Priscilla K. Coleman, PhD

Bowling Green State University

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Decision-making regarding unplanned pregnancy resolution is, by nature, difficult and highly stressful for a significant percentage of women. Among women considering abortion, a large proportion view it as a moral decision and experience decisional ambivalence and distress. Adaptive, sound reproductive decision-making requires substantive information on each alternative, freedom from pressure or coercion, and time to consider options. Compared to adult decision-making, adolescent decision-making is generally less competent and more impulsive, and this distinction has implications for abortion decision-making. The purpose of this article is to review the scientific literature on decision-making specific to the abortion context in order to underscore the necessity of waiting periods between an initial consult/counseling for an abortion and the procedure. Waiting periods facilitate informed consent and reproductive decision-making that is consonant with women arriving at independent choices consistent with their deepest desires. The psychology of human decision-making is the foundation utilized for the discussion of the more central issues.

 

I.  The Psychology of Decision-Making.

Psychological research reviewed below has revealed the nature of decision-making varies depending on the context, types of decisions, and characteristics of the individuals. An analysis of normative decision-making presented herein reveals the complexity and time-dependent nature of human decision-making processes.

 

In the well-documented Self-Regulation Model of Decision-Making (Byrnes, 1998), there are three phases of decision-making. First, there is the generation phase wherein there are options and/or strategies identified. Second, there is the evaluation phase during which the pros and cons of each option are considered and the best one selected. Third, there is the learning phase involving implementation and evaluation of a decision. Various factors may affect the generation, evaluation, and learning phases, including biases and the level of emotional content. Before an abortion, women are likely in the second phase, which requires time to optimize decisional processes.

           

A wealth of data has revealed that human beings do not always make strategic decisions that are thoughtfully considered. Instead, they make decisions based on biases and other non-rational or intuitive tendencies, notably when sufficient time is not available prior to choosing an option (Starcke & Brand, 2012). For example, neuropsychological decision-making research suggests that decisions made in uncertain situations are guided by past emotional experiences that followed prior decisions. Somatic states (bodily responses associated with previous decisions) are then re-experienced during a current decision and “mark” the available alternatives. These somatic markers or feelings in the body that are associated with emotions experienced while making an earlier decision (e.g., rapid heart rate, sweating, or nausea), essentially act as a starting point that guides the current decision and may limit cognitive processing of options (Damasio, 1996; Starcke & Brand, 2012). In a review of the literature, George and Dane (2016) concluded not only that current emotions can impact decision-making in numerous ways, but also that memories of past emotional experiences and inklings of future emotions permeate the decisions people make.

 

The Dual-Process Theory of Moral Judgment (Greene et al., 2001; Greene et al., 2004; Suter & Hertwig, 2011) has received a great deal of empirical support in recent years and has relevance to abortion decision-making, given the data addressed later clearly suggesting that abortion is a moral decision for many women. According to the theory, there are two neurological systems responsible for moral judgments. The first system involves a conscious, rational evaluation of the facts that produce a utilitarian response (the greatest good to the most possible persons). Actions are evaluated according to the merits of consequences. This system is believed to be activated when there is reduced personal/emotional involvement with the decision-making process. The second system involves affective responses and is the result of being emotionally invested in the situation; in this case, responses tend to be non-utilitarian and less rational. When the latter approach is employed, consequences are not entirely overlooked, but circumstances can arise that require and allow us to take actions that will not necessarily yield the best consequences for all concerned.

 

When a dilemma is personal, alarm-like emotional responses are triggered. In order to reach a rational judgment when faced with a personal dilemma, emotional impulses need to be cognitively controlled. This process takes time and requires the engagement of higher cognitive processes. According to Suter and Hertwig (2011), when cognitive control of the first moral gut response is lacking, the likelihood of an emotional response increases.

