PRCH © 2007
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Pregnancy and Options
Counseling and
Adolescents
PRCH © 2007
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Outline

Adolescent sexuality and pregnancy
data

Goals of effective pregnancy options
counseling

Pregnancy options

Options counseling in practice

Cases
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Objectives

By the end of this presentation,
participants will be able to:
 Identify
3 elements of effective options
counseling relating to adolescents
 Describe
the healthcare provider’s role
in the process of options counseling
 Discuss
the important issues regarding
each pregnancy option
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Adolescent Sexuality


Most adolescents become sexually active in
teenage years
The majority of these sexual relationships:
 Are consensual
 Healthy expressions of human sexuality
 Vary according to the adolescent’s culture
and psychological, physical, and
relationship development
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Adolescent Sexual Behaviors:
Results from the 2005 YRBS
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Have Had
Intercourse
Currently
Sexually
Active
Intercourse
Before Age
13
4 or More
Parnters
HaveBeen
Been
Have
Forced to
to
Forced
HavePRCH
Sex© 2007
Have
Sex
6
Japan
Italy
Teen Pregnancy
Rates Worldwide,
2000
Netherlands
Spain
Germany
France
(per 1000)
Switzerland
Israel
Norway
Scotland
Australia
Canada
England
Latvia
Romania
United
States
0
10
20
30
40
50
60
70
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80
90
7
Pregnancy Outcomes for Teenagers 15–19
Years by Race and Hispanic Origin,
Rates per 1,000 women
1990 and 2002
250
Abortion rate
200
Birth rate
150
223.8
134.2
116.3
100
75.4
169.1
131.5
98.8
65.0
50
0
1990 2002
All Races
1990 2002
White
1990 2000
Black
1990 2002
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Hispanic
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Adolescent Attitudes Toward
Pregnancy

82% of teen pregnancies are
unintended

1 in 3 teenage girls has positive and/or
ambivalent feelings about immediate
childbearing

22% identified their pregnancies as
neither mistimed nor unwanted
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Adolescents, Sexual Assault,
and Pregnancy
Violent crimes are more common among
adolescents than other age groups
 Among adolescents ages 12–17 years,
5.3% of rapes cause pregnancy
 Adolescents may be unaware of or have
limited access to emergency
contraception
 May not be using any long-term
contraceptive method at the time of the
assault

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Implications of Teen
Pregnancy

Many teen mothers:
 Are less likely to graduate from high
school
 Are more likely to have symptoms of
depression
 Lack resources to foster children’s
development
 Have a higher risk of repeat births
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Implications of Teen
Pregnancy

Many teen fathers are more likely to have:
 Poor academic performance
 Higher school drop-out rates
 Limited financial resources
 Decreased income capacity
 Difficulties staying involved in children’s
lives
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Implications of Teen
Pregnancy

Many babies born to teen mothers are at
higher risk of
 Being born prematurely and of having a
low birth weight
 Physical neglect and abuse
 Poor school performance
 Substance abuse
 Being teenage parents themselves
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Pregnancy
Options
Counseling
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Goal of Pregnancy Options
Counseling
 To
provide a careful process of
evaluation and decision-making
based on young women’s
 Personal
circumstances
 Psychosocial
development
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Effective Pregnancy Options
Counseling





Reduces anxiety so that the pregnant teen can
concentrate on the decisions she has to make
Creates a safe environment in which she can
discuss her hopes and fears about her decision
Imparts knowledge and facts about various
options and their implications
Clarifies her choices and her feelings about
them
Takes into account her cognitive and
psychosocial development
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Effective Pregnancy Options
Counseling

Helps her
 Make a decision that is right for her
 Accept responsibility for her
decision
 Act on her decision, with referrals as
needed
 Mobilize resources, including family
and medical care
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Practitioner Should Be Aware of:






Local support services
Necessity of early prenatal care and
follow up
Developmental issues that may impact her
decision
Importance of completing high school
State laws regarding parental notification
and consent for termination
Increased safety of early abortion
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Key Point

If the healthcare provider does not feel
comfortable providing unbiased,
accurate information regarding
pregnancy options, he/she should
refer the patient to someone who
does.
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Pregnancy Options
 Continuation
of
Pregnancy (47.7%)
 Adoption (2%)
 Parenthood (45.5%)
 Pregnancy Termination
(33.4%)
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Continuation of Pregnancy:
Adoption and Raising a Baby
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Health Needs of Pregnant
Teens
Special understanding
 Access to psychological counseling
 Education about





Nutrition
Infections
Substance abuse
Complications of pregnancy
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Health Needs of Pregnant
Teens
 Less
likely to seek early medical
care
 Increased
risk for medical
complications, including:
 Anemia
 Low
birth weight
 Pre-term delivery  Neonatal
admission
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Pregnant Teens’ Needs





