Welcome to the Options Counseling Nursing Education Module

 

As nurses, we are witness to some of the most vulnerable and life-changing moments in a patient’s life. Sometimes we are invited to participate in life-changing discussions and decision-making when a patient asks for information about a treatment option. Often, we can answer with facts and figures about quantifiable outcome measures: this medication works X% of the time or this procedure results in an X% cure rate. But when a patient is unsure about an unintended pregnancy, facts and figures lose their impact because the decision at its core is emotional.

This module uses realistic patient scenarios as the framework for facilitating patient-centered, non-directive options counseling on parenting, abortion and adoption.

How to Use This Module 

Provide’s Nursing Education Curriculum is designed for a flipped classroom model to incorporate unintended pregnancy prevention and care into existing curricula.

Students are encouraged to complete the Pre-Assessment below and then work through the module. Definitions and Orienting Facts provide context for the Patient Situations, which are clinical scenarios designed to raise critical issues and questions to put unintended pregnancy prevention and care in the context of Options Counseling. Students may complete the Recommended Reading at any time while going through the Patient Situations. Please complete the Post-Assessment after finishing the module.

Faculty are encouraged to open the Faculty Guide tab below to access teaching tips, exercises and handouts for incorporating module content into the classroom, and to learn more about obtaining a “Site Code” to download and access students’ Pre- and Post-Assessment data. Each module has an accompanying PowerPoint. Look for the hyperlink presentation in the Faculty Guide for each module.

Pre- and Post-Assessments

Please complete the Pre- and Post-Assessments. A new window will open to a Survey Monkey Pre-Assessment and the window must remain open while you work with the module. Once you have completed the module you will return to the Survey Monkey window to complete the Post-Assessment. If your faculty requires completion of this module as a course requirement, please check with them about due dates and credit allocations.

Learning Objectives

  • Apply patient centered care concepts in delivering pregnancy test results.
  • Describe three available options for an unintended pregnancy.
  • Demonstrate non-directive, patient-centered options counseling techniques.
  • Identify available resources to assist patients with their decision-making.
  • Demonstrate knowledge of community-based resources for prenatal care, adoption services and abortion care.

Relevant UPPC Essential Competencies

Through a national Delphi study, Essential Competencies in Unintended Pregnancy Prevention and Care for Nursing Education (Hewitt, C. and Cappiello, J., 2015) 85 nursing experts in unintended pregnancy prevention and care reached consensus on 27 core educational competencies for nursing education which provide a framework for curricular development in an important area of nursing education. The following competencies are relevant to this nursing education module.

  1. Demonstrate the ability to provide unintended pregnancy prevention and care that is free of evidence of bias and judgment.
  2. Demonstrate ability to recognize unique reproductive health needs of women from vulnerable and special populations (e.g. adolescents, women with mental or physical disabilities, survivors of violence) affected by many factors (e.g. relationship status, sexual orientation).
  3. Demonstrate knowledge of types of induced abortion methods, including risks and benefits, which are legally available in the U.S.
  4. Demonstrate knowledge of state and local adoption options and resources and applicable regulatory laws and statutes.
  5. Demonstrate proficiency in providing client‐centered pregnancy options counseling including parenting, adoption and abortion.
  6. Demonstrate proficiency in providing pregnancy test results in patient-centered manner.
  7. Demonstrate proficiency in using essential counseling techniques (e.g. motivational interviewing, shared decision making and patient engagement) in provision of unintended pregnancy prevention and care.
  8. Demonstrate proficiency in effective communication skills that encompasses respect for of culture, sexual orientation and gender identity.
  9. Demonstrate ability to make appropriate referrals to community‐based prenatal care providers and resources.
  10. Demonstrate proficiency in referring clients with unintended pregnancy to area providers and support services.
  11. Demonstrate ability to confirm pregnancy and determine gestation age.

Closed Adoption:  A type of adoption whereby no identifying information is shared and there is no contact between the biological and adoptive families.

Early Pregnancy Decision-Making:  Refers to the decision-making process that a woman engages in when faced with an unintended pregnancy. Pregnancy options include continuing the pregnancy with the intention to parent, continuing the pregnancy with the intention to adopt, or choosing abortion care.

Induced or Therapeutic Abortion (commonly referred to as “abortion”):  An abortion that is brought about intentionally, also called a therapeutic abortion. Medical terminology refers to induced and spontaneous abortion (commonly referred to as a miscarriage).

Medication Abortion:  This method of early abortion is currently used up to 63 days of pregnancy in the U.S. The most commonly used regimen includes mifepristone (formerly known as RU486) followed by misoprostol. Generally a woman has an appointment with a provider where she obtains mifepristone and misoprostol. After taking mifepristone in her provider’s office, she self-administers misoprostol one to three days later at home. Within a few hours, she has miscarriage with cramping and bleeding that ends the pregnancy.

Open Adoption:  A type of adoption whereby the biological and adoptive families have varying degrees of access to each other’s personal information during the adoption decision and have the option of ongoing contact after the adoption is finalized.

Options to Pregnancy:  A pregnant woman has three options to consider for her pregnancy, which are parenting, adoption, and abortion. If she chooses adoption, she has a choice of open adoption (i.e. having a relationship with the adoptive parents) or closed adoption (i.e. not having a relationship with the adoptive parents) and many options in between. If she chooses abortion she may choose a medication abortion or aspiration abortion depending on how many weeks pregnant she is and what the relevant laws are in her state.

Spontaneous Abortion (SAB):  A miscarriage, or naturally occurring loss of a fetus prior to the 20th week of pregnancy.

Unintended Pregnancy:  An unintended pregnancy is a pregnancy that is mistimed, unplanned, or unwanted at the time of conception.

