A client facing the decision of whether or not to have an abortion is likely to consider a wide range of factors before making the final decision. This often is the case for clients regardless of whether they view themselves as generally for or against abortion (or somewhere in between), as the decision is different when considering how it applies to one’s own life.
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The types of factors that can influence a client’s decisions include (but are not limited to) physical health considerations, educational background, cultural values, and predictions about short- and long-term consequences of abortion.
The Assignment (2- to 3-page paper):
- Explain potential factors that might influence whether or not a client decides to have an abortion. Include short- and long-term considerations that might impact this decision.
- Explain why certain factors might have a stronger impact on a client’s decision regarding abortion depending on the client’s background (e.g., age, gender, religion, socioeconomic status).
Support your Assignment with specific references to all resources used in its preparation. You are to provide a reference list for all resources, including those in the resources for this course.
Patient Education and Counseling 81 (2010) 362–367
Structured contraceptive counseling—A randomized controlled trial
Aileen M. Langston *, Linette Rosario, Carolyn L. Westhoff
Division of Family Planning and Preventive Services, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, USA
A R T I C L E I N F O
Article history:
Received 10 February 2010
Received in revised form 30 July 2010
Accepted 4 August 2010
Keywords:
Contraceptive counseling
Unintended pregnancy
Abortion
Contraception
Birth control
Structured counseling
A B S T R A C T
Objective: To evaluate the addition of structured contraceptive counseling to usual care on choice,
initiation, and continuation of very effective contraception after uterine aspiration.
Methods: We conducted a RCT of a version of the WHO Decision-Making Tool for Family Planning Clients
and Providers with women having a procedure for a spontaneous or induced abortion. Our intervention
provided structured, standardized counseling. We randomized women to usual care or usual care with
structured counseling. Our outcomes included choosing a very effective contraceptive method and 3
months continuation.
Results: Fifty-four percent of all participants chose a very effective method. Women in the intervention
group were no more likely to choose a very effective method (OR 0.74, 95% CI 0.44, 1.26) or to initiate
their method compared to the usual care group (OR 0.65, 95% CI 0.31, 1.34). In multivariate models,
structured counseling was not associated with using a very effective method at 3 months (AOR 1.06, 95%
CI 0.53, 2.14).
Conclusion: In this setting, structured counseling had little impact on contraceptive method choice,
initiation, or continuation.
Practice implications: Adding structured counseling did not increase the proportion choosing or
initiating very effective contraception in a practice setting where physicians already provide
individualized counseling.
� 2010 Elsevier Ireland Ltd. All rights reserved.
Contents lists available at ScienceDirect
Patient Education and Counseling
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / p a t e d u c o u
1. Introduction
Despite the availability of very effective contraceptive methods,
the rate of unintended pregnancy in the United States (US)
remained stagnant at 49% from 1995 to 2001 [1]. Most women in
the US have not used the most effective methods available [2], and
47% have had a repeat abortion [3]. Women’s health professionals
have regarded counseling as an important component of improv-
ing contraceptive use [4], and access to counseling services has
been considered an integral part of informed choice [5]. The World
Health Organization (WHO) has supported the practice of
contraceptive counseling so that patients can make informed
decisions in conjunction with their provider [6].
Accepted practice within contemporary healthcare has been to
offer patients information regarding diagnoses and proposed
treatment options. Contraceptive counseling, where options are
presented with mechanisms of action, efficacy, risks and benefits,
has been a challenge due to the limited resources in the clinical
* Corresponding author at: Division of Family Planning and Preventive Services,
Columbia University Medical Center, 622 West 168th Street, PH 1669, New York,
NY 10032, USA. Tel.: +1 212 305 4805; fax: +1 212 305 6438.
E-mail address: al2632@columbia.edu (A.M. Langston).
0738-3991/$ – see front matter � 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2010.08.006
setting and the ability of any person to receive and comprehend a
large amount of information.
A recent Cochrane Review found that ‘‘little evidence from
randomized controlled trials supports the hypothesis that
counseling improves contraceptive use,’’ and a systematic review
of the literature on counseling to prevent unintended pregnancy
also [7] found limited evidence regarding its effectiveness [8]. In
1996 the US Preventive Services Task Force (USPSTF) recom-
mended contraceptive counseling, but the 2002 USPSTF withdrew
this recommendation due to insufficient evidence [9,10].
Limited data has suggested a possible benefit to using
structured counseling—consisting of audio–visual materials with
standardized information—for contraceptive counseling. Two
randomized controlled trials (RCTs) utilized structured audio–
visual educational material with standardized information about
contraceptive methods. The results from both studies showed
increased contraceptive use or continuation of effective contracep-
tive methods (pill and injection) 1 year later [11,12].
In a post-abortion population, one RCT of counseling performed
by a contraceptive specialist along with advanced provision of
contraceptive methods compared to routine counseling found
increased uptake of long acting reversible contraceptives and
increased continuation at 4 months but no difference in repeat
abortion rates at 2 years [13]. The information given by the
http://dx.doi.org/10.1016/j.pec.2010.08.006
mailto:al2632@columbia.edu
http://www.sciencedirect.com/science/journal/07383991
http://dx.doi.org/10.1016/j.pec.2010.08.006
A.M. Langston et al. / Patient Education and Counseling 81 (2010) 362–367 363
specialist counselor in this study was not standardized or given in a
structured audio-visual format.
In an attempt to meet family planning counseling needs, the
WHO developed a series of family planning guidelines and tools,
including the Decision-Making Tool for Family Planning Clients
and Providers (DMT) [14]. A double-sided flipchart with one side
for the client to aid in decision-making and the other side for the
provider to aid in the counseling process by giving information and
guidance, this tool was studied for improving communication with
clients in limited resource settings [15,16]. The DMT was found to
improve communication, particularly with clients choosing a new
contraceptive method [15].
Given the need for resource efficiency in health care, the belief
by many providers and organizations that contraceptive counsel-
ing is necessary and worthwhile, and the limited literature [7–
10,17], we aimed to study this topic using a structured and
standardized counseling intervention based on the DMT in a post-
abortion setting with most modern methods available for
immediate initiation. Our study evaluated structured, standard-
ized contraceptive counseling for its influence on participants
choosing a very effective contraceptive method at the time of first
trimester vacuum aspiration, method initiation, and 3 months and
6 months method continuation.
2. Methods
2.1. Setting and participants
From December 2008 to July 2009, we enrolled participants
from a family planning referral clinic to a private practice setting
serving a predominantly Hispanic (Dominican) population with
Medicaid coverage in New York City. Providers at the practice were
all physicians: faculty, fellows, and residents at Columbia
University Medical Center (CUMC). Vacuum aspiration procedures
were offered 1 day per week, and on a given day, 3–4 physicians
each cared for 6–8 patients.
The study population consisted of women seeking a first trimester
procedure for a spontaneous or induced abortion. Inclusion criteria
were (1) age � 18 years, (2) no desire to become pregnant right away,
(3) fluency in Spanish or English, and (4) access to a telephone. The
CUMC Institutional Review Board approved this study.
2.2. Structured contraceptive counseling intervention
In this study we sought to address whether structured,
standardized, non-directive counseling (the intervention) in the
setting where contraceptive methods are immediately available and
the women have confirmed fertility, will result in increased choosing
of very effective contraceptive methods, method initiation, and
method continuation at 3 months. Structured counseling consisted
of the trained research coordinator reading and displaying a
contraceptive flipchart in its entirety to the participant in a private
office with samples of each method available for patients to see and
touch. The counseling was structured in that the format included
visual and audio components allowing the participant to both
visualize and hear the information. The counseling was standardized
in that the same information was presented every time the
counseling was performed. Participants were encouraged to ask
questions and to write down questions for their physician on
supplied note cards. The research assistants were trained to answer
questions using only the information from the flipchart. If a question
was not able to be answered by the information on the flipchart, the
research assistant was instructed to request the participant ask her
provider this question during usual care.