Referral for prenatal care, including
nutrition counseling and prenatal vitamins
Assistance in obtaining Medicaid/CHIP
Referral for parenting classes
Smoking cessation classes and/or
alcohol/drugs counseling
Development of support and parenting
plan
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Adoption



Closed Adoption: Records about birth
parents are sealed
Open Adoption: Birth parents choose
adoptive parents and maintain some level of
contact
Adoption Arrangements
 Private adoption agency
 Individual county adoption services
 Non-profit adoption agencies
 Attorneys
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Changes in Adoption Norms

The percentage of infants placed for
adoption has decreased in the last 4
decades
 From
8.7% in 1972 to 2% in 1988.
>3% of Caucasian unmarried women
place their children for adoption
 >2% of African American unmarried
women place their children for
adoption

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State Statutes Surrounding
Adoption: As of June 2006

40 states and DC allow minors to place their
children for adoption



28 states and DC explicitly allow consent
12 states make no distinction between minor and
adult parents
10 states require adult involvement in process



5 states require legal representation for minors
4 states require parental consent
1 state requires parental notification
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Pregnancy Termination
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Abortion Rates: 15-19 Year Olds
per 1,000
50
45
40
35
30
25
20
15
10
5
0
88
89
90
91
92
93
94
95
96
97
98
99 2000 2001 2002
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Adolescents and Abortion

Reasons most often given by teens
for choosing to have an abortion are
 Concern
about how having a baby
would change their lives
 Feeling
that they are not mature
enough to have a child
 Financial
problems
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Parental Involvement in Minors’
Abortions
 61%
of minors who have
abortions do so with at least one
parent’s knowledge
 45%
voluntarily inform parents of
intentions to have an abortion
 Majority
of parents support their
daughters’ decisions
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Mandatory Counseling and
Waiting Periods for Abortion:
As of June 2006

32 states require counseling before an
abortion
22 are mandated to provide state-developed
abortion-related materials
 6 require that counseling be provided in
person, 18 hours in advance of the procedure
 24 require mandatory waiting periods (usually
24 hours) between the counseling and the
procedure

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Mandatory Parental Involvement in
Minors’ Abortions: As of June 2006

34 states require some parental
involvement
 22
require parental consent; 2 require
both parents to consent
 13 require parental notification; 1
requires that both parents be notified
 1 state requires both parental consent
and notification
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Mandatory Parental Involvement in
Minors’ Abortions: As of June 2006

All of the 34 states that require parental
involvement have an alternative process
for minors seeking an abortion
 All 34 states include a judicial bypass
procedure
 6 states also permit a minor to obtain an
abortion if a grandparent or other adult
relative is involved in the decision
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Judicial Bypass
Minor petitions court to waive the
notification/consent requirement
 Judge decides if:
 Minor is mature and sufficiently well
informed
 Abortion without informing parents is
in her best interest
 Notification could lead to physical,
sexual, or emotional abuse

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Mandatory Parental Involvement in
Minors’ Abortions: As of June 2006

Most states that require parental
involvement make exceptions under
certain circumstances
 28 permit a minor to obtain an abortion
in a medical emergency
 12 permit a minor to obtain an abortion
in cases of abuse, assault, incest, or
neglect
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Pregnancy Termination
Options
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Medication Abortion
An abortion option for the first 49–63
days of pregnancy
 Requires 2–3 visits to office/clinic
 Most common regimen consists of:
 An oral dose of mifepristone, which
blocks the receptors of progesterone
 Followed by a dose of misoprostol,
which causes the uterus to contract
and empty

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Medication Abortion



Pros
Avoids surgical
procedure and
sedation (in most
cases)
Some women feel
more in control
Sometimes more
culturally acceptable
because noninvasive



Cons
Requires patient
compliance
Necessitates 2–3
office/clinic visits
This option is
appropriate for
early pregnancy
only
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First Trimester Aspiration
Abortion

Manual Vacuum Aspiration




Abortion option through 12 weeks of pregnancy
Requires a vacuum syringe that creates suction
Actual procedure takes less than 5 minutes
Electric Vacuum Aspiration



Performed up to 12 weeks of pregnancy
A suction catheter removes products of conception
Takes between 5 and 10 minutes after the cervix
has been dilated
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Second Trimester Options (12–24 Wks)


Dilation and Evacuation (D & E)
 Performed under general or local anesthetic
between 13 and 20 weeks
 Requires 2 visits to hospital/clinic for dilation
and removal of the fetus
 Currently the most common method used in the
second trimester
Dilation and Extraction (D & X)
 D & X procedures are extremely rare
 Requires 2 visits to hospital or clinic for dilation
and removal of the fetus
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Second Trimester Options (12–24 Wks)

