Patient‐centered approach to pregnancy options counseling and 

abortion referral and care

JodySteinauer,MD,MASProfessor

Dept.ofObstetrics,Gynecology&ReproductiveSciencesUniversityofCalifornia,SanFrancisco

Disclosures‐ July 6, 2017

• Ihavenofinancialdisclosures.

After this talk you will be able to:

• Dounbiased,supportivepregnancyoptionscounseling

• Describetheepidemiologyofabortion• Describebasicsofabortiontechniques

– Medicationabortionupdates

• Discussprofessionalobligationsforreferral

Do you or someone in your practice/clinic offer some type of abortion service?

• Yes• No

Is a clinician obligated to provide comprehensive pregnancy options counseling to women who are unsure about their pregnancy plans even if the clinician feels abortion is wrong?

• Yes• Itdepends• Notsure• No

Enacted legislation to restrict women’s abortion access has been increasing in the last decade.

• True• False

Case:Saraisa24‐year‐oldwomanwhohadababy2yearsagowhopresentstoyoucomplainingofamissedperiod.Herpregnancytestispositive.

Case:Saraisa24‐year‐oldwomanwhohadababy2yearsagowhopresentstoyoucomplainingofamissedperiod.Herpregnancytestispositive.

Preparing to Disclose Results

• Whatdoyouthink theresultwillbe?– Thesequestionscanbeapartofyourpre‐ assessment

• Whatareyouhoping theresultwillbe?– Nomatterwhattheresult,Icanhelpyoumakeaplan

Disclosing pregnancy test results

Your Goals as a Healthcare Provider

• Tocreateaspacewherepatientsfeelthatitissafetoaskquestions.

Youarelisteningwithoutanagenda.• Tobethepersonwhompatientstrust.

Youwillgivethemaccurateinformation.• Toestablishanenvironmentfreeofstigmaaroundpregnancydecisions.

Youaremodelingunbiasedlanguage.

Fundamental Principle

Thepatienthastheanswer.

Sheisagoodpersonmakingamoraldecisionforherself.Thereisnoknowledgethatyoupossessabouttheanswerto

herdilemmathatshedoesnot.

Approach

• Listen• Donotassume• Self‐reflect

Listening means…

• Silence• Askingopen‐endedquestions• Beingopento,curiousabout,fascinatedwith,andinterestedinthepatient’sprocess– whilenothavinganagendafortheoutcome

Not assuming means that you…

• Don’ttakeforgrantedthatyouandthepatientsharethesameunderstandingofmedicalterminology,feelings,orbeliefs

• Arefreetoinquire,investigate,andlearnfromthepatient

• Takeastepbackfrom“professionalmode.”YoudonothaveTheAnswer,norareyouobligatedtofinditforthepatient

Self‐reflecting means…

Askingyourself:• Whatscenariosarehardforme?• WhatparticulardecisionsdoIwant patientstomake?• WhatdecisionsdoIthinkarefoolishorwrong?

Pregnancy Test Counseling

Step1:PreparetodiscloseresultsStep2:DiscloseresultsStep3:Discussafterapositivepregnancytestresult

Disclosing Results

Comparethefollowingtwostatements:Comparethefollowingtwostatements:

Yourtestresultcamebackpositive.Doyouwanttokeepthebabyornot?

Yourtestresultcamebackpositive.Doyouwanttokeepthebabyornot?

Ihavetheresultsofyourpregnancytest.Thetestcamebackpositive;that

meansthatyouarepregnant.

Howareyoudoingwiththatinformation?

Ihavetheresultsofyourpregnancytest.Thetestcamebackpositive;that

meansthatyouarepregnant.

Howareyoudoingwiththatinformation?

Reactions to  Pregnancy Test Results

• Feelings• Absolutestatements• Shock• Uncertainty• Certainty

Framework

1. Validatethefeelingsthatyouseeandhear– Normalizeexperiencestocommunicate,“Youare

unique,butnotalone.”

2. Seekunderstandingoffeelingsandbeliefs3. Optionscounselingand/orreferrals

Validate

• It’sokaytocryhere.• Icanhelpyouwiththat.• It’sokaytonotknowtheanswer.• Iimaginethatmusthavebeenverydifficult.• Iseeyourpoint;thatmakessense.• Icanseewhyitmighthavebeenhardforyoutocomehere.

