Pregnancy counselling in Britain: a review of the literature
By Ellie Lee
Nadine Dorries MP and Frank Field MP have put in an amendment to the Health and Social Care (HSC) Bill (which concerns the general reorganisation of the national Health Service in England) to be debated later this year. In it they seek to separate, 'information, advice and counselling services for women requesting termination of pregnancy' from the provision of abortion procedures. They call the provision they seek to establish 'independent', defining 'independent' as 'information, advice and counselling' provided by either, 'a private body that does not itself provide for the termination of pregnancies' or 'a statutory body'. They also seek to make it the case that the National Institute for Clinical Excellence (NICE) be required by law, 'to make recommendations with regard to the care of women seeking an induced termination of pregnancy' (work currently undertaken by the Royal College of Obstetricians and Gynaecologists, who have published documents titled 'Evidence-based Guidelines for the Care of Women Seeking Induced Abortion' since the late 1990s).
This proposal has already generated quite a lot of debate. Some have expressed concern that by 'independent' Dorries and Field in fact mean organisations opposed to legal abortion, for example Life and CARE (Christian Action Research and Education), who have, for many years promoted their 'crisis pregnancy' counselling services. These services, it is claimed by those promoting them, are important because they are highly attuned to the spiritual and psychological upheavals that they contend precede and also follow abortion. (The term 'abortion trauma' is frequently used to summarise this representation of the experience of abortion overall).
Field has responded to this discussion in a short letter to the Guardian, stating that the amendment, '[H]as one simple aim. It is to ensure that advice about abortion is given separately from the body that picks up a fee if the pregnant mother [sic] proceeds with an abortion' (Field 2011). He has also reportedly stated that: he is going to have talks with officials at the Department of Health about changing counselling arrangements in advance of debate about the HSC Bill (so without the matter become an open question debated in Parliament); he believes 'family doctors' would provide better counselling than women receive currently (i.e. that counselling should be provided by GPs); and that it would increase not diminish choice were women no longer offered and provided with counselling by abortion providers (Merrick 2011). Dorries has made in clear in other debates, however, that she considers the organisation Life to have a very important role to play in the development of services in this area.
No further detail has yet been given about exactly what 'information, advice and counselling' Field and Dorries believe women need to receive, that is not provided currently. There has been no indication given, beyond the assertion that it is not right that abortion providers provide women with information, advice and counselling, of the reasons why these MPs consider it so important that arrangements in this area are changed. There is also no clarity at all about what distinctions, if any, they consider there to be between 'information', 'advice' and 'counselling'.
These issues have, however, been the subject of discussion over many years, and the aim of what follows is to summarise accounts from the published social science literature about the evolution of 'abortion counselling' in Britain. In 1998, Pro Choice Forum (PCF) sought to bring together some of those who had spent time thinking about this area at a conference held in Oxford, 'Issues in pregnancy counselling: what do women need and want?' (Materials from this event are available on the 'Psychological Issues' section of the PCF website
This commentary revisits and summarises some of the main issues and themes raised at that event and in the relevant literature on the subject published subsequently. If politicians are to consider changing the law regarding this aspect of abortion provision, it is to be hoped that discussion would have some cognisance of the debates and issues raised over many years hitherto, and are aware of the relevant complexities and what follows aims to bring some of these to light.
The Lane Committee
Following the passing of the 1967 Abortion Act, which made abortion legal in Britain under the terms set out in the Act, discussion of how best to address the needs of women presenting for abortion became an official concern. The Committee on the Working of the Abortion Act (the Lane Committee) was set up by the then Department of Health and Social Services (DHSS) and published its report (the Lane Report) in 1974. Its conclusions formed the basis for government guidelines for abortion providers issued in 1977. These guidelines, 'Arrangements for Counselling of Patients Seeking Abortion' mandated that providers needed to ensure adequate counselling provision was available to all women, drawing directly on the interpretation of counselling set out in the Lane Report; hence the Lane Report should form the starting point for discussion of counselling as part of abortion services in Britain.
Wivel's (1998) analysis of the raft of evidence and documents considered by the Committee (it met regularly over a period of three years) draws attention to the way its overarching conclusions indicated how far the provision of abortion to address the problem of unwanted pregnancy had come to be validated as a social good. The Committee (in contrast to what some expected, given the Chair of the Committee was known to be unsupportive of legal abortion) concluded that significant efforts needed to be made to ensure abortion was provided within the mainstream of medical care; that there should be greater equality of opportunity for women to obtain abortion and that women should not have to seek abortion outside the NHS; and that more needed to be done to research the subject of contraception and unwanted pregnancy.
