Do women need pre-abortion counselling?

While we’re waiting for the Department of Health to launch its consultation on the future of pre-abortion counselling, a new study has been published by the Guttmacher Institute which sheds some interesting light on women’s needs and choices at the point at which they make contact with abortion service providers.

The study, ‘Attitudes and Decision Making Among Women seeking abortions at one US clinic‘ shows, unsurprisingly, that the vast majority of women have very firmly made up their mind about having an abortion before making contact with an abortion clinic:

For 87% of the abortions sought, women had high confidence in their decision before receiving counseling.

Although only a single centre study, the paper is based on data extracted from the pre-assessment and clinical intake forms of more than 5,000 women who voluntarily took up the clinic’s offer of counselling of which only 7% did not to go ahead with the abortion for reasons we’ll come to shortly.

The paper usefully identifies a number of factors that were found to negatively associated with high levels on confidence in the decision to seek an abortion including:

…being younger than 20, being black, not having a high school diploma, having a history of depression, having a fetus with an anomaly, having general difficulty making decisions, having spiritual concerns, believing that abortion is killing and fearing not being forgiven by God.

Perhaps unsurprisingly this list is broadly in line with the risk factors identified in research looking at the relationship between abortion and mental health:

The most reliable predictor of post-abortion mental health problems was having a history of mental health problems prior to the abortion, a finding that emerged regardless of the specific outcome measure or method of reporting used. This confirmed the findings of the APA review. Additional confirmation of this finding came from considering only the prospective studies that found the single consistent factor associated with poorer mental health outcomes post-abortion to be pre-abortion mental health problems. It also appeared that any mental health problem prior to pregnancy increased the risk of post-abortion mental health problems, although studies often were not specific about the pre-abortion mental health problem.

A range of other potentially associated factors had more mixed results, although there was some suggestion that life events, feeling pressure from a partner to have an abortion, and negative attitudes towards abortions in general and towards a woman’s personal experience of abortion, may have a negative impact on mental health. In other reviews, stigma, the perceived need for secrecy and lack of social support have also been reported to be important factors associated with poorer post-abortion outcomes. Importantly, the findings suggesting that women who show a negative emotional reaction immediately following the abortion are likely to have a poorer outcome, may act as a useful means of identifying those at risk of developing mental health problems.

However the study also reports that a positive association between high confidence in the decision to seek an abortion and the presence of supportive mother or male partner, so overall the picture we have here is one of a readily identifiable subgroup of women for whom pre-abortion counselling is likely to prove beneficial at the decision-making stage and hence a need for screening at the initial assessment stage but not for actual counselling.

What the evidence tells us here is that an offer of counselling should be made if a woman exhibits one or more these risk factors or displays a degree of ambivalence in regards to their decision prior to an abortion but, otherwise, there is nothing here to support a need for mandatory counselling.

The study also flatly contradicts claims made by Nadine Dorries and her supporters that the introduction of so-called ‘independent’ abortion counselling would lead to 30% decrease in the number of abortions carried out in the UK. That particular claim is, in any case, based on the wholly false assumption that laws requiring mandatory pre-abortion counselling in countries like Germany account for the difference in their abortion rate compared to that of the UK but here we have a study which shows that only 2% of the women who received pre-abortion counselling either chose not to go ahead with and abortion or were sent home by the clinic to think things over after demonstrating ambivalence over their decision. If Dorries’s preferred counselling measures were to have the same effect, that would net her a reduction of under 2,000 abortions a year, providing we assume that these women aren’t already amongst the 10-20% of women who contact providers like BPAS and Marie Stopes International about an abortion only to choose not to go ahead with the procedure.

The claim that honest, non-directive, pre-abortion counselling will lead to a significant reduction in the number of abortions carried out is the UK is a complete and utter fabrication.

That said, and as one might well expect, this study has been very quickly attacked and labelled ‘biased’ by anti-choice activists in the United States, and although shooting down the arguments of anti-choices is generally a matter of shooting fish in a barrel, on this occasion its weel work taking a look at how they’ve gone about misrepresenting this study’s findings as these arguments will no doubt be repeated by Dorries’s backers and supporters on this side of the big pond.

After announcing that the study is biased, the first charge laid against the study runs as follows.

But this study contains major flaws: it studies only one abortion clinic; it does not mention the state in which that clinic does business; and it does not indicate whether that state has any informed consent laws.

Yes, its a single centre study and the implications of this for the research are clearly acknowledged in the ‘Limitations’ section:

All of the data used in this study came from clients of one large U.S. abortion clinic. Our clinic population was demographically similar to the national population of women seeking abortion, except women in our sample were more likely to be white and less likely to be Hispanic, to have received a high school diploma and to have completed some college or technical school. In addition, women in our sample were more likely than women nationally to be seeking a second-trimester abortion, because the study clinic—unlike many— performs such procedures.