• You’redoingagoodjob.

Normalize

• It’sokaytobescared.• Youknow,lotsofpeoplehaveaskedmethatquestion.

• That’snotastrangequestionatall;I’mgladyou’veasked.

• Thisisaclinicwhereit’sokaytotalkaboutthat.• Otherwomenhaveexpressedthosesamefeelings.• It’sokaytobeunsureaboutwhattodo.

Seek understanding

• Howareyoudoingwiththatinformation?• What’scomingupforyou?• Howareyoufeeling?• Saymoreaboutthat.• What’sthatlikeforyou?

Working with shock

• Silence• It’sokaytonotknowwhichwaytogo.

– validate

• Areyoufeeling[overwhelmed]bythenewsofbeingpregnant?– closed‐ended

• Whocamewithyoutoday?Howfardidyoutravel?– changethesubject

• I’mgoingtogeteachofusaglassofwater.– breakstate

When she asks: What do you think I should do?

• Iactuallydon’tknowwhatIwoulddoifIwereyou– ifIweremakingapregnancydecisionI’dhavetolookatmyownlifeandmyownsituationtoseewhatwasthebestwaytogoforme.

• LotsofpeopleaskmewhatIwoulddo;that’snormal.WhileitmightmakeyoufeelbetterrightnowifItoldyouwhatIwoulddo,thereliefwouldonlybetemporary.That’sbecausethatonlyyouknowtheanswerandonlyyouknowwhatistherightdecisionforyou.

Reassuring Statements

• Iwillsupportyounomatterwhichwayyoudecidetogo.

• Youareagoodpersonnomatterwhichwayyoudecidetogo;onewaydoesnotmakeyouabetterpersonthantheother.

• Youhavetimetochangeyourmind.• Youdon’thavetodecidetoday.

Transition/Close

• Reframe– You’rereallybrave;you’redoingagreatjob

• Expressyourowngratitude– Thanksforsharingyourthoughtsaboutthat

• Normalizeherplanorhernextstep– Youhaveagoodplan;lotsofpeopletakethisnextstep

• Presentinformation/referrals

Pregnancy Options

• Abortion• Adoption• Parenting

Language

• Abortioninsteadof“termination.”

• Makeanadoptionplanorplacethebaby foradoptioninsteadof“puttingthechildupforadoption.”

• Continuingthepregnancyinsteadof“keepingthebaby.”

Seek Understanding

• Howdidyoucometoyourbeliefsaboutabortion?• Whathaveyouheardaboutadoption?• Whatareyourthoughtsaboutsingleparenthood?

Resources

Resources Describe Options 

• EarlyAbortion– Inanabortion,thedoctoremptiestheuterususinggentlesuction.Thedoctorusessomethingcalledacannula,whichisathinplasticstraw.Thecannulaisinsertedthroughthenaturalopeningoftheuterus– that’scalledthecervix.

• OpenAdoption– Openadoptionisaformofadoptioninwhichthebiologicalandadoptivefamilieshaveaccesstovaryingdegreesofeachother'spersonalinformationandhaveanoptionofongoingcontact fromjustsendingmailand/orphotos,toface‐to‐facevisitsbetweenbirthandadoptivefamilies.

Making an Abortion Referral

Gettoknowyourcommunityabortionproviders

• Whatistheirgestationallimit?– Dotheyoffermedicationabortion?– Whatisthegestationallimitforasingle‐visitabortion?

• Whatisthecostforservices?– Isanalgesia/anesthesiaincluded?RhoGAM?

• Whattypesofinsurancedoestheclinicaccept?– Asfullpaymentforservices?

Making an Abortion Referral

• Askaboutmedicalexclusions– Willtheyseepatientswithmedicalconditions?– Willtheyseepatientswithcurrentdrugoralcoholuse?

• Doestheclinicofferpost‐abortioncontraception?• Doestheclinicofferemotionalsupportbefore/duringtheabortion?

Making an Adoption ReferralGettoknowyourcommunityadoptionagencies

• Lookforadoptionagenciesthatsupportall optionsforthepregnantwoman,includingabortionandparenting.

• Lookforagenciesthatacceptdiversepeopleasadoptiveparentsandasbirthfamilies.

