How patients view mandatory waiting periods for abortion.
In recent years, various legislatures have enacted laws and ordinances mandating a waiting period for women seeking to obtain abortions. Legal challenges to such statutes have been successful, except in one instance (Akron, Ohio), and a federal judge in Tennessee recently struck down a waiting period statute.
As part of the appeal against the Tennessee law, two surveys were made of some 400 women who experienced such a delay to probe their opinions about the benefits and drawbacks of the mandated waiting period. More than seven in 10 women were unable to name a single benefit to be derived from waiting, and six in 10 pointed to one or more problems they had experienced, including extra expense, missed work or school, experiencing some discomfort and entering the second trimester of pregnancy, among others. About $7,600 in extra expenses were incurred by about 200 of the women (with a median of $24 per woman), adding about 48 percent to the costs for the typical low-income woman and 14 percent for the typical higher income woman. The cost of the second visit increased in direct proportion to the distance a woman lived from the family planning clinic and to the number of hours she was employed per week. The typical woman was found to hold a negative view of the statute. Women who were surveyed before and after the waiting period said that they actually realized fewer benefits and experienced more problems from the waiting period than they had anticipated.
Laws requiring waiting periods have been overturned or enjoined in Illinois, Louisiana, Maine, Massachusetts, Missouri, Nebraska, North Dakota and Rhode Island. (1) There have been conflicting opinions in Kentucky about the constitutionality of waiting periods. In 1976, the U.S. Court of Appeals for the Sixth Circuit upheld the constitutionality of a 24-hour waiting period imposed by a 1974 Kentucky law. (2) In December 1980, however, a federal district court struck down that law. In doing so, the district court pointed out that unlike the plaintiffs in the case being heard, the plaintiffs in the earlier sixth circuit case did not present any evidence that the waiting period "would, in effect, impose increased health risks or increased financial burdens upon pregnant women seeking an abortion." (3) A waiting period requirement has been upheld in Akron, Ohio, and is being appealed; a similar law had been in effect in Tennessee, (4) but was struck down on March 23 by the federal court in which the case had been pending. (5) The court held that the waiting period imposed an undue burden on the women.
The Tennessee statute, originally adopted in March 1978, required that a woman seeking an abortion, after being examined by her physician and informed of the "benefits and risks... attendant either to continued pregnancy and childbirth or to abortion," (6) must wait at least two days before having an abortion. The penalty for ignoring the waiting period was one to three years' imprisonment of the physician who performed the abortion.
Efforts to challenge the Tennessee law began as soon as it went into effect in September 1979; although the issue has been resolved in that state, the effort to impose mandatory waiting periods may continue in other jurisdictions. One aspect of the Tennessee case is, therefore, of special interest. Attorneys for the plaintiffs, reviewing similar cases elsewhere, noted that no attempt had been made to evaluate systematically and empirically the impact of the law, i.e., to gauge the effect of the mandatory waiting period on women seeking abortion. We were commissioned to assess the law's impact, by conducting two surveys of women who were candidates for abortions at clinics in Memphis and Knoxville from October 1979 through January 1980. (*)
The surveys were designed to measure the benefits and costs of the waiting period for abortion candidates: What benefits did the women believe they derived by waiting? What problems did the waiting period create for them? What costs, if any, did they incur by having to return to the clinic a second time? In addition, we wanted to determine whether the women favored or opposed the required waiting period.
The first survey focused on women who had already completed the waiting period. The second survey, identical in content to the first, questioned women both before and after the waiting period, to determine whether any appreciable change in outlook had occurred as a result of waiting.
Respondents and interviews
A total of 332 women constituted the sample in the first survey.(*) They were randomly drawn from among abortion candidates at three clinics in Memphis and Knoxville, in numbers reflecting the proportionate volume of patients treated at the three centers. All of the women were interviewed during October-December 1979; prior to the interview, they all had received counseling, had been examined by a physician, had completed the mandatory wait and had signed the necessary consent forms for abortion.
