Jody Steinauer, MD, MAS - UCSF CME · Jody Steinauer, MD, MAS Professor Dept. of Obstetrics,...
Transcript of Jody Steinauer, MD, MAS - UCSF CME · Jody Steinauer, MD, MAS Professor Dept. of Obstetrics,...
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