A woman faced with the decision of whether or not to seek an abortion will ask herself many questions. The question she may least consider until after the fact-is how an abortion will affect her future health. Will it jeopardize her ability to have other children? Will it increase her chance of developing a life-threatening disease, like breast cancer?

With tens of millions of women having undergone one or multiple abortions, these are questions for which there are still no definitive answers. Not because science is unable to provide them, but because political pressures work against objective research.

Instead, women who have had abortions are subject to an almost monthly assault of conflicting information about what risks, exactly, they may have incurred. On the cancer issue, for instance, media reports produced the following over three years: "Higher risk of breast cancer found in young women who had abortions" (October 1994); "Strong abortion-breast cancer link revealed" (October 1996); "New study questions abortion-cancer link" (December 1996); "Study finds no link between abortion and breast cancer" (1997). Reports have raised the specter of other potentially serious long-term health effects-among them infertility, miscarriage, and ectopic pregnancies-only to have them refuted by one study, and then raised again by another. Which is right?

Journalists often have their own ax to grind on this issue, of course, but even the few who attempt to interpret the research objectively run into a wall of half-truths and distortions. Try to obtain unbiased information on abortion related health risks and here are some of the "experts" one encounters: At one end of the spectrum is Joel Brind, professor of endocrinology at the City University of New York and a celebrity in the pro-life camp, who publishes a newsletter called the Abortion-Breast Cancer Quarterly. Brind is often quoted by journalists on the abortion issue, but his publication sounds less than scientific, fond as he is of words like "cover-up," "crisis pregnancy," "desperate mothers," and "mainstream denial" of "a woman's right to know." "Is it worth $45 a year," he asks in his advertisements, "to spare even one woman the life-threatening agony of breast cancer?"

But are those in the pro-choice camp any more reliable? And should federal agencies responsible for monitoring the nation's health be disseminating these advocates' research as the last word in objectivity? Carol Rowland Hogue, a feminist academic who holds an endowed chair at Emory University in Atlanta, reviews research papers on the effect of abortion on future reproduction. Her conclusions are cited and distributed by the federal Centers for Disease Control. But get her on the telephone and it becomes clear that she prefers lengthy harangues against the pro-life movement to any boring discussion of health risks. And when she does discuss such risks, her views sound disturbingly tainted by personal politics.

Hogue notes approvingly, for example, that "many feminists now recommend barrier devices, backed up by abortion" as the "safest" contraceptive strategy for women. When asked if that wouldn't encourage multiple abortions, she replies that multiple abortions are not a problem. After all, she says, in Eastern Europe under the communists, it was not uncommon for women to have as many as twenty-five abortions and feel no ill effects at all. Besides, women who have multiple abortions really can't help it. Such women, Hogue insists, are simply "more fertile" than other women. And how does she know? Because studies comparing women one month after an abortion with women one month after childbirth show that the abortion group have much higher rates of repeat pregnancy during that period.

That such a remark might sound idiotic to some women-particularly those who know firsthand just how sexy they feel within a month of having a baby-apparently never occurs to Hogue. But don't ask her to elaborate. When I did she bristled: "It's apparent that I'm not talking to someone with an open mind on this issue!"

The effect is to leave those of us trying to sort out the facts caught somewhere between "The sky is falling!" and "What, me worry?" Anecdotal reports of risks related to abortion, particularly miscarriage, are troubling. Of the six women I know who have had abortions, five later experienced multiple miscarriages and were unable to carry a pregnancy to term. But this kind of evidence can be misleading too.

The problem-and this is true for epidemiological research as well-is that it is impossible for an observer to know all of the other risk factors such women may have incurred. Genetic predisposition, for example, may present the clearest risk for developing breast cancer, but other studies have implicated fatty diets, alcohol consumption, oral contraceptives, pesticides, a late first pregnancy, smoking, failure to breast-feed, age at the onset of menstruation, and even a woman's weight at birth! Similarly, a woman's ability to become pregnant and successfully carry a pregnancy to term may be adversely affected by age, a history of IUD use, sexually transmitted disease, pelvic inflammatory disease, inherited physiological disorders, and even psychological problems.