  • The Guttmacher Institute reports that “the average American woman spends about five years pregnant, postpartum or trying to become pregnant, and three decades—more than three-quarters of her reproductive life—trying to avoid an unintended pregnancy.” Guttmacher’s Fact Sheet on Induced Abortion in the United States indicates the likelihood of having an abortion rises over the course of a lifetime: 1 in 10 women will have an abortion by age 20, and 1 in 3 will have an abortion by age 45.
  • When separating pregnancies into two categories—intended or unintended—we recognize that a number of nuances are ignored and several assumptions are made. For example, not everyone who is capable of becoming pregnant but not using a method of birth control is intending to become pregnant. Many people have an ambivalent stance toward becoming pregnant – not actively seeking or preventing pregnancy. Also, intending or not intending a pregnancy assumes that the pregnant person understands the fundamentals of reproduction, fertility, and how their body works. However, statistics insist that we divide pregnancies into two categories of intended and unintended, and when we do, we find that the numbers are almost perfectly split down the middle: According to Finer and Zolna (2014) and the Guttmacher Institute, about half of pregnancies are considered intended and half are considered unintended.
  • Of the unintended pregnancies, we lose the nuance of miscarriages, adoptions, and parenting, but Finer and Zolna (2014) find that about 60% result in birth and 40% result in termination of the pregnancy.
  • In a perfect world, it would be easy to become pregnant or to prevent pregnancy with access to ample resources and comprehensive sexuality education. However, the statistics show us that despite the existence of resources and education, they are not always known or accessible to the people who could use them. Factors leading to unintended pregnancy come for both external and internal forces, including:
  • Contraceptive failure
  • Lack of access to contraception
  • Lack of understanding of reproduction/fertility
  • Sexual assault, abuse, or coercion
  • Religious beliefs
  • Emotional and psychological reasons
  • Lack of knowledge/access of emergency contraception
  • The Guttmacher Institute also reports that births resulting from unintended or closely spaced pregnancies are associated with adverse maternal and child health outcomes such as delayed prenatal care, premature birth and negative physical and mental health effects for children.
  • No federal law guarantees adolescents the universal right to consent to confidential reproductive services. The Guttmacher Institute brief, An Overview of Minors’ Consent Law, provides background information and includes a chart with laws by state on minors’ right to consent without parental permission to contraception, STI, abortion, prenatal care, and medical care for minor’s child.

Each scenario described in this module is broken into sections to enable self-guided learning. Detailed information is provided on the patient and the setting. The scenarios are based on the complex and often controversial nature of unintended pregnancy prevention and care.

Ivy’s Choice (Patient Situation #1)

The Patient

Ivy is 16 years old and her last menstrual period was 11 weeks ago. Sometimes she uses oral contraceptives and sometimes condoms, but neither consistently. She has never been pregnant before.

See Ivy’s Intake Form.

The Setting

A large health center with a Family Planning Department for contraceptive services and comprehensive reproductive health care.

What Happened

Ivy and her mother, Jody, come into the health center to confirm the pregnancy test Ivy took at home. While Ivy is in the bathroom, Jody reveals to the nurse that she was 17 years old when she gave birth to Ivy, and she knows how challenging it can be to be a young mother. She does not want this life for Ivy and would like the nurse to focus on abortion or adoption options if the test comes back positive.

What can the nurse say to Jody?
It is the nurse’s job to describe all of Ivy’s options in neutral, non-directive and non- judgmental language. The article Caring for Women with Unintended Pregnancies by Simmonds and Likis (2011) highlights the nurse’s professional responsibilities in providing care to women with unintended pregnancies, which includes appropriate assessment, options counseling, referrals and care coordination, and prevention efforts. This nurse is comfortable with her role. She has worked in reproductive health for years and routinely counsels women and couples on their pregnancy options. She could say to Jody: “It is so wonderful that Ivy has you with her here today to support her. We always encourage family involvement in reproductive decision-making with minors. After we run a pregnancy test, and if it is positive, my role will be to describe all of Ivy’s options, if she wants me to. We will discuss abortion, making an adoption plan, and continuing the pregnancy and parenting. Once I’ve provided information on these options, you and Ivy can discuss her plans together. I will be able to give you more information and give you a referral for whatever decision Ivy makes.”

Jody waits in the waiting room and when Ivy returns from the bathroom the nurse leaves to run the test. It is positive. Ivy and the nurse are alone together in the exam room.

Nurse: Ivy, your pregnancy test is positive.  This means that you are pregnant. (Pauses to let this information sink in).

Ivy: That’s what I thought.

Nurse: How are you feeling about this? Many women have mixed feelings about a pregnancy.

Ivy: I think Brian would be a great dad. Maybe having a baby would be great for us, bring us closer together. I don’t know.

Nurse: Tell me more about what you are thinking. (Pause. Ivy does not respond). Ivy, this is a really important decision for you and sometimes it can be helpful to get support and talk it through with family or friends. Would you like me to ask your mother to come in here to be with you?

Ivy: Yes.

The nurse leaves and returns with Jody who sits next to Ivy.

Nurse: Ivy, you have several options to consider. You could choose to continue the pregnancy and parent the child, you could chose to have an abortion or you could continue the pregnancy and plan an adoption.

Non-directive, patient-centered options counseling
Innovating Education in Reproductive Health provides exercises and presentations on providing quality options counseling to adolescents, and other related sexual and reproductive health issues such as Caring for Challenging Patients and A Counseling Model for Ambivalent Patients. Completing these tools will help learners develop necessary skills to provide unintended pregnancy prevention and care.

The nurse estimates that Ivy is approximately 11 weeks pregnant. She asks Ivy if she would like information on her options regarding the pregnancy, and Ivy agrees. The nurse explains that Ivy could have a first trimester abortion procedure, she could continue with the pregnancy, or she could make an adoption plan. When working with patients to help them understand their options the most important points to remember are:

  1. The patient has the answers.
  2. Any choice a patient makes is the right one for her.

Our role as nurses is to be a mirror and a map for the patient: as a mirror we reflect back what we hear the patient saying, and as a map we provide information regarding the different paths a patient can take and it is up to the patient to choose the path that is right for her. Training in Early Abortion for Comprehensive Healthcare (TEACH) details the fundamentals of presenting all options to women including counseling techniques using open-ended questions, dealing with ambivalence and moral conflict in Chapter 2, Counseling and Informed Consent of their “Early Abortion Training Workbook.” The workbook is an extensive comprehensive resource on abortion care with recommendations and guidance on issues ranging from confidentiality and consent procedures to medications and pain management for different abortions procedures.

