Mandatory Counseling For Abortion

Evidence You Can Use: Mandatory Counseling for Abortion is designed to give advocates, service providers and policymakers the data and resources they need to engage in ongoing policy discussions in their states. It includes information on state laws and policies, a synthesis of the relevant research, information on states in which the issue has been debated in the past three years and links to state-specific data. The toolkit provides an evidence base for understanding the impact of mandatory counseling on access to abortion.


Abortion is a safe and legal medical procedure that does not require expanded counseling. Abortion providers—like all medical providers—are ethically bound to provide patients with information about options, procedure details and any other information a provider deems pertinent after assessing each patient’s unique health needs and circumstances. Providers are also required to obtain informed consent, which means they must verify that patients possess the capacity to make decisions about their care, that their participation in these decisions is voluntary, and that they receive adequate and appropriate information.

However, some states have specific abortion counseling provisions, and many of these laws require providers to give inaccurate or misleading information to women seeking abortion care in order to dissuade them from obtaining an abortion. These requirements violate the principles of informed consent, intrude on the provider-patient relationship, and infringe patients’ right to receive relevant, accurate and unbiased information prior to obtaining medical care so they can make sound decisions about their treatment.

State Laws and Policies

For a chart of current laws and policies in each state related to mandatory counseling for abortion, see Counseling and Waiting Periods for Abortion.

For information on state laws and policies related to other sexual and reproductive health and rights issues, see State Laws and Policies, issue-by-issue fact sheets updated monthly by the Guttmacher Institute’s policy analysts to reflect the most recent legislative, administrative and judicial actions.

Relevant Data and Analysis

Abortion Providers’ Adherence to Ethics for Consent

Abortion providers operate under medical principles of informed consent and are bound by the same code of medical ethics as doctors who do not perform abortions.

  • The American Medical Association (AMA) and American College of Obstetricians and Gynecologists (ACOG) affirm that providers have an ethical and legal duty to obtain voluntary and informed consent from patients.1,2 ACOG asserts that “seeking informed consent…respects a patient’s moral right to bodily integrity.”2
  • According to ethical principles for abortion care developed by the National Abortion Federation, it is the role of any abortion provider to “ascertain before providing an abortion that the patient…has freely chosen to end her pregnancy, is prepared to do so and has not been coerced in any way.”3

Women’s Certainty About Abortion

Women who obtain an abortion are sure of their decision.

  • A study of Wisconsin’s 2013 mandatory preabortion ultrasound law found that 93% of women were certain of their decision to obtain an abortion, both before and after the law was implemented.4
  • In a nationally representative survey of abortion patients conducted in 2008, 92% of women reported they had made up their mind to have an abortion prior to making an appointment.5
  • Ninety-nine percent of abortion patients in a 2008 clinic study reported that they were “sure” or “kind of sure” of their decision to have an abortion, and 98% reported that “abortion is a better choice for me at this time than having a baby.”6
  • Standards of care dictate that a woman facing an unintended pregnancy should receive information about all of her options—prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination—in a nonjudgmental manner.3,7

Inaccurate Information on Mental Health

State-mandated counseling sometimes includes inaccurate information on the mental health consequences of having an abortion.

  • Some states require abortion providers to tell women that an abortion may lead to a PTSD-like condition they call “postabortion stress syndrome.” The American Psychological Association and the American Psychiatric Association do not recognize this condition, and there is no evidence it exists.8,9
  • An expert panel convened by the National Academies of Sciences, Engineering and Medicine in 2018 concluded that having an abortion does not increase a person’s risk of mental health conditions such as depression, anxiety, and post-traumatic stress disorder.10
  • A 2014 study found that among women seeking an abortion in Utah, the proportion who falsely believed that abortion causes depression or anxiety increased from 24% to 34% after receiving inaccurate state-developed counseling on the mental health risk of an abortion.11
  • Many studies have shown that abortion does not increase women’s risk of mental health problems.12,13 Two reviews of the evidence by the American Psychological Association in 1989 and 2006 concluded that an abortion of an unintended pregnancy during the first 12 weeks of pregnancy “does not pose a psychological hazard for most women.” More specifically, the risk of mental health problems is no greater if a woman who has an unintended pregnancy has an elective first-trimester abortion than if she carries the pregnancy to term.8,14
  • Results from a recent longitudinal study of Dutch women who had had an abortion found no link between abortion and negative mental health outcomes. Instead, mental health problems among study participants were associated with being in an unstable relationship when pregnant, experiencing negative life events in the past year, or having a history of mental health problems.15
  • Women may experience a range of emotions after an abortion, and many report feeling satisfied or relieved.16 Adolescents are no more likely than older women to experience negative mental health outcomes after an abortion.17 The best indication of a woman’s mental health after an abortion is her mental health before the abortion.8
  • There is no evidence of “postabortion stress syndrome,” but there is a body of evidence on the potential negative mental health outcomes associated with giving birth. Postpartum depression affects approximately 15% of women who give birth,18 and results of a recent longitudinal study of a cohort of Wisconsin women found that unplanned births are associated with poor mental health outcomes in later life.19
  • The U.S. Preventive Services Task Force has designated unintended pregnancy as a risk factor for depression during and after pregnancy.20

Inaccurate Information on Fetal Pain

Some states require abortion patients to receive inaccurate information on the ability of a fetus to feel pain at 20 weeks’ gestation.

