Abigail Aiken on Using Research to Inform Abortion, Reproductive Health Policy

[ABIGAIL AIKEN]

A lot of people are very supportive of abortion rights, which I think is wonderful, but we have to remember that when we walk outside of those circles, there are people who really feel strongly the other way about this. They feel that it’s terribly wrong morally to do this. And if you forget that and you come out there with your evidence, and perhaps your own feelings about the topic, and you forget how to talk to other people who may not agree with you, you may as well have stayed at home.

[J.B. WOGAN]

I’m J.B. Wogan from Mathematica and welcome back to On the Evidence, a show that examines what we know about today’s most urgent challenges and how we can make progress in addressing them.

On this episode, we’re going to hear from Abigail Aiken, this year’s winner of the David N. Kershaw Award and Prize, which is awarded to scholars under 40 whose contributions to research-based knowledge have advanced the design, implementation, and evaluation of public policies. Long-time listeners may remember our past interviews with the last two winners of the Kershaw Award, Sanya Carley and Kirabo Jackson. Abigail is the 22nd recipient of the prize.

The award is named after Mathematica’s first president, David N. Kershaw, who also helped establish the Association for Public Policy Analysis & Management, otherwise known as APPAM. The award and prize are made possible by a memorial endowment established in Kershaw's honor after his death from cancer at the age of 37. Mathematica and APPAM jointly administer the award and prize.

I met Abigail in November at the APPAM Fall Research conference in Washington, D.C., where she received her award. Though she is originally from Northern Ireland, she is now based out of Austin at the Lyndon B. Johnson School of Public Affairs and her research focuses on reproductive health, with an emphasis on understanding the use of self-managed abortion through telemedicine.

We’re going to break this episode into two parts.

Part one, which you’re listening to right now, will be Abigail’s formal address at APPAM about her journey as a researcher in the area of evidence-based reproductive health policy. Calling in an address makes it sound a little formal and academic, but it’s not. It’s mostly the story of how Abigail became a researcher interested in self-managed abortions through telemedicine, punctuated by surprising data-driven insights, and the ways in which those insights have influenced abortion policy in her native Ireland, the United States, and Latin America.

Part two is mainly my interview with Abigail, along with some of her answers to audience questions that anticipated what I was going to ask her. Whereas part one of the episode is about Abigail’s personal and professional arc, part two focuses specifically on how Abigail ensures that her research informs the policy debate, even on a polarizing topic like abortion.

The Mathematica blog that accompanies this episode will include transcripts for both Part 1 and Part 2. We’ll include more information about the Kershaw Award, Abigail’s work, and our previous podcast interviews with Kershaw Award winners.

I hope you find both parts of episode interesting and useful.

[ABIGAIL AIKEN]

When Paul called me to tell me that I was this year’s recipient, I was actually in labor, and it was the first time I think that had happened for him. He calls me up and tells me, “I’m delighted to tell you this news. You’re the recipient of this year’s Kershaw Award.” And I was like, “Oh, thanks. I’m having a baby right now,” and he said, “Oh, yeah. No, really right now?” And I considered it a very auspicious sign that everything would go well, and it did. So my 11-week old is with me here in DC.

I am hoping that I’ll be able to make sense for the next 50 minutes. I’m a little sleep deprived, so you’ll have to excuse me. But, yes, so, so delighted, and I’m so delighted to see people here. I know this topic is one that has risen to national prominence, but as many of you probably know, it's been around, it’s been a big deal, it’s been important for quite a long time, and it’s lovely to have a platform, I guess, to talk a little bit about it today.

I would like to sort of share with you the research journey that kind of brought me here and into the field of public policy. And although my work does focus on several aspects of reproductive health, today, I’m mostly going to be talking about abortion, partly because it’s the part of my work that I feel is the most interesting journey. It’s not the most methodological complex of my work, but I think it’s the most interesting from a policy angle.

A lot of people are very supportive of abortion rights, which I think is wonderful, but we have to remember that when we walk outside of those circles, there are people who really feel strongly the other way about this. They feel that it’s terribly wrong morally to do this. And if you forget that and you come out there with your evidence, and perhaps your own feelings about the topic, and you forget how to talk to other people who may not agree with you, you may as well have stayed at home. You talk to a brick wall. You have to really try to help yourself to see how other people feel about this, even if it’s very different from how you feel or how you think people even should feel. So, I’m going to plant that seed in your mind, because when I talk about going to the Irish Parliament, that’s something that it was extremely important to remember about.

So, knowing that people feel really polarized often about this, feel strongly in different ways about this, if you feel you have evidence on this topic, what do you do with it and how do you talk about it?

To talk about this, I’m going to take us on a little tour, and a tail of two settings. First of all, the country where I’m from, I grew up in Northern Ireland. I left there when I was 18 to go to college, and since 1983, there was a Constitutional Amendment in Ireland, in the south of Ireland, that basically said, you have to equate the rights of the pregnant person and the rights of the fetus. You have to make them the same. And you can imagine the bind that puts doctors in. If someone is arriving, for example, in a situation where an abortion would be lifesaving for them, but there is a fetal heartbeat, doctors didn’t know how to act. They didn’t know what to do.

In Northern Ireland, the part where I’m from, the law there was dating from the 1800s, and it was that you were liable for criminal penalties, up to life in prison, if you procure an abortion in the Country of Northern Ireland. So that is where I’m from. I think that’s why I’ve thought a lot about reproductive rights in a long time, because I grew up in a country where there were none. And so it is interesting to be now standing here. I live in Texas, and to have seen things moving in a direction so different from where Ireland and Northern Ireland has been going.

The Eighth Amendment is that Amendment to the Constitution that I told you about just to refresh there. You really have to guarantee that you will weigh both lives equally. That was established in 1983 by referendum, and 67 percent of the population of Ireland voted in support of putting this in the Constitution in 1983. So, that’s the context of where we’re coming from.

So, if you experience an unwanted pregnancy in Northern Ireland or Ireland, you had a couple of options. You could remain pregnant. And, you know, the total fertility rates are higher in Ireland, not only because of this, but I think that’s part of the story. You could travel. You could get yourself to a clinic in England, Wales, or Scotland, but those would be a flight or a ferry ride away. You have to cross the sea to get away from the Island of Ireland. You have to stay overnight, and your costs would not be covered. If this is sounding familiar to anybody, like me, lives in a state where you do not currently have the right to end a pregnancy with an abortion, it should feel familiar.

But there’s also another way that people often will seek when they cannot access a clinic, mostly due to abortion laws, and that’s find a way to have an abortion outside the formal health-care setting, i.e., to self-manage your abortion, and I’ll talk about what that means shortly. But just to give you the legal context, in Ireland and Northern Ireland, that would be criminalized behavior. You could be sent to jail for that. In Northern Ireland, as I said, life in prison was what’s on the books for that. No one has ever, in recent memory, been subject to such an extreme punishment, but you would be brought into the courts and you would, potentially, be prosecuted.

So, a self-managed abortion is one that takes place outside the formal health-care setting. It could be anything. It could be herbs. It could be teas. It could be self-harm. But it could also be abortion pills. And that is something that really has changed in character about what a self-managed abortion in 2022 means, as opposed to in, say, 1970, 1960, the sort of pre-Roe times as we think about the U.S. context. But it could really mean any way that someone could end a pregnancy on their own without engaging in the formal health-care setting.

You can imagine, from the research point of view, that is a difficult thing to study; right? Because by the very nature, this is something that is happening in private. It’s not usually something that people want to tell researchers about, or tell anybody about, particularly if there’s a criminal risk or a risk of surveillance or legal penalty. So, part of the challenge to try to figure out what are the impacts of these laws is to try to figure out what are the impacts on the self-managed abortion. In the presence of laws that would restrict people from getting to clinics, would restrict people from accessing abortions in other ways, do more people seek this out?

