prch © 2006 1 pregnancy and options counseling and values clarification

PRCH © 2006 1

Pregnancy and Options Counseling and

Values Clarification

PRCH © 20062

OutlineOutline Sexuality and pregnancy data

Goals of effective pregnancy options counseling

Pregnancy options

Options counseling in practice

Values Clarification

PRCH © 20063

ObjectivesObjectives By the end of this presentation,

participants will be able to: Identify 3 elements of effective options

counseling relating

Describe the health care provider’s role in the process of options counseling

Discuss the important issues regarding each pregnancy option

Clarify their own feelings around abortion provision and counseling

PRCH © 20064

Pregnancy in the United StatesPregnancy in the United States

More than six million women become More than six million women become pregnant annually pregnant annually

Slightly fewer than two-thirds of these Slightly fewer than two-thirds of these pregnancies result in live birthspregnancies result in live births

20% result in abortions20% result in abortions

The remainder end in miscarriageThe remainder end in miscarriage

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Pregnancy Outcomes for Teenagers 15–19 Pregnancy Outcomes for Teenagers 15–19 Years by Race and Hispanic Origin, Years by Race and Hispanic Origin,

1990 and 20021990 and 2002

0

50

100

150

200

250

1990 2002 1990 2002 1990 2000 1990 2002

Abortion rate

Birth rate

All Races White Black Hispanic

116.3

75.4 98.865.0

223.8

134.2 169.1131.5

Rates per 1,000 women

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Unwanted PregnancyUnwanted Pregnancy

About half of all pregnancies are About half of all pregnancies are unintendedunintended

42% of unintended pregnancies are 42% of unintended pregnancies are terminated by abortionterminated by abortion

Approximately 1/3 of American Approximately 1/3 of American women will have an abortion in their women will have an abortion in their lifetimelifetime

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Legal abortion rate per 1,000 Legal abortion rate per 1,000 women aged 15-44 women aged 15-44

Pennsylvania vs the United StatesPennsylvania vs the United States

05

101520253035404550

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

US

PA

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Women Who Have AbortionsWomen Who Have Abortions

60% are already mothers60% are already mothers More than half intend to have children in the More than half intend to have children in the

futurefuture Nearly 8 in 10 women report religious Nearly 8 in 10 women report religious

affiliationaffiliation 1/3 of women aged 18-44 live in a county 1/3 of women aged 18-44 live in a county

with no abortion providerwith no abortion provider 1 in 4 women have to travel at least 50 1 in 4 women have to travel at least 50

milesmiles

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PennsylvaniaPennsylvania

In 2000, there were 73 abortion providers In 2000, there were 73 abortion providers in Pennsylvaniain Pennsylvania

This represents a 20% increase from This represents a 20% increase from 1996, when there were 61 abortion 1996, when there were 61 abortion providersproviders

The increase in Pennsylvania may have The increase in Pennsylvania may have resulted from the use of state health resulted from the use of state health department data to identify hospitals that department data to identify hospitals that performed small numbers of abortions performed small numbers of abortions

PRCH © 200610

Legal Abortions by Age in PALegal Abortions by Age in PA

0

10

20

30

40

50

60

PA% US%

Ages Up to 19

Ages 20-29

Ages 30-39

Ages 40 andAbove

Unknown

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Access in PennsylvaniaAccess in Pennsylvania

In 2000, 75% of Pennsylvania counties In 2000, 75% of Pennsylvania counties had no abortion providerhad no abortion provider

39% of Pennsylvania women lived in these 39% of Pennsylvania women lived in these countiescounties

In Pennsylvania, 7 metropolitan areas lack In Pennsylvania, 7 metropolitan areas lack an abortion provider: Altoona; Erie; an abortion provider: Altoona; Erie; Johnstown; Lancaster; Scranton-Wilkes-Johnstown; Lancaster; Scranton-Wilkes-Barre-Hazleton; Sharon; Williamsport Barre-Hazleton; Sharon; Williamsport

PRCH © 200612

Abortions in Philadelphia by AgeAbortions in Philadelphia by Age20042004

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Under15

15-19 20-24 25-29 30-34 35-39 40-44 45 &over

Philadelphia

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Pregnancy Pregnancy Options Options

CounselingCounseling

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Effective Pregnancy Options Effective Pregnancy Options CounselingCounseling

Reduces anxiety so that the woman can concentrate on the decisions she has to make

Creates a safe environment in which she can discuss her hopes and fears about her decision

Imparts knowledge and facts about various options and their implications

Clarifies her choices and her feelings about them

Takes into account her cognitive and psychosocial development (if adolescent)

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Effective Pregnancy Options Effective Pregnancy Options CounselingCounseling

Helps herMake a decision that is right for herAccept responsibility for her

decisionAct on her decision, with referrals as

neededMobilize resources including family

and medical care

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Practitioner Should Be Aware Of:Practitioner Should Be Aware Of:

