The role of nurses and midwives in the provision of abortion care: A scoping review

A nurse-led model of care to improve access to contraception and abortion in rural general practice: Co-design with consumers and providers

AIM

To describe key features of a co-designed nurse-led model of care intended to improve access to early medication abortion and long-acting reversible contraception in rural Australian general practice.

DESIGN

Co-design methodology informed by the Experience-Based Co-Design Framework.

METHODS

Consumers, nurses, physicians and key women's health stakeholders participated in a co-design workshop focused on the patient journey in seeking contraception or abortion care. Data generated at the workshop were analysed using Braun and Clarkes' six-step process for thematic analysis.

RESULTS

Fifty-two participants took part in the co-design workshop. Key recommendations regarding setting up the model included: raising awareness of the early medication abortion and contraceptive implant services, providing flexible booking options, ensuring appointment availability, providing training for reception staff and fostering good relationships with relevant local services. Recommendations for implementing the model were also identified, including the provision of accessible information, patient-approved communication processes that ensure privacy and safety, establishing roles and responsibilities, supporting consumer autonomy and having clear pathways for referrals and complications.

CONCLUSION

Our approach to experience-based co-design ensured that consumer experiences, values and priorities, together with practitioner insights, were central to the development of a nurse-led model of care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The co-designed nurse-led model of care for contraception and medication abortion is one strategy to increase access to these essential reproductive health services, particularly in rural areas, while providing an opportunity for nurses to work to their full scope of practice.

IMPACT

Nurse-led care has gained global recognition as an effective strategy to promote equitable access to sexual and reproductive healthcare. Still, nurse-led contraception and abortion have yet to be implemented andevaluated in Australian general practice. This study will inform the model of care to be implemented and evaluated as part of the ORIENT trial to be completed in 2025.

REPORTING METHOD

Reported in line with the Standards for Reporting Qualitative Research (SRQR) checklist.

PATIENT OR PUBLIC CONTRIBUTION

Two consumer representatives contributed to the development of the co-design methodology as members of the ORIENT Intervention Advisory Group Governance Committee.

What do Australian primary care clinicians need to provide long-acting reversible contraception and early medical abortion? A content analysis of a virtual community of practice

BACKGROUND

Uptake of long-acting reversible contraception (LARC) is lower in Australia compared with other high-income countries, and access to early medical abortion (EMA) is variable with only 11% of general practitioners (GPs) providing EMA. The AusCAPPS (Australian Contraception and Abortion Primary Care Practitioner Support) Network is a virtual community of practice established to support GPs, nurses and pharmacists to provide LARC and EMA in primary care. Evaluating participant engagement with AusCAPPS presents an opportunity to understand clinician needs in relation to LARC and EMA care.

METHODS

Data were collected from July 2021 until July 2023. Numbers of online resource views on AusCAPPS were analysed descriptively and text from participant posts underwent qualitative content analysis.

RESULTS

In mid-2023 AusCAPPS had 1911 members: 1133 (59%) GPs, 439 (23%) pharmacists and 272 (14%) nurses. Concise point-of-care documents were the most frequently viewed resource type. Of the 655 posts, most were created by GPs (532, 81.2%), followed by nurses (88, 13.4%) then pharmacists (16, 2.4%). GPs most commonly posted about clinical issues (263, 49% of GP posts). Nurses posted most frequently about service implementation (24, 27% of nurse posts). Pharmacists posted most about health system and regulatory issues (7, 44% of pharmacist posts).

CONCLUSIONS

GPs, nurses and pharmacists each have professional needs for peer support and resources to initiate or continue LARC and EMA care, with GPs in particular seeking further clinical education and upskilling. Development of resources, training and implementation support may improve LARC and EMA provision in Australian primary care.

Effect of extended precision nursing on neurobehavioral function and pregnancy outcome in patients with threatened abortion

This study aimed to assess the impact of continuous precision nursing on neurobehavioral function and pregnancy outcomes in patients experiencing threatened abortion. A total of 130 patients with early threatened abortion admitted to our hospital between October 2020 and January 2023 were selected and categorized into 2 groups based on intervention methods. The control group received routine nursing intervention, whereas the observation group received continuous precision nursing intervention. Changes in affective status scores, SF-36 scores, knowledge mastery scores, and satisfaction scores in the neurobehavioral function test before and after intervention were recorded in both groups. Additionally, pregnancy outcomes, obstetric adverse reaction rates, and neonatal conditions were documented. Following intervention, scores for tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment gradually decreased in both groups, with significantly lower scores observed in the observation group compared to the control group (P < .05). SF-36 scores in 8 dimensions, including physical functioning, role-physical, bodily pain, and overall health rating, showed a gradual increase in both groups, with the observation group scoring higher than the control group (P < .05). Knowledge mastery and satisfaction scores also increased significantly after intervention, with the observation group surpassing the control group (P < .05). The observation group exhibited lower rates of abortion and premature birth, along with a higher rate of full-term pregnancy compared to the control group, with statistically significant differences (P < .05). Furthermore, the observation group displayed lower rates of adverse reactions and low birth weight infants, with significant differences compared to the control group (P < .05). No significant differences were observed in neonatal mortality and neonatal intensive care unit transfer rates between the observation and control groups (P > .05). Continuous precision nursing contributes to improved pregnancy outcomes for patients with threatened miscarriage within the first 12 weeks of pregnancy. This comprehensive care approach is associated with enhanced knowledge retention, protection of neurological function, and an overall improvement in quality of life.

