Levels of suicidal ideation were similarly low between women who had abortions and women who were denied abortions. Policies requiring that women be warned that they are at increased risk of becoming suicidal if they choose abortion are not evidence based.

One week after abortion seeking, 1.9% of the near-limit group and 1.3% of the turnaway-birth group reported any suicidal ideation symptoms on the BSI. Over the 5-year study period, the proportion of women with any suicidal ideation symptoms on the BSI declined significantly to 0.25% for women in the near-limit group and nonsignificantly to 0.21% for those in the turnaway-birth group. In four out of 7,247 observations (0.06%), women reported being imminently suicidal. There was no statistically significant differential loss to follow-up by baseline report of suicidal ideation or history of depression or anxiety. There were no statistically significant group differences on any suicidal ideation outcome over the 5-year study period.

The authors recruited 956 women from 30 U.S. abortion facilities. Women were interviewed by telephone 1 week after their abortion visit, then every 6 months for 5 years. Women who received near-limit abortions were compared with women who were denied an abortion and carried their pregnancies to term (turnaway-birth group). Women completed the suicidal ideation items on the Brief Symptom Interview (BSI) and the Patient Health Questionnaire (PHQ-9). The Sheehan Suicidality Tracking Scale was used to assess imminent suicidality. Adjusted mixed-effects regression analyses accounting for clustering by site and individual were used to assess whether levels and trajectories of suicidality differed by group.

The aim of this study was to assess the effects of receiving compared with being denied an abortion on women’s experiences of suicidal ideation over 5 years.

The notion that women who have an abortion are at higher risk of suicide has been used as a rationale to discourage women from having abortions (1). For example, in Texas, as part of a mandated counseling law, women are given a booklet warning them that they are at increased risk of becoming suicidal if they choose abortion (2). This view is supported by several studies in the United States and one in Finland finding that abortion increases a woman’s risk for suicidal ideation, suicide attempts (3), and suicide (4–7). However, these studies suffer from some serious methodological shortcomings (8) that limit the validity of their results. The Finnish study (5–7) did not control for the factors that are known to lead to the need for abortion, such as history of mental health conditions, violence, and abuse, and to increase a person’s risk of experiencing suicidal ideation or behaviors (8–11). When studies fail to account for these preexisting risk factors, they may misattribute any adverse mental health outcomes to the abortion rather than to those factors. Studies that control for these confounding factors have found that abortion is not associated with an increased risk of suicidal ideation or behaviors (12–14).

An additional methodological problem is that many studies use inappropriate comparison groups by comparing women who have abortions to women who have never had an abortion or who choose to give birth (3, 5, 7, 12, 13). These comparisons are problematic because differences in financial or socieomotional resources may explain the decision to carry to term and therefore confound the effect of abortion on mental health. Very few studies have examined the effects on women of being denied an abortion. A U.K. study examined deliberate self-harm by comparing women who gave birth with women who received abortions and women who were denied abortions (15). While women seeking abortion were at higher risk of deliberate self-harm than those who did not seek abortion, rates were highest among women denied an abortion, although the researchers did not test whether the differences between women who had and women who were denied an abortion were statistically significant (15).

In this study, we assessed the effects of having or being denied an abortion on women’s experiences of suicidal ideation over 5 years, using data from the Turnaway Study (16). The Turnaway Study compares women who seek and obtain an abortion just under a facility’s gestational age limit with women who are denied an abortion because they are just beyond the gestational age limit. Previous Turnaway Study analyses have found that women who obtain an abortion have levels of depression and posttraumatic stress similar to those of women who are denied an abortion, yet fewer symptoms of anxiety and higher self-esteem 1 week later (17–20). The present analysis assesses whether women who have an abortion and women denied an abortion have different suicidal ideation levels over 5 years.

