Advancing Sexual and Reproductive Health and Rights
 
Guttmacher Policy Review
Spring 2009, Volume 12, Number 2
 

All That's Old Is New Again: The Long Campaign To Persuade Women to Forego Abortion

By Rachel Benson Gold

Just days after assuming office, prochoice President Barak Obama laid out his vision for a public policy agenda that would respond constructively to the ongoing national debate over abortion. “While this is a sensitive and often divisive issue,” he argued, “no matter what our views, we are united in our determination to prevent unintended pregnancies, reduce the need for abortion, and support women and families in the choices they make.” Within weeks, the administration announced an initiative to seek the advice of a wide range of individuals representing a diversity of views on how to move forward on this presumed common ground.

Leading abortion opponents reacted quickly with alarm. Concerned Women for America President Wendy Wright, for one, requested a meeting with the White House, to protest how the administration's initiative was being framed. Calling concepts such as the need for abortion and unintended pregnancy "completely subjective," Wright argued instead for an explicit goal of reducing abortions. "What I think is important is [to] have measurable goals….That's why it's important to look at the number of abortions."

Indeed, the organized antiabortion movement has never thrown its weight behind efforts to address abortion by helping women avoid unintended pregnancies in the first place. On the contrary, most national "profamily" and antiabortion organizations are either actively hostile to or, as in the case of the National Right to Life Committee, resolutely "neutral" on contraception and family planning service programs. Instead, they have worked to eliminate abortion altogether, by trying to ban the procedure outright. Failing that, or as a way of laying the groundwork, they have promoted a wide range of policies aimed at deterring as many women as possible from having an abortion. Many of these policies, at their heart, are premised on the notion that women who intend to have an abortion (and, to some extent, the public at large) do not fully understand what an abortion really is—and that, if they did, they would behave differently. As state Sen. Tony Fulton, sponsor of a legislative proposal in Nebraska to require women to be shown an ultrasound image of the fetus prior to having an abortion, recently argued, "If we can provide information to a mother who is in a desperate situation—information about what she's about to choose; information about the reality inside her womb—then this is going to reduce the number of abortions."

Dissuading Women

The campaign to dissuade women dates back decades. Outside facilities where abortions are performed, protesters for many years have confronted women with pictures of bloody fetuses, while "sidewalk counselors" implore women not to kill their babies. In the realm of public policy, a major initiative of long standing has been to enact mandatory "informed consent" policies; indeed, such policies have been addressed by the Supreme Court on three separate occasions. In its 1983 ruling on an ordinance passed by the city of Akron, Ohio, the Supreme Court struck down a law that required abortion providers to give women a litany of information the Court considered to be "designed not to inform the woman's consent but rather to persuade her to withhold it altogether." Nearly a decade later, however, a differently constituted Court revisited the issue in Planned Parenthood of Southeastern Pennsylvania et. al., v. Casey, and allowed states to provide information under the aegis of informed consent, even if the stated purpose was "to persuade the woman to choose childbirth over abortion." Most recently, in Gonzales v. Carhart, the Court invited states to take a new look at the information women are required to receive prior to an abortion, specifically that regarding a description of "the way in which the fetus will be killed," on the grounds that "a necessary effect of [such a requirement] and the knowledge it conveys will be to encourage some women to carry the infant to full term."

State antiabortion activists widely accepted these judicial invitations. Currently, 33 states have some law or policy requiring the provision of specific information to women prior to having an abortion. According to a 2007 Guttmacher Institute analysis, the information required in 10 of these states generally comports with widely held principles of informed consent: a description of the procedure to be performed and information on the stage of the pregnancy. The laws in the remaining 23 states, however, are designed more to influence rather than inform the woman's decision. These laws, for example, often exaggerate the physical or mental health risks of abortion or include information on either fetal development or abortion procedures irrelevant to the abortions being sought by most women (related article, Fall 2007, page 6).