Failure of the Law to Grant Access to Legal Abortion in Chile

Introduction

In 2017, Chile decriminalized abortion on three grounds: (i) if the pregnant person's life is at risk, (ii) fetal nonviability, and (iii) rape or incest. This multicase study explores the experiences of pregnant people legally entitled to but denied access to legal abortion in Chile.

Methods

Through a snowball sampling approach, we recruited adult Chilean residents who sought, were eligible for, and were denied a legal abortion after September 2017. We conducted semistructured interviews with participants to explore their experiences in seeking and being denied legal abortions. We recorded and transcribed the interviews, then coded and analyzed the transcriptions to identify common themes.

Results

We identified four women who met the eligibility criteria. The interviews revealed five common themes in their experiences: (i) disparate levels of social support in accessing abortion, (ii) abundant access barriers, (iii) forced pregnancy, (iv) abortion stigma, and (v) a failure of the law to provide access to abortion.

Discussion and Health Equity Implications

Although the 2017 law expanded legal access to abortion in Chile, significant barriers remain. Compounded with social stigma, and the socioeconomic disparities in abortion access, pregnant people continue to face insurmountable obstacles in obtaining legal abortions, even when their lives are at risk and the pregnancy is not viable. The state must prioritize equity of access to legal abortions. Future studies should continue to explore the challenges people face accessing legal abortion care to inform strategies to ensure people are able to obtain the quality care that they are legally entitled to.

White Tears: A Phenomenological Study of Perinatal Loss

Perinatal loss is a traumatic experience for parents. This research was conducted to evaluate the experiences and needs of parents after perinatal loss. An interpretative phenomenological study was carried out between January 2021 and July 2022 with 6 parental pairs (12 people in total, 6 mothers and 6 fathers) who experienced a perinatal loss. Participants were reached by snowball sampling method. Data were collected using semi-structured audio recording interviews that were transcribed and analyzed using thematic analysis. The themes of this study were determined as "attributing meaning to loss", "fragmented parenting roles and expectations", "changing relationships", "expectations from healthcare professionals", and "emotional responses". Five sub-themes were created from the emotional responses theme which included. These are sadness and pain, denial, anger, guilt and fear. In the study, it was concluded that the experience of perinatal loss may have negative consequences on the psychological health of the parents. Therefore, specific, professional, adequate nursing support and continuity of support are needed to help parents cope with perinatal losses.

Advanced midwifery practice: A scoping review

PROBLEM

There is no international standard for advanced midwifery scope of practice.

BACKGROUND

Globally, there is variance in how scope of midwifery practice is determined and regulated, with no consensus on extended or advanced scope. This can lead to under-utilised staff potential, un-met consumer need, and loss of professional skill.

AIMS

The aim of this scoping review was to synthesise and map what is reported in the international literature on the advanced scope of midwifery practice.

METHODS

A systematic scoping review methodology was adopted utilising Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A full search was conducted of databases including MEDLINE, CINAHL, Scopus, Google. Publications from 2019 to August 2022 that met criteria were included. Reported skills were mapped to the International Confederation of Midwives (ICM) competencies of pre-conception, antenatal, labour and birth, postnatal plus globally identified areas for midwifery investment.

FINDINGS

28 articles met inclusion criteria. Reported skills included abortion care (n = 6), prescribing (n = 7), ultrasound (n = 2), advanced practice skills (n = 7), midwifery-led skills, primary health, post-graduate education, HIV/AIDS testing, advocacy, and acupressure (all n = 1).

DISCUSSION

This review presents a synopsis of publications describing what has been defined as advanced midwifery scope of practice in international contexts.

CONCLUSION

Establishing evidence of midwives working to the peak of professional scope is important to continue to develop professional capacity and support contemporary practice, regulation, governance, and policy while improving consumer access to equitable care. Findings aid service development, provision, and professional planning.

Multicountry research on comprehensive abortion policy implementation in Latin America: a mixed-methods study protocol

INTRODUCTION

Access to comprehensive abortion care could prevent the death of between 13 865 and 38 940 women and the associated morbidity of 5 million women worldwide. There have been some important improvements in Latin America in terms of laws and policies on abortion. However, the predominant environment is still restrictive, and many women, adolescents and girls still face multiple barriers to exercise their reproductive rights. This research will systematically assess comprehensive abortion policies in five Latin American countries (Argentina, Colombia, Honduras, Mexico and Uruguay). The aim is to identify barriers, facilitators and strategies to the implementation of abortion policies, looking at four key dimensions-regulatory framework, abortion policy dynamics, abortion service delivery and health system and health outcomes indicators-to draw cross-cutting lessons learnt to improve current implementation and inform future safe abortion policy development.

METHODS AND ANALYSIS

A mixed-method design will be used in the five countries to address the four dimensions through the Availability, Accessibility, Acceptability and Quality of Care model. The data collection tools include desk reviews and semi-structured interviews with key actors. Analysis will be performed using thematic analysis and stakeholder analysis. A regional synthesis exercise will be conducted to draw lessons on barriers, facilitators and the strategies.

ETHICS AND DISSEMINATION

The project has been approved by the WHO Research Ethics Review Committee (ID: A66023) and by the local research ethics committees. Informed consent will be obtained from participants. Data will be treated with careful attention to protecting privacy and confidentiality. Findings from the study will be disseminated through a multipurpose strategy to target diverse audiences to foster the use of the study findings to inform the public debate agenda and policy implementation at national level. The strategy will include academic, advocacy and policy arenas and actors, including peer-reviewed publication and national and regional dissemination workshops.