Method

This study used all 11 semiannual interview waves from the Turnaway Study, a longitudinal study designed to look at the effects of receiving compared with being denied an abortion on women’s socioeconomic, mental health, and emotional well-being. Study details have been reported elsewhere (16–20). Women seeking an abortion were recruited at 30 facilities in 21 U.S. states. Facilities with the latest gestational age limit of any other facility within 150 miles were selected as recruitment sites. Women were recruited from January 2008 to December 2010 into three main study groups, in a 2:1:1 ratio: a near-limit group (N=452), women who sought and obtained an abortion within 2 weeks under the facility’s gestational age limit; a turnaway group (N=231), women who sought but were denied an abortion because they were within 3 weeks over the facility’s gestational age limit; and a first-trimester group (N=273), women who sought and obtained a first-trimester abortion. This third group served as a secondary comparison to assess whether outcomes differed for women who obtained abortions earlier compared with later in pregnancy. Because some women in the turnaway group miscarried or had an abortion elsewhere, this group was further divided into a turnaway-birth group (N=161) and a turnaway-no-birth group (N=70). The 15 women who placed their babies for adoption were included in the turnaway-birth group. A participant flow chart has been published elsewhere (17). Women were interviewed by telephone approximately 1 week after seeking an abortion, and then again every 6 months through 5 years. The structured interview asked women about their experiences accessing abortion, childbearing, mental and physical health, and history of traumatic events.

Outcome Variables

Our main outcome variables rely on two validated suicidal ideation items from the Brief Symptom Inventory (BSI) (21) and the Patient Health Questionnaire (PHQ-9) (22). The BSI item asks respondents to indicate whether in the past 7 days they have had thoughts of ending their life, with choices ranging from 0, “not at all,” to 4, “extremely.” The PHQ-9 item asks respondents, “Over the last 2 weeks, how often have you been bothered by any of the following problems? Thoughts that you would be better off dead or of hurting yourself in some way?” Options ranged from 0, “not at all,” to 3, “nearly every day.” The PHQ-9 was included from the second interview wave (6 months after abortion seeking) forward. The two main dichotomous outcomes included any BSI symptoms of suicidal ideation (“extremely,” “quite a bit,” “moderately,” or “a little bit” versus “not at all”) and PHQ-9 symptoms of suicidal ideation (“nearly every day,” “more than half the days,” or “several days” versus “not at all”). Average BSI and PHQ-9 symptoms (continuous) are presented in Table S1 in the online supplement.

Our secondary outcome measure, imminent suicidality, was assessed with an adapted version of the Sheehan Suicidality Tracking Scale (23) among respondents indicating any suicidal ideation symptoms on either the BSI or the PHQ-9. The adapted scale included six questions: “Over the past week, how seriously did you: Think that you would be better off dead or wish you were dead? Want to harm yourself or to hurt or injure yourself? Think about suicide? Plan for a suicide? Take active steps to prepare for a suicide attempt in which you expected or intended to die?” and “Over the past week, did you injure yourself on purpose, in an effort to kill yourself?” As recommended by the scale authors, if the participant raised the possibility of suicide herself or responded “moderately,” “very,” or “extremely” to all of the items and/or “yes” to the last item, she was considered imminently suicidal.

Careful steps were taken to support women identified to be at risk of suicide. During the consent process and at the outset of each interview, participants were informed of the limits to confidentiality, including possible intervention and loss of confidentiality in the event that they expressed a plan to harm themselves. In cases where the participant met the criteria for being imminently suicidal or showed indications that she might inflict self-harm, research assistants immediately implemented a protocol to further evaluate the participant’s risk level and ensure her timely access to social and professional support.

Independent Variables

Our primary independent variables of interest were a four-part study group variable (near-limit, turnaway-birth, turnaway-no-birth, and first-trimester), time (in years) since recruitment, and study group-by-time interactions. The near-limit group served as the reference group to allow for simultaneous comparisons with both the turnaway-birth and first-trimester groups. The time variable served to assess whether near-limit outcomes changed significantly over time. The study group-by-time interaction assessed whether a study group’s trajectory differed significantly from that of women in the near-limit group.

