BACKGROUND

Individuals have the right to receive relevant, accurate and unbiased information prior to obtaining medical care so they can make sound decisions regarding treatment. 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. Abortion is a safe and legal medical procedure that does not require expanded counseling.

For consent to be considered informed, patients must possess the capacity to make decisions about their care; their participation in these decisions must be voluntary; and they must be given adequate and appropriate information. However, some states’ abortion counseling provisions 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 and intrude into the provider-patient relationship.

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 free 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.

  • 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.4
  • Ninety-nine percent of abortion patients in a 2008 clinic study reported that they are “sure” or “kind of sure” of their decision to have an abortion, and 98% report that “abortion is a better choice for me at this time than having a baby.”5
  • Standards of care dictate that a woman facing an unintended pregnancy should receive information about all her options—prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination—in a nonjudgmental manner.6

 

Inaccurate Information on Mental Health

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.7,8
  • Time and again, studies have shown that abortion does not increase women’s risk of mental health problems.9,10 Two reviews of the evidence initiated by the American Psychological Association in 1989 and 2006 concluded that legal abortion of an unwanted pregnancy “does not pose a psychological hazard for most women.”11,12
  • Women of all ages experience a range of emotions after an abortion. Most commonly, women report feeling relieved. Teenagers are no more likely than older women to experience negative mental health outcomes after an abortion.13 The best indication of a woman’s mental health after an abortion is her mental health before the abortion.13
  • While there is no evidence of “postabortion stress syndrome,” postpartum depression affects approximately 15% of women who give birth.14 Furthermore, results based on a longitudinal study of a cohort of Wisconsin women found that unintended births were associated with poor mental health outcomes in later life.15
  • The U.S. Preventive Services Task Force recently designated unintended pregnancy as a risk factor for depression during and after the pregnancy.16

Inaccurate Information on Fetal Pain

Counseling sometimes includes inaccurate information on the ability of a fetus to feel pain at 20 weeks’ gestation.

  • Many states require that a woman be given counseling materials detailing the entire fetal development spectrum despite the fact that almost all abortions take place in the first trimester.17
  • Some states also require that patients be counseled 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.”18
    • A 2005 comprehensive literature review by researchers from the University of California, San Francisco concluded that that “fetal perception of pain is unlikely before the third trimester.”19 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 Information on Medication Abortion Reversal

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

  • Starting in 2015, states began to adopt counseling requirements that include the notion that it is possible to “reverse” a medication abortion by taking a high dose of progesterone after the first medication (mifepristone) is administered.
  • 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 where six abortion patients who had taken mifepristone—but not misoprostol, the second drug in the approved two-stage regimen—were then given high doses of progesterone. The study author did not follow best practices for research.20,21 For example, the author did not apply for ethical approval and did not use any controls.
    • Scientists and doctors have not replicated the findings and have no reason to think that the method used in the study should be practiced. Specifically, ACOG is concerned that the high doses of progesterone could have negative health impacts for patients.21 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. Many women (30–50%) who only take the mifepristone experience an incomplete abortion and require misoprostol or a surgical abortion.21

 

Inaccurate Information on Breast Cancer, Future Fertility

Some counseling includes inaccurate information linking abortion to an increased risk of breast cancer or future infertility.

  • Some states require that counseling materials include inaccurate information on long-term risks of abortion, such as assertions a false link between abortion and breast cancer and future infertility. Experts dismiss these claims.
    • In 2003, the National Cancer Institute published a report categorically dismissing any causal link between induced abortion and breast cancer.22 This position has been affirmed by medical associations such as ACOG.23

    • The scientific consensus—as endorsed by ACOG—is that a first-trimester vacuum aspiration abortion poses virtually no risk to a woman’s ability to have children in the future.24,25

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 an abortion is performed

Alabama (2014)

A

Arizona (2015)

E

Arkansas (2015)

E

Florida (2015)

E

Indiana (2013)

A

Kansas (2014, 2013)

E

Louisiana (2014)

E

Montana (2015)

V

Ohio (2013)

E

Oklahoma (2015, 2014)

E

Tennessee (2015)

E

Wisconsin (2015)

E

States that require counseling materials to include a statement that personhood begins at conception

Oklahoma (2015)

E

States that require counseling materials to include information on the ability of a fetus to feel pain

Arkansas (2015)

E

Montana (2015)

V

REFERENCES

1. American Medical Association (AMA), Opinion 8.08- informed consent, Nov. 2006, http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-....

