CONTRACEPTION –

NOT MUCH REALLY…. • Natural oestrogen COCPs – Zoely, Qlaira, theoretically may have lower DVT risk but no proof

• Pills work better without frequent pill-free intervals. So 3-4 months back to back, and 4 day PFI

ALMOST NOTHING…. • Mirena and copper IUDs first-line contraception for all women, including nulliparous, can be done in GP

Except this…. • Only one diaphragm available, CAYA • 1 size fits most.

And this… • Ulipristal - EllaOne available for emergency contraception from April 2016 • Prescription only • More effective than levonorgestrel on day 5 after

unprotected sex • Seems more effective than levonorgestrel for women

over 70kg • Contraindicated with severe asthma, or high

corticosteroid use • DON’T COMMENCE HORMONAL CONTRACEPTION

FOR 5 DAYS AFTER USE

And very importantly…. • Depo Provera and Implanon are NOT the same hormone, do not have the same range of side effects

• Contraception is ALWAYS safer than pregnancy

Unplanned pregnancy Dr Angela Cooney

Disclaimer Who am I to lecture on this topic???

What is in this presentation? • Values, morals, ethics and law • The legislation – WA & other States • Non directive discussions • The options for an unexpected pregnancy • Questions

• Values = what I believe • Morals = what my neighbours believe • Ethics = what my profession believes • Laws = what the community believes

Values and Ethics

• Values – rules by which we decide ‘right vs wrong’ ‘good vs bad’. Personal • Ethics – formal system of rules adopted by a group, eg doctors. Professional

Values and Morals • How do our own values and morals affect our interaction with patients?

• Be aware of CONFLICTS OF INTEREST between our own values, and societal (ethics and laws)

MEDICAL ETHICS/CODE OF CONDUCT From the Medical Board of Australia website http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx In clinical practice, the care of your patient is your primary concern. Providing good patient care includes:

• Assessing the patient, taking into account the history, the patient’s views, and an appropriate physical examination. The history includes relevant psychological, social and cultural aspects.

• Formulating and implementing a suitable management plan (including arranging investigations and providing information, treatment and advice).

• Facilitating coordination and continuity of care.

• Referring a patient to another practitioner when this is in the patient’s best interests.

• Recognising and respecting patients’ rights to make their own decisions.

WA HEALTH ACT 1911 - SECT 334 Performance of abortions • 1) A reference in this section to performing an abortion includes a reference to • (a) attempting to perform an abortion • (b) doing any act with intent to procure an abortion, whether or not

the woman concerned is pregnant

• 2) No person, hospital, health institution, other institution or service is under a duty, whether by contract or by statutory or other legal requirement, to participate in the performance of any abortion.

Medical Ethical Framework “First do no harm” At SRHWA we often see patients who

have been HARMED by doctors • Feeling judged • Advised to have unnecessary ultrasounds and

other investigations • Unnecessary delays (eg you have to have the

ultrasound before I can refer you) • Referred for counselling to directive services eg

faith-based

MDO Recommendation Dr Penny Browne, Avant Senior Medical Officer

“If you are uncomfortable treating a patient based on your own beliefs, you should apologise to the patient for not being able to meet their needs, and arrange for them to receive the treatment they require”

Medical Ethical Framework Prevention of harm:

Notice on website or in waiting room eg.

Dr Smith does not provide referrals for

abortion

Pregnancy options • Continue pregnancy and become a mum

Antenatal care as usual

• Continue pregnancy and offer for adoption Antenatal care as usual, plus Early contact with DCP:

https://www.dcp.wa.gov.au/FosteringandAdoption/Pages/PregnantAndConsideringAdoption.aspx

• Abortion

Making decisions • Usually women have done their own pregnancy test prior to seeing a doctor

• They may have already decided on their future course of action and don’t need to ‘cool off’.

• If the pregnancy has been diagnosed that day, they may need longer to decide what to do.

Making decisions • GP can help with non directive discussions • Providing wanted information, eg ‘dates and examination suggest that

you are 7 weeks pregnant’ • NOT providing undesired information, eg ‘your baby will have all its

fingers and toes now’ • Helping the woman/couple to balance pros and cons of each choice • Asking ‘does anyone else have a strong view about what you should

do?’ Awareness of DV as a risk. • Provide information about gestation and time left before a decision

needs to be made • Refer for counselling early if ambivalent

What else the consultation might include

• Assessing contraindications or medical risks to pregnancy or termination

• STI risk assessment/testing • Past and future contraception – what went wrong??

Abortion law in WA What does the law actually SAY??? https://www.health.wa.gov.au/publications/documents/Termination_of_Pregnancy_Info_for_Medical_Practitioners_Dec_07.pdf

In May 1998 the Acts Amendment (Abortion) Act 1998 (WA) was enacted. The effect of the amendment to the Code was to make it lawful to perform an abortion where: • the abortion is performed by a medical practitioner in good faith and with reasonable care and skill; and • the performance of the abortion is justified under section 334 of the Health Act. Under section 334 of the Health Act, the performance of an abortion is justified for the purposes of section 199(1) of the Criminal Code if: • the woman has given informed consent; or • in some other limited circumstances (eg involving guardianship)

Abortion law in WA WHAT IS INFORMED CONSENT?? 1) Advise the woman of the risks of continuing the

pregnancy and of finishing the pregnancy 2) Advise the woman of the availability of psychological

counselling (government funded) before she makes a decision

3) Advise the woman of the availability of psychological counselling at any time in the future if she so wishes

Abortion law in WA Two different doctors must be involved 1) the referring doctor – for providing information according to the requirements of the legislation (INFORMED CONSENT)

2) the performing doctor

Counselling Dept of Health funding for unplanned pregnancy (UPP) counselling:

• SRHWA – North and South metro sites • telephone counselling an option for rural/regional

Other counselling services are no longer funded for UPP counselling

MOST WOMEN DO NOT NEED COUNSELLING!

