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What about us? Staff reactions to D & E
Abstract
National statistics are beginning to suggest that dilatation and evacuation (D & E) may have important advantages for the patient experiencing a second-trimester abortion. However, significant emotional reactions of medical and counseling staff tend to accompany this procedure.
The present study used a self-administered questionnaire followed by an interview. The respondents were 15 present and former staff members of a small outpatient abortion clinic. All the respondents were asked to describe the various reactions to the D & E procedures, which are performed up to the 23rd menstrual week of gestation. A follow-up study was conducted one year later.
There was clear agreement that D & E is qualitatively a different procedure, medically and emotionally, than early abortion. Many of the respondents reported serious emotional reactions that produced physiological symptoms, sleep disturbances, effects on interpersonal relationships, and moral anguish. This study attempts to evaluate these reactions in the context of the reports of the medical advantages of D & E.
... The characteristics of medical and surgical methods drive management decisions and influence choices about which to offer and how to set up and implement services. For example, a busy clinic that already provides first trimester aspiration abortions might more easily add [13][14][15][16][17][18] week D&E services, with referrals to an area hospital for complicated or later cases. Facilities offering medical abortion can use a small, private room on their obstetrics ward with a small number of reclining chairs or beds. ...
... Terminating pregnancies with fully formed fetuses is often emotionally draining for staff despite their commitment to the women needing care. 15 Confirming completion of a 7-8 week abortion involves sorting through blood clots and tissue, while that of a second trimester abortion means examining fetal parts or an intact fetus. To support the team and reduce burn-out, managers in Nepal rotate staff responsibilities within the abortion service. ...
This paper describes experiences and lessons learned about how to establish safe second trimester abortion services in low-resource settings in the public health sector in three countries: Nepal, Viet Nam and South Africa. The key steps involved include securing the necessary approvals, selecting abortion methods, organising facilities, obtaining necessary equipment and supplies, training staff, setting up and managing services, and ensuring quality. It may take a number of months to gain the necessary approvals to introduce or expand second trimester services. Advocacy efforts are often required to raise awareness among key governmental and health system stakeholders. Providers and their teams require thorough training, including values clarification; monitoring and support following training prevents burn-out and ensures quality of care. This paper shows that good quality second trimester abortion services are achievable in even the most low-resource settings. Ultimately, improvements in second trimester abortion services will help to reduce abortion-related morbidity and mortality.
Résumé
Cet article décrit les expériences et les enseignements obtenus sur la création de services sûrs d'avortement du deuxième trimestre en situation de ressources limitées dans le secteur de la santé publique de trois pays : Népal, Viet Nam et Afrique du Sud. Les étapes clés étaient l'obtention des autorisations, la sélection des méthodes d'avortement, l'organisation des centres, l'acquisition des équipements et fournitures nécessaires, la formation du personnel, la mise en place et la gestion des services et la garantie de qualité. Plusieurs mois sont parfois nécessaires pour obtenir l'autorisation d'introduire ou d'élargir les services d'avortement du deuxième trimestre. Des activités de plaidoyer sont souvent requises pour sensibiliser les acteurs clés de l'administration et du système de santé. Les prestataires et leurs équipes exigent une formation approfondie, notamment une clarification des valeurs ; après la formation, un suivi et un soutien préviennent l'épuisement professionnel et garantissent la qualité des soins. L'article montre que des services de bonne qualité d'avortement au deuxième trimestre sont possibles même dans les environnements aux ressources les plus limitées. En fin de compte, les améliorations dans ces services aideront à réduire la morbidité et la mortalité liées à l'avortement.
Resumen
En este artículo se describen las experiencias y lecciones aprendidas sobre cómo establecer servicios seguros de aborto en el segundo trimestre, en lugares con escasos recursos, en el sector salud pública de tres países: Nepal, Vietnam y Sudáfrica. Los pasos fundamentales son: obtener la autorización necesaria, seleccionar los métodos de aborto, organizar los establecimientos de salud, obtener el equipo y los suministros necesarios, capacitar al personal, establecer y manejar los servicios y garantizar la calidad. Posiblemente tome varios meses obtener la autorización necesaria para lanzar o ampliar los servicios en el segundo trimestre. Por lo general, se necesitan esfuerzos de promoción y defensa para concientizar a las partes interesadas del gobierno y del sistema de salud. Los prestadores de servicios y su equipo necesitan capacitación completa, que incluya aclaración de valores; el monitoreo y apoyo post-capacitación ayudan a evitar agotamiento y garantizar la calidad de la atención. Es posible lograr servicios de alta calidad de aborto en el segundo trimestre, incluso en los lugares donde existe la mayor escasez de recursos. A la larga, las mejoras en los servicios de aborto en el segundo trimestre ayudarán a disminuir las tasas de morbilidad y mortalidad relacionadas con el aborto.
