- Email: [email protected]
Decision rightness and relief predominate over the years following an abortion
Journal Pre-proof Decision rightness and relief predominate over the years following an abortion Julia R. Steinberg PII:
S0277-9536(20)30001-0
DOI:
https://doi.org/10.1016/j.socscimed.2020.112782
Reference:
SSM 112782
To appear in:
Social Science & Medicine
Received Date: 15 December 2019 Accepted Date: 1 January 2020
Please cite this article as: Steinberg, J.R., Decision rightness and relief predominate over the years following an abortion, Social Science & Medicine (2020), doi: https://doi.org/10.1016/ j.socscimed.2020.112782. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
Running head: Decision certainty and relief follow an abortion
Decision rightness and relief predominate over the years following an abortion Julia R. Steinberg
Author Correspondence:
a
Julia R. Steinberg Department of Family Science School of Public Health University of Maryland, College Park 301.314.1404 [email protected]
Department of Family Science, School of Public Health, University of Maryland College Park
1
Abstract A recent analysis from the Turnaway study focused on women who were just under the gestational limit of a clinic and received an abortion and those who had first trimester abortions to examine trends in decisional rightness and negative and positive emotions over 5 years after the abortion. Specifically, Rocca et al. (in press) analyzed these data and found that women were overwhemingly sure of their decision: Over 95% felt their decision was the right one at each assessment after their abortion, and the predicted probability of abortion being the right decision was 99% at 5 years afterwards. Relief was the most common emotion felt by women, and negative emotions or decision regret did not emerge over time. These results and others from studies conducted globally counter assertions by abortion opponents that women are not certain of their decisions, or that women regret or have negative emotins about their abortions if not in the short run then after a long period of time. This commentary addresses not only these findings but also relevant U.S. abortion policies based on these unsubstantiated claims. Policies should not be based on the notions that women are unsure of their decision or come to regret it or have negative emotions because there is no evidence to support these claims.
Keywords: abortion, emotions, decision rightness, policies
Introduction Currrent estimates indicate that a quarter of US women will have an abortion by the time they are 45 (Jones & Jerman, 2017). Abortion may be a stressful experience, and it often occurs in the context of an unintended pregnancy (Finer & Zolna, 2011), which itself may be stressful. In addition, abortion often occurs in the context of other disruptive events such as loss of employment or a dissolution of a relationship (Jones, Frohwirth, & Moore, 2013). Although previous studies have found that women experience a range of emotions or are satisfied with their decision to have an abortion (Adler, 1975; Major et al., 2000), this research was conducted 20 to 40 years ago when the sociopolitical climate around having an abortion in the US may have differed. Thus, a scientific understanding of women’s decision making and emotions around an abortion in the more recent sociopolitical climate—such as the one conducted by Rocca et al. (in press)—is warranted Such an understanding may inform public policy and practice. Abortion policies are based on presumed notions that negative emotions such as sadness or guilt prevail after an abortion, that most women do not feel that abortion was the right decision for them or certainty regarding their decision, and that abortion leads to mental health problems. These notions are used to justify laws in 12 states (see Figure 1a for which states) requiring women be informed of negative psychologial effects of having an abortion (National Academies of Sciences, Engineering, and Medicine, 2018), laws in 28 states (see Figure 1b for which states) requiring waiting periods after receiving pre-abortion counseling, with 8 states requiring at least 48 hours (Guttmacher Institute, 2019); and laws in 15 states (see figure 1c for which states) requring women make two trips to the clinic to have an abortion (Guttmacher Institute, 2019). Two trip laws are distinct from waiting period laws; the latter only require women to get information on
1
the phone and then wait the specified amount of time to have an abortion. In contrast, two trip laws require women receive information in person at the clinic and then wait at least 24 hours to have an abortion. These notions are also increasingly being used for a range of other types of policies or as the basis for court decisions (Gruender, 2012; Kennedy, 2007). For instance, these notions are used to justify restricting specific abortion procedures such as the dilation and evacuation (D&E) method (Paxton et al., 2017) or those requirng women be informed of the medically inaccurate information that a medication abortion can be reversed (North Dakota HB 1336, 2019). Proponents defend these policies by arguing that there is scientific evidence that women are unsure of their decision, that negative emotions occur afterwards, and that regret regarding the decision is common (Reardon, 2018; Speckhard & Rue, 1992). Proponents further claim that negative emotions such as decision regret may not emerge until much later after the abortion (Reardon, 2018; Speckhard & Rue, 1992). However, Rocca et al. (in press) eloquently show that the notions that abortion leads to negative emotions or regret regarding one’s abortion decision are not supported by scienctific evidence. That is, negative emotions including sadness, guilt, and anger, and feeling that abortion was the not the right decision did not dominate after an abortion or emerge years afterwards (Rocca, Samari, Foster, Gould, & Kimport, in press). Thus, the importance of this study’s findings cannot be overstated. Rocca and Colleagues’ Analysis of the Turnaway Study Rocca et al. (in press) used data from the Turnaway study, focusing on women who were just under the gestational limit and received an abortion and those who had first trimester abortions to examine trends in decisional rightness, negative emotions (e.g., sadness, anger, and guilt), and positive emotions (e.g., relief and happiness) over 5 years after the abortion. The
