Patient information should be confidential and only shared with people directly involved in that patient’s care, if the patient gives permission to do so, or by exception, such as to comply with:
- Health department laws about required infectious disease reporting
- Required reporting of suspected child abuse
- Required reporting of domestic violence
- A formal subpoena
- Insurance company (if patient consents to submitting claim)
Disclosure of information under any other circumstance is a breach of confidentiality. Voluntary and informed consent must be obtained from the patient and documented prior to the procedure. Use appropriate translation services for comprehension, privacy, and true informed consent. State laws, malpractice standards, and the ethical standards of medical practice define the parameters of the informed consent process. Follow all applicable laws related to the consent process. For current state laws: http://www.guttmacher.org/statecenter/updates/index.html or https://www.aclu.org/issues/reproductive-freedom/abortion.
Referral begins with providing information to your patient if they need services beyond what you can provide in clinic. In addition to referrals for abortion services not offered at your site, competent referral making may involve the following (Zurek 2015):
- Prenatal care or adoption facilitators (open and closed adoption)
- A pregnancy options talk line for undecided patients
- Intimate partner violence specialists
- Sexual abuse care
- Mental health and/or substance use services
- Post-abortion counseling referrals
Improving care coordination is critical in settings with limited access where patients face greater stigma. Taking a more active role in referral making can help clear up misperceptions or deliberate misinformation about legality and safety of abortion, and can assist with complex social or medical circumstances (Zurek 2015). Important next steps to fully assist the patient may include:
- Scheduling an appointment
- Helping access supportive services such as transportation, childcare, abortion funding or insurance coverage, interpreter services
- Following up on the patient’s satisfaction and outcomes with the care received.
First pelvic exam
If this is a patient’s first pelvic exam, take extra care and time to explain what will happen, what a speculum is, and how to best position and relax one’s body. Explain that future pelvic exams/pap tests will only involve speculum placement so the patient does not anticipate the additional experiences of the abortion.
Gender spectrum and pregnancy
“Transgender” is an umbrella term that refers to an individual whose gender identity (one’s innermost sense of male, female, both or neither) does not match the sex assigned to them at birth. As with anyone who may become pregnant, gender diverse people may experience intended or unintended pregnancy, and may desire prenatal care or may need abortion or adoption services. (Light 2014, Richards 2014)
Many of these patients have limited interaction with the medical field, and may have faced stigmatizing care in the past. Patients may prefer to refer to their body parts using alternative terminology (e.g. “chest exam” instead of “breast exam”). For some transgender patients, gynecological or pregnancy care can be a difficult experience and may trigger gender dysphoria. Fortunately there are a number of excellent resources available to clinicians to help provide medically appropriate and culturally sensitive care to this population. The UCSF Center for Excellence in Transgender Care and information from bedsider.org can provide more in depth information on sex and gender orientation and excellent provision of care.
Provide patient-centered, nonjudgmental care to all clients. To create an affirming environment for transgender and gender non-conforming people, ask patients about their name and pronouns, ensure all staff are aware of these preferences, provide patient intake forms that use gender-neutral language, and include a way to share current gender. (CDC 2016)
The services provided to transgender patients should be based not only on their gender expression but also on hormonal status, and surgical status (i.e. the organs present) which guides appropriate screening. A key concept for transgender men on testosterone is that testosterone is not birth control, and that testosterone is potentially teratogenic.
Contraception counseling in the setting of abortion care
It can be helpful to provide contraceptive options to patients at the time of abortion. While some patients are ready to start contraception and may have chosen a method, many prefer to return for that care or decline contraception (Matulich 2014). Stay focused on the patient’s priorities when discussing options, and see Chapter 6: Contraceptive Counseling for details.
When the provider does not do the abortion counseling/consenting
Depending on how your services are set up, a counselor may conduct pre-abortion counseling instead of the provider. In this case, the provider might check in with patient, “I know you have spoken to the counselor. I wanted to see what questions you may still have for me;” or use teach back on any subject, “Tell me what you learned about (the topic, i.e. breathing)” as a method to assess your patient’s absorption of counseling.
Early Pregnancy Loss
If a pregnancy loss is diagnosed, be sure that the patient understands the diagnosis, implications, and various management options. Reassure the patient that most pregnancy loss is caused by random genetic errors, not something they might have thought/wished for/done. Do not assume how they will react in the context of abortion care, as some patients feel relief, while others still feel sadness or guilt about the loss. See Chapter 8 Counseling Tips for EPL for more information.
Twin pregnancies currently makeup approximately 1% of all pregnancies but occur at higher rates with assisted reproductive technologies and increasing maternal age; additionally miscarriage and complication rates are higher among twin pregnancies. It is not uncommon to discover a multiple gestation during the ultrasound evaluation. While many patients want to know if they have a multiple pregnancy, others do not. This information will occasionally change a patient’s decision. Unless state law requires ultrasound viewing, routinely ask each patient if they want to know prior to the ultrasound, so you can honor their wishes.
Sexual Abuse, Rape and Incest
Patients who have endured sexual abuse, rape, or incest have had little control over the abusive situation and are likely to feel especially vulnerable.You might help a patient feel safe and supported by suggesting:
- “This isn’t your fault. I’m so sorry this has happened to you.”
- “I’m glad you told me; you’re brave to do that.”
- “Many patients in this situation feel alone; you don’t have to feel alone with us.”
- “No one ever deserves for this to happen to them.”
Ask for permission to begin the exam, check in frequently, and explain each step so the patient is prepared. Assure that they control the pace. Consider stating your intention to be gentle. For example, “I am going to gently insert the speculum. Please let me know if it is uncomfortable, so I can stop or readjust it.” You can also offer to let the patient insert it.
If the experience was recent, confirm it has been reported. If not, you can identify the closest sexual assault service providers (from RAINN.org) who are most familiar with local reporting laws and counseling.
While many clinical settings have integrated intimate partner violence screenings, some miss subtle acts of power and control in relationships. Reproductive coercion (RC) refers to explicit attempts to coerce a partner to have unprotected sex, interfere with contraceptive methods, or control outcomes of a pregnancy. These actions limit a patient’s reproductive autonomy and compromise their ability to make decisions around contraception, pregnancy and abortion.
Recent research has shown that RC is common and may lead to an unintended pregnancy. Among women in family planning clinics, 19% of respondents reported ever experiencing pregnancy coercion and 15% reported birth control sabotage by a partner (Miller, 2010). In addition to asking generally about your patient’s support people, you might ask them if anyone is pressuring them to make a decision about this pregnancy or has tampered with or prevented their contraceptive use.