• Provideaccurateinformationabouthowadoptionispracticedtoday.– Openadoption– birthparent(s)canselectandmeettheadoptiveparents,canhavecontinuedcontactwiththechild.

• Thepregnantwomanshouldnever becoercedormadetofeelanobligationtoplaceherbabyforadoption.

Parker Dockray, MSW, Backline

Case:AftercounselingSaradecidestohaveanabortion.

Case:AftercounselingSaradecidestohaveanabortion.

Case:AftercounselingSaradecidestoplacethebabyforadoption.

Case:AftercounselingSaradecidestoplacethebabyforadoption.

Case:AftercounselingSaradecidestocontinuethepregnancy.

Case:AftercounselingSaradecidestocontinuethepregnancy.

CHALLENGINGENCOUNTER

Howareyoufeelingaboutthispatient?

Whatmightbegoingoninherlife?

Canyoutakeactiontosupporther/minimizehersuffering?

Howcanyouprovidehigh‐qualitycare?

CHALLENGINGENCOUNTER

Whatupsetsyouaboutherchoosingtohaveanabortion?

Whywouldsomeonechoosetohaveanabortion?

Howcanyousupporther? Howcanyou

providehigh‐qualitycare?

Epidemiology of Abortion in the US

Pregnancies in the United States 

• 6.1millionpregnanciesin2011

Intended55%Mistimed

27%

Unwanted18%

Intended Mistimed Unwanted

Untended Pregnancy in the United States, Guttmacher, 2016.

Outcomes of Unintended Pregnancies

• 2.8millionin2011

0%

20%

40%

60%

80%

100%

Abortion Birth

42%

58%

Untended Pregnancy in the United States, Guttmacher, 2016.

1.07 million in 2011926,000 in 2014

Who has Abortions? Age

<2012%

20‐2434%

25‐2926%

30‐3416%

35‐399%

≥403%

<20 20‐24 25‐29 30‐34 35‐39 ≥40

Characteristics of US Abortion Patients in 2014 and Changes Since 2008, Guttmacher, 2016.

Who has Abortions? Income Level

<100%ofFPL49%

100‐199%ofFPL26%

≥200%ofFPL25%

<100%ofFPL 100‐199%ofFPL ≥200%ofFPL

Characteristics of US Abortion Patients in 2014 and Changes Since 2008, Guttmacher, 2016.

Who has Abortions? Race/Ethnicity

White38%

Black28%

Hispanic25%

AsianorPI6%

OtherBackground3%

White Black Hispanic AsianorPacificIslander OtherBackground

Characteristics of US Abortion Patients in 2014 and Changes Since 2008, Guttmacher, 2016.

Who has Abortions? Religious Affiliation

MainlineProtestant

17%

EvangelicalProtestant

13%

RomanCatholic24%

Other8%

NoReligion38%

MainlineProtestant EvangelicalProtestantRomanCatholic OtherReligionNoReligion

Characteristics of US Abortion Patients in 2014 and Changes Since 2008, Guttmacher, 2016.

Source: Jones et al., 2002

Who has Abortions? Prior Births

None41%

One39%

Twoormore20%

None One Twoormore

Characteristics of US Abortion Patients in 2014 and Changes Since 2008, Guttmacher, 2016.

Abortion Restrictions in the U.S.

• 37states– parentalnotificationorconsent• 27states– waitingperiods• 32states+DC– nostatefundingforabortion• 21states– restrictionsoncounselingandreferral• 16statesmandatecounseling

– linkbetweenabortionandbreastcancer(5)– long‐termmentalhealthconsequences(6)– abilityofafetustofeelpain(12)

Guttmacher Institute, NARAL

Abortion Access in the US

NARAL

Legal Status of Abortion

Center for Reproductive Rights Guttmacher Institute

8‐18%ofmaternalmortality8‐18%ofmaternalmortality

Guttmacher Institute

Conclusions: Epidemiology

• Unintendedpregnancyiscommon.• Weshouldbepreparedtocounselwomenaboutpregnancyoptions.

• Abortionshouldbelegalandsafe.

Abortion Safety

Abortion Is Safe in the U.S.

• Abortionisoneofthesafestmedicalprocedures• Abortionissaferthancontinuingapregnancy• Complicationsarerare• Abortionissaferearlierinpregnancy

Abortion Methods

Induced abortion in the United States, Guttmacher, 2017.

