1. Patient-Centered Options Counseling for Unintended Pregnancy Ruth Lesnewski, MD Linda Prine, MD Beth Israel Residency in Urban Family Practice

2. Pregnancies in the United States (Approximately 6.4 Million Annually) UnintendedIntended Source: Henshaw, 2006 (2001 data)

3. Outcomes of Unintended Pregnancies (Approximately 3.0 Million Annually) Source: Henshaw, 2006 (2001 data)

4. Abortion Rates in Western Industrialized Countries Source: Henshaw et al., 1999 (1996 data)

5. Unintended Pregnancy & Abortion among Teens: An international perspective, comparing US with other developed countries

6. Differences in levels of teenage sexual activity across developed countries are small. NOTE: Data are for mid-1990s. Darroch et al. 2001.

7. Half of young women in all study countries begin intercourse between ages 17 and 18. NOTE: Data are for mid-1990s Darroch et al, 2001.

8. U.S. teenagers have higher pregnancy, birth and abortion rates than adolescents in other developed countries. NOTE: Data are for mid-1990s. Darroch et al, 2001.

9. Higher teenage pregnancy, birth and abortion rates in the United States compared with other developed countries reflect: Less contraceptive use Less use of high-efficacy hormonal methods Less sex education – both at school and at home Darroch et al, 2001.

10. Recent trends in unintended pregnancy Overall, teen pregnancy in the US has declined over the past decade However, unintended pregnancy rates have increased among low-income teens and women The gap between rich & poor women’s abortion rates has steadily widened since 1987 Henshaw 1998 Finer and Henshaw 2006

11. Children born from unintended pregnancies are more likely to: Receive no prenatal care Be exposed to tobacco, alcohol, and drugs in utero Have low birth weight Experience abuse as children Die during the first year of life Brown SS and Eisenberg L, 1995

12. Wanted children born to older, better educated parents are more likely to: Succeed in school Avoid addiction and criminal behavior Enjoy healthier relationships Myhrman et al, 1995 Matejcek Z, Dytrich Z, Schuller V, 1985

13. Issues for clinical practice Understand causes of unintended pregnancy Develop strategies for prevention Improve options counseling techniques Refer appropriately

14. Values Clarification Before starting to provide abortion care, values clarification exercises can help faculty, residents and staff to assess their own beliefs. Values clarification exercises can help create a nonjudgmental environment for patients

15. Participants in Values Clarification Workshops Learn to: Identify the myths and reality surrounding the provision of abortion services in this country and the women who have them. Identify their own beliefs and attitudes towards the provision of abortion services and the women who have them. Separate their personal beliefs from their professional role in the provision of abortion services.

16. Exercise 1 Think of a time when you were in trouble, or had a problem and went to someone for help What was it like to ask for help? What was helpful? What was NOT helpful? What are important values to consider when dealing with someone in crisis?

17. Exercise 2 Do you smoke? Ever overeat? Cross between cars? Work too hard for too many hours? Ever have unprotected sex while not trying to become pregnant?

18. Exercise 2 We have all done something we know isn’t good for us, even when we know the consequences. We all have the right to "make bad choices.“ How do we provide a service without imposing our judgment on others? There is nothing that is "not judgmental". The goal is to separate the personal from the professional and to relate to clients on their terms.

19. What beliefs do you have about these statements? Every woman has the right to choose to terminate a pregnancy Parental consent should be required for any teen requesting an abortion Women who have more than one abortion are irresponsible Male partners should have the right to be part of the decision about terminating a pregnancy Abortions should be legal only up to 12 weeks of pregnancy.

20. Sentence Completions Abortions are __________. Women who have abortions are __________. A woman facing an unwanted pregnancy should _________. With a patient who has an unwanted pregnancy, the role of a primary care physician should be to_________. My biggest concern about introducing abortion services is _________. Providing abortions here is __________. In this country, abortion should be __________.