Covariates

We included age, race/ethnicity (white, black, Hispanic or Latina, and other), education level (less than high school, high school or equivalent, associate’s degree or technical school or some college, and college degree or higher), employment (full-time or part-time and not employed), parity (nulliparous, birth in the past year, one child and no birth in the past year, two or more children and no birth in the past year), and marital status (single, married, and divorced or widowed) as demographic covariates. Additional covariates included other factors known to be associated with suicidal ideation during pregnancy (12, 24): ever diagnosed with depression or anxiety (whether a doctor or health professional had ever told them that they had a “depressive disorder such as major depression, depression, dysthymia, or bipolar disorder” or an “anxiety disorder, including panic, obsessive-compulsive, anxiety, and posttraumatic stress”); experiences of intimate partner violence in the past year, including psychological (“frightened for your safety as a result of anger or threats made by another person”) and physical (“pushed, hit, slapped, kicked, choked, or physically hurt in any way”); ever been sexually assaulted or raped; history of child abuse or neglect (physical abuse, neglect, or sexual abuse during childhood); any prepregnancy illicit drug use; and any prepregnancy problem alcohol use (drinking first thing in the morning or inability to remember what happened after drinking). Gestational age at the time of recruitment was not included as a model covariate because it was highly correlated with study group, by study design. All covariates were measured at baseline and were time invariant.

Statistical Analysis

We used mixed-effects regression analyses, accounting for clustering by recruitment site, to assess baseline differences in demographic characteristics and mental health history between women in the near-limit abortion group and the three other study groups. For categorical variables with more than two categories (e.g., race/ethnicity), we used an omnibus postestimation test to accommodate multiple category associations. For longitudinal analyses, we used mixed-effects logistic regression to assess whether trajectories in experience of any suicidal ideation differed by study group. In supplemental analyses, we modeled mean suicidal ideation symptoms using mixed-effects linear regression analyses. Longitudinal analyses accounted for clustering by site and individual. Mixed-effects models produce unbiased estimates even in the context of missing observations. They also accommodate irregular time measurement and clustering by recruitment site and individuals, as in the case of our panel data. We assessed whether trajectories were curvilinear by testing whether including quadratic terms for time improved the model fit. None of the models required quadratic terms for time, as indicated by a nonsignificant (p>0.05) likelihood ratio test. For all longitudinal analyses, we ran unadjusted and adjusted models. The threshold for statistical significance was set at a p value of 0.05.

Attrition and Sensitivity Analyses

To determine whether women with suicidal ideation or related risk factors were more likely to discontinue participation in the study, we used mixed-effects regression to test associations between previous reports of suicidal ideation, history of depression or anxiety, history of child abuse or neglect, and past-year history of intimate partner violence with being lost to follow-up. To determine whether women lost to follow-up may have been lost because of suicide, we conducted verbal autopsies when deaths were reported to us by participants’ relatives during data collection. After data collection concluded, we used LexisNexis, a public records search tool, to confirm those deaths and identify possible new deaths. Both protocols were approved by our institutional review board, and verbal autopsies were conducted only with secondary contacts with whom the participant had previously given us permission to speak. Using a secure server, we provided LexisNexis with names, dates of birth, and last known addresses for all participants lost at any point after recruitment. For each death identified, we conducted a Google search for obituaries or other information about the death and sought death certificates from the city or county where the death occurred.

To account for the possibility that some women with suicidal ideation symptoms may have skipped the suicidal ideation items to avoid the research team’s mandatory reporting requirements, we ran an additional set of longitudinal analyses. In these analyses, anyone who skipped a suicidal ideation item and indicated moderate signs of depression (as indicated by a score ≥8 on either the full BSI or PHQ-9 depression scales) was treated as having suicidal ideation symptoms.

Results

Of the 1,132 eligible women recruited, 956 (84.5%) completed baseline interviews and 558 (58%) completed the last interview, with an average of 5% lost from wave to wave. There was no significant differential loss to follow-up by study group at any study wave. One site was dropped from the analysis (N=76) because most (95%) women in the turnaway group went on to have an abortion elsewhere. Three women who changed their mind about wanting abortion were also removed from the analysis, leaving a final analysis sample of 877 (413 in the near-limit group, 160 in the turnaway-birth group, 50 in the turnaway-no-birth group, and 254 in the first-trimester group).

