The Reproductive Health Access Project strives to integrate early abortion into primary care so that women can receive abortions where they get their general medical care. Incorporating abortion services is a process, requiring thoughtful planning, sensitivity, and ongoing dialogue. It is a change that can take months or even years. It is not just a matter of adding a new medication or procedure; it requires an exploration of core attitudes and values. At the end of this process, women gain access to abortion care in a safe, private, familiar environment; and health center staff members at all levels gain not only a deeper understanding of reproductive health, but also an enhanced ability to handle controversial issues in a positive, patient-centered manner.
Integrating abortion requires sensitivity and determination to overcome obstacles and barriers. Barriers depend on the existing culture of the practice, the level of knowledge and skill, as well as the attitudes and feelings of the staff (see Frequently Asked Questions). In order to effectively integrate abortion services, these concerns need to be identified and addressed. No single strategy will work for all health centers; cultural, geographic, and political differences call for individualized approaches.
If you are thinking about adding early abortion services at your health center, here are some suggestions about how to begin:
1. Start by identifying other medical providers, administrators and/or staff within your setting who might be interested and committed to providing abortion services. Initiate an informal discussion with colleagues about offering the service. Develop a plan for regular meetings of this Planning Committee. The Planning Committee will discuss tasks, timeline, potential obstacles and solutions to those obstacles. Possible tasks for the Committee (these vary from site to site) could include:
- A survey of staff to ascertain how they feel about providing medical abortion at your site.
- Values clarification exercise to address opposition/discomfort with providing MAB
- Site-specific training for all staff who will be involved in MAB
- Review of/development of site-specific protocol, including whether misoprostol will be provided on-site or prescribed.
- Development of Forms for charts
- Ordering mifepristone
- Coverage of call for MAB patients
- Identifying suction back-up
- Ultrasound:
If on-site, clinician training
If off-site, developing smooth referrals and educating Sonography staff.
- Developing administrative support – who are key “players” who need to support this effort?
- Educating your billing department and sharing coding information
- Letting patients know MAB is available – informational materials, prochoice posters in offices, etc.
- All of these materials are available on this website
2. Find out about other local health centers or medical providers who have successfully integrated abortion services into their practice. Invite them to a meeting of the Planning Committee so they can describe their experiences.
3. Identify and attend training programs relating to early abortion methods.
4. Advise staff members that you are considering the implementation of abortion at the health center, and that you are interested in getting an idea of people’s thoughts and feelings about this. Implement an anonymous Staff Attitude Survey.
5. Establish regular meetings with staff (possibly in sub-groups depending on the size of the health center), to provide information and address concerns. Elicit staff members’ input into the agenda for the meetings. Helpful topics could include:
- Discussion of abortion service delivery in the context of reproductive choice, family planning, and the concept of helping every child to be a wanted child, and every mother to have her children when she feels she can best care for them. Ask staff members: what do our patients do when faced with an unwanted pregnancy? How do we counsel them, and where do we refer them? How might this process change if we offered abortion here?
- Education of staff to the reality of the abortion provider shortage, and the potential impact on women. Provide them with a history of abortion. Younger staff members may be unfamiliar with women’s experiences prior to abortion legalization. Share public health and research information about abortion.
- Acknowledge that people on both sides of this issue have strong feelings.
- Allow staff members to talk about how they feel and demonstrate respect for powerful feelings, even if they are hard to understand.
- Use case scenarios or examples from actual practice.
- Implement Values Clarification Exercises in relatively small groups. This workshop should be co-facilitated and carefully planned. Strong feelings can be elicited during this workshop, so it is important that it is not the first time that staff hears that the center is considering the provision of abortion services. If you decide to implement the workshop, it is best delivered by skilled co-facilitators.
- Help Staff to Stay Focused on the Needs of Patients
6. Present information on Early Abortion, including medication abortion and MVA, to all staff, including medical providers, nurses, and ancillary staff. It is important to avoid the assumption that everyone has the facts straight about abortion. For example, some staff members may mistakenly envision medical abortion as a “procedure” similar to a suction abortion. Staff may think a manual aspiration abortion is identical to an electric vacuum abortion procedure, so having the manual aspirator available for staff to see and handle is helpful. Therefore this initial overview may be the first step in de-mystifying the process, realizing the benefits for women, and embracing the possibility within one’s practice. Even before a practice integrates early abortion, accurate knowledge facilitates appropriate referral to abortion providers. Brief role-plays of a provider-patient medical abortion encounter, with a question and answer period can be easily done in a 45 minute to one hour meeting with ancillary staff, nurses and even colleagues (sample script).
7. Consider implementing an anonymous Patient Attitude Survey. In some settings, demonstrating patient support for a service can help foster staff support.
8. Inform staff of survey results, and address staff concerns based on these results.
For example, even staff members who support women’s choices may worry about security. It is important to address this concern, and develop a plan for security (see Frequently Asked Questions).
9. Develop a policy regarding staff members who feel that they are unable to participate in providing abortion services. In discussing these issues, it is important to clarify the differences between participating (i.e. counseling, administering medication, providing on-call services), from customary health center functions such as answering telephones, drawing blood, etc.) Be clear on the message that staff members will be given regarding these decisions.
10. When interviewing applicants for staff vacancies, discuss the issue of abortion. Applicants should assess how comfortable they would feel working in an office that provides abortion.
A Final Thought
Increasing abortion access for women is important and difficult. There will be moments of great satisfaction, along with moments of deep frustration. In the long run, a well thought out plan will enable you to provide sustainable and high quality services.
We applaud your efforts to ensure that every woman can access full reproductive health services from her primary healthcare provider.