The flipchart was a version of the WHO 2005 Decision-Making
Tool for Family Planning Clients and Providers (DMT) [14]. We did
not intend the intervention to provide tailored counseling, though
that is one of the common uses of the DMT. We chose to use the
format of the DMT for its ready-made structure, simple language
and images to create our structured and standardized intervention.
We utilized the portion of the DMT focused on choosing a method
and the method tabs (overview and information for choice,
medical eligibility criteria, possible side effects, how to use, when
to start, and what to remember). We modified this portion of the
DMT to add methods available in the US (patch, ring, levonorges-
trel IUD, and etonogestrel implant) and to remove information
about methods not available in the US (NET-EN injections, monthly
injections, and Norplant) or not appropriate for post procedure
patients (lactational amenorrhea and fertility awareness). Thus the
flipchart administered by a research coordinator gave our
intervention a structured format with visual and audio compo-
nents. The research coordinators gave standardized information
using this structured tool. The simple language and images in the
flipchart, as well as reading the pages aloud as they were viewed,
mitigated any effects of low literacy. Information on contraceptive
methods (female sterilization, male sterilization, copper IUD,
levonorgestrel IUD, etonogestrel implant, depo provera injection,
ring, patch, pill, and condom) was presented on 5–7 double-sided
pages per method with patient and counselor focused content on
the front and back, respectively. We used flipcharts printed in
English for our participants who preferred English and flipcharts
translated and printed in Spanish for our participants who
preferred Spanish. The flipchart included information on con-
traceptive effectiveness, how to use each method, possible side
effects, and when to seek help.
Usual care consisted of a single physician performing the
medical history, physical exam, ultrasound, obtaining informed
consent for the suction aspiration procedure, and carrying out this
procedure for each patient. This visit required about one hour to
complete. Contraceptive counseling was routinely offered by the
physician as well and was embedded in the visit. As part of usual
care, the content and duration of contraceptive counseling
performed by the provider was left to their discretion.
2.3. Study procedures
Two research coordinators fluent in English and Spanish
performed enrollment and follow-up. We used training scripts
and role play to standardize interactions with participants.
Questionnaires were piloted and adjusted based on responses
prior to enrollment.
We assessed all women aged 18 or older registered in the clinic
for eligibility. To ease anxiety, the coordinator first gave each
patient basic information about routine clinic procedures before
discussing the study. Interested and eligible women were
consented. A baseline questionnaire was administered to collect
demographic characteristics as well as partnership, reproductive,
and contraceptive histories. Participants were then randomized to
usual care with intervention versus usual care alone. Those
randomized to the intervention group received structured
counseling by a coordinator immediately prior to usual care
during the same visit. Attention was paid to minimize delay for
women in the intervention group.
Using a random-number table, we determined the sequence for
1:1 allocation constrained by blocks of 10. Randomization
assignments were sealed inside numbered, opaque envelopes.
The coordinator opened the next sequentially numbered envelope
after completing informed consent. No blinding of participants or
coordinators was feasible due to the nature of the intervention.
Physician-providers did not know the participant’s allocation
group, did not discuss the study with patients, and were asked not
to change their counseling.
A.M. Langston et al. / Patient Education and Counseling 81 (2010) 362–367364
Contraceptive methods available to participants immediately
following their procedure included intrauterine devices (IUDs),
implants, injections, rings, and pills. The IUDs and implants were
donated and available at no cost to all clinic patients. All
participants had either New York State Medicaid coverage for
prescription contraceptives or access to additional free supplies at
a safety net clinic so all contraceptives offered were available free
of charge. The patch was available by prescription only and
sterilization by referral only. Those who chose pill or ring received
either a prescription or a 1-month supply and prescription. All
participants received condoms with handouts on emergency
contraception and condom use.
After each enrollment day, we reviewed charts to confirm that a
procedure was performed and to identify the contraceptive
method chosen as well as whether initiation was immediate or
delayed. Coordinators called participants 3 months after enroll-
ment to assess contraceptive use. A subset of patients received 6
months follow-up phone calls. Initial analysis of the first 101
participants to complete both 3 and 6 months data found no
significant differences, so 6 months follow-up was stopped to focus
on maximizing 3 months follow-up.
2.4. Outcomes and analysis
The primary outcome of this study was proportion of
participants choosing a very effective contraceptive method.
Secondary outcomes were method initiation on the day of the
procedure and method continuation of very effective and/or
effective methods at 3 months, and at 6 months for the sub-group
for whom we collected data.
The WHO defined very effective contraceptive methods as those
with 1 year typical use pregnancy rates of <1% (sterilization, IUDs,
and implants) [6]. Effective methods have typical use pregnancy
rates of 1–9% (pills, rings, patches, and injections). The WHO
defined additional categories for methods with �10% and >25%
typical use pregnancy rates. In this study, we used the WHO
[(Fig._1)TD$FIG]
Fig. 1. Participant enrollment and follow-up in a randomized con
definition for very effective and effective methods and defined less
effective methods as those with �10% pregnancy rate (condoms,
withdrawal, periodic abstinence, and no method).
We defined initiation of effective and very effective methods as
leaving the clinic with a method requiring no healthcare provider
contact to begin use. If a participant requested pills and left clinic
with a pill pack and a prescription, this was coded as immediate
initiation. If she left with a prescription only, this was considered
delayed initiation because she needed to go to a pharmacy to begin
using the method. Less effective contraceptive methods (condoms,
withdrawal, and periodic abstinence) were coitally dependent and,
therefore, were not able to be initiated in the clinic.
We defined continuation as using a contraceptive method at 3
or 6 months that was in the same effectiveness group as the
method requested at enrollment. For example, two patients
requested sterilization and were using an IUD at the 3
months
follow-up interview. Both these participants were counted as
‘continuers’ for the very effective group.
In this clinic in 2003–2004, 29% of patients chose the most
effective available methods (injection, copper IUD, or sterilization)
following a first trimester aspiration procedure [18]. We designed
our study to identify an increase from 30% to 50% of women
requesting a very effective method in the intervention arm. With
up to 20% loss due to exclusion after randomization, a two-sided
alpha of .05, and power of .80, we needed 125 women in each arm.
We used SAS, version 9.2 (SAS Institute, Cary, NC) for statistical
analyses to compare the intervention and control groups. We
performed Chi-square analyses to assess differences between
allocation groups. We calculated two-sided p-values and 95%
confidence intervals. We performed logistic regression analyses
with two dependent outcomes: very effective method use at 3
months; or very effective or effective method use at 3 months. The
8 participants who reported sexual abstinence since enrollment
due to no partner were excluded from these analyses. We
performed univariate logistic regression with (1) intervention,
(2) immediate initiation, (3) age, (4) education, (5) ethnicity, (6)
trolled trial of structured contraceptive counseling, NY 2009.
Table 2
Structured contraceptive counseling versus usual care: contraceptive method
chosen and 3 months continuation.
Intervention
(N = 114)
Usual care
(N = 108)
Total
(N = 222)
p-Value*
Contraceptive method chosen
Very effective methodsa 57 (50%) 62 (58%) 119 (54%) 0.27
Effective methodsa 48 (42%) 37 (34%) 85 (38%) 0.27
Less effective methodsa 9 (8%) 9 (8%) 18 (8%) 1.0
(N = 89) (N = 83) (N = 172b)
3 months continuation
Very effective methodsc 41/48 (85%) 40/52 (77%) 81/100 (81%) 0.28
Effective methodsc 28/41 (68%) 21/31 (68%) 49/72 (68%) 0.96
* Chi-square p-value.
a Very effective methods—copper IUD, levonorgestrel IUD, etonogestrel implant,
sterilization. Effective methods—DMPA, ring, patch, pill. Less effective methods—
intervention group: 1 undecided, 2 abstinence, 2 declined contraception, 4
condoms. Control group: 3 undecided, 1 natural family planning, 1 coitus
interruptus, 1 declined contraception, 3 condoms.
b Less effective methods are not represented in this total.
c Numerators are continuers and denominators are those who chose this method
group and completed 3 months follow-up.
