Ethics, Abortion Access, and Emergency Care Post-Dobbs: The Gray Areas.

Clinical management of emergency pregnancy care, such as ectopic pregnancy or heavy bleeding with pregnancy of unknown location, includes upholding legal and ethical standards. For health care providers unwilling to provide evidence-based life-saving abortion care due to personal beliefs, clear guidance dictates disclosure of these limitations to the patient and colleagues, followed by immediate referral for appropriate care. However, this decision-making pathway may not be engaged due to a variety of factors: providers' beliefs preclude adherence to referral responsibilities, political discourse confuses patients as to their options and rights, and a constantly changing state and national legal landscape leads providers to question their ability to practice to their full scope of clinical care. Although this disruption of evidence-based standard of care existed pre-Dobbs, the moral disorder is now heightened. This Clinical Rounds highlights a patient vignette describing the risks of abortion restrictions for patients and providers alike, particularly when an individual provider's concerns for violating institutional guidelines sets a precedent for nursing response and forecloses on collaborative input or ethics consultation. The history of physician-only abortion exceptionalism and exclusion of nurses and midwives despite a significant history of nurses and midwives in abortion care grounds an argument for focusing on the impact of unethical and substandard care on the interprofessional care team leading to moral distress and negative patient outcomes. Patient-centered models of care, such as frameworks common in nursing and midwifery, offer opportunities to consider how all providers practicing to their full scope in interprofessional and collaborative ways, such as in emergency rooms and labor departments, might mitigate obstructions to abortion care that risk pregnant people's lives.

The Ethical Justification for Conscience Clauses in Nurse-Midwifery Practice: Context, Power, and a Changing Landscape.

In the last century, conscientious objection has moved from objection to conscripted military service to include health care providers who have moral concerns about participation in specific aspects of health care. Although guidance for the use of conscientious objection has developed in both nursing and midwifery, changes in the political landscape may be creating a source of conflict between providers and the use of conscientious objection. Particularly in aspects of sexual and reproductive care like abortion, contraception, and lesbian, gay, bisexual, transgender, or queer health care, the ethical requirement for prompt referral is becoming increasingly difficult to meet in many contexts. Changes to federal regulations protecting conscience clauses have tilted strongly in favor of the rights of providers in recent years; this challenges the delicate balance of patient and provider rights that has developed over the years. These may now represent an unavoidable conflict between different aspects of the ethical obligations of providers, in particular the obligation to seek justice, and bring into question whether the current status of conscientious objection is sustainable. In this article, we examine these conflicts in the context of the current political climate.

Attitudes of California Registered Nurses About Abortion.

OBJECTIVE: To describe attitudes about abortion among registered nurses (RNs) licensed in California and to determine if demographic characteristics were associated with these attitudes. DESIGN: Cross-sectional, one-time survey. SETTING: Online between 2015 and 2017. PARTICIPANTS: Nurses with active RN licenses in California (N = 2,500). METHODS: An anonymous survey was sent to a random sample of 2,500 RNs with active California licenses between 2015 and 2017 to assess their personal and professional demographic characteristics and their attitudes toward abortion. Using scores on the Abortion Attitudes Scale, we dichotomized participants into proabortion and antiabortion categories. We used chi-square tests to determine differences based on demographic characteristics. RESULTS: Data from 504 RNs licensed in California are included in this analysis. Most respondents identified as female (n = 462, 92%), older than 50 years of age (n = 379, 75%), married (n = 364, 72%), White (n = 354, 70%), and Christian (n = 322, 64%). They were more likely to have negative attitudes toward abortion care if they identified as Christian (p < .001) and more positive attitudes if they identified as White (p < .001) independent of identifying as Christian. CONCLUSIONS: Respondents had a complex range of attitudes about abortion. In some cases, these attitudes aligned and/or conflicted with stated religious orientation. This study highlights the demographic characteristics that are associated with the attitudes and beliefs about abortion among RNs licensed in California.

