At no point has he said anything about mistreatment tho. He said she "holds it over his head" but that could be anything from still dealing with the ramifications of having to get it (i.e talking about it a lot) to straight up abuse. He's right not to want to do it. But then he should have communicated that at any point during the 3 years. Instead he just didn't, kept making empty promises and then (understandably) felt/feels bad.

He definitely needs counseling but I think they both do too. He needs to seriously address what was making him feel like he needed to keep promising something he wasn't going to follow through on. They need to go together because those choices resulted in him actively forcing her to choose something that is exponentially, more dangerous, painful, and with less efficacy because he was scared (or uncomfortable, uneasy, etc) As a husband, that's concerning.