Patient centered approach to pregnancy options counseling and - PDF document

Disclosures ‐ July 6, 2017 • I have no financial disclosures. 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 Do you or someone in your practice/clinic offer After this talk you will be able to: some type of abortion service? • Do unbiased, supportive pregnancy options • Yes counseling • No • Describe the epidemiology of abortion • Describe basics of abortion techniques – Medication abortion updates • Discuss professional obligations for referral

Is a clinician obligated to provide comprehensive pregnancy Enacted legislation to restrict women’s abortion options counseling to women who are unsure about their access has been increasing in the last decade. pregnancy plans even if the clinician feels abortion is wrong? • Yes • True • It depends • False • Not sure • No Preparing to Disclose Results • What do you think the result will be? Case: Sara is a 24‐year‐old woman who had a baby 2 Case: Sara is a 24‐year‐old woman who had a baby 2 – These questions can be a part of your pre‐ assessment years ago who presents to you complaining of a years ago who presents to you complaining of a • What are you hoping the result will be? missed period. Her pregnancy test is positive. missed period. Her pregnancy test is positive. – No matter what the result, I can help you make a plan

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. Disclosing pregnancy test results You will give them accurate information. • To establish an environment free of stigma around pregnancy decisions. You are modeling unbiased language. Fundamental Principle Approach • Listen • Do not assume The patient has the answer. • Self‐reflect 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.

Not assuming means that you… Listening means… • Silence • Don’t take for granted that you and the patient share the same understanding of medical • Asking open‐ended questions terminology, feelings, or beliefs • Being open to, curious about, fascinated with, and • Are free to inquire, investigate, and learn from the interested in the patient’s process – while not patient having an agenda for the outcome • 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… Pregnancy Test Counseling Asking yourself: Step 1: Prepare to disclose results • What scenarios are hard for me? Step 2: Disclose results • What particular decisions do I want patients to make? Step 3: Discuss after a positive pregnancy test result • What decisions do I think are foolish or wrong?

Reactions to Pregnancy Test Results Disclosing Results • Feelings Compare the following two statements: Compare the following two statements: • Absolute statements • Shock • Uncertainty I have the results of your I have the results of your pregnancy test. The test pregnancy test. The test • Certainty came back positive; that came back positive; that Your test result came back Your test result came back means that you are pregnant. means that you are pregnant. positive. Do you want to positive. Do you want to keep the baby or not? keep the baby or not? How are you doing with that How are you doing with that information? information? Framework Validate 1. Validate the feelings that you see and hear • It’s okay to cry here. Normalize experiences to communicate, “You are • I can help you with that. – unique, but not alone.” • It’s okay to not know the answer. 2. Seek understanding of feelings and beliefs • I imagine that must have been very difficult. 3. Options counseling and/or referrals • 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 Seek understanding • It’s okay to be scared. • How are you doing with that information? • You know, lots of people have asked me that • What’s coming up for you? question. • How are you feeling? • That’s not a strange question at all; I’m glad you’ve • Say more about that. asked. • What’s that like for you? • 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. When she asks: Working with shock What do you think I should do? • Silence • 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 • It’s okay to not know which way to go. own life and my own situation to see what was the best – validate way to go for me. • Are you feeling [overwhelmed] by the news of • Lots of people ask me what I would do; that’s normal. being pregnant? While it might make you feel better right now if I told you – closed‐ended what I would do, the relief would only be temporary. • Who came with you today? How far did you travel? That’s because that only you know the answer and only you know what is the right decision for you. – change the subject • I’m going to get each of us a glass of water. – break state

Reassuring Statements Transition/Close • I will support you no matter which way you decide • Reframe to go. – You’re really brave; you’re doing a great job • You are a good person no matter which way you • Express your own gratitude decide to go; one way does not make you a better – Thanks for sharing your thoughts about that person than the other. • Normalize her plan or her next step • You have time to change your mind. – You have a good plan; lots of people take this next step • You don’t have to decide today. • Present information/referrals Pregnancy Options Language • Abortion • Abortion • Adoption instead of “termination.” • Parenting • 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 Resources • How did you come to your beliefs about abortion? • What have you heard about adoption? • What are your thoughts about single parenthood? 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 other'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 Making an Abortion Referral Get to know your community abortion providers • Ask about medical exclusions – Will they see patients with medical conditions? • What is their gestational limit? – Will they see patients with current drug or alcohol use? – Do they offer medication abortion? • Does the clinic offer post‐abortion contraception? – What is the gestational limit for a single‐visit abortion? • Does the clinic offer emotional support • What is the cost for services? before/during the abortion? – Is analgesia/anesthesia included? RhoGAM? • What types of insurance does the clinic accept? – As full payment for services? Making an Adoption Referral Get to know your community adoption agencies • Look for adoption agencies that support all options for the Case: After counseling Sara decides to have an Case: After counseling Sara decides to have an pregnant woman, including abortion and parenting. abortion. abortion. • 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 place the Case: After counseling Sara decides to place the Case: After counseling Sara decides to continue the Case: After counseling Sara decides to continue the baby for adoption. baby for adoption. pregnancy. pregnancy. Can you take action to How can you support her / How can you How can you support her? minimize her provide high‐ provide high‐ Why would What might be suffering? quality care? quality care? someone choose to going on in her life? have an abortion? CHALLENGING CHALLENGING ENCOUNTER ENCOUNTER How are you feeling What upsets you about about this patient? her choosing to have an abortion?

Pregnancies in the United States • 6.1 million pregnancies in 2011 Intended Mistimed Unwanted Unwanted Epidemiology of Abortion in the US 18% Intended Mistimed 55% 27% Untended Pregnancy in the United States, Guttmacher, 2016. Outcomes of Unintended Pregnancies • 2.8 million in 2011 100% 80% 1.07 million in 2011 926,000 in 2014 58% 60% 42% 40% 20% 0% Abortion Birth Untended Pregnancy in the United States, Guttmacher, 2016.