May 21, 2019 6:00 AM

Abortion Bans Create a Public Health Nightmare

Making abortion mostly illegal will kick off an unintentional, vast experiment in public health—one where the outcomes are sick or dying women and children.

On Friday, the legislature of Missouri passed a ban on abortions, among the most extreme of any state. It prohibits any abortions after eight weeks of gestation, putting it among the category of misleadingly named “heartbeat bills” that use fetal cardiac activity as a marker for … well, illegality, really. Like a law signed earlier last week in Alabama, the Missouri bill contains no exceptions for cases of rape or incest. That makes eight US states with similar extreme bans on their books—each vying to be the law that makes its way to the Supreme Court and overturns Roe v. Wade, the 1973 decision that made abortion legal in the United States.

None of the restrictions have gone into effect, either because of delays built into the legislation itself or legal challenges. If they do, they’ll spark an unintentional, vast experiment in public health. Already, states with the most restrictions on access to abortions are also those with the highest rates of maternal and infant mortality. The connection isn’t direct—abortion access can be a kind of proxy for access to all sorts of pre- and postnatal health care, not to mention correlating roughly with better-funded education systems, lower poverty rates, and tighter environmental regulation. But evidence from history does suggest a hypothesis: More women and babies are going to get sick, be poor, and die.

In the mid 2000s, billboards worrying about the mental health of women who’d gotten abortions were common, and justices on the Supreme Court expressed concern that those women might experience psychologically damaging “regret.” Diana Greene Foster, a demographer and director of research at the Advancing New Standards in Reproductive Health program at UC San Francisco, started wondering if any of that was true. Until then, most research looking at abortion outcomes compared women who’d gotten one to women who’d gotten pregnant and had a baby. That’s science—isolate the thing you want to study by looking at people who have it and people who don’t.

It’s not great science, though, because, as Foster realized, the control group wasn’t actually controlling. It didn’t isolate the variable. What you really need to do is to look at women with unwanted pregnancies who sought an abortion, and compare those who got one with those who did not. “If you make abortion restrictions, who they’ll affect are people who want abortions and get births, so it was important to get the science right,” Foster says. “What’s the effect if women are able to get the abortion they want? Or can’t get the abortion they want?”

Foster and her colleagues painstakingly set up a new experiment. Between 2008 and 2010 they used abortion clinic visits to recruit women in three groups: 273 women who got a first-trimester abortion, 452 who got an abortion at up to two weeks under the clinic’s “gestational limit,” and 231 whose pregnancies were up to three weeks over the clinic’s gestational limit and were therefore denied an abortion. In other words: got, barely got, didn’t get.

(Half of these women, it’s worth noting, had incomes below the federal poverty line. Three-quarters said they didn’t have enough money for food, housing, and transportation. More than half already had kids.)

Then Foster’s team spent the next five years following up with the women by phone to see what happened. It was called the Turnaway Study, and the first thing it found was that mental health concerns for women who wanted abortions and got them were unfounded. “We found no differences in mental health over time, with the exception that people who are denied were worse off in terms of self-esteem,” Foster says. (Even that effect was short-lived, spiking at one week after the denial; the groups’ self-esteem and anxiety levels¹ were the same six months later.)

The Turnaway Study did find differences, though. Women in the turnaway group were more likely to be poor six months after their clinic visit—and still poor four years later. Of the turnaways, those who had more children after the one they were turned away for had worse maternal bonding with the child they had than women who got an abortion and then had a child later.² If a turnaway woman already had children—as 61 percent did—those children scored lower on standard measures of development, and again were more likely to live below the federal poverty line in the years that followed. And poverty, to be clear, is a prime risk factor for health problems and for diminished access to good health care. “Half of these women said, the reason I want an abortion is that I can’t afford to have a kid,” Foster says. “This study doesn’t say that poor women should get abortions. It says women who want abortions should get abortions.”

Nor does the Turnaway Study say that being a mother makes women poor. Not by itself, anyway. “It’s a major predictor of poverty in our country, not because of its prevalence but because we penalize every aspect of it,” Foster says. “The supports we have for low-income women are not sufficient to keep them from falling into poverty.” She says that something like 4,000 women get turned away from clinics every year because of gestation time limits—exactly what are getting more restrictive under the six-week bans. If those laws go into effect, that number will likely go up.

It’s true, though, that poverty is only a proxy for health outcomes. Foster’s team has a paper in review on actual, longer-term health consequences among the turnaways, but it’s not out yet, and I didn’t find any research comparing outcomes in states with different abortion access levels beyond when women get abortions during a pregnancy—second-trimester abortions become more common—and the admittedly blunt statistical instruments of maternal and infant mortality.