21. Why do women experience unintended pregnancies? Contraceptive failures Lack of access to primary health care services Lack of understanding of reproduction/fertility Sexual assault/abuse/coercion Religion and/or partner forbid use of contraception Poor access to/knowledge about Emergency Contraception

22. Pregnancy Options Counseling Following a positive pregnancy test result, what are a woman ’ s options? Continue pregnancy and: 1. Parent 2. Make an adoption plan Terminate pregnancy through: 1. Medication abortion 2. Aspiration abortion

23. Suggested steps in pregnancy options counseling 1.Explore woman ’ s feelings about the positive test result 2.If she is unsure of her plans, help her to consider her options 3.Identify social supports 4.Help her to reach a decision; or if she is not ready, discuss timetable for decision-making 5.Refer her to or provide her with appropriate services

24. Address Common Concerns: Will an abortion make me infertile? Which method hurts more? What will I see? What will I hear? Do I need my parents’/partner’s permission? How much work will I need to miss with each method?

25. Language Pay attention to language, both verbal and non- verbal Avoid referring to embryo/fetus as “baby” Demonstrate empathy by using patient’s terms & following her cues Use active listening techniques

26. Options for Continuing the Pregnancy Adoption - have referral resources ready - prenatal care often done through adoption agency Continue pregnancy and raise a child - begin prenatal care If still unsure - leave all options open, keep language neutral

27. Adoption 2% of all US children are adopted Private adoption = through an agency or through an intermediary/attorney Public adoption = through foster care Open adoption allows birth parents to choose placement and to have some ongoing contact with the child – an increasing trend in the US

29. Resources for Ambivalent Patients National Abortion Federation – counseling guide: LinkLink Planned Parenthood Federation of America – options guide: LinkLink The Resource Center for Adolescent Pregnancy Prevention –difficult decision worksheet: LinkLink

30. Pregnancy Termination: Medication vs. Aspiration Abortion

31. Medication vs. Aspiration Abortion Gestational age limit: 49-63 days for medication, longer for aspiration Psychological factors: Medication is perceived as more natural, with enhanced control Support: Medication requires privacy, social support

32. Medication Abortion: Advantages 95-98% effective No surgical/anesthetic risk Psychological advantages - feels more private Potential to increase availability of abortion Potential to shield abortion providers Increases choice Winikoff B. 1995. Henshaw RC, 1993. Henshaw SK,1998. Henry J Kaiser Family Foundation, 1998.

33. Medication Abortion Regimens Mifepristone (RU-486) + Misoprostol Methotrexate + Misoprostol Misoprostol alone Finer LB, Henshaw SK, 2000.

34. Key Points for Medication Abortion with Mifepristone/Misoprostol Two step process - First pill swallowed in office, second medication used at home usually 1 or 2 days later and then cramping and bleeding occur Follow up appointment generally recommended to assure success of process Experience is most similar to a spontaneous miscarriage

35. Aspiration Abortion: Advantages More effective (about 99%) Shorter time to completion Shorter bleeding duration No exposure to possible teratogens Can be performed later in gestation Creinin M, Edwards J, 1997.

36. Aspiration Abortion: Manual Vacuum Aspiration (MVA) vs. Electric Vacuum Aspiration (EVA) MVA Inexpensive Small Portable Quiet Better for early pregnancy EVA More expensive Bulky Less portable Noisy Can be used later in pregnancy

37. Referral Once a woman has made her decision, she may need help implementing the plan. Know where you are sending her, and help her understand what to expect.

38. Follow-up After an unintended pregnancy, no matter what the outcome, don’t forget to check on contraception and STI prevention. Take a pro-active approach: review contraception regularly with all patients (men and women) of reproductive age.

39. Women underestimate their risk of getting an STI Women’s perceived greatest health risks: 1.Breast cancer 2.Reproductive cancers (uterine, ovarian, cervical) 3.Heart disease 4.Depression 5.STIs Actual lifetime risk: 1.Heart disease (1 in 2) 2.STIs (1 in 4) 3.Depression (1 in 5) 4.Breast cancer (1 in 8) 5.Reproductive cancers (uterine: 1 in 37; ovarian: 1 in 70; cervical: 1 in 123) Hoff T et all, 2003.

40. Preventing Unintended Pregnancies Primary Prevention: Educate patients about contraception and safer sex practices Regularly ask men, women, and teens about contraceptive needs Encourage use of high-efficacy methods Secondary Prevention: Assure access to Emergency Contraception (EC) through advance prescription and nursing protocols/standing orders

41. Options Counseling Clinicians treating women of reproductive age should be able to describe all options Clinicians unwilling to present all options should refer in a timely fashion to a colleague - without allowing the patient to feel judged or demeaned