The participants’ baseline demographic and clinical characteristics are summarized in Table 1. By study design, when compared with women in the near-limit group (mean=19.7 weeks), women in the turnaway-birth group sought abortion at later gestational ages (mean=23.1 weeks), and women in the first-trimester and turnaway-no-birth groups sought abortion earlier in pregnancy (mean=7.6 weeks and mean=18.9 weeks, respectively). Across groups, one-quarter of women had ever been diagnosed with anxiety or depression (25%), 14% had experienced psychological or physical intimate partner violence in the past year, and 21% had a history of sexual assault or rape. There were no significant differences between women in the near-limit abortion group and the other three study groups with regard to education, marital status, mental health history, history of psychological or physical intimate partner violence, history of drug use, and history of problem alcohol use. However, when compared with the near-limit group, the turnaway-birth group was younger on average and less likely to be employed, the first-trimester group was older on average and more likely to be employed, and the turnaway-no-birth group was less likely to have experienced intimate partner violence in the past year. The turnaway-birth group was less likely than the near-limit group to have already had children. The near-limit and first-trimester groups also differed with regard to race/ethnicity.

TABLE 1. Characteristics of Participants in a Study of Suicidal Ideation in Women Who Sought and Either Received or Were Denied Abortion (N=877)a Characteristic Near-Limit Abortion Group (Reference) (N=413) Turnaway-Birth Group (N=160) Turnaway-No-Birth Group (N=50) First-Trimester Abortion Group (N=254) Mean SD Mean SD Mean SD Mean SD Age (years) 24.9 5.9 23.4* 5.6 24.4 6.2 25.9* 5.7 Gestational age (weeks) 19.7 4.1 23.1* 3.4 18.9* 4.0 7.6* 2.3 N % N % N % N % Race/ethnicity * White 132 32 40 25 21 42 99 39 Black 131 32 54 34 14 28 80 32 Hispanic or Latina 87 21 45 28 7 14 54 21 Other 63 15 21 13 8 16 21 8 Education level Less than high school 76 18 39 24 10 20 41 16 High school or equivalent 142 34 55 34 13 26 78 31 Some college, associate’s degree, or technical school 167 40 57 36 23 46 107 42 College degree or higher 28 7 9 6 4 8 28 11 Employed (full-time or part-time) 224 54 64 40* 24 48 161 63* Parity * Nulliparous 140 34 75 47 20 40 97 38 Past-year birth 51 12 10 6 4 8 28 11 1 previous birth, no past-year birth 110 27 33 21 14 28 54 21 ≥2 previous births, no past-year birth 112 27 42 26 12 24 75 30 Marital status Single 329 80 134 84 39 78 194 76 Married 33 8 16 10 3 6 28 11 Divorced or widowed 51 12 10 6 8 16 32 13 Mental health and trauma history Ever diagnosed with anxiety or depression 97 23 33 21 15 30 76 30 History of child abuse or neglect 108 26 41 26 7 14* 70 28 Any past-year psychological or physical intimate partner violence 61 15 15 9 5 10 37 15 History of sexual assault or rape 85 21 32 20 9 18 59 24 Drug and problem alcohol use Any drug use before discovering pregnancy 52 13 22 14 4 8 45 18 Problem alcohol use before discovering pregnancy 18 4 11 7 5 10 18 7 TABLE 1. Characteristics of Participants in a Study of Suicidal Ideation in Women Who Sought and Either Received or Were Denied Abortion (N=877)a Enlarge table

Any BSI Suicidal Ideation

The proportion of women in the near-limit group who had any BSI suicidal ideation did not differ significantly from the three other study groups at any point in time (Table 2). However, for women obtaining an abortion (those in the near-limit and first-trimester groups), the proportion with any BSI suicidal ideation declined significantly from 1 week to 5 years after abortion (Table 2 and Figure 1). Neither turnaway group experienced a significant decline in any BSI suicidal ideation (Table 2). The results of the adjusted and unadjusted mixed-effects logistic regression analyses are presented in Tables 3 and 4, respectively. Baseline characteristics associated with having any BSI suicidal ideation (Table 3) included being Latina (adjusted odds ratio=3.59; 95% CI=1.44, 8.95), a history of intimate partner violence (adjusted odds ratio=3.34; 95% CI=1.26, 8.87), a history of depression or anxiety (adjusted odds ratio=2.96; 95% CI=1.37, 6.38), and prior problem alcohol use (adjusted odds ratio=3.38; 95% CI=1.11, 10.23). Five women skipped the BSI suicidal ideation item at one of their interviews, two of whom completed the remainder of the BSI-depression subscale. The results of analyses in which the women who skipped the suicidal ideation item and showed indications of moderate depression were recoded as suicidal were similar to those of the main analyses (data not shown).