So, part of what I’m going to talk about today is the challenge of doing that kind of research, because even if you were to launch a survey, you can imagine how do you get it to the right people, and then how do you get them to want to answer that question; right? There’s risk to it.

Women on Web began in 2006 by a doctor called Rebecca Gomperts, who lives in the Netherlands. And she was a Greenpeace doctor, and so she had been on ships all around the world. And it occurred to her that when you are in international waters, the law of the country where the ship is from is what applies, not the country that you’re closest too. So she took a boat and she sailed to Ireland, and I remember this, because I was a teenager there at the time, and I felt like that was something. You know, she showed up with this boat and not really for the purpose of trying to provide abortion on a mass scale, but to get people talking about this, because, in the ‘80s and ‘90s, even talking about this with somebody was very difficult. To mention the word abortion would have been extremely uncomfortable, and it still is in some circles. But it really opened a conversation.

And later, in about 2006, she realized that she could reach a lot more people with an online service. Rather than taking a boat around the world, trying to help people get onto this boat, you could actually get onto the internet and you could have people contact you that way. So, Women on Web is an organization that provides abortion pills, Mifepristone, that round tablet, Misoprostol, those little hexagonal tablets, around the world in countries where safe abortion is not legally available or is restricted. And this, to me, was one way to get a handle on the idea of self-managed abortion. Most times, when someone is doing this, there is no dataset; right? Where are you going to go for data? But Women on Web does have data.

So, at a conference in Lithuania, I met Dr. Gomperts, and I went up to her on the dance floor. Yes we do have dance floors at family planning conferences, and she’s a really good dancer, and I don’t really have the moves for this, but I kind of danced my way into her line of sight, and I asked her, “Could I talk to you? You know, I’m from Ireland, and I, you know, know that you provide self-managed abortion there, and I know there’s not a lot of research on that, and I wanted to know how do you feel about the possibility of some kind of partnership or being able to perhaps share data so that we could maybe think about, you know, starting some research around this?” And it’s a difficult conversation; right? Because on one hand, you can see how, yeah, if we have a data source on this, the researcher in you wants to take advantage of that.

But she also has people to care about; right? And the idea of making this public or bringing it to political attention could go one way or the other; right? There could be serious consequences for people. And so we thought about it. We talked about it. After several kind of round of conversation, she said, you know -- and you can imagine, she’s the kind of person that launches this, she said, “You know, when we don’t talk about these things, we sensor ourselves, and we need to do this,” so we did. And I need to credit her for a lot of my own career, because without these data, I wouldn’t be standing here in front of you giving this talk.

So, let’s talk about what needed to happen in Ireland. There had been a tragic event. Savita Halappanavar was a 36-year-old dentist who showed up in the hospital in Galway with a septic miscarriage. She would not survive this unless abortion care was provided. But the doctors in the hospital could hear a fetal heartbeat. And because of the Eighth Amendment that said they had to value both lives equally, they felt they couldn’t act without the possibility of criminal punishment, so she died. It was the kind of event that I think a lot of people are waiting for to happen in other settings. In Poland, this happened. It may happen here. It was completely unnecessary, of course, and it opened up a conversation. People in Ireland could not accept this, and they began to talk about it.

So, when they happened, seeing the trajectory of this as a researcher, trying to think about what kind of evidence might we need if this becomes a bigger conversation, because people on the ground were talking about this, activists and advocates, but also the news, people you know, just out there saying this shouldn’t happen in our country. So, we began to think about what kind of questions we might want to answer with the Women on Web data.

First of all, you want to know it’s prevalent; right? How many people actually do this? How many people get in touch with the service? How many people actually have abortions using the service, and what are their characteristics? Are they a particular demographic group or is this something that’s widespread and prevalent. Is it safe? This is a key question. People often hear self-managed abortion, and they tend to completely, you know, think to themselves that will never be safe. It will always be a desperate dangerous thing to do. Is that so? Does it work; right? Is this actually effective? Are people actually managing to end their pregnancies? And then is it acceptable? And by “acceptable,” I mean to the person who is self-managing. What kind of an experience is this for the person on the ground using these pills?

So let me explain to you a little bit about how Women on Web service works. If you have a computer, you can look it up, and the first thing you’ll see is “Start a Consultation,” and you press that button and you start to fill in some medical history. It’s pretty straightforward. It will ask about gestational age. It will ask about some of your characteristics. Do you have any contraindications to certain medications? It’s not very common to have that. And then when you’ve filled that out, the service will get in touch with you and say, “Can you make a donation?”

They’re a nonprofit, so they have a suggested amount you can donate. But if you can’t afford that, they will do a sliding fee scale. Or if you can’t afford anything, they will still try to provide the pill to you. Those are then shipped to the person’s home, and they come with instructions for how to use them. So these abortion pills that you would get in the clinic are in the hands of the person in their home with the instructions. And then there is a Helpdesk that’s online, where you can basically get in touch at any time to ask, you know, is what I’m seeing normal, how is this going.

Now, it’s a remote model of care; right, so no one can diagnose you the way someone could in a clinic if something is going wrong. But it is the case that the red flag symptoms that would require someone to go and be seen are very clear in the instructions that people receive.

[J.B. WOGAN]

Hi listeners, since you can’t see Abigail’s next slide, let me briefly describe what you would see. There’s a line graph with the title “Irish and Northern Irish Women Seeking Abortion Using Women on Web 2010 through 2015.” The Y Axis is number of women. The X Axis is years. Between 2010 and 2015, the number of women using the service steadily rises from a little under 600 women in 2010 to a little more than 1,400 in 2015.

[ABIGAIL AIKEN]

At the same time, travel to the mainland, to England, Scotland, Ireland, was decreasing. Now you can’t obviously put that together and just say that one was making up for the other. There were absolutely certainly people remaining pregnant that I’m sure they did not want to be. But the overall trend of this is upwards.

And it’s not a trivial number of people; right? We’re not talking about a country the size of the U.S. here. We’re talking about five women a day or five people a day in Ireland and Northern Island getting in touch with the service, looking for abortion pills. That’s quite a lot over time.

Basically the key outcome is, is someone still pregnant after using these pills, because they took them so they wouldn’t be? And the vast majority, 99.2 percent of people, were no longer pregnant. And what we call a complete of successful medication abortion is one where the pregnancy is ended using the pills alone, that you would not need to go to a clinician to have an in-person procedure to help empty the uterus. And when you subtract the people who said, “Yeah, I had to go and get an intervention,” you’re at about 95 percent of people having a successful or complete medication abortion. Now that is on par with what we see in studies in the clinic. And in some ways, it’s perhaps not surprising. It’s the same pills, the same dose, the same instructions. The difference is, you’re not in the presence, the physical presence of a provider, and you may not have had an ultrasound.

There’s a lot of debate in the medical community about whether you need an ultrasound before an abortion. The FDA now says, no, you don’t, because of some of research that folks in my field, and our group as well, have done to say that, look, you seem to get the same success rates whether or not someone has an ultrasound to date their pregnancy. Most of the time, people can do that using their last menstrual period date. So it’s effective.

Is it safe? This is another big question; right?

[J.B. WOGAN]

Hi listeners, pardon the interruption again. Abigail is about to discuss some information audience members could see in her slide. It’s a table listing results on the safety of using self-managed abortions through Women on Web. In red, at the bottom, is 3.1 percent, which is the share of women with an adverse event. As a reminder, that’s 3.1 percent out of 1,000 pregnant women who used Women on Web.

[ABIGAIL AIKEN]

And an adverse event would be defined by the FDA as serious bleeding, resulting in hemorrhage that would require blood transfusion, an infection that would need to be treated with antibiotics in a hospital, and, of course, death. And you can’t report your own death to a service, but no family member, no person ever got in touch with the service. That’s a caveat on the death one.