Training in aspiration abortion care: An observational cohort study of achieving procedural competence.

BACKGROUND: Studies in multiple countries have found that the provision of aspiration abortion care by trained nurses, midwives, and other front-line health care workers is safe and acceptable to women. In the United States, most state abortion laws restrict the provision of abortion to physicians; nurse practitioners, nurse-midwives, and physician assistants, can legally perform medication abortion in only twelve states and aspiration abortion in five. Expansion of abortion care by these providers, consistent with their scopes of practice, could help alleviate the increasing difficulty of accessing abortion care in many states. OBJECTIVES: This study used a competency-based training model to teach advanced practice clinicians to perform vacuum aspiration for the abortion care. Previous research reporting on the training of providers other than physicians primarily focused on numbers of procedures performed, without assessment of skill competency or clinician confidence. DESIGN: In this prospective, observational cohort study, advanced practice clinician trainees were recruited from 23 clinical sites across six partner organizations. Trainees participated in a standardized, competency-based didactic and clinical training program in uterine aspiration for first-trimester abortion. SETTINGS: Trainee clinicians needed to be employed by one of the six partner organizations and have an intention to remain in clinical practice following training. PARTICIPANTS: California-licensed advanced practice clinicians were eligible to participate in the training if they had at least 12 months of clinical experience, including at least three months of medication abortion provision, and certification in Basic Life Support. METHODS: A standardized, competency-based training program consisting of both didactic and clinical training in uterine aspiration for first-trimester abortion was completed by 46 advanced practice clinician participants. Outcomes related to procedural safety and to the learning process were measured between August 2007 and December 2013, and compared to those of resident physician trainees. RESULTS: Essentially identical odds of complications occurring from advanced practice clinician-performed procedures were not significantly different than the odds of complications occurring from resident-performed procedures (OR: 0.99; CI: 0.46-2.02; p > 0.05) after controlling for patient sociodemographic and medical history. The number of training days to foundational competence ranged from six to 10, and the number of procedures to competence for those who completed training ranged from 40 to 56 (median = 42.5). CONCLUSIONS: A standardized, competency-based trainingprogram can prepare advanced practice clinicians to safely provide first-trimester aspiration abortions. Access to safe abortion care can be enhanced by increasing the number of providers from cadres of clinicians other than physicians.

Role development in midwifery education: A place for simulation.

OBJECTIVE: simulation-based learning is increasingly seen as an effective strategy to develop student nurse-midwives into effective healthcare team members. A gap exists concerning the use of simulation to promote role transition/development of the student midwife. The purpose of this paper is to describe an evolving simulation curriculum aimed at role development of the student midwife as well as technical skills training. SETTING: the University of New Mexico, College of Nursing and the Interprofessional Healthcare Simulation Center. PARTICIPANTS: this program involves students enrolled in the Masters in Nursing Program, Midwifery Concentration and students enrolled in the pre-licensure Bachelor of Science in Nursing program. FINDINGS: simulation allows for an opportunity to focus on communication skills with other team members, practicing the importance of clear delegation of responsibilities in high-stress situations. CONCLUSIONS: the value of practicing the necessary communication skills, as well as the opportunity to engage in simulated delegation of tasks, is an important aspect of midwifery role development.

Expanding Access to Sexual and Reproductive Health Services Through Nursing Education.

Thoughtful, unbiased, evidence-based content in nursing education is crucial for the development of confident and competent nurses who provide care in every setting. The purpose of this article is twofold: to provide evidence to show that comprehensive sexual and reproductive health care by nurses is informed by educational exposure to content and to provide recommendations for change at the individual, institutional, and structural levels to improve and expand sexual and reproductive health services.

The Annual Gynecologic Examination Updated for the 21st Century.

