Pregnancy and Options
Counseling and
Values Clarification
PRCH © 2006
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Outline

Sexuality and pregnancy data

Goals of effective pregnancy options
counseling

Pregnancy options

Options counseling in practice

Values Clarification
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Objectives

By the end of this presentation,
participants will be able to:

Identify 3 elements of effective options
counseling relating

Describe the health care provider’s role in the
process of options counseling

Discuss the important issues regarding each
pregnancy option

Clarify their own feelings around abortion
provision and counseling
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Pregnancy in the United States

More than six million women become
pregnant annually

Slightly fewer than two-thirds of these
pregnancies result in live births

20% result in abortions

The remainder end in miscarriage
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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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Unwanted Pregnancy

About half of all pregnancies are
unintended

42% of unintended pregnancies are
terminated by abortion

Approximately 1/3 of American
women will have an abortion in their
lifetime
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Legal abortion rate per 1,000
women aged 15-44
Pennsylvania vs the United States
US
PA
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
50
45
40
35
30
25
20
15
10
5
0
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Women Who Have Abortions





60% are already mothers
More than half intend to have children in the
future
Nearly 8 in 10 women report religious
affiliation
1/3 of women aged 18-44 live in a county
with no abortion provider
1 in 4 women have to travel at least 50
miles
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Pennsylvania



In 2000, there were 73 abortion providers
in Pennsylvania
This represents a 20% increase from
1996, when there were 61 abortion
providers
The increase in Pennsylvania may have
resulted from the use of state health
department data to identify hospitals that
performed small numbers of abortions
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Legal Abortions by Age in PA
60
Ages Up to 19
50
Ages 20-29
40
Ages 30-39
30
Ages 40 and
Above
Unknown
20
10
0
PA%
US%
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Access in Pennsylvania



In 2000, 75% of Pennsylvania counties
had no abortion provider
39% of Pennsylvania women lived in these
counties
In Pennsylvania, 7 metropolitan areas lack
an abortion provider: Altoona; Erie;
Johnstown; Lancaster; Scranton-WilkesBarre-Hazleton; Sharon; Williamsport
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Abortions in Philadelphia by Age
2004
4500
4000
3500
Philadelphia
3000
2500
2000
1500
1000
500
0
Under
15
15-19
20-24
25-29
30-34
35-39
40-44
45 &
over
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Pregnancy
Options
Counseling
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Effective Pregnancy Options
Counseling





Reduces anxiety so that the woman 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 (if adolescent)
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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

Financial issues that may impact her
decision

Increased safety of early abortion

State laws regarding parental notification
and consent for termination (for teens)
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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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Pregnant Womens’ 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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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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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 under 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 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 adults

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I: Address Immediate Concerns

Continuing Pregnancy

Access to prenatal care
 Medicaid enrollment
 Finishing school
Finances
 Housing
 Co-parent


Adoption
Open vs. 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 anymore questions
 Schedule follow-up visit
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Values Clarification
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Key Point

If the health care 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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Values Clarification

If 1 in 4 pregnant women will choose an
abortion




How can she trust you won’t judge her?
There is nothing that is “not judgmental”
The goal: identify personal beliefs & reflex
reactions
Then: distinguish these from professional
role in the provision of care
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Everyone stand up

We all do things that we “know better” not to
do even though we know the consequences

Sit down if you smoke

Sit down if you ever eat too much

Sit down if you cross in between cars

Sit down if you work too hard

Sit down if you do not maintain the recommended
30min cardio 3 days a week
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Everyone stand again

Move to the side of the room that is most
appropriate for you:

I love chocolate cake

There are good reasons a minor should involve her
parents in an abortion decision

It is better to have an abortion at 8 weeks rather than
18 weeks

A woman having her 4th abortion is just as justified as
a woman having her 1st
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Case 1:
Ruth
is 34 years old, married with 3
children.
She
had just ended a month long affair and
had committed herself to her marriage when
she discovered she was pregnant.
She
is unsure with which man she became
pregnant. Her husband is very loving and
supportive but is unaware of his wife’s
involvement with another man.
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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:
Sue
is 37 years old and married.
She and her husband had been trying to
get pregnant for 3 years.
She just got back the results of her
amniocentesis that indicate the baby has a
severe genetic abnormality.
She is 16 weeks pregnant.
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Please Complete Your
Evaluations Now
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