Labor-Induction Abortion Methods
 Involves laboring and delivering a stillborn
fetus
 Intra-amniotic hypertonic solutions, such as
urea or saline
 Prostaglandin inductions (e.g., prostaglandin
E2 suppositories)
 Uncommon method of abortion
 Woman may choose labor induction
because it preserves the fetus intact
 May be useful in confirming fetal anomalies
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Surgical Abortion
Pros




During 1st trimester:
 Can be completed in
one visit
 Procedure itself takes
between 5–10
minutes
2nd trimester procedure
possible
Performed under local
anesthesia
Can be performed
under sedation
Cons

Some women find
process invasive

Procedure takes
place in hospital
or clinic (rather
than at home)

External locus of
control*
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Pregnancy Options
Counseling in Practice
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What To Do







Ask open-ended questions
Reflect: “I am hearing you say that you…”
Validate: “Many young women feel…”
Give the patient control: “Which would you
prefer?”
Pay attention to non-verbal cues
Communicate acceptance: Tone, eye
contact
Use silence: Let her finish
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What To Avoid
False reassurances: “You’ll be fine.”
 Over-identification: “I know how you
feel.”
 Medical jargon: “Have you had
previous terminations?”
 Loaded and/or judgmental statements
 Giving advice: “I think you should…”

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Utilizing DECISION
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D: Determine Reason for Visit
What can I help you with today?
 Why do you think you may be
pregnant?
 When was your last period?
 Have you ever been pregnant before?
 What were the outcome(s)?
 Are you currently using any form of
contraception?

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E: Evaluate Feelings
What do you hope will be the results of
this test?
 Have you ever wanted to get pregnant?
 How do you feel about the sexual
encounter that brought you here today?
 Do you have any friends who are
pregnant or who have had a baby?
 How do you feel about that?

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C: Confirm Pregnancy Results



Give results and remain silent, allowing
patient to initiate response
IF TEST IS NEGATIVE: How do you feel
about the result?
If she is relieved: What are some ways
that you can prevent pregnancy in the
future?
 Contraception?
Abstinence?
 Condom use?
 Disappointment: Refer for further
counseling regarding parenting plans.
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C: Confirm Pregnancy Results

IF THE TEST IS POSITIVE: How do
you feel about this result?
 What
does a positive pregnancy test
mean to you?
 Clarify facts regarding gestational
timeline, trimesters, due date
What do you think you want to do?
 What other information do you need to
make your decision?

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I: Identify Personal Circumstances

Place pregnancy in perspective of her
life
 What
is your picture of the next year of
your life? Five years?
 How
does this pregnancy affect this?

How do your personal/spiritual/
religious beliefs affect your decision
process?

Validate fears and conflicting emotions
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S: Assess Support
Who in your life can help you in a
supportive way?
 What is your relationship with the
man that you are pregnant by?
 Do you have a current partner?
 How would s/he feel about you being
pregnant?
 Discuss if and when to involve
another adult

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I: Address Immediate Concerns

Continuing Pregnancy

Access to prenatal care
 Medicaid enrollment
 Finishing school
Finances
 Housing
 Co-parent


Adoption
Open v. closed
 Social service
organizations

Parenting


Abortion
Types of abortion
 Access to
abortion in your
state
 Timing
 Cost

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O: Offer a Timeline
How much time do you need to make this
decision?
 If you decide to continue the pregnancy:

 By
what date will you make an
appointment for prenatal care?

If you decide to have an abortion:
 By
what date will you schedule an
appointment?
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N: Next Steps
Provide the patient with written
resources and necessary referrals
 Discuss future contraceptive options
 Write an advanced prescription for
EC
 Ask if she has any more questions
 Schedule follow-up visit

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Case 1:
A 15-year-old, African American Muslim woman
misses a period. She comes to your office with
an “earache.” When you question her further
you learn she suspects she is pregnant and this
is confirmed. She asks you to not tell her
mother and is confused over what to do.
 Would you tell her mother and are you
required to under your state’s law?
 What further counseling steps would you
take?
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Case 2:
A 17-year-old Caucasian woman enters your
office suspecting she is pregnant. A
pregnancy test confirms her suspicions. She
has already spoken to her parents about her
situation. She states, “My mom told me I
should have an abortion.”
 How do you proceed with counseling?
 When do you involve her mother in the
discussion (if at all)?
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Case 3:
A 16-year-old pregnant woman comes to your
office. She tells you that she thinks she may have
been raped while unconscious at a party she
attended several weekends ago. The young
woman tells you that prior to this incident, she has
never had sexual intercourse before. She states
that she does not want to be a mother right now
yet she does not know if she could have an
abortion. The young woman is obviously
frightened.
 How do you proceed with the counseling?
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Please Complete Your
Evaluations Now
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Pregnancy Options Counseling