2. American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics, ACOG committee opinion no. 439: informed consent, Obstetrics & Gynecology, 2009, 114(2):401–408, http://www.acog.org/Resources-And-Publications/Committee-Opinions/Commit....

3. National Abortion Federation (NAF), Ethical principles for abortion care, 2011, http://prochoice.org/wp-content/uploads/NAF_Ethical-_Principles.pdf.

4. 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.

5. 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.

6. Dailard C, Out of compliance? Implementing the infant adoption awareness act, Guttmacher Policy Review, 2004, 7(3):10–14, http://www.guttmacher.org/about/gpr/2004/08/out-compliance-implementing-....

7. American Psychological Association (APA), Mental health and abortion, no date, http://www.apa.org/about/gr/issues/women/mental-health-and-abortion.aspx.

8. Brief of American College of Obstetricians and Gynecologists et al. as Amici Curiae in support of Plaintiffs-Appellants, Hope Clinic for Women, Ltd. v Adams, 2011, IL App (1st) No. 1-10-1463, http://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Libra....

9. Cohen SA, Still true: abortion does not increase women’s risk of mental health problems, Guttmacher Policy Review, 2013, 16(2):13–17, http://www.guttmacher.org/pubs/gpr/16/2/gpr160213.pdf.

10. 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.

11. Statement of Professor Nancy Adler, University of California at San Francisco on behalf of the American Psychological Association, House Committee on Government Operations, Mar. 16, 1989.

12. American Psychological Association (APA), Task Force on Mental Health and Abortion, Report of the APA Task Force on Mental Health and Abortion, Washington, DC: APA, 2008, http://www.apa.org/pi/wpo/mental-health-abortion-report.pdf.

13. Guttmacher Institute, Abortion and mental health, news release, New York: Guttmacher Institute, Jan. 1, 2011, https://www.guttmacher.org/article/2011/01/abortion-and-mental-health-up....

14. American Psychological Association (APA), Postpartum depression, no date, http://www.apa.org/pi/women/resources/reports/postpartum-dep.aspx.

15. 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.

16. 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, http://jamanetwork.com/journals/jama/fullarticle/2484345.

17. Guttmacher Institute, Induced abortion in the United States, Fact Sheet, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/fact-sheet/induced-abortion-united-states.

18. U.S. House of Representatives, Committee on the Judiciary, Pain of the Unborn, Hearing, Nov. 1, 2005, Serial No. 109-57, Washington, DC: Government Printing Office, 2005.

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

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

21. ACOG and ACOG Arizona Section, Medication abortion reversal, 2015, http://www.acog.org/~/media/departments/state%20legislative%20activities....

22. National Cancer Institute, Abortion miscarriage, and breast cancer risk, 2010, http://www.cancer.gov/types/breast/abortion-miscarriage-risk#summary-report.

23. ACOG, Induced abortion and breast cancer risk. ACOG committee opinion no. 434, Obstetrics & Gynecology, 2009, 113(6):1417–1418, http://www.acog.org/Resources-And-Publications/Committee-Opinions/Commit....

24. Gold RB and Nash E, State abortion counseling policies and the fundamental principles of informed consent, Guttmacher Policy Review, 2007, 10(4):6–13, https://www.guttmacher.org/sites/default/files/pdfs/pubs/gpr/10/4/gpr100....

25. ACOG, Frequently asked questions: induced abortion, May 2015, http://www.acog.org/~/media/For%20Patients/faq043.pdf.