Patient centered approach to pregnancy options counseling and - - PDF document

Patient‐centered approach to pregnancy options counseling and abortion referral and care

Jody Steinauer, MD, MAS

Professor

• Dept. of Obstetrics, Gynecology & Reproductive Sciences

University of California, San Francisco

Disclosures‐ July 6, 2017

• I have no financial disclosures.

After this talk you will be able to:

• Do unbiased, supportive pregnancy options

counseling

• Describe the epidemiology of abortion
• Describe basics of abortion techniques

– Medication abortion updates

• Discuss professional obligations for referral

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

• Yes
• No

Is a clinician obligated to provide comprehensive pregnancy

• ptions counseling to women who are unsure about their

pregnancy plans even if the clinician feels abortion is wrong?

• Yes
• It depends
• Not sure
• No

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

• True
• False

Case: Sara is a 24‐year‐old woman who had a baby 2 years ago who presents to you complaining of a missed period. Her pregnancy test is positive. Case: Sara is a 24‐year‐old woman who had a baby 2 years ago who presents to you complaining of a missed period. Her pregnancy test is positive.

Preparing to Disclose Results

• What do you think the result will be?

– These questions can be a part of your pre‐ assessment

• What are you hoping the result will be?

– No matter what the result, I can help you make a plan

Disclosing pregnancy test results

Your Goals as a Healthcare Provider

• To create a space where patients feel that it is safe

to ask questions. You are listening without an agenda.

• To be the person whom patients trust.

You will give them accurate information.

• To establish an environment free of stigma around

pregnancy decisions. You are modeling unbiased language.

Fundamental Principle

The patient has the answer.

She is a good person making a moral decision for herself. There is no knowledge that you possess about the answer to her dilemma that she does not.

Approach

• Listen
• Do not assume
• Self‐reflect

Listening means…

• Silence
• Asking open‐ended questions
• Being open to, curious about, fascinated with, and

interested in the patient’s process – while not having an agenda for the outcome

Not assuming means that you…

• Don’t take for granted that you and the patient

share the same understanding of medical terminology, feelings, or beliefs

• Are free to inquire, investigate, and learn from the

patient

• Take a step back from “professional mode.” You do

not have The Answer, nor are you obligated to find it for the patient

Self‐reflecting means…

Asking yourself:

• What scenarios are hard for me?
• What particular decisions do I want patients to make?
• What decisions do I think are foolish or wrong?

Pregnancy Test Counseling

Step 1: Prepare to disclose results Step 2: Disclose results Step 3: Discuss after a positive pregnancy test result

Disclosing Results

Compare the following two statements: Compare the following two statements:

Your test result came back

• positive. Do you want to

keep the baby or not? Your test result came back

• positive. Do you want to

keep the baby or not? I have the results of your pregnancy test. The test came back positive; that means that you are pregnant. How are you doing with that information? I have the results of your pregnancy test. The test came back positive; that means that you are pregnant. How are you doing with that information?

Reactions to Pregnancy Test Results

• Feelings
• Absolute statements
• Shock
• Uncertainty
• Certainty

Framework

• 1. Validate the feelings that you see and hear

– Normalize experiences to communicate, “You are unique, but not alone.”

• 2. Seek understanding of feelings and beliefs
• 3. Options counseling and/or referrals

Validate

• It’s okay to cry here.
• I can help you with that.
• It’s okay to not know the answer.
• I imagine that must have been very difficult.
• I see your point; that makes sense.
• I can see why it might have been hard for you to

come here.

• You’re doing a good job.

Normalize

• It’s okay to be scared.
• You know, lots of people have asked me that

question.

• That’s not a strange question at all; I’m glad you’ve

asked.

• This is a clinic where it’s okay to talk about that.
• Other women have expressed those same feelings.
• It’s okay to be unsure about what to do.

Seek understanding

• How are you doing with that information?
• What’s coming up for you?
• How are you feeling?
• Say more about that.
• What’s that like for you?

Working with shock

• Silence
• It’s okay to not know which way to go.

– validate

• Are you feeling [overwhelmed] by the news of

being pregnant?

– closed‐ended

• Who came with you today? How far did you travel?

– change the subject

• I’m going to get each of us a glass of water.

