CHAPTER 1 TEACHING POINTS: ORIENTATION: ABORTION IN PERSPECTIVE

EXERCISE 1: Feelings about Providing Abortions

Purpose: This exercise will help clarify your feelings about abortion provision.

1. As you embark on this experience, consider how you might disclose this training to others. Are there parallels between the stigma that patients and providers experience?

• As you explore your level of involvement with options counseling and abortion care, consider if and / or how you will disclose this to family, friends, or acquaintances.
• A “prevalence paradox” is a phenomenon affecting patients and providers alike (Harris 2013). The less something is talked about, the more stigmatized and rare it seems, when in fact it is very common. Silence creates a vicious cycle that often distorts the true nature of things. Research supports that having a safe space to discuss the stigma around abortion may alleviate burdens on providers (Debbink 2016).
• Utilize faculty support to discuss whether you experience a sense of burden or stigma.

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2. Consider the following quotation on the role of conscience in abortion provision, and not just the historical focus on the refusal to participate. What are your thoughts on how this view might decrease stigma?

“[Providers] continue to offer abortion care because deeply held, core ethical beliefs compel them to do so. They see women’s reproductive autonomy as the linchpin of full personhood and self-determination, or they believe that women themselves best understand the life contexts in which childbearing decisions are made, among other reasons.” (Harris 2012)

• It is important to recognize the conscience in abortion provision and not just in the refusal to participate. The goal of this exercise is to assess how provision can address stigma and impact clinical practice, law, religion, and bioethics.
• Some learners find it helpful to hear about other providers’ path to abortion care. See Physicians for Reproductive Health, Clinicians in Abortion Care, or Ho 2019.

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3. Consider the following quotation on the role of conscience in abortion provision, and not just the historical focus on the refusal to participate. What are your thoughts on how this view might decrease stigma?

Keep in mind the following questions:

• How can we frame questions with patients that center their preferences and acknowledge them as experts in their own lives?
• How can we promote dialogue that fosters inquiry, collaboration, and mutual feedback between faculty and trainees?
• How can we create safe spaces in which issues of power are addressed in more transparent ways?

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EXERCISE 2: Practice environment

1. Reflect on the pros/cons of patients receiving abortion care in a primary care setting compared to a specialty setting.

• Studies evaluating abortion setting preferences have varied, but many patients prefer primary care environment for abortion care (Amico 2018, Logsdon 2012).
• Some potential advantages of receiving abortion care in a primary care setting:
  • Personalized care with a provider they know and trust
  • Continuity of care
  • Decreased stigma and normalized abortion in health care context
  • Not having to travel or face protesters
  • Attention to preventive care integrated into abortion care (i.e. pap test)
  • Demonstrated safety in primary care environments
• Potential disadvantages of receiving abortion care in a primary care setting:
  • There may be less privacy in a smaller community
  • There may be more consequence of judgment
  • There may be more memory of an abortion during ongoing care
  • The staff or provider may be less specifically trained for every situation
  • Possibly more need to refer out for complex issues
• While most primary care providers (PCPs) believe PCPs have an obligation to provide abortion referrals, only one in four in a national sample reported routine options counseling compared to 60% who routinely discuss prenatal care (Holt 2017), highlighting a need for professional guidelines and training.

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2. How would a one-week delay impact a patient’s abortion care? Consider impacts of mandatory waiting periods, or changes to legislation in your area.

• A one-week delay in abortion care might:
  • Put a patient over the gestational limit for a provider or type of abortion
  • Change the cost or travel needs for an abortion
  • Increase complication risk with additional delays (NASEM 2018).
  • Force a patient to be pregnant longer than they want to be

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EXERCISE 3.1: General feelings about pregnancy options

Values exploration exercises can be challenging, satisfying, and thought provoking. Consider the origin of your beliefs. How do your feelings affect the interactions you have with a patient? How could recognizing these feelings have a positive impact upon patient care? How do you anticipate your feelings could change with this training experience? For Full Questions see A Values Clarification Guide for Health Care Professionals. NAF 2005.

1. In general, how do you feel about your patients choosing abortion, adoption, or parenthood in each of these situations? Are you challenged to accept a patient’s decision in the following circumstances? Were you surprised by any of your reactions? How have your life experiences contributed to your feelings?

Consider the following key points:

• There are no right or wrong answers to this exercise.
• Patients have the right to make decisions for themselves, follow their own moral authority, and to receive legally available medical services supporting these decisions.
• You serve patients best by providing active listening and accurate information. Even subtle negative reactions to patient behavior may harm the provider-patient relationship.
• Each of us is shaped by our life experiences, families, communities, class, ethnicity, religious beliefs, and other factors that may affect our judgments.
• Self-exploration helps us promote a non-judgmental climate for patient care.
• We cannot know the best decision for each patient.
• Family planning recommendations by providers are found to vary by patient ethnicity and socioeconomic status, contributing to healthcare disparities (Dehlendorf 2010).
• Family planning decisions are well served by a shared decision-making approach that integrates the patient’s priorities with the best scientific evidence.
• If you feel uncertainty about one of these scenarios, consider what patient situation would change your view.

