The Importance of Access to Abortion

Abortion is a medical procedure that is used to end a pregnancy.

There 4 types of abortions performed by medical facilities in the United States (US). One can be performed at home, while the other 3 are performed in a clinical setting. Length of gestation and patient preference impact the type of abortion procedure used to end a pregnancy. Over half of abortions performed in the United States are medication.

Types of abortions recognized in the US:

• Medication abortion (also called self-managed abortion or the abortion pill).
  • This method uses two medications: mifepristone and misopristol.
    • Mifepristone blocks progesterone, which makes the uterus unable to support a pregnancy.
    • Misoprostol causes cramping and bleeding to empty the uterus.
  • Medication abortions are very effective in ending pregnancy.
  • This method can be used until 11 weeks after the last period.
  • This method can be performed in a clinic or at home.
  • In many states, abortion pills are available by mail.
• Suction abortion (also called vacuum aspiration).
  • This method uses gentle suction to empty the uterus.
  • Suction abortions are very effective in ending pregnancy.
  • This method can be used until 14-16 weeks after the last period.
  • This method is performed in a clinic.
• Dilation and evacuation abortion (also called D&E).
  • This method uses suction and medical implements to empty the uterus.
  • D&E abortions are very effective in ending pregnancy.
  • This method can be used beyond 16 weeks after the last period; it is typically used when a suction abortion is no longer feasible.
  • This method is performed in a clinic.
  • Some states have passed laws making D&E abortion illegal or inaccessible to people who are pregnant.
• Induction abortion (login required) (also called medical abortion).
  • Induction abortions are very rare in the US.
    • In 2018, induction abortions accounted for <2% of US abortions performed after 14 weeks gestation.
  • This method uses medications to induce labor and delivery of a fetus.
  • Induction abortions tend to be slower, more expensive, and more physically uncomfortable than D&E abortions; as such, they are used less frequently.
  • Induction abortions are very effective in ending pregnancy.
  • This method is performed in a clinic and can sometimes require a hospital stay.

The National Academy of Sciences (login required) has concluded that abortion does not increase the risk of physical or mental health conditions:

• There is no link between abortion and infertility, pregnancy-related hypertension, abnormal placentation, pre-term birth, or breast cancer.
• Abortion does not increase risk of depression, anxiety, or posttraumatic stress disorder.
• There is a body of misleading published literature that claims there is a link between abortion and mental/physical health conditions. These studies do not meet the standards (login required) for rigorous, unbiased research.

Abortions performed by medication, suction, D&E, or induction are safe and effective (login required) .

Approximately 18% of pregnancies in the US end in abortion.

Multiple factors impact incidence of abortion, including access to sexual and reproductive health services, access to contraception, availability of abortion providers, state regulations around abortion, and economic circumstances.

Abortion rates in the US have declined in recent decades due to decreases in unintended pregnancies and increased contraceptive access and use. Abortion rates among adolescents have seen greater declines than among adults.

Abortion rates vary by age group:

• Young adults in their 20’s have the highest rates of abortion.
• Younger adolescents (<15) have the lowest rates of abortion.
• Adolescents (<15 and 15-19) have the highest ratio of abortion, which is the rate of abortion relative to the rate of live births in their age group.

AAP supports options counseling for youth who are pregnant.

In June 2022, AAP reaffirmed its position that adolescents who are pregnant have the right to be informed and counseled on their pregnancy options. Pediatricians should:

1. Inform the pregnant adolescent of all their options, which include continuing the pregnancy and raising the child; continuing the pregnancy and making an adoption, kinship care, or foster care plan; or terminating the pregnancy.
2. Be prepared to provide a pregnant adolescent with accurate information about each of these options in a developmentally appropriate manner involving a trusted adult, when possible; support the decision-making process; and assist in making connections with community resources that will provide quality services during and after the pregnancy.
3. Be familiar with laws and policies impacting access to abortion care, especially for minor adolescents, as well as laws that seek to limit health care professionals’ provision of unbiased pregnancy options counseling and referrals for abortion care. Pediatricians should oppose efforts by state governments to interfere in the patient-physician relationship or to levy criminal sanctions on physicians for the provision of care.
4. Examine their own beliefs and values to determine whether they can provide nonjudgmental, factual pregnancy options counseling that includes the full range of pregnancy options. If they cannot fulfill this role, they should facilitate a prompt referral for counseling by another knowledgeable professional in their practice setting or community who is willing to have such discussions with adolescent patients. The impact on the patient should be minimized and the patient should not know the reasons a referral to another provider is needed. When referral is not possible or feasible, the pediatrician has an ethical obligation to provide this counseling. The AAP acknowledges the tension that pediatricians may face between their ethical duty to the patient and their duty to observe the law, and that pediatricians may choose not to follow these AAP recommendations when it is illegal to do so.

