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Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol

  • Foluso Ishola   ORCID: orcid.org/0000-0002-8644-0570 1 ,
  • U. Vivian Ukah 1 &
  • Arijit Nandi 1  

Systematic Reviews volume  10 , Article number:  192 ( 2021 ) Cite this article

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A country’s abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women’s access to and use of health services, as well as their health outcomes, is uncertain. First, there are methodological challenges to the evaluation of abortion laws, since these changes are not exogenous. Second, extant evaluations may be limited in terms of their generalizability, given variation in reforms across the abortion legality spectrum and differences in levels of implementation and enforcement cross-nationally. This systematic review aims to address this gap. Our aim is to systematically collect, evaluate, and synthesize empirical research evidence concerning the impact of abortion law reforms on women’s health services and outcomes in LMICs.

We will conduct a systematic review of the peer-reviewed literature on changes in abortion laws and women’s health services and outcomes in LMICs. We will search Medline, Embase, CINAHL, and Web of Science databases, as well as grey literature and reference lists of included studies for further relevant literature. As our goal is to draw inference on the impact of abortion law reforms, we will include quasi-experimental studies examining the impact of change in abortion laws on at least one of our outcomes of interest. We will assess the methodological quality of studies using the quasi-experimental study designs series checklist. Due to anticipated heterogeneity in policy changes, outcomes, and study designs, we will synthesize results through a narrative description.

This review will systematically appraise and synthesize the research evidence on the impact of abortion law reforms on women’s health services and outcomes in LMICs. We will examine the effect of legislative reforms and investigate the conditions that might contribute to heterogeneous effects, including whether specific groups of women are differentially affected by abortion law reforms. We will discuss gaps and future directions for research. Findings from this review could provide evidence on emerging strategies to influence policy reforms, implement abortion services and scale up accessibility.

Systematic review registration

PROSPERO CRD42019126927

Peer Review reports

An estimated 25·1 million unsafe abortions occur each year, with 97% of these in developing countries [ 1 , 2 , 3 ]. Despite its frequency, unsafe abortion remains a major global public health challenge [ 4 , 5 ]. According to the World health Organization (WHO), nearly 8% of maternal deaths were attributed to unsafe abortion, with the majority of these occurring in developing countries [ 5 , 6 ]. Approximately 7 million women are admitted to hospitals every year due to complications from unsafe abortion such as hemorrhage, infections, septic shock, uterine and intestinal perforation, and peritonitis [ 7 , 8 , 9 ]. These often result in long-term effects such as infertility and chronic reproductive tract infections. The annual cost of treating major complications from unsafe abortion is estimated at US$ 232 million each year in developing countries [ 10 , 11 ]. The negative consequences on children’s health, well-being, and development have also been documented. Unsafe abortion increases risk of poor birth outcomes, neonatal and infant mortality [ 12 , 13 ]. Additionally, women who lack access to safe and legal abortion are often forced to continue with unwanted pregnancies, and may not seek prenatal care [ 14 ], which might increase risks of child morbidity and mortality.

Access to safe abortion services is often limited due to a wide range of barriers. Collectively, these barriers contribute to the staggering number of deaths and disabilities seen annually as a result of unsafe abortion, which are disproportionately felt in developing countries [ 15 , 16 , 17 ]. A recent systematic review on the barriers to abortion access in low- and middle-income countries (LMICs) implicated the following factors: restrictive abortion laws, lack of knowledge about abortion law or locations that provide abortion, high cost of services, judgmental provider attitudes, scarcity of facilities and medical equipment, poor training and shortage of staff, stigma on social and religious grounds, and lack of decision making power [ 17 ].

An important factor regulating access to abortion is abortion law [ 17 , 18 , 19 ]. Although abortion is a medical procedure, its legal status in many countries has been incorporated in penal codes which specify grounds in which abortion is permitted. These include prohibition in all circumstances, to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, and on request with no requirement for justification [ 18 , 19 , 20 ].

Although abortion laws in different countries are usually compared based on the grounds under which legal abortions are allowed, these comparisons rarely take into account components of the legal framework that may have strongly restrictive implications, such as regulation of facilities that are authorized to provide abortions, mandatory waiting periods, reporting requirements in cases of rape, limited choice in terms of the method of abortion, and requirements for third-party authorizations [ 19 , 21 , 22 ]. For example, the Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds. It is considered liberal, as it permits legal abortions for more indications than most countries in Sub-Saharan Africa; however, abortions must only be provided in registered hospitals, and three medical doctors—one of whom must be a specialist—must provide signatures to allow the procedure to take place [ 22 ]. Given the critical shortage of doctors in Zambia [ 23 ], this is in fact a major restriction that is only captured by a thorough analysis of the conditions under which abortion services are provided.

Additionally, abortion laws may exist outside the penal codes in some countries, where they are supplemented by health legislation and regulations such as public health statutes, reproductive health acts, court decisions, medical ethic codes, practice guidelines, and general health acts [ 18 , 19 , 24 ]. The diversity of regulatory documents may lead to conflicting directives about the grounds under which abortion is lawful [ 19 ]. For example, in Kenya and Uganda, standards and guidelines on the reduction of morbidity and mortality due to unsafe abortion supported by the constitution was contradictory to the penal code, leaving room for an ambiguous interpretation of the legal environment [ 25 ].

Regulations restricting the range of abortion methods from which women can choose, including medication abortion in particular, may also affect abortion access [ 26 , 27 ]. A literature review contextualizing medication abortion in seven African countries reported that incidence of medication abortion is low despite being a safe, effective, and low-cost abortion method, likely due to legal restrictions on access to the medications [ 27 ].

Over the past two decades, many LMICs have reformed their abortion laws [ 3 , 28 ]. Most have expanded the grounds on which abortion may be performed legally, while very few have restricted access. Countries like Uruguay, South Africa, and Portugal have amended their laws to allow abortion on request in the first trimester of pregnancy [ 29 , 30 ]. Conversely, in Nicaragua, a law to ban all abortion without any exception was introduced in 2006 [ 31 ].

Progressive reforms are expected to lead to improvements in women’s access to safe abortion and health outcomes, including reductions in the death and disabilities that accompany unsafe abortion, and reductions in stigma over the longer term [ 17 , 29 , 32 ]. However, abortion law reforms may yield different outcomes even in countries that experience similar reforms, as the legislative processes that are associated with changing abortion laws take place in highly distinct political, economic, religious, and social contexts [ 28 , 33 ]. This variation may contribute to abortion law reforms having different effects with respect to the health services and outcomes that they are hypothesized to influence [ 17 , 29 ].

Extant empirical literature has examined changes in abortion-related morbidity and mortality, contraceptive usage, fertility, and other health-related outcomes following reforms to abortion laws [ 34 , 35 , 36 , 37 ]. For example, a study in Mexico reported that a policy that decriminalized and subsidized early-term elective abortion led to substantial reductions in maternal morbidity and that this was particularly strong among vulnerable populations such as young and socioeconomically disadvantaged women [ 38 ].

To the best of our knowledge, however, the growing literature on the impact of abortion law reforms on women’s health services and outcomes has not been systematically reviewed. A study by Benson et al. evaluated evidence on the impact of abortion policy reforms on maternal death in three countries, Romania, South Africa, and Bangladesh, where reforms were immediately followed by strategies to implement abortion services, scale up accessibility, and establish complementary reproductive and maternal health services [ 39 ]. The three countries highlighted in this paper provided unique insights into implementation and practical application following law reforms, in spite of limited resources. However, the review focused only on a selection of countries that have enacted similar reforms and it is unclear if its conclusions are more widely generalizable.

Accordingly, the primary objective of this review is to summarize studies that have estimated the causal effect of a change in abortion law on women’s health services and outcomes. Additionally, we aim to examine heterogeneity in the impacts of abortion reforms, including variation across specific population sub-groups and contexts (e.g., due to variations in the intensity of enforcement and service delivery). Through this review, we aim to offer a higher-level view of the impact of abortion law reforms in LMICs, beyond what can be gained from any individual study, and to thereby highlight patterns in the evidence across studies, gaps in current research, and to identify promising programs and strategies that could be adapted and applied more broadly to increase access to safe abortion services.

The review protocol has been reported using Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 40 ] (Additional file 1 ). It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database CRD42019126927.

Eligibility criteria

Types of studies.

This review will consider quasi-experimental studies which aim to estimate the causal effect of a change in a specific law or reform and an outcome, but in which participants (in this case jurisdictions, whether countries, states/provinces, or smaller units) are not randomly assigned to treatment conditions [ 41 ]. Eligible designs include the following:

Pretest-posttest designs where the outcome is compared before and after the reform, as well as nonequivalent groups designs, such as pretest-posttest design that includes a comparison group, also known as a controlled before and after (CBA) designs.

Interrupted time series (ITS) designs where the trend of an outcome after an abortion law reform is compared to a counterfactual (i.e., trends in the outcome in the post-intervention period had the jurisdiction not enacted the reform) based on the pre-intervention trends and/or a control group [ 42 , 43 ].

Differences-in-differences (DD) designs, which compare the before vs. after change in an outcome in jurisdictions that experienced an abortion law reform to the corresponding change in the places that did not experience such a change, under the assumption of parallel trends [ 44 , 45 ].

Synthetic controls (SC) approaches, which use a weighted combination of control units that did not experience the intervention, selected to match the treated unit in its pre-intervention outcome trend, to proxy the counterfactual scenario [ 46 , 47 ].

Regression discontinuity (RD) designs, which in the case of eligibility for abortion services being determined by the value of a continuous random variable, such as age or income, would compare the distributions of post-intervention outcomes for those just above and below the threshold [ 48 ].

There is heterogeneity in the terminology and definitions used to describe quasi-experimental designs, but we will do our best to categorize studies into the above groups based on their designs, identification strategies, and assumptions.

Our focus is on quasi-experimental research because we are interested in studies evaluating the effect of population-level interventions (i.e., abortion law reform) with a design that permits inference regarding the causal effect of abortion legislation, which is not possible from other types of observational designs such as cross-sectional studies, cohort studies or case-control studies that lack an identification strategy for addressing sources of unmeasured confounding (e.g., secular trends in outcomes). We are not excluding randomized studies such as randomized controlled trials, cluster randomized trials, or stepped-wedge cluster-randomized trials; however, we do not expect to identify any relevant randomized studies given that abortion policy is unlikely to be randomly assigned. Since our objective is to provide a summary of empirical studies reporting primary research, reviews/meta-analyses, qualitative studies, editorials, letters, book reviews, correspondence, and case reports/studies will also be excluded.

Our population of interest includes women of reproductive age (15–49 years) residing in LMICs, as the policy exposure of interest applies primarily to women who have a demand for sexual and reproductive health services including abortion.

Intervention

The intervention in this study refers to a change in abortion law or policy, either from a restrictive policy to a non-restrictive or less restrictive one, or vice versa. This can, for example, include a change from abortion prohibition in all circumstances to abortion permissible in other circumstances, such as to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, or on request with no requirement for justification. It can also include the abolition of existing abortion policies or the introduction of new policies including those occurring outside the penal code, which also have legal standing, such as:

National constitutions;

Supreme court decisions, as well as higher court decisions;

Customary or religious law, such as interpretations of Muslim law;

Medical ethical codes; and

Regulatory standards and guidelines governing the provision of abortion.

We will also consider national and sub-national reforms, although we anticipate that most reforms will operate at the national level.

The comparison group represents the counterfactual scenario, specifically the level and/or trend of a particular post-intervention outcome in the treated jurisdiction that experienced an abortion law reform had it, counter to the fact, not experienced this specific intervention. Comparison groups will vary depending on the type of quasi-experimental design. These may include outcome trends after abortion reform in the same country, as in the case of an interrupted time series design without a control group, or corresponding trends in countries that did not experience a change in abortion law, as in the case of the difference-in-differences design.

Outcome measures

Primary outcomes.

Access to abortion services: There is no consensus on how to measure access but we will use the following indicators, based on the relevant literature [ 49 ]: [ 1 ] the availability of trained staff to provide care, [ 2 ] facilities are geographically accessible such as distance to providers, [ 3 ] essential equipment, supplies and medications, [ 4 ] services provided regardless of woman’s ability to pay, [ 5 ] all aspects of abortion care are explained to women, [ 6 ] whether staff offer respectful care, [ 7 ] if staff work to ensure privacy, [ 8 ] if high-quality, supportive counseling is provided, [ 9 ] if services are offered in a timely manner, and [ 10 ] if women have the opportunity to express concerns, ask questions, and receive answers.

Use of abortion services refers to induced pregnancy termination, including medication abortion and number of women treated for abortion-related complications.

Secondary outcomes

Current use of any method of contraception refers to women of reproductive age currently using any method contraceptive method.

Future use of contraception refers to women of reproductive age who are not currently using contraception but intend to do so in the future.

Demand for family planning refers to women of reproductive age who are currently using, or whose sexual partner is currently using, at least one contraceptive method.

Unmet need for family planning refers to women of reproductive age who want to stop or delay childbearing but are not using any method of contraception.

Fertility rate refers to the average number of children born to women of childbearing age.

Neonatal morbidity and mortality refer to disability or death of newborn babies within the first 28 days of life.

Maternal morbidity and mortality refer to disability or death due to complications from pregnancy or childbirth.

There will be no language, date, or year restrictions on studies included in this systematic review.

Studies have to be conducted in a low- and middle-income country. We will use the country classification specified in the World Bank Data Catalogue to identify LMICs (Additional file 2 ).

Search methods

We will perform searches for eligible peer-reviewed studies in the following electronic databases.

Ovid MEDLINE(R) (from 1946 to present)

Embase Classic+Embase on OvidSP (from 1947 to present)

CINAHL (1973 to present); and

Web of Science (1900 to present)

The reference list of included studies will be hand searched for additional potentially relevant citations. Additionally, a grey literature search for reports or working papers will be done with the help of Google and Social Science Research Network (SSRN).

Search strategy

A search strategy, based on the eligibility criteria and combining subject indexing terms (i.e., MeSH) and free-text search terms in the title and abstract fields, will be developed for each electronic database. The search strategy will combine terms related to the interventions of interest (i.e., abortion law/policy), etiology (i.e., impact/effect), and context (i.e., LMICs) and will be developed with the help of a subject matter librarian. We opted not to specify outcomes in the search strategy in order to maximize the sensitivity of our search. See Additional file 3 for a draft of our search strategy.

Data collection and analysis

Data management.

Search results from all databases will be imported into Endnote reference manager software (Version X9, Clarivate Analytics) where duplicate records will be identified and excluded using a systematic, rigorous, and reproducible method that utilizes a sequential combination of fields including author, year, title, journal, and pages. Rayyan systematic review software will be used to manage records throughout the review [ 50 ].

Selection process

Two review authors will screen titles and abstracts and apply the eligibility criteria to select studies for full-text review. Reference lists of any relevant articles identified will be screened to ensure no primary research studies are missed. Studies in a language different from English will be translated by collaborators who are fluent in the particular language. If no such expertise is identified, we will use Google Translate [ 51 ]. Full text versions of potentially relevant articles will be retrieved and assessed for inclusion based on study eligibility criteria. Discrepancies will be resolved by consensus or will involve a third reviewer as an arbitrator. The selection of studies, as well as reasons for exclusions of potentially eligible studies, will be described using a PRISMA flow chart.

Data extraction

Data extraction will be independently undertaken by two authors. At the conclusion of data extraction, these two authors will meet with the third author to resolve any discrepancies. A piloted standardized extraction form will be used to extract the following information: authors, date of publication, country of study, aim of study, policy reform year, type of policy reform, data source (surveys, medical records), years compared (before and after the reform), comparators (over time or between groups), participant characteristics (age, socioeconomic status), primary and secondary outcomes, evaluation design, methods used for statistical analysis (regression), estimates reported (means, rates, proportion), information to assess risk of bias (sensitivity analyses), sources of funding, and any potential conflicts of interest.

