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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
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Counseling in abortion care

Counseling in abortion care
Literature review current through: Jan 2024.
This topic last updated: May 10, 2023.

INTRODUCTION — Approximately one-half of pregnancies in the United States are unintended [1]. Close to one in four females in the United States will have an abortion during their reproductive lifespan, and over half of patients presenting for abortion have already given birth to at least one child.

Patients considering abortion may seek information from various sources. Some may go directly to an abortion clinic, while others may seek the advice of a primary care clinician, gynecologist, midwife, or other clinician and are then referred to an abortion provider or clinic.

The preabortion conversation, which includes elements to facilitate high-quality health care decision making, also known as abortion counseling, is reviewed here. Psychological sequelae of abortion and other issues regarding abortion are discussed separately. (See "Pregnancy termination and potential psychiatric outcomes" and "Overview of pregnancy termination".)

OVERVIEW — Counseling for abortion follows the model of the legal and ethical doctrine of informed consent. The elements of this model include the patient having an understanding of the nature and purpose of the procedure (including alternatives), the risks and benefits of each, an appreciation of the consequences of the decision, voluntariness, and evidencing a choice [2]. (See "Informed procedural consent".)

These elements are operationalized in the preabortion conversation in four main realms:

A description of the procedure – This description prepares the patient for the procedure, reviews pain control options, and sets appropriate expectations for pain.

Decision assessment – The decision assessment addresses decision certainty, support, and expectations for coping. Decision counseling can be performed as needed.

Aftercare instructions – This discussion includes expectations after the abortion and a patient-centered conversation around contraception.

Consent form – This includes a review of the risks and likelihood of their occurrence.

Most patients who receive abortion counseling find the experience helpful [3]. Some states in the United States have legal requirements for giving patients information about potential adverse emotional consequences of abortion. However, patients who receive state-mandated written materials are less likely to find counseling helpful compared with those seeking care at facilities not subject to these laws [3]. In addition, living in a state with a state-mandated waiting period has not been shown to increase decision certainty [4]. Clinicians should consult with their professional organization and local government authority about legal regulations on abortion counseling.

Patients are concerned about the safety of abortion. The safety of legal abortion was illustrated in a consensus study report by the National Academies of Science, Engineering, and Medicine, which concluded that methods of abortion in the United States are safe and complications are rare [5].

Studies of patients' coping before and after abortion have identified factors associated with postabortion coping. Positive postabortion coping is more likely when there is a positive framing of the abortion and of oneself, when there is positive support for the decision, and when the patient reports self-efficacy for coping [6].

After an abortion, studies show that patients experience a mix of positive and negative emotions, with relief predominating and with all emotions diminishing over time [7]. In a five-year longitudinal study comparing patients obtaining abortions with those denied a wanted abortion, the vast majority of participants maintained confidence in the rightness of their abortion decision over time. However, there were factors associated with lower levels of decision rightness: a pregnancy that was more planned, greater difficulty making the decision, and having a partner who did not want to or was unsure about terminating the pregnancy [7]. The vast majority of patients who have negative emotions about their abortion still think it was the right decision [8].

The evidence regarding psychiatric outcomes of abortion is reviewed separately. (See "Pregnancy termination and potential psychiatric outcomes".)

ADDRESSING PRIVACY AND CONFIDENTIALITY — Providers should begin the conversation with patients with a summary of their privacy rights and the limits to confidentiality. Providers should familiarize themselves with the laws of their state and craft a relevant confidentiality statement. A sample statement addressing privacy and confidentiality for adults is available in the table (table 1).

In creating the space of confidentiality and privacy, patients may disclose information that triggers mandatory reporting in most states [9]. Patients presenting for abortion have higher rates of a history of rape, child sexual abuse, and intimate partner violence than those who continue their pregnancies. A study from the Pregnancy Risk Assessment Monitoring System (PRAMS) database of patients who delivered live infants found that 2 percent of patients had experienced intimate partner violence in the year preceding their pregnancy [10]. By contrast, a study of 986 patients presenting for an abortion found the rate of intimate partner violence approached 10 percent [9]. Providers should screen for current and past abuse per routine health guidelines, as appropriate. (See "Intimate partner violence: Diagnosis and screening".)

DESCRIBING THE PROCEDURE — Part of the clinician's duties in satisfying the requirements of informed consent is giving the patient a description of the procedure and what to expect. This includes the steps of the procedure, how long it will take, whether the patient will need to have one or more visits before the procedure (eg, to place osmotic dilators), what to expect in terms of pain and bleeding, and whether the patient is allowed to drive after the procedure.

