墮胎限制對歷史上邊緣化人群的心理健康影響
資料來源：n engl j med 387;17 nejm.org October 27, 2022 / 財團法人台灣紅絲帶基金會編譯
Lucy Ogbu Nwobodo, M.D., Ruth S. Shim, M.D., M.P.H., Sarah Y. Vinson, M.D., Elizabeth M. Fitelson, M.D., M. Antonia Biggs, Ph.D., Monica R. McLemore, Ph.D., M.P.H. , R.N., Marilyn Thomas, Ph.D., M.P.H., Micaela Godzich, M.D. 和 Christina Mangurian, M.D.
2022 年 6 月 24 日，美國最高法院推翻了具有里程碑意義的 1973 年羅訴韋德案 (Roe v. Wade) 裁決，廢除了維持了近半個世紀的憲法墮胎權。有多個跡象顯示，多布斯訴傑克遜婦女健康組織案(Dobbs v. Jackson Women’s Health Organization) 中影響深遠的決定，將不成比例地傷害歷史上已經面臨公平醫療保健障礙的邊緣化群體。在後羅伊 (post-Roe) 時代，生殖健康自主權受到威脅，最近多個州的限制性立法激增表明了這一點。多布斯的決定限制了數百萬可能懷孕的人獲得基本醫療服務——包括順性別婦女和女孩；非二元性、跨性別和雙靈者 (Two Spirit people，註 )；和跨性別男性。在這樣的情況下，多布斯將加劇健康不平等。（當不引用其他人的工作時，我們不分性別使用「分娩和懷孕的人」一詞來包容所有人；在引用使用該詞的研究時，我們使用「女性」）。
我們認為，多布斯決定的影響最好透過一個交叉鏡頭來看待，包括結構性種族主義、生殖上的不公平和心理健康，因為有心理健康狀況、創傷和物質使用障礙病史的人，更容易在懷孕及之後出現受到污名化、歧視和不良之健康狀況。
墮胎與心理健康
首先，墮胎不會對心理健康造成傷害——這一事實已被數據證實，並得到美國國家科學、工程和醫學研究院以及美國心理學會的認可。Turnaway 研究，一項比較墮胎者和拒絕墮胎者的心理健康結果的研究發現，拒絕墮胎者與最初獲得墮胎治療者相比，其壓力、焦慮和低自尊水平更高。而進行過人工流產的人罹患任何精神健康障礙的風險並未增加，包括抑鬱、焦慮、自殺意念、創傷後壓力症候群或物質使用障礙。不論是拒絕墮胎抑或尋求墮胎後，最容易產生不良心理後果的人是那些有精神健康狀況或兒童期有被虐待或忽視史的人，以及那些認知墮胎污名者（即他們覺得別人會因為他們尋求墮胎而看不起他們）。此外，受到社會高度壓迫和邊緣化的人更容易受到心理困擾。
有證據顯示，平均而言，尋求墮胎的人的基本心理健康狀況比不尋求墮胎的人更差。然而，這種更差的心理健康狀況部分是由於結構性不公平，導致一些人口不成比例地暴露於貧困、創傷、童年不良經歷（包括身體和性虐待）以及親密伴侶的暴力。人們出於多種原因尋求墮胎，包括（但不限於）時間問題、需要關注其他孩子、關心自己的身體或心理健康、避免讓孩子暴露於暴力或虐待伴侶之願望，以及撫養孩子缺乏經濟保障。此外，對於有精神疾病史的人來說，懷孕和產後期是精神症狀的複發率以及不良妊娠和分娩結果發生率增加的高風險期。由於恥辱和歧視，患有嚴重精神疾病的分娩或孕婦正如一項針對雙相情感障礙女性的小型研究所強調的那樣，衛生專業人員更有可能建議他們避免或終止妊娠。一項研究發現，在患有精神健康問題的女性中，人工流產時再入院率住院率並未提高，但分娩時在精神病院住院的比例則有所增加。數據還顯示，對於有心理健康問題的人，無論他們是否進行流產或生孩子，心理健康結果都很差。
結構性種族主義的作用
結構性種族主義——定義為廣大層面之系統和機構之間的持續互動導致了邊緣化種族和族裔群體的資源、機會和權力的限制——被廣泛認為是健康狀況不佳和種族不平等的根本原因，包括不利的孕產婦健康結果。結構性種族主義導致了廣泛的健康促進資源和機會的不公平分配，這些資源和機會不公平地有利於白人，也不公平地損害歷史上被邊緣化的種族和族裔群體（例如，教育、帶薪休假、獲得高品質的醫療保健、安全的社區和負擔得起的住房）。此外，結構性種族主義是造成許多不同人群中的不平等和不良心理健康結果的原因。
儘管沒有社會所定義的種族或族裔群體佔絕大多數尋求墮胎者的資料，但數據顯示，相對於她們在總人口中的百分比，在美國黑人和拉丁裔女性在墮胎患者中的比例過高而白人女性的比例偏低，低收入婦女（家庭收入低於聯邦貧困線的 100%）在所有接受墮胎的患者中所佔比例最高，75% 接受墮胎的患者的家庭收入低於聯邦貧困線的 200%。