The concept of an annual gynecologic screening visit to identify disease at an early stage has long been an established component of women's health care. Women and their health care providers have historically accepted the schedule of an annual gynecologic examination with cervical cancer screening and a pelvic examination. Recently, researchers questioned the value of the annual breast and pelvic examinations in asymptomatic women and re-established the intervals for Pap test screening with the addition of human papillomavirus co-testing to establish cervical cancer risk. The updated well woman examination is now an opportunity to engage women in health education, screening for chronic disease risks, and health care concerns such as depression and violence.

Core competencies in sexual and reproductive health for the interprofessional primary care team.

OBJECTIVE: A primary care workforce that is well prepared to provide high-quality sexual and reproductive health (SRH) care has the potential to enhance access to care and reduce health disparities. This project aimed to identify core competencies to guide SRH training across the primary care professions. STUDY DESIGN: A six-member interprofessional expert working group drafted SRH competencies for primary care team members. Primary care providers including family physicians, nurses, nurse practitioners and certified nurse midwives, physician assistants and pharmacists were invited to participate in a three-round electronic Delphi survey. In each round, participants voted by email to retain, eliminate or revise each competency, with their suggested edits to the competencies incorporated by the researchers after each round. RESULTS: Fifty providers from six professions participated. In Round 1, 17 of 33 draft competencies reached the 75% predetermined agreement level to be accepted as written. Five were combined, reducing the total number to 28. Based on Round 2 feedback, 21 competencies were reworded, and 2 were combined. In Round 3, all 26 competencies reached at least 83.7% agreement, with 9 achieving 100% agreement. CONCLUSION: The 33 core competencies encompass professional ethics and reproductive justice, collaboration, SRH services and conditions affecting SRH. These core competencies will be disseminated and adapted to each profession's scope of practice to inform required curricula. IMPLICATIONS: SRH competencies for primary care can inform the required curricula across professions, filling the gap between an established standard of care necessary to meet patient needs and the outcomes of that care.

Calculus formation: nurses' decision-making in abortion-related care.

Nurses routinely provide care to patients in ethically challenging situations. To explore the continuum between conscientious objectors and designated staff in the provision of care to women seeking abortions, the aim of this study was to thickly describe decision-making, using abortion as the clinical context to elucidate how nurses approach ethically challenging work. A purposive sample of 25 nurses who worked in abortion clinics, emergency departments, intensive care units, labor, and delivery, operating rooms, and post anesthesia care units were interviewed. Qualitative description and thematic analysis were used to identify the cognitive, emotional, and behavioral processes in nurses' decisions to care for women needing abortions. Nurses developed and used multifaceted, real-time calculi when making decisions about their participation in emergent or routine abortion care. Nurses tacked back and forth between the personal and professional and/or held multiple contradictory positions simultaneously. Nurses weighed the role and opinion of others to determine if they know how to or know why they would provide abortion care to women, particularly in the elective abortion context. The parameters of the nurse-patient relationship were complex and specific to the experiences of both the nurse and patient. Findings from this study further develop the science of ethically challenging decision-making and expand our understanding of factors that influence how nurses develop relationships to ethically challenging work.

Recruitment and retention strategies for expert nurses in abortion care provision.

OBJECTIVE(S): The purpose of this thematic analysis is to describe recruitment, retention and career development strategies for expert nurses in abortion care provision. STUDY DESIGN: Thematic analysis influenced by grounded theory methods were used to analyze interviews, which examined cognitive, emotional, and behavioral processes associated with how nurses make decisions about participation in abortion care provision. The purposive sample consisted of 16 nurses, who were interviewed between November 2012 and August 2013, who work (or have worked) with women seeking abortions in abortion clinics, emergency departments, labor and delivery units and post anesthesia care units. RESULTS: Several themes emerged from the broad categories that contribute to successful nurse recruitment, retention, and career development in abortion care provision. All areas were significantly influenced by engagement in leadership activities and professional society membership. The most notable theme specific to recruitment was exposure to abortion through education as a student, or through an employer. Retention is most influenced by flexibility in practice, including: advocating for patients, translating one's skill set, believing that nursing is shared work, and juggling multiple roles. Lastly, providing on the job training opportunities for knowledge and skill advancement best enables career development. CONCLUSION(S): Clear mechanisms exist to develop expert nurses in abortion care provision. IMPLICATIONS: The findings from our study should encourage employers to provide exposure opportunities, develop activities to recruit and retain nurses, and to support career development in abortion care provision. Additionally, future workforce development efforts should include and engage nursing education institutions and employers to design structured support for this trajectory.

