Is relief the most common reaction to abortion? Self-assessed intensity of emotions attributed to abortion in a national sample of women aged 41 to 45

Introduction

Planned Parenthood, the largest abortion provider in America, claims that “Over 95% of people who have had abortions say that they mostly felt relief after their abortion”.¹ But this claim conflicts with a substantial body of literature showing abortion is associated with higher rates of mental illness and widespread negative emotions.^2–10 It is important for those considering abortion, and those providing medical advice, to have accurate information about emotions which commonly follow an abortion.

A literature search identified two studies that appear to be the primary basis for the claim that relief is the most common reaction to an abortion.

First, there is a longitudinal study of 442 women recruited at abortion clinics in 1993 which found that women reported “more relief than negative emotions” both one hour after their abortions and at a subsequent interview two years later.¹¹ But notably, the researchers also found that over the two-year period relief and positive emotions declined and negative emotions had significantly increased. This study had numerous limitations. First, the list of negative emotions assessed included only six items. They were “sad,” “blue,” “low,” “disappointed,” “guilty,” and “feelings of loss.” Second, the investigators did not disclose how each of these six items individually compared to relief. Therefore, the average of six variables compared to a single variable (relief ) may have concealed the prominence of single negative emotions (such as guilt) relative to relief. Fourth, three of the negative emotions (“sad” “blue” and “low”) would appear to be measures of the same affect, depriving the scale of breadth. Fifth, while sadness, guilt, and feelings of loss have been widely reported in qualitative studies, disappointment has not.¹² If “disappointed” is a weak or infrequently experienced emotion, inclusion of this item would tend to suppress the aggregate score for negative emotions. As a result, it is quite possible that the average score of guilty, for example, was greater than that for relief, but this could not be determined with reporting of only the aggregate average of the six negative emotions. Notably, both requests for clarification of these concerns and requests for the anonymized data for reanalysis were refused.¹² The sixth, and most important limitation of this study is that the percentage of invited participants (n = 1117) dropped from 74.9% participation in a pre-abortion interview to 52.3% at the one-month post-abortion interview, and only 37.6% at the two-year post abortion interview. This high drop-out rate introduces the risk of substantial self-censure bias. If the women who experienced the most negative reactions were most prone to dropping out, the longitudinal analysis has less merit and might even be misleading. Finally, for unexplained reasons, women whose pregnancies were intended or were seeking second trimester abortions were excluded from the study. This introduced methodological sampling bias.

Second, there is a longitudinal survey of 667 women recruited at abortion clinics which reported that “Relief was the most commonly felt emotion at all times over 5 years post-abortion”.¹³ In this assessment, only four negative emotions were considered: guilt, sadness, regret, anger. As in the prior study, relief declined over time, but the authors’ analyses indicated the likelihood that it remained above the average scores for each of the negative emotions over the five years investigated. The major shortcomings of this study include both methodological and self-censure bias. Invitations to participate were at the discretion of abortion clinic counselors and were therefore not random. In addition, women seeking abortions when there was a diagnosis of fetal malformation were automatically excluded. Most seriously, despite an inducement of $50 per interview, only 31% of those who were invited participated in the first interview and participation declined to 17% participation at the last interview, five years later.

Non-participation and concealment of abortions are common problems. In national surveys, it is typical that the number of abortions women admit having had are only half of the expected rate based on national abortion statistics.^14,15 Studies conducted with the cooperation of abortion clinic staff have revealed reasonably high rates of participation can be achieved in pre-abortion interviews^11,16 but there are very high dropout rates for post-abortion interviews after subjects have left the abortion provider. Studies examining attrition associated with pre-abortion interview data reveal that those who dropout are more likely to fit into the categories of those who anticipate and/or experience the most negative emotional and mental health reactions self-attributed to their abortions.^7,17,18 This is most likely due to a fear that such interviews may arouse, or even intensify, negative feelings.¹² This is consistent with previous research which has shown that women reporting both a history of abortion and substance abuse reported higher levels of stress in completing a survey touching on these topics.¹⁹

Regarding the women who do experience more negative emotions, a number of other studies have reported that those who feel pressured to abort or otherwise feel most conflicted about their own decision are most likely to report less relief and more negative outcomes.^11,20–26 One study, focused on women who participating in post-abortion healing programs, found that only 38% reported having felt strong feelings of relief following their abortions.⁵ Of those reporting relief, 60% stated these feelings of relief dissipated within weeks and only 25% reported they persisted for years. More common reactions were guilt (93%), grief (85%), regret (85%), anger (81%), and others.⁵ This predominance of negative reactions in this investigation was clearly due to this study’s exclusive reliance on women seeking post-abortion emotional support. Despite this limitation, it underscores the fact that underrepresentation of this subset of women in abortion clinic-based surveys, whether due to methodological or self-censure bias, would most likely lead to dramatic understatement of negative emotions and an overstatement of relief.