 

The Dual Process Theory is supported by functional magnetic resonance imaging (fMRI) data that has identified brain regions associated with both rational processing and emotional processing during moral decision-making tasks (Forbes & Grafman, 2010; Moll et al., 2005; Robertson et al., 2007; Young & Koenigs, 2007). Specifically, there is activation of the prefrontal cortex (PFC), the executive center of the brain, responsible for cognitive processing and decision-making, as well as activation of the inferior parietal lobes, the anterior temporal lobes, and the anterior cingulate gyrus, areas responsible for processing emotions.

 

Theories of decision-making postulate that decision-makers will choose the course of action that is most likely to lead to the outcome best suited to meet their goals, given their values and beliefs. In order to compare all available options effectively based on expected risks and benefits, individuals must be in an appropriate state of mind to receive and assimilate the information adequately. If uncertainty is high, as is often the case with abortion (evidence reviewed below), and the decisional context offers few appropriate cues to make a strategic decision (as when abortion facilities neglect to present all options substantively), then the intuitive–experiential system likely plays a more prominent role compared to the rational–analytical system. The intuitive-experiential system is typically fast and uses gut feelings and experiences, whereas the rational-analytical system is slower and employs reason and deliberation. In order for women to make fully informed, well-thought-out decisions, not made too rapidly under stress, they need accurate information, time, and sensitivity.

 

Decades of research have shown acute stress influences cognition, with mounting evidence indicating stress biases decision-making in particular (Galvin & Rahdar, 2013). Early work on this topic showed that stressors result in decision-making that is hurried, unsystematic, and lacking full consideration of options (Galvin & Rahdar, 2013). Further, experimental studies have shown that stress potentially exacerbates biases in decision-making by inducing more conservative choices for those who are generally risk-averse and riskier choices for those who tend to be risk-seekers (Porcelli & Delgado, 2009).

 

Decisions made while individuals are experiencing stress and uncertainty tend to be fast, and effortless heuristics dominate over slow, demanding deliberation in making decisions. Stress elicits a switch from an analytic reasoning system to intuitive processes associated with diminished activity in the prefrontal executive control regions of the brain and exaggerated activity in subcortical reactive emotion-based areas (Yu, 2016). Moreover, studies have shown that when stressed, individuals tend to make more habitual responses than goal-directed choices, are less likely to adjust their initial judgment, and rely more on gut feelings (Yu. 2016). Stress influences individuals' ability to use higher-order strategic thinking. In an assessment designed to measure the depth of reasoning, participants under stress used less strategizing (Leder, et al., 2013).

 

Stress triggers cardiovascular, hormonal, and neural reactions that may affect fine-tuned decision-making. This appears to be detrimental in situations that require risk avoidance, strategy use, or the reliance on higher-level systems in general (Starcke & Brand, 2012). Stress-induced changes specifically involve physiological and endocrine reactions that, in turn, impact brain regions associated with decision-making. Specific regions of the brain known to underlie decision-making, including the prefrontal, limbic, and basal ganglial regions, have numerous receptors for stress hormones (Starcke & Brand, 2012).

 

In the next sections of this article, decisions specific to the abortion context are described in detail, focusing on the moral nature of abortion decisions and informed consent initially. Next, abortion-decisional stress, ambivalence, coercion, and an elevated risk for post-abortion negative psychological consequences are the focus. Finally, abortion-decisions by adolescents are covered.

 

II.  The Nature of Abortion Decisions, Informed Consent, and Averting Adverse Consequences

Abortion is distinct among all medical procedures because it involves a woman and the demise of her biologically distinct offspring. A developing fetus, whether viewed as an actual life or as a potential life, is purposefully exterminated through the act of abortion. Women generally understand that abortion is different from other procedures. For many women, the choice to abort is relational, as others are likely implicated by the decision, moral, religious, and/or ethical. Arrival at the decision to abort thus is naturally connected with personal belief systems. As described below, the idea of the fetus possessing at least some degree of personhood, with a concomitant moral objection to the procedure, is a commonly held belief.

