Evaluation of a Training for Health and Social Service Providers on Abortion Referral-Making

"At the End of the Day it's Their choice": An Exploratory Qualitative Study of Pregnancy Options Counseling

This study's purpose was to explore the current models and approaches of pregnancy options counseling across three types of agency settings in a Northeastern state. Additionally, this study aimed to determine if individuals who receive pregnancy options counseling obtained medically factual, non-directive, and non-biased information needed to make informed decisions related to their pregnancy decisions. Using qualitative research methodology, semi-structured interviews were conducted with 10 participants across three different agency settings in one state in the Northeastern United States. Results indicated agencies shared a definition of pregnancy options counseling. Outcomes also suggest agency type impacted how pregnancy options counseling was delivered, as variations were found in education provided to patients. Lastly, the interviews imply no standardized model or training for pregnancy options counselors is currently being used.

The practice of pregnancy options counseling in social service and healthcare settings in the United States: a systematic literature review

INTRODUCTION

The purpose of this systematic literature was to summarize the literature on pregnancy options counseling for women and patients who experience an unintended pregnancy across healthcare and social service settings.

METHODS

We conducted a systematic literature review using the PRISMA Checklist. Following the literature search of 8 electronic databases, we used a three-stage search process to screen articles for inclusion.

RESULTS

A total of 20 peer-reviewed articles met the inclusion criteria for this study. Half (n = 10) of the articles reviewed were empirical studies utilizing quantitative or qualitative methodology while the other half (n = 10) were conceptual or non-empirical. The articles affirmed a shared definition of pregnancy options counseling, but terminology differences were noted over time. Lastly, variations of intervention practices appeared across practice settings, with referral practice variations being the most notable.

CONCLUSION

Pregnancy options counseling practices varied across settings, suggesting patients who received this intervention may not have accessed equitable or ethical care.

Identification of Clinician Training Techniques as an Implementation Strategy to Improve Maternal Health: A Scoping Review

Training is a key implementation strategy used in healthcare settings. This study aimed to identify a range of clinician training techniques that facilitate guideline implementation, promote clinician behavior change, optimize clinical outcomes, and address implicit biases to promote high-quality maternal and child health (MCH) care. A scoping review was conducted within PubMed, CINAHL, PsycInfo, and Cochrane databases using iterative searches related to (provider OR clinician) AND (education OR training). A total of 152 articles met the inclusion/exclusion criteria. The training involved multiple clinician types (e.g., physicians, nurses) and was predominantly implemented in hospitals (63%). Topics focused on maternal/fetal morbidity/mortality (26%), teamwork and communication (14%), and screening, assessment, and testing (12%). Common techniques included didactic (65%), simulation (39%), hands-on (e.g., scenario, role play) (28%), and discussion (27%). Under half (42%) of the reported training was based on guidelines or evidence-based practices. A minority of articles reported evaluating change in clinician knowledge (39%), confidence (37%), or clinical outcomes (31%). A secondary review identified 22 articles related to implicit bias training, which used other reflective approaches (e.g., implicit bias tests, role play, and patient observations). Although many training techniques were identified, future research is needed to ascertain the most effective training techniques, ultimately improving patient-centered care and outcomes.

Pregnancy options counseling

PURPOSE OF REVIEW

This article reviews key aspects of pregnancy options counseling, and highlights how inappropriate counseling can create barriers to timely and safe abortion care.

RECENT FINDINGS

Access to safe abortion services in the United States is increasingly constrained. One way to combat this hostile environment is to ensure that individuals presenting for care early in pregnancy have access to comprehensive and unbiased pregnancy options counseling. There are unfortunately many barriers to individuals receiving adequate pregnancy options counseling, and marginalized groups experience disproportionate effects of inappropriate counseling. Research shows that individuals desire appropriate pregnancy options counseling when seeking early pregnancy care, and that providers often serve as a barrier to this care. Provider miseducation and opposition to pregnancy options counseling, particularly as it concerns abortion care, creates challenges and delays for people seeking abortion services. Crisis Pregnancy Centers use misinformation to further these barriers to appropriate care.

