The study was designed to assess a variety of outcomes of receiving an abortion compared with carrying an unwanted pregnancy to term. All participants provided informed consent. From to , the Turnaway Study recruited women from 30 abortion facilities across the United States. Study sites were identified using the National Abortion Federation membership directory and by referral.
Sites were selected based on their gestational age limits to perform an abortion procedure, where each facility had the latest gestational limit of any facility within miles. Gestational age limits ranged from 10 weeks to the end of the second trimester. Facilities performed over 2, abortions a year on average [ 10 ].
They were located in 21 states distributed relatively evenly across the country. For this analysis, the Turnaway group was divided into Parenting Turnaways and Non-Parenting Turnaways which included Turnaways who subsequently had an abortion elsewhere, reported that they had miscarried, or placed the child for adoption. Women were eligible for participation if they sought an abortion within the gestational limits for each of the study groups, spoke English or Spanish, and were aged 15 years or older. Further details on recruitment and methods can be found elsewhere [ 12 , 13 ].
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After the baseline survey, participants were contacted for a follow-up phone interview every six months for five years. Turnaway Study data for this analysis come from interviews done at baseline one week , six months, and one year after they were recruited at their abortion-seeking visit. When participants could not be reached, researchers called each day for up to 5 days. If she still could not be reached, researchers sent up to 3 follow-up letters by mail or email according to her stated contact preferences and continued to call at the same frequency for a maximum of 10 sequential days.
Respondents were permitted to provide as long a response as desired. The 6-month and one-year follow-up interviews included questions about whether they were going to school, whether they were working full or part time, what they did for work, their personal and household income, their household composition, their relationships, their children, their life satisfaction, and their emotions regarding the abortion. These items were used to assess whether women achieved their one-year plans. Many women reported multiple one-year plans. The Other category included vague plans, plans for personal growth, car ownership, health and other plans that did not fit into one of the other eight topics.
Then, the outlook of the plan was determined—whether it was positive, negative or neutral. This determination was based on the tone of the statement and the qualifiers used. If determination was unclear, the plan was categorized as neutral. Two researchers reviewed each plan.
Identification of a plan as positive or negative required both researchers agreeing. Finally, survey items in the six-month and one-year interviews that would indicate achievement of the plan were identified. Some specific plans required all co-authors to discuss and agree upon the meaning of the plan and whether our interview items were sufficient to measure achievement. The exact timing for residential moves could not be determined so when a plan involved a residential move, she was considered to have achieved the goal if there was evidence that she moved by the second year of the study. First, sample was described, comparing the socio-demographic characteristics of each group to the Turnaway-Parenting group.
For all analyses, mixed-effects regression models that included random effects for facility were used, and p -values that adjust for the clustering of participants within each site are presented. The Turnaway-Parenting group was the reference category for all comparisons. Mixed-effects multinomial logistic regression was used to assess differences in proportions among the study groups. Finally, two mixed-effects logistic regression models were conducted: The first modeled the likelihood of having an aspirational one-year goal and the second modeled the likelihood of having an aspirational goal and achieving it.
The unit of analysis was one-year plans and because some women reported multiple plans, mixed-effects models were used to account for clustering by woman and within each site. Overall, A total of women completed a baseline interview 8 days after seeking an abortion.
Three women in the Near-Limit abortion group and First-Trimester group were excluded because they reported that they chose not to have an abortion after agreeing to participate in the study, leaving a final sample of participants at baseline. The final sample of participants in this analysis was Parenting Turnaways were younger and less likely to have previous children than Near-Limits.
Because each respondent could give multiple one-year plans, the respondents reported a total of 1, plans. Among all participants, plans were distributed among the following themes: Educational The majority of one-year plans were aspirational The following are examples of typical aspirational one-year plans in each category each quoted clause represents a different participant :.
Causes And Effects Of Abortion Paper
The following are examples of typical neutral one-year plans in each category:. The following are examples of typical negative one-year plans in each category:. It will be very difficult for me.
I think it will be a little bit more challenging. One-year plans were significantly more likely to be aspirational among First Trimester The only other significant predictor of having an aspirational plan was marital status with married women less likely to have positive one-year plans than unmarried women Among the 1, total aspirational plans across study groups, it was possible to assess whether Achievement of Among the aspirational plans that were measurable, There was no difference by study group in the achievement of aspirational plans among women who reported them—Parenting Turnaways: Among the measurable aspirational plans, women were most likely to achieve child-related plans Women were also highly likely to achieve their financial They were least likely to achieve their educational There were no significant differences in achievement within each plan type by study group.
