Racial disparities in pregnancy options counseling and referral in the US South.

OBJECTIVE: The objective of this study is to examine racial variation in receipt of counseling and referral for pregnancy options (abortion, adoption, and parenting) following pregnancy confirmation. Equitable offering of such information is a professional and ethical obligation and an opportunity to prevent racial disparities in maternal and child health. DATA SOURCE: Primary data from patients at southern United States publicly funded family planning clinics, October 2018-June 2019. STUDY DESIGN: Patients at 14 clinics completed a survey about their experiences with pregnancy options counseling and referral following a positive pregnancy test. The primary predictor variable was patients' self-reported racial identity. Outcomes included discussion of pregnancy options, referral for those options, and for support services. DATA COLLECTION: Data from eligible patients with non-missing information for key variables (n = 313) were analyzed using descriptive statistics, χ2 tests, and multivariable logistic regression. PRINCIPAL FINDINGS: Patients were largely Black (58%), uninsured (64%), and 18-29 years of age (80%). Intention to continue pregnancy and receipt of prenatal care referral did not differ significantly among Black as compared to non-Black patients. However, Black patients had a higher likelihood of wanting an abortion or adoption referral and not receiving one (abortion: marginal effect [ME] = 7.68%, p = 0.037; adjusted ME [aME] = 9.02%, p = 0.015; adoption: ME = 7.06%, p = 0.031; aME = 8.42%, p = 0.011). Black patients intending to end their pregnancies had a lower probability of receiving an abortion referral than non-Black patients (ME = -22.37%, p = 0.004; aME = -19.69%, p = 0.023). In the fully adjusted model, Black patients also had a higher probability of wanting access to care resources (including transportation, childcare, and financial support) and not receiving them (aME = 5.38%, p = 0.019). CONCLUSIONS: Clinical interactions surrounding pregnancy confirmation provide critical opportunities to discuss options, coordinate care, and mitigate risk, yet are susceptible to systemic bias. These findings add to limited evidence around pregnancy counseling and referral disparities. Ongoing assessment of pregnancy counseling and referral disparities can provide insight into organizational strengths or the potential to increase structural equity.

Patient-reported experience with discussion of all options during pregnancy options counseling in the US South.

OBJECTIVE: To estimate the association between discussion of all options (adoption, abortion, and parenting) in pregnancy options counseling and patient-reported experience with counseling. STUDY DESIGN: Patients (n = 316) who received a positive pregnancy test Oct 2018-June 2019 at one of 14 randomly selected clinics in a southern US publicly funded family planning system participated in an anonymous digital survey about their experience with counseling. The survey assessed which options (parenting, adoption, abortion) they discussed with their provider and how they rated their counseling experience using a 20-item scale based on validated measures of patient reproductive health counseling experience. We used Poisson regression to estimate the prevalence ratio for discussing all pregnancy options and rating their provider with a perfect score. RESULTS: Approximately 10% of patients reported their provider discussed all options. After adjustment for patient, provider, and clinic characteristics, patients were approximately 80% more likely to rate their counseling as "excellent" on all analyzed scale items when their provider discussed all options compared to when they did not (adjusted prevalence ratio [aPR] = 1.80, 95% CI: 1.43, 2.28). Discussion of all pregnancy options was associated with a more positive patient-reported experience among patients who planned to continue their pregnancy (aPR = 1.82, 95% CI: 1.37, 2.42) and among those who did not (aPR = 1.62, 95% CI: 1.08, 2.44). Patients whose provider had received options counseling training were more likely to report all options were discussed. CONCLUSION: Discussion of all options during pregnancy counseling is associated with a more positive patient experience. These findings indicate patient preference for supportive, nondirective counseling on all pregnancy options. IMPLICATIONS: Our study's findings support nondirective discussion of all pregnancy options (including parenting, abortion and adoption) as a best practice, and stand in contrast to regulations that restrict discussion of all options.

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.

Evaluation of a Training for Health and Social Service Providers on Abortion Referral-Making.

Purpose Engaging trusted care providers and empowering them with information and skills about abortion is a critical opportunity to improve coordination of care for women seeking abortion, if and when these services are needed. Description Provide, a nonprofit that works in partnership with health and social service providers to build a health system that is equipped to respond to women's health care needs around abortion, launched a referrals training program in 2013. To assess the effectiveness of this training program, we conducted an evaluation of satisfaction with training and the impact of the intervention on provider knowledge of safety of abortion, self-efficacy to provide abortion referrals, and intention to provide pregnancy options counseling and referrals in the future. Assessment Approximately 90% of participants were "very satisfied" with their training experience. Results show significant increase in intention to provide non-judgmental pregnancy options counseling and referrals for abortion care after participants went through training. Post-training, significantly more reported that they would present all pregnancy options without judgment or bias (94 vs. 82%, p < .0001), provide a referral for abortion care if needed (80 vs. 50%, p < .0001), and follow-up with the client (71 vs. 39%, p < .0001). Further, more also reported they would refer a client for prenatal care if the client requested it (78 vs. 67%, p < .0001). Conclusion Our results suggest that abortion referrals training hold potential to build the capacity of health and social service providers' ability to meet client needs related to pregnancy and could be implemented at a larger scale.

Abortion training in three family medicine programs: resident and patient outcomes.

BACKGROUND: Three family medicine residency programs in California integrated abortion training into routine gynecology rotations in academic years 2003-2004 and 2004-2005. METHODS: Forty-six (88%) of 52 eligible residents participated in the abortion training sessions. Of these 46 residents, 39 (85%) chose to perform abortion procedures, and seven residents elected to provide other aspects of patient care only. RESULTS: Resident evaluations of the training program were overwhelmingly positive. Moreover, two thirds of the 43 post-training survey respondents reported that the training program increased their interest in providing abortion services, and no resident reported decreased interest. The resident complication rate was 1.0%. In post-procedure surveys completed by 155 patients at two training sites, patients reported a high level of satisfaction with the care they received from the training team. CONCLUSIONS: These program evaluation results suggest that abortion training can safely be integrated into family medicine residency programs, with a positive reception by both residents and patients.

Papaya: a simulation model for training in uterine aspiration.

Family medicine physicians from several residency programs received training in manual vacuum aspiration (MVA) using papayas as low-cost simulation models. Ninety-two percent of trainees (n = 26) rated the value of the simulation practice as "high," and 73% of trainees from a separate session (n = 11) reported that it would change the way they managed patients. Trainees asked to rate their perceptions before and after simulated practice (n = 16) indicated a 55% decrease in perceived difficulty of uterine evacuation and a 275% increase in procedural confidence. These preliminary measures suggest that simulation is an effective first step in teaching uterine aspiration procedures.