 

Smetana (1981) first identified several profiles of women based on their reasoning about an abortion decision. The most common types are described below and indicate that for a significant percentage of women, abortion is not devoid of moral content. Moral Reasoners are women for whom justice concerning two human lives is salient during the pregnancy. The genetic or spiritual potential of the embryo at conception is considered and viewed as sufficient to these women for defining human life. They are concerned with justifications (or lack thereof) for taking a life. Personal Reasoners are women for whom personal issues are most dominant in pregnancy. These women consider the criterion of physical and/or emotional independence from the mother (occurring at birth) as the most relevant feature to assigning human life. The unborn child is viewed as a physical/emotional extension of the woman during the pregnancy, and judgments focus on the woman's control over her reproductive life. Coordinated Personal/Moral Reasoners are women who consider abortion a personal issue first and then a moral issue. After the point at which these women believe human life begins, abortion is considered a justice issue similar to other issues of life. Uncoordinated Reasoners incorporates women whose thinking about abortion lacks coordination between the personal and moral domains in various ways. First, some women treat abortion as a personal issue until viability and then experience conflict between personal and moral issues. Second, some women report personal and moral conflicts across the pregnancy. Finally, some women respond with equivocation and confusion, with no clear definition of life evident.

 

The prevalent mode of response in Smetana’s study was to consider abortion a personal issue (35% of the subjects), but substantial portions of the sample engaged in moral reasoning about abortion (25%), or coordinated the two domains (24%). Nearly half of women, in other words, viewed abortion as having moral content. Smetana (1981) found that 25% of women facing an abortion decision considered the fetus to be human and regarded abortion as the taking of life. Allanson and Astbury (1995) reported that 25% of women seeking an abortion agreed with the statement “abortion is against my beliefs.” When women undergoing abortions were asked by Kero and colleagues (2001), whether thoughts of terminating the pregnancy caused any conflict of conscience, nearly half (46%) of the women answered in the affirmative.

           

Many women have abortions despite moral opposition to the procedure (Allanson & Astbury, 1995; Kero & Laos, 2000; Smetana, 1981). Leading professional associations and abortion providers contend that women's personal values should be adequately addressed within the decision-making process (ACOG, 2004; Baker et al., 2009; NAF, 2018). Kero, Hogberg, and Lalos (2004) found that 30% of women facing an abortion reported feeling guilty. The results of a major national poll by the Los Angeles Times revealed that 56% of women who had an abortion experienced a sense of guilt (Skelton, 1989). If a woman doubts her decision to abort, and she believes it is morally wrong, she is likely to experience feelings of guilt after the abortion. Research conducted by Patterson, Hill, and Maloy (1995) revealed many women who were morally opposed to abortion decided to abort despite their personal views of abortion in order to appease others or because they were unable to see how they would be able to raise a child due to other life circumstances. This incongruence between women's beliefs and behavior is likely to engender guilt feelings.

           

In an analysis of qualitative data, Hess (2004) reported that many women who have experienced an abortion in the distant past felt as though they had been on an emotional roller coaster for decades and found themselves frequently thinking about their abortions and the children they never delivered. In a study by Coleman and Nelson (1998), 73% of college women who had an abortion reported having thoughts about what the child would have been like.

           

In a Florida-based study by Brown and colleagues (1993), the most frequently reported long-term sequela of abortion, particularly among those who had been coerced to abort, was a prolonged feeling of guilt. Fantasies involving the aborted fetus were the second most frequently mentioned long-term experience. Half of the participants referred to their abortions as "murder," and 44% voiced regret about their decision to abort. Other long-term effects included depression (44%), feelings of loss (31%), shame (27%), and phobic responses to infants (13%). For 42% of these women, the adverse psychological effects of abortion endured over ten years.

           

Over the past several decades, the number of peer-reviewed studies identifying adverse mental health outcomes associated with abortion have increased dramatically, as has the scientific rigor of research on this topic. The literature base, comprised of hundreds of studies, has revealed women, who choose abortion experience increased risk of mental health problems, including substance abuse, anxiety, depression, suicidal ideation, and suicide, among other conditions and symptoms (e.g., Bradshaw & Slade, 2003; Coleman et al., 2002a, 2002b; Coleman, 2005, 2006; Cougle et al., 2003, 2005; Dingle, 2008; Fergusson et al., 2006, 2008; Gissler et al., 2005; 2015; Mccarthy, 2015; Mota et al., 2010; Pedersen, 2007, 2008; Rees &Sabia, 2007; Sullins, 2016).