In fact, on a first reading of the paper, the limitations section clearly identifies pretty much everything I spotted as a potential source of confounding, which is exactly what you’d expect of a well written study.

As for whether the study was conducted in a state with ‘informed consent laws’, the paper describes the clinic’s services in the following terms.

The data used in this study were from all women seeking an abortion at one privately owned, dedicated abortion facility in 2008. This clinic provides 5,000–6,000 first and second-trimester abortions annually and is located in a state that does not mandate parental involvement for minors seeking abortion services. All women seeking an abortion at the facility are asked to complete a precounseling needs assessment form along with other intake forms at the time they present for care..

…After intake, patients have an ultrasound to determine the gestational age of the fetus; learn about the abortion procedure, possible complications and aftercare; and then meet individually with a counselor. Counselors – who have at least a bachelor’s degree and have received significant training in pregnancy options and abortion counseling—answer any questions and review women’s needs assessment form with them. In addition to confirming that patients have come to a final, voluntary decision and ensuring informed consent, counselors routinely offer contraceptive information and family planning referrals; they offer referrals for postabortion emotional support and other health and social services when they think they would be beneficial to patients.

However, if counselors notice any signs that a patient might feel regret or cope poorly after her abortion, they advise her to go home and return to the clinic at a later date if she still desires to terminate her pregnancy. (Warning signs include a woman’s describing uncertainty about the decision, a feeling that someone had pressured her to have an abortion, a lack of support, extreme guilt or shame, and an expectation of regret or inability to cope.) Such patients are given reading materials and referrals designed to help clarify their decision, resolve conflicts and bolster support for whatever decision they make about the pregnancy, including abortion, parenting and adoption.

That all seems eminently reasonable to me, which rather suggests that the clinic is not in a state that has specific ‘informed consent laws’, given that these laws tend to amount to nothing more than the conservative male politicians forcing doctors to give women misleading and inaccurate information in the hope that they will be emotional blackmailed into not having an abortion.

 The study is based entirely on a pre-counseling survey asking women to respond to a number of statements with either “true,” “kind of,” or “false.” For example, one statement was “I am sure of my decision to have an abortion.” Before counseling, 94 percent of women responded with “true.” Five percent of women responded with “kind of”—yet the researchers concluded that these women were “sure” of their abortion decision. Overall, the study found that 87 percent of the woman had high pre-counseling confidence in their decision. But what about the other 13 percent? Shouldn’t 100 percent of women who abort deserve to be “sure” of their decision?

The confidence assessment was based on response to four questions.

1. ‘I am sure of my decision to have an abortion’ – Results: ‘True’ 94%, ‘Kind of’ 5%, ‘False’ 1%

2. ‘I want to have the baby instead of an abortion’ – Results: ‘True’ 1%, ‘Kind of’ 5%, ‘False’ 94%

3. ‘I want to put the baby up for adoption rather than have an abortion’ – Results: ‘True’ 0%, ‘Kind of’ 1%, ‘False’ 99%

4. ‘Abortion is a better choice for me than having a baby at this time’ – Results: ‘True’ 95%, ‘Kind of’ 3%, ‘False’ 2%

Women were rated as having high confidence in their decision if they answered true to 1 and 4 and false to 2 and 3, any other responses were considered to be a sign of doubt or indecision, hence the discrepancy between the ‘headline’ figures for each individual question and the pooled assessment figure of 87%.

As regards the outcome of these pregnancies, 92.8% of women went ahead the termination, although the figure was a litlle lower for women under 20 (89.7%) than for the 20+ age group (93.6%). As for the remaining 75 or so, the study gives the outcomes as follows:

Seven percent of abortions sought by women were not performed. In 2% of cases, the woman changed her mind and left the clinic or, demonstrating ambivalence about the decision, was sent home by the counselor for further reflection and did not return (not shown). In another 2%, the woman wanted an abortion, but her pregnancy was beyond the gestational limit at which the clinic would perform the procedure; teenagers were significantly more likely than adults to present beyond the clinic’s gestational limit. In 1% of cases, women did not have a uterine pregnancy: They either had already miscarried, had not been pregnant or had an ectopic pregnancy. Fifteen women were referred to another provider for medical reasons.

This rather seems to dispose of the ‘what about the kind-ofs’ comment and, indeed, the next couple of paragraphs…

Moreover, the study only considered women’s pre-counseling responses to the survey. It did not indicate how women felt after “counseling” by a clinic staff person. How many women responded with “kind of” after counseling? Of course, because we don’t know in what state the clinic operates, we don’t know what kind of counseling the women received. And “[i]t was not the goal of [the] study to follow the emotional outcomes of women following an abortion.”