Planned Parenthood has also reported that “Terminating a wanted pregnancy can be associated with negative psychological experiences comparable to those associated with stillbirth or death of a newborn”.²⁷ This is consistent with the American Psychological Association’s 2008 literature review that found that women who feel pressured to abort, and/or are more emotionally attached to their pregnancies, and/or are ambivalent about their abortion decisions, are at greater risk of more negative reactions and less relief.^12,28 There is evidence that the majority of women seeking abortions fall within one or more of these higher risk categories.^6,7,12 Therefore, it is reasonable to expect the degrees of feelings of relief to vary significantly by abortion decision types. It is also reasonable to expect that differences in abortion decision types may make the abortion experience more or less similar to that of a miscarriage or other natural loss.

Given these observations, this investigation is an attempt to measure the degree to which relief and a broad variety of negative emotions are self-reported by a random sample of women, to investigate any self-selection bias and the degree of stress reported in participating in such research, and to identify differences across different abortion decision types in comparison to the degree of feelings reported by women who experienced natural pregnancy losses.

Methods

The questionnaire was developed with experts with experience in abortion and mental health research.

The survey was hosted by LimeSurvey.org, utilizing the open source web survey tool, LimeSurvey v6.10.4, and distributed using the services of Cint.com, one of the world’s largest digital marketing and social sciences survey research firms. Cint has over 28 million U.S. residents in their survey panels. Cint panelists voluntarily participate in surveys using their personal electronic devices in exchange for small incentives, which, for this study, were valued at under $2 per completed survey. Panelists electronically signed a consent form including the disclosure that the survey might include “sensitive” subject matter. To avoid introducing any survey selection bias, no additional description of the subject matter was provided. A random sample of Cint panelists pre-identified as female residents of the United States, aged 41 to 45, were invited to complete the survey until 1,500 surveys were completed by women reporting at least one pregnancy outcome. The selected age range minimized the confounding effects of age and focused the sample on those whose history of pregnancies was mostly completed. The survey was distributed electronically, and data collection occurred over three days in July 2024.

Survey design and stigma reduction questions

The first page of the questionnaire asked about age and gender to qualify respondents. The second page asked respondents to identify any mental illnesses for which they had ever been diagnosed. This served as the first response bias test regarding respondent’s willingness to share sensitive information.

Prior to asking about reproductive histories, three abortion stigma reduction questions were presented to respondents. These were developed in light of the fact that national surveys of women have typically disclosed only half of the expected number of abortions compared to national statistics.^14,15 It is hypothesized that concealment of abortion histories are most likely due to feelings of shame, guilt, secrecy or similar feelings that disincline some women to share their abortion histories. To diffuse such reluctance, our survey included three stigma reduction questions, prior to a direct inquiry about whether the respondent had ever had an abortion. The first stigma reduction question was: “Some women feel pressured into abortions by other people (like a male partner) or by circumstances (like poverty). Do you believe the problem of women feeling pressured to have abortions is very rare, uncommon, somewhat common, or very common?” The second was, “How many people do you know who felt pressured to have abortions?” The third asked, “Even if you did not go through with it, have you ever felt pressured to consider an abortion?”

This approach was designed to incrementally prepare respondents to consider disclosing past abortions by first allowing them to consider and share whether they had experienced pressure to have an abortion from other people or circumstances. Since this is a major risk factor for more negative feelings,⁶ this question invites those who might otherwise be initially inclined to conceal their abortions to acknowledge that portion of their experience which was a feeling of facing pressures to choose an abortion. They are then invited to consider if and how many other women they know who may have had a similar experience. Then, and only then, are they directly asked if they themselves ever felt pressured to consider an abortion, even if they had not gone through with it. For those who felt such pressures, an affirmative response to the last question is at least half a step toward revealing their own abortion experience. In previous studies using these abortion stigma reduction questions, the number of women reporting a history of abortion closely matched the national estimate for abortion rates.^6,7

Respondents were then asked to identify the number of times they had (a) given birth to a live born child, (b) had given birth to a child that was the result of an “unplanned, mistimed, unwanted, or otherwise difficult pregnancy” (problematic pregnancy), (c) had a “miscarriage, still birth, or other pregnancy loss”, or (d) had an induced abortion.