SUMMARY

Nondirective and patient-centered pregnancy options counseling is standard of care. People seeking pregnancy options counseling desire and deserve comprehensive and accurate information. Providers must not serve as barriers to safe and appropriate care. Increasing nondirective pregnancy options counseling research, education, and training is crucial to ensuring access to safe and appropriate abortion care.

Making a third-trimester abortion referral: Learning from patients

OBJECTIVES

Research on abortion referral practices has focused on referral to first-trimester abortion care. Research has not examined whether and how these recommendations apply to referrals for abortion later in pregnancy.

METHODS

We conducted a secondary analysis of semi-structured interviews with thirty third-trimester abortion patients of their experiences of referral from prenatal and/or pre-third-trimester abortion care. We used thematic coding to identify referral-related actions participants desired or wished providers would avoid.

RESULTS

Participants reported needs in referral for information that third-trimester abortion was a possibility and about third-trimester providers and funding resources. Several also reported a need for emotional support from the prenatal or abortion care provider who denied them abortion care.

CONCLUSIONS

Many factors important for first-trimester abortion referral are important in third-trimester abortion referral, but the specifics of third-trimester care (namely the paucity of clinics, need for travel, and possibility of strong emotional attachment to the pregnancy) require additional practice actions.

PRACTICE IMPLICATIONS

Providers can support their patients in need of third-trimester abortion care by proactively providing: information that third-trimester abortion is available; information on third-trimester providers and funding support (e.g., an abortion referral hotline); and clear, non-judgmental emotional support.

Society for Maternal-Fetal Medicine Consult Series #55: Counseling women at increased risk of maternal morbidity and mortality

Women should be provided with evidence-based information when considering options for contraception and pregnancy management. When counseling about health conditions and available treatments, healthcare practitioners should employ strategies that encourage the incorporation of informed patient preferences into a shared decision-making process with the patient. To optimize the health of women at risk of experiencing adverse health outcomes during or after pregnancy, counseling should be a continuous process throughout the reproductive life course. The purpose of this Consult is to provide guidance for all healthcare practitioners about counseling reproductive-aged women who may be at high risk of experiencing maternal morbidity or mortality.

Pregnancy Options Counseling and Abortion Referral Practices Among Colorado Nurse Practitioners, Nurse-Midwives, and Physician Assistants

INTRODUCTION

Access to abortion is a public health priority. Yet little is known about pregnancy options counseling and abortion referral practices, both essential to timely abortion care, among advanced practice clinicians (APCs; nurse practitioners, nurse-midwives, physician assistants).

METHODS

Data were drawn from a stratified random sample of Colorado APCs, oversampling certified nurse-midwives (CNMs), women's health nurse practitioners (WHNPs), and rural clinicians. Pregnancy options counseling and abortion referral practices were described. Weighted multivariate logistic regression models were used to examine associations between participant characteristics and providing options counseling, referring for abortion, and referring to crisis pregnancy centers.

RESULTS

Of 513 participants (response rate 21%), 419 provided pregnancy testing. Only 201(48%) reported they were willing and able to counsel on all 3 options. Religious or personal objection was the primary rationale for unwillingness to present abortion as an option (63%). However, lack of knowledge was the main rationale for unwillingness (64%) and inability to counsel (79%), whereas institutional barriers fueled inability to refer (59%). Although 53% referred for abortion care, 31% referred to crisis pregnancy centers. Characteristics positively associated with providing options counseling included being a CNM or WHNP (odds ratio [OR], 2.73; 95% CI, 1.32-5.66), having received options counseling training (OR, 2.84; 95% CI, 1.48-5.43), and feeling adequately trained on abortion counseling (OR, 6.61; 95% CI, 3.62-12.08). Characteristics positively associated with referring for abortion included being a CNM or WHNP (OR, 2.27; 95% CI, 1.18-4.36), having received options counseling training (OR, 2.39; 95% CI, 1.36-4.22), and feeling adequately trained on abortion counseling (OR, 3.5; 95% CI, 2.00-6.11). Only provider type was associated with referring to crisis pregnancy centers; CNMs and WHNPs had the lowest odds (OR, 0.29; 95% CI, 0.15-0.54).