2
Turnaway study recruited and prospecitvely followed women seeking abortions from one week after their abortion until 5 years later, conducting assessments every 6 months (Dobkin et al., 2014). Rocca et al. (2010) found that women overwhemingly felt abortion was the right decision: over 95% felt their decision was the right one at each assessment after their abortion, and the predicted probability that abortion was the right decision one week and 5 years after the abortion was 97.5% and 99.0% respectively. These results confirm other recent and past findings in the U.S. and Netherlands on the related constructs of decisional certainty, satisfaction, or confidence (Foster, Gould, Taylor, & Weitz, 2012; Major et al., 2000; Ralph, Foster, Kimport, Turok, & Roberts, 2017; van Ditzhuijzen, Ten Have, de Graaf, van Nijnatten, & Vollebergh, 2017). Rocca et al. (in press) also found that negative emotions such as sadness, guilt, and anger did not emerge over time but instead declined, countering notions that negative emotions emerge over time (Reardon, 2018). In fact, experiencing low emotions regarding the abortion increased over time and by 5 years, 84% of their sample had low emotions (65%) or primarily positive eomtions (19%) regarding their abortion. That is, the majority of individuals reported feeling few emotions (and much fewer than 1 week after the abortion) in the past week regarding their abortion that occurred 5 years ago. In addition to examining trends in decisional rightness and emotions over time, Rocca et al. (in press) examined two main predictors of these outcomes and their trends over time: decision difficulty and perceived community abortion stigma (henceforth abortion stigma). A little over a quarter of the women (26.7%) experienced decision difficulty, 27.0% reported the decision was somewhat difficult, and 46.3% experienced no difficulty. Compared to those who found had no difficulty deciding to have an abortion, those experiencing the most difficulty were both shortly after the abortion and five years afterwards less likely to endorse that the abortion
3
was the right decision for them. Nevertheless, at 1 week after the abortion and 5 years afterwards, 94.6% and 97.9% of those reporting the most decision difficulty reported that abortion was the right decision, which is a significant increase in decisional rightness over time for this group. Compared to those having no difficulty deciding to have an abortion, those with the most difficulty had more sadness shortly after and 5 years after the abortion. However, feelings of sadness decreased more sharply among those reporting more decision difficulty. Those who experienced the most difficulty deciding to have an abortion also had less relief shortly after an abortion than those who had no difficulty. However, by 5 years there were no longer differences in feelings of relief by decision difficulty. Relief was the most common emotion felt by everyone, including those who had a difficult time deciding, at all time points. These results highlight that experiencing difficulty is not the same as thinking the decision was wrong, and that a difficult decision can nevertheless be the right one for a person. Future research would benefit from further exploration of how interrelated are women’s assessments— both before and after the abortion—of their decision to have an abortion. Included in women’s assessments should be items regarding decision difficulty, certainty, confidence, satisfaction, and rightness, and such items should be assessed before the abortion and multiple assessments afterwards. The association between abortion stigma and decisional rightness and emotions was slightly different than the association between decision difficulty and these outcomes. Experiencing high abortion stigma was associated with sadness and anger shortly after the abortion. While sadness and anger decreased for everyone, by 5 years there were still differences in anger by abortion stigma. The pattern was slightly different for the association between abortion stigma and decision rightness. Shortly after the abortion, perceived community abortion
4
stigma was not predictive of decsion rightness. Only at two years and beyond did those who perceived high levels of abortion stigma have a lower likelihood of indicating decision rightness than those who perceived no abortion stigma. Still at 5 years, the overwhleming majority of those who experienced high abortion stigma, 97.7%, felt abortion was the right decision. Coinciding with the time (2011-2013) that abortion stigma seemed to have an effect on decision rightness in this study was a spike in restrictive abortion policies in the U.S. (Boonstra & Nash, 2016). Rocca et al. (in press) did not examine whether decisional difficulty or rightness, or emotions relate to mental health problems such as depression or an anxiety disorder. It is important to do so because negative emotions may be conflated with or thought to lead to mental health problems, and claims that abortion leads to mental health problems are used to justify informed consent, waiting period, and two trip policies. Thus, by showing that experiencing more negative emotions is not related to mental health problems as van Ditzhuijzen et al. (2017) did, there is evidence that more negative emotions around the time of an abortion do not lead to mental health problems. This study had a similar portion of women experiencing decision difficulty (van Ditzhuijzen, Brauer, Boeije, & van Nijnatten, 2019) as the Rocca et al. (in press) study and it found that decision difficulty, decision certainty, and negative emotions were not associated with recurrent or new mental health problems in unadjusted or adjusted models (van Ditzhuijzen et al., 2017). That is while women have varying emotions—both positive and negative—or levels of decision difficulty around the time of an abortion, it is not the case that having more negative emtions or more decision difficulty leads to mental health problems. This research thus suggests that women may have varying emotions around an abortion or varying