AAP supports the right to confidential care when considering abortion.

AAP policy from June 2022 reaffirms its position that the right of adolescents to access confidential care when considering abortion for an unintended pregnancy should be protected. AAP conclusions and recommendations are as follows:

• Although the stated intent of mandatory parental involvement laws is to enhance family communication and parental responsibility, there is no supporting evidence that these effects are achieved. There is evidence that such legislation may have an adverse impact on some families and pose medical and psychological harm to some adolescents. Similarly, judicial bypass provisions do not
  ameliorate risks and may delay access to safe and appropriate care.
• Because of the harms of restrictive abortion laws and the dangers associated with unsafe abortions, adolescents should have access to legal abortion services.
• When safe and appropriate, health care professionals should encourage adolescents to seek
  adult guidance and support when considering their pregnancy options.
• It should be recognized that most adolescents do involve a parent or trusted adult when making the decision to proceed with legal abortion therapy. Ultimately, the pregnant adolescent’s right to decide whom to involve in the decision to seek abortion care should be respected. This approach is consistent with basic ethical, legal, and health care principles.
• Health care professionals should understand state and regional laws regulating abortion services, including restrictions on health care professionals’ counseling about or referring

Adolescents have the ability to make personal healthcare decisions:

• Adolescents under age 18 are just as competent as adults in consenting for abortion services.
• Adolescents understand the risks and benefits of their options for an unintended pregnancy.
• Adolescents are capable of making rational, voluntary, and independent decisions.

Most adolescents who are pregnant engage trusted adults in their decisions around abortion:

• Family dynamics, including trusting and warm relationships impact parental engagement.
• Most adolescents who are pregnant tell their parent about their intent to have an abortion.
• Younger adolescents are more likely to engage their parents than older adolescents.
• Adolescents who do not engage their parents typically involve another trusted adult.

AAP opposes mandatory parental involvement in abortion.

AAP is opposed to legislation that mandates parental involvement in abortion.

Mandatory parental involvement:

• Does not achieve the stated benefit of improving family communication or relationships.
• Puts youth at risk for punishment, coercion, or abuse.
• Delays access to timely medical care.
• Deters adolescents from seeking health services.
• Delays termination of pregnancy, which can increase medical risk, increase financial costs, or eliminate abortion as an option.

States with mandatory parental involvement legislation typically allow judicial bypass proceedings, wherein a judge determines whether a minor adolescent is mature enough to choose to have an abortion without parent involvement.

Judicial bypass provisions do not eliminate the risks of mandatory parental involvement, and can delay access to safe and appropriate abortion, making it a more complicated procedure or eliminating abortion as an option.

Judicial bypass provisions are harmful to adolescents’ emotional health:

• Adolescents have reported that the judicial bypass process is stressful and humiliating.
• In these proceedings, young people are required to share the details of their sexual history and private life with many people involved with the court system, in order to obtain a hearing with a judge.
• The proceeding itself may be traumatic for the adolescent, and may delay care, making the procedure more costly or removing abortion as an option entirely.

Access to a wanted abortion is a critical component of sexual and reproductive health for youth who are able to become pregnant.

Pregnant adolescents deserve the information, resources, and supports that they need to:

• Make informed decisions about whether to carry their pregnancy to birth or obtain an abortion.
• Obtain a wanted abortion using the method that is best suited to their needs and preferences.
• Have access to a wanted abortion without hardship or barriers.
• Be supported in their decisions about their sexual and reproductive health.