But I think it’s likely that the service would probably have known if that had happened, but we can’t be a hundred-percent sure. However, with the assumption, only three percent of people reported receiving any of these treatments. The antibiotics, we cannot say whether that was IV or oral; right? So there are some limitations to this. And 3.1 is probably an overcount for that reason, because people may just have shown up. Oftentimes, providers are not used to seeing patients post-abortion. They will give things just out of an abundance of caution. So 3.1 is higher than in the clinic setting, but we don’t know whether or not that reflects real actual complications or whether some of those are providers who are saying, “Yeah, we’ll give you some of those just to cover you,” which is not uncommon in places where abortion care is not prevalent.

So, again, from those 1,000 people who completed the abortion through Women on Web, they also filled in a little survey to talk about how they felt about this. And you see that, overwhelmingly, people felt like this was the option that worked for them. They were grateful for it. They thought it was the right choice. They would recommend it to others. It doesn’t mean it was a perfect solution for them, but it at least means this was not something that they regretted having done.

They were also asked about their feelings. And this is a really interesting one, because quite often when you talk with politicians or others about this, they will ask you about forced abortion regret. That’s a really big thing in people’s minds out there, that everyone who has an abortion is going to regret it. As you can see from this graph that that’s really not the case. Most of the time, somebody feels relief, or they could feel a total mix of things. You could choose more than one option; right? So you could feel sad, but also satisfied. They could feel guilty, but they might also feel empowered. It’s a complex thing; right?

But this data was gathered to counteract the idea, or to sort of put some evidence to the idea that all the time people who have abortions are going to feel really, really bad about that. You could hear from the people themselves.

So, to go along with these quantitative data -- and, again, like I said, nothing is particularly complex about this analysis. What’s interesting about it is that it’s the first time there have been data behind the idea of self-managed abortion in the Irish context. People kind of knew it was happening, but there was really no way to say anything about it, except that it might happen sometimes. Now we know, at least through one pathway, how many people seem to be doing it, what their outcomes are like in terms of the safety and effective, and what their experiences are like.

So, we decided to supplement this with some qualitative work. And you can imagine what this is like. You know, we didn’t go to people’s houses and talk to them in person. We did this from across the ocean to protect them and to make sure that we didn’t ever have any information about them, except that we had gotten on a signal call to talk to each other about this experience, because all of this has to be done with the mindset that, at any time, someone may want access to these data. They may subpoena you. They may take legal action against you, and you do not want to be in a position of endangering somebody in your research. I think we all agree on that.

So, we did these qualitative interviews, asking people to contact us so we would never have any information about them. They could choose what name we wanted to call them, and we talked through encrypted apps to talk about what this experience was like. So, here are the key takeaways from that. The first one, this is Adelle, she’s 29. She has four kids, and she used the pills at home with Women on Web. And she’s talking about the experience of before and after her abortion, when she wanted to talk to somebody.

She wanted to go to the doctor to talk about the decision, and, also, to talk about how things were going afterwards. But she was, like, no, you cannot do that. In the legal context we’re in, you would, at best, be judged, at worst, you could actually be reported for this. So, the idea that she would walk in and they would say, oh, yeah, you know, you’re pregnant, congratulations. We’ll put you in for your scan, without asking her what any of her options were. So, it was not a comfortable environment in terms of the interaction with the formal health-care setting.

Here is Stacy, 37, with two kids. She’s talking about feeling unsupported; right, that if she had to go in, she would have had to have lied. You can’t medically tell the difference if someone has had a pregnancy loss or mischarge or whether they’ve had a medication abortion. Provided they don’t use the pills vaginally and they use them orally, there is no way to know whether someone has had an abortion. So Women on Web actually advises people, if you have to go see a doctor in a country where you could be legally at risk, you should tell them that you’ve had a pregnancy loss. They won’t know the difference.

But the idea here; right, I think her quote, “I shouldn’t have to wonder in what way will I lie,” right? Doctor/patient relationships are based on trust. You want, as a doctor, to have that relationship with your patient. And if they can’t really talk to you and tell you what’s going on, that really erodes the relationship from both points of view.

Then there’s the isolation. You know, this worked for a lot of people. It was safe. It was effective. They were grateful it existed. But a lot the time, it was a lonely and isolating experience. Because that threat of legal action, that threat of judgment from others, and the idea that you could be reported, I think, made a lot of people feel very, very lonely.

Alex, who was 34 and a mom of three, was quite, I think, representative of others in the study when she talked about the idea, “I would have just liked to have been able to talk to someone, but because of the law, that wasn’t an option for me.”

This is a sad one, real sad. But this is particularly sad. This is Frankie, 35, and a mom of four. And she’s Googling ways to try to figure out how to end a pregnancy before she found Women on Web, and she’s talking about this. She’s saying when you’re desperate and your support system is nonexistent, you may do desperate things.

And, of course, those things are not going to work. They may harm her, actually. And before she found the option of Women on Web, this is what she was doing. This is not uncommon.

Okay, the interviews of not representative, of course, of any wider sample. But there were 80 of them, and most people had tried something else before they found Women on Web, and usually something that was not going to work and was potentially harmful for them.

Rebecca, another one, 39-year-old mother of two. She’s talking about reading pregnancy sites to see what you should do to find a way to end her pregnancy. And you’ll notice that, interestingly, a lot of the folks who contacted the service, and indeed, a lot of folks who have abortions are moms. They are people who know what it is to be pregnant, perhaps to go through childbirth, perhaps to have children. Depending on the outcome of that pregnancy, a lot of the time, those are people with children. They know what abortion is. And I think a lot of times when you talk to politicians, there is a sense that people don’t know what they’re getting themselves into. Anyone else who is a mom in the room will know you do.

So, key findings, medication self-management was common. On average, five people a day are doing this, and often saying, I don’t want to travel. I have no way to travel, I can’t get out of the country, either because of money, because of privacy, because I don’t want to, so I contacted Women on Web. And, of course, that’s only one way of doing this. There may be other ways people are finding that we can’t count.

It’s medically safe and effective, but it’s also an experience that’s really fraught for most people. The fear, the isolation, the disconnect from the formal setting when you feel like you wanted either pre-care or after- care. And that people may try these unsafe methods when they are looking for other options. So, the law is not totally effective. There are for sure -- I mean, I haven’t interviewed them, but I’m certain there are people in Ireland who have remained pregnant when they don’t want to be.

But if the goal of that amendment is to stop all abortions, guess what, it has not. It is not working. Abortions are happening in the Island of Ireland. And more than that, the current law negatively effects the physical and mental health of the people who are looking for abortion, because they’re stressed, they’re lonely, they’re isolated, and they may be trying things that are not safe for them in the meantime.

So, the process around the law change in Ireland in 2018 is so interesting that I have to take a moment to share it with you, because it’s so different than what we do here. What they decided to do was call a citizens’ assembly. And a Citizens’ assembly is where they reach out to a hundred people across the island, and they say, are you willing to come to a location for four weekends throughout a four-month period and hear about an issue, really get educated on it, not from advocates or activists, not even from researchers most of the time, sometimes, but just to hear people talk about the issue, whatever is it that’s on the ballot. That’s what a Citizens’ Assembly is.

They’re selected at random. They are people who might have had abortions. People who might have never thought about abortion. Ireland has a lot of farmers. A lot of sheep farmers were there. There were teachers. There were doctors. There were lawyers. There were all kinds of people in this room together. And they have to talk about the issue and come up with a set of recommendations for the Parliament. And this happens when something is a really big issue, and this was thought to be that way, so Citizens’ Summit was called.

And this here was Judge Mary Laffoy. She was the chairwoman. And she said we’ve really got -- the Citizens’ Assembly has asked politicians to examine the increasing use of abortion pills. Now, if you’re a researcher who is researching this, you’re thinking, okay, I have something to say about this. I wonder if I can get in on that conversation. And I can really take no credit for that, but I was in the right place at the right time. A politician in the Irish Parliament reached out to me, and she said, “Will you come? Will you come to Ireland and address us on your research?” At first, I thought, this is not real; right? This hasn’t happened. But it was, and I went. That’s me talk to the Oireachtas, which is the Irish Parliament, saying something very serious, which you can see, committee on the Eighth Amendment. It was very serious. And I had two colleagues from the WHO with me in the same session.

