | <0.001 | 15.1 | |
43.6 | 35.0 | 0.030 | 40.3 | |
34.8 | 38.6 | 0.323 | 36.2 | |
Not at all | 38.9 | 41.0 | 0.412 | 39.7 |
A little | 14.2 | 13.7 | 14.0 | |
Moderately | 14.5 | 16.5 | 15.2 | |
Quite a bit | 13.0 | 12.5 | 12.8 | |
Extremely | 19.5 | 16.5 | 18.3 | |
3.2 | 3.2 | 0.869 | 3.2 | |
70.1 | 70.0 | 0.776 | 70.0 |
a One participant aged 14 was recruited before the minimum age was changed to 15.
Compared to the
In crude data, approximately 95% of women completing each follow-up interview reported that having the abortion was the right decision for them. Based on the mixed-effects model, which accounts for attrition and baseline characteristics and allows for individual variation in trajectories over time, the predicted probability of the average participant reporting that the abortion was the right decision was >99% across all times, with an increase over three years (adjusted odds ratio [aOR] = 1.05 per month, 95% confidence interval [CI] [1.00, 1.08]) (
The line represents the trajectory of the average participant (average intercept and slope), based on a multivariable mixed-effects model of reporting that abortion was the right decision, with mean-centered covariables equal to zero.
Abortion was the right decision | ||
---|---|---|
Adjusted Odds Ratio | 95% CI | |
1.00–1.08 | ||
1.58 | 0.70–3.55 | |
0.99 | 0.95–1.03 | |
0.60–0.85 | ||
0.36–0.64 | ||
0.80 | 0.41–1.60 | |
Not sure | 0.58 | 0.24–1.44 |
Did not want | 0.65 | 0.26–1.61 |
Not involved | 1.92 |
0.66–5.61 |
Left decision up to participant | 0.86 | 0.30–2.44 |
|
0.91 | 0.49–1.71 |
|
1.01 | 0.51–2.01 |
0.84 | 0.69–1.02 | |
1.43 | 0.90–2.30 | |
0.82 | 0.41–1.63 | |
1.06 | 1.00–1.14 | |
Black | 0.68 | 0.29–1.59 |
Latina | 0.13–0.74 | |
Other | 2.09 | 0.61–7.09 |
High school | 1.63 | 0.62–4.24 |
Some college, technical school | 0.69 | 0.23–2.06 |
≥College graduate | 0.83 | 0.31–2.22 |
1 | 1.05 | 0.47–2.32 |
2+ | 0.86 | 0.37–2.00 |
1.23 | 0.64–2.37 | |
In school only | 1.60 | 0.54–4.68 |
Employed only | 1.43 | 0.68–3.03 |
Both | 1.06–9.81 | |
0.52 | 0.22–1.19 |
***p≤.001.
**p≤.01.
*p≤.05.
†Different from “Other” at p≤.01.
‡Different from “Not sure” and “Did not want” at p≤.05.
Note: Effect estimates are based on 3,758 observations of 650 women (mean 5.8 observations/woman).
Women thought about the abortion less frequently over time (b = -0.019 [-0.023, -0.016] per month), with no differences between study groups (data not shown). At six months post-abortion, participants on average thought about the abortion “sometimes” (mean = 1.8, range 0–4); by three years, they thought about it “rarely” (mean = 1.2, range 0–4).
The average negative emotions score (range 0–16) among
Lines represent the trajectory of the average participant (average intercept and slope), based on a multivariable mixed-effects model of negative emotions, with mean-centered covariables equal to zero.
Negative Emotions, range: 0–16 | ||
---|---|---|
Adjusted Coefficient | 95% CI | |
|
-0.28 –-0.14 | |
|
0.005–0.013 | |
|
-0.001 –-0.001 | |
|
-0.21 | -0.76–0.34 |
|
0.02 | -0.08–0.13 |
|
-0.002 | -0.009–0.005 |
|
0.001 | -0.001–0.001 |
0.17–0.42 | ||
0.61–0.92 | ||
0.05 | -0.37–0.47 | |
Not sure | 0.01 | -0.59–0.61 |
Did not want | 0.18 | -0.43–0.78 |
Not involved | 0.19 | -0.42–0.81 |
Left decision up to participant | 0.12 | -0.51–0.76 |
|
0.15 | -0.25–0.56 |
|
-0.18 | -0.61–0.24 |
0.31–0.58 | ||
-0.93 –-0.29 | ||
0.34 | -0.09–0.78 | |
0.01 | -0.04–0.05 | |
Black | 0.15 | -0.38–0.68 |
Latina | 0.47 | -0.11–1.06 |
Other | -0.06 | -0.73–0.61 |
High school | 0.01 | -0.61–0.63 |
Some college, technical school | 0.09 | -0.66–0.84 |
≥College graduate | -0.01 | -0.65–0.65 |
1 | -0.09 | -0.60–0.42 |
2+ | 0.01 | -0.54–0.55 |
-1.00 –-0.16 | ||
In school only | -0.33 | -1.03–0.37 |
Employed only | -0.33 | -0.82–0.17 |
Both | -0.58 | -1.23–0.06 |
0.55 | -0.03–1.14 |
***p≤.001.
**p≤.01.
*p≤.05.
