Welcome to the Public Health Nursing Education Module
Many women experience barriers to accessing family planning and preconception care. Cost of services and lack of insurance may be a barrier. The Affordable Care has addressed the cost barrier for insured women by mandating insurance coverage of contraceptives, and federal and state family planning programs provide low cost services, which specifically target the uninsured or underinsured. Other barriers to accessing reproductive health services include a lack of transportation, or cost of transportation, clinic hours and scheduling restrictions (e.g. lack of same day appointments), clinic policies that create barriers (e.g. unavailability of same day insertions for IUDs and implants). In addition, seeking care to prevent pregnancy may not be a priority for some women.
This module explores five public health problems: insecure housing, substance use, inadequate sex education, intimate partner violence, and cultural differences in the context of unintended pregnancy prevention and care. Three of the scenarios are designed for student self-directed learning; two additional scenarios are designed for classroom discussion with faculty facilitation points included. While unintended pregnancy is a public health concern in and of itself, other public health issues complicate women’s control of their reproductive lives. Using social psychology theory that people are more likely to engage with an individual’s story than with a global concept, the modules begin with patient story, then discuss public health concepts.
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 Public Health. 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.
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.
- Understand concepts of population health and integrate into the care of the individual patient.
- Understand the unique challenges of providing sexual health information to people from different backgrounds.
- Analyze systemic barriers to family planning/pregnancy prevention for vulnerable populations.
- Develop skills in providing effective referrals for unintended pregnancy prevention and care health services.
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.
- Demonstrate knowledge of the nurse’s professional responsibilities in providing health care to clients in need of unintended pregnancy prevention and care.
- 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).
- Demonstrate knowledge of current state-specific laws regulating minors’ access to reproductive care for the state(s) in which nurse practices (including contraceptive access and abortion care).
- Demonstrate basic understanding of female and male anatomy and physiology related to conception and reproduction” (no quotes) in numerical order using the same format as the others.
- Demonstrate knowledge of confidentiality regulations specific to unintended pregnancy prevention and care.
- Demonstrate knowledge of state and local adoption options and resources and applicable regulatory laws and statutes.
- Demonstrate proficiency in promoting sexual-health self-care practices.
- Demonstrate proficiency in providing patient-centered risk reduction counseling specific to unintended pregnancy prevention.
- Demonstrate proficiency in identifying preconception health risks.
- Demonstrate ability to make appropriate referrals to community-based prenatal care providers and resources.
- Demonstrate proficiency in assessing risk for intimate partner violence including sexual violence and coercion).
- Demonstrate proficiency in referring clients with unintended pregnancy to area providers and support services.
Comprehensive Sexuality Education: According to the Sexuality Information and Education Council of the United States “comprehensive sex education includes age-appropriate, medically accurate information on a broad set of topics related to sexuality including human development, relationships, decision making, abstinence, contraception, and disease prevention. They provide students with opportunities for developing skills as well as learning.”
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.
Fetal Alcohol Spectrum Disorder (FASD): FASD is a combination of mental and physical health defects in children whose mother consumed excessive amounts of alcohol during pregnancy. Permanent neurological damage is common.
Housing Insecurity: A state of marginal housing: a person is not homeless but does not have a stable or predictable place to live.
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).
Intimate Partner Violence: Physical, sexual, or psychological harm by a current or former partner or spouse including reproductive control behaviors such as birth control sabotage. This type of violence can occur among heterosexual or same-sex couples and does not necessarily involve sexual intimacy.
Long Acting Reversible Contraceptives (LARC): LARCs refer to methods of contraception that can last for several years. Examples are intrauterine devices (which range from 3-10 years) or a hormonal implant called Nexplanon (3 years). Some people also consider the Depo-provera injection (which lasts for 3 months) to be a LARC.
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.
Methadone Maintenance Treatment: The U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) defines methadone as “A synthetic opioid that blocks the effects of heroin and other prescription drugs containing opiates. Used successfully for more than 40 years, methadone has been shown to eliminate withdrawal symptoms and relieve drug cravings from heroin and prescription opiate medications.” MMT can reduce/eliminate cravings for opioid drugs, prevent the onset of withdrawal, and block the effects of other opioids.
Minimum Wage vs. Living Wage: The minimum wage is the lowest amount that an employer may legally pay an employee and varies by state. A living wage is the amount that an employee must earn to live locally based on cost of living.
Oral Contraceptive Pills: Daily hormonal pills taken by women to prevent pregnancy.
Pregnancy Resource Center (also known as Crisis Pregnancy Centers): PRCs are federally and privately funded “clinics” that offer women free prenatal care and new baby supplies but are also designed to discourage women contemplating ending a pregnancy from choosing abortion care. PRCs are often affiliated with anti-abortion organizations or religious organizations. PRCs often provide women thinking about abortion care with provide false and misleading information about abortion and take actions to delay or impede a woman’s access to abortion care. Often they look like a medical clinic, but are not staffed by medical professionals nor do they use clinical guidelines. While PRCs can be a good option for women who are certain they want to continue a pregnancy and need access to free pre- and post-natal care, they are not a good option for women who unsure about whether or not to continue a pregnancy. No health care provider should pressure a woman into a decision about her pregnancy. All real family planning clinics will give patients accurate information about all of their options.
Prenatal Care: Prenatal care is the medical care that women receive when they are pregnant. According to the Office on Women’s Health, “babies of mothers who do not receive prenatal care are three times more likely to have a low birth weight and five times more likely to die than those born to mothers who do get care.”
Primary/Secondary/Tertiary Public Health Prevention: Different stages of prevention that work together to promote health and prevent disease. Each stage can work at an individual level or population level. Generally, primary prevention is seen as preventing the onset of disease, secondary prevention is seen as screening for disease, and tertiary prevention is treatment of disease.
Public Health: The science and art of preventing disease, prolonging life, and promoting health of the community through population health analysis.
Reproductive Coercion: The American College of Obstetricians and Gynecologists describes reproductive and sexual coercion as involving behavior that includes “explicit attempts to impregnate a partner against her will, control outcomes of a pregnancy, coerce a partner to have unprotected sex, and interfere with contraceptive methods.”
School-Based Health Centers: Health centers that range in services and staffing patterns but all of them are located in schools. Parents must opt-in in order for their children to receive treatment at a school-based health center. Health center staff work in collaboration with school staff to make sure that the health center is an integral part of life at the school.
Second Trimester Abortion: Termination of pregnancy performed between weeks 13-28 often using a dilation and evacuation method (D & E).
Sexually Transmitted Infections (STI): STIs are infections spread mainly from sexual contact between individuals. There are many types of STIs and some (such as chlamydia, gonorrhea, HIV, and herpes) can cause complications to a pregnancy. Some STIs are curable and others are manageable with medication.
Survival Sex: When someone exchanges sex for basic needs such as housing or food.
Teen Pregnancy: Refers to young women who have not reached legal adulthood who have become pregnant. According to the National Campaign to Prevent Teen and Unplanned Pregnancy teens who become pregnant face unique health and socioeconomic challenges.
Unintended Pregnancy: An unintended pregnancy is a pregnancy that is mistimed, unplanned, or unwanted at the time of conception.
The Healthy People Goals focus on national health indicators of physical activity, overweight/obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization, and access to health care. Improving responsible sexual behavior with the goal of improving pregnancy planning, preventing unintended pregnancy, and improving the health and well-being of women, infants, and families is the cornerstone of the national reproductive health goals.
- According to Finer and Zolna (2014) half of pregnancies among American women are unintended, and four in 10 of these are terminated by abortion.