生殖上的不公平
貧困與墮胎之間的關聯是多方面的，其根源在於生殖上的不公平，包括保險覆蓋率和獲得避孕藥具的機會與就業掛鉤，而能夠懷孕的黑人和拉丁裔人的失業率和就業不足率遠高於白人，且在公共醫療保險補助 (Medicaid) 計畫中的比例過高，而在這些計畫中取得墮胎的機會，在根據海德和赫爾姆斯修正案(the Hyde and Helms Amendments) 中被嚴重地限制。由於結構性種族主義的有害影響，這些社會人口族群都是處在相同的精神疾病和物質使用障礙負面結果之風險下的人群。
獲得生殖保健自由上的限制，會加劇所有人面對結構性種族主義、性別種族主義和階級歧視等交叉因素，尤其是那些已經存在有心理健康問題的人。這些限制對心理健康產生不利影響，這與分娩和懷孕的人在整個生殖生命週期中所做的決定密切相關。例如，有經濟能力的人可以更輕鬆地跨州獲得墮胎服務；低收入和其他受壓迫和邊緣化的人群、LGBTQ 人群以及患有嚴重心理健康狀況和物質使用障礙的人群，往往缺乏同樣的旅行就診機會。
歷史上被邊緣化的群體在身體自主權和個人權利方面已經面臨重大限制；有限的墮胎機會進一步侵蝕了這些權利。甚至在多布斯案 (Dobbs) 之前，患有精神健康或物質使用障礙的分娩和懷孕的人就因在懷孕期間使用物質或甚至企圖自殺而危及兒童或被控謀殺因而被監禁。在羅訴韋德案 (Roe v. Wade) 所保障的隱私權被消除，並且在許多州將墮胎定為刑事犯罪，由於生育決定，甚至在人工流產的情況下，涉及刑事法律制度的懲罰性風險，對於歷史上邊緣化群體且具有精神疾病的成員來說可能尤其地高——而這些人在刑事法律體系中早已經是被過度代表的人群。
懷孕上的風險
合法流產是一種安全的臨床程序，併發症和死亡率極低。相反，與分娩相關的死亡風險是合法流產的 14 倍。事實上，美國與其他高收入國家相比，美國孕產婦的死亡率很高。結構性種族主義（如表現在限制性墮胎法規中）導致黑人婦女的孕產婦死亡率是白人婦女的 3.55 倍。經驗證據還支持結構性種族主義與孕產婦健康不平等之間的關聯，包括在種族不平等最明顯的地理區域的所有婦女中早產率和更嚴重的孕產婦併發症比率更高，因此黑人婦女擁有不成比例高的不良結果。
此外，精神疾病越來越被認為是與妊娠相關死亡率的主要原因——自殺和過量服用藥物是孕婦和產後婦女死亡的主要原因。對於親密伴侶暴力的倖存者來說，懷孕是一個特別危險的時期，在美國他們極有可能是黑人或原住民；這些倖存者面臨著許多不良的心理健康後果，包括抑鬱、焦慮、創傷後壓力症候群、物質使用障礙和自殺未遂。在最近對美國孕產婦死亡率的分析中，懷孕期間或懷孕結束後 42 天內的兇殺案造成的死亡人數是其他任何原因的兩倍多。黑人婦女尤其處於危險之中。消除生殖選擇可能會加劇這些令人擔憂的趨勢。
對於許多患有精神疾病的分娩和孕婦來說，妊娠併發症是另一個主要且不公平的風險；這些不平等在種族和民族邊緣化的女性中比在白人女性中更為明顯。研究顯示，精神分裂症或情感障礙患者的產科和新生兒併發症發生率高於平均水平。此外，產婦抑鬱症是母子聯結關係受損以及孕產婦產前抑鬱是早產的獨立預測因素。生殖服務障礙可能導致一些孕婦使用非循證方法進行人工流產，這增加了她們罹患併發症。儘管米索前列醇和米非司酮 (misoprostol and mifepristone) 等墮胎藥的安全性和有效性，但患者和臨床醫生都缺乏對這些選擇的足夠認識，並且可能不確定它們的使用是如何地受到國家墮胎禁令的影響。在最近的一項研究中，調查人員使用人口統計估計方法預測，與 2017 年相比，全國範圍內禁止墮胎服務將導致所有美國女性中與懷孕相關的死亡人數有21% 的增長，以及在黑人女性中增加了 33%。這些估計值是基於妊娠和分娩併發症，並不包括不安全、自我誘導或非臨床醫生協助流產的潛在影響或致命家庭暴力的風險。
生殖正義方面另一個值得考慮的是照護者對孩子的家庭和環境做出決定的自主權。大多數進行墮胎的婦女已經是母親。在對 1000 多名接受墮胎的患者進行的結構化調查中，尋求墮胎的最常被引用的原因是再生育一個孩子會干擾患者的教育、工作或照顧其他依賴者的能力，這些理由在一個在公共補貼兒童保育、帶薪育兒假和社會安全網絡服務方面上繼續落後於同儕的社會中尤為重要——其中黑人、拉丁裔和原住民家庭以及患有精神疾病的母親不成比例地受到撫育照護系統的監督和侵擾。
結論
