Abortion counselling: issues and approaches
By Gill Holden, Deborah Russell & Dr Catherine Paterson

Introduction

What follows is the text of a paper given at a conference organised by Pro-Choice Forum called 'Issues in Pregnancy Counselling: What do Women Need and Want?' The conference was held at Ruskin College, Oxford in May 1997. It's aim was to give students, academics, service providers and others interested in ensuring pregnancy services meet women's needs, the opportunity for a critical discussion of the provision of counselling as part of these services.

Gill Holden

For those of you who do not know much about the British Pregnancy Advisory Service (BPAS), it was set up after the 1967 Abortion Act to provide counselling, advice, information and referral for termination of pregnancy (TOP).

We are a not-for-profit charitable organisation offering private and NHS contracted-out TOP, and now see in excess of 40 000 women per year for TOP, contraception and pregnancy testing services through our network of 30 consultation centres and nine clinics throughout the UK. The background to counselling as part of the service In the social and political climate of the late 1960s and early 70s there was a great need to lead women seeking TOP through the legal and psychological minefield of services and to counter negative and hostile attitudes to their situation. It was in this context that pre-termination counselling emerged. Little was known about the possible psychological effects of being in an unplanned pregnancy situation and the after effects of undergoing TOP. The early stages of pregnancy counselling responded to the experience of individual counsellors. Traditionally then BPAS as with others in the charitable sector, believed that women had to have in-depth counselling to support them in making the decision to terminate pregnancy. However, in the late 1980s, BPAS began the process of taking a second look at client satisfaction and in particular pregnancy counselling, and it is from this body of work that we chose to revise our working practice.

In 1985 BPAS in partnership with the Department of Social Administration at the University of Birmingham and the Health Services Management Centre commissioned a three year Quality Assurance Research Project, which involved in depth interviews with clients, BPAS Managers and Staff. The project determined attributes of quality which all groups rated as valued components of a quality managed abortion service. These attributes were: information; professionalism and safety; individual attention; confidentiality; waiting time; staff attitude; access; and privacy (this was identified as an important attribute by the Branch Standards Group at a later forum).

BPAS and pregnancy counselling

This research contributed an insight into the clients' perspective in producing a structure of stages and aspects of service on which clients judge the quality of their experience in seeking an abortion. From this lead we needed as an organisation to look at whether the service being offered and the way it was being offered was consistent with what clients had already defined as 'quality'. In December 1989, BPAS therefore established a working party consisting of four Board members and the Director of BPAS, to review BPAS counselling services. The terms of reference were:

To review the appropriateness of BPAS counselling practice to the needs of our clients.
To review arrangements for assuring quality and consistency of service delivery.
To review relevant professional and research literature and take evidence from staff.

The first step of this working party was to commission a literature review about women's needs in abortion counselling to up-date the exiting review which had been conducted in 1981. The new work was published in 1990 and seemed to uphold previous findings. These in essence were:

Most women cope well with abortion. Very few women appear to feel that their decision to terminate was the wrong one, although this does not mean that they will not experience some sadness or distress. Long-term psychological trauma is extremely rare and often with further investigation it becomes clear that the problems leading to psychological problems are likely to have been present prior to the termination. The needs of women at this time seem to be more related to information provision and referral. A lack of factual information was the most common complaint.

In our work we know that for some women the decision and procedure need very little intervention, given an accepting and supportive environment, but for others a lot of support and help is needed. Nevertheless, previously most women would have seen what they had from their contact with us as being the same. In other words, the staff could define who had received 'counselling' and who had had 'support' but in being asked if they were counselled they all said yes. So an aim of the review was a move towards client self-determination: that women seeking abortion should be able to identify their own requirements for the amount of counselling, caring, support and information they need providing that they are fully aware of the choices available to them.

Pilot surveys

By 1990 the working party had devised a new approach to the counselling process which we were ready to pilot. There was one final stage however, in that in order to encourage a woman to make her own choices concerning her care, these choices needed explanation. A new leaflet was therefore designed explaining the process and the choices and staff were trained in the introduction of the new system and the use of the leaflet within the session. By early 1991 there was a widespread implementation of this new system and initial evaluation of the numbers of women requesting 'counselling' was available.