- 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.
- Healthy People 2020 cites negative outcomes associated with unintended pregnancy as a greater risk of birth defects, low birth weight and infant mortality. Unintended pregnancy can also result in delays in initiating prenatal care, inadequate folic acid intake through multivitamins or diet, tobacco and alcohol use in pregnancy, increased physical abuse and violence in pregnancy, reduced likelihood of breastfeeding, and maternal depression.
- In contrast, birth spacing helps to reduce the risk of adverse outcomes: less prematurity, fewer low birth weight babies, fewer small for gestational age babies and less perinatal death. Public health measures are needed to promote ideal birth spacing and to promote the benefits of preconception care.
- According to the U.S. Department of Housing and Urban Development, (HUD) on any night in January 2013, it is estimated that about 610,000 people were homeless in the United States and approximately 65% were living in shelters or transitional housing.
- HUD also reports more than 1 in 10 individuals who are homeless are between the ages of 18 and 24 years old.
- A study by Winetrobe et al. (2013) found that over 62% of homeless females between the ages of 14 and 27 years old reported having ever been pregnant.
- Housing insecurity is associated with poor health outcomes for young children. (Cutts et al., 2011)
- Homeless women have a higher rate of pregnancy and a higher proportion of unintended pregnancy than women with secure housing. (Saver et al., 2012)
- The U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) report on Methadone Treatment for Pregnant Women defines methadone as “a long-acting opioid medication used with counseling and other services to treat individuals addicted to short-acting opioid drugs.” MMT can reduce/eliminate cravings for opioid drugs, prevent the onset of withdrawal, and block the effects of other opioids.
- According to the CDC there are between 0.2 and 2.0 cases of Fetal Alcohol Spectrum Disorder per 1,000 births in the United States.
- The Guttmacher Institute reports that states have varying laws about when and how women can receive abortions and a joint report from Ibis Reproductive Health and the Center for Reproductive Rights showed that states with more abortion restrictions performed worse overall on women’s and infant’s health indicators compared with states with fewer restrictions.
- The 2012 ACOG Committee Opinion on Opioid Abuse, Dependence, and Addiction in Pregnancy states that “according to the 2010 National Survey on Drug Use and Health, an estimated 4.4% of pregnant women reported illicit drug use in the past 30 days. A second study showed that whereas 0.1% of pregnant women were estimated to have used heroin in the past 30 days.”
- The same report also states that “during pregnancy, chronic untreated heroin use is associated with an increased risk of fetal growth restriction, abruptio placentae, fetal death, preterm labor, and intrauterine passage of meconium.”
Inadequate Sexuality Education
- According to Advocates for Youth comprehensive sexuality education has been shown to reduce teen pregnancy, reduce sexually transmitted infections and increase teen comfort with negotiating relationships.
- Sexuality education programs are not standard across the United States. Individual states and/or local school districts are able to determine if and to what extent sexuality education is taught in schools. The American Medical Association “urges schools to implement comprehensive, developmentally appropriate sexuality education programs” and “supports federal funding of comprehensive sex education programs that stress the importance of abstinence in preventing unwanted teenage pregnancy and sexually transmitted infections, and also teach about contraceptive choices and safer sex.”
- 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 public health scenario that unfolds in this module provides detailed information on the patient, the setting and what happened. Each situation highlights the complex and often controversial nature of unintended pregnancy prevention and care.
Nancy – insecure housing (Patient Situation #1)
Contemporary Health Concerns in Community Health Nursing: Homelessness
Homelessness is often defined as a person who lacks a fixed, regular, and adequate place in which to sleep. Usually, homelessness is a temporary condition, not a permanent condition, so it is important to define the number of people who experience homelessness over time, hence the methodology for defining homelessness is either a Point-in-Time Count or a Period Prevalence Count.
A Point-in-Time Count provides a snapshot of who is homeless on a given night; it is a one-day, statistically reliable, unduplicated count of sheltered and unsheltered homeless individuals and families in the country. This information is important for communities to use in planning local homeless assistance systems, to tailor programs to meet existing needs, and to raise public awareness of homelessness. The U.S. Department of Housing and Urban Development requires a Point-in-Time Count each year in January for groups that coordinate homeless services. A limitation of this type of count is that it is more likely to count the chronically homeless and underestimate temporary homelessness. In this type of count, Nancy in the following scenario would not be counted as struggling with homelessness, as she is not sleeping at a shelter, sleeping on the street, or using a soup kitchen.
A second method of counting homeless people examines the number of people who are homeless over a given period of time, also called a Period Prevalence Count. Critics of this method point to the difficulty of standardizing measurements including the duration of counting and time of year of counting.
The U.S. Conference of Mayors conducts an annual assessment of hunger and homelessness. The 2014 report found an increased demand for emergency food and housing across 25 cities. Low wages led the list of causes of hunger citied by officials in the cities surveyed, and lack of affordable housing was seen as the chief cause of homelessness for both families with children and unaccompanied individuals. Highlights of the 2014 report include:
- 1% increase in total number of homeless persons (in the 25 cities that were assessed). In general, there is more homelessness in urban areas.
- 3% increase in families experiencing homelessness.
- Characteristics of homeless adults:
- 28% were severely mentally ill
- 22% were physically disabled
- 15% had experienced domestic violence
- 3% were HIV positive
- 18% were employed
- 13% were veterans.
- Leading case of homelessness for families were lack of affordable housing, followed by unemployment, poverty and low-paying jobs.
The National Coalition for the Homeless is a national network of people who are currently experiencing or who have experienced homelessness, activists and advocates, community-based and faith-based service providers, and others committed to a single mission: to prevent and end homelessness while ensuring the immediate needs of those experiencing homelessness are met and their civil rights protected. The coalition’s report Senseless Violence: A Survey of Hate Crimes/Violence Against the Homeless in 2012 provides information on violence against homeless people:
- 79% of all perpetrators were under the age of 30
- 96% of all perpetrators were male
- 72% of all victims > 40 years
- 88% of all victims were male
- 21% of the attacks ended in death
Nancy is a 24 year old, English-speaking Caucasian woman. She does not have a regular place to live because she cannot afford rent despite working at a fast food restaurant. She splits her time between two friends’ apartments and her primary partner’s apartment.
She takes oral contraceptive pills (OCPs) but has difficulty taking them regularly because she leaves the pill pack in one apartment or another for a few days at a time.
See Nancy’s Intake Form.
A Family Planning Department in a federally qualified community health center that provides comprehensive reproductive health services. A full range of FDA-approved contraceptives are available on site.
Nurse: Hi Nancy, tell me what brings you in today.
Nancy: Well, I missed my period last week so I’m afraid I might be pregnant and I wanted to get tested here.
Nurse: Ok, I’ll run a pregnancy test. Before I do, I see on the intake form that you indicated that you do not want to be pregnant right now. Do you want to talk about this?
Nancy: I mean, I love babies, and I want to be a mom someday, but I wasn’t trying to get pregnant. I left my pills at Brian’s place so I didn’t take them for a few days. I don’t even have a place to live, how would I take care of a kid?
Nurse: Ok, Nancy, let’s run the test and we can talk more after. I’ll be back in a few minutes. (Nurse leaves to run the urine pregnancy test and it is negative.)
Nurse: Nancy, the pregnancy test is negative. You are not pregnant. (Pauses to let this information sink in. Nancy looks relieved).
Nancy: Wow, ok. I guess… that’s good to know.
Nurse: Nancy, you seem relieved about this news. Tell me more about how you are doing with the pills you are on. You said you left them somewhere?