5
difficulty levels in making the abortion decision, and such expriences do not translate into mental health problems. Why women experiencing decision difficulty also experience a lower likelihood of decesional rightness is not clear. It may be that there is a direct relationship between decision difficulty and decision rightness. That is, it may be reflective of a woman’s individual circumstances. For instance, the pregnancy may have been desired within a particular relationship at a particular time, but then the relationship ended. Or a woman may be considering whether she can raise a child at this point in her life having become pregnant years earlier than intended. Alternatively, it may be that there is an underlying trait of indecisisveness and those who have a more indecisive personality may have a more difficult time making this decision and other decisions; having a more indecisive personality may also be associated with a lower likelihood of rating one’s decision as the right one. Indeed prior research has found that being indecisive is associated with lower confidence in one’s abortion decision before having an abortion (Foster et al., 2012). Similarly, the study of women in the Netherlands found that one dimension of decision difficulty around an abortion was being an indecisive person (van Ditzhuijzen et al., 2019). It is also possible that abortion stigma leads to both difficulty with the decision and less certainty afterwards. Future research should assess trait-like indecisiveness and decision-making processes before pregnancy, while pregnant, and after pregnancy. Although the Turnaway study did assess abortion stigma over time, decision difficulty was only assessed at 1 week after the abortion. The results may have changed had decision difficulty been assessed both before the abortion and at multiple points after the abortion. It is worth knowing whether women’s reports of decision difficulty change over time. Rocca et al. (in
6
press) did report that perceptions of abortion stigma changed over time. Future research should assess decision difficulty before and after the abortion to see if individuals ratings are similar. What Policies Not Based on Science May Be Doing to Women Abortion policies requiring women be informed of the negative psychological effects of having an abortion, waiting periods, and two trips do not make individuals change their minds (Roberts, Belusa, Turok, Combellick, & Ralph, 2017; Roberts, Turok, Belusa, Combellick, & Upadhyay, 2016; Sanders, Conway, Jacobson, Torres, & Turok, 2016). Instead such policies may lead to logistical and financial burdens associated with making two trips, having to travel further for an abortion, and unnecessary stress for women (Joyce, Henshaw, Dennis, Finer, & Blanchard, 2016; Roberts et al., 2016; Sanders et al., 2016). In addition, societal messages, provided either directly or perceived in the environment, of negative psychological effects of having an abortion or of expectations about decision difficulty or uncerainty around an abortion may actually create stress that otherwise would not have existed (Major et al., 2009). This is known as a self-fulfilling prophency because psychological effects would not have existed had an external source (and in this case the external information is required by law) not conveyed that women are expected to have negative psychological effects, decision difficulty, or decision unrightness due to their abortion. Even if waiting periods are not necessary for all women, there are claims that waiting periods or two-trip requirements benefit some women—for instance, those who are less certain of their decision (Reardon, 2018). However, there is no evidence that requiring women wait or make two trips to have an abortion helps in having higher decisional certainty. Instead, as discussed by Roberts et al. (2016; 2017), an individualized approach that involves helping women who are experiencing uncertainty regarding their decision come to a more certain
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decision about what to do, as is already being carried out in U.S. abortion clinical care settings is warranted (Foster et al., 2012; Gould, Perrucci, Barar, Sinkford, & Foster, 2012). As mentioned earlier, paternalistic claims about high decision uncertainty, decision regret, and negative psycholgical effects of having an abortion are increasingly being used for a range of abortion policies, the latest of which are reversal laws or those that require telling individuals that they can reverse their abortions after taking mifepristone. These laws are not just medically inaccurate but also may be harmful to women (Creinin & Chen, 2019; Creinin, Hou, Dalton, Steward, & Chen, 2019; Grossman & White, 2018; Grossman et al., 2015). There is no medical basis that medication abortion can be reversed (Creinin & Chen, 2019; Grossman & White, 2018). Quite the contrary, there is very recent research suggesting that only taking mifepristone (which is what reversal laws encourage) may be dangerous for women’s health, leading to significantly more bleeding or hemorrhage than when follwed by misoporostol (Creinin et al., 2019). Conclusions In sum, the Rocca et al. (in press) study and other research demonstrate women overwhelmingly rate their decision to have an abortion as right or one in which they are certain, even women having more difficulty making the decision. Negative emotions such as sadness or anger or decision regret regarding one’s decision do not emerge years after an abortion. Relief is the most common emotion felt by women. Policies should not be based on unsubstantiated notions that women are unsure of their decision or come to regret it or that abortion increases risk of negative emotions or mental health problems because there is no evidence to support these claims.