Abortion stigma, abortion exceptionalism, and medical curricula

ABSTRACTWhile it is well established that medical student learning about abortion is inadequate and lacks systemisation, there is little research on why this might be the case. This exploratory study draws on a survey sent to 438 medical educators at Australia's 21 accredited medical schools through March-May 2021. Forty-eight educators responded to the survey. In this article, I examine their responses alongside policy and research on medical education to consider how curricula are determined. I conceptualise abortion exceptionalism - the singling out of abortion from other areas of medicine on the grounds that it is special, different, or more complex or risky than is empirically justified - as a mode of 'stigma-in-action', arguing that medical curricula are powerful sites for its reproduction and undoing.

Midwifery care for late termination of pregnancy: Integrative review

Midwives provide reproductive healthcare to women, including during termination of pregnancy (TOP) after 12 weeks (late TOP). Their expertise, knowledge and woman-centred care approach sees them ideally placed for this role. However, the medical, social and emotional complexities of late TOP can cause midwives significant distress. An integrative review methodology was used to examine the research on midwifery care for late TOP and identify support strategies and interventions available to midwives in this role. Five databases and reference lists were searched for relevant studies published between 2000 and 2021. A total of 2545 records were identified and 24 research studies included. Synthesis of research findings resulted in three themes: Positive aspects, negative aspects and carers need care. Midwives reported a high level of job satisfaction when caring for women during late TOP. Learning new skills and overcoming challenges were positive aspects of their work. Yet, midwives felt unprepared to deal with challenging aspects of late TOP care such as the grief and the psychological burden of the role. Caring for the baby with dignity had both positive and negative aspects. Midwives relied predominantly on close colleagues for help and debriefing as they felt poorly supported by management, judged by co-workers and lacked appropriate support to reduce the emotional effects of late TOP care. Midwives need support, although current evidence has not identified the most appropriate and effective strategy to support them in this role.

Supply of obstetrician-gynecologists and gynecologic oncologists to the US Medicare population: a state-by-state analysis

BACKGROUND

The supply of obstetrician-gynecologists and gynecologic oncologists across the United States has been described. However, these studies focused on reproductive-age patients and did not assess the growing demand for services to the advanced-age female population.

OBJECTIVE

This study aimed to evaluate the supply of obstetrician-gynecologists and gynecologic oncologists who serve the US Medicare population per 100,000 female Medicare beneficiaries, over time and by state and region.

STUDY DESIGN

The supply of obstetrician-gynecologists and gynecologic oncologists was extracted from the Physician and Other Supplier Public Use File database of Medicare Part B claims submitted to the US Centers for Medicare & Medicaid Services. Data were only available from 2012 to 2019. The supply of providers was divided by the number of original female Medicare beneficiaries obtained from the Kaiser Family Foundation; all values reported are providers per 100,000 female beneficiaries by state. Trends over time were assessed as the difference in provider-to-beneficiary ratio and the percentage change from 2012 to 2019. All data were collected in 2021. All analyses were performed with SAS, version 9.4. This study was exempt from institutional review board approval.

RESULTS

In 2019, the average number of obstetrician-gynecologists per 100,000 female beneficiaries across all states was 121.32 (standard deviation±33.03). The 3 states with the highest obstetrician-gynecologist-to-beneficiary ratio were the District of Columbia (268.85), Connecticut (204.62), and Minnesota (171.60), and the 3 states with the lowest were Montana (78.37), West Virginia (82.28), and Iowa (83.92). The average number of gynecologic oncologists was 4.48 (standard deviation±2.08). The 3 states with the highest gynecologic oncologist-to-beneficiary ratio were the District of Columbia (11.30), Rhode Island (10.58), and Connecticut (9.24), and the 3 states with the lowest were Kansas (0.82), Vermont (1.41), and Mississippi (1.47). The number of obstetrician-gynecologists per 100,000 female beneficiaries decreased nationally by 8.4% from 2012 to 2019; the difference in provider-to-beneficiary ratio from 2012 to 2019 ranged from +29.97 (CT) to -82.62 (AK). Regionally, the Northeast had the smallest decrease in the number of obstetrician-gynecologists per 100,000 female beneficiaries (-3.8%) and the West had the largest (-18.2%). The number of gynecologic oncologists per 100,000 female beneficiaries increased by 7.0% nationally during the study period; this difference ranged from +8.96 (DC) to -3.39 (SD). Overall, the West had the smallest increase (4.7%) and the Midwest had the largest (15.4%).

CONCLUSION

There is wide geographic variation in the supply and growth rate of obstetrician-gynecologists and gynecologic oncologists for the female Medicare population. This analysis provides insight into areas of the country where the supply of obstetrician-gynecologists and gynecologic oncologists may not meet current and future demand. The national decrease in the number of obstetrician-gynecologists is alarming, especially because population projections estimate that the proportion of elderly female patients will grow. Future work is needed to determine why fewer providers are available to see Medicare patients and what minimum provider-to-enrollee ratios are needed for gynecologic and cancer care. Once such ratios are established, our results can help determine whether specific states and regions are meeting demand. Additional research is needed to assess the effect of the COVID-19 pandemic on the supply of women's health providers.

Nurse practitioners on 'the leading edge' of medication abortion care: A feminist qualitative approach

AIMS

To explore nurse practitioners' experiences of medication abortion implementation in Canada and to identify ways to further support the implementation of medication abortion by nurse practitioners in Canada.

DESIGN

A qualitative approach informed by feminist theory and integrated knowledge translation.