First Trimester Abortion

This chart, First Trimester Abortion: A Comparison of Procedures from the National Abortion Federation shows a side-by-side comparison of early abortion procedures: Mifespristone, Methotrexate, vacuum aspiration. The chart details how they work as well as the advantages and disadvantages of each. In addition, the National Abortion Federation has Clinical Policy Guidelines, which are evidence-based guidelines and standards on abortion care. They include clinical practices on patient care and counseling and different types of abortions. These guidelines, which are revised annually, are based on rigorous review of medical literature and known patient outcomes to support and educate providers on the most current information, standards, and recommendations. The following modules are specific to this competency:

  • Module 5: Limited Sonography in Abortion Care
  • Module 6: Early Medication Abortion
  • Module 7: First-Trimester Aspiration Abortion
  • Module 9: Abortion by Dilation and Evacuation
  • Module 10: Second-Trimester Induction Abortion

Making an Adoption Plan

If Ivy were to make an adoption plan, she would likely place the baby for adoption shortly after birth. In a domestic infant adoption there are several options for how the process could work for Ivy and the adoptive family. The Basics of Adoption Practices: A Bulletin for Professionals from the U.S. Department of Health and Human Services’ Administration for Children and Families via the Child Welfare information Getaway, details types of adoption, family and child assessments, birth parent involvement, and how the placement and adoption process works including post-adoption services. In addition to prenatal care, the nurse would need to refer Ivy to a social worker who would work with Ivy to find an optimal match in an adoptive family. Ivy could chose to have an open adoption, where identifying information is shared between families with an agreed-upon level of contact, or she could opt for a closed adoption with no shared identifying information. The nurse could also direct Ivy and Jody to view Open Adoption: Could Open Adoption be the Best Choice for You and Your Baby? a resource from the U.S. Department of Health and Human Services’ Administration for Children and Families for expectant parents. There is a specific section on open adoption which details how it works, the benefits, legalities and action steps for this type of adoption. With the choice to make an adoption plan, Ivy commits to continuing the pregnancy. Her prenatal care must focus on maintaining optimal physical and emotional health, with a focus on continuing her education.

Continuing the Pregnancy and Parenting

If Ivy chooses to continue the pregnancy and to parent the nurse would provide her with some basic prenatal health information, including the importance of taking daily folic acid, and provide her with a referral for prenatal care services. In addition, the nurse could show Ivy and her mother several online resources for teens that provide unbiased support for teen parents including the following:

Backline
This website offers information and provides contact information for a support “talkline” that offers unbiased, nonjudgmental counseling on pregnancy, abortion, adoption, and parenting.

Girl-Mom
A support website written by and for young mothers.

TeenHealth
This website offers advice for teens dealing with pregnancy and provides guidance on talking with parents and doctors about sexuality and pregnancy.

According to the National Institutes of Health, teens are at a higher risk for developing medical complications during pregnancy than pregnant females older than 20 years of age. Infants born to teens are also at a higher medical risk for low birth weight, prematurity and inadequate fetal growth. The Mayo Clinic indicates that pregnant teens are at higher risk due to a lack of knowledge about the kind of prenatal care required for healthy pregnancy. Teens are also more likely to be unaware of the health risks associated with substance use or unprotected sex. Pre-eclampsia, a condition in which the pregnant mother experiences dangerously high blood pressure, and high protein in the urine is a common complication in first pregnancies. Pre-eclampsia may result in early delivery of the baby due to the risk of harm or potential death to the mother or baby. According to the Centers for Disease Control and Prevention, there are often high social and economic costs of teen pregnancy and childbearing. As an example, teen pregnancy and childbirth contribute significantly to drop-out rates among high school girls: only about 50% of teen mothers receive a high school diploma by age 22, compared with nearly 90% of those who did not give birth during adolescence. The CDC also states that children who are born to teen mothers also experience a wide range of problems and are more likely to:

  • Have fewer skills and be less prepared to learn when they enter kindergarten.
  • Have behavioral problems and chronic medical conditions.
  • Rely more heavily on publicly funded health care.
  • Be incarcerated at some time during adolescence.
  • Drop out of high school.
  • Give birth as a teenager.
  • Be unemployed or underemployed as a young adult.

While options counseling is a critical component to high quality health care, not all health care workers have the knowledge and skill to provide effective options counseling. Simmonds and Likis address the conflicts that nurses may experience when providing unintended pregnancy prevention and care, and examine the intersection of personal values with professional responsibilities in their 2005 article Providing Options Counseling for Women with Unintended Pregnancies. The article also provides epidemiological data on unintended pregnancy and strategies for providing options counseling.

In some cases, it can help nurses to identify their values and beliefs that might affect their ability to provide the highest quality of care to patients. A set of exercises in The Abortion Option from the National Abortion Federation supports health care workers to identify their values and define their boundaries related to abortion care and the role of health care workers in providing abortion services.

Ivy: But doesn’t having an abortion mean I can’t have kids later? What if this is my only chance to be a mom?

What are the risks to having an abortion?
There are many myths about the dangers of abortion. The scientific evidence suggests that abortion is one of the safest outpatient procedures available. Raymond et al. (2014) conducted a literature review and compared mortality rates of abortion to other outpatient procedures commonly performed on healthy young women. The mortality rate associated with abortion between 2000 – 2009 was 0.7 per 100,000 abortions, lower than the rate for plastic surgery (0.8 – 1.7/100,000) and dental procedures (0 – 1.7/100,000 procedures). Induced abortion may be safer than running marathons (0.6 – 1.2 deaths/100,000 marathons run). Another study by Raymond and Grimes (2012) found that legal induced abortions had a lower mortality rate than birthing live neonates, which was 8.8 per 100,000 cases between 1998 and 2005. This fact sheet from the National Abortion Federation details the safety of abortion and the uncommon, but possible complications from aspiration abortion. In addition, according to the 2013 Guttmacher Institute report, Still True: Abortion Does Not Increase Women’s Risk of Mental Health Problems, there have been numerous scientific studies which conclude that abortion does not pose an additional threat to women’s mental health compared with women who continue with a pregnancy.

Nurse: No matter what you chose to do, making a decision like this is often very difficult even when you know what the right choice for you is.

Jody: Thanks so much. Do you perform these procedures here, or do we need to make an appointment somewhere else?

