October 28, 2015 — Summary of "Contraceptive Care at The Time of Medical Abortion: Experiences of Women and Health Professionals in a Hospital or Community Sexual and Reproductive Health Context," Carrie Purcell et al., Contraception, Oct. 2, 2015.
"Little research to date has looked in depth at health professionals' experiences with providing contraceptive care at medica[tion] abortion, and even less brings together the perspectives of women and health professionals," according to Carrie Purcell of the University of Edinburgh's Centre for Population Health Sciences and colleagues.
According to the researchers, the study "offers a holistic analysis of providing and receiving contraceptive care at medica[tion] abortion in a traditional hospital context and a more recently established [sexual and reproductive health center (SRHC)] setting, offering comparison of experiences in these two clinical contexts." The study "foregrounds concordant and conflicting priorities of women and health professionals, and highlights tensions between facilitating women's contraceptive decisions and preventing subsequent unintended conceptions."
For the study, the researchers interviewed 46 patients presenting for medication abortion and 25 health care providers at "[t]wo hospital[s] and one SRHC in the same area of urban Scotland ... to compare and evaluate provision from the hospital and community contexts."
The interviews with health care professionals "addressed areas including: participants' current role in abortion care; work satisfaction; quality of care; post-abortion contraceptive provision; differences in clinical settings; areas for improvement." The interviews with patients "covered: reasons for requesting abortion; experiences of care; experiences of passing the pregnancy at home; post-abortion contraceptive care and reasons for (non)uptake."
According to the researchers, the "participating sites use a medica[tion] abortion regimen ... at the end of an initial assessment appointment, during which women receive verbal counselling and written information on their abortion and contraceptive options by an assessing doctor or nurse." The women have a second appointment 24 to 48 hours later to receive the second medication abortion drug, at which time "[w]omen requesting the contraceptive implant, injectable, or user-controlled methods are provided with these." Meanwhile, "[w]omen who have not agreed to a method or changed their mind by the [second] appointment are provided with further counselling." Women attending any site also can opt to receive an intrauterine device, which would be implanted at the SRHC one week after the provision of medication abortion.
Addressing contraception at medica[tion] abortion
The researchers found that more than half of women "said they had wanted or were happy to address contraception at abortion." According to the researchers, "Those who had already explored" contraceptive options "did not feel they needed to discuss contraception further, but were amenable to having their chosen method provided at abortion," while those "who had not considered options prior to attending the clinic were happy to have the opportunity to discuss and arrange a method."
A minority of women in the study "experienced being asked about contraception as implying [judgment] of their [behavior]." Some women in this minority said their feelings could "have stemmed from their own unease about the abortion," while others "described more explicitly negative experiences."
Meanwhile, according to the researchers, health care professionals "predominantly felt that abortion is an appropriate time to address contraception because most women are likely to be 'receptive' at that time," although "they also tended to focus on the sensitivities of doing so," particularly on how to be nonjudgmental. Providers also "described putting considerable work into creating an atmosphere of joint decision-making in a way which made women feel the choice had been theirs," although they noted that some women tended to agree to a contraceptive option and change their minds at the second appointment.
Preventing subsequent abortions
Purcell and colleagues noted, "Women who were in [favor] of addressing contraception at abortion often related this to their desire to prevent subsequent unintended conceptions and abortions," a trend that "paralleled health professional accounts, in which the prevention of subsequent abortions was also presented as a priority, and post-abortion contraceptive care was framed as a measure 'to make sure this doesn't happen again.'"
According to the researchers, "These examples highlight the challenges for health professionals of facilitating 'choice' in the face of some resistance to contraceptive uptake, whilst also trying to practice what they believe is best for women, both medically and otherwise."