A.M. Langston et al. / Patient Education and Counseling 81 (2010) 362–367 365
parity, (7) prior abortion, (8) stable relationship status, (9) provider
and (10) current smoking. Variables were chosen for multivariate
logistic regression based upon univariate results and overall
importance to the clinical outcome. We constructed the final
model using the likelihood ratio test as variables were added
sequentially to determine the most parsimonious model. The
Hosmer–Lemeshow statistic was calculated to test the goodness-
of-fit of the final model.
3. Results
3.1. Enrollment
We screened 380 women and enrolled 250 women (Fig. 1). We
excluded 28 women after randomization because they did not
have a procedure that day primarily due to pregnancies in the
second trimester, completed spontaneous abortions, and ectopic
pregnancies. The remaining 222 women were eligible for analysis
and follow-up.
The groups were well balanced with regard to baseline
characteristics (Table 1). They were mainly Hispanic and in stable
relationships, defined as a relationship the participant reported
will continue for >1 year. Participants’ ages ranged from 18 to 45
years with a mean age of 26.2 years. Participants were seeking
induced abortion (94%) or spontaneous abortion management
(6%). The time used to conduct the structured counseling
intervention was, on average, 20 min (standard deviation �8 min).
3.2. Methods requested
The intervention and control groups were similar in the
methods requested (Table 2). Participants in the intervention
group were similar to the usual care group in often choosing a very
effective method (OR 0.74, 95% CI 0.44, 1.26). Most women
requested very effective methods (levonorgestrel IUD (27%),
copper IUD (15%), implant (9%) and sterilization (2%)). Many
women requested effective methods (oral contraceptive pills
(18%), vaginal ring (9%), injection (7%), and patch (5%)). Fewer
women requested less effective methods (undecided/declined
(n = 7), condoms (n = 7), abstinence (n = 2), withdrawal (n = 1) and
periodic abstinence (n = 1)).
Comparing the demographics of participants who chose very
effective methods to those who did not, parous women and women
in a stable relationship were more likely to choose a very effective
method (OR 2.51, 95% CI 1.35, 4.67 and OR 1.98, 95% CI 1.11, 3.54,
Table 1
Demographics and reproductive history—structured contraceptive counseling
versus usual care (N = 222).
Intervention (N = 114)
N (%)
Usual care (N = 108)
N (%)
Age (SD) 25.6 (5.7) 26.8 (6.7)
Age < 25 years 59 (52%) 49 (45%)
Hispanica 98 (87%) 97 (90%)
Education�12th grade 74 (65%) 77 (71%)
Birthplace
United States 47 (41%) 43 (40%)
Dominican Republic 50 (44%) 53 (49%)
Other 17 (15%) 12 (11%)
Current smokersb 20 (18%) 20 (19%)
Gravida > 1 98 (86%) 96 (89%)
Parous 84 (74%) 81 (75%)
Ever had a prior abortion 57 (50%) 58 (54%)
Ever used contraception 109 (96%) 104 (96%)
Current stable relationship 78 (68%) 77 (71%)
a One missing value from intervention group.
b One missing value from intervention group.
respectively). Six providers saw the majority (91%) of the
participants. No differences were seen in the methods requested
(p = 0.44) or the proportion of methods initiated immediately
(p = 0.83) among these providers. There was no difference between
the intervention and control groups in the physician-providers
from whom they received usual care (p = .59).
3.3. Immediate versus delayed initiation
Participants in the intervention group were not more likely to
initiate the requested method immediately compared to those in
the usual care group (OR 0.65, 95% CI 0.31, 1.34) (Table 2). Only 15
percent of participants chose a method that could not be initiated
the same day (18 less effective methods, 10 patches, and 5
sterilizations). The other 189 participants selected a method that
could be initiated the same day; 80% of these women initiated their
method the same day (80 IUDs, 28 pills, 19 implants, 15 injections,
and 10 rings). The remaining 20% of participants had delayed
initiation of their method (14 IUDs, 11 pills, 10 rings, 1 injection,
and 1 implant). Of these, 3 women preferred to delay IUD insertion,
and 1 woman wanted to obtain her pill prescription from her
personal physician. The physician-providers delayed 9 initiations
due to infection, 2 due to bleeding, and 1 due to lack of
confirmatory products of conception at the time of the procedure.
Twenty-one women were given prescriptions only (10 rings, and
11 pills).
3.4. Follow-up and continuation
Of 222 participants, 186 (84%) completed 3 months follow-up
(Fig. 1). Loss to follow-up was equal between the intervention and
control group. The baseline characteristics and requested methods
of the women who completed 3 months follow-up and those who
did not were similar (data not shown). Those in the intervention
group who completed 3 months follow-up had chosen similar
methods compared to those in the control group (p = 0.51). No
participants reported a repeat pregnancy at 3 months.
For those who chose a very effective or effective method, 3
months continuation of the requested method and 3 months
continuation of immediately initiated methods were not signifi-
cantly different comparing the intervention group to the usual care
group (OR 1.24, 95% CI 0.62, 2.50 and OR 1.43, 95% CI 0.58, 3.52,
respectively) (Table 2). Fourteen (78%) participants who chose a
less effective method completed 3 months follow-up; 13 reported
being sexually active; and only 2 reported adopting an effective
Table 3B
Predictors of contraceptive method use at 3 months, multivariate model (N = 186).
Very
effective method
use
Very effective or ef-
fective method use
AOR 95% CI AOR 95% CI
Structured counseling 1.06 (0.53, 2.14) 1.59 (0.77, 3.28)
Immediate initiation 15.5 (6.02, 39.7) 4.26 (2.05, 8.87)
Age 0.91 (0.43, 1.89) 1.67 (0.81, 3.47)
Education – – – –
Prior abortion – – – –
Parous 3.17 (1.37, 7.32) – –
Hispanic – – – –
Relationship – – – –
Smoking – – – –
*Excluded participants abstinent since enrollment from the analysis (N = 8). **The
reference group is ‘no’ and the comparison group is ‘yes’ except for age where
reference group is <25 years and comparison group is �25 years.
A.M. Langston et al. / Patient Education and Counseling 81 (2010) 362–367366
method (pills). In a sub-group analysis of those who initiated a very
effective method on the day of enrollment (n = 83), the interven-
tion group trended towards increased 3 months continuation
compared to the usual care group (98% versus 83%; p = .06).
With the initial participants at the start of the study, we took
the opportunity to conduct 6 months follow-up interviews. We
completed 6 months follow-up with 131 (59%) participants. For
these participants, 6 months continuation between the inter-
vention group (67%) and the usual care group (68%) was similar
(OR 0.95, 95% CI 0.45, 2.02). Two participants reported a repeat
pregnancy at 6 months, one from each randomization group.
3.5. Predictors of using a very effective and/or effective method at 3
months
When limiting our outcome to using a very effective method at
3 months, the counseling intervention did not have a strong effect
in univariate or multivariate models (Tables 3A and 3B). In
univariate analyses, completing at least the 12th grade in school
and immediate initiation of a requested contraceptive method had
the strongest associations with using a very effective or effective
method at 3 months (Table 3A). In a multivariate model, the
counseling intervention did not have a strong association with
using a very effective or effective method at 3 months (AOR 1.59,
95% CI 0.77, 3.28).
4. Discussion and conclusion
4.1. Discussion
We sought to address whether structured, standardized, non-
directive counseling (the intervention) in the setting where
contraceptive methods are immediately available and the women
have confirmed fertility, will result in increased choosing of very
effective contraceptive methods. We specifically chose a counsel-
ing format that would not be performed by a physician to reflect
the reality of limited health resources and the common practice of
family planning clinics in the US to utilize non-physicians to
perform counseling. We chose standardized counseling in contrast
to tailored counseling to ensure that participants in the interven-
tion group received the same information to minimize bias from
the counselor. Minority women have been shown to be more likely
to receive contraceptive and sterilization counseling compared to
white women [19], and our clinic serves a predominantly minority
population.
