National Partnership for Women & Families

Monthly Women's Health Research Review

Study Examines Effect of N.C. Mandatory Delay, Biased Counseling Law on State Providers

Summary of "The Experiences and Adaptations of Abortion Providers Practicing Under a New TRAP Law: a Qualitative Study," Mercier et al., Contraception, March 6, 2015.

Targeted regulations of abortion providers (TRAP laws) impose "unique challenges" on abortion providers, potentially "impact[ing] the number of abortion providers within a state or region and ... contribut[ing] to a stigmatizing and threatening atmosphere," according to Rebecca Mercier of the Sidney Kimmel Medical College of Thomas Jefferson University's Department of Obstetrics and Gynecology and colleagues.

The researchers examined one such law, North Carolina's "Women's Right to Know" (WRTK) Act (SL 2011-405), which went into effect in October 2011. The law, similar to those in 37 other states, imposes a 24-hour delay after health care providers tell women state-mandated information, with "no provisions for providers to use discretion in consideration of specific patient circumstances," according to the researchers. The researchers noted that a provision in the law requiring an ultrasound and a description of the image "was enjoined and later overturned."

Mercier and colleagues "performed a qualitative study of abortion providers in North Carolina to investigate how providers perceived the [WRTK] law and how compliance affected their abortion practice."


For the study, the researchers conducted interviews with providers who "worked under the WRTK law and had prior experience practicing in a less restrictive environment."

The researchers then analyzed the interview responses to determine themes about the experiences of providers.


The researchers interviewed 31 providers, including 17 physicians, nine nurses, three clinic administrators, one physician assistant and one counselor. In total, the providers represented 11 different clinical practices and eight of North Carolina's 100 counties.

According to the researchers, "[p]roviders adapted their practice not only to comply with the law but also to ameliorate its effects on patients," meaning that "providers' overall experience was defined both by the requirements of the law itself and by effects of the adaptations they made on the institutional and individual level to protect their patients' interests."

Provider Objections, Challenges

According to the researchers, all of the respondents "had negative opinions of the WRTK law," with five major themes emerging during the interviews, including:

~ Ethical and professional objections to the law;

~ The law's negative effect on providers;

~ The law's negative effect on providers' relationships with patients; and

~ The law's negative effect on the patient.

Specifically, the researchers found that providers thought the law was "an unreasonable intrusion into the practice of medicine" that "targeted [abortion] above and beyond other areas of medicine." In addition, the providers said they "resented the regulation of medical practice by politicians with little medical knowledge." They also said they believed that the "actual purpose" of the law, while "purportedly intended to improve patient knowledge and safety ... was to discourage women from obtaining abortions by restricting access or providing misleading information."

Further, most providers said that the law "created a substantial institutional burden" to comply with the measure. According to the study, providers cited the increased costs associated with implementing the mandatory counseling requirement and added emotional and physical stress stemming from complying with a law that they did not believe "matter[ed] for the provision of safe abortion care."

Respondents also said the law could negatively affect the patient-provider relationship and the patient herself, including by:

~ Creating further barriers to abortion access;

~ Making women feel as if providers were attempting to deny care or impose barriers to treatment; and

~ Making patients feel as if providers were questioning the woman's decision or not supporting her decision.

Further, the providers noted that some patients experienced "emotional distress" from the counseling and that the standardized mandatory counseling information was "inappropriate, irrelevant or harmful," particularly for women seeking abortions in cases of rape, health or fetal anomalies.

According to the study, "[n]o provider recalled a case where a patient seemed to change her mind about having an abortion as a result of the law."

Providers Adapting to the Measure

Mercier and colleagues noted several ways that providers changed their practices to adapt to the law. For example, on an institutional level:

~ Most providers had to switch from offering abortion care within one office visit to either offering abortion care in two visits or by "perform[ing] the required counseling by phone prior to the abortion visit," which "required staffing and bureaucratic changes;"

~ Facilities where fellows and residents provided counseling had to divert time "from other clinical and academic duties to perform" the mandatory counseling by phone; and

~ Providers had to seek other revenue sources to compensate for cost increases so they would not be passed on to patients.

In addition, on an individual level, many respondents said they employed strategies to reduce the potentially negative effects of the mandatory counseling on women, including "prefac[ing] the counseling with statements which distanced themselves from the content or apologiz[ing] for what they were about to say." According to the study, some providers "shared their own contrary opinions regarding" the state-mandated content and some "expressed agreement with patients' negative statements regarding the counseling."

Meanwhile, providers also said "the ultrasound provision of WRTK would have been extremely burdensome to both patients and providers."


Mercier and colleagues wrote, "Providers viewed the law as intrusive and politically motivated," with their negative reactions in the study "stemm[ing] from ... ethical and professional objections to the law, challenges faced in compliance and concern about potential impacts on patients."

The researchers added that "[t]he individual adaptations providers employed to distance themselves from the law and align themselves with patients' interests might help to preserve the [patient-provider] relationship in the face of" the challenges presented by the law.

Further, they wrote "the finding that the patient-provider relationship is in fact compromised in certain situations" by the law "may give insight" into a potential legal argument against such measures based on the concept of compelled speech being unconstitutional.

Mercier and colleagues concluded, "While less likely to lead to clinic closures and access barriers" than TRAP laws in some other states, "WRTK still has [a] significant" negative effect "on providers and patients."