From this reported pregnancy history women were divided by a program algorithm into one of five groups, by order of priority, (a) induced abortion group, (b) natural pregnancy loss group, (c) problematic pregnancy group, (d) live birth group, and (e) never pregnant group. Given the programmatic priority structure, women in the abortions group may also have had one or more other pregnancy outcomes. But women in the natural pregnancy loss group would not have reported any abortions but could have had live births and/or problematic pregnancies.

The study population is shown in Figure 1. Respondents who failed to complete all survey questions or fell outside the specified gender and age criteria were excluded from analysis. Of the 2,361 participants who completed the first two demographic questions, 123 (5.2%) dropped out when presented with the psychiatric history section. An additional 25 (1.1%) dropped out when presented with the abortion stigma reduction questions followed by another 22 (1.0%) who discontinued participation when asked to number all of their own pregnancy outcomes. Another 166 (7.0%) withdrew after reporting their pregnancy histories but before completing the full survey. In consultation with Cint, since the survey was designed to take approximately five to seven minutes for respondents to complete, 100 respondents (4.6%) were excluded for finishing in under four minutes to eliminate “speedsters.” This is a subset of persons signing up to complete Cint distributed surveys who randomly respond to questions as quickly as possible in the hope of earning Cint credits without actually reading or attentively responding to the survey items.

Figure 1. Survey population.

Results

Our final study population consisted of 1,925 completed surveys, of whom 409 (21.2%) reported one or more abortions which is only 10.5% lower than estimated 23.7% lifetime abortion rate estimated for women between 41-45 years of age by the Guttmacher Institute.²⁹ Another 573 (29.8%) respondents reported a natural pregnancy loss and did not also have a history of abortion. Within the abortion group, 56.3% (n=230) also reported having one or more natural pregnancy losses. Among women who had abortions, 122 (29.9%) described their abortions as wanted and consistent with their values and preferences (Wanted), 145 (35.5%) described it as accepted but inconsistent with their values and preferences (Inconsistent), 90 (22.0%) described it as unwanted and contrary to their values and preferences (Unwanted), and 52 (12.7%) described it as coerced and contrary to their values and preferences (Coerced).

Table 1 shows descriptive statistics and Mann Whitney test results comparing the intensity of emotions reported by women in the abortion group compared to women in the pregnancy loss group. These findings found that while there are statistically significant differences in the degree some emotions are felt by each group, the low Hedge’s g score (all below 0.3) indicate the degree of differences are small. Specifically, emotions that were significantly higher (p < 0.05) following abortion included guilt, shame, regret, unforgiveness of self. In contrast, following a pregnancy loss, feelings of emptiness, weeping, grief, anger, anxiety, and child related thoughts were significantly higher, but with low effect sizes (g < 0.3). There were no statistically significant differences regarding depression and difficulty completing the grief process. These findings suggest rejection of the null hypothesis (H1) which posited that relief is the most common reaction following an abortion and support H2 which posited that negative emotions are more common than relief post-abortion. These results also partially support H3, which posited that there are similarities in emotions following abortion and natural pregnancy losses.

Table 2 disaggregates the results for women who had abortions and shows the descriptive statistics and Mann Whitney test results for each abortion decision type, using Wanted decisions as the reference group. These results show significantly more intense negative emotions (and less relief ) for each emotion examined (p < 0.001) for the Inconsistent, Unwanted, and Coerced abortion decision types compared to the Wanted decision type. The effect size was moderate (g > 0.3) to strong (g > 0.5) in nearly every comparison, with the greatest differences observed between freely wanted abortions and those respondents described as coerced. Notably, IQR scores indicate that responses for the middle 50% of the Wanted group are widely spread out (IQR > 50) while responses for Coerced were typically more tightly grouped (IQR < 30), indicating more uniformity in the latter group. These results strongly support hypothesis H4, which posited that the degree and type of negative reactions would vary according to abortion decision types.