Evaluation

More detailed evaluation followed in the form of an in-depth questionnaire to clients looking at their overall experience of the service, and more particularly to identify the percentage of women opting for counselling in the hope of assessing the level of satisfaction from clients in the new system.

We found a confusion about the term 'counselling', and if not confusion then certainly a number of different interpretations. A large number of clients still saw counselling as only necessary if no decision had been made, although a few clearly request counselling if the decision proved difficult.

When the system of 'offering' counselling was first implemented there was anxiety that the client opting for 'no counselling' would not be encouraged to discuss any areas of concern or doubt or get her needs met or questions answered. However, one message was clear from the surveys is that whatever the clients received, whether this was counselling, help, information or support, in most cases they felt it met their needs if given a private space and non directive support -as is the case in BPAS.

Of the total number of replies received at that time just over 60 per cent identified themselves as not having had counselling, 31 per cent said they had received counselling and 8 per cent could not be analysed.

Future plans

A quality service once attained does not automatically maintain itself, but needs constant assessment and adjustment. BPAS has gone on to devise an ad hoc and constant monitoring system for client feedback in the form of client satisfaction questionnaires and client commentary forms as well as annual audits.

What was shown to be important during our survey, and now informs our approach in the process of consultation are the following:

friendliness
being accepted as individuals
having decisions accepted
not waiting around
being well informed
not being neglected or patronised
being treated as adults
the client feeling they are being treated by 'professionals'
privacy and confidentiality


In fact these are all the quality attributes identified in the BPAS Quality Assurance Research Project. We are also using our experiences of listening to women at the pre-abortion stage to develop services for women post-abortion and later on in their lives. As a provider we believe we have a responsibility to women who have come to us for help at whatever stage.

Conclusion

A definition of counselling that is appropriate for BPAS is 'counselling is a process through which one person helps another by purposeful conversation in an understanding atmosphere'.

Our awareness to an individual woman's needs means that we understand counselling means different things to different people. Our experience in supporting women means we understand the anxiety for women is to gain prompt access to abortion which can override any provision of pre-abortion counselling.

Our current policy is one of adapting to each individual by :

the provision of information
the provision of support
clarifying that every woman understands all options open to her

This will enable a woman to be respected in her decision and make an informed choice. BPAS continues to move towards a 'total care system'. Our latest focus for development is around increased inclusion of partners at the request of the women and the provision of post-abortion care once the woman had had time to reflect on her experiences.

Deborah Russell

I would like to discuss the approach taken by Marie Stopes House to offering optional counselling for women seeking termination of pregnancy.

Marie Stopes House approach to counselling

The principle which underlies our approach is 'person-centred counselling', by which we mean listening to the client in order to gain some insight about her thoughts and feelings about her situation. We then encourage her to explore her feelings, so that she can make the decision she feels is right for her. This is done without judgement or criticism, making the client feel comfortable and supported, and I'm sure this is a standard that many other organisations use too.

Choice in counselling

For some time, we at Marie Stopes International had realised that some clients did not wish to go through counselling. Our telephonists were constantly answering callers who were making it clear that they positively did not want to see a counsellor. There may be all kinds of reasons for this, such as they might think that the counsellor may try to dissuade them from having an abortion or perhaps they have a negative view of counselling. The result was that the resident Marie Stopes House counsellor would see these women for five or 10 minutes at the most out of a 30 minute slot.

We recognised that before calling us, many women had been able to call on a variety of other sources, partners, friends or family, so they already felt quite supported in their decision. For women who are so very sure of their choice to terminate pregnancy, and we felt it was important to offer choice in our service to them. Our belief in offering choice led us to implement a trial in the latter part of 1994, bearing in mind that this was not only new for Marie Stopes International but also for Marie Stopes House to do this. In this trial we offered our clients the choice to see a qualified lay counsellor. We then split our appointments throughout the day into slots where counselling was included and slots where it was not. There was always a counsellor available, so even if a woman had chosen a non-counselling appointment, she could still see a counsellor if she so wished.