Methods of Induced Abortion

1st trimester 2nd trimester

Surgical Uterineaspiration/“D&C”

–Manualsuction

–Electricsuction

Dilation&Evacuation(D&E)

–StandardD&E

–IntactD&E

Medical Medication

–Mifepristone+Misoprostol

–Misoprostol

–(Methotrexate+Miso)

Inductiontermination

–Misoprostol+/‐ Mife

1st Trimester Abortion

• VacuumAspirationAbortion– Manualorelectric– Lessthan14weeksgestation

• MedicalAbortion(31%)– Lessthan10weeksgestation

Induced abortion in the United States, Guttmacher, 2017.

1st Trimester Aspiration Abortion

• Counseling– Pregnancyoptions– Procedural– Contraception

• PreoperativeAssessment• AnalgesiaandAnesthesia• CervicalDilation• Aspiration• Recovery

Manual Vacuum Aspiration

• About50%ofU.S.abortionprovidersuseMVAs1

• Usuallywithoutsharpcurettage• Mustemptysyringeduringprocedurewithgestation>7or8wks

• Womenappreciatelessnoise2,3,4

1. O’Connell, 2008, 2. Bird, 2001; 3. Edelman, 2001; 4. Dean, 2003.

First‐Trimester Aspiration Abortion 1st Trimester Medical Abortion 

• Counselingandassessment• Takemifepristoneinoffice• Gohomewithpainmedications• Sixhourstothreedayslater:

– Placemisoprostolpillsinvagina– Overnext4to24hours+bleeding

• Returntoclinicasearlyas3dayslater– Newevidence– follow‐upregimens

Medical Abortion Worldwide

• Over60%ofoutpatientabortionsinseveralEuropeancountries

• AbortionsoccurearlierwhereMABwidelyavailable

Medical Abortion Regimens

• Mifepristone+misoprostolto10wks– Mosteffectiveifavailable,95‐99%

• Methotrexate+misoprostolto7wks– 92‐96%effectivewithin4weeks– 50mg/m2IM+800mcgmiso3‐ 5dayslater

• Misoprostolaloneto9wks– 75‐90%effectivewithin2weeks– 800mcgevery3‐24hoursfor1to3doses

FDA Mifepristone Labeling 2016 Medical abortion innovations

• ExtendingFDAlabelingto10weeks’gestation• Homeuseofmifepristone• Routeofadministrationofmisoprostol• Remotecommunicationwithpatientsbeforeandafterabortion– Stateswithmandatorycounseling– telemedicinecanhelptoavoidtravel

– WHOsaysnoneedtofollowupinperson– Strategiestoconfirmcompletion

2016 FDA label doubles eligible medical abortion patients 

75%ofabortionsare< 10wks

36%ofeligibleabortions

Jones, Perspect Sex Repro Health, 2014

Medical abortion efficacy

97%

2% 1%0%

25%

50%

75%

100%

Success Incompleteabortion

Continuingpregnancy

Professional Obligations

Obligations to Patient

• Studyof1200physicians:theoreticalcase• Woulditbeethicaltodescribewhythephysicianobjectstotherequestedprocedure?– 63%yes

• Doesthephysicianhaveobligationtopresentalloptionstopatient,includinginformationabouttherequestedprocedure?– 86%yes

• Doesthephysicianhaveanobligationtorefer?– 71%yes

Curlin, NEJM, 2007.

ACOG Guidelines: Conscientious Refusal

• Whencliniciansclaimarighttorefusetoprovidecertainservices,toreferpatients,ortoinformpatientsabouttheirexistingoptions

ACOG:AmericanCongressofObstetriciansandGynecologistsACOG:AmericanCongressofObstetriciansandGynecologists

• Claimthattoprovideserviceswouldcompromisetheirmoralintegrity

• Widespreadinreproductivemedicine• PharmacistsECandcontraception,IUI,abortion

ACOG Practice Bulletin #385, 2007.