Table 3 shows Mann-Whitney U statistics, p-values and Hedge’s g effect sizes for each emotion comparing each abortion decision type to pregnancy loss. The results show that, with the exception of shame, negative emotions were significantly less severe for women who had wanted abortions compared to women who had natural pregnancy losses with most differences being of moderate effect size (g > 0.3 and g < 0.5). For abortion decision types Inconsistent and Unwanted, the intensity of grief, depression, anxiety, emptiness, anger, weeping, thoughts of the child and difficulty completing the grief process were all similar (p > 0.5 and g < 0.1). But in the same group comparisons, feelings of guilt, regret, shame, and unforgiveness, all of which are related to self-judgment, were significantly more intense following an Inconsistent or Unwanted abortion with small to moderate effect sizes, Hedge’s g statistics ranging from 0.21 to 0.38. Similar findings were observed in the comparison of pregnancy loss to coerced abortions, but the effect sizes were stronger (g > 0.3) and the intensity of depression (g = 0.34), anxiety (g = 0.31), anger (g = 0.29), weeping (g = 0.18), and difficulty overcoming grief (g = 0.32) were also significantly and moderately greater for women who had coerced abortions. These findings support hypothesis H4 (decision types effect emotional reactions) and partially support hypothesis H3 which posited a similarity between natural pregnancy loss and abortion. H3 needs to be refined to reflect the effects of abortion decision types. Specifically, compared to natural pregnancy losses significantly fewer negative emotions are associated with wanted abortions and significantly more are associated with coerced abortions. The negative emotions associated with pregnancy loss are very similar to those following Inconsistent and Unwanted abortion decision types with the exception that additional negative emotions related to self-judgment appear with these abortions which are significantly less common among women with natural pregnancy losses.

Table 4 (Extended data) shows the emotion intensity scales ranked from highest to lowest median for each group with Wilcoxon signed rank statistics for each emotion compared to Relief within each group. The results show that Relief was the most strongly felt emotion only among women whose abortions were wanted and consistent with their values and preferences. The effect size was moderate (RBC > 0.3) to large (RBC > 0.5) for most comparisons. For all other abortion decision types, Relief was the least strongly felt emotion. All negative emotions were significantly greater than Relief for the Coerced and Pregnancy Loss groups. For the Unwanted group, only guilt, depression and grief were significantly greater than relief, though many of the other negative reactions approached significance and appear likely to be significant with a larger sample size. Effect sizes varied within the groups. For example, in the Inconsistent group, there was only a small difference in the intensity of anxiety (RBC = -0.29) compared to relief but a moderate difference in depression (RBC = -0.37) and large degrees of difference relative to shame (RBC = -0.52) and guilt (RBC = -0.63). The differences within the Coerced group were all very large, with RBC < -0.7). These results suggest rejecting the null hypothesis, H1, except for women whose abortions are freely chosen and are consistent with their values and preferences. The results also support hypotheses H2 and H4, positing that negative emotions are more prominent than relief, especially when the abortion decision is not aligned with women’s own values and preferences.

A linear regression analysis was performed using the scale grading the degree of stress experienced in completing the survey as the dependent variable with all thirteen emotion variables and abortion decision types as covariates. The model was statistically significant, F(16, 392) = 8.40, p < .001, and explained 22% of the variance in survey taking stress levels (Adjusted R² = 0.22). Unstandardized (B) and standardized (β) coefficients are shown in Table 5. Anxiety (β = 0.22, p = .006) and anger (β = 0.14, p = .04) significantly increased stress levels. Additionally, women in the Inconsistent (B = 8.43, p = .03) and Coerced (B = 10.82, p = .05) decision type groups reported significantly higher stress when completing the survey. These findings support hypothesis H5, which posited that more negative feelings would be associated with greater stress in completing surveys about the abortion experience.

Discussion

These findings challenge the assertion that relief is the most common emotional reaction to abortion, as previously suggested by studies with high attrition rates and potential selection biases.^11,13 Notably, our findings align with previous research indicating that women who experience pressure to abort or feel conflicted about their decision are more likely to report enduring negative emotions.^6,7 The presence of these negative feelings suggests that the psychological impact of abortion is complex and cannot be generalized as a uniformly positive or neutral experience.

One of the key findings of this study is the strong association between abortion decision type and emotional outcomes. Women who classified their abortions as coerced reported significantly more distressing emotions than those who described their abortions as fully wanted. The intensity of negative emotions among women in the coerced and unwanted abortion groups suggests that external pressures and a lack of personal autonomy in decision-making may contribute to psychological distress.

Conclusion

Overall, these findings strongly refute the claim that for 95% of abortion patients their most dominant feeling will be relief. These findings also highlight the importance of abortion decision type on post-abortion emotional outcomes. The presence of significant negative emotions among women whose abortions conflicted with their own values suggests the need for greater attention to pre-abortion screening, informed consent, and referrals for support services. Policies and counseling approaches should acknowledge the diversity of post-abortion emotions and provide appropriate psychological support, particularly for women who feel pressured into abortion or who experience significant emotional distress afterward. More research, resources and training should be directed toward improving the effectiveness and availability of post-abortion counseling for those who experience distress.