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Fig. 1. (a) States requiring women be informed of negative psychological effects of having an abortion; (b) States requiring women take two trips to have an abortion; and (c) States requiring women wait some time after counseling before having an abortion. A. Purple states require being informed of the negative psychological effects of having an abortion.
B. Red states require two trips to have an abortion.
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C. Green states require waiting to have an abortion after counseling for at least 18 hours.
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References Adler, N. E. (1975). Emotional responses of women following therapeutic abortion. The American Journal of Orthopsychiatry, 45(3), 446–454. https://doi.org/10.1111/j.1939-
0025.1975.tb02555.x Boonstra, H. D., & Nash, E. (2016). A Surge of State Abortion Restrictions Puts Providers—And the Women They Serve—In the Crosshairs. Guttmacher Policy Review, 17(1), 9–15. Creinin, M. D., & Chen, M. J. (2019). Mifepristone antagonization requires real studies to evaluate safety and efficacy. Contraception, 100(6), 427–429. https://doi.org/10.1016/j.contraception.2019.10.016 Creinin, M. D., Hou, M. Y., Dalton, L., Steward, R., & Chen, M. J. (2019). Mifepristone Antagonization With Progesterone to Prevent Medical Abortion: A Randomized Controlled Trial. Obstetrics and Gynecology. https://doi.org/10.1097/AOG.0000000000003620 Dobkin, L. M., Gould, H., Barar, R. E., Ferrari, M., Weiss, E. I., & Foster, D. G. (2014). Implementing a prospective study of women seeking abortion in the United States: Understanding and overcoming barriers to recruitment. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 24(1), e115-123.
https://doi.org/10.1016/j.whi.2013.10.004 Finer, L. B., & Zolna, M. R. (2011). Unintended pregnancy in the United States: Incidence and disparities, 2006. Contraception, 84(5), 478–485. https://doi.org/10.1016/j.contraception.2011.07.013
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Foster, D. G., Gould, H., Taylor, J., & Weitz, T. A. (2012). Attitudes and decision making among women seeking abortions at one U.S. clinic. Perspectives on Sexual and Reproductive Health, 44(2), 117–124. https://doi.org/10.1363/4411712
Gould, H., Perrucci, A., Barar, R., Sinkford, D., & Foster, D. G. (2012). Patient education and emotional support practices in abortion care facilities in the United States. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 22(4),
e359-364. https://doi.org/10.1016/j.whi.2012.04.003 Grossman, D., & White, K. (2018). Abortion “Reversal”—Legislating without Evidence. The New England Journal of Medicine, 379(16), 1491–1493.
https://doi.org/10.1056/NEJMp1805927 Grossman, D., White, K., Harris, L., Reeves, M., Blumenthal, P. D., Winikoff, B., & Grimes, D. A. (2015). Continuing pregnancy after mifepristone and “reversal” of first-trimester medical abortion: A systematic review. Contraception, 92(3), 206–211. https://doi.org/10.1016/j.contraception.2015.06.001 Gruender. Planned Parenthood v Rounds. , (United States Court of Appeals for the Eighth Circuit July 24, 2012). Guttmacher Institute. (2019, December 1). An Overview of Abortion Laws. Retrieved December 11, 2019, from https://www.guttmacher.org/print/state-policy/explore/overview-abortionlaws Jones, R. K., Frohwirth, L., & Moore, A. M. (2013). More than poverty: Disruptive events among women having abortions in the USA. The Journal of Family Planning and Reproductive Health Care, 39(1), 36–43. https://doi.org/10.1136/jfprhc-2012-100311
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Jones, R. K., & Jerman, J. (2017). Population Group Abortion Rates and Lifetime Incidence of Abortion: United States, 2008–2014. American Journal of Public Health, 107(12), 1904– 1909. https://doi.org/10.2105/AJPH.2017.304042 Joyce, T. J., Henshaw, S. K., Dennis, A., Finer, L. B., & Blanchard, K. (2016, January 28). The Impact of State Mandatory Counseling and Waiting Period Laws on Abortion: A Literature Review. Retrieved December 25, 2019, from Guttmacher Institute website: https://www.guttmacher.org/report/impact-state-mandatory-counseling-and-waitingperiod-laws-abortion-literature-review Kennedy. Gonzales v Carhart. , No. 550 (Supreme Court of the United States April 18, 2007). Major, B., Appelbaum, M., Beckman, L., Dutton, M. A., Russo, N. F., & West, C. (2009). Abortion and mental health: Evaluating the evidence. American Psychologist, 64(9), 863–890. https://doi.org/10.1037/a0017497 Major, B., Cozzarelli, C., Cooper, M. L., Zubek, J., Richards, C., Wilhite, M., & Gramzow, R. H. (2000). Psychological responses of women after first-trimester abortion. Archives of General Psychiatry, 57(8), 777–784. https://doi.org/10.1001/archpsyc.57.8.777
National Academies of Sciences, Engineering, and Medicine. (2018). The Safety and Quality of Abortion Care in the United States. Retrieved from
http://www.ncbi.nlm.nih.gov/books/NBK507236/ North Dakota HB 1336 House Standing Committee Minutes. (2019, July 19).