Nancy: Yeah. I stay with my boyfriend, Brian, a lot, but his place is kind of far from work. When I work late I usually stay with Rafael – he’s an old friend. Sometimes I leave my stuff at one apartment and then end up staying at a different place so I don’t have my pills or my makeup or anything. It’s usually fine, though, because Brian and I use condoms, too.
Nurse: With your permission, I want to ask about any other sexual partners that you may have.
Nancy: Sometimes I sleep with Rafael. He’s had a crush on me forever and I feel like I owe him ‘cause I stay at his place all the time. He doesn’t like to use condoms, though.
Nurse: Condoms are the best way to protect yourself from getting a STD – I can suggest some ways you could have that conversation with Rafael. Would you be interested?
Nancy: Yeah, sure.Communicable Infections/Sexually Transmitted Infections
- Gonorrhea: Approximately 300,000 cases were reported in 2010. Although the reported rates are at historically low levels, there is a slight increase in the actual number of cases. There are worrisome signs that the infection is developing resistance to our current treatment options. The resistance pattern has been noted every few decades with the gonorrheal bacteria.
- Chlamydia: Approximately 1.3 million chlamydia cases were reported in 2010. A majority of infections go undiagnosed, as the person may not experience symptoms. Less than half of sexually active young women are screened annually as recommended by CDC.
- Syphilis: The syphilis rate decreased during the 1990s and in 2000, the rate was the lowest since reporting began in 1941. The low rate of syphilis and the concentration of the majority of syphilis cases in a small number of geographic areas in the United States led to the development of CDC’s National Plan to Eliminate Syphilis, which was announced by the Surgeon General in October 1999 and revised in May 2006. However, syphilis remains a major health problem in certain populations. Men who have sex with men (MSM) have high rates of HIV co-infection, high-risk sexual behaviors and high rates of syphilis.
Prevalence: The proportion of individuals in a population having a disease or characteristic. For example, young people (ages 15-24) account for about 50% of all new STIs, although they represent only 25% of the sexually experienced population. Nancy, at age 24, is in the 20–24 year age group, which has the highest rates of chlamydia (3,722.5 cases per 100,000 females) and gonorrhea (584.2 cases per 100,000 females) compared with any other age and sex group in 2011. Syphilis rates in women have been highest each year among those aged 20–24 years with 3.8 cases per 100,000 females in 2011.
Screening: Screening for disease is part of a public health approach of secondary prevention. The Unites States Preventive Services Task Force (USPSTF) recommends screening for chlamydia and gonorrhea in sexually active women age 24 years and younger (B rating). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men (I rating). This recommendation is helpful on a population level when developing screening programs. On an individual patient level, a risk assessment is needed to determine a male’s need for screening. If the individual has symptoms of an STI, the testing is no longer done for screening purposes but is considered diagnostic testing.
The USPSTF recommends screening for HIV infection in adolescents and adults up to age 65. Other individuals who are at increased risk should also be screening (A rating). All pregnant women should be tested for HIV (A rating). Universal screening will help to ensure the use of effective therapies to reduce mother-to-child transmission. Mother-to-child transmission is responsible for more than 90% of pediatric HIV infections in the U.S.
Women experience more frequent and more serious STI complications than men do. Complications include chronic pelvic pain, pelvic inflammatory disease, ectopic pregnancy, and infertility. In terms of health care costs, STIs cost the healthcare system about $16 billion in direct medical costs. A Healthy People 2020 Goal aims to reduce the proportion of females aged 15 to 24 years with Chlamydia trachomatis infections attending family planning clinics. Currently 7.4% of females aged 15 to 24 years who attend family planning clinics in tested positive for Chlamydia trachomatis infection. The goal is to reduce this number to 6.7%, which would be a 10 % reduction of infections.
Condom Negotiation Skills
The nurse could work with Nancy around her condom negotiation skills to protect herself and her partners from STIs. A few examples of things to say are:
- “I can’t relax without a condom – I want to protect us both.”
- “You won’t have to pull out if we wear a condom and it can feel even better.”
- “I really like this kind of condom, let’s give it a try.”
The nurse could show Nancy the Bedsider website, which is specifically designed for young people and contains videos of young men discussing their condom-use practices. Nancy might be interested in personal stories from other young women who want to convince their male partners to wear a condom during sex at Gurl.com.
VOICES/VOCES: Video Opportunities for Innovative Condom Education from the CDC is a single-session, video-based HIV/STD prevention program designed to encourage condom use and improve condom negotiation skills. The program is based on the theory of reasoned action, which explains how behaviors are guided by attitudes, beliefs, experiences, and expectations of other persons’ reactions. VOICES/VOCES is grounded in extensive formative research exploring the culture- and gender-based factors that can facilitate behavior change. An evaluation of the intervention showed that VOICES/VOCES is effective when delivered at a “teachable moment,” for instance when a visit to an STD clinic or a negative pregnancy test may motivate a person to change behavior.
With Nancy’s permission, the nurse can explore Nancy’s feelings of obligation to have sex with Rafael as a favor for overnight stays.
Nurse: We can discuss other methods of contraception, too. Would you like to hear about some contraceptive methods that do not involve taking a daily pill or that you need not worry about leaving somewhere?
Nancy: Yes, that would be great.
Nurse: Let’s discuss some other contraceptive methods to see what be a good fit for you. Tell me, do you see yourself becoming a mom in the next year? Or the next 3 – 5 years?What is reproductive life plan counseling?
Historically public health programs and strategies have focused on interconception health. In 2006, the CDC released 10 preconception health and health care recommendations to improve the health of women, men, and couples before conception of a first or subsequent pregnancy. The CDC developed these recommendations based on a review of published research and the opinions of specialists from the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. The recommendations are aimed at achieving four goals to:
- Improve the knowledge and attitudes and behaviors of men and women related to preconception health.
- Assure that all women of childbearing age in the United States receive preconception care services (e.g., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health.
- Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children.
- Reduce the disparities in adverse pregnancy outcomes.
Assessing and helping a patient understand his/her reproductive life plan is a way for clinicians to provide preconception care including recommending a contraception that will work best for the patient to prevent unintended pregnancy. In Preconception Health and Health Care: Information for Health Professionals the CDC provides information on the evidence-based effectiveness of preconception interventions, how to incorporate them into clinical practice, and links to other resources such as “Clinical Content for Women” and “Reproductive Life Plan Tool.”
Before, Between, & Beyond Pregnancy also describes how to assess a patient’s reproductive life plan, provides some key questions that will help solidify the plan, and makes recommendations on integrating reproductive life plan assessments into clinic operations.
Nancy: I don’t know. Definitely not this year. I want to be a mom someday, but I’m not ready. I want to go back to school, get a better job. I don’t know when that’s going to happen.Family planning is considered one of the ten greatest public health achievements in the 20th century: Which contraceptive method might work best for Nancy?
This interactive website, Method Match, from the Association of Reproductive Health Professionals (ARHP) provides fact sheets on different methods of contraception that includes information on efficacy, how each method works, benefits and contraindications to each. In addition, this Counseling Session video from LARC First is available in English and in Spanish, and provides a demonstration of high quality, non-directive counseling on contraception options.
Since Nancy expressed that she is not ready to become pregnant for several years, a long-acting reversible contraceptive (LARC) method could work well for her. Nancy’s unstable housing situation means she moves frequently, thus using a contraceptive method that she doesn’t have to remember would be ideal. The nurse presents information on the hormonal implant (Nexplanon), which would last up to 3 years or an IUD. Current IUDs are FDA approved for up to 3, 5 or 10 years.
