Turn Away Study

The Turn Away Study is an ongoing study of women who had first and second trimester abortions compared to women who were "turned away" from late term abortions because they approached the clinics in their state after the gestational age limit for performing abortions. The Turn Away Study is conducted by the pro-abortion advocacy group Advancing New Standards in Reproductive Health (ANSIRH)

The Turn Away Study is seriously flawed by the non-representative sample of women included in the study.

Of women approached to participate 62.5% declined. Another 15% dropped out before the baseline interview. After the baseline interview, women continued to drop out at each six month followup period. While the number of women who dropping out at each stage is has not been revealed. Instead, the authors imply a high retention rate by declaring that 93% participated "in at least one" of the six month followups.
While not explicitly stated by the researchers, the numbers they do reveal indicate that only 27.0% of the eligible women were interviewed at the three year follow-up.
The sample is disproportionately filled with women having late abortions. The sample used includes 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester.
Demographically, the sample used is not representative of women having abortions. The average age at the time of the abortion was 25, of which 62% were raising children. The percentage of women with living children is typical of national averages for women seeking abortion.

Decision Rightness with Regard to Abortion

Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study Rocca CH, Kimport K, Roberts SC, Gould H, Neuhaus J, Foster DG. PLoS One. 2015 Jul 8;10(7):e0128832. doi: 10.1371/journal.pone.0128832. eCollection 2015.

Abstract

BACKGROUND: Arguments that abortion causes women emotional harm are used to regulate abortion, particularly later procedures, in the United States. However, existing research is inconclusive. We examined women's emotions and reports of whether the abortion decision was the right one for them over the three years after having an induced abortion.

METHODS: We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities across the United States, selected based on having the latest gestational age limit within 150 miles. Two groups of women (n=667) were followed prospectively for three years: women having first-trimester procedures and women terminating pregnancies within two weeks under facilities' gestational age limits at the same facilities. Participants completed semiannual phone surveys to assess whether they felt that having the abortion was the right decision for them; negative emotions (regret, anger, guilt, sadness) about the abortion; and positive emotions (relief, happiness). Multivariable mixed-effects models were used to examine changes in each outcome over time, to compare the two groups, and to identify associated factors.

RESULTS: The predicted probability of reporting that abortion was the right decision was over 99% at all time points over three years. Women with more planned pregnancies and who had more difficulty deciding to terminate the pregnancy had lower odds of reporting the abortion was the right decision (aOR=0.71 [0.60, 0.85] and 0.46 [0.36, 0.64], respectively). Both negative and positive emotions declined over time, with no differences between women having procedures near gestational age limits versus first-trimester abortions. Higher perceived community abortion stigma and lower social support were associated with more negative emotions (b=0.45 [0.31, 0.58] and b=-0.61 [-0.93, -0.29], respectively).

CONCLUSIONS: Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years. Emotional support may be beneficial for women having abortions who report intended pregnancies or difficulty deciding.

Comments & Criticisms

Non-Representative Sample

This study's findings and conclusions are overreaching in many regards, beginning with the fact that the sample of women is not representative of the national population of women having abortions due to high rates of self-exclusion plus high drop out rates. To quote from the study: "Overall, 37.5% of eligible women consented to participate, and 85% of those completed baseline interviews (n = 956). Among the Near-Limit and First-Trimester Abortion groups, 92% completed six-month interviews, and 69% were retained at three years; 93% completed at least one follow-up interview." This means 62.5% of women refused to participate in the study, at first request, and another 15% dropped out before or during the baseline interview, yielding a 31.9% participation rate at baseline.
With 68.1% of eligible women refusing to participate in the study at baseline, it is improper for the authors to suggest that their findings reflect the general experiences of most women. There are numerous risk factors which have been identified as predicting which women will have the most severe post-abortion reactions. One of these risk factors, for example, is ambivalence about having an abortion or carrying to term. Another is the expectation that one will have more negative feelings about the abortion. In a similar post-abortion interview study by Soderberg, the author reported that in interviews with those declining to participate "the reason for non-participation seemed to be a sense of guilt and remorse that they did not wish to discuss. An answer often given was: ' Do do not want to talk about it. I just want to forget.'"
It is very likely that the self-selected 31.9% of women participating at baseline were more highly confident of their decision to abort prior to their abortions and anticipated fewer negative outcomes. This concern about selection bias is highlighted by the study's own finding that "women feeling more relief and happiness at baseline were less likely to be lost [to follow-up]." Clearly, due to the large numbers of women choosing not to be questioned about their experience, and the large drop out of those who did agree, this sample is not representative of the national population of women having abortions.
Despite the initial selection bias, 15% of those agreeing to be interviewed subsequently opted out of the baseline interview and another 31% opted out within the three year followup period. This means that at the three year followup, only 27.0% of the eligible women were interviewed. This continuing drop out rate suggests even among women who expected little or no negative reactions, the stress of participating in follow up interviews lead to a change of mind. Previous research shows that women with a history of abortion feel more discomfort in answering questions about their reproductive history.
Another oddity, the authors report that in the final group analyzed, average age 25, 62% were raising children. This would appear to be a very high rate that is not typical of national averages for women seeking abortion.
The study population is also non-representative of the women having abortion in that it included 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester. This is totally disproportionate. It again shows that the authors should not be extending conclusions about this non-representative sample to the general population.
The authors report that sample has an elevated number of low socioeconomic backgrounds. That, too, makes the sample non-representative. The offer of $50 per interview may also have created a participation bias.

