Measuring the long-term cost of restricting abortion access

When Diana Greene Foster and her team at the University of California, San Francisco, started their study on the lives of women who were denied abortions in 2008, they sought to investigate a rather commonly held view: That having an abortion hurt women’s mental and physical health, including by leading to PTSD and drug and alcohol use disorder.

A series of laws had been passed based on this belief, introducing compulsory counseling and waiting periods for people seeking abortions, thereby adding barriers to accessing the procedure, especially for patients with lower incomes who couldn’t afford repeated time off work, travel, and associated costs such as child care.

The researchers of what is known as the Turnaway Study followed 1,000 women (recruited over a three-year span in 30 abortion centers) for five years, and compared the outcomes of those who were able to receive the abortion they wanted to those who were not, and ended up having a child. 

What they found through 8,000 interviews wasn’t simply that women who got abortions did not suffer in the long term, and overwhelmingly (95%) did not regret their decision. They found the opposite: It was the women who were forced to carry an unwanted pregnancy to term who suffered grave harm — to their health and their economic and social well-being. So did their children.

“We had no idea when we started it that the really relevant group was going to be the people denied [abortions],” said Foster, who was awarded a 2023 MacArthur “genius” grant on Oct. 4 in recognition of the importance of her work. 

Yet the Turnaway Study — now heralded as landmark — ended up changing the conversation about abortion in the U.S., and its role in a healthy society. 

Longitudinal data on harms

The study’s findings were unequivocal. Women denied abortions were almost four times more likely to live below the federal poverty line, and even years later, often struggled to pay for basic needs, and had higher rates of debt, bankruptcies, and evictions. Women who were denied abortions also had a higher likelihood of staying with abusive partners or raising children alone. They had worse health, too: They were more likely to experience preterm birth, preeclampsia, and hemorrhage, and were more prone to developing chronic conditions, such as migraines. 

The children born out of denied abortions, and their siblings, were also worse off than the children of mothers who were able to have an abortion. “Many people who have abortions are already parents, and they’re concerned about their existing kids,” explained Foster. “We have the data to show they’re justly concerned, we see their existing kids are worse off.” The cost of raising a child weighs heavily on a family that can’t afford it, including on their other children, who are more likely to experience financial distress and suffer from developmental delays. Further, the children who are born out of the denied abortion are less likely to build a solid bond with their mother, which can have lifelong mental health consequences. 

And being forced to give birth before being ready for it often means not having the opportunity to do so at a later time. “[It replaces] more intended kids that could come along later,” said Foster. “I think it’s pretty important to emphasize that when parents are able to make decisions about whether to become parents, their kids do better, and that we should trust their decision-making for the good of society,” she said. 

The long-term impact of the study was to provide hard data in lieu of anecdotal observations. 

“Diana’s study is groundbreaking. When she went into it, in the U.S. we didn’t have any longitudinal studies that focused on people who obtained abortions or who tried to obtain abortions and didn’t and followed their trajectories over time,” said Rachel Jones, a principal research scientist at the Guttmacher Institute.

“I think it did shift the conversation to say, ‘no, actually, the data show that abortion doesn’t hurt women and shows actually if you prevent people from having abortions when they want them, there are harms,’” said Foster. 

Recognizing the economic dimension

Prior to the study, there was hardly any data that measured the long-term economic impact of abortion denial. That, said Foster, was arguably the study’s takeaway that had the greatest resonance, as it reframed abortion not simply as a personal choice, but as a social necessity with important economic consequences.

Abortion has always been an economic issue, said Mary Fissell, a professor of history of medicine at Johns Hopkins University, who is working on a book about the history of abortion. 

Think about ancient Rome, said Fissell, where a largely permissive attitude toward abortion changed, in part because elite Romans, concerned with maintaining their power, found in abortion a challenge to growing their share of the population. Or in Nikita Khrushchev’s USSR, where a shortage of contraceptives made abortion the de facto birth control method, and was encouraged with the goal of keeping women in the workforce. 

When it comes to America, the economic piece was present from the very beginning of the anti-abortion movement. “You can’t talk about abortion in the U.S. without thinking about the legacy of chattel slavery,” said Fissell. “The meanings of abortion in America are shaped by concerns during enslavement that women were aborting in order to resist slavery, because they didn’t want to give birth to a child who would be enslaved.”

The Turnaway Study provided substantial evidence to support the economic dimension of abortion, which has been crucial for abortion rights advocates as the debate heated up in recent years. After the Dobbs decision, Foster’s work was fiercely contested by the anti-abortion movement (including through later-retracted articles in scientific publications). 

“Her research has definitely been cited in a variety of legal and political [contexts]. When people are proposing to enact restrictive or supportive legislation, or trying to remove restrictive legislation, her research is cited extensively,” said Jones.

After the MacArthur

For Foster, the MacArthur grant of $800,000 will help fund two research projects. The first is a Turnaway Study underway in Nepal, a country where abortion laws are less restrictive than they were in the U.S. even prior to the Dobbs decision, but where overall socioeconomic conditions are far worse. 

The second is research primarily funded by the William and Flora Hewlett Foundation and focuses on states with restrictions on abortion, looking at the consequences of the end of Roe v. Wade, and the consequences of abortion being denied for legal reasons (which was rarely the case in the Turnaway Study). This research presents a new set of challenges. “As soon as abortion becomes illegal, it becomes a lot harder to study. People don’t want to participate in studies where they have to give their names. The researchers become worried if someone’s going to subpoena their data,” said Foster.

The rest of the award, she said, will go toward promoting the Turnaway Study’s findings on the stage, via “The Turnaway Play.” “My older sister in upstate New York [Lesley Lisa Greene] wrote a play that’s about the science, the study, how we did it, the findings, the women from the study, the interviewers. And it’s funny and smart. It’s playing in Ithaca, New York, in May, so I’m going to try and see what I can do to help it play more places,” said Foster.

Correction: The Turnaway study followed 1,000 women for five years, rather than the 10 years originally reported.