Paxton et al. (2017, August 11). Defendants’ response to plaintiffs’ motion for a temporary restraining order.
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Ralph, L. J., Foster, D. G., Kimport, K., Turok, D., & Roberts, S. C. M. (2017). Measuring decisional certainty among women seeking abortion. Contraception, 95(3), 269–278. https://doi.org/10.1016/j.contraception.2016.09.008 Reardon, D. C. (2018). The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities. SAGE Open Medicine, 6, 2050312118807624. https://doi.org/10.1177/2050312118807624 Roberts, S. C. M., Belusa, E., Turok, D. K., Combellick, S., & Ralph, L. (2017). Do 72-Hour Waiting Periods and Two-Visit Requirements for Abortion Affect Women’s Certainty? A Prospective Cohort Study. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 27(4), 400–406. https://doi.org/10.1016/j.whi.2017.02.009
Roberts, S. C. M., Turok, D. K., Belusa, E., Combellick, S., & Upadhyay, U. D. (2016). Utah’s 72-Hour Waiting Period for Abortion: Experiences Among a Clinic-Based Sample of Women. Perspectives on Sexual and Reproductive Health, 48(4), 179–187. https://doi.org/10.1363/48e8216 Rocca, C. H., Samari, G., Foster, D. G., Gould, H., & Kimport, K. (in press). Emotions and decision rightness over five years following an abortion: An examination of decision difficulty and abortion stigma. Social Science & Medicine. Sanders, J. N., Conway, H., Jacobson, J., Torres, L., & Turok, D. K. (2016). The Longest Wait: Examining the Impact of Utah’s 72-Hour Waiting Period for Abortion. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 26(5), 483–487.
https://doi.org/10.1016/j.whi.2016.06.004
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Speckhard, A. C., & Rue, V. M. (1992). Postabortion syndrome: An emerging public health concern. Journal of Social Issues, 48(3), 95–119. https://doi.org/10.1111/j.15404560.1992.tb00899.x van Ditzhuijzen, J., Brauer, M., Boeije, H., & van Nijnatten, C. H. C. J. (2019). Dimensions of decision difficulty in women’s decision-making about abortion: A mixed methods longitudinal study. PloS One, 14(2), e0212611. https://doi.org/10.1371/journal.pone.0212611 van Ditzhuijzen, J., Ten Have, M., de Graaf, R., van Nijnatten, C. H. C. J., & Vollebergh, W. A. M. (2017). Correlates of Common Mental Disorders Among Dutch Women Who Have Had an Abortion: A Longitudinal Cohort Study. Perspectives on Sexual and Reproductive Health, 49(2), 123–131. https://doi.org/10.1363/psrh.12028
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S0277-9536(20)30001-0
DOI:
https://doi.org/10.1016/j.socscimed.2020.112782
Reference:
SSM 112782
To appear in:
Social Science & Medicine
Received Date: 15 December 2019 Accepted Date: 1 January 2020
Please cite this article as: Steinberg, J.R., Decision rightness and relief predominate over the years following an abortion, Social Science & Medicine (2020), doi: https://doi.org/10.1016/ j.socscimed.2020.112782. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
Running head: Decision certainty and relief follow an abortion
Decision rightness and relief predominate over the years following an abortion Julia R. Steinberg
Author Correspondence:
a
Julia R. Steinberg Department of Family Science School of Public Health University of Maryland, College Park 301.314.1404 [email protected]
Department of Family Science, School of Public Health, University of Maryland College Park
1
Abstract A recent analysis from the Turnaway study focused on women who were just under the gestational limit of a clinic and received an abortion and those who had first trimester abortions to examine trends in decisional rightness and negative and positive emotions over 5 years after the abortion. Specifically, Rocca et al. (in press) analyzed these data and found that women were overwhemingly sure of their decision: Over 95% felt their decision was the right one at each assessment after their abortion, and the predicted probability of abortion being the right decision was 99% at 5 years afterwards. Relief was the most common emotion felt by women, and negative emotions or decision regret did not emerge over time. These results and others from studies conducted globally counter assertions by abortion opponents that women are not certain of their decisions, or that women regret or have negative emotins about their abortions if not in the short run then after a long period of time. This commentary addresses not only these findings but also relevant U.S. abortion policies based on these unsubstantiated claims. Policies should not be based on the notions that women are unsure of their decision or come to regret it or have negative emotions because there is no evidence to support these claims.