These points about how best to proceed with abortion provision in fact formed the overall context for the recommendation that all women should be provided with assessment and 'counselling' when considering abortion. As Lee (2003) indicates, counselling was in part envisaged together with 'assessment' as a necessary process to ensure that doctors did not deny women abortions they should be able to legally access, and/or did not treat woman in an unprofessional, shoddy manner. Counselling was thus advocated as a means of encouraging doctors to make sure that they themselves considered all requests adequately, or ensured they had 'assistants', or 'counsellors', who would do this on their behalf. In other words, counselling was originally envisaged, in part at least, as a means of addressed the barriers to abortion placed in the way of women by some medical practitioners in the early years of legal abortion.
The Lane Committee report also, however, raised a wider set of questions about counselling (discussed in Unwanted Pregnancy and Counselling (1977) authored by one Lane commissioner, Juliet Cheetham, as well as in the report itself). The report noted that in evidence it had received there was much confusion about the objectives and purposes of counselling. While there seemed to be certainty that women were too frequently refused abortion and/or denied the opportunity to discuss their situation properly with a doctor, what 'counselling' entailed specifically was less clear.
A definition was offered in the final report in which counselling was described as the provision of an opportunity to discuss, gain information, obtain explanations, and obtain advice. It was also strongly emphasised that the decision to terminate a pregnancy should be free, that is, not the result of pressure from other people, and counselling could help ascertain if this were the case (Lee 2003). This approach reflected the concern of the Lane Commissioners that as well as denying some women abortion, some doctors were also failing to take abortion-seeking women seriously and were not paying those who were referred for abortion proper attention. The Lane report contended that some 'hurried doctors' were rushing women into abortion, who may not fully certain about what they wanted to do, or aware of what help might be available did they continue the pregnancy. They were also concerned whether enough time was being taken to make sure all women were not being pressurised by partners or family members into abortion. These points were reflected in the DHSS 1977 circular mentioned above.
The Lane Report also presented opinion on the matter of which people should provide counselling to women considering abortion. The Lane Committee did not envisage the development of the 'abortion counsellor' as a specialist professional. Rather, it considered it to be the case that many groups (including doctors and nurses by also lay personnel) would come into contact with women in need of counselling (as they defined it). The Lane Report suggested that, on the basis of the evidence they have reviewed, all these groups would benefit from extra training. (This contrasts with developments elsewhere. Joffe's study of the work of the' abortion counselor' in the US., published shortly after the Supreme Court Ruling Roe v. Wade, notes how the 'abortion counselor' has a different history there. She argues that feminism is, 'the major ideological underpinning of abortion counseling' and that before abortion was legally available in the US, those helping women obtain illegal abortion called themselves 'counselors'; at this time, 'abortion counseling not only involved offering emotional support to recipients, but a substantial amount of activism on the part of the counselor'. She explains how, following the legalisation of abortion, the 'abortion counselor' evolved significantly, 'to the status of a new "human service profession" with a base in mainstream agencies' (Joffe 1978, 113). Unlike in Britain, the 'abortion counselor' has thus existed for some time in the U.S. as a category of professional).
As Allen notes (1985, introduction) by 1981 the DHSS had funded 24 abortion counselling training courses in various Health Authorities. The Authorities were asked to evaluate their impact, but apparently the DHSS was subsequently provided with insufficient evidence about this matter. This, together with the development over the same period of time of various training initiatives in counselling for those considering vasectomy, sterilisation, sexual difficulties, and marital problems, led the DHSS to commission a more detailed analysis of what was happening with the provision of counselling in a range of areas.
This resulted in a study led by Isobel Allen, the results of which were published in 1985 by the Policy Studies Institute as Counselling services for sterilisation, vasectomy and termination of pregnancy. It still stands as the largest study conducted about this area of service provision.