We performed a RCT of an intervention utilizing a modified
version of a readily reproducible counseling intervention (DMT)
Table 3A
Predictors of method use at 3 months, univariate analyses (N = 186).
Very effective method
use
Very effective or
effective method
use
OR 95% CI OR 95% CI
Structured counseling 0.97 (0.53, 1.74) 1.35 (0.68, 2.68)
Immediate initiation 14.02 (5.58, 35.22) 3.87 (1.90, 7.89)
Age 1.05 (0.58, 1.89) 1.44 (0.73, 2.86)
Education 1.65 (0.87, 3.14) 2.11 (1.04, 4.25)
Prior abortion 0.91 (0.50, 1.64) 1.62 (0.82, 3.22)
Parous 2.43 (1.19, 4.95) 1.37 (0.65, 2.89)
Hispanic 0.86 (0.33, 2.24) 1.46 (0.52, 4.10)
Relationship 1.38 (0.72, 2.65) 1.10 (0.53, 2.29)
Smoking 0.77 (0.35, 1.69) 1.12 (0.46, 2.74)
*Excluded participants abstinent since enrollment from the analysis (N = 8). **The
reference group is ‘no’ and the comparison group is ‘yes’ except for age where
reference group is <25 years and comparison group is �25 years.
that is available online and developed by experts. Our structured
and standardized counseling intervention did not result in more
women choosing a very effective contraceptive method, immedi-
ately initiating more methods, or significantly increasing 3 months
continuation of their chosen method in our setting. In our clinic,
physicians who specialize in family planning are providing
contraceptive counseling with the patients as an integrated part
of their visit for a first trimester uterine aspiration. Additional
counseling may have been unnecessary in this setting.
Our study had several limitations. Our clinic setting had
specialized providers as well as a specific ethnic demographic that
limited the generalizability of our study’s findings. We utilized the
DMT for structured, standardized counseling, and it was designed
for tailored counseling. This approach may have affected the
effectiveness of the intervention. Our 3 months contraceptive data
was self-reported and vulnerable to social desirability bias. We
made an effort to reduce patients’ anxiety but could not eliminate
it before the intervention. This anxiety could have lessened the
effects of the structured counseling intervention. A further
limitation was that the providers in our setting were aware of
the study and could have altered their counseling during the study,
minimizing the effect of the intervention, though they were asked
not to do so. We also did not collect data on participant satisfaction
specifically with the contraceptive counseling or detailed data on
participants’ desires for future pregnancy beyond whether they
desired contraception.
One further limitation of our study was that it was powered for
the outcome of choosing a very effective contraceptive method;
however, it was not powered for the other outcomes collected—
initiation and continuation. The initiation outcome for very
effective methods was so similar between the intervention and
control groups (84% versus 82%, respectively) that, though
underpowered, the trend showed no difference. The continuation
outcome for very effective methods was less similar between the
two groups (85% versus 77%, respectively). A larger sample size
could have benefited this outcome in our study.
We had a very high proportion of patients in both the
intervention and control group who chose IUDs (42%) compared
to the 2% of contracepting women using IUDs in the US in 2002
[20]. Hispanic women in the US have been found to have higher
ever-use of IUDs (10.0%) and implants (4.0%) compared to non-
Hispanic White (4.7% and 1.4%) and non-Hispanic Black (5.5% and
3.2%) women [20]. The community served by our practice is
predominantly Hispanic, and greater baseline usage of these long-
acting methods among Hispanic women could partially explain the
high proportion of women choosing an IUD. In one study of post-
abortion contraception, 53% chose the pill, 11% chose the IUD, 8%
chose DMPA and 17% declined or were undecided on the day of
A.M. Langston et al. / Patient Education and Counseling 81 (2010) 362–367 367
their procedure so our findings were not typical though the
literature is limited on post-abortion contraceptive use [21]. The
proportion of our participants selecting very effective methods was
also higher than found in the same population and setting in 2003–
2004—54% compared to 29% [18]. The larger than expected
proportion of women in the control group who chose a very
effective method was an unexpected outcome and decreased the
power for our sample size.
The physicians and patients participating in this study may
have been further motivated by the fact that these very effective
contraceptive methods were available for insertion on the same
day as the procedure. Previously in this same clinic, patients who
chose a very effective method had to make an additional visit on a
different day to have the method initiated. Immediate access to
very effective contraceptives following an abortion has been
shown to decrease repeat abortion [22,23]. The intervention to
increase uptake of very effective post-abortion contraception may
be to provide increased access to contraceptives while the specific
counseling methods may be less significant as long as contracep-
tive counseling is provided. Interventions to improve contracep-
tive uptake and use to better meet family planning needs deserve
continued study.
4.2. Conclusion
Contraceptive counseling is valuable. The exact amount and
extent of counseling appropriate for each patient likely varies
though a common minimum should be standard to give patients
the opportunity to make an informed choice. All our patients
received contraceptive counseling by the physician doing their
procedure with the structured counseling done in addition if
they were part of the intervention group. Due to a higher than
expected proportion choosing a very effective method in the
control group, our power was less than planned and needs to be
considered in the interpretation of our outcomes. Structured
contraceptive counseling in our setting did not have a significant
impact on method choice, method initiation, or 3 months
continuation. Interventions to improve contraceptive use
deserve continued study.
4.3. Practice implications
Adding structured contraceptive counseling did not increase
the proportion choosing or initiating a very effective contraceptive
method in a practice setting where specially trained physicians
already provide informal individualized counseling.
Conflict of interest
None.
Acknowledgements
The authors acknowledge Heidi Jones and Sara Fuentes,
Division of Family Planning and Preventive Services, Columbia
University and Sarah Johnson, Department of Reproductive Health
and Research, WHO.
Financial support provided by a grant from an anonymous
foundation. This foundation approved the study design. It did not
have a direct role in the collection, analysis and interpretation of
data; the writing of the manuscript; or the decision to submit the
manuscript for publication.
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- Structured contraceptive counseling-A randomized controlled trial
Introduction
Methods
Setting and participants
Structured contraceptive counseling intervention
Study procedures
Outcomes and analysis
Results
Enrollment
Methods requested
Immediate versus delayed initiation
Follow-up and continuation
Predictors of using a very effective and/or effective method at 3 months
Discussion and conclusion
Discussion
Conclusion
Practice implications
Conflict of interest
Acknowledgements
References
Inadequate preabortion counseling and decision conflict as predictors of subsequent relationship difficulties and psychological stress in men and women.
Reference : Coyle, C. T., Coleman, P. K., & Rue, V. M. (2010). Inadequate preabortion counseling and decision conflict as predictors of subsequent relationship difficulties and psychological stress in men and women. Traumatology, 16(1), 16–30.
https://doi-org.ezp.waldenulibrary.org/10.1177/1534765609347550
By: Catherine T. Coyle
APART Inc., Madison, WI, USA;
Priscilla K. Coleman
Bowling Green State University, Bowling Green, OH, USA
Vincent M. Rue
Institute for Pregnancy Loss, Jacksonville, FL, USA
Acknowledgement: Catherine T. Coyle, RN, PhD, is a co-director of the Alliance for Post-Abortion Research & Training, Inc. Her research interests include the psychological effects of abortion on men and the psychology of forgiveness.
Priscilla K. Coleman, PhD, is an Associate Professor of Human Development and Family Studies at Bowling Green State University. Her current research focuses on women’s responses to induced abortion including mental health (anxiety, depression, suicide ideation), substance abuse, intimate partner relationship issues, and parenting.
Vincent M. Rue, PhD, is the director of the Institute for Pregnancy Loss in Jacksonville, FL. For 35 years he has treated women and men who have experienced abortion as traumagenic and is an active litigation consultant.
The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.
The authors received no financial support for the research and/or authorship of this article.