And our charge was to come there and sit in a room like this, but the politicians are all in their big chairs around you, and you’re at the front. And you get 12 minutes to talk about your research, which I did, basically what I just told you all. And then there’s two hours of questions. So think about how different this is from walking up to a legislature and having your two minutes for testimony. Anyone who has ever done testimony, you know what that’s like; right? You get your two minutes at the microphone, and then you go home and you hope you’ve done something. But, you know, if you’re in Texas, you kind of know that it’s already been decided. And you knew you should show up. But, certainly, no one is going to engage you in two hours of conversation; right?

And so we sat and we talked. They asked questions. They wanted to know about these data. They wanted to know about the experiences. And there were no people, by the way, who had had abortions in Ireland, self-managed or travel, invited to this at all. So this research, in some ways, I hope, helped to represent some of the people who had talked with us, and the wider body of people who were in these situations. It felt very important to try to help have that out there, because there were no people with the actual experience invited, which is a downside of this.

But there were politicians in there who were already supportive. They were politicians who were absolutely unsupportive of abortion rights, and there were politicians who were undecided. Imagine an undecided politician. Can you believe it, you know; right? So when we think about the policy impact that this research hopefully made, it’s part of the context; right? I want to emphasize that when you have a Citizens’ Assembly, when you have people hearing about an issue, getting together four weekends in a row and talking about this, sending a set of recommendations to a Parliament, that then invites people to come and talk to them and have a conversation -- I got asked about, you know, is it only irresponsible teenagers that have abortions? No. Our data says that there are people from every age demographic, all racial and ethnic background, all kinds of employment levels, all kind of incomes, all of them were represented in the women on Web data.

Did everybody regret their abortion? You know, if we allow this, are we going to see a mental health crisis in Ireland? That was a serious question. It was like, no. Look at these data. Look what people were saying afterwards. If these pills are coming into the country, what does it mean for public health? And we were able to address that question by saying, “Here is the data on the safety and effectiveness of this.” Is this going to harm people? No, the pills are not harming people. The law is harming people, because of the isolation experienced they talked about in their qualitative interviews. So, it’s not complicated research. But in some ways, that’s the beauty of it, because you can talk to anybody about it. You don’t have to understand anything particularly complicated to get this.

So, it was a cool experience to actually get to talk to politicians and have real conversations with them. And, in the end, they recommended legalizing abortion up to 12 weeks, which is on par with most European countries, with the exception of England, which has a later gestational limit. But with exceptions thereafter. So, you know, a person who is super supportive of abortion rights writ large would not think this was the best outcome. But, at the same time, from the amendment you saw to this is quite a big change.

To think that you were able to bring some evidence, to talk and have dialogue and be able to come to someplace of, okay, you know, we see this is happening. Where even the politicians that were on the side of, this is really immoral and we want to keep this out of Ireland, the swaying point there was the idea that, yes, I appreciate that, but you’re not; right? You have to really face the music on this and see the practical pragmatic reality that people are going to make their own decisions about this, and they are; right?

You have five abortions happening in Ireland every day, on average, so if you really want to keep abortion out of Ireland this is not the way to go about it. It’s debatable whether you should even want to do that, but that’s not my business, that’s yours. That’s your own idea. But you’re not doing it, that’s the point, so it was very interesting. And I take heart in this because, again, like I said, it’s not the conversation I tend to have here. So let’s move to that.

Let’s look at the United States. Here we are, and we have just seen the Dobbs decision, the overturn of Roe. We saw states act immediately; right? We saw trigger bans come into effect. We saw reliance on laws that were passed pre-Roe to outlaw abortion completely.

So, we at UT -- and I want to credit the research team here. These are the folks I work with at UT. We have data scientists, sociologists, public health folks. We’re a very interdisciplinary team. Those of you from Mathematica might recognize Jen Starling there at the bottom, works for Mathematica and is part of our Data Science Team.

So we started the Self-Managed Abortion Needs Assessment Project to try to replicate what was done in Ireland, and try to figure out, do we see something similar when we look at those same questions, and then try to think about how to use those in terms of informing evidence-based policy. You know, I think public policy should tend to do two things; one, be informed by evidence; and, B, act in the interest of the people it’s supposed to serve. So, this research tries to do both, partly with a quantitative part, and then partly with a qualitative part, in terms of trying to figure out what people need.

This slide looks familiar, because it acts as a sister service to Women on Web. It’s the same doctor, but it is a different organization. Because of the legal liability, we are talking about a very different place when we talk about the United States. When it comes to the surveillance of people, the incarceration of people, the prosecution of people, it looks a bit different from Ireland, let’s put it that way, and so it acts as the same service. But to avoid liability to the Women on Web service, Rebecca Gomperts runs this as a [inaudible]. It’s the same thing though, the abortion pills coming by mail to people here. So, it’s happening. This is even before Dobbs.

[J.B. WOGAN]

Hi listeners, sorry for interrupting. Let me describe briefly the slide that Abigail showed the audience here. It’s a color-coded map of the United States. Some states, such as Texas, Mississippi, Louisiana, and Alabama, are colored in dark red, which indicates that they are states where the most requests for abortion are coming from.

[ABIGAIL AIKEN]

Those are the states where most requests for abortion are coming from. And, look, it tends to be the places where abortion is most restricted. There is definitely a correlation between the restrictive laws and the more requests that are coming in, and this is before Dobbs. I think for some people who maybe don’t think about this very much, it feels like things just suddenly changed. If you’ve been in this field for a while, you know that things didn’t just suddenly change. You know that abortion access has been really, really difficult here for a really long time. In fact, since, Roe was passed; right, the first thing congress did was pass the Hyde Amendment; right, to try to stop public funding through Medicaid. And Henry Hyde, who passed that amendment, was very transparent. He stood up and he said, “We can’t stop people now from choosing abortion, but we can stop poor people from getting abortions.” That’s what he said. And so since then, this has been extremely difficult for people.

[J.B. WOGAN]

Hi listeners, here’s one more place where I need to describe what’s happening in the slides. There’s a bar chart with the Y Axis showing the percent of people citing the reason for their request. The X Axis shows a list of potential reasons. The most common reason is cost; they cannot afford an abortion in a clinic. Almost 75 percent gave that reason.

The next slide draws from Abigail’s qualitative work from the same research. The slide shows a quote from a woman named Kendra, who is 29, who tried several methods of self-managed abortion before turning to telemedicine through Women on Web. The quote mentions drinking an herb thought to cause abortions and punching herself in the stomach.

[ABIGAIL AIKEN]

Again, a really, really sad quote to read but so important to see, because although I don’t think we’re going back to the pre-Roe days of emergency rooms filled with people suffering from infections from abortions that were not properly carried out, that is not to say we won’t see some people in these situations, and it’s important for us and the politicians to know that.

As I said before, we don’t know what proportion of all self-managed abortions happen through Aid Access in the U.S. But because, again, of the cost piece on this, knowing that they will help you even when you don’t have a cent in your bank account, I think, means they are one of the more widespread methods.

So, I wanted to show you that on the background is very restricted access, before Dobbs and post-Dobbs, every time we see a state or several states act with what I would call a policy shock; right, to try to restrict abortion, we see a jump in requests to Aid Access, and it’s too much of a trend now. It’s not causal inference. I know that. But at the same time, we see it every single time this happens.

So, you look at Texas’s executive order, Governor Abbott, back when Covid first appeared on the scene, March 2020, he used that to say abortion is a nonessential medical procedure. We were without abortion care for four weeks in Texas. Then we had Texas Senate Bill Eight the six-week ban, which is once you have heart activity detected in the fetus, you can no longer have an abortion. And then post-Roe or post-Dobbs, abortion bans in 12 states.

