The WHO Clinical Practice Handbook for Safe Abortion Care requires counseling “using simple language, maintaining privacy, supporting women to ask questions and taking time to give answers, and not imposing our personal values and beliefs.” Patient-centeredness is one of the National Academy of Medicine’s six dimensions of health care quality. This intentional approach requires the provision of care that is respectful of and responsive to individual patient preferences, needs, and values and empowers people to take charge of their own health.

Healthcare providers, including physicians, nurse practitioners, nurses, counselors, and clinic staff, often lack the training, language, or techniques to guide patients to self-directed decisions. This is especially evident within sexual and reproductive health (SRH) where stigma makes open discussion uncomfortable for patients and providers alike.

This workshop is intended to teach patient-centered pregnancy decision counseling in patient scenarios that often prove to be challenging when providing patient-centered care.

Each activity has a didactic video lecture that provides a knowledge base, terminology, and techniques, along with group activities and case studies. The counseling videos and decision aids are intended to provide learners with a counseling framework and facilitate patient-centered counseling.

Workshop Objectives:

• Understand that induction termination and D&E are both safe and effective methods for ending a pregnancy after a fetal diagnosis and patients should be able to choose a method based on their preferences.
• Use a decision aid in a shared decision-making progress for pregnancy termination method selection for fetal anomalies and demise.

AFTER WATCHING THESE VIDEO LECTURES, LEARNERS WILL:

• Discuss unique challenges for patients seeking abortion after the first trimester.
• Understand that patients have diverse and strong preferences about methods for pregnancy termination.
• Acknowledge the role of clinician preference in patient decisions about termination method, including clinician skills, bias, and support from colleagues.

Learners can watch didactic lectures before the workshop in a flipped classroom model or during the workshop.

Group Activity:

Directions:  Play the decision aid video. After this video divide learners into groups of 3-4.

Small Group Activity:

Read the case aloud to the group and ask them to discuss case and questions listed below.

Case Study:

Andrea is 28 years old and at 21 weeks. She has received a diagnosis of severe CNS anomalies and an amniocentesis showing a normal karyotype. This is her second pregnancy resulting in fetal anomalies and Andrea has decided on termination. During her last termination Andrea was only given the option of having a D&E. How would you counsel Andrea?

1. How would you describe the difference between the two methods of termination to a patient seeking an abortion after the first trimester?
2. Do you have any feelings about whether a patient having an abortion after the first trimester should have induction termination or D&E? Do those feelings change if the termination is due to anomalies or a demise?
3. In pairs, demonstrate how would you work with your patient to facilitate choosing a termination method. What preferences should you try to elicit from conversations with the patient?
4. How would you help a patient uncover their own personal values for deciding a termination method? How would you engage in a shared decision-making process with your patient?

Facilitation Notes: Teaching Points

1. Medical induction terminations are mostly offered in hospital L&D units and surgical D&E procedures are mostly offered in freestanding clinics.
2. One method of abortion after the first trimester is not “better” than another. The best method is the one chosen by the patient. If you are unable to provide the patient’s requested method in your setting, referral to another provider may be required.
3. Clinicians often feel that the alternative procedure would be so difficult to access that offering counseling about the other option is presenting a false choice. It is not for a clinician to decide what lengths a patient should go to access the care they prefer; it is solely for the patient to decide.
4. Actively listening to patients can help clinicians guide patients in a shared decision-making process. Using phrases like, “I hear you saying this is important to you. Is that correct?” can improve patient experience.

If you’re interested in using this aid with patients, please view the OPT Decision Aid here.

Readings:

• Kerns J, Vanjani R, Freedman L, Meckstroth K, Drey EA, Steinauer J. Women’s decision making regarding choice of second trimester termination method for pregnancy complications. International Journal of Obstetrics and Gynecology. 2012:116(3):244-8.