Just days after assuming office, prochoice President Barak Obama laid out his vision for a public policy agenda that would respond constructively to the ongoing national debate over abortion. "While this is a sensitive and often divisive issue," he argued, "no matter what our views, we are united in our determination to prevent unintended pregnancies, reduce the need for abortion, and support women and families in the choices they make." Within weeks, the administration announced an initiative to seek the advice of a wide range of individuals representing a diversity of views on how to move forward on this presumed common ground.

Leading abortion opponents reacted quickly with alarm. Concerned Women for America President Wendy Wright, for one, requested a meeting with the White House, to protest how the administration's initiative was being framed. Calling concepts such as the need for abortion and unintended pregnancy "completely subjective," Wright argued instead for an explicit goal of reducing abortions. "What I think is important is [to] have measurable goals….That's why it's important to look at the number of abortions."

Indeed, the organized antiabortion movement has never thrown its weight behind efforts to address abortion by helping women avoid unintended pregnancies in the first place. On the contrary, most national "profamily" and antiabortion organizations are either actively hostile to or, as in the case of the National Right to Life Committee, resolutely "neutral" on contraception and family planning service programs. Instead, they have worked to eliminate abortion altogether, by trying to ban the procedure outright. Failing that, or as a way of laying the groundwork, they have promoted a wide range of policies aimed at deterring as many women as possible from having an abortion. Many of these policies, at their heart, are premised on the notion that women who intend to have an abortion (and, to some extent, the public at large) do not fully understand what an abortion really is—and that, if they did, they would behave differently. As state Sen. Tony Fulton, sponsor of a legislative proposal in Nebraska to require women to be shown an ultrasound image of the fetus prior to having an abortion, recently argued, "If we can provide information to a mother who is in a desperate situation—information about what she's about to choose; information about the reality inside her womb—then this is going to reduce the number of abortions."

Dissuading Women

The campaign to dissuade women dates back decades. Outside facilities where abortions are performed, protesters for many years have confronted women with pictures of bloody fetuses, while "sidewalk counselors" implore women not to kill their babies. In the realm of public policy, a major initiative of long standing has been to enact mandatory "informed consent" policies; indeed, such policies have been addressed by the Supreme Court on three separate occasions. In its 1983 ruling on an ordinance passed by the city of Akron, Ohio, the Supreme Court struck down a law that required abortion providers to give women a litany of information the Court considered to be "designed not to inform the woman's consent but rather to persuade her to withhold it altogether." Nearly a decade later, however, a differently constituted Court revisited the issue in Planned Parenthood of Southeastern Pennsylvania et. al., v. Casey, and allowed states to provide information under the aegis of informed consent, even if the stated purpose was "to persuade the woman to choose childbirth over abortion." Most recently, in Gonzales v. Carhart, the Court invited states to take a new look at the information women are required to receive prior to an abortion, specifically that regarding a description of "the way in which the fetus will be killed," on the grounds that "a necessary effect of [such a requirement] and the knowledge it conveys will be to encourage some women to carry the infant to full term."

State antiabortion activists widely accepted these judicial invitations. Currently, 33 states have some law or policy requiring the provision of specific information to women prior to having an abortion. According to a 2007 Guttmacher Institute analysis, the information required in 10 of these states generally comports with widely held principles of informed consent: a description of the procedure to be performed and information on the stage of the pregnancy. The laws in the remaining 23 states, however, are designed more to influence rather than inform the woman's decision. These laws, for example, often exaggerate the physical or mental health risks of abortion or include information on either fetal development or abortion procedures irrelevant to the abortions being sought by most women (related article, Fall 2007, page 6).

In 24 states, meanwhile, a "counseling" requirement is combined with a mandatory waiting period, a provision upheld by the Court in Casey on the premise that "important decisions will be more informed and deliberate if they follow some period of reflection." In most states, a woman may receive the mandated counseling information either over the telephone or via the Internet; in seven states, however, the law requires the counseling to be provided in-person at least 24 hours prior to the abortion, a provision that requires the woman to make two separate trips to the abortion facility.