Epidemiologists trying to credibly establish, or disprove, a connection between abortion and disease or dysfunction have to try to eliminate or in some way account for these other risk factors. Certainly many women experience infertility, miscarriage, and breast cancer, with no previous history of abortion; others who have had abortions may have no problems at all.

What is worse, getting sound health information to the public is hampered by the fact that we live in an era of grant-driven research, where vague conclusions and poorly designed studies are nevertheless used to grab headlines, whip up public hysteria, underpin absurd government policies on everything from radon exposure to secondhand smoke-and get more grants. Two years ago in the New York Times, Dr. Charles H. Hennekens of the Harvard School of Public Health characterized the situation with surprising honesty: "Epidemiology is a crude and inexact science. Eighty percent of the cases are almost all hypothesis. We tend to overstate findings, either because we want attention or more grant money."

Those of us who follow this degradation of science tend to take a cynical view of new research results, particularly those announced with great fanfare at press conferences. But here are the troubling facts we do know: the incidence of breast cancer among women took a big jump after 1980, particularly among black women under fifty, a group that also shows a high rate of abortion. Breast cancer among men, a more rare condition, increased not at all. What is more, the possibility that undergoing an induced abortion can increase a woman's risk of developing breast cancer-or lead to problems with infertility and miscarriage-is biologically plausible, and that is the first test of whether a risk factor should be taken seriously or not.

What may link abortion to breast cancer is this: in pregnancy, a woman's body experiences a huge surge in the hormone estrogen-as much as twenty-fold-resulting in dramatic increases in the number of new breast cells. Because of the known link between estrogen and cancer, these rapidly dividing new cells are thought to be particularly susceptible to malignancy. But then something interesting happens. While estrogen begins the process of rapid cell division and tissue growth, a second hormone released during the last trimester shuts it down, allowing the cells to mature and differentiate into specialized cells that can produce milk. This hormone also sorts out and eliminates cells growing out of control, making the woman's breast tissue actually less susceptible to cancer. An abortion, whether performed in a clinic or induced chemically-with RU-486, for example-would interrupt the release of this protective second hormone.

Evidence purporting to show a positive association between induced abortion and breast cancer was first published in 1957 in Japan in a comprehensive study examining risk factors for cancer. Since then, more than forty studies have looked at induced abortion as a possible risk factor for breast cancer but, like the Japanese study, the overwhelming majority were not designed to examine solely the breast cancer/induced abortion relationship. Instead, they combined induced abortion with spontaneous abortion (miscarriage), oral contraceptive use, environmental factors, and other risks, which tended to confuse conclusions about any effect attributable solely to abortion. Moreover, many studies did not control for age, family history, or other contributing factors such as diet, alcohol consumption, and income, which affects a woman's access to health care. When a positive association was found, it was often dismissed as largely due to "recall bias"-the notion that when women are asked to recollect risk factors, those stricken with breast cancer are more likely to reveal a past abortion than those free of disease.

As a result, little public attention was paid to a possible breast cancer/ abortion link until 1994, when Janet Daling, of the Fred Hutchinson Cancer Research Center in Seattle, published a paper in the Journal of the National Cancer Institute. She concluded that women who had undergone an induced abortion incurred a fifty percent greater risk of developing breast cancer before age forty-five, with even higher risks for women under eighteen or over thirty at the time of their abortions, or for those who had aborted a pregnancy after the eighth week. For the women aged seventeen or younger who aborted a first pregnancy after the eighth week-a small subset of Daling's study-the risk went up an alarming eight hundred percent.

Interestingly, Daling found that a miscarriage did not elevate a woman's risk of breast cancer. She speculated that, with miscarriage, the fetus may have died days earlier than when it was actually expelled or that the woman may not have experienced a sufficient hormonal surge to sustain the pregnancy to begin with. Even more intriguing, Daling tested for "recall bias" by conducting a concurrent study of induced abortion and cervical cancer. Experts agree there is no relationship between abortion and cervical cancer, but if "recall bias" was a factor, this study should have turned up a similar elevated risk; it did not.