In 24 states, meanwhile, a "counseling" requirement is combined with a mandatory waiting period, a provision upheld by the Court in Casey on the premise that "important decisions will be more informed and deliberate if they follow some period of reflection." In most states, a woman may receive the mandated counseling information either over the telephone or via the Internet; in seven states, however, the law requires the counseling to be provided in-person at least 24 hours prior to the abortion, a provision that requires the woman to make two separate trips to the abortion facility.

Mandating Ultrasound

In 1985, portions of The Silent Scream, a lurid and medically inaccurate film portraying an ultrasound image of an abortion, were screened at a hearing held by a subcommittee of the Senate Judiciary Committee. The highly emotional narration depicts the image of the fetus as having its "wide mouth open in…the silent scream of a child threatened eminently with extinction." The film then goes on to urge that every woman considering an abortion should view the film before providing her consent.

A decade later, state antiabortion activists began working to have the same type of information as in The Silent Scream included in state-developed mandatory abortion counseling materials, but personalized to each abortion client's own fetus. Beginning in the mid-1990s, 13 states have adopted some provisions relating to ultrasound that stop short of requiring that the procedure be performed. These provisions range from requirements that all women seeking an abortion be given information about ultrasound technology to requirements that abortion providers offer women the opportunity to have the procedure and then view the image.

Some states have gone further by actually mandating that the procedure be performed for at least some women. Beginning with Arizona and Louisiana in 1999, five states currently require providers to perform an ultrasound on at least some women seeking an abortion and then offer them the option to view the image. Finally, in the most extreme example, Oklahoma adopted legislation in 2008 that actually requires not only that an ultrasound be performed prior to every abortion, but also that the physician review the image with the woman; the legislation explicitly mandates that, if she chooses, the woman be permitted to "avert her eyes." Implementation of the Oklahoma measure is enjoined pending legal action, while similar legislation was introduced in Alabama, Indiana, Kentucky, North Carolina, Rhode Island, Texas and Wyoming.

Finally, Colorado-based Focus on the Family in 2005 launched "Option Ultrasound," an initiative to provide ultrasound machines to 650 crisis pregnancy centers across the country, based on their belief that the technology "carr[ies] the potential to save a significant number of lives." As of March 2009, the group claims to have provided 430 grants for ultrasound machinery or training in 49 states.

Unlikely to Succeed

Providing women information specifically geared to dissuading them from having an abortion is a perversion of medical ethics in general and the informed consent process in particular. But no matter how well-worn the tactic, it does not appear to be effective in its purported goal of materially reducing the number of procedures performed. In fact, there is no persuasive evidence that state abortion policies aimed, in one way or another, at talking women out of an abortion stop large numbers of women from having them. At most, there is some indication from the data that erecting substantial, direct roadblocks in the path of women seeing an abortion—such as denying Medicaid subsidies to poor women or requiring women to make two separate trips to a facility to receive in-person counseling, and then wait 24 hours before the abortion—may have that result (see box, page 21).

What Do State Abortion Restrictions Do?

Over the three and a half decades since Roe v. Wade states have adopted a plethora of abortion policies designed to dissuade women from having an abortion. Recent literature reviews conducted by researchers from Guttmacher, Ibis Reproductive Health and Baruch College show this strategy to be largely unsuccessful. For the most part, abortion access restrictions, in addition to demeaning women, may result in procedures taking place later in gestation, when they are more troubling, more dangerous and more expensive—but by and large, they do not prevent abortions. The one clear exception are restrictions that take aim specifically at disadvantaged women, who often do not have the resources to navigate the hurdles imposed by state restrictions and may be left with little recourse other than to carry an unintended pregnancy to term.

Thirty-four states mandate parental involvement when a minor is seeking an abortion—restrictions premised on the notion that involving parents in teens' abortion decisions will give them an opportunity to persuade the teen to not have an abortion. The literature, however, shows that these laws do little to affect the abortion rate, and there is no evidence that they improve parent-child communication. Instead, they lead many teens to navigate complicated judicial bypass systems to obtain waivers or to seek abortions in a state without parental involvement requirements. One caveat: In at least one state (Texas), parental involvement laws appear to have led to an increase in the teen birthrate, because teens were unable to travel the long distances necessary to access abortion services out of state. This highlights the likely impact if more states or groups of contiguous states were to enact these restrictions, making it harder for teens to travel to a state without a parental involvement requirement and leaving them no recourse other than an unwanted birth.

