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Medical News & Perspectives
Quick Uptakes
August 7, 2019

Among Women Seeking Abortion, Continuing Pregnancy Linked to Worse Physical Health

JAMA. Published online August 7, 2019. doi:10.1001/jama.2019.10313

Among women with unwanted pregnancies, those who experienced childbirth reported worse overall health 5 years later than those who underwent an abortion, according to a recent study in Annals of Internal Medicine.

The Back Story

Antiabortion groups and individuals argue that abortion harms women.

“I think the public narrative is often that abortion is dangerous to women and that includes their overall physical and mental health,” said coauthor Lauren Ralph, PhD, MPH, an epidemiologist at the University of California, San Francisco’s Bixby Center for Global Reproductive Health.

And yet, past research found that abortion is much safer than childbirth in the short-term, Ralph said. Major complications from abortion occur in only 0.25%, making the procedure safer than wisdom tooth extraction, according to Bixby Center data. And one study concluded that the risk of death from childbirth is 14 times higher than that from abortion.

In addition, being denied an abortion was associated with a greater risk of adverse short-term psychological outcomes than having an abortion, found a 2017 JAMA Psychiatrystudy. By the time 5 years had passed, though, psychological well-being was comparable to that of women who’d had an abortion.

Ralph’s study about physical health outcomes involved the same cohort, the Turnaway Study, which recruited women from 30 abortion facilities around the country from 2008 to 2010 and followed up with them for 5 years. Women seeking an abortion because of a fetal abnormality or demise were not eligible for the study.

Addressing Limitations
“Healthy Mother Effect”

Previous studies generally looked at the health differences between women who chose to give birth and those who chose to have an abortion, Ralph said. Although they found that abortion was associated with better health than childbirth, they could have underestimated the relative safety of abortion because healthy women might be more likely to continue a pregnancy than women who aren’t in good health, a phenomenon called the “healthy mother effect.”

The Turnaway Study minimized the healthy mother effect by including only women who had sought an abortion, albeit not always successfully. Of the 1132 included in Ralph’s analysis, 163 went on to give birth because they had surpassed their clinic’s gestational age limit.

Early vs Late Abortion

Since Roe v Wade made abortion more accessible, the vast majority are performed in the first trimester, so minimal research has examined the health effects of abortion earlier vs later in a pregnancy, the authors wrote. But, Ralph said, that question is becoming increasingly relevant as states pass laws limiting abortions, potentially delaying women’s ability to obtain one. To help answer it, her study included more women who had a second-trimester abortion than those who had a first-trimester abortion: 383 and 328, respectively.

The Design

  • The following self-reported outcomes were measured twice a year for 5 years, beginning approximately 8 days after receipt or denial of an abortion:

  • Current overall health on a 5-point Likert scale (strongly predictive of future health and mortality). Also, at baseline, prepregnancy health.

  • New diagnosis of gestational or nongestational diabetes or hypertension, asthma, hyperlipidemia, or other chronic conditions.

  • Chronic abdominal, pelvic, back, and joint pain as well as headaches or migraines and “other” pain.

  • Height and weight (to determine obesity).

Researchers also collected demographic information (eg, race/ethnicity and work and marital status), and information about smoking, drug and alcohol use, intimate partner violence, subsequent pregnancies, and breastfeeding.

What We’ve Learned

  • Among women who gave birth, 27% reported fair or poor health compared with 20% of women who had a first-trimester abortion and 21% who had a second-trimester abortion.

  • Women who gave birth reported more chronic headaches or migraines and joint pain over time than the women who had an abortion.

  • These differences persisted even after controlling for smoking, obesity, subsequent births, and heavy drug use before pregnancy and other demographic factors such as age, employment, and marital status.

  • All 3 groups reported similar physical health for the other outcomes measured.


  • Only 37.5% of the 3016 eligible women approached about enrolling in the study agreed to participate.

  • The study lost 41% of participants to follow-up at 5 years, including half the women who gave birth, the authors wrote. But the differential loss to follow-up only emerged between the last 2 interviews, and women’s health reported in the first interview was not related to whether they stayed in the study.

Questions Without Answers

The study couldn’t determine whether indications of worse physical health among women who gave birth after being denied an abortion were due to childbirth itself or to the cumulative effects of childbirth and raising a child, the authors noted.

In addition, the researchers didn’t know whether participants were unable to access health care and, as a result, might have undiagnosed chronic conditions. However, by 2 years of follow-up, they found no differences in health insurance coverage between the women who had an abortion and those who gave birth.

And they’re not sure whether their findings are generalizable to all women receiving a second-trimester abortion, because, by design, the average gestational age of those in their study (21 weeks) was higher than is typical in the United States.

The Upshot

Ralph noted that pregnancy has been called a stress test for women. In fact, a recently published study found that pregnant women’s sustained metabolic rates were nearly as high as endurance athletes’ maximum sustainable rates.

“It’s not surprising that women who gave birth reported the worst of all self-rated health over 5 years,” said Ralph. “They experienced childbirth.”