When a patient is eligible for both medication abortion and aspiration abortion, it is important to frame both options neutrally and avoid showing preference. Patients' fears and assumptions about the nature of abortion methods are often relieved when learning about each in greater detail. Sample language on describing an abortion is outlined in the table (table 2). Many patients have already accessed information about abortion methods (eg, medication abortion, uterine aspiration, dilation and evacuation [D&E]) online before coming to clinic. (See "Overview of pregnancy termination" and "Overview of pregnancy termination", section on 'Choice of procedure'.)

Providers should give patients a realistic expectation regarding the degree of pain they may experience during and after the procedure. Options for pain management should be reviewed with the patient. Setting expectations for pain depends on the available options for analgesia and/or anesthesia.

A description of medication abortion should include the steps of the procedure, what the patient needs to do, deciding on the place to be during the process, and the experience of bleeding and passing pregnancy tissue. Setting expectations for pain during medication abortion includes describing the spectrum of experience, including the possibility of severe pain and the length of time the patient can expect to feel pain. As an example: "Passing the pregnancy can take between one and four hours. This is usually the time where you feel the strongest cramping." Patients may be advised that they can manage pain and other side effects at home using both prescription medications and other remedies such as heat packs.

Aspiration abortion can be described in a manner that includes the minimization of patient participation in the removal of the pregnancy, what to expect during the procedure, how many clinic visits are involved, and how long the patient is likely to be in the clinic on the day of the procedure. Descriptions of the nature of D&E and realistic expectations for pain during dilator insertion foster trust between the patient and provider (table 2).

During aspiration abortion, expectations of pain will depend somewhat on the availability of different forms of analgesia and anesthesia. Most first-trimester aspiration abortions in the United States are achieved with conscious sedation or oral medications with a paracervical block [11]. Some patients are concerned about the paracervical block. The counselor can explain that it is a valuable asset to pain control, for example: "The numbing medicine is important. It goes to work immediately to dull sensation in the cervix. It can be uncomfortable going in, so if we find a sensitive spot, we can give you more medicine in that area if you would like."

Building trust between patient and provider requires honesty on the part of the provider about the possibility of discomfort duration the D&E procedure. Fears about pain can be allayed by reminding patients that they are in control and that the team will stop at any time if patients need to take a break.

Pregnancy termination procedures are described in detail separately. (See "First-trimester pregnancy termination: Uterine aspiration" and "First-trimester pregnancy termination: Medication abortion" and "Second-trimester pregnancy termination: Dilation and evacuation" and "Second-trimester pregnancy termination: Induction (medication) termination".)

DECISION ASSESSMENT — During decision assessment, the patient-provider conversation elucidates several aspects of informed consent: evidencing a choice, voluntariness, and appreciation of the consequences of the decision.

An important aspect of the assessment is ascertaining whether patients feel pressured from people in their support system into making a particular pregnancy decision. Clinicians should provide unbiased counseling to help patients arrive at their own decision. For adolescent patients, attention should be paid to possible pressure to terminate or to continue the pregnancy by the partner, parents, or guardians. (See "Consent in adolescent health care".)

The decision assessment has three components, outlined in the table (table 3).

Decision certainty — A decision assessment can be approached as a closed-ended or open-ended question. Two examples of a closed-ended decision assessment are:

Are you clear and confident in your decision to have an abortion?

Do you feel that abortion is the best decision for you given your life circumstances?

Two examples of an open-ended question are:

What was it like for you to make the decision to have an abortion?

How was it for you to make the decision to have an abortion?

An open-ended question enables the provider to learn the story of the decision, which includes information on voluntariness and appreciation of the consequences. One aspect of high-quality decision making involves a consideration of different outcomes that might result from different decisions and ascribing a likelihood to these outcomes [12]. Patients' decision narratives typically describe their path through these considerations.

Support — Studies suggest that support before and after the abortion can have a positive effect on mental state and perception of the abortion experience [13]. Assessing support can also identify negative support, allowing the counselor and patient to develop strategies to augment coping. Patients with negative support or no support can be given referrals for postabortion talk lines [14] or counseling, or offered a follow-up phone call from the provider to check in.

When assessing support, the provider can also do an assessment for intimate partner violence. As noted above, there are high rates of prior sexual or physical violence among patients presenting for abortion [9]. (See "Intimate partner violence: Diagnosis and screening".)