METHODS

Qualitative interviews with stakeholders and nurse practitioners between January 2020 and May 2021. Data were analysed using critical feminist theory.

RESULTS

Participants included 20 stakeholders, 16 nurse practitioner abortion providers, and seven nurse practitioners who did not provide abortions. We found that nurse practitioners conduct educational, communication and networking activities in the implementation of medication abortion in their communities. Nurse practitioners navigated resistance to abortion care in the health system from employers, colleagues and funders. Participants valued making abortion care more accessible to their patients and indicated that normalizing medication abortion in primary care was important to them.

CONCLUSION

When trained in abortion care and supported by employers, nurse practitioners are leaders of abortion care in their communities and want to provide accessible, inclusive services to their patients. We recommend nursing curricula integrate abortion services in education, and that policymakers and health administrators partner with nurses, physicians, midwives, social workers and pharmacists, for comprehensive provincial/territorial sexual and reproductive health strategies for primary care.

IMPACT

The findings from this study may inform future policy, health administration and curriculum decisions related to reproductive health, and raise awareness about the crucial role of nurse practitioners in abortion care and contributions to reproductive health equity.

PATIENT OR PUBLIC CONTRIBUTION

This study focused on provider experiences. In-kind support was provided by Action Canada for Sexual Health & Rights, an organization that provides direct support and resources to the public and is committed to advocating on behalf of patients and the public seeking sexual and reproductive health services.

Barriers and enablers to nurse practitioner implementation of medication abortion in Canada: A qualitative study

In this study we explored nurse practitioner-provided medication abortion in Canada and identified barriers and enablers to uptake and implementation. Between 2020-2021, we conducted 43 semi-structured interviews with 20 healthcare stakeholders and 23 nurse practitioners who both provided and did not provide medication abortion. Data were analyzed using interpretive description. We identified five overarching themes: 1) Access and use of ultrasound for gestational dating; 2) Advertising and anonymity of services; 3) Abortion as specialized or primary care; 4) Location and proximity to services; and 5) Education, mentorship, and peer support. Under certain conditions, ultrasound is not required for medication abortion, supporting nurse practitioner provision in the absence of access to this technology. Nurse practitioners felt a conflict between wanting to advertise their abortion services while also protecting their anonymity and that of their patients. Some nurse practitioners perceived medication abortion to be a low-resource, easy-to-provide service, while some not providing medication abortion continued to refer patients to specialized clinics. Some participants in rural areas felt unable to provide this service because they were too far from emergency services in the event of complications. Most nurse practitioners did not have any training in abortion care during their education and desired the support of a mentor experienced in abortion provision. Addressing factors that influence nurse practitioner provision of medication abortion will help to broaden access. Nurse practitioners are well-suited to provide medication abortion care but face multiple ongoing barriers to provision. We recommend the integration of medication abortion training into nurse practitioner education. Further, widespread communication from nursing organizations could inform nurse practitioners that medication abortion is within their scope of practice and facilitate public outreach campaigns to inform the public that this service exists and can be provided by nurse practitioners.

Co-design of a nurse-led model of care to increase access to medical abortion and contraception in rural and regional general practice: A protocol

PROBLEM

Women in rural and regional Australia experience a number of barriers to accessing sexual and reproductive health care including lack of local services, high costs and misinformation.

SETTING

Nurse-led task-sharing models of care for provision of long-acting reversible contraception (LARC) and early medical abortion (EMA) are one strategy to reduce barriers and improve access to services but have yet to be developed in general practice.

KEY MEASURES FOR IMPROVEMENT

Through a co-design process, we will develop a nurse-led model of care for LARC and EMA provision that can be delivered through face-to-face consultations or via telehealth in rural general practice in Australia.

STRATEGIES FOR CHANGE

A co-design workshop, involving consumers, health professionals (particularly General Practitioners (GPs) and Practice Nurses (PNs)), GP managers and key stakeholders will be conducted to design nurse-led models of care for LARC and EMA including implant insertion by nurses. The workshop will be informed by the 'Experience-Based Co-Design' toolkit and involves participants mapping the patient journey for service provision to inform a new model of care.

EFFECTS OF CHANGE

Recommendations from the workshop will inform a nurse-led model of care for LARC and EMA provision in rural general practice. The model will provide practical guidance for the set-up and delivery of services.

LESSONS LEARNT

Nurses will work to their full scope of practice to increase accessibility of EMA and LARC in rural Australia.

A Model of True CHOICES: Learnings from a Comprehensive Sexual and Reproductive Health Clinic in Tennessee that Provides Abortions and Opened the City's First Birth Center

CHOICES

Memphis Center for Reproductive Health staff is passionate about ensuring that everyone has access to the full continuum of comprehensive reproductive health care (including abortion, gender-affirming care, miscarriage management, and community birth) regardless of race, gender identity, sexual orientation, HIV status, economic status, or religious beliefs. Memphis, Tennessee, has a history of limited community birth options (birthing outside of hospital walls). In 2017, when home birth services were added to CHOICES and plans for opening Memphis' first freestanding birth center were being imagined, it was intentional to create a model in which midwifery care could be accessible for patients who may be eligible for state-funded health care services, those considered at higher health risk than traditional low-risk midwifery patients, or both. In fact, individuals and their families with limited out-of-pocket funds and those historically marginalized would purposely receive holistic, individualized care based on their unique health care needs and personal desires, driven by a reproductive justice framework. In this article, we outline the success and challenges of addressing the reproductive health needs of marginalized communities, including the benefits of a nonprofit business model, operationalizing reproductive justice concepts, and the reclamation of Black midwifery. We also discuss the challenges of caring for Black birthing people and providing abortion and gender-affirming care in a politically hostile environment. Although individuals have complex needs, at its core, CHOICES believes that every person must be seen as whole human beings and that each can be cared for by a midwife. The CHOICES approach is informed by evidence-based information, clinical judgment, and an intentional partnership with and investment in a people who have historically been and are presently pushed to the margins, neglected, and blamed for poor health outcomes and demise. Striving to adapt the CHOICES model of care in other parts of the country is important now more than ever following the Supreme Court decision to overturn Roe v. Wade.