Fortunately—well, maybe not “fortunately,” but you get what I mean—other countries have already run this experiment.

Take Romania. Abortion was legal there until 1966, when Nicolae Ceausescu became president and outlawed it, along with contraception. He said he wanted to increase the number of native-born Romanians. Women were forced to get pelvic inspections at work. Police informers roamed maternity hospitals. Performing abortions was a crime.

As a result, the birth rate in Romania went up for a couple years, and then in 1970 it went into freefall. Deaths from complications resulting from attempted, illegal abortions increased to 10 times that of the rest of Europe—about 500 women a year, more than 10,000 women over two decades. The maternal mortality rate spiked to 150 women per 100,000 births. That number is insanely high. Today, when the US has the worst maternal mortality in the industrialized world, it’s only a sixth of that (except in Louisiana, where the maternal mortality rate for women over 35 years of age is a 1980s-Romania-adjacent 145.9 per 100,000 births). Also, nearly 200,000 children were put in hellish orphanages.

In December of 1989 a revolution cleared out Ceausescu’s government. The new leadership instituted an emergency public health measure to legalize abortion and contraception. The maternal mortality rate fell 50 percent in the first year.

Is this bumming you out? Here’s the converse. Amid worries about maternal mortality, Nepal legalized abortion in 2002. Over the next decade or so, 1,200 clinicians learned to provide abortions, and 500,000 women got them. The maternal mortality rate dropped from 360 to 170 per 100,000 live births, and while the number of abortion complications went up—along with total hospital admissions and total live births—the number of serious complications went down.

While pregnancy, in general, is something like 14 times as risky as a legal abortion, much of the danger in the past came from illegal abortions—often performed without a trained clinician, sometimes with dangerous methods that involve inserting objects into a woman’s uterus. When people talk about “back-alley” abortions and deaths from coat hangers in the United States, that’s what they mean. Before legalization, hundreds of women died every year in the US from botched induced abortions (as opposed to “spontaneous abortions,” the technical term for a miscarriage). Legalization also resulted in fewer low-weight births and pre-term births.

But there’s reason for hope here, in a backwards sort of way. If abortions become illegal again, the drugs mifepristone and misoprostol could combat the more dangerous surgical improvisations. Today in the US, both drugs are used, often in combination, to induce an abortion. It’s called, weirdly, a “medical” abortion (because of the medicine, not because it needs a doctor) as distinct from a “surgical” abortion, even though that generally uses suction—aspiration—not a scalpel. By law, pharmacies can fill prescriptions for misoprostol; only abortion providers, clinicians, can provide mifepristone.

The standard dosages to induce an abortion—up to 10 weeks of gestation—are 200 milligrams of mifepristone and 800 micrograms of misoprostol, though lower doses of the latter, down to 400 mcg, can also work. Taking those medications at those doses will induce an abortion. An organization called Plan C has a lot more information about that.

So in Romania, for example, “abortion mortality skyrocketed because people were doing illegal things, and eventually people figured out how to do safer illegal things,” Foster says. “When it’s illegal, it can be extremely unsafe, but I’m hoping that doesn’t happen in the United States. I’m hoping pills online or something will meet the needs.”

As any recreational drug user on the Dark Web (or man too embarrassed to ask a doctor for boner pills) knows, online sellers offer the same medications otherwise only available by prescription. That can seem like a scary prospect—are they reliable, are the pills real, will they just steal the money? But when one team of researchers tried to get abortion medications online, they found it actually worked. The misoprostol was often lower-concentration than FDA-approved pills in the US, and some of the packages were damaged, but what they got from 16 different online pharmacies tested as chemically the same, and was usually cheaper than going to a clinic.

Online pills might make this next chapter of abortion history better than the last. “That’s not a crazy idea. It’s not necessarily an unsafe thing to do,” says Elizabeth Raymond, an ob-gyn and researcher at Gynuity Health Products who led the online-buying study. “Part of what’s problematic about the situation is, it’s not clearly legal … If a woman orders these pills from overseas, it’s not clear what the legality of that is.” Raymond’s also doing a study now to see how telemedicine and prescriptions for those drugs could help supplant the dwindling number of clinics in the US.

If six-week bans go into effect, if Roe gets overturned, some states will make abortion mostly illegal or illegal altogether, while others try to ensure continued legality. The public health experiment will commence, with the two populations every experiment needs. Some women will have access to safe abortions; others will not. Gets, doesn’t get. Control group and experimental. And as with all cutting-edge science, no one really knows how this experiment is going to turn out.

Charts and additional research by Joanna Pearlstein.

¹Updated 5/21/19 11:25 AM PDT to expand the scope of the results ²Updated 5/21/19 11:25 AM PDT to include the comparison group