Introduction
Few contemporary social issues have evoked more controversy than elective abortion. The continuing debate over abortion and mental health has focused on the nature and frequency of adverse postabortion psychological sequelae. There is now consensus, however, that a significant percentage of women experience negative psychological reactions following abortion (
Bradshaw & Slade, 2003
;
Coleman, Reardon, Strahan, & Cougle, 2005
;
Wilmoth, deAlteriis, & Bussell, 1992
). This study was designed to identify potentially key factors predictive of postabortion relationship problems and psychological stress in both women and men.
Women and Abortion
Recent studies have corrected methodological weaknesses of earlier studies and have revealed increased mental health risks associated with the experience of abortion. The most thoroughly researched adverse consequences include anxiety, depression, substance abuse, suicidal ideation, and suicide (Broen, Moum, Bodtker, & Ekeberg, 2004;
Coleman et al., 2005
; Cougle, Reardon, & Coleman, 2003; Cougle, Reardon, Coleman, & Rue, 2005;
Coleman, Reardon, Rue, & Cougle, 2002
;
Fergusson, Horwood, & Ridder, 2006
; Gissler, Berg, Bouvier-Colle, & Buekens, 2005; Gissler, Hemminki, & Lonnqvist, 1996;
Pedersen, 2007
,
2008
;
Reardon & Cougle, 2002
;
Reardon, Coleman, & Cougle, 2004
;
Reardon et al., 2003
;
Rees & Sabia, 2007
;
Soderberg, Janzon, & Sojberg, 1998
;
Thorp, Hartman, & Shadigan, 2003
).
An estimated 43% of U.S. women will experience at least one anxiety disorder in their lifetime (
Breslau, Schultz, & Peterson, 1995
). Posttraumatic stress disorder (PTSD) is a relatively common and particularly disabling anxiety disorder that may be caused by one or more profound stressors. Extensive research has documented how traumatic stress can significantly alter the quality of individuals’ lives (Kapfhammer, Rothenhausler, Krauseneck, Stoll, & Schelling, 2004;
Marshall et al., 2001
; Schnurr, Hayes, Lunney, McFall, & Uddo, 2006; Warshaw et al., 1993). In the United States, an estimated 13% of women develop PTSD in their lifetime (
Butterfield, Becker, & Marx, 2002
). Systematic exploration of the role of elective abortion as a traumatic stressor associated with symptoms of PTSD has grown substantially in recent years (
American Psychological Association, 2008
;
Bradshaw & Slade, 2003
). Various clinicians have identified abortion as potentially traumagenic (Bagarozzi, 1993,
1994
;
Burke & Reardon, 2002
;
De Puy & Dovitch, 1997
;
Speckhard, 1987
;
Speckhard & Rue, 1993
;
Torre-Bueno, 1996
). Moreover, recent research has provided empirical evidence of this link between abortion and PTSD symptomatology (Kubany, Hill, & Owens, 2003; Mufel, Speckhard, & Sivuha, 2002;
Rue, Coleman, Rue, & Reardon, 2004
;
Steinberg & Russo, 2008
;
Suliman et al., 2007
).
Rue et al. (2004)
and
Suliman et al. (2007)
reported that 12% to 18% of women met the full diagnostic criteria for PTSD after an abortion. An even greater number of women in these studies experienced subthreshold or partial PTSD symptoms following abortion (
Barnard, 1990
;
Rue et al., 2004
). The higher the number of these subthreshold symptoms present, the greater the risk of impairment, comorbidity, and suicidal ideation (
Marshall et al., 2001
).
Informed consent and preprocedure counseling can benefit the patient’s decision making and postprocedure emotional and physical adjustment (
Baker, Beresford, Halvorson-Boyd, & Garrity, 1999
). The perceived adequacy of preabortion counseling may also play an important role in mitigating or increasing the amount of stress women feel following abortion. Preabortion counseling has been criticized as being too time limited, inadequate to address the ambivalence and the complexity inherent in the abortion decision, lacking in discussion of alternatives to abortion, deficient in assessing coercion or pressure to abort, provided by nonprofessionals who are biased, and not tailored to the needs of the individual patient (
Singer, 2004
;
Steinberg, 1989
; Stites, 1982).
The National Abortion Federation (2007)
advises that “there should be an opportunity for discussion of the patient’s feelings about the abortion decision” (p. 3). However, there is no current standard of care in abortion clinics requiring individualized and thorough counseling regarding the patient’s feelings and decision making. In a cross-cultural study,
Rue et al. (2004)
reported that only 29% of women in the U.S. sample received preabortion counseling, and 84% stated that it was inadequate.
Individual psychological responses to abortion have also been found to be related to the quality of preabortion decision making and, particularly, lack of partner support for the decision (
Bradshaw & Slade, 2003
;
Coleman et al., 2005
). Research has consistently identified ambivalence and absence of partner support as predictive of negative abortion outcomes (
Bracken, 1978
;
Coleman et al., 2005
;
Major & Cozzarelli, 1992
;
Major et al., 1990
;
Osofsky & Osofsky, 1972
).
Payne, Kravitz, Notman, and Anderson (1976)
found that women electing abortion were significantly more angry and depressed afterward, if they were in conflict with their husband or lover over the abortion.
Rue et al. (2004)
reported that most women were unsure about their decision at the time of the abortion, and only 24% perceived their partners as supportive. Thus, the degree of perceived partner support and perceived quality of preabortion counseling are seemingly central factors in possible adverse psychological outcomes following elective abortion and they are addressed in this investigation.
Men and Abortion
Although few studies have addressed men’s psychological responses to elective abortion (
Coyle, 2007
), there are identifiable, recurring themes within the scientific literature. A number of reports have noted men’s need and/or desire for counseling (
Gordon, 1978
;
Lauzon, Roger-Achim, Achim, & Boyer, 2000
; Myburgh, Gmeiner, & van Wyk, 2001a;
Rothstein, 1977a
; Shostak & McLouth, 1984). Most men who experience a partner’s abortion do not perceive it to be a benign experience (
Blumberg, Golbus, & Hanson, 1975
;
Gordon & Kilpatrick, 1977
; Poggenpoel & Myburgh, 2002; Shostak, 1979,
1983
;
White van-Mourik, Connor, & Ferguson-Smith, 1992
) and specific emotions identified among men include anger, anxiety, guilt, grief, and powerlessness (
Gordon & Kilpatrick, 1977
;
Holmes, 2004
; Mattinson, 1985;
Speckhard & Rue, 1993
). In studies of men dealing with therapeutic abortion following amniocentesis, 82% (
Blumberg et al., 1975
), 50% (
Jones et al. 1984
) and 47% (
White van-Mourik et al. 1992
) of men have reported depression. Furthermore, clinicians have observed symptoms among postabortion men that are consistent with delayed or complicated grief reactions and PTSD (Mattinson, 1985;
Robson, 2002
;
Speckhard & Rue, 1993
). These clinical reports involved small numbers of men and, to date, no quantitative studies have looked at the potential for PTSD among men following a partner’s abortion. In light of established comorbidity of PTSD with depression and other forms of anxiety (
Shalev, 2001
), further investigation is warranted to determine the extent of risk of psychological trauma among men whose partners undergo elective abortion.
Men tend to defer the abortion decision to their partners and suppress their own emotions and desires as they attempt to support their partners (
Gordon & Kilpatrick, 1977
;
Robson, 2002
; Shostak & McLouth, 1984), and men who disagree with their partners’ abortion decisions may be more susceptible to intense anger (Naziri, 2007;
Reich & Brindis, 2006
). Even men who agree with the abortion decision may suffer from ambivalence (Kero & Lalos, 2000,
2004
; Kero, Lalos, Hogberg, & Jacobsson, 1999) and their relationships, both social and sexual, with their partners may be strained or come to an end (
Berger, 1994
;
Coleman, Rue, Spence & Coyle, 2008
; Myburgh, Gmeiner, & van Wyk, 2001b; Naziri, 2007;
Rothstein, 1977b
;
White van-Mourik et al., 1992
).
Although little is known about the long-term effects on men,
M. Buchanan and Robbins (1990)
provided evidence that adolescent pregnancy resolution may have effects that last into adulthood. These authors found that adult men who experienced abortion during adolescence were more psychologically distressed than adult men who became fathers during adolescence.
