Methods: Using the PRISMA guidelines, a systematic search of nine databases initially yielded 3,374 articles from peer-reviewed journals. Following titles and abstracts screening, 224 potentially relevant articles were identified and evaluated for inclusion. Articles were eligible for inclusion if they addressed pre-abortion counseling from women's perspectives, analyzed primary data, and were published in English. Articles were excluded if they focused on other types of pregnancy counseling or abortion providers' experiences. From each eligible study, the following data were extracted: location, year, methodology, design, sample, measurements, findings, biases, and ethical considerations. The methodological quality of all studies was thoroughly assessed, and no studies were excluded because of quality concerns. Following this detailed appraisal, 23 articles met the criteria, and a narrative synthesis of their relevant findings was conducted, based on the principles of thematic analysis.
Results: Of the 23 studies that were selected for this review, 11 were quantitative, 11 qualitative, and one used a mixed methodology. Studies were conducted in 8 different countries with diverse socio-legal contexts, and no clear consensus on the definition of pre-abortion counseling. Although studies were highly heterogeneous in terms of counseling characteristics, they presented strikingly similar findings concerning women's certainty: the overwhelming majority of women who sought abortion were certain about their decision to have an abortion prior to counseling. They had concluded the decision-making process before approaching pre-abortion counseling, which often did not change their decision. When counseling was optional, many chose to decline the service altogether because they felt it was unnecessary. Furthermore, when women did receive pre-abortion counseling, they expressed satisfaction from non-judgmental, supportive counselors that de-escalated stigma, normalized their abortion decision, and provided factual, unbiased, and non-directive information. A universal counseling script that was not personalized was less likely to be perceived as helpful. Overall, women wanted pre-abortion counseling to be tailored to their individual needs and circumstances.
Conclusions and Implications: As supported by the findings of this review, pre-abortion counseling should be optional, individualized, and available to those who want it, but must not be imposed on all women who seek abortion care. Treating all women as if they are all ambivalent, emotional, and undecided is unnecessary and unhelpful. Policies that require the provision of universal scripts are not aligned with women's needs. Mandating pre-abortion counseling is yet just another burden on women and abortion providers.