DISCUSSION

Pregnant patients in Colorado may not receive evidence-based pregnancy options counseling or abortion referrals. Clinician training on options counseling and abortion referrals is needed.

Breaking the silence in the primary care office: patients' attitudes toward discussing abortion during contraceptive counseling

Objectives

Abortions are common health experiences in the United States, yet they are siloed from mainstream health care. To provide guidance on how clinicians could break down these silos, normalize conversations about abortion, and potentially improve patient experience and contraceptive decision-making, we sought to understand patient attitudes regarding discussing abortion during contraceptive counseling.

Study design

In 2018, we completed in-depth semi-structured interviews with reproductive-aged women recruited from primary care clinics of two politically disparate regions within California. We elicited acceptability, preferences, and implications of clinicians mentioning abortion during contraceptive counseling. Using directed content analysis, we coded transcripts for inductive and deductive themes.

Results

We achieved thematic saturation after 49 interviews. Interviewees were diverse in reproductive history, race/ethnicity, religiosity, and abortion attitudes. Participants with diverse attitudes about abortion reported that having abortion mentioned during contraceptive counseling was generally viewed as acceptable, and even helpful, when delivered in a non-directive manner focused on information provision. For some patients, mentioning abortion may reduce abortion stigma and help contraceptive decision-making. Careful attention to a non-judgmental communication style is critical to safeguard against potential contraceptive coercion.

Conclusions

Discussing abortion during contraceptive counseling was acceptable among this diverse population, and our findings suggest ways to best structure such counseling. Coupled with research on clinician perspectives, our findings can inform development of patient-centered contraceptive counseling approaches that integrate abortion in an attempt to facilitate patient care and reduce stigma.

Implications

Mentioning abortion during contraceptive counseling can be acceptable, and even helpful, to patients when delivered in a non-directive manner focused on information provision, even among patients who believed abortion should be illegal in all or most cases. For some patients, mentioning abortion may reduce abortion stigma and help contraceptive decision-making.

Future health providers' willingness to provide abortion services following decriminalisation of abortion in Chile: a cross-sectional survey

OBJECTIVE

To assess Chilean medical and midwifery students' attitudes and willingness to become trained to provide abortion care, shortly after abortion was decriminalised in 2017.

DESIGN

We fielded a cross-sectional, web-based survey of medical and midwifery students. We used generalised estimating equations to assess differences by type of university and degree sought.

SETTING

We recruited students from a combination of seven secular, religiously-affiliated, public and private universities that offer midwifery or medical degrees with a specialisation in obstetrics and gynaecology, located in Santiago, Chile.

PARTICIPANTS

Students seeking medical or midwifery degrees at one of seven universities were eligible to participate. We distributed the survey link to medical and midwifery students at these seven universities; 459 eligible students opened the survey link and 377 students completed the survey.

PRIMARY AND SECONDARY OUTCOMES

Intentions to become trained to provide abortion services was our primary outcome of interest. Secondary outcomes included moral views and concerns about abortion provision.

RESULTS

Most students intend to become trained to provide abortion services (69%), 20% reported that they will not provide an abortion under any circumstance, half (50%) had one or more concern about abortion provision and 16% agreed/strongly agreed that providing abortions is morally wrong. Most believed that their university should train medical and midwifery students to provide abortion services (70%-79%). Secular university students reported higher intentions to provide abortion services (beta 0.47, 95% CI: 0.31 to 0.63), more favourable views (beta 0.52, CI: 0.32 to 0.72) and were less likley to report concerns about abortion provision (adjusted OR 0.47, CI: 0.23 to 0.95) than students from religious universities.

CONCLUSION

Medical and midwifery students are interested in becoming trained to provide abortion services and believe their university should provide this training. Integrating high-quality training in abortion care into medical and midwifery programmes will be critical to ensuring that women receive timely, non-judgemental and quality abortion care.