Counseling for medical abortion

Counseling and education are correlated with women's satisfaction with all abortion care. They often assume a larger role in medical abortion because the patient is a more active participant in the abortion process. This article aims to enhance the practitioner's expertise in providing the information and care necessary for women considering early abortion with medical regimens. It offers general counseling guidelines and several likely clinical scenarios regarding the decision-making process, the screening of patients, and the initial and follow-up visits. Through effective communication, practitioners can provide the information and support that patients need to complete the abortion process safely and can help to strengthen women's confidence in managing their reproductive health experiences.

Medical abortion service delivery

Medical abortion with mifepristone and methotrexate regimens may be offered in a variety of American medical practice settings. In this article the new provider will find information on all aspects of the patient care delivery system for medical abortion, including physical space requirements, staffing and training, patient flow, cost, security, marketing, and quality assurance. Because of the limited published data available regarding logistic issues surrounding abortion care, the information in this article derives largely from the experiences of providers who have established medical abortion practices in their offices or clinics. Its goals are to help make the initial start-up phase briefer and more rewarding for new providers, to offer helpful guidelines for incorporation of medical abortion into practice, and to encourage more practitioners to see the benefits of adding this option to their practices.

The counseling component of medical abortion

OBJECTIVE

To investigate the specifics of counseling for medical abortion.

METHODS

We used both self-administered surveys and semi-structured interviews to collect information from 77 medical abortion providers working in 56 sites. Providers were asked about staff training needs, the essential factors to be stressed in counseling, the time involved, and how counseling for medical abortion compares to counseling for surgical.

RESULTS

Providers reported that counseling for medical abortion took longer than for surgical and that the time medical abortion takes to complete was the most important element to convey. The majority of respondents considered direct experience with patients to be the most effective form of training.

CONCLUSION

This article presents some practical information and strategies for providers and clinic administrators interested in adding medical abortion to their services.

The impact of patient experience on practice: the acceptability of emergency contraceptive pills in inner-city clinics

OBJECTIVES

This article reports on a study of 119 women who sought and used emergency contraceptive pills (ECPs) at Planned Parenthood of New York City (PPNYC) clinics between June 1996 and May 1997. It focuses on their satisfaction with the method, their attitudes toward ECPs, their reactions to the service, and the impact their perceptions had on changing the provision of care.

METHOD

The PPNYC clinical protocol employed the Yuzpe method and fairly conservative procedures, including restrictive screening, a pelvic examination for all new patients, and limited appointment slots. A two-part survey captured information on patient experience with ECPs.

RESULTS

The largest group of respondents (40%) found out about ECPs from friends. Almost 90% of the women were using contraception before their visit to the clinic. Sixty-eight percent reported that they sought ECPs because the condom failed. In the follow-up, a majority (57%) reported that they intended to change or had changed their method of contraception--more than three-quarters to a hormonal contraceptive. While generally satisfied with the service, many respondents were cautious of more extensive distribution of ECPs.

CONCLUSION

The survey results had a profound impact on services: PPNYC revised the ECP protocol, developed a staff training package, expanded its service, and planned a multidimensional public media campaign. Further research, including a closer examination of participants' cautious attitude toward unrestricted distribution of ECPs, will be needed as PPNYC expands access to ECP.

National survey of the states: policies and practices regarding drug-using pregnant women

OBJECTIVES

This study assessed the impact of national policy shifts on state policies and practices regarding substance-using mothers.

METHODS

A 1995 telephone survey of substance abuse and child protective services directors in all 50 states and the District of Columbia was compared with a similar 1992 survey.

RESULTS

There have been significant increases in state interventions for drug-using pregnant women (e.g., criminal prosecution, toxicology testing of women and neonates). Federal resources for treatment and oversight are being replaced by state control of reduced funds for treatment.

CONCLUSIONS

The earlier policy of expanding treatment for addicted women is being replaced by reduction of services and increased state intervention.