In order to support adolescents and all people in accessing the abortion care they deserve, pediatric health clinicians and health professionals can advocate for a future with broad, equitable access to abortion, where:

• The right to an abortion is codified by law, and the government cannot infringe upon this right.
• Abortion is affordable for all people who are pregnant.
• Abortion is covered under public and private insurance plans.
• All people who are pregnant who are seeking an abortion have access to the full range of abortion services, via in-person care, telehealth, or self-managed care at home.
• The workforce of abortion providers/clinical staff are fully trained in developmentally and culturally appropriate care.
• Patients and abortion providers are protected from discrimination, harassment, and violence.
• Abortion is fully integrated into the healthcare system.

The World Health Organization has characterized access to safe, timely, affordable, and respectful abortion care as a critical public health and human rights issue.

Many factors influence the decision to obtain an abortion.

There are many reasons that adolescents and other people who are pregnant may choose to seek an abortion.

Common factors influencing the decision to seek an abortion include:

• Barriers to access to comprehensive sex education.
• Barriers to access to contraception.
• Educational consequences of an unintended pregnancy.
• Economic consequences of an unintended pregnancy.
• Relationship impacts of an unintended pregnancy.
• Failure of contraception.
• Rape.
• Incest.
• Intimate partner violence or dating violence.
• Fetal anomalies.
• Pregnancy complications.
• Worsening of a pre-existing health condition.

Abortion is healthcare

Abortion is an essential component of healthcare for adolescents, women, and other people who are pregnant.

Just like other forms of medical care, decisions about abortion should be made by patients, in consultation with their healthcare provider and without interference from external forces.

Adolescents and other people who are pregnant face many barriers to abortion access. Common barriers are outlined below.

Legislative barriers to abortion access

The current legal climate in the US is threatening abortion rights.

Since the 1973 US Supreme Court decision in Roe v. Wade that affirmed the constitutional right to abortion, US states have enacted over 1200 laws and policies restricting abortion access.

In 2021, 13 US states attempted to ban abortion at 6 weeks gestation or earlier. When implemented, these bans have been successful in stopping abortion clinics from providing evidence-based, safe medical care to people who are pregnant.

Common legislative restrictions on abortion access include:

Targeted Regulation of Abortion Providers (TRAP Laws), which apply costly and medically unnecessary requirements on abortion providers and women’s health centers.

Restrictions on medication abortion, including limits on the type of prescribing-practitioners that are allowed to prescribe abortion pills, or bans on telemedicine appointments to facilitate a medication abortion.

Abortion refusal laws, which allow individual providers and institutions to refuse to provide or pay for abortion care or even provide information/referrals related to abortion.

Biased counseling provisions, which force healthcare providers to give patients information that discourages abortion or provide medically inaccurate information.

Mandatory waiting periods, which require a waiting period of 18-72 hours between a pre-abortion counseling visit and an abortion; thus requiring two trips to a clinic and delaying access to care.

Forced ultrasounds, which require patients seeking an abortion to undergo a medically unnecessary ultrasound prior to accessing an abortion.

Mandatory parental involvement, which require adolescents under 18 to notify or obtain permission from their parents prior to obtaining an abortion or endure a lengthy judicial bypass process.

Regulations on insurance coverage, which limit, restrict, or ban coverage of abortion services in public or private health insurance plans.

State laws that ban abortions and authorize enforcement from citizens, or state bills, that would make having an abortion grounds to be charged with homicide.

Economic barriers to abortion access.

There are significant economic disparities in a person who is pregnant’s ability to access an abortion.

Many people seeking an abortion are facing economic challenges:

• Half of people who seek an abortion have an income below the Federal Poverty Level.
• The most common reason to seek an abortion is concern about not being able to financially support a child.

A first-trimester abortion costs approximately $550, and cost increases as the pregnancy progresses.

• Over half of people seeking abortion report that the out-of-pocket costs (including medical expenses and travel costs) are more than 1/3 of their monthly income.
• 54% of people seeking an abortion report that having to raise funds to cover expenses delayed their abortion care.

