Texas Policy Evaluation Project
TEXPEP upper righthand gray scale identity logo

Letter to the Texas Department of State Health Services Regarding the Woman's Right to Know Booklet

[Download a PDF of this letter here]

July 29, 2016      

Department of State Health Services
Austin, TX
Sent via email to WRTK@dshs.state.tx.us

To Whom It May Concern:

As a group of academic researchers with the Texas Policy Evaluation Project (TxPEP), including an obstetrician-gynecologist, we are very concerned that the proposed revised version of the Woman’s Right To Know brochure contains medically inaccurate information. The language is also biased, using phrases like “baby that is growing in your womb,” rather than medically accurate terms such as embryo or fetus. Below we highlight some of the inaccurate statements:

• Page 2: The statement at the top of this page implies that fetuses can feel pain before 20 weeks gestation, after which most abortions are banned in Texas. The best medical evidence, as well as statements by the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynaecologists, indicate that this is not true.1,2,3

• Page 3, “week 10”: Neurologic connections from the periphery to the cerebral cortex that would allow for the perception of pain are not intact before 24 weeks gestation.3

• Women reading the pamphlet are choosing between abortion and carrying an unwanted or unsafe pregnancy to term. They cannot go back in time and not get pregnant. Therefore, any discussion of the consequences of abortion should be in light of these two choices. This fact is particularly relevant to the next several bullets, which address how the pamphlet discusses the consequences of abortion.

• Page 8: The statistics about the risk of death from abortion are from 1988-1997 and are no longer accurate. A more recent report with data from the US Centers for Disease Control and Prevention through 2010 was published last year.4 According to these most recent data, the risk of death is lower than what is included in this document for the later gestational ages. The risk of death is:

   o At 8 weeks or less: 0.3 deaths/100,000 procedures (or 1 death for every 333,333 procedures)

   o At 14-17 weeks: 2.5 deaths/100,000 procedures (or 1 death per 40,000 procedures)

   o At 18 weeks or later: 6.7 deaths/100,000 procedures (or 1 death per 15,000 procedures)

• Page 18: The risk of death associated with continuing a pregnancy is grossly underestimated. In Texas, according to DSHS, in 2013 the maternal mortality rate was 0.4 maternal deaths per 1,000 live births—or one death per 2,500 live births.5 This means that the risk of pregnancy-related death in Texas is higher than the risk of abortion-related death in the state (which was zero for at least the past 8 years).

• Page 8: The description of the mental health consequences of abortion is misleading and inadequate (and, in fact, this section has no references). The best data on the mental health outcomes after abortion come from the Turnaway Study, a prospective study of almost 1,000 women that compares the outcomes of women who obtained an abortion to those who were unable to obtain a desired abortion because they were just past the gestational age limit of the facility. Below are several important findings from that study and other research exploring mental health outcomes after abortion:

   o One week after an abortion, those denied the abortion reported significantly higher measures of regret and anger and lower measures of relief and happiness compared to women who obtained the abortion.6 Initial anxiety scores were higher and scores for self-esteem were lower for women denied the abortion, but after six months to one year, measures of anxiety and self-esteem improved and were similar to women who received the abortion.7,8 Depression symptoms were similar in both groups and declined over time.

   o An analysis of mental health diagnoses three years after receiving or being denied an abortion found that women who obtained an abortion were at no higher risk of depression or anxiety compared to those who carried an unwanted pregnancy to term.9

   o Women receiving an abortion were also not at higher risk of experiencing post-traumatic stress symptoms, and the main source of stress was prior history of violence, not the abortion.10

   o At all time points during a 3-year period of follow-up after abortion, 95% of abortion patients reported the abortion decision was right for her.11

   o Qualitative studies of women who reported post-abortion emotional difficulty suggest that negative emotions may not be the product of the abortion procedure or experience and, instead, stem from social experiences, including lack of social and emotional support and/or loss of a romantic relationship that co-occurred with the abortion.12,13

   o Research from the Turnaway Study has found no support for the claim that having an abortion leads women to use alcohol, tobacco, or drugs to cope with the stresses of having an abortion. Women who have abortions do not increase their binge drinking, problem alcohol use, tobacco use, or drug use over 2 – 2.5 years.14,15,16 While women who have abortions do increase their use of any alcohol over 2.5 years, women denied abortions increase their use of any alcohol more rapidly over this time period.15

   o Overall, these data indicate that negative mental health outcomes are not more common among women having an abortion compared to those who initially sought an abortion and continued the pregnancy to term.

• Page 9: In February 2003, the National Cancer Institute (NCI) convened a workshop of experts to review the existing population-based, clinical, and animal studies on the relationship between pregnancy and breast cancer risk, including studies of induced and spontaneous abortions. They concluded that having an abortion or miscarriage does not increase a woman’s subsequent risk of developing breast cancer.17 No recent data have altered this assessment.

• Page 9: It is inconsistent and misleading to mention the pain and bleeding associated with abortion but not mention these same symptoms with vaginal delivery and cesarean section.