Goodness-of-fit tests indicated that the sample was comparable to the population of Tennessee's women who have obtained abortions in terms of age, but contained 10 percent more nonwhites. In addition, the sample consisted entirely of women seeking abortions at outpatient, freestanding clinics, whereas only 88 percent of all abortion patients in Tennessee have obtained the procedure at such clinics; the remainder did so at hospitals or physicians' offices.(7)
Ninety-four women, all of whom were patients at the Memphis Association for Planned Parenthood's abortion clinic, were asked to participate in the second survey, conducted during the period January 12-24, 1980. All had already received abortion counseling and undergone laboratory tests, and were awaiting medical examinations, prior to the waiting period. Four of the 94 indicated uncertainty about proceeding with the abortion; to avoid any possibility that the interview itself might influence their decision, these women were not interviewed. The other 90 women completed the interview prior to the waiting period, and 73 of them, upon returning to the clinic after the waiting period, were reinterviewed.(+)
In the first survey, 69 percent of the respondents were white; 32 percent were teenagers and 40 percent were aged 20-25; 55 percent had no children and 26 percent had one; 62 percent were employed; 33 percent were students; 52 percent lived in the city where the clinic was located; 55 percent were interviewed at the Memphis Association for Planned Parenthood. In the second survey, the proportion of whites was slightly lower (60 percent); the proportion with no children, slightly higher (62 percent); and all the respondents were interviewed at the Memphis Association for Planned Parenthood.
All interviews for the first survey were conducted by counselors employed at the three clinics. These counselors, all of whom had a great deal of interviewing experience, were given instructions which stressed the importance of maintaining complete neutrality. They were admonished neither to express their own views nor to comment on the respondents' views. In addition, the counselors' interviews were spot-checked by their supervisors to assure reliability. The project directors monitored the recorded interviews to check for accuracy and completeness. As a result of this scrutiny, 51 of the original 383 interviews in the first survey were discarded as incomplete or possibly unreliable, reducing the final sample to 332 interviews.
The majority of the interviews for the second survey were conducted by a graduate student in psychology, and full-time counselors at the Memphis Association for Planned Parenthood conducted the remainder. Once again, all interviewers were given thorough instructions for conducting the interviews. None of the abortion candidates was interviewed by the same individual who had served as her abortion counselor.
Three drafts of the interview schedule were tested before the schedule used in the first survey was adopted. The interview schedule began with open-ended questions which permitted respondents to express their views in their own words, and progressed to specific, standardized attitude statements with which respondents were asked to agree or disagree. Every attempt was made to ensure that the open-ended questions were unbiased. Even in the latter part of the interview, when declarative attitude statements were introduced, statements were included that reflected both favorable and unfavorable attitudes toward the statute. (Six of the 10 attitudinal statements were favorable, and four were unfavorable; a slight positive bias was thus injected in the latter part of the interview.)
The first questions in the earlier survey assessed the amount of time respondents took to decide to have an abortion, and also the amount of time that elapsed between the date of the decision and the date of the abortion itself. The majority of respondents (59 percent) said that they had decided to have an abortion within 24 hours after receiving confirmation of their pregnancy, although the range of responses was 0-75 days. Two overlapping groups of women-black women and mothers of two or more young children-reported, however, that they had deliberated 2-3 days, on the average, before reaching the decision to have an abortion. Once having made the decision, white women most typically obtained the abortion 14 days later and black women, 21 days later.
Deciding to Have an Abortion
The overwhelming majority of women (88 percent) reported that they had talked with at least one person prior to meeting with the clinic counselor. Most commonly, respondents indicated that they had talked with their partner (42 percent) or a close friend (35 percent) about the advisability of an abortion. Less frequently, the respondents stated that they had talked with their mothers (17 percent); fathers (three percent); other relatives, including siblings or aunts (12 percent); health professionals, such as nurses or family physicians (seven percent); ministers or guidance counselors (two percent); or others (two percent).
