Adverse mental health, particularly depression, is not only a common complication of pregnancy but also a leading contributor to pregnancy-related mortality. [1] Parental experiences of adverse mental health, both during and after pregnancy, lead to reduced parent-child bonding, [2] which can result in developmental and behavioral problems for the children. [3] Approximately 13% of birthing parents experienced depression symptoms after pregnancy across the U.S. in 2018, but prevalence varies widely by state of residence, ranging from 10% (Illinois) to 24% (Mississippi). [4]

One critical predictor of antepartum and postpartum (henceforth, “perinatal”) mental health is pregnancy intention. People with unintended (i.e., unwanted or mistimed) pregnancies are estimated to have more than twice the risk of depression during and after pregnancy compared to people with intended pregnancies. [5], [6] These effects can persist beyond the postpartum period—in one cohort, those who carried unintended pregnancies to term had a 40% increase in having a depression episode later in life relative to those with intended pregnancies. [7]

Since the 1973 Roe v. Wade decision, and even before the 2022 Dobbs v. Jackson Women’s Health Organization decision by the U.S. Supreme Court, states have increasingly passed legislation restricting abortion. Restrictive legislation includes mandatory waiting periods between an intake appointment and a procedure; two-visit laws requiring patients to be in the clinic at least once before the procedure day; minor consent laws requiring approval from one or both parents; mandatory ultrasounds; funding restrictions; and provider license barriers or onerous building regulations. Such laws have led to abortion facilities closing, increased wait times, restrictions on types of abortion care provided in facilities, and other barriers to abortion care for those seeking abortions, leading ultimately to a reduction in abortions. [8] As a result, people carrying unintended pregnancies are more likely to carry their pregnancies to term as state abortion laws become more restrictive. [9]

Given the links between unintended pregnancy and perinatal depression, the geographic variation in both perinatal mental health and abortion legislation, and recent increases in restrictive abortion policies, it is critical to examine the role of restrictive abortion legislation in exacerbating adverse perinatal mental health. Emerging research has begun to elucidate these relationships but has several limitations. For example, research using the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System reveals that people living in states without public funding for abortion have increased risks for postpartum depression. [10] However, evaluating the impact of a single policy has limited public health impact, given that multiple policies are often enacted simultaneously as part of a larger bill—as a result, variation in individual laws may be less salient to health outcomes than variation in state abortion policy climate. More recently, ecological data have demonstrated that abortion restrictions are linked to a 6% increase in state-level suicides among women of reproductive age. [11] Crucially, the ecological design precluded examination of individual-level data (e.g., depression) or potential mediators and no study to date has examined the relationship between state-level abortion laws and mental health during pregnancy, nor examined the role of pregnancy intention.

In the present study, we examined the association between state-level abortion legislation and the risk for adverse perinatal mental health, as well as whether these associations are mediated by pregnancy intention. We used data from the Nurses’ Health Study 3, a cohort of primarily non-Hispanic White healthcare workers who were surveyed both during their second trimester and in the postpartum. We hypothesized that more restrictive abortion policy climates would be associated with a higher proportion of unintended pregnancies and that unintended pregnancies, relative to intended pregnancies, would be associated with higher risks of adverse perinatal mental health outcomes.