Risk of bias and quality assessment

Two independent reviewers with content and methodological expertise in methods for policy evaluation will assess the methodological quality of included studies using the quasi-experimental study designs series risk of bias checklist [ 52 ]. This checklist provides a list of criteria for grading the quality of quasi-experimental studies that relate directly to the intrinsic strength of the studies in inferring causality. These include [ 1 ] relevant comparison, [ 2 ] number of times outcome assessments were available, [ 3 ] intervention effect estimated by changes over time for the same or different groups, [ 4 ] control of confounding, [ 5 ] how groups of individuals or clusters were formed (time or location differences), and [ 6 ] assessment of outcome variables. Each of the following domains will be assigned a “yes,” “no,” or “possibly” bias classification. Any discrepancies will be resolved by consensus or a third reviewer with expertise in review methodology if required.

Confidence in cumulative evidence

The strength of the body of evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system [ 53 ].

Data synthesis

We anticipate that risk of bias and heterogeneity in the studies included may preclude the use of meta-analyses to describe pooled effects. This may necessitate the presentation of our main findings through a narrative description. We will synthesize the findings from the included articles according to the following key headings:

Information on the differential aspects of the abortion policy reforms.

Information on the types of study design used to assess the impact of policy reforms.

Information on main effects of abortion law reforms on primary and secondary outcomes of interest.

Information on heterogeneity in the results that might be due to differences in study designs, individual-level characteristics, and contextual factors.

Potential meta-analysis

If outcomes are reported consistently across studies, we will construct forest plots and synthesize effect estimates using meta-analysis. Statistical heterogeneity will be assessed using the I 2 test where I 2 values over 50% indicate moderate to high heterogeneity [ 54 ]. If studies are sufficiently homogenous, we will use fixed effects. However, if there is evidence of heterogeneity, a random effects model will be adopted. Summary measures, including risk ratios or differences or prevalence ratios or differences will be calculated, along with 95% confidence intervals (CI).

Analysis of subgroups

If there are sufficient numbers of included studies, we will perform sub-group analyses according to type of policy reform, geographical location and type of participant characteristics such as age groups, socioeconomic status, urban/rural status, education, or marital status to examine the evidence for heterogeneous effects of abortion laws.

Sensitivity analysis

Sensitivity analyses will be conducted if there are major differences in quality of the included articles to explore the influence of risk of bias on effect estimates.

Meta-biases

If available, studies will be compared to protocols and registers to identify potential reporting bias within studies. If appropriate and there are a sufficient number of studies included, funnel plots will be generated to determine potential publication bias.

This systematic review will synthesize current evidence on the impact of abortion law reforms on women’s health. It aims to identify which legislative reforms are effective, for which population sub-groups, and under which conditions.

Potential limitations may include the low quality of included studies as a result of suboptimal study design, invalid assumptions, lack of sensitivity analysis, imprecision of estimates, variability in results, missing data, and poor outcome measurements. Our review may also include a limited number of articles because we opted to focus on evidence from quasi-experimental study design due to the causal nature of the research question under review. Nonetheless, we will synthesize the literature, provide a critical evaluation of the quality of the evidence and discuss the potential effects of any limitations to our overall conclusions. Protocol amendments will be recorded and dated using the registration for this review on PROSPERO. We will also describe any amendments in our final manuscript.

Synthesizing available evidence on the impact of abortion law reforms represents an important step towards building our knowledge base regarding how abortion law reforms affect women’s health services and health outcomes; we will provide evidence on emerging strategies to influence policy reforms, implement abortion services, and scale up accessibility. This review will be of interest to service providers, policy makers and researchers seeking to improve women’s access to safe abortion around the world.

Abbreviations

Cumulative index to nursing and allied health literature

Excerpta medica database

Low- and middle-income countries

Preferred reporting items for systematic review and meta-analysis protocols

International prospective register of systematic reviews

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We thank Genevieve Gore, Liaison Librarian at McGill University, for her assistance with refining the research question, keywords, and Mesh terms for the preliminary search strategy.

The authors acknowledge funding from the Fonds de recherche du Quebec – Santé (FRQS) PhD doctoral awards and Canadian Institutes of Health Research (CIHR) Operating Grant, “Examining the impact of social policies on health equity” (ROH-115209).

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Public Health in the Field: The Public Health Case for Abortion Rights

Annalies Winny

Lindsay Smith Rogers

This article is adapted from a special episode of the Public Health On Call Podcast called Public Health in the Field. You can hear the full episode here .

Please note: Throughout this article, the gendered terms “woman” and “women” are used as that’s how the CDC and other sources record related data. 

More coverage:

  • Overturning Roe v. Wade and Public Health
  • What We Know—and Don't Yet Know—About The Leaked Supreme Court Draft Opinion That Could Overturn Roe v. Wade

A single case before the Supreme Court will likely decide the future of Roe v. Wade.

In 2018, the Mississippi legislature passed and the governor signed House Bill 1510, known as the  Gestational Age Act , which bans abortions after 15 weeks. There are exceptions if the life of the fetus or parent is at risk—but not in cases of rape or incest. The law violated Roe v. Wade, a Supreme Court decision that protects the right to abortion prior to “viability” of the fetus, which is at around 24 weeks. The bill was quickly blocked by lower federal courts but now the law’s fate is up to the Supreme Court.

The outcome of this case— Dobbs v. Jackson Women’s Health Organization —has implications for abortion rights far beyond Mississippi: A decision that previability bans are not unconstitutional could upend longstanding protections established by Roe v. Wade, the 1973 landmark case that legalized abortion nationwide. 

The conversation about abortion rights in the U.S. is a noisy one involving politics, precedents, and personal beliefs. What often gets short shrift, however, is the public health reality that restricting access to abortion results in erosion of the health of women, especially low-income and women of color. This is why abortion is so much more than a legal battle. 

The Public Health Case for Abortion Rights

Many women who were denied wanted abortions had higher levels of household poverty, debt, evictions, and other economic hardships and instabilities, according to Joanne Rosen , JD , associate director of the  Johns Hopkins Center for Law and the Public’s Health .

The findings come from a 10-year study,  The Turnaway Study , which followed nearly 1,000 women who either had or were denied abortions and tracked their mental and physical health and financial impacts. 

“The study also found that women who were seeking but unable to obtain abortions endured higher levels of physical violence from the men who had fathered these children,” Rosen says. “And people who were turned away when seeking abortions endured more health problems than women who were able to obtain [them], as well as more serious health problems.

“That gives you a sense of the ways in which being unable to obtain abortions had really long lasting impacts on these peoples’ lives.”

A 2020 study in the  American Journal of Preventive Medicine found that women living in states with less restrictive reproductive health policies were less likely to give birth to low-weight babies. Other research  published in The Lancet found that restrictive abortion laws actually mean a higher rate of abortion-related maternal deaths.

Restrictive abortion laws affect more than just the health of individuals and families—they affect the economy, too. Research from The Lancet found that “ensuring women’s access to safe abortion services does lower medical costs for health systems.”  

The  Institute for Women’s Policy Research has a host of data around how reproductive health restrictions impact women’s earning potential, including an interactive map tool, Total Economic Losses Due to State-level Abortion Restrictions. In Mississippi , for example, the data indicate that an absence of abortion restrictions would translate to a 1.8% increase of Black women in the labor force, over 2% for Hispanic women, and a leap of more than 2.6% for women who identify as Asian-Pacific Islander. This same tool calculates that removing abortion restrictions would translate to an estimated $13.4 million in increased earnings at the state level for Black women alone. 

Abortion restrictions disproportionately affect people of color and those with low-incomes. According to  data from the CDC , Black women are five times more likely to have an abortion than white women, and Latinx women are two times as likely as whites. Seventy-five percent of people who have abortions are low-income or poor. 

Mississippi, Texas, and The Supreme Court   

On December 1, the Supreme Court will hear Dobbs v. Jackson Women’s Health Organization and Joanne Rosen thinks it’s unlikely the Court would agree to hear the case if they were just going to affirm the status quo. 

The case isn’t the only one on the docket, however. Texas’ Senate Bill 8, which bans abortion after six weeks of pregnancy, made headlines earlier this month and may impact SCOTUS’ ultimate decision on the Mississippi case. The high-profile law came before the Supreme Court in November 2021 and Rosen said the important thing to note is that the Court didn’t actually address whether the six-week ban is constitutional. Rather, they examined the unusual enforcement scheme of the law—where, when, and by whom the Texas law could be challenged.

Rosen says that the justices may compare the Texas law with the Mississippi law and, when considering a six-week abortion ban, a 15-week ban may seem less extreme. In this way, the Texas case could give the Court some cover to uphold Mississippi’s 15-week ban.

It’s likely to be months before an opinion is released; Rosen says the Court typically releases its decisions on high-stakes or controversial cases in June. And high stakes this is: for the future of abortion, for reproductive health rights, and for public health. 

Annalies Winny is an associate editor for  Global Health NOW . 

Alissa Zhu is a journalist and current  MSPH student at the Bloomberg School.

Lindsay Smith Rogers, MA, is the producer of the  Public Health On Call podcast and the associate director of content strategy for the Johns Hopkins Bloomberg School of Public Health.

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People hold up signs in Union Square during a demonstration against the Supreme Court on July 4, 2022 in New York City. The Supreme Court's June 24th decision in the Dobbs v Jackson Women's Health case overturned the landmark 50-year-old Roe v Wade case, removing a federal right to an abortion.

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  • Published: 15 February 2024

Effectiveness and safety of telehealth medication abortion in the USA

  • Ushma D. Upadhyay   ORCID: orcid.org/0000-0002-2731-2157 1 ,
  • Leah R. Koenig 1 , 2 ,
  • Karen Meckstroth 1 ,
  • Jennifer Ko 1 ,
  • Ena Suseth Valladares 3 &
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Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 μg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2–98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6–99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.

In 2021, the US Food and Drug Administration (FDA) removed the in-person dispensing requirement on mifepristone, the first drug used in a medication abortion. This ruling allowed clinicians to begin offering a ‘no-test’ telehealth model of medication abortion care. Clinicians could now offer entirely remote consultations, using the patient’s self-reported medical history instead of ultrasonography or other tests to screen for medical eligibility.

Moving abortion out of the clinic reduced travel, cost and stigma-related barriers and increased convenience for patients 1 , 2 . While telehealth abortion is usually conducted through synchronous communication, with a real-time scheduled videoconference appointment with the patient, some virtual clinics rely on entirely asynchronous communication, using secure text messaging without a scheduled interaction. Follow-up for both models is usually asynchronous, through secure text messaging.

This expansion of services became critical after the June 2022 Supreme Court Dobbs v. Jackson Women’s Health Organization decision allowed states to ban abortion. In states such as Illinois, Kansas and Colorado, where abortion remained legal but neighboring states banned abortion, clinics experienced large increases in patient volume 3 . Telehealth became vital to meeting increased demand by reducing appointment waiting times and serving patients from states with abortion bans 4 . Some individuals from US states with an abortion ban use methods such as mail forwarding and mailing medications to a friend or Post Office box close to the border in states where abortion is permitted, minimizing the travel required 5 . Additionally, some clinicians have begun to use the legal protections of their state’s “shield laws” to provide medication abortion via telehealth to patients in banned states 6 .

However, access to mifepristone for medication abortion has been under threat, with a federal court ruling to reverse FDA regulatory approvals of mifepristone, including the 2021 decision that allowed telehealth for abortion to continue even after the pandemic. This ruling was issued despite multiple FDA reviews and abundant evidence demonstrating the effectiveness and safety of mifepristone 7 . According to the mifepristone label, 97.4% of 16,794 patients in US clinical trials of in-person medication abortion had a complete abortion and less than 0.5% had a serious adverse event 8 .

While decades of evidence support the effectiveness and safety of mifepristone provided in person, the evidence supporting no-test direct-to-patient telehealth abortion is more limited. Before 2021, US research on the effectiveness and safety of telehealth abortion was limited to clinic-to-clinic 9 , 10 , 11 or direct-to-patient models that required pre-abortion ultrasonography or other tests 12 . To date, only five US studies have examined the outcomes of no-test direct-to-patient telehealth abortion models; four of these had small (fewer than 350) samples of patients receiving such care; thus, they were underpowered to examine outcomes as rare as serious adverse events 13 , 14 , 15 , 16 . The fifth study was a retrospective examination of no-test medication abortion provided either in-person or by telehealth and mail. Among 3,779 medication abortions, 95% were complete without procedural intervention and 0.5% experienced a serious adverse event. Effectiveness and safety were similar whether medications were dispensed in-person or by mail 17 , 18 . However, this study did not report the effectiveness and safety outcomes of asynchronous telehealth abortion.

In this study, we used data from the California Home Abortion by Telehealth (CHAT) study to follow a large sample of patients across the US from three virtual clinics to estimate the effectiveness and safety of medication abortion care provided via telehealth. Clinicians provided telehealth abortion care via either synchronous (video) or asynchronous (secure text messaging) methods. They screened patients using a published, standardized no-test protocol, primarily relying on patient medical history to assess medical eligibility 19 . Patients who had any risk factors for or symptoms of ectopic pregnancy or were potentially beyond the gestational limit of the virtual clinic were referred for pre-abortion ultrasonography. Eligible patients received 200 mg mifepristone and 800 or 1,600 μg buccal or vaginal misoprostol via mail order pharmacy. Outcome data were collected by scheduled follow-up interactions conducted remotely 3–7 days after intake and again 2–4 weeks after medication administration (Fig. 1 ). Our primary aim was to assess the effectiveness and safety of telehealth medication abortion care. Our secondary aim was to compare effectiveness and safety outcomes between synchronous and asynchronous models of telehealth.

figure 1

Timing and content of the electronic medical records and survey data analyzed in the CHAT study.

We received electronic medical records for 6,974 encounters. Among those, 6,154 patients met the eligibility criteria and had abortion medications dispensed to them in 20 states and Washington, DC. We excluded cases where the patient took neither mifepristone nor misoprostol ( n  = 120) leaving 6,034 patients in the analytical sample (Fig. 2 ). Among these, 1,600 patients provided supplementary self-reported data on their outcomes via surveys (Extended Data Table 1 ).

figure 2

Patient flow chart depicting the exclusion criteria.

All patients were pregnant and seeking abortion. Half (50.3%) were 30 years or older and 4.6% were aged under 20 years (Table 1 ). Race, ethnicity or ethnic grouping was unknown for one-third (34.3%) of patients because one of the clinics did not record these data in their medical records for the first half of the study period. Among the subsample with known race, ethnicity or ethnic grouping, nearly two-thirds (62.7%) were white. Most (84.3%) patients had pregnancy durations under 7 weeks (≤49 days). Medical records did not document patient sex or gender.

Overall, 72.3% of patients received asynchronous care. Among patients of the clinic that offered asynchronous care but allowed patients to request a phone or video call, 0.3% requested a call with the provider. Patients who were younger (100.0% for 16–18 years, 79.3% for 18–19 years), Asian, Native Hawaiian or Pacific Islander (82.3%), Middle Eastern or North African (80.0%), living in an urban area (72.7%) and who had pregnancy durations over 56 days (74.8% for 50–56 days, 99.6% for 57–63 days and 100.0% for 64–70 days) were more likely to have received asynchronous care.

Of the sample, 76% (4,613 of 6,034) of cases had any follow-up contact with the virtual clinic or by surveys (Fig. 2 ). Abortion outcomes were known (ascertained using a test or the patient’s history) for 74% (4,454 of 6,034) of the analytical sample. There were few sociodemographic characteristics associated with unknown outcomes. Outcomes were less likely to be known for American Indian or Alaska Native patients (57.1%), Middle Eastern or North African patients (64.0%), patients with a previous birth (70.4%), patients with a pregnancy duration of 57–63 days (66.7%) and 64–70 days (68.4%), and patients receiving asynchronous care (69.6%) (Extended Data Table 2 ). Among patients with unknown outcomes, two requested abortion pill reversal after they took mifepristone but before misoprostol. Both were advised that evidence-based reversal treatment does not exist and referred to urgent in-person care. No further information on their outcomes was available.

