Original research article| Volume 95, ISSUE 3, P269-278, March 2017

Measuring decisional certainty among women seeking abortion



      Evaluating decisional certainty is an important component of medical care, including preabortion care. However, minimal research has examined how to measure certainty with reliability and validity among women seeking abortion. We examine whether the Decisional Conflict Scale (DCS), a measure widely used in other health specialties and considered the gold standard for measuring this construct, and the Taft–Baker Scale (TBS), a measure developed by abortion counselors, are valid and reliable for use with women seeking abortion and predict the decision to continue the pregnancy.


      Eligible women at four family planning facilities in Utah completed baseline demographic surveys and scales before their abortion information visit and follow-up interviews 3 weeks later. For each scale, we calculated mean scores and explored factors associated with high uncertainty. We evaluated internal reliability using Cronbach's alpha and assessed predictive validity by examining whether higher scale scores, indicative of decisional uncertainty or conflict, were associated with still being pregnant at follow-up.


      Five hundred women completed baseline surveys; two-thirds (63%) completed follow-up, at which time 11% were still pregnant. Mean scores on the DCS (15.5/100) and TBS (12.4/100) indicated low uncertainty, with acceptable reliability (α=.93 and .72, respectively). Higher scores on each scale were significantly and positively associated with still being pregnant at follow-up in both unadjusted and adjusted analyses.


      The DCS and TBS demonstrate acceptable reliability and validity among women seeking abortion care. Comparing scores on the DCS in this population to other studies of decision making suggests that the level of uncertainty in abortion decision making is comparable to or lower than other health decisions.


      The high levels of decisional certainty found in this study challenge the narrative that abortion decision making is exceptional compared to other healthcare decisions and requires additional protection such as laws mandating waiting periods, counseling and ultrasound viewing.