Choosing LARC at medica[tion] abortion
The researchers noted that patients tended to frame the consideration of contraceptives based on their prior experiences with contraception and, particularly for LARCs, on "the experiences of friends and relatives." According to the researchers, providers frequently presented LARC "as the most appropriate contraceptive method for most women following an abortion," but their efforts to "encourag[e] LARC uptake" were challenged by patients' tendency to rely on the experiences of friends and family rather than statistics on the contraceptive method.
The researchers also found women weighed the "perceived advantage[s] and disadvantages" of LARCs, including a concern among some women about "relative lack of user control inherent in LARC" and women's interest in LARC's "reliability and 'forgetability.'"
Reasons for non-uptake of contraception at medica[tion] abortion
Purcell and colleagues cited several "complex and context-specific" reasons why women opted against contraceptive uptake at medication abortion, including:
~ A desire to avoid further "bodily intrusion";
~ A feeling "that they were not in a position to make a longer-term decision at the time of medica[tion] abortion," sometimes due to the hope for a planned pregnancy within a year;
~ "[N]egative prior experiences with perceived unwanted effects from hormonal methods"; and
~ "Concerns about pain on insertion, fear of needles, or embarrassment about having an [IUD] fitted."
According to the researchers, some women "said that they had in fact chosen a contraceptive method but that no health professional was available to provide this at medica[tion] abortion." While providers acknowledged that time constraints made it difficult to address contraception in a hospital setting, they "tended to present non-uptake primarily in terms of women's indecision and reluctance to 'take control' of their fertility," the researchers wrote.
The researchers wrote that the study raises several "points of interest" that can "inform research and provision of contraceptive care at abortion," particularly as to "why post-abortion contraception is seen as important by women and health professionals; the ways in which their priorities converge and differ; and how provision might be best addressed or improved."
Purcell and colleagues cited a "concordance" among patients and health professionals to consider post-abortion contraception as a way to avoid subsequent abortions. However, they noted that their "analysis ... highlights a tension for health professionals between encouraging contraceptive uptake (specifically LARC) in order to prevent subsequent abortions and providing women with choice, including the choice to decline contraception." According to the researchers, this tension surfaced as:
~ Some providers described their "'gentle man[e]uvering' of women towards making a contraceptive decision before leaving the abortion service";
~ Some women reported that some providers seemed "'pushy'"; and
~ Some women's tendency to "prioriti[ze] experiential over clinical knowledge," which some providers cited as a "challenge" and "barrier" to LARC uptake.
The researchers noted that women's criticisms of health professionals "were more commonly levelled at hospital than SRHC providers," which could be related to SRHC providers' specialized training and practice.
Further, the researchers wrote that while providers "described abortion as an appropriate time to address contraception, there was variability in the degree to which they were equipped to address the many challenges of doing so," including in their desire to be nonjudgmental. The researchers noted that when women "'[took] control'" over their fertility by following providers' contraceptive recommendations "any tension between women's decisions and policy priorities is obscured," but "when 'taking control' manifests as women resisting further intervention at the time of abortion, this tension becomes apparent as an issue for health professionals to address."
Meanwhile, "the majority of women interviewed considered addressing contraception at the time of medica[tion] abortion to be acceptable, providing it was done in a non-[judgmental] way, and that many said they felt motivated to obtain a reliable method." However, both providers and patients displayed "a tension between the facilitation of 'choice' and the perceived role of contraceptive uptake at abortion in preventing subsequent abortions." According to the researchers, this tension can "illustrate different interpretations of patient [centered] care in this context," in that some providers believed "appropriate care involved a stance of empathic neutrality" while others thought it "involves guiding women towards the 'choice' prioriti[z]ed by the health professional."
The study "indicate[s] that not all health professionals have the requisite skills, and foreground a grey area between 'gentle [maneuvering]' and pressure which challenges women's rights to reproductive autonomy in a more fundamental way," and this "has implications for vulnerable groups in particular," the researchers wrote. They concluded, "What is required therefore is training for all providers of contraception at abortion which explicitly addresses these tensions and their implications in practice."