Insurance coverage can help with the cost of abortion care, however, there are significant gaps in insurance coverage in both private and public insurance.

Public insurance gaps in abortion coverage:

The Hyde Amendment, passed in 1977, bans federal Medicaid dollars from being used to cover abortion expenses (with limited exceptions for rape, incest, or if the abortion is needed to save the life of the woman).

The Hyde Amendment restricts access to abortion in 2 ways:

• Directly prohibits Medicaid coverage for abortion in 34 states and Washington DC. (The remaining 16 states provide alternative funding for abortion coverage for people enrolled in Medicaid).
• Withholds abortion coverage from millions of people who are insured through other federal programs, including:
  • Federal employees.
  • Military veterans and active-duty personnel.
  • Indigenous and American Indian/Alaska Native communitie.
  • People who are imprisoned or detained by the federal government.

The Hyde Amendment exacerbates racial and ethnic disparities in access to abortion.

• Due to the economic impacts of systemic racism, women who are Black and Latinx are more likely to enroll in Medicaid.
• Half of people impacted by the Hyde Amendment are women of color.

Private insurance gaps in abortion coverage:

US states have the power to ban or limit abortion coverage in private insurance plans, including those sponsored by employers and those offered through insurance exchanges, such as the Affordable Care Act.

• 11 US states restrict abortion coverage in all private insurance plans written in the state.
• 25 US states restrict abortion coverage in all insurance plans offered through health insurance exchanges.
• 22 states restrict abortion coverage in insurance plans for public employees.

In addition, individual employers can restrict coverage for abortion services through their employer-sponsored health plans.

• 10% of US workers with employer-based insurance have abortion coverage excluded from their health plan.
• Exclusion of abortion coverage in an employer-sponsored health plan varies by:
  • Company size.
  • Ownership structure.
  • Company’s religious affiliation.

Economic barriers to abortion can delay care, resulting either in a more expensive procedure or eliminating abortion as an option due to stage of gestation.

Geographic barriers to abortion access.

A person who is pregnant’s ability to access an abortion in the US varies by where they live. This disparity in access to health services based on location is called spatial inequity.

Abortion clinics are concentrated in urban areas, creating access barriers for people who are pregnant in rural communities.

People who are pregnant and live farther from abortion clinics are less likely to access a wanted abortion.

When states pass laws restricting access to abortion, people who are pregnant are forced to travel—often across state lines—to access the care they need.

Needing to travel to an abortion clinic creates logistical barriers:

• Traveling to a clinic requires people to take time off work and arrange for transportation and childcare.
• In states that require mandatory waiting periods between abortion counseling and an abortion procedure, people who are pregnant may have to take multiple days off work or pay for a hotel stay.
• People who travel to access abortion care report challenges with travel logistics, navigating the healthcare system, limited clinic options, and expenses.
• These barriers to care can delay abortion services and negatively impact mental health.

Geographic barriers exacerbate economic disparities in abortion care; as people with lower incomes have fewer resources to pay for transportation and may face greater challenges in taking time off work.

Furthermore, state of residence impacts how late in a pregnancy a person can obtain an abortion.

• Approximately 4,000 people each year are denied an abortion because there are no clinics in their area that perform abortion at their stage of gestation.

Stigma as a barrier to abortion access

Perceived stigma around abortion from a person’s family, community, or society can serve as a barrier to accessing abortion.

More than half of people who are pregnant and seeking an abortion report perceived stigma in their communities or families, noting that they believed people would look down on them if they knew they had sought an abortion.

People who are pregnant and who report that their partner was not involved in the abortion decision report higher levels of perceived stigma than those who report that their partner wanted to carry the pregnancy to term.

People who are pregnant and who report lower perceived stigma are more likely to tell other people that they are seeking an abortion.

People who encounter protestors when arriving at an abortion clinic are more likely to report perceived stigma.

People who are pregnant and who report high levels of abortion stigma at the time of seeking their abortion are more likely to report psychological distress in future years.

Crisis pregnancy centers as a barrier to abortion access.

Crisis pregnancy centers (CPCs) seek to discourage people who are pregnant from considering abortion, often by using misleading and unethical practices.