Unwarranted concern continues to exist regarding IUD use and young women. Pelvic inflammatory disease (PID) was once thought to be higher in IUD users. Current research from Grimes (2000) suggests that PID and infertility are no more likely to occur with IUDs than with any other method of contraception. The presence of STIs, usually chlamydia, not IUDs, use causes PID, thus all adolescents should be screened for STIs at the time of insertion of an IUD to reduce the risk of PID. In addition, a 2001 study conducted by Hubacher et al. concluded that “tubal infertility was not associated with the duration of IUD use, the reason for the removal of the IUD, or the presence or absence of gynecologic problems related to its use.”
Nancy: I guess the implant sounds good. It’s only 3 years, and I’ll be in a better place by then. Also, I won’t leave it anywhere by accident! Can we do it today?
Nurse: We can insert an implant for you today. If you are ready, we can begin the paperwork.
Nancy: I am, thanks.
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.Same-day implant insertion is not available? How can the nurse support Nancy to prevent pregnancy until her appointment?
This presentation, EC: Dispelling the Myths, from the Society of Teachers of Family Medicine (STFM) introduces emergency contraception using data, case studies, and providing information on mechanisms of action and contraindications.
Until her next visit, Nancy can continue to use her oral contraceptive pills. Together, Nancy and the nurse make a plan to help Nancy be more consistent in taking her pills to avoid unwanted pregnancy. Nancy decides to carry her pill pack with her and set a daily alarm on her cell phone until her implant insertion appointment.
This presentation, Giving Pregnancy Test Results: A Primer for Nursing Students, from Provide serves as a guide for nursing students on giving pregnancy test results, identifying immediate health concerns, providing referrals. An overview of laboratory pregnancy tests is also provided. 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.
After giving Nancy the results of the pregnancy test, the nurse would have to determine gestational age. Nancy mentioned she missed her period about a week ago. Pregnancy wheels are commonly used to determine the due date or estimated date of confinement (EDC). Wheels are based on Naegele’s Rule which estimates the EDC by adding one year, subtracting three months, and adding seven days to the first day of a woman’s LMP. The result is approximately 280 days (40 weeks) from the LMP. Wheels may vary by a day or two and it is easy for a health care provider to misread a wheel by a day or two. Applications for electronic calculation of EDC are freely available and eliminate calculation errors.
Depending on Nancy’s reaction to the test results, and with her permission, the nurse would discuss Nancy’s options in a non-directive, patient-centered manner. Nancy could have a first trimester abortion procedure, continue with the pregnancy, or she could make an adoption plan. Options Counseling for Unintended Pregnancy is a presentation from Provide’s ROE (Reproductive Options Education) Consortium. It is designed to give nurses and APRNs 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 is for a woman. In Options Counseling: Techniques for Caring for Women with Unintended Pregnancies, Singer provides a guidance for clinicians on examining their own beliefs and values to improve their skills in providing nonjudgmental and nondirective options counseling for women experiencing unplanned pregnancy
First Trimester Abortion
These nursing education modules use the term aspiration abortion when discussing first trimester abortion care because it more accurately depicts a first trimester abortion than does aspiration abortion. According to Weitz et al. (2004) surgical “implies incision, excision and suturing and is associated with the physician subpopulation of surgeons” whereas, first trimester abortion in practice uses no incisions, excisions, or suturing.
The chart First Trimester Abortion: A Comparison of Procedures from the National Abortion Federation shows a side-by-side comparison of three types of abortion procedures, how they work as well as advantages and disadvantages to 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
Making an Adoption Plan
If Nancy 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 Nancy and the adoptive family. A social worker can work with Nancy to find an optimal good match in an adoptive family. Nancy could then 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 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.
The nurse could also direct Nancy 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 that details how it works, the benefits, legalities and action steps for this type of adoption.
If she chose to make an adoption plan, Nancy would commit to continuing the pregnancy. Obtaining regular prenatal care could be challenging because of Nancy’s unstable living situation.
Continuing the Pregnancy
Nancy could chose to continue the pregnancy and decide 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.
According to the National Center on Family Homelessness from American Institutes for Research, children experiencing homelessness:
- Are sick four times more often than other children.
- Have 4 times as many respiratory infections, 2 times as many ear infections, 5 times more gastrointestinal problems, and are 4 times more likely to have asthma.
- Are twice as likely to go hungry compared to children in stable housing.
- Have 3 times the rate of emotional and behavioral problems compared to children with stable housing.
- Are 4 times more likely to show delayed development and 2 times as likely to have learning disabilities as non-homeless children.
Given these risk factors, Nancy would need additional and intensive support to secure housing while continuing her pregnancy and either placing the child for adoption or parenting. The nurse could provide her with referrals to social service agencies in the community that could assist her with securing housing and other related services such as financial assistance and/or Women, Infants, and Children (WIC).
Regina – substance use (Patient Situation #2)
Contemporary Health Concerns in Community Health Nursing: Substance Abuse
According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Survey on Drug Use and Health, 9.4% (24.6 million people) of the population had used an illicit drug in the past month in 2013. Of those, 8.2 million people met criteria for a substance use disorder. The misuse of prescription drugs is second only to marijuana as the nation’s most common drug problem after alcohol and tobacco. Many areas of the country are experiencing a dramatic increase in heroin abuse: first-time users have increased by nearly 60% percent in the last decade.
Primary Prevention: Data have shown that early intervention following the first episode of a serious mental illness can make an impact on improving mental health and prevent or decrease the risk of substance abuse. The Institute of Medicine and National Research Council released a report in 2009 that reported the cost-benefit ratios for prevention and early treatment programs for addictions and mental illness programs range from 1:2 to 1:10. This means a $1 investment yields $2 to $10 savings in health costs, criminal and juvenile justice costs, educational costs, and lost productivity (O’Connell, et al., 2009). Prevention science is focusing on trying to better understand why some people become addicted while others do not. Prevention research may identify the factors that put people at increased risk of drug abuse or protect them from it.
Secondary Prevention: Screening tools are used to identify people who may be using an addictive substance. Screening tools may include a written or oral questionnaire or may involve scheduled or random urine, blood, saliva, or hair samples. Nursing students may be familiar with drug testing as many clinical placement sites require a criminal background check and a random drug screening prior to beginning a clinical rotation.
Tertiary Prevention: Only 11% of people who need treatment for addiction involving alcohol or drugs receive any form of treatment.
Regina is a 36-year old woman who is living out of state. Her pregnancy history is G4P1 (1 preterm, 2 abortions, 1 living) and her 5-year-old child is in state custody. She has been in and out of methadone clinics and is currently in treatment. She found out that she was pregnant when the methadone clinic tested her urine for pregnancy, and she is now 18 weeks pregnant.
A clinic that provides comprehensive reproductive health care and related preventative health services, including a full range of contraceptive options that are available on site. A sliding fee scale is available for patients in need of financial assistance. The clinic does not provide abortions, but does provide comprehensive options counseling, information, and referrals.
Regina decided to seek abortion care. Before coming into the clinic, Regina went to a Pregnancy Resource Center (PRC) because she saw a bus advertisement that claimed they would provide help to pregnant women. After speaking with the PRC, Regina believed that she could obtain abortion care at their clinic and tried to schedule an appointment. The staff at the PRC kept delaying her appointment, and when she finally made it in, it was clear to Regina that they do not provide abortions as promised. Instead, the staff gave her a long counseling session on how much she will regret her decision to abort. The counselor gave her a fetus-like doll to take home. Regina left feeling confused, unsupported, disheartened, and sad. She comes in to this clinic with a lot of abortion misinformation and anxiety. She is also somewhat distrustful of clinics as a result of her recent experience with the Pregnancy Resource Center.