Effect Analysis of Midwife Education and Training with PDCA Model

With the improvement of social living standards, pregnant women have higher and higher requirements for health and medical personnel. As the main body of medical service personnel, the service objects of midwives are increasing rapidly, while the existing working conditions and abilities of midwives are difficult to meet the growing medical needs of pregnant women. In order to improve the imbalance between supply and demand between limited medical resources and patients' medical treatment, this paper proposed to use PDCA model to educate and train midwives in order to improve their professional ability and work efficiency. Based on the analysis of the structure and functional principle of PDCA model, according to the working requirements of midwives, PDCA model was used to provide midwives with scientific teaching plan, implementation scheme, inspection requirements, and result evaluation methods. In order to test the effect of the application of this model, a group of hospitalized pregnant women were selected as samples and randomly divided into control group and observation group. Through comparative experiments, the effectiveness of PDCA model in midwife education and training was verified. The experimental results showed that the scores of midwife and patient satisfaction, theory and operation skills in the observation group were higher than those in the control group. Compared with the conventional nursing mode, the use of PDCA cycle mode to educate and train midwives had not only effectively improved the theoretical knowledge and professional skills of nurses, but also significantly improved the nursing and delivery monitoring ability of pregnant women. This study has certain reference and guiding significance for clinical medicine and other related application fields.

Willing but not able: A survey of New Zealand health practitioners' interests in providing second trimester abortion care and the obstacles they face

BACKGROUND

In 2020, abortion was removed from the Crimes Act. Abortions under 20 weeks gestation no longer require an indication and criteria for abortion above 20 weeks gestation has broadened. Prior to law reform, all abortions were provided on licensed premises and the responsible health practitioner was a doctor. Subsequently, any health practitioner with abortion in their scope of practice can provide abortion care.

AIMS

To describe the characteristics of health practitioners who expressed an interest in participating in second trimester abortion care, and to identify and describe the barriers to providing an optimal second trimester abortion service.

MATERIALS AND METHODS

This was an exponential non-discriminating snowball email survey using tick boxes and open comments. Quantitative data were analysed using descriptive statistics and free-text components were analysed using a general inductive approach.

RESULTS

The 113 respondents included: 38 hospital-based obstetrics and gynaecology doctors, 22 primary care doctors, 13 midwives and 14 nurses/nurse practitioners. Thirty-three (29.2%) and 62 (54.9%) respondents reported interest in providing second trimester surgical and medical abortion care respectively. The most commonly identified barrier to both surgical and medical second trimester abortion provision was lack of trained staff, followed by an unsupportive work environment. Thematic analysis aligned with these findings and commonly featured difficulty in accessing feticide.

CONCLUSIONS

We need to actively recruit and train all health practitioners interested in providing second trimester abortion care to strengthen the workforce. This requires an organisation to oversee an inclusive national framework for abortion training, including feticide, and provide professional supervision.

Working with or against the system: Nurses' and midwives' process of providing abortion care in the context of gender-based violence in Australia

AIMS

The aim of this study was to explain the process through which Australian nurses and midwives provide abortion care to people affected by gender-based violence (GBV).

DESIGN

A constructivist grounded theory study.

METHODS

This study took place between 2019 and 2021. The lead author conducted semi-structured interviews with 18 Australian nurses and midwives who provided abortion care. Participants were recruited through pro-abortion, nursing and midwifery networks using a snowballing technique. Data collection and analysis proceeded using purposive and theoretical sampling until we reached data saturation.

FINDINGS

Participants revealed they underwent a process of working with or against the system contingent on the degree to which the system (the interconnected networks through which a pregnant person, victimized by trauma, travels) was woman centred. When participants encountered barriers to person-centred abortion care, they bent or broke the law, local policy and cultural norms to facilitate timely holistic care. Though many participants felt professionally compromised, their resolve to continue working against the system continued.

CONCLUSION

Conservative abortion law, policies and clinical mores did not prevent participants from providing abortion care. The professional obligation to provide person-centred care was a higher priority than following the official or unofficial rules of the organizations.

IMPACT

This study addresses the clinical care of people accessing abortions in the context of GBV. Nurses and midwives may act out against the law, organizational policies and norms if prevented from providing person-centred care. This research is relevant for any location that restricts abortion through stigma, pro-life influences or politics.

Views and practice of abortion among Queensland midwives and sexual health nurses

Background

A significant barrier to the access of safe abortion is the lack of trained abortion providers. Recent studies show that with appropriate education, nurses and midwives can provide abortions as safely as medical practitioners.

Aims

To examine the attitudes and practices of registered midwives (RMs) and sexual health nurses (SHNs) in Queensland toward abortion.

Materials and Methods

A cross‐sectional mixed‐methods questionnaire was distributed to RMs and SHNs from the Queensland Nursing and Midwifery Union. Data were described and analysed both quantitatively and qualitatively.