Making effective referrals
To provide high quality patient care, it is vitally important that nurses are either able to participate in the care of the patient or to provide effective referrals so the patient can receive the health care she needs as soon as possible. When a woman chooses to have an abortion, and if the health center cannot do the procedure on site, it is essential to provide her with a referral that will facilitate accessing care quickly. One major barrier to providing effective referrals is that clinicians are often unaware of where abortion services are offered. In this case, the nurse is familiar with the local facilities and even knows which one will be able to schedule an appointment the soonest. This web page from the National Abortion Federation includes an interactive map that gives state-specific information on abortion services and clinic contact information for each state. Another barrier to providing abortion care and/or referrals is nurses’ willingness to participate.

What If…

This section offers a twist or a different perspective on “What Happened” to guide and encourage learners to tease apart various aspects of the Patient Situation.

Ivy wanted to terminate the pregnancy but Jody doesn’t believe in abortion?
Maradiegue provides a detailed historical overview of privacy and confidentiality laws for minors obtaining contraception and abortion, and discusses the clinical implications for practice: Minor’s Rights Versus Parental Rights: Review of Legal Issues in Adolescent Health Care.

Each state has different laws regarding a minor’s right to consent to health care services without parental permission. The Guttmacher Institute brief, An Overview of Minors’ Consent Law, provides background information and includes a chart with laws by state on minors’ right to consent without parental permission to contraception, STI, abortion, prenatal care, and medical care for minor’s child.

Ivy was 8 weeks pregnant?
Ivy’s options remain the same: she could have a first trimester abortion procedure, she could continue with the pregnancy, or she could make an adoption plan. The difference here is that at only 8 weeks gestation, Ivy could choose to have a medication abortion which would be more private and wouldn’t require an in-clinic procedure. When mifepristone was first approved by the FDA in 2000, it was recommended for pregnancies up to 7 weeks (49 days) after LMP. Since then, studies have shown that it is safe to extend its use up to 8 weeks and then 9 weeks of pregnancy. Most recently, a 2012 study by Winikoff et al. found that extending outpatient medical abortion services through 70 days of gestational age is safe and effective.

In the article Mifepristone for Medical Abortion: Exploring a New Option for Nurse Practitioners, Taylor and Hwag introduce Mifespristone, commonly referred to as RU-486, and provide clinical considerations including a chart comparing regimens and a chart comparing medication abortion with vacuum aspiration. The fact sheet What is Medical Abortion? from the National Abortion Federation (NAF) defines and provides details of medication abortions including how the medications work, how long they take, possible complications, and follow-up care. NAF also defines Mifepristone, a medication that blocks the action of progesterone, discusses how it works, effectiveness as an abortifacent when combined with Misoprostol, possible side effects, and what women can expect when using it in this fact sheet: Facts About Mifepristone (RU-486).

In Care for Women Choosing Medication Abortion Taylor et al. discusses the nurse practitioner’s role in providing medication abortions and uses case studies to present counseling, complications and potential sides effects, and confirming complete abortion in the article.

Meg’s Choice (Patient Situation #2)

The Patient

Meg is a 41-year old woman who is married with two young children. She thought she was menopausal and not fertile so she and her husband do not use birth control consistently. Her periods have been highly irregular for over a year, and she hasn’t had her period in about 3 months.

See Meg’s Intake Form

The Setting

A private primary care practice that includes comprehensive reproductive health services. This is Meg’s primary care office, the same office she went when she was pregnant with each of her children.

What Happened

Meg and her husband Dave just found out that Meg is 12-weeks pregnant with twins. They are here to discuss their options.

Nurse: Tell me what brings you in today, Meg.

Meg: Well, we just found out that I’m pregnant with twins and we want to talk about our options. I’m 41 and if we have a baby, TWO babies, we will be in our 60s by the time they are in high school! Also, we are doing fine financially, but I don’t know if we can afford two more kids in the house. Two more college tuitions… (she trails off)

Dave: Can you tell us about the risks involved… for Meg… if we have twins?

What are the risks for Meg if she continues with the pregnancy?
Pregnancy at age 35 years or older is associated with higher genetic anomalies and higher age related health issues such as hypertension and diabetes. A healthy woman over the age of 35 with a healthy lifestyle with a negative family history has a low risk of age related illnesses and pregnancy related problems.

With twin pregnancies there is an increased risk of preterm labor and birth with resulting low birth weight babies, and higher neonatal morbidity and mortality. Multifetal pregnancies present increased maternal risks of gestational diabetes, gestational hypertension, preeclampsia, acute fatty liver and pulmonary embolism. In addition, Meg would be more likely to have a cesarean section with twins, which carries its own health risks. All of these risks are the same for women over the age of 35. A woman with a twin pregnancy has the same risks but maybe not additional risks beyond the risk of having twins and the risk of maternal age.

Dave: (looks at Meg, worried): Honey, whatever you want to do is what I want, too. I’ll support any choice you make.

Meg: It’s so scary to think about the possibility of health complications for me and for the babies. I just don’t want to make a decision we will regret. I don’t know what to do.

How can the nurse facilitate decision-making?
Exploring All Options: Pregnancy Counseling Without Bias from the Title X Family Planning National Training Centers contains a video series of five different scenarios on options counseling provided in a neutral, non-judgmental manner and includes a discussion guide that addresses topics such as “Essentials of Options Counseling” and “Balancing Personal Values and Your Professional Role”. Faculty can use the videos to facilitate a discussion of effective counseling. The videos present scenarios that illustrate the decision-making process when a patient receives positive pregnancy test results. Following each scenario, experts analyze the counseling and offer commentary.

The nurse can provide them with information and nonjudgmental options counseling whereby she explains the benefits and risks to having an abortion procedure (dilation and evacuation), continuing with the pregnancy, or making an adoption plan. Regardless of the nurse’s beliefs or opinion on how the couple should proceed, non-directive options counseling is an essential component to quality patient care.

Options Counseling for Unintended Pregnancy is a presentation from Provide’s ROE (Reproductive Options Education) Consortium was designed to give nurses and advanced practice nurses information on attitude, skills, and knowledge needed to provide options counseling to patients who experience unintended pregnancy:

Truly non-directive options counseling can be difficult because of one’s own beliefs, especially when there is a strong feeling that we know what the best option would be for a woman. In Options Counseling: Techniques for Caring for Women with Unintended Pregnancies Singer provides a guidance for clinicians to examine their own beliefs and values to improve their skills in providing nonjudgmental and nondirective options counseling for women experiencing unplanned pregnancy.