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EXERCISE 3.2: Your feelings about gestational age and abortion

1. At what gestational age do you start feeling uncomfortable about your patient choosing to have an abortion?

• Consider what happens between the gestational age that feels acceptable and the one that doesn’t.
• Does your response have to do with your understanding of fetal development, concerns about fetal pain, physical risk to the patient, what it feels like doing the procedure as a provider, or other perceived ethical concerns?
• When (if ever) you first saw a gestational sac or fetal parts, how did you feel about it? Were there any factors that influenced how you felt?

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2. Does it matter if you are making a referral vs. performing an abortion? Or the reason for the abortion? If so, why?

• If you are struggling with the idea of making referrals, consider if the situation differs from other medical circumstances where we value accurate, evidence-based information and patient autonomy.
• Are there ways to respect the moral autonomy of the patient, without undermining your own?
• What if no other alternative abortion services were accessible? What kind of patient hardship would motivate you to offer services?
• Each provider is different and needs to find their own comfort level.

Return to Exercises

EXERCISE 3.3: Your feelings about patient’s reasons or situation

1. How would you feel about referring or providing an abortion for a patient who:

a. Is ambivalent about having an abortion but whose partner wants them to terminate the pregnancy

• • • While this decision is important for both partners, the pregnant person not only has the legal right to the decision but will bear the ultimate responsibility for whatever decision they make; including the risks of pregnancy and childbearing, should they choose to continue.

b. Wishes to obtain an abortion because they are carrying a female fetus

• • • Sex selection brings up complicated ethical and cultural issues. It might be helpful to ask if there are medical or cultural reasons that support their preference (i.e. sex-linked genetic conditions or family pressure to have a male child). Discussing these with the patient may help you better understand their position.

c. Has had a number of previous abortions

• • • Over half (54%) of patients obtaining abortions used a contraceptive method during the month they became pregnant (Jones 2018. Patients have multiple abortions for many reasons. Discussion may help you better understand their personal barriers to avoiding undesired pregnancy. However, it is important to remember that patients are not responsible for making you comfortable with their decision.
    • Patient-centered counseling may help them find a method that meets their needs and preferences. However, many patients prefer not to engage in contraceptive counseling while navigating an unexpected pregnancy.

d. Indicates that they do not want any birth control method to use in the future

• • • Remember that many patients will not desire contraceptive counseling at the time of an abortion (Brandi 2018). And patients often wish to avoid sex after abortion. Remind the patient that their choice to be sexually active and their choice to become pregnant are two separates considerations. Considering contraception doesn’t mean they intend to or will have sex sometime soon. Alternatively recommend they return if their situation changes.

e. Conceived using assisted reproductive technology, but changed their mind

• • • Think about why your feelings about abortion might differ in a pregnancy conceived by assisted reproductive technologies (ARTs). Are there ways to respect the moral autonomy of the patient, without undermining your own?
    • Patients facing infertility may pursue ART but may still face pregnancy indecision in the face of changing relationships, stressors, or pregnancy abnormalities (Daar 2015).

f. Is in a surrogacy contract and decided to end it

• • • Surrogacy is a method used for treating patients with infertility caused by uterine factors, and by LGBTQ individuals. Most surrogacy arrangements are successfully implemented and most surrogate mothers are well-motivated, psychologically balanced, and have little difficulty separating from children born (Söderström-Anttila 2016).
    • The criteria which influence surrogacy relationships are the expectations of both parties, the type of exchange involved in surrogacy arrangements, the frequency and character of contact pre- and post-birth, and cultural, legal, and economic contexts (Payne 2020)
    • Consider if your feelings about abortion differ in a pregnancy conceived for the purposes of surrogacy, and which party in the surrogacy relationship you identify with.

g. Tried unsuccessfully to end their pregnancy on their own before seeing you.

• • • Self-managed abortions are criminalized in some countries and U.S. states and people can face prosecution.
    • No blood tests confirm whether a patient took abortion medications, although misoprostol used vaginally may sometimes be detected on exam, should ER care be needed.
    • No states require providers to report suspected self-managed abortion

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2. How might you handle your discomfort when caring for patients under these circumstances?

• Many providers avoid asking patients the reasons for an abortion, which allows for patient autonomy. Are there ways to respect the moral autonomy of the patient, without undermining your own?
• Recognizing personal discomfort with a situation is also an important step towards providing unbiased care. Remember there may be more to the situation than the patient communicates directly.
• Sometimes referral is the best option for a patient. Sometimes talking with colleagues may be helpful. Consider how best to provide appropriate support for the patient.