When Francine Almash became pregnant in 2004, she was 34 and in love, so the timing seemed perfect. Son Ruben was heartily welcomed in January 2005.

Nine months later, a second pregnancy rattled but did not displease her. “Shawnie wasn’t planned, but he wasn’t unwanted,” she continues.

Flash forward to early 2008. Despite the fact that Almash’s relationship with her sons’ father was now strained, she again became pregnant. Worse, Almash says that she didn’t feel like she could talk to her friends and family about whether to carry the pregnancy to term. “Everyone thought that having another child was a really bad idea,” she explains. “But I was conflicted. I was almost 38 and realized that I would probably not have more kids. I wasn’t sure what I wanted to do so I made an appointment to see a counselor at Planned Parenthood.”

“Planned Parenthood has been my go-to place since college,” she says. “When I got to my appointment I laid out my situation for the social worker. She was amazing. One of things I remember most vividly is her telling me that I couldn’t make a wrong decision. It was the first time anyone had said this to me. She was telling me that either way—having a baby or having an abortion—was okay. She didn’t tell me what I should or shouldn’t do, but instead helped me think about the issues. As I talked I understood that my problem was not the pregnancy but the relationship I was in. By listening and not judging me the counselor helped me clarify what I had to do: Abort the father, keep the baby.”

Almash’s speech is salted with adjectives: Great, helpful, compassionate. That’s why, she continues, she gets so riled up when conservative politicians condemn Planned Parenthood and other reproductive health providers. “I want these legislators to know that my three-year-old is here, not despite, but because of, Planned Parenthood.”

Indeed, comprehensive options counseling—to help women determine whether abortion, adoption, or childbearing is right for them—is deeply woven into the care offered at women’s health facilities throughout the United States.

Alexandra Milspaw, director of counseling at the Allentown Women’s Center in Allentown, Pennsylvania, wants to be sure each patient has weighed the pros and cons of these options so she begins each session by questioning the woman about her decision. If she appears to waiver, Milspaw asks the woman to “hold” the piece of themselves that wants to continue the pregnancy in one hand and the part that wants an abortion in the other. “Next, I ask her to describe what each hand feels like, what emotions and thoughts come up. The goal is to find out what will help this particular woman feel happy, healthy, and whole,“ Milspaw says. In addition, she and her colleagues attempt to tease out the voices that are playing in each woman’s head, whether it’s her priest, parents, husband, boyfriend, or other friends.

Myths are also addressed—and busted. Patients, Milspaw continues, have often heard a boatload of fallacies, among them that abortion causes breast cancer, infertility, or chronic depression. They may also have anticipated entering a dank, unsanitary facility where they expect to be mistreated.

Once the client’s fears are calmed, the counseling intensifies. “I can’t tell a woman how to think but I can act as a mirror,” Milspaw says. “When I repeat what she’s said back to her we can assess whether that’s how she really feels.” Milspaw further helps patients deconstruct the beliefs they were raised with to see which ones still resonate. Other concerns, including whether they have an in-place support system, are also addressed. Lastly, writing a letter to the pregnancy is sometimes recommended. “That way, when they reprocess their decision, they’ll have a reminder about why they thought their choice was best,” she says.

Esther Priegue, director of counseling at Choices Women’s Medical Center in Queens, New York, always begins by asking the patient if she was forced to come to the clinic. “You can tell by their body language, or because they’re crying or shaking or not looking you straight in the eye, that something is going on,” she begins. “Most women have already made up their minds about what they want, but we still always ask if the decision is their own. We ask if they’re aware that they can have the baby or put it up for adoption. If the woman decides to keep the pregnancy we transfer her to our on-site prenatal care unit. She can stay with us until the delivery.” What’s more, Priegue makes referrals to adoption agencies as needed.

Choices sees between 40 and 60 patients a day; typically, one or two will express ambivalence, Priegue says. Sometimes, she adds, the patient is sent home to give more thought to how she wants to proceed. Then there’s the issue of coercion. “Recently the mother of an 18-year-old insisted that her daughter have an abortion. When the patient told me that she wanted the child, I had to tell the mother that her daughter had the right to continue the pregnancy. The mother screamed at me and ended up kicking her daughter out of the house. We had to find a residence for this girl and helped her create a plan for the next few months.”

“Every case is different,” Priegue shrugs.

And therein lies the challenge. It seems obvious that good counseling requires a mix of concrete information and careful listening so that individuals can decide which alternative best meets their needs.

Francine Almash agrees. “The Planned Parenthood social worker helped me work through the most difficult decision I’ve ever had to make,” she says. “I’ll always be grateful to her.”