The National Abortion Federation designed exercises in The Abortion Option: A Values Clarification Guide for Health Care Professionals to help nurses critically examine factors that might influence their beliefs about parenting, adoption, and abortion and, for some, their desire to become involved in abortion care. There are tools for clarifying values related to abortion, views about the role of health care providers, and case studies are used to identify and examine potential biases.

What If...

This section offers a twist or a different perspective on “What Happened” to guide and encourage learners to tease apart various aspects of the Patient Situation.

Meg was 29 years old instead of 41?
While Meg’s age does not change her options of continuing the pregnancy, having an abortion, or making an adoption plan, the risks associated with continuing with the pregnancy are reduced if she is 29 years old instead of 41 years old with either a singleton or twin pregnancy.
Meg's was a singleton pregnancy instead of twins?
While many of the risks associated with a twin pregnancy and birth would not apply in this twist, Meg is still 41 years old with several possible adverse pregnancy outcomes including preterm birth, low birth weight, still birth, chromosomal defects, labor complications, and cesarean section. (Cleary-Goldman, 2005; Jacobsson, 2004; Joseph, 2007; Bayrampour, 2010)

In addition, The Mayo Clinic identifies the following risks:

  • She is more likely to develop gestational diabetes. This type of diabetes, which occurs only during pregnancy, is more common as women get older. Left untreated, gestational diabetes can cause a baby to grow significantly larger than average — which increases the risk of injuries during delivery.
  • She is more likely to develop high blood pressure during pregnancy. Research suggests that high blood pressure that develops during pregnancy is more common in older women. She might need to take medication or birth the baby before her due date to avoid complications.
  • She is more likely to have a low birth weight baby and a premature birth. Premature babies, especially those born earliest, often have complicated medical problems.
  • She might need a cesarean section. Older mothers have a higher risk of pregnancy-related complications that might lead to a C-section delivery, such as placenta previa — a condition in which the placenta blocks the cervix.
  • The risk of chromosome abnormalities is higher. Babies born to older mothers have a higher risk of certain chromosome problems, such as Down syndrome.
  • The risk of pregnancy loss is higher. The risk of pregnancy loss — by miscarriage and stillbirth — increases as you get older, perhaps due to pre-existing medical conditions or fetal chromosomal abnormalities.

Nurses could also consult chapters on risk assessment and risk management in Prenatal and Postnatal Care: A Woman-Centered Approach from Jordan et al. (2013), which is written by midwives and nurse practitioners.

In this twist, it is possible Meg and Dave might feel less financial pressure since it would be one child instead of two. However, this is an unplanned pregnancy, and it is critical to discuss all of Meg’s options for continuing the pregnancy, having an abortion, or making an adoption plan. It is up to the nurse to provide nonjudgmental and non-directive counseling to help Meg and Dave decide what to do.

What if the nurse is not comfortable discussing a full range of reproductive options? What are the nurse’s ethical obligations to the patient?

Counseling Techniques

Innovating Education in Reproductive Health
This website provides exercises and presentations from on providing quality options counseling to adolescents, and other related sexual and reproductive health issues such as “Caring for Challenging Patients” and “A Counseling Model for Ambivalent Patients.”

Exploring All Options: Pregnancy Counseling Without Bias
This website from the Title X Family Planning National Training Centers contains a video series of five different scenarios on options counseling provided in a neutral, non-judgmental manner and includes a discussion guide that addresses topics such as “Essentials of Options Counseling” and “Balancing Personal Values and Your Professional Role.”

Caring for Women with Unintended Pregnancies (Simmonds, K. and Likis, F.E., 2011)
This article highlights the nurse’s professional responsibilities in providing care to women with unintended pregnancies which includes appropriate assessment, options counseling, referrals and care coordination, and prevention efforts.

Giving Pregnancy Test Results: A Primer for Nursing Students
This presentation from Provide serves as a guide for nursing students on giving pregnancy test results, identifying immediate health concerns, providing referrals, and gives an overview of laboratory pregnancy tests. Recommendations are given on specific questions to ask and counseling language to use when providing negative and positive test results, and working with a patient who is ambivalent about the test results.

Motivational Interviewing: A Tool for Behavior Change (AGOG, 2014)
This American College of Obstetricians and Gynecologists (AGOG) Committee Opinion defines the principles of motivational interviewing including the stages of readiness for change, its effectiveness as a counseling strategy, practical applications for use during visits, and provides tips on the associated medical coding.

Objective Structure Clinical Examination: Non-Directive Pregnancy Options Counseling with Communication and Ethical Challenges (Lupi, C., et al., 2012)
This resource consists of two case studies of women who are diagnosed with unexpected early intrauterine pregnancy. The evaluation tool can be used to assess competency in non-directive options counseling, responding to patient ambivalence, delivering bad or unexpected news, and responding to a patient’s request for moral guidance.

Patient-Centered Options Counseling for Unintended Pregnancy
This presentation from the STFM (Society of Teachers of Family Medicine) Resource Library provides current pregnancy data in the United States, a values clarification exercise, steps to options counseling, an early abortion method comparison worksheet, and key language for providers to use with patients experiencing unintended pregnancy.

Providing Options Counseling for Women with Unintended Pregnancies (Simmonds, K. and Likis, F.E., 2005)
This article addresses the conflicts that nurses may experience when providing unintended pregnancy prevention and care, and examines the intersection of personal values with professional responsibilities. The article also provides epidemiological data on unintended pregnancy and strategies for providing options counseling.

Options Counseling: Techniques for Caring for Women with Unintended Pregnancies (Singer, J., 2004)
This article serves as a guide for clinicians to examine their own beliefs and values to improve their skills in providing nonjudgmental and nondirective options counseling for women experiencing unplanned pregnancy.

Options Counseling for Unintended Pregnancy
This presentation from Provide’s ROE (Reproductive Options Education) Consortium was designed to give nurses and APRNs information on attitude, skills, and knowledge needed to provide options counseling to patients who experience unintended pregnancy.

Sexual History Taking Role Play
This exercise from CORE (Curricula Organizer for Reproductive Health Education) is designed to help health care professionals improve their knowledge, skills, and comfort with sexual history taking and risk assessments. The worksheet includes questions to ask when taking a sexual history, specifically when working with LGBTQ patients.