TABLE 2. Marginal Predicted Probabilities of Suicidal Ideation in Women Who Sought and Either Received or Were Denied Abortion, Based on Adjusted Mixed-Effects Logistic Regression Analysesa Percent With Any Suicidal Ideation Symptoms Measure and Assessment Time Near-Limit Abortion Group (Reference) Turnaway-Birth Group Turnaway-No-Birth Group First-Trimester Abortion Group Total Brief Symptom Inventory Overall average over time 0.94 0.67 0.68 0.88 0.85 1 week 1.92 1.29 2.02 1.53 1.68 1 year 1.31 0.92 1.00 1.16 1.17 2 years 0.87 0.64 0.47 0.87 0.80 3 years 0.58 0.45 0.21 0.64 0.56 4 years 0.38 0.31 0.10 0.48 0.38 5 years 0.25 0.21 0.04 0.35 0.27 Change from 1 week to 5 years –1.67* –1.08 –1.97 –1.18* –1.41* Change p value 0.006 0.138 0.230 0.046 <0.001 Patient Health Questionnaire Overall average over time 1.07 1.18 0.67 1.03 1.05 6 months 1.67 0.85 1.84 1.89 1.61 1 year 1.51 0.90 1.37 1.64 1.44 2 years 1.17 1.05 0.63 1.13 1.11 3 years 0.91 1.22 0.28 0.77 0.89 4 years 0.70 1.42 0.12 0.52 0.74 5 years 0.54 1.64 0.05 0.35 0.64 Change from 6 months to 5 years –1.13 +0.80 –1.79 –1.54* –0.97* Change p value 0.057 0.856 0.167 0.012 0.003 TABLE 2. Marginal Predicted Probabilities of Suicidal Ideation in Women Who Sought and Either Received or Were Denied Abortion, Based on Adjusted Mixed-Effects Logistic Regression Analysesa Enlarge table

FIGURE 1. Trends in the Proportion of Women Seeking Abortion With Any Suicidal Ideation Symptoms According to the Brief Symptom Inventory and the Patient Health Questionnairea a Values are marginal probabilities based on results of mixed-effects logistic regression analyses adjusting for baseline age, race/ethnicity, education level, parity, marital status, history of child abuse or neglect, history of intimate partner violence, history of sexual assault, history of depression or anxiety, any prior drug use, and prior problem alcohol use. The Brief Symptom Inventory was administered 1 week after abortion seeking and again every 6 months through 5 years, and the Patient Health Questionnaire was administered at 6 months and again every 6 months through 5 years. The suicidal ideation items in the two measures are described in the text.