... The characteristics of medical and surgical methods drive management decisions and influence choices about which to offer and how to set up and implement services. For example, a busy clinic that already provides first trimester aspiration abortions might more easily add [13][14][15][16][17][18] week D&E services, with referrals to an area hospital for complicated or later cases. Facilities offering medical abortion can use a small, private room on their obstetrics ward with a small number of reclining chairs or beds. ...
... Terminating pregnancies with fully formed fetuses is often emotionally draining for staff despite their commitment to the women needing care. 15 Confirming completion of a 7-8 week abortion involves sorting through blood clots and tissue, while that of a second trimester abortion means examining fetal parts or an intact fetus. To support the team and reduce burn-out, managers in Nepal rotate staff responsibilities within the abortion service. ...
This paper describes experiences and lessons learned about how to establish safe second trimester abortion services in low-resource settings in the public health sector in three countries: Nepal, Viet Nam and South Africa. The key steps involved include securing the necessary approvals, selecting abortion methods, organising facilities, obtaining necessary equipment and supplies, training staff, setting up and managing services, and ensuring quality. It may take a number of months to gain the necessary approvals to introduce or expand second trimester services. Advocacy efforts are often required to raise awareness among key governmental and health system stakeholders. Providers and their teams require thorough training, including values clarification; monitoring and support following training prevents burn-out and ensures quality of care. This paper shows that good quality second trimester abortion services are achievable in even the most low-resource settings. Ultimately, improvements in second trimester abortion services will help to reduce abortion-related morbidity and mortality.
... Even staff who are supportive of women and are trained and willing to provide second-trimester abortion care may feel some stress. As Hern and Corrigan have stated, "Failing to recognize the symptoms and signs of this stress may have important consequences for continuation of the service" (Hern and Corrigan, 1980). Managers can support staff and the smooth functioning of services by using the following strategies. ...
Several procedures can be used to perform abortion in the second
trimester. In general, these procedures can be described as surgical or
medical; the latter method, which involves the use of medication, is often
called induction abortion. Both types of methods are recommended by
the World Health Organization (WHO, 2003) and are used in various
countries. In the United States, approximately 95 percent of all secondtrimester
abortions are performed with dilatation and evacuation (D&E)
(Darney et al., 1996), and it is the method most commonly used by
non–National Health Service abortion providers in the United Kingdom
(Royal College of Obstetricians and Gynaecologists [RCOG], 2005). In
parts of Western Europe, such as France and Sweden, induction abortions
are more common than D&E procedures are. This guide provides
information about both surgical and induction-abortion methods for
pregnancies from 13 through 24 weeks of pregnancy, on the basis of the
most recent scientific evidence available.
Bioethicists commenting on conscientious objection and abortion should consider the empirical data on abortion providers. Abortion providers do not fall neatly into groups of providers and objectors, and ambivalence is a key theme in their experience. Practical details of abortion services further upset the dichotomy. These empirical facts are important because they demonstrate that the way the issue is described in analytical bioethics does not reflect reality. Addressing conscientious objection as a barrier to patient access requires engaging with those who provide the service and those who are able to but do not. The experiences of doctors facing these decisions potentially challenge and expand our understanding of the issue as an ethical concern.
This chapter discusses the emotional factors related to stress among professional staff who participate in the performance of second-trimester abortions. The opinions presented herein are based on unstructured interviews with physicians and nurses in special abortion services and general hospitals in various parts of the country, as well as upon a review of published literature and unpublished research reports.
The Fourteenth Amendment rights of various parties in the abortion context-the pregnant woman, the fetus, the fetus's father, the state-have been discussed at length by commentators and the courts. Surprisingly, the Fourteenth Amendment rights of the healthcare provider asked to provide the abortion have not. Roe and Casey establish a pregnant woman's Fourteenth Amendment right to decide for herself whether to have an abortion. Do those same precedents also protect her doctor's right to decide whether to participate in abortion procedures? The Court's substantive due process analysis typically looks for rights that are "deeply rooted" in our history and traditions. Accordingly, this article addresses the historical basis for finding that providers do indeed have a Fourteenth Amendment right not to participate in abortions. This historical analysis shows that this right to refuse passes the Court's stated test for Fourteenth Amendment protection. In fact, the right to refuse actually has better historical support, and better satisfies the Court's stated tests, than the abortion right itself. Beyond this historical case, a healthcare provider's right to make this decision also fits squarely within the zone of individual decision making protected by the Court's opinions in Casey and Lawrence v. Texas, and protects providers from the types of psychological harm that the Court recognized in Roe and Casey. For these reasons, under Roe and Casey, a healthcare provider has a Fourteenth Amendment right not to participate in abortions.