Expectations for coping — Most patients cope well after an abortion, with preservation of self-esteem and perception of control [15,16]. A study of more than 5000 patients seeking abortion found that, before the procedure, most patients anticipated positive emotions following pregnancy termination [17]. In the same study, patients who anticipated poor coping included adolescents, patients with a history of depression, patients who were ambivalent or felt pushed into terminating the pregnancy, patients who had spiritual concerns about abortion, and patients terminating pregnancies with fetal anomalies [17]. High self-efficacy for coping has been shown to be associated with more positive coping after abortion [18], whereas low self-efficacy was associated with more negative emotions [19].

Counselors should assess their patients' expectations of how they will cope postabortion and help patients identify potential coping mechanisms, especially for those who are experiencing or anticipating emotional distress. Individual counseling about abortion should also identify factors associated with improved coping after an abortion. This includes positive framing of the abortion and oneself [20], positive social support and an absence of negative support [21], and a belief that one can cope after the abortion [22]. The patient's response may indicate that the patient expects to feel a range of feelings. This is an opportunity for the counselor to normalize this range. The patient's response may also indicate some concerns about postabortion coping that were not revealed during the first part of the decision assessment. The provider and patient can plan for coping through recommendations and referrals.

DECISION COUNSELING — Decision counseling becomes relevant when the patient's response to the decision assessment reveals conflict with the decision or decision uncertainty.

Conflict with the decision to terminate a pregnancy can be present alongside decision certainty. Patients may express conflict but at the same time express certainty that abortion is the decision they need to make. Part of the provider's role is to validate and normalize the conflict, seek to understand its origin, and offer a reframe of the conflict based on the patient's personal situation. We have found decision conflict can generally be divided into three categories: emotional conflict, spiritual conflict, and moral conflict. Examples of patient statements expressing conflict are in the table (table 4).

The goals of exploring decision conflict are to reduce negative self-directed emotions, to introduce a positive framing of the abortion, and to improve coping. This is accomplished using a framework based in open-ended questions and probes that accomplish the following [23]:

Normalize and validate

Seek understanding

Reframe the abortion

Examples of statements that normalize and validate, seek understanding, and reframe the abortion are given in the table (table 5). A sample conversation between a patient and provider using the described framework to explore decision conflict is given in the table (table 6). It is not always necessary to make it all the way to a positive reframing. There is substantial value in normalizing and validating a patient's experience. Normalizing tells a patient, "You are unique, but not alone." Validating says, "I see you, and I bear witness to your experience."

Psychiatric outcomes after abortion — During counseling for patients seeking an abortion, those at risk for mental health problems should be identified. For patients who express clinically significant distress, mental health referrals should be made; additional referrals to further in-clinic counseling, community support organizations, or abortion talk lines may also be helpful [14]. (See "Pregnancy termination and potential psychiatric outcomes", section on 'Factors that may increase risk of postabortion psychiatric problems'.)

Online resources are also available for patients. (See 'Resources' below.)

AFTERCARE — The goals of aftercare education are to help patients understand the ways to distinguish normal experiences from issues that require medical attention. Counselors should instruct patients how to recognize and respond to postabortion complications. When providing different types of information, some patients benefit from an approach using more than one learning modality (verbal discussion, visual aids). Patients should be counseled about recovery time, normal duration and severity of pain or bleeding, restrictions, and the impact of their procedure on their ability to return to their everyday life before they consent to the procedure.

An important part of informed consent is providing the patient with information on what to expect after the procedure, precautions and restrictions, and contact information in case of an emergency.

Postprocedure instructions are discussed in detail separately. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Recovery and follow-up' and "Overview of second-trimester pregnancy termination", section on 'Postprocedure considerations' and "First-trimester pregnancy termination: Medication abortion", section on 'Follow-up'.)

Contraceptive health education — Reversible contraceptive methods are typically safe to initiate on the day of or soon after an abortion [24]. A more detailed discussion of postabortion contraceptive methods and initiation is presented separately. (See "Contraception: Postabortion".)

It is important for providers to be sensitive to the unintended consequences of conversations about contraception in the context of the abortion visit. Skillful framing of the discussion around contraception helps to promote autonomy and reduce stigma. Above all, contraceptive counseling is best received when it is patient-centered and respects the patient's preferences and concerns [25].

Assessing a patient's future pregnancy goals guides the conversation about contraception. It can be easy to assume that patients seeking an abortion do not desire pregnancy soon. However, some patients who have abortions do desire to become pregnant again shortly after an abortion. Because patients seek abortions for a variety of reasons, they also have many factors influencing their postabortion reproductive goals.