– break state

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

• I actually don’t know what I would do if I were you – if I

were making a pregnancy decision I’d have to look at my

• wn life and my own situation to see what was the best

way to go for me.

• Lots of people ask me what I would do; that’s normal.

While it might make you feel better right now if I told you what I would do, the relief would only be temporary. That’s because that only you know the answer and only you know what is the right decision for you.

Reassuring Statements

• I will support you no matter which way you decide

to go.

• You are a good person no matter which way you

decide to go; one way does not make you a better person than the other.

• You have time to change your mind.
• You don’t have to decide today.

Transition/Close

• Reframe

– You’re really brave; you’re doing a great job

• Express your own gratitude

– Thanks for sharing your thoughts about that

• Normalize her plan or her next step

– You have a good plan; lots of people take this next step

• Present information/referrals

Pregnancy Options

• Abortion
• Adoption
• Parenting

Language

• Abortion

instead of “termination.”

• Make an adoption plan or place the baby for adoption

instead of “putting the child up for adoption.”

• Continuing the pregnancy

instead of “keeping the baby.”

Seek Understanding

• How did you come to your beliefs about abortion?
• What have you heard about adoption?
• What are your thoughts about single parenthood?

Resources Resources Describe Options

• Early Abortion

– In an abortion, the doctor empties the uterus using gentle

• suction. The doctor uses something called a cannula, which is

a thin plastic straw. The cannula is inserted through the natural opening of the uterus – that’s called the cervix.

• Open Adoption

– Open adoption is a form of adoption in which the biological and adoptive families have access to varying degrees of each

• ther's personal information and have an option of ongoing

contact from just sending mail and/or photos, to face‐to‐face visits between birth and adoptive families.

Making an Abortion Referral

Get to know your community abortion providers

• What is their gestational limit?

– Do they offer medication abortion? – What is the gestational limit for a single‐visit abortion?

• What is the cost for services?

– Is analgesia/anesthesia included? RhoGAM?

• What types of insurance does the clinic accept?

– As full payment for services?

Making an Abortion Referral

• Ask about medical exclusions

– Will they see patients with medical conditions? – Will they see patients with current drug or alcohol use?

• Does the clinic offer post‐abortion contraception?
• Does the clinic offer emotional support

before/during the abortion?

Making an Adoption Referral

Get to know your community adoption agencies

• Look for adoption agencies that support all options for the

pregnant woman, including abortion and parenting.

• Look for agencies that accept diverse people as adoptive

parents and as birth families.

• Provide accurate information about how adoption is

practiced today.

– Open adoption – birth parent(s) can select and meet the adoptive parents, can have continued contact with the child.

• The pregnant woman should never be coerced or made to

feel an obligation to place her baby for adoption.

Parker Dockray, MSW, Backline

Case: After counseling Sara decides to have an abortion. Case: After counseling Sara decides to have an abortion.

Case: After counseling Sara decides to place the baby for adoption. Case: After counseling Sara decides to place the baby for adoption. Case: After counseling Sara decides to continue the pregnancy. Case: After counseling Sara decides to continue the pregnancy.

CHALLENGING ENCOUNTER

How are you feeling about this patient? What might be going on in her life? Can you take action to support her / minimize her suffering? How can you provide high‐ quality care?

CHALLENGING ENCOUNTER

What upsets you about her choosing to have an abortion? Why would someone choose to have an abortion? How can you support her? How can you provide high‐ quality care?

Epidemiology of Abortion in the US

Pregnancies in the United States

• 6.1 million pregnancies in 2011

Intended 55% Mistimed 27% Unwanted 18% Intended Mistimed Unwanted

Untended Pregnancy in the United States, Guttmacher, 2016.

Outcomes of Unintended Pregnancies

• 2.8 million in 2011

0% 20% 40% 60% 80% 100% Abortion Birth

42% 58%

Untended Pregnancy in the United States, Guttmacher, 2016.

