TEACHING POINTS FOR CHAPTER 10: PRACTICE INTEGRATION EXERCISES

EXERCISE 10.1

Purpose: These exercises will help you consider potential barriers and strategies for integrating reproductive health services into practice. Although they refer to abortion and miscarriage services, they could be used for other services you may be planning.

1. List 3 barriers that you think you may encounter in trying to integrate reproductive health services in your practice. How would you address each?

• Controversy: There will tend to be controversy where there is change.
  
  • Work gradually on building support for reproductive health services, so staff might first understand the benefits to patients of offering comprehensive contraception and miscarriage services.
    • Begin by offering updates about reproductive health services.
    • Share stories of challenges patients have had accessing services.
  • It will be important to find the root cause of the controversy and try to directly address that issue.
  • Gradually build up to the idea of including abortion in your service, and if staff objects, refer to the tools included for working through values clarification.
  • In primary care settings, suggest that most integrated clinics perform a low volume of abortions (i.e. 1-2 per week, which rarely draws attention).
  • Draw on shared values, such as providing comprehensive care for patients, being a trusted first source of care for your community, etc.
  • Talk to other sites that have done the same thing for a “reality check.”

To respond to common concerns, it can be compelling to include the experience of patients. Being able to offer comprehensive care is the most important reason to start abortion services, and will benefit the practice in terms of client retention.

“No one ever asks for an abortion here. It’s not a needed service.”-“We can just send our miscarriage patients to the ER.”

If you care for pregnant patients in your practice, consider that nearly half of pregnancies are unintended, approximately 1 in 5 pregnancies end in miscarriage, and 1 of 4 pregnant patients choose to have an abortion (Guttmacher 2019). You can anticipate that a certain percentage of your patients will seek services both for miscarriage management and abortion. Studies have shown that many patients prefer receiving abortion services through their primary care physician, citing “comfort” as the top reason for this preference (Summit 2016, Godfrey 2010, Rubin 2009). Providing these services in a primary care setting helps to broaden access for communities and reduces the stigma associated with abortion and EPL care. Offering these services in a primary care setting is often more cost-effective and with respect to miscarriage care, better for patient’s emotional well-being (Dalton 2006). Patients experiencing EPL report having negative experiences in the ER, including feeling rushed and dismissed and reporting that their priorities (both physical and emotional) are not met or respected (Baird 2018, MacWilliams 2016).

Fear of complications

First trimester abortion is one of the safest medical procedures, with minimal risk of major complication. It is at least 10-fold safer than continuing a pregnancy to term. Nearly 90% of patients obtain abortions at less than 12 weeks GA (Guttmacher 2019).

Myths about abortion such as “our patients don’t need abortion services”

Patients with a uterus from every reproductive age group, every socio-economic background, and who use every type of contraception, seek out abortion services. When faced with these myths, it is helpful to move the discussion away from punishing the patient to dispelling common biases.

“There are other providers in the area. Why do we have to take this on?”

There are many areas where there are multiple services being offered – management of hypertension, management of diabetes, dentistry. The reason to offer the services is to meet the needs of your patients, not to compete with other providers. The idea that abortion is just part of the spectrum of comprehensive care for our patients is the most compelling argument. In addition, as noted above, for many patients the comfort and ease of accessing abortion care within their primary care setting is a strong preference, as this allows for quality care without the stigma and barriers sometimes associated with other clinical settings.

“Abortion is out of our scope of practice.”

Early pregnancy termination is within the scope of practice of primary care physicians, as well as advanced practice clinicians in an increasing number of states. Safety and efficacy of abortion in the first trimester are equivalent between physicians and advanced practice clinicians (Barnard 2015). Appropriate training in abortion care and demonstrated competency are the key issues. Clinicians from many specialties have excelled at abortion provision and have come to make significant advances in the reproductive health field.

“Isn’t abortion is a form of reproductive coercion? Are we pushing abortions on communities of color?”

Reproductive coercion is a behavior that is intended to maintain power and control over another person. This is opposed to increasing access to abortion which is rooted in a person having bodily autonomy. As stated so clearly by SisterSong Reproductive Justice, “There is no choice where there is no access.” For people who cannot afford the travel and cost of abortion services, there is not the same choice as those who have these financial resources. Building services into primary care settings improves access, dignified care, and a sense of autonomy for patients of all racial and economic backgrounds.