Data on patient preferences about contraceptive counseling at the time of an abortion are limited. One pilot study found that motivational interviewing increased the uptake of long-acting reversible contraceptives in patients after an abortion [26]. A survey of patients presenting for a first-trimester abortion found that approximately two-thirds did not want to discuss contraception on the day of their abortion [27]. When raising the topic of postabortion contraception, the counselor should recognize that patients will have different views on when and with whom they feel comfortable discussing birth control.

INFORMED CONSENT — A general discussion of informed consent for procedures is discussed separately. (See "Informed procedural consent".)

A review of the risks of the procedure and the likelihood of their occurrence is one of the final pieces in counseling for pregnancy termination. This also provides an opportunity to ask questions and for an invitation from the provider in the form of an open-ended question (eg, "What questions do you have for me?"). Informed consent is then documented in the patient record and on the consent form.

ROLE OF THE REFERRING CLINICIAN — Pregnancy decisions are often made under the pressure of time, cost, availability of services, and legal requirements. This increases the need for timely and appropriate referrals to ensure that patients are able to have an abortion once they have made the decision to do so.

Many requirements associated with abortion are not anticipated by the patient and often delay or increase the cost of the procedure. Most states in the United States have legal restrictions on access to abortion, which may include waiting periods, multiple visits, mandatory preabortion visits with the providing clinician, parental involvement laws, and bans on coverage by Medicaid and commercial insurances. These legal restrictions, in addition to increased travel distance to access available services [28], are associated with lower abortion rates.

With increasing gestational age, the availability of abortion care providers becomes vastly more limited, and the number of days needed to complete the procedure and cost of the procedure increase. Patients often need to arrange dependent care or time away from work to have an abortion. Undesired pregnancy and abortion are experienced disproportionately by the poor [1].

Clinicians who care for adolescents or adults, particularly primary care or urgent care clinicians or gynecologists, are likely to encounter patients who request abortion information or referral. These clinicians can play an important role in counseling patients [29]. For patients requesting a referral, competencies for abortion referral have been described (table 7) [30]. Using a behavior-focused model for making abortion referrals highlights strategies that may also be applicable to other stigmatized health needs (eg, substance abuse treatment, mental health services, etc) [30].

Referring clinicians should be able to provide contact information for abortion providers and offer assistance with scheduling and other necessary arrangements. A referral list of local providers is helpful to patients and preferable to advising a patient to check a printed or online directory. For clinicians, resources such as the National Abortion Federation, Planned Parenthood, or fellow clinicians may be resources to find local abortion providers.

Clinicians should be aware that it may be difficult for patients to bring up the subject of abortion and should be proactive in raising the topic in a manner that puts patients at ease and avoids a perception of stigma. One qualitative study of pregnant patients discussing pregnancy options found that patients desired their clinicians to respect their autonomy; avoid assumptions about their desired pregnancy outcome; and consider patients' needs, including their health and fertility intentions, beyond the pregnancy [31]. Practically speaking, patients who are pregnant want to be asked how they feel about their pregnancy. Clinicians should let patients express their pregnancy desires and then tailor the conversation moving forward. Poor support from the patient's gynecologist or primary care provider may be associated with emotional distress in patients undergoing abortion. Addressing abortion stigma during counseling may decrease a patient's psychological distress [32].

Clinicians may have differing personal views of abortion. Regardless of a clinician's personal views, codes of medical ethics require that clinicians provide impartial information and referrals to patients. Regarding abortion, the American College of Obstetricians and Gynecologists advises that "All health care providers must provide accurate and unbiased information so that patients can make informed decisions" [33].

ROLE OF THE CLINICIAN IN REDUCING STIGMA — In many sections of this topic, we present sample statements, questions, and dialogues for providers to use in their conversations. The authors' goal is to provide language that does not contribute to the stigma of abortion. When continuing a pregnancy and abortion are presented as equally valid options in resolving a pregnancy decision, this increases patient-provider trust and decreases stigma. Many decisions that our patients make may come into conflict with our own personal values and beliefs. Pregnancy decisions are no different. In the same way that we assist our patients in other health care decisions, it is key to remember that "the patient has the answer" to the dilemma. It can be helpful to recognize and remember that our patients' decisions do not directly negatively impact our lives; we are here to support them in navigating the complexity of their lives, even when those decisions do not seem like ones that we ourselves would make.