The Benefits and Costs of Waiting
Early in the interview, respondents were reminded of the waiting-period requirements and were asked, "Did you gain any benefits by waiting a few extra days to have the abortion?" Seventy-seven percent of the women were unable to name a benefit, whereas 23 percent named one or more. Among the benefits were the following:
* had time to consider the wisdom of the decision (15 percent);
* had time to adjust psychologically (seven percent);
* had time to learn about the medical aspects of abortion (four percent);
* had time to consider effects of abortion on others (two percent); and
* other (two percent).
In response to the question "Did waiting a few extra days create any problems for you?" 41 percent were unable to name any problems, while 59 percent identified one or more problems. Among the problems named were these: ++
* experienced additional mental anguish (29 percent);
* incurred additional transportation expenses (24 percent);
* experienced additional nausea (19 percent);
* missed additional time at work (15 percent);
* had to make up extra excuses to explain absences (15 percent);
* others had to miss additional time at work to transport me (eight percent);
* missed additional time at school (six percent);
* had to arrange for additional babysitters (five percent);
* may have entered fourth month of pregnancy (one percent); and
* other (seven percent).
The statute, because it required multiple visits to clinics, increased the costs of health care for many women seeking abortions, Of the 332 women interviewed for the first survey, 313 were able to provide estimates of the costs of compliance with the statute, Of these, 62 percent reported that the necessity of returning for a second visit cost them additional money in terms of reduced salary, transportation expenses or additional childcare expenses. (*) For the 194 women who reported additional expenses because of the required second visit, the total cost was $7,602, and the median was $24 per woman. Since the cost of the abortion itself ranged from $50 to $175, depending upon the woman's economic circumstances, compliance with the statute increased costs for the typical low-income woman by at least 48 percent and for the typical higher income woman by at least 14 percent.
We submitted each woman's expenses resulting from compliance with the statute to regression analysis to detect factors which contributed most directly to her expenses. Two factors were identified: the distance a woman lived from the clinic and the number of hours she was employed each week. (+) Compliance was more costly for women in rural than in urban areas and for women who were employed than for women who did not work. Regression analysis produced no evidence that the costs of compliance with the law differed according to the women's race, age, income level or student status.
The costs of compliance were broken down into components, and each was examined in detail:
(*) Transportation expenses. Forty-eight percent of all respondents lived in communities other than the one in which they were being treated--typically, some 80 miles from the urban center where the clinic was located. Among all respondents, including those who lived in the city where they were to obtain the abortion, 59 percent reported having to bear extra transportation expenses in order to return for the second visit. The median additional cost was $15.
(*) Employment and salary. Sixty-two percent of the sample reported that they had full-time or part-time jobs. Sixty percent of employed women stated that they had to miss time at work in order to return for the second visit, and 41 percent of all jobholders reported losing pay because of the required second visit. The median amount of pay lost by jobholders was $32.
(*) Child-care expenses. Forty-five percent of respondents were mothers--typically, with one or two young children at home. Among mothers with young children, 57 percent had to arrange for additional child care in order to return for the second visit, and 22 percent had to pay for this extra child care. The median payment was $10.
In addition, students comprised 33 percent of the sample; about 41 percent of the students had to miss classes in order to comply with the statute. On the average, students missed two additional days of classes in order to make the second visit.
Attitudes Toward the Statute
Part of the interview was devoted to assessing the women's attitudes toward the mandatory waiting period. Two types of attitude measurement were used: a structured question soliciting the women's attitudes; and a Likert-type attitude scale requiring respondents to agree or disagree with a series of opinions about the waiting period. (++)
All respondents were asked: "As you know, the law has required you to wait a few days before having the abortion. Do you think that was a good idea, or would it have been better to have the abortion on your first visit here?" Seventy-one percent of the women in the first survey reported that they believed the law was not a good idea, compared with 26 percent who considered it a good idea. About three percent indicated that they were undecided about the law's merits.