Similarly, a review of the literature on state counseling and waiting period requirements found that laws allowing women to receive state-mandated counseling over the Internet or by mail 24 hours prior to an abortion had little impact. However, seven of the 24 states with these laws require that the counseling be done in person at least 18–24 hours prior to an abortion, effectively requiring two separate visits to the facility. Multiple studies of the implementation of such a two-visit requirement in Mississippi show that it can have a significant negative impact, causing some women to have their abortion considerably later in pregnancy, and impeding others from having an abortion at all.

Of all the types of abortion restrictions, those that take aim specifically at disadvantaged women have the greatest impact in actually blocking access. As a result of state funding restrictions, about one in four women who would have had a publicly funded abortion instead will carry an unwanted pregnancy to term. Moreover, those women who are able to access abortion services are likely to be delayed in doing so, which increases both the cost and the risk of the procedure.

For more information:

Dennis A et al., The Impact of Laws Requiring Parental Involvement for Abortion: A Literature Review, New York: Guttmacher Institute, 2009.

Joyce TJ et al., The Impact of State Mandatory Counseling and Waiting Period Laws on Abortion: A Literature Review, New York: Guttmacher Institute, 2009.

Henshaw SK et al., Restrictions on Medicaid Funding for Abortions: A Literature Review, New York: Guttmacher Institute, 2009 (forthcoming).

The reasons women express for deciding to have an abortion, and the way they talk about how they made their decision, make it clear that they carefully consider the realities of their own lives and their ability, at that time, to be the kind of parent they want to be to their current and future children (see chart). For many women having an abortion, the issue of caring for dependents is not an abstract one, but a reflection of their current lives. Among such women, six in 10 are already a parent.

THOUGHTFUL DECISION
The reasons women give for having an abortion underscore their understanding of the serious consequences of unplanned childbearing for themselves and their families.
Reasons % of women giving each reason
Concern for/responsibility to other individuals* 74
Cannot afford a baby now 73
A baby would interfere with school/ employment/ability to care for dependents 69
Would be a single parent/ having relationship problems 48
Has completed childbearing 38
Note: *Includes financial, partner and relationship problems resulting in the inability to care for or support a (or another) child; possible problems affecting the health of the fetus; difficult family situtations, such as a current child’s chronic illness; financial impacts on existing children; and the need to care for other dependents. Source: Guttmacher Institute 2006.

For most women, the decision to end a pregnancy—even a very early pregnancy—is a complex and deliberative one. Moreover, all evidence indicates that women overwhelmingly make a final decision about abortion before they arrive at an abortion facility. Six in 10 women having an abortion say that they consulted with someone, most often their husband or partner, in making their decision. Women typically take 10 days between having a positive pregnancy test and trying to make an appointment for an abortion. And providers report that almost all women obtaining abortions are sure of their decision to terminate their pregnancy before they have even picked up the phone to make an appointment. This kind of carefully considered decision-making is unlikely to be swayed by inaccurate and emotionally laden attempts to persuade them otherwise.

In short, attempting to persuade women who are already pregnant and who do not want to be that they really would prefer to carry their pregnancies to term is an unrealistic way to have a substantial effect on the nation's abortion rate. The primary way to lower levels of abortions is to take aim at the proximate cause, unintended pregnancy. And the most effective ways to do that are to promote consistent use of effective contraception by all sexually active women and men who are not actively seeking pregnancy; support the development of better, more user-friendly contraceptive methods; expand access to family planning counseling and contraceptive services for those who cannot afford them on their own; and ensure that all people are provided the medically accurate, age-appropriate and comprehensive sex education they need to equip them to make and implement responsible decisions about their sexual behavior and their sexual health.