How clinicians develop confidence in their competence in performing aspiration abortion.

In this article we explore how nurse practitioners, physician assistants, and nurse midwives in California (collectively referred to as clinicians) developed confidence while learning to provide vacuum aspiration abortion. We interviewed clinicians (n = 30) who worked in reproductive health care settings and had participated in a large abortion-training study. Although the training had moral and political significance for the trainees, in this article we focus on their experience of skill development and how they gained confidence and competence in aspiration abortion, a procedure typically performed by physicians. We argue that confidence is not one dimensional. Understanding the diverse ways in which clinicians arrive at confidence might inform health care training and education generally. By examining attained competency from the clinicians' perspectives, we continue the discussion within the social science of health care and medicine about how clinicians know what they know and what expertise feels like to them.

Premature or just small? Training Guatemalan birth attendants to weigh and assess gestational age of newborns: an analysis of outcomes.

We describe Guatemalan birth attendants' identification of vulnerable newborns, their evaluation of gestational age and anthropometry, and the validity of the Capurro and New Ballard newborn gestational age assessment methods. We interviewed 49 birth attendants and trained 10 of these women to assess 63 newborns. The Capurro and Ballard methods were correlated (Spearman rho = .75, p < .001) and showed agreement (Bland-Altman plot, difference and bias, -0.33 ± 1.3 weeks). Prematurity was estimated at 27% (Ballard) and 24% (Capurro); low birth weight (LBW) was 30%. Capurro provided a simplified, equivalent estimate of gestational age compared with New Ballard that could be used by birth attendants.

A radio-education intervention to improve maternal knowledge of obstetric danger signs.

OBJECTIVE: To examine whether a radio-education intervention (REI) is associated with improved maternal knowledge of pregnancy danger signs (PDS) in Nicaragua. METHODS: This cross-sectional pilot study used pretests and posttests to evaluate whether an REI was associated with improved knowledge of PDS among 77 pregnant and postpartum women in Nicaragua. RESULTS: The total number of PDS identified by study participants increased from 130 before the intervention to 200 after the intervention, an increase of 53.8% (Wilcoxon signed-rank test (z) = -4.18; P < 0.00001). The three PDS for which participant knowledge increased significantly after the intervention were 1) swelling of the face and hands, 2) convulsions, and 3) vaginal bleeding. Participants who 1) reported having a sister who had experienced a pregnancy complication, 2) lived in an urban setting, and 3) had more than a sixth-grade education were significantly more likely to score higher on posttests related to knowledge of PDS than those without those attributes (90.9% versus 56.9% [Χ² (degrees of freedom) = 4.60 (1); P = 0.043; n = 76]; 75% versus 45.9% [Χ² = 6.8 (1); P = 0.009; n = 77]; and 62.5% (12+ years education) versus 79.3% (6-12 years) versus 50.0% (0-6 years education) versus 25.0% (no education) [Χ² = 8.11 (1); P = 0.044; n = 77] respectively). CONCLUSIONS: Exposure to the REI was associated with a significant increase in the ability to identify PDS. Further studies should establish whether this increase in knowledge of PDS is associated with increases in use of maternity care services and decreases in delays in seeking care.