Nurse: Hi Regina, tell me what brings you in today.
Regina: Well, I have some questions and the last place I went to wasn’t very helpful. The Pregnancy Resource Center, downtown.
Nurse: I’m sorry to hear that. I am more than happy to answer all of your questions. How about I tell you what we do here, is that OK with you?
Regina: Sure.What are Pregnancy Resource Centers and how are they different from medical clinics?
In some communities, Pregnancy Resource Centers or Crisis Pregnancy Centers offer free ultrasounds to women, which can be a supportive service and an extremely valuable resource. Many crisis pregnancy centers, however, are anti-choice organizations, established to persuade women not to have abortions. The centers will do this by providing misleading and false information about the link between future fertility, breast cancer, depression, and abortion. False and Misleading Health Information Provided By Federally Funded Pregnancy Resource Centers is a full report from the U.S. House of Representatives’ Committee of Government Reform, which details the false and misleading information that was provided during an investigative study of pregnancy resource centers.
To assess the crisis pregnancy centers in your community, visit their website to read their vision and mission, then decide if this center will meet the needs of your patients.
Regina: OK. Well I am about 18 weeks pregnant, but I don’t think now is a good time for me to have a baby. I’m trying to stay sober, get my treatment, and I just got full time retail work. It’s only minimum wage, but it pays the bills. I don’t know if I could support a kid, and my schedule is so crazy, I don’t know where I’d find time… (trails off)
Nurse: It sounds like you have a lot on your plate right now. Tell me more about what you are thinking you’d like to do about the pregnancy.
Regina: I want to have an abortion. I’ve had them before, but not when I was this far along. I tried to do it earlier, but I couldn’t get an appointment at that place I thought would help me.
Nurse: OK, Regina, it sounds like you are interested in having a termination and I can assist you with that. Our neighboring state has a health center right on the border that will provide second trimester abortions. That is the closest place since our state only allows terminations up to 14 weeks. If you would like, I can give them a call right now to schedule your appointment.What is involved in a second trimester abortion?
- Module 9: Abortion by Dilation and Evacuation
- Module 10: Second-Trimester Induction Abortion
In addition, NAF’s Safety of Abortion publication details the safety of different types of abortion procedures, possible complications, complication management techniques, and aftercare.
Access to essential health services including abortion care is critical to women’s health. A joint report from Ibis Reproductive Health and the Center for Reproductive Rights, Evaluating Priorities: Measuring Women’s and Children’s Health and Well-being Against Abortion Restrictions in the States, showed that states with more abortion restrictions performed worse overall on women’s and infant’s health indicators compared with states with fewer restrictions, including higher maternal and infant mortality rates.
Regina: I have to go out of state? I don’t know how that can work with my schedule. I can’t just leave my life for a few days to travel. I can’t miss work, or treatment for that matter.
Together, the nurse and Regina develop a plan. The nurse is able to make an appointment for Regina at the health center for three days later. Regina’s sister has a car and agrees to drive Regina the 2.5 hours to the clinic. Her sister has to bring her 6-month old baby with her as she does not have childcare. Regina’s appointment is scheduled for 8:00am for cervical preparation with her procedure scheduled for noon. On the day of the appointment, everything proceeds as planned: Regina terminates the pregnancy and is discharged in time to drive home later the same day with her sister. She only misses one day of work without missing a methadone treatment.
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.Regina continued the pregnancy?
In this twist on the patient scenario, Regina is able to maintain sobriety and continues to take methadone throughout her pregnancy. ACOG states “medically supervised tapered doses of opioids during pregnancy often result in relapse to former use. Abrupt discontinuation of opioids in an opioid-dependent pregnant woman can result in preterm labor, fetal distress, or fetal demise. During the intrapartum and postpartum period, special considerations are needed for women who are opioid dependent to ensure appropriate pain management, to prevent postpartum relapse and a risk of overdose, and to ensure adequate contraception to prevent unintended pregnancies. Patient stabilization with opioid-assisted therapy is compatible with breastfeeding. Neonatal abstinence syndrome is an expected and treatable condition that follows prenatal exposure to opioid agonists.”
ACOG’s 2012 Committee Opinion on Opioid Abuse, Dependence, and Addiction in Pregnancy provides recommendations for substance use screening, treatment and intrapartum and postpartum management for women with opioid dependence. Early identification of pregnant women with opioid dependence improves maternal and child health outcomes.
The National Center on Substance Abuse and Child Welfare provides information, expert consultation, training and technical assistance to child welfare, dependence court and substance abuse treatment professionals to improve the safety, permanency, wellbeing and recovery outcomes for children, parents and families.
In addition to national resources, local agencies can provide support to specific communities. As an example, Children and Recovering Mothers (CHARM), based in Burlington, Vermont, is a multidisciplinary group of agencies serving pregnant women with opioid dependence, their infants and families. The agency put out a webinar on Opioid Use in Pregnancy. The discussion centers on services provided and collaborative practice elements across systems at multiple points of intervention: prenatal, birth, and postpartum.
Liz – inadequate sexuality education (Patient Situation #3)
Contemporary Health Concerns in Community Health Nursing: Adolescent Pregnancy
Adolescent pregnancy is an important public health issue in which nurses play an important role. According to the CDC’s National Vital Statistics Report Births: Final Data for 2012, a total of 305,388 babies were born to women aged 15–19 years in 2012, for a live birth rate of 29.4 per 1,000 women in this age group. In comparison to other western countries, the U.S. has significantly higher rates of teen pregnancy and births and sexually transmitted infections. In addition, rates of teen births are higher in certain ethnic populations: the same report shows that in 2012 Black and Hispanic teens comprised 57% of U.S. teen births. The teen birth rates for Non-Hispanic Black and Hispanic adolescents were more than two times higher than the rate for non-Hispanic White teens, and the American Indian/Alaska Native teen birth rate was nearly twice as high as the White teen birth rate.
Teen pregnancy and childbearing bring substantial social and economic costs. The CDC reports that high school drop out rates are high – only half of teen mothers have received a high school diploma by their early twenties compared to 90% on non-parenting teens. In addition, the children of teen moms are more likely to experience underachievement in school, have more health problems, face higher unemployment and incarceration rates and are more likely to become teen parents. These effects remain for the teen mother and her child even after researchers have adjusted for factors that increase a teenager’s risk for pregnancy, such as growing up in poverty, having parents with low levels of education, growing up in a single-parent family, and having poor performance in school. The CDC’s site About Teen Pregnancy shows that teen pregnancy and birth accounted for at least $9.4 billion in costs to U.S. taxpayers for increased health care and foster care, increased incarceration rates among children of teen parents, and lost tax revenues in 2011.
Primary Prevention: To address the need to improve the life opportunities of adolescents facing significant health disparities, the CDC lists teen pregnancy prevention as one of its top six priorities in public health. Evidence-based teen pregnancy prevention programs typically address knowledge, skills, beliefs, attitudes related to teen pregnancy and identifies the following key issues:
- Knowledge of sexual issues, HIV, other STDs, and pregnancy (including methods of prevention).
- Perception of HIV risk.
- Personal values about sex and abstinence.
- Attitudes toward condoms (pro and con).
- Perception of peer norms and sexual behavior.
- Individual ability to refuse sex and to use condoms.
