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PRCH © 2006 1 Pregnancy and Options Counseling and Values Clarification
PRCH © 2006 2 Outline Sexuality and pregnancy data Goals of effective pregnancy options counseling Pregnancy options Options counseling in practice Values Clarification
PRCH © 2006 3 Objectives 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 © 2006 4 Pregnancy in the United States More than six million women become pregnant annually More than six million women become pregnant annually Slightly fewer than two-thirds of these pregnancies result in live births Slightly fewer than two-thirds of these pregnancies result in live births 20% result in abortions 20% result in abortions The remainder end in miscarriage The remainder end in miscarriage
PRCH © 2006 5 Pregnancy Outcomes for Teenagers 15–19 Years by Race and Hispanic Origin, 1990 and 2002 All RacesWhiteBlackHispanic 116.3 75.4 98.8 65.0 223.8 134.2 169.1 131.5 Rates per 1,000 women
PRCH © 2006 6 Unwanted Pregnancy About half of all pregnancies are unintended About half of all pregnancies are unintended 42% of unintended pregnancies are terminated by abortion 42% of unintended pregnancies are terminated by abortion Approximately 1/3 of American women will have an abortion in their lifetime Approximately 1/3 of American women will have an abortion in their lifetime
PRCH © 2006 7 Legal abortion rate per 1,000 women aged 15-44 Pennsylvania vs the United States
PRCH © 2006 8 Women Who Have Abortions 60% are already mothers 60% are already mothers More than half intend to have children in the future More than half intend to have children in the future Nearly 8 in 10 women report religious affiliation Nearly 8 in 10 women report religious affiliation 1/3 of women aged 18-44 live in a county with no abortion provider 1/3 of women aged 18-44 live in a county with no abortion provider 1 in 4 women have to travel at least 50 miles 1 in 4 women have to travel at least 50 miles
PRCH © 2006 9 Pennsylvania In 2000, there were 73 abortion providers in Pennsylvania In 2000, there were 73 abortion providers in Pennsylvania This represents a 20% increase from 1996, when there were 61 abortion providers This represents a 20% increase from 1996, when there were 61 abortion providers The increase in Pennsylvania may have resulted from the use of state health department data to identify hospitals that performed small numbers of abortions The increase in Pennsylvania may have resulted from the use of state health department data to identify hospitals that performed small numbers of abortions
PRCH © 2006 10 Legal Abortions by Age in PA
PRCH © 2006 11 Access in Pennsylvania In 2000, 75% of Pennsylvania counties had no abortion provider In 2000, 75% of Pennsylvania counties had no abortion provider 39% of Pennsylvania women lived in these counties 39% of Pennsylvania women lived in these counties In Pennsylvania, 7 metropolitan areas lack an abortion provider: Altoona; Erie; Johnstown; Lancaster; Scranton-Wilkes- Barre-Hazleton; Sharon; Williamsport In Pennsylvania, 7 metropolitan areas lack an abortion provider: Altoona; Erie; Johnstown; Lancaster; Scranton-Wilkes- Barre-Hazleton; Sharon; Williamsport
PRCH © 2006 12 Abortions in Philadelphia by Age 2004
PRCH © 2006 13 Pregnancy Options Counseling
PRCH © 2006 14 Effective Pregnancy Options Counseling 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)
PRCH © 2006 15 Effective Pregnancy Options Counseling Helps her Make a decision that is right for her Accept responsibility for her decision Act on her decision, with referrals as needed Mobilize resources including family and medical care
PRCH © 2006 16 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)
PRCH © 2006 17 Pregnancy Options Continuation of Pregnancy (47.7%) Adoption (2%) Parenthood (45.5%) Pregnancy Termination (33.4%)
PRCH © 2006 18 Continuation of Pregnancy: Adoption and Raising a Baby
PRCH © 2006 19 Pregnant 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
PRCH © 2006 20 Adoption 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
PRCH © 2006 21 Changes 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
PRCH © 2006 22 Pregnancy Termination
PRCH © 2006 23
PRCH © 2006 24 Abortion Rates: 15-19 Year Olds per 1,000
PRCH © 2006 25 Pregnancy Termination Options
PRCH © 2006 26 Medication 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 © 2006 27 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
PRCH © 2006 28 First Trimester Aspiration Abortion 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 © 2006 29 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
PRCH © 2006 30 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
PRCH © 2006 31 Surgical Abortion Pros Cons During 1 st trimester: Can be completed in one visit Procedure itself takes between 5–10 minutes 2 nd 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*
PRCH © 2006 32 Pregnancy Options Counseling in Practice
PRCH © 2006 33 What 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
PRCH © 2006 34 What 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 © 2006 35 Utilizing DECISION
PRCH © 2006 36 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?
PRCH © 2006 37 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 © 2006 38 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
PRCH © 2006 39 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
PRCH © 2006 40 I: Identify Personal 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 © 2006 41 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
PRCH © 2006 42 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 © 2006 43 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: Offer a Timeline
PRCH © 2006 44 N: Next 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 © 2006 45 Values Clarification
PRCH © 2006 46 Key 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 © 2006 47 Values Clarification If 1 in 4 pregnant women will choose an abortion If 1 in 4 pregnant women will choose an abortion 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: identify personal beliefs & reflex reactions The goal: identify personal beliefs & reflex reactions Then: distinguish these from professional role in the provision of care Then: distinguish these from professional role in the provision of care
PRCH © 2006 48 Everyone stand up We all do things that we “know better” not to do even though we know the consequences We all do things that we “know better” not to do even though we know the consequences Sit down if you smoke Sit down if you smoke Sit down if you ever eat too much Sit down if you ever eat too much Sit down if you cross in between cars Sit down if you cross in between cars Sit down if you work too hard Sit down if you work too hard Sit down if you do not maintain the recommended 30min cardio 3 days a week Sit down if you do not maintain the recommended 30min cardio 3 days a week
PRCH © 2006 49 Everyone stand again Move to the side of the room that is most appropriate for you: Move to the side of the room that is most appropriate for you: I love chocolate cake I love chocolate cake There are good reasons a minor should involve her parents in an abortion decision There are good reasons a minor should involve her parents in an abortion decision It is better to have an abortion at 8 weeks rather than 18 weeks It is better to have an abortion at 8 weeks rather than 18 weeks A woman having her 4 th abortion is just as justified as a woman having her 1 st A woman having her 4 th abortion is just as justified as a woman having her 1 st
PRCH © 2006 50 Case 1: Ruth is 34 years old, married with 3 children. Ruth is 34 years old, married with 3 children. She had just ended a month long affair and had committed herself to her marriage when she discovered she was pregnant. She had just ended a month long affair and had committed herself to her marriage when she discovered she was pregnant. She is unsure with which man she became pregnant. Her husband is very loving and supportive but is unaware of his wife’s involvement with another man. She is unsure with which man she became pregnant. Her husband is very loving and supportive but is unaware of his wife’s involvement with another man.
PRCH © 2006 51 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 © 2006 52 Case 3: Sue is 37 years old and married. Sue is 37 years old and married. She and her husband had been trying to get pregnant for 3 years. She and her husband had been trying to get pregnant for 3 years. She just got back the results of her amniocentesis that indicate the baby has a severe genetic abnormality. She just got back the results of her amniocentesis that indicate the baby has a severe genetic abnormality. She is 16 weeks pregnant. She is 16 weeks pregnant.
PRCH © 2006 53 Please Complete Your Evaluations Now
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