  • Some states require providers to tell patients that the fetus may be able to feel pain during an abortion procedure, which is a highly disputed assertion. Depending on the state, this counseling may be required for all abortions or only for those at 20 weeks’ gestation or beyond.
  • According to ACOG, there is “no legitimate scientific data or information that supports the statement that a fetus experiences pain at 20 weeks’ gestation.”21
  • A 2005 comprehensive literature review by researchers from the University of California, San Francisco concluded that “fetal perception of pain is unlikely before the third trimester.”22 A fetus does not develop cortical function (“required for conscious perception of pain”) until 29–30 weeks’ gestation, and, without a psychological understanding of pain and the consciousness to know that stimuli are unpleasant, a fetus cannot experience pain. This literature review also cited increased risk to the pregnant woman as a reason not to administer anesthesia and analgesia to a fetus during an abortion.

Inaccurate Counseling on Medication Abortion Reversal

Some states require abortion counseling to include inaccurate information on the possibility of reversing a medication abortion.

  • Starting in 2015, a few states began to adopt counseling requirements that include statements claiming a medication abortion can be “reversed” by taking a high dose of progesterone after mifepristone is administered.23
  • No rigorous evidence supports the contention that a medication abortion can be reversed.
    • These laws are primarily based on a case study published in 2012 about six abortion patients who had taken mifepristone—but not misoprostol, the second drug in the approved two-stage regimen—and were then given high doses of progesterone.24 The study did not adhere to basic best practices for research.25,26 For example, the authors did not apply for ethical approval and did not use a control group. A more recent observational study of more than 500 abortion patients conducted by some of the same authors27 has similar methodological shortcomings.28,29
    • Scientists and doctors have not replicated the findings and have no reason to think that the method used in this case study should be practiced. Specifically, ACOG asserts that abortion “reversal” treatments are not based on scientific evidence and do not adhere to clinical standards.26 The U.S. Food and Drug Administration has not evaluated the claim that medication abortion can be reversed.
    • Medication abortion is most effective when the patient follows the evidence-based protocol and takes both drugs. Up to half of all women who take only mifepristone experience a continuing pregnancy.26

Inaccurate Information on the Risks of Abortion

Some state-mandated abortion counseling includes inaccurate information linking abortion to an increased risk of breast cancer or future infertility. However, the only risk proven to be associated with abortion are the minor risks involved in the actual procedure.

  • Some states require that counseling materials include inaccurate claims that abortion poses long-term health risks. Experts dismiss these claims.
    • In 2003, the National Cancer Institute published a report categorically dismissing any causal link between abortion and breast cancer.30 This position has been affirmed by ACOG and other medical associations.31
    • Abortions performed in the first trimester pose virtually no long-term risk of such problems as infertility, ectopic pregnancy, miscarriage, congenital malformation, or preterm or low-birth-weight delivery.32,33
  • An expert panel convened by the National Academies of Sciences, Engineering, and Medicine in 2018 concluded that “requiring providers to inform women about risks that are not supported and are even invalidated by scientific research violates the accepted standards of informed consent.”10
  • Abortion procedures themselves carry some risks, but they are extremely low. Abortion-related fatalities are very rare, occurring at a rate of 0.7 per every 100,000 procedures.34 A first-trimester abortion is one of the safest medical procedures and carries minimal risk—less than 0.5%—of major complication requiring hospital care.35,36 While the risk of complications is higher after 12 weeks of pregnancy, the absolute risk of abortion is low when skilled practitioners are involved.

Data Center

Recent State Action On This Issue

States that have addressed this issue over the past three years are listed below.

E: State enacted a relevant measure

V: State vetoed measure

A: State adopted measure in at least one chamber


States that require women to receive counseling before having an abortion

Kansas (2017)


Missouri (2017)


Oklahoma (2017)


Texas (2017, 2019)



States that require counseling on the possibility of reversing a medication abortion

Arkansas (2019)


Indiana (2017)


Kansas (2019)

A, V

Kentucky (2019)


Nebraska (2019)


North Dakota (2019)


Ohio (2019)


Oklahoma (2019)


Utah (2017)


Wisconsin (2019)



1. American Medical Association, Opinion 2.1.1: Informed consent, 2016,

2. American College of Obstetricians and Gynecologists (ACOG), Informed consent, ACOG Committee Opinion No. 439, Obstetrics & Gynecology, 2009, 114(2):401–408,

3. National Abortion Federation, Ethical principles for abortion care, 2011,

4. Upadhyay UD et al., Evaluating the impact of a mandatory pre-abortion ultrasound viewing law: a mixed methods study, PLoS ONE, 2017, 12(7):e0178871.