CPCs take an anti-abortion approach to care:

• Pregnancy options counseling in CPCs is typically limited to adoption or parenting.
• CPCs do not refer to abortion clinics.

CPCs are designed to look like healthcare facilities, however, there are many limitations to the care provided:

• CPCs are exempt from the regulatory, licensure, and credentialing oversight that applies to medical settings.
• CPCs are often staffed by lay volunteers who are not licensed medical providers.
• CPCs fail to adhere to medical standards around sexual and reproductive health care and informed consent.
• CPCs frequently provide misleading or false information about abortion risks and contraception.
• Only 66% of CPCs offer limited medical services beyond pregnancy testing and counseling.

There are over 2,500 CPCs in the US:

• CPCs outnumber abortion clinics 3 to 1.
• CPCs exist in all 50 states but are most prevalent in the southern and midwestern US.
• CPCs are more common in states that provide direct funding for them.
• CPCs are more prevalent in states with other legislation that restricts abortion access.

National medical associations have highlighted ethical concerns with CPCs:

• The American Medical Association Journal of Ethics has categorized that the misinformation provided at CPCs is an ethical violation that harms the health of women and people who are pregnant.
• The Society for Adolescent Health and Medicine (SAHM) and North American Society of Pediatric Adolescent Gynecologists (NASPAG) published a joint position statement asserting that CPCs pose a risk to adolescent health by failing to adhere to medical and ethical standards of practice.
• SAHM and NASPAG encourage health professionals to educate themselves and their patients about CPCs to help youth better identify safe and medically-accurate sources of sexual and reproductive health care.

Bans or restrictions on abortion interfere with the right to bodily autonomy.

Bodily autonomy is the right for a person to decide and control what happens to their body.

The right to make one’s own decisions about their body and reproductive health is at the core of the basic human rights to equality and privacy, as outlined in the United Nations’ (UN) International Covenant on Civil and Political Rights.

In 2017, the UN Human Rights Working Group reaffirmed that people who are pregnant have the right to decide whether to continue or terminate a pregnancy, as this decision has significant implications for one’s personal life, family life, and human rights.

Adolescents and all people who are pregnant have the right to make autonomous decisions about whether to carry or terminate a pregnancy, and should receive safe, effective, appropriate medical care to support this decision.

Bans or restrictions on abortion access cause an increase in unsafe abortions.

Bans or restrictions on abortion do not reduce the number of abortions; instead, they force people who are pregnant to seek unsafe abortions to terminate an unintended pregnancy.

When abortion is banned or restricted, people who are pregnant seek unsafe means of terminating their pregnancies, including:

• Self-inflicted injury to their bodies.
• Self-medication with drugs or chemicals.
• Seeking treatment from an unqualified abortion provider.

The World Health Organization (WHO) defines an unsafe abortion as a procedure for terminating an unintended pregnancy that is performed “either by persons lacking the necessary skills, or in an environment lacking minimum medical standards, or both.”

Unsafe abortions result in the death of approximately 47,000 women per year worldwide and leave millions more with significant physical health consequences.

Deaths and injuries from unsafe abortions are entirely preventable via:

• Comprehensive sex education.
• Contraception and family planning.
• Provision of safe, legal abortion.

Access to safe and effective abortion is a health and safety concern for adolescents and other people who are pregnant.

Bans or restrictions on abortion increase morbidity and mortality in people who are pregnant.

Limitations on abortion access increase pregnancy-related morbidity and mortality rates and poor maternal health outcomes.

Pregnancy involves a range of health risks, many of which are severe:

• More than 50,000 people who are pregnant in the US face severe complications of pregnancy each year.
• Approximately 700 people who are pregnant in the US die from pregnancy or delivery complications each year.

Abortion is safer than childbirth in the US:

• Abortion, when provided safely via the medication, suction, D&E, or induction procedures outlined above, poses lower risks of morbidity and mortality than childbirth.

The risk of death from childbirth is 14 times higher than the risk of death from abortion.

A 2021 study found that a ban on abortion would increase pregnancy-related deaths in the US by 7% in the first year following the ban, rising to 21% in subsequent years.