Counselling services for sterilisation, vasectomy and termination of pregnancy
This study set out to, 'look at the views and experience of both consumers of the services [sterilisation, vasectomy and TOP] and the professionals engaged in giving counselling'. The research involved, '[I]n- depth interviews in two health authorities, one an industrial city in the north and the other an Outer London Borough, with random samples of professionals engaged in counselling people seeking sterilisation, vasectomy or termination of pregnancy, and with clients who had has these operations'. For TOP, interviews took place with, '231 women (111 from the private sector and 120 NHS patients)….. and 226 professionals involved in the provision of counselling services for abortion, sterilisation and vasectomy'. The questions the study sought to consider included: How many people they [the professionals] saw and how much time they spend on counselling?; Did they see any differences between counselling in connection with unwanted pregnancy, sterilisation or vasectomy, and any other matter where counselling seemed indicated?; What did professionals aim to achieve and how far did they think they achieved these aims……and what did they think were the main reasons for their failure?; [Are] skills transferable between professionals and do they have any training in counselling?; and How should counselling services be provided in the future? Clients were asked about their views of the counselling they had received; how they had come to reach their decision and discussions had with friends and relations; what their views were on what counsellors were trying to achieve and the impact counselling had on their decision-making; and, what they wanted from counselling and the extent to which they considered it necessary (Allen, 1985 introduction).
For terminations of pregnancy, in the summary of findings, Allen reported the following:
'There was clear evidence of a very functional approach by women to the professionals who offered them counselling. Many women thought that abortion should be easier and quicker to get, and that counselling should be available for those who wanted it, but not overdone. It seemed clear that counselling services offered in connection with unwanted pregnancies were not always successful in picking up those in need while avoiding over-counselling those who resented counselling and did not need it' (Allen 1985 p342).
The study also found that three quarters of the women said they had had enough counselling or advice, but ten per cent said they had had too much. Eight per cent said they had not had enough information although they had had enough discussion about their decision, and seven per cent said they had not had enough discussion about their decision. One third only thought it had been necessary to talk to a doctor about their decision whether to have a termination; the majority said they had made their minds up and only needed to see a doctor for agreement to perform the operation or refer. 36 per cent of the woman's said they had not thought it necessary to talk to anyone at all about their decision, which they had made in the light of their circumstances.
The interviews with professionals identified that counselling meant different thing to different groups, and there was 'considerable scepticism about the concept' particularly among doctors; that while counselling in abortion (and the other services considered) was essentially similar to counselling in other contexts, the people involved 'were not ill' and 'had a choice'; some thought it 'more emotional' than other types of counselling, but others disagreed, and some questioned, 'the appropriateness of applying therapeutic techniques of counselling in requests [such as for TOP] which called for quick solutions'. Allen also highlighted, 'considerable disagreement on who were the best people to counsel' and that 'the main aim of professionals was to ensure that people understood the full implications of their action' which for TOP meant that, 'people should be making the right decision for themselves with no pressure from others and the should be able to live with their decision'.
Professionals involved with counselling for TOP, 'found that significant regrets about [TOP] were rare', and some 'stressed that over the years they had become more ready to accept a woman's request for termination of pregnancy' and that 'it was possible to create guilt and misery in people through counselling and that this should be avoided'. Evidence was found of, 'considerable lack of liaison among professionals and considerable ignorance of the counselling being offered by others, both in the private sector and in the NHS'. Professionals 'most involved in counselling', it was reported, 'often said that in the end people had to be responsible for their own actions and that the counsellor should make sure that they were making an 'informed decision' but should not 'impose' counselling when it was neither needed or appreciated' (Allen 1985 p345).
27 recommendations were made by Allen, which included:
- Greater liaison between professionals and less duplication of 'counselling' since 'identification of the actual needs of clients is more important than the provision of more counselling'
- Increasing sensitivity to the needs of women who are ambivalent about their pregnancy
- More attention to be given to identifying women with doubts about their decision at an early stage to give them time to express their feelings and talk about the alternatives in a non-medical setting. This recommendation also related to recognising the need for post-abortion counselling to be available (but that this should not be 'pressed on people, since so many stressed they if they had any regrets afterwards they would prefer to discuss them with family or friends')
- Increasing awareness among professionals of how women regard abortion and of their particular needs for counselling, including encouraging understanding that 'moralising' is disliked and is counterproductive.
Developments in counselling: 1990s and 2000s
Allen's report generated a considerable amount of discussion and attracted media attention on publication. Her findings about 'over counselling' and the 'functional attitude' of women towards encounters with professionals attracted particular attention, and did the observation that there was considerable lack of consensus about what was meant by 'counselling' as a specific activity (Lee 2001, 2003). The recommendations made by Allen were not taken forward in full by the Department of Health, however. There is also no single piece of work that has subsequently evaluated what has changed in this area of service provision since the mid-1980s. Since Allen's study there have been no further large scale studies of counselling provision in abortion, and also no large studies that have considered counselling more widely, as part of reproductive health services. However, the topic of counselling has been a routine feature of research about abortion provision (and research about other areas of related health care provision). From the studies that have been conducted, there is evidence that themes raised by the Lane Committee and by Allen have some continued relevance, but other developments and issues have been raised, and the available evidence indicates that this aspect of abortion provision has developed in important ways.
