CORE COMPETENCIES FOR ABORTION CARE

This chapter describes competencies for clinicians providing abortion care, regardless of setting. These have been adapted from Cappiello 2016, Health Workforce Pilot Project Evaluation, and TEACH.

I. Competence Level Descriptors: Measurement of achievement and progress

Competence is a baseline level for safe independent practice, with further (post-training) exposure and experience leading to proficiency and subsequent expertise. Attainment and assessment of any competency should progress through the following stages. These tools have been updated with the following scale where relevant, to align with the move towards Competency Based Medical Education (CBME); alternative scales may be used depending on the training program (Ross 2016).

1. N/A: Not applicable or not observed.
2. Beginner (B): Limited fund of knowledge; requires constant assistance/supervision.
3. Advanced Beginner (AB): Developing independent thinking. Requires intermittent observation/assistance. Knows limits and seeks guidance as needed.
4. Developing Competence (DC): Developing independent thinking. Needs intermittent assistance/ supervision; knows limitations, seeks guidance as needed.
5. Competent (C): Occasional assistance/supervision. Knows limits, seeks guidance as needed. Asks appropriate questions to advance understanding and technique.
6. Advanced Competence (AC): No observation required. Rare assistance or consultation. Knows limits and seeks guidance as needed. Discusses complex cases.

II. Specific competencies to be attained

Prerequisite to training: Pregnancy Options Competencies

• Perform comprehensive, person-centered, unbiased, and non-directive pregnancy options counseling and care coordination (for abortion, adoption, prenatal care).
• Effectively communicate with patients, respecting diversity of beliefs.
• Effectively counsel the psychosocially complex patient (e.g. ambivalence, mental health conditions, religious belief conflicts).
• Perform pregnancy test, including appropriate type (urine v. serum), interpret results and deliver results neutrally:
  • If positive, calculate estimated gestational duration and discuss pregnancy options in an unbiased, non-directive manner;
  • If negative, provide appropriate preconception or contraceptive counseling.
• If planning pregnancy continuation: initiate prenatal/adoption care pathways/clinical guidelines.
• If planning termination: initiate abortion care pathways/clinical guidelines.
• If the patient requires more time to come to a decision, provide space and appropriate counseling regarding gestational duration limits and all options for follow-up.
• Assess and manage identified clinical and non-clinical risks, including potential legal barriers to care and risks of pregnancy criminalization, depending on practice setting.
• Provide person-centered contraceptive education and counseling and provide selected method, or refer, as appropriate.
• Provide supportive counseling and education (written, verbal, electronic) to promote closure of encounter, including follow-up and care coordination or referral.
• Steward cost-effective care and resource allocation, without compromising quality.
• Describe the foundations and incorporate trauma-responsive care and Reproductive Justice into reproductive care provision.

Pre-Abortion Assessment Competencies 

• Consider the role of telehealth or remote care for evaluation, medication abortion provision, and/or follow-up.
• Perform pre-abortion clinical history including relevant health, reproductive, sexual and social history and risk assessment.
• Manage responses appropriately to provide necessary screenings (e.g. STI, IPV), counseling (risk reduction), referrals, and partner notification, as needed.
• Perform appropriate clinical exams including assessment of gestation:
  • Arrange/perform labs, ultrasounds, and other tests as prompted by history and exam;
  • Conduct assessment to confirm gestational duration (history, ultrasound, and/or bimanual exam for uterine size);
  • Describe when gestational duration can be assessed by LMP and history vs. ultrasound.
• Manage unexpected findings from routine assessment per clinical guidelines (e.g. early pregnancy loss, ectopic, molar pregnancy, or pregnancy of unknown location).
• Communicate effectively with patients and desired support persons:
  • Arrange interpreter/signer/accommodations if needed;
  • Explain treatment options, side effects and complications clearly without bias;
  • Demonstrate consistent respect for diversity of beliefs and values;
  • Counsel patients with psychosocial complexity or particular vulnerability (ambivalence, family conflicts, religious conflicts, mental health conditions, minors, intimate partner violence, incarceration, those with disabilities, those with limited social support, etc.). Engage other health professionals as needed (e.g. therapist, social worker) to ensure an effective plan and referrals as needed.
• Arrange abortion procedure or refer as needed:
  • Arrange interpreter/signer/accommodations if needed;
  • Consider locally available resources, potential barriers (religiously-affiliated institutions, legal restrictions, cost), and possible need for travel.
• Prescribe medications required for chosen procedure including cervical prep, antibiotic prophylaxis, analgesia, and contraception per clinical guidelines.
• Complete documentation including consent:
  • Perform informed consent;
  • Document episode accurately.
• Formulate, implement and modify management plans, as needed with patient.