- Intent to abstain from sex or limit number of partners.
- Communication with parents or other adults about sex, condoms, and contraception.
- Individual ability to avoid HIV/STD risk and risk behaviors.
- Avoidance of places and situations that might lead to sex.
- Intent to use a condom.
Primary Prevention can make a difference. According to the Guttmacher Institute, teen pregnancy, birth and abortion rates are declining to record lows and rates are declining across all ethnic populations. Pregnancies among 18–19-year-olds constituted the majority (69%) of teen pregnancies. This age group reports increasing rates of sexual activity yet proportionally fewer of them become pregnant. The likely reason is improved contraceptive use, the use of more effective methods and the greater availability of contraceptive services.
Liz is 14 and hasn’t been feeling well for a couple of weeks. She took a home pregnancy test last night and it was positive. She is scared and confused and doesn’t know whom she can talk to.
A school-based health center located within the local high school. In this school district, the advanced practice nurse on staff at the health center cannot provide contraceptive methods. In schools without a health center, the school nurse generally can provide medications such as acetaminophen or ibuprofen if a parental consent form is on file but would not be able to provide students with contraceptive methods. In either case, the nurse is aware of local community resources for reproductive health care including contraceptive care, screening for sexually transmitted diseases and pregnancy options.
The school does not have a comprehensive sexuality education curriculum and science classes do not include the biology of conception as part of the curriculum. There is a one-day “sex ed” course taught as part of gym class but the gym teacher has not been given the opportunity to receive additional training or education to teach the course. The gym teacher is not comfortable with the subject matter and believes parents should be the ones to discuss sex with their kids because it is a private matter.
Nurse: Hi Liz. You look so upset, tell me what’s going on.
Liz: I took a test last night and I’m pregnant. I don’t know what to do. I haven’t even gotten my period yet, I don’t know how this happened!
Nurse: You mean you missed your period? How long ago?
Liz: No! I’ve never even gotten my period. The gym teacher said that you can’t get pregnant if you’ve never gotten your period.
Nurse: We’ll talk about this. First, though, can I ask you some personal questions about your sexual activity?
Liz: I guess so.
Nurse: Ok. Have you had intercourse, meaning penis in your vagina?
Liz: Yeah. My boyfriend and I started having sex a couple of months ago.
Nurse: Do you have an idea of when you might have gotten pregnant?
Liz: I don’t know. Wait, are you going to tell my parents?
Nurse: No matter what you decide to do about this pregnancy, it will be important to have support. Legally, you do not need to involve your parents in this decision. However, it might be good for you to discuss this situation with them. Let’s discuss your feelings about involving your parents in your decision.Parents’ involvement in minors’ reproductive health decisions
Liz: OK we can talk about my parents, but right now I’m thinking about how I will talk to my boyfriend.
Nurse: Let’s discuss your boyfriend.
Liz: We’ve been fighting a lot lately. I dunno, maybe having a baby will make us closer. I know he’d be a great dad, and I’ve been babysitting since I was, like, 10.Screening for intimate partner violence
The nurse should ask outright if Liz feels safe and happy in her relationship, what happens when they fight and what they tend to fight about. The nurse needs to remain open and non-judgmental and should not ask Liz to leave the relationship. If needed, the nurse can refer Liz to a social worker or domestic violence advocate.
It is possible that Liz would not disclose violence the first time she was asked. Disclosing violence to someone can take time because victims are often afraid of how they will be perceived and may be afraid of being blamed for the violence. The nurse could follow up with her and assess her safety by asking her every time they meet; this way Liz knows the nurse cares and is always available to talk. Maintaining a non-judgmental and open demeanor is essential to building the trust needed for a victim to feel safe enough to open up about her situation.
Nurse: Liz, there is a really wonderful woman I think you should meet who will be able to talk you through all of your options. Her name is Gloria and she works at the community health center down town. She will be able to help you make a decision that feels right to you. Once you have decided what to do, Gloria will make sure you get connected to the care and resources you need. Let’s go ahead and call her together right now together and schedule an appointment for you.Providing referrals for unintended pregnancy care
This presentation from Provide called Giving Pregnancy Test Results: A Primer for Nursing Students serves as a guide for nursing students on giving pregnancy test results, identifying immediate health concerns, providing referrals, and an overview of laboratory pregnancy tests is provided. 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.
The nurse is able to schedule an appointment with Gloria at the health center for the following afternoon.
Nurse: I’m glad you will be able to see Gloria tomorrow. Shall we talk about what you would like to say to your parents?
Liz: Yes, I’m so nervous!How can the nurse support Liz to involve her parents in her decision?
Liz: I just don’t understand how this happened if I haven’t gotten my period.
Male and female anatomy related to conception
The nurse could begin with explaining male and female anatomy to Liz as it relates to conception. To help with this discussion, the nurse could show Liz the Keep Your Rebel Covered Series from the University of Nevada, Las Vegas Health Center, which show and explain details of male and female anatomy, as well as the physiology of sexual intercourse, fertilization and the implantation processes.
The nurse could role play with Liz to build her skills and confidence to have a discussion with her parents about the pregnancy. The nurse could use Mom, Dad I’m Pregnant, a resource from the Abortion Care Network, that is for young people, partners, and parents around disclosing a pregnancy, how to respond, and the options for next steps. They could also look the TeenHealth website, which offers advice for teens dealing with pregnancy, to help prepare Liz to have this conversation with her parents.
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.Liz was the third student with the same situation in the past 2 months?
The nurse could work with the school administration to develop and implement a comprehensive sexuality education program in the school. It seems that what is being taught in the one-day session as part of gym class is inadequate to help students protect themselves from unintended pregnancy.
One strategy could include an “open education hour” during lunch or some other convenient time so that students could drop by and have their questions answered. This allows the nurse to be more available for students and would provide the opportunity to correct any misconceptions the students have.
It would be important to involve the parents, school community, and local youth groups to identify initiatives that could be implemented in the community to address the problem of teen pregnancy. Initially, the nurse and the school administration could use existing forums such as parent/teacher boards and town meetings to introduce the issue. Then sub-committees and/or a task force could be formed to develop initiatives aimed at addressing the issue of teen pregnancy in the community.
2013 Annual Homelessness Assessment Report to Congress
This report from the U.S. Department of Housing and Urban Development provide point-in-time estimates of homelessness in the United States including demographics, trends, and prevalence.
An Evidence-Based Guideline for Unintended Pregnancy Prevention (Taylor, D. and James, E.A., 2011)
This article discusses a public health model of an “evidenced-based blueprint for a coordinated system of primary, secondary, and tertiary prevention” strategies for health professionals who care for patients at risk for an unintended pregnancy.
Provision of Contraceptive Services to Homeless Women: Results of a Survey of Health Care for Homeless Providers (Saver, B.G., et al., 2012)
This small study found that significant barriers exist for homeless women seeking contraceptive services, specifically LARC methods, which may contribute to the higher proportion of unintended pregnancies in the homeless population compared to those with stable housing.
Comprehensive Counseling for Reproductive Health: An Integrated Curriculum
Part 5, “Helping Clients Assess Their Comprehensive SRH Needs and Providing Appropriate Information” of this EngenderHealth handbook addresses patient risk assessments and improving clients’ own perception of risk, including identifying barriers and recognizing risk factors. The handbook consists of a series of workshop sessions with key discussion points designed to help providers work with clients to assess their comprehensive sexual health needs. These sessions include Session 22, “Risk Assessment – Improving Clients’ Perception of Risk”, which defines risk assessment and explores barriers to clients’ perception of their own risks. It explores key points for practitioners, sample questions to ask, assessing patients’ risk for pregnancy/STIs, and exploring patients’ sexual relationships.