儘管公認的複雜和高度政治化，生殖正義，包括及時和容易地獲得墮胎，毫無疑問是一個醫療保健問題——一個影響深遠的心理（和身體）健康的社會決定因素。民主國家的法律應該反映人民的意願，公正社會的結構體系應該產生公平的結果。多布斯的裁決在這兩個方面都落入缺失。對於來自歷史上被邊緣化群體的分娩和孕婦來說，這種影響尤其嚴重，尤其是那些患有精神健康和藥物濫用障礙的人群–這將進一步危及面臨令人震驚的高妊娠相關發病率和死亡率的人群。
作者提供的披露表可在 NEJM.org 上獲取。
來自美國加利福尼亞大學舊金山分校精神病學和行為科學系 (L.O.-N., M.T., C.M.) 和產科、婦科和生殖科學系 (M.A.B.)；加州大學戴維斯分校薩克拉門托分校精神病學和行為科學系 (R.S.S.) 以及家庭和社區醫學系 (M.G.)；亞特蘭大莫爾豪斯醫學院精神病學和行為科學系 (S.Y.V.)；紐約哥倫比亞大學精神病學系 (E.M.F.)；和西雅圖華盛頓大學護理學院兒童、家庭和人口健康護理系 (M.R.M.)。Ogbu-Nwobodo博士和 Shim 對本文做出了同等貢獻。
註：雙靈 (Two-spirit) ：雙靈是一個現代泛北美原住民的概括性詞彙，被一些北美原住民用來描述社區中滿足傳統第三性別的原住民在他們的文化中的禮儀和社會角色。 雙靈一詞是在 1990 年在溫尼伯舉行的原住民男女同性戀國際聚會上所創造的，「專門用來區分美洲原住民/第一民族與非原住民並使其保持距離。」
Mental Health Implications of Abortion Restrictions for Historically Marginalized Populations
n engl j med 387;17 nejm.org October 27, 2022
Lucy Ogbu Nwobodo, M.D., Ruth S. Shim, M.D., M.P.H., Sarah Y. Vinson, M.D., Elizabeth M. Fitelson, M.D., M. Antonia Biggs, Ph.D., Monica R. McLemore, Ph.D., M.P.H., R.N., Marilyn Thomas, Ph.D., M.P.H., Micaela Godzich, M.D., and Christina Mangurian, M.D.
On June 24, 2022, the U.S. Supreme Court reversed the landmark 1973 Roe v. Wade ruling, dismantling the constitutional right to abortion that had been upheld for nearly half a century. There are multiple indicators that the far-reaching decision in Dobbs v. Jackson Women’s Health Organization will disproportionately harm historically marginalized groups who already face barriers to equitable health care. In the post-Roe world, reproductive health autonomy is under threat, as indicated by the recent surge of restrictive legislation across multiple states. The Dobbs decision restricts access to essential medical care for millions of people who can become pregnant — including cisgender women and girls; nonbinary, intersex, and Two Spirit people; and transgender men (when not citing others’ work, we use the term “birthing and pregnant people” to be inclusive of all people, regardless of gender; we use “women” when citing research that used that term). In doing so, Dobbs will exacerbate health inequities.