Results

There was a 20% response rate (n = 624) to the survey from the overall study population. There were 53.5% who reported they would support the provision of abortion in any situation at all; 7.4% held views based on religion or conscience that would make them completely opposed to abortion. There were 92.9% who felt that education surrounding abortion should be part of the core curriculum for midwifery and/or nursing students in Australia. The qualitative responses demonstrated a variety of views and suggestions regarding the practice of abortion.

Conclusions

There was a wide variation in views toward induced abortion from RMs and SHNs in Queensland. While a proportion of respondents opposed abortion in most circumstances, a significant group was in support of abortion in any situation and felt involvement in initiating and/or performing abortion would be within the scope of RMs and SHNs.

A qualitative study of early career Australian midwives' encounters with perinatal grief, loss and trauma

PROBLEM

The health of women is dependent on midwifery workforce stability. Retaining new midwives is paramount, however without support, the early career can be a vulnerable time for midwives.

BACKGROUND

Midwives care for women who experience poor perinatal outcomes like stillbirth and neonatal death. Midwifery care in these sentinel events is complex. There is limited understanding of early career midwives' experiences within these encounters.

AIM

To understand the experiences of Australian early career midwives' clinical encounters with perinatal grief, loss and trauma.

METHODS

A qualitative descriptive/exploratory study using in-depth interviews.

FINDINGS

Four themes were identified from interview data: (1) all eyes on the skills; (2) support is of the essence; (3) enduring an emotional toll; (4) at all times, the woman. Most participants had minimal exposure to perinatal loss as a student. As a result, most felt unskilled and unprepared for this as a new midwife.

DISCUSSION

Types and degrees of support varied in these encounters. Early career midwives who were well supported reflected positively on working with grief and loss. In contrast, inadequate or absent support had detrimental effects on participant wellbeing. Poorly supported encounters with death (intrapartum fetal, early neonatal, and maternal) in the early career period were significantly distressful, giving rise to mental and emotional distress.

CONCLUSION

Pre-registration perinatal loss skill development and supported experiences are necessary for preparedness. Continued education, formalised debriefing and mentoring, institutional philosophies which promote collegial ethics of care, and the expansion of continuity of midwifery care models will improve new midwives' experiences.

Viewing the image? Ultrasound examination during abortion preparations, ethical challenges

During preparation for early abortion in Norway, an ultrasound examination is usually performed to determine gestation and viability. This article aims to provide a deeper understanding of women’s and health care personnel’s (HCP) experiences with ultrasound viewing during abortion preparation in the first trimester. Qualitative in-depth interviews with women who had been prepared for early abortion and focus group interviews with HCP from gynaecological units were carried out. A hermeneutic-phenomenological analysis, inspired by van Manen, was chosen. Thirteen women who were pregnant and considering abortion in their first trimester and 20 HCP, namely, 19 registered nurses and one medical doctor, were recruited from gynaecological units at six hospitals. The study was approved by the ethics committee (2014/1276). The essential meaning structure of ‘autonomy under pressure’ consisted of two themes that expressed the different experiences of both the women and the HCP, namely, expectations versus precautions and choice versus protection. The women and HCP expressed different attitudes before the consultation that affected their experiences of the ultrasound examination. While the women had expectations of a clarification based on their choice to either see or not see the ultrasound image, HCP seemed to be more concerned with predetermined rules that they believed would protect the women. Consequently, the basis for dialogue was not optimal, and women’s autonomy was under pressure. Health care personnel are ethically challenged during preabortion ultrasound examinations. Meeting the individual woman’s needs and respecting her autonomy during preparation for abortion requires sensitivity, involvement, and dialogue skills by health personnel. According to the woman’s desire to be informed about the possibility of viewing the image during the abortion preparations, a dialogue that is focused in this direction should arise before the examination.

Immediate IUD insertion after second trimester abortion: implications for service delivery

Background

The availability of modern contraception including long-acting reversible contraceptives (LARC), is a fundamental component of postabortion care. Findings from a recent randomized controlled trial (RCT) in South Africa comparing immediate to delayed insertion of the copper intrauterine device (IUD) after medical abortion (MA) at 17-20 gestational weeks showed that immediate insertion resulted in higher IUD use at 6 weeks postabortion, but that expulsion rates were significantly higher than for delayed insertion. This study aims to explore barriers, facilitators, and context-specific factors relevant to the implementation of immediate IUD provision after second trimester medical abortion.

Methods

We performed a qualitative study alongside the RCT in which we conducted in-depth interviews with 14 staff providing healthcare to study participants and 24 study participants. Research questions explored barriers and facilitators to implementation of immediate IUD insertion, contraceptive decision-making, and the impact of context and supplementary trial activities on service provision. Interviews were recorded and transcribed, with translation into English if needed. We performed a triangulated thematic analysis at the level of the transcribed interview text.

Results

Contraceptive counselling at the abortion facility by a study nurse improved knowledge, corrected misconceptions, and increased demand for the IUD postabortion. Women expressed a clear preference for immediate insertion. Convenience, protection from pregnancy and privacy issues were paramount and women expressed preference for engagement with staff who knew their abortion history, and with whom they had an established connection. Doctors and nurses were generally in favour of immediate insertion and said it could be incorporated into standard care if women wanted this. This contrasted with the need for interventions by the research team to reinforce adherence by staff to provide contraception as allocated during the trial.

Conclusions

Women and staff favour immediate IUD insertion after second trimester medical abortion, but service delivery may require structures that ensure timely insertion postabortion, continuity of care, communication that mitigates loss to follow-up and training of staff to ensure competence.