Our objectives

In offering this choice of counselling or non-counselling appointments, our objectives were:

To offer women an optional counselling choice.
To improve the counselling service provided at Marie Stopes House with counsellors able to give quality attention to those who choose the counselling option.

We hoped to meet the individual's needs, for example by being able to slow or speed up the process, according to the individual client. Overall we hoped to provide a more streamlined service.

Our initial worries and concerns

In offering this kind of service, we did have some initial worries and concerns:

Clients who need counselling would be missed.
Emotional issues may arise within the consultation time and doctors would be unable to deal with them.
Post-abortion counselling client figures would rise.
Concern about the legality of offering non-counselling appointments.
There would be opposition to this kind of service from counsellors.
There would be opposition from administrative team members. They might feel unable to deal with problems that might arise where women were not counselled.

Some members of staff felt that women sometimes do not realise they need counselling until they see the counsellor. Some also suggested that women who say they do not want to see a counsellor may be the women who need to most.

The results

We began to monitor uptake of counselling and non-counselling slots on a monthly basis in January 1995. Over that year there was no consistent pattern, with each different month giving different results (see graph 1 overleaf). At the end of the year the average rate of clients opting for non- counselling appointments was 54 per cent. We therefore thought it worthwhile to continue the trial into 1996. In 1996, the rate of uptake of non-counselling slots started to change dramatically in May that year. The reasons for this are not clear, but there was a steady increase in the number of clients choosing the non-counselling option, peaking in December 1996, with over 70 per cent of appointments of this type in that month (see graph 2 overleaf). Results from the first months of 1997 have been no different, with over 64 per cent of clients choosing non-counselling appointments during January to April, so the trend is continuing.

Issues that affect the results

We felt that were certain issues that would affect the results, one being local area health authority contracts, which can be problematic. At Marie Stopes House all clients referred to us by the local health authority have to receive counselling. This requirement is often part of the contract between us the health authority. At Marie Stopes we would like to question whether this should be a requirement, who makes the decision that counselling must be provided, and on what grounds has the decision has been made to make counselling an obligatory been made. Dealing with problems that arise during consultations There are a small number of non-counselling clients who are very distressed. At that point we can stop the consultation and ask the client if they wish to see a counsellor, showing we can slow down the process if necessary. Doctors or administrative staff always offer to stop the consultation and let the woman see a counsellor if this is needed.

Conclusion

In our previous system, everybody saw a counsellor. The counsellor carried out various administrative tasks. She made the booking for the appropriate centre, while the client was in front of her. Clients who now opt for counselling have a full 30 minutes available to them. The counsellor does not make bookings into other centres, she is merely there to listen, discuss and answer questions. The client has her full attention, without the pressure of crammed counselling appointments.

Some of the counsellors who work with us still feel that we 'miss' some women who may need counselling, and they might be right. However, we receive only a very small number of complaints and our satisfaction ratings remain high.

We have at one and the same time been surprised at how easily team members have adapted to this system and how the take up for non-counselling slots has increased and yet shrugged our shoulders and said that, in the end, this was our gut feeling about the likely outcome to begin with.

We like to feel that by offering optional counselling we are ensuring a client chooses her own path in termination of pregnancy, by choosing:

Her choice of consultation type.
Her choice of termination method, whether surgical or medical.
Her choice of anaesthetic, between local or general.
Her choice of centre to attend for the procedure.

It is interesting for us to mull over the idea of what would happen if we were to offer clients the choice of same day procedures, or what would happen if the current law were amended to give abortion on request, which would give women real choice.

Dr Catherine Paterson

I work in one NHS unit which has a dedicated abortion service. I thought it might be useful to explain how we run a counselling session for those coming to us for an abortion, and who talks to the women at various stages of her contact with us.

We started out originally with counselling for all women as we felt that this was an important component of the service. However it was obvious that some women did not want to see a counsellor, and only did it under duress because they felt that it was a necessary hurdle in the path to getting an abortion.