Effectiveness

Overall, results from both the complete case analysis and the imputed models found that 97.7% (95% confidence interval (CI) = 97.2–98.1%) of abortions were complete without a subsequent known intervention or ongoing pregnancy after initial treatment (Table 2 and Extended Data Table 3 ). The effectiveness of synchronous and asynchronous telehealth was similar; in the complete case analysis effectiveness was 98.3% (95% CI = 97.5–99.0%) in the synchronous group and 97.4% (95% CI = 96.9–98.0%) in the asynchronous group. In the final imputed analysis, effectiveness was 98.3% (95% CI = 97.7–99.0%) in the synchronous group and 97.4% (95% CI = 96.9–98.0%) in the asynchronous group. Effectiveness also did not differ according to patient age, pregnancy duration, race, ethnicity or ethnic grouping, urbanicity, previous birth, previous abortion or whether the patient had screening ultrasonography.

Among the 2.3% (95% CI = 1.9–2.8%) of patients whose abortion was not initially complete, 0.56% were treated with more than 200 mg mifepristone, more than 1,600 μg misoprostol or other uterotonic medication to complete the abortion, 1.4% were treated with an aspiration or other abortion procedure, 0.16% were treated for an ectopic pregnancy and 0.94% had a confirmed or suspected continuing pregnancy (Table 3 ).

Overall, six (0.16%) patients had ectopic pregnancies; three (0.12%) were suspected ectopic pregnancies treated with methotrexate; one (0.07%) was an ectopic pregnancy treated with an unknown treatment; one (0.12%) was a cesarean scar ectopic pregnancy treated with an unknown treatment; and one (0.09%) was a ruptured ectopic pregnancy treated with a salpingectomy.

Overall, the rate of abortions that were not followed by a serious adverse event was 99.7% (95% CI = 99.5–99.8%) in the complete case analysis and 99.8% (95% CI = 99.6–99.9%) in the final imputed model (Table 2 and Extended Data Table 3 ). Safety was similar between patients who received synchronous and asynchronous care; in the complete case analysis, the safety rate was 99.7% (95% CI = 99.4–100.0%) in the synchronous group and 99.6% (95% CI = 99.4–99.9%) in the asynchronous group. In the final imputed model, safety was 99.8% (95% CI = 99.5–100.0%) among synchronous patients and 99.7% (95% CI = 99.6–99.9%) among asynchronous patients. In the final imputed models, safety was lower among Black or African American patients (99.3%, 95% CI = 98.7–100.0%) than among white patients (99.8%, 95% CI = 97.0–100.0%). No other factors were significantly associated with reduced safety.

Among the 0.25% of patients who experienced a serious adverse event, 0.10% received blood transfusions and 0.02% had abdominal surgery to treat a ruptured ectopic pregnancy; 0.17% of patients had hospital admissions requiring overnight stays. Among the ten (0.17%) hospital admissions, four (0.12%) received inpatient aspiration procedures, two (0.10%) were treated for infection and received an aspiration, one (0.09%) involved a blood transfusion and aspiration, one (0.09%) underwent surgery to treat a ruptured ectopic pregnancy, one (0.08%) was treated with intravenous antibiotics and one (0.09%) had a uterine infection treated with unknown treatment.

Other outcomes

Overall, 1.3% (95% CI = 1.1–1.6%) of abortions were followed by a known emergency department visit, 38.3% of which resulted in no treatment. Emergency department visits were similar between synchronous patients (1.2%, 95% CI = 0.7–1.7%) and asynchronous patients (1.4%, 95% CI = 1.0–1.7%). We identified no cases where, at the subsequent follow-up, it was determined that the abortion occurred beyond 70 days’ gestation.

Sensitivity analyses

The first sensitivity analysis, where we conservatively categorized the 25 patients who were referred to in-person care and were subsequently lost to follow-up as requiring additional intervention to complete the abortion, resulted in effectiveness rates that were not significantly different from the primary analysis; overall 97.1% (95% CI = 96.5–97.6%), with 98.1% (95% CI = 97.3–98.8%) among synchronous patients and 96.7% (95% CI = 96.0–97.3%) among asynchronous patients.

In the second sensitivity analysis modeling effectiveness, we considered patients as having complete abortions regardless of the amount of misoprostol they received, which is consistent with the Medical Abortion Reporting of Efficacy (MARE) guidelines 20 . (Total misoprostol dosages according to pregnancy duration are reported in Extended Data Table 4 .) This also resulted in effectiveness rates that were not significantly different from the primary analysis: 97.9% (95% CI = 97.4–98.3%) overall, 98.4% (95% CI = 97.8–99.0%) among patients who received synchronous care and 97.7% (95% CI = 97.1–98.2%) among patients who received asynchronous care.

The third sensitivity analysis, where we examined effectiveness and safety only among the subsample of patients with supplementary self-reported data on their outcomes via surveys in addition to standard clinical follow-up ( n  = 1,600), resulted in effectiveness rates that were not significantly different from the primary analysis: 96.7% (95% CI = 95.7–97.6%), with 97.1% (95% CI = 95.6–98.6%) among those who received synchronous care and 96.4% (95% CI = 95.2–97.6%) among those who received asynchronous care. This sensitivity analysis resulted in a similar safety rate of 99.3% (95% CI = 98.9–99.7%), and rates of 99.4% (95% CI = 98.7–100.0%) among those who received synchronous care versus 99.3% (95% CI = 98.8–99.8%) of those who received asynchronous care.

In the fourth sensitivity analysis, we conducted delta-adjusted pattern-mixture modeling to examine the potential impact of loss to follow-up on the observed results (Extended Data Table 5 ). Across a range of delta values, we found that the results were largely consistent with the main analysis. Under an extreme scenario in which those with unknown outcomes had ten times the odds of an incomplete abortion or serious adverse event, effectiveness for the entire sample would be 93.3% (95% CI = 92.1–94.5%) and safety would be 98.9% (95% CI = 98.3–99.4%). Under this scenario, effectiveness would be higher in the synchronous group than the asynchronous group, but there would be no differences in safety. Under the opposite and also extreme scenario in which those with unknown outcomes had ten times lower odds of an incomplete abortion, effectiveness would be 98.2% (95% CI = 97.9–98.6%) and safety would be 99.7% (95% CI = 99.6–99.9%), with no significant differences in effectiveness and safety between synchronous and asynchronous groups.

In this large prospective cohort study, telehealth medication abortion provided primarily without tests was effective and safe. The overall 98% effectiveness rate of our primary analysis, and the effectiveness rates from the sensitivity analyses, were similar to previous large US studies of in-person medication abortion care, which found rates of 95–98% 21 , 22 , 23 , 24 . The serious adverse event rate of 0.25% and ectopic pregnancy rate of 0.14% were also similar to previous studies of in-person medication abortion care, which found adverse event rates of 0.2–0.5%, and ectopic pregnancy rates of 0.2% 8 , 23 , 24 , 25 . Both effectiveness and safety rates were similar to the rates for medication abortions with in-person screening tests as published on the FDA label (Fig. 3 ) 8 .

figure 3

The gray bars represent published estimates from the FDA label for in-person dispensing of mifepristone; the blue bars represent the rates found in the CHAT study. Estimates for the CHAT study were calculated using marginal estimates from logistic regression analyses conducted on n  = 6,034 patients. The published estimates of in-person dispensing represent the published rates drawn from the FDA label for mifepristone in 2016. The 95% CIs are represented by the black error bars.

The effectiveness and safety rates found in this study are consistent with, although slightly lower than, those found in studies of no-test telehealth abortion in other countries. A national study in the UK, which included 18,435 telehealth medication abortions, found that 99% were complete without intervention and serious adverse events occurred in 0.02% (refs. 26 , 27 , 28 ). This higher documented effectiveness rate may be explained by the lack of routine follow-up after medication abortion care in the UK; additional interventions that patients may receive may not be systematically reported to the original abortion provider.

The rates in our study are also similar to the effectiveness and safety rates documented from self-managed medication abortion models (defined as using abortion pills to end a pregnancy outside of the formal healthcare system), in the USA 29 and internationally, including in contexts where abortion is legally restricted 30 , 31 .

The effectiveness rates for both synchronous and asynchronous services were very high and similar to in-person care. These findings have important implications for service delivery and health equity. Synchronous models with videoconferencing require strong Internet connectivity. Asynchronous models can be accessed using more types of devices; they may be more private, require shorter waiting times and can be more easily integrated into work or home schedules because no appointment is needed 32 , 33 , 34 . Offering patients a choice between synchronous and asynchronous care is consistent with patient-centered care and may increase access for people historically excluded from healthcare, particularly those living in rural areas or those who live far from an abortion-providing facility 1 , 35 , 36 .

We used a more conservative definition of effectiveness than recommended by the MARE guidelines 20 but used in previous studies 17 , 37 . Our definition included an additional 22 patients who received a second medication abortion (mifepristone plus misoprostol) or more than one additional dose of misoprostol. In the context of telehealth and in the wake of the Dobbs decision, patients living in states that have banned abortions may experience more barriers to procedural treatment for incomplete abortion and thus be more likely to obtain additional medications to complete the abortion. Therefore, our definition of effectiveness may better account for patient experience.

While safety was over 99% among all ethnic groups, Black patients had significantly higher rates of serious adverse events than white patients. This finding is consistent with research showing higher rates of adverse obstetric outcomes among Black patients. Growing consensus finds that these disparities in obstetric health are rooted in implicit biases and structural racism 38 , 39 .

This analysis provides an initial picture of the real-world effectiveness and safety of a rapidly expanding model of abortion care among a large US cohort. However, this analysis has several limitations. One is the lack of clinic-level variation in synchronous and asynchronous models, which may limit generalizability. However, each virtual clinic had multiple providers offering care, thereby increasing variation within each clinic and thus the generalizability of our findings. For example, different providers may use different thresholds or criteria for when to refer patients to in-person care for an ultrasound or exam, which may impact effectiveness rates. This natural variation strengthens the premise that these results could be applied to other providers offering synchronous or asynchronous care. While there was no direct comparison group, we were able to compare our results to widely accepted rates in the published literature using standardized guidelines for measuring medication abortion outcomes.

Additionally, we identified no cases of unexpected pregnancy durations beyond 70 days. This is surprising given that a previous study of no-test medication abortion found a rate of 0.38% 17 . This lack of evidence may be due to underreporting. Although most patients can accurately assess their pregnancy duration 40 , 41 , patients who later learned that they provided a date of last menstrual period that underestimated their pregnancies may have felt that they could be held responsible and thus not reported it to the virtual clinic, particularly if it resulted in an abortion beyond 70 days.

Finally, another limitation is the follow-up rate; at 74% it was similar or higher than other studies on abortion 17 , 31 , 42 , 43 ; attrition may have introduced selection bias given that some groups had lower follow-ups than others. In particular, we observed lower follow-up rates in the asynchronous group than the synchronous group. Telehealth is a less medicalized healthcare model, and asynchronous care even less so; those who opt for it may prefer a more autonomous experience. This differential follow-up may overestimate effectiveness and safety rates for asynchronous patients if those with concerning symptoms seek additional care without informing the virtual clinic. On the other hand, it might underestimate effectiveness rates if patients who have a negative pregnancy test or clear signs of complete abortion do not feel that they must report their outcome back to the virtual clinic. We attempted to limit this potential bias with multiple imputation. We also explored this limitation through a sensitivity analysis simulating higher and lower odds of incomplete abortions and serious adverse events among those lost to follow-up relative to those with known outcomes. This analysis demonstrated that differences in effectiveness between synchronous and asynchronous groups could reach significance under extreme scenarios, but differences in safety remained nonsignificant in all scenarios tested.

These findings provide evidence that telehealth for abortion is effective and safe, with rates similar to in-person care. Additionally, synchronous and asynchronous care are comparably effective and safe. Although telehealth models cannot serve the needs and preferences of everyone, such as those who do not have electronic devices or those who are beyond the first trimester of pregnancy, offering people telehealth options has the potential to expand access to abortion care. These results are reassuring as more clinicians begin to provide telehealth abortion care to patients in US states with a ban, under the legal protections of their state’s shield laws. At the same time, 11 states continue to permit abortion but have prohibitions on no-test telehealth abortion ( https://www.rhites.org/state-based-resources ). This study demonstrates that policies that restrict telehealth abortion owing to concerns or claims about effectiveness or safety need to be revisited and revised to ensure equitable access to this essential healthcare service.

The CHAT study was approved by the University of California, San Francisco institutional review board (no. 20-32951) and registered with ClinicalTrials.gov (registration: NCT04432792 ). We used Strengthening the Reporting of Observational studies in Epidemiology guidelines to design and report the results of this study. All survey respondents provided consent to participate in the research.

Data source and study cohort

The CHAT study followed the patients of three US virtual abortion clinics: Choix (which opened in October 2020); Hey Jane (which opened in January 2021); and Abortion on Demand (which opened in April 2021). These virtual clinics were selected because they were among the first to open in the USA after the FDA temporarily suspended the in-person dispensing requirement during the COVID-19 emergency, and because they operated in states with large populations.

Medication protocols included 200 mg mifepristone orally and 800 µg misoprostol buccally or vaginally for pregnancy durations less than 63 days or 1,600 µg for pregnancy durations of 63 or more days. Care was provided based on a published protocol 19 by nurse practitioners, nurse midwives, physician assistants and physicians who specialize in abortion care. Clinics offered synchronous (video) or asynchronous (secure text messaging) telehealth abortion with mail order pharmacy delivery. One clinic offered only synchronous medication abortion care, one offered only asynchronous care and one offered asynchronous care with an option to have a phone or video call with the provider if preferred. Patients learned about the services through Web searches, social media or referrals.

During the study period, one clinic offered abortion care up to 56 days (8 weeks) of pregnancy, whereas the two other clinics offered it up to 70 days (10 weeks). As per the published protocol, patients were evaluated for medical eligibility based on the reported medical history. Pregnancy duration at intake was primarily based on self-reported date of last menstrual period or by ultrasonography, if available. Some patients had already had ultrasonography before contacting the virtual clinic. Additionally, patients were referred for pre-abortion ultrasonography if they had any risk factors for, or symptoms of, ectopic pregnancy 19 or were potentially beyond the gestational limit of the virtual clinic. Some of these patients returned to the virtual clinic after their eligibility was confirmed by ultrasonography and obtained a telehealth abortion; thus, they were included in the study. Others opted for in-person care and thus were excluded.

Each clinic had two scheduled follow-up interactions. The first confirmed medication administration and assessed symptoms of complete abortion 3–7 days after intake. The second was a low-sensitivity pregnancy test at 2 weeks or a high-sensitivity test at 4 weeks after medication administration. Follow-up interactions were conducted by text messaging, secure messaging or telephone. At each scheduled follow-up, clinicians made up to four attempts to contact patients. Clinicians referred patients to in-person care if any adverse event or incomplete abortion was suspected and outcomes of care were documented whenever possible.

For this analysis, we evaluated data collected from two sources, both imported into REDCap 44 . We obtained anonymized medical record data of consecutive patients receiving care from the participating virtual clinics between April 2021 and January 2022.

Additionally, each virtual clinic invited all patients seen between June 2021 and January 2022 to enroll in three surveys about their abortion experience, including any additional treatments received. After providing electronic informed consent, participants completed a baseline survey on the date of the intake, which included sociodemographic characteristics and medical history. Participants completed a second survey 3–7 days after the intake, to assess medication administration, additional medical care and any adverse events, and a final survey 4 weeks after the intake to assess additional medical care and adverse events (Fig. 1 ). The survey sample was powered to assess the acceptability of telehealth (published separately 2 ); thus, we aimed to collect complete sets of surveys from 1,600 participants. Survey participants received a US$50 electronic debit card on completion of all three surveys.

