Termination of Pregnancy in
Lothian
A Health Needs Assessment
Rosemary Cochrane
Subspecialty trainee
Chalmers Centre for Sexual and Reproductive Health
Edinburgh
November 2011
Aims
•
•
•
•
describe the population accessing
termination of pregnancy services in
Lothian
describe the current service in Lothian
identify areas where delay in service
provision exists and to recommend ways
to decrease delay
identify areas of unnecessary complexity
in the patient’s journey through the
service
Aims
• elicit stakeholders views - patients, staff
and management
• consider evidence of effective intervention
to improve termination services
• recommend potential interventions to
improve the service for patients and staff,
and to eliminate waste.
• support planning for change from 2011
onwards.
Total in Scotland
2010 =12386
•2254 were carried out in Lothian
•12.1 women per 1000 aged 15-44
•508 (25.2%) TOPs were in women <19 years
•31.8% were repeat TOP (Scotland 28.4%)
•In Depcat 1 16.9/1000 women
Abortion mapping – over 20 years
Terminations from Depcat 1-2:
• 22.3 / 1000 in 2007
• 16.9 / 1000 in 2010.
Current service in Lothian
• 2254 per year
• Royal Infirmary of Edinburgh 80%
• St John’s Hospital, Livingston 20%
• 37% of Gynaecology budget
• 70% before 9 weeks gestation
• 78% are medical procedures
• 55% of those at RIE are by EMD
Number of abortions by method at RIE 2005-2010
2500
2000
Number of terminations
1123
1102
1061
1047
631
496
115
1500
136
STOP
142
146
138
MID
MTOP
187
1000
1432
500
988
1112
1147
1202
2006
2007
2008
1516
0
2005
Year
2009
2010
Patient pathway
• primary care appointment
→ referral to hospital
→ hospital assessment clinic: counselled,
?DVD, ultrasound to establish gestation,
consent, blood sample, urine for STI
screen
→ plan made for next step
→ if medical, may get 1st part same day
→ contraceptive plan
• approximately 2 hour visit
Patient pathway
N1
N1
N2
N2
D
D
US
US
CSW
CSW
T
T
REC
REC
W/A
W/A
Key: REC = Reception
D = Doctor’s room
W/A = waiting area
N1 = First nurse’s room
T = toilet
N2 = Second nurse’s room
US = Ultrasound room CSW = Clinical support
worker
Service Standards
• HIS Standard 6: Termination of Pregnancy
requires that women receive safe
termination of pregnancy with
minimal delay, followed by contraceptive
advice and psychological support.
• 70% of TOP should be before 63 days
gestation
• 60% of women should leave service with
effective contraceptive plan
RCOG and FSRH Consensus
Statement 2008
Delays in referral associated with
• a lack of awareness of the possibility of
pregnancy
• delays in diagnosis
• access to and the availability of abortion services
• negative attitudes of some referring practitioners
• “In many services the patient journey from
suspicion of pregnancy to completion of the
procedure can be overly complex, particularly in
the patients' perception. This is even more
pertinent for vulnerable members of the
community for whom particular support
is needed to enable them to use the
services more effectively.”
• A large minority of patients accessing TOP
services within Lothian are either young
people(<19 years) or from the most deprived
areas of the region, for whom the complexity of
the TOP journey may well lead to delay,
dissatisfaction with, or even avoidance of the
service.
The patient experience
• Women’s choices pragmatic, related to finite
household and psychosocial resources
• Positive responses to, and outcomes from TOP,
are associated with:
 rapid access to services
 supportive non-judgemental staff
 home TOP
 good information and support
• Patients keep their experiences secret from
family and friends - “The Silent Consumer”
1. Zapka et al 2001
Methodology
• Service users and service providers
interviewed
• 17 staff members and 17 service
users
• Staff
– Doctors
– Nurses
– Receptionists
– Sonographer
– Clinical support workers
– Managers
Results
Service user interviews:
•
•
•
•
•
•
66 eligible patients
17 agreed to take part
17-34 years, mean age 24
6/17 repeat TOP (cf 32% for Lothian)
14 white UK
3 non-UK



1 student
1 married to Scottish man
1 travelling to UK solely for purpose of obtaining TOP
Results: service users
• In general, women
were very satisfied
with the service they
received
“They (Dean Terrace) were
really nice, the doctor was
great, really understanding.
You feel bad enough yourself,
you don’t want anyone making
you feel worse. It was very
clear and quick.”