As Table 1 shows, the majority of women also expressed negative attitudes toward the statute in responding to the 10 statements forming the Likert attitude scale. Their responses to the statements were aggregated to yield for each woman a single attitude score on the scale. Scores on the Likert scale ranged from 10, indicating maximum approval of the statute, to -10, indicating maximum disapproval of the statute, with 0 being the neutral point. The mean score for all women was -1.9, suggesting that the typical woman had a negative view of the statute mandating a waiting period.
We submitted the composite attitude scores to regression analysis to identify factors which distinguished supporters from opponents of the statute. Seven significant factors emerged and are listed below, in decreasing order of their power to discriminate opponents from supporters. Opponents of the statute, who constituted the majority of the respondents, tended to be women who reported no benefits from the waiting period, could name one or more problems created by the wait, reached the decision to have an abortion in a short period of time, were older, were white, incurred extra transportation expenses because of the required second visit, and were patients at the Memphis Center for Reproductive Health.
The minority of women who favored the required waiting period were distinguished primarily by their ability to name one or more benefits but no problems resulting from the mandatory wait; by their tendency to take a longer time to reach a decision to have an abortion; by their youth; and by their not incurring any extra transportation expenses.
Views Before and After Waiting
The primary purpose of the second survey was to determine whether the women's views of the required waiting period had changed from the first clinic visit, before they had gone through the waiting period, to the second visit, after they had experienced the mandatory wait.
Although there was a high correlation (*) between the responses made at the first and second interviews, respondents' expectations about the benefits and costs of the waiting period proved to be significantly different from the benefits and costs they actually experienced. Table 2 shows that the women realized fewer benefits and more problems from the wait than they had anticipated. When initially asked, "Do you think you will gain any benefits by waiting a few days to have the abortion?" 16 percent of the women were able to name one or more expected benefits. This proportion dropped to seven percent by the end of the required waiting period.
More striking were changes in response to the question, "Do you think that waiting a few days for the abortion will cause any problems for you?" Prior to the waiting period, 46 percent anticipated one or more problems. This proportion rose to 64 percent following the mandatory wait, the increase being due primarily to four problems (not shown): more nausea and physical discomfort than expected (a shift from 10 percent who anticipated this problem to 25 percent who experienced it); a greater occurrence of mental anguish (from 10 percent to 25 percent); a greater need to lie and make excuses to explain absences (from one percent to 12 percent); and a greater incidence of transportation expenses (from 16 percent to 25 percent).
The actual financial costs of returning for the second visit also turned out to be greater than expected for the women in the second survey. At the time of counseling, the typical woman expected that the necessity of a second visit would cost her approximately $15 in terms of reduced salary, extra transportation expenses and additional child-care expenses. In fact, the median cost was $29 per respondent.
We also examined the women's attitudes toward the statute before and after the required waiting period. As shown in Table 2, both measures of women's attitudes (their responses to the structured question and their scores on the Likert attitude scale) revealed slight but nonsignificant shifts in the direction of greater opposition to the statute. Before experiencing the waiting period, 70 percent of the women disapproved of the required wait. This proportion increased to 73 percent by the time of the second visit.
During the same period, mean scores on the Likert attitude scale shifted slightly, from -2.0 to -2.5. (+) Altogether, the data suggest that no overall change in attitude toward the statute occurred as a function of experiencing the required wait.
Survey Data as Legal Evidence
Portions of the foregoing report were submitted on February 7, 1980, as an exhibit in a suit brought by the Memphis Association for Planned Parenthood against the state of Tennessee. The senior author was subsequently called to testify about the report. Most of the questions raised in cross-examination pertained to the methodology of the surveys, and specifically to the issue of interviewer bias.
We would like to describe more fully our responses to questions about interviewer bias because this issue figured so prominently in cross-examination. All the interviews in the first survey and a portion of the interviews in the second were conducted by family planning counselors who were employees of the plaintiff. For this reason, and also because many of the counselors were assumed to oppose the mandatory waiting period, the defense attorneys alleged that the counselors might have allowed their personal opinions to bias the interviewing process. According to this argument, the responses of abortion candidates might not have reflected their own opinions as much as they reflected the biasing influence of the interviewers.