Originally counsellors were provided by that local authority social service department, to provide support to women requesting abortion. About four years ago, following restructuring of their service, the local authority no longer had adequate resources to provide this. This provided and opportunity to review our counselling services. We decided that while many women did not wish to receive formal counselling, about 25 per cent of women needed more support. Social workers are not fully trained counsellors in the classical sense but they all have counselling training and, in addition, are very practical and understand the problems that women can have with an unplanned pregnancy. They can also give advice, if required, about adoption, fostering and benefits available to women. We therefore approached the local social services department and arranged for a social worker to attend each abortion assessment clinic and to be available to those women who needed them on the day of assessment. Because of the infrastructure of their own department this allowed much more flexibility than employing specific people for each session and generated a bank of six counsellors for three assessment clinics each week. They will also see women outside clinic times if necessary. This service is financed by the hospital as part of the abortion services contract.

Women who are referred come to the service via several routes. The majority are referred from GPs, some of whom have their own counselling services. The next largest group are from family planning clinics, and women also come from other hospital departments, especially genitourinary medicine, and from the Brook Advisory Services. Women from Brook have already seen a counsellor, and some women such as those who are HIV positive, or are substance abusers may have had access to specialist counselling from within those fields. These counsellors can relate the problems of unplanned pregnancy to the medical and social problems particular to these women.

A small proportion of women are very uncertain about what they want to do when they find they have an unplanned pregnancy. They will be offered a counselling appointment before they decide whether they want an abortion assessment appointment. This means a small number of women will actually have counselling but never come to the service to request an abortion.

The assessment procedure

The majority of women are initially booked by an administrator. They are then seen by a family planning nurse, who will take a medical history and a social history. We don't note down all of the social history, but we might use it to highlight points that suggest that the woman needs more support and time to talk through her decision. In particular this may apply to women who are young or women who are socially isolated. I emphasise again what has previously been said however, that many women have given their decision a lot of thought, talked issues through with friends and family and don't need to see a counsellor.

After they have been seen by the nurse, they see a doctor. Between the nurse and the doctor, the woman will have the course of events that will take place described to her. She will be told what options are available-medical or surgical abortion and how long she will stay in hospital. The doctor fills in any gaps and answers any questions she has. Once everything is arranged (or not if she is still ambivalent) she will be asked if she wants to see a counsellor. About 20 per cent of women do. What has been said before in this discussion applies to the NHS setting too. The counsellor has plenty of time to give to the woman. The other experience we have quite often is that women don't want to see a counsellor pre-termination, but say they might want to see one later. We make it clear to women that they can come back to the clinic at any time after the abortion to see someone. Interestingly enough, the take up of post-abortion counselling is very low. I get the feeling that women feel well supported knowing that they can come back. They know what they want to do, and think they are going to cope well, but are anxious that they might not. So knowing that there is someone they can go to afterwards is I think helpful and supportive. Although the service is not used much, women know it is there if they need it.

We look at the counselling session as giving information, explaining all the options available and trying to encourage women to make their own choice. By doing this we hope to avoid regrets in the future. What is clear to us from the various people that see these women, is that the abortion procedure itself is a source of anxiety. The questions women ask are: What will happen? Will it hurt? How long does it take? Will I be able to have a baby in the future? We try to answer these questions for them.

There isn't time for detailed counselling. One of the awful things about finding yourself with an unplanned pregnancy is that decisions have to be made in a fairly limited time, and therefore it is difficult to open up a box of anxieties and worries that women have.

There have been a few women, who from seeing a counsellor in our service, have then moved on to more formal counselling, but generally in relation to other aspects of their lives. You cannot undo an unplanned pregnancy, but offering a woman abortion offers relief from that particular problem. The fact that a woman has become pregnant accidentally, and the fact either she didn't want to or was unable to continue with the pregnancy. are things that cannot be undone.

I think it is important that women are able to think their decision through, make a choice and be at peace with their choice, so really in an actual abortion clinic we are not offering unbiased counselling. We are offering counselling to give women strength to have confidence about the decision they have made. They are worried about what people might say. The most important thing is to support them in their decision, if necessary offer counselling off site at a different time, if they really want to talk about whether or not they want to terminate pregnancy.

Women want to talk to someone who is friendly, who understands their problem and who will explain everything to them, and who they don't feel embarrassed to ask questions of and get answers from.