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The United States Supreme Court’s decision to overturn the Roe vs Wade ruling in June 2022 was met with alarm from health care providers, who expressed grave concern about the inevitable negative effects on the health of women and others who can become pregnant.1-3 For those with certain medical conditions, pregnancy may pose the risk for serious complications or death — and clinicians will be legally prohibited from providing life-saving care in many of these cases.4
In addition to the physical risks, experts anticipate a myriad of mental health ramifications stemming from the loss of abortion access and the associated economic and occupational repercussions. The expected burden is especially high for marginalized groups such as people of color and LGBTQ+ individuals, who are already more likely to live in poverty and face reduced access to all types of medical and mental health care.
“It’s horrifying to think about the ramifications for these populations,” said Rubiahna L. Vaughn, MD, MPH, assistant professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine and director of psychiatry services at Jack D. Weiler Hospital, part of Montefiore Health System in the Bronx.
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Dr Vaughn, who is currently developing a reproductive psychiatry program, also notes the risk for mental health complications associated with pregnancy in general. “In the lay public, there’s this myth that pregnancy is a time when women feel good and have that ‘pregnancy glow.’ However, the data suggest otherwise,” she said. There is an increased risk for new onset and recurrence of major depressive disorder, bipolar disorder, and anxiety disorders during pregnancy and the postpartum period, and the risk for psychiatric admissions is higher during the first year postpartum compared with any other life period.5,6
Additionally, the mortality risk due to childbirth is 50-130 times greater than the risk for death due to abortion, according to the Centers for Disease Control and Prevention.1
Given the range of possible consequences associated with both pregnancy and restrictions on reproductive choices, clinicians should be prepared to provide the necessary support and resources to patients who wish to terminate a pregnancy. “As physicians we are charged to facilitate patient autonomy and treat our patients fairly regardless of their perspectives and preferences — this is a central tenet of medical ethics,” Dr Vaughn stated. “If a physician is unable to facilitate patient autonomy, they should immediately refer that patient to someone who can.”
For further discussion regarding the potential psychological effects of the Roe vs Wade decision and how clinicians can support patients affected by the ruling, we interviewed the following experts: board-certified adult and forensic psychiatrist Susan B. Trachman, MD, associate professor at George Washington University in Washington, DC, and assistant professor at Virginia Commonwealth University in Richmond, Virginia; and Joanne Bagshaw, PhD, an American Association of Sexuality Educators, Counselors and Therapists (AASECT) certified sex therapist, psychology professor at Montgomery College in Germantown, Maryland, and author of The Feminist Handbook.
What are the potential mental health effects of being denied access to an abortion?
Dr Bagshaw: Based on the Turnaway Study published in 2017, women who were denied an abortion experienced greater levels of distress in the short term than those who had an abortion.7 The study was conducted between 2008 and 2010. Researchers recruited 1000 women from 30 abortion clinics scattered throughout the US, and they split participants into 2 groups — women who had an abortion and women who were turned down for an abortion — and followed their outcomes for 5 years.
Those turned down for an abortion experienced significant life disruptions, including anxiety as well as lower life satisfaction and self-esteem. While their distress tended to improve over the course of the 5 years, their financial distress lasted at least 5 years.8
Women who were denied an abortion have also demonstrated health consequences including persistent headaches, migraines, and joint pain, as well as poorer overall health at the 5-year mark compared with women who had an abortion.9 Although we don’t have this data yet, clinicians should consider that even with improved levels of depression and anxiety at 5 years, the effects of chronic financial distress and poor overall health can significantly impact a woman’s mental health.
Women are already diagnosed with higher rates of depression, anxiety, PTSD, and lower self-esteem due to everyday experiences of sexism and discrimination such as street harassment or the lack of equitable division of labor in heterosexual relationships. Losing the ability to maintain bodily autonomy can also impact a woman’s health and is an additional source of discrimination and stress that can increase risk factors for psychiatric disorders.
What is known about the effects of unwanted pregnancy?
Dr Trachman: According to multiple studies, women who conceived unintentionally were more likely to smoke cigarettes, drink alcohol, and take illicit drugs. In addition, they were less likely to receive prenatal care.10 This affects their children as well. Children born after unwanted pregnancies showed cognitive delays, an increase in behavioral problems, and a greater likelihood of substance abuse.11
Because Roe has been a constitutional right for women for nearly 50 years, there is not a lot of research on unwanted pregnancies and women’s mental health during this time span. However, a 2016 study from the American Journal of Public Health examined pregnancies resulting in birth prior to Roe and found persistent negative mental health effects for women with unwanted pregnancies.12
What are the potential additional mental health effects on disenfranchised groups such as people of color, LGBTQ+ individuals, and those with lower incomes or disabilities?