Keywords: abortion, emotions, decision rightness, policies
Introduction Currrent estimates indicate that a quarter of US women will have an abortion by the time they are 45 (Jones & Jerman, 2017). Abortion may be a stressful experience, and it often occurs in the context of an unintended pregnancy (Finer & Zolna, 2011), which itself may be stressful. In addition, abortion often occurs in the context of other disruptive events such as loss of employment or a dissolution of a relationship (Jones, Frohwirth, & Moore, 2013). Although previous studies have found that women experience a range of emotions or are satisfied with their decision to have an abortion (Adler, 1975; Major et al., 2000), this research was conducted 20 to 40 years ago when the sociopolitical climate around having an abortion in the US may have differed. Thus, a scientific understanding of women’s decision making and emotions around an abortion in the more recent sociopolitical climate—such as the one conducted by Rocca et al. (in press)—is warranted Such an understanding may inform public policy and practice. Abortion policies are based on presumed notions that negative emotions such as sadness or guilt prevail after an abortion, that most women do not feel that abortion was the right decision for them or certainty regarding their decision, and that abortion leads to mental health problems. These notions are used to justify laws in 12 states (see Figure 1a for which states) requiring women be informed of negative psychologial effects of having an abortion (National Academies of Sciences, Engineering, and Medicine, 2018), laws in 28 states (see Figure 1b for which states) requiring waiting periods after receiving pre-abortion counseling, with 8 states requiring at least 48 hours (Guttmacher Institute, 2019); and laws in 15 states (see figure 1c for which states) requring women make two trips to the clinic to have an abortion (Guttmacher Institute, 2019). Two trip laws are distinct from waiting period laws; the latter only require women to get information on
1
the phone and then wait the specified amount of time to have an abortion. In contrast, two trip laws require women receive information in person at the clinic and then wait at least 24 hours to have an abortion. These notions are also increasingly being used for a range of other types of policies or as the basis for court decisions (Gruender, 2012; Kennedy, 2007). For instance, these notions are used to justify restricting specific abortion procedures such as the dilation and evacuation (D&E) method (Paxton et al., 2017) or those requirng women be informed of the medically inaccurate information that a medication abortion can be reversed (North Dakota HB 1336, 2019). Proponents defend these policies by arguing that there is scientific evidence that women are unsure of their decision, that negative emotions occur afterwards, and that regret regarding the decision is common (Reardon, 2018; Speckhard & Rue, 1992). Proponents further claim that negative emotions such as decision regret may not emerge until much later after the abortion (Reardon, 2018; Speckhard & Rue, 1992). However, Rocca et al. (in press) eloquently show that the notions that abortion leads to negative emotions or regret regarding one’s abortion decision are not supported by scienctific evidence. That is, negative emotions including sadness, guilt, and anger, and feeling that abortion was the not the right decision did not dominate after an abortion or emerge years afterwards (Rocca, Samari, Foster, Gould, & Kimport, in press). Thus, the importance of this study’s findings cannot be overstated. Rocca and Colleagues’ Analysis of the Turnaway Study Rocca et al. (in press) used data from the Turnaway study, focusing on women who were just under the gestational limit and received an abortion and those who had first trimester abortions to examine trends in decisional rightness, negative emotions (e.g., sadness, anger, and guilt), and positive emotions (e.g., relief and happiness) over 5 years after the abortion. The
2
Turnaway study recruited and prospecitvely followed women seeking abortions from one week after their abortion until 5 years later, conducting assessments every 6 months (Dobkin et al., 2014). Rocca et al. (2010) found that women overwhemingly felt abortion was the right decision: over 95% felt their decision was the right one at each assessment after their abortion, and the predicted probability that abortion was the right decision one week and 5 years after the abortion was 97.5% and 99.0% respectively. These results confirm other recent and past findings in the U.S. and Netherlands on the related constructs of decisional certainty, satisfaction, or confidence (Foster, Gould, Taylor, & Weitz, 2012; Major et al., 2000; Ralph, Foster, Kimport, Turok, & Roberts, 2017; van Ditzhuijzen, Ten Have, de Graaf, van Nijnatten, & Vollebergh, 2017). Rocca et al. (in press) also found that negative emotions such as sadness, guilt, and anger did not emerge over time but instead declined, countering notions that negative emotions emerge over time (Reardon, 2018). In fact, experiencing low emotions regarding the abortion increased over time and by 5 years, 84% of their sample had low emotions (65%) or primarily positive eomtions (19%) regarding their abortion. That is, the majority of individuals reported feeling few emotions (and much fewer than 1 week after the abortion) in the past week regarding their abortion that occurred 5 years ago. In addition to examining trends in decisional rightness and emotions over time, Rocca et al. (in press) examined two main predictors of these outcomes and their trends over time: decision difficulty and perceived community abortion stigma (henceforth abortion stigma). A little over a quarter of the women (26.7%) experienced decision difficulty, 27.0% reported the decision was somewhat difficult, and 46.3% experienced no difficulty. Compared to those who found had no difficulty deciding to have an abortion, those experiencing the most difficulty were both shortly after the abortion and five years afterwards less likely to endorse that the abortion