           

In a 2013 narrative review of the literature published between 1995 and 2011, incorporating 30 peer-reviewed journal articles by Italian researchers Bellieni and Buonocore, the authors concluded that abortion is a risk factor for mental illness when compared to childbirth. In 2011, Coleman published a meta-analysis titled “Abortion and Mental Health: A Quantitative Synthesis and Analysis of Research Published from 1995-2009” in the British Journal of Psychiatry. This review offers the largest quantitative estimate of mental health risks associated with abortion available in the world. After applying methodologically-based selection criteria and extraction rules to minimize bias, the sample consisted of 22 studies, 36 measures of effect, and 877,297 participants (163,880 of whom experienced an abortion). Results revealed that women who aborted compared to women who had not experienced an 81% increased risk for mental health problems. When compared specifically to unintended pregnancies delivered, abortions were associated with a 55% increased risk of mental health problems. Separate effects were calculated based on the type of mental health outcome, with the results revealing the following increased risks: anxiety disorders 34%; depression 37%; alcohol use/abuse 110%; marijuana use/abuse 220%; and suicide behaviors 155%. Calculation of a composite Population Attributable Risk (PAR) statistic revealed that nearly 10% of the incidence of mental health problems was directly attributable to abortion.

           

The scientific evidence linking abortion to increased rates of mental health problems is published in leading peer-reviewed journals in psychology and medicine. There are now dozens of large-scale prospective studies with 1000's of participants incorporating different types of comparison groups and other control techniques, effectively fortifying the level of confidence in the results derived. Potentially confounding variables, controlled in the various studies, include prior mental health, reproductive history, the experience of abuse of various forms, and several demographic variables, thereby increasing the reliability and validity of the findings.

 

III.  Abortion-Related Stress, Decisional Ambivalence, and Coercion

Due to the stress and complexity involved in the prospect of an abortion, as indicated by the evidence described in this article, decision-making is likely to require more time in order to avoid lapsing into more affective, less thoroughly reasoned decisions that result in suboptimal outcomes. Stress is typically defined as a subjective response to a perceived psychological, emotional, or physical threat. Abortion is well-established as a potentially significant stressor in the lives of those who consider and experience it (Adler et al., 1990; Bradshaw & Slade, 2003; Coleman, 2011; Kero et al., 2001; Major et. al, 1992; Soderberg et al., 1998; Zolese & Blacker, 1992), with significant proportions of women reporting decisional conflict before an abortion. Decisional conflict is defined as a state of uncertainty about the preferred course of action (O'Connor et al., 2003), and it often occurs when choices involve risk or uncertainty of outcomes, high stakes in terms of potential gains and losses, and anticipated regret over the positive aspects of the rejected options (Hunter et al., 2005; O’Connor et al., 2003).

           

Decisional conflict and ambivalence, leading to abortion-related decisional distress, are very commonly reported experiences of women presenting for abortion. Husfeldt and colleagues (1995) reported that 44% of women surveyed had doubts about their decision to abort prior to an appointment for an abortion, with 30% continuing to express doubts when the abortion date arrived. According to Kero, Hogberg, and Lalos (2004), 20.6% of 58 women sampled several months after an abortion said the decision to abort was difficult and entailed much conflict. Rocca and colleagues (2015) reported that 53% of women seeking abortions described the decision as difficult or very difficult. Similarly, Tornbom and colleagues (1999) found that more than half of the women who chose abortion said it was difficult or very difficult to make the decision. Kjelsvik and Gjengedal (2011) reported that studies show that 25–30% experience ambivalence and find the decision difficult to make.