Dr Bagshaw: Women and pregnant people who are lower income or live in poverty are more vulnerable to the effects of financial hardship and socioeconomic distress. Being denied an abortion is likely to significantly impact Black, Brown, and indigenous folks the hardest, particularly if their identity intersects with other marginalized groups. For instance, Black women are already 3 times more likely to die in childbirth than White women and may experience even more emotional distress if they are unable to access abortion services.1 The compounded stress may also increase their risk for maternal mortality.
Dr Trachman: Some of the known risk factors for postpartum depression and perinatal depression include a prior history of depression, stressful life events, poor relationship quality, current or previous abuse, and low socioeconomic status. Based on this data, the new ruling will likely affect these groups in a negative way.
What additional effects might there be for people living with mental illness, victims of rape and incest, and victims of domestic violence, especially in the context of reproductive coercion and abuse?
Dr Bagshaw: The Turnaway Study highlights the effects on women’s mental health when denied an abortion. For women with pre-existing mental illness, the stress of being denied an abortion, along with the associated financial and health decline, is likely to worsen their overall mental health.
Mental health providers should not underestimate the level of compounded trauma on a rape victim, whose autonomy and bodily integrity were first violated by the rapist and then by laws that violate their human rights and force them to give birth. Clinicians — especially those not already trained in social work — may need a robust resource list and highly attuned trauma treatment skills.
Being unable to access abortion services significantly limits the choices a pregnant person could make to flee an abusive relationship. Plus, remaining pregnant while in an abusive relationship could impact maternal mental health, and remaining pregnant puts women at higher risk for intimate partner violence.13
Dr Trachman: There is a very sparse literature on the effects on women of rape-related pregnancy. One reason is that, until recently, abortion was a constitutional right for women to make decisions about their reproductive health. Another reason is that the majority of rape victims do not come forward and thus would not be included in a scientific study.However, there is a study14 published in The American Journal of Obstetrics and Gynecology in 1996 that looked at estimates and descriptive characteristics of women who experienced rape-related pregnancy. Their main findings were:
- Psychologically, rape has been identified as a significant risk factor for the development of posttraumatic stress disorder, with 35% to 50% of victims affected.
- Less than 15% of rape victims report the crime to law enforcement.
- Of the 3000 women included in the study, pregnancy resulting from rape was reported in only 30 women. Remember this was 1996, so many of the others may have chosen abortion.
- Of the pregnancies that resulted from rape, 60% were discovered within the first trimester. Almost one-third did not know they were pregnant until the second trimester.
- Outcomes of rape-related pregnancy cases confirmed the majority of these pregnancies were unwanted. The infant was kept by the mother in one-third of cases. One-half of the women had abortions and 6% carried to term and then gave the babies up for adoption.
What are some ways that mental health care providers can best support their patients who are facing these issues?
Dr Bagshaw: Clinicians of all types who work with girls, women, and people who can get pregnant should have an updated resource list for abortion care services and where to get emergency contraception. The resource list should include abortion services in the state their client lives in — if abortion is still legal there — and should also include nearby states with safe haven laws and organizations that provide funding for travel as well as abortion services.
Clinicians who work in a state that criminalizes abortion without exception will need to be on the lookout for women who will try to take abortion into their own hands through self-medication or other means. Additionally, clinicians need to pressure licensing bodies to ensure that if a client reports a pregnancy, miscarriage, or abortion, that disclosure remains privileged and confidential and not subject to any mandatory reporting laws.15
Dr Trachman: As always, it is critical to be nonjudgmental. If your patient does not want to keep an unwanted or unplanned pregnancy, there are several ways to support her.
- If she lives in a state where abortion is still legal, help her find a local facility that provides the procedure.
- Plan B and other emergency contraceptive pills are still an option but are not the same as an abortion pill. Emergency contraception prevents someone from getting pregnant in the first place. It can prevent more than 95% of pregnancies when taken within 3 to 5 days of unprotected sex.16
- If she lives in a state that has severely restricted or eliminated access to abortion, she can find her nearest clinic through Power to Decide’s abortion finder.
- For many patients, traveling out of state to an abortion clinic is prohibitively expensive. The Women’s Reproductive Rights Assistance Project (WRRAP) or the I Need an A database can show local clinics as well as organizations that can help with funding.
To improve abortion access, a group of local and national organizations known as “abortion funds” have formed over the years to help people pay for the procedure. WRRAP is the largest national, independent, nonprofit abortion fund. It provides financial assistance to people seeking abortions or emergency contraception through a network of 700 clinics and doctors spanning the country.
The Brigid Alliance was launched in 2018 and serves clients who must travel an average of 1000 miles to get an abortion. They cover costs like gas, plane tickets, childcare, and food. They also provide virtual support to help clients along their journey.
