Pregnancy Options Counseling Should Reflect Best Evidence on Mental Health Effects

Approximately one in four women will have one or more abortions in their lifetime. As such, options counseling is a routine and integral part of family medicine. An American Family Physician (AFP) article highlighted best practices for pregnancy options counseling, emphasizing that counseling should be nondirective and unbiased and include connecting patients with appropriate services if those services are not available within the practice.

Many patients present to care having already made a decision about how they wish to manage their pregnancy. In a study of more than 5,000 individuals presenting for abortion care at a single US clinic, the majority reported being certain of their decision before their visit. Therefore, family physicians function less often as co–decision-makers but instead as trusted sources of accurate information and facilitators of timely access to care. In practice, options counseling visits commonly involve discussions of medication vs procedural abortion, rather than deliberation about whether to continue a pregnancy.

A Letter to the Editor responding to the AFP article on best practices for pregnancy options counseling raised questions about the mental health effects of abortion. It is essential for family physicians to critically evaluate the quality and methodology of the studies informing our counseling.

Although some studies suggest an association between abortion and adverse mental health outcomes, many are limited by methodological problems, including inappropriate comparison groups and inadequate control for confounding variables. Notably, comparing individuals who have abortions with those who carry pregnancies to term introduces significant bias because these groups differ in fundamental ways that influence both decision-making and mental health.

The Turnaway Study offers a more rigorous approach. This longitudinal cohort study compared individuals who received abortion care with those who were denied care at 30 facilities throughout the United States from 2008 to 2010. Among nearly 1,000 participants, those who were turned away experienced higher levels of anxiety and lower self-esteem, whereas rates of depression were similar between groups. Importantly, individuals who received abortions were no more likely to experience symptoms of posttraumatic stress disorder over the next 4 years than those denied care. Over time, mental health outcomes between the groups converged, with no significant differences observed at 5 years.

Individual experiences, of course, vary. Those who experience negative mental health outcomes after an abortion are more likely to have preexisting mental health conditions or history of trauma. These individuals appear more likely to experience worse outcomes when denied abortion care than when they can access it. This further reinforces the importance of avoiding assumptions and providing patient-centered care.

Major medical organizations, including the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, Society for Maternal-Fetal Medicine, National Academies of Sciences, and American Psychological Association, consistently support nondirective, unbiased counseling. None recommend routine counseling on potential mental health harms of abortion, reflecting the current state of evidence.

As family physicians, we understand that mental health is complex and shaped by a wide range of factors. Patients seeking abortion care—whether they receive it or not—may experience psychological distress related to the circumstances of their pregnancy, structural barriers to care, stigma, or a sense of lost autonomy. Our role is not to amplify unsupported risks but to provide clear, evidence-based information and compassionate support.

In doing so, we uphold the core principles of family medicine: respect for patient autonomy, commitment to scientific integrity, and dedication to meeting patients where they are.

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Dr. Wetterer is an assistant professor of family medicine at the University of Pennsylvania in Philadelphia, where she serves as the Reproductive Health Education in Family Medicine (RHEDI) director for the residency program and is a member of the obstetrics call group.