This is a summary of key points in the written submission by AWARE to the Ministry of Health, as part of its public consultation on proposed changes to the criteria for mandatory pre-abortion counselling.

Background

AWARE is Singapore’s leading gender equality advocacy group. We seek to remove gender-based barriers in society, so that women and men can reach their fullest potential.

As part of our work to support informed choice, we provide the public with scientifically accurate and practical information on reproductive healthcare.

Currently, our webpage on abortion is the top Google hit for the search terms ‘abortion Singapore’ and the second for ‘unwanted pregnancy Singapore’. As of 1 December, this page had received over 80 hits a day (close to 29,000 in total). It was the most viewed page on our site in 2013 (21,926 visits).

We also receive telephone inquiries from members of the public seeking information about the nature and availability of abortion services.

Purpose of counselling

Every patient should be free to decide whether to terminate a pregnancy, based on her own circumstances, needs, values and aspirations.

We hope that the following principles will shape government policy on pre-abortion counselling:

• The purpose of the counselling is to empower women to make informed choices.
• The counselling regime is non-directive, supporting patients in making their own choices, rather than aiming at specific reproductive outcomes (for any demographic groups or among the population at large).

Access to counselling

In view of these objectives, the previous criteria for mandatory counselling (based on education, background etc.) are inappropriate. Informative, supportive and non-directive pre-abortion counselling should be provided equally to all abortion patients.

Content of counselling

The content of counselling should have the following features:

• A non-directive approach which seeks to support and facilitate, rather than influence, patients’ choices.
• Neutral, informative presentation of scientifically accurate information. The medical risks associated with abortion should not be exaggerated or described in a way that causes undue fear, panic or guilt in the patient.
• Patients who express a need for further information about social support should receive assistance from unbiased sources.

Accordingly, materials used in pre-abortion counselling should be neutral and informative, facilitating independent choices by patients. In particular, it should:

• Use appropriate imagery. Pictures of full-term pregnant abdomens or newborns (e.g. baby fingers grasping an adult hand) are inaccurate depictions of pregnant women or foetuses at the point of abortion. Dramatic fonts should be avoided.
• Use appropriate language. Neutral medical terminology such as “foetus” should be used, rather than “unborn baby” or “infant”.
• Contextualise health risks: Information about the medical risks of abortion should be supplemented with the following:

• Probability: If complications are described, their incidence should be included, to avoid an exaggerated picture of their likelihood. A good model is the UK NHS website. Researchers suggest that “Women should be informed that abortion is a safe procedure, for which major complications and mortality are rare at all gestations.”
• Risks of pregnancy: By describing only the risks of abortion, brochures give an incomplete picture. The risks of pregnancy and childbirth should also be included (e.g. diabetes, hypertension, infection, mental health issues, hyperemesis gravidarum and ectopic pregnancy). The severity and incidence of these risks is greater than those of abortions.

• Video: The video “Abortion: Consider with Care” is sensationalist and should be replaced. We hope the new video will be non-directive, in line with the general purpose of the counselling regime. In particular:

• Information on the risks of abortion should be contextualised with their probability and the risks of pregnancy. Abortion should not be presented as a threat to fertility. “Abortions performed in the first trimester pose virtually no long-term risk of such problems as infertility.” (Guttmacher Institute)
• Emotional music and dramatic images should be avoided.
• Negative emotions should not be emphasised. The Royal College of Obstetricians and Gynaecologists (RCOG) finds that after abortions, patients feel primarily “relief and diminution of stress.” There is no causal association between abortion for an unwanted pregnancy and psychiatric illness or self-harm.

We are happy to work with the Ministry and/or the Health Promotion Board to develop new versions of any materials.

Training and quality control

Pre- and post-abortion counselling should only be performed by qualified professionals who receive training from KKH social workers in applying a non-directive approach. We urge that all prospective and current counsellors complete training or a refresher at KKH to ensure that they comply with the non-directive approach.

Parties who do not undergo this training or comply with this approach should not conduct abortion-related activities at (or access patients through) polyclinics, to ensure quality control and consistency in all the information received by patients.

Referrals to third party agencies

During pre- and post-abortion counselling, patients may be referred to third party agencies. Patients need non-judgmental services that prioritise their welfare without promoting a moral or religious agenda. Agencies should not harm patients by inducing guilt or creating emotional or psychological difficulties. We urge the Ministry to ensure that patients are only referred to neutral agencies.