Note: Effect estimates are based on 3,754 observations of 650 women (mean 5.8 observations/woman).
Over the three years post-abortion, women who had pregnancies that were more planned (b = 0.29 [0.17, 0.42]), who had greater difficulty deciding to seek abortion (b = 0.77 [0.61, 0.92]), and who perceived more community abortion stigma (b = 0.45 [0.31, 0.58]) reported more negative emotions (
For positive emotions about the abortion, average scores (range 0–8) in the
Lines represent the trajectory of the average participant (average intercept and slope), based on a multivariable mixed-effects model of positive emotions, with mean-centered covariables equal to zero.
Loss-to-follow-up did not differ by study group, sociodemographic characteristics, nor baseline decision rightness or negative emotions. However, women feeling more relief and happiness at baseline were less likely to be lost (mean score 3.8 for those maintained versus 3.0 for those lost, p = 0.03).
When repeating analyses among sites with >50% participation and, separately, among sites with all
Arguments that abortion causes women emotional harm, and that women come to regret abortions they decided to have, are used to shape public opinion and advance legislation restricting access to abortion in the US. Existing studies suffer from shortcomings, leaving the question of women’s post-abortion emotions unresolved. Using three years of data from the
Women in this study overwhelmingly felt that the decision was the right one for them: at all time points over three years, 95% of participants reported abortion was the right decision, with the typical participant having a >99% chance of reporting the abortion decision was right for her. Women also experienced reduced emotional intensity over time: the feelings of relief and happiness experienced shortly after the abortion tended to subside, as did negative emotions. Notably, we found no differences in emotional trajectories or decision rightness between women having earlier versus later procedures. Important to women’s reports were social factors surrounding the pregnancy and termination-seeking. Having had difficulty deciding to terminate the pregnancy, and reporting higher pregnancy planning levels, were strongly associated with negative emotions and lower decision rightness, while being in school and working at the time of the pregnancy was associated with far higher feelings of decision rightness. Community stigma and lower social support were associated with negative emotions.
Analyses included data collected through three years post-abortion. Participant follow-up to five years is ongoing; future analyses will explore how changing circumstances of women’s lives affect feelings about the abortion further into the future.
Because no formal measures of abortion emotions exist, the scales we used may not have validly captured women’s emotions. Although the emotions we examined were similar to those assessed in prior studies [
We were unable to assess the effects of continuously measured gestational age on outcomes due to the study design, by which
Finally, the relatively low participation rate might raise concerns about selection bias. In a review of high-impact public health journals, 63% of prospective studies reported no recruitment information; those that did had participation rates as low as 20% [
This study has several features that strengthen the validity of findings. Our use of prospective data helped to reduce recall and selection biases, and we are unaware of other studies prospectively assessing decision rightness and emotions up to three years. Our sample was relatively large, and participants were recruited from diverse geographic locations and across gestational ages, improving generalizability. Only 7% of women were lost-to-follow-up completely after baseline, and our statistical approach accounted for attrition and individual variation in outcomes. Much prior research on post-abortion emotions has been conducted in Europe, where abortion is a viewed differently than in the US; research on US women is an important contribution.
Results from this study suggest that claims that many women experience abortion decision regret are likely unfounded. The random slope model we fit allowed for individual variability in decision rightness trajectory: some women have lower predicted values of the outcome and others higher values. The typical participant, however, had >99% chance of reporting that the abortion was right for her over three years, and her negative emotions subsided over time. These findings differ from those of the only other large-scale US prospective study, which found that negative emotions increased, and satisfaction with the abortion decision decreased slightly, over two years [
The patterns of emotions found in this study—reduced negative and positive emotions over time after an abortion—indicate a general trend of declining emotional intensity. Various dimensions of psychological welfare, including emotions, are important to women’s well-being after an abortion [
Finally, that higher community abortion stigma was associated with negative emotions—and that having more social support, which may mitigate stigma, was associated with fewer negative emotions—highlights that social context matters for women’s emotions after an abortion [
In the three years after terminating a pregnancy, women tended to cope well emotionally. Women overwhelmingly felt abortion was the right decision in both the short-term and over three years, and the intensity of emotions and frequency of thinking about the abortion declined over time. Yet high coping and resilience were not observed among all individuals: those with more intended pregnancies and difficulty making the abortion decision experienced poorer emotional outcomes after an abortion. Individualized counseling for women having difficulty with the abortion decision might help improve their emotional welfare over time [
The authors thank Rana Barar and Sandy Stonesifer for study coordination and management; Mattie Boehler-Tatman, Janine Carpenter, Undine Darney, Ivette Gomez, Selena Phipps, Brenly Rowland, Claire Schreiber, Danielle Sinkford, and C. Emily Hendrick for conducting interviews; Michaela Ferrari, Debbie Nguyen and Elisette Weiss for project support; Jay Fraser for database assistance; and all the participating providers for their assistance with recruitment.