Do Ask, Do Tell (Potter, J.E., 2002)
This article examines the importance of creating an environment that allows patients to disclose their sexual orientation and behaviors, a critical component to establishing a productive, therapeutic patient/doctor relationship. The author uses her own experiences as a lesbian patient and doctor to illustrate how creating such an environment is essential to the provision of preventive health counseling and the challenges and rewards of coming out as a gay physician.

Improving the Health Care of Lesbian, Gay, Bisexual and Transgender People: Understanding and Eliminating Health Disparities
This publication from The Fenway Institute includes facts and terminology regarding the LGBT population, charts and recommendations for collecting key sexual health and behaviors information from patients, and recommendations for improving health care settings to better serve this population.

If Transmen Can Have Babies, How Will Perinatal Nursing Adapt? (Adams, E., 2010)
This article explores the role of the nurse in providing care during the birth experience for a transgender male and his significant other. The article articulates a plan of care to assist the nurse in providing nonjudgmental, nondiscriminatory physical and emotional nursing care.

Six Steps of Shared Decision Making (SDM)
This presentation from Informed Medical Decisions Foundation defines shared decision making and provides six steps providers can use which includes sample language for effective patient engagement.

Values Clarification

Values Clarification and Options Counseling for Unintended Pregnancy (Hart, J.A., et al., 2013)
This article emphasizes the importance of providing unbiased, compassionate, and factual options counseling for women experiencing unintended pregnancy, and identifies the difficulties of counseling women with religious affiliations to help them address conflicting feelings between their religious beliefs and their abortion decision.

The Abortion Option: A Values Clarification Guide for Health Care Professionals
These exercises from the National Abortion Federation are designed to help nurses critically examine factors that might influence their beliefs about parenting, adoption, and abortion and, for some, their desire to become involved in abortion care. There are tools for clarifying values related to abortion, views about the role of health care providers, and case studies are presented to identify and examine potential biases.

Abortion

Fact sheet: Induced Abortion in the United States (Guttmacher Institute, 2014)
This document from the Guttmacher Institute provides an overview of the incidence of abortion, a discussion of who has abortions, safety, information on providers and service, explanation of early medication abortion and law and policy.

Abortion: Quality Care and Public Health Implications
This course from the University of California, San Francisco addresses abortion in a global context, professionalism and patient-centered care, different abortion procedures, obstacles to access.

First Trimester Abortion: A Comparison of Procedures
This chart from the National Abortion Federation shows a side-by-side comparison of three types of abortion procedures and how they work as well as advantages and disadvantages to each.

Providing Abortion Care: A Professional Toolkit for Nurse-Midwives, Nurse Practitioners, and Physician Assistants
This toolkit provides a thoroughly researched and referenced discussion of scope of practice and abortion care as pertains to APNs and physician assistants.

Clinical Training Curriculum in Abortion Practice, 2nd Edition
Module 7, “Vacuum Aspiration and D&E Technique”, of this evidence-based curriculum from the National Abortion Federation provides specific details on vacuum aspiration and dilation and evacuation procedures.

Mifepristone for Medical Abortion: Exploring a New Option for Nurse Practitioners (Taylor D., and Hwang, A.C., 2004)
This article introduces Mifespristone, commonly referred to as RU-486, provides clinical considerations including a chart comparing regimens and a chart comparing medical abortion with vacuum aspiration.

Early Abortion Training Workbook
Chapter 5 and Chapter 7 of this workbook from Advancing New Standards in Reproductive Health (ANSIRH) workbook provides details on uterine aspiration including step-by-step instructions, managing complications, and exercises are provided with relevant questions to evaluate the learner’s understanding. This is an extensive comprehensive resource on abortion care with recommendations and guidance on issues ranging from confidentiality and consent procedures to medications and pain management for different abortions procedures.

Care for Women Choosing Medication Abortion (Taylor et al., 2004)
This article addresses the nurse practitioner’s role in providing medication abortions, details the pharmacology involved, and uses case studies to present counseling, complications and potential sides effects, and confirming complete abortion.

What is Medical Abortion?
This fact sheet from the National Abortion Federation defines and provides details of medication abortions including how the medications work, how long they take, possible complications, and follow-up care.

Facts About Mifepristone (RU-486)
This fact sheet from the National Abortion Federation defines Mifepristone – a medication that blocks the action of progesterone – discusses how Mifepristone works, effectiveness as an abortifacient when combined with Misoprostol, possible side effects, and what women can expect when using it.

Mortality of Inducted Abortion, Other Outpatient Surgical Procedures and Common Activities in the United States (Raymond, E.G., et al., 2014)
The safety of induced abortion as practiced in the United States for the past decade met or exceeded expectations for outpatient surgical procedures and compared favorably to that of two common nonmedical voluntary activities.

The Comparative Safety of Legal Induced Abortion and Childbirth in the United States (Raymond, E.G. and Grimes, D.A., 2012)
The authors estimate mortality rates associated with live births and legal induced abortions in the United states in 1998-2005 and conclude that the mortality rate of abortion is far less than the mortality rate among women who birth live neonates.

Minors and Reproductive Health

Preventing Pregnancies in Younger Teens (CDC, 2014)
These resources from Centers for Disease Control and Prevention (CDC) include a fact sheet on teen pregnancy, two brief case studies, ways parents/guardians, health care professionals, and teens can address the issue, and a list of related resources.

An Overview of Minors’ Consent Law (Guttmacher Institute, 2014)
This Guttmacher Institute brief provides background information and includes a chart with laws by state on minors’ right to consent without parental permission to contraception, STI treatment, abortion, prenatal care, and medical care for minor’s child.

Minor’s Rights Versus Parental Rights: Review of Legal Issues in Adolescent Health Care (Maradiegue, A., 2003)
This article gives a detailed historical overview of privacy and confidentiality laws for minors obtaining contraception and abortion, and discusses the clinical implications for practice.

Parental Involvement in Minors’ Abortions (Guttmacher Institute, 2014)
This Guttmacher Institute brief provides background, highlights, and a chart with state-by-state information on requirements for parental involvement in minors’ abortions including consent, notification, and judicial bypass.