This study found that women who were denied an abortion were less likely to have aspirational one-year plans than those who obtained an abortion. Those who were denied an abortion were more likely to have neutral or negative expectations for their future. Whether or not a person has aspirational plans is indicative of her hope for the future. Without such plans or hopes, she misses out on opportunities to achieve milestones in life. These findings suggest that shortly after being denied an abortion, many Turnaways may have scaled back their one year plans knowing that they were going to have to carry an unwanted pregnancy to term.
Turnaways likely changed their one year plans in two ways after learning of being denied an abortion: First, they often incorporated their forthcoming child into their aspirational one-year plans; these child-related goals were often achieved simply by carrying the pregnancy to term.
Turnaways were significantly less likely to have vocational goals compared to women who obtained an abortion, likely because employment-related goals felt unattainable while parenting a newborn. Second, women who were denied a wanted abortion were adjusting to the idea of carrying an unwanted pregnancy to term and likely changed from having more aspirational one-year plans to more neutral or negative expectations for the future. The greater focus on relationship goals among women in the Near-Limit group may reflect their desires for new and better relationships; women who have an abortion may feel free to leave poor relationships compared to women who are going to have a child with the man involved in the pregnancy.
Indeed, as reported in other papers from these data, one-third of participants reported their partner as a reason to have an abortion, including poor relationships and undesirable characteristics for fatherhood [ 14 ] and women denied an abortion were slower to end a relationship with the man involved in the pregnancy compared to Near-Limits who received their wanted abortion [ 15 ]. In addition to the straightforward goals of gaining employment or education, many women mentioned personal psychosocial goals they wanted to achieve.
A strength of this study is that many points of data on a wide variety of psychosocial and emotional outcomes were available, including life satisfaction, anxiety, and depression allowing us to assess achievement in goals related to mood and happiness which were relatively common. Future studies should aim to measure life stability as well as other emotional outcomes to understand how they are affected by pregnancy decisions.
A strength of the study was the use of appropriate comparison groups to understand the effects of abortion. All of the women in our sample had unintended pregnancies and all sought abortion. Comparing those who were denied an abortion to those who received a wanted abortion allows us to control for any unobserved characteristics that would be associated with abortion-seeking for example, the life circumstances that brought women to their abortion decision. In addition, confounders thought to affect our outcome measures were controlled for. While most women in all groups had positive one-year plans, fewer than half of the goals were achieved within one year.
In other words, many women overestimated what they could achieve in one year. This study has several limitations. First, the Turnaway study is limited to fewer than one thousand women and many women who were invited to participate declined. Additionally, due to sample size limitations, the analysis was unable to determine achievement by specific theme of the goal.
Another limitation is that the analysis was unable to evaluate whether all goals were met and for some goals, measurement may have been imprecise, for example, the timing of residential moves. Future studies should attempt to assess personal goals before unintended pregnancy to further understand the effect of abortion on life course outcomes. This study demonstrates that women who receive a wanted abortion are better able to aspire for the future than women who are denied a wanted abortion and must carry an unwanted pregnancy to term.
Support for a woman to have access to abortion is often based on a belief that when faced with an unintended pregnancy, women who have an abortion have better life course trajectories than women who carry their unintended pregnancies to term. There is a belief that access to abortion is important for equal opportunities for women and for their financial stability [ 7 ]. These findings provide evidence to support this premise. Women seek abortion for a range of reasons tied to their individual life circumstances and stage of life and oftentimes for the profound effects they perceive that having a baby would have on their life plans.
Our analysis is unique because it allowed women to express their life plan in their own words. This study shows that abortion enables women to aspire for a better life in the future and achieve these goals. Understanding why women seek abortions in the US. BMC Womens Health. Reasons U. Perspect Sex Reprod Health. Reasons women give for abortion: a review of the literature. Arch Womens Ment Health. Over the study period, health care use and the population of reproductive aged women increased.
Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity.
The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The publication benefited from resources available to Dr. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The authors wish to thank an anonymous donor and the Richard and Rhoda Goldman Fund for study support.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There are no patents, products in development or marketed products to declare. An estimated 5 million women are hospitalized for abortion-related complications per year in the developing world . Rates of unsafe abortion are rising worldwide, and the legal status of abortion is associated with the risk of maternal morbidity and mortality .
While policy conditions on abortion have become more restrictive in many countries, some have recognized the public health potential of a more liberal policy. In Nepal, legislation making abortion legal was passed in , supported by advocacy efforts highlighting very high maternal mortality in the country, much attributed to unsafe abortion . Previously, induced abortion in Nepal was equated with homicide, and punished with imprisonment . Sex-selective abortion is prohibited, and adult consent is required for girls less than 16 years old.