           

Substantive interviews by Kimport (2012) illustrate the fact that women often express ambivalence before having an abortion. One participant, already a single mother, who aborted, was described as a college graduate, upwardly mobile, with high expectations on her from her mother. In her own words, she states:

 

I was preparing—like just so I could make a sound decision—I mean, somebody might call it weird, but I was actually preparing for an abortion, but I was also preparing as if I was having a baby. So I would, I would—I made [prenatal] appointments and stuff like that with the doctor to actually go see and make sure the health of the baby was fine, and I was smoking, and I stopped smoking. So I was, I was really, a small part of me, and it was a small part of me, but it was a part of me that wanted to have this baby. Like, I really wanted to have a baby. (p. 115).

 

The story of a married woman, who had experience with infertility and felt that her pregnancy was a miracle is also described. She told the researcher: “ [I was] just feeling really like my head was telling me that the wise decision was to have an abortion but then my heart was just wanting to hold onto this baby and, you know, just not, you know, just feeling like it was some kind of hopeful opportunity… I would have the feeling when I was by myself and thinking about it that I definitely wanted to keep it.” (p. 115).  However, she reported that when thinking through the situation with others, including her husband, “[those conversations] just made it seem like it wasn’t really the best decision, you know, to keep the baby.” (p.115). The researchers described this woman’s decision to have the abortion as wrenching after spending five weeks trying to decide. Her ambivalence was evident right up to the procedure, as she told the interviewer about her vivid dream with a baby the night before her scheduled abortion.

           

Allanson and Astbury (1996) reported some startling statistics conveying women's ambivalence before having a first-trimester abortion. Below are percentages of women who endorsed statements conveying a connection with the fetus and ambivalence regarding abortion, with "quite" or "very" like me:

 

“I've thought or daydreamed about (if I were to continue the pregnancy) whether I'd have a boy or girl” (50%)

           

“I've talked to the pregnancy in my mind or out loud” (40%)

           

“I've patted my tummy affectionately” (30%)

           

“I've imagined coming into some money so that I can continue the pregnancy” (30%);

           

“I've made plans in my head to continue the pregnancy” (25%).

           

Kjelsvik and Gjengedal (2010) captured a key component of abortion decision ambivalence, wherein many women intellectually divorce themselves from the powerful experience of their bodies transforming.

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The informants described mixed feelings at the confirmation of the pregnancy. They felt happy about being pregnant as well as despair, worry, and anger at themselves … All informants stated that they protected the pregnant body by making choices in accordance with the knowledge they gained. They started taking vitamins and avoided or reduced the use of alcohol, cigarettes, and painkillers. Some expressed surprise at the desire they felt to protect the foetus parallel with contemplating terminating the pregnancy. Despite attempting not to take in that she was pregnant, she said she made choices for the sake of the foetus … One woman said she attempted to keep a distance by thinking of it as being no more than a birthmark. When she had decided to complete the pregnancy, she started using words such as life and baby. One woman described the bodily experience of being pregnant as enhancing the wish to complete the pregnancy: I feel that when I was about to make the decision to keep it, it was because I felt it so strongly in my body. (p. 172)

           

The participants revealed evidence of trying to make the choice to abort tolerable by suppressing real or deeper feelings. Ultimately, half of the women interviewed by Kjelsvik and Gjengedal decided to abort and half chose to carry to term. The authors of the study end by recommending that a considerate nurse, “give time and room for reflection. Room where the ambivalent woman may remain long enough to shed light upon the situation and evaluate alternatives for action and consequences. Løgstrup describes this as to free the other person from his or her confinement and to give his or her vision the widest possible horizon” (p. 175).

           

A significant percentage of women planning to undergo an abortion report experiencing decisional uncertainty upon arrival at the abortion clinic, demonstrating that many women are likely to need more information, compassionate counseling, and time to arrive at a comfortable decision. For example, among women who had abortions, 24% of women in a study by Kero, Hogberg, and Lalos (2004) indicated that they could have been persuaded to change their minds. Similarly, in a study by Kero and colleagues (2001), 32% said it may have been possible to change their minds. Eight percent of the women in the Kero et al. study received the abortion "more or less against their own will," and more than half of the women (52%) stated that their present partner wanted them to have an abortion. Without sufficient information, time to make a thoughtful decision, and adequate support to pursue an alternative to abortion, many women are likely undergoing abortions they would have preferred to avoid.