Preconception Care Clinical Toolkit
This extensive, interactive website from Before, Between & Beyond Pregnancy was designed to help primary care providers and their practices incorporate preconception health into the routine care of women of childbearing age. The toolkit includes clinical guidance, patient resources, talking points, risk reduction strategies, and reproductive life planning assessments.
Birth Spacing and Risk of Adverse Perinatal Outcomes: A Meta-analysis (Conde-Agudelo, A., et al., 2006)
This meta analysis of 11 births worldwide suggests that birth spacing less than 18 months is associated with an increased risk of adverse perinatal outcomes.
Reproductive Life Planning Assessment
This web page from Before, Between & Beyond Pregnancy describes how to assess a patient’s reproductive life plan, key questions that will help solidify her plan, and how to integrate reproductive life plan assessments in a clinic operations.
Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs
This set of guidelines for the provision of quality family planning and related preventive health services in primary care settings was released as a CDC Morbidity and Mortality Weekly Report (MMWR) in April 2014. The report details recommendations for the provision of contraceptive services, pregnancy testing and counseling, including effective 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.
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.
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.
National Abortion Federation 2015 Clinical Policy Guidelines
These evidence-based guidelines and standards on abortion care from the National Abortion Federation include clinical practices on patient care, counseling, and different types of abortions. These guidelines are revised annually and 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.
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, how they work as well as the advantages and disadvantages of each.
“Medical” and “Surgical” Abortion: Rethinking the Modifiers (Weitz, T.A., et al., 2004)
Two descriptors, “medical” and “surgical,” have become the most commonly used modifiers for abortion. While these modifiers are comprehensible to most professionals active in the abortion field, the phrases “medical abortion” and “surgical abortion” are confusing for health service providers outside the abortion field, policymakers and the public. The authors suggest that the term “medication” abortion is clearer that the term “medical” and that “aspiration” abortion more accurately describe first trimester procedures.
This interactive website from the Association of Reproductive Health Professionals (ARHP) provides fact sheets on different methods of contraception that includes information on efficacy, how each method works, benefits and contraindications to each.
Increasing Use of Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy (ACOG, 2009)
This AGOG Committee Report recommends LARC methods be used as first-line contraceptive methods and encouraged for most women.
Emergency Contraception: Dispelling the Myths?
This presentation from the Society of Teachers of Family Medicine (STFM) introduces emergency contraception using data and case studies. It also provides information on mechanisms of action of emergency contraception and contraindications.
Intrauterine Device and Upper-Genital-Tract Infection (Grimes, D.A., 2000)
This article suggests that pelvic inflammatory disease (PID) and infertility are no more likely to occur with IUDs than with any other method of contraception. The presence of STIs, usually chlamydia, not IUDs, use causes PID, thus all adolescents should be screened for STIs at the time of insertion of an IUD to reduce the risk of PID.
Use of Copper Intrauterine Devices and the Risk of Tubal Infertility among Nulligravid Women (Hubacher, D., et al., 2001)
This study concluded that “tubal infertility was not associated with the duration of IUD use, the reason for the removal of the IUD, or the presence or absence of gynecologic problems related to its use.”
The Stages of Prevention
Chapter 4 of the Association of Faculties of Medicine of Canada Primer of Population Health details different stages of prevention that work together to promote health and prevent disease. Each stage can work on an individual level or population level. Generally, primary prevention is seen as preventing the onset of disease, secondary prevention is seen as screening for disease, and tertiary prevention is treatment of disease.
“Pregnancy Diagnosis and Gestational Age Assessment” in Prenatal and Postnatal Care: A Woman Centered Approach (Jordan, R.G., et al., 2013)
Chapter 7 “Pregnancy Diagnosis and Gestational Age Assessment” by Engstrom and Capiello (2013) reviews approaches to accurate diagnosis of early pregnancy and gestational age assessment plus counseling after pregnancy diagnosis. Counseling strategies include giving a negative pregnancy test as well as a positive pregnancy test. A full range of counseling options for unintended pregnancy are reviewed.
Early Abortion Training Workbook
Chapter 3, “Evaluation Before Uterine Aspiration”, of this workbook from Training in Early Abortion for Comprehensive Healthcare (TEACH) discusses all types of pregnancy testing, includes a chart with methods and tips for dating ultrasounds, recommended lab tests, and evaluation for ectopic pregnancy.
State Policies in Brief: Substance Abuse During Pregnancy (Guttmacher Institute, 2014)
This brief provides an overview of state specific laws that govern a health care provider’s need for reporting if drug use is suspected during pregnancy.
Methadone Treatment for Pregnant Women
This U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) publication outlines how methadone treatment works, infant withdrawal, breastfeeding and birth control recommendations, and clarifies the role of child protective services.
Opioid Use, Dependence, and Addiction in Pregnancy (ACOG, 2012)
This is American College of Obstetricians and Gynecologists Committee Opinion describes how to assist women using opiods during pregnancy in obtaining effective treatment.
Evaluating Priorities: Measuring Women’s and Children’s Health and Well-being Against Abortion Restrictions in the States
This joint report from Ibis Reproductive Health and the Center for Reproductive Rights showed that states with more abortion restrictions performed worse overall on women’s and infant’s health indicators compared with states with fewer restrictions.
Maternal Decision Making, Ethics, and the Law (ACOG, 2005)
This American College of Obstetricians and Gynecologists Committee Opinion summarizes legal cases, which have impacted the criminalization of pregnant women who use drugs and have challenged the rights of pregnant women to make decisions about medical interventions.
“Crisis Pregnancy Centers” (CPCs)
This web page from NARAL Pro-Choice America describes a typical experience at a CPC, the false information that is often presented by CPCs, and some state-specific information on CPCs.
False and Misleading Health Information Provided By Federally Funded Pregnancy Resource Centers
This report from the U.S. House of Representatives’ Committee of Government Reform details the false and misleading information that was provided during an investigative study of pregnancy resource centers.
Inadequate Sexuality Education
Scenes with Teens
These sample scripts from the Office of Adolescent Health are designed to help parents set the stage for talking with kids about sex, sexuality, and relationships.
What Is Behind the Declines in Teen Pregnancy Rates? (Guttmacher Institute, 2014)
This articles reviews data on teen births over three decades and discusses possible reasons for the declining birth rate. The most likely reason is access to effective contraception.
Parents and Teens Talking Together About Contraception
Advocates for Youth developed these talking points for parents to engage their teenagers in conversations regarding sexuality and contraception.
VOICES/VOCES: Video Opportunities for Innovative Condom Education (CDC)
This video-based intervention from the CDC is a single-session HIV/STD prevention program designed to encourage condom use and improve condom negotiation skills. The program is based on the theory of reasoned action, which explains how behaviors are guided by attitudes, beliefs, experiences, and expectations of other persons’ reactions. VOICES/VOCES is grounded in extensive formative research exploring the culture- and gender-based factors that can facilitate behavior change. An evaluation of the intervention showed that VOICES/VOCES is effective when delivered at a “teachable moment,” for instance when a visit to an STD clinic or a negative pregnancy test may motivate a person to change behavior.
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., 2013)
This article provides a detailed historical overview of privacy and confidentiality laws for minors obtaining contraception and abortion, and discusses the clinical implications for practice.
National Sexuality Education Standards: Core Content and Skills, K-12
This publication from the Future of Sex Education provides clear, consistent and straightforward guidance on the essential minimum, core content for sexuality education that is developmentally and age-appropriate for students in grades K–12.