1.07 million in 2011 926,000 in 2014

Who has Abortions? Age

< 20 12% 20‐24 34% 25‐29 26% 30‐34 16% 35‐39 9% ≥ 40 3%

< 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% of FPL 49% 100‐199% of FPL 26% ≥ 200% of FPL 25%

< 100% of FPL 100‐199% of FPL ≥ 200% of FPL

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

Who has Abortions? Race/Ethnicity

White 38% Black 28% Hispanic 25% Asian or PI 6% Other Background 3%

White Black Hispanic Asian or Pacific Islander Other Background

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

Who has Abortions? Religious Affiliation

Mainline Protestant 17% Evangelical Protestant 13% Roman Catholic 24% Other 8% No Religion 38%

Mainline Protestant Evangelical Protestant Roman Catholic Other Religion No Religion

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

Source: Jones et al., 2002

Who has Abortions? Prior Births

None 41% One 39% Two or more 20%

None One Two or more

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

Abortion Restrictions in the U.S.

• 37 states – parental notification or consent
• 27 states – waiting periods
• 32 states + DC – no state funding for abortion
• 21 states – restrictions on counseling and referral
• 16 states mandate counseling

– link between abortion and breast cancer (5) – long‐term mental health consequences (6) – ability of a fetus to feel pain (12)

Guttmacher Institute, NARAL

Abortion Access in the US

NARAL

Legal Status of Abortion

Center for Reproductive Rights Guttmacher Institute

8‐18% of maternal mortality 8‐18% of maternal mortality

Guttmacher Institute

Conclusions: Epidemiology

• Unintended pregnancy is common.
• We should be prepared to counsel women about

pregnancy options.

• Abortion should be legal and safe.

Abortion Safety

Abortion Is Safe in the U.S.

• Abortion is one of the safest medical procedures
• Abortion is safer than continuing a pregnancy
• Complications are rare
• Abortion is safer earlier in pregnancy

Abortion Methods

Induced abortion in the United States, Guttmacher, 2017.

Methods of Induced Abortion

1st trimester 2nd trimester Surgical

Uterine aspiration / “D&C” –Manual suction –Electric suction Dilation & Evacuation (D&E) –Standard D&E –Intact D&E

Medical

Medication –Mifepristone + Misoprostol –Misoprostol –(Methotrexate +Miso) Induction termination –Misoprostol +/‐ Mife

1st Trimester Abortion

• Vacuum Aspiration Abortion

– Manual or electric – Less than 14 weeks gestation

• Medical Abortion (31%)

– Less than 10 weeks gestation

Induced abortion in the United States, Guttmacher, 2017.

1st Trimester Aspiration Abortion

• Counseling

– Pregnancy options – Procedural – Contraception

• Preoperative Assessment
• Analgesia and Anesthesia
• Cervical Dilation
• Aspiration
• Recovery

Manual Vacuum Aspiration

• About 50% of U.S. abortion providers use MVAs1
• Usually without sharp curettage
• Must empty syringe during procedure with

gestation > 7 or 8 wks

• Women appreciate

less noise2,3,4

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

First‐Trimester Aspiration Abortion 1st Trimester Medical Abortion

• Counseling and assessment
• Take mifepristone in office
• Go home with pain medications
• Six hours to three days later:

– Place misoprostol pills in vagina – Over next 4 to 24 hours+ bleeding

• Return to clinic as early as 3 days later

– New evidence – follow‐up regimens

Medical Abortion Worldwide

• Over 60% of outpatient

abortions in several European countries

• Abortions occur earlier

where MAB widely available

Medical Abortion Regimens

• Mifepristone + misoprostol to 10 wks

– Most effective if available, 95‐99%

• Methotrexate + misoprostol to 7 wks

– 92‐96% effective within 4 weeks – 50 mg/m2 IM + 800 mcg miso 3 ‐ 5 days later

• Misoprostol alone to 9 wks

– 75‐90% effective within 2 weeks – 800 mcg every 3‐24 hours for 1 to 3 doses

FDA Mifepristone Labeling 2016 Medical abortion innovations

• Extending FDA labeling to 10 weeks’ gestation
• Home use of mifepristone
• Route of administration of misoprostol
• Remote communication with patients before and

after abortion

– States with mandatory counseling – telemedicine can help to avoid travel – WHO says no need to follow up in person – Strategies to confirm completion

2016 FDA label doubles eligible medical abortion patients

75% of abortions are < 10 wks

36% of eligible abortions

Jones, Perspect Sex Repro Health, 2014

Medical abortion efficacy

97% 2% 1% 0% 25% 50% 75% 100%

Success Incomplete abortion Continuing pregnancy

Professional Obligations

Obligations to Patient

• Study of 1200 physicians: theoretical case
• Would it be ethical to describe why the physician
• bjects to the requested procedure?

