This is not about COVID19, but another important public health topic

Abortion

If you can’t tell from the title, this post isn’t about COVID-19. Epidemiologists don’t just study infectious diseases. As a field, we all focus on the health of populations. Some epidemiologists study cancer, others study violence (like me), others study women’s health. No matter what we’re studying, we find patterns to develop a healthier life for our community. This post focuses on another important public health topic in the United States. It isn’t COVID19 related, but it is data-driven and timely. If you’re not interested, feel free to stop reading at this point. I will be back to COVID-19 tomorrow.

An abortion law was put into effect this week in my home state of Texas: banning all abortions after six weeks of pregnancy. Last night the Supreme Court decided not to block it, making it a reality for Texans. This means that about 85% of abortions in Texas are now illegal. This will likely lead to an overturned Roe vs. Wade decision in 2022, which will introduce a wave of strict abortions laws across the United States.

It’s important to review the science so you can equip yourself with the facts and, maybe one day, policymakers can make more evidence-based, data-driven decisions. Here’s the science on abortions.

Epidemiology

The CDC has an abortion surveillance program so we can easily understand the rate of abortions in the United States. Unfortunately this data isn’t perfect due to the voluntary reporting structure (i.e. all data is underreported), but it’s the best we have in real-ish time. The latest data published was from a 2018 study in the MMWR journal:

  • In 2018, 611,376 people got an abortion. This equals 11.3 abortions per 1,000 women aged 15–44 years. This also equals 189 abortions per 1,000 live births. This is an underestimate; the true number of abortions in the United States is closer to 1.2 million a year.

  • The abortion rate has decreased overtime. From 2009 to 2018, the total number of reported abortions decreased 22% (thank you Obamacare and access to birth control)

  • In 2018, New York had the highest number of abortions (77,250) followed by Florida (70,082) and Texas (55,140).

Number of abortions, rate (Number of abortions per 1,000 women aged 15–44 years) and ratio (Number of abortions per 1,000 live births) of abortions performed, by year — selected reporting areas, United States, 2009–2018

Who typically gets abortions and when?

  • Women in their 20s accounted for more than half of abortions (57.7%)

  • 3 out of 4 abortions were performed at ≤9 weeks’ gestation. Nearly all (92.2%) were performed in the first trimester

  • Case Fatality Rate of legal abortions is rare: 0.44 deaths per 100,000 legal abortions. So, on average, 0.44 women die out of 100,000 abortions.

Why do women get an abortion?

The reasons are complex, as more than 60% of women report multiple reasons. More than 900 women in a U.S. study were asked why they got an abortion. The scientists categorized what they heard into 11 broad themes. They were:

  1. Financial reasons (40%): “[It was] all financial, me not having a job, living off death benefits, dealing with my 14 year old son. I didn't have money to buy a baby spoon.

  2. Timing (36%): Like a 21 year old pointed out, “Mainly I didn't feel like I was ready yet - didn't feel financially, emotionally ready. Due date was at the same time as my externship at school. Entering the workforce with a newborn would be difficult - I just wasn't ready yet.”

  3. Partner related reasons (31%): Like “being with the wrong guy” or “partner issues”

  4. Need to focus on other children (29%): “I already had 2 kids and it would be really overwhelming. It's kind of hard to raise 2 kids by yourself,”

  5. Interfere with future opportunities (20%):“I didn't think I'd be able to support a baby and go to college and have a job.” 

  6. Not emotionally or mentally prepared (19%)

  7. Health-related reasons (12%)

  8. Want a better life for the baby than she could provide (7%)

  9. Lack of maturity or independence (7%)

  10. Influences from friends and/or family (5%)

  11. Don’t want a baby or place baby for adoption (4%)

What’s the problem if women are denied an abortion?

Safety and Death

Illegal abortions, for now, are incredibly rare in the United States. You can’t even see the rate of illegal abortions on histogram when compared to other regions of the world.