[J.B. WOGAN]

Hi listeners, I’m going to describe briefly what Abigail shows in her slides here. There’s a line graph showing that requests to Aid Access doubled after the Texas governor’s executive order. On the following slide, she shows that in the four-week period after Texas Senate Bill 8 went into effect, requests for services was triple what we would have expected. And then after the U.S. Supreme Court’s Dobbs decision, requests for Aid Access increased by 160 percent.

[ABIGAIL AIKEN]

So you can see people were already doing this, of course, post-Dobbs, but it has increased. And when people were asked what the reasons why they made the requests, in these states they were saying it’s because these laws have just been passed, I no longer can get to a clinic.

In other states, we also saw an uptick, which was very interesting, and those people were saying, this is something I actually prefer to do. I prefer the comfort. I prefer the privacy, even in the absence of a ban. And I think that’s really interesting, because one of the unintended consequences, I would say, of abortion bans is that it actually gets people talking about self-managed abortions. Y’all may have heard about it, perhaps even before this talk, because since Dobbs was handed down, the media has been talking about it. There’s been Reddit forums about it. There’s been spotlight kind of shone on this in a way that I’m sure was not intended by the folks who wanted this decision in place. And so you have people now who are saying, hey, this is safe. It’s effective. In some states you can get telehealth abortion within the formal health-care setting, why can’t we have it in Texas? Why can’t we have it in other states as well? So I think people are beginning to realize that too.

So, I’m at the end now, and I wanted to talk a little bit about how to use this evidence in the post-real world. Disclaimer, I don’t have the answer to this. I’m thinking about it. If you have thoughts, I’d love to hear about them. But I think, again, you know, there are some bottom lines here, which is that pragmatic place that a lot of the Irish politicians managed to get themselves to, to understand that you’ve seen it time and time again. You can look outside the U.S. in other context. You can look at the pre-Roe days. You can look at the data I just showed you. Restricting or outlawing abortion doesn’t reduce the need for abortion. It doesn’t just make abortion magically go away. So what you’re going to have is some people remaining present where they don’t want to be, a public health crisis, you could argue, in its own right, but then the idea that it doesn’t even prevent all abortions. So if the goal is a total ban, it’s not going to work. I think we know this. We’ve seen it. But here is the evidence for it.

And, you know, while we’re not necessarily going back to pre-Roe times, you can see that even medically safe self-managed abortion can be legally risky, it can be fraught, and it can be very isolating, because of total abortion bans in the law. It also won’t work for everyone; right? We know that there will be people over the gestational limit, and people who, again, will remain pregnant. So, this is not new; right? We’ve seen this in Ireland. We see it here too. How to talk about this is very, very difficult, because, partly, you don’t have the benefit of a Citizens’ Assembly. You don’t have this, for the most part, in the hands or in the decision trees of people out there. It tends to be politicians who represent -- if you don’t vote in primaries, please vote in primaries -- representing about three percent of the people who actually, you know, live in the state or a place.

And you see that when it does go to referendum, like in Kansas for example, it was in the ballot in a couple of states this past midterm election, people tend to oppose total abortion bans. And oftentimes, people feel quite personally conflicted about abortion oppose total abortion bans, because they know, well I just told you, and they also perhaps don’t believe it’s their -- you know, they don’t need to make anyone else’s decision.

But in the absence of all that political structure, what can you do if you have evidence that no one wants to hear? Well, you can try to get it out there into the conversation. You can talk to journalists. I spent a lot of time doing that. It doesn’t always go perfectly. If anyone has ever talked to the media, knows you don’t have full control over what happens, and you certainly don’t get to write the headlines. But at the same time, you can try. You can try to get that message out there, try to get your research linked so that people can see it, and see it and become well informed, even in the absence of a Citizens’ Assembly, they can help them with that. They can perhaps pick it up at an outlet and read about it.

You can try to form partnerships.

[J.B. WOGAN]

Hi listeners, what you would see on the slide is a series of screen shots showing different ways Abigail’s research on self-managed abortions has been cited by the media and in official government documents, such as an amicus brief that went to the U.S. Supreme Court.

[ABIGAIL AIKEN]

So a lot of this is kind of hawking your research around, trying to see who wants to listen to you.

And then there’s Redditors. If anyone goes on Reddit, you’ll see these forums where people are talking about this. Trying just to get your research into the public conversation is really the goal for our team right now. And we still show up at the legislature, and we still talk, and we still know that, you know, it’s been decided. But, you know, even when local politics are a certain way, even when your state politics are a certain way, there is usually something else coming. It may be the Supreme Court. Less likely right now. But there’s also people; right? And at the end of the day, the track record of governments that try to go against the word of people, that try to oppress them, that try to take decisions out of their hands, I think we know what the arc of history looks like there. So I always hold hope that evidence will be heard at some level, and, you know, we hold that hope of changing this conversation.

[Applause]

[J.B. WOGAN]

Thanks for listening to part one of our two-part episode about Abigail Aiken, the 22nd winner of the David N. Kershaw Award and Prize. My Mathematica colleague Rick Stoddard produced this episode. We’re indebted to the Association for Public Policy Analysis and Management for helping us record Abigail’s address at the association’s fall research conference. Part two of this episode, which features my interview with Abigail, is also available now. You can find it on your favorite podcasting app or the blog associated with this episode at Mathematica.org. To stay up-to-date on future episodes of On the Evidence, the Mathematica podcast, subscribe wherever you listen to podcasts or follow us on Twitter. I’m at JBWogan. Mathematica is at MathematicaNow.

[ABIGAIL AIKEN]

I think because we’re public policy folks, it is our charge to do research, but it’s also our charge to try to get that research and that evidence in the hands of people who make the decisions to hopefully help them make better informed decisions that perhaps will meet the interests of people that they represent.

[J.B. WOGAN]

I’m J.B. Wogan from Mathematica and welcome to back to On the Evidence, a show that examines what we know about today’s most urgent challenges and how we can make progress in addressing them.

This is the second part to a two-part episode about Abigail Aiken, this year’s recipient of the David N. Kershaw Award and Prize, which recognizes early-career professionals for their contributions to research and public policy. It is among the largest and most prestigious awards of its kind, honoring Mathematica’s first president, David Kershaw.

Part one of this episode features an address Abigail gave in receiving the award at a recent conference hosted by the Association for Public Policy Analysis and Management. It’s an entertaining and poignant talk about her personal and professional journey, explaining how she became interested in researching self-managed abortions through telemedicine and then how she has engaged with policymakers about her findings.

The second part, which you’re listening to now, is about that engagement piece. After she publishes her findings, how does she ensure that they don’t go unread and ignored? It’s worth noting here that Abigail is active in speaking with the policymakers and the media. For example, in 2018, she provided testimony to the Irish Parliament on the prevalence and safety of self-managed abortion through telemedicine in Ireland that informed language on a national referendum.

In 2020, her work on the impacts of restrictive state abortion policy was cited by the U.S. Supreme Court as key evidence in cases that proved decisive for maintaining abortion rights in Texas and Louisiana.

And in 2021, her research on the safety and effectiveness of telemedicine was cited by the U.S. Food and Drug Administration as part of the basis for its landmark decision to remove the in-person dispensing requirements for mifepristone.

She has also been the subject of a New Yorker profile and has been quoted in prominent media outlets including the Associated Press, Reuters, the New York Times, the Washington Post, The Economist, and the Wall Street Journal.

Which is all to say, she has a proven track record of extending the reach of her work beyond peer-reviewed journals to ensure policy impact.

We’ll start with a few curated questions Abigail answered from audience members after her address as the research conference, including one from me. Then we’ll switch to a brief interview that Abigail and I squeezed in between her talk and the awards ceremony. Please forgive the background noise – the only way we could record the interview that day was to forgo a formal studio and talk in the empty room where she had just given her address.