The Space in the Middle: Attitudes of Women's Health and Neonatal Nurses in the United States about Abortion

INTRODUCTION

Despite playing an integral part in sexual and reproductive health care, including abortion care, nurses are rarely the focus of research regarding their attitudes about abortion.

METHODS

A sample of 1,820 nurse members of the Association of Women's Health, Obstetric, and Neonatal Nurses were surveyed about their demographic and professional backgrounds, religious beliefs, and abortion attitudes. Scores on the Abortion Attitudes Scale were analyzed categorically and trichotomized in multinomial regression analyses.

RESULTS

Almost one-third of the sample (32%) had moderately proabortion attitudes, 29% were unsure, 16% had strongly proabortion attitudes, 13% had strongly antiabortion attitudes, and 11% had moderately antiabortion attitudes. Using trichotomized Abortion Attitudes Scale scores (proabortion, unsure, antiabortion), adjusted regression models showed that the following characteristics were associated with proabortion attitudes: being non-Christian, residence in the North or West, having no children, and having had an abortion.

CONCLUSIONS

Understanding nurses' attitudes toward abortion, and what characteristics may influence their attitudes, is critical to sustaining nursing care for patients considering and seeking abortion. Additionally, because personal characteristics were associated with antiabortion attitudes, it is likely that personal experiences may influence attitudes toward abortion. A large percentage of nurses held attitudes that placed them in the "unsure" category. Given the current ubiquitous polarization of abortion discourse, this finding indicates that the binary narrative of this topic is less pervasive than expected, which lends itself to an emphasis on empathetic and compassionate nursing care.

Practice nurse provision of early medical abortion in general practice: opportunities and limitations

Approximately one in three Australian women with an unintended pregnancy will have an abortion, yet significant barriers remain to ensure the delivery of equitable and timely medical abortion services, including lack of trained providers, high out-of-pocket costs, abortion stigma, conscientious objection and large geographical distance to services. Practice nurses can be suitably trained to provide early medical abortion in general practice; however, there remain several key limitations to the implementation of nurse-led models of care. This forum article discusses these limitations, including issues concerning legislation, funding models, lack of access to medical abortion training, practice structure and systems, and makes recommendations as to how increased access to medical abortion in Australia can be achieved.

The emotional responses of women when terminating a pregnancy for medical reasons: A scoping review

BACKGROUND

In most countries of the world the only basis for considering a termination of pregnancy is for medical reasons. Depending on the circumstances and determinants of each case, the emotional responses to this event vary greatly. The aim of this study is to map the emotional responses of women when their pregnancy is terminated for medical reasons.

METHODS

A scoping review was carried out. This covered all types of qualitative and quantitative studies published in English or Spanish since 2014 which included first-person accounts of women's emotional responses when they had a termination. A bibliographic search was made of four databases (CINAHL, Cochrane Library, PsycINFO and Pubmed) along with an additional manual search and backward and forward citation chaining of the studies included. The data were reported in narrative form and the results grouped according to the descriptive characteristics of the study and the emotions involved.

FINDINGS

The review process resulted in the inclusion of thirty-four studies. nineteen of these followed a qualitative approach and fifteen used quantitative methodology, with six of them being intervention studies. The emotions found ranged from anxiety and depression to guilt and thankfulness, so various authors stressed the need to improve training for health professionals to provide information, advice and support to the women during the entire process of the termination of pregnancy for medical reasons.

CONCLUSIONS

The available studies cannot be compared given the variety of designs. The predominant emotions underlying the termination for medical reasons were stress, anxiety and depression. Future research should be carried out using samples of participants covering all causes of termination for medical reasons in a particular context so that an intervention can be designed to help lessen the impact of the process on women's mental health.

The experiences of nurses and midwives who provide surgical abortion care: A qualitative systematic review

AIM

To synthesize qualitative evidence on nurses' and midwives' experiences in the provision of surgical abortion care. We address three specific questions: (a) what are the experiences of nurses and midwives in surgical abortion care? (b) what are their responses and coping strategies? (c) what are the deficiencies in surgical abortion care?

DESIGN

Qualitative studies were synthesized using Thomas and Harden's qualitative thematic synthesis method.

DATA SOURCES

Electronic databases, including PubMed, Embase, CINAHL, PsycINFO, Scopus and Web of Science were searched. Grey literature using ProQuest was searched. The databases were searched from inception to 5 August 2020.

REVIEW METHODS

The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation and Research type) search tool was used in the literature search. Data synthesis was conducted using the three-stage thematic synthesis method described by Thomas and Harden.

RESULTS

966 studies were identified in the initial search and 18 studies were included. Four analytical themes were generated: 'Providing abortion care requires high emotional labour'; 'Professionalism of abortion care providers'; 'Initiatives in professional development' and 'Improving directions for high-quality abortion care'.

CONCLUSION

Nurses and midwives indicated that they require support to enhance psychological health and improve professional skills. Hospital managers should organize regular debriefing or structured group workshops for exchange of practical experiences and strengthening emotional support. More research is required to establish comprehensive training related to abortion care for nurses and midwives. The findings demonstrate that optimization of abortion services should start from hospital management models, pain management and bereavement care.

IMPACT

Understanding the experiences of nurses and midwives in abortion provision will inform future clinical practice in surgical abortion care, which would be helpful in improving the professionalism and confidence of abortion providers. Our findings have implications for the training, development of policies and standards for surgical abortion care for nurses and midwives.