TABLE 3. Associations Between Receipt and Denial of Abortion and Suicidal Ideation Outcome Variables Over Time Using Adjusted Mixed-Effects Logistic Regression Any Suicidal Ideation Symptoms Brief Symptom Inventory Patient Health Questionnaire Variable Adjusted Odds Ratio 95% CI Adjusted Odds Ratio 95% CI Study group Near-limit group (reference) Turnaway-birth group 0.63 0.17, 2.34 0.36 0.14, 1.81 Turnaway-no-birth group 1.07 0.14, 8.01 1.57 0.32, 25.70 First-trimester group 0.77 0.28, 2.14 1.26 0.38, 4.11 Time 0.64* 0.46, 0.88 0.76 0.59, 1.01 Turnaway-birth group by time 1.06 0.58, 1.95 1.56 0.94, 2.60 Turnaway-no-birth group by time 0.69 0.17, 2.74 0.57 0.10, 3.15 First-trimester group by time 1.14 0.72, 1.78 0.87 0.54, 1.41 Race/ethnicity White (reference) Black 1.89 0.69, 5.19 1.78 0.74, 4.30 Hispanic or Latina 3.59* 1.44, 8.95 1.48 0.59, 3.74 Other 0.72 0.19, 2.80 1.24 0.42, 3.66 Education level Less than high school (reference) High school or equivalent 0.41 0.16, 1.05 0.74 0.33, 1.69 Some college, associate’s degree, or technical school 0.53 0.23, 1.24 0.36* 0.15, 0.89 College degree or higher 0.81 0.17, 3.86 0.28 0.04, 1.84 Age 0.94 0.87, 1.02 1.00 0.94, 1.07 Marital status Single (reference) Married 1.39 0.42, 4.63 0.61 0.16, 2.41 Divorced or widowed 2.17 0.79, 6.00 1.75 0.71, 4.34 Employed 0.98 0.49, 1.94 0.95 0.49, 1.85 Parity Nulliparous (reference) Baby under age 1 1.45 0.46, 4.51 2.03 0.59, 6.92 1 previous birth, no past-year birth 1.23 0.47, 3.20 3.27* 1.29, 8.32 ≥2 previous births, no past-year birth 0.85 0.28, 2.57 1.59 0.56, 4.55 History of child abuse or neglect 1.35 0.50, 3.65 1.67 0.65, 4.24 Intimate partner violence and sexual assault 3.34* 1.26, 8.87 1.84 0.84, 4.03 History of depression or anxiety 2.96* 1.37, 6.38 4.07* 1.96, 8.46 Any prior drug use 1.28 0.51, 3.19 1.84 0.84, 4.03 Prior problem alcohol use 3.38* 1.11, 10.23 3.00* 1.04, 8.68 TABLE 3. Associations Between Receipt and Denial of Abortion and Suicidal Ideation Outcome Variables Over Time Using Adjusted Mixed-Effects Logistic Regression Enlarge table

TABLE 4. Associations Between Receipt and Denial of Abortion and Suicidal Ideation Outcomes Over Time Using Unadjusted Mixed-Effects Logistic Regressiona Any Suicidal Ideation Symptoms Brief Symptom Inventory Patient Health Questionnaire Variable Odds Ratio 95% CI Odds Ratio 95% CI Study group Near-limit group (reference) Turnaway-birth group 1.84 0.60, 5.61 0.46 0.11, 1.95 Turnaway-no-birth group 1.75 0.28, 10.81 2.86 0.28, 28.40 First-trimester group 1.19 0.44, 3.26 1.53 0.50, 4.69 Time 0.61* 0.45, 0.83 0.76* 0.59, 1.00 Turnaway-birth group by time 0.81 0.45, 1.45 1.35 0.84, 2.17 Turnaway-no-birth group by time 0.76 0.25, 2.32 0.47 0.11, 2.00 First-trimester group by time 1.11 0.72, 1.73 0.81 0.52, 1.28 TABLE 4. Associations Between Receipt and Denial of Abortion and Suicidal Ideation Outcomes Over Time Using Unadjusted Mixed-Effects Logistic Regressiona Enlarge table

Any PHQ-9 Suicidal Ideation

The proportion of women in the near-limit group with any PHQ-9 suicidal ideation did not differ significantly from the three other study groups at any time interval (Table 2). The first-trimester group was the only group to experience a significant (p=0.01) decline in any PHQ-9 suicidal ideation, declining from 1.89% at 6 months to 0.35% at 5 years (Table 2). Baseline characteristics associated with any PHQ-9 suicidal ideation (Table 3) included parity, history of depression or anxiety (adjusted odds ratio=4.07; 95% CI=1.96, 8.46), having a prior history of problem alcohol use (adjusted odds ratio=3.00; 95% CI=1.04, 8.68), and education level. Seven women skipped the PHQ-9 suicidal ideation item at one of their interviews, five of whom showed signs of moderate depression. In analyses where these five women were recoded as having suicidal ideation symptoms, results were similar to those of the main analyses (data not shown).

Imminent Suicidality

In 109 of 7,247 interviews, women reported any suicidal ideation symptoms, either on the BSI or PHQ-9 suicidal ideation items, over the 5-year study period, and these women completed the Sheehan Suicidality Tracking Scale to assess whether they were imminently suicidal. In four of the 109 observations (two each in the near-limit and first-trimester groups), the women scored as imminently suicidal at one point during the 5-year study period. All four indicated that the abortion was the right decision for them, three had a prepregnancy history of depression or anxiety, and all had a history of child abuse and/or neglect.