Although men are involved with conception and abortion, they are not routinely offered abortion counseling. Despite the call for greater inclusion of and attention to males in abortion clinics (Shostak, 2007), little has changed. Most men who accompany women for abortion do not receive counseling and are left alone to wait.
Given that abortion is a highly personal and sensitive issue, an online investigation seems ideally suited to this topic. Participants may remain anonymous thereby increasing their comfort with self-disclosure. The very existence of an online survey concerning the emotional and relational aspects of abortion may serve to normalize respondents’ experiences and encourage them to seek help if needed.
Web-Based Research
This investigation represents one of the first online studies pertaining to the topic of abortion and, in this section, established advantages and disadvantages of this contemporary data collection mode are examined. Use of the Internet to engage in data collection is time- and cost-efficient (
Duffy, 2000
;
Wilson, 2003
), effective in accessing difficult-to-reach populations (
Mangan & Reips, 2007
; Yeaworth, 2001), and enhances respondents’ comfort with the process and motivation to participate (
Adler & Zarchin, 2002
;
Gosling, Vazire, Srivastava, & John, 2004
). A review of Web-based studies published in the American Psychological Association journals between 2003 and 2004 (Skitka & Sargis, 2006) revealed that 21% of those journals had published at least one such study.
Gosling et al. (2004)
compared a large Internet sample with 510 traditional samples and found that Internet samples “are generally more diverse than samples published in a highly selective psychology journal” (p. 99). Similarly, Mathy, Schillace, Coleman, and Berquist (2002) reported their Internet sample as being more representative in terms of education, income, and ethnic diversity than that of a large sample obtained through random digit dialing. Still others have argued that Internet samples are at least as representative as the ubiquitous college-student samples (
Gosling et al., 2004
;
Smith & Leigh, 1997
).
Because data collected through Web-based surveys are often obtained from self-selected, convenience samples, generalization must be approached with caution. However, the voluntary nature of such samples offers considerable benefits (
Buchanan & Smith, 1999
; Reips, 2000) such as superior responses in terms of clarity and completeness (
Petit, 2002
;
Walsh, Kiesler, Sproull, & Hesse, 1992
), and responses that are less likely to be contaminated by social desirability (
Richman, Kiesler, Weisb, & Drasgow, 1999
). Furthermore, research indicates that data collected online appears to be equivalent to that collected via more traditional methods (
Ballard & Prine, 2002
;
Hewson & Charlton, 2005
;
Knapp & Kirk, 2003
; Robie & Brown, 2006) and
Meyerson and Tryon (2003)
concluded that “data collection on the Web is (1) reliable, (2) valid, (3) reasonably representative, (4) cost effective, and (5) efficient” (p. 614).
Potential risks of online survey administration such as inaccurate responses, failure to respond, and the influence of phrasing and ordering of questions are applicable to traditional survey administration methods as well. The risks of multiple survey submissions and nonserious responses (
Buchanan & Smith, 1999
;
Schmidt 1997
) may be avoided by using Internet protocol numbers to identify surveys coming from the same respondent (
Birnbaum, 2004
;
Gosling et al., 2004
). Furthermore, the anonymity afforded by the Internet facilitates honest disclosure (
Levine, Ancill, & Roberts, 1989
;
Locke & Gilbert, 1995
;
Mangan & Reips, 2007
).
Ethical considerations in Web-based research are the same as those for other research forms. Consent to participate may be defined as and verified by submission of an online survey. The risk of psychological harm in online surveys has been deemed to be no greater than that of offline surveys (
Kraut et al., 2004
) if initial instructions include a clear statement respecting the participant’s freedom to withdraw from the study at any time. For studies involving sensitive subjects, information concerning referrals for counseling or support may be provided.
Objectives and Hypotheses
Based on the literature reviewed here, it appears that preabortion counseling for women may be limited, whereas for men, it is nonexistent. In addition, men and women may be arriving at abortion decisions that are made without adequate communication and candor between them thus resulting in decisions that are less than satisfactory to one or both parties. Consequent to both the crisis of pregnancy resolution and insufficient communication, relationships may be strained (
Rue et al., 2004
;
Speckhard & Rue, 1993
) and psychological stress increased (Bagarozzi, 1994;
Coleman & Nelson, 1998
;
Fergusson et al., 2006
).
Both inadequate preabortion counseling and the incongruence of partner abortion decision making may therefore predict postabortion relationship difficulties and/or psychological trauma. Given that some studies on women have found factors such as prior mental health (
Major et al., 2000
), religious beliefs (
Adler et al., 1990
;
Major, Richards, Cooper, Cozzarelli, & Zubek, 1998
), opinions or attitudes about abortion (
Soderberg et al., 1998
; Zolese & Blacker, 1992), number of abortions (
Rue et al., 2004
), and various sociodemographic characteristics (Zavodny, 2001) are likely to influence the decision to abort and/or postabortion adjustment, these factors were used as control variables in this study. In addition, history of physical or sexual abuse during childhood or adulthood may be a confounding variable in terms of postabortion mental health given the evidence that such abuse may contribute to emotional problems (
Fergusson, Horwood, & Lynskey, 1996
;
Schilling, Aseltine, & Gore, 2007
). Therefore, controls were also implemented for various forms of childhood and adulthood victimization.
The primary objective of this study was to investigate the extent to which perceived inadequacy of preabortion counseling and partner incongruence in abortion decision making predicted postabortion relationship problems and psychological stress. The following hypotheses were tested:
Hypothesis 1: Men and women who do not perceive preabortion counseling as having been adequate will be at significantly greater risk for abortion-related anger, relationship problems, and sexual problems after controlling for sociodemographic and personal history variables.
Hypothesis 2: Men and women who do not perceive preabortion counseling as adequate will report significantly higher abortion-related stress as evidenced by symptoms of intrusion, avoidance, and hyperarousal, and they will be at significantly greater risk of meeting the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) diagnostic criteria for PTSD after controlling for sociodemographic and personal history variables.
Hypothesis 3: Men and women who were not in agreement with their partners regarding the decision to abort will be at significantly greater risk for abortion-related anger, relationship problems, and sexual problems after controlling for sociodemographic and personal history variables.
Hypothesis 4: Men and women who were not in agreement with their partners regarding the decision to abort will report significantly higher abortion-related stress as evidenced by symptoms of intrusion, avoidance, and hyperarousal, and they will be at significantly greater risk of meeting the DSM-IV diagnostic criteria for PTSD after controlling for sociodemographic and personal history variables.
Method
Procedure
Surveys were posted at
www.abortionresearch.net
from April, 2005 through August, 2008. The surveys consisted of questions concerning sociodemographics, meaningfulness of religious affiliation, abortion history, reasons for abortion, perceived adequacy of preabortion counseling, agreement in abortion decision making, opinion regarding abortion at time of procedure, relationship status with partner postabortion, mental health history, abuse history, trauma symptoms related to abortion, abortion-related anger, relationship problems, sexual problems, and general stress attributed to abortion. The introduction to the survey clarified that submission of the survey would qualify as consent to participate and that respondents could withdraw from participation at any time. Links were provided for those respondents who desired support or counseling. Participants were recruited through e-mail requests to crisis pregnancy centers across the United States and to a few other organizations that offer postabortion counseling. Potential participants could also find the survey via search engines using phrases such as “men and abortion,” “women and abortion,” or “abortion research.”