This study projected disproportionate impacts on mortality in communities that are Black and Latinx :

• Populations that are white would see an estimated 4% increase in the first year, and 13% increase in subsequent years.
• Populations that are Black would see an estimated 12% increase in the first year, and 33% in subsequent years.
• Populations that are Latinx would see an estimated 6% increase in the first year, and 18% in subsequent years.

In the Birth Equity Organization Amicus Brief in Dobbs v Jackson Women’s Health, numerous communities, including those that are Indigenous and American Indian/Alaska Native, describe how Dobbs v Jackson Women’s Health Organization would exacerbate the harms already imposed on communities that are Indigenous, including increased morbidity and mortality in people who are pregnant.

These disparities are particularly problematic as communities that are Black already face disproportionate levels of maternal mortality due to systemic inequities and structural racism.

Bans or restrictions on abortion exacerbate disparities in access to care.

When bans or restrictions on abortion are enacted, people with sufficient economic resources can travel to obtain safe and legal services in other areas or seek private care.

Adolescents and people who are pregnant without these economic resources are thus disproportionately impacted by bans.

Populations that face disproportionate logistical and economic challenges to accessing abortion include:

• Communities that are low-income.
• Populations of refugee and migrant individuals.
• Adolescents.
• People who are pregnant and are LGBTQ2S+.
• People who are Indigenous or American Indian/Alaska Native .
• People who are pregnant and who are Black or Latinx.
• People who are pregnant and who live in rural areas.

There are already significant geographic disparities in access to abortion:

• 27% of women in the US would need to travel at least 30 miles to the nearest abortion clinic.
• 38% of women ages 15-44 live in a county that does not have an abortion clinic.

If the US Supreme Court weakens or overturns federal protections for abortion, 26 states are likely to ban abortion. This will increase disparities in access to care by requiring people who are pregnant in those states to travel to access an abortion.

Bans or restrictions on abortion exacerbate disparities in sexual and reproductive health outcomes.

When discussing disparities in sexual health, it is critical to note that health outcomes are not directly tied to race, sexuality, or community. Rather, they are caused by systemic inequities in social drivers of health, structural racism, and disparities in access to care, including comprehensive sex education, contraception, and other sexual health services.

These systemic inequities and discrimination have resulted in disparities in sexual and reproductive health outcomes:

• Individuals who are Black and Latinx have higher rates of unintended pregnancies than communities that are white.
• Individuals who are Black and Latinx have higher rates of HIV and STIs than the general population.
• Individuals who are Black and Latinx, Indigenous or American Indian/Alaska Native are overrepresented among abortion patients.
• Individuals who are LGBTQ2S+ and can get pregnant are more likely to experience unintended pregnancy or seek an abortion than their peers who are straight.

Abortion restrictions have been shown to worsen maternal and child health and associated disparities.

State-level bans or restrictions on abortion are associated with:

• Poorer health outcomes for women and children.
• Increased risk of infant mortality.
• Increased probability of pre-term birth in individuals who are Black compared to peers who are non-Black.
• Increased probability of low birthweight in people without a college degree compared to college graduates.

The current trend in state legislation to lower gestational age for abortion disproportionately affects adolescents, who:

• May not access care when first miss menses
• May have irregular cycles (common up to 2 years after menarche) and may not know they are pregnant
• May have conditions that cause irregular cycles, such as untreated polycystic ovary syndrome (PCOS) and may not realize they are pregnant.

States with more restrictive abortion policies also tend to have fewer policies supporting maternal and child health through the lifespan.

Being denied a wanted abortion removes a person’s ability to make decisions about their body and health and changes the decisions they are able to make about their future.

95% of people who have an abortion report that they made the right decision, 5 years later.

People who are pregnant and who are denied a wanted abortion face negative impacts on their health, finances, and well-being.