1. The organisation of services
Although there has been no centrally led review or re-organisation of counselling services for pregnancy and related areas, research first indicates that counselling as part of reproductive health services has continued to evolve in a sector-based way . For example, these years have seen the development and rapid expansion of infertility medicine and assisted conception services, and since the law has required counselling to be provided to those seeking treatment counselling this area have developed in a particular way (Jackson 2001). Other areas of provision have also expanded markedly, for example provision of contraceptive and allied services directed at young people specifically.
An important factor influencing abortion services has been the significant expansion of NHS-funded independent sector provision, and so the emergence of specialist abortion provision on a new scale. Independent sector agencies, primarily British Pregnancy Advisory Service (bpas) and Marie Stopes International (MSI), have taken on increasingly responsibility for providing NHS funded procedures, especially those performed at later gestations of pregnancy (Lee 2005, Lee and Ingham 2010). In turn, counselling has been provided 'in house' as part of the service offered by these agencies.
Differences or commonalities between providers (between independent sector and between units in the NHS) have not been explored or documented in any systematic way. In particular, little has been written in how counselling in provided as part of abortion services in NHS hospitals. However, studies asking women about their experience of abortion reflect well on the independent sector particularly. Accounts emphasise the importance for women of being given clear information about abortion procedures and service arrangements. The other dominant theme is the value women place both on being treated with 'kindliness' and feeling it to be the case that staff genuinely do not consider it wrong or problematic that they are considering/seeking abortion (Harden and Ogden 1999, Lee 2004, Lee et al 2004). (These findings, notably, accord with experiences highlighted by Allen (1985) from her interviews carried out in the early 1980s with women obtaining abortion in what was then termed the 'private sector').
The official approach has been to continue to address abortion service provision specifically (rather than consider counselling across various areas of health care provision) and generate guidelines accordingly. For example, the Department of Health (DH) produced updated Required Standard Operating Principles (RSOPs) in 1999 for termination of pregnancy services specifically, which stated that, 'Counselling must be offered to women who request it or who appear to need help in deciding on the management of pregnancy or who are having difficulty in coping emotionally. Counselling should be offered to women under-16 and to those with a history of psychiatric illness, who lack social or emotional support or who their partner, family or employer is possibly coercing into having an abortion' (Cited in Lee 2003). An expanded form of this guidance appeared in 2001, meaning there is detailed regulation of counselling provision in all abortion units (independent sector and NHS) (DH 2001).
The recent work of the RCOG, in collating evidence and setting standards for care in abortion provision specifically has also been noted (Lee 2003,2004), and this includes the collation of evidence about counselling. The RCOG's guidelines thus discuss the need for clinicians to have accurate knowledge about medical complications associated with abortion, to ensure that discussion with woman can allow for valid consent to be given by them. It also states that all women should be offered the opportunity to discuss their decision with a non-directive counsellor, and/or clinician. It is recommended that additional counselling be made available for women who request it, and that while no woman should be required to discuss continuing the pregnancy or adoption as options, all should have the opportunity to do so.
2. What is counselling?
Research has continued to reflect upon issue of the definition of 'counselling' raised by the Lane Report (1974) and by Allen (1985) (Brien and Fairbairn 1996). Efforts have been made by some to be more precise about what 'counselling' is and what it seeks to achieve as an activity, and indeed whether 'counselling' is the best word to describe some activities that often fall under this rubric. Some commentaries have thus drawn distinctions between on the one hand provision of factual information (increasingly understood as part of the process of obtaining informed consent) and ensuring abortion is chosen by the individual woman and is not the result of pressure from another person (also considered part of consent), and on the other hand assisting with other needs, for example 'decision-making' (considered to involve emotional and psychological aspects, as well as practical aspects associated with looking after a child as opposed to ending the pregnancy). A broad distinction has emerged between the task of ensuring abortion is provided as a result of informed consent, and other purposes of 'counselling'.