By the way, the Mathematica blog that accompanies this episode will include transcripts for both parts one and two. We’ll include more information about the Kershaw Award, Abigail’s work, and our previous podcast interviews with Kershaw Award winners.

I hope you find both parts of episode interesting and useful.

[FEMALE SPEAKER]

What you’re doing a courageous. I mean, it’s amazing. But my question for you is, you know, as a researcher, you know, there’s that line between research and advocacy, and I’m sure that’s always top of mind for you. How do you stay unbiased when you can see, you know, very clearly what the answer is? And, you know, can you just talk about any struggles that you might have in that, and, you know, how you’ve navigated that.

[ABIGAIL AIKEN]

Thank you. It’s such a good question. It’s something I think about a lot. I mean, I think everybody probably has their own position; right, on this topic, and on any topic that you go to research, and this is a particularly charged one. I think that, for me, it’s important to acknowledge that I, having grown up in Ireland, have experienced this myself, and that, you know, puts me in a place, I think, of empathy for other people. But it also means that I certainly do have strong feelings about it.

At the same time though, I think it would be disingenuous for me to sort of say, you know, I do this research from a completely neutral standpoint in terms of my personal feelings. But when it comes to analyzing data, that’s where I think it’s important; right, that you don’t let the questions that you choose, or the way that you analyze your data, or the way that you talk about your data become the same thing as your own personal feelings, and that’s partly why I sort of began this with thinking about the subject of abortion and how many people feel complicated about it, or they have very strong feelings. And so, yeah, I think trying to pretend that you’re totally neutral is not a good idea when you’re not. But at the same time, not allowing that to affect the -- sorry, I’m struggling for word, this is the sleep deprivation -- can I say ingenuity, like the way that you analyze your data, the way that you think about it.

You know, obviously, one day, I guess my biggest fear is that I will come up with a research finding that I didn't want to see? And, you know, the ethical question there is what do you do with that? Do you stick it in a desk drawer and pretend you didn’t see it, or do you send it out there, because there’s no surprise to you, the research community in which I operate is also one that I think oftentimes feels quite attacked, feels quite protective of this subject. And, you know, what do you do when you have findings that you don’t like? My answer to that is you publish them and you talk about them, because you have to. That’s what research is. You need to be – I’m, first and foremost, a researcher on this.

But I had an interesting conversation once on a plane. I was heading to Ireland. In fact, it was going to the Citizens’ Assembly, and I was sitting on a plane beside a guy, and I was working on my slides still for going to this thing. I know. And he was kind of looking over, and he goes, “I couldn’t help but notice.” I was like, “You totally could help but notice, but you were looking at my slides.” And he go, “Do you work for a pro-life organization?” And I thought, I wonder what about my slides makes you think that, because they’re not biased in any way. I’m not going out there that Ireland should do anything in particular. I’m just giving the evidence, and politicians are going to come to their own decision on that. But I wondered why he said that.

I said, “No, actually, I’m a researcher. I don’t, you know, advocate one way or the other. I’m just here with my evidence and my data.” And he goes, “Oh, because I’m a sidewalk counselor for the last abortion clinic in Mississippi. I live there, and I’m very religious, and I go there every day, and I talk to people about what they’re doing and how, you know, awful it is. Like how could you conscience this? I try to help them to understand what it is they’re doing. And this is so interesting; right?

And I just could not -- I couldn’t resist just talking with him. I really wanted to hear how it was that he had come to do this, how he felt about it. And, you know, he was very, very, very, very -- I think, heartfeltly believed that he was doing the right thing; right? For him, it was that these babies are going to be murdered, and if I don’t try to stop that, part of it, I’m complicit; right? I haven’t intervened, I haven’t acted, and so I must do this work.

And, you know, we talked. And I said to him, you know, I see that, and I wonder, you know, if that abortion clinic were to get shut down, what do you think that people would do? And we started talking about self-managed abortion. It was really interesting. He was like, “Oh, I didn’t know that people did that.” And I was like, “Yeah, we’re kind of just -- you know, we know it happens, but we’re trying to put some data to this.”

And we actually had a very civil -- I mean, the people around us were probably just sitting there going, please stop talking about this, like what are you doing? But I really wanted to hear what he had to say. I think part of it is wanting to hear what other people who don’t agree with you have to say, and I really do. I like knowing that, because then I know something that’s not my own opinion; right? Because I do, I do support abortion rights, and I do think the evidence is in favor of that, but at the same time, I understood where he was coming from.

We came to a place where he said, you know what, maybe shutting down that clinic wouldn’t be such a good idea. And I said, “You know, I’m with you on that. I don’t think it would. I think people who want to do that should have the choice.” He said, “Yeah, you know, I’ll be there to talk to them and to try to explain to them why they’re not doing the right thing.” I thought, well, you know, that’s probably as close to, you know, getting there as we’re ever going to get with you. But it was very interesting.

And so, for me, I think it’s about trying to remain open-minded about things, trying to always question, am I asking the right questions? Am I thoroughly analyzing my data? And when I do have a finding that I don’t, you know, really wish that I had found, being brave enough to go out there and say, here it is, and what do we make of it. That was very long-winded. I’m sorry. But there it is.

[FEMALE SPEAKER]

We bring all of who we are, our beliefs, our identities. And I think in this topic specifically, I worry about making statements like that, because it is so racialized. It’s gendered beyond the binary. There’s so many implications, and so as I know people are saying, like, this should be neutral, but none of our research is. We bring all of our biases, and so I’m just wondering how do you, like, negotiate that? And, like, at what point do you make a statement about, this is my research, and this is, like, what I want to do, this is what I stand for? And I know that it’s difficult when you’re trying to influence policy, but that happens across, you know, the policy spectrum. And so just wondering kind of how you grapple with those things?

[ABIGAIL AIKEN]

Yeah, I mean -- let me try and clear the baby fog a little bit so I can answer this. I’ve been asked it already, and I’m trying to sort of get my thoughts together on it. So, here’s what I would say, I am pretty much in agreement with you that the questions you choose to ask, the experiences that you have in your life, the people that you know and talk to and engage with, all of that will be brought to bear on what you choose to study and how you choose to study it; right? The very fact that I’m asking questions to these folks, and not, as the point was made over here, you know, trying to engage with science on, for example, what we can determine about fetuses and fetal consciousness. I’m not in that area; right? I still want to know about it. But, certainly, these questions are the ones that I choose to ask.

And I must say I think you may have come across it, you may not, I’ve been up front about my own experience with self-managed abortion. As a teenager in Ireland, I do come out of that context, and I think I understand what it is to go through that. So that does definitely influence how I perceive this, what I expect to find in my analyses. I think you’re right, you can’t divorce yourself and sort of say, “Oh, I’m going to study abortion from a totally neutral lens, and I’m going to pretend like I don’t have any experiences or feelings or empathy for anybody.” You’re right; so I do bring all of that.

But, at the same time, I think where it really matters is in terms of what you do with the research and how you go about your analyses; right? If I went into this and promised, you know, Woman on Web, look, if I find that this is really not safe and effective, I’m not going to publish that; right, that’s where I start to see the difficulty; right, that you would not want to see a certain thing, and, therefore, you’re just going to completely close your mind to it. Or people were saying this is actually a horrible experience and I wish I’d never done it; right, if that happen, you have to be truthful about it, and you have to include it in your results.

And then I think when you come to talk to people in the political sphere about this, you know, it’s going to be, as you say, obvious to them when you’re bringing this research, the fact that you do research this, it probably, you know, at least signals that you are comfortable in some way with abortion, otherwise you probably wouldn’t want to research this at all, or you might take a different approach to it. But at the same time, I think then it becomes important to try to engage with other perspectives. I think that’s the best that I’ve found that I can do, is to say, look, I acknowledge that I have experiences and I choose to ask certain questions, and I even have ideas about what probably is the right policy to go for.

