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What about us? Staff reactions to D & E

Authors:
  • University of Colorado at Boulder; University of Colorado Denver Health Sciences Center

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. ...
Article
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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. ...
Article
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. ...
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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.
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Chapter
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.
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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.
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