“All very private, discreet and
non-judgemental”
Theme/comment
No. of
replies/times
mentioned
No questions unanswered and certain
about next step
17
Friendly clinic staff
17
Positive attitude from GP/CY/FPC
11
Time to clinic quick or about right
8
Discreet pleasant helpful reception staff
8
Non-judgemental staff
8
Mix of patients in waiting area lends
anonymity
5
Female staff in clinic
2
Staff professional and helpful, pt not
made to feel bad or hurried
4
Military efficiency, gathering all info
good idea
2
Lots of written information
1
Hospital easy to find
1
Results: service users
• Not all views of
assessment clinic were
positive
“the doctor I spoke to
said he didn’t deal with
that so he would have
to get someone else to
speak to me -I didn’t
like that”
“My name was called at
least 4 times across the
waiting room. Four
times I was sent back
out there!”
Theme/comment
No of
replies/times
mentioned
Would have preferred shorter wait from
GP/FP to assessment clinic
9
Assessment clinic very long and
complicated
8
Communal waiting area viewed
negatively
5
Name being called on several occasions
4
Not enough information available in
primary care
4
Negative attitude from GP or wrong info
from GP
3
Distant/unfriendly/intimidating staff
3
Repetition of tests at GP and hospital
2
Excluding partner from clinical area
1
Getting through to family planning clinic
on phone
1
Results: service users follow up
• Positive comments
reflect those prior
to procedure
• Negative comments
despite extensive
written information
given to every patient
Theme/comment
No. of replies/times
mentioned
Supportive friendly staff
9
Information before was accurate
about what happened
6
Non- judgemental attitude of
staff
3
Efficiency and speed of visit
4
Pain worse than expected
7
Lack of accuracy about procedure
3
Poor signposting and information
within hospital
2
Perception of coercion into MTOP
3
Results: providers
• Positive responses
Reduced waiting times
have made a huge
difference; can make
the difference between
STOP and MTOP, or
even having the
termination at all
Nurse CY
Description of issue
Who is
affected?
No of times
mentioned
Reduced waiting times due to
EMD/reorganisation of clinics
Patient
7
Integrated service means
staff better informed re TOP,
contraception etc
Patient/staff
4
Increased nurse-led services
felt to be an advantage
Patient/staff
4
1st part of TOP given at
assessment streamlines
process for patient
Patient
3
Good private facilities for
patients
Patient
3
Enjoyable supportive service
to work in
Staff
2
Good relationship with
primary care
Staff/patient
1
Results:
providers
Theme/comment
Who is
affected?
No of
times
raised
Complexity and timing of assessment
clinic (Both sites)
Patient
11
Difficulty dealing with TOP emotionally
Staff
7
• Negative
responses
Waiting area (Both sites)
Patient
6
Capacity at assessment clinic - rooms,
staff
Staff/Patient
5
Fear of judgment– anonymity
Patient
5
Delays due to capacity i.e. beds available
within wards
Patient
5
Challenges providing effective follow-up
contraception
Staff/Patient
5
Amount of information given to patients
Patient
4
Privacy for procedure
Patient
4
IT/paperwork
Staff
4
Number of repeat abortions
Staff/Patient
3
Difficulty accessing service
Patient
3
Distance to Bruntsfield Suite from clinic
Staff
3
Implementation of multiple changes to
service
Staff
3
Staff cover for clinicians not wishing to be
involved in TOP
Staff
2
Patients not attending – wasted
resources
Staff
1
That whole waiting area
needs to be looked at.
That’s where we really
fall down. The women
might as well have a sign
round their necks. Feel
that its common
knowledge that
Bruntsfield is for TOP –
‘people know’.
Research Nurse
Results: suggestions for
improvement
From service users:
• Increased information about pain
• Written info about other patients in waiting areas e.g.
pregnant women
• Shorter, less complex assessment clinic
• Weekend appointments
• Encourage surgical methods
• Publicise EMD
Results: suggestions for
improvement
From service providers:
• Self referral
• Assessment/first medication in primary care
• Nurse-led service
• Move all EMD to new community SRH facility
• Weekend service
• Streamlined service, one practitioner performing scan,
bloods, consent, counselling and arranging onward care
• Lean
Conclusion:
• Large busy TOP service
• Meets HIS and RCOG Standards
• Ascertaining the needs of women using
the TOP service is a difficult process
• Flaws in system in general are minor
• Improvements are feasible and many are
planned/in progress
• Service users in general very pleased with
current pathway
Acknowledgements:
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•
•
•
•
Dona Milne, Specialist in Public Health, Edinburgh
Sheila Wilson, Senior health Policy Officer, Edinburgh
Staff at St John’s Hospital Livingston
Staff at The Royal Infirmary of Edinburgh
Women attending the TOP service in Lothian
Thank you