But at the same time, I don’t come in saying, y’all are absolutely wrong for, you know, having your total abortion ban, you know, how could you be so ridiculous, because that’s not going to help. If I come in and say that, and if I don’t try to really understand that there are people out there who have, you know, really, really strong opinions about this in other ways, then I can’t talk about it with anybody.

And I think maybe if you look at the way we talk about abortion in media, it’s very, very polarized; right? You either have to be all for it or all against it. And I think the reality for a lot of folks out there is that -- not everybody, but for some folks, that it is more complicated within that. So the best I can do, and to answer this question, is to say I try to remain open-minded, and I try not to come into a room with the attitude that my way is the only way, and that I know what’s right, you know, because I can’t speak for everybody, and I also can’t persuade people of facts that they may want to hear if I come in saying, you know, you’re ridiculous and I don’t hear your opinion.

[J.B. WOGAN]

So, I noticed that both, in your remarks, and then in some of your research, you use storytelling quite effectively, the qualitative testimonials from women’s experiences, but, also, you know, everything from the story of you sashaying on the dance floor, and to meet Dr. Gomperts, to the young man you met on the airplane. I was just wondering if you could speak to how you think about and use storytelling in policy research, and what the role is of storytelling in policy research?

[ABIGAIL AIKEN]

Thank you, JB. That’s a really interesting question. I think that it is -- you’re right, I never really thought about it, but it is really important to what I do, and I do use it a lot. I think it’s an Irish thing too. I think we like to talk about our stories in Ireland. Usually, you’ll sit down, and the person beside you will be somehow related to you as well, and you’re like, oh, yeah, you’re Aunt Mary. Yeah, I know it’s my Uncle Tom. It’s very much an Irish thing. But I think, as well, it’s really important to understand, when walking into a policy arena, that you, as a researcher, or I, as a researcher, oftentimes love to talk in numbers; right? I love to talk to my colleagues about my analysis. I didn’t present anything methodologically complicated today, but I like to talk about those things. I like to talk to with my [inaudible] colleagues about how I should do things, what they think.

And when you come into a political sphere, and this is a case in the Irish Parliament for sure, the quantitative stuff was definitely received, like people were hearing it, but the stories, I think, were really what persuaded folks; right, because that connection to a person out there, to be able to say I’m sitting here in charge of making this policy, and you can give me numbers, and that is good, but to really understand what people are experiencing, I think, for a lot of folks, particularly folks who go into politics, because you have to be interested, in some level, in other people, to do that, otherwise you wouldn’t do it. And I think for some folks to have heard about people’s experiences was really what swayed them more than the idea that, yeah, this is happening. You haven’t managed to stop it. Some folks were on that page. For other folks, it was like, well, I really didn’t realize what people were going through.

The other side of that, of course, is that when you walk into that kind of arena, there was a worry in my mind that, what if I come in here and say that this is happening, and, all of a sudden, these people in front of me say, “Well, we’ll start cracking down on this.” Like well didn’t know it was happening, so we’re going to really start enforcing it; right? It’s a risk that you take when you come into the environment. So my judgment of it having been some sort of back researching with the politician who invited me was that that was probably not going to happen, and I would, of course, not have wanted to have been responsible for that.

But also the idea of self-censorship; right? As I said, not a single person who had experienced this was in the room, either a negative experience or a positive experience, a person who remained pregnant and perhaps found that was, in the end, a good experience for them, or a person who had an abortion, none of those folks were there. And I think the power of storytelling in terms of trying -- obviously, you can’t represent everybody, but try to at least get some human element to this, I think, helped people to see that perhaps, at least people with the capacity to become pregnant, were not being served well by the law.

[J.B. WOGAN]

Hi listeners, we’re switching now to my interview with Abigail, so the rest of the questions will be exclusively from me and you might notice a slight change in the mics. Hopefully the audio quality is still good enough. OK, back to the show!

[J.B. WOGAN]

Okay. I noticed that you have sections on your research group’s website about policy impact and media coverage, and I think that’s a reflection of just how active you are at engaging with policy-makers and the media in your work. So I have a couple questions. Big picture, how do you think about the importance of engaging with policy-makers, and engaging with the media? And then I’d also be interested in sort of the nitty-gritty elements, like how much time do you allot in a given week or a month to those activities, which I assume are, in some ways, in competition with the core research work that you’re doing?

[ABIGAIL AIKEN]

Yes, particularly at times when states like Texas, you know, act to ban abortion at six-week gestation, or when the Supreme Court decides to overturn Roe v. Wade, those are intense times. I will field maybe 30 to 40 maybe calls in a week sometimes or email requests, and it does get quite intense. But I think that because I’m from a public policy school, and because that’s my profession, I see it as part of the work. You know, I think because we’re public policy folks, it is our charge to do research, but it’s also our charge to try to get that research and that evidence in the hands of people who make the decisions to hopefully help them make better informed decisions that perhaps will meet the interests of people that they represent.

And so, to me, engaging with the media or talking with colleagues outside of the academic setting is a really key part of what I would call my research writ large, and so it can be very tough to make time for it, especially, if for example, if a research paper is hitting or something is happening in the policy world and you’re getting requests coming from all directions. But I really try to meet as many of those as I can, with interview, if that’s requested. And it’s also important, you know, sometimes you’ll get media requests from outlets that you perceive perhaps would be less receptive to the evidence that you have, and those are also important to do, because, you know, if you’re just always talking, for example, to the New York Times and a lot of the readers there are already going to be on the same page as your evidence, it’s not as impactful as being able to perhaps reach an audience that doesn’t have a preconceived idea, or perhaps it’s a preconceived idea that looks very different to what your research might suggest be the course of action. So I try to engage with many different media outlets, when they will have me.

[J.B. WOGAN]

And do you actually set aside, like I’m going to set aside ten hours a week? I interviewed someone, Jennifer Doleac at Texas A&M, where that’s her model. She tries to carve out a certain discrete period of time per work for those kinds of activity.

[ABIGAIL AIKEN]

I wish I were that organized.

[J.B. WOGAN]

Okay.

[ABIGAIL AIKEN]

I think, for me, I’m very much a sort of pick one and get it done person, so I don’t have a set schedule. I’ll sort of make a priority list of things as they come along, and I will try to put it around, you know, for example, the last couple of months have been very busy since the overturn of Roe. And at that time, I was in the very late stages of pregnancy, and then I had a newborn, and I would tell reporters, you know what, you can give me your number, I will call you when I have a sleeping baby or when I have a free hand.

[J.B. WOGAN]

Yeah. Yeah. So that makes sense. I guess it makes sense, also, that, as there are policy events, there may be sort of rises and falls in terms of your engagement. I have a related request about interacting with policymakers in the media, which is, do you calibrate your language or your framing for those audiences? What has past experience taught you about those audiences’ needs and priorities that might be different from, say, speaking at a research conference. This one is at least policy research conference, but, like, is there anything you do differently when you’re trying to address those audiences?

[ABIGAIL AIKEN]

Well, I think that it’s quite important to not assume that the person you’re talking to knows what a self-managed abortion is even. For example, quite often, the calls with media will begin with just a question or sort of a statement about what a self-managed abortion is so that we’re on the same page. Quite often, I think people are not familiar with the term, or they have a preconceived idea of what it means, and so making sure they understand what I might be talking about is always my first step.

Then there’s the idea that often people will want me to opine on something that I think pushes me into the advocacy territory a little too far. And while I think that any time you’re bringing evidence into the policy sphere, you are in some sense, advocating for something; right? Because you want your research to be used, you probably have a clear idea of what your evidence is telling you, so you can’t not, in some ways, advocate for a policy to be constructed a certain way, or perhaps to move away from a particular kind of policy. But at the same time, I tend to not want to opine for example -- let me see, what’s a good example? You know, oftentimes, people will ask me is, is what Aid Access is doing right? And I’m not going to have an opinion on that question. It’s not my place to say whether Aid Access is doing something right or wrong. I’m here with some data that I can tell you, you know. I can tell you what that speaks to. I don’t wade into sort of the more opinion-based questions.