Sex Education Programs: Definitions & Point-by-Point Comparison
This publication from Advocates for Youth includes a chart showing the differences between comprehensive sex education and abstinence-only education, highlighting the inadequacies of abstinence-only programs in meeting the needs of adolescents.
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.
Counseling Teen Clients Experiencing Sexual Coercion
This 32-minute video from John Snow, Inc. shows a counseling session wherein a teenager discloses sexual coercion to a family planning counselor. The video can be used to improve communication and counseling skills when addressing sexual violence or coercion with patients.
Keep Your Rebel Covered Series: Female Sexual Anatomy
This video from the University of Nevada, Las Vegas Health Center explains and shows details of the female internal and external anatomy as well as the physiology of sexual intercourse and fertilization and implantation processes.
Keep Your Rebel Covered Series: Male Sexual Anatomy
This video from the University of Nevada, Las Vegas Health Center explains and shows details of the anatomy of internal and external male sexual organs, and discusses the physiology of an erection, the formation of sperm and the physiology of ejaculation.
Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices (ACOG, Reaffirmed 2014)
This American College of Obstetricians and Gynecologists Committee Opinion states that “Increasing adolescent access to LARC is a clinical and public health opportunity. With top-tier effectiveness, high rates of satisfaction and continuation, and no need for daily adherence, LARC methods should be first-line recommendations for all women and adolescents. As with all non-barrier methods, to decrease the risk of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), health care providers should advise sexually active adolescents to consistently use condoms along with LARC methods”.
Intimate Partner Violence
Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-Partner Sexual Violence (WHO, 2013)
This report from the World Health Organization details the prevalence of violence against women and the resulting negative health effects worldwide.
National Intimate Partner and Sexual Violence Survey (CDC, 2010)
This report from the Centers for Disease Control and Prevention (CDC) includes extensive data on the prevalence of various forms of intimate partner and sexual violence, provides information on the impact of such violence, and implications for prevention.
Reproductive Coercion and Co-occurring Intimate Partner Violence in Obstetrics and Gynecology Patients (Clark, L.E., et al., 2014).
This article details a survey that was conducted with 641 women regarding their experiences with reproductive coercion and intimate partner violence and the results underscore the need for increased screening for intimate partner violence in health care settings.
Reproductive Coercion: Connecting the Dots Between Partner Violence and Unintended Pregnancy (Miller, E. et al., 2011)
In this article the authors introduce the concept of “reproductive coercion” and highlight the need for improved family planning prevention practices to support women in using contraception to prevent unwanted pregnancies.
Reproductive and Sexual Coercion (ACOG, 2013)
This committee opinion from the American College of Obstetricians and Gynecologists describes reproductive and sexual coercion as involving behavior that includes “explicit attempts to impregnate a partner against her will, control outcomes of a pregnancy, coerce a partner to have unprotected sex, and interfere with contraceptive methods.”
Intimate Partner Violence During Pregnancy, A Guide for Clinicians
This set of slides from the Centers for Disease Control and Prevention provide facts about intimate partner violence, identifies types of abuse, provides data on violence and pregnancy, and gives recommendations for clinicians to identify abuse and support victims.
Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (CDC, 2007)
This resource from Centers for Disease Control and Prevention (CDC) is an extensive compilation of screening and assessment tools for intimate partner violence and sexual violence. When applicable, scoring tools, administration methods, follow up procedures, and psychometric properties are included.
Assessing Patients for Sexual Violence (National Sexual Assault Resource Center, 2001)
This guide from the National Sexual Violence Resource Center is for health care professionals that provides tips on assessing patients for violence, which include sample language, developing protocols, use of clinical instruments, and collaborating with community partners.
Understanding and Preventing Violence (CDC, 2013)
This document from Centers for Disease Control and Prevention (CDC) highlights risks for violence and prevention strategies as well as protective influences for different forms of violence including intimate partner violence, youth violence, and dating violence.
Emergency Contraception: OTC or Not, Pharmacists are Important (American Pharmacists Association, 2013)
This opinion piece from the American Pharmacists Association highlights the importance of access to emergency contraception, discusses conscience, and discusses EC in relation to intimate partner violence.
Structural Competency: Theorizing a New Medical Engagement with Stigma and Inequality (Metzl, J. M., and Hansen, H., 2014).
The term “structural competency” refers to a shift away from approaches that focus solely on cross-cultural understandings of individual patients, toward a broader view of the social and economic forces that affect patient’s health in addition to their individual interactions with health care providers.
Cultural Humility is the First Step to Becoming Global Care Providers (Miller, S., 2009)
This paper describes the shift in nursing education from teaching cultural competency with its focus on the ability of nurses to interact effectively with people of different cultures, to cultural humility. Cultural humility does not have the goal of mastering another culture, rather it suggests a continual, active process of self-reflection; a way of being in the world and being in relationships with others.
The Process of Inquiry – Communicating in a Multicultural Environment
This online education module from the National Center for Cultural Competence presents a rationale for the importance of communication in health care systems. The module addresses quality of care, attitudes and knowledge, and communication skills building with Limited English Speakers.
Six Steps of Shared Decision Making (SDM)
This presentation from the Informed Medical Decisions Foundation defines shared decision making and provides six steps providers can use which includes sample language for effective patient engagement.
Clinical Content of Preconception Care: Preconception Care for Special Populations (Ruhl, C. and Moran, B., 2008)
This article discusses preconception management and guidance as essential for women with disabilities, immigrant and refugee women, and cancer survivors to ensure they are able to make informed reproductive decisions for optimal reproductive outcomes.
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.
This website offers advice for teens dealing with pregnancy and provides guidance on talking with parents and doctors about sexuality and pregnancy.
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.
A support website written by and for young mothers.
This website offers information and provides contact information for a support “talkline” that offers unbiased, nonjudgmental counseling on pregnancy, abortion, adoption, and parenting.
This website offers information and resources, and provides contact information to call and get after-abortion support.
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.
Teens often turn to the internet for their sexual health information. Below are a few good resources to direct teen patients:
This module looks at unintended pregnancy prevention and care in the context of five public health problems: insecure housing, cultural differences, inadequate sex education, substance use, and intimate partner violence. Three of these issues are addressed in the online patient scenarios and two patient scenarios are described in a class handout in the Exercises and Handouts section below.
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.
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.
Public Health Intimate Partner Violence Scenario: This handout from Provide includes definitions, orienting facts, and a clinical case on intimate partner violence in the context of unintended pregnancy prevention for students to consider in a classroom setting. The Teaching Tips document for this module provides guidance on facilitating classroom discussion related to the scenario described in this handout.
Public Health Cultural Humility Scenario: This handout from Provide includes definitions, orienting facts, and a clinical case on cultural competency in the context of unintended pregnancy prevention for students to consider in a classroom setting. The Teaching Tips document for this module provides guidance on facilitating classroom discussion related to the scenario described in this handout.
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.
HOW to Refer: Use materials in Module 2 of Referrals for Unintended Pregnancy: A Curriculum for Health and Social Service Providers from Provide to present referrals as part of services provision, identify general barriers to accessing abortion care, and demonstrate best practices for referrals.
Patient Education and Risk Reduction Messages: This exercise from CORE (Curricula Organizer for Reproductive Health Education) is designed for nursing faculty to use in class. The activity uses interactive case studies, role play with scenarios, and group discussion questions are provided.
Public Health In-Class Presentation
For a more traditional approach to classroom learning, content from the Public Health 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.