Making Effective Referrals

Caring for Women with Unintended Pregnancies (Simmonds, K. and Likis, F.E., 2011)
This article highlights the nurse’s professional responsibilities in providing care to women with unintended pregnancies which includes appropriate assessment, options counseling, referrals and care coordination, and prevention efforts.

Referrals for Unintended Pregnancy: A Curriculum for Health and Social Service Providers
This curriculum from Provide includes six modules with training tips, materials, role plays, and other exercises to support health care and social service professionals to provide effective referrals for high quality abortion care.

Referral-making in the Current Landscape of Abortion Access (Zurek, M., et al., 2014)
This article highlights the increasing importance of providing effective referrals for abortion care as clinic closures further limit women’s access to these services.

National Abortion Federation Find a Provider
This web page from the National Abortion Federation includes an interactive map that gives state-specific information on abortion services and clinic contact information for each state.

Find a Nurse Practitioner
This resource from the American Association of Nurse Practitioners uses an interactive map to help a consumer find a nurse practitioner in their geographic area.

DoctorFinder
This resource from the American Medical Association provides professional information on almost every licensed physician in the United States and can be used to locate doctors who specialize in prenatal care.

Pregnancy and Parenting

Prenatal and Postnatal Care: A Woman-Centered Approach (Jordan, R.G., et al., 2013)
Nurses will appreciate the difference in this text written by midwives and nurse practitioners compared to standard medical textbooks with a clear focus on women-centered care. See chapters on risk assessment and risk management in prenatal care and prenatal genetic counseling, screening and diagnosis. Chapter 7 “Pregnancy Diagnosis and Gestational Age Assessment” provides essential information on confirming pregnancy and determining gestational age.

Impact of Maternal Age on Obstetric Outcome (Cleary-Goldman, J., et al., 2005)
A study of total of over 36,000 women compared age and pregnancy outcomes. Increasing age was significantly associated with miscarriage, chromosomal abnormalities, congenital anomalies, gestational diabetes, placenta previa, cesarean delivery, increased risk for abruption, preterm delivery, low birth weight, and perinatal mortality. Increasing age was a continuum rather than a discreet age.

Advanced Maternal Age and Adverse Perinatal Outcome (Jacobsson, B., et al., 2004)
This national prospective, population-based, cohort study in over 1.5 million women aged 40-44, 45 years or older compared to a control group of women aged 20-29 years who delivered during a 15 year period. Perinatal mortality, intrauterine fetal death, and neonatal death increased with age. There was also an increase in illnesses and pregnancy complications with increasing age, but this did not entirely explain the increase in perinatal mortality with age. Level Of Evidence: II-3

Advanced Maternal Age and the Risk of Cesarean Birth: A Systematic Review (Bayrampour, H. and Heaman, M., 2010)
This systematic review of 21 studies that met the inclusion criteria were reviewed. All studies demonstrated an increased risk of cesarean birth among women at advanced maternal age compared with younger women, for both nulliparas and multiparas (relative risk varied from 1.39 to 2.76). However, the associated factors for this increased risk are not totally understood in the literature.

Clinical Manifestations and Diagnosis of Early Pregnancy (Bastian, L. A. and Brown, H. L., 2014)
Diagnosis of pregnancy and knowledge of normal findings associated with early pregnancy are common issues in the health care of reproductive-age women. This article reviews history findings, clinical exam findings and appropriate laboratory testing to diagnosis pregnancy.

Shifts in Intended and Unintended Pregnancies in the United States, 2001-2008 (Finer, L. B. and Zolna, M. R., 2014)
The authors monitored trends in pregnancy intendedness nationally and within subpopulations and also reported on pregnancy outcomes.

Ectopic Pregnancy: Incidence, Risk Factors, and Pathology (Tulandi, T., 2013)
Management of ectopic pregnancies has changed dramatically over the years with a focus on a conservative approach that attempts to save the tube, rather than salpingectomy. However, hemorrhage from ectopic pregnancy is still the leading cause of pregnancy related maternal death in the first trimester and accounts for 4 to 10 percent of all pregnancy related deaths, despite improved diagnostic methods leading to earlier detection and treatment.

Ectopic Pregnancy Clinical Manifestations and Diagnosis (Tulandi, T., 2015)
The clinical manifestations and diagnosis of ectopic pregnancy are reviewed in this article. The diagnosis of ectopic pregnancy is based upon a combination of measurement of the serum quantitative human chorionic gonadotropin (hCG) and findings on transvaginal ultrasonography. Management with methotrexate is reviewed.

Adoption

The Basics of Adoption Practices: A Bulletin for Professionals
This resource from the U.S. Department of Health and Human Services’ Administration for Children and Families via the Child Welfare information Getaway details types of adoption, family and child assessments, birth parent involvement, and how the placement and adoption process works including post-adoption services.

Adoption Directory
This resource has an interactive United States map that provides links to adoption-related organizations in each state. There is also a search feature, and various adoption-related categories to find information on adoption agencies, home studies, foster care, counseling, embryo adoption, medical evaluation, etc.

Consent to Adoption
This resource from the U.S. Department of Health and Human Services’ Administration for Children and Families via the Child Welfare information Getaway addresses issues related to consenting to adoption including who is involved and when and how it can take place.

Open Adoption: Could Open Adoption be the Best Choice for You and Your Baby?
This resource from the U.S. Department of Health and Human Services’ Administration for Children and Families via the Child Welfare information Getaway is designed for expectant parents and details open adoption, how it works, the benefits, legalities, and action steps.

Patient Resources

These are resources for patients that health care providers can use with patients, or direct patients to, in order to find out more information about pregnancy options.

Pregnancy Options Workbook
This workbook offers information, exercises, and guidance to help patients clarify their thoughts and feelings in order to make an informed decision about what is right for them.

Adoption: Resources for Those Interested in Making an Adoption Plan
This web page from the Abortion Care Network offers information and resources for women experiencing unintended pregnancy who are considering making an adoption plan. This resource includes links to support networks including adoption agencies that are committed to helping women make informed decisions.

Open Adoption: Could Open Adoption be the Best Choice for You and Your Baby?
This resource from the U.S. Department of Health and Human Services’ Administration for Children and Families via the Child Welfare information Getaway is designed for expectant parents and details open adoption, how it works, the benefits, legalities, and action steps.