Read (1994) discussed four types of counselling in abortion: Information counselling, implications counselling, support counselling and therapeutic counselling. Her book was entitled Counselling for Fertility Problems, indicating she considered there to be a great deal of overlap between abortion provision and assisted conception in regard to women's needs in these areas. A model of the 'aims of counselling' was described by Hunter (1994) as having two distinct components, and she viewed this model as generally applicable to counselling in obstetrics and gynaecology (not just abortion). One aim involves meeting the needs of women, 'for good communication, provision of adequate information, and emotional support' and the other, offering, 'specific kinds of help for those with particular issues, such as women faced with difficult decisions, those who are distressed, or those who need help to clarify problems r come to terms with ill-health' (1994, p50). In a very thorough review of relevant literature by Rowlands (2008), spanning 1967 onwards, attention was drawn to the way thinking had developed in previous decades along these lines. Rowlands detected from his reading of the literature that the term 'counselling' has been (and still is) used widely and in a loose sense, and is frequently used to describe the activity of information provision. He noted, however, that this has been distinguished by some from 'decision counselling', which emerges from the literature as counselling it is 'purer' sense. Noting that while 'hard evidence' for the beneficial effects of such counselling is rare, Rowlands also observes that a general agreement emerges from 1970s onwards that this service, seeking to assist those with difficulties making decision about the outcome of a pregnancy, should be provided.
There has been no disagreement about the proposition that all women presenting for abortion need to be given information about matters including possible medical complications. On this question, a notable aspect of the Lane Report (1974) was the degree to which 'medical complications' appeared to be a relatively settled question. While it was noted that some who opposed the provision of abortion had sought to suggest to the Committee that abortion was a dangerous procedure, the Commissioners noted that most evidence suggested otherwise. It seemed very clear to the Lane Committee that abortion was a relatively safe procedure medically, and that women could be informed this was the case.
This issue, of the 'health risks' of abortion, and the associated claim that information provision should highlight a high degree of risk to physical and mental health if consent is to be deemed 'fully informed' has, however, emerged as heated focus for contest since the mid-1980s (Lee 2003b, Cannold 2002). The issue of the relation between abortion and mental health has become especially hotly contested. While no case was put to the Lane Committee by those opposed to abortion that terminating a pregnancy was associated with significant levels of mental ill health (qualitatively and quantitatively), this issue has subsequently moved to the centre of the case made by those opposed to abortion (Lee 2003b, Cannold 2002). The development of this area of debate has impacted markedly on discussion of post-abortion counselling (not considered here). Additionally it has acted to some extent to re-introduce the problems discussed above of lack of clarity in definition and concepts. Confusion has been encouraged about what is meant by 'counselling', as this term become bound up with debates about what women should be told about the medical effects of abortion. Discussion centring on the concepts 'post abortion syndrome' and 'abortion trauma' have, in particular, blurred the dividing line between information provision and obtaining informed consent, and 'counselling', as advocates of these concepts claim women are insufficiently 'counselled' about the dangers of abortion.
The conceptual distinction discussed above between how abortion providers ensure 'informed consent' (which has its heart the provision of factual information and includes providing information about mental illness) and the provision of 'therapeutic counselling' has been retained, however, in better informed studies and commentaries.
3. Who needs counselling?
As Rowland's review indicates, the question, 'Who needs pregnancy options and pre-abortion counselling?' has attracted considerable interest. On the basis of the distinction above, between obtaining informed consent and other objectives of counselling, this question addresses the need or demand for counselling of a more 'pure' or 'therapeutic' type.
The claim that there is unmet or under-estimated need for counselling of this kind has been pressed by some over the years. Cheetham's (1977) work, drawing on her involvement with the Lane commission, concluded that the need for counselling could be considered to be large, and she argued that distinctions between abortion seeking and other pregnant women should be considered unclear. She suggested instead that 'unwanted pregnancy' covered the experience of probably the majority of women, as it was in her view rarely the case that pregnancy is clearly and unambiguously 'wanted.' Ambivalence' from the perspective becomes the majority experience and can be addressed through counselling.