           

In a study conducted in Utah, where there is a 72-hour waiting period in effect, data by Roberts and colleagues (2016) revealed that 8% of women changed their minds regarding pursuing an abortion between the initial visit and the date of the procedure. Data from other countries corroborate studies in the United States. For example, in Norway, the number of annual requests for abortions is 14,000 and as reported by Lokeland and colleagues (2018), as cited in Kjelsvik et al. (2018), nearly 10% of these requests are withdrawn before performance of the abortion, but after the woman has been prepared for surgery at the gynecology unit.

           

A study conducted by Vandamme and colleagues (2013) of women requesting an abortion at one of the five Flemish abortion centers in Flanders revealed the specific nature of the information women seeking abortions desire at clinics. It underscored the fact that interest in substantive counseling prior to deciding to abort is normal, not exceptional. The data from nearly 1000 participants yielded the following percentages of women who desired counseling on various topics:

 

• 82% information about the procedure

• 40% decisions and doubts

• 31% their emotions

• 36% reasons for the abortion request

• 76% information about the consequences of abortion

• 16% the role of others in urging the woman to pursue the abortion

• 31% alternatives to abortion

• 18% learn the experiences of others

• 8% feelings of guilt

• 7% religious aspects of abortion.

           

After counseling, women evaluated the sessions as extremely positive; they were very satisfied, experienced less distress and greater decisiveness, and they found the counseling to be more helpful than they anticipated it would be. These data directly support the notion that women arriving at abortion facilities are not necessarily sure about their decisions to abort and that they desire specific forms of information in order to make decisions regarding going forward with an abortion.

           

Women arrive at abortion clinics with varying abilities to understand and process information, decisional uncertainty, pressures from others and circumstances, and other risk- factors for experiencing adverse post-abortion psychological responses. Abortion decisions are not voluntary and informed until women meet with a provider who conveys relevant medical information that the women thoroughly understand.

           

Informed consent stipulates that medical decisions are made knowingly, competently, and voluntarily. According to the American Medical Association (AMA) Code of Ethics: In seeking a patient’s informed consent, physicians should: (a) Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision; (b) Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information. The physician should include information about: (i) the diagnosis, (ii) the nature and purpose of recommended interventions; (iii) the burdens, risks, and expected benefits of all options, including forgoing treatment." https://www.ama-assn.org/delivering-care/ama-code-medical-ethics.

           

The relationship context of abortion is complex, comprised of intimate partners, family members including parents and children, friends, and all others whose behavior and attitudes (before, during, and after the abortion) potentially impact the woman's choices, behavior, and emotional health prior to the pregnancy, while contemplating an abortion, and in the months and years after an abortion. With so many individuals likely to play a role in influencing women's decisions, abortion providers need to determine definitively that women who consent to undergo an abortion have not been pressured or coerced by others into a decision they would not have otherwise made and are likely to regret. In a review of literature related to pre-abortion counseling, Joffe (2013) recommended that clinic personnel ascertain whether anyone is influencing a woman’s decision to abort. In order for an abortion decision to meet the AMA requirements of informed consent outlined above, the decision must be voluntary and completely free from pressure or coercion.

           

There is extensive research revealing the fact that abortion is often not freely chosen, but is instead the result of pressure of varying degrees from close family, friends, or abortion clinic personnel, violating one of the basic dictates of informed consent. Kimport, Foster, and Weitz (2011) described partner pressure to abort experienced by a participant in their study: “Melissa wanted the opportunity to decide to have the baby. Without that opportunity (due to partner pressure to abort), having an abortion did not feel like a choice. Her relationship ended soon after the abortion, and Melissa continues to feel distressed by the experience.” (p.103). Harvey-Knowles (2012) reported that 31% of women made their pregnancy outcome decision based on persuasive messages from others.