A radio-education intervention to improve maternal knowledge of obstetric danger signs / Una intervención de educación por radio para mejorar el conocimiento materno de los signos de peligro obstétrico

OBJECTIVE: To examine whether a radio-education intervention (REI) is associated with improved maternal knowledge of pregnancy danger signs (PDS) in Nicaragua. METHODS: This cross-sectional pilot study used pretests and posttests to evaluate whether an REI was associated with improved knowledge of PDS among 77 pregnant and postpartum women in Nicaragua. RESULTS: The total number of PDS identified by study participants increased from 130 before the intervention to 200 after the intervention, an increase of 53.8% (Wilcoxon signed-rank test (z) = -4.18; P < 0.00001). The three PDS for which participant knowledge increased significantly after the intervention were 1) swelling of the face and hands, 2) convulsions, and 3) vaginal bleeding. Participants who 1) reported having a sister who had experienced a pregnancy complication, 2) lived in an urban setting, and 3) had more than a sixth-grade education were significantly more likely to score higher on posttests related to knowledge of PDS than those without those attributes (90.9% versus 56.9% [Χ² (degrees of freedom) = 4.60 (1); P = 0.043; n = 76]; 75% versus 45.9% [Χ² = 6.8 (1); P = 0.009; n = 77]; and 62.5% (12+ years education) versus 79.3% (6-12 years) versus 50.0% (0-6 years education) versus 25.0% (no education) [Χ² = 8.11 (1); P = 0.044; n = 77] respectively). CONCLUSIONS: Exposure to the REI was associated with a significant increase in the ability to identify PDS. Further studies should establish whether this increase in knowledge of PDS is associated with increases in use of maternity care services and decreases in delays in seeking care.

OBJETIVO: Analizar si una intervención de educación por radio se asocia con un mejor conocimiento materno de los signos de peligro durante el embarazo (SPE) en Nicaragua. MÉTODOS: Este estudio piloto transversal evaluó si la intervención se asociaba con un mejor conocimiento de los SPE en 77 mujeres embarazadas o puérperas de Nicaragua mediante evaluaciones previas y posteriores a la intervención. RESULTADOS: El número total de SPE reconocidos por las participantes en el estudio aumentó de 130 antes de la intervención a 200 después de esta, un aumento de 53,8% (prueba de los rangos con signo de Wilcoxon (z) = -4,18; P < 0,00001). Los tres SPE cuyo conocimiento aumentó significativamente entre las participantes después de la intervención fueron 1) la hinchazón de la cara y las manos, 2) las convulsiones y 3) la hemorragia vaginal. Las participantes que 1) notificaron que tenían una hermana que había presentado una complicación del embarazo, 2) vivían en un entorno urbano y 3) tenían un nivel educativo superior al sexto grado tenían significativamente más probabilidades de obtener una mayor puntuación en las evaluaciones posteriores relacionadas con el conocimiento de los SPE que las que no cumplían esas condiciones (90,9 frente a 56,9% [Χ² (grados de libertad) = 4,6 (1); P = 0,043; n = 76]; 75 frente a 45,9% [Χ² = 6,8 (1); P = 0,009; n = 77]; y 62,5% (más de 12 años de formación) frente a 79,3% (6 a 12 años), frente a 50,0% (0 a 6 años), frente a 25,0% (sin formación) [Χ² = 8,1 (1); P = 0,044; n = 77], respectivamente). CONCLUSIONES: La exposición a la intervención de educación por radio se asoció con un aumento significativo de la capacidad de reconocer los SPE. Sería preciso llevar a cabo otros estudios para establecer si este aumento de conocimientos en materia de SPE se asocia con un incremento en el uso de los servicios de atención a la maternidad y una disminución de las demoras en la búsqueda de atención.

Women's empowerment in rural China: the impact of community health workers.

Surmang Foundation's Clinic is located in Qinghai Province, Yushu Prefecture, Xiao Surmang Township, China. It is a remote, 97 percent ethnic Tibetan, mountainous region with little access to organized health care services. Surmang Foundation, a US 501(c)3 charity, has organized a cadre of local women to provide community-based care and education to women, resulting in a notable reduction in maternal mortality based on the report of community members. A festival organized to celebrate the accomplishments of the community health workers provided an opportunity for the women to demonstrate how their roles benefit themselves and their community. Both health care services and support for community empowerment are provided through the community health worker model.