Local support services Necessity of early prenatal care and

follow up Financial issues that may impact her

decision

Increased safety of early abortion

State laws regarding parental notification and consent for termination (for teens)

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Pregnancy OptionsPregnancy Options

Continuation of Pregnancy (47.7%) Adoption (2%) Parenthood (45.5%)

Pregnancy Termination (33.4%)

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Continuation of Pregnancy: Continuation of Pregnancy: Adoption and Raising a BabyAdoption and Raising a Baby

PRCH © 200619

Pregnant Womens’ NeedsPregnant Womens’ Needs Referral for prenatal care including

nutrition counseling and prenatal vitamins Assistance in obtaining Medicaid/CHIP Referral for parenting classes Smoking cessation classes and/or

alcohol/drugs counseling Development of support and parenting

plan

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AdoptionAdoption Closed Adoption: Records about birth

parents are sealed Open Adoption: Birth parents choose

adoptive parents and maintain some level of contact

Adoption Arrangements Private adoption agency Individual county adoption services Non-profit adoption agencies Attorneys

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Changes in Adoption NormsChanges in Adoption Norms

The percentage of infants placed for adoption has decreased in the last 4 decades From 8.7% in 1972 to 2% in 1988.

>3% of Caucasian unmarried women place their children for adoption

>2% of African American unmarried women place their children for adoption

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Pregnancy TerminationPregnancy Termination

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Abortion Rates: 15-19 Year Oldsper 1,000

0

5

10

15

20

25

30

35

40

45

50

88 89 90 91 92 93 94 95 96 97 98 99 2000 20012002

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Pregnancy Termination Pregnancy Termination OptionsOptions

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Medication AbortionMedication Abortion An abortion option for the first 49–63

days of pregnancy Requires 2–3 visits to office/clinic Most common regimen consists of:

An oral dose of mifepristone which blocks the receptors of progesterone

Followed by a dose of misoprostol which causes the uterus to contract and empty

PRCH © 200627

Medication Abortion Pros

Avoids surgical procedure and sedation (in most cases)

Some women feel more in control

Sometimes more culturally acceptable because non-invasive

Cons Requires patient

compliance Necessitates 2–3

office/clinic visits This option is

appropriate for early pregnancy only

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First Trimester Aspiration First Trimester Aspiration AbortionAbortion

Manual Vacuum Aspiration Abortion option through 12 weeks of pregnancy Requires a vacuum syringe that creates suction Actual procedure takes under 5 minutes

Electric Vacuum Aspiration Performed up to 12 weeks of pregnancy A suction catheter removes products of conception Takes between 5 and 10 minutes after the cervix

has been dilated

PRCH © 200629

Second Trimester Options (12–24 Wks)Second Trimester Options (12–24 Wks)

Dilation and Evacuation (D & E) Performed under general or local anesthetic

between 13 and 20 weeks Requires 2 visits to hospital/clinic for dilation

and removal of the fetus Currently the most common method used in the

second trimester Dilation and Extraction (D & X)

D & X procedures are extremely rare Requires 2 visits to hospital or clinic for dilation

and removal of the fetus

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Second Trimester Options (12–24 Wks)

Labor-Induction Abortion Methods Involves laboring and delivering a stillborn

fetus Intra-amniotic hypertonic solutions, such as

urea or saline Prostaglandin inductions (e.g., prostaglandin

E2 suppositories) Uncommon method of abortion

Woman may choose labor induction because it preserves the fetus intact

May be useful in confirming fetal anomalies

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Surgical Abortion Pros Cons During 1st trimester:

Can be completed in one visit

Procedure itself takes between 5–10 minutes

2nd trimester procedure possible

Performed under local anesthesia

Can be performed under sedation

Some women find process invasive

Procedure takes place in hospital or clinic (rather than at home)

External locus of control*

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Pregnancy Options Pregnancy Options Counseling in PracticeCounseling in Practice

PRCH © 200633

What To DoWhat To Do Ask open-ended questions Reflect: “I am hearing you say that you…” Validate: “Many women feel…” Give the patient control: “Which would you

prefer?” Pay attention to non-verbal cues Communicate acceptance: Tone, eye

contact Use silence: Let her finish

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What To AvoidWhat To Avoid

False reassurances: “You’ll be fine.” Over-identification: “I know how you

feel.” Medical jargon: “Have you had

previous terminations?” Loaded and/or judgmental statements Giving advice: “I think you should…”

PRCH © 200635

Utilizing Utilizing DECISIONDECISION

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D: Determine Reason for Visit What can I help you with today? Why do you think you may be

pregnant? When was your last period? Have you ever been pregnant before?

What were the outcome(s)? Are you currently using any form of

contraception?

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E: Evaluate Feelings What do you hope will be the results of

this test? Have you ever wanted to get pregnant? How do you feel about the sexual

encounter that brought you here today? Do you have any friends who are

pregnant or who have had a baby?How do you feel about that?

PRCH © 200638

Give results and remain silent allowing patient to initiate response

IF TEST IS NEGATIVE: How do you feel about the result?