“Professionalism in the New Millennium:  A Physician Charter”

ThreePrinciplesThreePrinciples

Principleofprimacyofpatientwelfare

Principleofprimacyofpatientwelfare

Principleofpatient

autonomy

Principleofpatient

autonomy

PrincipleofsocialjusticePrincipleofsocialjustice

• Signedby130Organizations

American Board of Internal Medicine Foundation Foundation, the ACP Foundation and the European Federation of Internal Medicine

Similartonursingcodesofethics,andosteopathicmedicalassociations

Ethical Responsibilities

• Criteriaforassessingconscientiousrefusal– Potentialforimposition

• onpatientswhodonotsharetheirbeliefs

– Effectonpatienthealth– Scientificintegrityoftheclaim

• EC,abortionandbreastcancer

– Potentialfordiscrimination• Fertilityassistanceinsame‐sexcouples

ACOG Practice Bulletin

Professional Responsibilities

• Prioritizepatient’swell‐being• Provideaccurate&unbiasedinformation• Providepotentialpatientswithaccurateandpriornoticeofmoralcommitmentsandtonotusetheirauthoritytoarguetheirposition

• Referinatimelymanner• Emergency– obligationtoprovidemedicallynecessaryservices

ACOG Practice Bulletin

Resources:  Innovating Education in Reproductive Health

• AbortionSafety• TRAPLaws• WaitingPeriods• TheTurnaway Study• AbortioninFilmandTelevision• EffectsofFaith‐BasedHospitalsonWomen’s

Healthcare• EffectsofAbortiononWomen’sMentalHealth• ImpactofAbortionRestrictionsonClinical

Practice• WhoCanSafelyProvideAbortions?• StateRegulationofMedicationAbortion

Lecturesavailablenow:

Online Abortion Course: Clinical, Social Science, Public Health, Policy

www.innovating‐education.orgwww.innovating‐education.org

Conclusion

• Incounselingwomenaboutpregnancyoptions–thepatientknowstheanswer

• Abortionissafe• Themajorityofabortionsareinthefirsttrimesterofpregnancy

• Createsystemsforabortionandadoptionreferral• Advocateforaccesstosafeabortioncare

Acknowledgements

ThankstoKarenMeckstroth,AlissaPerruccci,InnovatingEducationinReproductiveHealthteam,andothercolleagues

ThankstoKarenMeckstroth,AlissaPerruccci,InnovatingEducationinReproductiveHealthteam,andothercolleagues

ACGME Competencies 1995/1996

1995TheAccreditationCouncilforGraduateMedicalEducationpassedrequirementforroutineabortiontraininginob‐gynprograms.

“Noprogramorresidentwithareligiousormoralobjectionshallberequiredtoprovidetraininginortoperforminducedabortions.Otherwise,accesstoexperiencewithinducedabortionmustbepartofresidencyeducation.Thiseducationcanbeprovidedoutsidetheinstitution.”

ACGME:AccreditationCouncilforGraduateMedicalEducationACGME:AccreditationCouncilforGraduateMedicalEducation

Graduate Medical Education:Family Medicine Training 

• Nationalinitiative– RHEDIProgram– Fundingandassistanceinestablishingtraining– 29establishedprogramswithfullyintegratedtraining

ACGME– pregnancyoptionscounselingAmericanAcademyofFamilyPhysicians–abortionuptotenweeksgestationadvancedexpectations.STFM – opportunityfortraininginuterineevacuation

http://www.aafp.org/afp/980700ap/corematr.htmlwww.rhedi.org

Undergraduate Medical Education:     APGO Learning Objectives

APGO:AssociationofProfessorsofGynecologyandObstetricsAPGO:AssociationofProfessorsofGynecologyandObstetrics

Responsibilities in Abortion Care

• Providenon‐directive,optionscounseling– Accurate,unbiasedinformation– Notincludepersonalopinion

• Referforabortioncare• Provideabortioncare• Managepost‐abortioncare• Provideemergencycare

What if a resident wants to opt out of abortion training?

• Residentsshouldbeabletocounselpregnantpatientsonalternativestocontinuingpregnancy,includinginducedabortionandadoption.

• Residentswhodecidenottoprovidethisservicebecauseofamoralobjectionstillshouldbeabletocounselpatients,makeappropriatereferrals,andmanagepost‐abortioncomplications.

CREOG:CouncilonResidentEducationinObstetricsandGynecologyCREOG:CouncilonResidentEducationinObstetricsandGynecology

Milestones: Patient Care