We acknowledged the potential danger of interviewer bias and pointed out the steps taken at the beginning of the project to minimize the danger: A detailed interview schedule to be followed precisely by the interviewers was written, leaving no opportunity for improvisation; declarative attitude statements were used, of which 60 percent expressed a favorable attitude toward the mandatory wait and the rest, a negative attitude (see Table 1); and the interviewers were given training which stressed the importance of neutrality. In addition, we pointed out that for the second survey, a graduate student in psychology who had no affiliation with any family planning organization conducted all of the interviews prior to the waiting period, as well as many of the interviews following the waiting period. The responses obtained in this survey by the graduate student (shown in Table 2) were remarkably similar to the responses obtained by the counselors in the earlier survey.
A further argument against the allegation of negative interviewer bias invoked the research literature on social influence. Several investigators (8) have found that susceptibility to social influence diminishes with age, i.e., that young adolescents are more susceptible than late adolescents, who, in turn, are more susceptible than adults. Accordingly, if the interviewers in the first survey were conveying a negative bias toward the statute and influencing respondents to conform to this bias, then we should have found the youngest girls expressing the most negative attitudes. In fact, the opposite results were obtained. Respondents under 18 years of age comprised the only age-group to express a favorable attitude toward the waiting period, their mean on the Likert scale being 0.7, compared to means of-0.8 for women aged 18-22,-3.5 for women aged 23-30, and-4.5 for women aged 31-40.
Therefore, we concluded that there was no tangible evidence to support the charge that negative interviewer bias accounted for the results obtained in the surveys.
Michael Lupfer is Professor of Psychology and Bohne Goldfarb Silber is a doctoral student in the Department of Psychology, Memphis State University, Memphis. The authors acknowledge the assistance of the staffs of the Memphis Association for Planned Parenthood, the Memphis Center for Reproductive Health and the Knoxville Center for Reproductive Health in conducting the surveys reported in this article. In addition, they are indebted to Gail O. Mathes, counsel for the Memphis Association for Planned Parenthood, and 0. Philip Arnold and Thomas M. Daniel. attorneys for the West Tennessee American Civil Liberties Union, who served as the plaintiffs legal team. A different version of this article was submitted as an exhibit in the case of Planned Parenthood of Memphis et al. v. Alexander et al., Case No. C-78-2310, U.S.D.Ct. W.D. Tenn. (1978).
(*.) The surveys were commissioned by the Memphis Association for Planned Parenthood.
(*.) We calculated with 95 percent confidence that percentage estimates drawn from a sample of this size contained sampling errors of 4-6 percent.
(++.) The remaining 17 women were not reinterviewed for the following reasons: Seven returned to the clinic to complete the abortion procedure after interviewing had ceased; four were discovered to have entered the second trimester of pregnancy and were referred elsewhere; two were referred elsewhere for medical problems and did not return; two decided to continue their pregnancies; one miscarried during the waiting period; and one did not return for unknown reasons. The responses of these 17 women to the initial interview questions were compared with the responses of the 73 women who were reinterviewed; no significant differences were found.
(++.) This was an open-ended question, and the women did not include financial matters pertaining to the waiting period as among the problems (although some did make mention of additional transportation costs and work missed). Either the question was not clear enough or costs were placed in another category in the respondents minds.
(*.) Respondents were not asked to estimate the cost of lodging or income lost by family members or friends who missed work to provide transportation.
(+.) Standardized correlation coefficients (beta) = 0.40 and 0.27, respectively.
(++.) Responses to the two types of questions were significandy correlated (r=0.64). This coefficient, plus the Cronbach's alpha coefficient of 0.82 for the Likert attitude scale, provided evidence for the reliability of the measures. (For a discussion of Cronbach's alpha coefficient, see: J. C. Nunnally, Psychometric Theory, 2nd ed., McGraw-Hill, New York, 1978, pp. 229-230.)
(*.) Test-retest correlations were all positive (from 0.47 to 0.87) and significant at the p<0.01 level.