Medication Abortion Competencies

• Provide appropriate counseling regarding options and answer patient questions regarding differences between medication and procedural abortion.
• Confirm no medical contraindications.
• Assess gestational duration accurately (by history or ultrasound) and ensure eligibility based on local guidelines.
• Prescribe mifepristone and misoprostol in appropriate doses and routes of administration, and counsel on how to use them.
• Understand pathways for prescribing mifepristone in compliance with the FDA REMS (in-person, mail-order or delivery, via certified pharmacies)
• Provide appropriate aftercare information.
• Provide clinician contact information and arrange for appropriate follow up (in person, via telehealth, or on as-needed basis).
• Discuss pain management options and prescribe as appropriate.
• Other competencies as above (including pre abortion evaluation, counseling, referral, and post-procedure assessment as needed).

Procedural Competencies for Aspiration Abortion <14 weeks 

By manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA)

• Confirm consent for procedure.
• Assess desire to discuss contraception; confirm all medications prescribed/administered, including cervical prep, antibiotics, analgesia, sedation, and contraception.
• Check equipment and supplies for procedure.
• Counsel regarding management options, and manage pain:
  • Use trauma-responsive care, non-pharmacologic support, analgesia, local anesthesia, and/or moderate/conscious sedation (within institutional guidelines).
  • Refers when facility limitations do not meet patient preferences.
• Complete abortion procedure by MVA and/or EVA:
  • Position patient (including patient instruction to position themselves);
  • Use “no-touch” clean technique throughout procedure;
  • Perform:
    • Bimanual exam (empty bladder) as needed;
    • Speculum placement and exam;
    • Tenaculum placement;
    • Application of local anesthetic to cervix;
    • Cervical dilation;
    • Aspiration of uterine contents;
    • Use ultrasound guidance, as needed and available;
    • Gross identification of products of conception; dispose with respect and dignity.
• Manage immediate complications including:
  • Dilation difficulties
  • Aspiration difficulties (i.e. poor aspiration of uterine contents, cannula blockage)
  • Excessive bleeding/hemorrhage, uterine atony
  • Continuing pregnancy
  • Vasovagal reaction
  • Allergic reaction
  • Uterine false passage/perforation
  • Cervical laceration
  • Acute hematometra
• Provide requested immediate post-abortion contraception.
• Communicate with patients during the procedure (when patient level of sedation permits), with attention to comfort.
• Foster communication with other team members participating in patient care.

Additional Competencies for Procedural Abortion at 14-18 weeks

• See other sections for all listed competencies (including pre-abortion evaluation counseling, procedure, contraception, post-procedure assessment, complication management and referral, as needed).
• Evaluate for placental location and understand when to refer out appropriately (suspected previa with cesarean history, placenta accreta, etc.).
• Understand and apply alternatives for cervical preparation.
• Be familiar with and able to safely use forceps for more advanced gestational durations, including at least two forceps types (e.g. ring and finks, or sopher and finks) depending on availability.
• Use ultrasound guidance, as needed and available.
• Assess bleeding risk and use uterotonics as needed.

Post-Procedure Assessment and Follow-up Competencies 

• Perform immediate post-procedure clinical assessment:
  • Confirm procedure complete by consistent and accurate tissue exam of pregnancy elements (or additional pathology exam, as needed);
  • Utilize ultrasound, and/or laboratory assessments (e.g. beta hCG) to confirm resolution of pregnancy, as needed;
  • Assess and tend to physical and psychological well being of patient;
  • Manage inadequate products of conception (i.e. incomplete procedure, rule out ectopic, molar pregnancy, etc.).
• Provide referral for mental health services, web-based resources, peer support, or other care as needed (see “Pre-Abortion Assessment Competencies” above).
• Provide anticipatory guidance, follow-up, primary care, and/or family planning care as desired.
• Detect and manage delayed complications including bleeding, infection, retained products of conception, ongoing pregnancy, and emotional distress.
• Complete documentation.