– 63% yes

• Does the physician have obligation to present all
• ptions to patient, including information about the

requested procedure?

– 86% yes

• Does the physician have an obligation to refer?

– 71% yes

Curlin, NEJM, 2007.

ACOG Guidelines: Conscientious Refusal

• When clinicians claim a right to refuse to provide

certain services, to refer patients, or to inform patients about their existing options

ACOG: American Congress of Obstetricians and Gynecologists ACOG: American Congress of Obstetricians and Gynecologists

• Claim that to provide services would

compromise their moral integrity

• Widespread in reproductive medicine
• Pharmacists EC and contraception, IUI,

abortion

ACOG Practice Bulletin #385, 2007.

“Professionalism in the New Millennium: A Physician Charter”

Three Principles Three Principles Principle of primacy of patient welfare Principle of primacy of patient welfare Principle of patient autonomy Principle of patient autonomy Principle of social justice Principle of social justice

• Signed by 130 Organizations

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

Similar to nursing codes of ethics, and

• steopathic medical associations

Ethical Responsibilities

• Criteria for assessing conscientious refusal

– Potential for imposition

• on patients who do not share their beliefs

– Effect on patient health – Scientific integrity of the claim

• EC, abortion and breast cancer

– Potential for discrimination

• Fertility assistance in same‐sex couples

ACOG Practice Bulletin

Professional Responsibilities

• Prioritize patient’s well‐being
• Provide accurate & unbiased information
• Provide potential patients with accurate

and prior notice of moral commitments and to not use their authority to argue their position

• Refer in a timely manner
• Emergency – obligation to provide

medically necessary services

ACOG Practice Bulletin

Resources: Innovating Education in Reproductive Health

• Abortion Safety
• TRAP Laws
• Waiting Periods
• The Turnaway Study
• Abortion in Film and Television
• Effects of Faith‐Based Hospitals on Women’s

Healthcare

• Effects of Abortion on Women’s Mental Health
• Impact of Abortion Restrictions on Clinical

Practice

• Who Can Safely Provide Abortions?
• State Regulation of Medication Abortion

Lectures available now:

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

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

Conclusion

• In counseling women about pregnancy options –

the patient knows the answer

• Abortion is safe
• The majority of abortions are in the first trimester
• f pregnancy
• Create systems for abortion and adoption referral
• Advocate for access to safe abortion care

Acknowledgements

Thanks to Karen Meckstroth, Alissa Perruccci, Innovating Education in Reproductive Health team, and other colleagues Thanks to Karen Meckstroth, Alissa Perruccci, Innovating Education in Reproductive Health team, and other colleagues

ACGME Competencies 1995/1996

1995 The Accreditation Council for Graduate Medical Education passed requirement for routine abortion training in ob‐gyn programs. “No program or resident with a religious or moral

• bjection shall be required to provide training in
• r to perform induced abortions. Otherwise,

access to experience with induced abortion must be part of residency education. This education can be provided outside the institution.”

ACGME: Accreditation Council for Graduate Medical Education ACGME: Accreditation Council for Graduate Medical Education

Graduate Medical Education: Family Medicine Training

• National initiative – RHEDI Program

– Funding and assistance in establishing training – 29 established programs with fully integrated training

ACGME – pregnancy options counseling American Academy of Family Physicians – abortion up to ten weeks gestation advanced expectations. STFM – opportunity for training in uterine evacuation

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

Undergraduate Medical Education: APGO Learning Objectives

APGO: Association of Professors

• f Gynecology and Obstetrics

APGO: Association of Professors

• f Gynecology and Obstetrics

Responsibilities in Abortion Care

• Provide non‐directive, options counseling

– Accurate, unbiased information – Not include personal opinion

• Refer for abortion care
• Provide abortion care
• Manage post‐abortion care
• Provide emergency care

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

• Residents should be able to counsel pregnant

patients on alternatives to continuing pregnancy, including induced abortion and adoption.

• Residents who decide not to provide this

service because of a moral objection still should be able to counsel patients, make appropriate referrals, and manage post‐ abortion complications.

CREOG: Council on Resident Education in Obstetrics and Gynecology CREOG: Council on Resident Education in Obstetrics and Gynecology

Milestones: Patient Care