Mom, Dad I’m Pregnant
This resource from the Abortion Care Network is for young people, partners, and parents around disclosing a pregnancy, how to respond, and the options for next steps.

Open Adoption and Family Services
This is a pro-choice, non-profit, open adoption organization based out of the Pacific Northwest which offers services nationwide that include all-options pregnancy counseling, open adoption planning, and lifelong support at no cost to birthparents.

Backline
This website offers information and provides contact information for a support “talkline” that offers unbiased, nonjudgmental counseling on pregnancy, abortion, adoption, and parenting.

Exhale
This website offers information and resources, and provides contact information to call and get after-abortion support.

Girl-Mom
A support website written by and for young mothers.

Adoption Resources & Support for Birth Parents
This website from the Independent Adoption center contains resources and support for people considering making an adoption plan.

Before Abortion
“Making a choice you live with, living with the choice you made”. Options counseling and self-tests regarding confident decision making.

A Heartbreaking Choice
A website for patients contemplating terminating a pregnancy due to catastrophic fetal anomaly or serious maternal diagnosis.

National Abortion Federation: Think You’re Pregnant?

Men and Abortion

Abortion Care Network: Men and Abortion

1 in 3

Our Bodies Ourselves: Stories

Personal Stories of Women Who Have Had Abortions

The Abortion Diary

Untold Stories: Life, Love, and Reproduction

Resources in Film and Literature

Bring the Popcorn: Using Film to Teach Sexual and Reproductive Health (Capiello, J.D. and Vroman, K., 2011) discusses the use of film for nursing students to explore the intersection of science, theory, and personal values to prepare for providing sexual and reproductive health care for patients.

Abortion Onscreen
This webpage from Advancing New Standards in Reproductive Health (ANSIRH) describes a research program that explores how abortion stories are incorporated into American film and television culture and how this may impact the broader social understanding of abortion.

Movies About Abortion

  • 4 Months, 3 Weeks and 2 Days (2007)
  • The Cider House Rules (1999)
  • If These Walls Could Talk (1996)
  • Bella (2006)
  • Citizen Ruth (1996)
  • The Group (1966)
  • Junebug (2005)
  • Juno (2007)
  • Knocked Up (2007)
  • Obvious Child (2014)
  • Vera Drake (2004)
  • Waitress (2007)

Documentaries

  • 12th & Delaware (2010)
  • After Tiller (2013)
  • From Danger to Dignity: The Fight for Safe Abortion (1995)
  • The American Nurse (2014)
  • I Had an Abortion (2005)
  • Lake of Fire (2006)
  • Let’s Talk About Sex (2009)

Movies About Adoption

  • The Cider House Rules (1999)
  • Juno (2007)

Movies About Pregnancy/Parenting

  • For Keeps (1988)
  • Junebug (2005)
  • Knocked Up (2007)
  • Waitress (2007)

TV Shows Featuring Diverse Views About Pregnancy

  • Lost
  • Grey’s Anatomy
  • Private Practice
  • Six Feet Under
  • Call the Midwife
  • Downton Abbey
  • Friday Night Lights
  • House
  • Mad Men
  • Maude
  • Murphy Brown
  • Party of Five
  • Rosanne
  • Sex and the City

Books

  • The Girls Who Went Away: The Hidden History of Women Who Surrendered Children for Adoption in the Decades before Roe v. Wade by Ann Fessler
  • I Wish for You a Beautiful Life: Letters from the Korean Birth Mothers of Ae Ran Won to Their Children edited by Sara Dorow
  • Second Chance Mother By Denise Roessle
  • Untold Stories: Life, Love, and Reproduction edited by Kate Cockrill, Lucia Leandro Gimeno, and Steph Herold
  • What If Your Mother by Judith Arcana

Poetry

  • Abortion Care Network and Split this Rock’s Poetry Contest Winners
  • What If Your Mother, by Judith Arcana

Videos

Visual Art

  • 4000 Years for Choice

Since over half of the pregnancies in the United States are unintended, it is likely nurses will encounter a woman with an unintended pregnancy. Providing non-direction, patient-centered options counseling is an essential component to quality care. This module provides tools, exercises and resources for learners to improve their skills and confront their values related to unintended pregnancy prevention and care.

These modules are designed to use with a flipped classroom model in which students are directed to complete the module as homework, including the Pre- and Post-Assessments. Once students have completed the module in its entirety, including the recommended reading, faculty can use the Teaching Tips document and materials from the Exercises and Handouts section below to integrate concepts from the module into the classroom or group setting.

Teaching Tips

Exercises and Handouts

These materials can be used to enhance classroom learning. The Teaching Tips document provides recommendations on how to incorporate these materials into a classroom or group setting.

Lane’s Intake Form: This exercise introduces Lane, a patient who identifies as a lesbian who is experiencing an unintended pregnancy and wants to know more about her options.

Sexual History Taking Role Play: This worksheet includes questions to ask when taking a sexual history, specifically when working with LGBTQ patients.

The Abortion Option: A Values Clarification Guide for Health Care Professionals: These exercises from the National Abortion Federation include tools that can be used in class for clarifying values related to abortion and discussing the role of health care providers.

Options Counseling In-Class Presentation

For a more traditional approach to classroom learning, content from the Options Counseling online module was used to develop this 15 – 20 minute presentation. Faculty can use this presentation in the classroom as a substitute for students completing the module independently. The Teaching Tips document and exercises and handouts that are provided as part of the module can be used to supplement this presentation and incorporate student participation in class.

Accessing Student Pre- and Post-Assessment Data

Pre- and Post-Assessments are designed to measure students’ satisfaction with the module as well as what they have learned. To be able to complete the Assessments students will need to enter a “Site Code” prior to working through the online module. Faculty will use this Site Code to download and review students’ Pre- and Post-Assessment data. To obtain a Site Code your institution must e-mail Provide. In the text of the email, please include your name (as instructor), the name of the institution, and the module(s) for which you would like to access data. Provide will send you 1) a Site Code for your students to enter at the beginning of the assessment, 2) a web link to access the results from each module, and 3) an “answer key” to help grade your students’ responses. You may also assign a unique Student Code to each student that you would like to assess on an individual basis. Students must enter the correct Site Code for faculty to be able to access their data.

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