AIMS: Concern about the effects of alcohol and drug use during pregnancy is intertwined with debates about abortion. There is concern that alcohol abstinence recommendations lead women using low levels of alcohol to terminate otherwise wanted pregnancies. This study examines how women describe alcohol, tobacco and/or drug use (ATOD) as reasons for deciding to have abortions and assesses the differences between women reporting and not reporting ATOD as reasons for deciding to have an abortion. METHODS: Data come from the UCSF Turnaway Study which recruited 956 women seeking an abortion at one of 30 US clinics between 2008 and 2010. Mixed methods were used and data were analyzed through thematic coding and logistic regression. RESULTS: Nearly 5% reported ATOD as a reason for abortion. Women worried that their ATOD had affected their baby’s health and that their or their partner’s ATOD would influence parenting. Most women (84%) who reported alcohol as a reason binge drank or had an alcohol-problem symptom in the month before discovering their pregnancy. Sixty-one percent who reported drugs as a reason used drugs, with 88% using more than once/week. Although two-thirds smoked tobacco, no woman reported tobacco alone as a reason. Ninety-eight percent of women reporting ATOD as a reason had unintended pregnancies. CONCLUSION: Women reporting ATOD as a reason drink at levels exceeding a low threshold and do not appear to be terminating otherwise wanted pregnancies. Thus, findings are inconsistent with hypotheses that abstinence recommendations and punitive policies lead women using low levels of alcohol or using drugs to terminate otherwise wanted pregnancies.