At the conclusion of the program, you should be able to:
- List key elements of pregnancy options and informed consent counseling
- Describe management options for early pregnancy loss
- Perform uterine aspiration for abortion and / or early pregnancy loss
- Describe the steps involved in, and / or provide, early medication abortion
- Describe the management of complications related to early pregnancy loss, medication abortion, and uterine aspiration
- And provide patient-centered contraceptive counseling and management.
- Abortion Modifers:
- We use the term “medication abortion” instead of the previously common term “medical abortion” as it more accurately represents the use of effective medication-based methods to terminate pregnancies. The term “medical abortion” can be associated with medical necessity (Weitz 2004).
- We have adopted the term “aspiration abortion” instead of “surgical abortion” as this avoids the connotation of abortion as a surgical procedure that requires an operating room and/or incisions.
- Gender-neutral language:
- In recognition of a non-binary gender spectrum, we have incorporated gender-neutral language where appropriate including using the term “patient” and the singular “they” instead of “he” or “she.”
- We continue to use gender-specific language to report most research and legal decisions. Also see Chapter 2: Gender Spectrum and Pregnancy.
- Pregnancy loss:
- We have chosen to use “early pregnancy loss” and “miscarriage” interchangeably, and have purposefully avoided terms like “pregnancy failure” that can leave patients with a sense of responsibility for the pregnancy loss.
PROFESSIONAL ETHICS IN REPRODUCTIVE HEALTH
Prevention is increasingly recognized as the most effective means of ensuring health within populations and is receiving heightened focus by recent initiatives including Healthy People 2020 and the Affordable Care Act. Because unintended pregnancy rates in the U.S. are higher than in any other developed country and pose a significant challenge to individual patients and the public health, a comprehensive approach to unintended pregnancy is an essential component within the national public health framework (Taylor 2011).
When assisting patients with the prevention of unintended pregnancies is considered within this framework, there are important expectations that fall on primary care providers. Prevention through contraceptive provision, pregnancy options counseling and provision or referral to appropriate services are among the ethical responsibilities of healthcare providers to assist patients if they desire pregnancy prevention. The availability of modern contraception can reduce but not eliminate the need for abortion.
The concept of pregnancy intention is complex, and not all unintended pregnancies are created equal. While unintended pregnancy pertains to both unplanned and mistimed pregnancies, the index is meant to help us understand fertility, the need for contraception, and a patient’s ability to determine whether and when to have children (Santelli 2003). New research suggests that our current conceptual framework that views pregnancy-related behaviors from a strict planned behavior perspective is limited, particularly among low-income populations (Borrero 2014). Ambivalence, partner influence, and cultural perspective all inform how patients feel about pregnancy intention.
Even with this variation, the significant political and emotional dissonance surrounding reproduction and sexuality has limited funding, research, and guidelines for unintended pregnancy prevention. This in turn poses a significant burden on patients, their families, and the medical system at large. Additionally, it has limited training for providers interested in comprehensive reproductive health care.
Without national guidelines that incorporate prevention and management of unintended pregnancies, approaches vary widely between states and organizations. Until recently there has been a considerable lack of progress with regard to unintended pregnancy in the U.S. (Finer 2016, Institute of Medicine 2010). As the national approach to public health issues shifts toward the promotion of prevention, there is the potential for pregnancy planning, when aligned with patient priorities, to be addressed as a part of a comprehensive public health framework.
While attempting to make reproductive health more accessible, we must bear in mind a reproductive justice or rights framework. Given that coercive practices have historically devalued the childbearing of marginalized populations (Brown 2014), we must remain focused on providing care that is respectful of, and responsive to, individual patient preferences, needs, and values (Gomez 2014) and ensure that patient values guide all our clinical decisions (Institute of Medicine 2001).
This program will vary depending on the training setting. We encourage use in professional training programs, higher-volume clinics, or individual practice in the U.S. or abroad. During this training program, each trainee should:
- Review the training plan and meet with faculty for orientation
- Participate in values clarification around pregnancy options
- Have the opportunity to follow patient(s) through an abortion visit from counseling to recovery
- Review routine aftercare and follow-up
- Discuss case studies involving immediate and delayed abortion complications and manage rare complications when they occur
- Learn contraceptive options, initiation, and contraindications to specific methods
- Discuss case studies and participate in the counseling, evaluation, and treatment of patients experiencing early pregnancy loss
- Complete evaluations to provide feedback about the training program
Those participating in uterine aspiration training for abortion and / or early pregnancy loss will also:
- Handle procedure instruments and manual vacuum aspirator (MVA) with the “no touch” technique
- Observe faculty performing first-trimester uterine aspiration procedures
- Perform uterine aspiration under the direct supervision of faculty
- Perform tissue examinations to identify pregnancy elements accurately
LENGTH OF TRAINING
- For all participants (including opt-out or partial participants): time for orientation, observation, workbook review, and completion of Training Plan and Evaluations.
- For those learning uterine aspiration: time for “hands on” procedural training plus workbook review.
- We encourage evaluation focused on core competencies for individual learners rather than a specific number of procedures or sessions. As a general guide, 4-8 day long sessions may be adequate for a full participant and 1-4 sessions may provide adequate exposure for a partial participant not learning uterine aspiration.
ADVANCED TRAINING OPPORTUNITIES
- See Advanced Column of Training Plan for suggested skills (next page), for which shaded boxes indicate optional activities depending on training goals.
- Those interested in gaining more in-depth skill and knowledge may add:
- Complete elective clinical sessions and procedural exposure
- Complete further training on complex cases and complication simulations
- Read Chapter 9 on Becoming a Provider
- Complete suggested supplemental readings in the Textbook: Management of Unintended and Abnormal Pregnancy (Paul M. et al, Wiley-Blackwell, 2009)
- Consider participating in networking, advocacy, and leadership activities (Chapter 9).
- Plan for additional training, mentorship, fellowship opportunities, and / or future practice in reproductive health.