Sample
Surveys were completed by 374 women and 198 men. U.S. citizens comprised 81% of the female sample and 78% of the male sample. Citizens from England (6.5% male and 4% female surveys), Canada (4.5% male and 6.4% female surveys), and Australia (2.5% male and 2.7% female surveys) contributed the next largest number of surveys. Respondents also identified the following as country of citizenship: France, Ireland, Norway, Romania, Czechoslovakia, Germany, Sweden, New Zealand, South Africa, Kenya, Mexico, Nicaragua, Brazil, Nepal, and South Korea. The average age of both male and female respondents was 38 years (SD = 12.8 for males and 11.1 for females). Religious affiliation of women was as follows: 81.6% Christian, 0.3% Jewish, 9.5% Other, and 8.6% None. Religious affiliation of males was 82% Christian, 0.5% Jewish, 0.5% Islam, 7.2% Other, and 9.8% None. Females reported an average of 15 years (SD = 11.8) had elapsed since abortion and males reported a mean of 14.7 years (SD = 12) had passed since abortion occurred. Approximately half of the respondents endorsed liberal views prior to abortion with 21% of males and 24% of females agreeing that abortion “should be legal for any reason at any time during pregnancy” and 27% of males and 36% of females agreeing that abortion “should be legal for any reason during the first trimester of pregnancy.” Additional demographic information can be found in
Table 1
.
Descriptive Statistics for Primary Study Variables and Control Variables
Measures
Perceived adequacy of preabortion counseling was assessed via a single item question, “Do you think the counseling you received at the abortion clinic was adequate?” to which respondents indicated “yes” or “no.” Agreement regarding abortion decision making was determined by respondents’ endorsement of agreement or disagreement with their partners about the decision to abort.
Relationship quality was assessed with single item variables indicating the presence or absence of abortion-related relationship problems, abortion-related anger, and abortion-related sexual problems. These items had dichotomous (yes/no) responses.
Psychological stress was assessed using the PTSD Checklist–Civilian Version (PCL-C). The entire PCL-C was contained within the online survey. The PCL is composed of 17 items that measure the severity of PTSD symptoms. The PCL yields a total score of 17 to 85 and assesses three symptom clusters: arousal, avoidance of, and re-experiencing of the traumatic event. The response format of the PCL is a 5-point Likert-type scale with higher scores indicative of greater traumatic stress. The diagnosis of PTSD was determined using DSM-IV criteria: (a) one or more endorsements of re-experience symptoms; (b) three or more endorsements of avoidance symptoms; and (c) two or more endorsements of hyperarousal symptoms not present prior to the abortion. Reliability and validity of the PCL have been established (
Weathers, Litz, Herman, Huska, & Keane, 1993
). With the current sample, internal consistency reliability estimates for the full scale and for the arousal, avoidance, and re-experiencing subscales were equal to .89, .77, .78, .80, and .92, .82, .80, .82 using the women’s and men’s data, respectively.
Results
Table 1
provides frequency data for the independent variables, sociodemographic and personal history control variables, and dependent variables separately for men and women. To test the first and third hypotheses, which predicted that perceptions of inadequate preabortion counseling and disagreement with one’s partner regarding the decision to abort would be associated with increased risk for abortion-related anger, relationship, and sexual problems after employing various controls, three sets of logistic regression analyses were conducted separately for males and females in the sample. In the first set, perceptions of counseling inadequacy and partner disagreement operated as the independent variables with abortion-related anger problems functioning as the dependent variable. A similar logistic regression analysis was then conducted incorporating the control variables listed in
Table 1
. In the second set of two logistic regression analyses, the analyses were structured similarly to the first set except relationship problems functioned as the dependent variable. Finally, in the third set of logistic regressions employing a similar structure to the preceding analyses, sexual problems operated as the dependent variable.
The results of these tests are provided in
Table 2
for the female respondents and in
Table 3
for the male respondents. As indicated by the data presented in
Table 2
, prior to inclusion of the control variables, both independent variables (disagreement regarding the abortion decision and perceptions of preabortion counseling as inadequate) were significant predictors of abortion-related anger, relationship, and sexual problems. However, once the controls were entered into the analyses, only the inadequate preabortion counseling variable significantly predicted postabortion-related anger, relationship, and sexual problems in the women sampled. More specifically, the inadequate counseling variable was associated with a 592%, 831%, and 340% increased risk for anger, relationship, and sexual problems, respectively, among the females.
Results of Logistic Regression Analyses With Relationship-Based Dependent Variables for Females
Results of Logistic Regression Analyses With Relationship-Based Dependent Variables for Males
A different pattern of results emerged with the male data. As indicated in
Table 3
, both independent variables were significant predictors of postabortion-related anger, relationship, and sexual problems after statistically controlling for the wide range of sociodemographic and personal situational variables. Inadequate counseling was specifically associated with a 1,797% increased risk of postabortion anger, a 1,421% increased risk of postabortion relationship problems, and a 407% increased risk of postabortion-related sexual problems. In addition, disagreement with one’s partner regarding the abortion decision was associated with a 4,248%, 469%, and a 331% increased risk of postabortion-related anger, relationship problems, and sexual problems, respectively.
To test the first part of the second and fourth hypotheses, two sets (one for males and one for females) of analyses of variance were conducted. In each test, the independent variables of partner disagreement on the decision and preabortion counseling inadequacy served as the independent variables with scores on the single item measure of abortion-related stress serving as the dependent variable. Higher scores on the stress measure are indicative of greater stress. One analysis in each set incorporated controls and one did not. Using the female data, without controls employed, the main effect for counseling inadequacy was significant, F(1, 334) = 71.92, p < .0001, as was the main effect for partner disagreement, F(1, 334) = 71.92, p < .0001, and the interaction was significant as well, F(1, 334) = 20.58, p < .0001. Then, with the controls instituted, the results were similar—counseling inadequacy: F(1, 218) = 36.31, p < .0001; partner disagreement: F(1, 218) = 12.23, p < .0001; interaction: F(1, 334) = 5.45, p < .0001. Means were as follows—no agreement, counseling inadequate: 8.80 (SE = .21); no agreement, counseling adequate: 8.26 (SE = .23); agreement, counseling inadequate: 6.78 (SE = .77); agreement, counseling adequate: 3.96 (SE = .56).
Using the male data, without controls employed, only the main effect for partner disagreement was significant, F(1,152) = 10.99, p < .001. Then, with the controls instituted, partner disagreement remained significant, F(1, 95) = 8.24, p = .005, and the interaction effect was likewise significant, F(1, 95) = 4.00, p = .048. Adjusted means were as follows—no agreement, counseling inadequate: 7.81 (SE = .36); no agreement, counseling adequate: 8.28 (SE = 1.77); agreement, counseling inadequate: 6.94 (SE = .38); agreement, counseling adequate: 3.49 (SE = .73).
To test the second part of the second and fourth hypotheses, which predicted that inadequate preabortion counseling and partner disagreement on the abortion decision would be associated with higher risk for experiencing intrusion, avoidance, hyperarousal, and with meeting diagnostic criteria for PTSD after employing controls, four sets of logistic regression analyses were conducted separately for males and females in the sample. The dependent variable in each of the four sets of two analyses was different (intrusion criteria, avoidance criteria, hyperarousal criteria, and general PTSD criteria met) and as in the previous set of logistic regressions performed to test the first and third hypotheses, there were separate tests conducted with and without the controls.
Table 4
provides these results for women, and
Table 5
provides these results for men.
Results of Logistic Regression Analyses With Posttraumatic Stress Disorder (PTSD) Subscales and Total Scale Criteria Met for Females
Results of Logistic Regression Analyses With Posttraumatic Stress Disorder (PTSD) Subscales and Total Scale Criteria Met for Males
With the female data, both independent variables were associated with increased risk for meeting the DSM-IV criteria for intrusion (202% and 2,383% for the partner disagreement and inadequate counseling variables, respectively) and full PTSD diagnostic criteria after the controls were applied (89% and 283% for the partner disagreement and inadequate counseling variables, respectively.) However, only the inadequate counseling variable was a significant predictor after the controls were included on the avoidance subscale (559% increased risk) and on the hyperarousal subscale (425% increased risk). Using the male data, both independent variables were associated with increased risk of meeting the DSM-IV criteria on the intrusion subscale (925% and 1,737% for the partner disagreement and inadequate counseling variables, respectively). However, only the inadequate counseling variable was associated with increased risk for meeting the DSM-IV criteria for the avoidance subscale (1,005%) after controls were applied. Only partner disagreement over the abortion decision increased risk for experiencing hyperarousal symptoms (384%) and for meeting the full diagnostic criteria for PTSD (210%).