Attrition Analysis

Results of mixed-effects regression analyses testing the association between history of depression or anxiety, history of child abuse or neglect, and past-year intimate partner violence with being lost to follow-up indicated that none of these variables were significantly associated with loss to follow-up (data not shown). Results of our death record search indicated that five women died during our study period. These five women (three in the near-limit group and two in the turnaway-birth group) were identified by a verbal autopsy and/or by a LexisNexis death record search. None had a previous history of depression or suicidal ideation symptoms according to previous assessments. Two died from car accidents, one from a heart attack, and two from unknown causes.

Discussion

Consistent with previous reviews of the literature on the psychological effects of abortion (9, 25) and studies on the effects of abortion on suicidal ideation (12, 14), we found that having an abortion does not place women at higher risk of experiencing suicidal thoughts than being denied an abortion. We also found that rates of suicidal ideation were low across groups, when compared with other studies of pregnant and postpartum women (24, 26–29). This study is one of the few to specifically examine the effects of abortion on women’s risk for suicidal ideation. It improves on the previous studies by controlling for mental health history and abuse, which are factors known to be strongly associated with suicidal ideation. We find that when we account for the factors that predominantly predispose women to experiencing suicidal ideation, having an abortion does not increase women’s risk of experiencing suicidal thoughts when compared with women who are denied an abortion and carry the unwanted pregnancy to term.

We used two validated suicidal ideation items, which rendered similar but not identical results, suggesting that the scales capture somewhat different constructs. Although there were no study group differences on either measure at any point in time, the trajectories on the two measures were somewhat different. Whereas BSI symptoms declined over time for all groups, PHQ-9 symptoms declined for all groups except the turnaway-birth group. Given that the increase in the turnaway-birth group was not statistically significant, and because the changes over time were so small, the conclusions stemming from both measures are consistent.

This is the only study we are aware of that specifically looks at the effects of abortion on suicidal ideation by comparing women who have an abortion to women denied an abortion. This comparison group eliminates much of the selection bias that occurs when comparisons are made to women who never considered abortion (5, 7). Women who have abortions usually have a higher incidence of prepregnancy suicidal ideation risk factors than women who choose to give birth (30–32). Thus, choosing a comparison group that also considered abortion is an important addition to the literature. Furthermore, by including an additional comparison group of women who obtained first-trimester abortions, we were able to assess the effects of gestational age on suicidal ideation. We found that women who had abortions at a time near the facility’s gestational age limit were no more likely to experience suicidal thoughts than women who had a first-trimester abortion, suggesting that gestational age when seeking an abortion has no significant effect on suicidal ideation.

A large proportion of women in this study had a previous history of intimate partner violence, abuse, and mental health concerns. More than one in 10 women had experienced physical or psychological abuse from an intimate partner in the past year, and one in five had experienced sexual assault in their lifetime. These rates are estimated to be higher than those found in the general U.S. population (33), consistent with the finding that women seeking abortion may often have the risk factors that predispose them to experiencing adverse psychological outcomes.

This study had a number of limitations. Women may have chosen to alter or skip their responses on the suicidal ideation items in order to avoid our mandated reporting requirements. Furthermore, women with suicidal thoughts or deaths due to suicide may have been lost to follow-up. While we cannot completely exclude the possibility that some of these deaths may have been suicides, we found no evidence to suggest that this was the case. The lack of differential loss to follow-up by study group, baseline suicidal ideation, and mental health history, even distribution of deaths by study group, and the similar results obtained from a sensitivity analyses that assumed that women with missing items had suicidal symptoms, strengthen the validity of our findings.

By following women for 5 years, we are able to assess whether abortion is followed by an increase in suicidal ideation and whether the suicidal ideation trajectories of women who obtained an abortion differ from those of women denied an abortion. For women having an abortion, we found that the proportion with any symptoms did not increase but rather decreased over the 5-year period. We also found no effect of receiving compared with being denied an abortion on either of our two suicidal ideation measures at any time point, dispelling the notion that abortion increases women’s risk for suicidal ideation over time. Thus, policies requiring that women be warned that they are at increased risk of becoming suicidal if they choose abortion are not evidence based.