In , the first certified abortion clinic opened, followed by steady expansion of services. The Nepali government, in partnership with non-governmental organizations, instituted a nationwide program to train abortion providers and regulate the safety and availability of care .
Initially, training in manual vacuum aspiration MVA was offered only to physicians; however, starting in , staff nurses and auxiliary nurse midwives became eligible to perform MVA up to 8 weeks. Second trimester abortion training and certification for physicians began in , and in medication abortion was added to the safe abortion program. By the end of , over 1, clinicians and clinical sites were trained and certified .
Many women are still not aware of the change in the legal status of abortion, or have erroneous beliefs about the law e. Maternal mortality is estimated to have declined from to per , live births from to , although limitations in the available data for estimating maternal mortality have been noted  , . We assess serious abortion complications over a ten year period spanning the legalization of abortion — The study is modeled on those conducted in the United States and elsewhere, where declines in mortality and morbidity from abortion were observed after legalization  — .
We hypothesized that a decline in serious abortion complications would occur at major referral hospitals in Nepal, following implementation of the abortion law. The study relied on retrospective review of medical charts, and did not include abstraction of personal identifiers, therefore, the institutional review boards waived the need for written informed consent from the patients, for their information to be stored in the hospital database and used for research. This study is a retrospective medical chart review of all abortion-related admissions occurring from January through December at four large, public referral hospitals, serving predominantly poor women most likely to experience unsafe abortion.
It is a central referral hospital for maternal and neonatal care, receiving patients from the entire country. Tribhuvan University Teaching Hospital TUTH in Kathmandu is the largest and oldest academic public hospital in Nepal beds , and receives referrals for serious and complicated gynecological admissions from all regions of the country. To identify abortion complication cases, we reviewed all gynecological admissions as well as maternal and neonatal mortality cases presenting to all units of the hospitals, including emergency, post-abortion care, gynecology and obstetrics.
We used broad criteria to ensure capturing cases that may have been poorly documented before legalization. To determine eligibility, diagnostic fields were reviewed and charts indicating abortion were abstracted threatened, inevitable, incomplete, complete, and septic; spontaneous and induced. When a diagnostic field did not specify abortion, but was suggestive of abortion, other fields were reviewed to assess eligibility. Likely abortion complications, such as repair of uterine perforation, were abstracted and further evaluated for eligibility before analysis.
In cases of questionable eligibility, a senior obstetrician-gynecologist or senior nurse involved in post-abortion care at the hospital reviewed the chart . Eligible charts were abstracted using a study form containing fields for demographic characteristics, reproductive history, contraceptive use, clinical assessment on admission and during hospitalization, treatments received, and outcome.
Charts for patients receiving elective abortion services at the hospital were not screened unless the patient was later hospitalized. Trained research assistants with medical backgrounds conducted the chart review from to A pilot study of 1, charts from the years — at TUTH and MH was conducted to test and refine the eligibility determination process and study instruments. For example, during the pilot study we verified that obstetric ward charts did not contain abortion cases, and focused our data collection on gynecology ward charts.
We also eliminated and added fields and response categories to the abstraction tool based on data availability. Throughout data collection, random samples of registry entries and abstraction forms were compared to the original medical charts to ensure accuracy. Abstraction forms were manually coded and data were entered and checked for consistency in the database program dBase IV Binghamton, NY. Inconsistencies were compared with the original medical chart and corrected. Cleaned data were transferred into Stata v Before analysis, cases that did not reference abortion in the chart were evaluated to assess whether they were likely abortion-related complications.
For example, the protocol required abstraction of all cases of uterine repair, but some were for vaginal prolapse. The study outcome is the proportion of serious complications, relative to all abortion complication cases. Our analysis includes complications arising from spontaneous and induced abortion, because they cannot be accurately differentiated . Women are often reluctant to disclose attempted induced abortion and it is not always documented in medical charts, especially in an illegal context .
Health complications from spontaneous abortion are likely to remain relatively constant in the population, whereas those arising from induced abortion should decline with safer care since sepsis and injuries are primarily due to unsafe induced abortion procedures. We assessed the proportion of serious abortion complications relative to all abortion complications presenting to help account for secular trends in fertility, health care use, and abortion, and to test whether a shift toward less serious health complications would occur following abortion legalization.