Inappropriate Measures & Study Design Flaws

The focus of this report in on women's persistent satisfaction with their abortion decisions, "decision rightness," as measured by a single question of whether or not the "abortion was right for them." Women were asked to answer this question "yes", "no" or "uncertain." This measure is flaws in several ways:
1. A better research approach would have been to have this question rated on a numeric scale (1 to 10, for example) in order to better identify any shift in attitudes.
There is no report of tests to verify the validity and reliability of the questions used. In other words, the authors do not report on any efforts made to evaluate whether the question(s) used provide reliable consistency...or are even understood by women in the same way. For example, do all women interpret the question the "Was my abortion right?" in the same way it is being interpreted by researchers? Or might it be interpreted in numerous ways by different people? Was it "right" as in "moral"? Was it right as in "the best choice I could make at the time?" Was it right in that it was the best choice any person could make? Was it right meaning one would make the same choice if one became pregnant again? Was it right in that "It made my life far better"? Or was it right only in the sense that "What's done is done, and I'm moving my life forward doing the best I can so that is my focus so I guess it was right . . . or at least what I have to work with."
A feeling that a person made the right decision due to circumstances at that time is not the same as an assertion that it was the right decision regardless of circumstances or "if I knew what I knew now."
The decisions assessment were conducted through telephone interviews approximately every six months. A well known problem with interview based studies is that many participants will try to please the interviewer by giving the answer they believe is expected of them. Similarly, some interviewers may be more prone to elicit certain types of response. The investigators did not report on any tests made to verify that such influences were not at play.
As a general rule, questions regarding decision satisfaction (even about things such as the purchase of a purse) may produce reaction formation and therefore defensive answers affirming the rightness of a decision even if there are actually unresolved anxieties or other issues. (To voice dissatisfaction may invite anxiety provoking thoughts. Responding the way one is expect to respond, avoids reflection).
Rather than rely on a single question about the "rightness" of the abortion decision, additional questions should have been asked to better gauge the subjects thoughts. For example, in the Soderberg study, including a one year post-abortion interview of 847 women (after a 33% self-exclusion rate), 80% of the women reported they were satisfied with their decision to abort but at the same time 76% also stated that they would never abort again if faced with an unwanted pregnancy. In this case, the second question offers a great deal of additional insight. A woman expressing unwillingness to not have another abortion may be telling us more than her abortion experience than she is when she says that a past decision was "right."
Another difficulty raised by the researcher's methodology is that their interviews apparently did not inquire about any steps women took to resolve negative emotions. It is necessary to know if women who had negative feelings sought any help to deal with those feelings, perhaps with a therapist, a pastor, or family or friends. The increase in the number of women participating in post-abortion programs should, for example, help to reduce the longevity of negative reactions to abortion. But if this is the case, the conclusion of the authors that negative reactions to abortion naturally diminish over time may be wrong if, in fact, the decrease is due to women receiving post-abortion psychological or spiritual counseling. In other words, if the decline in negative reactions is real (and not due to denial, repression, or just a desire to rush through the phone interview to collect the $50 gift card) it is important to understand the reason for this. Is it due to support given to those having negative feelings, or is it "natural" and permanent?
The authors did not use any validated measures of psychological illness, as has been done in many other studies. Instead the assessment of psychological health is all inferred from a two scales created from six questions in which rated six emotions associated with their abortion women rated each emotion on a five point scale from "not at all" to "extremely." The six emotions were: relief, happiness, regret, guilt, sadness and anger. From these six self-assessments, reported by telephone to an interviewer, the scores for the four negative emotions were combined for a single scale and the two positive emotion scores were combined for a positive emotion scale. These scales were not tested for validity or reliability. Nor were they tested as a measure of overall psychological health or, conversely, psychological illness.

