Mental Health Implications of Abortion Restrictions: NEJM

Authors Lucy Ogbu‑Nwobodo and team believed the implications of the Dobbs decision are best viewed through an intersectional lens encompassing structural racism, reproductive injustice, and mental health, since people with a history of mental health conditions, trauma, and substance use disorders are more vulnerable to stigma, discrimination, and adverse health outcomes in pregnancy and beyond.

To begin with, abortion does not lead to mental health harm-a fact that has been established by data and recognized by the National Academies of Sciences, Engineering, and Medicine and the American Psychological Association. The Turnaway Study, a longitudinal study that compared mental health outcomes among people who obtained an abortion with those among people denied abortion care, found that abortion denial was associated with initially higher levels of stress, anxiety, and low self-esteem than was obtaining of wanted abortion care.

People who had an abortion did not have an increased risk of any mental health disorder, including depression, anxiety, suicidal ideation, post-traumatic stress disorder, or substance use disorders. Whether people obtained or were denied an abortion, those at greatest risk for adverse psychological outcomes after seeking an abortion were those with a history of mental health conditions or of child abuse or neglect and those who perceived abortion stigma (i.e., they felt others would look down on them for seeking an abortion). Furthermore, people who are highly oppressed and marginalized by society are more vulnerable to psychological distress.

There is evidence that people seeking abortion have poorer baseline mental health, on average, than people who are not seeking an abortion. However, this poorer mental health results in part from structural inequities that disproportionately expose some populations to poverty, trauma, adverse childhood experiences (including physical and sexual abuse), and intimate partner violence. People seek abortion for many reasons, including (but not limited to) timing issues, the need to focus on their other children, concern for their own physical or mental health, the desire to avoid exposing a child to a violent or abusive partner, and the lack of financial security to raise a child.

In addition, for people with a history of mental illness, pregnancy and the postpartum period are a time of high risk, with increased rates of recurrence of psychiatric symptoms and of adverse pregnancy and birth outcomes. Because of stigma and discrimination, birthing or pregnant people with serious mental illnesses or substance use disorders are more likely to be counseled by health professionals to avoid or terminate pregnancies, as highlighted by a small study of women with bipolar disorder. One study found that among women with mental health conditions, the rate of readmission to a psychiatric hospital was not elevated around the time of abortion, but there was an increased rate of hospitalization in psychiatric facilities at the time of childbirth. Data also indicate that for people with preexisting mental health conditions, mental health outcomes are poor whether they obtain an abortion or give birth.

Structural racism — defined as ongoing interactions between macro-level systems and institutions that constrain the resources, opportunities, and power of marginalized racial and ethnic groups — is widely considered a fundamental cause of poor health and racial inequities, including adverse maternal health outcomes. Structural racism ensures the inequitable distribution of a broad range of health-promoting resources and opportunities that unfairly advantage White people and unfairly disadvantage historically marginalized racial and ethnic groups (e.g., education, paid leave from work, access to high-quality health care, safe neighborhoods, and affordable housing). In addition, structural racism is responsible for inequities and poor mental health outcomes among many diverse populations.

The association between poverty and abortion is multifactorial and is grounded in reproductive injustice. Because of the deleterious effects of structural racism, these demographic groups are the same populations that are at greater risk for negative outcomes of mental illnesses and substance use disorders.

Limiting the freedom to access reproductive health care exacerbates intersecting factors of structural racism, gendered racism, and classism for all people — especially those with preexisting mental health issues. These restrictions adversely affect mental well-being, which is closely tied to the decisions that birthing and pregnant people make throughout their reproductive life course.

Legal abortion is a safe clinical procedure, with extremely low rates of complications and death. Conversely, the risk of death associated with childbirth is 14 times that associated with legal abortion. Empirical evidence also supports a link between structural racism and maternal health inequities, including higher rates of preterm births and more severe maternal complications among all women in geographic areas where racial inequities are most marked, though Black women have disproportionately worse outcomes.

In addition, mental illness has been increasingly recognized as a major contributor to pregnancy-associated mortality — suicide and overdose are leading causes of death among pregnant and postpartum women. Pregnancy is a particularly risky time for survivors of intimate partner violence, who in the United States are disproportionately likely to be Black or Indigenous; these survivors face numerous adverse mental health outcomes, including depression, anxiety, posttraumatic stress disorder, substance use disorders, and suicide attempts.

Complications of pregnancy are another major and inequitable risk for many birthing and pregnant people with mental illness; these inequities are more pronounced among racially and ethnically marginalized women than among White women. Studies reveal higher-than-average rates of obstetric and neonatal complications in patients with schizophrenia or affective disorders. Furthermore, maternal depression is a risk factor for impairment in mother and child bonding, and maternal antenatal depression is an independent predictor of preterm delivery.

Barriers to reproductive services can lead some pregnant people to induce abortion using methods that are not evidence-informed, which increases their risk of complications. Despite the safety and efficacy of abortifacients such as misoprostol and mifepristone, both patients and clinicians lack adequate awareness of these options and may be unsure how their use is affected by state abortion bans.

Another aspect of reproductive justice worth consideration is a caregiver's autonomy to make decisions about their children's household and environment. The majority of women who have abortions are already mothers.

In a structured survey of more than 1000 patients undergoing abortion, the most frequently cited reason for seeking the procedure was that having another child would interfere with the patient's education, work, or ability to care for dependents. These reasons hold particular relevance in a society that continues to lag behind its peers in the availability of publicly subsidized child care, paid parental leave, and social safety-net services. Though admittedly complex and highly politicized, reproductive justice, including timely and easy access to abortion, is indisputably a health care issue — a social determinant of mental (and physical) health with far-reaching repercussions. Laws in a democratic nation should reflect the will of the people, and structural systems in a just society should produce equitable outcomes. The Dobbs ruling falls short on both counts. The implications are especially grave for birthing and pregnant people from historically marginalized groups — especially those with mental health and substance use disorders — further endangering populations that face alarmingly high pregnancy-related morbidity and mortality.

Source: Lucy Ogbu‑Nwobodo, M.D., Ruth S. Shim, M.D., M.P.H., Sarah Y. Vinson; n engl j med 387;17