The medical community has and continues to contribute to institutionalized racism, and there is much work ahead to address care disparities and rebuild trust. Universal access to comprehensive reproductive healthcare, including abortion care, will decrease racial healthcare inequities and increase access to services to meet the needs and desires of individuals and communities, from prenatal care to abortion care.

Concerns about security

There are many resources and people to help assess the actual risk, and determine if there are areas that may need additional security reinforcement. Most medical centers have security protocols in place that can be adapted as necessary. See the security section for more information and resources.

Expense of malpractice/unable to obtain malpractice coverage.

Providers who do not have coverage for EPL and abortion services under their institutions’ professional liability insurance, can obtain supplemental malpractice insurance, of which a number of options exist. (See Malpractice Section for possible solutions and support)

Advocacy for improved regulation of the insurance industry could also help ensure that clinicians trained and willing to provide services to their patients are not limited by the decisions of liability insurers (Dehlendorf 2008).

Expense of starting new services.

There are ways to initiate reproductive health services without investing too much early on. One is to start with medication abortion, and to assess for patients’ medication abortion completion by clinical history or hCG testing, rather than ultrasound (NAF 2022), referring out for ultrasound as needed.

If you choose to integrate in-clinic aspiration for EPL or abortion, keep in mind that some organizations may provide funding to offset start-up costs for EPL and/or abortion services. Additionally, manual vacuum aspiration (MVA) is a safe and effective alternative to conventional electric vacuum aspiration.

Reimbursement considerations

Limited reimbursement will be more of an issue in states where there is no Medicaid funding of abortion. Connecting to local or national abortion funds can help patients cover the cost of services, and supportive services such as travel support (i.e. brigidalliance.org). Miscarriage care should be covered by Medicaid and other insurers as a standard component of prenatal care.

Return To Exercises

2. Who are the key stakeholders in starting this service? How would you approach getting buy-in from your stakeholders or staff?

See the Key Stakeholders Section for important players and what may be important to discuss with them. Various parties may be particularly interested in concepts of broadened patient services, increased patient continuity and retention, cost-effectiveness of minimizing referrals or getting services out of the operating room, and the training/faculty development options. As you meet with different stakeholders, emphasize what will resonate most with them.

In the process of incorporating staff, allow time and space for values clarification to process ambivalent or negative reactions. These reactions need to be aired, and will not mean you will be unable to offer abortion services. Consider the following actions to encourage participation in others:

Model:

• • Commitment to person-centered care
  • Commitment to addressing each person’s reproductive health care needs
  • Confidence in your technical skills and your ability to assist staff in transition to offering this service

Train – offer formal and informal staff meetings on the following:

• • Values Clarification exercises
  • Evidence based talks, with Q&A about the services you want to provide (EPL management, telemedicine abortion, or in-clinic abortion)
  • Shared experiences from your training

Reassure:

• • “We will begin slowly and have all the training and support that we require.”
  • “We will offer broader reproductive health services that will enhance rather than disrupt our services.”
  • “We intend to help our patients who trust us already.”

Personalize:

• • “I would want my sister or friend to be cared for by a staff like this.”
  • Share success stories from your training regarding specific patient challenges

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3. What might you do if you have a complication in your clinical site? How will you secure appropriate gynecologic or hospital back up?

Despite careful planning, systems development, and staff training, complications will occur. Pre-screening and sound medical practices will minimize their severity.

When integrating medication abortion only, finding procedural back up is an important early step. If you work within a healthcare organization, this may involve reaching out to the heads of the OB/GYN and Emergency Medicine departments to alert them that you will be starting to offer medication abortion. If no back up is available within your network, an established abortion health center in your area could serve as unofficial back up. Use your contacts to help identify abortion-friendly hospitals.

When a complication arises, remain calm and clear. Let your other patients know there may be a delay. Document clearly and completely. Pay attention to details. Allow time for staff to ask questions and debrief, particularly if the complication required a hospital transfer. Send complete notes, and communicate directly with your referral provider. Meet all state and local reporting requirements.

Most complications can be cared for by the primary care provider on either an outpatient or inpatient basis, as appropriate. Primary care providers can treat pelvic infections and hemorrhage (as they would for OB patients), and do aspirations for retained products or hematometra, or refer as needed (Prine 2003). Most first trimester perforations are benign and can usually be managed conservatively, but occasionally may require antibiotics and/or OB-Gyn operative management.