Mandating Ultrasound

In 1985, portions of The Silent Scream, a lurid and medically inaccurate film portraying an ultrasound image of an abortion, were screened at a hearing held by a subcommittee of the Senate Judiciary Committee. The highly emotional narration depicts the image of the fetus as having its "wide mouth open in…the silent scream of a child threatened eminently with extinction." The film then goes on to urge that every woman considering an abortion should view the film before providing her consent.

A decade later, state antiabortion activists began working to have the same type of information as in The Silent Scream included in state-developed mandatory abortion counseling materials, but personalized to each abortion client's own fetus. Beginning in the mid-1990s, 13 states have adopted some provisions relating to ultrasound that stop short of requiring that the procedure be performed. These provisions range from requirements that all women seeking an abortion be given information about ultrasound technology to requirements that abortion providers offer women the opportunity to have the procedure and then view the image.

Some states have gone further by actually mandating that the procedure be performed for at least some women. Beginning with Arizona and Louisiana in 1999, five states currently require providers to perform an ultrasound on at least some women seeking an abortion and then offer them the option to view the image. Finally, in the most extreme example, Oklahoma adopted legislation in 2008 that actually requires not only that an ultrasound be performed prior to every abortion, but also that the physician review the image with the woman; the legislation explicitly mandates that, if she chooses, the woman be permitted to "avert her eyes." Implementation of the Oklahoma measure is enjoined pending legal action, while similar legislation was introduced in Alabama, Indiana, Kentucky, North Carolina, Rhode Island, Texas and Wyoming.

Finally, Colorado-based Focus on the Family in 2005 launched "Option Ultrasound," an initiative to provide ultrasound machines to 650 crisis pregnancy centers across the country, based on their belief that the technology "carr[ies] the potential to save a significant number of lives." As of March 2009, the group claims to have provided 430 grants for ultrasound machinery or training in 49 states.

Unlikely to Succeed

Providing women information specifically geared to dissuading them from having an abortion is a perversion of medical ethics in general and the informed consent process in particular. But no matter how well-worn the tactic, it does not appear to be effective in its purported goal of materially reducing the number of procedures performed. In fact, there is no persuasive evidence that state abortion policies aimed, in one way or another, at talking women out of an abortion stop large numbers of women from having them. At most, there is some indication from the data that erecting substantial, direct roadblocks in the path of women seeing an abortion—such as denying Medicaid subsidies to poor women or requiring women to make two separate trips to a facility to receive in-person counseling, and then wait 24 hours before the abortion—may have that result (see box, page 21).

The reasons women express for deciding to have an abortion, and the way they talk about how they made their decision, make it clear that they carefully consider the realities of their own lives and their ability, at that time, to be the kind of parent they want to be to their current and future children (see chart). For many women having an abortion, the issue of caring for dependents is not an abstract one, but a reflection of their current lives. Among such women, six in 10 are already a parent.

For most women, the decision to end a pregnancy—even a very early pregnancy—is a complex and deliberative one. Moreover, all evidence indicates that women overwhelmingly make a final decision about abortion before they arrive at an abortion facility. Six in 10 women having an abortion say that they consulted with someone, most often their husband or partner, in making their decision. Women typically take 10 days between having a positive pregnancy test and trying to make an appointment for an abortion. And providers report that almost all women obtaining abortions are sure of their decision to terminate their pregnancy before they have even picked up the phone to make an appointment. This kind of carefully considered decision-making is unlikely to be swayed by inaccurate and emotionally laden attempts to persuade them otherwise.

In short, attempting to persuade women who are already pregnant and who do not want to be that they really would prefer to carry their pregnancies to term is an unrealistic way to have a substantial effect on the nation's abortion rate. The primary way to lower levels of abortions is to take aim at the proximate cause, unintended pregnancy. And the most effective ways to do that are to promote consistent use of effective contraception by all sexually active women and men who are not actively seeking pregnancy; support the development of better, more user-friendly contraceptive methods; expand access to family planning counseling and contraceptive services for those who cannot afford them on their own; and ensure that all people are provided the medically accurate, age-appropriate and comprehensive sex education they need to equip them to make and implement responsible decisions about their sexual behavior and their sexual health.