           

In a study published by van Ditzhuijzen and colleagues (2015), the data revealed that 17.6% of women with a pre-existing psychiatric history experienced pressure to abort. As indicated in the next section of this report, women with pre-existing mental health problems are already a highly vulnerable population relative to experiencing adverse psychological consequences of abortion. Women seeking an abortion have higher than average rates of pre-existing mental illness that can interfere with effective decision-making. Van Ditzhuijzen and colleagues (2013) found that compared to a reference sample, women who had an abortion were three times more likely to report a pre-abortion history of any mental disorder, nearly five times more likely to experience drug dependence, and over four times more likely to report alcohol dependence. Several studies have linked mental illness with poor decision-making. As noted by Cáceda, Nemeroff, and Harvey (2014, p. 208), mental illness impairs one’s “ability to make functional and healthy decisions. This impairment may be related to disorganization or global deficits in attention, working memory, and language, such as those observed in schizophrenia and bipolar disorder. However, it can be subtler and lead to abnormal risk assessment or reward processing as found in depression.” Decisions during depressed states are often tainted by negative affect and distorted negative cognitions (Martin-Soelch, 2009). In several anxiety disorders including Generalized Anxiety Disorder, Posttraumatic Stress Disorder, Social and Specific Phobias, and Obsessive-Compulsive Disorder, amygdala hyper-responsivity heightens the cognitive and affective responses to potential threats resulting in everyday decisions revolving around avoiding exaggerated perceived threats and reduced ability to function adaptively (Cisler & Koster, 2010).

           

In addition to the evidence reviewed above pertaining to abortion decisional ambivalence, distress, and coercion, available data has revealed that a significant percentage of women regret abortion decisions, further indicating the need for time and sensitive, individualized counseling to help women make decisions that can live with and not regret. In order to experience regret, a person must compare an actual outcome with an outcome foregone. Pieters and Zeelenberg (2005) found that not only can people regret bad outcomes, but they can also regret the process of poor decision-making. According to Ritov and Baron (1995), the phenomenon of "omission bias" refers to when the outcome of a decision is negative, people believe that the decision was worse if it was a consequence of an action rather than inaction (or omission). Ritov and Baron suggest that people are inclined to feel more regret over actions versus inactions that lead to negative consequences because acts are viewed more causally than omissions. The decision to abort is, by nature, an action of the sort likely to prompt "omission bias" regret.

           

As the crisis of the pregnancy and the pressure to make the decision have passed, and women have had time to process an abortion, those morally opposed to it may begin to believe their reasons for terminating the pregnancy (e.g., in order to stay in school, save money, please a partner, etc.) were insufficient justification for terminating a human life. In a study by Keros, Hoeberg, and Lalos (2004) in which women were asked to choose words expressing their feelings about an abortion when facing the procedure and one year later, only 11% selected “injustice,” at the time of the procedure, but 24% chose the word one year after the abortion.

           

The decision to abort is obviously often conflict-ridden, with many women seriously questioning their decision and suffering from their choice to abort. In a study by Coleman and Nelson (1998), 38.7% of female college students voiced regret in the first few years following an abortion. Moreover, the results of a study by Soderberg and colleagues (1998) indicated that 76.1% of women who had a past abortion would never consider repeating the experience.

 

IV.   Adolescent Decision-Making

In a review by Galvin and Rahdar (2013), the examined studies provided compelling evidence that adolescence is a time of risky decision-making. According to research conducted by Halpern-Felsher and Cauffman (2001), adolescents’ and adults’ decision-making competence differs, with adults generally outperforming adolescents. Specifically, compared to adolescents, adults are more likely to consider risks and benefits associated with decisions and seek decisional advice from more knowledgeable others. Epidemiological and empirical studies demonstrate that risky decision-making peaks during adolescence, and the impact of stress on decision-making may be particularly harmful during adolescence. (Galvin & Rahdar, 2013). Adolescents' brains work differently than adults when they make decisions because, at this stage of development, the emotionally reactive amygdala is more active in decisional processes than the logical frontal cortex, which is more fully developed and dominant in adult decision-making (American Academy of Child and Adolescent Psychiatry, 2016). Given the above evidence, adolescents are apparently prone to making impulsive decisions, which implies that additional time and adult support through the decision-making process are likely to lead minors toward formulating well-reasoned pregnancy decisions.