Inconsistency With Prior Research Findings

As mentioned above, a similarly designed followup study by Soderberg study reported that 80% of the women reported they were satisfied with their decision to abort but at the same time 76% also stated that they would never abort again if faced with an unwanted pregnancy. Soderberg also found that even though many women reported satisfaction with their decision they also experienced negative psychological outcomes, with 50-60% of women undergoing induced abortion experienced some measure of emotional distress, classified as severe in 30% of cases.
1. Notably, the claim of declining regret and declining negative reactions is at odds with Brenda Major's two year longitudinal study, which also had high drop out rates, which found that there was a trend in decline in relief and increase in negative emotions over the two year period among those who did not drop out of her study. (See Major B, et al. Psychological responses of women after first-trimester abortion. Archives of General Psychiatry. 2000: 57(8), 777-84.)
Their claim that there is no evidence of mental health problems after abortion is not consistent with the findings of studies utilizing validated measures of mental health, including a five year longitudinal study nor with the Christchurch Health and Development Study, a lifetime longitudinal study.
Their findings are not consistent with findings of record linkage studies which have shown an elevated risk of psychiatric admissions following abortion, an elevated rates of suicide and elevated rates of sleep disorders.
Their findings are not consistent with the results of meta-analyses comparing a large number of studies, including reviews by Bellini, Fergusson, and Coleman.

Unreported Details

According to an infographic about the study published by the research group, the followup interviews were actually continued every six months for five years, not just three. Why then did this report limit itself to three years rather than cover the full five years covered by the study?
The study population included 413 women who had an abortion near the end of the second trimester and only 254 women having an abortion in the first trimester. Overall, only 31% participated at the baseline interview (35.7% agreed to be interviewed, but 15% of those dropped out before or during the baseline interview). The authors should report the drop out rate for each of the two groups: first trimester and second trimester.

Overreaching Conclusions

While the report and accompanying press release claim that this study proved there is "no evidence of widespread 'post-abortion trauma syndrome,' in fact it did not use any standard scales for assessment of psychological well being.
The authors report a decline in the negative emotions reported by the women remaining in the study over the three year period.
The bias of the research team is made clear in press releases and a infographic purporting to summarize the study. In these "summaries" the research group conceals the details regarding the high non-participation rate and boldly claims "95% of women who had abortions felt it was the right decision, both immediately and over 3 years," omitting the fact that 62.5% refused to answer the question at the time of their abortion and of those interviewed at the time 31% were out of the study by the third year. Notably, the problem of high non-participation and drop out rates is not mentioned in the abstract, press release, or other summarizing materials published by the authors. To the contrary, they consistently imply that their results apply to the entire population of women having abortions.
The authors make much of the claim that 93% of the participants "completed at least one follow up interview" which the media outlets incorrectly reported as meaning "Only 7% of the participants dropped out of the study during follow-up." It would have been far more accurate to state that of the "Only 37.5% of eligible women agreed to be interviewed, of whom 85% actually did complete the complete baseline interviews (n = 956). Of this group, only 7% refused to do at least one followup interview."
From the observation that the scale created from four negative reactions showed a modest decline in negative reactions over three years, the authors they draw the very broad conclusion that there is no evidence of widespread negative psychological reactions to abortion. As indicated above, this conclusion is contradicted by better designed studies. Moreover, this conclusion ignores the fact that many psychological problems are characterized by denial and repression of negative emotions. There is, in fact, clear evidence from other studies that many women experience symptoms of post-traumatic stress disorder which includes symptoms of denial and avoidance behavior. In a study by Rue, for example, among women reporting intrusive memories or thoughts related to their abortion, only half denied that these thoughts were attributed (caused) by their abortions. In other words, it is not always easy for women to recognize which feelings may be attributable to their abortions. For example, it is only when in post-abortion counseling that many women may attribute increased feelings of anger after their abortions to unresolved feelings over the abortion which they were projecting onto other people and situations. This is all fairly basic psychology. Negative emotions often crop up in other parts of our lives because we have trouble dealing with them at the source. Therefore, women reporting less "anger" relative to their abortion may in fact have more feelings of anger in their lives than before their abortion but are simply attributing it to other issues. This demonstrates the difficulty in trying to judge the post-abortion emotional adjustment of women based on just six oversimplified questions about six basic emotions.