• Page 14: Hemorrhage after medical abortion is rare, and it is always treatable with vacuum aspiration and/or medications. A PubMed search of “mifepristone,” “abortion,” and “hysterectomy” revealed no reports of hysterectomy done to treat hemorrhage after first-trimester medical abortion.

• Page 15: The description of medical abortion is not consistent with the recently updated final printed label of Mifeprex approved by the Food and Drug Administration. The woman is no longer required to return to the facility for misoprostol.18

• Page 18: The complications described for vaginal delivery and cesarean birth are incomplete. In particular, there are complications listed in the abortion section, such as retained placenta requiring another procedure, or an amniotic fluid embolus, which may also occur with term delivery.

We hope you will consider revising this document to be consistent with the most recent peer-reviewed published literature. As a public health agency, DSHS has a responsibility to ensure that the information it disseminates is up to date and accurate.


Daniel Grossman, MD
Professor, University of California, San Francisco
Investigator, TxPEP

Joseph E. Potter, PhD
Professor, University of Texas at Austin
Lead Investigator, TxPEP

Kari White, PhD, MPH
Assistant Professor, University of Alabama at Birmingham
Investigator, TxPEP

Kristine Hopkins, PhD
Research Assistant Professor, University of Texas at Austin
Investigator, TxPEP

Amanda J. Stevenson
PhD Candidate, University of Texas at Austin
Graduate Research Associate, TxPEP



1 Lee SJ, Ralston HJ, Drey EA, Partridge JC, Rosen MA. Fetal pain: a systematic multidisciplinary review of the evidence. JAMA. 2005 Aug 24;294(8):947-54.

2 ACOG Practice Bulletin No. 135: Second-trimester abortion. Obstet Gynecol. 2013 Jun;121(6):1394-406.

3 Royal College of Obstetricians and Gynaecologists. Fetal awareness: review of research and recommendations for practice. Report of a working party. Available at https://www.rcog.org.uk/globalassets/documents/guidelines/rcogfetalawarenesswpr0610.pdf. Accessed July 27, 2016.

4 Zane S, Creanga AA, Berg CJ, Pazol K, Suchdev DB, Jamieson DJ, Callaghan WM. Abortion-Related Mortality in the United States: 1998-2010. Obstet Gynecol. 2015 Aug;126(2):258-65.

5 Texas Department of State Health Services. Table 5: Resident infant, maternal and fetal deaths, 2013. Available at http://www.dshs.texas.gov/chs/vstat/vs13/t05.aspx. Accessed July 27, 2016.

6 Rocca CH, Kimport K, Gould H, Foster DG. Women's emotions one week after receiving or being denied an abortion in the United States. Perspect Sex Reprod Health. 2013 Sep;45(3):122-31.

7 Foster DG, Steinberg JR, Roberts SC, Neuhaus J, Biggs MA. A comparison of depression and anxiety symptom trajectories between women who had an abortion and women denied one. Psychol Med. 2015 Jul;45(10):2073-82.

8 Biggs MA, Upadhyay UD, Steinberg JR, Foster DG. Does abortion reduce self-esteem and life satisfaction? Qual Life Res. 2014 Nov;23(9):2505-13.

9 Biggs MA, Neuhaus JM, Foster DG. Mental Health Diagnoses 3 Years After Receiving or Being Denied an Abortion in the United States. Am J Public Health. 2015 Dec;105(12):2557-63.

10 Biggs MA, Rowland B, McCulloch CE, Foster DG. Does abortion increase women's risk for post-traumatic stress? Findings from a prospective longitudinal cohort study. BMJ Open. 2016 Feb 1;6(2):e009698.

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

12 Kimport K, Foster K, Weitz TA. Social sources of women's emotional difficulty after abortion: lessons from women's abortion narratives. Perspect Sex Reprod Health. 2011 Jun;43(2):103-9.

13 Kimport K. (Mis)understanding abortion regret. Symbolic Interaction 2012;35(2):105-22.

14 Roberts SC, Rocca CH, Foster DG. Receiving versus being denied an abortion and subsequent drug use. Drug Alcohol Depend. 2014 Jan 1;134:63-70.

15 Roberts SC, Delucchi K, Wilsnack SC, Foster DG. Receiving Versus Being Denied a Pregnancy Termination and Subsequent Alcohol Use: A Longitudinal Study. Alcohol Alcohol. 2015 Jul;50(4):477-84.

16 Roberts SC, Foster DG. Receiving versus being denied an abortion and subsequent tobacco use. Matern Child Health J. 2015 Mar;19(3):438-46.

17 National Cancer Institute. Cancer facts: abortion, miscarriage, and breast cancer risk. Issues Law Med. 2005 Fall;21(2):159-60.

18 Mifeprex labeling. Available at http://www.earlyoptionpill.com/wp-content/uploads/2016/03/MIFEPREX-Labeling-and-MG-FINAL_March2016.pdf. Accessed July 27, 2016.

  • Texas Policy Evaluation Project

    Population Research Center
    University of Texas at Austin
    305 E. 23rd Street
    Stop G1800
    Austin, Texas 78712