Improving access to abortion care
Bournemouth University, Bournemouth, UK
The following ways of overcoming barriers to access to abortion will be presented: Elabouration by Health ministries as to precisely what the abortion law allows; Exemptions or reimbursement in jurisdictions in which women have to pay for abortions; Drafting by professional societies of country-specific abortion guidelines or dissemination of international guidelines for the benefit of health care professionals; Advocacy by clinicians for improved clinical standards in abortion care; Wide dissemination of information about abortion services to allow choice for women; Availability of medical and surgical methods of abortion at all legal gestations; More first trimester procedures offered within a primary care setting; The option of making appointments via a centralised booking system; Delivery of services as close to women’s homes as possible; Special arrangements for women who live far away from cities or towns; Seamless care pathways for the whole of a woman’s journey; Greater participation in all elements of abortion procedures by staff other than doctors; Tightly regulated and monitored conscientious objection; Information and postabortion care provision by clinicians in jurisdictions in which self-administered abortion is prevalent.
Risk management in abortion care
Sam Rowlands (Great Britain)
University of Warwick, Coventry, United Kingdom
The aim of risk management is to identify potential risk and thereby reduce untoward events and the loss and harm that may result. An error in management of a client which leads to an adverse event can be termed an incident. An incident that is narrowly avoided can be termed a near miss. Near misses occur at higher frequency than actual incidents, yet with limited impact; they are rich learning material. Examples of incidents are: procedure performed on the wrong client, wrong procedure performed, inaccurate gestational assessment leading to commencement of inappropriate procedure, IUD inserted/not inserted after abortion in error, anti-D given/not given in error, client intercepted at clinic entrance by protestors.
It is necessary to create a no-blame culture in the workplace. Errors are the result of human failure, but there is often a systems component in the background. Self-reporting of errors (one’s own or other people’s) is encouraged. This should be done at the time of the incident by filling in a specially-designed form. During discussions about incidents, the anonymity of those who have reported incidents should be preserved. When harm has been done, it is good practice to give a detailed explanation of what went wrong and to say sorry to the client; this is not admitting legal liability. General ways of reducing risk include: designing procedures to counteract error and taking complaints seriously. Specific ways of reducing risk include: adequate consent procedures, routine ultrasound scanning, having a low threshold for transferring a client to hospital from a free-standing clinic if events deviate from the normal pathway, supplementary security measures (for instance access control system, panic buttons, police liaison).
Sam Rowlands, University of Warwick, Coventry,United Kingdom
When a woman becomes pregnant, her adjustment to it and decision on how to proceed can be broken down into five stages:
- Acknowledgement of the pregnancy
- Formulation of the three options: continuation of the pregnancy to keep the baby, continuation of the
pregnancy to give the baby up for adoption and abortion
- Selection of continuation of the pregnancy or abortion by a balancing exercise
- Commitment to the chosen outcome
- Adherence to the decision
Many women who learn a pregnancy test is positive have already rehearsed how they would feel; this speeds up the process. Most women are certain about their decision on the three options. Some women have a strong emotional reaction to learning they are pregnant – these include shock, disbelief and self-reproach. Ambivalence is a normal part of the decision-making process; however it delays the decision in only around 1 in 10 individuals. For a large majority, the decision-making process is made quickly.
The decision can be viewed as a balancing exercise between on the one hand constraints such as career, quality of relationship, family size and immaturity and on the other hand the desire to procreate. During the process most individuals discuss their situation with other people, typically partner, significant others and health professionals. A study by Ashton showed that the number of discussants was positively correlated with the stability of the decision.
There are certain difficulties faced by younger women making their decisions. They tend to have more discussants, but to talk at a more superficial level. Their decisions tend to take longer to make; sometimes they conceal the pregnancy so as to avoid having to make a decision. Often for young people,
this is the first major decision they have ever had to make.
When considering the ability of very young women to make decisions, it is helpful to consider intellectual function according to age. At 12 years of age, a young person is able to think in an abstract way. By 14 years of age, a young person is able to make a complex moral and personal decision.
For all women, delay in the decision-making process can occur for the following reasons:
- Variable “recognition threshold”
- Blocks in the five-stage process
- Subtle psychodynamic factors
- Denial of the pregnancy (rare)
For those involved in counselling women faced with an unintended pregnancy, predictors of poor outcome following abortion should be looked for. These include:
- History of mental health problems
- Poor practical or emotional support from family and friends
- Suspected coercion
- Overt ambivalence
The development of a nationwide central booking service for abortion
Sam Rowlands, Clinical Director bpas and Visiting Senior Lecturer, University of Warwick (UK)
bpas is a national abortion charity in the UK that provides around 48,000 procedures each year to UK residents and women from other countries on a not for profit basis. Central booking services have been proven to facilitate access to abortion services. City-wide models have previously been described. A nationwide central booking service has been developed in the UK.
A nationwide central booking service was introduced in 1993. Initially a manual booking system was used. In 1996 the appointment system was computerised.
More than ¼ million calls are now received each year. The highest demand weekday is a Monday. The volume of calls peaks at mid-morning. There is a 36% increase in calls between December and January. More than a quarter of calls originate from mobile phones.
The computerised central booking service has radically improved the efficiency of the organisation. Waiting times can be actively managed using data from the system.
Parental authorisation of abortion
Sam Rowlands1,2 1Bournemouth University, Bournemouth, UK, 2Dorset HealthCare, Bournemouth, UK - firstname.lastname@example.org - www.samrowlands.net
Parental authorisation/notification requirements operate in 34/203 jurisdictions around the world; in the USA 38/50 states require parental involvement. Most of the abortion laws requiring parental involvement insist on one parent giving their consent; some require only that a parent is notified. The age threshold for parental involvement is usually either 16 or 18. Young people usually achieve mental capacity to consent to treatment by the age of 14. Adolescents have the same reproductive rights as adults. Health care professionals have a duty to protect young people from exploitation. Adolescents should expect to have their confidentiality respected and be free to make their own decision about whether or not to continue a pregnancy. A young person’s decision to involve their parents/guardian should be determined by the quality of the family relationship, not by laws. Compulsory parental notification is a strong barrier to a young person’s access to abortion care. Coercion to continue a pregnancy has an adverse psychosocial impact on young people. Breaching confidentiality risks violence and abuse in non-supportive families. Introduction of parental involvement laws in US states has been shown to result in out-of-state travel of young people and an increase in second trimester abortions in this age group. Based on scientific evidence and on basic human rights for young people, those sections of abortion laws insisting on parental involvement should be repealed.