If patients can’t travel to a clinic or prefer to manage their own abortion, they can get care online through aidaccess.org. The site provides online consultations for abortions and medication from overseas.
How should clinicians handle self-disclosure regarding their own views on abortion rights, and when should they refer out because of conflicting views that may not allow them to support these patients?
Dr Bagshaw: Since denying access to abortion care is a violation of one’s human rights, clinicians should feel comfortable noting their support for reproductive freedom, either in session or on their website. I feel grave concern for anti-choice clinicians who work with people who can get pregnant, especially if they are unwilling to provide appropriate resources for emergency contraception or abortion care, because removing access to abortion can be a life and death issue. If a clinician’s anti-choice beliefs prevent them from providing the care their clients need, I recommend supervision or training to work with a different population.
Dr Trachman: Providers who have strong negative feelings about abortion may have to recuse themselves from treating a patient with an unwanted pregnancy and refer to someone who is more objective.
References
1. Harris LH. Navigating loss of abortion services – a large academic medical center prepares for the overturn of Roe v. Wade. N Engl J Med. 2022;386(22):2061-2064. doi:10.1056/NEJMp2206246
2. Decision to overturn Roe v. Wade could worsen reproductive health in U.S., exacerbate health inequities. National Academy of Sciences and the National Academy of Medicine. Published June 24, 2022. Accessed July 22, 2022. https://www.nationalacademies.org/news/2022/06/decision-to-overturn-roe-v-wade-could-worsen-reproductive-health-in-u-s-exacerbate-health-inequities
3. ACOG District I Statement on Supreme Court Decision Dobbs v. Jackson. The American College of Obstetricians and Gynecologists. Published June 24, 2022. Accessed July 22, 2022. https://www.acog.org/community/districts-and-sections/district-i/whats-new/district-i-statement-supreme-court-decision-dobbs-v-jackson
4. Goodman JD, Ghorayshi A. Women face risks as doctors struggle with medical exceptions on abortion. The New York Times. Published June 24, 2022. Accessed online July 22, 2022. https://www.nytimes.com/2022/07/20/us/abortion-save-mothers-life.html
5. Yan H, Ding Y, Guo W. Mental health of pregnant and postpartum women during the coronavirus disease 2019 pandemic: a systematic review and meta-analysis. Front Psychol. 2020;11:617001. doi:10.3389/fpsyg.2020.617001
6. Appleby L. Suicide during pregnancy and in the first postnatal year. BMJ. 1991;302(6769):137-140. doi:10.1136/bmj.302.6769.137
7. Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women’s mental health and well-being 5 years after receiving or being denied an abortion: a prospective, longitudinal cohort study. JAMA Psychiatry. 2017;74(2):169-178. doi:10.1001/jamapsychiatry.2016.3478
8. Miller S, Wherry LR, Foster DG. The economic consequences of being denied an abortion. NBER. Revised January 2022. 2020;2662: doi:10.3386/w26662
9. Ralph LJ, Schwarz EB, Grossman D, Foster DG. Self-reported physical health of women who did and did not terminate pregnancy after seeking abortion services: a cohort study. Ann Intern Med. 2019;171(4):238-247. doi:10.7326/M18-1666
10. Upadhyay AK, Srivastava S. Effect of pregnancy intention, postnatal depressive symptoms and social support on early childhood stunting: findings from India. BMC Pregnancy Childbirth. 2016;16:107. doi:10.1186/s12884-016-0909-9
11. de La Rochebrochard E, Joshi H. Children born after unplanned pregnancies and cognitive development at 3 years: social differentials in the United Kingdom Millennium Cohort. Am J Epidemiol. 2013;178(6):910-20. doi:10.1093/aje/kwt063
12. Herd P, Higgins J, Sicinski K, Merkurieva I. The implications of unintended pregnancies for mental health in later life. Am J Public Health. 2016;106(3):421-429. doi:10.2105/AJPH.2015.302973
13. Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: maternal and neonatal outcomes. J Womens Health (Larchmt). 2015;24(1):100-106. doi:10.1089/jwh.2014.4872
14. Holmes MM, Resnick HS, Kilpatrick DG, Best CL. Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women. Am J Obstet Gynecol. 1996;175(2):320-325. doi:10.1016/s0002-9378(96)70141-2
15. Spector-Bagdady K, Mello MM. Protecting the privacy of reproductive health information after the fall of Roe v Wade. JAMA Health Forum. 2022;3(6):e222656. doi:10.1001/jamahealthforum.2022.2656
16. Emergency contraception. World Health Organization. Published November 9, 2021. Accessed online July 22, 2022. https://www.who.int/news-room/fact-sheets/detail/emergency-contraception
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