Chapter 1: The Turnaway Study CHAPTER 1 The Turnaway Study In the summer of 1987, President Ronald Reagan addressed the leaders of the right-to-life movement during a gathering in Washington, DC, and did what Republican presidents have been doing ever since abortion become legal in the United States.1 He promised to fight to overturn Roe v. Wade , the 1973 Supreme Court decision that continues to rankle the Grand Old Party''s religious-right base all these decades later. "I will not rest until a human life amendment becomes a part of our Constitution," Reagan promised, referring to the name given to various proposed constitutional amendments introduced since 1973 that would have granted legal personhood to embryos and fetuses and effectively criminalized all abortions, sometimes without exceptions. To date, no such proposal has gone far in Congress, and Reagan clearly didn''t expect it to go far in his last years in office. Before the anti-abortion leaders ceased their applause, Reagan quickly turned the conversation to incremental attacks on abortion. "At the same time," he said, "we must continue to search for practical steps that we can take now, even before the battle for the human life amendment is won." Reagan listed four steps his administration had taken, steps he believed represented "powerful examples of what can be done now to protect the lives of unborn children.

" The third step on his list, however, did not address those "unborn children," but rather the need for proof that abortion harms women. "Growing numbers of women who''ve had abortions now say that they have been misled by inaccurate information," he said. "Making accurate data on maternal morbidity available to women before an abortion is performed is an essential element of informed consent. I am, therefore, directing the Surgeon General to issue a comprehensive medical report on the health effects, physical and emotional, of abortion on women." That task fell to Surgeon General C. Everett Koop, an acclaimed pediatric surgeon who very publicly opposed abortion. The doctor had written a book and produced short films arguing that abortion would inevitably lead to forced euthanasia for seniors and people with disabilities.2 He had previously toured the country giving multimedia presentations on the evils of abortion.

This is the man who was charged with finding evidence that abortion harms women. Reagan and his religious-right constituents hoped that Koop''s report would provide the basis for abortion to be legislated accordingly. However, Koop could find no such evidence. And it wasn''t for lack of trying. As he would write in his final letter to President Reagan a year and a half later, the surgeon general reviewed more than 250 studies pertaining to the psychological impact of abortion.3 He interviewed women who''d had abortions and talked to dozens of medical, social, and philosophical groups on both sides of the debate. Koop surprised his initial critics with his commitment to science and public health, even in the face of religious and political opposition, when he ultimately concluded that the existing data, showing either that abortion was harmful or that it wasn''t, were rife with methodological problems: "I regret, Mr. President, that in spite of a diligent review on the part of many in the Public Health Service and in the private sector, the scientific studies do not provide conclusive data about the health effects of abortion on women.

" In Koop''s 1989 letter to President Reagan, he called for more and better research of abortion''s effects, specifically a five-year prospective study analyzing all the many outcomes of sex and reproduction, including the psychological and physical effects of trying but failing to conceive; having planned and unplanned, wanted and unwanted pregnancies; and delivering, miscarrying, or aborting pregnancies. His call for better research would go unfulfilled for twenty years. Until, that is, 2007, when my team of social scientists decided to take on a portion of what Koop had envisioned: to study the outcomes of both birth and abortion for women with unwanted pregnancies. Abortion is a medical procedure so controversial it decides elections and ruins Thanksgiving dinners. Yet it is also extremely common--between one in four and one in three women in the U.S. will have an abortion during their lifetime.4 But being common does not make it easy to study.

We needed to overcome the methodological pitfalls that had discredited all the earlier studies Koop had reviewed. In particular, we needed to avoid comparisons between women who have abortions and those who have wanted pregnancies. After all, the set of circumstances that in some cases makes a pregnancy unwanted--such as poverty, poor mental health, or lack of social support--might be the primary stressor that causes poor outcomes, rather than the abortion itself. And given the difficulties brought to the fore when a woman discovers she is pregnant but doesn''t have the job, housing, family support, or other resources required to raise a child, it may not only be the unintended pregnancy that causes distress, but the life reckoning that comes when making the decision to have an abortion. An unbiased study would focus on women who share the same circumstance of becoming pregnant and not feeling able or willing to have a baby. Pregnant women like Jessica, a 23-year-old mother of two whose previous pregnancies had exacerbated her serious health problems and who was married to a man she described as abusive and whom she wanted to leave. Or Sofia, who at 19 was in what she called a "rocky" relationship and whose family had just been evicted from their home. Then we would compare the outcomes--physical, psychological, financial, romantic, familial--of women who got the abortions they wanted, like Jessica, to women who were turned away because they were too far along, like Sofia.

Our study design is what social scientists call a natural experiment, where randomness in access to a program or a service allows researchers to compare people who received it and people who didn''t. A classic example is a lottery that determines which people get health insurance, as was done in Oregon in the rollout of an expansion in Medicaid.5 Obviously, it would be unethical to randomly deny women wanted abortions for the sake of science. But women are denied abortions all the time in the United States--sometimes because they cannot afford one and, sometimes (for at least 4,000 women per year) because there are no clinics nearby that perform abortions at their gestation.6 The strength of the Turnaway Study''s design is that women just above and just below the gestational limit are women facing the same circumstances--sometimes just a few days determines whether a woman can access abortion. Any divergences in their outcomes are likely a result of whether they received their wanted abortion. Over the course of three years, 2008 through 2010, we recruited more than 1,000 pregnant women from the waiting rooms of 30 abortion facilities in 21 states. Facilities set their gestational limits to reflect their doctors'' level of comfort and ability, as well as to comply with state law.

Because most of the facilities we chose have limits in the second trimester but more than 90% of women in the U.S. have abortions in the first trimester, we also recruited first-trimester patients, who would represent a more typical abortion experience. At each site, for every woman denied the abortion, we recruited two women who received an abortion just under the gestational limit and one who received an abortion in the first trimester. We interviewed these women by phone twice a year for up to five years--through both easy and difficult recoveries from abortion and birth. We asked about their emotions and mental health, their physical health, their life goals and financial well-being, and the health and development of their children. For those denied abortions, we followed some who continued their search for another clinic that could provide their abortion. The great majority (70%) of those turned away carried the pregnancy to term, and we asked them about their childbirth and subsequent decisions about parenting.

We examined nearly every aspect of how receiving or being denied an abortion affected these women''s lives and the lives of their families. We gathered data about why women want to end their pregnancies and how hard it is to get an abortion in the U.S. We had study participants take us back to the day of their abortions, to the protesters they encountered, to the ultrasound images of embryos or fetuses that some state laws required their doctors to offer to show them. We wanted to learn how these experiences affected women''s long-term emotions about their abortion. We documented their physical health and how it changed with pregnancy, abortion, and birth and in the years that followed. We analyzed the role of men in abortion-related decision-making and how the outcome of the pregnancy affected women''s romantic relationships. A team of UCSF researchers used the latest statistical techniques to analyze data from thousands of interviews, often collaborating with scientists across the country.

Launching the Turnaway Study I would not have been able to carry out the Turnaway Study on my own. As you will see, I had help from many other people from the beginning. In 2007, when I first conceived of the study, Sandy Stonesifer was working as the assistant to the chief of the famil.