The primary outcomes were effectiveness and safety based on standard definitions in previous studies 17 , 24 , 37 , 45 . We generally followed the MARE guidelines for reporting outcomes 20 . We defined effectiveness as the proportion of medication abortions that were complete after initial treatment with 200 mg mifepristone and 1,600 µg or less of misoprostol without known subsequent intervention. Abortions were not considered complete if (1) the patient had an aspiration, dilation and evacuation, other procedure or surgical intervention to complete the abortion; (2) the patient received more than 200 mg mifepristone, more than 1,600 µg misoprostol, or a uterotonic medication to complete the abortion; (3) the patient received treatment for suspected or confirmed ectopic pregnancy; or (4) the patient had a continuing pregnancy confirmed by ultrasonography or suspected at last contact. While MARE guidelines define effectiveness as successful expulsion of pregnancy without the need for procedural intervention, we chose a more conservative definition, recognizing that patients may view the need to have what constitutes a second medication abortion treatment as a failure of the medication abortion protocol.

We defined safety using standardized definitions from the Procedural Abortion Incident Reporting and Surveillance Framework 45 and Standardizing Abortion Research Outcomes protocol 46 as the proportion of abortions that were not followed by a known abortion-related serious adverse event. Serious adverse events included: blood transfusion; abdominal surgery (including salpingectomy, laparotomy and laparoscopy to treat an ectopic pregnancy); hospital admission requiring overnight stay; or death.

Effectiveness and safety outcomes were determined from all information collected in the medical records and surveys. Abortion completion was determined based on the virtual clinic’s designation, either using a test (urine pregnancy test, ultrasonography or serum human chorionic gonadotrophin) or using the patient’s medical history (using a checklist reflecting symptoms of complete abortion) without further contact related to the abortion for at least 6 weeks after the intake visit. Patients without outcomes noted in the medical records were determined to have complete abortions if they completed a survey at least 28 days after screening and did not report an intervention or ongoing pregnancy.

Secondary outcomes included the number of cases where, at the subsequent follow-up, it was determined that at intake the patient had been beyond 70 days’ gestation. We also evaluated rates of suspected or confirmed ectopic pregnancy and emergency department visits.

We examined the categorical covariates reflecting participant age at abortion intake in years (16–17 years, 18–19 years, 20–24 years, 25–29 years, 30–34 years and 35 years or older), and pregnancy duration in days at abortion intake (less than 35 days, 35–49 days, 50–56 days, 57–63 days, 64–70 days or unknown). We also included a measure of race, ethnicity or ethnic grouping indicated by participants on an intake form or in the surveys (American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, Black or African American, Middle Eastern or North African, White, Multiracial or Unknown). We included binary covariates for urbanicity (suburban or rural versus urban), whether the patient had a previous abortion, whether the patient had a previous birth and whether the patient had confirmatory pre-abortion ultrasonography.

The key exposure was a binary measure reflecting whether the patient received care synchronously (video) or asynchronously (secure text messaging).

Statistical analysis

The study was powered to detect differences in the rarest primary outcome, that is, serious adverse events. We aimed to have outcome data from 4,202 patients. The study was designed to detect a difference of 0.4% or more in the rate of serious adverse events compared to 0.5%, the rate for in-person medication abortions as published in the FDA label 8 , with 90% power and a two-sided alpha of 0.05. With a final sample size of 4,454, the study had more than 90% power to detect a difference of 2% or more in the effectiveness rate compared to the 3% rate for in-person medication abortions as published on the FDA label 8 .

We described the characteristics of the overall sample and the subsample of patients who completed the surveys. We examined the extent of loss to follow-up and whether loss to follow-up differed between those who obtained synchronous and asynchronous care. We then conducted multiple imputation by chained equations to account for missing covariate and outcome data with 100 replications for primary regression analyses, assuming that missing data were related to observed patient and abortion characteristics. Multiple imputation by chained equations iteratively impute missing data using predictive models based on other variables in the dataset, and accounts for statistical uncertainty in the imputations 47 . Imputation models included patient age, urbanicity, whether the patient obtained screening ultrasonography, whether the patient obtained synchronous or asynchronous telehealth care, whether the patient participated in CHAT surveys, virtual clinics, and whether the patient used an abortion fund to pay for any portion of their abortion.

We developed logistic regression models for all effectiveness and safety outcomes. We used multivariable models for outcomes n  > 15, adjusting for a binary measure of whether the patient received screening via synchronous or asynchronous methods. These models were also adjusted for baseline patient and abortion characteristics, including patient age, race, ethnicity or ethnic grouping, and pregnancy duration. We included binary measures reflecting whether the patient had a previous abortion or birth, and whether the patient had pre-abortion ultrasonography 21 . For rare outcomes ( n  < 15), we used unadjusted logistic regression models.

We calculated marginal estimates, the corresponding 95% CIs and P values from the logistic regression results to estimate the predicted probability of each effectiveness and safety outcome. Primary estimates came from logistic regression analyses performed on imputed data. P values correspond to a Wald test in the logistic regressions, comparing each group to the reference group. We then compared results with published estimates of effectiveness and safety. All statistical tests were two-tailed with significance set at 0.05. All analyses were conducted using Stata v.17.0 (StataCorp LLC).

We conducted several sensitivity analyses to assess the robustness of our findings. First, we replicated the effectiveness analysis, assuming that patients who were referred to in-person care after taking the medications and were then lost to follow-up required further intervention to complete the abortion. Second, we replicated the effectiveness analysis by categorizing all patients who received any additional misoprostol as completed abortions. This is consistent with the MARE guidelines and previous studies 26 , 48 , which classified patients who received more than 1,600 μg of misoprostol (more than two doses) as successful abortions. Third, we examined both effectiveness and safety outcomes only among the subsample of patients who completed the surveys to evaluate whether the main findings held true among this sample with supplementary self-reported data on their outcomes. Finally, to test how robust our results were to the follow-up rates, we used delta-adjusted pattern-mixture model imputation 49 to simulate the outcomes under different assumptions regarding patients with missing outcome data, hypothesizing results if they had lower or higher odds of incomplete abortion or serious adverse events than those with outcome data.

Reporting summary

Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article.

Data availability

The datasets analyzed during this study are not publicly available because the patients who underwent an abortion did not consent to sharing their data beyond the primary researchers and because the legal status of abortion care is continually changing. The de-identified, individual-level data used to reach the study conclusions are available to qualified investigators from the corresponding author. Requesters must include a description of their research project, the qualifications of the research team, whether the analysis has institutional review board approval and how the results will be disseminated. Requesters must also sign a data use agreement to (1) use the data only for research purposes, (2) not attempt to re-identify the data or contact the study participants, (3) secure the data using appropriate computer technology and (4) destroy the data after the analyses are completed. Responses can be expected within 1 month of a request.

Code availability

Data analyses were carried out using Stata v.17.0 (StataCorp LLC) as specified in the Methods . The code is available on GitHub ( https://github.com/Upadhyay-Lab ).

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Acknowledgements

We thank M. Cervantes, L. Shin, K. Song, A. Becker and L. Peters for their contributions to data collection and management and other input on the CHAT study. We also thank C. Adam, M. Adam, K. Baron, S. Bussmann, L. Coplon, L. Dubey, L. DuBois, K. Freedman, G. Izarra, J. Phifer and A. Wagner for their support with data acquisition. We thank E. Wells and F. Coeytaux for their early input on study design, and E. Raymond for thoughtful guidance on classifying adverse events. We thank W. J. Boscardin for his input on pattern-mixture modeling. The CHAT study was supported by the BaSe Family Fund, the Erik E. and Edith H. Bergstrom Foundation, the Isabel Allende Foundation, Jess Jacobs, the Kahle/Austin Foundation, the Lisa and Douglas Goldman Fund, Preston-Werner Ventures (all to U.D.U.) and a Resource Allocation Program Award from the University of California, San Francisco National Center of Excellence in Women’s Health (to M.A.B.). L.R.K. was funded in part by a training grant from the National Institute of Child Health and Human Development of the National Institutes of Health under award no. F31HD111277 for the duration of the study. The funders had no role in study design, data collection and analysis, the writing of the manuscript or the decision to submit the manuscript for publication.

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Contributions

U.D.U. obtained the funding for the study. U.D.U., L.R.K., E.S.V. and K.M. conceptualized and designed the study. L.R.K. conducted the data analysis. U.D.U. supervised the data analysis. J.K. provided management and administration for the study. U.D.U., L.R.K. and M.A.B. drafted the manuscript. All authors interpreted the data, reviewed the manuscript drafts, provided substantive input on its content and approved the final version of the manuscript. U.D.U. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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Correspondence to Ushma D. Upadhyay .

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K.M. reports receiving personal fees from Danco Laboratories, a distributor of mifepristone, for staffing a US Food and Drug Administration-mandated expert hotline. The other authors declare no competing interests.

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Upadhyay, U.D., Koenig, L.R., Meckstroth, K. et al. Effectiveness and safety of telehealth medication abortion in the USA. Nat Med (2024). https://doi.org/10.1038/s41591-024-02834-w

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Why restricting access to abortion damages women’s health

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Citation: The PLOS Medicine Editors (2022) Why restricting access to abortion damages women’s health. PLoS Med 19(7): e1004075. https://doi.org/10.1371/journal.pmed.1004075

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Competing interests: The authors’ individual competing interests are at http://journals.plos.org/plosmedicine/s/staff-editors . PLOS is funded partly through manuscript publication charges, but the PLOS Medicine Editors are paid a fixed salary (their salaries are not linked to the number of papers published in the journal).

The PLOS Medicine editors are Raffaella Bosurgi, Callam Davidson, Philippa Dodd, Louise Gaynor-Brook, Caitlin Moyer, Beryne Odeny, and Richard Turner.

In late June, the landmark Roe v . Wade ruling was overturned by the United States Supreme Court, a decision, decried by human rights experts at the United Nations [ 1 ], that leaves many women and girls without the right to obtain abortion care that was established nearly 50 years ago. The consequences of limited or nonextant access to safe abortion services in the US remain to be seen; however, information gleaned from abortion-related policies worldwide provides insight into the likely health effects of this abrupt reversal in abortion policy. The US Supreme Court’s decision should serve to amplify the global call for strategies to mitigate the inevitable repercussions for women’s health.

Upholding reproductive rights is crucial for the health of women and girls worldwide, and access to a safe abortion is central to this, yet policies in several countries either severely limit or actively prevent access to appropriate abortion care and services [ 2 ]. However, there is little to suggest that those countries and jurisdictions with abortion bans or heavily restrictive laws see fewer abortions performed. According to a modeling study of pregnancy intentions and abortion from the 1990s to 2019, rates of unintended pregnancies ending in abortion are broadly similar regardless of a country’s legal status of abortion, and unintended pregnancy rates are higher among countries with abortion restrictions [ 3 ]. Abortion is widely considered to be a low-risk procedure. Abortion-related deaths most likely occur in the context of unsafe abortion practices and are reported to account for 8% (95% UI 4.7–13.2%) of maternal deaths [ 4 ], making them a top direct contributor to maternal deaths globally, alongside hemorrhage, hypertension, and sepsis. Restrictive abortion policies may not lower the overall rates of abortion, but they can drive increasing rates of unsafe abortions, as women resort to seeking abortions covertly. Such abortions are often performed by untrained practitioners or involve harmful methods. Perhaps unsurprisingly, most abortions that take place in countries with restrictive abortion access policies are not considered safe [ 5 ], potentially contributing to maternal morbidity and mortality. A study of 162 countries found that maternal mortality rates are lower in countries with more flexible abortion access laws [ 6 ], suggesting that changes in abortion policies could have grievous implications for maternal deaths.

It is not yet known if the reneging of federal protection of abortion rights will impact maternal deaths in the US; however, in the years following the 1973 Roe v . Wade decision, numbers of reported deaths associated with illegal abortions, defined as those performed by an unlicensed practitioner, declined, hovering between zero and 2 deaths from the 1980s to 2018, down from 35 in 1972 [ 7 ] and 19 reported in 1973 [ 8 ]. It is possible that limits on access to timely and safe abortion care could drive this number back up and add to the already unacceptably high maternal mortality rate in the US, potentially exacerbating the persistent disparities in maternal mortality based on socioeconomic deprivation, race and ethnicity, and other factors [ 9 ].

Legal and social barriers that impede access to safe abortions are detrimental to the health and survival of women and girls; thus, constructing policies ensuring access to safe abortion services should be an urgent priority. Placing undue hurdles between women and access to abortion care is associated with undesirable health outcomes. For example, a 2011 change to medication abortion laws in one US state that involved increased medication costs and restricted the timing and location where abortion services could be provided was associated with an increase in rates of women requiring additional medical interventions [ 10 ]. Lending international weight to this argument, dissolution of barriers to safe abortion access was emphasized in the March 2022 update of WHO guidance on abortion care [ 11 ], echoing a 2018 comment on the International Covenant on Civil and Political Rights released by the United Nations Human Rights Committee [ 12 ] that called on member states to remove existing barriers and not enact new restrictions on provision of safe abortion services so that pregnant women and girls do not need to turn to unsafe abortions.

In jurisdictions where prohibitive policies exist, more could be done to counter the impacts of new barriers by changing how abortion care is delivered and increasing accessibility. Protocols for the safe self-management of abortion can be implemented alongside provision of information and provider support. WHO guidance [ 11 ] suggests expanding the breadth of practitioners authorized to prescribe medical abortions to include nurses, midwives, and other cadres of healthcare workers. The guidelines also mention telemedicine as an approach to circumvent obstacles to seeking safe abortion services [ 11 ]. For those with access to the necessary technology, telemedicine services together with self-management of medication abortion can overcome travel-related barriers and ensure the privacy of those seeking treatment. Demands for telehealth services increased during the COVID-19 pandemic, and, according to one study, remote provision of abortion services in the US may be a promising option to counteract barriers and facilitate access [ 13 ].

In 2022, restrictive policies or outright bans on abortion services are discriminatory against women, obstructing their right to maintain autonomy over their own sexual and reproductive health. A post- Roe legal landscape that renders abortion more difficult or impossible to obtain safely will exacerbate an increasingly bleak picture of maternal health in the US; however, the US is just one example where increased effort is needed to overcome barriers to improving women’s healthcare. The reality is that such barriers continue to represent a threat to the health of women worldwide. Evidence-based changes to policy and practice that break down barriers and build new roads are required to enable women to access the healthcare they need.

  • 1. United Nations, Human Rights Office: UN Human Rights Media Center [Internet]. Geneva: Office of the United Nations High Commissioner for Human Rights (OHCHR); c1996–2022. Joint web statement by UN Human rights experts on Supreme Court decision to strike down Roe v. Wade; 2022 Jun 24 [cited 30 Jun 2022]. Available from: https://www.ohchr.org/en/statements/2022/06/joint-web-statement-un-human-rights-experts-supreme-court-decision-strike-down ]
  • 2. Center for Reproductive Rights. The World’s Abortion Laws [Internet]. New York (NY): Center for Reproductive Rights; c1992–2022. [cited June 30, 2022]. Available from: https://reproductiverights.org/maps/worlds-abortion-laws/
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  • 11. World Health Organization. Abortion Care Guideline. Geneva: World Health Organization; 2022 Mar 8. 170 p. Available from: https://www.who.int/publications/i/item/9789240039483 .
  • 12. United Nations, Human Rights Committee (124th session (8 Oct– 2 Nov 2018). General comment no. 36, Article 6, Right to life. Geneva: UN Human Rights Committee; 2019 Sep 3. 21 p.

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1. americans’ views on whether, and in what circumstances, abortion should be legal.

A chart showing Americans’ views of abortion, 1995-2022

As the long-running debate over abortion reaches another  key moment at the Supreme Court  and in  state legislatures across the country , a majority of U.S. adults continue to say that abortion should be legal in all or most cases. About six-in-ten Americans (61%) say abortion should be legal in “all” or “most” cases, while 37% think abortion should be  illegal  in all or most cases. These views have changed little over the past several years: In 2019, for example, 61% of adults said abortion should be legal in all or most cases, while 38% said it should be illegal in all or most cases.    Most respondents in the new survey took one of the middle options when first asked about their views on abortion, saying either that abortion should be legal in  most  cases (36%) or illegal in  most  cases (27%). 