We believe the implications of the Dobbs decision are best viewed through an intersectional lens encompassing structural racism, reproductive injustice, and mental health, since people with a history of mental health conditions, trauma, and substance use disorders are more vulnerable to stigma, discrimination, and adverse health outcomes in pregnancy and beyond.
Abortion and Mental Health
To begin with, abortion does not lead to mental health harm — a fact that has been established by data and recognized by the National Academies of Sciences, Engineering, and Medicine and the American Psychological Association. The Turnaway Study, a longitudinal study that compared mental health outcomes among people who obtained an abortion with those among people denied abortion care, found that abortion denial was associated with initially higher levels of stress, anxiety, and low self-esteem than was obtaining of wanted abortion care. People who had an abortion did not have an increased risk of any mental health disorder, including depression, anxiety, suicidal ideation, post-traumatic stress disorder, or substance use disorders. Whether people obtained or were denied an abortion, those at greatest risk for adverse psychological outcomes after seeking an abortion were those with a history of mental health conditions or of child abuse or neglect and those who perceived abortion stigma (i.e., they felt others would look down on them for seeking an abortion). Furthermore, people who are highly oppressed and marginalized by society are more vulnerable to psychological distress.
There is evidence that people seeking abortion have poorer baseline mental health, on average, than people who are not seeking an abortion. However, this poorer mental health results in part from structural inequities that disproportionately expose some populations to poverty, trauma, adverse childhood experiences (including physical and sexual abuse), and intimate partner violence. People seek abortion for many reasons, including (but not limited to) timing issues, the need to focus on their other children, concern for their own physical or mental health, the desire to avoid exposing a child to a violent or abusive partner, and the lack of financial security to raise a child.5,12 In addition, for people with a history of mental illness, pregnancy and are a time of high risk, with increased rates of recurrence of psychiatric symptoms and of adverse pregnancy and birth outcomes. Because of stigma and discrimination, birthing or pregnant people with serious mental illnesses or substance use disorders are more likely to be counseled by health professionals to avoid or terminate pregnancies, as highlighted by a small study of women with bipolar disorder. One study found that among women with mental health conditions, the rate of readmission to a psychiatric hospital was not elevated around the time of abortion, but there was an increased rate of hospitalization in psychiatric facilities at the time of childbirth. Data also indicate that for people with preexisting mental health conditions, mental health outcomes are poor whether they obtain an abortion or give birth.
The Role of Structural Racism
Structural racism — defined as ongoing interactions between macro-level systems and institutions that constrain the resources, opportunities, and power of marginalized racial and ethnic groups — is widely considered a fundamental cause of poor health and racial inequities, including adverse maternal health outcomes. Structural racism ensures the inequitable distribution of a broad range of health-promoting resources and opportunities that unfairly advantage White people and unfairly disadvantage historically marginalized racial and ethnic groups (e.g., education, paid leave from work, access to high-quality health care, safe neighborhoods, and affordable housing). In addition, structural racism is responsible for inequities and poor mental health outcomes among many diverse populations.9
Although no socially defined racial or ethnic group accounts for the majority of people seeking abortions, data show that, relative to their percentages in the general population, Black and Latina women are overrepresented and White women are underrepresented as patients undergoing abortion in the United States. Low-income women (with household incomes below 100% of the federal poverty level) are the most overrepresented of all population groups among patients obtaining abortions, and 75% of all patients undergoing abortion have a household income of less than 200% of the federal poverty level.
Reproductive Injustice
The association between poverty and abortion is multifactorial and is grounded in reproductive injustice, including the fact that insurance coverage and access to contraception are tied to employment, while Black and Latinx people capable of becoming pregnant have higher rates of unemployment and underemployment than White people and are overrepresented in public insurance (Medicaid) programs that severely limit access to abortion under the Hyde and Helms Amendments. Because of the deleterious effects of structural racism, these demographic groups are the same populations that are at greater risk for negative outcomes of mental illnesses and substance use disorders.
Limiting the freedom to access reproductive health care exacerbates intersecting factors of structural racism, gendered racism, and classism for all people — especially those with preexisting mental health issues. These restrictions adversely affect mental well-being, which is closely tied to the decisions that birthing and pregnant people make throughout their reproductive life course. For example, people with financial means can more easily access abortion services across state lines; low-income and other oppressed and marginalized populations, LGBTQ people, and people with serious mental health conditions and substance use disorders often lack the same opportunities to travel for care.