We do know that seven percent of women who sought abortions did not have them performed, with at least two percent of women changing their minds before abortion. However, we do not know if that shift in decision was before or after counseling. But considering the clinic studied performs between 5,000 and 6,000 abortions per year, that percentage translates to at least 100 to 120 women (2 percent) changing their mind each year. It does not take a study to know that those 120 children appreciate that decision.

To be honest, I think we do know what kind of counselling these women received and its not the kind where they’re lied to, given false information, subjected to emotional blackmail and, in some state, subjected to state-mandated rape, and that the real problem here for the anti-choicers – what they call ‘counselling’ is what every credible professional body representing members of the health care professions would call ‘unethical’.

After compiling the data, the researchers “conducted a phone interview with the clinic’s director of counseling to solicit her interpretation of the results.” As to be expected, the clinic employee believed that the results were incorrect, and that more women were confident in their decision than demonstrated by the survey, and that fewer women were unsure in their decision than demonstrated by the survey. The researchers then adopted the clinic employee’s interpretation of the data.

This is an outright lie – the study clearly and faithfully reports the views of the Clinic’s Director of Counselling but otherwise there is nothing whatsoever in the study to indicate that the researchers  have ‘adopted’ anyone’s interpretation of the data other than their own – what they have to say about the data in the study is entirely consistent with the data reported in the study, no more and no less.

The clinic employee also stated that “the great majority of patients change their responses away from believing that abortion is like killing after discussing their beliefs with a counselor.” I.e., after discussing a belief that she is killing her baby, a woman is persuaded by a pro-abortion “counselor” paid by a clinic which is making money from the abortion that abortion is not “killing.” The clinic employee also stated that “an important aspect of the counseling session is attempting to calm women who are upset by their interactions with antiabortion protestors outside the clinic.”

Here’s the relevant section in full, minus the deliberate cherry-picking and pejorative misinterpretations…

During the interview with the clinic’s director of counseling, she explained that items on the needs assessment form— especially the provocative ones, such as the statement equating abortion with killing—were included with the aim of sparking discussion about personal values, stigma and anticipated coping. She reported that women frequently change their responses to items to reflect less negative views about abortion after having a chance to clarify their meaning, learning more about the abortion procedure and reflecting on their feelings in a nonjudgmental, supportive environment. For example, she said the great majority of patients change their response away from believing that abortion is like killing after discussing their beliefs with a counselor.

According to the director, an important aspect of the counseling session is attempting to calm women who are upset by their interactions with antiabortion protesters outside the clinic. She explained that protesters would regularly attempt to discourage patients from entering the clinic by addressing them, giving them antiabortion materials and presenting graphic signs. In her opinion, exposure to protesters may influence some women’s responses, given that women fill out the needs assessment form shortly after entering the clinic.

What’s interesting here that both the age of the woman and the gestational age of the foetus appear to have a significant effect on their initial view of abortion…

Abortion as “killing.” In 4% of cases, women answered “true” to the statement that abortion at their stage of pregnancy was the same as killing a baby already born; in another 13%, women answered “kind of.” The proportion of cases in which women held the view that abortion is the same as or similar to “killing” differed significantly by gestational age (15% of first-trimester pregnancies vs. 26% of second-trimester pregnancies, p<.05; not shown) and by age-group (28% of abortions among women younger than 20 vs. 14% of those among women 20 or older, p<.05).

One would, of course, expect older women to have a somewhat more mature and pragmatic view of abortion than younger women, so its no great surprise to see that twice as many under 20s were more willing to equate abortion with ‘killing’ than over 20s. It’s also no real surprise to find that women presenting in the second trimester were more likely to hold that view, the longer a pregnancy goes on the more ‘real’ it naturally becomes, which is of course one of the main reasons why anti-abortion groups are so keen on mandatory counselling, ‘cooling-off’ periods and other ‘roadblocks’ which delay the procedure. By dragging it out as long as possible they hope some women will have a change of heart, and maybe some do but the net effect is still that of making the procedure itself more risky if its delayed past the end of the first trimester – so much for being ‘pro women’ eh?

Overall, the study has its limitations, which are openly acknowledged by the researchers, but biased it isn’t and its conclusions are entirely sound.

It was not the goal of this study to follow the emotional outcomes of women following an abortion, or to provide evidence supporting the implementation of a particular needs assessment tool or a specific model for educating or counseling abortion patients. Instead, we demonstrate a need for individualized approaches to patient education and counseling regarding abortion. A needs assessment form that can elucidate women’s specific concerns may be a useful tool for offering client-centered care, allowing providers to allocate counseling time to women with the greatest needs. Future research should explore how differing approaches to needs assessment, education and counseling affect women’s emotional well-being following an abortion.

As usual, the only thing that biased against the anti-choice lobby is reality itself