Respondents who said abortion should either be legal in  all  cases or illegal in  all  cases received a follow-up question asking whether there should be any exceptions to such laws. Overall, 25% of adults initially said abortion should be legal in all cases, but about a quarter of this group (6% of all U.S. adults) went on to say that there should be some exceptions when abortion should be against the law.

Large share of Americans say abortion should be legal in some cases and illegal in others

One-in-ten adults initially answered that abortion should be illegal in all cases, but about one-in-five of these respondents (2% of all U.S. adults) followed up by saying that there are some exceptions when abortion should be permitted. 

Altogether, seven-in-ten Americans say abortion should be legal in some cases and illegal in others, including 42% who say abortion should be generally legal, but with some exceptions, and 29% who say it should be generally illegal, except in certain cases. Much smaller shares take absolutist views when it comes to the legality of abortion in the U.S., maintaining that abortion should be legal in all cases with no exceptions (19%) or illegal in all circumstances (8%). 

There is a modest gender gap in views of whether abortion should be legal, with women slightly more likely than men to say abortion should be legal in all cases or in all cases but with some exceptions (63% vs. 58%). 

Sizable gaps by age, partisanship in views of whether abortion should be legal

Younger adults are considerably more likely than older adults to say abortion should be legal: Three-quarters of adults under 30 (74%) say abortion should be generally legal, including 30% who say it should be legal in all cases without exception. 

But there is an even larger gap in views toward abortion by partisanship: 80% of Democrats and Democratic-leaning independents say abortion should be legal in all or most cases, compared with 38% of Republicans and GOP leaners.  Previous Center research  has shown this gap widening over the past 15 years. 

Still, while partisans diverge in views of whether abortion should mostly be legal or illegal, most Democrats and Republicans do not view abortion in absolutist terms. Just 13% of Republicans say abortion should be against the law in all cases without exception; 47% say it should be illegal with some exceptions. And while three-in-ten Democrats say abortion should be permitted in all circumstances, half say it should mostly be legal – but with some exceptions. 

There also are sizable divisions within both partisan coalitions by ideology. For instance, while a majority of moderate and liberal Republicans say abortion should mostly be legal (60%), just 27% of conservative Republicans say the same. Among Democrats, self-described liberals are twice as apt as moderates and conservatives to say abortion should be legal in all cases without exception (42% vs. 20%).

Regardless of partisan affiliation, adults who say they personally know someone who has had an abortion – such as a friend, relative or themselves – are more likely to say abortion should be legal than those who say they do not know anyone who had an abortion.

Religion a significant factor in attitudes about whether abortion should be legal

Views toward abortion also vary considerably by religious affiliation – specifically among large Christian subgroups and religiously unaffiliated Americans. 

For example, roughly three-quarters of White evangelical Protestants say abortion should be illegal in all or most cases. This is far higher than the share of White non-evangelical Protestants (38%) or Black Protestants (28%) who say the same. 

Despite  Catholic teaching on abortion , a slim majority of U.S. Catholics (56%) say abortion should be legal. This includes 13% who say it should be legal in all cases without exception, and 43% who say it should be legal, but with some exceptions. 

Compared with Christians, religiously unaffiliated adults are far more likely to say abortion should be legal overall – and significantly more inclined to say it should be legal in all cases without exception. Within this group, atheists stand out: 97% say abortion should be legal, including 53% who say it should be legal in all cases without exception. Agnostics and those who describe their religion as “nothing in particular” also overwhelmingly say that abortion should be legal, but they are more likely than atheists to say there are some circumstances when abortion should be against the law.

Although the survey was conducted among Americans of many religious backgrounds, including Jews, Muslims, Buddhists and Hindus, it did not obtain enough respondents from non-Christian groups to report separately on their responses.

Abortion at various stages of pregnancy 

As a  growing number of states  debate legislation to restrict abortion – often after a certain stage of pregnancy – Americans express complex views about when   abortion should generally be legal and when it should be against the law. Overall, a majority of adults (56%) say that how long a woman has been pregnant should matter in determining when abortion should be legal, while far fewer (14%) say that this should  not  be a factor. An additional one-quarter of the public says that abortion should either be legal (19%) or illegal (8%) in all circumstances without exception; these respondents did not receive this question.

Among men and women, Republicans and Democrats, and Christians and religious “nones” who do not take absolutist positions about abortion on either side of the debate, the prevailing view is that the stage of the pregnancy should be a factor in determining whether abortion should be legal.

A majority of U.S. adults say how long a woman has been pregnant should be a factor in determining whether abortion should be legal

Americans broadly are more likely to favor restrictions on abortion later in pregnancy than earlier in pregnancy. Many adults also say the legality of abortion depends on other factors at every stage of pregnancy. 

One-in-five Americans (21%) say abortion should be  illegal  at six weeks. This includes 8% of adults who say abortion should be illegal in all cases without exception as well as 12% of adults who say that abortion should be illegal at this point. Additionally, 6% say abortion should be illegal in most cases and how long a woman has been pregnant should not matter in determining abortion’s legality. Nearly one-in-five respondents, when asked whether abortion should be legal six weeks into a pregnancy, say “it depends.” 

Americans are more divided about what should be permitted 14 weeks into a pregnancy – roughly at the end of the first trimester – although still, more people say abortion should be legal at this stage (34%) than illegal (27%), and about one-in-five say “it depends.”

Fewer adults say abortion should be legal 24 weeks into a pregnancy – about when a healthy fetus could survive outside the womb with medical care. At this stage, 22% of adults say abortion should be legal, while nearly twice as many (43%) say it should be  illegal . Again, about one-in-five adults (18%) say whether abortion should be legal at 24 weeks depends on other factors. 

Respondents who said that abortion should be illegal 24 weeks into a pregnancy or that “it depends” were asked a follow-up question about whether abortion at that point should be legal if the pregnant woman’s life is in danger or the baby would be born with severe disabilities. Most who received this question say abortion in these circumstances should be legal (54%) or that it depends on other factors (40%). Just 4% of this group maintained that abortion should be illegal in this case.

More adults support restrictions on abortion later in pregnancy, with sizable shares saying ‘it depends’ at multiple points in pregnancy

This pattern in views of abortion – whereby more favor greater restrictions on abortion as a pregnancy progresses – is evident across a variety of demographic and political groups. 

Democrats are far more likely than Republicans to say that abortion should be legal at each of the three stages of pregnancy asked about on the survey. For example, while 26% of Republicans say abortion should be legal at six weeks of pregnancy, more than twice as many Democrats say the same (61%). Similarly, while about a third of Democrats say abortion should be legal at 24 weeks of pregnancy, just 8% of Republicans say the same. 

However, neither Republicans nor Democrats uniformly express absolutist views about abortion throughout a pregnancy. Republicans are divided on abortion at six weeks: Roughly a quarter say it should be legal (26%), while a similar share say it depends (24%). A third say it should be illegal. 

Democrats are divided about whether abortion should be legal or illegal at 24 weeks, with 34% saying it should be legal, 29% saying it should be illegal, and 21% saying it depends. 

There also is considerable division among each partisan group by ideology. At six weeks of pregnancy, just one-in-five conservative Republicans (19%) say that abortion should be legal; moderate and liberal Republicans are twice as likely as their conservative counterparts to say this (39%). 

At the same time, about half of liberal Democrats (48%) say abortion at 24 weeks should be legal, while 17% say it should be illegal. Among conservative and moderate Democrats, the pattern is reversed: A plurality (39%) say abortion at this stage should be illegal, while 24% say it should be legal. 

A third of Republicans say abortion should be illegal six weeks into pregnancy; among Democrats, a third say abortion should be legal at 24 weeks

Christian adults are far less likely than religiously unaffiliated Americans to say abortion should be legal at each stage of pregnancy.  

Among Protestants, White evangelicals stand out for their opposition to abortion. At six weeks of pregnancy, for example, 44% say abortion should be illegal, compared with 17% of White non-evangelical Protestants and 15% of Black Protestants. This pattern also is evident at 14 and 24 weeks of pregnancy, when half or more of White evangelicals say abortion should be illegal.

At six weeks, a plurality of Catholics (41%) say abortion should be legal, while smaller shares say it depends or it should be illegal. But by 24 weeks, about half of Catholics (49%) say abortion should be illegal. 

Among adults who are religiously unaffiliated, atheists stand out for their views. They are the only group in which a sizable majority says abortion should be  legal  at each point in a pregnancy. Even at 24 weeks, 62% of self-described atheists say abortion should be legal, compared with smaller shares of agnostics (43%) and those who say their religion is “nothing in particular” (31%). 

As is the case with adults overall, most religiously affiliated and religiously unaffiliated adults who originally say that abortion should be illegal or “it depends” at 24 weeks go on to say either it should be legal or it depends if the pregnant woman’s life is in danger or the baby would be born with severe disabilities. Few (4% and 5%, respectively) say abortion should be illegal at 24 weeks in these situations.

Majority of atheists say abortion should be legal at 24 weeks of pregnancy

Abortion and circumstances of pregnancy 

Majorities say abortion should be legal if pregnancy threatens woman’s life; more uncertainty when it comes to baby being born with severe disabilities

The stage of the pregnancy is not the only factor that shapes people’s views of when abortion should be legal. Sizable majorities of U.S. adults say that abortion should be legal if the pregnancy threatens the life or health of the pregnant woman (73%) or if pregnancy is the result of rape (69%). 

There is less consensus when it comes to circumstances in which a baby may be born with severe disabilities or health problems: 53% of Americans overall say abortion should be legal in such circumstances, including 19% who say abortion should be legal in all cases and 35% who say there are some situations where abortions should be illegal, but that it should be legal in this specific type of case. A quarter of adults say “it depends” in this situation, and about one-in-five say it should be illegal (10% who say illegal in this specific circumstance and 8% who say illegal in all circumstances). 

There are sizable divides between and among partisans when it comes to views of abortion in these situations. Overall, Republicans are less likely than Democrats to say abortion should be legal in each of the three circumstances outlined in the survey. However, both partisan groups are less likely to say abortion should be legal when the baby may be born with severe disabilities or health problems than when the woman’s life is in danger or the pregnancy is the result of rape. 

Just as there are wide gaps among Republicans by ideology on whether how long a woman has been pregnant should be a factor in determining abortion’s legality, there are large gaps when it comes to circumstances in which abortions should be legal. For example, while a clear majority of moderate and liberal Republicans (71%) say abortion should be permitted when the pregnancy is the result of rape, conservative Republicans are more divided. About half (48%) say it should be legal in this situation, while 29% say it should be illegal and 21% say it depends.

The ideological gaps among Democrats are slightly less pronounced. Most Democrats say abortion should be legal in each of the three circumstances – just to varying degrees. While 77% of liberal Democrats say abortion should be legal if a baby will be born with severe disabilities or health problems, for example, a smaller majority of conservative and moderate Democrats (60%) say the same. 

Democrats broadly favor legal abortion in situations of rape or when a pregnancy threatens woman’s life; smaller majorities of Republicans agree

White evangelical Protestants again stand out for their views on abortion in various circumstances; they are far less likely than White non-evangelical or Black Protestants to say abortion should be legal across each of the three circumstances described in the survey. 

While about half of White evangelical Protestants (51%) say abortion should be legal if a pregnancy threatens the woman’s life or health, clear majorities of other Protestant groups and Catholics say this should be the case. The same pattern holds in views of whether abortion should be legal if the pregnancy is the result of rape. Most White non-evangelical Protestants (75%), Black Protestants (71%) and Catholics (66%) say abortion should be permitted in this instance, while White evangelicals are more divided: 40% say it should be legal, while 34% say it should be  illegal  and about a quarter say it depends. 

Mirroring the pattern seen among adults overall, opinions are more varied about a situation where a baby might be born with severe disabilities or health issues. For instance, half of Catholics say abortion should be legal in such cases, while 21% say it should be illegal and 27% say it depends on the situation. 

Most religiously unaffiliated adults – including overwhelming majorities of self-described atheists – say abortion should be legal in each of the three circumstances. 

White evangelicals less likely than other Christians to say abortion should be legal in cases of rape, health concerns

Parental notification for minors seeking abortion

Age, ideological divides in views of whether parents should be notified before abortion performed on minor

Seven-in-ten U.S. adults say that doctors or other health care providers should be required to notify a parent or legal guardian if the pregnant woman seeking an abortion is under 18, while 28% say they should not be required to do so.  

Women are slightly less likely than men to say this should be a requirement (67% vs. 74%). And younger adults are far less likely than those who are older to say a parent or guardian should be notified before a doctor performs an abortion on a pregnant woman who is under 18. In fact, about half of adults ages 18 to 24 (53%) say a doctor should  not  be required to notify a parent. By contrast, 64% of adults ages 25 to 29 say doctors  should  be required to notify parents of minors seeking an abortion, as do 68% of adults ages 30 to 49 and 78% of those 50 and older. 

A large majority of Republicans (85%) say that a doctor should be required to notify the parents of a minor before an abortion, though conservative Republicans are somewhat more likely than moderate and liberal Republicans to take this position (90% vs. 77%). 

The ideological divide is even more pronounced among Democrats. Overall, a slim majority of Democrats (57%) say a parent should be notified in this circumstance, but while 72% of conservative and moderate Democrats hold this view, just 39% of liberal Democrats agree. 

By and large, most Protestant (81%) and Catholic (78%) adults say doctors should be required to notify parents of minors before an abortion. But religiously unaffiliated Americans are more divided. Majorities of both atheists (71%) and agnostics (58%) say doctors should  not  be required to notify parents of minors seeking an abortion, while six-in-ten of those who describe their religion as “nothing in particular” say such notification should be required. 

Penalties for abortions performed illegally 

Public split on whether woman who had an abortion in a situation where it was illegal should be penalized

Americans are divided over who should be penalized – and what that penalty should be – in a situation where an abortion occurs illegally. 

Overall, a 60% majority of adults say that if a doctor or provider performs an abortion in a situation where it is illegal, they should face a penalty. But there is less agreement when it comes to others who may have been involved in the procedure. 

While about half of the public (47%) says a woman who has an illegal abortion should face a penalty, a nearly identical share (50%) says she should not. And adults are more likely to say people who help find and schedule or pay for an abortion in a situation where it is illegal should  not  face a penalty than they are to say they should.

Views about penalties are closely correlated with overall attitudes about whether abortion should be legal or illegal. For example, just 20% of adults who say abortion should be legal in all cases without exception think doctors or providers should face a penalty if an abortion were carried out in a situation where it was illegal. This compares with 91% of those who think abortion should be illegal in all cases without exceptions. Still, regardless of how they feel about whether abortion should be legal or not, Americans are more likely to say a doctor or provider should face a penalty compared with others involved in the procedure. 

Among those who say medical providers and/or women should face penalties for illegal abortions, there is no consensus about whether they should get jail time or a less severe punishment. Among U.S. adults overall, 14% say women should serve jail time if they have an abortion in a situation where it is illegal, while 16% say they should receive a fine or community service and 17% say they are not sure what the penalty should be. 

A somewhat larger share of Americans (25%) say doctors or other medical providers should face jail time for providing illegal abortion services, while 18% say they should face fines or community service and 17% are not sure. About three-in-ten U.S. adults (31%) say doctors should lose their medical license if they perform an abortion in a situation where it is illegal.

Men are more likely than women to favor penalties for the woman or doctor in situations where abortion is illegal. About half of men (52%) say women should face a penalty, while just 43% of women say the same. Similarly, about two-thirds of men (64%) say a doctor should face a penalty, while 56% of women agree.

Republicans are considerably more likely than Democrats to say both women and doctors should face penalties – including jail time. For example, 21% of Republicans say the woman who had the abortion should face jail time, and 40% say this about the doctor who performed the abortion. Among Democrats, far smaller shares say the woman (8%) or doctor (13%) should serve jail time.  

White evangelical Protestants are more likely than other Protestant groups to favor penalties for abortions in situations where they are illegal. Fully 24% say the woman who had the abortion should serve time in jail, compared with just 12% of White non-evangelical Protestants or Black Protestants. And while about half of White evangelicals (48%) say doctors who perform illegal abortions should serve jail time, just 26% of White non-evangelical Protestants and 18% of Black Protestants share this view.