When do things get tricky?

• Woman is under age 16 • Pregnancy is beyond 19’6” gestation

Dependent Minors

A dependent minor is under 16 years of age and supported by a custodial parent.

Informed consent from the minor should be obtained, and

A custodial parent/guardian must be informed that an abortion is being considered, and provided with an opportunity to participate in counselling and consultations between the woman and her doctor. OR...

Dependent Minors • A dependent minor may apply to the Children’s Court for an order that the custodial parent NOT be consulted

• It is up to the Magistrate to decide whether the parents’ participation is required or not

• An order once given cannot be challenged or appealed against

• If the Magistrate feels that an order is not justified, the parent must be involved (but in practice this rarely happens)

Minors: court practicalities • Facilitate contact with Legal Aid or ALS • Client presents to local Children’s Court, (Perth: 160 Pier St, 9am-4pm), and sees The Managing Registrar or The Presiding Magistrate (legal aid lawyers will help organise this).

• Cases will be heard within 3 days.

• Recommend: • Legal Aid 1300 650 579 • Aboriginal Legal Service 1800 019 900 • a support person to assist

Abortion over 20 weeks • “the performance of an abortion is not justified unless the woman or the foetus has a severe medical condition that justifies the procedure”

• 2 medical practitioners who are members of a panel of 6 appointed by the Minister for the purposes of this section must agree that the procedure is justified. (Application by GP on her behalf)

• The abortion is performed in an approved facility (ie KEMH)

In practice, approval is never given for non-medical indications

Over 20 weeks - practicalities • Refer to Social Work Dept KEMH

• Valda Duffield (head of social work) 9340 2222 • Panel only consents for life threatening conditions

• Alternatively, women can go to Victoria • Very costly • Only available up to 24 weeks

Laws in other States & Territories • Legal in Vic, SA, NT, ACT and Tas with specific conditions

• In Criminal Code in NSW and Qld, but case law says abortion can be done if risks to woman justify it

• Specific information on Children by Choice website

http://www.childrenbychoice.org.au/

Abortion method options - medical • Mifepristone plus misoprostol “MS 2 step” • Up to 9 weeks gestation • Most effective earlier in pregnancy • Main contraindications

• Ectopic pregnancy • IUD in situ • Severe disease requiring corticosteroid Rx • Chronic adrenal failure • Haemorrhagic disorders or using anticoagulants

Medical abortion Mifepristone 200ug orally, then 36-48 hours later 4x200ug misoprostol

buccal.

What to expect? Sometimes light bleeding occurs after mifepristone

Side effects from misoprostol • N&V, diarrhoea, fever/chills • generally mild and short-lived

Bleeding and cramping, passage of tissue • usually within 1 – 4 hours after misoprostol • cramping ranges from mild to severe • cramps decrease once pregnancy expelled • average duration of bleeding10-16 days

Medical abortion • Women given analgesia and 24 hour phone number if any concerns

• Followup at 2 weeks to ensure abortion is complete

• Overall very low risk of complications • Infection, heavy bleeding • Incomplete expulsion requiring further misoprostol or

surgical intervention

Abortion options - surgical • Lowest risk prior to 12 weeks gestation, can be performed up to legal limit of 20 weeks

• Low risk of complications • Infection, heavy bleeding, injury to uterus

• Usually done under sedation, sometimes “vocal local”

• Can have implants and IUDs inserted at conclusion of procedure

Where can abortions be done in Perth?

• Nanyara, Rivervale • 9277 6070 www.nanyaraclinic.com

• Dr Marie, Midland • 1800 003 707 www.drmarie.org.au

• Some private gynaecologists • KEMH only if medical necessity

• However, financial assistance available if patient can’t pay – contact Family Services Coordinator

Adoption • Arranged through Department for Child Protection

• Very few women giving birth in WA relinquish their children for adoption (around 8 per year)

• All adoptions in WA have been open (identity of birth family, adoptive family and child available to all) since 1995

• More information available on Dept website: https://www.dcp.wa.gov.au/FosteringandAdoption/Pages/PregnantAndConsideringAdoption.aspx

Training in abortion care • Unplanned Pregnancy Counselling course

• Three day course, held each year at SRHWA

• ms2Step – 3 hour online course to become a provider of medical abortion https://www.ms2step.com.au/

• For extra training options, contact Medical Educator at SRHWA alison.creagh@srhwa.com.au

Resources • Children by Choice

• Information on abortion for patients • Limited support for patients in financial difficulty • Summaries of law in each State

http://www.childrenbychoice.org.au/

• Family Services Coordinator, KEMH • 9340 2222 (ask front desk to page)

• Information book: • http://kemh.health.wa.gov.au/services/termination_of_pregnancy/

docs/wnhs0459.pdf

Questions?