3
was the right decision for them. Nevertheless, at 1 week after the abortion and 5 years afterwards, 94.6% and 97.9% of those reporting the most decision difficulty reported that abortion was the right decision, which is a significant increase in decisional rightness over time for this group. Compared to those having no difficulty deciding to have an abortion, those with the most difficulty had more sadness shortly after and 5 years after the abortion. However, feelings of sadness decreased more sharply among those reporting more decision difficulty. Those who experienced the most difficulty deciding to have an abortion also had less relief shortly after an abortion than those who had no difficulty. However, by 5 years there were no longer differences in feelings of relief by decision difficulty. Relief was the most common emotion felt by everyone, including those who had a difficult time deciding, at all time points. These results highlight that experiencing difficulty is not the same as thinking the decision was wrong, and that a difficult decision can nevertheless be the right one for a person. Future research would benefit from further exploration of how interrelated are women’s assessments— both before and after the abortion—of their decision to have an abortion. Included in women’s assessments should be items regarding decision difficulty, certainty, confidence, satisfaction, and rightness, and such items should be assessed before the abortion and multiple assessments afterwards. The association between abortion stigma and decisional rightness and emotions was slightly different than the association between decision difficulty and these outcomes. Experiencing high abortion stigma was associated with sadness and anger shortly after the abortion. While sadness and anger decreased for everyone, by 5 years there were still differences in anger by abortion stigma. The pattern was slightly different for the association between abortion stigma and decision rightness. Shortly after the abortion, perceived community abortion
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stigma was not predictive of decsion rightness. Only at two years and beyond did those who perceived high levels of abortion stigma have a lower likelihood of indicating decision rightness than those who perceived no abortion stigma. Still at 5 years, the overwhleming majority of those who experienced high abortion stigma, 97.7%, felt abortion was the right decision. Coinciding with the time (2011-2013) that abortion stigma seemed to have an effect on decision rightness in this study was a spike in restrictive abortion policies in the U.S. (Boonstra & Nash, 2016). Rocca et al. (in press) did not examine whether decisional difficulty or rightness, or emotions relate to mental health problems such as depression or an anxiety disorder. It is important to do so because negative emotions may be conflated with or thought to lead to mental health problems, and claims that abortion leads to mental health problems are used to justify informed consent, waiting period, and two trip policies. Thus, by showing that experiencing more negative emotions is not related to mental health problems as van Ditzhuijzen et al. (2017) did, there is evidence that more negative emotions around the time of an abortion do not lead to mental health problems. This study had a similar portion of women experiencing decision difficulty (van Ditzhuijzen, Brauer, Boeije, & van Nijnatten, 2019) as the Rocca et al. (in press) study and it found that decision difficulty, decision certainty, and negative emotions were not associated with recurrent or new mental health problems in unadjusted or adjusted models (van Ditzhuijzen et al., 2017). That is while women have varying emotions—both positive and negative—or levels of decision difficulty around the time of an abortion, it is not the case that having more negative emtions or more decision difficulty leads to mental health problems. This research thus suggests that women may have varying emotions around an abortion or varying
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difficulty levels in making the abortion decision, and such expriences do not translate into mental health problems. Why women experiencing decision difficulty also experience a lower likelihood of decesional rightness is not clear. It may be that there is a direct relationship between decision difficulty and decision rightness. That is, it may be reflective of a woman’s individual circumstances. For instance, the pregnancy may have been desired within a particular relationship at a particular time, but then the relationship ended. Or a woman may be considering whether she can raise a child at this point in her life having become pregnant years earlier than intended. Alternatively, it may be that there is an underlying trait of indecisisveness and those who have a more indecisive personality may have a more difficult time making this decision and other decisions; having a more indecisive personality may also be associated with a lower