The Turnaway Study:

Much of what is known about the impacts of accessing or being denied a wanted abortion comes from the Turnaway Study, a longitudinal study that examines the impact of unintended pregnancy on the lives of people who are pregnant:

• In over 50 publications, the authors of the Turnaway Study have outlined the health and socioeconomic consequences of receiving an abortion versus carrying an unintended pregnancy to term.
• The Turnaway Study was led by a team of scientists at the University of California, San Francisco.
• The Turnaway Study compared the experiences of people who have abortions and those who are denied a wanted abortion over a 5-year period.
• The study tracked the outcomes of a diverse cohort of 1,000 women, recruited from 30 abortion facilities across the US.

The main findings of the Turnaway Study indicate that:

• Receiving an abortion does not harm the health and well-being of people who are pregnant.
• Being denied a wanted abortion has negative health, family, and financial impacts.

A selection of results from the Turnaway Study are highlighted below.

Being unable to access a wanted abortion impacts physical health.

People who are pregnant and who are denied a wanted abortion are more likely to experience serious pregnancy complications:

• Eclampsia.
• Post-partum hemorrhage.
• Death.

People who are pregnant and who are denied a wanted abortion are more likely to report poor health outcomes:

• Chronic pain.
• Headaches and migraines.
• Gestational hypertension.

Being unable to access a wanted abortion impacts mental health.

People who are pregnant and who are denied a wanted abortion have a higher risk of short-term impacts on anxiety, self-esteem, and stress.

Anxiety:

• People who are pregnant and who are denied a wanted abortion report more anxiety than their peers who received an abortion.
• Anxiety is highest around the time of denial and in the following months and reduces over time.
• Prior mental health history and history of abuse increase incidence of anxiety after seeking an abortion.

Self-esteem:

• People who are pregnant and who are denied a wanted abortion report lower self-esteem than their peers who receive an abortion.
• Self-esteem and life satisfaction tends to improve or remain steady over time.

Stress:

• People who are pregnant and who are denied an abortion and go on to parent report high levels of stress after being turned away.
• Stress levels are higher among people who are pregnant seeking abortions in their 2nd trimester, compared with peers seeking abortions in the 1st trimester.

Other mental health outcomes:

• Accessing or being denied a wanted abortion does not impact risk of depression, suicidal thoughts, or post-traumatic stress symptoms.
• Prior experience with mental health symptoms, violence, abuse, or sexual assault are most strongly linked to poor mental health outcomes after an abortion.

The most significant mental health impacts of abortion denial happen in the short term. This indicates that people who are pregnant and who are denied an abortion are resilient, and able to find ways to cope emotionally in the long-term, despite economic and health impacts.

Being unable to access a wanted abortion impacts economic outcomes.

Many people who are pregnant and who seek an abortion are already experiencing economic hardship.

• Not having enough money to care for a child or support another child is the most common reason for seeking an abortion.
• Many women who seek an abortion have incomes below the Federal Poverty Level and report that they do not have enough money for basic expenses.

Being denied a wanted abortion often exacerbates economic challenges: women who carry an unintended pregnancy to term are 4 times more likely to have an income below the Federal Poverty Level.

People who are pregnant and who are denied a wanted abortion report:

• Higher levels of unemployment.
• Higher likelihood of being unable to pay for basic needs, such as food, transportation, and housing.
• Lower credit scores, higher debt, and more negative financial effects (eg, bankruptcies, evictions).

People who are pregnant and who are denied a wanted abortion often seek support from federal programs, such as Temporary Assistance for Needy Families (TANF), Women Infants and Children (WIC), Medicaid, and food assistance (SNAP). These programs are important, but do not protect families from falling below the Federal Poverty Line.

People who are pregnant and who do receive a wanted abortion report more financial stability in the future.

Being unable to access a wanted abortion increases the likelihood of staying with a violent partner.

People who are pregnant and who are unable to access a wanted abortion are more likely to remain in an abusive relationship.

This can impact experience of domestic violence or intimate partner violence over time:

• People who are pregnant and who access a wanted abortion report a reduction in physical violence from the partner involved in their pregnancy over time.
• People who are pregnant and who are denied a wanted abortion are more likely to experience sustained violence.
• Intimate partner violence has documented negative health consequences on both the victim of the violence and on any children in the family.

Being unable to access a wanted abortion impacts the health and development of all children in the family.

People who are pregnant and denied a wanted abortion are more likely to raise children alone, without the support of a partner or family.