[J.B. WOGAN]

Okay. Maybe I misremember this, but I think you gave an example during your talk about the decision to have the 12 weeks be a cut-off in Ireland, and that was something where sort of the details of exactly what the amendment should be; that was, you weren’t necessarily recommending a specific threshold.

[ABIGAIL AIKEN]

Right. Exactly. You know, with that data from Ireland, I think the main points I wanted to get across were, you have the total ban on abortion is what you’re going for. That hasn’t happened. And that it has to, I think, be realized that the law does have negative impacts on people who are seeking abortion or pregnancies that they don’t want. But, at the same time, if they had asked me, what’s the right gestation limit to go for, I don’t have any evidence that speaks to that. You know, I think we can look at national evidence and what it places, and say that, you know, most people are not choosing to have later abortions. People tend to want to have abortions as early as they can to deal with their unintended pregnancy quickly. But at the same time, no, I did not -- you know, they hadn’t asked me, but I wouldn’t have felt comfortable going further than the evidence on the day.

[J.B. WOGAN]

We actually heard this in some of the questions after your talk. But I hear more and more about the importance of lived experience in informing policy research. How has the experience of now going through pregnancy and becoming a parent informed your work? And I think you also talked about the talk and in the New Yorker profile about the lived experience of going through a self-managed abortion. But, just those different experiences, you know, it does seem like it would be viable. It’s an expertise that you bring to the work.

[ABIGAIL AIKEN]

Yes. I think there are a couple of things there. It’s such an interesting question. One is that I think that it makes me less able to understand the kinds of policies that you see Texas and other states, and Act, that seem to be directed at trying to educate women and people that can become pregnant about what an abortion is. I think if you have been through pregnancy, birth, and you have a child, you understand exactly what pregnancy is, and you understand that an abortion is going to end your pregnancy.

So the idea that, for example, compulsory view on ultrasound or having to listen to fetal heart auscultation is going to teach a person who has had a child or has been pregnant something they don’t already know, I think, is very misguided. You know, you hear politicians say, if only these people realize what they were doing, they wouldn’t choose this. I don’t think that’s the case. I think that if you’ve been through pregnancy and childbirth you know, and I think that it’s quite cruel to require somebody, then, to view ultrasounds or hear fetal heart auscultations. But, of course, if they want to, I think they should be allowed to. But I think the idea that you require it is actually quite a cruel thing to do to people.

I think it’s also the case that there is something, for me, now having had my own children, that makes abortion sadder. I think I have to be very honest and say that. But I feel like it’s a sad thing for me. But at the same time, I also recognize that that’s not everyone’s opinion, and that just because I think that it’s sad doesn’t mean that people shouldn’t be allowed to make their own reproductive choices about their own bodies. I think it’s very interesting to feel that way, because it kind of puts me in a position where, you know, I’m not sort of saying, you know, there’s absolutely nothing, you know, sad about this or that it should always be something that people do. But at the same time, I think it’s so interesting how that has also made me very, very cognizant of the fact that that perspective should not be imposed upon anybody else. It’s very interesting.

I think it’s also the case that having been through some of the very difficult parts of pregnancy and childbirth, it’s also very much apparent to me why people cannot be compelled to do this against their will. I think it’s a very cruel thing. It’s an extremely hard thing for a body to do, for a person to come to terms with mentally. There’s great joy. But there’s also a lot of really, really hard parts to this too. And the idea of it being forced upon someone to be a parent or to go through childbirth or to be pregnant, I think when you’ve done those things you’re, you can really feel viscerally what that would mean for someone and can be empathetic to that.

[J.B. WOGAN]

There was a statement, I think it was the kicker, the final line of the New Yorker story, where you say something along the lines of, “In order for parenthood to be a choice, access to abortion has to be available.” Something like abortion has to be accessible or has to be equal. Is that a term, is this something you always knew or is that something that is more of an epiphany after you became a parent?

[ABIGAIL AIKEN]

Good question. I think that it did become crystallized for me having become a parent, because it really hits home to you that the opposite -- the other side of the coin of the choice to have abortion is also the choice of the parent, and I think choosing to be a parent is very important in terms of how you then are able to cope with all the changes that are going to be in your life. I, myself, through my first pregnancy, it was a very big surprise. It was not a planned or intended pregnancy, and I was sitting there in Texas with this positive pregnancy test going, whoa, this is not what I expected to see on the stick right now. And it became really apparent to me that actually having the choice of what to do about this was partly what really led me to say, no, I’m going to, in this case, parent. I’m going to have this pregnancy and hope I parent, you know, if everything goes well. But it really hit home to me in that moment that abortion is a choice to end a pregnancy, but it also creates a choice to parent, and that was extremely important to me. And I think partly having grown up in that Irish context, where there wasn’t a choice afforded to someone really, really made that important to me.

[J.B. WOGAN]

You talked about the research in Ireland about feelings of isolation, even women who are labeled who use Women on Web, that, you know, there were still kind of social/emotional consequences or costs, is that going to be an area of future research? Now, with women who are using this in states where abortion is illegal, are we going to need to document sort of what happens to women who still -- or I guess I should say pregnant people, women, who are able to have safe abortions through this mechanism, but it it’s not as simple as, well, then everything is hunky-dory because they’re able to have abortions?

[ABIGAIL AIKEN]

Yes, I think we are going to document that. And we have some research where we interviewed folks who’ve used the service to ask them about that experience. And some of those same themes, I didn’t have time to present it here today, but some of those same themes around, you know, disconnect from in-person advice or help if they needed it in the formal health care setting or being very afraid to talk to anybody in case of judgment, or worse, sexual reporting to the authorities came to the fore for people, and so that isolation, that stress, the also trying of things that perhaps would be less safe for a person or less effective before finding Aid Access, those are all themes that came out in our first look at this kind of qualitative data here in the U.S.

And I think it is so important to document, because there is a sense in which someone might say, well, if people are just getting around an abortion law by self-managing, then is that the solution? Are we done there? Is that the end of the story? And I think it’s not; right? Because I think that we have to see is that there is not any one kind of abortion that’s going to work for everybody. For a lot of people, there’s a way in which they see this process going, or that it’s very important to them that it go a certain way, be that in a clinic, be that in their own home. There’s a complexity to this that I don’t think we hear talked about, because we don’t talk about abortion a lot outside of certain spaces, and I think that research needs to speak to that to try to sort of say, you know, I suspect you might find something similar to Ireland, which is that people are grateful they have some options. But that, for some people, the self-management process did not meet their needs or was not the way in which they would have preferred to carry out this kind of care.

[J.B. WOGAN]

Okay. I’m mindful of time, so thank you so much for talking with me. Thank you for your research on this really important topic. And thanks for being willing to talk with me in the midst of -- you know, you’re very much in demand. You’re also, you know, sleep deprived and all of that.

[ABIGAIL AIKEN]

It was a pleasure. Thank you very much.

[J.B. WOGAN]

Thanks for listening to our two-part episode about Abigail Aiken, the 22nd winner of the David N. Kershaw Award and Prize. My Mathematica colleague Rick Stoddard produced this episode. Part one of this episode, which features Abigail’s remarks at the fall research conference hosted by the Association for Public Policy Analysis and Management, is also available now. You can find it on your favorite podcasting app or the blog associated with this episode at Mathematica.org. To stay up-to-date on future episodes of On the Evidence, the Mathematica podcast, subscribe wherever you listen to podcasts or follow us on Twitter. I’m at JBWogan. Mathematica is at MathematicaNow.