(+.) Because the composite score on the Likert scale was based on 10 responses, we assumed it was a more sensitive and reliable measure of attitude than the responses to the single question. The correlation coefficients (not shown in Table 2), which may be viewed as test-retest coefficients of reliability, support this assumption.
(1.) Charles v. Carey. No. 79-2399 (7th Cir., July 29, 1980); Margaret I. v. Edwards, 488 F. Supp. 181 (E.D. La. 1980); Stewart v. Petit, 477 F. Supp. 542 (D. Me. 1979); Planned Parenthood League of Mass. v. Belotti, No. 80-1580 (1st Cir., Feb. 9, 1981); Planned Parenthood Ass'n of Kansas City, Mo., Inc. v. Ashcroft, 483 F. Supp. 679 (W.D. Mo. 1980); Women's Services v. Thone, 483 F. Supp. 1022 (D. Nebr. 1979); Leigh v. Olson, 497 F. Supp. 1340 (D.N.D. 1980); and Women's Medical Center of Providence Inc. v. Roberts, Civil Action No. 880-0292 (D.R.I., July 3. 1980).
(2.) Wolfe v. Schroering. 541F 2 dd 523 (6th Cir. 1976).
(3.) Wolfe v. Stumbo, Civil Action No. C-80-0285 L (A) (W.D. Ky. Dec. 3,1980).
(4.) Akron Center for Reproductive Health. Inc. v. City of Akron, 479 F. Supp. 1172 (N.D. Ohio 1979); and Planned Parenthood v. Blanton, No. 78-2310 (W.D. Tenn. Aug. 31, 1979).
(5.) Planned Parenthood of Memphis et al. v. Alexander et al., No. 78-2310 (W.D. Tenn. Mar. 23,1981).
(6.) Tennessee Code Annotated, Section 39-302.
(7.) Tennessee Department of Public Health, Induced Abortions Reported in Tennessee, 1976-1977, Nashville, April 1979, summary table.
(8.) W. R. Nord, "Social Exchange Theory: An Integrative Approach to Social Conformity," Psychological Bulletin, 71:198, 1969.
Table 1 Percentage of respondents agreeing with, disagreeing with or undecided about various statements concerning the waiting period, Memphis and Knoxville, 1980 (N = 332) Statement Percent Agree Disagree Undecided The required waiting period has been benedicial because it has given me time to think to be sure I was doing the right thing. 42 55 2 I'm afraid that postponing the abortion for a few days has increased the chance that people will find out. 36 58 6 Postponing the abortion has been helpful because it has given me extra time to prepare myself mentally for what's to come. 39 55 6 The few days of required waiting have not made me any more nervous than I was already. 44 55 1 I thought carefully about the morality of having an abortion before coming here the first time. I didn't need the required waiting period to think more about that question. 82 16 2 Even though I've experienced some nausea and stomach upset during this pregnancy, the extra days of waiting have not added to my discomfort. 43 53 5 The required waiting period has been beneficial because I have learned more about the medical aspects of abortion during the wait. 35 62 3 Having to wait for the abortion has caused a lot of added stress and worry about my condition. 60 36 3 The required waiting period has been helpful because it has given me a chance to reconsider the abortion with people close to me. 30 69 2 Having to make an extra trip here has forced me to make up additional excuses and "stories" to explain my absences. 51 47 2 Table 2 Comparison of responses to key questions before and after the waiting period, and scores on the Likert attitudinal scales, by various measures (N = 73) Measure Before After Test of significant waiting waiting change period period % who could name no 84 93 z=2.40 (*) benefits of required wait % who could name one or 16 7 more benefits % who could name no 54 36 z=2.99 (+) problems caused by required wait % who could name one 46 64 or more problems Total cost incurred by $15 $29 t=6.07 (+) having to make 2nd visit % who thought waiting 25 21 z=0.82 period a good idea % who disapprove of wait 70 73 % undecided 5 5 Mean scores on Likert -2.0 -2.5 t=1.56 attitude scale (++) (*)p < 0.05. (+)p < 0.01. (++)Scores range from -10 to +10.