Children who are born as the result of an abortion denial are more to live below the Federal Poverty Line.

People who are pregnant and who go on to parent a child after an abortion denial report poorer maternal bonding, and higher rates of resenting the baby or feeling trapped than they experience with their subsequent children.

The other children of people who are pregnant and who are denied a wanted abortion have poorer developmental outcomes.

People who are pregnant and who do receive a wanted abortion raise their other children under more economically-stable conditions, and are more likely to have a child from a wanted pregnancy in the future.

Being unable to access a wanted abortion impacts outlook on the future.

People who are pregnant and who are unable to access an abortion are less likely to have aspirational goals or plans for the future.

However, it is important to note that the likelihood of achieving personal goals is similar among people who receive a wanted abortion and those who are denied this care. This indicates that people who are pregnant and who are denied an abortion are resilient in achieving the goals they set.

Healthcare providers are also impacted by bans or limitations on abortion.

Bans or limitations on abortion interfere with providers’ ability to deliver basic medical care.

Bans or restrictions on abortion prevent pediatric health clinicians and other healthcare providers from providing safe, effective, clinically-indicated medical treatment to their patients.

• Common restrictions include TRAP laws, restrictions on care provision, or requirements to provide inaccurate information.
• These restrictions are politically motivated, and not based in evidence, science, or medicine.
• These restrictions cause complications and stressors for providers, harm patient-provider relationships, and interfere with the practice of medicine.
• For more information, see “Common Barriers to Abortion Access,” earlier in this resource.

AAP and other front-line physician groups oppose government restrictions on the information that patients can receive from their doctors. In a 2018 joint statement, AAP and its partners affirmed that:

• Patients expect medically accurate, comprehensive information from their doctors
• Provision of accurate information is critical to the integrity of the patient-physician relationship
• No governmental body should interfere in a physician’s obligation to provide evidence-based information to patients.

Stigma around abortion impacts the training and practice experiences of healthcare providers.

The current climate around abortion in the US reinforces cultural stigma, which can impact the training and clinical practice experiences of abortion providers.

There is a documented shortage of trained abortion providers in the US, even among obstetrician-gynecologists.

The gap in the abortion care workforce is influenced by systemic factors, including:

• Lack of access to training on abortion in residency programs.
• Options to “opt-out” of abortion care during medical school, residency, and advanced-practice clinician education.
• State-level limitations on the types of physicians or advanced-practice clinicians that can perform abortion procedures.

Abortion care in the US is separated from the rest of the healthcare system, which reinforces stigma and limits access to care:

• Most abortions are often performed in freestanding clinics, separated from other health facilities.
• Patients seeking abortion report that they would prefer to receive this care from their family doctor instead of at a specialized clinic.
• Abortion services are concentrated in urban areas, contributing to significant geographic disparities in access.
• Primary care providers can provide first-trimester abortions with appropriate training, however, many elect not to pursue this training due to stigma and politically-motivated restrictions on this care.
• Further integration of abortion care into primary care settings—particularly in rural and medically-underserved areas—could increase access to abortion care in the US.

Abortion providers report personal and career-related challenges related to the factors above, including:

• Limited training availability.
• Marginalization within their profession.
• Stigma and isolation.
• Concerns about personal safety.

Abortion providers face violence and safety risks.

Bans or restrictions on abortion promote stigma around a safe and effective medical procedure, and abortion providers and other medical staff at risk of discrimination and harassment.

Abortion patients, providers, and clinics face threats of violence, harassment, and intimidation.

From 1993-2016, 11 people in the US were murdered in incidents of violence against abortion providers, and 26 more survived attempted murder.

The National Abortion Federation tracks incidents of violence against abortion providers, including:

• Murder.
• Attempted murder.
• Bombings and bomb threats.
• Arson.
• Vandalism.
• Burglary.
• Assault.
• Death threats.
• Stalking.
• Harassment via phone, mail, or internet.

Rates of violence and harassment against abortion patients, providers, and clinics have escalated in recent years.

Anti-abortion violence limits access to abortion care and puts abortion providers and their families in serious danger.