Women's experiences of accessing a medical termination of pregnancy through a Queensland regional sexual health service: a qualitative study

Background An estimated 25% of Australian women will undergo induced abortion. Few studies have explored Australian women's experiences of accessing medical termination of pregnancy (MToP). This study explored the experiences of women accessing MToP through a regional sexual health service in North Queensland. It aimed to determine the aspects of the process from seeking information about abortion to completion that worked well and to identify areas for improvement.

METHODS

Semi-structured telephone interviews with 11 women who accessed MTOP at Cairns Sexual Health Service (CSHS) were conducted. Interviews were recorded and transcribed verbatim. A deductive analysis approach was used to analyse the data.

RESULTS

Most women had little prior knowledge of MToP or access options and used the Internet to source information. Accessing MToP through a sexual health service was considered positive, non-judgemental, discrete and low-cost despite challenges of fitting in with appointment times and obtaining off-site ultrasound. GPs did not always provide referral; some women described experiences of stigma, discrimination and judgemental care during consultation and when obtaining ultrasounds. Concern for women living in more rural/remote areas was raised. Potential solutions including increased provision through rural general practitioners (GPs) and telehealth.

CONCLUSION

Our study highlights the need for greater awareness of abortion options and access points among the community and healthcare providers. Access through sexual health clinics in regional settings is accepted; however, other options such as increased provision through rural GPs, primary health clinics, telehealth and nurse-led models of care could help overcome some of the barriers faced by rural and remote women.

An ethical issue: nurses' conscientious objection regarding induced abortion in South Korea

Background

The Constitutional Court of South Korea declared that an abortion ban was unconstitutional on April 11, 2019. The National Health Care System will provide abortion care across the country as a formal medical service. Conscientious objection is an issue raised during the construction of legal reforms.

Methods

One hundred sixty-seven perioperative nurses responded to the survey questionnaire. Nurses’ perception about conscientious objection, support of legislation regarding conscientious objection, and intention to object were measured. Logistic regression was used to explore the factors associated with support of the legislation and the intention to conscientiously object.

Results

Only 28.8% of the responding nurses were aware of health care professionals’ conscientious objection. The majority (68.7%) felt that patients’ rights should be prioritized over health care professionals’ conscientious objection. On the other hand, 45.8% supported the legislation on conscientious objection to abortion, and 42.5% indicated a willingness to refuse to participate in an abortion case if conscientious objection was permitted. Religion, awareness of conscientious objection, and prioritizing of nurses’ right to conscientious objection were significantly associated with supporting the legislation. Moreover, religion and prioritizing nurses' rights were significantly associated with the intention to conscientiously object.

Conclusions

This study provides information necessary for further discussion of nurses’ conscientious objection. Nursing leaders, researchers, and educators should appeal to nurses and involve them in making policies that balance a women's right to non-discrimination and to receiving appropriate care with nurses' rights to maintain their moral integrity without compromising their professional obligation.

A critical interpretive synthesis of the roles of midwives in health systems

BACKGROUND

Midwives' roles in sexual and reproductive health and rights continues to evolve. Understanding the profession's role and how midwives can be integrated into health systems is essential in creating evidence-informed policies. Our objective was to develop a theoretical framework of how political system factors and health systems arrangements influence the roles of midwives within the health system.

METHODS

A critical interpretive synthesis was used to develop the theoretical framework. A range of electronic bibliographic databases (CINAHL, EMBASE, Global Health database, HealthSTAR, Health Systems Evidence, MEDLINE and Web of Science) was searched through to 14 May 2020 as were policy and health systems-related and midwifery organisation websites. A coding structure was created to guide the data extraction.

RESULTS

A total of 4533 unique documents were retrieved through electronic searches, of which 4132 were excluded using explicit criteria, leaving 401 potentially relevant records, in addition to the 29 records that were purposively sampled through grey literature. A total of 100 documents were included in the critical interpretive synthesis. The resulting theoretical framework identified the range of political and health system components that can work together to facilitate the integration of midwifery into health systems or act as barriers that restrict the roles of the profession.

CONCLUSIONS

Any changes to the roles of midwives in health systems need to take into account the political system where decisions about their integration will be made as well as the nature of the health system in which they are being integrated. The theoretical framework, which can be thought of as a heuristic, identifies the core contextual factors that governments can use to best leverage their position when working to improve sexual and reproductive health and rights.

Attitudes and Opinions of Young Gynecologists on Pregnancy Termination: Results of a Cross-Sectional Survey in Poland

Background: This paper aims to explore the attitudes and opinions of a group of Polish young gynecologists toward pregnancy termination. Method: An anonymous questionnaire was completed by physicians who participated in obligatory trainee courses held in 2019 in Warsaw. Results: The study group included 71 physicians with an average age of 29 years (SD 3.05). A considerable number of the physicians accepted terminations for medical reasons up to the end of pregnancy, especially in cases of lethal defects (46%) and a serious disease in the mother (34%). Only 6% of the group of gynecologists not performing terminations claimed that the procedure was contrary to their conscience, and 62% of them stated that such procedures were not performed at their hospital. Terminations would be performed by 90% of the respondents in cases of lethal defects of the fetus and by 80% if severe irreversible fetal defects were diagnosed. Conclusions: The main problem associated with the inaccessibility of pregnancy termination in Poland is not linked to individuals, meaning medical personnel and the possibility of invoking the conscience clause, but probably to the lack of approval for terminations granted by hospital supervisors. Adequate knowledge on pregnancy termination procedures, fetal defects, and diseases in the mother translated into the changes of opinions on pregnancy terminations.