likelihood of rating one’s decision as the right one. Indeed prior research has found that being indecisive is associated with lower confidence in one’s abortion decision before having an abortion (Foster et al., 2012). Similarly, the study of women in the Netherlands found that one dimension of decision difficulty around an abortion was being an indecisive person (van Ditzhuijzen et al., 2019). It is also possible that abortion stigma leads to both difficulty with the decision and less certainty afterwards. Future research should assess trait-like indecisiveness and decision-making processes before pregnancy, while pregnant, and after pregnancy. Although the Turnaway study did assess abortion stigma over time, decision difficulty was only assessed at 1 week after the abortion. The results may have changed had decision difficulty been assessed both before the abortion and at multiple points after the abortion. It is worth knowing whether women’s reports of decision difficulty change over time. Rocca et al. (in
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press) did report that perceptions of abortion stigma changed over time. Future research should assess decision difficulty before and after the abortion to see if individuals ratings are similar. What Policies Not Based on Science May Be Doing to Women Abortion policies requiring women be informed of the negative psychological effects of having an abortion, waiting periods, and two trips do not make individuals change their minds (Roberts, Belusa, Turok, Combellick, & Ralph, 2017; Roberts, Turok, Belusa, Combellick, & Upadhyay, 2016; Sanders, Conway, Jacobson, Torres, & Turok, 2016). Instead such policies may lead to logistical and financial burdens associated with making two trips, having to travel further for an abortion, and unnecessary stress for women (Joyce, Henshaw, Dennis, Finer, & Blanchard, 2016; Roberts et al., 2016; Sanders et al., 2016). In addition, societal messages, provided either directly or perceived in the environment, of negative psychological effects of having an abortion or of expectations about decision difficulty or uncerainty around an abortion may actually create stress that otherwise would not have existed (Major et al., 2009). This is known as a self-fulfilling prophency because psychological effects would not have existed had an external source (and in this case the external information is required by law) not conveyed that women are expected to have negative psychological effects, decision difficulty, or decision unrightness due to their abortion. Even if waiting periods are not necessary for all women, there are claims that waiting periods or two-trip requirements benefit some women—for instance, those who are less certain of their decision (Reardon, 2018). However, there is no evidence that requiring women wait or make two trips to have an abortion helps in having higher decisional certainty. Instead, as discussed by Roberts et al. (2016; 2017), an individualized approach that involves helping women who are experiencing uncertainty regarding their decision come to a more certain
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decision about what to do, as is already being carried out in U.S. abortion clinical care settings is warranted (Foster et al., 2012; Gould, Perrucci, Barar, Sinkford, & Foster, 2012). As mentioned earlier, paternalistic claims about high decision uncertainty, decision regret, and negative psycholgical effects of having an abortion are increasingly being used for a range of abortion policies, the latest of which are reversal laws or those that require telling individuals that they can reverse their abortions after taking mifepristone. These laws are not just medically inaccurate but also may be harmful to women (Creinin & Chen, 2019; Creinin, Hou, Dalton, Steward, & Chen, 2019; Grossman & White, 2018; Grossman et al., 2015). There is no medical basis that medication abortion can be reversed (Creinin & Chen, 2019; Grossman & White, 2018). Quite the contrary, there is very recent research suggesting that only taking mifepristone (which is what reversal laws encourage) may be dangerous for women’s health, leading to significantly more bleeding or hemorrhage than when follwed by misoporostol (Creinin et al., 2019). Conclusions In sum, the Rocca et al. (in press) study and other research demonstrate women overwhelmingly rate their decision to have an abortion as right or one in which they are certain, even women having more difficulty making the decision. Negative emotions such as sadness or anger or decision regret regarding one’s decision do not emerge years after an abortion. Relief is the most common emotion felt by women. Policies should not be based on unsubstantiated notions that women are unsure of their decision or come to regret it or that abortion increases risk of negative emotions or mental health problems because there is no evidence to support these claims.
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Fig. 1. (a) States requiring women be informed of negative psychological effects of having an abortion; (b) States requiring women take two trips to have an abortion; and (c) States requiring women wait some time after counseling before having an abortion. A. Purple states require being informed of the negative psychological effects of having an abortion.
B. Red states require two trips to have an abortion.
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C. Green states require waiting to have an abortion after counseling for at least 18 hours.
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