Discussion
The purpose of this study was to explore associations between two independent variables (perceptions of preabortion counseling adequacy and partner abortion decision congruence) and two sets of dependent variables (postabortion relationship problems and psychological stress). Perceptions of inadequate preabortion counseling significantly predicted all the dependent relationship variables for both men and women with utilization of control variables. Although other research has found abortion in itself to be associated with abortion-related anger (Kero, Hogberg, & Lalos, 2004; Naziri, 2007), relationship difficulties (
Barnett, Freudenberg, & Wille, 1992
;
Lauzon et al., 2000
;
Rue et al., 2004
), and sexual dysfunction (
Bradshaw & Slade, 2003
;
Rue et al., 2004
), no studies had previously investigated the association between preabortion counseling and postabortion relationship challenges. The inclusion of participants’ perceptions of counseling adequacy is therefore an important contribution of the current study.
For women, perceived inadequate counseling also predicted all trauma subscale scores (i.e., intrusion, avoidance, hyperarousal) and predicted meeting diagnostic criteria for PTSD. For men, only intrusion and avoidance scores were predicted by perceptions of inadequate counseling. Similarly,
Peters, Issakidis, Slade, and Andrews (2006)
observed that whereas women were significantly more likely to report arousal symptoms, men were significantly more likely to report avoidance symptoms particularly the symptom of detachment. Both biological (
Bryant & Harvey, 2003
) and sociocultural (Gavranidou & Rosner, 2003) explanations have been proposed to explain these observed differences between men’s and women’s endorsement of specific PTSD symptoms. From a biological perspective, males and females may have innate predispositions that differentiate their responses to trauma. Alternatively, culturally prescribed gender roles may influence which trauma symptoms men and women are likely to endorse depending on whether symptoms are perceived as being gender appropriate.
Sex differences in the association between perceived counseling inadequacy and meeting full diagnostic criteria for PTSD may be related to women’s direct participation in the abortion procedure, which could predispose them to greater trauma and an increased likelihood of developing PTSD regardless of the quality of counseling. Nonetheless, a large majority of both women and men (85.8% and 86.6%, respectively) in this study indicated that they did not perceive preabortion counseling to be adequate. Because abortion is the legal right of females in the United States and continues to be viewed as an exclusively women’s issue, there are no requirements or incentives to offer counseling to male partners. If men receive any counseling at all, it is likely to occur informally if and when they accompany their partners for preabortion clinic visits.
When unplanned pregnancy is experienced as a crisis situation for one or both partners, the individuals tend to use more primitive coping skills and to be psychologically vulnerable as they struggle to solve the problem and regain equilibrium (
Caplan, 1961
). The emotional strain of the crisis and the lack of effectiveness of one’s usual coping mechanisms may result in anxiety and an inability to function (
Caplan, 1961
). Thus, men and women facing a crisis pregnancy may need considerably more counseling than is currently being offered.
With control variables applied, incongruence of abortion decision significantly predicted trauma symptoms of intrusion and meeting diagnostic criteria for PTSD for both men and women. Contrary to the findings concerning counseling adequacy, disagreement about the abortion decision predicted hyperarousal in men but not in women. Furthermore, decision incongruence predicted abortion-related anger, relationship problems, and sexual difficulties for men only. The inherent inequality of abortion decisions may explain these differential associations.
Numerous studies (
Bracken, Hachamovitch, & Grossman, 1974
;
Major, Zubek, Cooper, Cozzarelli, & Richards, 1997
;
Moseley, Follingstad, Harley, & Heckel, 1981
;
Payne et al., 1976
) have identified conflict with one’s partner and lack of partner support for abortion as predictors of women’s postabortion distress. In contrast, very few studies, with the exception of work by Shostak and McLouth (1984) and Naziri (2007), have examined the male’s reaction to an abortion that occurs against his wishes. Our findings suggest that disagreement about abortion decisions may be a more robust predictor of traumatic stress among men compared with women.
A notable feature of this study is that it is the first to explore the association between preabortion counseling and postabortion relationship problems and postabortion psychological stress. Employment of numerous control variables, including prior mental health, which has been found to be a determinant of both postabortion adjustment (
Major et al., 2000
) and PTSD (
Brewin, Andrews, & Valentine, 2000
), is a major strength of this investigation. Also included as control variables were other known risk factors for the development of PTSD, including history of childhood sexual abuse (Astin, Lawrence, & Foy, 1993), childhood physical abuse (Bremner, Southwick, Johnson, Yehuda, & Charney, 1993;
O’Keefe, 1998
), physical abuse during adulthood (
Breslau, Davis, Andreski, & Peterson, 1991
), and sexual abuse during adulthood (
Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995
).
The use of the Internet is another asset of this study as it enabled acquisition of an international sample and offered anonymity for those who may have been hesitant to participate in research concerning such a sensitive topic. The anonymity afforded by an online survey may augment respondents’ perceptions of safety and enhance honest disclosure. Finally, the inclusion of men as well as women is an essential strength of this investigation as the research pertaining to men’s responses to abortion is severely inadequate.
A limitation of this study is the fact that the sample was self-selected. Although self-selection may bring some benefits such as a high level of motivation and a genuine desire to contribute to science, self-selected samples limit generalizability of findings. Moreover, the high rate of PTSD among respondents (54.9% of women, 43.4% of men) is indicative of a traumatized sample. By comparison, prevalence of PTSD among women with a history of assault has been reported as 21% (
Breslau et al., 1991
), among rape survivors, 50% (Foa, 1997), and among Vietnam veterans with high combat exposure, 31% (Kulka et al., 1988).
On the other hand, this highly traumatized sample may represent those who drop out of other studies concerning abortion. In a review of 17 such studies (
Adler, 1976
), the attrition rate was found to be from 13% to 86% leading to the conclusion that those women who do not participate in follow-up assessments tend to be the most stressed by abortion. As a result, follow-up studies may underestimate negative responses to abortion. Conceivably, anonymous surveys conducted online may be an effective means to reach these traumatized individuals and to gather information from them concerning their abortion experience.
Abortion is one of the most common surgical procedures among women aged 15 to 44 years (
Owings & Kozak, 1996
) and from 1973 through 2005, more than 45 million elective abortions were performed in the United States (
Guttmacher Institute, 2008
). If even a small percentage of the men and women involved in abortion are severely traumatized, this may represent a large absolute number of individuals who need psychological support. In addition, the increase in suicidal ideation among those with PTSD (
Sareen, Houlahan, Cox, & Asmundson, 2005
) and with subthreshold PTSD symptoms (
Marshall et al., 2001
) raises serious public health concerns if these individuals are not identified and offered help.
In this study, perceptions of preabortion counseling inadequacy were associated with more negative postabortion outcomes in both women and men. Future research should seek to identify the specific elements of counseling that need to be changed or added to achieve better satisfaction with the content and process. Aspects of preabortion counseling to explore further might include the following: (a) the sufficiency of time allotted for counseling, (b) the nature and quality of training of counselors, (c) the inclusion of men in the preabortion counseling process, (d) whether it is better for men and women to be counseled separately or together, and (e) the comprehensiveness and accuracy of information provided.
Findings reported herein provide preliminary evidence that perceptions of inadequate preabortion counseling and abortion decision incongruence may contribute to relationship challenges between partners and to individual psychological stress. Future research to investigate factors that improve the quality and comprehensiveness of preabortion counseling as well as factors that contribute to decision congruence could do much to improve men’s and women’s postabortion adjustment. In-depth interviews with men and women prior to and after abortion might reveal specific counseling needs that could be incorporated into preabortion counseling protocols. Qualitative studies are needed to delve more deeply into the processes of decision making between women and men facing crisis pregnancies to further our understanding of both intraindividual factors and interpersonal dynamics that may affect the quality and congruence of abortion decisions.
