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Gillian Levy

Mr. Daly

AP Research

15 November 2020

Literature Review Rough Draft

A Note from the Researcher

The purpose of this project is not to debate the ethics of abortion or to say that abortion is

right or wrong or that one option is better than another; this project is just meant to find the most

helpful information--meaning the information that will provide women with the least decision

difficulty when needing to make the decision of parenting, adoption, or abortion for an

unexpected pregnancy.

Context and Introduction

Millions of women in the United States alone, experience unplanned pregnancies every

year. An article from the Washington Post found that as of 2018 “45 percent of the 6 million

pregnancies in the United States each year [were] unintended” (Weese 2018). While not all of

those women will consider options other than parenting, many women do seek options for an

unplanned pregnancy. There are three main options provided for an unplanned pregnancy--

assuming that women would consider pregnancy a choice. The first of the options is parenting,

meaning that the woman would carry her pregnancy to term (40 weeks) and raise her child.

Another option is adoption, in which the woman would carry her pregnancy to term and

surrender the child to either an adoption agency or a preselected guardian. The last option offered

at some clinics in the United States is abortion, also known as pregnancy termination. Abortion

takes two forms: Medication abortion is offered for women up to 10 weeks of gestation in the
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form of an FDA-approved pill known as mifepristone (“Medical Abortion” 2020) or as a surgical

procedure for up to 24 weeks of gestation.

For all women who get to the point of considering options for an unplanned pregnancy, it

is expected to be a challenging decision to make; but, depending on the clinic a woman chooses

to go to, the decision can increase in difficulty depending on the information provided. Despite

guidelines meant to ensure that women receive medically accurate information about all of their

options for an unplanned pregnancy, some abortion counselors “do not feel obligated to discuss

procedures they feel are immoral, such as abortion” (French et al. 2017). Not providing

information on abortion limits women in their options. Guidelines--such as referring a patient to

another clinic or physician if the abortion counselor has a bias towards an option such as

abortion--are put in place to give women comprehensive information on all of the options they

have (French et al. 2017). Not following these guidelines only further complicates the decision.

But, many clinics give differing information about abortion in abortion counseling sessions.

While research has shown that informed decision making often leads to more decision

confidence, they do not know how information given with an emotional appeal versus

information given with a logical appeal leads to more or less decision difficulty.

Previous Work

While the logical approach is often successful in helping women come to a confident

decision of how to continue in their pregnancy, there is a lack of knowledge on how information

appealing to emotion, aids or contradicts the decision-making process. A study from the

Netherlands attempted to separate the general indecisiveness that surrounds the decision-making

process of abortion from decision conflict. When considering decision conflict, the researchers

asked their subjects the question of “To what extent did you have difficulty when making the
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decision to have an abortion?” (Ditzhuijzen et al 2019) to measure the extent to which patients

felt either ease or conflict during the decision making process. The researchers found a total of

six dimensions to decision difficulty--meaning six different factors that contribute to difficulty

during the decision making experience. The six dimensions were compiled into the Dimensions

of Abortion Decision Difficulty scale (DADD) and eventually narrowed down to four

dimensions: “(1) unrealistic fears about abortion and fantasies about the pregnancy; (2) decision

conflict; (3) negative abortion attitudes; and (4) general indecisiveness” (Ditzhuijzen et al 2019).

While the researchers did not find what aided these four main dimensions of decision difficulty,

their scale provides a starting point for the assumption that women indeed experience difficulty

during their decision-making process that is impacted by external factors such as information.

A systematic review conducted by researchers at the Dartmouth Institute for Health

Policy and Clinical Practice focuses on the effect of information from sources such as libraries,

doctor’s offices, as well as online sources such as Google and the app store as decision aids from

women seeking an abortion. Donnelly et al. (2018) believe that while many tools are available

for women contemplating abortion, many are of low quality or inaccurate and there need to be

new sources to support patients in evaluating their options to ease their decision-making process.

These authors use a mix of a systematic review and environmental scan on the internet to provide

evidence for their evaluation of DAs as well as to make a list of criteria to measure interviews

upon. Additionally, the authors provide explanations for the effects of inaccurate DAs, specialist

made DAs, and non-specialist made DAs on their effectiveness. Donnelly et al. claim that DAs

made by non-specialist or ones found in the environmental study (including Google) had less

accurate content and no development or effectiveness on informing women about abortion. Their

conclusion that inaccurate, non-specialist mead DA often proved to be less effective displays that
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the accuracy of information plays a significant role in the decision-making process of women

considering abortion.

The Royal College of Obstetricians and Gynaecologists in London conducted a study that

focuses on the effects of a control pamphlet versus a specifically designed pamphlet meant to be

used as a decision aid for women seeking options for an unplanned pregnancy. Wong et al.

(2006) believe that decision aids and patient-designed care are important in helping women

come to an easier and more confident decision during abortion counseling. These authors use

information from other organizations, both U.S. and U.K. based such as the Family Planning

Association of the U.K. to provide evidence for their decision and pamphlet design and

information. The pamphlet detailed both the advantages and disadvantages of both pregnancy

termination options (surgical or medical) as well as risks of both options; all information within

the decision aid pamphlet was accurate at the time of the study (2002). Additionally, the authors

provide explanations for the effects the simple control pamphlet had on decision confidence,

knowledge about the procedures, and attitudes about abortions. Wong et al. (2006) claim that

because the decision aid pamphlet included more detailed and accurate information about the

two offered abortion procedures, women felt more confident in their decisions, felt there was less

risk with abortion, and even less decision conflict; this proves that the medically accurate

pamphlet significantly improved the decision making process when deciding between medical or

surgical abortion because women were more informed when making their decision. Furthermore,

the authors do say that there were equal amounts of anxiety between both the control group as

well as the decision aid group; so, while the medically accurate pamphlet may ease the decision-

making process of abortion, it does not however alleviate anxiety. The authors’ conclusion (or

process) is of interest to me in my research on the decision-making process and influences of

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abortion because their study provides information on how information from medically accurate

sources aid women’s decision-making process.

Similarly, Viemmix et al. (2012) believe that decision aids including medically accurate

information have a positive effect on making an informed decision. The researchers conducted a

systematic review of ten articles that present decision aids and the effectiveness of decision

conflict scores according to the decision conflict score (DCS) scale. These authors use studies

from Medline, Embase, and Central that were all assessed for credibility and bias to provide

evidence for their systematic review results of how decision aids impact decision making around

the topic of pregnancy and pregnancy termination. Additionally, the authors provide

explanations for the effects decisional regrets and external opinions regarding abortion

(information from family, Google, or other) had on the effectiveness of the decision aids.

Viemmix et al. (2012) claim decision aids overall improved the decision-making process and

overall knowledge regarding abortion by providing the patient with an increase in information

allowing her to make a more informed decision regarding her pregnancy termination.

Furthermore, the authors recommend that further studies be conducted with a specific focus on

implementing decision aids into the clinical setting as well as identifying possible barriers to

implementation and effectiveness. Barriers would include state regulation, opinions about

abortion, and accuracy of information provided to women at women’s health clinics. The

authors’ conclusion is of interest to me in my research on the decision-making process of

abortion because the decision-making process is often aided by decision aids, but depending on

the design and overall information included in the DAs, their effectiveness varies. In order to

come to a reputable conclusion about effective decision aids, I need to first know what works
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and what does not and this study provides evidence that accurate information is the most

effective decision aid but does not describe the impact of inaccurate information.

Word count: 1429 (unfinished)