Relatively few say women, medical providers should serve jail time for illegal abortions, but three-in-ten say doctors should lose medical license

  • Only respondents who said that abortion should be legal in some cases but not others and that how long a woman has been pregnant should matter in determining whether abortion should be legal received questions about abortion’s legality at specific points in the pregnancy.  ↩

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Table of contents, majority of public disapproves of supreme court’s decision to overturn roe v. wade, wide partisan gaps in abortion attitudes, but opinions in both parties are complicated, key facts about the abortion debate in america, about six-in-ten americans say abortion should be legal in all or most cases, fact sheet: public opinion on abortion, most popular.

About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009

Affiliation.

  • 1 Human Development and Family Studies, 16 D FCS Building, Bowling Green State University, Bowling Green, Ohio 43402, USA. [email protected]
  • PMID: 21881096
  • DOI: 10.1192/bjp.bp.110.077230

Background: Given the methodological limitations of recently published qualitative reviews of abortion and mental health, a quantitative synthesis was deemed necessary to represent more accurately the published literature and to provide clarity to clinicians.

Aims: To measure the association between abortion and indicators of adverse mental health, with subgroup effects calculated based on comparison groups (no abortion, unintended pregnancy delivered, pregnancy delivered) and particular outcomes. A secondary objective was to calculate population-attributable risk (PAR) statistics for each outcome.

Method: After the application of methodologically based selection criteria and extraction rules to minimise bias, the sample comprised 22 studies, 36 measures of effect and 877 181 participants (163 831 experienced an abortion). Random effects pooled odds ratios were computed using adjusted odds ratios from the original studies and PAR statistics were derived from the pooled odds ratios.

Results: Women who had undergone an abortion experienced an 81% increased risk of mental health problems, and nearly 10% of the incidence of mental health problems was shown to be attributable to abortion. The strongest subgroup estimates of increased risk occurred when abortion was compared with term pregnancy and when the outcomes pertained to substance use and suicidal behaviour.

Conclusions: This review offers the largest quantitative estimate of mental health risks associated with abortion available in the world literature. Calling into question the conclusions from traditional reviews, the results revealed a moderate to highly increased risk of mental health problems after abortion. Consistent with the tenets of evidence-based medicine, this information should inform the delivery of abortion services.

Publication types

  • Abortion, Induced / adverse effects
  • Abortion, Induced / psychology*
  • Abortion, Induced / statistics & numerical data
  • Evidence-Based Practice
  • Mental Disorders / epidemiology*
  • Meta-Analysis as Topic
  • Pregnancy, Unplanned / psychology
  • Pregnancy, Unwanted / psychology
  • Risk Factors
  • Substance-Related Disorders / epidemiology
  • Suicide / psychology
  • Suicide / statistics & numerical data

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Abortions by Telemedicine and Mailed Pills Are Safe and Effective, Study Finds

Pam Belluck

By Pam Belluck

Pam Belluck has covered reproductive health for more than a decade.

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Taking abortion pills prescribed through telemedicine and received by mail — a method used by growing numbers of abortion patients — is as safe and effective as when the pills are obtained by visiting a doctor, a large new study found. The method was about 98 percent effective and was safe for over 99 percent of patients, the study reported.

A stack of orange Mifeprex boxes sits next to a stack of plastic cups.

The research

The study, led by researchers at the University of California, San Francisco, looked at the experience of more than 6,000 patients in the months after the federal government began allowing abortion pills to be mailed , from April 2021 to January 2022.

The patients used one of three telemedicine abortion organizations — Hey Jane, Abortion on Demand or Choix — that served 20 states and Washington, D.C. The research, published on Thursday in Nature Medicine, ended five months before the Supreme Court overturned Roe v. Wade, igniting a wave of state abortion bans and restrictions. Since then, more telemedicine services have opened, and are used by many patients who consider the method more convenient, private and affordable than visiting clinics or doctors, especially if they have to travel to another state.

The services in the study prescribed pills to patients who were 10 weeks pregnant or less (one service had an eight-week limit) and screened patients for medical issues that would make them ineligible , like ectopic pregnancies or blood-clotting disorders.

In most cases, the services’ doctors, nurse practitioners, physician assistants and midwives were able to determine eligibility from patients’ written or verbal information about their pregnancy and health, without requiring them to have ultrasounds, which are logistically difficult for some patients to obtain. If medical eligibility was unclear, patients were asked to get ultrasounds — 486 did and were then prescribed pills, comprising about 8 percent of the 6,034 patients who received pills in the study.

The results

Researchers reviewed the medical records of the services and were able to determine abortion outcomes for three-fourths, or 4,454, of the patients. A vast majority — 4,351 patients, or 97.7 percent — completed abortions with the standard regimen: mifepristone, which stops a pregnancy’s development, followed a day or two later by misoprostol, which causes contractions to expel the tissue.

Of the remaining patients, 85 needed additional measures to complete the abortion, usually with additional medication or a suction procedure in a medical facility.

Eighty-one patients visited emergency departments, and 15 patients had serious complications. Ten patients were hospitalized. Six received blood transfusions, two were treated for infections and one had surgery for an ectopic pregnancy.

Six patients turned out to have ectopic pregnancies, which would have made them ineligible for the pills. Studies show that ectopic pregnancies cannot always be identified early, even by ultrasound.

Of the patients who visited emergency departments, 38 percent ended up needing no treatment. Patients sometimes visit emergency departments because “they don’t know whether what they’re experiencing is normal and they sometimes don’t have anyone to ask and they don’t want to tell a lot of people about their abortion,” said Dr. Ushma Upadhyay, a public health scientist at U.C.S.F. and one of the study’s authors.

No patients were found to be beyond 10 weeks into pregnancy.

The effectiveness and safety rates were similar to those in several large studies of in-person medication abortion and of telemedicine abortion where ultrasounds were required . They were also similar to the rates on the Food and Drug Administration’s label for mifepristone .

Researchers also found no difference in safety or efficacy for patients who received real-time video consultations compared to those who received prescriptions based on written information they provided via text messaging, which most patients did.

Two patients asked about “abortion pill reversal,” a nonscientific theory that abortions can be stopped after taking the first drug. Both were told that “evidence-based reversal treatment does not exist” and were referred to urgent in-person care, the study reported.

Larger implications

Medication abortion is being challenged in a lawsuit filed against the F.D.A. by abortion opponents seeking to curtail mifepristone. One of the plaintiffs’ claims is that abortion pills are dangerous. The F.D.A. has cited overwhelming scientific evidence that the pills are safe , and two studies that abortion opponents referenced to support their claims were recently retracted by a scientific journal publisher .

In August, an appeals court said mifepristone could remain legal, but ordered significant restrictions that would prevent mailing or prescribing it by telemedicine. The Supreme Court will hear arguments in the case next month. The new study results may be mentioned by those urging the court to keep telemedicine abortion available.

Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics. More about Pam Belluck

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  • Copy URL https://www.pbs.org/newshour/health/more-patients-rely-on-early-prenatal-testing-as-states-toughen-abortion-laws

More patients rely on early prenatal testing as states toughen abortion laws

WASHINGTON (AP) — Since Roe v. Wade was overturned, many health care providers say an increasing number of patients are deciding the fate of their pregnancies on whatever information they can gather before state abortion bans kick in.

But early ultrasounds show far less about the condition of a fetus than later ones. And genetic screenings may be inaccurate.

When you find out your fetus has a serious problem, “you’re in crisis mode,” said doula Sabrina Fletcher. “You’re not thinking about legal repercussions and (state) cutoff dates, and yet we’re forced to.”

WATCH: Study estimates 64,000 pregnancies from rape in states that enacted abortion bans post-Roe

About half of states ban abortion or restrict it after a certain point in pregnancy.

This leaves millions of women in roughly 14 states with no option to get follow-up diagnostic tests in time to feasibly have an abortion there if they wanted,  a paper  published last March in the journal Obstetrics and Gynecology found. Even more states have abortion cutoffs too early for mid-pregnancy ultrasounds.

“More people are trying to find these things out earlier to try to fit within the confines of laws that in my mind don’t have a place in medical practice,” said Dr. Clayton Alfonso, an OB-GYN at Duke University in North Carolina.

Checking for prenatal problems

When done at the right time, doctors said prenatal testing can identify problems and help parents decide whether to have an abortion or continue a pregnancy and prepare for a baby’s complex needs after delivery.

One of the most common tests is the 20-week ultrasound. It checks on the fetal heart, brain, spine, limbs and other parts of the body, looking for signs of congenital problems. It can detect things like brain, spine and heart abnormalities and signs of chromosomal problems such as Down syndrome. Follow-up testing may be needed to make a diagnosis.

The earlier ultrasounds, in the first trimester for example, are not standard practice because it is too soon to see many of the fetus’ limbs and organs in detail, the American College of Obstetricians and Gynecologists says.

It’s impossible to spot problems like serious heart defects much before mid-pregnancy because the fetus is so small, said Dr. Cara Heuser, who practices maternal-fetal medicine in Utah. Nonetheless, she said, more patients are having ultrasounds at 10 to 13 weeks to get access to abortion if they choose.

READ MORE: In states with abortion bans, rape exceptions ‘fail to provide reasonable access’ to survivors, researchers say

Experts say there are no statistics on how many people opt for early ultrasounds or make choices based on them. But some health care providers say they’ve noticed an uptick in requests for the scans, including Missouri genetic counselor Chelsea Wagner. She counsels patients from around the nation through telehealth.

But she said doctors can’t provide patients with “an everything looks good’ or a clean bill of health off of an ultrasound at 10 weeks.”

Doctors also can’t make a firm diagnosis from a genetic screening, which is done at 10 weeks gestation or later. These screenings are designed to detect abnormalities in fetal DNA by looking at small, free-floating fragments circulating in a pregnant woman’s blood.

They screen for chromosomal disorders such as trisomy 13 and 18, which often end in miscarriage or stillbirth, Down syndrome and extra or missing copies of sex chromosomes.

The accuracy of these tests varies by disorder, but none is considered diagnostic.

Natera, one of only a handful of U.S. companies that makes such genetic tests, said in an email that prenatal test results are reported as either “high risk” or “low risk” and that patients should seek confirmatory testing if they get a “high risk” result.

Some may be pretty accurate, doctors said, but false positives are possible. In 2022, the Food and Drug Administration issued a warning about the screenings, reminding patients and doctors that results need further confirmation.

The agency is poised to release a new regulatory framework in April that would require prenatal screenings, and thousands of other lab tests, to undergo FDA review.

An ‘awful’ decision to make

In states with tough abortion laws, health care providers said, there’s more urgency because of the timing of diagnostic tests.

CVS or chorionic villus sampling, is offered at 10 to 13 weeks gestation. Initial results take a few days and more detailed ones around two weeks. Amniocentesis is typically done at 15 to 20 weeks, with similar timing for results.

If a state has a 12-week abortion ban, for instance, “some people may have to act on a screening,” Alfonso said.

Wagner said she’s had to counsel patients who couldn’t afford to travel out of state for an abortion if they waited for diagnostic testing. “They are forced to use the information they have to make choices they never thought they’d have to make,” she said.

READ MORE: What to know as the battle over abortion rights shifts to state ballots in 2024

Some states restrict abortion so early that women would not have the chance to get any prenatal testing done before the cutoff.

That was the case for 26-year-old Hannah in Tennessee, which has a strict abortion ban. An ultrasound in late November, at about 18 weeks, revealed she had amniotic band sequence, when very thin pieces of the amniotic membrane get attached to the fetus. In Hannah’s case, the bands were attached to many of her baby’s body parts and ripped open multiple areas of his body.

After calling clinics in Ohio and Illinois to terminate the pregnancy, she finally found one 4 ½ hours away in Illinois and had the procedure in early December at 19 weeks gestation. Results from the amniocentesis – which was done to look for the cause of the problem – came back the day after her abortion, and other results after that.

Hannah, who didn’t want her last name used for fear of backlash, said it’s “awful” to have to think about state timelines, and to travel long distances when dealing with something like this. But she’s grateful she had enough information to feel confident in her decision.

“I know some women are not that lucky,” Hannah said. She named her son Waylen.

Ungar reported from Louisville, Kentucky.

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Study estimates 64,000 pregnancies from rape in states that enacted abortion bans post-Roe

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  • Asian Bioeth Rev
  • v.14(1); 2022 Jan

The Moral Significance of Abortion Inconsistency Arguments

William simkulet.

1 Park University, Parkville, MO USA

2 Dodge City Community College, Dodge City, KS USA

Most opponents of abortion (OA) believe fetuses matter . Critics argue that OA act inconsistently with regards to fetal life, seeking to restrict access to induced abortion, but largely ignoring spontaneous abortion and the creation of surplus embryos by IVF. Nicholas Colgrove, Bruce Blackshaw, and Daniel Rodger call such arguments inconsistency arguments and contend they do not matter. They present three objections to these arguments — the other beliefs, other actions, and hypocrisy objection. Previously, I argued these objections fail and threaten to undermine ethical inquiry. Colgrove et al. have recently replied, but here, I argue their reply fails as well and raises a new criticism of the other actions’ objection. This essay sets out to show, as well as any philosophical argument can, that inconsistency arguments are morally significant.

Introduction

Nicholas Colgrove, Bruce Blackshaw, and Daniel Rodger ( 2020 ) set out to show that inconsistency arguments “do not matter”; by inconsistency argument , they mean to pick out a variety (Fleck 1979 ; Murphy 1985 ; Ord 2008 ; Lovering 2013 , 2014 , 2017 , 2020 ; Berg 2017 ; Simkulet 2016 , 2017 , 2019a , b , c , 2020 ; Bovens 2006 ; Schlumpf 2019 ) of disparate criticisms identifying apparent inconsistencies in how opponents of abortion (OA) treat fetuses. Unfortunately, this term is misleading, as practically all philosophical arguments involve identifying some form of inconsistency, confusion, or misunderstanding.

Critics of the prolife anti-abortion position argue that OA hold inconsistent moral beliefs; they claim to believe that fetuses are persons from conception, but they neglect the welfare of fetuses who are spontaneously aborted by natural causes, and overlook the well-being of the surplus frozen human embryos created for IVF. Perhaps the strangest argument that Colgrove et al. ( 2020 ) label as an inconsistency argument comes from Sister Joan Chittister (Schlumpf 2019 ), who chastises those who call themselves “pro-life” for neglecting the welfare of born persons. Proponents of inconsistency arguments argue that OA hold inconsistent moral beliefs, arguing that upon revision, they will conclude that they either (i) need to do more, or (ii) need not oppose abortion.

Colgrove et al. ( 2020 ) contend that such arguments “do not matter.” This paper interprets this as the claim that inconsistency arguments are morally irrelevant for any (widely held) OA view. This paper will show that such arguments are morally relevant to the most widely held OA position.

Another way to read Colgrove et al. is as claiming they “do not matter” because they cannot show that OA need to adopt (ii) over (i). They say, “Inconsistency arguments simply are not equipped to undermine OAs’ views; at most, they reveal what OAs should do (or believe).” (Colgrove et al. 2020 ) This is uncharitable. First, while some inconsistency theorists (Ord 2008 ; Berg 2017 ) might believe that OA do not really believe fetuses are persons from conception, these arguments identify apparent inconsistency, but need not take a stance on how OA ought to resolve this inconsistency. Second, even if OA choose (i) and conclude they ought to do more to prevent spontaneous abortion (education, research, increased access to healthcare (Simkulet 2017 , 2020 ), and perhaps a major shift in social priorities (Ord 2008 ; Berg 2017 ), and more for surplus IVF embryos (adoption, and gestation (Lovering 2020 ; Blackshaw and Colgrove 2020 ; Blackshaw 2021 ), this matters . Colgrove et al. jest that if OA embrace option (i) it would “make the world a (much) worse place (from the critic’s perspective)”; but fail to note that it would make the world a much better place from the perspective of OA!