But if we do change the laws, it will not result in lower abortion rates. The abortion rate is 37 per 1000 in countries that prohibit abortion and the abortion rate is 34 per 1000 in countries that allow abortion. What does shift is the number of illegal abortions. Our histogram will go up. Before Roe vs. Wade (1950’s and 1960’s), the number of illegal abortions in the United States ranged from 200,000 to 1.2 million per year.

And illegal abortions are incredibly dangerous for women. Women with illegal abortions are at higher risk for serious medical problems including:

  • Incomplete abortions

  • Heavy bleeding (hemorrhaging)

  • Infection

  • Uterine perforation (or the uterus pieced by a sharp object)

  • Damage to the genital tract and internal organs (due to inserting dangerous objects like sticks, knitting needles, broken glass)

Each year, 7 million women worldwide are admitted to hospitals for unsafe abortions. 4.7-13% of those women typically die.

Mental Health Issues

Women who are denied an abortion also have more mental illness problems. A major JAMA study followed 956 women who had abortions or women who tried to get abortions but were turned away from the offices where they first sought care. The scientists surveyed these women two times a year for 5 years. Scientists were particularly interested in the mental health differences immediately seeking care and mental health thereafter. What did they find?

  • Women denied an abortion reported more anxiety, lower self-esteem, and lower life satisfaction. Depression among the two groups were the same.

  • Women who were denied an abortion, in particular those who later miscarried or had an abortion elsewhere, had the most elevated levels of anxiety and lowest self-esteem and life satisfaction

  • The mental health between groups by 1 year were about the same

This rejects the common misconception that abortion increases women’s risk of mental illness. In fact the inability to get an abortion does this.

The most vulnerable of populations will suffer

In an older study on pregnant rape victims, 1 in 3 of these victims did not discover they were pregnant until they had already entered the second trimester (long after 6 week mark from the Texas law). Of pregnant rape victims, 50% underwent abortion. Victims of rape or domestic abuse are not an exception to the new Texas law. Victimization, alone, causes long-term mental and physical health problems. Adding the inability to get an abortion only exacerbates health problems for years and years to come.

Women in Texas will also now have to travel to other states to get an abortion. Or, if they don’t have the means, they may have to preform an unsafe abortion in their home state. Poor and minority women experience both greater need for and reduced access to abortion services.

  • Women with incomes less than 100% of the federal poverty level (FPL) have an abortion rate of 52 abortions per 1000 women, compared to 9 per 1000 among women with incomes greater than 200% FPL

  • The abortion rate for non-Hispanic White women was 12 abortions per 1000 reproductive-age women, compared with 29 per 1000 for Hispanic women, and 40 per 1000 for non-Hispanic Black women.

Health inequity in the United States will only be exacerbated with these laws.

A Better Picture

As a mixed methods scientist, I’ve found that numbers are important but when numbers are married with stories we get a more comprehensive picture of the public health problem. I’m not nearly strong enough to talk about my story, but many, many women are. I suggest you read this one. Here is an excerpt:

Most people talk about abortion as if something is ending. Even the language that pro-choicers use—saying that we ‘ended’ a pregnancy or using the word ‘termination’—reflects that mindset. It’s not that those words aren’t accurate, exactly—but they’re also not complete. Because for me, and for so many others, abortion was the start of something. 

The truth is that all abortions create something. Paths forward, lives lived, connections made. Some are hard, some are beautiful—but all are chosen.

Bottom Line: Access to safe and legal abortion is vital to the physical and mental health of women in the United States. The science says this. The women on the ground say this. If only policy-makers would come to the same conclusion.

Love, YLE

There’s a lot you can do. For immediate help, please consider donating to the Lilith Fund so Texans can be financially supported to leave the state for abortions needed now. Donate to the ACLU who is representing the plaintiffs in the case to fight for abortion access in Texas. For more options, here is an amazing list. You can find abortion funds to help and people to follow on this thread too.