5. Moore A, Frohwirth L and Blades N, What women want from abortion counseling in the United States: a qualitative study of abortion patients in 2008, Social Work in Health Care, 2011, 50(6):424–442.

6. Foster DG et al., Attitudes and decision making among women seeking abortions at one U.S. clinic, Perspectives on Sexual and Reproductive Health, 2012, 44(2):117–124.

7. Dailard C, Out of compliance? Implementing the Infant Adoption Awareness Act, Guttmacher Policy Review, 2004, 7(3):10–14,

8. American Psychological Association (APA) Task Force on Mental Health and Abortion, Report of the APA Task Force on Mental Health and Abortion, 2008,

9. Brief of ACOG et al. as Amici Curiae in support of Plaintiffs-Appellants, Hope Clinic for Women v. Adams, No. 1-10-1463, Ill. App. Ct., 2011,

10. National Academies of Sciences, Engineering and Medicine, The Safety and Quality of Abortion Care in the United States, Washington, DC: National Academies Press, 2018.

11. Berglas NF et al., State-mandated (mis)information and women’s endorsement of common abortion myths, Women’s Health Issues, 2017, 27(2):129–135.

12. Cohen SA, Still true: abortion does not increase women’s risk of mental health problems, Guttmacher Policy Review, 2013, 16(2):13–17,

13. Foster DG et al., A comparison of depression and anxiety symptom trajectories between women who had an abortion and women denied one, Psychological Medicine, 2015, 45(10):2073–2082.

14. Statement of Professor Nancy Adler, University of California at San Francisco on behalf of the APA, U.S. House Committee on Government Operations, Mar. 16, 1989.

15. Ditzhuijzen JV et al., Correlates of common mental disorders among Dutch women who have had an abortion: a longitudinal cohort study, Perspectives on Sexual and Reproductive Health, 2017, 49(2):123–131,

16. Major B et al., Psychological responses of women after first-trimester abortion, Archives of General Psychiatry, 2000, 557:777–784.

17. Warren JT, Harvey SM and Henderson JT, Do depression and low self-esteem follow abortion among adolescents? Evidence from a national study, Perspectives on Sexual and Reproductive Health, 2010, 42(4):230–235,

18. APA, Postpartum Depression, 2007,

19. Herd P et al., The implications of unintended pregnancies for mental health in later life, American Journal of Public Health, 2016, 106(3):421–429.

20. Siu AL and U.S. Preventive Services Task Force, Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement, Journal of the American Medical Association, 2016, 315(4):380–387,

21. Statement of ACOG, U.S. House Committee on the Judiciary, Pain of the Unborn hearing, Nov. 1, 2005.

22. Lee SJ et al., Fetal pain: a systematic multidisciplinary review of the evidence, Journal of the American Medical Association, 2005, 294(8):947–954.

23. Nash E et al., 2015 year-end state policy roundup, News in Context, Jan. 4, 2016,

24. Delgado G and Davenport ML, Progesterone use to reverse the effects of mifepristone, Annals of Pharmacotherapy, 2012, 46(12):e36.

25. Louisiana Department of Public Health, Legislative Report on 2016 House Concurrent Resolution 87, 2017,

26. ACOG, Facts are important: Medication abortion “reversal” is not supported by science, 2017,….

27. Delgado G et al., A case series detailing the successful reversal of the effects of mifepristone using progesterone, Issues in Law & Medicine, 2018, 33(1):3–14.

28. Sherman C, Medical community slams study pushing “abortion reversal” procedure, Vice News, Apr. 5, 2018,

29. Walker M, Will latest “abortion reversal” case series change practice?, MedPage Today, Apr. 4, 2018,

30. National Cancer Institute, Summary report: early reproductive events and breast cancer workshop, 2003,

31. ACOG, Induced abortion and breast cancer risk, ACOG Committee Opinion No. 434, Obstetrics & Gynecology, 2009, 113(6):1417–1418,

32. Gold RB and Nash E, State abortion counseling policies and the fundamental principles of informed consent, Guttmacher Policy Review, 2007, 10(4):6–13,

33. ACOG, Frequently asked questions: induced abortion, 2015,

34. Zane S et al., Abortion-related mortality in the United States, 1998–2010, Obstetrics & Gynecology, 2015, 126(2):258–265,

35. Upadhyay UD et al., Incidence of emergency room visits and complications after abortion, Obstetrics & Gynecology, 2015, 125(1):175–183.

36. White K, Carroll E and Grossman D, Complications from first-trimester aspiration abortion: a systematic review of the literature, Contraception, 2015, 92(5):422–438.

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