Daling, who is pro-choice (in the current climate, scientists must now state their politics along with their results), was unprepared for the furor her report touched off. Pro-choice activists sought to discredit her conclusions; even some of her own colleagues implied that she had somehow cooked her results to impede a woman's legal right to abortion. Editors at the Journal of the National Cancer Institute got so testy, they took the unusual step of publishing an editorial disclaimer in the same issue as Daling's report.

But since 1994, seven additional studies have been published, honing in on the breast cancer/induced abortion relationship. Results have been mixed. Daling also published a study of abortion and breast cancer among young white women in August 1996; she found a ninety percent increased risk. In December 1996, the Journal of the National Cancer Institute published a Dutch study that also found a ninety percent increased risk, but the editors-and the authors themselves-then went to great lengths to explain why the results were irrelevant, including a claim of reporting bias among Catholic women.

Then, this past January, a retrospective look at the medical records of 1.5 million Danish women was published in the New England Journal of Medicine. The authors concluded that induced abortion posed no increased risk of breast cancer and only a tiny risk for those having late-trimester abortions; indeed, an editorial in the same issue stated flatly that now "a woman need not worry."

Unfortunately, the Danish study has since been shown to have serious flaws. The authors admitted in their report that they "might have obtained an incomplete history of induced abortions for some of the oldest women" in the group, an error that likely misclassified tens of thousands of women with breast cancer as having had no abortions. In addition, many of the younger women studied-those who'd had the most abortions-had not yet reached an age where most breast cancers begin to develop.

So what are women to make of the cancer risk? To begin with, the association between induced abortion and an overall increase in the risk of breast cancer is still weak. Even Joel Brind concedes this. Claims by some pro-life activists that thousands of breast cancer deaths are attributable solely to induced abortion cannot be credibly substantiated, and allegations of a "cover-up" are needlessly inflammatory. But neither can we confidently insist-as some in the pro-choice movement do-that there is no risk. Scattered throughout these studies are unsettling results among certain subsets of women: Daling's teenagers in her 1994 paper, for example; women who have undergone second- and third-trimester abortions (also heavily represented among teenagers); or women who aborted a first pregnancy after age forty.

It would be premature to draw any conclusions from the incidence of breast cancer in these women, because the smaller the group studied the larger the margin for error. But researchers are getting better at identifying high-risk populations. What is needed now is to locate such women at the time of their abortions and to track them over time. That is a costly process that yields no quick answers, but it could yield some conclusive ones.

For many women, however, risks to future pregnancies are a much greater and more immediate concern than cancer, especially since environmentalists in recent years have repeatedly promoted various bogus cancer scares, even as life expectancy has gone up and up. Surveys by the Alan Guttmacher Institute show that just over seventy percent of the women undergoing abortion do intend, at some point, to have other children. And here, some noteworthy developments have taken place. The Family Growth Survey of the National Center for Health reports that women who have never had a child, who once accounted for just seventeen percent of all women experiencing infertility and miscarriage, now account for half, with married black women showing higher rates than married white women.

In fact, women have been flooding into fertility clinics in recent years, and physician visits to treat infertility have more than tripled in the last three decades. Researchers peg this change to a greater prevalence of sexually transmitted diseases and pelvic inflammatory disease and, perhaps more important, baby boomers delaying marriage and childbearing until their late thirties or early forties. But how much of that delay is due to abortion, no one seems to know.

Abortion and Women's Health, a publication of the Alan Guttmacher Institute-which is partly funded by the Planned Parenthood Federation of America, an abortion provider-reassures women about future fertility, citing "an extensive review of the worldwide literature," conducted by researchers from the federal Centers for Disease Control (CDC) and the Population Council-i.e., Carol Hogue and colleagues. It concludes that a single, first trimester abortion by vacuum aspiration entails no increased risk of subsequent infertility, ectopic pregnancy, or miscarriage. But it is only by reading the footnotes that one learns that this review was published way back in 1982. Moreover, Hogue's review hedges on the effect of multiple abortions or abortions after the first trimester, saying only that additional research is needed.

Susan Tew, deputy communications director for Guttmacher, concedes that its data on long-term risks are pretty old and "pretty poor." The National Abortion Federation should have this information "but they don't because the providers don't follow up on their patients." Also, she says, pregnancy risks can be difficult to measure because the primary cause may be STDs or infection.