To check our results, we also analyzed the outcome of proportion of serious abortion complication relative to live births over the time period. We adapted a categorization scheme proposed by others to code the severity of complications using clinical signs and symptoms to distinguish between uncomplicated incomplete abortion cases and those with more serious health implications .
Our approach differed only slightly: we did not code cases with any sign of interference as high severity, and we did not attempt to distinguish between low and medium severity cases. A separate variable was constructed to identify cases where induced abortion was explicitly documented in the medical chart. Complications during three periods were described with counts and frequencies: before implementation — , early implementation — , and later implementation — Types of complications were compared across the three time periods with the Fisher Exact test for categorical differences.
Tests for trend for each phase were conducted using segmented Poisson regression with flexible splines fit to the time periods  , .
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Count of cases per month is the dependent variable with time as an independent variable representing the incidence-rate ratio IRR with the natural log of total cases as an offset variable. We used splines to test the trend in slope for each time period. Marginal splines were used to compare changes in the rate of increase or decrease from the previous period.
Multiple variable logistic regression models were also used to estimate the odds of a serious abortion complication by time period, adjusted for and testing the odds of risk by stage of pregnancy at admission, patient age, and whether induced abortion was documented in the medical chart. We also assessed the odds of sepsis, the most common complication of unsafe abortion, by these factors.
The multivariable logistic regression models were also adjusted for season spring, summer, winter, fall and hospital. Logistic models estimated only on the documented induced abortion cases were also tested to check if results were consistent with the main findings. The mean age of the women presenting with abortion complications was Nearly one-third of women were nulliparous, and over one-third had had two or more births.
Induced abortion was documented in the medical chart in 9. From to the number of abortion complications presenting at hospitals rose, ranging from a low of 2, in to a high of 2, in This is consistent with a secular increase in health care use occurring over the time period, particularly in the most recent years when no-cost services at government clinics were instituted . A review of total hospital admissions, live births, and gynecological admissions at the hospitals also reflects this increase in health care use.
At MH, for example, in there were 21, admissions and in there were 29, admissions. The mean proportion of gynecological cases that were abortion-related remained stable over time 0. The overall proportion of serious abortion complications relative to all complications was lowest in the later implementation period. Figure 1 illustrates the emergence of a decline in that steepens after There was a significant overall decline in the proportion of total complications and septic abortion cases across the ten year study. Declines were greatest for sepsis and for systemic complications Table 2. Women who were older and those presenting at later gestation were more likely to have serious abortion complications, as were women with induced abortion documented in their medical chart.
To confirm results, we also analyzed the trend in serious complications as a proportion of live births at two of the hospitals with available data, and found significant downward trends in the serious abortion complication rate.
At MH, there were 6. At LZN live birth data were available starting in , with a serious complications ratio of Observations in Nepal are instructive for developing countries with high maternal mortality and restricted access to safe abortion care. The declining severity of abortion complications presenting at public referral hospitals, primarily serving poor women most at risk of mortality from unsafe abortion, is evidence that abortion legalization in Nepal has benefited maternal health.
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Women appear less likely to experience serious complications, and are receiving treatment for complications, likely contributing to reductions in maternal mortality  ,  , . The overall decline is significant in the most recent phase of implementation, beginning approximately 4 years from the initiation of services, although sepsis complications declined earlier.
In Nepal, limited health care infrastructure, challenging terrain, and political instability presented significant challenges for abortion care implementation. The Maoist insurgency in Nepal was at its strongest in , causing major disruptions to roads and supplies just as the safe abortion program began . Nonetheless, persistent expansion of safe abortion care in the face of considerable obstacles appears to have effectively reduced unsafe abortion and its negative health consequences.
The abortion law in Nepal permits abortion on request up to 12 weeks. As a result, women seeking later procedures without a legal indication i. Indeed, women seeking abortion at later gestation are at greatest risk of life-threatening complications; we found a greater likelihood of serious complications for cases presenting in the second and third trimester, and the steepest decline in serious complications after initiation of second trimester provider training. Expanding the availability of trained providers, and potentially the limits of the law, may be necessary to further reduce abortion morbidity and mortality in Nepal  , .
Nepal also faces formidable barriers to extending safe abortion care to isolated rural areas, with steep mountain terrain and slow transportation. It is important to support efforts to improve access in these areas, including the training and licensing of lower level health workers to administer medication abortion. There are several limitations and threats to validity in a hospital-based, natural experiment of this type. Co-occurring demographic, social, and policy changes must be taken into account when interpreting the trend in serious abortion complications at hospitals over a year time period.
Use of health care increased over the study period and free maternal health services were instituted in the later years of the study.