If she is relieved: What are some ways that you can prevent pregnancy in the future? Contraception? Condom use? Disappointment: Refer for further

counseling regarding parenting plans.

Abstinence?

C: Confirm Pregnancy Results

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IF THE TEST IS POSITIVE:IF THE TEST IS POSITIVE: How do you feel about this result? What does a positive pregnancy test

mean to you? Clarify facts regarding gestational

timeline, trimesters, due date What do you think you want to do? What other information do you need to

make your decision?

C: Confirm Pregnancy Results

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I: II: Identifydentify Personal CircumstancesPersonal Circumstances

Place pregnancy in perspective of her life What is your picture of the next year of

your life? Five years? How does this pregnancy affect this?

How do your personal/spiritual/ religious beliefs affect your decision process?

Validate fears and conflicting emotions

PRCH © 200641

Who in your life can help you in a supportive way?

What is your relationship with the man that you are pregnant by?

Do you have a current partner? How would s/he feel about you being

pregnant? Discuss if and when to involve

another adults

S: Assess Support

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I: Address Immediate Concerns Continuing Pregnancy

Access to prenatal care Medicaid enrollment Finishing school

Adoption Open vs. closed Social service

organizations

Parenting Finances Housing Co-parent

Abortion Types of abortion Access to

abortion in your state

Timing Cost

PRCH © 200643

How much time do you need to make this decision?

If you decide to continue the pregnancy: By what date will you make an

appointment for prenatal care? If you decide to have an abortion:

By what date will you schedule an appointment?

O:O: OfferOffer a Timeline a Timeline

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N:N: NNext Stepsext Steps Provide the patient with written

resources and necessary referrals Discuss future contraceptive

options Write an advanced prescription

for EC Ask if she has anymore questions Schedule follow-up visit

PRCH © 200646

Key PointKey Point If the health care provider does not

feel comfortable providing unbiased, accurate information regarding pregnancy options, he/she should refer the patient to someone who does.

PRCH © 200647

Values ClarificationValues Clarification

If 1 in 4 pregnant women will choose an If 1 in 4 pregnant women will choose an abortionabortion How can she trust you won’t judge her?How can she trust you won’t judge her?

There is nothing that is “not judgmental” There is nothing that is “not judgmental” The goal: The goal: identify identify personal beliefs & reflex personal beliefs & reflex

reactionsreactions Then: Then: distinguish these from professional distinguish these from professional

role in the provision of carerole in the provision of care

PRCH © 200648

Everyone stand upEveryone stand up We all do things that we “know better” not to We all do things that we “know better” not to

do even though we know the consequencesdo even though we know the consequences Sit down if you smokeSit down if you smoke

Sit down if you ever eat too muchSit down if you ever eat too much

Sit down if you cross in between carsSit down if you cross in between cars

Sit down if you work too hardSit down if you work too hard

Sit down if you do not maintain the recommended Sit down if you do not maintain the recommended 30min cardio 3 days a week30min cardio 3 days a week

PRCH © 200649

Everyone stand againEveryone stand again

Move to the side of the room that is most Move to the side of the room that is most appropriate for you:appropriate for you: I love chocolate cakeI love chocolate cake

There are good reasons a minor should involve her There are good reasons a minor should involve her parents in an abortion decisionparents in an abortion decision

It is better to have an abortion at 8 weeks rather than It is better to have an abortion at 8 weeks rather than 18 weeks18 weeks

A woman having her 4A woman having her 4thth abortion is just as justified as abortion is just as justified as a woman having her 1a woman having her 1stst

PRCH © 200650

Case 1:Case 1:Ruth is 34 years old, married with 3 Ruth is 34 years old, married with 3 children.children.

She had just ended a month long affair and She had just ended a month long affair and had committed herself to her marriage when had committed herself to her marriage when she discovered she was pregnant. she discovered she was pregnant.

She is unsure with which man she became She is unsure with which man she became pregnant. Her husband is very loving and pregnant. Her husband is very loving and supportive but is unaware of his wife’s supportive but is unaware of his wife’s involvement with another man.involvement with another man.

PRCH © 200651

Case 2:Case 2:A 17-year-old Caucasian woman enters your office suspecting she is pregnant. A pregnancy test confirms her suspicions. She has already spoken to her parents about her situation. She states, “My mom told me I should have an abortion.” How do you proceed with counseling? When do you involve her mother in the discussion (if at all)?

PRCH © 200652

Case 3: Case 3: Sue is 37 years old and married. Sue is 37 years old and married. She and her husband had been trying to She and her husband had been trying to get pregnant for 3 years. get pregnant for 3 years. She just got back the results of her She just got back the results of her amniocentesis that indicate the baby has a amniocentesis that indicate the baby has a severe genetic abnormality. severe genetic abnormality. She is 16 weeks pregnant.She is 16 weeks pregnant.

prch © 2006 1 pregnancy and options counseling and values clarification

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