Ay, and there's the rub. Aside from those instances where an abortion turns out badly and the woman ends up with a hysterectomy, only a handful of infertility cases have been attributed solely to induced abortion-such as cases where fetal bone fragments have been left in the uterus where they act, researchers believe, in much the same way as an IUD. But several studies have now shown an association between induced abortion in women with untreated sexually transmitted disease-largely chlamydia-and infertility and miscarriage. Chlamydia, it must be noted, has reached epidemic proportions in the United States, with nearly half a million cases diagnosed each year.

In 1992, a Danish study found that twenty percent of the women harboring chlamydia at the time of their abortions progressed to pelvic inflammatory disease, a serious chronic infection which can result in miscarriage and/or scarring of the fallopian tubes. Of those, ten percent became infertile and twenty-two percent miscarried a subsequent pregnancy. The researchers advised that women seeking abortion be examined for chlamydia and treated with appropriate antibiotics no later than at the time of their abortion. Another Danish study, published in Germany in 1994, found that seventy-two percent of the women studied whose chlamydia was not treated at the time of their abortions, progressed to pelvic inflammatory disease within two years. Debates over whether pregnancy problems that may arise from this effect are truly "abortion-related" hinge on whether the STD is considered the primary cause, even if the abortion was the mechanism for introducing infection into the uterus.

Meanwhile, each year some seven hundred thousand American women undergo at least their second abortion, some three hundred thousand at least their third. According to the CDC, about fifteen percent of all abortions in the United States will be performed in the second trimester or later. Yet incredibly, there is little research being done on the effect of multiple and late-term abortions on women's future reproduction. In the dozen or so states that have Supreme Court-sanctioned informed consent laws, women are told that multiple abortions may make it difficult to have children later in life. Some infertility support groups also list two or more abortions as a risk factor for infertility and miscarriage.

But an updated review of the literature published in 1990, again by Carol Hogue and colleagues, still focused only on single, vacuum-aspiration abortions performed during the first trimester. The report concluded that there were generally no long-term risks, except in those abortions complicated by infection, but noted that "a variety of conditions"-among them sterility, miscarriage, tubal pregnancies, stillbirths, premature births, birth defects, and emotional disorders-had been "ascribed anecdotally to induced abortion."

So what we have at this point are some associations between induced abortion and long-term health risks that are biologically plausible, and some evidence along the lines of what we might expect to see if indeed there were a cause-and-effect relationship. What we don't see (and unfortunately the definitive studies are not being done) is conclusive statistical evidence linking the two.

This controversy, however, should provoke caution. Political pressures as demonstrated by the editorial disclaimers accompanying abortion studies published in scientific journals-work against the funding of abortion research. Moreover, because breast cancer in women usually develops after age forty, if there is any increased risk to certain subgroups-i.e., women who aborted a first pregnancy before age eighteen-the first of these cancers would only just now be showing up twenty-five years after Roe v. Wade.

It cannot be stressed enough that having an abortion, whether chemically or surgically induced, can carry certain risks. As Susan Tew of the Alan Guttmacher Institute puts it, the magnitude of these risks may "depend on how well the patient chooses to inform herself." In the current political climate, obtaining accurate information is almost impossible. And as deliberately misleading as some pro-life activists can be, much of the blame for this situation must fall on those who have made abortion an unassailable shibboleth.

The bottom line is that women seeking abortions would do well to identify factors that may put them into one of the groups thought to be at a higher risk for breast cancer, and take that into consideration when making their decision. They should certainly ensure that any sexually transmitted disease is diagnosed and treated before undergoing an abortion. And, given the uncertainties, women should regard the idea that multiple abortion is a reasonable contraception strategy as the obvious nonsense that it is. There are many debatable points about this issue. Health should not be one of them.

Candace C. Crandall writes on women's health issues for the Science & Environmental Policy Project in Fairfax, Virginia: this article first appeared in the Summer, 1997 issue of The Women's Quarterly (published by the Independent Women's Forum in Washington, D.C.) and is reprinted here with permission ((D 1997 by the Independent Women's Forum).

Copyright Human Life Foundation, Incorporated Fall 1997
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