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        • Janis I
        • Mann L
        Decision making — psychological basis for defining the construct.
        The Free Press, New York1977
        • Lau YK
        • Caverly TJ
        • Cao P
        • et al.
        Evaluation of a personalized, Web-based decision aid for lung cancer screening.
        Am J Prev Med. 2015; 49: e125-e129
        • Meade T
        • Dowswell E
        • Manolios N
        • Sharpe L
        The motherhood choices decision aid for women with rheumatoid arthritis increases knowledge and reduces decisional conflict: a randomized controlled trial.
        BMC Musculoskelet Disord. 2015; 16: 260
        • Collins ED
        • Moore CP
        • Clay KF
        • et al.
        Can women with early-stage breast cancer make an informed decision for mastectomy?.
        J Clin Oncol. 2009; 27: 519-525
        • Hollinghurst S
        • Emmett C
        • Peters TJ
        • et al.
        Economic evaluation of the DiAMOND randomized trial: cost and outcomes of 2 decision aids for mode of delivery among women with a previous cesarean section.
        Med Decis Making. 2010; 30: 453-463
        • Mersereau JE
        • Goodman LR
        • Deal AM
        • Gorman JR
        • Whitcomb BW
        • HI S
        To preserve or not to preserve: how difficult is the decision about fertility preservation?.
        Cancer. 2013; 119: 4044-4050
        • Gould H
        • Perrucci A
        • Barar R
        • Sinkford D
        • Foster DG
        Patient education and emotional support practices in abortion care facilities in the United States.
        Women Health Issues. 2012; 22: e359-e364
        • Guttmacher Institute
        State policies in brief: an overview of abortion laws.
        • Boonstra H
        • Nash E
        A surge of state abortion restrictions puts providers — and the women they serve — in the crosshairs.
        Guttmacher Policy Rev. 2014; 17: 9-15
        • Kumar U
        • Baraitser P
        • Morton S
        • Massil H
        Decision making and referral prior to abortion: a qualitative study of women's experiences.
        J Fam Plann Reprod Health Care. 2004; 30: 51-54
        • Goenee MS
        • Donker GA
        • Picavet C
        • Wijsen C
        Decision-making concerning unwanted pregnancy in general practice.
        J Fam Pract. 2014; 31: 564-570
        • Gatter M
        • Kimport K
        • Foster DG
        • Weitz TA
        • Upadhyay UD
        Relationship between ultrasound viewing and proceeding to abortion.
        Obstet Gynecol. 2014; 123: 81-87
        • Cameron ST
        • Glasier A
        Identifying women in need of further discussion about the decision to have an abortion and eventual outcome.
        Contraception. 2013; 88: 128-132
        • Foster DG
        • Gould H
        • Taylor J
        • Weitz TA
        Attitudes and decision making among women seeking abortions at one U.S. clinic.
        Perspect Sex Reprod Health. 2012; 44: 117-124
        • O'Connor AM
        Validation of a Decisional Conflict Scale.
        Med Decis Making. 1995; 15: 25-30
      1. Management of unintended and abnormal pregnancy: comprehensive abortion care.
        Blackwell Publishing Ltd., West Sussex, UK2009
        • Roberts SCM
        • Turok DK
        • Belusa E
        • Combellick S
        • Upadhyay UD
        Utah's 72-hour waiting period for abortion: experiences among a clinic-based sample of women.
        Perspect Sex Reprod Health. 2016; ([Epub 2016 March 24])
        • Bessett D
        • Gerdts C
        • Littman LL
        • Kavanaugh ML
        • Norris A
        Does state-level context matter for individuals' knowledge about abortion, legality and health? Challenging the ‘red states v. blue states’ hypothesis.
        Cult Health Sex. 2015; 17: 733-746
        • Littman LL
        • Jacobs A
        • Negron R
        • Shochet T
        • Gold M
        • Cremer M
        Beliefs about abortion risks in women returning to the clinic after their abortions: a pilot study.
        Contraception. 2014; 90: 19-22
        • Wiebe ER
        • Littman L
        • Kaczorowski J
        • Moshier EL
        Misperceptions about the risks of abortion in women presenting for abortion.
        J Obstet Gynaecol Can. 2014; 36: 223-230
        • Sereno S
        • Leal I
        • Maroco J
        The role of psychological adjustment in the decision-making process for voluntary termination of pregnancy.
        J Reprod Infertil. 2013; 14: 143-151
        • Foster DG
        • Gould H
        • Kimport K
        How women anticipate coping after an abortion.
        Contraception. 2012; 86: 84-90
        • Ralph L
        • Gould H
        • Baker A
        • Foster DG
        The role of parents and partners in minors' decisions to have an abortion and anticipated coping after abortion.
        J Adolesc Health. 2014; 54: 428-434
        • O'Connor AM
        User manual — Decisional Conflict Scale (16 item statement format).
        Ottawa Hospital Research Institute, Ottawa1993
        • Viera AJ
        • Garrett JM
        Understanding interobserver agreement: the kappa statistic.
        Fam Med. 2005; 37: 360-363
        • Bland JM
        • Altman DG
        Statistics notes: Cronbach's alpha.
        BMJ. 1997; 314: 572
        • Kapadia F
        • Finer LB
        • Klukas E
        Associations between perceived partner support and relationship dynamics with timing of pregnancy termination.
        Women Health Issues. 2011; 21: S8-13
        • StataCorp
        Stata statistical software: release 14.
        StataCorp LC, College Station, TX2015
        • Watson K
        A piece of my mind. Reframing regret.
        JAMA. 2014; 311: 27-29
        • King L
        • O'Neill SC
        • Spellman E
        • Peshkin BN
        • Valdimarsdottir H
        • Willy S
        • et al.
        Intentions for bilateral mastectomy among newly diagnosed breast cancer patients.
        J Surg Oncol. 2013; 107: 772-776
        • Caleshu C
        • Shiloh S
        • Price C
        • Sapp J
        • Biesecker B
        Invasive prenatal testing decisions in pregnancy after infertility.
        Prenat Diagn. 2010; 30: 575-581
        • Walton GD
        • Ross LE
        • Stewart DE
        • Grigoriadis S
        • Dennis CL
        • Vigod S
        Decisional conflict among women considering antidepressant medication use in pregnancy.
        Arch Womens Ment Health. 2014; 17: 493-501
        • de Achaval S
        • Fraenkel L
        • Volk RJ
        • Cox V
        • Suarez-Almazor ME
        Impact of educational and patient decision aids on decisional conflict associated with total knee arthroplasty.
        Arthritis Care Res. 2012; 64: 229-237
        • Johnson DC
        • Mueller DE
        • Deal AM
        • Dunn MW
        • Smith AB
        • Woods ME
        • et al.
        Integrating patient preferences into treatment decisions for men with prostate cancer at the point of care.
        J Urol. 2016; ([Epub 2016 Jun 23])
        • Ferron Parayre A
        • Labrecque M
        • Rousseau M
        • Turcotte S
        • Legare F
        Validation of SURE, a four-item clinical checklist for detecting decisional conflict in patients.
        Med Decis Making. 2014; 34: 54-62
        • Rocca CH
        • Kimport K
        • Gould H
        • Foster DG
        Women's emotions one week after receiving or being denied an abortion in the United States.
        Perspect Sex Reprod Health. 2013; 45: 122-131
        • Sisson G
        • Kimport K
        Facts and fictions: characters seeking abortion on American television, 2005–2014.
        Contraception. 2016; 93: 446-451
        • Norris A
        • Bessett D
        • Steinberg JR
        • Kavanaugh ML
        • De Zordo S
        • Becker D
        Abortion stigma: a reconceptualization of constituents, causes, and consequences.
        Women Health Issues. 2011; 21: S49-S54
        • Daniels CR
        • Ferguson J
        • Howard G
        • Roberti A
        Informed or misinformed consent? Abortion policy in the United States.
        J Health Polit Policy Law. 2016; 41: 181-209
        • Jones RK
        • Finer LB
        • Singh S
        Characteristics of U.S. abortion patients, 2008.
        Guttmacher Institute, New York, NY2010
        • Dobkin LM
        • Perrucci AC
        • Dehlendorf C
        Pregnancy options counseling for adolescents: overcoming barriers to care and preserving preference.
        Curr Probl Pediatr Adolesc Health Care. 2013; 43: 96-102
        • Sepucha KR
        • Fowler Jr., FJ
        • Mulley Jr., AG
        Policy support for patient-centered care: the need for measurable improvements in decision quality.
        Health Aff. 2004; : 54-62