Later contributions stressing that extent of the need for counselling had been underestimated come from some psychoanalytically oriented feminists (Dana 1987, Walker 1990, Ashurst and Hall 1989) and also by some opposed to abortion (Jarmulowicz 1992, Doherty 1995). While entirely different in regards to their views about the legal status of abortion, both strands of thought considered it to be the case that levels of ambivalence are considerable among women seeking abortion, and that deciding to have an abortion often raises profound psychologically difficult issues of a variety of kinds. Feminist approaches, exemplified by counselling offered by the Women's Therapy Centre during the 1980s and 1990s, viewed therapeutic counselling to be a necessary intervention that enabling feelings surround abortion to be addressed (Dana 1987). Further, it was considered to be the case that of preceded by (and also followed by) therapeutic intervention abortion can be experienced as part of process of psychological maturation and development. Those opposed to abortion have, in contrast, considered it strongly associated with further severe psychological problems, post abortion (these claims are considered here). Some contributions from the 'mainstream' of the counselling profession more recently has echoed the position developed by feminists regarding the importance of therapeutic counselling for all (Brien and Fairbairn 1996, Hodson 2002).
Following Allen (1985), another case has been made by some that extent of need for therapeutic counselling is often overstated, and that more women than is often suggested in public commentaries are certain of their wishes. It is argued that while women find being in the position of needing an abortion distressing and difficult, at the same time many, and even most, find decision making relatively untroubling (Hadley 1997, Boyle 2000). In so far as there is empirical evidence, studies do also seem to indicate a shift over time, with lower proportions of women indicating they perceive they need counselling to assist with decision-making in abortion (Rowlands 2008). It has been noted also that the most usual experience is where women discuss their decision with friends, parents and family members before they approach a medical professional (or abortion provider). The majority 'decision-make' in private rather than medical settings and find this acceptable and appropriate (Kumar et al 2004). This again resonates with Allen's (1985) findings. In so far as a dominant perspective has emerged it is that that which construes counselling as necessarily overtly voluntary for adult women.
While there may be disagreement over the proportion of women needing counselling, there is a high level of agreement, however, that so long as informed consent is given, no requirement should be made that woman discuss their feelings. The notion that therapeutic counselling should be explicitly a voluntary activity that women choose to engage with is uncontroversial, as is the proposition that all women should have option do so and know this is available to them.
4. Who does and who should counsel?
The area that has attracted the least consideration through research since Allen (1985) is the matter of who should provide counselling? As noted above, Allen found a variety of personnel were involved. How this compares to the present in abortion services as a whole, and across reproductive health services more widely, has not been the subject of much research. Multiple demands have been noted namely: for information provision (requiring staff possess detailed knowledge of procedures, evidence regarding medical complications, and legal framework); practical support (requiring knowledge of range of options available for resolution of pregnancy and how systems work in regards to all of them ); and 'therapeutic' support (Rowlands 2008). For abortion, most is known about the approach that has developed in the independent sector, as procedures are uniform across a large number of units, and have been the subject of some research (Harden and Ogden 1999, Lee 2001, 2003, Lee et al 2004). This sector has developed a particular category of staff, the 'admin counsellor' who (together with medical personnel) has responsibility for information provision, and support. In addition, women who need it have access to staff trained and specialist in therapeutic counselling (Lee 2003). In so far as studies have assessed counselling provision in this form, as noted above, they find women report their experiences in very positive terms. In particular, information provision and staff attitudes (kindliness and acting in a manner that reduces women's feelings of anxiety and isolation) feature in women's reports (Harden and Ogden 1999, Lee et al 2004). Research suggests that in NHS units medical social workers have historically counselled abortion seeking women (e.g. Hare and Heywood 1981, and see also comments by Everett, Paterson and Ross). There are no recent studies that provide an overview of and review practice in the NHS, but where studies have reported on counselling in these settings, the same themes emerge as for independent sector provision when women discuss their experience in positive terms (Harden and Ogden 1999, Lee et al 2004).
There are no published studies that provide an overview of the counselling provided by family doctors, although the problem of GPs sometimes being unable to provide correct information, and creating delays when women are trying to access abortion, especially those whose pregnancies are more advanced, has been discussed (Harden and Ogden 1999, Lee et al 2004,2010). The counselling provided by lay counsellors or organisations opposed to abortion has not the been the subject of any focussed research and no data are available about how many women such counsellors counsel, for what reasons, or what women's experience of such counselling is.
- Debate about service reorganisation should take into account existing research
- Care needs to be taken with the definition of purpose when term 'counselling' is used
- Confusion between the process of obtaining informed consent and counselling should be avoided
- Variation in the needs of women needs to be respected and the importance of the process of decision-making in 'private' settings recognised
- Problems of delaying women who know they want to terminate pregnancy, and allowing ambivalent women time to reach a decision that they feel is right, both need to be given due regard
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