SPECIAL CONSIDERATIONS

Abortion for patients with fetal abnormalities — Some patients will choose an abortion after learning the pregnancy is complicated by a fetal abnormality (eg, genetic, anatomic). An important part of this counseling is for the clinician to inquire about how the patient is coping, assess the patient's comprehension of the diagnosis and prognosis, and convey condolences for the circumstances. We have found that listening for the language that the patient uses (eg, baby, fetus, pregnancy) and mirroring that language back to the patient provides a safe and patient-centered environment. Examples of language we use include:

"How are you doing with what you have learned about the pregnancy?"

"I am sorry to hear about your baby's diagnosis."

"What is your understanding of your baby's diagnosis?" Validation or clarification can follow.

It is important to remember that receiving a fetal diagnosis does not always lead to the same decision points. For some, the discovery of a particular diagnosis (eg, aneuploidy) is the reason they choose abortion. For others, continuing the pregnancy and allowing the natural course of the diagnosis to unfold is the best alternative; this may include preparing for potentially life-sustaining interventions or palliative/hospice care for the newborn [34] (see "Pediatric palliative care", section on 'Perinatal palliative care'). And yet others may feel that they have the resources to parent a child who may have different abilities and challenges. Each person knows what is realistic and acceptable to them. Communicate support for the patient no matter which path is taken.

Abortion for patients with medical comorbidities — Some patients will choose an abortion because they have an underlying illness (eg, malignancy, cardiopulmonary disease), pregnancy complication (eg, prelabor rupture of the fetal membranes [PROM] before or at the limit of viability), or other indication (eg, pregnancy resulting from sexual assault). A full assessment of the patient's medical and surgical history should occur prior to the abortion procedure. (See "Overview of preoperative evaluation and preparation for gynecologic surgery" and "Overview of pregnancy termination", section on 'Preparation for procedure'.)

RESOURCES — Resources that provide information and support for individuals who are considering abortion include [35]:

Miscarriage & Abortion Hotline (https://www.mahotline.org)

All-Options (https://www.all-options.org/)

Connect & Breathe (https://www.connectandbreathe.org/about.html)

Exhale (https://exhaleprovoice.org/)

Reprocare Healthline (https://abortiononourownterms.org/resources/reprocare-healthline/)

Ending a Wanted Pregnancy (https://endingawantedpregnancy.com/)

A heartbreaking choice (http://aheartbreakingchoice.com/)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pregnancy termination".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Abortion (The Basics)")

Beyond the Basics topics (see "Patient education: Abortion (pregnancy termination) (Beyond the Basics)")

SUMMARY

General principles – Abortion counseling plays an important role in ensuring compassionate, patient-centered care and in reducing abortion stigma. (See 'Overview' above and 'Role of the clinician in reducing stigma' above.)

Components of the counseling visit – Counseling before an abortion ensures the fulfilment of the legal and ethical doctrine of informed consent. This includes:

A description of the procedure, including the steps of the procedure, how long it will take, whether the patient will need to have one or more visits before the procedure (eg, to place osmotic dilators), what to expect in terms of pain and bleeding, and whether the patient is allowed to drive after the procedure. (See 'Describing the procedure' above.)

Decision assessment, in which the patient-provider conversation elucidates several aspects of informed consent: choice, voluntariness, and appreciation of the consequences of the decision. (See 'Decision assessment' above and 'Decision counseling' above.)

Aftercare instructions, including ways to distinguish normal experiences from issues that require medical attention, and how to recognize and respond to postabortion complications. (See 'Aftercare' above.)

Completing the informed consent form, after reviewing the risks of the procedure and the likelihood of their occurrence. (See 'Informed consent' above.)

Addressing confidentiality – Informing patients of their confidentiality rights and the limits to confidentiality is critical for preserving patient-provider trust in the event of mandatory reporting. (See 'Addressing privacy and confidentiality' above.)

Sample language – We provide sample patient statements that reveal possible decision conflict (table 4), sample language for each aspect of the decision counseling framework (table 5), and a short patient-provider dialogue that illustrates the discussion framework (table 6). (See 'Decision counseling' above.)

Referring clinicians – Clinicians in all aspects of medicine play an important role in accurate, timely referrals and can play an important role in counseling patients considering abortion. (See 'Role of the referring clinician' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Uta Landy, PhD, and Philip Darney, MD, MSc, who contributed to earlier versions of this topic review.

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Topic 114587 Version 18.0

References

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