Complicating matters, there seems to be disagreement among Colgrove, Blackshaw, and Rodger regarding what opposition to abortion requires. Notably, Bruce Blackshaw ( 2021 , 166) contends that Christians ought to act as neighbors, and offers a robust, clear account of what this requires:

Treating frozen embryos as neighbors requires securing them a life like ours through adoption and gestation, and as well as opposing abortion, Christians must work toward this goal for the vast numbers of frozen embryos that would otherwise be discarded.

Blackshaw and Rodger ( 2019 ) attempt to justify OA disinterest in spontaneous abortion, claiming that most cases of spontaneous abortion are not currently preventable; but Blackshaw ( 2021 ) notes that “if we regard all human life as equally valuable, we have at least some obligation toward helping reduce deaths from spontaneous abortion where possible”.

This paper argues that inconsistency arguments matter. It is divided into three main sections. The first draws a distinction between restrictivist and moralist views on abortion, arguing only restrictivist views are OA. The second sets out to defend my earlier criticism (Simkulet 2021 ) of the other beliefs, other actions, and hypocrisy objections from Blackshaw et al.’s ( 2021 ) recent response. The third offers a new argument against the other actions objection; I argue that if this objection were to succeed, it would undermine restrictivist opposition to abortion.

Opposition to Abortion

On miscarriage.

Before his collaboration (Colgrove et al. 2020 ) with Blackshaw and Rodger, Colgrove ( 2019 ) raised a different criticism of Berg’s ( 2017 ) inconsistency argument. Berg argues that because miscarriage is so common, if we believe fetuses matter , we ought to devote more medical resources to protecting them. Colgrove replies that “miscarriage is not a cause of death,” but rather “it is an outcome.” Blackshaw et al. ( 2021 ) accuse me of the same error.

This is rather uncharitable, but it also misses two key points common in inconsistency arguments. First, if OA believe that fetuses matter, one would expect them to be concerned with both spontaneous and induced abortion, as both are tragic. Second, even if spontaneous abortion has many disparate causes, there may be a common solution. For example, Aspirin can treat a wide variety of conditions, from scraped knee to eye strain to migraine. Many proposals inconsistency theorists discuss (for example, education, gene therapy, and ectogenesis technology) would prevent spontaneous abortion by many different causes.  In short, even if miscarriage is not a single cause of death, there is good reason to think a single solution might address many different cases, saving many fetal lives.

On Opposition to Abortion

To play on Colgrove, note that opposition to abortion is not a moral theory, it is an action or stance one can take toward abortion. There are many reasons why one might oppose abortion; one might merely find the word “abortion” to be distasteful, might oppose abortion on teleological grounds, argue that it is outside the scope of medicine, or that it violates the Hippocratic Oath.

However, most opposition to abortion rests on a single belief. Judith Jarvis Thomson ( 1972 ) says, “Most opposition to abortion relies on the premise that the fetus is a human being, a person, from the moment of conception.” Don Marquis ( 1989 ) says “Many of the most insightful and careful writers on the ethics of abortion… believe that whether or not abortion is morally permissible stands or falls on whether or not a fetus is the sort of being whose life it is seriously wrong to end.”

In short, most opposition to abortion turns on the belief that a fetus matters from conception (or soon afterwards (Marquis 2007 , 2013 ); that the fetus is morally comparable to an adult human person. This view is usually abbreviated as the view that fetuses are persons, broadly construed to mean one of many disparate theories about moral status; that human fetuses are human organisms (Mulder 2013 ), rational substances (Lee and George 2005 ; Beckwith 2007 ; George and Tollefsen 2008 ; Friberg-Fernros 2015 ), have a possible future it would be wrong to deprive them of Marquis 1989 ; Stone 1987 ), etc.

Colgrove et al. ( 2020 ) seek to show that inconsistency arguments are morally irrelevant for any (widely held) anti-abortion view, and there seems to be widespread consensus the most widely held anti-abortion view claims fetuses are persons, broadly construed, from conception (PAC). This paper defends the position that inconsistency arguments are morally relevant to the PAC view.

Restrictivism and Moralism

It will be practical to distinguish between two groups of anti-abortion positions — Restrictivism  (Davis 1984 ; Carroll and Crutchfield Forthcoming ), the view that we should adopt social policies that restrict a woman’s access to induced abortion, and Moralism , the view that abortion is merely immoral, but that we do not need adopt Restrictivist social policies.

It is not hard to see why PAC theorists might embrace restrictivism. On this view, fetuses are comparable to adult human persons, and society has adopted policies aimed at protecting the rights of adult human persons, so it is prima facie plausible that we should adopt similar social policies regarding fetuses. However, Thomson ( 1972 ) demonstrates that it is not enough to show that fetuses merely have a right to life by way of the violinist case:

Violinist: The Society of Music Lovers kidnaps you and attaches your circulatory system to a famous, innocent, unconscious violinist suffering from a kidney ailment that will kill him unless he remains connected to your kidneys for nine months. (Adapted)

The violinist obviously has a right to life, but Thomson argues that the right to life does not give him the right to use your body; it is morally permissible for you to disconnect yourself from the violinist. Thomson says it would be a “great kindness” to stay attached to the violinist but that you do not have to accede to this.

Disconnecting the violinist from your body is comparable to disconnecting a patient from life support to let him die. Restrictivists might argue that induced abortion is not a matter of letting die; but of killing; but this will not do, as one can terminate a pregnancy without killing the fetus by severing the umbilical cord or removing the uterus, “merely” letting the fetus die. If this distinction mattered, restrictivists would not be anti-abortion, they would merely oppose how most abortions are currently performed.

Thomson shows it is not enough for restrictivists to believe fetuses are persons with a right to life, they must also believe something more , that (a) the fetus’s right to life is a positive right to assistance, or (b) the gestational mother somehow comes to have a special obligation to provide assistance to the fetus. She argues that this special obligation cannot be explained by merely risking the chance of pregnancy, as this would imply any woman who leaves the house without a hysterectomy has consented to pregnancy, even by rape. Furthermore, David Boonin ( 2002 ) argues that even if one consents to provide aid, one can withdraw consent.

Bone Marrow: Your neighbor is diagnosed with a condition that will kill him unless he receives monthly bone marrow transplants over the course of nine months from a match. You are a match and you agree to donate. However, it soon becomes clear that these surgeries ask more than you are willing to give, and you refuse to go in for the second surgery. (Adapted)

These thought experiments demonstrate that restrictivists must do more than argue fetuses are persons, they must argue that the fetus has a positive right to assistance.

However, one can believe abortion is immoral without believing we ought to adopt restrictivist social policies. There are many prima facie immoral things that it would be inappropriate to restrict by law. For example, I think most of us would agree that it is prima facie immoral to waste scarce resources, but that individuals might have a right to do so in some cases. One might hold that it is wrong to waste food without holding that throwing away leftovers should be illegal. Similarly, one might hold that adultery outside of an open marriage is immoral, but that adopting social policies that restrict such behavior would be undesirable, in part, because they are difficult to enforce, and in part because it might incentivize other immoral behavior, such as murdering one’s spouse to keep one’s adultery secret.

Moralism is the view that abortion is often, all things considered, immoral, but does not require that we adopt social policies that restrict woman’s access to abortion. There are many reasons why moralists might reject restrictivism independent of Thomson and Boonin-style concerns.

For example, restrictivist views have a hard time making exceptions for rape cases, despite the fact that many restrictivists believe such exceptions should be made. Rape victims are often reluctant to report rape and reluctant to take medical exams. Convictions in rape cases are difficult to obtain, especially within the short window in which inducing abortion would be medically preferable. As such, restrictivists face a dilemma – (a) if they require proof of rape, then few rape victims are allowed to abort; while (b) if they do not require proof of rape, they encourage women to merely say they were raped (whether true or not), failing to prevent most induced abortions and encouraging deception.

Restrictivists face a similar challenge with regards to self-defense, as all pregnancies are medically risky. The prospect of drawing a nonarbitrary line with regards to legally obligatory medical risk is dubious, but even if such a task could be achieved, those physicians sympathetic to abortion might overestimate risk and those opposing abortion might underestimate or ignore risk. Furthermore, medical risk of abortion increases with malnutrition and other medical emergencies, so those seeking abortion on medical grounds are incentivized to harm themselves to pass this threshold.

In light of these, and other, difficulties, many people who believe abortion are immoral reject restrictivism and adopt moralism. Notably, moralists need not hold that fetuses have a positive right to assistance, like restrictivists. I have contended (Simkulet 2021 ) that most OA believe fetuses have a positive right to assistance — that most OA are restrictivists. Blackshaw et al. ( 2021 ) claim that I miss “the target,” as one can be an OA without being committed to the belief that fetuses have a positive right to assistance.

Perhaps Colgrove et al. wish OA to pick out both restrictivist and moralist positions, but this will not do. Although moralists believe induced abortion is immoral, they are prochoice, while Colgrove et al. identify OA as prolife. Perhaps Colgrove et al. mean to say restrictivism does not require the belief that fetuses have a positive right to assistance, but this would merely introduce greater inconsistency regarding medical and legal ethics, as illustrated by Thomson ( 1972 ) and Boonin ( 2002 ).

Do Inconsistency Arguments Matter?

Colgrove et al. ( 2020 ) raise three objections to inconsistency arguments — the other beliefs, other actions, and hypocrisy objections. I contend (Simkulet 2021 ) these objections threaten to undermine moral analysis completely; opposing parties could always claim to have other beliefs, other actions, or interpret criticism as an ad hominem attack impinging their character.

This section is divided into four subsections. The first looks at two inconsistency arguments. The next three subsections briefly summarize Colgrove et al.’s objections, and my criticisms (Simkulet 2021 ) of these arguments.

Inconsistency Arguments

OA often point to high numbers of induced abortion as a call to action. Upwards of 60% (Boklage 1990 ; Léridon 1977 ) of human pregnancies end in spontaneous abortion, prompting critics to ask why OA do not see spontaneous abortion as a call to action. Toby Ord ( 2008 ) compares spontaneous abortion to a scourge that kills over half of humanity. Berg ( 2017 ) compares it to Heart Disease, Cancer, and Stroke. Faced with these overwhelming numbers, inconsistency theorists conclude that if fetuses matter, then the problem of spontaneous abortion calls for a massive shift in our social and political priorities. I have noted (Simkulet 2021 ) that we recently underwent such a shift to address the COVID-19 pandemic.

Henrik Friberg-Fernros ( 2015 , 2019 , 2018 ) challenges this position, contending that while fetal death is always tragic, not all fetal deaths are equally tragic; that killing is worse than letting die, and even that fetal lives are worth less than adult human lives because they lack time relative interests (Friberg-Fernros 2019 )! However, inconsistency arguments do not assume that all fetal deaths are equally tragic, merely that if fetuses matter, their deaths are tragic.

OA face a dilemma — either they (i) need to do more to prevent fetal death, or (ii) should withdraw opposition to induced abortion. Some proponents think OA should choose (ii) — that the argument demonstrates they do not really believe fetuses are persons. However, others propose a wide variety of methods by which OA might reasonably seek to confront the problem of fetal death, from increased education and better access to healthcare, to technologies like ectogenesis and gene therapy that those on both sides of the abortion debate could reasonably support (Simkulet 2020 ).

While many inconsistency arguments focus on unaddressed fetal loss, Colgrove et al. ( 2020 ) also categorize Chittister's tweet (Schlumpf 2019 ) as an inconsistency argument. She asks whether it makes sense to call OA “pro-life” merely because they oppose abortion, noting all OA seem to be concerned with is ensuring the child is born, not fed, educated, or housed; asserting “That’s not pro-life. That’s pro-birth.”

Colgrove et al. ( 2020 ) contend that Chittister is using the term “pro-birth” pejoratively, but this is rather uncharitable. The term “pro-life” carries with it a positive emotive context, and when OA present their view as “pro-life,” they may mislead their audience about their position. In contrast, the term “pro-birth” seems to capture the one unifying feature of OA.

Even if Chittister is angry or disappointed that OA misrepresent their position, neglect their moral obligations, or the like… so what? That is how moral judgements work. If you think Φing is wrong, and you see someone Φing, it makes sense to be angry or disappointed. Colgrove et al. speak as though this, and accusations of pro-life hypocrisy are ad hominem attacks on OA; not so. An ad hominem fallacy occurs when one attacks person rather than their argument or view. Inconsistency arguments do not do this; they identify apparent inconsistency within the OA view, and call for change, as Chittister does when she concludes, “We need a much broader conversation on what the morality of pro-life is.”

Other Beliefs Objection and Response

Colgrove et al. ( 2020 ) raise three objections to inconsistency arguments. In the first, they contend that inconsistency arguments do not matter because there is a diversity of beliefs among OA, suggesting that no one inconsistency argument undermine them all; “This diversity makes broad accusations of inconsistency problematic.” Following this, one might argue that when an OA is confronted with apparent inconsistency within one view, they can jump ship to another OA view. But moral analysis is not a shell game. If inconsistency arguments identify a problem within even one OA position, they matter; and if they threaten the most widely held OA position, it seems they matter quite a bit.

Colgrove et al. ( 2020 ) suggest that OA may have other beliefs which explain away apparent inconsistency and justify their inaction with regards to spontaneous abortion; for example they ask us to consider someone who both opposes induced abortion and opposes universal healthcare; noting these beliefs would justify rejecting the conclusion that we should adopt universal health care to help address the problem of induced and spontaneous abortion (and suffering and death due to lack of medical care, more broadly). To this, I reply (Simkulet 2021 ):

It is not enough to show that some [OA] have some beliefs that are prima facie at odds with some [inconsistency theorist] proposals; they must show that the current level of apparent indifference that many [OA] show is justified by their other beliefs; and it is not clear what set of other beliefs would be both internally consistent and justify the conclusion that while persons [matter], this right requires very little in the way of sacrifice from anyone but gestational mothers.

Blackshaw et al. ( 2021 ) contend that I argue “this [apparent] indifference must be justified by their other beliefs…” continuing “there is an obvious belief that justifies [OA]’s actions and priorities —… [OA] believe that induced abortion is a more important priority than these other issues.” However, this misses the point. As we have seen above, inconsistency theorists do not claim that OA need to treat the problem of spontaneous abortion as equally important to the problem of induced abortion, but rather they must consistently recognize both are tragic.

Blackshaw et al. ( 2021 ) continue “induced abortion is the leading preventable cause of death of human beings, as spontaneous abortions are largely unpreventable.” However, they seem to understand “preventable” in an opportunistically narrow way — as preventable with our current technology — to disregard the problem of spontaneous abortion. Amy Berg ( 2017 ) challenges this opportunistically narrow caveat:

But imagine throwing up our hands about a horrible disease… Imagine saying that we should let AIDS, or cancer, or heart disease take its course, rather than expending more effort researching how we might prevent that disease or treat people who contract it. That’s not what we do.

Berg ( 2017 ) notes that just because spontaneous abortion is medically intractable now does not mean it will be in the future, comparing to the AIDs epidemic, “In just a couple of decades, AIDS went from a mysterious underground disease, to a devastating and fatal epidemic, to a relatively manageable chronic condition.”

Perhaps more troublingly, Blackshaw et al. ( 2021 ) say, “If OAs sincerely believe these claims, then they are acting consistently with their beliefs, and the Other Beliefs Objection succeeds.” Above I have argued that even if one sees one form of abortion as a greater priority than another, this does not justify apparent indifference OAs show with regards to spontaneous abortion.

The real challenge here is “sincerity,” most people have inconsistent beliefs of one form or another and do not realize it; but it is possible that one can realize that they hold two sincere beliefs while also sincerely believing those beliefs to be inconsistent. Consider the problem of evil; one might sincerely believe that God exists, that evil exists, and that God would not allow evil to exist. This belief set is inconsistent, but does not necessarily yield conflicting implications for how we ought to live our lives.

But what if an OA sincerely believes the following?

  • All human death is morally tragic.
  • Not all human death is morally tragic.
  • Propositions (a) and (b) are apparently a contradiction.