           

As noted in a review by Manian (2016), scientific research supports two notions: 1) adolescents are more advanced in their reasoning abilities than younger children, and 2) they are less advanced than adults in the quality of their decision-making. Adolescents specifically differ from adults in attitude toward risk, impulsiveness, more weight attached to short-term as opposed to long-term consequences, and in the perception of importance attached to personal appearance and peer influence. Further, according to Manian, research also indicates that, when guided by caring and competent adults, adolescents are able to formulate critical decisions for themselves and their children. (p. 204).

           

In a recently published large scale study by Ralph and colleagues (2018), prior to implementation of the Illinois parent notification law, 23% of minors were uncertain of their decision, and 29% were uncertain after the law when into effect. The percentage of uncertain young adults was stable at 18% pre and post institution of the law. Foster et al. (2012) reported that 13% of women were unsure about their decisions to terminate upon arrival at an abortion clinic. These figures are consistent with data described by Kjelsvik and colleagues (2018). The Norwegian research team noted: “Health personnel working at abortion clinics in the United States and the United Kingdom have reported that it is not a matter of course for a women’s decision to be absolute when she arrives at the clinic. Health personnel have learned that the decision to terminate a pregnancy might be challenging and that some women may change their minds.” (p. 4193).

           

Adolescent decision-making is also highly susceptible to the influence of others. Ralph, Gould, Baker, Foster (2014) analyzed data from 476 minors seeking abortion in San Francisco in 2008. They reported that 10% of the women seeking abortion care because someone wanted them to, with the largest percentage reporting pressure from their mothers (57%) followed by partners (32%), "everybody' (7%), and another family member (6%). Among the minors sampled, 31% reported thinking abortion was akin to killing a baby that is already born; 49% had spiritual concerns, and 24% voiced concern regarding God's forgiveness. These authors stated: "The fact that some young women have some negative feelings about abortion, yet are still presenting for abortion, is common and suggests that pre- and/or post-abortion counseling for young women may help ensure that they can discuss these feelings, carefully consider their options, and receive necessary post-abortion support referrals.” (p. 432)

 

Conclusion

Opponents of waiting period laws often argue that such regulations reveal a deep mistrust of women’s abilities to make informed and responsible judgments. The above data establishing that large percentages of women want information upon arrival at an abortion clinic, and desire counseling in order to arrive at a comfortable decision contradicts this opinion. As illustrated above, the abortion decision is not a simple one for most women. Opponents of waiting periods also often dispute the notion that many women have not made up their minds to abort prior to arrival at abortion clinics. Available data pertaining to decisional uncertainty generally described earlier contradicts this view. Moreover, studies explicitly examining decisional uncertainty in the context of waiting periods provide a direct challenge of the view that women arrive at abortion facilities completely sure of their decision. For example, Roberts and colleagues (2016) employed data related to Utah’s 72-hour waiting period for abortion and reported that 29% of the patients did not report low levels of decisional conflict upon arrival. Moreover, in a study by Ralph and colleagues (2017) also incorporating the Utah data, the results in response to the item: “This decision is easy for me to make” revealed less than half of women (34%) strongly agreed with the statement prior to the waiting period.

           

The above data describing the nature of abortion decision-making and establishing that large percentages of women want information upon arrival at abortion clinics and desire counseling in order to arrive at a comfortable decision underscore the central role of abortion waiting period laws in serving the needs of women. As of April 1, 2020, the Guttmacher Institute reported 34 states in the U.S. require women to receive counseling before undergoing an abortion and 27 of these states require women to wait a specified amount of time between the counseling and the abortion procedure (18 to 72 hours, with the majority requiring 24 hours). Currently, 14 states further require in-person counseling. As explained in detail above, with reliance on supportive empirical data, the merits of laws requiring women to wait for an abortion until a certain amount of time has elapsed is clearly evidence-based, and the waiting period laws are essential to upholding the core principals of informed consent.  

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