Substance abuse and maternity: the United States as a case study

Two themes pervade the issue of women and addiction in the United States: anger and blame directed at women who use alcohol and other drugs; and neglect and a consequent lack of appropriate treatment. Often the focus is on the addicted pregnant woman and the debate posits a woman's right to autonomy and privacy in opposition to the future child's right to be born free from harm. Others emphasize the tension between blaming individuals and holding the state accountable for provision of services. These conflicts have impeded the diagnosis of women with substance abuse problems, the availability of services and women's access to appropriate care.

Reproductive health and blurred professional boundaries

We recognize that many of the issues raised are not simple. Our proposal calls for the same thoughtful deliberation applied in other settings to be brought to bear on reproductive health care. Some have already tried alternative approaches. In Albuquerque, New Mexico, a university hospital neonatologist and the district attorney have collaborated to create an alternative to sentencing program for women who are arrested for drug-related crimes and found to be both pregnant and drug addicted. Rather than proceed with criminal sanctions, these women are offered entry into a drug treatment program that is geared to families with young children and run by the pediatrics department. Here, the physician and the district attorney collaboratively responded in ways congruent with the professional integrity of each. In another example in Portland, Oregon, physicians, drug treatment providers, and child protective social service representatives cooperatively defeated a legislative proposal to mandatorily test and report pregnant women for illicit drug use and, instead, formed a task force to jointly develop state policy regarding the issue. Drug use, HIV infection, child abuse, and poverty are all cause for alarm. Yet it is critical that our frustration about these difficult problems not be translated into blaming individuals for "deviance," or into short-term inadequate responses. In developing policy we should consider the impact on the legal and ethical rights and obligations of both patient and physician. For every course, we should evaluate both immediate and long-term efficacy, the consequences for the doctor-patient relationship, and the consequences for medical integrity. In the midst of the present regulatory and fiscal turmoil affecting health care, we urge physicians to be careful and deliberate in the policies they embrace and the actions they take.

The accessibility of drug treatment for pregnant women: a survey of programs in five cities

Through simulated calls to 294 drug treatment programs in five cities, this study investigated access for pregnant women and compared New York City's provision of services in 1989 to that in 1993. In all sites, the majority of programs accepted pregnant women. There was also a marked improvement in the availability of services in New York City. Yet options were more limited for Medicaid recipients and women needing child care, and an appointment or referral for prenatal care was usually not offered. Although the door for treatment may be opening for pregnant women, institutional barriers still remain.

Finding common ground: the necessity of an integrated agenda for women's and children's health

During the past decade, a new term has entered the medical/legal lexicon : maternal-fetal conflict. Implicit in the terminology is the assumption that a pregnant woman and her fetus have separate and competing rights. This concept has stimulated extensive legal and ethical debate, primarily in the context of medical interventions (cesarean sections and blood transfusions) forced on unwilling pregnant women, and in corporate efforts to bar fertile women from hazardous jobs. On one side of the debate are the proponents of the future child's right to be born of sound mind and body, and society's interest in the delivery of healthy newborns. On the other side, are advocates of a woman's right to reproductive autonomy, bodily integrity, due process, confidential medical treatment, and freedom from gender discrimination. Neither side has challenged the formulation of the problem, or has examined its permeation into public health policy.

Model Programs Addressing Perinatal Drug Exposure and Human Immunodeficiency Virus Infection: Integrating Women's and Children's Needs

Many of the efforts to address perinatal drug exposure and human immunodeficiency virus infection have been influenced by a perspective of conflict between the interests of mother and infant. This article highlights several programs that integrate women's and children's services while dealing with these health issues. It discusses the challenges encountered by these programs, such as funding restrictions, institutional barriers, professional attitudes, regulatory constraints, and local political issues. It presents strategies for overcoming these barriers including the creative coordination of funding streams, innovative relationships with child protective agencies, effective collaboration with other agencies, and advocacy on behalf of clients and programs, and makes recommendations for certain policy changes, which could foster the development of programs that serve women and children together.