It is easy to imagine a Socratic dialogue in which Socrates helps an OA to express position (a) and proposition (b), prompting them to reconsider their position; what’s less easy to imagine is what would happen if an OA freely admits proposition (c), but refuses to reconsider. Moral agency requires some degree of reason-responsiveness, and at least with regards to the topic at hand, it is not clear such an OA would be able to function as a moral agent without rejecting one of these three propositions.

Blackshaw et al. ( 2021 ) end their reply as follows “If critics of [OA] want to change the subject – to examining whether the things [OA] believe are true or false, rather than fixating on [OA’s] alleged inconstancy — then [our] essay has succeeded.” Here, they again miss the point of inconsistency arguments, as these arguments do set out to examine whether the things [OA] believe are true or false; if the principle of non-contradiction is true, and OA hold contradictory beliefs, then at least one of their beliefs are false !

Why do they miss this point? I cannot be sure, but at times Colgrove et al. ( 2020 ) and Blackshaw et al. ( 2021 ) talk as though inconsistency theorists are uniformly prochoice and hope to convince OA to abandon restrictivism; however, inconsistency arguments might just as easily lead one to believe they ought to do more to prevent spontaneous abortion, address surplus frozen human embryos, and the like. Some inconsistency theorists believe both would lead to less restrictivist opposition to abortion, but this is irrelevant.

What matters is that inconsistency arguments share the same form as the Socratic method, highlighting apparent inconsistency and prompting introspection. Perhaps Colgrove et al. ( 2020 ) would also conclude that the Socratic method does not matter , but I hope not.

Other Actions Objection and Response

Colgrove et al.’s second criticism of inconsistency arguments is that they are too specific with their recommendations, suggesting OA can address problems raised by these arguments with different actions than those proposed by inconsistency theorists. For example, rather than adopt and gestate frozen human Embryos, as Lovering ( 2020 ) (and Blackshaw 2021 !) advocate, Colgrove et al. ( 2020 ) suggest OA might fight “to change public perception of the status of embryos,” or lobby to change IVF laws.

There are three problems here. First, although inconsistency theorists propose a variety of recommendations, these recommendations are not meant to be exhaustive, but rather representative of the kinds of changes an OA would need to adopt to resolve their apparent inconsistency. Remember, inconsistency theorists argue that OA face a dilemma — either (i) do more, or (ii) abandon their opposition to abortion; to say that an OA can perform other actions to address the problem just is to embrace the first horn of the dilemma.

Second, I have pointed out (Simkulet 2021 ) that the other actions Colgrove et al. ( 2020 ) propose are not necessarily mutually exclusive; one might both lobby to change IVF laws and adopt and gestate frozen human embryos. The fact that one lobbies to change IVF laws may reduce the number of surplus embryos created and frozen in the future; but it fails to address the needs of currently existing frozen human embryos, highlighting a third problem, that many of Colgrove et al.’s “other actions” are simply not enough. I illustrate (Simkulet 2021 ) this with a case inspired by James Rachels ( 1979 ):

Jack 2 finds himself in a room with a starving child, surplus sandwich in hand. He receives a call… The caller asks, “Will you donate your sandwich?” and he replies, “I’ll do you one better; I’m going to fight to change the public perception of the status of such starving children and raise awareness!” He proceeds to tweet about the starving child, sets up a donation page to help spread awareness, and posts pictures and videos of the child’s deteriorating state. Jack 2 , an expert in such things, narrates as the child slowly dies.

Jack 2 ’s claim to act to raise awareness pokes fun at Colgrove et al.’s ( 2020 ) proposal to protect frozen embryos by fighting to change public perception. Despite his tweeting, it is clear Jack 2 fails morally — he lets a child starve to death when he could have easily saved that child’s life.

Blackshaw et al. ( 2021 ) argue that this case is disanalogous to OA (in)action, arguing that OA “live in a world where there are many important issues clamoring for their attention,” and suggest the following case is more analogous:

Jack 100 finds himself in a room with 100 needy children and only enough resources to save 1 child, which he does.

There are three substantive problems with this response. First, the case of Jack 2 is not meant to be analogous to OA inaction (despite poking fun at it); it is meant to demonstrate that merely having other actions is not sufficient to show that inconsistency arguments fail.

Second, the case of Jack 100 begs the question by assuming Jack is saving as many people as possible. However, as Lovering ( 2020 ) and Blackshaw ( 2021 ) seem to show, this simply is not how OA act. Inconsistency theorists argue that OA neglect to address the problems of spontaneous abortion, surplus frozen embryos, and even starving born children. Rather than save all they can, inconsistency theorists contend that OA act like Jack 2 , they do something , but fail to do everything they can.

Third, inconsistency theorists contend that most OA legislation and philosophical literature neglect to discuss the problems of spontaneous abortion, surplus frozen embryos, or starving born children. As such, perhaps the following case would be more analogous:

Jack 300 finds himself in a room with 300 needy children, and he says, “I see 100 needy children, but woe is me I can only save 1,” and so he saves 1 child.

It seems Jack 300 is unreliable; he says he sees 100 needy children in the room, but there are 300 needy children in the room. If we cannot trust Jack 300 to get an accurate headcount, it seems unreasonable to take his word that he is doing all he can.

With the Jack 100 case Blackshaw et al. ( 2021 ) seem to abandon the other actions objection, instead arguing that OA, like Jack 100 , do the “most good” they can. In short, Blackshaw et al. seem to treat the other actions’ objection as a surrogate for an argument from effective altruism, the view that we should try to do the most good we can. Colgrove et al. ( 2020 ) claim that there are many different beliefs about what it means to do the “most good”, and suggest that objectively measuring options might be difficult, as though to claim that it does not matter what other actions OA take as long as they are trying to do the “most good.”

But this will not do. Effective altruism asks us to use reason and empirical evidence to maximize the amount of good we do, and inconsistency arguments seem to show that OA fail to do just this. Like Jack 2 , OA seem to ignore the easily preventable deaths of some with an unearned confidence that their current course of action is sufficient. If OA strive for effective altruism, they should be at least open to the prospect of embracing the first horn of the inconsistency theorist’s dilemma — that maybe should do more. Suppose Jill 100 finds herself in the locked room with Jack 100 , and promises to show Jack 100 how he can save 3 needy children, rather than just 1, with the resources at hand; if Jack 100 seeks to be an effective altruist, should he not at least listen, time permitting?

Effective altruism requires that we guide our choices by reason and evidence; it is not enough to have a sincere belief that one is doing all that one can, the evidence has to back this up. If inconsistency theorists can show that OA are not doing all they can, then they have been succeeding in showing that OA fall short of effective altruism.

Of course, this is exactly what proponents of inconsistency theorists purport to show. Take the aforementioned inconsistency theorist Lovering ( 2020 ) who, like OA restrictivist Blackshaw ( 2021 ), argues that OA should do more than merely fight to change public perception or lobby to change IVF laws, in many cases they ought to also adopt and gestate actually existing frozen human embryos. Of course, not every OA can gestate frozen human embryos — without effective ectogenesis technology and universal healthcare this burden seems to fall on wealthy, female OA alone. However, few OA argue that adopting and gestating these embryos are obligatory for those with the means to do so, and this omission at least appears to be inconsistent with their assertion that all fetuses matter from conception, let alone the position that OA are acting as effective altruists.

Furthermore, Blackshaw ( 2021 ) does not merely side with Lovering regarding OA’s obligations regarding frozen human embryos; he says:

[I]f we regard all human life as equally valuable, we have at least some obligation toward helping reduce deaths from spontaneous abortion where possible. The parable of the Good Samaritan reinforces the notion that Christians do have some responsibility toward this neglected group of human beings, who are also our neighbors.

Here Blackshaw ( 2021 ) contends that these groups — frozen human embryos and those fetuses who die from spontaneous abortion — matter , and that at least some OA — those inconsistency arguments seek to criticize — neglect them. In short, Blackshaw’s ( 2021 ) view seems at odd with the view he expresses in Colgrove et al. ( 2020 ) and Blackshaw et al. ( 2021 ). This is not meant as a criticism of Blackshaw; philosophers revise their views over time, articles are often published long after their initial submission, and many articles are written for blind review which could disincentivize the author from discussing their previous works.

Note, however, that Colgrove et al. ( 2020 ) and Blackshaw et al. ( 2021 ) set out to argue that inconsistency arguments do not matter for any OA view and in doing so they bite off far more than they can chew. It is easy to contend that all OA have other possible actions – contra Frankfurt ( 1969 ), many philosophers believe alternate possibilities are required for moral agency and responsibility; but it is quite a different matter to argue that all OA are acting as effective altruists, or even that all OA merely sincerely believe they are acting as effective altruists, especially when confronted with criticism from inconsistency theorists. Blackshaw ( 2021 ) contends inconsistency arguments demonstrate that some OA neglect this group, and this alone seems sufficient to show inconsistency arguments are morally significant.

Hypocrisy Objection and Response

In their third objection, Colgrove et al. ( 2020 ) contend that inconsistency arguments aim to show that OA are hypocrites, rather than demonstrate inconsistency. I note (Simkulet 2021 ) that Colgrove et al. equivocate between hypocrisy and inconsistency, and that they characterize hypocrisy as a moral failing. Colgrove et al. ( 2020 ) say:

[OA] are often described as ’inconsistent’ (hypocrites) in terms of their beliefs, actions and/or priorities…These objections notwithstanding, perhaps some OAs do act in ways that can be shown to be inconsistent with their beliefs. If so, then they are hypocrites. Hypocrisy is a serious charge regarding the character of OAs, but it has nothing to say regarding the validity and consistency of their beliefs—and OAs’ beliefs are surely what critics should primarily be targeting.

In short, it seems that Colgrove et al. mischaracterize inconsistency arguments as ad hominem fallacies; but as we have already seen there is a difference. Inconsistency arguments are simply not aimed at showing OA are hypocrites; only that they have inconsistent beliefs.

In their reply to my previous work (Simkulet 2021 ), Blackshaw et al. ( 2021 ) say something bizarre “Simkulet offers no empirical evidence regarding [OA’s] supposed lack of interest in relevant issues.” But inconsistency theorists do this ; Lovering ( 2020 ) goes to great lengths to discuss OA who do go out of their way to address these concerns and provides evidence such altruism is rare . Still, it is difficult to take this call for empirical evidence seriously, as neither Colgrove et al. ( 2020 ) nor Blackshaw et al. ( 2021 ) provide such evidence on behalf of OA.

Blackshaw et al. ( 2021 ) also challenge my claim (Simkulet 2021 ) that legislation seeking to reduce the creation of surplus IVF embryos would be relatively easy to pass:

Not so. Italy, for example, passed a law in 2004 prohibiting the freezing of embryos, and requiring that all embryos be implanted. (Riezzo et al. 2016 ) The law was swiftly condemned, eventually overturned and, in one case, actions prescribed by the law were declared by the UN to have constituted a ‘human rights violation.’ (Scaffidi 2019 ) Thus, relevant laws would likely face international resistance. So, a central problem Simkulet puts forth as having an ‘easy’ solution does not.

There are two big problems here. First, I propose (Simkulet 2021 ) passing legislation to limit the creation of surplus embryos, not to force all created embryos to be implanted. The difference is obvious, my restrictivist proposal would limit the number of embryos created at a time, so it might take multiple tries before a successful embryo is created.

In contrast, the Italian law seems to place no limits on how many embryos can be created, rather it sets out to force women to undergo invasive, risky medical procedures. IVF has a relatively low chance of success; but imagine more attempts at fertilization succeed than expected; this law would compel physicians to perform, and women to undergo, dangerous medical procedures against their wills. This is hauntingly similar to forcing you to donate bone marrow even at the cost of your life in Boonin’s ( 2002 ) bone marrow case. In short, the Italian law threatens to harm citizens and undermine professional ethics by requiring medically risky and unnecessary interventions without the patient’s consent.

In contrast, my proposal (Simkulet 2021 ) would merely require physicians limit the number of embryos created at one time; not entirely dissimilar from legal limits on how many drugs a physician can prescribe within a period of time. Furthermore, I do not say such legislation would be easy, only “relatively easy” compared to restrictivist legislation – legislation that has far more in common with the Italian law than Blackshaw et al. ( 2021 ) acknowledge. Both restrictivist legislation and the Italian law seek to undermine women’s rights to control their body and force them to risk their lives for the sake of others. Meanwhile limiting the number of embryos created does not limit one’s reproductive freedom, nor compel them to take on additional medical risk.

Both OA restrictivist legislation and the Italian law seek to limit women’s reproductive choices and force women to take on additional medical risk. Legislation of this kind faces strong opposition from those seeking to protect women’s liberty and reproductive freedom. This kind of legislation also faces strong opposition from biomedical ethicists and medical professionals, as it threatens to violate patient autonomy and the Hippocratic Oath by forcing patient and physician to perform risky medical procedures to benefit a third party, not unlike forcing you to remain attached to the violinist in Thomson’s infamous violinist case (Thomson 1972 ).

In contrast, it is not clear that my proposed legislation (Simkulet 2021 ) to limit the number of embryos that can be created at a single time, would face much opposition at all. Perhaps eugenicists would oppose such legislation for limiting a parent’s right to choose the “best” fetus from the widest possible net, but this does not seem like a widely held position. Perhaps bioethicists and medical professionals would oppose such legislation believing it cumbersome and impractical, but this seems like a much weaker ground for opposition than the autonomy and professional ethics violations epitomized by OA restrictivist legislation and the Italian law.

The Prochoice Other Beliefs Objection

I have argued (Simkulet 2021 ) that if the other beliefs, other actions, and hypocrisy objections are not successful in showing inconsistency arguments “do not matter,” they threaten to undermine the discipline of ethics. No person has merely one moral belief, so if a diversity of beliefs invalidates moral analysis, ethics is impossible. In all cases in which a person acts morally responsibly (save maybe some interpretations of Frankfurt-style cases (Frankfurt 1969 ), agents have other possible actions, so if merely having other actions was sufficient to disregard moral analysis, ethics fails. Finally, if interpreting moral analysis as an ad hominem attack of hypocrisy was sufficient to rebuff criticism, one can shut down all moral debate merely by being thin-skinned. Here, I have argued that Blackshaw et al. ( 2021 ) fail to defend these objections, and fail to show that inconsistency arguments do not matter.

However, these are lofty claims about the discipline of ethics; let’s consider something a bit more down to Earth. Consider the following case:

Jacqueline is surprised to find herself pregnant, calling into question her school’s sexual education program. While discussing the matter with her physician, she learns that some people believe embryos are persons from conception! She finds this view intuitive and compelling, and outraged by her school’s poor sexual education program, she endeavors to work tirelessly to change the public perception of the status of embryos. Later, her physician expresses concern about her exertion, recommending that she puts her efforts to educate on hiatus during the pregnancy, fearing the worst. Jacqueline faces a choice — (i) continue with her pregnancy for the next 6 months, losing ground on her fight to change public perception of embryos or (ii) induce abortion (perhaps by hysterectomy) and continue the fight. When speaking with her physician, Jacqueline quotes an influential piece of literature (Colgrove et al. 2020 ), “It may be unclear, however, which option is superior. Many considerations apply to each, and they may be highly individualistic.” She continues “Objectively evaluating options to determine the most appropriate action for a particular belief held by a specific individual seems a very difficult task.” Upon careful and thoughtful reflection, she chooses (ii), judging that it will do the most good. After all, her embryo is but one embryo and while it is tragic to disconnect it from her body and let it die, her tireless efforts might do more good overall.

If the other actions objection shields OA from inconstancy arguments, it seems that it equally shields Jaqueline from restrictivist OA arguments that seek to restrict her freedom. Therefore, it seems that Blackshaw et al. face a dilemma — (i) reject the position that merely having other actions, beliefs, etc. is sufficient to shield a position from criticism, or (ii) abandon their opposition to induced abortion. If (i), then inconsistency arguments matter. Then again, if (ii), then it seems as though no ethical arguments matter.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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