Critique by Priscilla Coleman

The following is reprinted with permission from WECARE's website where it is titled The Turnaway Study Analyzed by WECARE Director: The Latest Attempt to Reverse Evidence-based, Women-Centered Advances in Abortion Policy

The PLoS ONE study titled “Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study” is riddled with serious design flaws that render the results meaningless. The problematic issues are described in detail below followed by evidence that the true motivation for publishing the study is likely political. In recent years, credible science has informed policy with 26 states, now requiring information regarding mental health effects be shared with women considering abortion. This study is a poor attempt to provide counter “evidence” and obscure the reality of women’s suffering, reminiscent of the highly flawed research from the 70s and 80s.

Methodological Issues:

1) As reported by the authors, the consent to participate rate is only 37.5%. This is unacceptable, as the missing 62.5% who were approached and declined were likely the women who had the most adverse psychological reactions to their abortions. With sensitive topic research, securing a high initial consent rate is vitally important and in order to approach being representative, a minimum of 70% should be retained.

2) The authors note that the sample was comprised of a high concentration of women from low socioeconomic backgrounds, rendering the sample not representative of US women undergoing abortion today. There is an ethical concern here as a well, since providing $350 to participate is coercive, as it would be difficult for most of the women to turn down the money.

3) The authors fail to reveal the specific consent to participate rates for each group. Because prior research has demonstrated that second trimester abortions are potentially more traumatizing than first trimester procedures, it is likely that a significantly higher percentage of women in the first-trimester group consented to participate; and the percentage of willing to participate, second trimester participants was likely well under 37.5%. If the rates were comparable, why not report this? Failure to report critical information increases suspicion that this “near limit’ group is in no way representative.

4) In the Turnaway Study, women who secured abortions near the gestational limits included women for whom the legal cut off ranged from 10 weeks through the end of the second trimester. There is a wealth of data indicating that women’s reasons for choosing abortion and their emotional responses to the procedure differ significantly at varying points of pregnancy. Women aborting at such widely different points should therefore not be lumped together, particularly when gestational age information is available in the data.

5) No information is provided regarding how the sites were actually chosen. What type of sampling plan was employed? Why were only those identified with the National Abortion Federation used? What cities were included? Which areas of the country were sampled?

6) The majority of the outcome measures are single items, and this is problematic given the many psychometrically sound multiple item instruments available in the literature for the variables examined. Well-trained behavioral science researchers should not attempt to measure complex human emotions in such a superficial manner; and ethically responsible scientists would not extrapolate from such minimalistic assessments to women’s emotional reactions to one of life’s more challenging decisions.

Bias issues:

7) The authors’ uneasiness with recent litigation is stated in the opening paragraph: “Arguments about emotional harms from induced abortion—including decision regret and increasing negative emotions over time—have been leveraged to support abortion regulation in the United States. To uphold a 2007 law banning a later abortions, Justice Kennedy of the Supreme Court stated: “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort...” In support of a state-level ban, a researcher testified that abortion “carries greater risk of emotional harm than childbirth.” Arguments about emotional harm have been used to forward parental consent, mandatory ultrasound viewing, and waiting period legislation as well.” This is a rather odd way to open a supposed scientific investigation and the authors’ unapologetic decision to do so reveals their rather transparent political motivation (i.e., to provide counter results no matter what the scientific cost).

8) The authors’ effort to draw sweeping conclusions from this single, seriously compromised study is evident in their remarks regarding the implications of the study: “Results from this study suggest that claims that many women experience abortion decision regret are likely unfounded.” As scientists we never make such sweeping conclusions based on a single study, particularly when there is an abundant literature comprised of hundreds of sophisticated studies wherein the conclusions are quite discrepant. Courts throughout the US have concluded that women should be appraised of the risks before consenting to abortion; it almost seems silly that these researchers hope to shift the tide based on this study alone.

9) Funding was secured from the David and Lucille Packard Foundation among other sources with a political agenda. As described on their website, “Our work in the United States seeks to advance reproductive health and rights for women and young people by improving access to quality comprehensive sexuality education, family planning and safe abortion care.”