Historically marginalized groups already face substantial limitations on bodily autonomy and personal rights; limited access to abortion further erodes these rights. Even before Dobbs, birthing and pregnant people with mental health or substance use disorders were incarcerated for child endangerment or homicide for using substances during pregnancy or even for suicide attempts. With the elimination of the right to privacy guaranteed by Roe v. Wade and the criminalization of abortion in many states, the risk of punitive involvement by the criminal legal system as a consequence of reproductive decisions, and potentially even in cases of miscarriage, is likely to be especially high for members of historically marginalized groups with mental illness — a population that is already overrepresented in the criminal legal system.
Pregnancy Risks
Legal abortion is a safe clinical procedure, with extremely low rates of complications and death. Conversely, the risk of death associated with childbirth is 14 times that associated with legal abortion. In fact, the United States has high maternal mortality as compared with other highincome countries, and structural racism (as manifested in restrictive abortion laws) contributes to maternal mortality among Black women that is 3.55 times that among White women. Empirical evidence also supports a link between structural racism and maternal health inequities, including higher rates of preterm births and more severe maternal complications among all women in geographic areas where racial inequities are most marked, though Black women have disproportionately worse outcomes.
In addition, mental illness has been increasingly recognized as a major contributor to pregnancy-associated mortality — suicide and overdose are leading causes of death among pregnant and postpartum women. Pregnancy is a particularly risky time for survivors of intimate partner violence, who in the United States are disproportionately likely to be Black or Indigenous; these survivors face numerous adverse mental health outcomes, including depression, anxiety, posttraumatic stress disorder, substance use disorders, and suicide attempts. In a recent analysis of maternal mortality in the United States, homicide during pregnancy or within 42 days after the end of pregnancy was responsible for more than twice as many deaths as any other cause. Black women were particularly at risk. The elimination of reproductive options is likely to exacerbate these concerning trends.
Complications of pregnancy are another major and inequitable risk for many birthing and pregnant people with mental illness; these inequities are more pronounced among racially and ethnically marginalized women than among White women. Studies reveal higher-than-average rates of obstetric and neonatal complications in patients with schizophrenia or affective disorders. Furthermore, maternal depression is a risk factor for impairment in mother and child bonding, and maternal antenatal depression is an independent predictor of preterm delivery. Barriers to reproductive services can lead some pregnant people to induce abortion using meth ods that are not evidence-informed, which increases their risk of complications. Despite the safety and efficacy of abortifacients such as misoprostol and mifepristone, both patients and clinicians lack adequate awareness of these options and may be unsure how their use is affected by state abortion bans. In a recent study, investigators used demographic estimation methods to predict that a nationwide ban on abortion services would lead to a 21% increase in the number of pregnancy-related deaths among all U.S. women and a 33% increase among Black women, as compared with 2017 rates. These estimates were based on the complications of pregnancy and childbirth and do not include the potential impact of unsafe, self-induced, or non– clinician-facilitated abortion or the risk of fatal domestic violence.
Another aspect of reproductive justice worth consideration is a caregiver’s autonomy to make decisions about their children’s household and environment. The majority of women who have abortions are already mothers. In a structured survey of more than 1000 patients undergoing abortion, the most frequently cited reason for seeking the procedure was that having another child would interfere with the patient’s education, work, or ability to care for dependents. These reasons hold particular relevance in a society that continues to lag behind its peers in the availability of publicly subsidized child care, paid parental leave, and social safety-net services — and in which Black, Latinx, and Indigenous families and mothers with mental illness are disproportionately subjected to the foster care system’s oversight and intrusion.
Conclusions
Though admittedly complex and highly politicized, reproductive justice, including timely and easy access to abortion, is indisputably a health care issue — a social determinant of mental (and physical) health with far-reaching repercussions. Laws in a democratic nation should reflect the will of the people, and structural systems in a just society should produce equitable outcomes. The Dobbs ruling falls short on both counts. The implications are especially grave for birthing and pregnant people from historically marginalized groups — especially those with mental health and substance use disorders —further endangering populations that face alarmingly high pregnancy-related morbidity and mortality.
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From the Department of Psychiatry and Behavioral Sciences (L.O.-N., M.T., C.M.) and the Department of Obstetrics, Gyne cology, and Reproductive Sciences (M.A.B.), University of Cali fornia, San Francisco, San Francisco; the Department of Psy chiatry and Behavioral Sciences (R.S.S.) and the Department of Family and Community Medicine (M.G.), University of Califor nia, Davis, Sacramento; the Department of Psychiatry and Be havioral Sciences, Morehouse School of Medicine, Atlanta (S.Y.V.); the Department of Psychiatry, Columbia University, New York (E.M.F.); and the Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle (M.R.M.). Drs. Ogbu-Nwobodo and Shim contributed equally to this article.