The safety and approach late second-trimester outpatient dilatation and evacuation abortion is controversial. In this series, 1000 dilataton and evacuation abortions were performed on patients from 17 through 25 menstrual weeks' gestation in a private office outpatient facility. Each patient experienced serial multiple laminaria treatment over two days before abortion. Patients at 20 weeks' gestation or more also received adjunctive urea amnioinfusion on the day of the procedure. Three patients (0.3%) experienced major complications. Although a wide variety of clinical problems was encountered, procedure times were short, blood loss was generally low, and other complication rates were low. Recommendations for staffing and the prevention of complications are discussed.
Recent years have seen the introduction of state bills seeking to ban abortions after 20 weeks, but little empirical data exist on who is affected when such bans become law.
As part of a larger study, 272 women who received an abortion at or after 20 weeks' gestation and 169 who received first-trimester abortions at 16 facilities across the country in 2008-2010 were interviewed one week after the procedure. Mixed effect logistic regression analyses were used to determine the characteristics associated with later abortion (i.e., at 20 weeks or later). Causes of delay in obtaining abortion were assessed in open- and closed-ended questions; profiles of women who received later abortions were identified through factor analysis.
Women aged 20-24 were more likely than those aged 25-34 to have a later abortion (odds ratio, 2.7), and women who discovered their pregnancy before eight weeks' gestation were less likely than others to do so (0.1). Later abortion recipients experienced logistical delays (e.g., difficulty finding a provider and raising funds for the procedure and travel costs), which compounded other delays in receiving care. Most women seeking later abortion fit at least one of five profiles: They were raising children alone, were depressed or using illicit substances, were in conflict with a male partner or experiencing domestic violence, had trouble deciding and then had access problems, or were young and nulliparous.
Bans on abortion after 20 weeks will disproportionately affect young women and women with limited financial resources.
The stigma surrounding abortion in the United States commonly permeates the experience of both those seeking this health service as well as those engaged in its provision. Annually there are approximately 1.2 million abortions performed in the United States; despite that existing research shows that abortion services are highly utilized, women rarely disclose their use of these services. In 2005 only 1787 facilities that offer abortion services remained, a drop of almost 40 percent since 1982 (Jones, Zolna, Henshaw, & Finer, 2008). While it has been acknowledged that all professionals working in abortion are labeled to some degree as different, no published research has explored stigmatization as a process experienced by the range of individuals that comprise the abortion-providing workforce in the USA. Using qualitative data from a group of healthcare professionals doing abortion work in a Western state, this study begins to fill that gap, providing evidence of how the experience of stigma can vary and is managed within interactions in the workplace, in professional circles, among family and friends, and among strangers. The analysis shows that the experience of stigma for those providing abortion care is not a static or fixed loss of status. It is a dynamic situation in which those vulnerable to stigmatization can avoid, resist, or transform the stigma that would attach to them by varying degrees within selective contexts.
Abortion is highly stigmatized in the United States. The consequences of stigma for abortion providers are not well understood, nor are there published accounts of tools to assess or alleviate its burdens. We designed The Providers Share Workshop to address this gap. Providers Share is a six-session workshop in which abortion providers meet to discuss their experiences, guided by an experienced facilitator. Seventeen workers at one US abortion clinic participated in a pilot workshop. Sessions were recorded and transcribed, and an iterative process was used to identify major themes. Participants highlighted stigma, located in cultural discourse, law, politics, communities, institutions (including the abortion clinic itself), and relationships with family, friends and patients. All faced decisions about disclosure of abortion work. Some chose silence, fearing judgment and violence, while others chose disclosure to maintain psychological consistency and be a resource to others. Either approach led to painful interpersonal disconnections. Speaking in the safe space of the Workshop fostered interpersonal connections, and appeared to serve as an effective stigma management tool. Participants reflected favorably upon the experience. We conclude that the Providers Share Workshop may alleviate some of the burdens of abortion stigma, and may be an important intervention in abortion human resources. We present a conceptual model of the dynamics of stigma in abortion work.
ResearchGate has not been able to resolve any references for this publication.